Sunitinib - Uses, Dosage, Efficacy, Side Effects, Precautions, and Warnings

Overview:

Sunitinib is an anti-cancer medication that comes as a capsule to be administered orally. It is a small-molecule and multi-targeted receptor tyrosine kinase inhibitor that received its Food and Drug Administration (FDA) approval for the treatment of various conditions in January 2006. The conditions include renal cell carcinoma (RCC) and gastrointestinal stromal tumor that is Imatinib-resistant. Sunitinib is considered the first cancer medication that got its approval concurrently for two distinct indications. Sunitinib has been available as a generic medicine since August 2021 in the United States.

Uses of Sunitinib:

• Renal Cell Carcinoma: Renal cell carcinoma, sometimes called renal cell adenocarcinoma or renal cell cancer, is the most common form of kidney cancer. About nine out of ten cases of kidney cancers can be renal cell carcinomas. Cancer generally develops as a single tumor and could affect both kidneys in the latter stages. The tumor begins in the cells that line the tubules of the kidney. Here, tubules are the tiny tubes that aid in returning the fluid and nutrients back to the bloodstream.

• Gastrointestinal Stromal Tumor: It is a form of cancer beginning in any part of the digestive system. But, it commonly occurs in the stomach and small intestine. They are the cancerous conditions that begin in the special nerve cells present in the wall of the digestive tract and associated organs. It is considered the most common mesenchymal tumor to develop in the digestive tract. They are rare, accounting for less than one percent of total gastrointestinal tumors.

• Pancreatic Neuroendocrine Tumors: Pancreatic neuroendocrine tumors, also referred to as islet cell tumors, are the less common tumors that begin in the pancreas. These tumors form in the hormone-producing cells called the islet cells. These cancers grow at gradual degrees and can potentially metastasize to other parts of the body. There is a range of pancreatic neuroendocrine tumors, all of which possess different types of signs and symptoms.

How Does Sunitinib Work?

Sunitinib is used in the treatment of gastrointestinal stromal tumors in individuals who are not treated successfully with the drug Imatinib or for individuals who are not able to take Imatinib. Sunitinib is also used in the treatment of advanced renal cell carcinoma. In addition, it is used in the prevention of the recurrence of renal cell carcinoma in individuals who have RCC but are not metastasized and with a history of kidney removal. Sunitinib is also used for the treatment of pancreatic neuroendocrine tumors in individuals in whom the tumors have progressed, and the surgical intervention does not seem to work. Sunitinib belongs to a class of drugs called kinase inhibitors. This medication works by blocking the abnormal protein and its action that help in signaling the cancer cells to multiply. So this results in inhibiting or slowing down the spread of cancer cells, causing the tumor to shrink.

What Are the Warnings and Precautions for Sunitinib?

The medicine Sunitinib possesses good needs as well as certain unwanted effects in specified populations or clinical conditions. So, the following should be taken into consideration before taking the medication.

• Allergies: This medication can induce hypersensitivity reactions in patients allergic to this drug. So, one should inform the doctor in case one has a previous history of allergy to Sunitinib or any other medication. Addedly, convey to the doctor if one has other non-medical allergies such as dyes, foods, preservatives, and animal products.

• Pediatrics: Adequate studies have not been performed so far in demonstrating the use and efficacy of Sunitinib in the pediatric population. Therefore, the safety and efficacy of Sunitinib have not been acclaimed in children.

• Geriatrics: The appropriate clinical studies fail to determine the geriatric-related problems associated with Sunitinib that could limit the use of this medication in the elderly.

• Breastfeeding: There are not sufficient studies conducted to determine the risk of Sunitib in infants when administered during the breastfeeding period. Hence, the doctors weigh and compare the potential benefits of Sunitinib against the possible risks and complications before the initiation of Sunitinib treatment in breastfeeding states.

• Pregnancy: This medication can harm the unborn infant while using this during pregnancy. It can also cause birth defects if the partner or the child’s father uses this medicine during the pregnancy of the mother. So, female patients are advised to use effective birth control aids during and four weeks after treatment. Male patients are advised to use effective birth control aids during and seven weeks following the last dose.

