Drug Formulary information is intended for use by healthcare professionals. It is not intended to be medical advice. Some of the information, including information about funding for cancer drugs, does not apply to all patients. Cancer treatment plans are unique to each patient. If you are a patient, please speak with your healthcare team to understand how this information applies to you.
alpelisib
Alpelisib is an inhibitor of phosphatidylinositol3kinase (PI3K) with inhibitory activity predominantly against PI3Kα. The PI3K signaling pathway plays a role in various biological processes, including proliferation, survival, translational regulation of protein synthesis, glucose metabolism, cell migration, and angiogenesis. Mutations in the gene encoding the catalytic α-subunit of PI3K (PI3KCA) leads to activation of PI3Kα and Akt-signaling, cellular transformation, and tumour generation. In breast cancer cell lines, alpelisib inhibits the phosphorylation of PI3K downstream targets, including Akt, and shows activity in cell lines harbouring a PIK3CA mutation. When compared with either agent alone, the combination of alpelisib with fulvestrant has synergistic antitumor activity in PIK3CA-mutated, estrogen receptor-positive models.
| Time to reach steady state |
3 days |
| Peak plasma levels |
2-4 hours |
| Effects with food |
Alpelisib absorption is affected by food. Co-administration of alpelisib, with a high-fat high-calorie meal increased AUC by 73% and Cmax by 84%, and co-administration with a low-fat low-calorie meal increased AUC by 77% and Cmax by 145% |
| PPB | 89% |
Alpelisib is primarily metabolized by chemical and enzymatic hydrolysis to form its metabolite and to a lesser extent by CYP3A4.
| Inactive metabolites |
Yes |
| Half-life |
~ 9 hours |
| Feces | 81% (36% as unchanged drug) |
| Urine |
14% (2% as unchanged drug) |
- Breast cancer
Refer to the product monograph for a full list and details of approved indications.
Emetogenic Potential:
The following table lists adverse effects that occurred in ≥ 10% of patients and with ≥ 2% higher incidence in the alpelisib arm in a phase III study of fulvestrant with alpelisib or placebo, in patients with hormone receptor positive, HER2-negative advanced breast cancer which progressed on or after aromatase inhibitor treatment. It also includes severe, life-threatening and post-marketing adverse effects from other sources.
| ORGAN SITE | SIDE EFFECT* (%) | ONSET** | |||
|---|---|---|---|---|---|
| Cardiovascular | Hypertension (9%) (may be severe) | E | |||
| Dermatological | Alopecia (20%) | E | |||
| Dry skin (18%) | E | ||||
| Erythema multiforme (1%) | E D | ||||
| Rash, pruritus (52%) (may be severe) | E D | ||||
| Stevens-Johnson syndrome (<1%) | E D | ||||
| Toxic epidermal necrolysis (rare) | E D | ||||
| Gastrointestinal | Abdominal pain (17%) | E | |||
| Anorexia, weight loss (36%) | E | ||||
| Colitis (rare) | E D L | ||||
| Diarrhea (58%) (may be severe) | E D L | ||||
| Dyspepsia (11%) | E | ||||
| Mucositis (30%) | E | ||||
| Nausea, vomiting (45%) | E | ||||
| General | Edema (15%) | E | |||
| Fatigue (42%) | E | ||||
| Fever (14%) | E | ||||
| Mucosal dryness (19%) (or inflammation) | E | ||||
| Hematological | Anemia (10%) | E | |||
| Myelosuppression (5%) | E | ||||
| Hepatobiliary | ↑ LFTs (10%) (may be severe) | E | |||
| Pancreatitis (<1%) | E | ||||
| Hypersensitivity | DRESS syndrome (rare) | E D | |||
| Hypersensitivity (4%) (may be severe) | I E | ||||
| Infection | Infection (10%) (UTI) | E | |||
| Metabolic / Endocrine | Hyperglycemia (65%) (37% severe) (including ketoacidosis <1%, hyperglycemic hyperosmolar non-ketotic syndrome (rare)) | E D L | |||
| Musculoskeletal | Osteonecrosis of jaw (4%) (2% severe) | D | |||
| Nervous System | Dysgeusia (18%) | E | |||
| Headache (18%) | E | ||||
| Ophthalmic | Blurred vision , dry eyes (5%) | E | |||
| Renal | Creatinine increased (10%) | E | |||
| Other (5%) - Acute Kidney Injury | E | ||||
| Respiratory | Pneumonitis (2%) (may be severe) | E | |||
* "Incidence" may refer to an absolute value or the higher value from a reported range.
