Rubraca Generic Name: rucaparib Brand Name: Rubraca Tablets Drug Class: How Do PARP Inhibitors Work? side effects drug center rubraca tablets (rucaparib ) drug Related Drugs Droxia Hexalen Hydrea Premarin Premarin Injection Premarin Vaginal Cream PROFESSIONAL CONSUMER SIDE EFFECTS Contents Drug Description Indications Dosage Side Effects & Drug Interactions Warnings & Precautions Overdosage & Contraindications Clinical Pharmacology Medication Guide Drug Description What is Rubraca and how is it used? Rubraca is a prescription medicine used to treat the symptoms of Ovarian Cancer and Prostate Cancer. Rubraca may be used alone or with other medications. Rubraca belongs to a class of drugs called Antineoplastics, PARP Inhibitors. It is not known if Rubraca is safe and effective in children. What are the possible side effects of Rubraca? Rubraca may cause serious side effects including: hives, difficulty breathing, swelling of your face, lips, tongue, or throat, easy bruising, unusual bleeding (nose, mouth, vagina, or rectum), purple or red pinpoint spots under your skin, blood in your urine, fever, mouth sores, skin sores, sore throat, cough, pale skin, unusual tiredness, lightheadedness, shortness of breath, and cold hands and feet Get medical help right away, if you have any of the symptoms listed above. The most common side effects of Rubraca include: low blood cell counts, shortness of breath, stuffy nose, sneezing, sore throat, stomach pain, bloating, loss of appetite, nausea, vomiting, diarrhea, constipation, mouth sores, changes in your sense of taste, weakness, tiredness, rash, and abnormal liver function tests Tell the doctor if you have any side effect that bothers you or that does not go away. These are not all the possible side effects of Rubraca. For more information, ask your doctor or pharmacist. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. DESCRIPTION Rucaparib is an inhibitor of the mammalian polyadenosine 5’-diphosphoribose polymerase (PARP) enzyme. The chemical name is 8-fluoro-2-{4-[(methylamino)methyl]phenyl}-1,3,4,5-tetrahydro-6H-azepino[5,4,3-cd]indol-6-one ((1S,4R)-7,7- dimethyl-2-oxobicyclo[2.2.1]hept-1-yl)methanesulfonic acid salt. The chemical formula of rucaparib camsylate is C19H18FN3O•C10H16O4S and the relative molecular mass is 555.67 Daltons. The chemical structure of rucaparib camsylate is shown below: Rucaparib camsylate is a white to pale yellow powder; formulated into a tablet for oral use. Rucaparib shows pHindependent low solubility of approximately 1 mg/mL across the physiological pH range. Rubraca (rucaparib) tablets contain rucaparib camsylate as the active ingredient. Each 200 mg tablet contains 344 mg rucaparib camsylate equivalent to 200 mg rucaparib free base. Each 250 mg tablet contains 430 mg rucaparib camsylate equivalent to 250 mg rucaparib free base. Each 300 mg tablet contains 516 mg rucaparib camsylate equivalent to 300 mg rucaparib free base. The inactive ingredients in Rubraca tablets include: microcrystalline cellulose, sodium starch glycolate, colloidal silicon dioxide, and magnesium stearate. The cosmetic blue film coating for 200 mg tablets, cosmetic white film coating for 250 mg tablets, and cosmetic yellow film coating for 300 mg tablets is Opadry II containing polyvinyl alcohol, titanium dioxide, polyethylene glycol/macrogol, and talc. The coating is colorized as blue using brilliant blue aluminum lake and indigo carmine aluminum lake, or yellow using yellow iron oxide. Indications INDICATIONSOvarian CancerRubraca is indicated for the maintenance treatment of adult patients with recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer who are in a complete or partial response to platinum-based chemotherapy.Rubraca is indicated for the treatment of adult patients with a deleterious BRCA mutation (germline and/or somatic)-associated epithelial ovarian, fallopian tube, or primary peritoneal cancer who have been treated with two or more chemotherapies. Select patients for therapy based on an FDA-approved companion diagnostic for Rubraca [see DOSAGE AND ADMINISTRATION].Metastatic Castration-Resistant Prostate Cancer With BRCA MutationsRubraca is indicated for the treatment of adult patients with a deleterious BRCA mutation (germline and/or somatic) associated metastatic castration-resistant prostate cancer (mCRPC) who have been treated with androgen receptor- directed therapy and a taxane-based chemotherapy. Select patients for therapy based on an FDA-approved companion  diagnostic for Rubraca [see DOSAGE AND ADMINISTRATION].This indication is approved under accelerated approval based on objective response rate and duration of response [see Clinical Studies]. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials. Dosage DOSAGE AND ADMINISTRATIONPatient SelectionTreatment Of BRCA-Mutated Ovarian Cancer After 2 Or More ChemotherapiesSelect patients for the treatment of epithelial ovarian, fallopian tube, or primary peritoneal cancer with Rubraca based on the presence of a deleterious BRCA mutation (germline and/or somatic) [see Clinical Studies].Treatment Of BRCA-Mutated mCRPC After Androgen Receptor-directed Therapy And ChemotherapySelect patients for the treatment of mCRPC with Rubraca based on the presence of a deleterious BRCA mutation (germline and/or somatic) in plasma specimens [see Clinical Studies]. A negative result from a plasma specimen does not mean that the patient’s tumor is negative for BRCA mutations. Should the plasma specimen have a negative result, consider performing further genomic testing using tumor specimens as clinically indicated.Information on the FDA-approved tests for the detection of a BRCA mutation in patients with ovarian cancer or with prostate cancer is available at: http://www.fda.gov/CompanionDiagnostics.Recommended DoseThe recommended dose of Rubraca is 600 mg (two 300 mg tablets) taken orally twice daily with or without food, for a total daily dose of 1,200 mg.Continue treatment until disease progression or unacceptable toxicity.If a patient misses a dose of Rubraca, instruct the patient to take the next dose at its scheduled time. Vomited doses should not be replaced.Patients receiving Rubraca for mCRPC should also receive a gonadotropin-releasing hormone (GnRH) analog concurrently or should have had