Votrient

What is Votrient and how is it used?

Votrient is a prescription medicine used to treat the symptoms of Soft Tissue Sarcomas and Advanced Renal Cell Carcinoma. Votrient may be used alone or with other medications.

Votrient belongs to a class of drugs called Antineoplastics, Tyrosine Kinase Inhibitor; Antineoplastics, VEGF Inhibitor.

It is not known if Votrient is safe and effective in children.

What are possible side effects of Votrient?

Side effects of Votrient include:

• hives,
• difficulty breathing,
• swelling of your face, lips, tongue, or throat,
• unusual bleeding or bruising,
• slow healing of a wound or surgical incision,
• any wound that will not heal,
• sudden chest pain or discomfort,
• wheezing,
• dry cough,
• headache,
• confusion,
• change in mental status,
• vision loss,
• seizure,
• sudden numbness or weakness,
• severe headache,
• slurred speech,
• vision problems,
• chest pain,
• sudden shortness of breath,
• pain or cold feeling in an arm or leg,
• chest pain or pressure,
• pain spreading to your jaw or shoulder,
• nausea,
• sweating,
• feeling short of breath,
• swelling or rapid weight gain,
• headache with chest pain and severe dizziness,
• fainting,
• fast or pounding heartbeats,
• bloody or tarry stools,
• coughing up blood,
• vomit that looks like coffee grounds,
• fever,
• sore throat,
• cough,
• flu symptoms,
• body aches,
• skin sores,
• pain or burning when you urinate,
• severe headache,
• blurred vision,
• pounding in your neck or ears, and
• anxiety

Get medical help right away, if you have any of the symptoms listed above.

The most common side effects of Votrient include:

• nausea,
• vomiting,
• diarrhea,
• stomach pain,
• loss of appetite,
• weight loss,
• trouble breathing,
• tumor pain,
• bone pain,
• muscle pain,
• headache,
• feeling tired,
• changes in hair color, and
• changes in your sense of taste

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 Votrient. 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

VOTRIENT (pazopanib) is a tyrosine kinase inhibitor (TKI). Pazopanib is presented as the hydrochloride salt, with the chemical name 5-[[4-[(2,3-dimethyl-2H-indazol-6-yl)methylamino]-2- pyrimidinyl]amino]-2-methylbenzenesulfonamide monohydrochloride. It has the molecular formula C₂₁H₂₃N₇O₂S•HCl and a molecular weight of 473.99. Pazopanib hydrochloride has the following chemical structure:

Pazopanib hydrochloride is a white to slightly yellow solid. It is very slightly soluble at pH 1 and practically insoluble above pH 4 in aqueous media.

Tablets of VOTRIENT are for oral administration. Each 200-mg tablet of VOTRIENT contains 216.7 mg of pazopanib hydrochloride, equivalent to 200 mg of pazopanib free base.

The inactive ingredients of VOTRIENT are: Tablet Core: Magnesium stearate, microcrystalline cellulose, povidone, sodium starch glycolate. Coating: Gray film-coat: Hypromellose, iron oxide black, macrogol/polyethylene glycol 400 (PEG 400), polysorbate 80, titanium dioxide.

INDICATIONS

Renal Cell Carcinoma

VOTRIENT^® is indicated for the treatment of adults with advanced renal cell carcinoma (RCC).

Soft Tissue Sarcoma

VOTRIENT is indicated for the treatment of adults with advanced soft tissue sarcoma (STS) who have received prior chemotherapy.

Limitations Of Use

The efficacy of VOTRIENT for the treatment of patients with adipocytic STS or gastrointestinal stromal tumors has not been demonstrated.

DOSAGE AND ADMINISTRATION

Recommended Dosage

The recommended dosage of VOTRIENT is 800 mg orally once daily without food (at least 1 hour before or 2 hours after a meal) until disease progression or unacceptable toxicity [see CLINICAL PHARMACOLOGY]. The dosage should be modified for hepatic impairment and in patients taking certain concomitant drugs [see Dosage Modifications For Hepatic Impairment, Dosage Modifications For Drug Interactions].

Swallow tablets whole. Do not crush tablets due to the potential for increased rate of absorption which may affect systemic exposure [see CLINICAL PHARMACOLOGY].

If a dose is missed, it should not be taken if it is less than 12 hours until the next dose.

Dosage Modifications For Adverse Reactions

Table 1 summarizes the recommended dose reductions.

Table 1. Recommended Dose Reductions of VOTRIENT for Adverse Reactions

Dose Reduction	For Renal Cell Carcinoma	For Soft Tissue Sarcoma
First	400 mg orally once daily	600 mg orally once daily
Second	200 mg orally once daily	400 mg orally once daily

Permanently discontinue VOTRIENT in patients unable to tolerate the second dose reduction.

Table 2 summarizes the recommended dosage modifications for adverse reactions.

Table 2. Recommended Dosage Modifications of VOTRIENT for Adverse Reactions

Adverse Reaction	Severitya	Dosage Modification
Hepatic Toxicity [see WARNINGS AND PRECAUTIONS]	Isolated ALT elevations between 3 x ULN and 8 x ULN	Continue and monitor liver function weekly until ALT returns to Grade 1 or baseline.
	Isolated ALT elevations of > 8 x ULN	Withhold until improvement to Grade 1 or baseline. If the potential benefit for resuming treatment with VOTRIENT is considered to outweigh the risk for hepatotoxicity, then resume at a reduced dose of no more than 400 mg once daily and measure serum liver tests weekly for 8 weeks.
		Permanently discontinue if ALT elevations > 3 x ULN recur despite dose reduction(s).
	ALT elevations > 3 x ULN occur concurrently with bilirubin elevations > 2 x ULN	Permanently discontinue and continue to monitor until resolution.
		Patients with only a mild, indirect (unconjugated) hyperbilirubinemia, known as Gilbert’s syndrome, and ALT elevations > 3 x ULN should be managed per the recommendations outlined for isolated ALT elevations.
Left Ventricular Systolic Dysfunction [see WARNINGS AND PRECAUTIONS]	Symptomatic or Grade 3	Withhold until improvement to Grade < 3. Resume treatment based on medical judgement.
	Grade 4	Permanently discontinue
Hemorrhagic Events [see WARNINGS AND PRECAUTIONS]	Grade 2	Withhold until improvement to Grade ≤ 1. Resume at reduced dose (see Table 1).
		Permanently discontinue if Grade 2 recurs after dose interruption and reduction.
	Grade 3 or 4	Permanently discontinue.
Arterial Thromboembolic Events [see WARNINGS AND PRECAUTIONS]	Any grade	Permanently discontinue.
Venous Thromboembolic Events [see WARNINGS AND PRECAUTIONS]	Grade 3	Withhold VOTRIENT and resume at same dose if managed with appropriate therapy for at least one week.
	Grade 4	Permanently discontinue.
Thrombotic Microangiopathy [see WARNINGS AND PRECAUTIONS]	Any grade	Permanently discontinue.
Gastrointestinal Perforation [see WARNINGS AND PRECAUTIONS]	Any grade	Permanently discontinue.
Gastrointestinal Fistula [see WARNINGS AND PRECAUTIONS]	Grade 2 or 3	Withhold and resume based on medical judgement.
	Grade 4	Permanently discontinue.
Interstitial Lung Disease (ILD)/Pneumonitis [see WARNINGS AND PRECAUTIONS]	Any grade	Permanently discontinue.
Posterior Reversible Encephalopathy Syndrome (PRES) [see WARNINGS AND PRECAUTIONS]	Any grade	Permanently discontinue.
Hypertension [see WARNINGS AND PRECAUTIONS]	Grade 2 or 3	Reduce dose (see Table 1) and initiate or adjust anti-hypertensive therapy. Permanently discontinue if hypertension remains Grade 3 despite dose reduction(s) and adjustment of anti-hypertensive therapy.
	Grade 4 or hypertensive crisis	Permanently discontinue.
Proteinuria [see WARNINGS AND PRECAUTIONS]	24-hour urine protein ≥ 3 grams	Withhold until improvement to Grade ≤ 1. Resume at a reduced dose (see Table 1).
		Permanently discontinue if 24-hour urine protein ≥ 3 grams does not improve or recurs despite dose reductions.
	Confirmed nephrotic syndrome	Permanently discontinue.
Abbreviations: ALT, alanine aminotransferase; LVEF, left ventricular ejection fraction; RCC, renal cell carcinoma; STS, soft tissue sarcoma; ULN, upper limit of normal. aNational Cancer Institute Common Terminology Criteria for Adverse Events, version 5.

Dosage Modifications For Hepatic Impairment

Moderate And Severe Hepatic Impairment

In patients with moderate hepatic impairment [total bilirubin > 1.5 to 3 x upper limit of normal (ULN) and any alanine aminotransferase (ALT) value], consider alternatives to VOTRIENT. If VOTRIENT is used in patients with moderate hepatic impairment, reduce the VOTRIENT dose to 200 mg orally once daily.

VOTRIENT is not recommended in patients with severe hepatic impairment (total bilirubin > 3 x ULN and any ALT value) [see Use In Specific Populations].

Dosage Modifications For Drug Interactions

Strong CYP3A4 Inhibitors

Avoid concomitant use of strong CYP3A4 inhibitors by use of an alternate concomitant medication with no or minimal potential to inhibit CYP3A4. If coadministration of a strong CYP3A4 inhibitor is warranted, reduce the dose of VOTRIENT to 400 mg [see DRUG INTERACTIONS].

Strong CYP3A4 Inducers

Avoid concomitant use of strong CYP3A4 inducers by use of an alternate concomitant medication with no or minimal enzyme induction potential. VOTRIENT is not recommended in patients who cannot avoid chronic use of strong CYP3A4 inducers [see DRUG INTERACTIONS].

Gastric Acid-Reducing Agents

Avoid concomitant use of gastric acid-reducing agents. If concomitant use of a gastric acid-reducing agent cannot be avoided, consider short-acting antacid in place of proton pump inhibitors (PPIs) and H2-receptor antagonists. Separate short-acting antacid and VOTRIENT dosing by several hours [see DRUG INTERACTIONS, CLINICAL PHARMACOLOGY].

HOW SUPPLIED

Dosage Forms And Strengths

Tablets

200 mg, modified capsule-shaped, gray, film-coated with ‘GS JT’ debossed on one side.

