Fosaprepitant

6 ADVERSE REACTIONS The following clinically significant adverse reactions are described elsewhere in the labeling: Hypersensitivity Reactions [see Warnings and Precautions (5.2) ] Infusion Site Reactions [see Warnings and Precautions (5.3) ] Most common adverse reactions in adults (≥2%) are: fatigue, diarrhea, neutropenia, asthenia, anemia, peripheral neuropathy, leukopenia, dyspepsia, urinary tract infection, pain in extremity. ( 6.1 ) To report SUSPECTED ADVERSE REACTIONS, contact NorthStar RxLLC at 1-844-375-6847 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 clinical practice. The overall safety of fosaprepitant for injection was evaluated in approximately 1600 adult patients. Adverse Reactions in Adults for the Prevention of Nausea and Vomiting Associated with MEC In an active-controlled clinical trial in patients receiving MEC, safety was evaluated in 504 patients receiving a single dose of fosaprepitant for injection in combination with ondansetron and dexamethasone (fosaprepitant dimeglumine regimen) compared to 497 patients receiving ondansetron and dexamethasone alone (standard therapy). The most common adverse reactions are listed in Table 6. Table 6 Most Common Adverse Reactions in Patients Receiving MEC * Fosaprepitant for injection, ondansetron, and dexamethasone † (N=504) Ondansetron and dexamethasone ‡ (N=497) fatigue 15% 13% diarrhea 13% 11% neutropenia 8% 7% asthenia 4% 3% anemia 3% 2% peripheral neuropathy 3% 2% leukopenia 2% 1% dyspepsia 2% 1% urinary tract infection 2% 1% pain in extremity 2% 1% * Reported in ≥2% of patients treated with the fosaprepitant dimeglumine regimen and at a greater incidence than standard therapy. † fosaprepitant dimeglumine regimen ‡ Standard therapy Infusion-site reactions were reported in 2.2% of patients treated with the fosaprepitant dimeglumine regimen compared to 0.6% of patients treated with standard therapy. The infusion-site reactions included: infusion-site pain (1.2%, 0.4%), injection-site irritation (0.2%, 0.0%), vessel puncture-site pain (0.2%, 0.0%), and infusion-site thrombophlebitis (0.6%, 0.0%), reported in the fosaprepitant dimeglumine regimen compared to standard therapy, respectively. Adverse Reactions in Adults for the Prevention of Nausea and Vomiting Associated with HEC In an active-controlled clinical study in patients receiving HEC, safety was evaluated for 1143 patients receiving a single dose of fosaprepitant for injection compared to 1169 patientsreceiving the 3-day regimen of oral aprepitant [see Clinical Studies (14.1)]. The safety profile was generallysimilar to that seen in the MEC study with fosaprepitant and prior HEC studies with aprepitant. However,infusion- site reactionsoccurred at a higher incidence in patients in the fosaprepitant group (3.0%) comparedto those in the aprepitant group (0.5%). The following additional infusion-site reactions occurredin the HEC study and were not reported in the MEC study describedabove: infusion-site erythema(0.5%, 0.1%), infusion-site pruritus (0.3%, 0.0%), and infusion-site induration (0.2%, 0.1%), reported in the fosaprepitant group compared to the aprepitant group, respectively. Because fosaprepitant is converted to aprepitant, those adverse reactions associated with aprepitant might also be expected to occur with fosaprepitant for injection. See the full prescribing information for aprepitant capsules for complete safety information regarding studies performed with oral aprepitant. Pediatric use information is approved for Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.’s Emend (fosaprepitant) for injection. However, due to Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.’s marketing exclusivity rights, this drug product is not labeled with that pediatric information. 6.2 Postmarketing Experience The following adverse reactions have been identified during post-approval use of fosaprepitant. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possibleto reliably estimatetheir frequency or establish a causal relationship to drug exposure. Skin and subcutaneous tissue disorders: pruritus, rash, urticaria, Stevens-Johnson syndrome/toxic epidermalnecrolysis. [see Warnings and Precautions (5.2) ] . Immune system disorders: hypersensitivity reactions including anaphylaxis and anaphylactic shock [see Contraindications (4) , Warnings and Precautions (5.2) ] . Nervous system disorders: ifosfamide-induced neurotoxicity reported after fosaprepitant and ifosfamide coadministration.

