Deferasirox

Indications and Usage, Limitations of Use (1.3) 7/2019

1 INDICATIONS AND USAGE Deferasirox tablets for oral suspension are an iron chelator indicated for the treatment of chronic iron overload due to blood transfusions in patients 2 years of age and older. (1.1) Deferasirox tablets for oral suspension is indicated for the treatment of chronic iron overload in patients 10 years of age and older with non-transfusion-dependent thalassemia (NTDT) syndromes, and with a liver iron (Fe) concentration (LIC) of at least 5 mg Fe per gram of dry weight and a serum ferritin greater than 300 mcg/L. (1.2) Limitations of Use: The safety and efficacy of deferasirox tablets for oral suspension when administered with other iron chelation therapy have not been established. (1.3) 1.1 Treatment of Chronic Iron Overload Due to Blood Transfusions (Transfusional Iron Overload) Deferasirox tablets for oral suspension are indicated for the treatment of chronic iron overload due to blood transfusions (transfusional hemosiderosis) in patients 2 years of age and older. 1.2 Treatment of Chronic Iron Overload in Non-Transfusion-Dependent Thalassemia Syndromes Deferasirox tablets for oral suspension are indicated for the treatment of chronic iron overload in patients 10 years of age and older with non-transfusion-dependent thalassemia (NTDT) syndromes and with a liver iron concentration (LIC) of at least 5 milligrams of iron per gram of liver dry weight (mg Fe/g dw) and a serum ferritin greater than 300 mcg/L. 1.3 Limitations of Use The safety and efficacy of deferasirox tablets for oral suspension when administered with other iron chelation therapy have not been established.

2 DOSAGE AND ADMINISTRATION Transfusional Iron Overload: Initial dose for patients with estimated glomerular filtration rate (eGFR) greater than 60 mL/min/1.73 m 2 is 20 mg per kg body weight once daily, as oral suspension. Calculate dose to the nearest whole tablet. ( 2.1 ) NTDT Syndromes: Initial dose for patients with eGFR greater than 60 mL/min/1.73 m2 is 10 mg per kg body weight once daily, as oral suspension. Calculate dose to the nearest whole tablet. ( 2. 2) 2.1 Transfusional Iron Overload Deferasirox tablets for oral suspension therapy should only be considered when a patient has evidence of chronic transfusional iron overload. The evidence should include the transfusion of at least 100 mL/kg of packed red blood cells (e.g., at least 20 units of packed red blood cells for a 40 kg person or more in individuals weighing more than 40 kg), and a serum ferritin consistently greater than 1,000 mcg/L. Prior to starting therapy or increasing dose, evaluate: • Serum ferritin level • Baseline renal function: o Obtain serum creatinine in duplicate (due to variations in measurements) to establish accurate baseline o Calculate the estimated glomerular filtration rate (eGFR). Use a prediction equation appropriate for adult patients (e.g., CKD-EPI, MDRD method) and in pediatric patients (e.g., Schwartz equations). o Obtain urinalyses and serum electrolytes to evaluate renal tubular function [see Dosage and Administration ( 2.4 ), Warnings and Precautions ( 5.1 )]. • Serum transaminases and bilirubin [see Dosage and Administration ( 2.4 ), Warnings and Precautions ( 5.2 )] • Baseline auditory and ophthalmic examinations [see Warnings and Precautions ( 5.10 )] Initiating Therapy: The recommended initial dose of deferasirox tablets for oral suspension for patients 2 years of age and older with eGFR greater than 60 mL/min/1.73 m 2 is 20 mg per kg body weight orally, once daily. Calculate doses (mg per kg per day) to the nearest whole tablet. During Therapy: • Monitor serum ferritin monthly and adjust the dose of deferasirox tablets for oral suspension, if necessary, every 3-6 months based on serum ferritin trends. • Use the minimum effective dose to achieve a trend of decreasing ferritin. • Make dose adjustments in steps of 5 or 10 mg per kg and tailor adjustments to the individual patient's response and therapeutic goals. • In patients not adequately controlled with doses of 30 mg per kg (e.g., serum ferritin levels persistently above 2,500 mcg/L and not showing a decreasing trend over time), doses of up to 40 mg per kg may be considered. Doses above 40 mg per kg are not recommended [see Warnings and Precautions ( 5.6 )]. • Adjust dose based on serum ferritin levels o If the serum ferritin falls below 1,000 mcg/L at 2 consecutive visits, consider dose reduction, especially if the dose is greater than 25 mg/kg/day [see Adverse Reactions ( 6.1 )]. o If the serum ferritin falls below 500 mcg/L, interrupt deferasirox tablets for oral suspension and continue monthly monitoring. o Evaluate the need for ongoing chelation therapy for patients whose conditions no longer require regular blood transfusions. o Use the minimum effective dose to maintain iron burden in the target range [see Warnings and Precautions ( 5.6 )]. • Monitor blood counts, liver function, renal function and ferritin monthly [see Warnings and Precautions ( 5.1 , 5.2 , 5.4 )]. • Interrupt deferasirox tablets for oral suspension for pediatric patients who have acute illnesses, which can cause volume depletion, such as vomiting, diarrhea, or prolonged decreased oral intake, and monitor more frequently. Resume therapy as appropriate, based on assessments of renal function, when oral intake and volume status are normal [see Dosage and Administration ( 2.4 , 2.5 ), Warnings and Precautions ( 5.1 ), Use in Specific Populations ( 8.4 ), Clinical Pharmacology ( 12.3 )]. 2.2 Iron Overload in Non-Transfusion-Dependent Thalassemia Syndromes Deferasirox tablets for oral suspension therap …