Storage And Handling

VOTRIENT 200 mg tablets are supplied as modified capsule-shaped, gray, film-coated with ‘GS JT’ debossed on one side and are available in:

• Bottles of 120 tablets: NDC 0078-0670-66

Store at room temperature between 20°C and 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: Novartis Pharmaceuticals Corporation, East Hanover, New Jersey 07936. Revised: Aug 2020

SIDE EFFECTS

The following serious adverse reactions are discussed in greater detail in other sections of the labeling:

• Hepatic Toxicity and Hepatic Impairment [see WARNINGS AND PRECAUTIONS]
• QT Prolongation and Torsades de Pointes [see WARNINGS AND PRECAUTIONS]
• Cardiac Dysfunction [see WARNINGS AND PRECAUTIONS]
• Hemorrhagic Events [see WARNINGS AND PRECAUTIONS]
• Arterial and Venous Thromboembolic Events [see WARNINGS AND PRECAUTIONS]
• Thrombotic Microangiopathy [see WARNINGS AND PRECAUTIONS]
• Gastrointestinal Perforation and Fistula [see WARNINGS AND PRECAUTIONS]
• Interstitial Lung Disease/Pneumonitis [see WARNINGS AND PRECAUTIONS]
• Reversible Posterior Leukoencephalopathy Syndrome [see WARNINGS AND PRECAUTIONS]
• Hypertension [see WARNINGS AND PRECAUTIONS]
• Hypothyroidism [see WARNINGS AND PRECAUTIONS]
• Proteinuria [see WARNINGS AND PRECAUTIONS]
• Tumor Lysis Syndrome [see WARNINGS AND PRECAUTIONS]
• Infection [see WARNINGS AND PRECAUTIONS]
• Increased Toxicity with Other Cancer Therapy [see WARNINGS AND PRECAUTIONS]

Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared with rates in the clinical trials of another drug and may not reflect the rates observed in practice.

Renal Cell Carcinoma

The safety of VOTRIENT has been evaluated in 977 patients in the monotherapy trials which included 586 patients with RCC at the time of NDA submission. With a median duration of treatment of 7.4 months (range, 0.1 to 27.6), the most commonly observed adverse reactions (greater than or equal to 20%) in the 586 patients were diarrhea, hypertension, hair color change, nausea, fatigue, anorexia, and vomiting.

The data described below reflect the safety profile of VOTRIENT in 290 RCC patients who participated in a randomized, double-blind, placebo-controlled trial [see Clinical Studies]. The median duration of treatment was 7.4 months (range, 0 to 23) for patients who received VOTRIENT and 3.8 months (range, 0 to 22) for the placebo arm. Forty-two percent of patients on VOTRIENT required a dose interruption. Thirty-six percent of patients on VOTRIENT were dose reduced. Table 1 presents the most common adverse reactions occurring in greater than or equal to 10% of patients who received VOTRIENT.

Table 1: Adverse Reactions Occurring in Greater Than or Equal to 10% of Patients with RCC Who Received VOTRIENT

Adverse Reactions	VOTRIENT (N = 290)			Placebo (N = 145)
	All Gradesa %	Grade 3 %	Grade 4 %	All Gradesa %	Grade 3 %	Grade 4 %
Diarrhea	52	3	< 1	9	< 1	0
Hypertension	40	4	0	10	< 1	0
Hair color changes	38	< 1	0	3	0	0
Nausea	26	< 1	0	9	0	0
Anorexia	22	2	0	10	< 1	0
Vomiting	21	2	< 1	8	2	0
Fatigue	19	2	0	8	1	1
Asthenia	14	3	0	8	0	0
Abdominal pain	11	2	0	1	0	0
Headache	10	0	0	5	0	0
Abbreviation: RCC, renal cell carcinoma. a National Cancer Institute Common Terminology Criteria for Adverse Events, version 3.

Other adverse reactions observed more commonly in patients treated with VOTRIENT than placebo and that occurred in less than 10% (any grade) were alopecia (8% versus less than 1%), chest pain (5% versus 1%), dysgeusia (altered taste) (8% versus less than 1%), dyspepsia (5% versus less than 1%), dysphonia (4% versus less than 1%), facial edema (1% versus 0%), palmar-plantar erythrodysesthesia (hand-foot syndrome) (6% versus less than 1%), proteinuria (9% versus 0%), rash (8% versus 3%), skin depigmentation (3% versus 0%), and weight decreased (9% versus 3%).

Additional adverse reactions from other clinical trials in RCC patients treated with VOTRIENT are listed below:

Musculoskeletal and Connective Tissue Disorders: Arthralgia, muscle spasms.

Table 2 presents the most common laboratory abnormalities occurring in greater than 10% of patients who received VOTRIENT and more commonly (greater than or equal to 5%) in patients who received VOTRIENT versus placebo.

Table 2: Selected Laboratory Abnormalities Occurring in Greater Than 10% of Patients with RCC Who Received VOTRIENT and More Commonly (Greater Than or Equal to 5%) in Patients Who Received VOTRIENT Versus Placebo

Parameters	VOTRIENT (N = 290)			Placebo (N = 145)
	All Gradesa %	Grade 3 %	Grade 4 %	All Gradesa %	Grade 3 %	Grade 4 %
Hematologic
Leukopenia	37	0	0	6	0	0
Neutropenia	34	1	< 1	6	0	0
Thrombocytopenia	32	< 1	< 1	5	0	< 1
Lymphocytopenia	31	4	< 1	24	1	0
Chemistry
ALT increased	53	10	2	22	1	0
AST increased	53	7	< 1	19	< 1	0
Glucose increased	41	< 1	0	33	1	0
Total bilirubin increased	36	3	< 1	10	1	< 1
Phosphorus decreased	34	4	0	11	0	0
Sodium decreased	31	4	1	24	4	0
Magnesium decreased	26	< 1	1	14	0	0
Glucose decreased	17	0	< 1	3	0	0
Abbreviation: ALT, alanine aminotransferase; AST, aspartate aminotransferase; RCC, renal cell carcinoma. a National Cancer Institute Common Terminology Criteria for Adverse Events, version 3.

Soft Tissue Sarcoma

The safety of VOTRIENT has been evaluated in 382 patients with advanced soft tissue sarcoma, with a median duration of treatment of 3.6 months (range, 0 to 53). The most commonly observed adverse reactions (greater than or equal to 20%) in the 382 patients were fatigue, diarrhea, nausea, decreased weight, hypertension, decreased appetite, vomiting, tumor pain, hair color changes, musculoskeletal pain, headache, dysgeusia, dyspnea, and skin hypopigmentation.

The data described below reflect the safety profile of VOTRIENT in 240 patients who participated in a randomized, double-blind, placebo-controlled trial [see Clinical Studies]. The median duration of treatment was 4.5 months (range, 0 to 24) for patients who received VOTRIENT and 1.9 months (range, 0 to 24) for the placebo arm. Fifty-eight percent of patients on VOTRIENT required a dose interruption. Thirty-eight percent of patients on VOTRIENT had their dose reduced. Seventeen percent of patients who received VOTRIENT discontinued therapy due to adverse reactions. Table 3 presents the most common adverse reactions occurring in greater than or equal to 10% of patients who received VOTRIENT.

Table 3: Adverse Reactions Occurring in Greater Than or Equal to 10% of Patients with STS Who Received VOTRIENT

Adverse Reactions	VOTRIENT (N = 240)			Placebo (N = 123)
	All Gradesa %	Grade 3 %	Grade 4 %	All Gradesa %	Grade 3 %	Grade 4 %
Fatigue	65	13	1	48	4	1
Diarrhea	59	5	0	15	1	0
Nausea	56	3	0	22	2	0
Weight decreased	48	4	0	15	0	0
Hypertension	42	7	0	6	0	0
Appetite decreased	40	6	0	19	0	0
Hair color changes	39	0	0	2	0	0
Vomiting	33	3	0	11	1	0
Tumor pain	29	8	0	21	7	2
Dysgeusia	28	0	0	3	0	0
Headache	23	1	0	8	0	0
Musculoskeletal pain	23	2	0	20	2	0
Myalgia	23	2	0	9	0	0
Gastrointestinal pain	23	3	0	9	4	0
Dyspnea	20	5	< 1	17	5	1
Exfoliative rash	18	< 1	0	9	0	0
Cough	17	< 1	0	12	< 1	0
Peripheral edema	14	2	0	9	2	0
Mucositis	12	2	0	2	0	0
Alopecia	12	0	0	1	0	0
Dizziness	11	1	0	4	0	0
Skin disorderb	11	2	0	1	0	0
Skin hypopigmentation	11	0	0	0	0	0
Stomatitis	11	< 1	0	3	0	0
Chest pain	10	2	0	6	0	0
Abbreviation: STS, soft tissue sarcoma. a National Cancer Institute Common Terminology Criteria for Adverse Events, version 3. b 27 of the 28 cases of skin disorder were palmar-plantar erythrodysesthesia.

Other adverse reactions observed more commonly in patients treated with VOTRIENT that occurred in greater than or equal to 5% of patients and at an incidence of more than 2% difference from placebo included insomnia (9% versus 6%), hypothyroidism (8% versus 0%), dysphonia (8% versus 2%), epistaxis (8% versus 2%), left ventricular dysfunction (8% versus 4%), dyspepsia (7% versus 2%), dry skin (6% versus less than 1%), chills (5% versus 1%), vision blurred (5% versus 2%), and nail disorder (5% versus 0%).

Table 4 presents the most common laboratory abnormalities occurring in greater than 10% of patients who received VOTRIENT and more commonly (greater than or equal to 5%) in patients who received VOTRIENT versus placebo.

Table 4: Selected Laboratory Abnormalities Occurring in Greater Than 10% of Patients with STS Who Received VOTRIENT and More Commonly (≥ 5%) in Patients Who Received VOTRIENT Versus Placebo

Parameters	VOTRIENT (N = 240)			Placebo (N = 123)
	All Gradesa %	Grade 3 %	Grade 4 %	All Gradesa %	Grade 3 %	Grade 4 %
Hematologic
Leukopenia	44	1	0	15	0	0
Lymphocytopeni a	43	10	0	36	9	2
Thrombocytopeni a	36	3	1	6	0	0
Neutropenia	33	4	0	7	0	0
Chemistry
AST increased	51	5	3	22	2	0
ALT increased	46	8	2	18	2	1
Glucose increased	45	< 1	0	35	2	0
Albumin decreased	34	1	0	21	0	0
Alkaline phosphatase increased	32	3	0	23	1	0
Sodium decreased	31	4	0	20	3	0
Total bilirubin increased	29	1	0	7	2	0
Potassium increased	16	1	0	11	0	0
Abbreviation: ALT, alanine aminotransferase; AST, aspartate aminotransferase; STS, soft tissue sarcoma. a National Cancer Institute Common Terminology Criteria for Adverse Events, version 3.