"Rare"
may refer to events with < 1% incidence, reported in post-marketing, phase 1 studies,
isolated data or anecdotal
reports.
** I = immediate (onset in hours to days)
E = early (days to weeks)
D = delayed (weeks to months)
L = late (months to years)
The most common side effects for alpelisib include hyperglycemia, diarrhea, rash, pruritus, nausea, vomiting, fatigue, anorexia, weight loss, mucositis, alopecia, mucosal dryness/inflammation and dry skin.
Severe hyperglycemia has been reported, including hyperglycemic hyperosmolar non-ketotic syndrome and fatal cases of diabetic ketoacidosis. Among patients who experienced ≥ grade 2 hyperglycemia, the median time to first occurrence of hyperglycemia was 15 days (range: 5 to 517 days). Patients with type I or uncontrolled type II diabetes were excluded from the phase 3 trial. The median duration of ≥ grade 2 hyperglycemia was 10 days. Median time to improvement from the first event for patients with ≥ grade 2 hyperglycemia with at least 1 grade improvement was 8 days. All who continued fulvestrant but discontinued alpelisib (due to hyperglycemia) had fasting plasma glucose (FPG) levels that returned to baseline. Patients with pre-diabetes, diabetes, BMI ≥ 30, elevated FPG or HbA1c > ULN, or age ≥ 75 years have a higher risk of developing severe hyperglycemia and/or associated complications (e.g. ketoacidosis).
Severe diarrhea, including dehydration and acute kidney injury have been reported. Among patients with grade ≥ 2 diarrhea, the median time to onset was 46 days (range: 1 to 442 days). Colitis has also been reported during post marketing.
Serious hypersensitivity reactions, including anaphylactic reaction and anaphylactic shock have been reported. Symptoms include, but are not limited to, dyspnea, flushing, rash, fever or tachycardia. Hypersensitivity and anaphylactic reactions were more common in Asian patients compared to other races. Angioedema has also been reported during post marketing.
Cases of osteonecrosis of the jaw (ONJ) have been reported. All patients experiencing ONJ were exposed to prior or concomitant bisphosphonates or denosumab.
Severe cutaneous adverse reactions, including SJS, EM, and DRESS, have been reported. The median time to first onset of ≥ grade 2 rash was 12 days (range: 2 to 220 days).
Refer to protocol by which patient is being treated.
Screen for hepatitis B virus in all cancer patients starting systemic treatment. Refer to the hepatitis B virus screening and management guideline.
Alpelisib is only for use in hormone receptor (HR) positive, HER2-negative advanced breast cancer patients with known a PIK3CA mutation confirmed using a validated test.
Fasting plasma glucose and/or HbA1c (hemoglobin A1c test) should be performed and glucose levels should be corrected in patients with abnormal fasting glucose levels in the range of prediabetic or diabetic before initiating treatment.
A dental examination with appropriate preventive dentistry is recommended prior to treatment in patients with risk factors for ONJ, such as invasive dental procedures, concomitant therapies, poor oral hygiene and comorbid disorders.
Other Supportive Care:
- Oral antihistamine administration may be considered prophylactically for rash and severe cutaneous reactions to decrease incidence and severity, at the time of treatment initiation.
Combination:
Oral: 300 mg Daily
| Dose Level | Alpelisib Dose (mg/day) |
| 0 | 300 |
| -1 | 250 |
| -2 | 200 |
| -3 | Discontinue |
Dose Modifications:
| Toxicity | Grade | Action |
| Fasting glucose |
Grade 1 |
No dosage adjustment required.† |
|
Grade 2 |
No dosage adjustment required.† If fasting glucose does not decrease to ≤ 8.9 mmol/L in ≤ 21 days, ↓ alpelisib by 1 dose level. |
|
|
Grade 3 |
Hold.† Consider additional antidiabetic medications* for 1-2 days until hyperglycemia improves. Administer intravenous hydration and consider appropriate treatment (e.g. intervention for electrolyte/ketoacidosis/hyperosmolar disturbances). If fasting glucose decreases to ≤ 8.9 mmol/L in ≤ 3-5 days, resume at 1 dose level ↓. If fasting glucose does not decrease to ≤8.9 mmol/L within:
|
|
|
Grade 4 |
Hold.† Administer intravenous hydration and consider appropriate treatment (e.g. intervention for electrolyte/ketoacidosis/hyperosmolar disturbances). Re-check fasting glucose within 24 hours and as clinically indicated. If fasting glucose decreases to ≤ 27.8 mmol/L, follow specific recommendations for hyperglycemia above. If fasting glucose is confirmed at > 27.8 mmol/L, discontinue.