3 DOSAGE FORMS AND STRENGTHS Deferasirox tablets for oral suspension are available as follows: 125 mg tablets White to off-white, round, unscored tablets, debossed with and 454 on one side and plain on the other side. 250 mg tablets White to off-white, round, unscored tablets, debossed with and 455 on one side and plain on the other side. 500 mg tablets White to off-white, round, unscored tablets, debossed with and 456 on one side and plain on the other side. Tablets for oral suspension: 125 mg, 250 mg, 500 mg. ( 3 ) 9c6b4e1d-figure-01 9c6b4e1d-figure-02 9c6b4e1d-figure-03

4 CONTRAINDICATIONS Deferasirox tablets for oral suspension are contraindicated in patients with: • Estimated GFR less than 40 mL/min/1.73 m 2 [see Dosage and Administration ( Error! Hyperlink reference not valid. ), Warnings and Precautions ( Error! Hyperlink reference not valid. )]; • Poor performance status [see Warnings and Precautions ( Error! Hyperlink reference not valid. , Error! Hyperlink reference not valid. )]; • High-risk myelodysplastic syndromes (this patient population was not studied and is not expected to benefit from chelation therapy); • Advanced malignancies [see Warnings and Precautions ( Error! Hyperlink reference not valid. , Error! Hyperlink reference not valid. )]; • Platelet counts less than 50 x 10 9 /L [see Warnings and Precautions ( Error! Hyperlink reference not valid. , Error! Hyperlink reference not valid. )]; Known hypersensitivity to deferasirox or any component of deferasirox tablets for oral suspension [see Warnings and Precautions ( Error! Hyperlink reference not valid. ), Adverse Reactions ( Error! Hyperlink reference not valid. )] . • Estimated GFR less than 40 mL/min/1.73 m 2 . ( 4 ) • Patients with poor performance status. ( 4 ) • Patients with high-risk myelodysplastic syndrome (MDS). ( 4 ) • Patients with advanced malignancies. ( 4 ) • Patients with platelet counts less than 50 x 10 9 /L. ( 4 ) • Known hypersensitivity to deferasirox or any component of deferasirox tablets for oral suspension. ( 4 )

