On May 13, 2016, the U.S. Food and Drug Administration (FDA) approved lenvatinib capsules (Lenvima) in combination with everolimus (Afinitor) for the treatment of advanced renal cell carcinoma following one prior antiangiogenic therapy. Lenvatinib was first approved in 2015 for the treatment of locally recurrent or metastatic, progressive, radioactive iodine–refractory differentiated thyroid cancer.
Lenvatinib is a multiple kinase inhibitor against the vascular endothelial growth factor receptors VEGFR1, VEGFR2, and VEGFR3.
The current approval was based on a randomized, multicenter study (clinicaltrials.gov identifier: NCT01136733) in patients with advanced or metastatic renal cell carcinoma who previously received antiangiogenic therapy.
The trial randomized 153 patients 1:1:1 to lenvatinib at 18 mg plus everolimus at 5 mg (n = 51), lenvatinib at 24 mg monotherapy (n = 52), or everolimus at 10 mg monotherapy (n = 50). All medications were administered orally once daily. Metastases were present in 95% of patients.
The hazard ratio for the comparison of investigator-assessed progression-free survival between lenvatinib plus everolimus and everolimus was 0.37 (95% confidence interval [CI] = 0.22–0.62). The median progression-free survival was 14.6 (95% CI = 5.9–20.1) months for the lenvatinib-plus-everolimus arm vs 5.5 (95% CI = 3.5–7.1) months for the everolimus arm.
This treatment effect was supported by a retrospective independent review of radiographs in these two arms with an observed hazard ratio of 0.43 (95% CI = 0.24–0.75). The hazard ratio for a post hoc, updated comparison of overall survival between the lenvatinib-plus-everolimus and everolimus arms was 0.67 (95% CI = 0.42–1.08).
Comparison of investigator-assessed progression-free survival between lenvatinib monotherapy and everolimus monotherapy supported the activity of lenvatinib in renal cell cancer. The combination of lenvatinib plus everolimus demonstrated numerically superior progression-free survival, objective response rate, and overall survival, compared to lenvatinib monotherapy.
The most common adverse reactions (> 30%) with lenvatinib plus everolimus were diarrhea, fatigue, arthralgia/myalgia, decreased appetite, vomiting, nausea, stomatitis/oral inflammation, hypertension, peripheral edema, cough, abdominal pain, dyspnea, rash, decreased weight, bleeding events, and proteinuria. Diarrhea was increased with the combination of lenvatinib plus everolimus (19% grade 3–4) and was added to the package insert as a new safety warning.
The recommended dose and schedule is lenvatinib at 18 mg plus everolimus at 5 mg taken by mouth once daily. ■