Diarrhea

Diarrhea occurred frequently and was predominantly mild-to-moderate in severity in both the RCC and STS clinical trials. Patients should be advised how to manage mild diarrhea and to notify their healthcare provider if moderate to severe diarrhea occurs so appropriate management can be implemented to minimize its impact.

Lipase Elevations

In a single-arm RCC trial, increases in lipase values were observed for 27% (48/181) of patients. Elevations in lipase as an adverse reaction were reported for 4% (10/225) of patients and were Grade 3 for 6 patients and Grade 4 for 1 patient. In the RCC trials of VOTRIENT, clinical pancreatitis was observed in less than 1% (4/586) of patients.

Pneumothorax

Two of 290 patients treated with VOTRIENT and no patient on the placebo arm in the randomized RCC trial developed a pneumothorax. In the randomized trial of VOTRIENT for the treatment of STS, pneumothorax occurred in 3% (8/240) of patients treated with VOTRIENT and in no patients on the placebo arm.

Bradycardia

In the randomized trial of VOTRIENT for the treatment of RCC, bradycardia based on vital signs (less than 60 beats per minute) was observed in 19% (52/280) of patients treated with VOTRIENT and in 11% (16/144) of patients on the placebo arm. Bradycardia was reported as an adverse reaction in 2% (7/290) of patients treated with VOTRIENT compared with less than 1% (1/145) of patients treated with placebo. In the randomized trial of VOTRIENT for the treatment of STS, bradycardia based on vital signs (less than 60 beats per minute) was observed in 19% (45/238) of patients treated with VOTRIENT and in 4% (5/121) of patients on the placebo arm. Bradycardia was reported as an adverse reaction in 2% (4/240) of patients treated with VOTRIENT compared with less than 1% (1/123) of patients treated with placebo.

Adverse Reactions In East Asian Patients

In an analysis of pooled clinical trials (N = 1938) with VOTRIENT, Grade 3 and Grade 4 adverse reactions were observed more frequently in patients of East Asian descent than in patients of non-East Asian descent for neutropenia (12% versus 2%), thrombocytopenia (6% versus less than 1%), and palmar-plantar erythrodysethesia syndrome (6% versus 2%).

Postmarketing Experience

The following adverse reactions have been identified during post-approval use of VOTRIENT. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate the frequency or establish a causal relationship to drug exposure.

Blood and Lymphatic System Disorders: Polycythemia

Eye Disorders: Retinal detachment/tear

Gastrointestinal Disorders: Pancreatitis

Metabolic and Nutrition Disorder: Tumor Lysis Syndrome (including fatal cases) [see WARNINGS AND PRECAUTIONS]

Vascular Disorders: Arterial (including aortic) aneurysms, dissections, and rupture

DRUG INTERACTIONS

Drugs That Inhibit Or Induce Cytochrome P450 3A4 Enzymes

In vitro studies suggested that the oxidative metabolism of pazopanib in human liver microsomes is mediated primarily by CYP3A4, with minor contributions from CYP1A2 and CYP2C8. Therefore, inhibitors and inducers of CYP3A4 may alter the metabolism of pazopanib.

CYP3A4 Inhibitors

Coadministration of pazopanib with strong inhibitors of CYP3A4 (e.g., ketoconazole, ritonavir, clarithromycin) increases pazopanib concentrations and should be avoided. Consider an alternate concomitant medication with no or minimal potential to inhibit CYP3A4 [see CLINICAL PHARMACOLOGY]. If coadministration of a strong CYP3A4 inhibitor is warranted, reduce the dose of VOTRIENT to 400 mg [see DOSAGE AND ADMINISTRATION]. Grapefruit or grapefruit juice should be avoided as it inhibits CYP3A4 activity and may also increase plasma concentrations of pazopanib.

CYP3A4 Inducers

CYP3A4 inducers, such as rifampin, may decrease plasma pazopanib concentrations. Consider an alternate concomitant medication with no or minimal enzyme induction potential. VOTRIENT should not be used if chronic use of strong CYP3A4 inducers cannot be avoided [see DOSAGE AND ADMINISTRATION].

Drugs That Inhibit Transporters

In vitro studies suggested that pazopanib is a substrate of P-glycoprotein (P-gp) and breast cancer resistance protein (BCRP). Therefore, absorption and subsequent elimination of pazopanib may be influenced by products that affect P-gp and BCRP.

Concomitant treatment with strong inhibitors of P-gp or BCRP should be avoided due to risk of increased exposure to pazopanib. Selection of alternative concomitant medicinal products with no or minimal potential to inhibit P-gp or BCRP should be considered.

Effects Of Pazopanib On CYP Substrates

Results from drug-drug interaction trials conducted in cancer patients suggest that pazopanib is a weak inhibitor of CYP3A4, CYP2C8, and CYP2D6 in vivo, but had no effect on CYP1A2, CYP2C9, or CYP2C19 [see CLINICAL PHARMACOLOGY].

Concomitant use of VOTRIENT with agents with narrow therapeutic windows that are metabolized by CYP3A4, CYP2D6, or CYP2C8 is not recommended. Coadministration may result in inhibition of the metabolism of these products and create the potential for serious adverse events [see CLINICAL PHARMACOLOGY].

Effect Of Concomitant Use Of VOTRIENT And Simvastatin

Concomitant use of VOTRIENT and simvastatin increases the incidence of ALT elevations. Across monotherapy trials with VOTRIENT, ALT greater than 3 x ULN was reported in 126/895 (14%) of patients who did not use statins, compared with 11/41 (27%) of patients who had concomitant use of simvastatin. If a patient receiving concomitant simvastatin develops ALT elevations, follow dosing guidelines for VOTRIENT or consider alternatives to VOTRIENT [see WARNINGS AND PRECAUTIONS]. Alternatively, consider discontinuing simvastatin [see WARNINGS AND PRECAUTIONS]. Insufficient data are available to assess the risk of concomitant administration of alternative statins and VOTRIENT.

Drugs That Raise Gastric pH

In a drug interaction trial in patients with solid tumors, concomitant administration of pazopanib with esomeprazole, a proton pump inhibitor (PPI), decreased the exposure of pazopanib by approximately 40% (AUC and Cmax). Therefore, concomitant use of VOTRIENT with drugs that raise gastric pH should be avoided. If such drugs are needed, short-acting antacids should be considered in place of PPIs and H2-receptor antagonists. Separate antacid and pazopanib dosing by several hours to avoid a reduction in pazopanib exposure [see CLINICAL PHARMACOLOGY].

WARNINGS

Included as part of the "PRECAUTIONS" Section

PRECAUTIONS

Hepatic Toxicity

Hepatotoxicity, manifested as increases in alanine aminotransferase (ALT), aspartate aminotransferase (AST) and bilirubin, occurred in patients who received VOTRIENT. This hepatotoxicity can be severe and fatal. Patients older than 65 years are at greater risk for hepatotoxicity [see Use In Specific Populations]. Transaminase elevations occur early in the course of treatment; 92% of all transaminase elevations of any grade occurred in the first 18 weeks.

In the randomized RCC trial (VEG105192), ALT > 3 x upper limit of normal (ULN) occurred in 18% and ALT > 10 x ULN occurred in 4% of the 290 patients who received VOTRIENT. Concurrent elevation in ALT > 3 x ULN and bilirubin > 2 x ULN in the absence of significant alkaline phosphatase > 3 x ULN occurred in 2%. In the monotherapy trials, 2 patients died with disease progression and hepatic failure.

In the randomized STS trial (VEG110727), ALT > 3 x ULN occurred in 18% and ALT > 8 x ULN occurred in 5% of the 240 patients who received VOTRIENT. Concurrent elevation in ALT > 3 x ULN and bilirubin > 2 x ULN in the absence of significant alkaline phosphatase > 3 x ULN occurred in 2%. One patient died of hepatic failure.

Monitor liver tests at baseline; at Weeks 3, 5, 7, and 9; at Month 3 and Month 4; and then periodically as clinically indicated. Increase to weekly monitoring for patients with elevated ALT until ALT returns to Grade 1 or baseline. Withhold VOTRIENT and resume at reduced dose with continued weekly monitoring for 8 weeks, or permanently discontinue with weekly monitoring until resolution based on severity of hepatotoxicity [see DOSAGE AND ADMINISTRATION].

Gilbert’s Syndrome

VOTRIENT is a uridine diphosphate (UDP)-glucuronosyl transferase 1A1 (UGT1A1) inhibitor. Mild, indirect (unconjugated) hyperbilirubinemia may occur in patients with Gilbert’s syndrome [see CLINICAL PHARMACOLOGY]. In patients with only a mild indirect hyperbilirubinemia known as Gilbert’s syndrome, manage elevation in ALT > 3 x ULN per the recommendations outlined for isolated ALT elevations [see DOSAGE AND ADMINISTRATION].

Concomitant Use Of Simvastatin

Concomitant use of VOTRIENT and simvastatin increases the risk of ALT elevations [see DRUG INTERACTIONS]. Insufficient data are available to assess the risk of concomitant administration of alternative statins and VOTRIENT.

QT Prolongation And Torsades De Pointes

In the RCC trials, 558/586 patients were subject to routine electrocardiogram (ECG) monitoring and QT prolongation ≥ 500 msec was identified in 2% of these 558 patients. In monotherapy trials, Torsades de pointes occurred in < 1% of 977 patients who received VOTRIENT.

In the randomized RCC (VEG105192) and STS (VEG110727) trials, 1% (3/290) and 0.4% (1/240) of patients, respectively, who received VOTRIENT had post-baseline values between 500 to 549 msec. Post-baseline QT data were only collected in the STS trial if ECG abnormalities were reported as an adverse reaction.

