Everolimus (Afinitor)

==General information==
Class/mechanism: mTOR kinase inhibitor; mTOR (mammalian target of rapamycin) is a serine-threonine kinase downstream of the PI3K/AKT pathway. In vitro, everolimus has been found to reduce cell proliferation, angiogenesis, and glucose uptake. Everolimus forms inhibitory complexes with mTORC1 by binding to the intracellular protein FKBP-12. Reduces activity of downstream effectors of mTOR that are involved in protein synthesis, S6 ribosomal protein kinase (S6K1) and eukaryotic elongation factor 4E binding protein (4E-BP1). Reduces expression of vascular endothelial growth factor (VEGF) and hypoxia-inducible factor (HIF-1).Everolimus (Afinitor) package insert Everolimus (Afinitor) package insert (locally hosted backup)Afinitor manufacturer's website
Route: PO
Extravasation: n/a
*Anecdotally, taking the pill in a small amount of whipped/sour creamDiscussion between Sara Hurvitz, MD and Neil Love, MD, 2012 or putting the pill in a marshmallowSimeon Bennett, Novartis’ Afinitor gets OK of FDA, Bloomberg News (July 29, 2012). Retrieved 9/11/2012. may decrease the likelihood of developing stomatitis/mucositis.
For conciseness and simplicity, HemOnc.org currently will focus on treatment regimens and not list information such as: renal/hepatic dose adjustments, metabolism (including CYP450), excretion, monitoring parameters (although this will be considered for checklists), or manufacturer. Instead, for the most current information, please refer to your preferred pharmacopeias or the prescribing information. 
==Diseases for which it is established (work in progress)==
*Renal cell carcinoma
**Non-clear cell renal cell carcinoma
*Subependymal giant cell astrocytoma
==Diseases for which it is used==
*B-cell acute lymphoblastic leukemia
*HR+ Breast cancer
*Diffuse large B-cell lymphoma
*Classical Hodgkin lymphoma
*Mantle cell lymphoma
*Neuroendocrine tumor
*Pancreatic NET
*Peripheral T-cell lymphoma
*Thymoma
*Waldenström macroglobulinemia
==Patient drug information==
*Everolimus (Afinitor) package insert
*Everolimus (Afinitor) patient drug information (Chemocare)Everolimus (Afinitor) patient drug information (Chemocare)
*Everolimus (Afinitor) patient drug information (UpToDate)Everolimus (Afinitor) patient drug information (UpToDate)
==History of changes in FDA indication==
===HR+ Breast cancer===
*2012-07-20: Approval expanded to include postmenopausal women with advanced hormone receptor-positive, HER2-negative breast cancer (advanced HR+ BC) in combination with exemestane after failure of treatment with letrozole or anastrozole. (Based on BOLERO-2)
===Neuroendocrine tumor===
*2016-02-26: Approval expanded for the treatment of adult patients with progressive, well-differentiated non-functional, neuroendocrine tumors (NET) of gastrointestinal (GI) or lung origin with unresectable, locally advanced or metastatic disease. (Based on RADIANT-4)
===Pancreatic NET===
*2011-05-05: Approval expanded to include progressive neuroendocrine tumors of pancreatic origin (PNET) that is unresectable, locally advanced or metastatic. (Based on RADIANT-3)
===Renal cell carcinoma===
*2009-03-30: Initial approval for the treatment of patients with advanced renal cell carcinoma after failure of treatment with sunitinib or sorafenib. (Based on RECORD-1)
===Tuberous sclerosis complex-associated renal angiomyolipoma===
*2012-04-26: Accelerated approval for adults with renal angiomyolipoma and tuberous sclerosis complex (TSC), not requiring immediate surgery. (Based on EXIST-2)
**2016-02-18: Converted to regular approval
===Tuberous sclerosis complex-associated subependymal giant cell astrocytoma===
*2010-10-29: Accelerated approval for subependymal giant cell astrocytoma (SEGA) associated with tuberous sclerosis (TS) who require therapeutic intervention but are not candidates for curative surgical resection. (Based on CCHMC 06-07-50)
**2016-01-29: Converted to regular approval for subependymal giant cell astrocytoma (SEGA) associated with tuberous sclerosis (TS) who require therapeutic intervention but are not candidates for curative surgical resection. (Based on EXIST-1)
==History of changes in EMA indication==
*2009-08-02: Initial marketing authorization as Afinitor. Afinitor is intended for the treatment of patients with advanced renal cell carcinoma, whose disease has progressed on or after treatment with VEGF-targeted therapy.
*2011-08-24: Extension of indication to include Afinitor is indicated for the treatment of unresectable or metastatic, well- or moderately-differentiated neuroendocrine tumours of pancreatic origin in adults with progressive disease.
*2012-06-21: Extension of indication to include Afinitor for the treatment of hormone receptor-positive, HER2/neu negative advanced breast cancer, in combination with exemestane, in postmenopausal women without symptomatic visceral disease after recurrence or progression following a non-steroidal aromatase inhibitor.
*2016-05-26: Extension of indication to include a new indication for the treatment of unresectable or metastatic, well-differentiated non-functional neuroendocrine tumours of gastrointestinal or lung origin in adults with progressive disease.
==History of changes in Health Canada indication==
*2011-06-30: Initial notice of compliance with conditions
*2016-09-23: Conditions were met
==History of changes in PMDA indication==
*2007-01-26: Initial approval for the prophylaxis of organ rejection in cardiac transplant.
*2010-01-20: New additional indication and a new dosage for the treatment of unresectable or metastatic renal cell carcinoma.
*2011-12-22: New additional indication and a new dosage for the treatment of pancreatic neuroendocrine tumor.
*2012-11-21: New additional indications and a new dosage for the treatment of renal angiomyolipoma associated with tuberous sclerosis complex and subependymal giant cell astrocytoma associated with tuberous sclerosis complex.
*2014-03-17: New additional indication and a new dosage for the treatment of unresectable or recurrent breast cancer.
*2016-08-26: revised indication from "pancreatic neuroendocrine tumor" to "neuroendocrine tumor."
==Also known as==
*Code names: RAD-001
*Brand names: Afilimus, Advacan, Afinitor, Afinitor Disperz, Certican, Everbliss, Evercon, EverGraf, Evermil, Everomus, Everotaj, Evertor, Lanolimus, Natlimus, Rapact, Rolimus, Torinat, Votubia, Xevirol, Zortress
==References==
Category:Drugs
Category:Oral medications
Category:Protein expression-specific medications
Category:mTOR inhibitors
Category:TSC1 inhibitors
Category:TSC2 inhibitors
Category:B-cell acute lymphoblastic leukemia medications
Category:Breast cancer medications
Category:Diffuse large B-cell lymphoma medications
Category:Classical Hodgkin lymphoma medications
Category:Mantle cell lymphoma medications
Category:Neuroendocrine tumor medications
Category:Non-clear cell renal cell carcinoma medications
Category:Pancreatic NET medications
Category:Peripheral T-cell lymphoma medications
Category:Renal_cell_carcinoma medications
Category:Subependymal giant cell astrocytoma medications
Category:Thymoma medications
Category:Waldenström macroglobulinemia medications
Category:EMA approved in 2009
Category:FDA approved in 2009
Category:Health Canada approved in 2011
Category:PMDA approved in 2007
Category:WHO Essential Cancer Medicine