bilateral orchiectomy.Dose Modifications For Adverse ReactionsTo manage adverse reactions, consider interruption of treatment or dose reduction. Recommended Rubraca dose modifications for adverse reactions are indicated in Table 1.Table 1: Recommended Dose Modifications for Adverse ReactionsDose ReductionDoseStarting Dose600 mg twice daily (two 300 mg tablets)First Dose Reduction500 mg twice daily (two 250 mg tablets)Second Dose Reduction400 mg twice daily (two 200 mg tablets)Third Dose Reduction300 mg twice daily (one 300 mg tablet) HOW SUPPLIEDDosage Forms And StrengthsTablets (200 mg): blue, round, immediate-release, film-coated, debossed with “C2”.Tablets (250 mg): white, diamond, immediate-release, film-coated, debossed with “C25”.Tablets (300 mg): yellow, oval, immediate-release, film-coated, debossed with “C3”.Storage And HandlingRubraca is available as 200 mg, 250 mg, and 300 mg tablets.200 mg TabletsBlue, round, and debossed with “C2” on one sideSupplied in bottles of 60 tablets (NDC: 69660-201-91)250 mg TabletsWhite, diamond, and debossed with “C25” on one sideSupplied in bottles of 60 tablets (NDC: 69660-202-91)300 mg TabletsYellow, oval, and debossed with “C3” on one sideSupplied in bottles of 60 tablets (NDC: 69660-203-91)StorageStore at 20°C to 25°C (68°F to 77°F); excursions permitted to 15°C to 30°C (59°F to 86°F) [see USP Controlled Room Temperature].Distributed by: Clovis Oncology, Inc. Boulder, CO 80301 1-844-258-7662. Revised: Oct 2020 Side Effects & Drug Interactions SIDE EFFECTSThe following serious adverse reactions are discussed elsewhere in the labeling:Myelodysplastic Syndrome/Acute Myeloid Leukemia [see WARNINGS AND PRECAUTIONS].Clinical Trials ExperienceBecause 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.The pooled safety population in the WARNINGS AND PRECAUTIONS section reflect exposure to Rubraca at 600 mg BID in 1146 patients in Study10 (CO-338-010), ARIEL2, ARIEL3, and TRITON2.Maintenance Treatment Of Recurrent Ovarian CancerThe safety of Rubraca for the maintenance treatment of patients with epithelial ovarian, fallopian tube, or primary peritoneal cancer was investigated in ARIEL3, a randomized (2:1), double-blind, placebo-controlled study in which 561 patients received either Rubraca 600 mg BID (n=372) or placebo (n=189) until disease progression or unacceptable toxicity. The median duration of study treatment was 8.3 months (range: < 1 month to 35 months) for patients who received Rubraca and 5.5 months for patients who received placebo.Dose interruptions due to an adverse reaction of any grade occurred in 65% of patients receiving Rubraca and 10% of those receiving placebo; dose reductions due to an adverse reaction occurred in 55% of Rubraca patients and 4% of placebo patients. The most frequent adverse reactions leading to dose interruption or dose reduction of Rubraca were thrombocytopenia (18%), anemia (17%), nausea (15%), and fatigue/asthenia (13%). Discontinuation due to adverse reactions occurred in 15% of Rubraca patients and 2% of placebo patients. Specific adverse reactions that most frequently led to discontinuation in patients treated with Rubraca were anemia (3%), thrombocytopenia (3%) and nausea (3%). Table 2 describes the adverse reactions occurring in ≥20% of patients; while Table 3 describes the laboratory abnormalities occurring in ≥25% of patients occurring in ARIEL3.Table 2: Adverse Reactions in ARIEL3 Occurring in ≥ 20% of PatientsAdverse reactionsRubracaN=372PlaceboN=189Gradesa 1-4 %Grades 3-4 %Gradesa 1-4 %Grades 3-4 %Gastrointestinal DisordersNausea764360.5Abdominal pain/distentionb463390.5Constipation372241Vomiting374151Diarrhea320.5221Stomatitisb281140.5General Disorders and Administration Site ConditionsFatigue/asthenia737463Skin and Subcutaneous Tissue DisordersRashb431230Nervous System DisordersDysgeusia40070InvestigationsAST/ALT elevation381140Blood and Lymphatic System DisordersAnemia392150.5Thrombocytopenia29530Neutropenia20851Respiratory, Thoracic, and Mediastinal DisordersNasopharyngitis/Upper respiratory tract infectionb290.3181Metabolism and Nutrition DisordersDecreased appetite231140a National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE version 4.03)b Consists of grouped related terms that reflect the medical concept of the adverse reactionAdverse reactions occurring < 20% of patients treated with Rubraca include headache (18%), dizziness (19%), dyspepsia (19%), insomnia (15%), dyspnea (17%), pyrexia (13%), peripheral edema (11%), and depression (11%).Table 3: Laboratory Abnormalities in ARIEL3 Occurring in ≥ 25% of PatientsLaboratory ParameteraRubracaN=372PlaceboN=189Grade 1-4 %Grade 3-4 %Grade 1-4 %Grade 3-4 %ChemistryIncrease in creatinine980.3900Increase in cholesterol844780Increase in ALT73740Increase in AST61140Increase in Alkaline Phosphatase370.3100HematologyDecrease in hemoglobin8813561Decrease in platelets44290Decrease in leukocytes443290Decrease in neutrophils386223Decrease in lymphocytes295203a Patients were allowed to enter clinical studies with laboratory values of CTCAE Grade 1.Treatment Of BRCA-mutated Recurrent Ovarian Cancer After 2 Or More ChemotherapiesRubraca 600 mg twice daily as monotherapy has also been studied in 377 patients with epithelial ovarian, fallopian tube or primary peritoneal cancer who have progressed after 2 or more prior chemotherapies in two open-label, single arm trials. In these patients, the median age was 62 years (range: 31 to 86), 100% had an ECOG performance status of 0 or 1, 38% had BRCA-mutated ovarian cancer, 45% had received 3 or more prior lines of chemotherapy, and the median time since ovarian cancer diagnosis was 43 months (range: 6 to 197). Table 4 describes the adverse reactions occurring in ≥20% of patients; while Table 5 describes the laboratory abnormalities occurring in ≥35% of patients occurring in ARIEL2.Table 4: Adverse Reactions Reported in ≥ 20% of Patients with Ovarian Cancer After ≥ 2 Chemotherapies Treated with Rubraca in Study 10 and ARIEL2Adverse ReactionAll Ovarian Cancer Patients(N = 377)Gradesa 1-4 (%)Grades 3-4 (%)Gastrointestinal DisordersNausea775Vomiting464Constipation402Diarrhea342Abdominal Pain323General DisordersAsthenia/Fatigue7711Blood and Lymphatic System DisordersAnemia4425Thrombocytopenia215Nervous System DisordersDysgeusia390.3Metabolism