Label: CABOMETYX- cabozantinib tablet

  • NDC Code(s): 42388-023-26, 42388-023-36, 42388-023-37, 42388-024-26, view more
    42388-024-37, 42388-025-26, 42388-025-37
  • Packager: Exelixis, Inc.
  • Category: HUMAN PRESCRIPTION DRUG LABEL
  • DEA Schedule: None
  • Marketing Status: New Drug Application

Drug Label Information

Updated January 31, 2021

If you are a consumer or patient please visit this version.

  • HIGHLIGHTS OF PRESCRIBING INFORMATION
    These highlights do not include all the information needed to use CABOMETYX safely and effectively. See full prescribing information for CABOMETYX.
    CABOMETYX® (cabozantinib) tablets, for oral use
    Initial U.S. Approval: 2012

    RECENT MAJOR CHANGES

    Indications and Usage, Renal Cell Carcinoma (1.1)                                            01/2021

    Dosage and Administration (2.2, 2.4 )                                                                 01/2021

    Warnings and Precautions, Hepatotoxicity (5.7)                                                  01/2021

    Warnings and Precautions, Adrenal Insufficiency (5.8)                                       01/2021

    INDICATIONS AND USAGE

    CABOMETYX is a kinase inhibitor indicated for the treatment of

    • patients with advanced renal cell carcinoma (RCC) (1.1)
    • patients with advanced renal cell carcinoma, as a first-line treatment in combination with nivolumab (1.1)
    • patients with hepatocellular carcinoma (HCC) who have been previously treated with sorafenib (1.2)

    DOSAGE AND ADMINISTRATION

    • Recommended Dose:
      • 60 mg orally, once daily. (2.2, 2.3)
      • 40 mg orally, once daily, administered in combination with nivolumab 240 mg every 2 weeks or 480 mg every 4 weeks (2.2)
    • Administer at least 1 hour before or at least 2 hours after eating. (2.1)
    • Do NOT substitute CABOMETYX tablets with cabozantinib capsules. (2.1)

    DOSAGE FORMS AND STRENGTHS

    Tablets: 20 mg, 40 mg, and 60 mg. (3)

    CONTRAINDICATIONS

    None (4)

    WARNINGS AND PRECAUTIONS

    • Hemorrhage: Do not administer CABOMETYX if recent history of hemorrhage. (5.1)
    • Perforations and Fistulas: Monitor for symptoms. Discontinue CABOMETYX for Grade 4 fistula or perforation. (5.2)
    • Thrombotic Events: Discontinue CABOMETYX for myocardial infarction or serious venous or arterial thromboembolic events. (5.3)
    • Hypertension and Hypertensive Crisis: Monitor blood pressure regularly. Interrupt for hypertension that is not adequately controlled with anti-hypertensive therapy. Discontinue CABOMETYX for hypertensive crisis or severe hypertension that cannot be controlled with anti-hypertensive therapy. (5.4)
    • Diarrhea: May be severe. Interrupt CABOMETYX immediately until diarrhea resolves or decreases to Grade 1. Recommend standard antidiarrheal treatments. (5.5)
    • Palmar-Plantar Erythrodysesthesia (PPE): Interrupt CABOMETYX treatment until PPE resolves or decreases to Grade 1. (5.6)
    • Hepatotoxicity: When used in combination with nivolumab, higher frequencies of Grade 3 and 4 ALT and AST elevation may occur than with CABOMETYX alone. Monitor liver enzymes before initiation of and periodically throughout treatment. Consider withholding CABOMETYX and/or nivolumab, initiating corticosteroid therapy, and/or permanently discontinuing the combination for severe or life- threatening hepatotoxicity. (5.7)
    • Adrenal Insufficiency: When used in combination with nivolumab, primary or secondary adrenal insufficiency may occur. For Grade 2 or higher adrenal insufficiency, initiate symptomatic treatment, including hormone replacement as clinically indicated. Withhold CABOMETYX and/or nivolumab depending on severity. (5.8)
    • Proteinuria: Monitor urine protein. Discontinue for nephrotic syndrome. (5.9)
    • Osteonecrosis of the jaw (ONJ): Withhold CABOMETYX for at least 3 weeks prior to invasive dental procedures and for development of ONJ. (5.10)
    • Impaired Wound Healing: Withhold CABOMETYX for at least 3 weeks before elective surgery. Do not administer for at least 2 weeks following major surgery and adequate wound healing. The safety of resumption of CABOMETYX after resolution of wound healing complications has not been established. (5.11)
    • Reversible Posterior Leukoencephalopathy Syndrome (RPLS): Discontinue CABOMETYX. (5.12)
    • Embryo-Fetal Toxicity: Can cause fetal harm. Advise females of reproductive potential of the potential risk to a fetus and to use effective contraception. (5.13, 8.1, 8.3)

    ADVERSE REACTIONS

    The most common (≥ 20%) adverse reactions are:

    • as a single agent: diarrhea, fatigue, decreased appetite, PPE, nausea, hypertension, vomiting, weight decreased, constipation, dysphonia. (6.1)
    • in combination with nivolumab: diarrhea, fatigue, hepatotoxicity, PPE, stomatitis, rash, hypertension, hypothyroidism, musculoskeletal pain, decreased appetite, nausea, dysgeusia, abdominal pain, cough, and upper respiratory tract infection. (6.1)

    To report SUSPECTED ADVERSE REACTIONS, contact Exelixis, Inc. at 1-855-500-3935 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

    DRUG INTERACTIONS

    • Strong CYP3A4 inhibitors: Reduce the CABOMETYX dosage if coadministration cannot be avoided. (2.5, 7.1)
    • Strong CYP3A4 inducers: Increase the CABOMETYX dosage if coadministration cannot be avoided. (2.6, 7.1)

    USE IN SPECIFIC POPULATIONS

    • Hepatic Impairment: Reduce the CABOMETYX dosage for patients with moderate hepatic impairment. Avoid in patients with severe hepatic impairment. (2.7, 8.6)
    • Lactation: Advise not to breastfeed. (8.2)

    See 17 for PATIENT COUNSELING INFORMATION and FDA-approved patient labeling.

    Revised: 1/2021

  • Table of Contents

    FULL PRESCRIBING INFORMATION: CONTENTS*

    1 INDICATIONS AND USAGE

    1.1 Renal Cell Carcinoma

    1.2 Hepatocellular Carcinoma

    2 DOSAGE AND ADMINISTRATION

    2.1 Important Dosage Information

    2.2 Recommended Dosage for Renal Cell Carcinoma

    2.3 Recommended Dosage for Hepatocellular Carcinoma

    2.4 Dosage Modifications for Adverse Reactions

    2.5 Dosage Modifications for Coadministration with Strong CYP3A4 Inhibitors

    2.6 Dosage Modifications for Coadministration with Strong CYP3A4 Inducers

    2.7 Dosage Modifications for Patients with Moderate and Severe Hepatic Impairment

    3 DOSAGE FORMS AND STRENGTHS

    4 CONTRAINDICATIONS

    5 WARNINGS AND PRECAUTIONS

    5.1 Hemorrhage

    5.2 Perforations and Fistulas

    5.3 Thrombotic Events

    5.4 Hypertension and Hypertensive Crisis

    5.5 Diarrhea

    5.6 Palmar-Plantar Erythrodysesthesia

    5.7 Hepatotoxicity

    5.8 Adrenal Insufficiency

    5.9 Proteinuria

    5.10 Osteonecrosis of the Jaw

    5.11 Impaired Wound Healing

    5.12 Reversible Posterior Leukoencephalopathy Syndrome

    5.13 Embryo-Fetal Toxicity

    6 ADVERSE REACTIONS

    6.1 Clinical Trial Experience

    6.2 Postmarketing Experience

    7 DRUG INTERACTIONS

    7.1 Effects of Other Drugs on CABOMETYX

    8 USE IN SPECIFIC POPULATIONS

    8.1 Pregnancy

    8.2 Lactation

    8.3 Females and Males of Reproductive Potential

    8.4 Pediatric Use

    8.5 Geriatric Use

    8.6 Hepatic Impairment

    8.7 Renal Impairment

    10 OVERDOSAGE

    11 DESCRIPTION

    12 CLINICAL PHARMACOLOGY

    12.1 Mechanism of Action

    12.2 Pharmacodynamics

    12.3 Pharmacokinetics

    13 NONCLINICAL TOXICOLOGY

    13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

    14 CLINICAL STUDIES

    14.1 Renal Cell Carcinoma

    14.2 Hepatocellular Carcinoma

    16 HOW SUPPLIED/STORAGE AND HANDLING

    17 PATIENT COUNSELING INFORMATION

    *
    Sections or subsections omitted from the full prescribing information are not listed.
  • 1 INDICATIONS AND USAGE

    1.1 Renal Cell Carcinoma

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

    CABOMETYX, in combination with nivolumab, is indicated for the first-line treatment of patients with advanced RCC.

    1.2 Hepatocellular Carcinoma

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

  • 2 DOSAGE AND ADMINISTRATION

    2.1 Important Dosage Information

    • Stop treatment with CABOMETYX at least 3 weeks prior to scheduled surgery, including dental surgery [see Warnings and Precautions (5.1, 5.10, 5.11)].
    • Do not substitute CABOMETYX tablets with cabozantinib capsules.
    • Do not administer CABOMETYX with food. Administer at least 1 hour before or at least 2 hours after eating [see Clinical Pharmacology (12.3)].
    • Swallow CABOMETYX tablets whole. Do not crush CABOMETYX tablets.
    • Do not take a missed dose within 12 hours of the next dose.
    • Modify the dose for certain patients with hepatic impairment and for patients taking drugs known to strongly induce or inhibit CYP450 [see Dosage and Administration (2.5, 2.6, 2.7)].

    2.2 Recommended Dosage for Renal Cell Carcinoma

    The recommended dosage of CABOMETYX as a single agent is 60 mg once daily without food until the patient no longer experiences clinical benefit or experiences unacceptable toxicity.

    The recommended dosage of CABOMETYX in combination with nivolumab is provided in the following table:

    Table 1. Recommended Dosage of CABOMETYX in Combination with Nivolumab
    Recommended DosageDuration of Therapy
    CABOMETYX 40 mg once daily without fooduntil disease progression or unacceptable toxicity
    Nivolumab 240 mg every 2 weeks (30-minute intravenous infusion) or 480 mg every 4 weeks (30- minute intravenous infusion)until disease progression or unacceptable toxicity for up to 2 years

    2.3 Recommended Dosage for Hepatocellular Carcinoma

    The recommended dosage of CABOMETYX is 60 mg once daily without food until disease progression or unacceptable toxicity.

    2.4 Dosage Modifications for Adverse Reactions

    Withhold CABOMETYX for:

    • Intolerable Grade 2 adverse reactions
    • Grade 3 or 4 adverse reactions
    • Osteonecrosis of the jaw

    Upon resolution/improvement (i.e., return to baseline or resolution to Grade 1) of an adverse reaction, reduce the dose as follows:

    Table 2. Recommended Dosage Reductions for CABOMETYX for Adverse Reactions
    Recommended DosageFirst Dosage Reduction ToSecond Dosage Reduction To
    *
    If previously receiving lowest dose, resume at same dose. If lowest dose not tolerated, discontinue CABOMETYX.
    CABOMETYX 60 mg daily40 mg daily20 mg daily*
    CABOMETYX 40 mg daily in combination with nivolumab20 mg daily20 mg every other day*

    Permanently discontinue CABOMETYX for any of the following:

    • Severe hemorrhage
    • Development of gastrointestinal (GI) perforation or Grade 4 fistula
    • Acute myocardial infarction or arterial or venous thromboembolic events that require medical intervention
    • Severe hypertension that cannot be controlled with anti-hypertensive therapy or hypertensive crisis
    • Nephrotic syndrome
    • Reversible posterior leukoencephalopathy syndrome

    The following table represents dosage modifications that are different from those described above for CABOMETYX or in the Full Prescribing Information for the drug administered in combination:

    Table 3. Recommended Specific Dosage Modifications for Hepatic Adverse Reactions for Combination
    *
    Consider corticosteroid therapy for hepatic adverse reactions if CABOMETYX is withheld or discontinued when administered in combination with nivolumab
    After recovery, rechallenge with one or both of CABOMETYX and nivolumab may be considered. If rechallenging with nivolumab with or without CABOMETYX, refer to nivolumab Prescribing Information.
    CABOMETYX in combination with nivolumabALT or AST >3 times ULN but ≤10 times ULN with concurrent total bilirubin <2 times ULNWithhold* both CABOMETYX and nivolumab until adverse reactions recover to Grades 0 or 1
    ALT or AST >10 times ULN or >3 times ULN with concurrent total bilirubin ≥2 times ULNPermanently discontinue both CABOMETYX and nivolumab

    When administering CABOMETYX in combination with nivolumab for the treatment of advanced RCC, refer to the nivolumab prescribing information.