|
|
|
Rash and cutaneous reactions** (excluding severe cutaneous adverse reactions etiology)
|
Grade 1 |
No dosage adjustment required; initiate topical corticosteroid treatment. Consider adding oral antihistamine treatment. If active rash does not improve within 28 days of appropriate treatment, add low dose oral corticosteroid. |
|
Grade 2 |
No dosage adjustment required; initiate/intensify topical corticosteroid and oral antihistamine treatment. Consider adding low dose systemic corticosteroid. If rash improves to ≤ grade 1 within 10 days, discontinue systemic corticosteroids. |
|
|
Grade 3 |
Hold and initiate or intensify topical/oral corticosteroid and antihistamine treatment. When resolved to ≤ grade 1, resume at 1 dose level ↓. |
|
|
Grade 4 (e.g. severe bullous, blistering or exfoliating skin conditions; any % BSA associated with extensive superinfection, with IV antibiotics indicated; life-threatening consequences) |
Discontinue | |
| Severe cutaneous adverse reactions, including Stevens-Johnson Syndrome /Toxic Epidermal Necrolysis, DRESS or erythema multiforme | Any | Discontinue |
| Diarrhea or Colitis | Grade 1 | No dosage adjustment required.† |
| Grade 2 |
Hold until resolved to ≤ grade 1 then resume at same dose level.† If it recurs, hold until ≤ grade 1 then resume at 1 dose level ↓.† |
|
| Grade 3 |
Hold until resolution to ≤ grade 1 then resume at 1 dose level ↓.† |
|
| Grade 4 | Discontinue | |
| Pancreatitis | Grade 2 or 3 |
Hold until resolved to ≤ grade 1 then resume at 1 dose level ↓. |
| Grade 4 | Discontinue | |
| Symptoms of pneumonitis | Any | Hold and investigate; discontinue if confirmed |
| Bilirubin | Grade 2 | Hold until resolved to ≤ grade 1:
|
| Grade 3 | Hold until resolution to ≤ grade 1 then resume at 1 dose level ↓. | |
| Grade 4 | Discontinue | |
| Serious hypersensitivity reactions / Anaphylactic reactions | Any | Discontinue |
| All other toxicities | Grade 1 or 2 | No dosage adjustment required.† |
| Grade 3 | Hold until resolved to ≤ grade 1 then resume at 1 dose level ↓. | |
| Grade 4 | Discontinue. |
†Initiate or intensify appropriate medical therapy (e.g. oral anti-diabetic or anti-diarrhea treatment) and monitor as clinically indicated. For Grade 2 or 3 colitis, consider additional treatment, such as steroids.
*As recommended in the phase III clinical study, insulin may be used for 1-2 days until hyperglycemia resolves. However, this may not be necessary in the majority of alpelisib-induced hyperglycemia, given the short half-life of alpelisib and the expectation of glucose levels normalizing after dose interruption.
**For all grades of rash, consider consultation with a dermatologist.
| Hepatic Impairment | Alpelisib Dose |
| Child-Pugh Class A, B or C | No dose adjustment required |
| Creatinine Clearance (mL/min) | Alpelisib Dose |
| ≥ 30 | No dose adjustment required |
| < 30 | Effect on alpelisib pharmacokinetics is unknown |
No dose adjustment is required as no overall differences in safety or efficacy were observed between patients ≥ 65 years of age and younger patients; however, gastrointestinal toxicity (primarily diarrhea and nausea), hyperglycemia, weight loss, hypokalemia and dyspnea were reported more frequently in older patients.
No dose adjustment is required; however, rash, severe cutaneous reactions, hypersensitivity and anaphylactic reaction, and pancreatitis were more frequently reported in Asian patients compared to Caucasian patients.