Important Precautions and Considerations:

• Sunitinib medication is known to cause serious heart ailments such as heart failure, heart attack, and cardiomyopathy. Inform right away if one experiences symptoms concerning heart problems like chest pain, dilated neck veins, dizziness, abnormal breathing, irregular heartbeat, daintiness, arm pain, nausea, sweating, tightness in the chest, or discomfort.

• The person under Sunitinib treatment can see the blood pressure getting too high. In addition, the person might feel daintiness, dizziness, or feel a fast, pounding heartbeat. So, seek professional help in case of increased blood pressure with this medicine.

• This medicine is known to raise the risk of bleeding and induce delayed wound healing. So, one should see the healthcare providers if any unusual bleeding, black, tarry stools, blood in the urine, bruising, or pinpoint red spots in the skin are noticed.

• It is vital to check with the doctor before getting any dental treatment or surgeries and before taking bisphosphonates like Alendronate, Risedronate, and Ibandronate.

• This medicine is known to cause serious jaw problems. So, inform the doctor if one has jaw pain, jaw tightness, swelling, pain, or tooth loss.

• Thrombotic microangiopathy, a condition causing damage in the smaller blood vessels, can occur with this medication. So, inform the doctor straight away if one has tiredness, fever, loss of vision, seizure, or confusion.

• Sunitinib medication can cause serious skin reactions such as necrotizing fasciitis, erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis. So, report to the doctor if facing any of these skin concerns: blistering, peeling, red skin lesions, severe acne, skin rash, sores or ulcers, and loss of the tightness of the skin. The other symptoms include fever, chills, weakness, and tiredness.

• A rare yet serious brain disorder called reversible posterior leukoencephalopathy syndrome (RPLS) can occur with this medicine. The symptoms include blurred vision, back pain, drowsiness, dizziness, headache, fever, seizures, confusion, and abnormal tiredness.

• Thyroid problems such as hypothyroidism and hyperthyroidism can occur with this medicine, according to clinical findings. One should inform the doctor in case of experiencing these symptoms, such as nervousness, heat sensitivity, weight loss, difficulty sleeping, constipation, mood declines, dry skin and hair, hair loss, hoarseness of voice, joint stiffness, muscle cramps, weight gain, husky voice, and unusual weakness.

• The medicine might also induce hypoglycemia (low blood sugar states). Inform the doctor right away if one detect any changes in the blood sugar level or experience symptoms like sweating, trembling, shaking, pounding heartbeat, hunger, lightheartedness, or faintness.

• Moreover, contact healthcare professionals if one feels abnormal or if there are any changes in the heart rhythm. Also, one should inform the doctor in case of a history of heart rhythm problems like QT prolongation.

For Patients:

What Is Renal Cell Carcinoma?

Renal cell carcinoma (RCC) is a cancerous condition of the kidney originating in the lining of the proximal convoluted tubule, a portion of smaller tubules in the kidney that is responsible for the transport of urine (filtration). So, RCC occurs as a result of unconstrained growth and proliferation of cancer cells in the lining of the tubules part of the kidney. It is the most prevailing form of cancer occurring in adults, accounting for about 90 to 95 % of cases. Males are more likely to have this cancerous condition than females. It is also referred to as renal adenocarcinoma, renal cancer, kidney cancer, or hypernephroma. The signs and symptoms of renal cell carcinoma include the following.

• A lump in the abdomen region.

• Blood in the urine.

• Loss of appetite.

• Fatigue.

• Vision concerns.

• Excessive hair growth.

• Persistent pain in the affected area.

How Serious Is Renal Cell Carcinoma?

There is no exact cause for the development of renal cell carcinoma. But the scientific researchers say that certain risk factors, including dialysis treatment, obesity, hypertension, family history of RCC, cigarette smoking, polycystic kidney disease, chronic abuse of certain medications, or a genetic condition called Von Hippel-Lindsay disease could increase the risk. It is a serious disease that can lead to potentially life-threatening complications. Nevertheless, early diagnosis and intervention are considered key to making the condition more likely to be cured. So, it can be efficiently treated when the tumor is still localized to the kidney and the closely surrounding structures. The probability of cure and the prognosis of the condition is directly connected to the degree or stage of tumor dissemination.

How Does Sunitinib Help Treat Renal Cell Carcinoma?