    2.5 Dosage Modifications for Coadministration with Strong CYP3A4 Inhibitors

    Reduce the daily CABOMETYX dose by 20 mg (for example, from 60 mg to 40 mg daily or from 40 mg to 20 mg daily). Resume the dose that was used prior to initiating the strong CYP3A4 inhibitor 2 to 3 days after discontinuation of the strong inhibitor [see Drug Interactions (7.1), Clinical Pharmacology (12.3)].

    2.6 Dosage Modifications for Coadministration with Strong CYP3A4 Inducers

    Increase the daily CABOMETYX dose by 20 mg (for example, from 60 mg to 80 mg daily or from 40 mg to 60 mg daily) as tolerated. Resume the dose that was used prior to initiating the strong CYP3A4 inducer 2 to 3 days after discontinuation of the strong inducer. Do not exceed a daily dose of 80 mg [see Drug Interactions (7.1), Clinical Pharmacology (12.3)].

    2.7 Dosage Modifications for Patients with Moderate and Severe Hepatic Impairment

    Reduce the starting dose of CABOMETYX to 40 mg once daily in patients with moderate hepatic impairment (Child-Pugh B). Avoid CABOMETYX in patients with severe hepatic impairment (Child-Pugh C) [see Use in Specific Populations (8.6), Clinical Pharmacology (12.3)].

  • 3 DOSAGE FORMS AND STRENGTHS

    Tablets:

    • 60 mg: yellow film-coated, oval shaped with no score, and debossed with "XL" on one side and "60" on the other side.
    • 40 mg: yellow film-coated, triangle shaped with no score, and debossed with "XL" on one side and "40" on the other side.
    • 20 mg: yellow film-coated, round with no score, and debossed with "XL" on one side and "20" on the other side.
  • 4 CONTRAINDICATIONS

    None.

  • 5 WARNINGS AND PRECAUTIONS

    5.1 Hemorrhage

    Severe and fatal hemorrhages occurred with CABOMETYX [see Adverse Reactions (6.1)]. The incidence of Grade 3 to 5 hemorrhagic events was 5% in CABOMETYX-treated patients in RCC and HCC studies.

    Discontinue CABOMETYX for Grade 3 or 4 hemorrhage [see Dosage and Administration (2.4)]. Do not administer CABOMETYX to patients who have a recent history of hemorrhage, including hemoptysis, hematemesis, or melena.

    5.2 Perforations and Fistulas

    Fistulas, including fatal cases, occurred in 1% of CABOMETYX-treated patients [see Adverse Reactions (6.1)]. Gastrointestinal (GI) perforations, including fatal cases, occurred in 1% of CABOMETYX-treated patients.

    Monitor patients for signs and symptoms of fistulas and perforations, including abscess and sepsis. Discontinue CABOMETYX in patients who experience a Grade 4 fistula or a GI perforation [see Dosage and Administration (2.4)].

    5.3 Thrombotic Events

    CABOMETYX increased the risk of thrombotic events [see Adverse Reactions (6.1)]. Venous thromboembolism occurred in 7% (including 4% pulmonary embolism) and arterial thromboembolism occurred in 2% of CABOMETYX-treated patients. Fatal thrombotic events occurred in CABOMETYX-treated patients.

    Discontinue CABOMETYX in patients who develop an acute myocardial infarction or serious arterial or venous thromboembolic events that require medical intervention [see Dosage and Administration (2.4)].

    5.4 Hypertension and Hypertensive Crisis

    CABOMETYX can cause hypertension, including hypertensive crisis [see Adverse Reactions (6.1)]. Hypertension was reported in 36% (17% Grade 3 and <1% Grade 4) of CABOMETYX- treated patients.

    Do not initiate CABOMETYX in patients with uncontrolled hypertension. Monitor blood pressure regularly during CABOMETYX treatment. Withhold CABOMETYX for hypertension that is not adequately controlled with medical management; when controlled, resume CABOMETYX at a reduced dose [see Dosage and Administration (2.4)]. Discontinue CABOMETYX for severe hypertension that cannot be controlled with anti-hypertensive therapy or for hypertensive crisis.

    5.5 Diarrhea

    Diarrhea occurred in 63% of patients treated with CABOMETYX. Grade 3 diarrhea occurred in 11% of patients treated with CABOMETYX [see Adverse Reactions (6.1)].

    Withhold CABOMETYX until improvement to Grade 1 and resume CABOMETYX at a reduced dose for intolerable Grade 2 diarrhea, Grade 3 diarrhea that cannot be managed with standard antidiarrheal treatments, or Grade 4 diarrhea [see Dosage and Administration (2.4)].

    5.6 Palmar-Plantar Erythrodysesthesia

    Palmar-plantar erythrodysesthesia (PPE) occurred in 44% of patients treated with CABOMETYX [see Adverse Reactions (6.1)]. Grade 3 PPE occurred in 13% of patients treated with CABOMETYX.

    Withhold CABOMETYX until improvement to Grade 1 and resume CABOMETYX at a reduced dose for intolerable Grade 2 PPE or Grade 3 PPE [see Dosage and Administration (2.4)].

    5.7 Hepatotoxicity

    CABOMETYX in combination with nivolumab can cause hepatic toxicity with higher frequencies of Grades 3 and 4 ALT and AST elevations compared to CABOMETYX alone.

    Monitor liver enzymes before initiation of and periodically throughout treatment. Consider more frequent monitoring of liver enzymes as compared to when the drugs are administered as single agents. For elevated liver enzymes, interrupt CABOMETYX and nivolumab and consider administering corticosteroids [see Dosage and Administration (2.4)].

    With the combination of CABOMETYX and nivolumab, Grades 3 and 4 increased ALT or AST were seen in 11% of patients [see Adverse Reactions (6.1)]. ALT or AST > 3 times ULN (Grade ≥2) was reported in 83 patients, of whom 23 (28%) received systemic corticosteroids; ALT or AST resolved to Grades 0-1 in 74 (89%). Among the 44 patients with Grade ≥2 increased ALT or AST who were rechallenged with either CABOMETYX (n=9) or nivolumab (n=11) as a single agent or with both (n=24), recurrence of Grade ≥2 increased ALT or AST was observed in 2 patients receiving CABOMETYX, 2 patients receiving nivolumab, and 7 patients receiving both CABOMETYX and nivolumab.

    5.8 Adrenal Insufficiency

    CABOMETYX in combination with nivolumab can cause primary or secondary adrenal insufficiency. For Grade 2 or higher adrenal insufficiency, initiate symptomatic treatment, including hormone replacement as clinically indicated. Withhold CABOMETYX and/or nivolumab depending on severity.

    Adrenal insufficiency occurred in 4.7% (15/320) of patients with RCC who received CABOMETYX with nivolumab, including Grade 3 (2.2%), and Grade 2 (1.9%) adverse reactions. Adrenal insufficiency led to permanent discontinuation of CABOMETYX and nivolumab in 0.9% and withholding of CABOMETYX and nivolumab in 2.8% of patients with RCC.

    Approximately 80% (12/15) of patients with adrenal insufficiency received hormone replacement therapy, including systemic corticosteroids. Adrenal insufficiency resolved in 27% (n=4) of the 15 patients. Of the 9 patients in whom CABOMETYX with nivolumab was withheld for adrenal insufficiency, 6 reinstated treatment after symptom improvement; of these, all (n=6) received hormone replacement therapy and 2 had recurrence of adrenal insufficiency.

    5.9 Proteinuria

    Proteinuria was observed in 7% of patients receiving CABOMETYX [see Adverse Reactions (6.1)]. Monitor urine protein regularly during CABOMETYX treatment. Discontinue CABOMETYX in patients who develop nephrotic syndrome [see Dosage and Administration (2.4)].

    5.10 Osteonecrosis of the Jaw

    Osteonecrosis of the jaw (ONJ) occurred in <1% of patients treated with CABOMETYX [see Adverse Reactions (6.1)]. ONJ can manifest as jaw pain, osteomyelitis, osteitis, bone erosion, tooth or periodontal infection, toothache, gingival ulceration or erosion, persistent jaw pain or slow healing of the mouth or jaw after dental surgery. Perform an oral examination prior to initiation of CABOMETYX and periodically during CABOMETYX. Advise patients regarding good oral hygiene practices. Withhold CABOMETYX for at least 3 weeks prior to scheduled dental surgery or invasive dental procedures, if possible. Withhold CABOMETYX for development of ONJ until complete resolution [see Dosage and Administration (2.1)].

    5.11 Impaired Wound Healing

    Wound complications occurred with CABOMETYX [see Adverse Reactions (6.1)]. Withhold CABOMETYX for at least 3 weeks prior to elective surgery [see Dosage and Administration (2.1)]. Do not administer CABOMETYX for at least 2 weeks after major surgery and until adequate wound healing. The safety of resumption of CABOMETYX after resolution of wound healing complications has not been established.

    5.12 Reversible Posterior Leukoencephalopathy Syndrome

    Reversible Posterior Leukoencephalopathy Syndrome (RPLS), a syndrome of subcortical vasogenic edema diagnosed by characteristic finding on MRI, can occur with CABOMETYX. Perform an evaluation for RPLS in any patient presenting with seizures, headache, visual disturbances, confusion or altered mental function. Discontinue CABOMETYX in patients who develop RPLS [see Dosage and Administration (2.4)].

    5.13 Embryo-Fetal Toxicity

    Based on data from animal studies and its mechanism of action, CABOMETYX can cause fetal harm when administered to a pregnant woman. Cabozantinib administration to pregnant animals during organogenesis resulted in embryolethality at exposures below those occurring clinically at the recommended dose, and in increased incidences of skeletal variations in rats and visceral variations and malformations in rabbits.

    Advise pregnant women of the potential risk to a fetus. Advise females of reproductive potential to use effective contraception during treatment with CABOMETYX and for 4 months after the last dose [see Use in Specific Populations (8.1, 8.3), Clinical Pharmacology (12.1)].

  • 6 ADVERSE REACTIONS

    The following clinically significant adverse reactions are discussed elsewhere in the labeling:

    6.1 Clinical Trial Experience

    The data described in the WARNINGS AND PRECAUTIONS section and below reflect exposure to CABOMETYX as a single agent in 409 patients with RCC enrolled in randomized, active-controlled trials (CABOSUN, METEOR) and 467 patients with HCC enrolled in a randomized, placebo-controlled trial (CELESTIAL), and in combination with nivolumab 240 mg/m2 every 2 weeks in 320 patients with RCC enrolled in a randomized, active-controlled trial (CHECKMATE-9ER).

    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.

    Renal Cell Carcinoma

    METEOR

    The safety of CABOMETYX was evaluated in METEOR, a randomized, open-label trial in which 331 patients with advanced renal cell carcinoma received CABOMETYX 60 mg once daily and 322 patients received everolimus 10 mg once daily until disease progression or unacceptable toxicity. Patients on both arms who had disease progression could continue treatment at the discretion of the investigator [see Clinical Studies (14)]. The median duration of treatment was 7.6 months (range 0.3 – 20.5) for patients receiving CABOMETYX and 4.4 months (range 0.21 – 18.9) for patients receiving everolimus.

    Adverse reactions which occurred in ≥ 25% of CABOMETYX-treated patients, in order of decreasing frequency, were: diarrhea, fatigue, nausea, decreased appetite, palmar-plantar erythrodysesthesia (PPE), hypertension, vomiting, weight decreased, and constipation. Grade 3-4 adverse reactions and laboratory abnormalities which occurred in ≥ 5% of patients were hypertension, diarrhea, fatigue, PPE, hyponatremia, hypophosphatemia, hypomagnesemia, lymphopenia, anemia, hypokalemia, and increased GGT.

    The dose was reduced in 60% of patients receiving CABOMETYX and in 24% of patients receiving everolimus. Twenty percent (20%) of patients received CABOMETYX 20 mg once daily as their lowest dose. The most frequent adverse reactions leading to dose reduction in patients treated with CABOMETYX were: diarrhea, PPE, fatigue, and hypertension. Adverse reactions leading to dose interruption occurred in 70% patients receiving CABOMETYX and in 59% patients receiving everolimus. Adverse reactions led to study treatment discontinuation in 10% of patients receiving CABOMETYX and in 10% of patients receiving everolimus. The most frequent adverse reactions leading to permanent discontinuation in patients treated with CABOMETYX were decreased appetite (2%) and fatigue (1%).