Monitor patients who are at significant risk of developing QTc prolongation, including patients with a history of QT interval prolongation, in patients taking antiarrhythmics or other medications that may prolong QT interval, and those with relevant preexisting cardiac disease [see DRUG INTERACTIONS]. Monitor ECG and electrolytes (e.g., calcium, magnesium, potassium) at baseline and as clinically indicated. Correct hypokalemia, hypomagnesemia and hypocalcemia prior to initiating VOTRIENT and during treatment.

Cardiac Dysfunction

Cardiac dysfunction, including decreased left ventricular ejection fraction (LVEF) and congestive heart failure, occurred in patients who received VOTRIENT.

In the RCC trials, cardiac dysfunction was observed in 0.6% of 586 patients without routine on-study LVEF monitoring. In the randomized RCC trial (VEG105192), myocardial dysfunction was defined as symptoms of cardiac dysfunction or ≥ 15% absolute decline in LVEF compared with baseline or a decline in LVEF of ≥ 10% compared with baseline that is also below the lower limit of normal. In an RCC trial (COMPARZ), myocardial dysfunction occurred in 13% of the 362 patients on VOTRIENT who had a baseline and post-baseline LVEF measurements. Congestive heart failure occurred in 0.5% of patients.

In the randomized STS trial (VEG110727), myocardial dysfunction occurred in 11% of the 142 patients who had a baseline and a post-baseline LVEF measurements. One percent (3/240) of patients who received VOTRIENT had congestive heart failure, which did not resolve in one patient. Fourteen of the 16 patients with myocardial dysfunction treated with VOTRIENT had concurrent hypertension which may have exacerbated cardiac dysfunction in patients at risk (e.g., those with prior anthracycline therapy) possibly by increasing cardiac afterload.

Monitor blood pressure and manage as appropriate [see Hypertension]. Monitor for clinical signs or symptoms of congestive heart failure. Conduct baseline and periodic evaluation of LVEF in patients at risk of cardiac dysfunction, including previous anthracycline exposure. Withhold or permanently discontinue VOTRIENT based on severity of cardiac dysfunction [see DOSAGE AND ADMINISTRATION].

Hemorrhagic Events

In the RCC trials, fatal hemorrhage occurred in 0.9% of 586 patients, and cerebral/intracranial hemorrhage was observed in less than 1% (2/586) of patients treated with VOTRIENT.

In the randomized RCC trial (VEG105192), 13% of 290 patients treated with VOTRIENT experienced at least 1 hemorrhagic event. The most common hemorrhagic events were hematuria (4%), epistaxis (2%), hemoptysis (2%), and rectal hemorrhage (1%). Nine of 37 patients treated with VOTRIENT who had hemorrhagic events experienced serious events including pulmonary, gastrointestinal, and genitourinary hemorrhage. One percent of patients treated with VOTRIENT died from hemorrhage.

In the randomized STS trial (VEG110727), 22% of 240 patients treated with VOTRIENT experienced at least 1 hemorrhagic event. The most common hemorrhagic events were epistaxis (8%), mouth hemorrhage (3%), and anal hemorrhage (2%). Grade 4 hemorrhagic events occurred in 1% of patients and included intracranial hemorrhage, subarachnoid hemorrhage, and peritoneal hemorrhage.

VOTRIENT has not been studied in patients who have a history of hemoptysis, cerebral hemorrhage, or clinically significant gastrointestinal hemorrhage in the past 6 months. Withhold VOTRIENT and resume at reduced dose or permanently discontinue based on severity of hemorrhagic events [see DOSAGE AND ADMINISTRATION].

Arterial Thromboembolic Events

In the RCC trials, fatal arterial thromboembolic events occurred in 0.3% of 586 patients. In the randomized RCC trial (VEG105192), 2% of 290 patients who received VOTRIENT experienced myocardial infarction or ischemia, 0.3% had a cerebrovascular accident, and 1% had an event of transient ischemic attack.

In the randomized STS trial (VEG110727), 2% of 240 patients who received VOTRIENT experienced a myocardial infarction or ischemia and 0.4% had a cerebrovascular accident.

VOTRIENT has not been studied in patients who have had an arterial thromboembolic event within the previous 6 months. Permanently discontinue VOTRIENT in case of an arterial thromboembolic event [see DOSAGE AND ADMINISTRATION].

Venous Thromboembolic Events

Venous thromboembolic events (VTEs), including venous thrombosis and fatal pulmonary embolus (PE), occurred in patients who received VOTRIENT.

In the randomized RCC trial (VEG105192), VTEs occurred in 1% of 290 patients who received VOTRIENT. In the randomized STS trial (VEG110727), VTEs were reported in 5% of 240 patients who received VOTRIENT. Fatal PE occurred in 1% (2/240).

Monitor for signs and symptoms of VTE and PE. Withhold VOTRIENT and then resume at same dose or permanently discontinue based on severity of venous thromboembolic event [see DOSAGE AND ADMINISTRATION].

Thrombotic Microangiopathy

Thrombotic microangiopathy (TMA), including thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS), occurred in clinical trials of VOTRIENT as monotherapy, in combination with bevacizumab, and in combination with topotecan. VOTRIENT is not indicated for use in combination with other agents. Six of the 7 TMA cases occurred within 90 days of the initiation of VOTRIENT. Improvement of TMA was observed after treatment was discontinued.

Monitor for signs and symptoms of TMA. Permanently discontinue VOTRIENT in patients developing TMA. Manage as clinically indicated.

Gastrointestinal Perforation And Fistula

In the RCC and STS trials, gastrointestinal perforation or fistula occurred in 0.9% of 586 patients and 1% of 382 patients who received VOTRIENT, respectively. Fatal perforations occurred in 0.3% (2/586) of these patients in the RCC trials and in 0.3% (1/382) of these patients in the STS trials.

Monitor for signs and symptoms of gastrointestinal perforation or fistula. Withhold VOTRIENT in case of Grade 2 or 3 gastrointestinal fistula and resume based on medical judgement. Permanently discontinue VOTRIENT in case of gastrointestinal perforation or Grade 4 gastrointestinal fistula [see DOSAGE AND ADMINISTRATION].

Interstitial Lung Disease/Pneumonitis

Interstitial lung disease (ILD)/pneumonitis, which can be fatal, has been reported with VOTRIENT across clinical trials. ILD/pneumonitis occurred in 0.1% of patients treated with VOTRIENT.

Monitor patients for pulmonary symptoms indicative of ILD/pneumonitis. Permanently discontinue VOTRIENT in patients who develop ILD or pneumonitis [see DOSAGE AND ADMINISTRATION].

Posterior Reversible Encephalopathy Syndrome

Posterior Reversible Encephalopathy Syndrome (PRES) has been reported in patients who received VOTRIENT and may be fatal. PRES is a neurological disorder which can present with headache, seizure, lethargy, confusion, blindness, and other visual and neurologic disturbances. Mild to severe hypertension may be present. Confirm diagnosis of PRES by magnetic resonance imaging.

Permanently discontinue VOTRIENT in patients who develop PRES.

Hypertension

Hypertension (systolic blood pressure ≥ 150 mmHg or diastolic blood pressure ≥ 100 mmHg) and hypertensive crisis were observed in patients treated with VOTRIENT.

Approximately 40% of patients who received VOTRIENT experienced hypertension, with Grade 3 occurring in 4% to 7% of patients [see ADVERSE REACTIONS]. About 40% of cases occurred by Day 9 and about 90% of cases occurred in the first 18 weeks across clinical trials. Approximately 1% of patients required permanent discontinuation of VOTRIENT because of hypertension.

Do not initiate VOTRIENT in patients with uncontrolled hypertension. Optimize blood pressure prior to initiating VOTRIENT. Monitor blood pressure as clinically indicated and initiate and adjust antihypertensive therapy as appropriate. Withhold and then dose reduce VOTRIENT or permanently discontinue based on severity of hypertension [see DOSAGE AND ADMINISTRATION].

Risk Of Impaired Wound Healing

Impaired wound healing complications can occur in patients who receive drugs that inhibit the VEGF signaling pathway. Therefore, VOTRIENT has the potential to adversely affect wound healing.

Withhold VOTRIENT at least 1 week prior to elective surgery. Do not administer for at least 2 weeks following major surgery and until adequate wound healing. The safety of resumption of VOTRIENT after resolution of wound healing complications has not been established.

Hypothyroidism

Hypothyroidism, confirmed based on a simultaneous rise of TSH and decline of T4, occurred in 7% of 290 patients who received VOTRIENT in the randomized RCC trial (VEG105192) and in 5% of 240 patients who received VOTRIENT in the randomized STS trial (VEG110727). Hypothyroidism occurred in 4% of the 586 patients in the RCC trials and 5% of the 382 patients in the STS trials.

Monitor thyroid tests at baseline, during treatment and as clinically indicated and manage hypothyroidism as appropriate.

Proteinuria

In the randomized RCC trial (VEG105192), proteinuria occurred in 9% of 290 patients who received VOTRIENT. In 2 patients, proteinuria led to discontinuation of VOTRIENT.

In the randomized STS trial (VEG110727), proteinuria occurred in 1% of 240 patients and nephrotic syndrome occurred in 1 patient. Treatment was discontinued in the patient with nephrotic syndrome.

Perform baseline and periodic urinalysis during treatment with follow up measurement of 24-hour urine protein as clinically indicated. Withhold VOTRIENT then resume at a reduced dose or permanently discontinue based on severity of proteinuria. Permanently discontinue in patients with nephrotic syndrome [see DOSAGE AND ADMINISTRATION].

Tumor Lysis Syndrome

Cases of tumor lysis syndrome (TLS), including fatal cases, have been reported in RCC and STS patients treated with VOTRIENT [see ADVERSE REACTIONS]. Patients may be at risk of TLS if they have rapidly growing tumors, a high tumor burden, renal dysfunction, or dehydration. Closely monitor patients at risk, consider appropriate prophylaxis, and treat as clinically indicated.

Infection

Serious infections (with or without neutropenia), including some with fatal outcome, have been reported. Monitor patients for signs and symptoms of infection. Institute appropriate anti-infective therapy promptly and consider interruption or discontinuation of VOTRIENT for serious infections.