6 ADVERSE REACTIONS The following clinically significant adverse reactions are also discussed in other sections of the labeling: Acute Kidney Injury, Including Acute Renal Failure Requiring Dialysis, and Renal Tubular Toxicity Including Fanconi Syndrome [see Warnings and Precautions (5.1, 5.6)] Hepatic Toxicity and Failure [see Warnings and Precautions (5.2, 5.6)] GI Hemorrhage [see Warnings and Precautions (5.3)] Bone Marrow Suppression [see Warnings and Precautions (5.4)] Hypersensitivity [see Warnings and Precautions (5.7)] Severe Skin Reactions [see Warnings and Precautions (5.8)] Skin Rash [see Warnings and Precautions (5.9)] Auditory and Ocular Abnormalities [see Warnings and Precautions (5.10)] In patients with transfusional iron overload, the most frequently occurring (greater than 5%) adverse reactions are diarrhea, vomiting, nausea, abdominal pain, skin rashes, and increases in serum creatinine. In deferasirox tablets for oral suspension-treated patients with NTDT syndromes, the most frequently occurring (greater than 5%) adverse reactions are diarrhea, rash, and nausea. (6.1) To report SUSPECTED ADVERSE REACTIONS, contact Alembic Pharmaceuticals Limited at 1-866-210-9797 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch . 6.1 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 to rates in the clinical trials of another drug and may not reflect the rates observed in practice. Transfusional Iron Overload A total of 700 adult and pediatric patients were treated with deferasirox tablets for oral suspension (deferasirox) for 48 weeks in premarketing studies. These included 469 patients with beta-thalassemia, 99 with rare anemias, and 132 with sickle cell disease. Of these patients, 45% were male, 70% were Caucasian, and 292 patients were less than 16 years of age. In the sickle cell disease population, 89% of patients were black. Median treatment duration among the sickle cell patients was 51 weeks. Of the 700 patients treated, 469 (403 beta-thalassemia and 66 rare anemias) were entered into extensions of the original clinical protocols. In ongoing extension studies, median durations of treatment were 88 to 205 weeks. Six hundred twenty-seven (627) patients with myelodysplastic syndrome (MDS) were enrolled across 5 uncontrolled trials. These studies varied in duration from 1 to 5 years. The discontinuation rate across studies in the first year was 46% (adverse events 20%, withdrawal of consent 10%, death 8%, other 4%, lab abnormalities 3%, and lack of efficacy 1%). Among 47 patients enrolled in the study of 5-year duration, 10 remained on deferasirox tablets for oral suspension at the completion of the study. Table 1 displays adverse reactions occurring in greater than 5% of deferasirox tablets for oral suspension-treated beta-thalassemia patients (Study 1), sickle cell disease patients (Study 3), and patients with MDS (MDS pool). Abdominal pain, nausea, vomiting, diarrhea, skin rashes, and increases in serum creatinine were the most frequent adverse reactions reported with a suspected relationship to deferasirox tablets for oral suspension. Gastrointestinal symptoms, increases in serum creatinine, and skin rash were dose related. Table 1. Adverse Reactions a Occurring in Greater Than 5% of Deferasirox Tablets for Oral Suspension-treated Patients in Study 1, Study 3, and MDS Pool Study 1 (Beta-thalassemia) Study 3 (Sickle Cell Disease) MDS Pool Adverse Reactions Deferasirox Tablets for Oral Suspension N=296 n (%) Deferoxamine N=290 n (%) Deferasirox Tablets for Oral Suspension N=132 n (%) Deferoxamine N=63 n (%) Deferasirox Tablets for Oral Suspension N=627 n (%) Abdominal Pain b 63 (21) 41 (14) 37 (28) 9 (14) 145 (23) Diarrhea 35 (12) 21 (7) 26 (20) 3 (5) 297 (47) Creatinine Increased c 33 (11) 0 (0) 9 (7) 0 89 (14) Nausea 31 (11) 14 (5) 30 (23) 7 (11) 161 (26) Vomiting 30 (10) 28 (10 …