    Table 4. Adverse Reactions Occurring in ≥ 10% Patients Who Received CABOMETYX in METEOR
       Adverse ReactionCABOMETYX
    (n=331)*
    Everolimus
    (n=322)
    All
    Grades
    Grades
    3-4
    All
    Grades
    Grades
    3-4
    Percentage (%) of Patients
    *
    One subject randomized to everolimus received cabozantinib.
    National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) Version 4.0
    Includes the following terms: abdominal pain, abdominal pain upper, and abdominal pain lower
    §
    Includes the following terms: rash, rash erythematous, rash follicular, rash macular, rash papular, rash pustular, rash vesicular, genital rash, intermittent leg rash, rash on scrotum and penis, rash maculo- papular, rash pruritic, contact dermatitis, dermatitis acneiform
    Includes the following terms hypertension, blood pressure increased, hypertensive crisis, blood pressure fluctuation
       Gastrointestinal
            Diarrhea7411282
            Nausea50428<1
            Vomiting32214<1
            Stomatitis222242
            Constipation25<119<1
            Abdominal pain234132
            Dyspepsia12<150
       General
            Fatigue569477
            Mucosal inflammation19<1233
            Asthenia194162
       Metabolism and Nutrition
            Decreased appetite46334<1
       Skin and Subcutaneous Tissue
            Palmar-plantar erythrodysesthesia4286<1
            Rash§23<143<1
            Dry skin110100
       Vascular
            Hypertension391683
       Investigations
            Weight decreased312120
       Nervous System
            Dysgeusia24090
            Headache11<112<1
            Dizziness11070
       Endocrine
            Hypothyroidism210<1<1
       Respiratory, Thoracic, and Mediastinal
            Dysphonia20<140
            Dyspnea193294
            Cough18<133<1
       Blood and Lymphatic
            Anemia1753816
       Musculoskeletal and Connective Tissue
            Pain in extremity1418<1
            Muscle spasms13050
            Arthralgia11<1141
       Renal and Urinary
            Proteinuria1229<1

    Other clinically important adverse reactions (all grades) that were reported in <10% of patients treated with CABOMETYX included: wound complications (2%), convulsion (<1%), pancreatitis (<1%), osteonecrosis of the jaw (<1%), and hepatitis cholestatic (<1%).

    Table 5. Laboratory Abnormalities Occurring in ≥ 25% Patients Who Received CABOMETYX in METEOR
       Laboratory AbnormalityCABOMETYX
    (n=331)
    Everolimus
    (n=322)
    All
    Grades
    Grade 3-4All
    Grades
    Grade 3-4
    Percentage (%) of Patients
    *
    Based on laboratory abnormalities
       Chemistry
            Increased AST74340<1
            Increased ALT68332<1
            Increased creatinine58<1710
            Increased triglycerides5347313
            Hypophosphatemia488365
            Hyperglycemia372598
            Hypoalbuminemia36228<1
            Increased ALP352291
            Hypomagnesemia3174<1
            Hyponatremia308266
            Increased GGT275439
       Hematology
            Leukopenia35<131<1
            Neutropenia31217<1
            Anemia*3147117
            Lymphopenia2573912
            Thrombocytopenia25<127<1
     ALP, alkaline phosphatase; ALT, alanine aminotransferase; AST, aspartate aminotransferase; GGT, gamma glutamyl transferase.
     NCI CTCAE, Version 4.0

    CABOSUN

    The safety of CABOMETYX was evaluated in CABOSUN, a randomized, open-label trial in patients with advanced renal cell carcinoma, in which 78 patients received CABOMETYX 60 mg once daily and 72 patients received sunitinib 50 mg once daily (4 weeks on treatment followed by 2 weeks off), until disease progression or unacceptable toxicity [see Clinical Studies (14.1)]. The median duration of treatment was 6.5 months (range 0.2 – 28.7) for patients receiving CABOMETYX and 3.1 months (range 0.2 – 25.5) for patients receiving sunitinib.

    Within 30 days of treatment, there were 4 deaths in patients treated with CABOMETYX and 6 deaths in patients treated with sunitinib. Of the 4 patients treated with CABOMETYX, 2 patients died due to gastrointestinal perforation, 1 patient had acute renal failure, and 1 patient died due to clinical deterioration. All Grade 3-4 adverse reactions were collected in the entire safety population. The most frequent Grade 3-4 adverse reactions (≥5%) in patients treated with CABOMETYX were hypertension, diarrhea, hyponatremia, hypophosphatemia, PPE, fatigue, increased ALT, decreased appetite, stomatitis, pain, hypotension, and syncope.

    The median average daily dose was 50.3 mg for CABOMETYX and 44.7 mg for sunitinib (excluding scheduled sunitinib non-dosing days). The dose was reduced in 46% of patients receiving CABOMETYX and in 35% of patients receiving sunitinib. The dose was held in 73% of patients receiving CABOMETYX and in 71% of patients receiving sunitinib. Based on patient disposition, 21% of patients receiving CABOMETYX and 22% of patients receiving sunitinib discontinued due to an adverse reaction.

    Table 6. Grade 3-4 Adverse Reactions Occurring in ≥ 1% Patients Who Received CABOMETYX in CABOSUN
       Adverse ReactionCABOMETYX
    (n = 78)
    Sunitinib
    (n = 72)
    Grade 3-4*Grade 3-4*
    Percentage (%) of Patients
       Patients with any Grade 3-4 Adverse Reaction6865
     
    *
    NCI CTCAE Version 4.0
    Laboratory abnormalities are reported as adverse reactions and not based on shifts in laboratory values
    ncludes the following term: hypertension
       Gastrointestinal
            Diarrhea1011
            Stomatitis56
            Nausea34
            Vomiting13
            Constipation10
       General
            Fatigue617
            Pain50
       Metabolism and Nutrition
            Hyponatremia98
            Hypophosphatemia97
            Decreased appetite51
            Dehydration41
            Hypocalcemia30
            Hypomagnesemia30
            Hypokalemia13
       Skin and Subcutaneous Tissue
            Palmar-plantar erythrodysesthesia84
            Skin Ulcer30
       Vascular
            Hypertension2821
            Hypotension51
            Angiopathy11
       Investigations
            Increased ALT50
            Weight decreased40
            Increased AST33
            Increased blood creatinine33
            Lymphopenia16
            Thrombocytopenia111
       Nervous System
            Syncope50
       Respiratory, Thoracic, and Mediastinal
            Dyspnea16
            Dysphonia10
       Blood and Lymphatic
            Anemia13
       Psychiatric
            Depression40
            Confusional state11
       Infections
            Lung Infection40
       Musculoskelatal and Connective Tissue
            Back pain40
            Bone pain31
            Pain in extremity30
            Arthralgia10
       Renal and Urinary
            Renal failure acute41
            Proteinuria31
     ALT, alanine aminotransferase; AST, aspartate aminotransferase

    CHECKMATE-9ER

    The safety of CABOMETYX with nivolumab was evaluated in CHECKMATE-9ER, a randomized, open-label study in patients with previously untreated advanced RCC [see Clinical Studies (14.1)]. Patients received CABOMETYX 40 mg orally once daily with nivolumab 240 mg over 30 minutes every 2 weeks (n=320) or sunitinib 50 mg daily, administered orally for 4 weeks on treatment followed by 2 weeks off (n=320) [see Clinical Studies (14.1)]. CABOMETYX could be interrupted or reduced to 20 mg daily or 20 mg every other day. The median duration of treatment was 14 months (range: 0.2 to 27 months) in CABOMETYX and nivolumab-treated patients. In this trial, 82% of patients in the CABOMETYX and nivolumab arm were exposed to treatment for >6 months and 60% of patients were exposed to treatment for >1 year.

    Serious adverse reactions occurred in 48% of patients receiving CABOMETYX and nivolumab. The most frequent (≥2%) serious adverse reactions were diarrhea, pneumonia, pneumonitis, pulmonary embolism, urinary tract infection, and hyponatremia. Fatal intestinal perforations occurred in 3 (0.9%) patients.

    Adverse reactions leading to discontinuation of either CABOMETYX or nivolumab occurred in 20% of patients: 8% CABOMETYX only, 7% nivolumab only, and 6% both drugs due to the same adverse reaction at the same time. Adverse reactions leading to dose interruption or reduction of either CABOMETYX or nivolumab occurred in 83% of patients: 46% CABOMETYX only, 3% nivolumab only, and 21% both drugs due to the same adverse reaction at the same time, and 6% both drugs sequentially.

    The most common adverse reactions reported in ≥20% of patients treated with CABOMETYX and nivolumab were diarrhea, fatigue, hepatotoxicity, PPE, stomatitis, rash, hypertension, hypothyroidism, musculoskeletal pain, decreased appetite, nausea, dysgeusia, abdominal pain, cough, and upper respiratory tract infection.

    Table 7. Adverse Reactions in >15% of Patients Receiving CABOMETYX and Nivolumab - CHECKMATE-9ER
       Adverse ReactionCABOMETYX and Nivolumab
    (n=320)
    Sunitinib
    (n=320)
    Grades 1-4Grades 3-4Grades 1-4Grades 3-4
    Percentage (%) of Patients
    *
    Includes abdominal discomfort, abdominal pain lower, abdominal pain upper.
    Includes gastroesophageal reflux disease.
    Includes asthenia.
    §
    Includes hepatotoxicity, ALT increased, AST increased, blood alkaline phosphatase increased, gamma-glutamyl transferase increased, autoimmune hepatitis, blood bilirubin increased, drug induced liver injury, hepatic enzyme increased, hepatitis, hyperbilirubinemia, liver function test increased, liver function test abnormal, transaminases increased, hepatic failure.
    Includes mucosal inflammation, aphthous ulcer, mouth ulceration.
    #
    Includes dermatitis, dermatitis acneiform, dermatitis bullous, exfoliative rash, rash erythematous, rash follicular, rash macular, rash maculo-papular, rash papular, rash pruritic.
    Þ
    Includes blood pressure increased, blood pressure systolic increased.
    ß
    Includes primary hypothyroidism.
    à
    Includes back pain, bone pain, musculoskeletal chest pain, musculoskeletal discomfort, myalgia, neck pain, pain in extremity, spinal pain.
    è
    Includes productive cough.
    ð
    Includes nasopharyngitis, pharyngitis, rhinitis.
       Gastrointestinal
            Diarrhea647474.4
            Nausea270.6310.3
            Abdominal pain*221.9150.3
            Vomiting171.9210.3
            Dyspepsia150220.3
       General
            Fatigue518508
       Hepatobiliary
            Hepatotoxicity§4411265
       Skin and Subcutaneous Tissue
            Palmar-plantar erythrodysesthesia408418
            Stomatitis373.4464.4
            Rash#363.1140
            Pruritus190.34.40
       Vascular
            HypertensionÞ36133914
       Endocrine
            Hypothyroidismß340.3300.3
       Musculoskeletal and Connective Tissue
            Musculoskeletal painà333.8293.1
            Arthralgia180.390.3
       Metabolism and Nutrition
            Decreased appetite281.9201.3
       Nervous System Disorders
            Dysgeusia240220
            Headache160120.6
       Respiratory, Thoracic and Mediastinal
            Coughè200.3170
            Dysphonia170.33.40
       Infections and Infestations
            Upper respiratory tract infectionð200.380.3
     Toxicity was graded per NCI CTCAE v4.
    Table 8. Laboratory Values Worsening from Baseline* Occurring in >20% of Patients Receiving CABOMETYX and Nivolumab - CHECKMATE-9ER
       Laboratory AbnormalityCABOMETYX and
    Nivolumab
    Sunitinib
    Grades 1-4Grades 3-4Grades 1-4Grades 3-4
    Percentage (%) of Patients
    *
    Each test incidence is based on the number of patients who had both baseline and at least one on-study laboratory measurement available: CABOMETYX and nivolumab group (range: 170 to 317 patients) and sunitinib group (range: 173 to 311 patients).
       Chemistry
            Increased ALT799.8393.5
            Increased AST777.9572.6
            Hypophosphatemia69284810
            Hypocalcemia541.9240.6
            Hypomagnesemia471.3250.3
            Hyperglycemia443.5441.7
            Hyponatremia43113612
            Increased lipase41143813
            Increased amylase4110286
            Increased alkaline phosphatase412.8371.6
            Increased creatinine391.3420.6
            Hyperkalemia354.7271
            Hypoglycemia260.8140.4
       Hematology
            Lymphopenia426.64510
            Thrombocytopenia410.3709.7
           Anemia372.5614.8
            Leukopenia370.3665.1
            Neutropenia353.26712

    Hepatocellular Carcinoma

    The safety of CABOMETYX was evaluated in CELESTIAL, a randomized, double-blind, placebo-controlled trial in which 704 patients with advanced hepatocellular carcinoma were randomized to receive CABOMETYX 60 mg orally once daily (n=467) or placebo (n=237) until disease progression or unacceptable toxicity [see Clinical Studies (14.2)]. The median duration of treatment was 3.8 months (range 0.1 – 37.3) for patients receiving CABOMETYX and 2.0 months (range 0.0 – 27.2) for patients receiving placebo. The population exposed to CABOMETYX was 81% male, 56% White, and had a median age of 64 years.