Increased Toxicity With Other Cancer Therapy

VOTRIENT is not indicated for use in combination with other agents. Clinical trials of VOTRIENT in combination with pemetrexed and lapatinib were terminated early due to increased toxicity and mortality. The fatal toxicities observed included pulmonary hemorrhage, gastrointestinal hemorrhage, and sudden death. A safe and effective combination dose has not been established with these regimens.

Increased Toxicity In Developing Organs

The safety and effectiveness of VOTRIENT in pediatric patients have not been established. VOTRIENT is not indicated for use in pediatric patients. Based on its mechanism of action, pazopanib may have severe effects on organ growth and maturation during early postnatal development. Administration of pazopanib to juvenile rats less than 21 days old resulted in toxicity to the lungs, liver, heart, and kidney and in death at doses significantly lower than the clinically recommended dose or doses tolerated in older animals. VOTRIENT may potentially cause serious adverse effects on organ development in pediatric patients, particularly in patients younger than 2 years of age [see Use In Specific Populations].

Embryo-Fetal Toxicity

Based on findings from animal studies and its mechanism of action, VOTRIENT can cause fetal harm when administered to a pregnant woman. Administration of VOTRIENT to pregnant rats and rabbits during the period of organogenesis resulted in maternal toxicity, teratogenicity, and abortion at systemic exposures lower than that observed at the maximum recommended human dose (MRHD) of 800 mg (based on area under the curve [AUC)]).

Advise pregnant women of the potential risk to a fetus. Advise females of reproductive potential to use effective contraception during treatment with VOTRIENT and for at least 2 weeks following the final dose. Advise males (including those who have had vasectomies) with female partners of reproductive potential to use condoms during treatment with VOTRIENT and for at least 2 weeks after the last dose [see Use In Specific Populations].

Patient Counseling Information

Advise the patient to read the FDA-approved patient labeling (Medication Guide).

Hepatic Toxicity

Inform patients that periodic laboratory testing will be performed. Advise patients to report signs and symptoms of liver dysfunction to their healthcare provider right away [see WARNINGS AND PRECAUTIONS].

QT Prolongation And Torsades De Pointes

Inform patients that ECG monitoring may be performed. Advise patients to inform their physicians of concomitant medications [see WARNINGS AND PRECAUTIONS].

Interstitial Lung Disease/Pneumonitis

Advise patients to report pulmonary signs or symptoms indicative of interstitial lung disease (ILD) or pneumonitis [see WARNINGS AND PRECAUTIONS].

Cardiac Dysfunction

Advise patients to report hypertension or signs and symptoms of congestive heart failure [see WARNINGS AND PRECAUTIONS].

Hemorrhagic Events

Advise patients to report unusual bleeding [see WARNINGS AND PRECAUTIONS].

Arterial Thromboembolic Events: Advise patients to report signs or symptoms of an arterial thrombosis [see WARNINGS AND PRECAUTIONS].

Pneumothorax And Venous Thromboembolic Events

Advise patients to report new onset of dyspnea, chest pain, or localized limb edema [see WARNINGS AND PRECAUTIONS, ADVERSE REACTIONS].

Posterior Reversible Encephalopathy Syndrome

Advise patients to inform their doctor if they have worsening of neurological function consistent with PRES (headache, seizure, lethargy, confusion, blindness, and other visual and neurologic disturbances) [see WARNINGS AND PRECAUTIONS].

Hypertension

Advise patients to monitor blood pressure early in the course of therapy and frequently thereafter and report increases of blood pressure or symptoms such as blurred vision, confusion, severe headache, or nausea and vomiting [see WARNINGS AND PRECAUTIONS].

Gastrointestinal Perforation And Fistula

Advise patients to report signs and symptoms of a GI perforation or fistula [see WARNINGS AND PRECAUTIONS].

Risk Of Impaired Wound Healing

Advise patients that VOTRIENT may impair wound healing. Advise patients to inform their healthcare provider of any scheduled surgical procedure [see WARNINGS AND PRECAUTIONS].

Hypothyroidism And Proteinuria

Inform patients that thyroid function testing and urinalysis will be performed during treatment [see WARNINGS AND PRECAUTIONS].

Tumor Lysis Syndrome

Advise patients to contact their healthcare provider promptly to report any signs and symptoms of TLS such as abnormal heart rhythm, seizure, confusion, muscle cramps or spasms, or a decrease in urine output [see WARNINGS AND PRECAUTIONS].

Infection

Advise patients to promptly report any signs or symptoms of infection [see WARNINGS AND PRECAUTIONS].

Embryo-Fetal Toxicity

Advise female patients to inform their healthcare provider of a known or suspected pregnancy during treatment with VOTRIENT. Inform female patients of the risk to a fetus and the potential loss of the pregnancy [see WARNINGS AND PRECAUTIONS, Use In Specific Populations].

Advise females of reproductive potential to use effective contraception during treatment and for at least 2 weeks after the last dose of VOTRIENT. Advise male patients with female partners of reproductive potential to use condoms during treatment with VOTRIENT and for at least 2 weeks after the last dose [see WARNINGS AND PRECAUTIONS, Use In Specific Populations].

Gastrointestinal Adverse Reactions

Advise patients on how to manage nausea, vomiting, and diarrhea and to notify their healthcare provider if moderate-to-severe vomiting or diarrhea occurs or if there is a decrease in oral intake [see ADVERSE REACTIONS].

Depigmentation

Advise patients that depigmentation of the hair or skin may occur during treatment with VOTRIENT [see ADVERSE REACTIONS].

Drug Interactions

Advise patients to inform their healthcare providers of all concomitant medications, vitamins, or dietary and herbal supplements [see DRUG INTERACTIONS].

Dosage And Administration

Advise patients to take VOTRIENT without food (at least 1 hour before or 2 hours after a meal) [see DOSAGE AND ADMINISTRATION].

Nonclinical Toxicology

Carcinogenesis, Mutagenesis, Impairment Of Fertility

The carcinogenic potential of pazopanib was evaluated in CD-1 mice, and Sprague-Dawley rats. Administration of pazopanib to mice for 2 years did not result in increased incidence of neoplasms at doses up to 100 mg/kg/day (approximately 1.4-fold the AUC at the MRHD of 800 mg/day). Administration of pazopanib to rats for 2 years resulted in findings of duodenal adenocarcinoma in males at 30 mg/kg/day (approximately 0.3-fold the AUC at the MRHD of 800 mg/day) and in females at greater than or equal to 10 mg/kg/day (approximately 0.3-fold the AUC at the MRHD of 800 mg/day). The human relevance of these neoplastic findings is unclear.

Pazopanib did not induce mutations in the microbial mutagenesis (Ames) assay and was not clastogenic in both the in vitro cytogenetic assay using primary human lymphocytes and in the in vivo rat micronucleus assay.

In an oral female fertility and early embryonic development study, female rats were administered pazopanib at least 15 days prior to mating, and for 6 days after mating. Pazopanib did affect fertility in female rats. Reduced fertility including increased pre-implantation loss and early resorptions were noted at dosages greater than or equal to 30 mg/kg/day (approximately 0.4-fold the AUC at the MRHD of 800 mg/day). Decreased corpora lutea and increased cysts were noted in mice given greater than or equal to 100 mg/kg/day for 13 weeks and ovarian atrophy was noted in rats given greater than or equal to 300 mg/kg/day for 26 weeks (approximately 1.3 and 0.85-fold the AUC at the MRHD of 800 mg/day). Decreased corpora lutea was also noted in monkeys given 500 mg/kg/day for up to 34 weeks (approximately 0.4-fold the AUC at the MRHD of 800 mg/day).

Pazopanib did not affect mating or fertility in male rats. However, there were reductions in sperm production rates and testicular sperm concentrations at doses greater than or equal to 3 mg/kg/day, epididymal sperm concentrations at doses greater than or equal to 30 mg/kg/day, and sperm motility at greater than or equal to 100 mg/kg/day following 15 weeks of dosing. Following 15 and 26 weeks of dosing, there were decreased testicular and epididymal weights at doses of greater than or equal to 30 mg/kg/day (approximately 0.35-fold the AUC at the MRHD of 800 mg/day); atrophy and degeneration of the testes with aspermia, hypospermia, and cribiform change in the epididymis was also observed at this dose in the 6-month toxicity studies in male rats.

Use In Specific Populations

Pregnancy

Risk Summary

Based on animal reproduction studies and its mechanism of action [see CLINICAL PHARMACOLOGY], VOTRIENT can cause fetal harm when administered to a pregnant woman. There are no available data on VOTRIENT use in pregnant women to evaluate for a drug-associated risk. In animal developmental and reproductive toxicology studies, oral administration of pazopanib to pregnant rats and rabbits throughout organogenesis resulted in teratogenicity, and abortion at systemic exposures lower than that observed at the MRHD of 800 mg (based on AUC) (see Data). Advise pregnant women of the potential risk to a fetus.

The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have a background risk of birth defect, loss or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects in clinically recognized pregnancies and miscarriage is 2 to 4% and 15% to 20%, respectively.

Data

Animal Data

In a female fertility and early embryonic development study, female rats were administered oral pazopanib at least 15 days prior to mating and for 6 days after mating, which resulted in increased pre-implantation loss and early resorptions at dosages greater than or equal to 30 mg/kg/day (approximately 0.4-fold the AUC at the MRHD of 800 mg/day). Total litter resorption was seen at 300 mg/kg/day (approximately 0.8-fold the AUC at the MRHD of 800 mg/day). Postimplantation loss, embryolethality, and decreased fetal body weights were noted in females administered doses greater than or equal to 10 mg/kg/day (approximately 0.3-fold the AUC at the MRHD of 800 mg/day).

In embryo-fetal developmental toxicity studies in rats and rabbits, oral pazopanib was administered to pregnant animals during organogenesis. In rats, dose levels of greater than or equal to 3 mg/kg/day (approximately 0.1-fold the AUC at the MRHD of 800 mg/day) resulted in teratogenic effects including cardiovascular malformations (retroesophageal subclavian artery, missing innominate artery, changes in the aortic arch), incomplete or absent ossification, increases in postimplantation loss, embryolethality and reduced fetal body weight. In rabbits, maternal toxicity, increased postimplantation loss and abortion were observed at doses greater than or equal to 30 mg/kg/day (approximately 0.007-fold the AUC at the MRHD of 800 mg/day). In addition, severe maternal body weight loss and 100% litter loss were observed at doses greater than or equal to 100 mg/kg/day (0.02-fold the AUC at the MRHD of 800 mg/day), while fetal weight was reduced at doses greater than or equal to 3 mg/kg/day (AUC not calculated).