and Nutrition DisordersDecreased appetite393Respiratory, Thoracic, and Mediastinal DisordersDyspnea210.5a National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE version 4.03)The following adverse reactions have been identified in < 20% of the 377 patients treated with Rubraca 600 mg twice daily: dizziness (17%), neutropenia (15%), rash (includes rash, rash erythematous, rash maculopapular and dermatitis) (13%), pyrexia (11%), photosensitivity reaction (10%), pruritus (includes pruritus and pruritus generalized) (9%), hypersensitivity (includes flushing, wheezing, eyelid edema, drug hypersensitivity, face edema, swelling face) (4%), palmar-plantar erythrodysaesthesia syndrome (2%), and febrile neutropenia (1%).Table 5: Laboratory Abnormalities Reported in ≥ 35% of Patients with Ovarian Cancer After ≥ 2 Chemotherapies Treated with Rubraca in Study 10 and ARIEL2Laboratory ParameterAll Patients with Ovarian Cancer(N = 377)Grade 1-4 a (%)Grade 3-4 (%)Clinical ChemistryIncrease in creatinine921Increase in ALTb7413Increase in ASTb735Increase in cholesterol402HematologicDecrease in hemoglobin6723Decrease in lymphocytes457Decrease in platelets396Decrease in absolute neutrophil count3510a At least one worsening shift in CTCAE grade and by maximum shift from baseline.b Increase in ALT/AST led to treatment discontinuation in 0.3% of patients (1/377).Treatment Of BRCA-mutated mCRPC After Androgen Receptor-directed Therapy And ChemotherapyThe safety of Rubraca 600 mg twice daily was evaluated in a single arm trial (TRITON2) [see Clinical Studies]. TRITON2 enrolled 209 patients with HRD-positive mCRPC, including 115 with BRCA-mutated mCRPC. Among the patients with BRCA-mutated mCRPC, the median duration of Rubraca treatment was 6.5 months (range 0.5 to 26.7).There were 2 (1.7%) patients with adverse reactions leading to death, one each attributed to acute respiratory distress syndrome and pneumonia.Dose interruptions due to an adverse reaction occurred in 57% of patients receiving Rubraca. Adverse reactions requiring dose interruption in >3% of patients included anemia, thrombocytopenia, asthenia/fatigue, nausea, vomiting, neutropenia, ALT/AST increased, creatinine increased, decreased appetite, acute kidney injury, and hypophosphatemia.Dose reductions due to an adverse reaction occurred in 41% of patients receiving Rubraca. Adverse reactions requiring dose reduction in >3% of patients were anemia (14%), asthenia/fatigue (10%), thrombocytopenia (7%), nausea (6%), decreased appetite (4%), and rash (3%).Discontinuation due to adverse reactions occurred in 8% of patients receiving Rubraca. None of the adverse reactions leading to discontinuation of Rubraca (ECG QT prolonged, acute respiratory distress syndrome, anemia, balance disorder, cardiac failure, decreased appetite/fatigue/weight decreased, leukopenia/neutropenia, ALT/AST increased, and pneumonia) occurred in more than one patient (<1%).Tables 6 and 7 summarize the adverse reactions and laboratory abnormalities, respectively, in patients with BRCA-mutated mCRPC in TRITON2.Table 6: Adverse Reactions Reported in ≥ 20% of Patients with BRCA-mutated mCRPC in TRITON2Adverse ReactionRubracaN = 115Gradesa 1-4 (%)Grades 3-4 (%)General disorders and administration site conditionsAsthenia/F atigue629Gastrointestinal disordersNausea523Constipation271Vomiting221Diarrhea200Blood and lymphatic system disordersAnemia4325Thrombocytopeniab2510Metabolism and nutrition disordersDecreased appetite282Skin and subcutaneous tissue disordersRashc272InvestigationsALT/AST increased335a National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE version 4.03)b Includes platelet count decreasedcIncludes blister, blood blister, dermatitis, dermatitis contact, eczema, genital rash, palmar-plantar erythrodysaesthesia syndrome, photosensitivity reaction, psoriasis, rash, rash maculo-papular, rash pruritic, skin exfoliation, skin lesion, urticariaOther clinically relevant adverse reactions that occurred in less than 20% of patients included dyspnea, dizziness, bleeding, urinary tract infection, dysgeusia, dyspepsia, hypersensitivity (including flushing, asthma, choking sensation, periorbital swelling, swelling face, and wheezing), pneumonia, sepsis, ischemic cardiovascular events, renal failure, and venous thromboembolism.Table 7: Laboratory Abnormalities in ≥ 35% (Grades 1-4) and ≥ 2% (Grades 3-4) Worsening from Baseline in Patients with BRCA-mutated mCRPC in TRITON2Laboratory ParameterRubracaN = 115aGrade 1-4b(%)Grade 3-4 (%)Clinical ChemistryIncrease in ALTc695Decrease in phosphate6815Increase in alkaline phosphatase442Increase in creatinine432Increase in triglycerides425Decrease in sodium383HematologicDecrease in leukocytes695Decrease in absolute neutrophil count6210Decrease in hemoglobin5925Decrease in lymphocytes4217Decrease in platelets4010a Denominator for each laboratory parameter is based on the number of patients with a baseline and post-treatment laboratory value available for 111 to 115 patients.b NCI CTCAE version 5.0; decrease in phosphate is graded using NCI CTACE Version 4.03c Grade 3-4 ALT or AST elevation led to drug interruption in 4 patients, of which 1 had dose reduction upon rechallenge DRUG INTERACTIONSEffect Of Rucaparib On Cytochrome p450 (CYP) SubstratesCo-administration of rucaparib can increase the systemic exposure of CYP1A2, CYP3A, CYP2C9, or CYP2C19 substrates [see CLINICAL PHARMACOLOGY], which may increase the risk of toxicities of these drugs.Adjust dosage of CYP1A2, CYP3A, CYP2C9, or CYP2C19 substrates, if clinically indicated. If co-administration with warfarin (a CYP2C9 substrate) cannot be avoided, consider increasing the frequency of international normalized ratio (INR) monitoring. Warnings & Precautions WARNINGSIncluded as part of the PRECAUTIONS section. PRECAUTIONSMyelodysplastic Syndrome/Acute Myeloid LeukemiaMyelodysplastic Syndrome (MDS)/Acute Myeloid Leukemia (AML) occur in patients treated with Rubraca, and are potentially fatal adverse reactions. In 1146 treated patients [see ADVERSE REACTIONS], MDS/AML occurred in 20 patients (1.7%), including those in long term follow-up. Of these, 8 occurred during treatment or during the 28 day safety follow-up (0.7%). The duration of Rubraca treatment prior to the diagnosis of MDS/AML ranged from 