VARDENAFIL

RECENT MAJOR CHANGES Warnings and Precautions, Effects on the Eye ( 5.4 ) 08/2017

1 INDICATIONS AND USAGE Vardenafil is a phosphodiesterase 5 (PDE5) inhibitor indicated for the treatment of erectile dysfunction. ( 1 ) Vardenafil hydrochloride tablets are indicated for the treatment of erectile dysfunction.

2 DOSAGE AND ADMINISTRATION Vardenafil tablets are taken as needed: For most patients, the starting dose is 10 mg, up to once daily. Increase to 20 mg or decrease to 5 mg based on efficacy/tolerability. ( 2.1 ) A starting dose of 5 mg vardenafil should be considered in patients ≥ 65 years of age. ( 2.3 ) Vardenafil tablets are taken orally, approximately 60 minutes before sexual activity. ( 2.1 ) The maximum recommended dosing frequency is one tablet per day. ( 2.1 ) Vardenafil tablets may be taken with or without food. ( 2.2 ) If taking strong or moderate inhibitors of CYP3A4, the dose of vardenafil should be adjusted as follows ( 2.4 , 5.2 , 7.2 ): Ritonavir: No more than 2.5 mg in a 72-hour period Cobicistat: No more than 2.5 mg in a 72 hours period Indinavir, saquinavir, atazanavir, ketoconazole 400 mg daily, itraconazole 400 mg daily, clarithromycin: No more than 2.5 mg in a 24-hour period Ketoconazole 200 mg daily, itraconazole 200 mg daily, erythromycin: No more than 5 mg in a 24-hour period. In patients on stable alpha-blocker therapy the recommended starting dose of vardenafil is 5 mg ( 2.4 , 5.6 ) The recommended starting dose of vardenafil is 5 mg in patients with moderate hepatic impairment (Child-Pugh B). The maximum dose in patients with moderate hepatic impairment should not exceed 10 mg. ( 2.3 , 8.6 ) 2.1 General Dose Information For most patients, the recommended starting dose of vardenafil is 10 mg, taken orally, as needed, approximately 60 minutes before sexual activity. The dose may be increased to a maximum recommended dose of 20 mg or decreased to 5 mg based on efficacy and side effects. The maximum recommended dosing frequency is once per day. Sexual stimulation is required for a response to treatment. 2.2 Use with Food Vardenafil tablets can be taken with or without food. 2.3 Use in Specific Populations Geriatrics: A starting dose of 5 mg vardenafil should be considered in patients ≥ 65 years of age [see Use in Specific Populations ( 8.5 )]. Hepatic Impairment: For patients with moderate hepatic impairment (Child-Pugh B), a starting dose of 5 mg vardenafil is recommended. The maximum dose in patients with moderate hepatic impairment should not exceed 10 mg. Do not use vardenafil in patients with severe hepatic impairment (Child-Pugh C) [ see Warnings and Precautions ( 5.8 ), Use in Specific Populations ( 8.6 ) and Clinical Pharmacology ( 12.3 )] . Renal Impairment: Do not use vardenafil in patients on renal dialysis [see Warnings and Precautions ( 5.9 ), Use in Specific Populations ( 8.7 ) and Clinical Pharmacology ( 12.3 )]. 2.4 Concomitant Medications Nitrates Concomitant use with nitrates and nitric oxide donors in any form is contraindicated [see Contraindications ( 4.1 )] . Guanylate Cyclase (GC) Stimulators, such as riociguat Concomitant use is contraindicated [ see Contraindications ( 4.2 )] . CYP3A4 Inhibitors The dosage of vardenafil may require adjustment in patients receiving strong CYP3A4 inhibitors such as ketoconazole, itraconazole, ritonavir, indinavir, saquinavir, atazanavir, cobicistat and clarithromycin as well as in other patients receiving moderate CYP3A4 inhibitors such as erythromycin [see Drug Interactions ( 7.2 )]. If taking strong or moderate inhibitors of CYP3A4, the dose of vardenafil should be adjusted as follows: Ritonavir: No more than 2.5 mg in a 72 hours period Indinavir, saquinavir, atazanavir, ketoconazole 400 mg daily, itraconazole 400 mg daily, clarithromycin: No more than 2.5 mg in a 24 hours period Ketoconazole 200 mg daily, itraconazole 200 mg daily, erythromycin: No more than 5 mg in a 24 hours period. Cobicistat: No more than 2.5 mg in a 72 hours period. Alpha-Blockers In those patients who are stable on alpha-blocker therapy, phosphodiesterase type 5 (PDE5) inhibitors should be initiated at the lowest recommended starting dose. Concomitant treatment should be initiated only if the patient is stable on his alpha-blocker therapy. Stepwise increase in alpha-blocker …