    Adverse reactions occurring in ≥ 25% of CABOMETYX-treated patients, in order of decreasing frequency were: diarrhea, decreased appetite, PPE, fatigue, nausea, hypertension, and vomiting. Grade 3-4 adverse reactions which occurred in ≥ 5% of patients were PPE, hypertension, fatigue, diarrhea, asthenia, and decreased appetite. There were 6 adverse reactions leading to death in patients receiving CABOMETYX (hepatic failure, hepatorenal syndrome, esophagobronchial fistula, portal vein thrombosis, pulmonary embolism, upper gastrointestinal hemorrhage).

    The median average daily dose was 35.8 mg for CABOMETYX. The dose was reduced in 62% of patients receiving CABOMETYX; 33% of patients required a reduction to 20 mg daily. The most frequent adverse reactions or laboratory abnormalities leading to dose reduction of CABOMETYX were: PPE, diarrhea, fatigue, hypertension, and increased AST. Adverse reactions leading to dose interruption occurred in 84% patients receiving CABOMETYX. Adverse reactions leading to permanent discontinuation of CABOMETYX occurred in 16% of patients. The most frequent adverse reactions leading to permanent discontinuation of CABOMETYX were PPE (2%), fatigue (2%), decreased appetite (1%), diarrhea (1%), and nausea (1%).

    Table 9. Adverse Reactions Occurring in ≥ 5% of CABOMETYX-Treated Patients in CELESTIAL*
       Adverse ReactionCABOMETYX
    (n=467)
    Placebo
    (n=237)
    All GradesGrade 3-4All GradesGrade 3-4
    Percentage (%) of Patients
    *
    Includes terms with a between-arm difference of ≥ 5% (all grades) or ≥ 2% (Grade 3-4)
    NCI CTCAE Version 4.0
    Includes the following terms: rash, rash erythematous, rash generalized, rash macular, rash maculo- papular, rash papular, rash pruritic, rash pustular, rash vesicular, dermatitis, dermatitis acneiform, dermatitis contact, dermatitis diaper, dermatitis exfoliative, dermatitis infected
    §
    Includes the following terms: hypertension, blood pressure diastolic increased, blood pressure increased
       Gastrointestinal
            Diarrhea5410192
            Nausea312182
            Vomiting26<1123
            Stomatitis13220
            Dyspepsia10030
       General
            Fatigue4510304
            Asthenia22782
            Mucosal inflammation1422<1
       Metabolism and Nutrition
            Decreased appetite48618<1
       Skin and Subcutaneous Tissue
            Palmar-plantar erythrodysesthesia461750
            Rash2129<1
       Vascular
            Hypertension§301662
       Investigations
           Weight decreased17160
       Nervous System
            Dysgeusia12020
       Endocrine
            Hypothyroidism8<1<10
       Respiratory, Thoracic, and Mediastinal
            Dysphonia19120
            Dyspnea12310<1
       Musculoskeletal and Connective Tissue
            Pain in extremity9<141
            Muscle spasms8<120
    Table 10. Laboratory Abnormalities Occurring in ≥ 5% of CABOMETYX-Treated Patients in CELESTIAL*
       Laboratory AbnormalityCABOMETYX
    (n=467)
    Placebo
    (n=237)
    All GradesGrade 3-4All GradesGrade 3-4
    Percentage (%) of Patients
    *
    Includes laboratory abnormalities with a between-arm difference of ≥ 5% (all grades) or ≥ 2% (Grade 3-4)
       Chemistry
            Increased LDH849292
            Increased ALT7312376
            Increased AST73244619
            Hypoalbuminemia511321
            Increased ALP438386
            Hypophosphatemia25984
            Hypokalemia23661
            Hypomagnesemia22330
            Increased amylase16292
            Hypocalcemia8200
       Hematology
            Decreased platelets5410161
            Neutropenia43781
            Increased hemoglobin8010
     ALP, alkaline phosphatase; ALT, alanine aminotransferase; AST, aspartate aminotransferase; LDH, blood lactate dehydrogenase

    6.2 Postmarketing Experience

    The following adverse reactions have been identified during postapproval use of CABOMETYX. 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.

    Vascular Disorders: Arterial (including aortic) aneurysms, dissections, and rupture

  • 7 DRUG INTERACTIONS

    7.1 Effects of Other Drugs on CABOMETYX

    Strong CYP3A4 Inhibitors

    Coadministration of a cabozantinib capsule formulation with a strong CYP3A4 inhibitor increased the exposure of cabozantinib, which may increase the risk of exposure-related adverse reactions [see Clinical Pharmacology (12.3)]. Avoid coadministration of CABOMETYX with strong CYP3A4 inhibitors. Reduce the dosage of CABOMETYX if coadministration with strong CYP3A4 inhibitors cannot be avoided [see Dosage and Administration (2.5)]. Avoid grapefruit or grapefruit juice which may also increase exposure of cabozantinib.

    Strong CYP3A Inducers

    Coadministration of a cabozantinib capsule formulation with a strong CYP3A4 inducer decreased the exposure of cabozantinib, which may reduce efficacy [see Clinical Pharmacology (12.3)]. Avoid coadministration of CABOMETYX with strong CYP3A4 inducers. Increase the dosage of CABOMETYX if coadministration with strong CYP3A4 inducers cannot be avoided [see Dosage and Administration (2.6)]. Avoid St. John’s wort which may also decrease exposure of cabozantinib.

  • 8 USE IN SPECIFIC POPULATIONS

    8.1 Pregnancy

    Risk Summary

    Based on findings from animal studies and its mechanism of action [see Clinical Pharmacology (12.1)], CABOMETYX can cause fetal harm when administered to a pregnant woman. There are no available data in pregnant women to inform the drug-associated risk. In animal developmental and reproductive toxicology studies administration of cabozantinib to pregnant rats and rabbits during organogenesis resulted in embryofetal lethality and structural anomalies at exposures that were below those occurring clinically at the recommended dose (see Data). Advise pregnant women of the potential risk to a fetus.

    In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively.

    Data

    Animal Data

    In an embryo-fetal development study in pregnant rats, daily oral administration of cabozantinib throughout organogenesis caused increased embryo-fetal lethality compared to controls at a dose of 0.03 mg/kg (approximately 0.12-fold of human area under the curve [AUC] at the recommended dose). Findings included delayed ossification and skeletal variations at a dose of 0.01 mg/kg/day (approximately 0.04-fold of human AUC at the recommended dose).

    In pregnant rabbits, daily oral administration of cabozantinib throughout organogenesis resulted in findings of visceral malformations and variations including reduced spleen size and missing lung lobe at 3 mg/kg (approximately 1.1-fold of the human AUC at the recommended dose).

    In a pre- and postnatal study in rats, cabozantinib was administered orally from gestation day 10 through postnatal day 20. Cabozantinib did not produce adverse maternal toxicity or affect pregnancy, parturition or lactation of female rats, and did not affect the survival, growth or postnatal development of the offspring at doses up to 0.3 mg/kg/day (0.05-fold of the maximum recommended clinical dose).

    8.2 Lactation

    Risk Summary

    There is no information regarding the presence of cabozantinib or its metabolites in human milk, or their effects on the breastfed child or milk production. Because of the potential for serious adverse reactions in breastfed children, advise women not to breastfeed during treatment with CABOMETYX and for 4 months after the final dose.

    8.3 Females and Males of Reproductive Potential

    Pregnancy Testing

    Verify the pregnancy status of females of reproductive potential prior to initiating CABOMETYX [see Use in Specific Populations (8.1)].

    Contraception

    CABOMETYX can cause fetal harm when administered to a pregnant woman [see Use in Specific Populations (8.1)].

    Females

    Advise females of reproductive potential to use effective contraception during treatment with CABOMETYX and for 4 months after the final dose.

    Infertility

    Females and Males

    Based on findings in animals, CABOMETYX may impair fertility in females and males of reproductive potential [see Nonclinical Toxicology (13.1)].

    8.4 Pediatric Use

    The safety and effectiveness of CABOMETYX in pediatric patients have not been established.

    Juvenile Animal Toxicity Data

    Juvenile rats were administered cabozantinib at doses of 1 or 2 mg/kg/day from Postnatal Day 12 (comparable to less than 2 years in humans) through Postnatal Day 35 or 70. Mortalities occurred at doses ≥1 mg/kg/day (approximately 0.16 times the clinical dose of 60 mg/day based on body surface area). Hypoactivity was observed at both doses tested on Postnatal Day 22. Targets were generally similar to those seen in adult animals, occurred at both doses, and included the kidney (nephropathy, glomerulonephritis), reproductive organs, gastrointestinal tract (cystic dilatation and hyperplasia in Brunner’s gland and inflammation of duodenum; and epithelial hyperplasia of colon and cecum), bone marrow (hypocellularity and lymphoid depletion), and liver. Tooth abnormalities and whitening as well as effects on bones including reduced bone mineral content and density, physeal hypertrophy, and decreased cortical bone also occurred at all dose levels. Recovery was not assessed at a dose of 2 mg/kg (approximately 0.32 times the clinical dose of 60 mg based on body surface area) due to high levels of mortality. At the low dose level, effects on bone parameters were partially resolved but effects on the kidney and epididymis/testis persisted after treatment ceased.

    8.5 Geriatric Use

    In CABOSUN and METEOR, 41% of 409 patients treated with CABOMETYX were age 65 years and older, and 8% were 75 years and older. In CELESTIAL, 49% of 467 patients treated with CABOMETYX were age 65 years and older, and 15% were 75 years and older.

    No overall differences in safety or effectiveness were observed between these patients and younger patients.

    Of the 320 patients randomized to CABOMETYX administered with nivolumab in CHECKMATE-9ER, 41% were 65 years or older and 9% were 75 years or older. No overall difference in safety was reported between elderly patients and younger patients.

    8.6 Hepatic Impairment

    Increased exposure to cabozantinib has been observed in patients with moderate (Child-Pugh B) hepatic impairment. Reduce the CABOMETYX dose in patients with moderate hepatic impairment. Avoid CABOMETYX in patients with severe hepatic impairment (Child-Pugh C), since it has not been studied in this population [see Dosage and Administration (2.7), Clinical Pharmacology (12.3)].

    8.7 Renal Impairment

    No dosage adjustment is recommended in patients with mild or moderate renal impairment. There is no experience with CABOMETYX in patients with severe renal impairment [see Clinical Pharmacology (12.3)].

  • 10 OVERDOSAGE

    One case of overdosage was reported following administration of another formulation of cabozantinib; a patient inadvertently took twice the intended dose for 9 days. The patient suffered Grade 3 memory impairment, Grade 3 mental status changes, Grade 3 cognitive disturbance, Grade 2 weight loss, and Grade 1 increase in BUN. The extent of recovery was not documented.

  • 11 DESCRIPTION

    CABOMETYX is the (S)-malate salt of cabozantinib, a kinase inhibitor. Cabozantinib (S)-malate is described chemically as N-(4-(6,7-dimethoxyquinolin-4-yloxy)phenyl)-N'-(4-fluorophenyl)cyclopropane-1,1-dicarboxamide, (2S)-hydroxybutanedioate. The molecular formula is C28H24FN3O5•C4H6O5 and the molecular weight is 635.6 Daltons as malate salt. The chemical structure of cabozantinib (S)-malate salt is:

    image of chemical structure of CABOMETYX

    Cabozantinib (S)-malate salt is a white to off-white solid that is practically insoluble in aqueous media.

    CABOMETYX (cabozantinib) tablets for oral use are supplied as film-coated tablets containing 20 mg, 40 mg, or 60 mg of cabozantinib, which is equivalent to 25 mg, 51 mg, or 76 mg of cabozantinib (S)-malate, respectively. CABOMETYX also contains the following inactive ingredients: microcrystalline cellulose, lactose anhydrous, hydroxypropyl cellulose, croscarmellose sodium, colloidal silicon dioxide, and magnesium stearate.

    The film coating contains hypromellose, titanium dioxide, triacetin, and iron oxide yellow.

  • 12 CLINICAL PHARMACOLOGY

    12.1 Mechanism of Action

    In vitro biochemical and/or cellular assays have shown that cabozantinib inhibits the tyrosine kinase activity of MET, VEGFR-1, -2 and -3, AXL, RET, ROS1, TYRO3, MER, KIT, TRKB, FLT-3, and TIE-2. These receptor tyrosine kinases are involved in both normal cellular function and pathologic processes such as oncogenesis, metastasis, tumor angiogenesis, drug resistance, and maintenance of the tumor microenvironment.