4 CONTRAINDICATIONS Fosaprepitant is contraindicated in patients: who are hypersensitive to any component of the product Hypersensitivity reactions includinganaphylactic reactions, flushing, erythema, and dyspnea have been reported [see Warnings and Precautions ( 5.2 ), Adverse Reactions ( 6.2 )]. taking pimozide. Inhibition of CYP3A4 by aprepitant, the active moiety,could result in elevated plasma concentrations of this drug, which is a CYP3A4 substrate, potentially causing serious or life- threatening reactions, such as QT prolongation, a known adverse reaction of pimozide [see Warnings and Precautions( 5.1 )]. Known hypersensitivity to any component of this drug. ( 4 , 5.2 ) Concurrent use with pimozide. ( 4 )

11 DESCRIPTION Fosaprepitant for injection is a sterile, lyophilized formulation containing fosaprepitant dimeglumine,a prodrug of aprepitant a substance P/neurokinin-1 (NK 1 ) receptor antagonist, an antiemetic agent, chemically described as 1­ Deoxy-1-(methylamino)-D-glucito[3-[[(2R,3S)-2-[(1R)-1-[3,5- bis(trifluoromethyl)phenyl]ethoxy]-3-(4­ fluorophenyl)-4-morpholinyl]methyl]-2,5-dihydro-5-oxo-1H-1,2,4-triazol-1-yl]phosphonate(2:1) (salt).Its empirical formula is C 23 H 22 F 7 N 4 O 6 P • 2(C 7 H 17 NO 5 ) and its structural formula is: Fosaprepitant dimeglumine is a white to off-white powder with a molecular weight of 1004.83. It is freely soluble in water soluble in N,N-Dimethylsulfoxide and insoluble in n-hexane.Each vial of fosaprepitant for injection for administration as an intravenous infusion contains 245.3 mg of fosaprepitant dimeglumine equivalent to 150 mg of fosaprepitant free acid and the following inactive ingredients: edetatedisodium (18.8 mg), lactose anhydrous(375 mg), polysorbate 80 (75 mg), sodium hydroxide and/orhydrochloric acid (for pH adjustment).

2 DOSAGE AND ADMINISTRATION Recommended Dosage ( 2.1 ) Administer fosaprepitant for injection as an intravenous infusion; complete the infusion approximately 30 minutes prior to chemotherapy. Adults: 150 mg on Day 1. Administer fosaprepitant for injection on Day 1 as an intravenous infusion over 20 to 30 minutes (adults). See Full Prescribing Information for dosages of concomitantantiemetic(s). ( 2.1 ) 2.1 Prevention of Nausea and Vomiting Associated with HEC and MEC in Adult Patients The recommended dosage of fosaprepitant for injection, dexamethasone, and a 5-HT 3 antagonist for the prevention of nausea and vomiting associated with administration of HEC or MEC in adults is shown in Table 1 or Table 2, respectively. Administer fosaprepitant for injectionas an intravenous infusion on Day 1 over 20 to 30 minutes, completing the infusion approximately 30 minutes priorto chemotherapy. Table 1 Recommended Adult Dosing for the Prevention of Nausea and Vomiting Associated with HEC Day 1 Day 2 Day 3 Day 4 Fosaprepitant for injection 150 mgintravenouslyover 20 to 30 minutes none none none Dexamethasone * 12 mg orally 8 mg orally 8 mg orally twice daily 8 mg orally twice daily 5-HT 3 antagonist See selected 5-HT 3 antagonist prescribing information for the recommended dosage none none none * Administer dexamethasone 30 minutes prior to chemotherapy treatment on Day 1 and in the morning on Days 2 through 4. Also administer dexamethasone in the evenings on Days 3 and 4. A 50% dosage reduction of dexamethasone on Days 1 and 2 is recommended to account for a drug interaction with fosaprepitant for injection [see ClinicalPharmacology (12.3)]. Table 2 Recommended Adult Dosing for the Prevention of Nausea and Vomiting Associated with MEC Day 1 Fosaprepitant for injection 150 mg intravenously over 20 to 30 minutes Dexamethasone * 12 mg orally 5-HT 3 antagonist See selected 5-HT 3 antagonist prescribing information for the recommended dosage * Administer dexamethasone 30 minutes prior to chemotherapy treatment on Day 1. A 50% dosage reduction of dexamethasone is recommended to account for a drug interaction with fosaprepitant dimeglumine [see Clinical Pharmacology (12.3)]. Pediatric use information is approved for Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.’s Emend (fosaprepitant) for injection. However, due to Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.’s marketing exclusivity rights, this drug product is not labeled with that pediatric information. 