Sunitinib sorts with a class of medications called kinase inhibitors. They work by blocking the type of enzyme called kinase in the system. The body contains various forms of kinase. But, renal cell carcinoma results when the abnormal protein kinase signals and help the cancer cells to grow and multiply in the lining of the tubules on the kidney. So, Sunitinib performs its action by blocking the abnormal protein kinase and its action from helping cancer cells to multiply. As a result, the spread of cancer cells in renal cell carcinoma is either halted or slowed, leading to the shrinkage of the tumor.

How to Use Sunitinib Medication?

• Sunitinib medication comes as a capsule that is to be taken orally.

• It is available in various dosages, so the doctors advise the appropriate dosage depending on the age factors, the condition to be treated, and the severity of the condition.

• For the renal cell carcinoma treatment, the dosage recommendation of Sunitinib is once a day for four weeks, followed by a two-week drug-free period before the initiation of the next dosing cycle and reparations every six weeks as far as the prescription.

• For renal cell carcinoma prevention, the recommendation is generally once daily for four weeks, followed by a two-week drug-free period prior to the beginning of the subsequent dosing schedule and repeating every six weeks to make up nine cycles.

• So, one should follow the doctor’s instructions and manufacturer's label information conscientiously.

• One should take Sunitinib medication exactly as directed. Take the drug around the same time each day.

Things to Consider and Inform the Doctor:

• Inform the doctor prior to the treatment if one is allergic to Sunitinib or any other ingredients of the prescribed medication. Also, other allergies should be discussed if present.

• Convey to the doctor about the medications, nonprescription medicines, nutritional supplements, and vitamins one takes. One should be more sure to inform the doctor of any of the following antibiotics like Clarithromycin, Rifampin, Rifapentine, Rifabutin, Telithromycin, antifungal drugs such as Itraconazole, Voriconazole, Ketaxonoazile. Also inform in case of any Dexamethasone, diabetes medications, medications for human immunodeficiency virus (HIV) infection such as Indinavir, Atazanavir, Nelfinavir, Sauinavir, and Nefazofone. Also, inform if one is under seizure medicines such as Carbamazepine, Phenytoin, and Phenobarbital.

• Addedly, tell the doctor if one is taking or has taken Alendronate, Ibandronate, Etidronate, Risedronate, Pamidronate, or Zoledronic acid injection.

• Inform the doctor about the herbal product one takes, particularly St. John’s wort. The doctors might advise not to take this during Sunitinib treatment.

• Convey to the doctor in case of the presence of any medical condition or disease. So, be sure to mention certain problems if one has them. This includes bleeding problems, QT prolongation (abnormal heart rhythm), blood clots in the lungs, heart attack, irregular heartbeat, heart failure, seizures, diabetes, low blood sugar, high blood pressure, problems with the oral cavity, low potassium and magnesium levels in the blood, thyroid, and heart diseases.

• Tell the doctor if one is pregnant or has any plans for pregnancy. The mother or her male partner should inform about the pregnancy or its plan prior to the initiation of treatment.

• Tell the doctor if one is breastfeeding. It is recommended not to breastfeed during Sunitinib treatment or four weeks after the last dose.

• One should know that Sunitinib might cause the skin to turn yellow or hair to lighten than its actual color. This is due to the yellow color of this medication which is not considered harmful.

• One should check the blood pressure regularly during Sunitinib treatment.

• If one is using this medicine, be cautious and inform the other dentist or doctor. The doctors might advise withholding this medication for about seven days before any surgery or medical test.

• One should not take any other prescription or nonprescription medicines while using this medicine without discussing it with the doctor.

Directions to Use Sunitinib Medication:

• Sunitinib medication is to be taken orally.

• Sunitinib capsules can be taken with or without food.

• Take the doses as per the physicians’ directions, including the number of capsules, doses, and total duration length of interval time.

• One may need to take one or two capsules at a time, depending on the dosage instructed.

• Swallow the Sunitinib capsule as a whole with a glass of water. One should not chew, open or break them.

• Do not bring to a stop taking the Sunitinib medication unless the doctor says.

• One should complete the exact dosage of the medication as prescribed by the doctor, though with an improvement.

• In addition, call the doctor if one feels no improvement or worsening of symptoms.

• Inform the doctor of any such adverse side effects experienced with the treatment. The doctors might consider adjusting the dose or discontinuation of treatment temporarily or permanently.