1 month to approximately 53 months. The cases were typical of secondary MDS/cancer therapy-related AML; in all cases, patients had received previous platinum-containing chemotherapy regimens and/or other DNA damaging agents.In TRITON2, MDS/AML was not observed in patients with mCRPC (n=209) regardless of homologous recombination deficiency (HRD) mutation [see ADVERSE REACTIONS].Do not start Rubraca until patients have recovered from hematological toxicity caused by previous chemotherapy (≤ Grade 1). Monitor complete blood counts for cytopenia at baseline and monthly thereafter for clinically significant changes during treatment. For prolonged hematological toxicities (> 4 weeks), interrupt Rubraca or reduce dose according to Table 1 [see DOSAGE AND ADMINISTRATION] and monitor blood counts weekly until recovery. If the levels have not recovered to Grade 1 or less after 4 weeks or if MDS/AML is suspected, refer the patient to a hematologist for further investigations, including bone marrow analysis and blood sample for cytogenetics. If MDS/AML is confirmed, discontinue Rubraca.Embryo-Fetal ToxicityRubraca can cause fetal harm when administered to a pregnant woman based on its mechanism of action and findings from animal studies. In an animal reproduction study, administration of rucaparib to pregnant rats during the period of organogenesis resulted in embryo-fetal death at exposures that were 0.04 times the AUC0-24h in patients receiving the recommended human dose of 600 mg twice daily. Apprise pregnant women of the potential risk to a fetus. Advise females of reproductive potential to use effective contraception during treatment and for 6 months following the last dose of Rubraca [see Use In Specific Populations and CLINICAL PHARMACOLOGY].Based on findings from genetic toxicity and animal reproduction studies, advise male patients with female partners of reproductive potential or who are pregnant to use effective contraception during treatment and for 3 months following the last dose of Rubraca [see Use In Specific Populations].Patient Counseling InformationAdvise the patient to read the FDA-approved patient labeling (PATIENT INFORMATION).MDS/AMLAdvise patients to contact their healthcare provider if they experience weakness, feeling tired, fever, weight loss, frequent infections, bruising, bleeding easily, breathlessness, blood in urine or stool, and/or laboratory findings of low blood cell counts, or a need for blood transfusions. These may be signs of hematological toxicity or a more serious uncommon bone marrow problem called ‘myelodysplastic syndrome’ (MDS) or ‘acute myeloid leukemia’ (AML) which have been reported in patients treated with Rubraca [see WARNINGS AND PRECAUTIONS].Embryo-Fetal ToxicityAdvise females to inform their healthcare provider if they are pregnant or become pregnant. Inform female patients of the risk to a fetus and potential loss of the pregnancy [see Use In Specific Populations]. Advise females of reproductive potential to use effective contraception during treatment and for 6 months after receiving the last dose of Rubraca. Advise male patients with female partners of reproductive potential or who are pregnant to use effective contraception during treatment and for 3 months after receiving the last dose of Rubraca. Advise male patients not to donate sperm during therapy and for 3 months following the last dose of Rubraca [see WARNINGS AND PRECAUTIONS and Use In Specific Populations].PhotosensitivityAdvise patients to use appropriate sun protection due to the increased susceptibility to sunburn while taking Rubraca [see Adverse Drug Reactions].LactationAdvise females not to breastfeed during treatment and for 2 weeks after the last dose of Rubraca [see Use In Specific Populations].Dosing InstructionsInstruct patients to take Rubraca orally twice daily with or without food. Doses should be taken approximately 12 hours apart. Advise patients that if a dose of Rubraca is missed or if the patient vomits after taking a dose of Rubraca, patients should not take an extra dose, but take the next dose at the regular time [see DOSAGE AND ADMINISTRATION].Nonclinical ToxicologyCarcinogenesis, Mutagenesis, Impairment Of FertilityCarcinogenicity studies have not been conducted with rucaparib.Rucaparib was clastogenic in an in vitro chromosomal aberration assay in cultured human lymphocytes. The clastogenic response in mitotically-stimulated cells was anticipated based on the mechanism of action of rucaparib and indicates potential genotoxicity in humans. Rucaparib was not mutagenic in a bacterial reverse mutation (Ames) test.Fertility studies with rucaparib have not been conducted. In 3-month repeat-dose general toxicology studies, rucaparib had no effects on male and female reproductive organs at doses up to 100 mg/kg/day and 20 mg/kg/day in rats and dogs, respectively. These dose levels resulted in systemic exposures of approximately 0.3 and 0.09 times the human exposure (AUC0-24h), respectively, at the recommended dose. Use In Specific PopulationsPregnancyRisk SummaryBased on findings from animal studies and its mechanism of action, Rubraca can cause fetal harm when administered to pregnant women. There are no available data in pregnant women to inform the drug-associated risk. In an animal reproduction study, administration of rucaparib to pregnant rats during organogenesis resulted in embryo-fetal death at maternal exposures that were 0.04 times the AUC0-24h in patients receiving the recommended dose of 600 mg twice daily [see Data]. Apprise pregnant women of the potential risk to a fetus.The background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.DataAnimal DataIn a dose range-finding embryo-fetal development study, pregnant rats received oral doses of 50, 150, 500, or 1000 mg/kg/day of rucaparib during the period of organogenesis. Post-implantation loss (100% early resorptions) was observed in all animals at doses greater than or equal to 50 mg/kg/day (with maternal systemic exposures approximately 0.04 times the human exposure at the recommended dose based on AUC0-24h).LactationRisk SummaryThere is no information regarding the presence of rucaparib in human milk, or on its effects on milk production or the breast-fed child. Because of the potential for serious adverse reactions