2.3 Preparation of Fosaprepitant for Injection Table 5 Preparation Instructions for Fosaprepitant for Injection (150 mg) Step 1 Aseptically inject 5 mL 0.9% Sodium Chloride Injection, USP into the vial. Assure that 0.9% Sodium Chloride Injection, USP is added to the vial along the vial wall in order to prevent foaming. Swirl the vial gently. Avoid shaking and jetting 0.9% Sodium Chloride Injection, USP into the vial. Step 2 Aseptically prepare an infusion bag filled with 145 mL of 0.9% Sodium Chloride Injection, USP. Step 3 Aseptically withdraw the entire volume from the vial and transfer it into the infusion bag containing 145 mL of 0.9% Sodium Chloride Injection, USP to yield a total volume of 150 mL and a final concentration of 1 mg/mL . Step 4 Gently invert the bag 2 to 3 times. Step 5 AdultsThe entire volume of the prepared infusion bag (150 mL) should be administered. Step 6 Before administration, inspect the bag for particulate matter and discoloration. Discard the bag if particulate and/or discoloration are observed. Caution: Do not mix or reconstitute fosaprepitant for injection with solutions for which physicaland chemical compatibility have not been established. Fosaprepitant for injection is incompatible with any solutions containing divalent cations (e.g., Ca 2+ , Mg 2+ ), including Lactated Ringer’s Solution and Hartmann's Solution. Storage The reconstituted final drug solution is stable for 24 hours at ambient room temperature [at or below 25°C (77°F)]. Pediatric use information is approved for Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.’s Emend (fosaprepitant) for injection. However, due to Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.’s marketing exclusivity rights, this drug product is not labeled with that pediatric information.

1 INDICATIONS AND USAGE Fosaprepitant for injection, in combination with other antiemetic agents, is indicated in adults for the prevention of: acute and delayed nauseaand vomiting associated with initial and repeat coursesof highly emetogenic cancer chemotherapy (HEC) including high-dose cisplatin. delayed nausea and vomiting associated with initial and repeat courses of moderately emetogenic cancer chemotherapy (MEC) Limitations of Use Fosaprepitant for injection has not been studied for the treatment of established nausea and vomiting. Pediatric use information is approved for Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.’s Emend (fosaprepitant) for injection. However, due to Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.’s marketing exclusivity rights, this drug product is not labeled with that pediatric information. Fosaprepitant for injection is a substance P/neurokinin-1 (NK 1 ) receptor antagonist, indicated in adults, in combination with other antiemetic agents, for the prevention of ( 1 ): acute and delayed nausea and vomiting associated with initial and repeat coursesof highly emetogenic cancer chemotherapy (HEC) including high-dose cisplatin delayed nausea and vomiting associated with initial and repeat courses of moderately emetogenic cancer chemotherapy (MEC). Limitations of Use ( 1 ) Fosaprepitant for injection has not been studied for treatment of established nausea and vomiting.

10 OVERDOSAGE There is no specificinformation on the treatment of overdosage with fosaprepitant or aprepitant.In the event of overdose, fosaprepitant should be discontinued and general supportive treatment and monitoring should be provided. Because of the antiemetic activity of fosaprepitant, drug-induced emesis may not be effective in cases of fosaprepitant overdosage.Aprepitant is not removedby hemodialysis.