Lactation

Risk Summary

There is no data on the presence of pazopanib or its metabolites in human milk or their effects on the breastfed infant or milk production. Because of the potential for serious adverse reactions in breastfed infants, advise women not to breastfeed during treatment with VOTRIENT and for 2 weeks after the final dose.

Females And Males Of Reproductive Potential

VOTRIENT can cause fetal harm when administered to a pregnant woman [see Pregnancy].

Pregnancy Testing

Verify pregnancy status of females of reproductive potential prior to starting treatment with VOTRIENT.

Contraception

Females

Advise females of reproductive potential to use effective contraception during treatment with VOTRIENT and for at least 2 weeks after the last dose.

Males

Advise males (including those who have had vasectomies) with female partners of reproductive potential to use condoms during treatment with VOTRIENT and for at least 2 weeks after the last dose.

Infertility

Based on findings from animal studies, VOTRIENT may impair fertility in females and males of reproductive potential while receiving treatment [see Nonclinical Toxicology].

Pediatric Use

The safety and effectiveness of VOTRIENT in pediatric patients have not been established.

Juvenile Animal Toxicity Data

In rats, weaning occurs at Day 21 postpartum which approximately equates to a human pediatric age of 2 years. In a juvenile animal toxicology study performed in rats, when animals were dosed from Day 9 through Day 14 postpartum (pre-weaning), pazopanib caused abnormal organ growth/maturation in the kidney, lung, liver, and heart at approximately 0.1-fold the AUC in adults at the MRHD of 800 mg/day of VOTRIENT. At approximately 0.4-fold the AUC in adults at the MRHD of 800 mg/day, pazopanib administration resulted in mortality.

In repeat-dose toxicology studies in rats including 4-week, 13-week, and 26-week administration, toxicities in bone, teeth, and nail beds were observed at doses greater than or equal to 3 mg/kg/day (approximately 0.07-fold the AUC at the MRHD of 800 mg/day). Doses of 300 mg/kg/day (approximately 0.8-fold the AUC at the MRHD of 800 mg/day) were not tolerated in 13-and 26-week studies and animals required dose reductions due to body weight loss and morbidity. Hypertrophy of epiphyseal growth plates, nail abnormalities (including broken, overgrown, or absent nails) and tooth abnormalities in growing incisor teeth (including excessively long, brittle, broken, and missing teeth, and dentine and enamel degeneration and thinning) were observed in rats at doses greater than or equal to 30 mg/kg/day (approximately 0.35-fold the AUC at the MRHD of 800 mg/day) at 26 weeks, with the onset of tooth and nail bed alterations noted clinically after 4 to 6 weeks. Similar findings were noted in repeat-dose studies in juvenile rats dosed with pazopanib beginning Day 21 postpartum (post-weaning). In the post-weaning animals, the occurrence of changes in teeth and bones occurred earlier and with greater severity than in older animals. There was evidence of tooth degeneration and decreased bone growth at doses greater than or equal to 30 mg/kg (approximately 0.1-to 0.2-fold the AUC at the MRHD of 800 mg/day). Pazopanib exposure in juvenile rats was lower than that seen at the same dose levels in adult animals, based on comparative AUC values. At pazopanib doses approximately 0.5-to 0.7-fold the AUC at the MRHD of 800 mg/day, decreased bone growth in juvenile rats persisted even after the end of the dosing period. Finally, despite lower pazopanib exposures than those reported in adult animals or adult humans, juvenile animals administered 300 mg/kg/dose pazopanib required dose reduction within 4 weeks of dosing initiation due to significant toxicity, although adult animals could tolerate this same dose for at least 3 times as long [see WARNINGS AND PRECAUTIONS].

Geriatric Use

In pooled clinical trials with VOTRIENT, 30% of 2080 patients were aged ≥ 65 years. More patients ≥ 65 years had ALT elevations > 3 x ULN compared to patients < 65 years (23% versus 18%) [see WARNINGS AND PRECAUTIONS].

In the RCC trials, 33% of 586 patients were aged ≥ 65 years. No overall differences in safety or effectiveness of VOTRIENT were observed between these patients and younger patients.

In the STS trials, 24% of 382 patients were aged ≥ 65 years. Patients aged ≥ 65 years had a higher incidence of Grade 3 or 4 fatigue (19% versus 12% for patients aged <65 years), hypertension (10% versus 6%), decreased appetite (11% versus 2%), ALT elevations (3% versus 2%) and AST elevations (4% versus 1%). In the randomized STS trial (VEG110727), no overall differences in effectiveness of VOTRIENT were observed between patients aged ≥ 65 years and younger patients.

Renal Impairment

No dose adjustment is recommended for patients with renal impairment. VOTRIENT has not been studied in patients with severe renal impairment or in patients undergoing peritoneal dialysis or hemodialysis.

Hepatic Impairment

No dose adjustment is required in patients with mild hepatic impairment (either total bilirubin ≤ ULN and ALT > ULN or bilirubin > 1 to 1.5 x ULN and any ALT value). VOTRIENT is not recommended in patients with moderate (total bilirubin > 1.5 to 3 x ULN and any ALT value) and severe (total bilirubin > 3 x ULN and any ALT value) hepatic impairment [see DOSAGE AND ADMINISTRATION, CLINICAL PHARMACOLOGY].

OVERDOSE

Dose-limiting toxicity (Grade 3 fatigue) and Grade 3 hypertension were each observed in 1 of 3 patients dosed at 2,000 mg daily (2.5 times the recommended dose) and 1,000 mg daily (1.25 times the recommended dose), respectively.

Provide general supportive measures to manage an overdose. Hemodialysis is not expected to enhance the elimination of VOTRIENT because pazopanib is not significantly renally excreted and is highly bound to plasma proteins.

CONTRAINDICATIONS

None.

CLINICAL PHARMACOLOGY

Mechanism Of Action

Pazopanib is a multi-tyrosine kinase inhibitor of vascular endothelial growth factor receptor (VEGFR)-1, VEGFR-2, VEGFR-3, platelet-derived growth factor receptor (PDGFR)-α and -β, fibroblast growth factor receptor (FGFR)-1 and -3, cytokine receptor (Kit), interleukin-2 receptor-inducible T-cell kinase (Itk), lymphocyte-specific protein tyrosine kinase (Lck), and transmembrane glycoprotein receptor tyrosine kinase (c-Fms). In vitro, pazopanib inhibited ligand-induced autophosphorylation of VEGFR-2, Kit, and PDGFR-β receptors. In vivo, pazopanib inhibited VEGF-induced VEGFR-2 phosphorylation in mouse lungs, angiogenesis in a mouse model, and the growth of some human tumor xenografts in mice.

Pharmacodynamics

Increases in blood pressure have been observed and are related to steady-state trough plasma pazopanib concentrations.

Cardiac Electrophysiology

The QT prolongation potential of pazopanib was assessed in a randomized, blinded, parallel trial (N = 96) using moxifloxacin as a positive control. VOTRIENT 800 mg orally under fasting conditions was administered on Days 2 to 8 and 1,600 mg was administered on Day 9 after a meal in order to increase exposure to pazopanib and its metabolites. No large changes (i.e., > 20 msec) in QTc interval following exposure to pazopanib were detected in this QT trial. The trial was not able to exclude small changes (< 10 msec) in QTc interval, because assay sensitivity below this threshold (< 10 msec) was not established in this trial [see WARNINGS AND PRECAUTIONS].

Pharmacokinetics

The recommended dosage of 800 mg once daily results in mean AUC of 1,037 mcg•h/mL and Cmax of 58.1 mcg/mL. There was no consistent increase in AUC or Cmax at pazopanib doses above 800 mg.

Administration of a single 400-mg crushed tablet increased AUC0-72h by 46% and Cmax by approximately 2-fold and decreased Tmax by approximately 2 hours compared with administration of the whole tablet [see DOSAGE AND ADMINISTRATION].

Absorption

The median time to achieve peak concentrations was 2 to 4 hours after a dose.

Effect of Food

Systemic exposure to pazopanib is increased when administered with food. Administration of pazopanib with a high-fat (approximately 50% fat) or low-fat (approximately 5% fat) meal results in an approximately 2-fold increase in AUC and Cmax.

Distribution

Binding of pazopanib to human plasma protein in vivo was > 99% with no concentration dependence over the range of 10 to 100 mcg/mL. In vitro studies suggest that pazopanib is a substrate for P-gp and BCRP.

Elimination

Pazopanib has a mean half-life of 31 hours after administration of the recommended dose of 800 mg.

Metabolism

In vitro studies demonstrated that pazopanib is metabolized by CYP3A4 with a minor contribution from CYP1A2 and CYP2C8.

Excretion

Elimination is primarily via feces with renal elimination accounting for < 4% of the administered dose.

Specific Populations

Patients With Hepatic Impairment

Table 7 presents a comparison of the median steady-state Cmax and the median AUC0-24h values for patients with normal, mild, moderate and severe hepatic impairment.

The median steady-state of pazopanib Cmax and AUC0-24h after a once-daily dose of 800 mg in patients with mild impairment were in a similar range as the median steady-state Cmax and median AUC0-24h in patients with no hepatic impairment.

The maximum tolerated pazopanib dose in patients with moderate hepatic impairment was 200 mg once daily. The median steady-state Cmax and the median AUC0-24h were approximately 43% and 29%, respectively, of the corresponding median values after administration of 800 mg once daily in patients with no hepatic impairment.

The median steady-state Cmax and the median AUC0-24h were approximately 18% and 15%, respectively, of the corresponding median values after administration of 800 mg once daily in patients with no hepatic impairment.

Table 7. Pharmacokinetic Parameters of Pazopanib in Patients with of Hepatic Impairment

	No Hepatic Impairment	Mild Hepatic Impairment (total bilirubin ≤ ULN and ALT > ULN or total bilirubin > 1 to 1.5 x ULN and any ALT value)	Moderate Hepatic Impairment (total bilirubin > 1.5 to 3 x ULN and any ALT value)	Severe Hepatic Impairment (total bilirubin > 3 x ULN and any ALT value)
Dose	800 mg once daily	800 mg once daily	200 mg once daily	200 mg once daily
Median steady-state Cmax (range) mcg/mL	52 (17 to 86)	34 (11 to 104)	22 (4.2 to 33)	9.4 (2.4 to 24)
Median AUC0-24h (range) mcg•h/mL	888 (346 to 1482)	774 (215 to 2034)s	257 (66 to 488)	131 (47 to 473)
Abbreviations: ALT, alanine aminotransferase; AUC, area under the curve; Cmax, maximum concentration; PK, pharmacokinetic; ULN, upper limit of normal.