    12.2 Pharmacodynamics

    The exposure-response or –safety relationship for cabozantinib is unknown.

    Cardiac Electrophysiology

    The effect of cabozantinib on QTc interval was evaluated in a randomized, double-blinded, placebo-controlled trial in patients with medullary thyroid cancer administered a cabozantinib capsule formulation. A mean increase in QTcF of 10 - 15 ms was observed at 4 weeks after initiation. A concentration-QTc relationship could not be definitively established. Changes in cardiac wave form morphology or new rhythms were not observed. No patients in this study had a confirmed QTcF > 500 ms nor did any patients in METEOR, CABOSUN, CELESTIAL, or CHECKMATE-9ER.

    12.3 Pharmacokinetics

    Repeat daily dosing of a cabozantinib capsule formulation for 19 days resulted in 4- to 5-fold mean cabozantinib accumulation (based on AUC) compared to a single dose administration; steady state was achieved by Day 15.

    Absorption

    Median time to peak cabozantinib concentrations (Tmax) ranged from 3 to 4 hours post-dose. A 19% increase in the Cmax of CABOMETYX compared to a cabozantinib capsule formulation was observed following a single 140 mg dose. A less than 10% difference in the AUC was observed between CABOMETYX and a cabozantinib capsule formulation [see Dosage and Administration (2.1)].

    Food Effect

    Cabozantinib Cmax and AUC increased by 41% and 57%, respectively, following a high-fat meal relative to fasted conditions in healthy subjects administered a single oral dose of a cabozantinib capsule formulation.

    Distribution

    The oral volume of distribution (Vz/F) of cabozantinib is approximately 319 L. Cabozantinib is highly protein bound in human plasma (≥ 99.7%).

    Elimination

    The predicted terminal half-life is approximately 99 hours and the clearance (CL/F) at steady-state is estimated to be 2.2 L/hr.

    Metabolism

    Cabozantinib is a substrate of CYP3A4 in vitro.

    Excretion

    Approximately 81% of the total administered radioactivity was recovered within a 48-day collection period following a single dose of radiolabeled 14C-cabozantinib in healthy subjects. Approximately 54% was recovered in feces and 27% in urine. Unchanged cabozantinib accounted for 43% of the total radioactivity in feces and was not detectable in urine following a 72-hour collection.

    Specific Populations

    The following patient characteristics did not result in a clinically relevant difference in the pharmacokinetics of cabozantinib: age (32-86 years), sex, race (Whites and non-Whites), or mild to moderate renal impairment (eGFR ≥ 30 mL/min/1.73 m2 as estimated by MDRD (modification of diet in renal disease equation)). The pharmacokinetics of cabozantinib is unknown in patients with eGFR < 29 mL/min/1.73m2 as estimated by MDRD equation or requiring dialysis.

    Patients with Hepatic Impairment

    Based on a population pharmacokinetic analysis of cabozantinib in healthy subjects and patients with cancer, no clinically significant differences in the mean cabozantinib exposure were observed between subjects with normal liver function (total bilirubin and AST ≤ ULN) and those with mild hepatic impairment (total bilirubin ≤ ULN and AST > ULN or total bilirubin > 1 to 1.5x ULN and any AST value). In a dedicated pharmacokinetic study, cabozantinib exposure (AUC0-INF) increased by 63% in patients with moderate hepatic impairment (Child-Pugh B). Patients with severe hepatic impairment have not been studied [see Dosage and Administration (2.7), Use in Specific Populations (8.6)].

    Drug Interaction Studies

    Clinical Studies

    CYP3A4 Inhibitors:

    Administration of a strong CYP3A4 inhibitor, ketoconazole (400 mg daily for 27 days), with a cabozantinib capsule formulation to healthy subjects increased single-dose cabozantinib exposure (AUC0-INF) by 38%.

    CYP3A4 Inducers:

    Administration of a strong CYP3A4 inducer, rifampin (600 mg daily for 31 days), with a cabozantinib capsule formulation to healthy subjects decreased single-dose cabozantinib exposure (AUC0-INF) by 77%.

    CYP2C8 Substrates:

    No clinically-significant effect on single-dose rosiglitazone (a CYP2C8 substrate) exposure (Cmax and AUC) was observed when co-administered with a cabozantinib capsule formulation at steady-state concentrations.

    Gastric Acid Reducing Agents:

    No clinically-significant effect on cabozantinib exposure (AUC) was observed following co- administration of the proton pump inhibitor (PPI) esomeprazole (40 mg daily for 6 days) with a single 100 mg dose of a cabozantinib capsule formulation to healthy subjects.

    In vitro Studies

    CYP Enzymes:

    Inhibition of CYP3A4 reduced the formation of the oxidative metabolite by > 80%. Inhibition of CYP2C9 had a minimal effect on cabozantinib metabolite formation (i.e., a <20% reduction). Inhibition of CYP1A2, CYP2A6, CYP2B6, CYP2C8, CYP2C19, CYP2D6 and CYP2E1 had no effect on cabozantinib metabolite formation.

    Although cabozantinib is an inhibitor of CYP2C8 in vitro, a clinical study of this potential interaction concluded that concurrent use did not result in a clinically relevant effect on CYP2C8 substrate exposure. Given this finding, other less sensitive substrates of pathways affected by cabozantinib in vitro (i.e., CYP2C9, CYP2C19, and CYP3A4) were not evaluated in a clinical study, because, although a clinically relevant exposure effect cannot be ruled out, it is unlikely. Cabozantinib does not inhibit CYP1A2 and CYP2D6 isozymes in vitro.

    Cabozantinib is an inducer of CYP1A1 mRNA; however, the clinical relevance of this finding is unknown. Cabozantinib does not induce CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19 or CYP3A4.

    Transporters:

    Cabozantinib is an inhibitor, but not a substrate, of P-gp transport activities and has the potential to increase concentrations of co-administered substrates of P-gp. The clinical relevance of this finding is unknown.

    Cabozantinib is a substrate of MRP2 in vitro and MRP2 inhibitors have the potential to increase concentrations of cabozantinib. The clinical relevance of this finding is unknown.

  • 13 NONCLINICAL TOXICOLOGY

    13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

    The carcinogenic potential of cabozantinib has been evaluated in two species: rasH2 transgenic mice and Sprague-Dawley rats. In the 2-year rat carcinogenicity study, once daily oral administration of cabozantinib resulted in a statistically significant increase in the incidence of malignant/complex malignant pheochromocytoma in combination with benign pheochromocytoma or in benign pheochromocytoma alone in male rats at a dose of 1 mg/kg (approximately 5 times the human exposure by AUC at the recommended 60 mg dose). Cabozantinib was not carcinogenic in a 26-week carcinogenicity study in rasH2 transgenic mice at a slightly higher exposure than the intended human therapeutic exposure.

    Cabozantinib was not mutagenic in vitro in the bacterial reverse mutation (Ames) assay and was not clastogenic in both the in vitro cytogenetic assay using human lymphocytes or in the in vivo mouse micronucleus assay.

    Based on nonclinical findings, male and female fertility may be impaired by treatment with CABOMETYX. In a fertility study in which cabozantinib was administered to male and female rats at doses of 1, 2.5, and 5 mg/kg/day, male fertility was significantly compromised at doses equal to or greater than 2.5 mg/kg/day (approximately 13-fold of human AUC at the recommended dose), with a decrease in sperm counts and reproductive organ weights. In females, fertility was significantly reduced at doses equal to or greater than 1 mg/kg/day (5-fold of human AUC at the recommended dose) with a significant decrease in the number of live embryos and a significant increase in pre- and post-implantation losses.

    Observations of effects on reproductive tract tissues in general toxicology studies were supportive of effects noted in the dedicated fertility study and included hypospermia and absence of corpora lutea in male and female dogs in a 6-month repeat dose study at plasma exposures (AUC) approximately 0.5-fold (males) and <0.1-fold (females) of those expected in humans at the recommended dose. In addition, female rats administered 5 mg/kg/day for 14 days (approximately 9-fold of human AUC at the recommended dose) exhibited ovarian necrosis.

  • 14 CLINICAL STUDIES

    14.1 Renal Cell Carcinoma

    Previously Treated with Anti-angiogenic Therapy

    The efficacy of CABOMETYX was evaluated in METEOR (NCT01865747), a randomized (1:1), open-label, multicenter trial of CABOMETYX versus everolimus conducted in patients with advanced RCC who had received at least 1 prior anti-angiogenic therapy. Patients had to have a Karnofsky Performance Score (KPS) ≥ 70%. Patients were stratified by the number of prior VEGFR tyrosine kinase inhibitors (TKIs) and Memorial Sloan Kettering Cancer Center (MSKCC) Risk Group.

    Patients were randomized to receive CABOMETYX (N=330) 60 mg orally once daily or everolimus (N=328) 10 mg orally once daily. The majority of the patients were male (75%), with a median age of 62 years. Sixty-nine percent (69%) received only one prior anti-angiogenic therapy. Patient distribution by MSKCC risk groups was 46% favorable (0 risk factors), 42% intermediate (1 risk factor), and 13% poor (2 or 3 risk factors). Fifty-four percent (54%) of patients had 3 or more organs with metastatic disease, including lung (63%), lymph nodes (62%), liver (29%), and bone (22%).

    The main efficacy outcome measure was progression-free survival (PFS) assessed by a blinded independent radiology review committee among the first 375 subjects randomized. Other efficacy endpoints were objective response rate (ORR) and overall survival (OS) in the Intent-to- Treat (ITT) population. Tumor assessments were conducted every 8 weeks for the first 12 months, then every 12 weeks thereafter. Patients received treatment until disease progression or experiencing unacceptable toxicity. Patients on both arms who had disease progression could continue treatment at the discretion of the investigator.

    Statistically significant improvements in PFS, OS, and ORR were demonstrated for CABOMETYX compared to everolimus. Efficacy results are presented in Tables 11 and 12 and Figures 1 and 2.

    Table 11: Efficacy Results in METEOR (First 375 Randomized)
       EndpointCABOMETYXEverolimus
    N = 187N = 188
    *
    stratified log-rank test with prior VEGFR-targeting TKI therapy (1 vs 2 or more) and MSKCC prognostic criteria for previously treated patients with RCC (0 vs 1 vs 2 or 3) as stratification factors (per IVRS data)
       Median PFS (95% CI), months7.4 (5.6, 9.1)3.8 (3.7, 5.4)
       HR (95% CI), p-value*0.58 (0.45, 0.74), p<0.0001

    Figure 1: Kaplan-Meier Curves of Progression-Free Survival in METEOR (First 375 Randomized)

    image of Kaplan-Meier Curves of Progression-Free Survival in METEOR (First 375 Randomized)

    Table 12: Efficacy Results in METEOR (ITT)
       EndpointCABOMETYXEverolimus
    N = 330N = 328
    *
    stratified log-rank test with prior VEGFR-targeting TKI therapy (1 vs 2 or more) and MSKCC prognostic criteria for previously treated patients with RCC (0 vs 1 vs 2 or 3) as stratification factors (per IVRS data)
    chi-squared test
       Median OS (95% CI), months21.4 (18.7, NE)16.5 (14.7, 18.8)
       HR (95% CI), p-value*0.66 (0.53, 0.83), p=0.0003
       Confirmed ORR (partial responses only) (95% CI)17% (13%, 22%)3% (2%, 6%)
       p-valuep<0.0001

    Figure 2: Kaplan-Meier Curve of Overall Survival in METEOR (ITT)

    image of Kaplan-Meier Curve of Overall Survival in METEOR (ITT)

    First-line Treatment

    CABOSUN

    The efficacy of CABOMETYX was evaluated in CABOSUN (NCT01835158), a randomized (1:1), open-label, multicenter trial of CABOMETYX versus sunitinib conducted in patients with advanced RCC who had not received prior therapy. Patients were randomized to receive CABOMETYX (N=79) 60 mg orally once daily or sunitinib (N=78) 50 mg orally once daily (4 weeks on treatment followed by 2 weeks off) until disease progression or unacceptable toxicity. All patients were required to have intermediate or poor risk disease as defined by the International Metastatic RCC Database Consortium (IMDC) risk group categories. Patients were stratified by IMDC risk group and presence of bone metastases (yes/no).

    The majority of patients were male (78%), with a median age of 63 years. Patient distribution by IMDC risk groups was 81% intermediate (1-2 risk factors) and 19% poor (≥3 risk factors). Thirty-six percent (36%) patients had bone metastases. Forty-six percent (46%) of patients were ECOG 0, 41% ECOG 1, and 13% ECOG 2.