7 DRUG INTERACTIONS Do not take deferasirox tablets for oral suspension with aluminum-containing antacid preparations. (7.1) Deferasirox tablets for oral suspension increases the exposure of the CYP2C8 substrate repaglinide. Consider repaglinide dose reduction and monitor blood glucose levels. (7.3) Avoid the use of deferasirox tablets for oral suspension with CYP1A2 substrate theophylline. (7.4) Deferasirox increases exposure of busulfan. Monitor plasma concentrations of busulfan when coadministered with deferasirox to allow dose adjustment of busulfan as needed. (7.7) 7.1 Aluminum-Containing Antacid Preparations The concomitant administration of deferasirox tablets for oral suspension and aluminum-containing antacid preparations has not been formally studied. Although deferasirox has a lower affinity for aluminum than for iron, do not take deferasirox tablets for oral suspension with aluminum-containing antacid preparations due to the mechanism of action of deferasirox tablets for oral suspension. 7.2 Agents Metabolized by CYP3A4 Deferasirox may induce CYP3A4 resulting in a decrease in CYP3A4 substrate concentration when these drugs are coadministered. Closely monitor patients for signs of reduced effectiveness when deferasirox is administered with drugs metabolized by CYP3A4 (e.g., alfentanil, aprepitant, budesonide, buspirone, conivaptan, cyclosporine, darifenacin, darunavir, dasatinib, dihydroergotamine, dronedarone, eletriptan, eplerenone, ergotamine, everolimus, felodipine, fentanyl, hormonal contraceptive agents, indinavir, fluticasone, lopinavir, lovastatin, lurasidone, maraviroc, midazolam, nisoldipine, pimozide, quetiapine, quinidine, saquinavir, sildenafil, simvastatin, sirolimus, tacrolimus, tolvaptan, tipranavir, triazolam, ticagrelor, and vardenafil) [see Clinical Pharmacology (12.3)] . 7.3 Agents Metabolized by CYP2C8 Deferasirox inhibits CYP2C8 resulting in an increase in CYP2C8 substrate (e.g., repaglinide and paclitaxel) concentration when these drugs are coadministered. If deferasirox tablets for oral suspension and repaglinide are used concomitantly, consider decreasing the dose of repaglinide and perform careful monitoring of blood glucose levels. Closely monitor patients for signs of exposure related toxicity when deferasirox tablets for oral suspension are coadministered with other CYP2C8 substrates [see Clinical Pharmacology (12.3)]. 7.4 Agents Metabolized by CYP1A2 Deferasirox inhibits CYP1A2 resulting in an increase in CYP1A2 substrate (e.g., alosetron, caffeine, duloxetine, melatonin, ramelteon, tacrine, theophylline, tizanidine) concentration when these drugs are coadministered. An increase in theophylline plasma concentrations could lead to clinically significant theophylline-induced CNS or other adverse reactions. Avoid the concomitant use of theophylline or other CYP1A2 substrates with a narrow therapeutic index (e.g., tizanidine) with deferasirox tablets for oral suspension. Monitor theophylline concentrations and consider theophylline dose modification if you must coadminister theophylline with deferasirox tablets for oral suspension. Closely monitor patients for signs of exposure related toxicity when deferasirox tablets for oral suspension are coadministered with other drugs metabolized by CYP1A2 [see Clinical Pharmacology (12.3)] . 7.5 Agents Inducing UDP-glucuronosyltransferase (UGT) Metabolism Deferasirox is a substrate of UGT1A1 and to a lesser extent UGT1A3. The concomitant use of deferasirox tablets for oral suspension with potent UGT inducers (e.g., rifampicin, phenytoin, phenobarbital, ritonavir) may result in a decrease in deferasirox tablets for oral suspension efficacy due to a possible decrease in deferasirox concentration. Avoid the concomitant use of potent UGT inducers with deferasirox tablets for oral suspension. Consider increasing the initial dose of deferasirox tablets for oral suspension if you must coadminister these agents together [see Dosage and Administration (2.5), …

