Classification: Tyrosine Kinase Inhibitor
About Cabozantinib (Cometriq)
Cabozantinib is a type of targeted therapy called a tyrosine kinase inhibitor. This means it works by targeting receptors present on the cancer cells. Cabozantinib targets several different receptors, which, in turn, blocks tumor growth and angiogenesis (the development of a blood supply to the tumor).
How to Take Cabozantinib
Cabozantinib comes in a capsule form, in several dosage strengths. It is taken once a day on an empty stomach. Do not eat for 2 hours before, or 1 hour after the dose. Swallow the capsules whole with a full glass (at least 8 ounces) of water; do not open or chew the capsules. If you miss a dose and it has been less than 12 hours since your regular dose time, take it as soon as you remember. If it has been more than 12 hours, skip the dose. Do not take 2 doses at once to make up for a missed dose.
The blood levels of this medication can be affected by certain foods and medications, so they should be avoided. These include: grapefruit, grapefruit juice, verapamil, ketoconazole, rifampin, phenytoin, St. John’s wort, and modafanil. Be sure to tell your healthcare provider about all medications and supplements you take.
Storage and Handling
Store this medication at room temperature in the original container. If you prefer to use a pillbox, discuss this with your oncology pharmacist. Ask your oncology team where to return any unused medication for disposal. Do not flush down the toilet or throw in the trash.
Where do I get this medication?
Cabozantinib is available through select specialty pharmacies. Your oncology team will work with your prescription drug plan to identify an in-network specialty pharmacy for distribution of this medication and shipment directly to your home.
This medication may be covered under your prescription drug plan. Patient assistance may be available to qualifying individuals without prescription drug coverage. A co-pay assistance program, which reduces the patient’s co-pay responsibility for eligible, commercially (non-government sponsored) insured patients, may also be available. Your care team can help you find these resources, if they are available.
Possible Side Effects
There are a number of things you can do to manage the side effects of cabozantinib. Talk to your doctor or nurse about these recommendations. They can help you decide what will work best for you. These are some of the most common side effects:
High Blood Pressure
This medication can cause high blood pressure (hypertension). Patients should have their blood pressure checked regularly during therapy. Any hypertension should be treated appropriately. If hypertension cannot be controlled, the medication may be stopped.
Your oncology team can recommend medications to relieve diarrhea. Also, try eating low-fiber, bland foods, such as white rice and boiled or baked chicken. Avoid raw fruits, vegetables, whole grain breads, cereals and seeds. Soluble fiber is found in some foods and absorbs fluid, which can help relieve diarrhea. Foods high in soluble fiber include: applesauce, bananas (ripe), canned fruit, orange sections, boiled potatoes, white rice, products made with white flour, oatmeal, cream of rice, cream of wheat, and farina. Drink 8-10 glasses on non-alcoholic, un-caffeinated fluid a day to prevent dehydration.
Certain cancer treatments can cause sores or soreness in your mouth and/or throat. Notify your doctor or nurse if your mouth, tongue, inside of your cheek or throat becomes white, ulcerated or painful. Performing regular mouth care can help prevent or manage mouth sores. If mouth sores become painful, your doctor or nurse can recommend a pain reliever.
- Brush with a soft-bristle toothbrush or cotton swab twice a day.
- Avoid mouthwashes that contain alcohol. A baking soda and/or salt warm water mouth rinse (2 level teaspoons of baking soda or 1 level teaspoon salt in an eight ounce glass of warm water) is recommended 4 times daily.
- If your mouth becomes dry, eat moist foods, drink plenty of fluids (6-8 glasses), and suck on sugarless hard candy.
- Avoid smoking and chewing tobacco, drinking alcoholic beverages and citrus juices.
Fatigue is very common during cancer treatment and is an overwhelming feeling of exhaustion that is not usually relieved by rest. While on cancer treatment, and for a period after, you may need to adjust your schedule to manage fatigue. Plan times to rest during the day and conserve energy for more important activities. Exercise can help combat fatigue; a simple daily walk with a friend can help. Talk to your healthcare team for helpful tips on dealing with this side effect.
Nausea and/or Vomiting
Talk to your doctor or nurse so they can prescribe medications to help you manage nausea and vomiting. In addition, dietary changes may help. Avoid things that may worsen the symptoms, such as heavy or greasy/fatty, spicy or acidic foods (lemons, tomatoes, oranges). Try antacids, (e.g. milk of magnesia, calcium tablets such as Tums), saltines, or ginger ale to lessen symptoms.
Call your doctor or nurse if you are unable to keep fluids down for more than 12 hours or if you feel lightheaded or dizzy at any time.
Decrease in Appetite
Nutrition is an important part of your care. Cancer treatment can affect your appetite and, in some cases, the side effects of treatment can make eating difficult. Ask your nurse about nutritional counseling services at your treatment center to help with food choices.
- Try to eat five or six small meals or snacks throughout the day, instead of 3 larger meals.
- If you are not eating enough, nutritional supplements may help.