in breast-fed children from Rubraca, advise lactating women not to breastfeed during treatment with Rubraca and for 2 weeks following the last dose.Females And Males Of Reproductive PotentialPregnancy TestingPregnancy testing is recommended for females of reproductive potential prior to initiating Rubraca.ContraceptionFemalesRubraca can cause fetal harm when administered to a pregnant woman [see Use In Specific Populations]. Advise females of reproductive potential to use effective contraception during treatment and for 6 months following the last dose of Rubraca.MalesBased on findings in genetic toxicity and animal reproduction studies, advise male patients with female partners of reproductive potential or who are pregnant to use effective methods of contraception during treatment and for 3 months following last dose of Rubraca. Advise male patients not to donate sperm during therapy and for 3 months following the last dose of Rubraca [see Use In Specific Populations and Nonclinical Toxicology].Pediatric UseThe safety and effectiveness of Rubraca in pediatric patients have not been established.Geriatric UseOf the 937 patients with ovarian cancer who received Rubraca in ARIEL3, ARIEL2, and Study 10, 41% were age 65 or older and 10% were 75 years or older. No major differences in safety were observed between younger and older patients with ovarian cancer.Of the 209 patients with mCRPC who received Rubraca in TRITON2, 77% were age 65 or older and 33% were 75 years or older. No major differences in safety were observed between younger and older patients with mCRPC.Hepatic ImpairmentNo starting dose adjustment is recommended for patients with mild hepatic impairment (total bilirubin less than or equal to upper limit of normal [ULN] and AST greater than ULN, or total bilirubin between 1.0 to 1.5 times ULN and any AST). No recommendation for starting dose adjustment is available for patients with moderate to severe hepatic impairment (total bilirubin greater than 1.5 times ULN) due to a lack of data [See CLINICAL PHARMACOLOGY].Renal ImpairmentNo starting dose adjustment is recommended for patients with mild to moderate renal impairment (baseline creatinine clearance [CLcr] between 30 and 89 mL/min, as estimated by the Cockcroft-Gault method). There is no recommended starting dose for patients with CLcr less than 30 mL/min or patients on dialysis due to a lack of data [See CLINICAL PHARMACOLOGY]. Overdosage & Contraindications OVERDOSEThere is no specific treatment in the event of Rubraca overdose, and symptoms of overdose are not established. In the event of suspected overdose, physicians should follow general supportive measures and should treat symptomatically. CONTRAINDICATIONSNone. Clinical Pharmacology CLINICAL PHARMACOLOGYMechanism Of ActionRucaparib is an inhibitor of poly (ADP-ribose) polymerase (PARP) enzymes, including PARP-1, PARP-2, and PARP-3, which play a role in DNA repair. In vitro studies have shown that rucaparib-induced cytotoxicity may involve inhibition of PARP enzymatic activity and increased formation of PARP-DNA complexes resulting in DNA damage, apoptosis, and cancer cell death. Increased rucaparib-induced cytotoxicity and anti-tumor activity was observed in tumor cell lines with deficiencies in BRCA½ and other DNA repair genes. Rucaparib has been shown to decrease tumor growth in mouse xenograft models of human cancer with or without deficiencies in BRCA.PharmacodynamicsThe pharmacodynamic response of rucaparib has not been characterized.Cardiac ElectrophysiologyThe effect of multiple doses of Rubraca on QTc interval was evaluated in an open-label single-arm study in 56 patients with solid tumors who were administered continuous doses of Rubraca ranging from 40 mg once daily (0.03 times the approved recommended dose) to 840 mg twice daily (1.4 times the approved recommended dose). A positive concentration-QTc relationship was observed. The mean QTcF increase from baseline (90% confidence interval [CI]) in population pharmacokinetics estimated 95th percentile Cmax (3019 ng/mL) at steady state of 600 mg rucaparib twice daily was 14.9 msec (11.1-18.7 msec).PharmacokineticsThe pharmacokinetic profile of rucaparib was characterized in patients with cancer. Rucaparib demonstrated linear pharmacokinetics over a dose range from 240 to 840 mg twice daily with time-independence and dose-proportionality. The mean steady-state rucaparib Cmax was 1940 ng/mL (54% coefficient of variation [CV]) and AUC0-12h was 16900 h•ng/mL (54% CV) at the approved recommended dose. Accumulation was 3.5 to 6.2 fold.AbsorptionThe median Tmax was 1.9 hours at the approved recommended dose. The mean absolute bioavailability of rucaparib immediate-release tablet was 36% with a range from 30% to 45%.Following a high-fat meal, the Cmax was increased by 20% and AUC0-24h was increased by 38%, and Tmax was delayed by 2.5 hours, as compared to dosing under fasted conditions [see DOSAGE AND ADMINISTRATION].DistributionRucaparib had a steady-state volume of distribution of 113 L to 262 L following a single intravenous dose of 12 mg to 40 mg rucaparib.In vitro, the protein binding of rucaparib was 70% in human plasma at therapeutic concentrations. Rucaparib preferentially distributed to red blood cells with a blood-to-plasma concentration ratio of 1.83.EliminationThe apparent clearance ranged from 15.3 to 79.2 L/hour, following rucaparib 600 mg orally twice daily. The clearance ranged from 13.9 to 18.4 L/hour, following a single intravenous dose of rucaparib 12 mg to 40 mg. The mean terminal T½ of rucaparib was 25.9 hours following a single oral dose of 600 mg rucaparib.MetabolismIn vitro, rucaparib had a low metabolic turnover rate and was metabolized primarily by CYP2D6 and to a lesser extent by CYP1A2 and CYP3A4.Following administration of a single oral dose of [14C]-rucaparib to patients with solid tumors, unchanged rucaparib accounted for 64.0% of the radioactivity in plasma. Oxidation, N-demethylation, N-methylation, and glucuronidation were the major metabolic pathways for rucaparib. Rucaparib accounted for 44.9% and 94.9% of radioactivity in urine and feces, respectively.Specific PopulationsAge, Race, Sex, And Body WeightBased on population pharmacokinetic analyses, age, race, sex, and body weight did not have a clinically