8 USE IN SPECIFIC POPULATIONS Lactation: Advise women not to breastfeed. (8.2 ) 8.1 Pregnancy Risk Summary There are no studies with the use of deferasirox in pregnant women to inform drug-associated risks. Administration of deferasirox to rats during pregnancy resulted in decreased offspring viability and an increase in renal anomalies in male offspring at doses that were about or less than the recommended human dose on an mg/m 2 basis. No fetal effects were noted in pregnant rabbits at doses equivalent to the human recommended dose on an mg/m 2 basis. Deferasirox should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. The 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. However, the background risk in the U.S. general population of major birth defects is 2% to 4% and of miscarriage is 15% to 20% of clinically recognized pregnancies. Data Animal Data In embryo-fetal developmental studies, pregnant rats and rabbits received oral deferasirox during the period of organogenesis at doses up to 100 mg/kg/day in rats and 50 mg/kg/day in rabbits (1.2 times the maximum recommended human dose (MRHD) on an mg/m 2 basis). These doses resulted in maternal toxicity but no fetal harm was observed. In a prenatal and postnatal developmental study, pregnant rats received oral deferasirox daily from organogenesis through lactation day 20 at doses of 10, 30, and 90 mg/kg/day (0.1, 0.3, and 1.0 times the MRHD on an mg/m 2 basis). Maternal toxicity, loss of litters, and decreased offspring viability occurred at 90 mg/kg/day (1.0 times the MRHD on a mg/m 2 basis) and increases in renal anomalies in male offspring occurred at 30 mg/kg/day (0.3 times the MRHD on a mg/m 2 basis). 8.2 Lactation Risk Summary No data are available regarding the presence of deferasirox or its metabolites in human milk, the effects of the drug on the breastfed child, or the effects of the drug on milk production. Deferasirox and its metabolites were excreted in rat milk. Because many drugs are excreted in human milk, and because of the potential for serious adverse reactions in a breastfeeding child from deferasirox and its metabolites, a decision should be made whether to discontinue breastfeeding or to discontinue the drug, taking into account the importance of the drug to the mother. 8.3 Females and Males of Reproductive Potential Contraception Counsel patients to use non-hormonal method(s) of contraception since deferasirox can render hormonal contraceptives ineffective [see Drug Interactions ( 7.2 )] . 8.4 Pediatric Use Transfusional Iron Overload The safety and effectiveness of deferasirox have been established in pediatric patients 2 years of age and older for the treatment of transfusional iron overload [see Dosage and Administration ( 2.1 )] . Safety and effectiveness have not been established in pediatric patients less than 2 years of age for the treatment of transfusional iron overload. Pediatric approval for treatment of transfusional iron overload was based on clinical studies of 292 pediatric patients 2 years to less than 16 years of age with various congenital and acquired anemias. Seventy percent of these patients had beta-thalassemia [see Indications and Usage ( 1 ), Dosage and Administration ( 2.1 ), Clinical Studies ( 14 )] . In those clinical studies, 173 children (ages 2 to < 12 years) and 119 adolescents (ages 12 to < 17 years) were exposed to deferasirox. A trial conducted in treatment-naïve pediatric patients, 2 to < 18 years of age with transfusional iron overload (NCT02435212) did not provide additional relevant information about the safety or effectiveness of the deferasirox granules dosage form compared to the deferasirox oral tablets for suspension dosage form. Iron Overload in Non-Transfusion-Dependent Thalassemia Syndromes The safety and effectiveness of defera …

12.1 Mechanism of Action Deferasirox tablets for oral suspension are an orally active chelator that is selective for iron (as Fe 3+ ). It is a tridentate ligand that binds iron with high affinity in a 2:1 ratio. Although deferasirox has very low affinity for zinc and copper there are variable decreases in the serum concentration of these trace metals after the administration of deferasirox. The clinical significance of these decreases is uncertain.

