Xermelo (telotristat ethyl) for Cancer: Dosage & Interactions

What is Survanta, and how does it work?

Xermelo is indicated for the treatment of carcinoid syndrome diarrhea, which is diarrhea caused by cancerous tumors, in combination with somatostatin analog (SSA) therapy in adults inadequately controlled by SSA therapy.

What are the side effects of Survanta?

Clinical Trials Experience

Because clinical trials are conducted under widely
varying conditions, adverse reaction rates observed in the clinical trials of a
drug cannot be directly compared to rates in the clinical trials of another
drug and may not reflect the rates observed in practice.

Xermelo was studied in a double-blind, placebo-controlled
clinical trial of 90 patients with metastatic
neuroendocrine tumors and
carcinoid syndrome
diarrhea.
Patients reported between 4 to 12 bowel movements daily despite the use
of SSA therapy at a stable dose for at least 3 months. Placebo or Xermelo 250 mg was administered three times daily
for 12 weeks.
Concomitant anti-diarrheal medications (e.g., loperamide) were
used by 43% (36% and 51% in the placebo and Xermelo group, respectively),
pancreatic
enzyme replacement medications by 39% (36% and 42% in the placebo
and Xermelo group, respectively), and
opioid analgesics by 29% (24% and 33% in
the placebo and Xermelo group, respectively) of patients during the 12-week
double-blind period of the trial.

Table 1 below lists adverse reactions occurring at an
incidence of at least 5% in the Xermelo group (N=45) and at an incidence greater
than placebo (N=45) during the 12-week placebocontrolled period of the trial.

Table 1: Percent Common Adverse Reactions^a by
Treatment Group at 12-Weeks in a Double-Blind Placebo-Controlled Clinical Trial
of Patients with Carcinoid Syndrome Diarrhea

Adverse Reaction
Xermelo 250 mg Three Times Daily,
N=45 (%)
Placebo,
N=45 (%)

Nausea
13
11

Headache
11
4

Increased gamma-glutamyl-transferase (GGT)
9
0

Depression^b
9
7

Peripheral edema
7
2

Flatulence
7
2

Decreased appetite
7
4

Pyrexia
7
4

^a incidence of at least 5% in the Xermelo
group and at an incidence greater than placebo
^b including depression, depressed mood and decreased interest

In another placebo-controlled clinical trial of patients
with carcinoid syndrome diarrhea and less than 4 bowel movements per day, the
following additional adverse reactions, not listed in Table 1, of abdominal
pain (including upper and lower abdominal pain, abdominal distention and gastrointestinal
pain) and constipation were reported in at least 5% of patients in the Xermelo
treated group and at an incidence greater than placebo.

Less Common Adverse Reactions

The following is a list of adverse reactions occurring in
less than 5% of patients receiving Xermelo during the 12-week
placebo-controlled period of the clinical trial:

Investigations: increased alkaline phosphatase,
increased alanine aminotransferase, and increased aspartate aminotransferase.

Fecaloma was reported in one patient treated with Xermelo
during the 36-week open-label extension period following the 12-week
double-blind period of the trial.

What is the dosage for Survanta?

The recommended dosage of Xermelo in adult patients is 250 mg three times daily for patients whose diarrhea is inadequately controlled by SSA therapy.

Administration

Take Xermelo with food.
When short-acting octreotide is used in combination with Xermelo, administer shortacting octreotide at least 30 minutes after administering Xermelo.
If a dose is missed, take the next dose at the regular time. Do not take 2 doses at the same time to make up for a missed dose.
Discontinue Xermelo if severe constipation develops.

What drugs interact with Survanta?

CYP3A4 Substrates

Concomitant use of Xermelo may decrease the efficacy of drugs that are
CYP3A4 substrates (e.g., midazolam) by decreasing their systemic exposure.
Monitor for suboptimal efficacy and consider increasing the dose for
concomitant CYP3A4 substrates, if necessary.

Short-Acting Octreotide

Concurrent administration of short-acting octreotide with Xermelo
significantly decreased the systemic exposure of telotristat ethyl and
telotristat, the active metabolite.
If treatment with short-acting octreotide is needed in combination with
Xermelo, administer short-acting octreotide at least 30 minutes after
administration of Xermelo.

Is Survanta safe to use while pregnant or breastfeeding?

There are no human data with Xermelo use in pregnant women to inform a drug-associated risk.
There are no data on the presence of telotristat ethyl in human or animal milk, the effects on the breastfed infant, or the effects on milk production.
The effects of local gastrointestinal and systemic exposure to telotristat ethyl on breastfed infants are unknown.
The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for Xermelo and any potential adverse effects on the breastfed infant from Xermelo or from the underlying maternal condition.