7 DRUG INTERACTIONS See Full Prescribing Information for a list of clinicallysignificant drug interactions. ( 4 , 5.1 , 5.4 , 5.5 , 7.1 , 7.2 ) Pediatric use information is approved for Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.’s Emend (fosaprepitant) for injection. However, due to Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.’s marketing exclusivity rights, this drug product is not labeled with that pediatric information. 7.1 Effect of Fosaprepitant/Aprepitant on the Pharmacokinetics of Other Drugs When administered intravenously, fosaprepitant, a prodrug of aprepitant, is converted to aprepitant within 30 minutes.Therefore, drug interactions following administration of fosaprepitant for injection are likely to occur with drugs that interact with oral aprepitant. Fosaprepitant, given as a single 150-mg dose, is a weak inhibitor of CYP3A4, and the weak inhibition of CYP3A4 continues for 2 days after single dose administration. Single dose fosaprepitant does not induce CYP3A4. Aprepitant is a substrate, an inhibitor, and an inducer of CYP3A4. Aprepitant is also an inducerof CYP2C9 [seeClinical Pharmacology (12.3) ] . Some substrates of CYP3A4 are contraindicated with fosaprepitant [see Contraindications (4) ] . Dosage adjustment of some CYP3A4 and CYP2C9 substrates may be warranted, as shown in Table 7. Table 7 Effects of Fosaprepitant/Aprepitant on the Pharmacokinetics of Other Drugs CYP3A4 Substrates Pimozide Clinical Impact Increased pimozide exposure Intervention Fosaprepitant is contraindicated [see Contraindications (4) ] . Benzodiazepines Clinical Impact Increased exposure to midazolam or other benzodiazepines metabolized via CYP3A4(alprazolam, triazolam) may increase the risk of adverse reactions [see Clinical Pharmacology (12.3) ]. Intervention Monitor for benzodiazepine-related adverse reactions. Dexamethasone Clinical Impact Increased dexamethasone exposure [see Clinical Pharmacology (12.3) ] . Intervention Reducethe dose of oral dexamethasone by approximately 50% [see Dosageand Administration (2.1) ] . Methylprednisolone Clinical Impact Increased methylprednisolone exposure [see Clinical Pharmacology (12.3) ] . Intervention Reduce the dose of oral methylprednisolone by approximately 50% on Days 1 and 2 for patients receiving HEC and on Day 1 for patients receiving MEC.Reduce the dose of intravenous methylprednisolone by 25% on Days 1 and 2 for patients receiving HEC and on Day 1 for patients receiving MEC. Chemotherapeutic agents that are metabolized by CYP3A4 Clinical Impact Increased exposure of the chemotherapeutic agentmay increase the risk of adverse reactions [see Clinical Pharmacology (12.3) ] . Intervention Vinblastine, vincristine, or ifosfamide or other chemotherapeutic agentsMonitor for chemotherapeutic-related adverse reactions.Etoposide, vinorelbine, paclitaxel, and docetaxelNo dosage adjustment needed. Hormonal Contraceptives Clinical Impact Decreased hormonal exposure duringadministration of and for 28 days after administration of the last dose of fosaprepitant [see Warnings and Precautions (5.5) , Use in Specific Populations (8.3) , and Clinical Pharmacology (12.3) ]. Intervention Effective alternative or back-up methods of contraception (such as condoms and spermicides) should be used during treatment with fosaprepitant and for 1 month following administration of fosaprepitant. Examples birth control pills, skin patches, implants, and certain IUDs CYP2C9 Substrates Warfarin Clinical Impact Decreased warfarin exposure and decreased prothrombin time (INR) [see Warnings and Precautions (5.4) , Clinical Pharmacology (12.3) ] . Intervention In patients on chronic warfarin therapy, monitor the prothrombin time(INR) in the2-week period, particularly at 7 to 10 days, following administration of fosaprepitant with each chemotherapy cycle. Other 5-HT 3 Antagonists Clinical Impact No change in the exposure of the 5-HT 3 antagonist [see Clinical Pharmacology (12.3) ] . Intervention No dosage adjustment needed Examples ondansetron, granisetron, dolasetron 7.2 Effect of Other Drugs on the Pharmacokinetics of Fosaprepitant/Aprepitant Aprepitant is a CYP3A4 substrate [see Clinical Pharmacology (12.3) ] . Co-administration of fosaprepitant