Drug Interactions Studies

Clinical Studies

Strong CYP3A4 Inhibitor

Coadministration of multiple doses of oral VOTRIENT 400 mg with multiple doses of oral ketoconazole 400 mg (strong CYP3A4/P-gp inhibitor) resulted in a 1.7-fold increase in the AUC0-24h and a 1.5-fold increase in the Cmax of pazopanib [see DOSAGE AND ADMINISTRATION, DRUG INTERACTIONS].

Weak CYP3A4 Inhibitor

Coadministration of 1,500 mg lapatinib, a substrate and weak inhibitor of CYP3A4, Pgp, and BCRP, with VOTRIENT 800 mg resulted in an approximately 50% to 60% increase in mean pazopanib AUC0-24h and Cmax.

CYP1A2, CYP2C9 and CYP2C19 Substrates

Clinical studies, using VOTRIENT 800 mg once daily, have demonstrated that pazopanib does not have a clinically relevant effect on the pharmacokinetics of caffeine (CYP1A2 probe substrate), warfarin (CYP2C9 probe substrate), or omeprazole (CYP2C19 probe substrate) in patients with cancer.

CYP3A4, CYP2D6, and CYP2C8 Substrates

Coadministration of VOTRIENT resulted in an increase of approximately 30% in the mean AUC and Cmax of midazolam (CYP3A4 probe substrate) and increases of 33% to 64% in the ratio of dextromethorphan to dextrorphan concentrations in the urine after oral administration of dextromethorphan (CYP2D6 probe substrate). Coadministration of VOTRIENT 800 mg once daily and paclitaxel 80 mg/m² (CYP3A4 and CYP2C8 substrate) once weekly resulted in a mean increase of 26% and 31% in paclitaxel AUC and Cmax, respectively [see DRUG INTERACTIONS].

Gastric Acid-Reducing Agents

Coadministration of VOTRIENT with esomeprazole, a PPI, decreased the exposure of pazopanib by approximately 40% (AUC and Cmax) [see DOSAGE AND ADMINISTRATION, DRUG INTERACTIONS].

In Vitro Studies

In vitro studies with human liver microsomes showed that pazopanib inhibited the activities of CYP enzymes 1A2, 3A4, 2B6, 2C8, 2C9, 2C19, 2D6, and 2E1. Potential induction of human CYP3A4 was demonstrated in an in vitro human pregnane X receptor (PXR) assay.

In vitro studies also showed that pazopanib inhibits UGT1A1 and organic anion-transporting polypeptide (OATP1B1) with IC₅₀s of 1.2 and 0.79 μM, respectively.

Pharmacogenomics

Pazopanib can increase serum total bilirubin levels [see WARNINGS AND PRECAUTIONS]. In vitro studies showed that pazopanib inhibits UGT1A1, which glucuronidates bilirubin for elimination. A pooled pharmacogenetic analysis of 236 white patients who received VOTRIENT showed that the (TA)7/(TA)7 genotype (UGT1A1*28/*28) (underlying genetic susceptibility to Gilbert’s syndrome) was associated with a statistically significant increase in the incidence of hyperbilirubinemia relative to the (TA)6/(TA)6 and (TA)6/(TA)7 genotypes.

In a pooled pharmacogenetic analysis of data from 31 clinical studies of pazopanib administered as either monotherapy or in combination with other agents, ALT > 3 x ULN (Grade 2) occurred in 32% (42/133) of HLA-B*57:01 allele carriers and in 19% (397/2101) of non-carriers and ALT > 5 x ULN (Grade 3) occurred in 19% (25/133) of HLA-B*57:01 allele carriers and in 10% (213/2101) of non-carriers. In this dataset, 6% (133/2234) of the patients carried the HLA-B*57:01 allele [see WARNINGS AND PRECAUTIONS].

Clinical Studies

Renal Cell Carcinoma

The efficacy of VOTRIENT was evaluated in VEG105192, a randomized, double-blind, placebo-controlled, multicenter trial (NCT00387764). Patients with locally advanced and/or metastatic RCC who had received either no prior therapy or one prior cytokine-based systemic therapy were randomized (2:1) to receive VOTRIENT 800 mg once daily or placebo once daily. Eligible subjects were stratified according to the following 3 stratification factors: baseline ECOG performance status 0 vs 1; prior nephrectomy yes vs no; and prior systemic therapy for advanced RCC: treatment-naive vs received one prior cytokine-based therapy. The major efficacy outcome measure was progression-free survival (PFS). Additional outcome measures were overall survival (OS), overall response rate (RR), and duration of response.

Of the total of 435 patients enrolled in this trial, 233 patients had no prior systemic therapy (treatment-naïve subgroup) and 202 patients received one prior IL-2 or INFα-based therapy (cytokine-pretreated subgroup). The baseline demographic and disease characteristics were balanced between the arms receiving VOTRIENT and placebo. The majority of patients were male (71%) with a median age of 59 years. Eighty-six percent of patients were white, 14% were Asian, and less than 1% were other. Forty-two percent were ECOG performance status 0 and 58% were ECOG performance status 1. All patients had clear cell histology (90%) or predominantly clear cell histology (10%). Approximately 50% of all patients had 3 or more organs involved with metastatic disease. The most common metastatic sites at baseline were lung (74%), lymph nodes (56%), bone (27%), and liver (25%).

A similar proportion of patients in each arm were treatment-naïve and cytokine-pretreated (see Table 8). In the cytokine-pretreated subgroup, the majority (75%) had received interferon-based treatment. Similar proportions of patients in each arm had prior nephrectomy (89% and 88% for VOTRIENT and placebo, respectively).

The analysis of the primary endpoint PFS was based on disease assessment by independent radiological review in the entire trial population. Efficacy results are presented in Table 8 and Figure 1.

Table 8. Efficacy Results in RCC Patients by Independent Assessment in VEG105192

Endpoint/Trial Population	VOTRIENT	Placebo	HR (95% CI)
PFS
Overall ITT	N = 290	N = 145
Median (months)	9.2	4.2	0.46a (0.34, 0.62)
Treatment-naïve subgroup	N = 155 (53%)	N = 78 (54%)
Median (months)	11.1	2.8	0.40 (0.27, 0.60)
Cytokine pre-treated subgroup	N = 135 (47%)	N = 67 (46%)
Median (months)	7.4	4.2	0.54 (0.35, 0.84)
Response Rate (CR + PR)   % (95% CI)	N = 290 30 (25.1, 35.6)	N = 145 3 (0.5, 6.4)	–
Duration of response
Median (weeks) (95% CI)	58.7 (52.1, 68.1)	–b
Abbreviations: CI, confidence interval; CR, complete response; HR, hazard ratio; ITT, intent-to-treat; PFS, progression-free Survival; PR, partial response; RCC, renal cell carcinoma. aP value < 0.001. bThere were only 5 objective responses.

Figure 1. Kaplan-Meier Curve for Progression-free Survival in RCC by Independent Assessment for the Overall Population (Treatment-naïve and Cytokine Pre-treated Populations) in VEG105192

At the protocol-specified final analysis of OS, the median OS was 22.9 months for patients randomized to VOTRIENT and 20.5 months for the placebo arm [HR = 0.91 (95% CI: 0.71, 1.16)]. The median OS for the placebo arm includes 79 patients (54%) who discontinued placebo treatment because of disease progression and crossed over to treatment with VOTRIENT. In the placebo arm, 95 (66%) patients received at least one systemic anticancer treatment after progression compared with 88 (30%) patients randomized to VOTRIENT.

Soft Tissue Sarcoma

The efficacy of VOTRIENT was evaluated in VEG110727, a randomized, double-blind, placebo-controlled, multicenter trial (NCT00753688). Patients with metastatic STS who had received prior chemotherapy, including anthracycline treatment, or were unsuited for such therapy, were randomized (2:1) to receive VOTRIENT 800 mg once daily or placebo. Patients with gastrointestinal stromal tumors (GIST) or adipocytic sarcoma were excluded from the trial. Randomization was stratified by the factors of WHO performance status (WHO PS) 0 or 1 at baseline and the number of lines of prior systemic therapy for advanced disease (0 or 1 versus 2+). The major efficacy outcome measure was PFS assessed by independent radiological review. Additional outcome measures were OS, overall response rate, and duration of response.

The majority of patients were female (59%) with a median age of 55 years. Seventy-two percent of patients were white, 22% were Asian, and 6% were other. Forty-three percent of patients had leiomyosarcoma, 10% had synovial sarcoma, and 47% had other soft tissue sarcomas. Fifty-six percent of patients had received 2 or more lines of prior systemic therapy and 44% had received 0 or 1 lines of prior systemic therapy.

Efficacy results are presented in Table 9 and Figure 2.

Table 9. Efficacy Results in STS Patients by Independent Assessment in VEG110727

Endpoint/Trial Population	VOTRIENT	Placebo	HR (95% CI)
PFS
Overall ITT	N = 246	N = 123	0.35a
Median (months)	4.6	1.6	(0.26, 0.48)
Leiomyosarcoma subgroup	N = 109	N = 49	0.37
Median (months)	4.6	1.9	(0.23, 0.60)
Synovial sarcoma subgroup	N = 25	N = 13	0.43
Median (months)	4.1	0.9	(0.19, 0.98)
‘Other soft tissue sarcoma’ subgroup	N = 112	N = 61	0.39
Median (months)	4.6	1.0	(0.25, 0.60)
Response Rate (CR + PR)
% (95% CI)	4 (2.3, 7.9)b	0 (0.0, 3.0)	–
Duration of response
Median (months) (95% CI)	9.0 (3.9, 9.2)
Abbreviations: CI, confidence interval; CR, complete response; HR, hazard ratio; ITT, intent-to-treat; PFS, progression-free survival; PR, partial response; STS, soft tissue sarcoma. aP value < 0.001. bThere were 11 partial responses and 0 complete responses.