3 DOSAGE FORMS AND STRENGTHS Vardenafil hydrochloride tablets 2.5 mg (equivalent to 2.963 mg vardenafil hydrochloride trihydrate), 5 mg (equivalent to 5.926 mg vardenafil hydrochloride trihydrate), 10 mg (equivalent to 11.852 mg vardenafil hydrochloride trihydrate), 20 mg (equivalent to 23.705 mg vardenafil hydrochloride trihydrate) ( 3 ) Vardenafil hydrochloride tablets are available as 2.5 mg (equivalent to 2.963 mg vardenafil hydrochloride), 5 mg (equivalent to 5.926 mg vardenafil hydrochloride), 10 mg (equivalent to 11.852 mg vardenafil hydrochloride), 20 mg (equivalent to 23.705 mg vardenafil hydrochloride). Vardenafil hydrochloride tablets, 2.5 mg are white to off-white colored, round, biconvex, bevel edged, film-coated tablets, debossed with "10" on one side and "68" on other side. Vardenafil hydrochloride tablets, 5 mg are light yellow colored, round, biconvex, bevel edged, film-coated tablets, debossed with "10" on one side and "69" on other side. Vardenafil hydrochloride tablets, 10 mg are light yellow to orange colored, round, biconvex, bevel edged, film-coated tablets, de bossed with "10" on one side and "70" on other side. Vardenafil hydrochloride tablets, 20 mg are light yellow to orange colored, round, biconvex, bevel edged, film-coated tablets, debossed with "10" on one side and "71" on other side.

4 CONTRAINDICATIONS Administration with nitrates and nitric oxide donors ( 2.4 , 4.1 ) Administration with guanylate cyclase (GC) stimulators, such as riociguat ( 2.4 , 4.2 ) 4.1 Nitrates Administration of vardenafil with nitrates (either regularly and/or intermittently) and nitric oxide donors is contraindicated [see Clinical Pharmacology ( 12.2 )] . Consistent with the effects of PDE5 inhibition on the nitric oxide/cyclic guanosine monophosphate pathway, PDE5 inhibitors, including vardenafil, may potentiate the hypotensive effects of nitrates. A suitable time interval following dosing of vardenafil for the safe administration of nitrates or nitric oxide donors has not been determined. 4.2 Guanylate Cyclase (GC) Stimulators Do not use vardenafil in patients who are using a GC stimulator, such as riociguat. PDE5 inhibitors, including vardenafil may potentiate the hypotensive effects of GC stimulators.