meaningful effect on rucaparib exposure.Renal ImpairmentIn patients who received Rubraca 600 mg twice daily, those with mild renal impairment (N=148; baseline CLcr between 60 and 89 mL/min, as estimated by the Cockcroft-Gault method) and those with moderate renal impairment (N=72; CLcr between 30 and 59 mL/min) showed approximately 15% and 32% higher steady-state AUC, respectively, compared to patients with normal renal function (N=143; CLcr greater than or equal to 90 mL/min). The pharmacokinetic characteristics of rucaparib in patients with CLcr less than 30 mL/min or patients on dialysis are unknown.Hepatic ImpairmentBased on population pharmacokinetic analyses, no apparent pharmacokinetic difference was observed in 34 patients with mild hepatic impairment (total bilirubin less than or equal to ULN and AST greater than ULN, or total bilirubin between 1.0 to 1.5 times ULN and any AST) who received Rubraca 600 mg twice daily as compared to patients with normal hepatic function (N=337). The pharmacokinetic characteristics of rucaparib in patients with moderate to severe hepatic impairment (total bilirubin greater than 1.5 times ULN) are unknown.CYP Enzyme PolymorphismBased on population pharmacokinetic analyses, steady-state concentrations following rucaparib 600 mg twice daily did not differ significantly across CYP2D6 or CYP1A2 genotype subgroups.Drug Interaction StudiesEffect Of Rucaparib On Other DrugsClinical StudiesA single dose of the following drugs was administered before and following rucaparib 600 mg twice daily for 7 days. The Cmax of each co-administered drug was ≤ 1.13-fold, and the AUC changed as follows:Caffeine (CYP1A2): caffeine AUC increased by 2.55-foldMidazolam (CYP3A4): midazolam AUC increased by 1.38-foldWarfarin (CYP2C9): warfarin AUC increased by 1.49-foldOmeprazole (CYP2C19): omeprazole AUC increased by 1.55-foldDigoxin (P-glycoprotein): digoxin AUC increased by 1.20-foldIn Vitro StudiesRucaparib inhibited CYP2C8, CYP2D6, and uridine diphosphate glucuronosyltransferase 1A1 (UGT1A1). Rucaparib induced CYP1A2, and down regulated CYP3A4 and CYP2B6.Rucaparib inhibited the P-glycoprotein (P-gp) efflux transporter, breast cancer resistance protein (BCRP), organic anion transporting polypeptides 1B1 and 1B3 (OATP1B1 and OATP1B3), organic anion transporters 1 and 3 (OAT1 and OAT3), multidrug and toxin extrusion 1 and 2-k (MATE1 and MATE2-K), organic cation transporters 1 and 2 (OCT1 and OCT2), and multidrug resistance-associated protein 4 (MRP4). No apparent inhibition was observed for MRP2, MRP3, or BSEP.Effects Of Other Drugs On RucaparibClinical StudiesIn a population pharmacokinetic (PPK) analysis, co-administration with proton pump inhibitors had no clinically significant effect on steady-state concentrations of rucaparib.In Vitro StudiesRucaparib was a substrate of P-gp and BCRP; however, rucaparib was not a substrate of OATP1B1, OATP1B3, OAT1, OAT3, and OCT2. Clinical StudiesOvarian CancerMaintenance Treatment Of Recurrent Ovarian CancerThe efficacy of Rubraca was investigated in ARIEL3 (NCT01968213), a double-blind, multicenter clinical trial in which 564 patients with recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer who were in response to platinum-based chemotherapy were randomized (2:1) to receive Rubraca tablets 600 mg orally twice daily (n=375) or placebo (n=189). Treatment was continued until disease progression or unacceptable toxicity. All patients had achieved a response (complete or partial) to their most recent platinum-based chemotherapy. Randomization was stratified by best response to last platinum (complete or partial), time to progression following the penultimate platinum therapy (6 to ≤ 12 months and > 12 months), and tumor biomarker status. The major efficacy outcome was investigator-assessed progression-free survival (PFS) evaluated according to Response Evaluation Criteria in Solid Tumors (RECIST), version 1.1 (v1.1).The median age was 61 years (range: 39 to 84) for patients receiving Rubraca and 62 years (range: 36 to 85) for those on placebo; the majority were White (80%); and 100% had an ECOG performance status of 0 or 1. All patients had received at least two prior platinum-based chemotherapies (range: 2 to 7). A total of 34% of patients were in complete response (CR) to their most recent therapy. The progression-free interval to penultimate platinum was 6-12 months in 40% of patients and > 12 months in 60%. Prior bevacizumab therapy was reported for 22% of patients who received Rubraca and 23% of patients who received placebo. Measurable disease was present at baseline in 37% of patients.Tumor tissue samples were tested using a clinical trial assay (CTA) (N=564), and the FoundationFocus™ CDx BRCA LOH test (n=518). Of the samples evaluated with both tests, homologous recombination deficiency (HRD) positive status (as defined by the presence of a deleterious BRCA mutation or high genomic loss of heterozygosity) was confirmed by the FoundationFocus™ CDx BRCA LOH test for 94% (313/332) of HRD-positive patients determined by the CTA; and of these, tumor BRCA (tBRCA) mutant status was confirmed by the FoundationFocus™ CDx BRCA LOH test for 99% (177/178) of tBRCA-positive patients determined by the CTA. Blood samples for 94% (186/196) of the tBRCA patients were evaluated using a central blood germline BRCA test. Based on these results, 70% (130/186) of the tBRCA patients had a germline BRCA mutation and 30% (56/186) had a somatic BRCA mutation.ARIEL3 demonstrated a statistically significant improvement in PFS for patients randomized to Rubraca as compared with placebo in all patients, and in the HRD and tBRCA subgroups. Results from a blinded independent radiology review were consistent. At the time of the analysis of PFS, overall survival (OS) data were not mature (with 22% of events).Efficacy results are summarized in Table 8 and Figures 1, 2, and 3.Table 8: Efficacy Results -ARIEL3 (Investigator Assessment)RubracaPlaceboAll PatientsaPatients, N375189PFS events, n (%)234 (62%)167 (88%)PFS, median in months10.85.4HR (95% CI)0.36 (0.30, 0.45)p-value< 0.0001HRD GroupbPatients, N236118PFS events, n (%)134 (57%)101 (86%)PFS, median in months13.65.4HR (95% CI)0.32 (0.24, 0.42)p-value< 0.0001tBRCA GroupcPatients, N13066PFS events, n (%)67 (52%)56 (85%)PFS, median in months16.65.4HR (95% CI)0.23 (0.16, 0.34)p-value< 0.0001a All randomized patients.b HRD includes all patients with a deleterious germline or somatic BRCA mutation or high genomic loss of heterozygosity, as determined by the CTA.c tBRCA includes all patients with a deleterious germline or somatic BRCA mutation, as determined by the CTA.Figure 1: Kaplan-Meier Curves of Progression-Free Survival in ARIEL3 as Assessed by Investigator: All PatientsFigure 2: Kaplan-Meier Curves of Progression-Free Survival in ARIEL3 as Assessed by Investigator: HRD GroupFigure 3: Kaplan-Meier Curves of Progression-Free Survival in ARIEL3 as Assessed by Investigator: tBRCA GroupTreatment Of BRCA-mutated Ovarian Cancer After 2 Or More ChemotherapiesThe efficacy of Rubraca was investigated in 106 patients in two multicenter, single-arm, open-label clinical trials, Study 10 (NCT01482715) and ARIEL2 (NCT01891344), in patients with advanced BRCA-mutant ovarian cancer who had progressed after 2 or more prior chemotherapies. All 106 patients received Rubraca 600 mg orally twice daily as monotherapy until disease progression or unacceptable toxicity. Objective response rate (ORR) and duration of response (DOR) were assessed by the investigator and IRR according to RECIST v1.1.The median age of the patients was 59 years (range: 33 to 84), the majority were White (78%), and 100% had an ECOG performance status of 0 or 1. All patients had received at least two prior platinum-based chemotherapies and 43% had received 3 or more prior lines of platinum-based chemotherapy. There were 18/106 patients (17%) who had deleterious BRCA mutations detected in tumor tissue and not in whole blood specimens. Tumor BRCA mutation status was verified retrospectively in 96% (64/67) of the patients for whom a tumor tissue sample was available by the companion diagnostic FoundationFocus™ CDxBRCA test, which is FDA approved for selection of patients for Rubraca treatment.Efficacy results are summarized in Table 9.Table 9: Overall Response and Duration of Response in Patients with BRCA-mutant Ovarian Cancer Who Received 2 or More Chemotherapies in Study 10 and ARIEL2Investigator-assessedN=106Objective Response Rate (95% CI)54% (44, 64)Complete Response9%Partial Response45%Median DOR in months (95% CI)9.2 (6.6, 11.6)Response assessment by independent radiology review was 42% (95% CI [32, 52]), with a median DOR of 6.7 months (95% CI [5.5, 11.1]). Investigator-assessed ORR was 66% (52/79; 95% CI [54, 76]) in platinum-sensitive patients, 25% (5/20; 95% CI [9, 49]) in platinum-resistant patients, and 0% (0/7; 95% CI [0, 41]) in platinum-refractory patients. ORR was similar for patients with a BRCA1 gene mutation or BRCA2 gene mutation.Metastatic Castration-Resistant Prostate Cancer With BRCA mutationsThe efficacy of Rubraca was investigated in TRITON2 (NCT02952534), an ongoing multi-center, single arm clinical trial in patients with BRCA-mutated mCRPC who had been treated with androgen receptor-directed therapy and taxane-based chemotherapy. There were 115 patients with either germline or somatic BRCA mutations enrolled in TRITON2, of whom 62 patients had measurable disease at baseline by independent radiology review (IRR). Patients received Rubraca 600 mg orally twice daily until disease progression or unacceptable toxicity. Patients also received concomitant GnRH analog or had prior bilateral orchiectomy. Objective response rate (ORR) and duration of response (DOR) were assessed in patients with measurable disease by blinded IRR and by the investigator according to modified RECIST v1.1/ Prostate Cancer Working Group 3 (PCWG3) criteria.For the 62 patients with measurable disease at baseline, the median age was 73 years (range 52 to 88); the majority were White (73%) and 10% were Black; and 98% of patients had an ECOG performance status of 0 or 1. All patients had received at least one prior androgen receptor-directed therapy, 34% had received 2 prior androgen receptor-directed therapies and 2% had received 3 prior androgen receptor-directed therapies, and all patients also received prior taxane chemotherapy. Eighteen percent of patients had lung and 21% had liver metastases at baseline. Twenty-four percent had metastases to lymph nodes alone. Forty percent had 10 or more bone lesions at baseline.All 62 patients had a deleterious somatic or germline BRCA mutation detected from either central plasma (26%), central tissue (32%), or local (42%) testing. Of the 62 patients, 66% had a somatic BRCA mutation, 34% had a germline BRCA mutation, 85% had a BRCA2 mutation, and 15% had a BRCA1 mutation.The major efficacy outcomes of the study were confirmed ORR by IRR using modified RECIST v1.1/PCWG3 criteria and DOR. Efficacy results of TRITON2 are provided in Table 10. The ORR by IRR was similar in patients with germline versus somatic BRCA mutation.Table 10: Efficacy Results in Patients with BRCA-mutated mCRPC -TRITON2 (IRR-assessed)Rubraca(N = 62)Confirmed Objective Response Rate (95% CI)a44% (31, 57)Median DOR in months (95% CI)bNE (6.4, NE)NE = not evaluablea Defined per modified RECIST v1.1 criteria and with no confirmed bone progression per PCWG3.b The range for the DOR was 1.7-24+ months. Fifteen of the 27 (56%) patients with a confirmed objective response had a DOR of ≥ 6 months. Medication Guide PATIENT INFORMATIONRubraca®(roo-brah’-kah)(rucaparib) tabletsWhat is the most important information I should know about Rubraca?Rubraca may cause serious side effects including: Bone marrow problems called Myelodysplastic Syndrome (MDS) or a type of cancer of the blood calledAcute Myeloid Leukemia (AML). Some people who have cancer and who have received previous treatment with chemotherapy or certain other medicines for their cancer have developed MDS or AML during or after treatment with Rubraca. MDS or AML may lead to death. If you develop MDS or AML, your healthcare provider will stop treatment with Rubraca.Symptoms of low blood cell counts are common during treatment with Rubraca, but can be a sign of serious problems, including MDS or AML. Tell your healthcare provider if you have any of the following symptoms during treatment with Rubraca:weaknessweight lossfeverfrequent infectionsblood in urine or stoolshortness of breathfeeling very tiredbruising or bleeding