    The major efficacy outcome measure was progression-free survival (PFS) by a retrospective blinded independent radiology review committee (BIRC).

    A statistically significant improvement in PFS, as assessed by a blinded independent radiology review committee, was demonstrated for CABOMETYX compared to sunitinib. Efficacy results are presented in Table 13, Figure 3, and Figure 4.

    Table 13: Efficacy Results in CABOSUN
       EndpointCABOMETYXSunitinib
    N = 79N = 78
       Progression-Free Survival*
    *
    as assessed by a retrospective blinded independent radiology review committee (BIRC)
    estimated from stratified Cox proportional hazards model with stratification factors IMDC risk group and presence of bone metastases and treatment as covariate
    two-sided stratified log-rank test with stratification factors IMDC risk group and presence of bone metastases
    §
    no multiplicity adjustments were made for overall survival or ORR
       Events, n(%)43 (54)49 (63)
       Median PFS (95% CI), months*8.6 (6.8, 14.0)5.3 (3.0, 8.2)
       Hazard Ratio (95% CI), p-value0.48 (0.31, 0.74), p=0.0008
       Overall Survival
       Events, n(%)43 (54)47 (60)
       Hazard Ratio, § (95% CI)0.80 (0.53, 1.21)
       Confirmed ORR, partial responses only (95% CI)*, §20% (12.0, 30.8)9% (3.7, 17.6)

    Figure 3: Kaplan-Meier Curve of Progression-Free Survival in CABOSUN

    image of Kaplan-Meier Curve of Progression-Free Survival in CABOSUN


    Figure 4: Kaplan-Meier Curve of Overall Survival in CABOSUN

    image of Kaplan-Meier Curve of Overall Survival in CABOSUN

    CHECKMATE-9ER

    CHECKMATE-9ER (NCT03141177) was a randomized, open-label study of CABOMETYX combined with nivolumab versus sunitinib in patients with previously untreated advanced RCC. CHECKMATE-9ER excluded patients with autoimmune disease or other medical conditions requiring systemic immunosuppression. Patients were stratified by IMDC prognostic score (favorable vs. intermediate vs. poor), PD-L1 tumor expression (≥1% vs. <1% or indeterminate), and region (US/Canada/Western Europe/Northern Europe vs. Rest of World).

    Patients were randomized to CABOMETYX 40mg orally daily and nivolumab 240mg intravenously every 2 weeks (n=323), or sunitinib 50 mg orally daily for the first 4 weeks of a 6-week cycle (4 weeks on treatment followed by 2 weeks off) (n=328). Treatment continued until disease progression per RECIST v1.1 or unacceptable toxicity. Treatment beyond RECIST- defined disease progression was permitted if the patient was clinically stable and considered to be deriving clinical benefit by the investigator. Tumor assessments were performed at baseline, after randomization at Week 12, then every 6 weeks until Week 60, and then every 12 weeks thereafter.

    The trial population characteristics were: median age 61 years (range: 28 to 90) with 38% ≥65 years of age and 10% ≥75 years of age. The majority of patients were male (74%) and White (82%) and 23% and 77% of patients had a baseline KPS of 70% to 80% and 90% to 100%, respectively. Patient distribution by IMDC risk categories was 22% favorable, 58% intermediate, and 20% poor.

    The major efficacy outcome measure was PFS (BICR assessed). Additional efficacy outcome measures were OS and ORR (BICR assessed). The trial demonstrated a statistically significant improvement in PFS, OS, and ORR for patients randomized to CABOMETYX and nivolumab compared with sunitinib. Consistent results for PFS were observed across pre-specified subgroups of IMDC risk categories and PD-L1 tumor expression status. Efficacy results are shown in Table 14 and Figures 5 and 6.

    Table 14: Efficacy Results in CHECKMATE-9ER
    CABOMETYX and
    Nivolumab
    (n=323)
    Sunitinib
    (n=328)
    *
    Based on Kaplan-Meier estimates.
    Stratified Cox proportional hazards model.
    Based on stratified log-rank test
    §
    2-sided p-values from stratified log-rank test.
    Not Reached
    #
    p-value is compared with the allocated alpha of 0.0111 for this interim analysis.
    Þ
    CI based on the Clopper and Pearson method.
    ß
    2-sided p-value from Cochran-Mantel-Haenszel test.
    Progression-free Survival
       Disease progression or deaths (%)144 (45)191 (58)
       Median PFS (months)* (95% CI)16.6 (12.5, 24.9)8.3 (7.0, 9.7)
       Hazard ratio (95% CI)0.51 (0.41, 0.64)
       p-value, §<0.0001
    Overall Survival
       Deaths (%)67 (21)99 (30)
       Median OS (months)* (95% CI)NRNR (22.6, NR)
       Hazard ratio (95% CI)0.60 (0.40, 0.89)
       p-value, §, #0.0010
    Confirmed Objective Response Rate (95% CI)Þ55.7% (50.1, 61.2)27.1% (22.4, 32.3)
       p-valueß<0.0001
       Complete Response (CR)26 (8%)15 (4.6%)
       Partial Response (PR)154 (48%)74 (23%)
       Median duration of response in months (95% CI)*20.2 (17.3, NR)11.5 (8.3, 18.4)

    Figure 5: Kaplan-Meier Curve of Progression-Free Survival in CHECKMATE-9ER

    image of Kaplan-Meier Curve of Progression-Free Survival in CHECKMATE-9ER

    Figure 6: Kaplan-Meier Curve of Overall Survival in CHECKMATE-9ER

    image of Kaplan-Meier Curve of Overall Survival in CHECKMATE-9ER

    14.2 Hepatocellular Carcinoma

    The efficacy of CABOMETYX was evaluated in CELESTIAL (NCT01908426), a randomized (2:1), double-blind, placebo-controlled, multicenter trial in patients with hepatocellular carcinoma (HCC) who had previously received sorafenib and had Child Pugh Class A liver impairment. Patients were randomized to receive CABOMETYX 60 mg orally once daily or placebo until disease progression or unacceptable toxicity. Randomization was stratified by etiology of disease (hepatitis B virus [HBV] with or without hepatitis C virus [HCV] vs. HCV [without HBV] vs. other [without HBV and HCV]), geographic region (Asia vs. other regions), and presence of extrahepatic spread of disease and/or macrovascular invasion (yes vs. no). The primary efficacy outcome measure was overall survival (OS). Additional outcome measures were progression-free survival (PFS) and objective response rate (ORR), as assessed by investigators per RECIST 1.1. Tumor assessments were conducted every 8 weeks.

    In CELESTIAL, a total of 707 patients were randomized, 470 to CABOMETYX and 237 to placebo. The median age was 64 years (range 22 to 86 years), 82% were male, 56% were White and 34% were Asian. Baseline ECOG performance status was 0 (53%) or 1 (47%). The etiology of HCC was attributed to HBV in 38% of patients and HCV in 21%; etiology was attributed to causes other than HBV or HCV in 40%. Macroscopic vascular invasion or extra-hepatic tumor spread was present in 78% of patients and 41% had alpha-fetoprotein (AFP) levels ≥ 400 mcg/L. All patients received prior sorafenib and 27% received two prior systemic therapy regimens.

    Efficacy results are summarized in Table 15, Figure 7, and Figure 8.

    Table 15: Efficacy Results from CELESTIAL
       EndpointCABOMETYXPlacebo
    N = 470N = 237
       Overall Survival
    *
    estimated using the Cox proportional-hazard model
    log-rank test stratified by etiology of disease (HBV [with or without HCV], HCV [without HBV], or Other), geographic region (Asia, Other Regions), and presence of extrahepatic spread of disease and/or macrovascular invasion (Yes, No) as stratification factors (per IVRS data)
    significance level = 0.021 for 78% information (484 deaths) based on O’Brien-Fleming method
    §
    Fisher’s exact test
       Number of Deaths, (%)317 (67)167 (70)
       Median OS in Months (95% CI)10.2 (9.1, 12.0)8.0 (6.8, 9.4)
       Hazard Ratio (95% CI)*0.76 (0.63, 0.92)
       p-valuep=0.0049
       Progression-Free Survival
       Number of Events, (%)349 (74)205 (86)
       Progressive Disease284 (60)186 (78)
       Death65 (14)19 (8)
       Median PFS in Months (95% CI)5.2 (4.0, 5.5)1.9 (1.9, 1.9)
       Hazard Ratio (95% CI)*0.44 (0.36, 0.52)
       p-valuep< 0.0001
       Overall Response Rate (ORR)
       Confirmed ORR (partial responses only) (95% CI)4% (2.3, 6.0)0.4% (0.0, 2.3)
       p-value§p=0.0086

    Figure 7: Kaplan-Meier Curve of Overall Survival in CELESTIAL

    image of Kaplan-Meier Curve of Overall Survival in CELESTIAL


    Figure 8: Kaplan-Meier Curve of Progression-Free Survival in CELESTIAL

    image of Kaplan-Meier Curve of Progression-Free Survival in CELESTIAL

  • 16 HOW SUPPLIED/STORAGE AND HANDLING

    CABOMETYX tablets are supplied as follows:

    60 mg tables are yellow film-coated, oval shaped with no score, debossed with "XL" on one side and "60" on the other side of the tablet; available in bottles of 30 tablets:
    NDC 42388-023-26

    40 mg tablets are yellow film-coated, triangle shaped with no score, debossed with "XL" on one side and "40" on the other side of the tablet; available in bottles of 30 tablets:
    NDC 42388-025-26

    20 mg tablets are yellow film-coated, round shaped with no score, debossed with "XL" on one side and "20" on the other side of the tablet; available in bottles of 30 tablets:
    NDC 42388-024-26

    Store CABOMETYX at 20°C to 25°C (68°F to 77°F); excursions are permitted from 15°C to 30°C (59°F to 86°F) [see USP Controlled Room Temperature].

  • 17 PATIENT COUNSELING INFORMATION

    Advise the patient to read the FDA-approved patient labeling (Patient Information).

    • Hemorrhage: Instruct patients to contact their healthcare provider to seek immediate medical attention for signs or symptoms of unusual severe bleeding or hemorrhage [see Warnings and Precautions (5.1)].
    • Perforations and fistulas: Advise patients that gastrointestinal disorders such as diarrhea, nausea, vomiting, and constipation may develop during CABOMETYX treatment and to seek immediate medical attention if they experience persistent or severe abdominal pain because cases of gastrointestinal perforation and fistula have been reported in patients taking CABOMETYX [see Warnings and Precautions (5.2)].
    • Thrombotic Events: Venous and arterial thrombotic events have been reported. Advise patients to report signs or symptoms of an arterial thrombosis. Venous thromboembolic events including pulmonary embolus have been reported. Advise patients to contact their health care provider if new onset of dyspnea, chest pain, or localized limb edema occurs [see Warnings and Precautions (5.3)].
    • Hypertension and hypertensive crisis: Inform patients of the signs and symptoms of hypertension. Advise patients to undergo routine blood pressure monitoring and to contact their health care provider if blood pressure is elevated or if they experience signs or symptoms of hypertension [see Warnings and Precautions (5.4)].
    • Diarrhea: Advise patients to notify their healthcare provider at the first signs of poorly formed or loose stool or an increased frequency of bowel movements [see Warnings and Precautions (5.5)].
    • Palmar-plantar erythrodysesthesia: Advise patients to contact their healthcare provider for progressive or intolerable rash [see Warnings and Precautions (5.6)].
    • Hepatotoxicity: Advise patients to contact their healthcare provider immediately for jaundice, severe nausea or vomiting, or easy bruising or bleeding [see Warnings and Precautions (5.7)].
    • Adrenal insufficiency: Advise patients receiving with nivolumab to contact their healthcare provider immediately for signs or symptoms of adrenal insufficiency [see Warnings and Precautions (5.8)].
    • Osteonecrosis of the jaw: Advise patients regarding good oral hygiene practices. Advise patients to immediately contact their healthcare provider for signs or symptoms associated with osteonecrosis of the jaw [see Warnings and Precautions (5.10)].
    • Impaired wound healing: Advise patients that CABOMETYX may impair wound healing. Advise patients to inform their healthcare provider of any planned surgical procedure [see Dosage and Administration (2.1), Warnings and Precautions (5.11)].
    • Reversible posterior leukoencephalopathy syndrome: Advise patients to immediately contact their health care provider for new onset or worsening neurological function [see Warnings and Precautions (5.12)].
    • Embryo-fetal toxicity:
    • Lactation: Advise women not to breastfeed during treatment with CABOMETYX and for 4 months following the last dose [Use in Specific Populations (8.2)].
    • Drug interactions: Advise patients to inform their healthcare provider of all prescription or nonprescription medications, vitamins or herbal products. Inform patients to avoid grapefruit, grapefruit juice, and St. John’s wort [see Drug Interactions (7.1)].