with drugs that are inhibitors or inducers of CYP3A4 may result in increased or decreased plasma concentrations of aprepitant, respectively, as shown in Table 8. Table 8 Effects of Other Drugs on Pharmacokinetics of Fosaprepitant/Aprepitant Moderate to Strong CYP3A4 Inhibitors Clinical Impact Significantly increased exposure of aprepitant may increase the risk of adverse reactions associated with fosaprepitant [see Adverse Reactions (6.1) and Clinical Pharmacology (12.3) ] . Intervention Avoid concomitant use of fosaprepitant Examples Moderate inhibitor: diltiazemStrong inhibitors:ketoconazole, itraconazole, nefazodone, troleandomycin, clarithromycin, ritonavir, nelfinavir Strong CYP3A4Inducers Clinical Impact Substantially decreased exposure of aprepitant in patients chronically taking a strong CYP3A4 inducer may decrease the efficacy of fosaprepitant [see Clinical Pharmacology (12.3) ] . Intervention Avoid concomitant use of fosaprepitant. Examples rifampin, carbamazepine, phenytoin

12 CLINICAL PHARMACOLOGY 12.1 Mechanism of Action Fosaprepitant is a prodrugof aprepitant and accordingly, its antiemetic effectsare attributable to aprepitant. Aprepitant is a selectivehigh-affinity antagonist of human substanceP/neurokinin 1(NK1) receptors. Aprepitant has little or no affinity for serotonin (5-HT 3 ), dopamine, and corticosteroid receptors, the targets of existing therapiesfor chemotherapy-induced nausea and vomiting(CINV). Aprepitant has been shown in animal models to inhibit emesis induced by cytotoxicchemotherapeutic agents, such as cisplatin, via central actions. Animal and human Positron Emission Tomography (PET) studies with aprepitant have shown that it crosses the blood brain barrier and occupies brain NK 1 receptors. Animal and humanstudies have shown that aprepitant augmentsthe antiemetic activityof the 5-HT 3 -receptor antagonist ondansetron and the corticosteroid dexamethasone and inhibitsboth the acuteand delayed phasesof cisplatin-induced emesis. 12.2 Pharmacodynamics Cardiac Electrophysiology In a randomized, double-blind, positive-controlled, thorough QTc study, a single 200-mgdose of fosaprepitant (approximately 1.3 times the recommended dose) had no effect on the QTc interval. 12.3 Pharmacokinetics Aprepitant after Fosaprepitant Administration Following administration of a single intravenous 150-mg dose of fosaprepitant, a prodrug of aprepitant administered as a 20-minute infusion to healthy subjects, the mean AUC 0-∞ of aprepitant was 37.4 (±14.8) mcg • hr/mL and the mean maximal aprepitant concentration (C max ) was 4.2 (±1.2) mcg/mL. Plasma concentrations of fosaprepitant are below the limits of quantification (10 ng/mL) within 30 minutes of the completion of infusion. Distribution Aprepitant is greater than 95% bound to plasma proteins. The mean apparent volume of distribution at steady state(Vd ss ) was approximately 70 L in humans.Aprepitant crossesthe blood brainbarrier in humans[see Clinical Pharmacology ( 12.1 )]. Elimination Metabolism Fosaprepitant is converted to aprepitant in in vitro incubations with human liver preparations and in S9 preparations from multiple other human tissues including kidney, lung and ileum. Thus, it appears that the conversion of fosaprepitant to aprepitant can occur in multiple extrahepatic tissues in addition to the liver.Aprepitant undergoes extensive metabolism. In vitro studies using human liver microsomes indicate that aprepitant is metabolized primarily by CYP3A4 with minor metabolism by CYP1A2 and CYP2C19. Metabolism is largely via oxidation at the morpholine ring and its side chains. No metabolism by CYP2D6, CYP2C9, or CYP2E1 was detected.In healthy young adults,aprepitant accounts for approximately 24% of the radioactivity in plasma over 72 hours following a single oral 300-mg dose of [ 14 C]-aprepitant, indicating a substantial presence of metabolites in the plasma. Seven metabolites of aprepitant, which are only weakly active, havebeen identified in human plasma. Excretion Following administration of a singleintravenous 100-mg dose of [ 14 C]-fosaprepitant to healthy subjects, 57% of the radioactivity was recovered in urine and 45% in feces.Aprepitant is eliminated primarilyby metabolism; aprepitant