6 ADVERSE REACTIONS Most common adverse reactions reported ( ≥ 2% of patients) are headache, flushing, nasal congestion, dyspepsia, sinusitis, flu syndrome, dizziness, increased creatine kinase, nausea, back pain. ( 6.1 ) To report SUSPECTED ADVERSE REACTIONS, contact Zydus Pharmaceuticals USA Inc. at 1-877-993-8779 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. The following serious adverse reactions with the use of vardenafil are discussed elsewhere in the labeling: Cardiovascular Effects [see Contraindications ( 4.1 ) and Warnings and Precautions ( 5.1 )] Priapism [see Warnings and Precautions ( 5.3 )] Effects on Eye [see Warnings and Precautions ( 5.4 )] Sudden Hearing Loss [see Warnings and Precautions ( 5.5 )] QT Prolongation [see Warnings and Precautions ( 5.7 )] 6.1 Clinical Studies 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. Vardenafil was administered to over 4,430 men (mean age 56, range 18 to 89 years; 81% White, 6% Black, 2% Asian, 2% Hispanic and 9% Other) during controlled and uncontrolled clinical trials worldwide. Over 2,200 patients were treated for 6 months or longer and 880 patients were treated for at least 1 year. In placebo-controlled clinical trials, the discontinuation rate due to adverse events was 3.4% for vardenafil compared to 1.1% for placebo. When vardenafil was taken as recommended in placebo-controlled clinical trials, the following adverse reactions were reported (see Table 1). Table 1: Adverse Reactions Reported By ≥2% of Patients Treated with Vardenafil and More Frequent on Drug than Placebo in Fixed and Flexible a Dose Randomized, Controlled Trials of 5 mg, 10 mg, or 20 mg Vardenafil a) Flexible dose studies started all patients at vardenafil 10 mg and allowed decrease in dose to 5 mg or increase in dose to 20 mg based on side effects and efficacy. b) All the events listed in the above table were deemed to be adverse drug reactions with the exception of accidental injury. Adverse Reaction Percentage of Patients Reporting Reactions Placebo N = 1,199 Vardenafil N = 2,203 Headache 4% 15% Flushing 1% 11% Rhinitis 3% 9% Dyspepsia 1% 4% Accidental Injury b 2% 3% Sinusitis 1% 3% Flu Syndrome 2% 3% Dizziness 1% 2% Increased Creatine Kinase 1% 2% Nausea 1% 2% Back pain was reported in 2.0% of patients treated with vardenafil and 1.7% of patients on placebo. Placebo-controlled trials suggested a dose effect in the incidence of some adverse reactions (headache, flushing, dyspepsia, nausea, and rhinitis) over the 5 mg, 10 mg, and 20 mg doses of vardenafil. All Vardenafil Studies Vardenafil hydrochloride film-coated tablets and vardenafil hydrochloride orally disintegrating tablets have been administered to over 17,000 men (mean age 54.5, range 18 to 89 years; 70% White, 5% Black, 13% Asian, 4% Hispanic and 8% Other) during controlled and uncontrolled clinical trials worldwide. The number of patients treated for 6 months or longer was 3,357, and 1,350 patients were treated for at least 1 year. In the placebo-controlled clinical trials for vardenafil hydrochloride film-coated tablets and vardenafil hydrochloride orally disintegrating tablets, the discontinuation rate due to adverse events was 1.9% for vardenafil compared to 0.8% for placebo. The following section identifies additional, less frequent adverse reactions (<2%) reported during the clinical development of vardenafil hydrochloride film-coated tablets and vardenafil hydrochloride orally disintegrating tablets. Excluded from this list are those adverse reactions that are infrequent and minor, those events that may be commonly observed in the absence of drug therapy, and those events that are not reasonably associated with the drug: Body as a whole Allergic edema and angioedema, feeling unwell, allergic reactions, che …