Dietetic Considerations:

A well-balanced diet is always considered the soundest for any disease or condition. One can follow the routine nutritious diet until the doctor suggests any changes. Nevertheless, one should not have grapefruit or juices, and smoothies made up of grapefruit while taking this medication.

In Case of Missed Dose of Sunitinib:

If one misses the dose by less than 12 hours, then the missed dose can be taken as soon as one has the thought, and then the subsequent dose can be taken at the scheduled time. But, if the missed dose is more than 12 hours, then skip the missed dose and go with the regular dosing schedule. One should not take a double dose of Sunitinib medication for the compensation of missed doses.

In Case of an Overdose of Sunitinib:

Call the poison control helpline services or reach out to the medical emergency services in case of an overdose of Sunitinib.

What Are the Side Effects of Sunitinib?

The possible side effects of the drug Sunitinib include the following,

• Diarrhea.

• Fatigue.

• Heartburn.

• Taste changes.

• Nausea and vomiting.

• Hypertension.

• Low blood counts, including red blood cells and platelets. These conditions could be a risk factor for infection and anemia.

• Skin discoloration.

• Headache.

• Poor appetite.

• Weakness.

• Constipation.

• Bleeding.

• Abdominal pain.

• Dry skin.

• Fever.

• Dizziness.

• Swelling of ankles and feet.

• Shortness of breath.

• Aches.

• Rash.

• Dehydration.

• Flatulence.

• Hand-foot syndrome.

• Cough.

• Hypothyroid.

• Hair loss.

• Hair color changes.

• Reduced potassium levels.

• Increased bilirubin levels.

• Increase amylase levels.

• Increased lipase levels.

• Increase in overall liver enzymes.

For Doctors:

Pharmacology of Sunitinib

Indications:

Sunitinib is generally indicated in the following conditions.

• Treatment of gastrointestinal stromal tumor (GIST) in adult patients following disease progression.

• Treatment of advanced renal cell carcinoma (RCC) in adult patients.

• Adjuvant treatment for adults at higher risk of recurrent renal cell carcinoma following nephrectomy.

• Treatment of progressive and well-differentiated forms of pancreatic neuroendocrine tumors (pNET) in adults having an unresectable metastatic or locally advanced disease.

Associated Conditions:

• Renal cell carcinoma (RCC).

• Recurrent forms of renal cell carcinoma.

• Gastrointestinal stromal tumor.

• Unresectable and locally advanced progressive neuroendocrine tumor with pancreatic origin.

• Unresectable and metastatic progressive neuroendocrine tumor with pancreatic origin.

Pharmacodynamics:

Sunitinib is a small-molecule and Multi-targeted receptor tyrosine kinase inhibitor (RTK).

Mechanism of Action:

Sunitinib is a small molecule and Multi-targeted therapy that inhibits the action of multiple receptor tyrosine kinases that are involved in tumor growth, diseases, angiogenesis, and metastasis of tumors. According to the evaluation of Sunitinib for its inhibitory action against multiple kinases, it was observed that Sunitinib inhibits platelet-derived growth factor receptors, stem cell factor receptors, vascular endothelial growth factor receptors, colony-stimulating factor receptor of type 1, FMS-like tyrosine kinase, and the glial cell line-derived neurotrophic factor receptor. The inhibition activity of Sunitinib of these receptor tyrosine kinases has been signified in the cellular and biochemical assays while the inhibitory action on function has been signified in the cell proliferation assays. The primary active metabolite of Sunitinib exerts potency similar to Sunitinib in cellular and biochemical assays.

Absorption:

• The maximum plasma concentration (C max) of Sunitinib after an oral administration is observed to be between 6 and 12 hours.

• Sunitinib can be taken with or without no food since food does not present any significant effect on the bioavailability of this drug.

• The clinical findings validate that the pharmacokinetics of Sunitinib was similar in healthy individuals and people with solid tumor such as renal cell carcinoma and gastrointestinal stromal tumor.

Distribution:

• The apparent volume of distribution is 2230 L for Sunitinib.

• The binding potency of Sunitinib and its primary metabolite with human plasma protein was 95 and 99 percent in vitro.

Metabolism:

• The drug sunitinib undergoes well metabolism to produce its primary active metabolite by CYP3A4, a cytochrome P450 enzyme.

• The primary active metabolite, in turn, undergoes further metabolism by CYP3A4.

• The primary active metabolite of Sunitinib makes up between 23 and 37 percent of the total exposure.