11 DESCRIPTION Deferasirox is an iron chelating agent. Deferasirox tablets for oral suspension contain 125 mg, 250 mg, or 500 mg deferasirox. Deferasirox is designated chemically as 4-[3,5-Bis (2-hydroxyphenyl)-1H-1,2,4-triazol-1-yl]-benzoic acid and its structural formula is: Deferasirox is a white to slightly yellow powder. Its molecular formula is C 21 H 15 N 3 O 4 and its molecular weight is 373.4 g/mol. Inactive Ingredients: colloidal silicon dioxide, crospovidone, dibasic sodium phosphate anhydrous, hydrogenated castor oil, hypromellose, low substituted hydroxy propyl cellulose, magnesium stearate, microcrystalline cellulose and sodium lauryl sulfate. def-str

10 OVERDOSAGE Cases of overdose (2 - 3 times the prescribed dose for several weeks)have been reported. In one case, this resulted in hepatitis, which resolved without long-term consequences after a dose interruption. In one pediatric case, a dose of 2-3 times the prescribed dose for 6 days, resulted in acute renal failure requiring hemofiltration and acute liver injury/failure, which were reversible with intensive care support. Single doses up to 80 mg per kg per day in iron overloaded beta-thalassemic patients have been tolerated with nausea and diarrhea noted. In healthy volunteers, single doses of up to 40 mg per kg per day were tolerated. There is no specific antidote for deferasirox. In case of overdose, induce vomiting and employ gastric lavage. Early signs of acute overdose are digestive effects such as abdominal pain, diarrhea, nausea, and vomiting. Hepatic and renal disorders have been reported, including cases of liver enzyme and creatinine increased with recovery after treatment discontinuation. An erroneously administered single dose of 90 mg/kg led to Fanconi syndrome which resolved after treatment. There is no specific antidote for deferasirox. In case of overdose, it may be treated with induction of vomiting or gastric lavage, and by symptomatic treatment.

16 HOW SUPPLIED/STORAGE AND HANDLING Deferasirox tablets for oral suspension are provided as 125 mg, 250 mg, and 500 mg tablets for oral suspension. 125 mg White to off white, round, flat, uncoated tablets, with debossing “D” on one side and “125” on other side. Bottles of 30 tablets................................. (NDC 69539-021-30) Bottles of 90 tablets................................ (NDC 69539-021-90) Bottles of 1000 tablets............................. (NDC 69539-021-99) Cartons of 100 (10 x 10) unit dose tablets ....... (NDC 69539-021-06) 250 mg White to off white, round, flat, uncoated tablets, with debossing “D” on one side and “250” on other side. Bottles of 30 tablets............................... (NDC 69539-022-30) Bottles of 90 tablets............................... (NDC 69539-022-90) Bottles of 1000 tablets............................ (NDC 69539-022-99) Cartons of 100 (10 x 10) unit dose tablets .......(NDC 69539-022-06) 500 mg White to off white, round, flat, uncoated tablets, with debossing “D” on one side and “500” on other side. Bottles of 30 tablets............................... (NDC 69539-023-30) Bottles of 90 tablets............................... (NDC 69539-023-90) Bottles of 500 tablets.............................. (NDC 69539-023-05) Cartons of 100 (10 x 10) unit dose tablets .......(NDC 69539-023-06) Store deferasirox tablets for oral suspension at 20°C to 25°C (68°F to 77°F); excursions are permitted between 15°C to 30°C (59°F to 86°F) [see USP Controlled Room Temperature]. Protect from moisture.