more easilyYour healthcare provider will do blood tests to check your blood cell counts:before treatment with Rubraca.every month during treatment with Rubraca.weekly if you have low blood cell counts for a long time. Your healthcare provider may stop treatment with Rubraca until your blood cell counts improve.See “What are possible side effects of Rubraca?” for more information about side effects.What is Rubraca?Rubraca is a prescription medicine used in adults for:the maintenance treatment of ovarian cancer, fallopian tube cancer, or primary peritoneal cancer when your cancer has come back and you are in response (complete or partial response) to a platinum-based chemotherapy.the treatment of ovarian cancer, fallopian tube cancer, or primary peritoneal cancer with a certain type of inherited (germline) or acquired (somatic) abnormal BRCA gene, and you have been treated with 2 or more chemotherapy medicines for your cancer. Your healthcare provider will perform a test to make sure Rubraca is right for you.the treatment of castration-resistant prostate cancer (prostate cancer that no longer responds to medical or surgical treatment that lowers testosterone):that has spread to other parts of the body, andhas a certain type of inherited (germline) or acquired (somatic) abnormal BRCA gene, and you have been treated with certain medicines for your cancer.Your healthcare provider will perform a test to make sure Rubraca is right for you.It is not known if Rubraca is safe and effective in children.Before you take Rubraca, tell your healthcare provider about all of your medical conditions, including if you:are pregnant or plan to become pregnant. Rubraca can harm your unborn baby and may cause loss of pregnancy (miscarriage). You should not become pregnant during treatment with Rubraca.If you are able to become pregnant, your healthcare provider may do a pregnancy test before you start treatment with Rubraca.Females who are able to become pregnant should use effective birth control during treatment and for 6 months after the last dose of Rubraca. Talk to your healthcare provider about birth control methods that may be right for you. Tell your healthcare provider right away if you become pregnant.Males with female partners who are pregnant or able to become pregnant should use effective birth control during treatment and for 3 months after the last dose of Rubraca.Males should not donate sperm during treatment and for 3 months after the last dose of Rubraca.are breastfeeding or plan to breastfeed. It is not known if Rubraca passes into breast milk. Do not breastfeed during treatment and for 2 weeks after the last dose of Rubraca. Talk to your healthcare provider about the best way to feed your baby during this time.Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements.How should I take Rubraca?Take Rubraca exactly as your healthcare provider tells you.Your healthcare provider may temporarily stop treatment with Rubraca or change your dose of Rubraca if you have side effects. Do not change your dose or stop taking Rubraca unless your healthcare provider tells you to.Take Rubraca 2 times a day. Each dose should be taken about 12 hours apart.Take Rubraca with or without food.If you are taking Rubraca for prostate cancer and you are receiving gonadotropin-releasing hormone (GnRH) analog therapy, you should continue with this treatment during your treatment with Rubraca unless you have had a surgery to lower the amount of testosterone in your body (surgical castration).If you miss a dose of Rubraca, take your next dose at your usual scheduled time. Do not take an extra dose to make up for a missed dose.If you vomit after taking a dose of Rubraca, do not take an extra dose. Take your next dose at your usual time.If you take too much Rubraca, call your healthcare provider or go to the nearest emergency room right away.What should I avoid while taking Rubraca?Avoid spending time in sunlight. Rubraca can make your skin sensitive to the sun (photosensitivity). You may sunburn more easily during treatment with Rubraca. You should wear a hat and clothes that cover your skin and use sunscreen to help protect against sunburn if you have to be in the sunlight.What are the possible side effects of Rubraca?Rubraca may cause serious side effects.See “What is the most important information I should know about Rubraca?”The most common side effects of Rubraca in people with ovarian cancer include:nauseatiredness or weaknessvomitingdecrease in hemoglobin (anemia)changes in how food tasteschanges in liver function testsconstipationdecreased appetitediarrhealow blood cell countsmouth soresupper respiratory tract infectionshortness of breathrashstomach (abdomen) pain or swellingThe most common side effects of Rubraca in people with prostate cancer include:tiredness or weaknessnauseadecrease in hemoglobin (anemia)changes in liver function testsdecreased appetiterashconstipationlow blood cell countsvomitingdiarrheaThese are not all of the possible side effects of Rubraca. For more information, ask your healthcare provider or pharmacist.Call your healthcare provider for medical advice about side effects. You may report side effects to FDA at 1-800FDA-1088.How should I store Rubraca?Store Rubraca at room temperature between 68°F to 77°F (20°C to 25°C).Keep Rubraca and all medicines out of the reach of children.General information about the safe and effective use of Rubraca.Medicines are sometimes prescribed for purposes other than those listed in a Patient Information leaflet. Do not use Rubraca for a condition for which it was not prescribed. Do not give it to other people, even if they have the same symptoms you have. It may harm them. You can ask your healthcare provider or pharmacist for more information about Rubraca.What are the ingredients in Rubraca?Active ingredient: rucaparibInactive ingredients: microcrystalline cellulose, sodium starch glycolate, colloidal silicon dioxide, and magnesium stearate. The film coating contains polyvinyl alcohol, titanium dioxide, polyethylene glycol/macrogol, and talc. The blue film coating contains brilliant blue aluminum lake and indigo carmine aluminum lake. The yellow film coating contains yellow iron oxide.This Patient Information has been approved by the U.S. Food and Drug Administration.
