Clinical Pharmacology for Lumakras
Mechanism Of Action
Sotorasib is an inhibitor of KRAS G12C, a tumor-restricted, mutant-oncogenic form of the RAS GTPase, KRAS. Sotorasib forms an irreversible, covalent bond with the unique cysteine of KRAS G12C, locking the protein in an inactive state that prevents downstream signaling without affecting wild-type KRAS. Sotorasib blocked KRAS signaling, inhibited cell growth, and promoted apoptosis only in KRAS G12C tumor cell lines. Sotorasib inhibited KRAS G12C in vitro and in vivo with minimal detectable off-target activity. In mouse tumor xenograft models, sotorasib-treatment led to tumor regressions and prolonged survival, and was associated with anti-tumor immunity in KRAS G12C models.
In the setting of KRAS G12C-mutant CRC, epidermal growth factor receptor (EGFR) activation has been identified as a mechanism of resistance to KRAS G12C inhibition. In a murine patient-derived colorectal tumor xenograft model, the combination of sotorasib and panitumumab, an EGFR antagonist, had increased antitumor activity compared to either sotorasib or panitumumab alone.
Pharmacodynamics
Sotorasib exposure-response relationships and the time course of the pharmacodynamic response are unknown.
Cardiac Electrophysiology
At the approved recommended dosage, LUMAKRAS does not cause large mean increases in the QTc interval (> 20 msec).
Pharmacokinetics
The pharmacokinetics of sotorasib have been characterized in healthy subjects and in patients with KRAS G12C-mutated solid tumors, including NSCLC. Sotorasib exhibited non-linear, time-dependent, pharmacokinetics over the dose range of 180 mg to 960 mg (0.19 to 1 time the approved recommended dosage) once daily with similar systemic exposure (i.e., AUC0-24h and Cmax) across doses at steady state. Sotorasib systemic exposure was comparable between film-coated tablets and film-coated tablets predispersed in water administered under fasted conditions. Sotorasib plasma concentrations reached steady state within 22 days. No accumulation was observed after repeat LUMAKRAS dosages with a mean accumulation ratio of 0.56 (coefficient of variation (CV):59%).
Absorption
The median time to sotorasib peak plasma concentration is 1 hour.
Effect Of Food
When 960 mg LUMAKRAS was administered with a high-fat, high-calorie meal (containing approximately 800 to 1000 calories with 150, 250, and 500 to 600 calories from protein, carbohydrate and fat, respectively) in patients, sotorasib AUC0-24h increased by 25% compared to administration under fasted conditions.
Distribution
The sotorasib mean volume of distribution (Vd) at steady state is 211 L (CV: 135%). In vitro, sotorasib plasma protein binding is 89%.
Elimination
The sotorasib mean terminal elimination half-life is 5 hours (standard deviation (SD): 2). At 960 mg LUMAKRAS once daily, the sotorasib steady state apparent clearance is 26.2 L/hr (CV: 76%).
Metabolism
The main metabolic pathways of sotorasib are non-enzymatic conjugation and oxidative metabolism with CYP3As.
Excretion
After a single dose of radiolabeled sotorasib, 74% of the dose was recovered in feces (53% unchanged) and 6% (1% unchanged) in urine.
Specific Populations
No clinically meaningful differences in the pharmacokinetics of sotorasib were observed based on age (28 to 86 years), sex, race (White, Black and Asian), body weight (36.8 to 157.9 kg), line of therapy, ECOG PS (0, 1), mild and moderate renal impairment (eGFR: ≥ 30 mL/min/1.73 m²), or mild hepatic impairment (AST or ALT < 2.5 × ULN or total bilirubin < 1.5 × ULN). The effect of severe renal impairment on sotorasib pharmacokinetics has not been studied.
Hepatic Impairment
The mean AUC of sotorasib decreased by 25% in subjects with moderate hepatic impairment (Child-Pugh B) and increased by 4% in subjects with severe hepatic impairment (Child-Pugh C) compared to subjects with normal hepatic function following a single dose of 960 mg LUMAKRAS.
Clinical Studies
Acid-Reducing Agents
Coadministration of repeat doses of omeprazole (PPI) with a single dose of LUMAKRAS decreased sotorasib Cmax by 65% and AUC by 57% under fed conditions, and decreased sotorasib Cmax by 57% and AUC by 42% under fasted conditions. Coadministration of a single dose of famotidine (H2 receptor antagonist) given 10 hours prior to and 2 hours after a single dose of LUMAKRAS under fed conditions decreased sotorasib Cmax by 35% and AUC by 38%.
Strong CYP3A4 Inducers
Coadministration of repeat doses of rifampin (a strong CYP3A4 inducer) with a single dose of LUMAKRAS decreased sotorasib Cmax by 35% and AUC by 51%.
Other Drugs
No clinically meaningful effect on the exposure of sotorasib was observed following coadministration of LUMAKRAS with itraconazole (a combined strong CYP3A4 and P-gp inhibitor) and a single dose of rifampin (an OATP1B1/1B3 inhibitor), or metformin (a MATE1/MATE2-K substrate).