    Important administration information

    • Instruct patients to take CABOMETYX at least 1 hour before or at least 2 hours after eating.

    Manufactured for Exelixis, Inc. Alameda, CA 94502




  • PATIENT PACKAGE INSERT

    PATIENT INFORMATION
    CABOMETYX® (Ka-boe-met-iks)
    cabozantinib
    tablets
    If your healthcare provider prescribes CABOMETYX in combination with nivolumab, also read the Medication Guide that comes with nivolumab.
    What is CABOMETYX?
    CABOMETYX is a prescription medicine used to treat:
    • people with advanced kidney cancer (renal cell carcinoma). CABOMETYX may be used:
      • alone to treat people with renal cell carcinoma (RCC) that has spread (advanced RCC).
      • in combination with nivolumab when your cancer has spread (advanced RCC), and you have not already had treatment for your advanced RCC.
    • people with liver cancer (hepatocellular carcinoma) who have been previously treated with the medicine sorafenib.
    It is not known if CABOMETYX is safe and effective in children.
    Before you take CABOMETYX, tell your healthcare provider about all of your medical conditions, including if you:
    • have had a liver problem other than liver cancer
    • have a recent history of bleeding, including coughing up or vomiting blood, or black tarry stools.
    • have an open or healing wound
    • have high blood pressure
    • plan to have any surgery, dental procedure, or have had a recent surgery. You should stop taking CABOMETYX at least 3 weeks before planned surgery. See "What are the possible side effects of CABOMETYX?"
    • are pregnant, or plan to become pregnant. CABOMETYX can harm your unborn baby.
      • If you are able to become pregnant, your healthcare provider will check your pregnancy status before you start treatment with CABOMETYX.
      • Females who are able to become pregnant should use effective birth control (contraception) during treatment and for 4 months after your final dose of CABOMETYX.
      • Talk to your healthcare provider about birth control methods that may be right for you.
      • If you become pregnant or think you are pregnant, tell your healthcare provider right away.
    • are breastfeeding or plan to breastfeed. It is not known if CABOMETYX passes into your breast milk. Do not breastfeed during treatment and for 4 months after your final dose of CABOMETYX.
    Tell your healthcare provider about all the medicines you take, including prescription or over-the-counter medicines, vitamins, and herbal supplements. CABOMETYX and certain other medicines may affect each other causing side effects.
    How should I take CABOMETYX?
    • Take CABOMETYX exactly as your healthcare provider tells you to take it.
    • Do not take CABOMETYX with food. Take CABOMETYX at least 1 hour before or at least 2 hours after eating.
    • Swallow CABOMETYX tablets whole.
    • Do not crush CABOMETYX tablets.
    • If you miss a dose and your next scheduled dose is in:
      • less than 12 hours, take your next dose at the normal time. Do not make up the missed dose.
      • 12 hours or more, take the missed dose as soon as you remember. Take your next dose at the normal time.
    What should I avoid while taking CABOMETYX?
    Avoid drinking grapefruit juice, eating grapefruit or taking supplements that contain grapefruit or St. John’s wort during treatment with CABOMETYX.
    What are the possible side effects of CABOMETYX?
    CABOMETYX may cause serious side effects, including:
    • bleeding (hemorrhage). CABOMETYX can cause severe bleeding that may lead to death. Tell your healthcare provider right away if you get any signs of bleeding during treatment with CABOMETYX, including:
      • coughing up blood or blood clots
      • vomiting blood or if your vomit looks like coffee-grounds
      • red or black (looks like tar) stools
      • menstrual bleeding that is heavier than normal
      • any unusual or heavy bleeding
    • a tear in your stomach or intestinal wall (perforation) or an abnormal connection between 2 parts of your body (fistula). Tell your healthcare provider right away if you get tenderness or pain in your stomach-area (abdomen) that is severe or that does not go away.
    • blood clots, stroke, heart attack, and chest pain. Get emergency help right away if you get:
      • swelling or pain in your arms or legs
      • shortness of breath
      • feel lightheaded or faint
      • sweating more than usual
      • numbness or weakness of your face, arm or leg, especially on one side of your body
      • sudden confusion, trouble speaking or understanding
      • sudden trouble seeing in one or both eyes
      • sudden trouble walking
      • dizziness, loss of balance or coordination
      • a sudden severe headache
    • high blood pressure (hypertension). Hypertension is common with CABOMETYX and sometimes can be severe. Your healthcare provider will check your blood pressure before starting CABOMETYX and regularly during treatment with CABOMETYX. If needed, your healthcare provider may prescribe medicine to treat your high blood pressure. Tell your healthcare provider if you develop severe headaches, nose bleeds, tiredness or confusion, vision changes, chest pain, trouble breathing, irregular heartbeat, or blood in your urine.
    • diarrhea. Diarrhea is common with CABOMETYX and can be severe. If needed, your healthcare provider may prescribe medicine to treat your diarrhea. Tell your healthcare provider right away, if you have frequent loose, watery bowel movements.
    • a skin problem called hand-foot skin reaction. Hand-foot skin reactions are common and can be severe. Tell your healthcare provider right away if you have rashes, redness, pain, swelling, or blisters on the palms of your hands or soles of your feet.
    • liver problems. Liver problems may happen during treatment with CABOMETYX. When CABOMETYX is taken in combination with nivolumab, severe changes in liver function tests may happen more often than if you take CABOMETYX alone. Your healthcare provider will do blood tests to check your liver function before and during treatment with CABOMETYX. Tell your healthcare provider right away if you develop symptoms of liver problems including: yellowing of your skin or the whites of your eyes, severe nausea or vomiting, pain on the right side of your stomach-area (abdomen), dark urine, bleeding or bruising more easily than normal.
    • adrenal gland problems. Your healthcare provider will monitor you for this problem. Your healthcare provider may prescribe hormone replacement therapy or corticosteroid medicines if needed. Tell your healthcare provider right away if you develop any of the following signs or symptoms: extreme tiredness, dizziness or fainting, weakness, nausea, or vomiting.
    • protein in your urine and possible kidney problems. Symptoms may include swelling in your hands, arms, legs, or feet. Your healthcare provider will check you for this problem during treatment with CABOMETYX.
    • severe jaw bone problems (osteonecrosis). Your healthcare provider should examine your mouth before you start and during treatment with CABOMETYX. Tell your dentist that you are taking CABOMETYX. It is important for you to practice good mouth care during treatment with CABOMETYX. Tell your healthcare provider right away if you develop any symptoms of jaw problems, including: jaw pain, toothache, or sores on your gums.
    • wound healing problems. Wound healing problems have happened in some people who take CABOMETYX. Tell your healthcare provider if you plan to have any surgery before or during treatment with CABOMETYX.
      • You should stop taking CABOMETYX at least 3 weeks before planned surgery.
      • Your healthcare provider should tell you when you may start taking CABOMETYX again after surgery.
    • Reversible Posterior Leukoencephalopathy Syndrome (RPLS). A condition called reversible posterior leukoencephalopathy syndrome can happen during treatment with CABOMETYX. Tell your healthcare provider right away if you have headaches, seizures, confusion, changes in vision, or problems thinking.
    Your healthcare provider may change your dose, temporarily stop, or permanently stop treatment with CABOMETYX if you have certain side effects.
    The most common side effects of CABOMETYX include:
    • tiredness
    • decreased appetite
    • nausea
    • vomiting
    • weight loss
    • constipation
    • difficulty in speaking
    The most common side effects of CABOMETYX when used in combination with nivolumab include:
    • tiredness
    • mouth sores
    • rash
    • low thyroid hormone levels (hypothyroidism)
    • pain in muscles, bones, and joints
    • decreased appetite
    • nausea
    • changes in the way things taste
    • stomach-area (abdominal) pain
    • cough
    • upper respiratory tract infection

    CABOMETYX may cause fertility problems in females and males, which may affect your ability to have children. Talk to your healthcare provider if you have concerns about fertility.
    These are not all of the possible side effects of CABOMETYX. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.
    How should I store CABOMETYX?
    • Store CABOMETYX at room temperature between 68°F to 77°F (20°C to 25°C).
    Keep CABOMETYX and all medicines out of the reach of children.
    General information about the safe and effective use of CABOMETYX.
    Medicines are sometimes prescribed for purposes other than those listed in a Patient Information leaflet. Do not use CABOMETYX for a condition for which it was not prescribed. Do not give CABOMETYX to other people, even if they have the same symptoms you have. It may harm them.
    You can ask your pharmacist or healthcare provider for information about CABOMETYX that is written for health professionals.
    What are the ingredients in CABOMETYX?
    Active ingredient: cabozantinib
    Inactive ingredients: microcrystalline cellulose, lactose anhydrous, hydroxypropyl cellulose, croscarmellose sodium, colloidal silicon dioxide, and magnesium stearate. The film coating contains hypromellose, titanium dioxide, triacetin, and iron oxide yellow.

    Manufactured for Exelixis, Inc. Alameda, CA 94502
    For more information, go to www.cabometyx.com or call 1-855-292-3935.
    This Patient Information has been approved by the U.S. Food and Drug Administration.Issued: 01/2021
  • PRINCIPAL DISPLAY PANEL


    Package Label - Bottle - 30 Tablets - 60mg CABOMETYX

    PRINCIPAL DISPLAY PANEL

    NDC 42388-023-26

    Cabometyx®
    (cabozantinib) tablets

    60 mg*

    Rx Only
    30 tablets
    Exelixis®

    *Each tablet contains 60 mg of
    cabozantinib (equivalent to 76 mg of
    cabozantinib (S)-malate).

    Take once each day on an empty
    stomach
    . Cabometyx should not
    be taken with food. Take
    Cabometyx at least 1 hour before
    or at least 2 hours after eating.
    Swallow Cabometyx tablets whole.
    Do not crush Cabometyx tablets.

    Store Cabometyx at 20°C to 25°C
    (68°F to 77°F); excursions are
    permitted from 15°C to 30°C
    (59°F to 86°F) [see USP Controlled
    Room Temperature].

    Keep out of the reach of children.

    Manufactured for Exelixis, Inc.
    Alameda, CA 94502
    Made in Canada

    image of bottle label - 60 mg - 30 tablets
  • PRINCIPAL DISPLAY PANEL


    Package Label - Bottle - 30 Tablets - 40mg CABOMETYX

    PRINCIPAL DISPLAY PANEL

    NDC 42388-025-26

    Cabometyx®
    (cabozantinib) tablets

    40 mg*

    Rx Only
    30 tablets
    Exelixis®

    *Each tablet contains 40 mg of
    cabozantinib (equivalent to 51 mg of
    cabozantinib (S)-malate).

    Take once each day on an empty
    stomach
    . Cabometyx should not
    be taken with food. Take
    Cabometyx at least 1 hour before
    or at least 2 hours after eating.
    Swallow Cabometyx tablets whole.
    Do not crush Cabometyx tablets.

    Store Cabometyx at 20°C to 25°C
    (68°F to 77°F); excursions are
    permitted from 15°C to 30°C
    (59°F to 86°F) [see USP Controlled
    Room Temperature].

    Keep out of the reach of children.

    Manufactured for Exelixis, Inc.
    Alameda, CA 94502
    Made in Canada

    image of bottle label - 40 mg - 30 tablets
  • PRINCIPAL DISPLAY PANEL


    Package Label - Bottle - 30 Tablets - 20mg CABOMETYX

    PRINCIPAL DISPLAY PANEL

    NDC 42388-024-26

    Cabometyx®
    (cabozantinib) tablets

    20 mg*

    Rx Only
    30 tablets
    Exelixis®

    *Each tablet contains 20 mg of
    cabozantinib (equivalent to 25 mg of
    cabozantinib (S)-malate).

    Take once each day on an empty
    stomach
    . Cabometyx should not
    be taken with food. Take
    Cabometyx at least 1 hour before
    or at least 2 hours after eating.
    Swallow Cabometyx tablets whole.
    Do not crush Cabometyx tablets.

    Store Cabometyx at 20°C to 25°C
    (68°F to 77°F); excursions are
    permitted from 15°C to 30°C
    (59°F to 86°F) [see USP Controlled
    Room Temperature].

    Keep out of the reach of children.

    Manufactured for Exelixis, Inc.
    Alameda, CA 94502
    Made in Canada

    image of bottle label - 20 mg - 30 tablets
  • PRINCIPAL DISPLAY PANEL


    Package Label - Professional Sample - Bottle - 15 Tablets - 60mg CABOMETYX

    PRINCIPAL DISPLAY PANEL

    PROFESSIONAL SAMPLE - NOT FOR SALE

    NDC 42388-023-37

    Cabometyx®
    (cabozantinib) tablets

    60 mg*

    Rx Only
    15 tablets
    Exelixis®

    *Each tablet contains 60 mg of
    cabozantinib (equivalent to 76 mg of
    cabozantinib (S)-malate).