is not renally excreted. The apparent terminal half-liferanged from approximately 9 to 13 hours. Specific Populations Age: Geriatric Population Following oral administration of a single 125-mg dose of aprepitant on Day 1 and 80 mg once daily on Days 2 through 5, the AUC 0-24hr of aprepitant was 21% higher on Day 1 and 36% higher on Day 5 in elderly (65 years and older) relativeto younger adults.The C max was 10% higher on Day 1 and 24% higher on Day 5 in elderly relative to younger adults. These differences are not considered clinically meaningful [see Use in Specific Populations (8.5)]. Sex Following oral administration of a single dose of aprepitant, ranging from 40 mg to 375 mg, the AUC 0-24hr and C max are 9% and 17% higher in females as compared with males. The half-life of aprepitantis approximately 25% lower in femalesas compared with males and T max occursat approximately the same time. These differences are not considered clinically meaningful. Race/Ethnicity Following oral administration of a single dose of aprepitant, ranging from 40 mg to 375 mg, the AUC 0-24hr and C max are approximately 27% and 19% higher in Hispanicsas compared with Caucasians. The AUC 0-24hr and C max were 74% and 47% higher in Asians as compared to Caucasians. There was no difference in AUC 0-24hr or C max between Caucasians and Blacks.These differences are not considered clinicallymeaningful. Renal Impairment A single 240-mg oral dose of aprepitant was administered to patients with severe renal impairment (creatinine clearance less than 30 mL/min/1.73 m 2 as measured by 24-hour urinary creatinine clearance) and to patients with end stage renal disease(ESRD) requiring hemodialysis. In patients with severe renal impairment, the AUC 0-∞ of total aprepitant (unbound and protein bound) decreased by 21% and Cmax decreased by 32%, relative to healthy subjects (creatinine clearance greater than 80 mL/min estimated by Cockcroft-Gault method). In patients with ESRD undergoing hemodialysis, the AUC 0-∞ of total aprepitant decreased by 42% and C max decreased by 32%. Due to Hemodialysis conducted4 or 48 hours after dosing had no significant effect on the pharmacokineticsof aprepitant; less than 0.2% of the dose was recovered in the dialysate. Hepatic Impairment Fosaprepitant is metabolized in various extrahepatic tissues; therefore hepaticimpairment is not expected to alter the conversion of fosaprepitant to aprepitant.Following administration of a single 125-mg oral dose of aprepitant on Day 1 and 80 mg once daily on Days 2 and 3 to patients with mild hepatic impairment (Child-Pugh score 5 to 6), the AUC 0-24hr of aprepitant was 11% loweron Day 1 and 36% lower on Day 3, as comparedwith healthy subjectsgiven the same regimen. In patientswith moderate hepatic impairment (Child-Pugh score 7 to 9), the AUC 0-24hr of aprepitant was 10% higher on Day 1 and 18% higher on Day 3, as compared with healthy subjects given the same regimen. These differences in AUC 0-24hr are not considered clinically meaningful. There are no clinical or pharmacokinetic data in patientswith severe hepaticimpairment (Child-Pugh scoregreater than 9) [see Use in Specific Populations ( 8.6 )] Body Mass Index (BMI) For every 5 kg/m 2 increase in BMI, AUC 0-24hr and C max of aprepitant decrease by 9% and 10%. BMI of subjects in the analysis ranged from 18 kg/m 2 to 36 kg/m 2 . This change is not considered clinically meaningful. Pediatric use information is approved for Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.’s Emend (fosaprepitant) for injection. However, due to Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.’s marketing exclusivity rights, this drug product is not labeled with that pediatric information. Drug Interactions Studies Fosaprepitant, given as a single 150-mg dose, is a weak inhibitor of CYP3A4, with no evidence of inhibition or induction of CYP3A4 observed on Day 4. The weak inhibition of CYP3A4 continues for 2 days after single dose administration of fosaprepitant. Aprepitant is a substrate, an inhibitor, and an inducer of CYP3A4. Aprepitant is also an inducer of CYP2C9.Fosaprepitant or aprepitant is unlikely to interact with drugs that are substrates for the P­ glycoprotein transporter. Effects