CYP3A4 substrates
Coadministration of LUMAKRAS with midazolam (a sensitive CYP3A4 substrate) decreased midazolam Cmax by 48% and AUC by 53%.
P-gp substrates
Coadministration of LUMAKRAS with digoxin (a P-gp substrate) increased digoxin Cmax by 91% and AUC by 21%.
MATE1/MATE2-K substrates
No clinically meaningful effect on the exposure of metformin (a MATE1/MATE2-K substrate) was observed following coadministration of LUMAKRAS.
BCRP substrates
Coadministration of LUMAKRAS with rosuvastatin (a BCRP substrate) increased rosuvastatin Cmax by 70% and AUC by 34%.
In Vitro Studies
Cytochrome P450 (CYP) Enzymes: Sotorasib may induce CYP2C8, CYP2C9 and CYP2B6. Sotorasib does not inhibit CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19, or CYP2D6.
Animal Toxicology And/Or Pharmacology
In rats, renal toxicity including minimal to marked histologic tubular degeneration/necrosis and increased kidney weight, urea nitrogen, creatinine, and urinary biomarkers of renal tubular injury were present at doses resulting in exposures approximately ≥ 0.5 times the human AUC at the clinical dose of 960 mg. Increases in cysteine S-conjugate β-lyase pathway metabolism in the rat kidney compared to human may make rats more susceptible to renal toxicity due to local formation of a putative sulfur-containing metabolite than humans.
In the 3-month toxicology study in dogs, sotorasib induced findings in the liver (centrilobular hepatocellular hypertrophy), pituitary gland (hypertrophy of basophils), and thyroid gland (marked follicular cell atrophy, moderate to marked colloid depletion, and follicular cell hypertrophy) at exposures approximately 0.4 times the human exposure based on AUC at the clinical dose of 960 mg. These findings may be due to an adaptive response to hepatocellular enzyme induction and subsequent reduced thyroid hormone levels (i.e., secondary hypothyroidism). Although thyroid levels were not measured in dogs, induction of uridine diphosphate glucuronosyltransferase known to be involved in thyroid hormone metabolism was confirmed in the in vitro dog hepatocyte assay.
Clinical Studies
KRAS G12C-mutated Locally Advanced Or Metastatic Non-Small Cell Lung Cancer
The efficacy of LUMAKRAS was demonstrated in a subset of patients enrolled in a single-arm, open-label, multicenter trial (CodeBreaK 100 [NCT03600883]). Eligible patients were required to have locally advanced or metastatic KRAS G12C-mutated NSCLC with disease progression after receiving an immune checkpoint inhibitor and/or platinum-based chemotherapy, an Eastern Cooperative Oncology Group Performance Status (ECOG PS) of 0 or 1, and at least one measurable lesion as defined by Response Evaluation Criteria in Solid Tumors (RECIST v1.1).
All patients were required to have prospectively identified KRAS G12C-mutated NSCLC in tumor tissue samples by using the QIAGEN therascreen® KRAS RGQ PCR Kit performed in a central laboratory. Of 126 total enrolled subjects, 2 (2%) were unevaluable for efficacy analysis due to the absence of radiographically measurable lesions at baseline. Of the 124 patients with KRAS G12C mutations confirmed in tumor tissue, plasma samples from 112 patients were tested retrospectively using the Guardant360® CDx. 78/112 patients (70%) had KRAS G12C mutation identified in plasma specimen, 31/112 patients (28%) did not have KRAS G12C mutation identified in plasma specimen and 3/112 (2%) were unevaluable due to Guardant360® CDx test failure.
A total of 124 patients had at least one measurable lesion at baseline assessed by Blinded Independent Central Review (BICR) according to RECIST v1.1 and were treated with LUMAKRAS 960 mg once daily until disease progression or unacceptable toxicity. The major efficacy outcome measures were objective response rate (ORR), and duration of response (DOR) as evaluated by BICR according to RECIST v1.1.
The baseline demographic and disease characteristics of the study population were: median age 64 years (range: 37 to 80) with 48% ≥ 65 years and 8% ≥ 75 years; 50% Female; 82% White, 15% Asian, 2% Black; 70% ECOG PS 1; 96% had stage IV disease; 99% with non-squamous histology; 81% former smokers, 12% current smokers, 5% never smokers. All patients received at least 1 prior line of systemic therapy for metastatic NSCLC; 43% received only 1 prior line of therapy, 35% received 2 prior lines of therapy, 23% received 3 prior lines of therapy; 91% received prior anti-PD-1/PD-L1 immunotherapy, 90% received prior platinum-based chemotherapy, 81% received both platinum-based chemotherapy and anti-PD-1/PD-L1. The sites of known extra-thoracic metastasis included 48% bone, 21% brain, and 21% liver.
Efficacy results are summarized in Table 7.