7 DRUG INTERACTIONS Vardenafil can potentiate the hypotensive effects of nitrates, alpha-blockers, and antihypertensives. ( 7.1 ) 7.1 Potential for Pharmacodynamic Interactions with Vardenafil Nitrates Concomitant use of vardenafil and nitrates and nitric oxide donors is contraindicated. The blood pressure lowering effects of sublingual nitrates (0.4 mg) taken 1 and 4 hours after vardenafil and increases in heart rate when taken at 1, 4 and 8 hours after vardenafil were potentiated by a 20 mg dose of vardenafil in healthy middle-aged subjects. These effects were not observed when vardenafil 20 mg was taken 24 hours before the nitroglycerin (NTG). Potentiation of the hypotensive effects of nitrates for patients with ischemic heart disease has not been evaluated, and concomitant use of vardenafil and nitrates is contraindicated [see Contraindications ( 4.1 ) and Clinical Pharmacology ( 12.2 ) . Alpha-Blockers Caution is advised when PDE5 inhibitors are co-administered with alpha-blockers. PDE5 inhibitors, including vardenafil and alpha-adrenergic blocking agents are both vasodilators with blood-pressure-lowering effects. When vasodilators are used in combination, an additive effect on blood pressure may be anticipated. Clinical pharmacology studies have been conducted with co-administration of vardenafil with alfuzosin, terazosin or tamsulosin. [See Dosage and Administration ( 2.4 ), Warnings and Precautions ( 5.6 ), and Clinical Pharmacology ( 12.2 ).] Antihypertensives Vardenafil may add to the blood pressure lowering effects of antihypertensive agents. In a clinical pharmacology study of patients with erectile dysfunction, single doses of vardenafil 20 mg caused a mean maximum decrease in supine blood pressure of 7 mmHg systolic and 8 mmHg diastolic (compared to placebo), accompanied by a mean maximum increase of heart rate of 4 beats per minute. The maximum decrease in blood pressure occurred between 1 and 4 hours after dosing. Following multiple dosing for 31 days, similar blood pressure responses were observed on Day 31 as on Day 1. Alcohol Vardenafil (20 mg) did not potentiate the hypotensive effects of alcohol during the 4-hour observation period in healthy volunteers when administered with alcohol (0.5 g/kg body weight, approximately 40 mL of absolute alcohol in a 70 kg person). Alcohol and vardenafil plasma levels were not altered when dosed simultaneously. 7.2 Effect of Other Drugs on Vardenafil In vitro studies Studies in human liver microsomes showed that vardenafil is metabolized primarily by cytochrome P450 (CYP) isoforms 3A4/5, and to a lesser degree by CYP2C9. Therefore, inhibitors of these enzymes are expected to reduce vardenafil clearance [see Dosage and Administration ( 2.4 ) and Warnings and Precautions ( 5.2 )] . In vivo studies Strong CYP3A4 inhibitors Ketoconazole (200 mg once daily) produced a 10-fold increase in vardenafil AUC and a 4-fold increase in maximum concentration (C max ) when co-administered with vardenafil (5 mg) in healthy volunteers. A 5-mg vardenafil dose should not be exceeded in a 24-hour period when used in combination with 200 mg once daily ketoconazole. Since higher doses of ketoconazole (400 mg daily) may result in higher increases in C max and AUC, a single 2.5 mg dose of vardenafil should not be exceeded in a 24-hour period when used in combination with ketoconazole 400 mg daily. [See Dosage and Administration ( 2.4 ) and Warnings and Precautions ( 5 ).] Indinavir (800 mg t.i.d.) co-administered with vardenafil 10 mg resulted in a 16-fold increase in vardenafil AUC, a 7-fold increase in vardenafil C max and a 2-fold increase in vardenafil half-life. It is recommended not to exceed a single 2.5 mg vardenafil dose in a 24-hour period when used in combination with indinavir. [See Dosage and Administration ( 2.4 ) and Warnings and Precautions ( 5.2 ).] Ritonavir (600 mg b.i.d.) co-administered with vardenafil 5 mg resulted in a 49-fold increase in vardenafil AUC and a 13fold increase …

2.3 Use in Specific Populations Geriatrics: A starting dose of 5 mg vardenafil should be considered in patients ≥ 65 years of age [see Use in Specific Populations ( 8.5 )]. Hepatic Impairment: For patients with moderate hepatic impairment (Child-Pugh B), a starting dose of 5 mg vardenafil is recommended. The maximum dose in patients with moderate hepatic impairment should not exceed 10 mg. Do not use vardenafil in patients with severe hepatic impairment (Child-Pugh C) [ see Warnings and Precautions ( 5.8 ), Use in Specific Populations ( 8.6 ) and Clinical Pharmacology ( 12.3 )] . Renal Impairment: Do not use vardenafil in patients on renal dialysis [see Warnings and Precautions ( 5.9 ), Use in Specific Populations ( 8.7 ) and Clinical Pharmacology ( 12.3 )].