Safety and efficacy in children have not been established.
-
Alpelisib should be administered once daily at approximately the same time each day immediately following a meal.
-
Tablets should be swallowed whole (tablets should not be chewed, crushed or split prior to swallowing). Tablets that are broken, cracked, or otherwise not intact should not be ingested.
-
If a dose is missed, it can be taken immediately following food and within 9 hours after the time it is usually administered. After more than 9 hours, the dose should be skipped for that day and the next dose should be taken at its usual time. Missed doses should not be made up the next day.
-
If a dose is vomited, do not administer an additional dose on that day; resume the dosing schedule the next day at the usual time.
-
Do not store above 30°C.
-
Store in the original package to protect from moisture.
- Patients who are hypersensitive to alpelisib or to any ingredient in the formulation, including any non-medicinal ingredient, or component of the container.
-
Caution should be exercised when alpelisib and drugs known to cause ONJ are used either simultaneously, or sequentially. Alpelisib treatment should not be initiated in patients with ongoing ONJ.
-
Do not initiate alpelisib treatment in patients with history of severe cutaneous reactions.
-
Alpelisib is associated with QT prolongation. Exercise caution if alpelisib is used concomitantly with medicinal products that are known to prolong the QTc interval. Patients with uncontrolled heart disease and/or recent cardiac events (including long QT syndrome, QTcF > 450 ms for males or > 460 ms for females) were excluded from the phase III clinical study.
-
The safety of alpelisib in patients with Type 1 and uncontrolled Type 2 diabetes has not been established as these patients were excluded from the phase III clinical study. Patients with pre-diabetes, diabetes, BMI ≥ 30, elevated FPG or HbA1c > ULN, or age ≥ 75 years have a higher risk of developing severe hyperglycemia and/or associated complications (e.g. ketoacidosis).
-
It is currently unknown whether alpelisib may reduce the effectiveness of systemically acting hormonal contraceptives.
Other Drug Properties:
-
Phototoxicity:
No
-
Mutagenicity:
No
-
Clastogenicity:
No
-
Genotoxicity:
No
-
Teratogenicity:
Documented in animals
-
Embryotoxicity:
Documented in animals
Alpelisib is not recommended for use in pregnancy. Adequate contraception should be used by both sexes during treatment, and for at least 1 week after the last dose.
-
Excretion into breast milk:
Unknown
Breastfeeding is not recommended during treatment and for at least 1 week after the last dose.
-
Fertility effects:
Probable
Based on animal studies, adverse effects were observed in reproductive organs of males and females, including vaginal atrophy and oestrus cycle variations.
Male patients should not donate or store semen during treatment and for at least 1 week after the last dose.
Alpelisib inhibits CYP3A4 in a time-dependent manner and induces cytochromes CYP2B6, CYP2C9 and CYP3A4.
Alpelisib is an inhibitor of P-gp (P-glycoprotein) and a substrate for BCRP transporter.
Alpelisib can be co-administered with acid reducing agents since it should be taken with food. Food exhibited a more pronounced effect on the solubility of alpelisib than the effect of gastric pH value.
Caution should be exercised when alpelisib and drugs known to cause ONJ are used either simultaneously, or sequentially.
| AGENT | EFFECT | MECHANISM | MANAGEMENT |
|---|---|---|---|
| CYP3A4 inducers (i.e. phenytoin, rifampin, dexamethasone, carbamazepine, phenobarbital, St. John’s Wort, etc) | ↓ alpelisib concentration and/or efficacy | ↑ metabolism of alpelisib | Avoid co-administration with strong CYP3A4 inducers |
| BCRP inhibitors (e.g. cyclosporine, eltrombopag, lapatinib) | ↑ alpelisib concentration and/or toxicity | ↑ alpelisib drug uptake | Avoid co-administration with BCRP inhibitors. If concomitant use is unavoidable, closely monitor for increased alpelisib adverse reactions |
| CYP 2C9 substrates (e.g. warfarin, meloxicam, fluvastatin) | ↓ substrate concentration and/or efficacy | ↑ metabolism of substrate | Caution and monitor CYP2C9 substrates with narrow therapeutic range |
| Drugs that may prolong QT (i.e. amiodarone, procainamide, sotalol, venlafaxine, amitriptyline, sunitinib, methadone, chloroquine, clarithromycin, haloperidol, fluconazole, moxifloxacin, domperidone, ondansetron, etc) | ↑ risk of QT prolongation | Additive | Caution. Perform additional ECG monitoring as clinically indicated. |
Treating physicians may decide to monitor more or less frequently for individual patients but should always consider recommendations from the product monograph.