Figure 2. Kaplan-Meier Curve for Progression-free Survival in STS by Independent Assessment for the Overall Population in VEG110727

At the protocol-specified final analysis of OS, the median OS was 12.6 months for patients randomized to VOTRIENT and 10.7 months for the placebo arm [HR = 0.87 (95% CI: 0.67, 1.12)].

PATIENT INFORMATION

VOTRIENT^®
(VO-tree-ent)
(pazopanib) tablets

What is the most important information I should know about VOTRIENT?

VOTRIENT can cause serious liver problems, including death. Your healthcare provider will do blood tests to check your liver before you start and while you take VOTRIENT.

Tell your healthcare provider right away if you get any of these signs of liver problems during treatment withVOTRIENT:

• yellowing of your skin or the whites of your eyes (jaundice)
• dark urine
• tiredness
• nausea or vomiting
• loss of appetite
• pain on the right side of your stomach area (abdomen)
• bruise easily

Your healthcare provider may need to prescribe a lower dose of VOTRIENT for you or tell you to stop taking VOTRIENT if you develop liver problems during treatment.

What is VOTRIENT?

VOTRIENT is a prescription medicine used to treat people with:

• advanced renal cell cancer (RCC)
• advanced soft tissue sarcoma (STS) who have received chemotherapy in the past

It is not known if VOTRIENT is effective in treating certain soft tissue sarcomas or certain gastrointestinal tumors.

It is not known if VOTRIENT is safe and effective in children under 18 years of age.

What should I tell my healthcare provider before taking VOTRIENT?

Before you take VOTRIENT, tell your healthcare provider if you:

• have or had liver problems. You may need a lower dose of VOTRIENT, or your healthcare provider may prescribe a different medicine to treat your advanced renal cell cancer or advanced soft tissue sarcoma.
• have high blood pressure
• have heart problems or an irregular heartbeat including QT prolongation
• have a history of a stroke
• have headaches, seizures, or vision problems
• have coughed up blood in the last 6 months
• had bleeding of your stomach or intestines in the last 6 months
• have a history of a tear (perforation) in your stomach or intestine, or an abnormal connection between two parts of your gastrointestinal tract (fistula)
• have had blood clots in a vein or in the lung
• have thyroid problems
• had recent surgery or are going to have surgery. You should stop taking VOTRIENT at least 1 week before scheduled surgery because VOTRIENT may affect healing after surgery. Do not take VOTRIENT for at least 2 weeks following major surgery and until your wound heals adequately. Your healthcare provider should tell you when you may start taking VOTRIENT again after surgery.
• have problems with your kidney function
• have any other medical conditions
• are pregnant or plan to become pregnant. VOTRIENT can harm your unborn baby. You should not become pregnant while you are taking VOTRIENT. You should use effective birth control during treatment with VOTRIENT and for at least 2 weeks after your final dose of VOTRIENT. Talk to your healthcare provider about types of birth control that may be right for you during this time.
• are a male (including one who has had a vasectomy) with a sexual partner who is pregnant, think that they may be pregnant, or who could become pregnant (including those who use other forms of birth control). You should use condoms during sexual intercourse during treatment with VOTRIENT and for at least 2 weeks after the last dose of VOTRIENT.
• are breastfeeding or plan to breastfeed. It is not known if VOTRIENT passes into your breast milk. Do not breastfeed during treatment with VOTRIENT and for 2 weeks after the final dose.

Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. VOTRIENT may affect the way other medicines work and other medicines may affect how VOTRIENT works.

Especially, tell your healthcare provider if you:

• take medicines that can affect how your liver enzymes work, such as:
  • certain antibiotics (used to treat infections)
  • certain medicines used to treat HIV-1
  • certain medicines used to treat depression
  • medicines used to treat irregular heart beats
• take a medicine that contains simvastatin to treat high cholesterol levels
• take medicines that reduce stomach acid (e.g., esomeprazole)
• drink grapefruit juice

Ask your healthcare provider if you are not sure if your medicine is one that is listed above.

Know the medicines you take. Keep a list of them and show it to your healthcare provider and pharmacist when you get a new medicine.

How should I take VOTRIENT?

• Take VOTRIENT exactly as your healthcare provider tells you. Your healthcare provider will tell you how much VOTRIENT to take.
• Your healthcare provider may change your dose.
• Take VOTRIENT on an empty stomach, at least 1 hour before or 2 hours after food.
• Do not crush VOTRIENT tablets. It may increase the amount of VOTRIENT in your body.
• Do not eat grapefruit or drink grapefruit juice during treatment with VOTRIENT. Grapefruit products may increase the amount of VOTRIENT in your body.
• If you miss a dose, take it as soon as you remember. Do not take it if it is close (within 12 hours) to your next dose. Just take the next dose at your regular time. Do not take more than 1 dose of VOTRIENT at a time.
• Your healthcare provider will test your urine, blood, and heart before you start and while you take VOTRIENT.

What are the possible side effects of VOTRIENT?

VOTRIENT may cause serious side effects including:

• See “What is the most important information I should know about VOTRIENT?”
• irregular or fast heartbeat or fainting
• heart failure. This is a condition where your heart does not pump as well as it should and may cause you to have shortness of breath.
• bleeding problems. These bleeding problems may be severe and cause death.
  Symptoms may include: unusual bleeding, bruising, or wounds that do not heal.
• heart attack or stroke. Heart attack and stroke can happen with VOTRIENT and may cause death. Symptoms may include: chest pain or pressure, pain in your arms, back, neck or jaw, shortness of breath, numbness or weakness on one side of your body, trouble talking, headache, or dizziness.
• blood clots. Blood clots may form in a vein, especially in your legs (deep vein thrombosis or DVT). Pieces of a blood clot may travel to your lungs (pulmonary embolism). This may be life-threatening and cause death.
  Symptoms may include: new chest pain, trouble breathing or shortness of breath that starts suddenly, leg pain, and swelling of the arms and hands, or legs and feet, a cool or pale arm or leg.
• Thrombotic microangiopathy (TMA), including thrombotic thrombocytopenia purpura (TTP) and hemolyticuremic syndrome (HUS). TMA is a condition involving blood clots that can happen while taking VOTRIENT. TMA is accompanied by a decrease in red blood cells and cells that are involved in clotting. TMA may harm organs such as the brain and kidneys.
• tear in your stomach or intestinal wall (perforation) or an abnormal connection between two parts of yourgastrointestinal tract (fistula).
  Symptoms may include: pain, swelling in your stomach area, vomiting blood, and black sticky stools.
• lung problems. VOTRIENT may cause lung problems that may lead to death. Tell your healthcare provider right away if you get a cough that will not go away or shortness of breath.
• Posterior Reversible Encephalopathy Syndrome (PRES). PRES is a condition that can happen while taking VOTRIENT that may cause death.
  Symptoms may include: headaches, seizures, lack of energy, confusion, high blood pressure, loss of speech, blindness or changes in vision, and problems thinking.
• high blood pressure. High blood pressure can happen with VOTRIENT, including a sudden and severe risein blood pressure which may be life-threatening. These blood pressure increases usually happen in the first several months of treatment. Your blood pressure should be well controlled before you start taking VOTRIENT. Your healthcare provider should begin checking your blood pressure within 1 week of you starting VOTRIENT and often during treatment to make sure that your blood pressure is well controlled.
  Have someone call your healthcare provider or get medical help right away for you, if you get symptoms of a severe increase in blood pressure, including: severe chest pain, severe headache, blurred vision, confusion, nausea and vomiting, severe anxiety, shortness of breath, seizures, or you pass out (become unconscious).
• thyroid problems. Your healthcare provider should check you for this during treatment with VOTRIENT.
• Tumor lysis syndrome (TLS). TLS is a condition that can happen during treatment with VOTRIENT that may cause death. TLS is caused by a fast breakdown of cancer cells. Your healthcare provider may do a blood test to check you for TLS. Call your healthcare provider or get emergency medical help right away if you develop any of these symptoms during treatment with VOTRIENT: irregular heartbeat, seizures, confusion, muscle cramps or spasms, or a decrease in urine output.
• protein in your urine. Your healthcare provider will check you for this problem. If there is too much protein in your urine, your healthcare provider may tell you to stop taking VOTRIENT.
• serious infections. Serious infections can happen with VOTRIENT and can cause death.
  Symptoms of an infection may include: fever, cold symptoms, such as runny nose or sore throat that do not go away, flu symptoms, such as cough, tiredness, and body aches, pain when urinating, cuts, scrapes or wounds that are red, warm, swollen or painful.
• collapsed lung (pneumothorax). A collapsed lung can happen with VOTRIENT. Air may get trapped in the space between your lung and chest wall. This may cause you to have shortness of breath.

Call your healthcare provider right away if you have any of the symptoms listed above.

The most common side effects in people who take VOTRIENT include:

• diarrhea
• change in hair color
• nausea or vomiting
• loss of appetite

Other common side effects in people with advanced soft tissue sarcoma who take VOTRIENT include:

• feeling tired
• decreased weight
• tumor pain
• muscle or bone pain
• stomach pain
• headache
• taste changes
• trouble breathing
• change in skin color

Tell your healthcare provider if you have any side effect that bothers you or that does not go away.

These are not all the possible side effects of VOTRIENT. For more information, ask your healthcare provider or pharmacist. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA1088.

How should I store VOTRIENT tablets?

Store VOTRIENT at room temperature between 68°F and 77°F (20°C to 25°C).

Keep VOTRIENT and all medicines out of the reach of children.

General information about the safe and effective use of VOTRIENT.

Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Do not use VOTRIENT for a condition for which it was not prescribed. Do not give VOTRIENT to other people even if they have the same symptoms that you have. It may harm them.

If you would like more information, talk with your healthcare provider. You can ask your pharmacist or healthcare provider for information about VOTRIENT that is written for healthcare professionals. For more information, go to www.VOTRIENT.com or call 1-888-669-6682.

What are the ingredients in VOTRIENT?

Active ingredient: pazopanib.

Inactive ingredients: Tablet core: Magnesium stearate, microcrystalline cellulose, povidone, and sodium starch glycolate. Coating: Gray film-coat: Hypromellose, iron oxide black, macrogol/polyethylene glycol 400 (PEG 400), polysorbate 80, and titanium dioxide.

This Medication Guide has been approved by the U.S. Food and Drug Administration.