8 USE IN SPECIFIC POPULATIONS Vardenafil is not indicated for use in pediatric patients. ( 8.4 ) Do not use vardenafil in patients with severe hepatic impairment (Child-Pugh C). ( 8.6 ) Do not use vardenafil in patients on renal dialysis. ( 8.7 ) 8.1 Pregnancy Risk Summary Vardenafil is not indicated for use in females. There are no data with the use of vardenafil in pregnant women to inform any drug-associated risks. In animal reproduction studies conducted in pregnant rats and rabbits, no adverse developmental outcomes were observed with oral administration of vardenafil during organogenesis at exposures for unbound vardenafil and its major metabolite at approximately 100 and 29 times, respectively, the maximum recommended human dose (MRHD) of 20 mg based on AUC (see Data) . Data Animal Data No evidence of specific potential for teratogenicity, embryotoxicity or fetotoxicity was observed in rats and rabbits that received vardenafil at up to 18 mg/kg/day during organogenesis. This dose is approximately 100 fold (rat) and 29 fold (rabbit) greater than the AUC values for unbound vardenafil and its major metabolite in humans given the MRHD of 20 mg. In the rat pre-and postnatal development study, the NOAEL (no observed adverse effect level) for maternal toxicity was 8 mg/kg/day. Retarded physical development of pups in the absence of maternal effects was observed following maternal exposure to 1 and 8 mg/kg possibly due to vasodilatation and/or secretion of the drug into milk. The number of living pups born to rats exposed pre-and postnatally was reduced at 60 mg/kg/day. Based on the results of the pre-and postnatal study, the developmental NOAEL is less than 1 mg/kg/day. Based on plasma exposures in the rat developmental toxicity study, 1 mg/kg/day in the pregnant rat is estimated to produce total AUC values for unbound vardenafil and its major metabolite comparable to the human AUC at the MRHD of 20 mg. 8.2 Lactation Risk Summary Vardenafil is not indicated for use in females. There is no information on the presence of vardenafil and its major metabolite in human milk, the effects on the breastfed infant, or the effects on milk production. Vardenafil is present in rat milk of lactating rats (see Data) . Data Vardenafil was secreted into the milk of lactating rats at concentrations approximately 10-fold greater than found in the plasma. Following a single oral dose of 3 mg/kg, 3.3% of the administered dose was excreted into the milk within 24 hours. 8.4 Pediatric Use Vardenafil is not indicated for use in pediatric patients. Safety and efficacy have not been established in this population. 8.5 Geriatric Use Elderly males 65 years of age and older have higher vardenafil plasma concentrations than younger males (18 to 45 years), mean C max and AUC were 34% and 52% higher, respectively. Phase 3 clinical trials included more than 834 elderly patients, and no differences in safety or effectiveness of vardenafil 5, 10, or 20 mg were noted when these elderly patients were compared to younger patients. However, due to increased vardenafil concentrations in the elderly, a starting dose of 5 mg vardenafil should be considered in patients ≥65 years of age [see Clinical Pharmacology ( …

12.1 Mechanism of Action Penile erection is a hemodynamic process initiated by the relaxation of smooth muscle in the corpus cavernosum and its associated arterioles. During sexual stimulation, nitric oxide is released from nerve endings and endothelial cells in the corpus cavernosum. Nitric oxide activates the enzyme guanylate cyclase resulting in increased synthesis of cyclic guanosine monophosphate (cGMP) in the smooth muscle cells of the corpus cavernosum. The cGMP in turn triggers smooth muscle relaxation, allowing increased blood flow into the penis, resulting in erection. The tissue concentration of cGMP is regulated by both the rates of synthesis and degradation via phosphodiesterases (PDEs). The most abundant PDE in the human corpus cavernosum is the cGMP-specific phosphodiesterase type 5 (PDE5); therefore, the inhibition of PDE5 enhances erectile function by increasing the amount of cGMP. Because sexual stimulation is required to initiate the local release of nitric oxide, the inhibition of PDE5 has no effect in the absence of sexual stimulation. In vitro studies have shown that vardenafil is a selective inhibitor of PDE5. The inhibitory effect of vardenafil is more selective on PDE5 than for other known phosphodiesterases (>15-fold relative to PDE6, >130-fold relative to PDE1, >300-fold relative to PDE11, and >1,000-fold relative to PDE2, 3, 4, 7, 8, 9, and 10).