    Take once each day on an empty
    stomach
    . Cabometyx should not
    be taken with food. Take
    Cabometyx at least 1 hour before
    or at least 2 hours after eating.
    Swallow Cabometyx tablets whole.
    Do not crush Cabometyx tablets.

    Store Cabometyx at 20°C to 25°C
    (68°F to 77°F); excursions are
    permitted from 15°C to 30°C
    (59°F to 86°F) [see USP Controlled
    Room Temperature].

    Keep out of the reach of children.

    Manufactured for Exelixis, Inc.
    Alameda, CA 94502
    Made in Canada

    image of bottle label - professional sample - 60 mg - 15 tablets
  • PRINCIPAL DISPLAY PANEL


    Package Label - Professional Sample - Bottle - 15 Tablets - 40mg CABOMETYX

    PRINCIPAL DISPLAY PANEL

    PROFESSIONAL SAMPLE - NOT FOR SALE

    NDC 42388-025-37

    Cabometyx®
    (cabozantinib) tablets

    40 mg*

    Rx Only
    15 tablets
    Exelixis®

    *Each tablet contains 40 mg of
    cabozantinib (equivalent to 51 mg of
    cabozantinib (S)-malate).

    Take once each day on an empty
    stomach
    . Cabometyx should not
    be taken with food. Take
    Cabometyx at least 1 hour before
    or at least 2 hours after eating.
    Swallow Cabometyx tablets whole.
    Do not crush Cabometyx tablets.

    Store Cabometyx at 20°C to 25°C
    (68°F to 77°F); excursions are
    permitted from 15°C to 30°C
    (59°F to 86°F) [see USP Controlled
    Room Temperature].

    Keep out of the reach of children.

    Manufactured for Exelixis, Inc.
    Alameda, CA 94502
    Made in Canada

    image of bottle label - professional sample - 40 mg - 15 tablets
  • PRINCIPAL DISPLAY PANEL


    Package Label - Professional Sample - Bottle - 15 Tablets - 20mg CABOMETYX

    PRINCIPAL DISPLAY PANEL

    PROFESSIONAL SAMPLE - NOT FOR SALE

    NDC 42388-024-37

    Cabometyx®
    (cabozantinib) tablets

    20 mg*

    Rx Only
    15 tablets
    Exelixis®

    *Each tablet contains 20 mg of
    cabozantinib (equivalent to 25 mg of
    cabozantinib (S)-malate).

    Take once each day on an empty
    stomach
    . Cabometyx should not
    be taken with food. Take
    Cabometyx at least 1 hour before
    or at least 2 hours after eating.
    Swallow Cabometyx tablets whole.
    Do not crush Cabometyx tablets.

    Store Cabometyx at 20°C to 25°C
    (68°F to 77°F); excursions are
    permitted from 15°C to 30°C
    (59°F to 86°F) [see USP Controlled
    Room Temperature].

    Keep out of the reach of children.

    Manufactured for Exelixis, Inc.
    Alameda, CA 94502
    Made in Canada

    image of bottle label - professional sample - 20 mg - 15 tablets
  • PRINCIPAL DISPLAY PANEL


    Package Label - Bottle - 30 Tablets - 60mg CABOMETYX

    PRINCIPAL DISPLAY PANEL

    NDC 42388-023-26

    Cabometyx®
    (cabozantinib) tablets

    60 mg*

    Rx Only
    30 tablets
    Exelixis®

    *Each tablet contains 60 mg of
    cabozantinib (equivalent to 76 mg of
    cabozantinib (S)-malate).

    Take once each day on an empty
    stomach
    . Cabometyx should not
    be taken with food. Take
    Cabometyx at least 1 hour before
    or at least 2 hours after eating.
    Swallow Cabometyx tablets whole.
    Do not crush Cabometyx tablets.

    Store Cabometyx at 20°C to 25°C
    (68°F to 77°F); excursions are
    permitted from 15°C to 30°C
    (59°F to 86°F) [see USP Controlled
    Room Temperature].

    Keep out of the reach of children.

    Manufactured for Exelixis, Inc.
    Alameda, CA 94502
    Made in Germany

    image of bottle label - 60 mg - 30 tablets
  • PRINCIPAL DISPLAY PANEL


    Package Label - Bottle - 30 Tablets - 40mg CABOMETYX

    PRINCIPAL DISPLAY PANEL

    NDC 42388-025-26

    Cabometyx®
    (cabozantinib) tablets

    40 mg*

    Rx Only
    30 tablets
    Exelixis®

    *Each tablet contains 40 mg of
    cabozantinib (equivalent to 51 mg of
    cabozantinib (S)-malate).

    Take once each day on an empty
    stomach
    . Cabometyx should not
    be taken with food. Take
    Cabometyx at least 1 hour before
    or at least 2 hours after eating.
    Swallow Cabometyx tablets whole.
    Do not crush Cabometyx tablets.

    Store Cabometyx at 20°C to 25°C
    (68°F to 77°F); excursions are
    permitted from 15°C to 30°C
    (59°F to 86°F) [see USP Controlled
    Room Temperature].

    Keep out of the reach of children.

    Manufactured for Exelixis, Inc.
    Alameda, CA 94502
    Made in Germany

    image of bottle label - 40 mg - 30 tablets
  • PRINCIPAL DISPLAY PANEL


    Package Label - Bottle - 30 Tablets - 20mg CABOMETYX

    PRINCIPAL DISPLAY PANEL

    NDC 42388-024-26

    Cabometyx®
    (cabozantinib) tablets

    20 mg*

    Rx Only
    30 tablets
    Exelixis®

    *Each tablet contains 20 mg of
    cabozantinib (equivalent to 25 mg of
    cabozantinib (S)-malate).

    Take once each day on an empty
    stomach
    . Cabometyx should not
    be taken with food. Take
    Cabometyx at least 1 hour before
    or at least 2 hours after eating.
    Swallow Cabometyx tablets whole.
    Do not crush Cabometyx tablets.

    Store Cabometyx at 20°C to 25°C
    (68°F to 77°F); excursions are
    permitted from 15°C to 30°C
    (59°F to 86°F) [see USP Controlled
    Room Temperature].

    Keep out of the reach of children.

    Manufactured for Exelixis, Inc.
    Alameda, CA 94502
    Made in Germany

    image of bottle label - 20 mg - 30 tablets
  • INGREDIENTS AND APPEARANCE
    CABOMETYX 
    cabozantinib tablet
    Product Information
    Product TypeHUMAN PRESCRIPTION DRUGItem Code (Source)NDC:42388-023
    Route of AdministrationORAL
    Active Ingredient/Active Moiety
    Ingredient NameBasis of StrengthStrength
    cabozantinib s-malate (UNII: DR7ST46X58) (CABOZANTINIB - UNII:1C39JW444G) CABOZANTINIB60 mg
    Inactive Ingredients
    Ingredient NameStrength
    CELLULOSE, MICROCRYSTALLINE (UNII: OP1R32D61U)  
    ANHYDROUS LACTOSE (UNII: 3SY5LH9PMK)  
    HYDROXYPROPYL CELLULOSE (1600000 WAMW) (UNII: RFW2ET671P)  
    CROSCARMELLOSE SODIUM (UNII: M28OL1HH48)  
    SILICON DIOXIDE (UNII: ETJ7Z6XBU4)  
    MAGNESIUM STEARATE (UNII: 70097M6I30)  
    HYPROMELLOSES (UNII: 3NXW29V3WO)  
    TITANIUM DIOXIDE (UNII: 15FIX9V2JP)  
    TRIACETIN (UNII: XHX3C3X673)  
    FERRIC OXIDE YELLOW (UNII: EX438O2MRT)  
    Product Characteristics
    ColoryellowScoreno score
    ShapeOVALSize11mm
    FlavorImprint Code XL;60
    Contains    
    Packaging
    #Item CodePackage DescriptionMarketing Start DateMarketing End Date
    1NDC:42388-023-2630 in 1 BOTTLE; Type 0: Not a Combination Product04/25/2016
    2NDC:42388-023-3630 in 1 BOTTLE; Type 0: Not a Combination Product11/16/2017
    3NDC:42388-023-3715 in 1 BOTTLE; Type 0: Not a Combination Product10/03/2018
    Marketing Information
    Marketing CategoryApplication Number or Monograph CitationMarketing Start DateMarketing End Date
    NDANDA20869204/25/2016
    CABOMETYX 
    cabozantinib tablet
    Product Information
    Product TypeHUMAN PRESCRIPTION DRUGItem Code (Source)NDC:42388-025
    Route of AdministrationORAL
    Active Ingredient/Active Moiety
    Ingredient NameBasis of StrengthStrength
    cabozantinib s-malate (UNII: DR7ST46X58) (CABOZANTINIB - UNII:1C39JW444G) CABOZANTINIB40 mg
    Inactive Ingredients
    Ingredient NameStrength
    CELLULOSE, MICROCRYSTALLINE (UNII: OP1R32D61U)  
    ANHYDROUS LACTOSE (UNII: 3SY5LH9PMK)  
    HYDROXYPROPYL CELLULOSE (1600000 WAMW) (UNII: RFW2ET671P)  
    CROSCARMELLOSE SODIUM (UNII: M28OL1HH48)  
    SILICON DIOXIDE (UNII: ETJ7Z6XBU4)  
    MAGNESIUM STEARATE (UNII: 70097M6I30)  
    HYPROMELLOSES (UNII: 3NXW29V3WO)  
    TITANIUM DIOXIDE (UNII: 15FIX9V2JP)  
    TRIACETIN (UNII: XHX3C3X673)  
    FERRIC OXIDE YELLOW (UNII: EX438O2MRT)  
    Product Characteristics
    ColoryellowScoreno score
    ShapeTRIANGLESize8mm
    FlavorImprint Code XL;40
    Contains    
    Packaging
    #Item CodePackage DescriptionMarketing Start DateMarketing End Date
    1NDC:42388-025-2630 in 1 BOTTLE; Type 0: Not a Combination Product04/25/2016
    2NDC:42388-025-3715 in 1 BOTTLE; Type 0: Not a Combination Product02/27/2019
    Marketing Information
    Marketing CategoryApplication Number or Monograph CitationMarketing Start DateMarketing End Date
    NDANDA20869204/25/2016
    CABOMETYX 
    cabozantinib tablet
    Product Information
    Product TypeHUMAN PRESCRIPTION DRUGItem Code (Source)NDC:42388-024
    Route of AdministrationORAL
    Active Ingredient/Active Moiety
    Ingredient NameBasis of StrengthStrength
    cabozantinib s-malate (UNII: DR7ST46X58) (CABOZANTINIB - UNII:1C39JW444G) CABOZANTINIB20 mg
    Inactive Ingredients
    Ingredient NameStrength
    CELLULOSE, MICROCRYSTALLINE (UNII: OP1R32D61U)  
    ANHYDROUS LACTOSE (UNII: 3SY5LH9PMK)  
    HYDROXYPROPYL CELLULOSE (1600000 WAMW) (UNII: RFW2ET671P)  
    CROSCARMELLOSE SODIUM (UNII: M28OL1HH48)  
    SILICON DIOXIDE (UNII: ETJ7Z6XBU4)  
    MAGNESIUM STEARATE (UNII: 70097M6I30)  
    HYPROMELLOSES (UNII: 3NXW29V3WO)  
    TITANIUM DIOXIDE (UNII: 15FIX9V2JP)  
    TRIACETIN (UNII: XHX3C3X673)  
    FERRIC OXIDE YELLOW (UNII: EX438O2MRT)  
    Product Characteristics
    ColoryellowScoreno score
    ShapeROUNDSize6mm
    FlavorImprint Code XL;20
    Contains    
    Packaging
    #Item CodePackage DescriptionMarketing Start DateMarketing End Date
    1NDC:42388-024-2630 in 1 BOTTLE; Type 0: Not a Combination Product04/25/2016
    2NDC:42388-024-3715 in 1 BOTTLE; Type 0: Not a Combination Product02/27/2019
    Marketing Information
    Marketing CategoryApplication Number or Monograph CitationMarketing Start DateMarketing End Date
    NDANDA20869204/25/2016
    Labeler - Exelixis, Inc. (785991949)
    Registrant - Exelixis, Inc. (785991949)
    Establishment
    NameAddressID/FEIBusiness Operations
    Patheon Inc.240769596manufacture(42388-023, 42388-024, 42388-025)
    Establishment
    NameAddressID/FEIBusiness Operations
    Rottendorf Pharma GmbH315974691manufacture(42388-023, 42388-024, 42388-025)