Refer to the hepatitis B virus screening and management guideline for monitoring during and after treatment.
| Monitor Type | Monitor Frequency |
|---|---|
CBC |
Baseline and as clinically indicated |
Fasting glucose |
Baseline and at least weekly for the first 2 weeks of treatment, followed by every 4 weeks and as clinically indicated. Monitor more frequently for the first few weeks in patients with pre-diabetes, diabetes, BMI ≥ 30, or age ≥ 75 years |
Fasting glucose (if patient experiences hyperglycemia after initiating alpelisib) |
Regularly, at least until fasting glucose decreases to normal levels. During treatment with antidiabetic medications, monitor at least once a week for 8 weeks, followed by once every 2 weeks and as clinically indicated |
HbA1c |
Baseline, every 3 months and as clinically indicated |
ECG |
Baseline and as clinically indicated. More frequently if taken concomitantly with medications known to prolong the QTc interval |
Liver function tests |
Baseline and as clinically indicated |
Electrolytes, including potassium and calcium |
Baseline and in patients experiencing gastrointestinal toxicity as clinically indicated |
Clinical toxicity assessment for edema, fatigue, fever/infection, ONJ, pancreatitis, dysgeusia, pneumonitis, hypersensitivity, renal, dermatological and gastrointestinal effects (including mucositis) |
As clinically indicated |
Grade toxicity using the current NCI-CTCAE (Common Terminology Criteria for Adverse Events) version
André F, et al.; SOLAR-1 Study Group. Alpelisib for PIK3CA-Mutated, Hormone Receptor-Positive Advanced Breast Cancer. N Engl J Med. 2019 May 16;380(20):1929-1940.
Prescribing information: Piqray® (alpelisib). Novartis Pharmaceuticals Corporation. July 2021.
Product Monograph: Alpelisib (Piqray®). Novartis Pharmaceuticals Canada Inc., August 24, 2022.
July 2023 Updated Adverse effects, Dosing, Special Precautions, and Clinical monitoring sections
Refer to the New Drug Funding Program or Ontario Public Drug Programs websites for the most up-to-date public funding information.
The information set out in the drug monographs, regimen monographs, appendices and symptom management information (for health professionals) contained in the Drug Formulary (the "Formulary") is intended for healthcare providers and is to be used for informational purposes only. The information is not intended to cover all possible uses, directions, precautions, drug interactions or adverse effects of a particular drug, nor should it be construed to indicate that use of a particular drug is safe, appropriate or effective for a given condition. The information in the Formulary is not intended to constitute or be a substitute for medical advice and should not be relied upon in any such regard. All uses of the Formulary are subject to clinical judgment and actual prescribing patterns may not follow the information provided in the Formulary.
The format and content of the drug monographs, regimen monographs, appendices and symptom management information contained in the Formulary will change as they are reviewed and revised on a periodic basis. The date of last revision will be visible on each page of the monograph and regimen. Since standards of usage are constantly evolving, it is advised that the Formulary not be used as the sole source of information. It is strongly recommended that original references or product monograph be consulted prior to using a chemotherapy regimen for the first time.
Some Formulary documents, such as the medication information sheets, regimen information sheets and symptom management information (for patients), are intended for patients. Patients should always consult with their healthcare provider if they have questions regarding any information set out in the Formulary documents.
While care has been taken in the preparation of the information contained in the Formulary, such information is provided on an “as-is” basis, without any representation, warranty, or condition, whether express, or implied, statutory or otherwise, as to the information’s quality, accuracy, currency, completeness, or reliability.
CCO and the Formulary’s content providers shall have no liability, whether direct, indirect, consequential, contingent, special, or incidental, related to or arising from the information in the Formulary or its use thereof, whether based on breach of contract or tort (including negligence), and even if advised of the possibility thereof. Anyone using the information in the Formulary does so at his or her own risk, and by using such information, agrees to indemnify CCO and its content providers from any and all liability, loss, damages, costs and expenses (including legal fees and expenses) arising from such person’s use of the information in the Formulary.