• Following a radiolabeled dose, Sunitinib and its primary active metabolite are chiefly detected in the plasma esteeming for about 92 percent of the radioactivity.

Elimination:

• The primary route of elimination of Sunitinib is through feces.

• A human mass balance study validates that approximately 16 percent of the administered dose was traced in the urine and 61 percent of the dose in feces, following a radiolabeled dose of Sunitinib.

• Sunitinib and its primary active metabolite are the significant compounds detected in the urine, accounting for about 86 and 74 percent of radioactivity consecutively.

Half-Life and Clearance:

• The terminal half-life of Sunitinib is approximately 40 to 60 hours, and the primary active metabolite is about 80 to 110 hours following a single dose of Sunitinib administration in healthy individuals.

• The total oral clearance is about 34 to 62 L/h.

Toxicity:

• The clinical findings say that the maximally tolerated dose of Sunitinib for animals such as mice, rats, and dogs is a sum greater than 500 mg/kg when at oral administration.

• The maximally tolerated dose in the case of non-human primates is higher than 1200 mg/kg.

Dosing of Sunitinib:

Renal Cell Carcinoma:

• Sunitinib is indicated for the treatment of advanced forms of renal cell carcinoma (RCC) and as the adjuvant treatment of individuals at higher risk of recurrent RCC after nephrectomy.

• The recommended dosage for renal cell carcinoma is 50 mg per day for about four weeks; then, two weeks could be drug-free, and the cycle has to be repeated.

• The recommended dosage for the adjuvant intervention of RCC is 50 mg once per day on a four weeks schedule followed by two weeks off schedule. Nine six-week cycles make up the total duration.

• The dosage is continued until the disease progresses or has unacceptable toxicity.

Gastrointestinal Stromal Tumor:

• The medication is indicated for gastrointestinal stromal tumor (GIST) treatment after disease progression with intolerance to Imatinib mesylate.

• The dosage is 50 mg once each day for four weeks, with two weeks drug-free and followed by a resume of the cycle.

• Continue the dosage until any unacceptable toxicity or progression of the disease.

Pancreatic Neuroendocrine Tumor:

• The recommended Sunitinib dosage for the pancreatic neuroendocrine tumor is 37.5 mg orally to be taken each day persistently without any off-therapy period.

• So, no drug-free weeks in adjacent weeks.

• Continue the dosage up until unacceptable toxicity or disease progression.

Dosage Modifications and Considerations

For Adverse Reactions:

Dosage modifications can be done according to the adverse reactions and their severity.

Hepatotoxicity:

Sunitinib is known to cause severe degrees of hepatotoxicity, resulting in liver failure. The signs of liver failure include jaundice, increased transaminase, and hyperbilirubinemia that is accompanied by coagulopathy, encephalopathy, or renal failure. Therefore, monitor liver function tests for alanine aminotransferase, bilirubin, and aspartate aminotransferase before initiation of Sunitinib therapy.

• For grade 3 hepatotoxicity, withhold the treatment until resolving to less than grade 1 or baseline. Moreover, discontinue permanently in case of recurring grade 3 hepatotoxicity.

• For grade 4, permanently discontinue the treatment.

Cardiovascular Events:

Cardiovascular events have been reported with Sunitinib treatment that includes cardiomyopathy, heart failure, myocardial infarction, and myocardial ischemia and some were fatal. Monitor conscientiously the signs and symptoms of congestive heart failure in individuals who are at higher risk. One should consider the baseline and periodic assessment of left ventricular ejection fraction (LVEF).

• It is recommended to permanently discontinue the treatment for the underlying clinical manifestation of congestive heart failure (CHF).

• In cases of asymptomatic cardiomyopathy, if LVEF is greater than 20 percent, but less than 50 percent, below baseline or below the lower limit of normal (LLN), or if the baseline is not obtained, withhold until it is resolved to grade less than 1 or baseline. Then, resume the treatment with a reduced dose.

Hypertension:

Clinical findings show that nearly 29 percent of adults treated with Sunitinib for various conditions presented with hypertension. Monitor individuals for hypertension and recommend standard antihypertensive therapy if required. Temporary suspension of Sunitinib therapy is recommended up until hypertension is resolved. Subsequently, consider permanent discontinuation of treatment in grade 4 hypertension.

