have been related to some cases. Haemorrhage and thrombosis can occur when VEGF is inhibited as VEGF promotes endothelial cell survival and helps maintaining vascular integrity. When VEGF is inhibited, the regenerative capacity of endothelial cells may diminish and pro-coagulant phospholipids could be exposed on the plasma membrane or the underlying matrix, possibly leading to either thrombosis or haemorrhage. Since VEGF increases production of NO and prostacyclin, the inhibition of VEGF leads to decrease in both chemicals which contributes to thromboembolic events. Reversible posterior leukoencephalopathy is often attributed to hypertensive encephalopathy as well as endothelial dysfunction. This can cause focal cerebral oedema, vasospasms, and even a breakdown in the blood–brain barrier. Inhibition of VEGF is implicated as a factor in the pathophysiology of the disease but has not yet been replicated after VEGF inhibition in preclinical models. Endocrine dysfunction has been reported as an adverse effect of VEGF inhibition. Hyperthyroidism is one such, since thyroid function can be damaged by capillary regression around the follicles of the thyroid. The fenestrated capillaries of the pituitary, adrenal cortex and pancreatic isle have also been known to regress as an effect of VEGF inhibition. The thyroid-hypothalamic feedback loop can also be impaired due to VEGF inhibition, followed by raised TSH blood concentration. Interactions Lenvatinib inhibits the liver enzyme CYP3A, which also happens to be a metabolic enzyme for the drug. It inhibits the UDP-glucuronosyltransferases UGT1A1 and UGT1A4. Lenvatinib induces CYP3A but not UGT1A1 and UGT1A4. Use of other drugs, especially ones metabolized by the liver enzyme CYP3A, should be monitored in case their plasma concentration changes. In vitro studies have shown that lenvatinib inhibits organic anion transporters 1 and 3 (OAT1 and OAT3). Sunitinib is metabolized in the liver by CYP3A4. It interacts with inducers and inhibitors of CYP3A4 leading to a decrease or increase in the plasma concentration of particular drugs metabolized by the same pathway. It will not change the amount of drug metabolized by the enzyme, because it does not inhibit or induce the enzyme directly. Sunitinib is a substrate of P-glycoprotein and ABCG2 transporters. It acts as an inhibitor for both transporters, especially for ABCG2. Therefore, drugs that are substrates of these carriers will have modified pharmacokinetics. Plasma concentration of sorafenib and paclitaxel may be increased when the drugs are co-administered along with carboplatin. This has no effect on carboplatin. It also increases the AUC of docetaxel, doxorubicin and