Table 7: Efficacy Results for Patients with KRAS G12C-mutated NSCLC who Received LUMAKRAS in CodeBreaK 100
| Efficacy Parameter |
LUMAKRAS
N = 124 |
| Objective Response Rate (95% CI)a |
36 (28, 45) |
| Complete response rate, % |
2 |
| Partial response rate, % |
35 |
| Duration of Responsea |
| Medianb, months (range) |
10 (1.3+, 11.1) |
| Patients with duration ≥ 6 monthsc, % |
58% |
CI = confidence interval
a Assessed by Blinded Independent Central Review (BICR).
b Estimate using Kaplan-Meier method.
c Observed proportion of patients with duration of response beyond landmark time. |
KRAS G12C-mutated Metastatic Colorectal Cancer
The efficacy of LUMAKRAS in combination with panitumumab was evaluated in CodeBreaK 300 [NCT05198934], a multicenter, randomized, open-label, active-controlled study conducted in previously treated patients with KRAS G12C-mutated mCRC. Key eligibility criteria included patients 18 years of age or older, who had received at least one prior line of therapy for mCRC, and who had received fluoropyrimidine, oxaliplatin, and irinotecan for metastatic disease unless there was a medical contraindication.
All patients were also required to have prospectively identified KRAS G12C-mutated mCRC in tumor tissue samples by using the QIAGEN therascreen® KRAS RGQ PCR Kit performed in a central laboratory. Other eligibility criteria included an ECOG PS of ≤ 2 and at least one measurable lesion as defined by RECIST v1.1.
A total of 160 patients with previously treated mCRC with the KRAS G12C mutation were randomized 1:1:1 to receive either LUMAKRAS 960 mg orally once daily and panitumumab 6 mg/kg IV every 2 weeks (N = 53), or LUMAKRAS 240 mg orally once daily and panitumumab 6 mg/kg IV every 2 weeks (N = 53), or investigator’s choice of SOC trifluridine/tipiracil or regorafenib (N = 54). Randomization was stratified by prior anti-angiogenic therapy (yes or no), time from initial diagnosis of metastatic disease to randomization (≥ 18 months; < 18 months), and ECOG status (0 or 1 versus 2). Patients received treatment until disease progression, lack of clinical benefit or intolerance to treatment. LUMAKRAS discontinuation required panitumumab discontinuation, however, patients could continue to receive LUMAKRAS if panitumumab was discontinued [see DOSAGE AND ADMINISTRATION]. Four patients randomized to LUMAKRAS 960 mg in combination with panitumumab continued LUMAKRAS single agent therapy after discontinuing panitumumab.
The major efficacy outcome measure was progression-free survival (PFS) as evaluated by BICR according to RECIST 1.1. Additional efficacy outcome measures included overall survival (OS), objective response rate (ORR), and duration of response (DOR). Only the results of the approved dosing regimen LUMAKRAS 960 mg in combination with panitumumab are described below.
Of the 107 patients randomized to either LUMAKRAS 960 mg once daily in combination with panitumumab or the control arms, the median age was 64 years (range: 34-81 years); 46% were age 65 years or older; 50% were female; 74% were White; 17% were Asian and 97% of the patients had ECOG PS 0 or 1. The primary site of disease was colon (69%) or rectum (31%). The median number of prior lines of therapy for metastatic disease was 2. Among the 107 patients, 100% received prior fluoropyrimidine, 99% received prior oxaliplatin, 93% received prior irinotecan and 18% of patients had received prior trifluridine and tipiracil, or regorafenib.
The efficacy results from CodeBreaK 300 are summarized in Table 8 and Figure 1.
Table 8: Efficacy Results for Patients with KRAS G12C-mutated mCRC in CodeBreaK 300
| Efficacy Parameters |
Sotorasib 960 mg QD + Panitumumab
(N = 53) |
SOC (trifluridine/tipiracil or regorafenib)
(N = 54) |
| Progression-Free Survival (PFS) per BICR |
| Number of Events (%) |
32 (60) |
35 (65) |
| Median in months (95% CI) |
5.6 (4.2, 6.3) |
2 (1.9, 3.9) |
| Hazard ratio (95% CI)a |
0.48 (0.3,0.78) |
| p-value (2-sided)b |
0.005 |
| Overall Survival (OS)c |
| Deaths (%) |
24 (45) |
30 (56) |
| Median in months (95% CI) |
NR (8.6, NR) |
10.3 (7, NR) |
| Hazard ratio (95% CI)a |
0.7 (0.41, 1.18) |
| Overall Response Rate (ORR) per BICR |
| ORR, % (95% CI)d |
26 (15, 40) |
0 (0, 7) |
| CR, n (%) |
1 (1.9) |
0 |
| PR, n (%) |
13 (25) |
0 |
| Duration of Response (DOR) |
| Median in months, (range)e |
4.4 (1.9+, 6+) |
|
N = Number of randomized subjects, NR = Not Reached, QD = once daily, SOC = standard of care, CR = complete response, PR = partial response, BICR = Blinded Independent Central Review Committee, CI = Confidence Interval a Hazard ratios and 95% CIs were estimated using
a stratified Cox proportional hazards model.
b p-value was calculated using a stratified log-rank test.
c OS analysis was based on 6-month additional follow-up data from the time of PFS primary analysis.
d 95% CIs were estimated using the Clopper-Pearson method.
e For DOR + indicates censored subjects. |
Figure 1: Kaplan-Meier Curve for Progression-Free Survival in CodeBreaK 300