11 DESCRIPTION Vardenafil hydrochloride tablets are administered orally for the treatment of erectile dysfunction. This monohydrochloride salt of vardenafil is a selective inhibitor of cyclic guanosine monophosphate (cGMP)-specific phosphodiesterase type 5 (PDE5). Vardenafil hydrochloride is designated chemically as piperazine, 1-[[3-(1,4-dihydro-5-methyl-4-oxo-7-propylimidazo[5,1- f ][1,2,4]triazin-2-yl)-4-ethoxyphenyl]sulfonyl]-4-ethyl-, monohydrochloride and has the following structural formula: Vardenafil hydrochloride trihydrate, USP is white or slightly brown or yellow powder. It is slightly soluble in water, freely soluble in anhydrous ethanol, practically insoluble in heptane. Each tablet contains active ingredient vardenafil 2.5 mg (equivalent to 2.963 mg vardenafil hydrochloride trihydrate) or 5 mg (equivalent to 5.926 mg vardenafil hydrochloride trihydrate) or 10 mg (equivalent to 11.852 mg vardenafil hydrochloride trihydrate) or 20 mg (equivalent to 23.705 mg vardenafil hydrochloride trihydrate) and inactive ingredients: colloidal silicon dioxide, hypromellose, iron oxide red (5 mg, 10 mg and 20 mg), iron oxide yellow (5 mg, 10 mg and 20 mg), microcrystalline cellulose, polyethylene glycol, pregelatinized starch (corn-zea mays), sodium stearyl fumarate, titanium dioxide. Vardenafil tablets

10 OVERDOSAGE The maximum dose of vardenafil for which human data are available is a single 120 mg dose administered to healthy male volunteers. The majority of these subjects experienced reversible back pain/myalgia and/or "abnormal vision." Single doses up to 80 mg vardenafil and multiple doses up to 40 mg vardenafil administered once daily over 4 weeks were tolerated without producing serious adverse side effects. When 40 mg of vardenafil was administered twice daily, cases of severe back pain were observed. No muscle or neurological toxicity was identified. In cases of overdose, standard supportive measures should be taken as required. Renal dialysis is not expected to accelerate clearance as vardenafil is highly bound to plasma proteins and not significantly eliminated in the urine.

16 HOW SUPPLIED/STORAGE AND HANDLING Vardenafil tablets USP, 2.5 mg (equivalent to 2.963 mg vardenafil hydrochloride trihydrate), 5 mg (equivalent to 5.926 mg vardenafil hydrochloride trihydrate), 10 mg (equivalent to 11.852 mg vardenafil hydrochloride trihydrate), 20 mg (equivalent to 23.705 mg vardenafil hydrochloride trihydrate) Vardenafil Tablets USP, 2.5 mg are white to off-white colored, round, biconvex, bevel edged, film-coated tablets, debossed with "10" on one side and "68" on other side and are supplied as: NDC 70710-1068-3 in bottle of 30 tablets with child-resistant closure. NDC 70710-1068-9 in bottle of 90 tablets with child-resistant closure. NDC 70710-1068-1 in bottle of 100 tablets Vardenafil Tablets USP, 5 mg are light yellow colored, round, biconvex, bevel edged, film-coated tablets, debossed with "10" on one side and "69" on other side and are supplied as: NDC 70710-1069-3 in bottle of 30 tablets with child-resistant closure. NDC 70710-1069-9 in bottle of 90 tablets with child-resistant closure. NDC 70710-1069-1 in bottle of 100 tablets Vardenafil Tablets USP, 10 mg are light yellow to orange colored, round, biconvex, bevel edged, film-coated tablets, debossed with "10" on one side and "70" on other side and are supplied as: NDC 70710-1070-3 in bottle of 30 tablets with child-resistant closure. NDC 70710-1070-9 in bottle of 90 tablets with child-resistant closure. NDC 70710-1070-1 in bottle of 100 tablets Vardenafil Tablets USP, 20 mg are light yellow to orange colored, round, biconvex, bevel edged, film-coated tablets, debossed with "10" on one side and "71" on other side and are supplied as: NDC 70710-1071-3 in bottle of 30 tablets with child-resistant closure. NDC 70710-1071-9 in bottle of 90 tablets with child-resistant closure. NDC 70710-1071-1 in bottle of 100 tablets Store at 20°C to 25°C (68°F to 77°F) [See USP Controlled Room Temperature].