Hemorrhagic Events:

Hemorrhagic events have been reported with post-marketing experience and were fatal at times. This included respiratory, gastrointestinal, urinary tract, brain, and tumor-related hemorrhages.

• In grades 3 and 4, consider withholding treatment until resolves to a grade less than one or baseline.

• Resume the Sunitinib treatment with a reduced dose or consider discontinuation of treatment depending upon the adverse reaction and its severity.

Thrombotic Microangiopathy:

Thrombotic microangiopathy has been reported with Sunitinib treatment in clinical trials and as a post-marketing experience. This included hemolytic Turkic syndrome and thrombotic thrombocytopenic purpura, resulting in renal failure or a fatal consequence. Discontinuation of Sunitinib treatment is strictly recommended in individuals developing or having any grade of thrombotic microangiopathy.

Proteinuria and Nephrotic Syndrome:

Proteinuria and nephrotic syndrome have also been reported with Sunitinib treatment; some of these conditions have turned out to be fatal. Monitor for the development or progression of Proteinuria in patients. So, consider baseline and periodic urine analyses during therapy.

• Withhold the treatment and resume with a reduced dosage for 24-hour urine protein greater than or equal to three grams.

• Permanently discontinue the treatment for nephrotic syndrome or recurrent episodes of proteinuria with less than three grams, regardless of dose reductions.

Dermatological Toxicities:

Severe degrees of cutaneous reactions, including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), necrotizing fasciitis, and erythema multiforme, have been reported. Some of these conditions were fatal. Consider discontinuation of treatment in cases of the presence of any signs and symptoms of these conditions.

Thyroid Dysfunction:

Hyperthyroidism cases, sometimes even hypothyroidism, have been reported in clinical trials. Hence, baseline laboratory assessment of thyroid function should be considered. Individuals with underlying hyperthyroidism and hypothyroidism should be according to the standard medical norms before the initiation of Sunitinib treatment. Also, monitor conscientiously for the signs and symptoms of thyroid dysfunctions.

Hypoglycemia:

Asymptomatic hypoglycemia has been reported in about two percent of individuals treated with Sunitinib therapy in clinical trials. Monitor blood glucose levels regularly before, during, and after the discontinuation of Sunitinib treatment.

Osteonecrosis of the Jaw:

Osteonecrosis of the jaw is one of the consequences observed in clinical trials and the postmarketing experience of Sunitinib. Advise preventive dentistry measures prior to treatment since concurrent exposure to dental diseases and bisphosphonates could increase its risks. Consider avoiding dental procedures during the treatment. The avoidance of dental procedures during Sunitinib treatment should be strictly followed in cases of individuals receiving intravenous bisphosphonate therapy.

Reversible Posterior Leukoencephalopathy Syndrome:

Discontinuation of Sunitinib treatment is recommended in any degree of reversible posterior leukoencephalopathy syndrome.

Impaired Wound Healing:

There prevail certain cases of impaired wound healing during Sunitinib treatment. Temporary discontinuity is recommended for precautionary measures in individuals undergoing major surgical interventions. The resume resolution should be considered depending upon the recovery from surgical intervention.

Renal Impairment:

• No dosage modification is required in the case of any degree of renal impairment in individuals who are not on dialysis.

• For individuals with end-stage renal disease on dialysis, no modification in the initial dose is required. However, Sunitinib exposure is about 47 percent lower in individuals with end-stage renal disease on dialysis than the exposure in normal healthy individuals. Therefore, a gradual dose increase is required based on tolerability.

Hepatic Impairment:

• For mild to moderate cases, dosage modification might not be required for the starting dose, but subsequent doses should be monitored.

• The safety and tolerability of Sunitib in severe cases of hepatic impairment have not been studied.

What Are the Possible Drug Interactions of Sunitinib?

The drug Sunitinib interacts with several drugs presenting certain adverse reactions. This drug is considered to be contraindicated with six drugs and is known to show serious interaction with about 111 drugs. Moreover, safety and tolerability are to be monitored closely when Sunitinib is used in conjugation with about 170 drugs. The drug even shows minor interactions with six drugs.

The drug Sunitinib is contraindicated with the following drugs-

• Dronedarone.

• Lefamulin.

• Posaconazole.

• Saquinavir.

• Thioridazine.

• Fluconazole.