Cabozantinib (Cometriq®, Cabometyx™)

How to Take Cabozantinib

Cabozantinib comes in both capsule and tablet form. You should never switch capsules for tablets or tablets for capsules. 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 or tablets whole with a full glass (at least 8 ounces) of water. Do not open, break, or chew the capsules or tablets. Do not take a missed dose if it is within 12 hours of the next dose. Do not take 2 doses at once to make up for a missed dose.

It is important to make sure you are taking the correct amount of medication every time. Before every dose, check that what you are taking matches what you have been prescribed.

The blood levels of this medication can be affected by certain foods and medications, so they should be avoided. Your dose may be changed if you are taking any of these medications. These include grapefruit, grapefruit juice, ketoconazole, posaconazole, voriconazole rifampin, phenytoin, phenobarbital, St. John’s wort, and carbamazepine. Tell your provider about all medications and supplements you take. There is an increased risk for liver toxicity and adrenal insufficiency when taking this medication with nivolumab. Your provider will monitor you for these side effects.

Storage and Handling

Store your medication in the original, labeled container at room temperature and in a dry location (unless told otherwise by your provider or pharmacist). This medication should not be stored in a pillbox. Keep containers out of reach of children and pets.

If a caregiver prepares your dose for you, they should consider wearing gloves or pour the pills directly from their container into the cap, a small cup, or directly into your hand. They should avoid touching the pills. They should always wash their hands before and after giving you the medication. Pregnant or nursing women should not prepare the dose for you. Ask your provider where to return any unused medication for disposal. Do not flush it down the toilet or throw it in the trash.

Where do I get this medication?

Cabozantinib is available through select specialty pharmacies. Your provider will work with your prescription drug plan to find an in-network specialty pharmacy for the distribution of this medication and shipment directly to your home.

Insurance Information

This medication may be covered under your prescription drug plan. Patient assistance may be available to qualifying individuals depending upon prescription drug coverage. Co-pay cards, which reduce the patient co-pay responsibility for eligible commercially (non-government sponsored) insured patients, may also be available. Your provider 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 provider about these recommendations. They can help you decide what will work best for you. These are some of the most common or important side effects:

Diarrhea

Diarrhea can be a serious side effect that can lead to dehydration and other gastrointestinal side effects. Call your provider right away if you are have an increase in the frequency of bowel movements or if your bowel movements become loose.

Fatigue

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 change 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 provider for helpful tips on dealing with this side effect.

Nausea and/or Vomiting

Talk to your provider 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 saltines, or ginger ale to lessen symptoms.

Call your provider 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 or Taste Changes

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 provider 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 Foot Syndrome

Hand-foot syndrome (HFS) is a skin reaction that appears on the palms of the hands and/or the soles of the feet, caused by certain chemotherapy medications being absorbed by the skin cells. HFS can begin as a mild tingling, numbness, pins-and-needles feeling, redness, pain, or swelling of the hands and/or feet. This can then worsen to painful swelling, blistering, or peeling skin that can affect your ability to do normal activities. Be sure to let your provider 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:

• Keep hands and feet clean and dry.
• Avoid tight shoes or socks.
• Avoid activities that put pressure on the palms or soles for 1 week after treatment.
• Apply an alcohol-free moisturizer liberally and often (avoid moisturizers with perfumes or scents).
• Avoid very hot water for baths and showers.

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. If hypertension cannot be controlled, the medication may be stopped. Report any headaches, vision changes, or dizziness to your provider.

Mouth Ulcers (Mucositis)

Certain cancer treatments can cause sores or soreness in your mouth and/or throat. Tell your provider if your mouth, tongue, inside of your cheek, or throat is painful, becomes white, or has ulcers. Doing regular mouth care can help prevent or manage mouth sores. If mouth sores become painful, your provider 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 with warm water mouth rinse (2 level teaspoons of baking soda or 1 level teaspoon of 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 to 8 glasses), and suck on sugarless hard candy.
• Avoid smoking and chewing tobacco, drinking alcoholic beverages, and citrus juices.

Important but Less Common Side Effects

• GI Perforations and Fistulas: This medication can cause a tear in the intestinal wall (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 (belly), new abdominal swelling, chills, fever, constipation, nausea, vomiting, coughing, gagging, and choking, especially when eating or drinking. If you experience any of these, contact your provider or go to the ER right away.
• Bleeding: Cabozantinib can cause abnormal bleeding. Call your provider right away if you have 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. Symptoms can include swelling, redness or pain in an arm or leg, 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. If you have any of these symptoms, call 911 right away. Let your provider know if you have a history of previous blood clots, as you may need 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. This medication be discontinued (stopped) 28 days before any surgery. In addition, any surgical incision (cut) should be fully healed before starting or restarting the medication. If you have a surgical wound that has not healed or has signs of infection (redness, swelling, warmth), call your provider.
• Proteinuria: This medication can cause increased protein in your urine. Your provider will monitor your kidney function while you are being treated with cabozantinib. If you have swelling of your hands, arms, legs, or feet, call your provider right away. This side effect is more common in patients who take the capsule form of this medication.
• Posterior Reversible Encephalopathy Syndrome (PRES): PRES is a rare, reversible neurological disorder that can happen with the use of cabozantinib. Symptoms of PRES are seizure, high blood pressure, headache, fatigue, confusion, blindness, and other visual or neurological disturbances. If you have any of these symptoms, call 911 right away.
• Hair Changes: This medication can cause your hair to turn gray, lose its color, or change color.
• Electrolyte and Blood Count Abnormalities: This medication can affect the normal levels of LFTs, calcium, phosphate, white blood cells, and platelets in your body. Your levels will be monitored using blood tests. If your levels become too low, your provider may prescribe electrolytes or blood products. Do not take any supplements without first talking with your provider.
• Heart failure: This medication can cause heart failure. Heart failure is when your heart is too weak to pump the blood that goes throughout your body. Symptoms may be shortness of breath, a new or worsening cough, swelling (edema), feeling tired or confused, not feeling hungry, a fast or irregular heart rate, and a sudden weight gain. If you have any of these symptoms, call your provider right away.
• Osteonecrosis of the Jaw: Osteonecrosis of the jaw (ONJ) is a rare side effect that is more common in patients who take the capsule form of this medication. 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 ONJ, this tissue is gone and the bone is exposed (showing). Symptoms of ONJ are pain, swelling, infection of the gums, loosening of the teeth, exposed bone (often at the site of a previous tooth extraction). Some patients may have numbness or tingling in the jaw or a "heavy" feeling jaw. ONJ may have no symptoms for weeks or months and may only be diagnosed when there is exposed bone. ONJ most often happens soon after a dental procedure, though not always. Stop treatment with cabozanitib at least 28 days before any dental procedures.
  • Before 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 provider to see if you can 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 provider right away. 
• Thyroid Issues: This medication can affect how your thyroid works. Your thyroid function will be checked before you start this medication and during treatment. Call your provider if you have trouble sleeping, weight loss or gain, muscle weakness, fatigue or hyperactivity, anxiety, irritability, nervousness, feeling too warm or too cold, or high heart rate.

Reproductive Concerns

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 for females during treatment and for at least 4 months after treatment. Even if your menstrual cycle stops, you could still be fertile and conceive. Males should ask their provider about birth control use during treatment. It is recommended you do not breastfeed during treatment and for 4 months after the final dose.