- You may experience a metallic taste or find that food has no taste at all. You may dislike foods or beverages that you liked before receiving cancer treatment. These symptoms can last for several months or longer after treatment ends.
- Avoid any food that you think smells or tastes bad. If red meat is a problem, eat chicken, turkey, eggs, dairy products and fish without a strong smell. Sometimes cold food has less of an odor.
- Add extra flavor to meat or fish by marinating it in sweet juices, sweet and sour sauce or dressings. Use seasonings like basil, oregano or rosemary to add flavor. Bacon, ham and onion can add flavor to vegetables.
Hand Food Syndrome
Hand and foot syndrome (HFS) is a skin reaction that appears on the palms of the hands and/or the soles of the feet as a result of certain chemotherapy agents being absorbed by the skin cells. HFS can begin as a mild tingling, numbness, pins-and-needles feeling, or pain or swelling of the hands and/or feet. This can then progress to painful swelling, blistering or peeling skin that can interfere with your ability to do normal activities. Be sure to let your oncology team know right away if you notice these symptoms, as they may need to adjust the chemotherapy dose or take a break to allow the skin to heal. Some tips to help prevent HFS include:
- Avoid tight shoes or socks.
- Avoid activities that put pressure on the palms or soles for 1 week after treatment.
- Apply moisturizer liberally and often.
- Avoid hot water for baths and showers.
GI Perforations and Fistulas
This medication can cause a tear in the intestinal wall, (gastrointestinal perforation) or a fistula (an abnormal connection between two parts of your body). Signs of this can include: new or worsening pain in the abdomen, new abdominal swelling, chills, fever, constipation, nausea, vomiting, or coughing, gagging and choking, especially when eating or drinking. If you experience any of these, contact your healthcare provider immediately or go to the emergency room.
Cabozantinib can cause abnormal bleeding. Contact your health care team immediately if you experience any bleeding, including: coughing up blood or blood clots, vomiting blood or if your vomit looks like coffee grounds, red or black stools, heavier than normal menstrual bleeding, or other unusual or heavy bleeding.
Blood Clots, Stroke and Heart Attack
This medication can increase the risk of blood clots, stroke and heart attack. If you experience symptoms of these problems, you should contact your healthcare provider immediately or go to an emergency room. Symptoms can include: swelling, redness or pain in an extremity, chest pain or pressure, pain in your arm, back, neck or jaw, shortness of breath, numbness or weakness on one side of the body, trouble talking, confusion or mental status changes. Let your care team know if you have a history of previous blood clots, as you may require preventive medication.
Wound Healing Complications
This medication can lead to slower or incomplete wound healing, such as a surgical wound not healing or staying closed. Therefore, it is recommended that the medication be discontinued 28 days prior to any surgery. In addition, any surgical incision should be fully healed prior to starting or restarting the medication. If you have a surgical wound that has not healed or begins to have signs of infection (redness, swelling, warmth), report this to your healthcare team.
Osteonecrosis of the Jaw
Osteonecrosis of the jaw (ONJ) is a rare side effect, however, it is important that you know about it and take steps to protect your dental health. The maxilla (upper jaw bone) and mandible (lower jaw bone) are normally covered by gum tissue. In the case of ONJ, this tissue is gone and the bone is exposed. Typical symptoms associated with ONJ are: pain, swelling or infection of the gums, loosening of the teeth, exposed bone (often at the site of a previous tooth extraction). Some patients may report numbness or tingling in the jaw or a "heavy" feeling jaw. ONJ may have no symptoms for weeks or months and may only be recognized by the presence of exposed bone. ONJ most often occurs soon after a dental procedure, though not always. Stop treatment with cabozanitib at least 28 days prior to any dental procedures.
- Prior to starting therapy, you should have a complete dental exam, cleaning, and removal of any teeth in poor health.
- Dentures should be checked for proper fit.
- Brush your teeth after meals and at bedtime with a soft brush. Floss gently once a day. If your gums bleed, talk with your healthcare team to see if you can continue to floss.
- Check your teeth and gums in a mirror daily for any sores, swelling, loose teeth, pain or numbness, or other changes and report these to your dentist or oncology team immediately.
This medication can cause increased protein in your urine. Your healthcare team will monitor your kidney function while you are being treated with cabozantinib. If you experience swelling of your hands, arm, legs or feet, inform your healthcare team immediately.
Posterior Reversible Encephalopathy Syndrome (PRES)
PRES is a rare, reversible neurological disorder that can occur with use of cabozantinib. Symptoms of PRES include seizure, high blood pressure, headache, confusion, fatigue, confusion, blindness and other visual or neurological disturbances. If you experience any of these symptoms, contact your care team or go to the emergency room immediately.
This medication can cause your hair to turn gray, lose its color or change color.
Exposure of an unborn child to this medication could cause birth defects, so you should not become pregnant or father a child while on this medication. Effective birth control is necessary during treatment and for at least 4 months after treatment. Even if your menstrual cycle stops or you believe you are not producing sperm, you could still be fertile and conceive. You should consult with your healthcare team before breastfeeding while receiving this medication.