of Fosaprepitant/Aprepitant on the Pharmacokinetics of Other Drugs CYP3A4 Substrates Midazolam : Fosaprepitant 150 mg administered as a single intravenous dose on Day 1 increased the AUC 0-∞ of midazolam by approximately 1.8-fold on Day 1 and had no effect on Day 4 when midazolam was coadministered as a singleoral dose of 2 mg on Days 1 and 4. [see Drug interactions ( 7.1 )]. Corticosteroids : Dexamethasone: Fosaprepitant administered as a single 150 mg intravenous dose on Day 1 increased the AUC 0-24hr of dexamethasone, administered as a single 8-mg oral dose on Days 1, 2, and 3, by approximately 2-foldon Days 1 and 2 [see Dosageand Administration ( 2.1 ),Drug Interactions ( 7.1 )]. Methylprednisolone : When oral aprepitant as a 3-day regimen (125-mg/80-mg/80-mg) was administered with intravenous methylprednisolone 125 mg on Day 1 and oral methylprednisolone 40 mg on Days 2 and 3, the AUC of methylprednisolone was increased by 1.34-fold on Day 1 and by 2.5-fold on Day 3 [see Drug Interactions ( 7.1 )].Chemotherapeutic agents:Docetaxel: In a pharmacokinetic study, oral aprepitant administered as a 3-day regimen (125­ mg/80-mg/80-mg) did not influence the pharmacokinetics of docetaxel. Vinorelbine: In a pharmacokinetic study,oral aprepitant administered as a 3-day regimen (125­ mg/80-mg/80-mg) did not influence the pharmacokinetics of vinorelbine to a clinically significant degree.Oral contraceptives: When oral aprepitant was administered as a 3-day regimen (125-mg/80-mg/80­ mg) with ondansetron and dexamethasone, and coadministered with an oral contraceptive containing ethinyl estradiol and norethindrone, the trough concentrations of both ethinyl estradiol and norethindrone were reduced by as much as 64% for 3 weeks post-treatment [see Drug Interactions (7.1)]. CYP2C9 substrates (Warfarin, Tolbutamide ):Warfarin: A single125-mg dose of oral aprepitant was administered on Day 1 and 80 mg/day on Days 2 and 3 to subjects who were stabilized on chronic warfarin therapy. Although there was no effect of oral aprepitant on the plasma AUC of R(+) or S(-) warfarindetermined on Day 3, there was a 34% decrease in S(-) warfarin trough concentration accompanied by a 14% decrease in the prothrombin time (reported as International Normalized Ratio or INR) 5 days after completion of dosing with oral aprepitant [see Drug Interactions ( 7.1 )]. Tolbutamide : Oral aprepitant, when given as 125 mg on Day 1 and 80 mg/day on Days 2 and 3, decreased the AUC of tolbutamide by 23% on Day 4, 28% on Day 8, and 15% on Day 15, when a single dose of tolbutamide 500 mg was administered prior to the administration of the 3-day regimen of oral aprepitant and on Days 4, 8, and 15. This effectwas not considered clinically important. Other Drugs P-glycoprotein substrates: Aprepitant is unlikely to interact with drugs that are substrates for the P­ glycoprotein transporter, as demonstrated by the lack of interaction of oral aprepitant with digoxin in a clinical drug interaction study. 5-HT 3 antagonists: In clinicaldrug interaction studies,aprepitant did not have clinically important effects on the pharmacokinetics of ondansetron, granisetron, or hydrodolasetron (the active metabolite of dolasetron). Effect of Other Drugson the Pharmacokinetics of Fosaprepitant/Aprepitant Rifampin : When a single 375-mgdose of oral aprepitant was administered on Day 9 of a 14-day regimen of 600 mg/day of rifampin, a strong CYP3A4 inducer, the AUC of aprepitant decreased approximately 11-fold and the mean terminal half-life decreased approximately 3-fold [see Drug Interactions ( 7.2 )].. Ketoconazole: When a single 125-mg dose of oral aprepitant was administered on Day 5 of a 10-day regimen of 400 mg/day of ketoconazole, a strong CYP3A4 inhibitor, the AUC of aprepitant increased approximately 5-foldand the mean terminal half-life of aprepitant increased approximately 3-fold [see Drug Interactions (7.2)]. Diltiazem: In a study in 10 patients with mild to moderate hypertension, administration of 100 mg of fosaprepitant as an intravenous infusion with 120 mg of diltiazem, a moderate CYP3A4 inhibitor administered three times daily, resulted in a 1.5-fold increase in the aprepitant AUC and a1.4-fold increase in the diltiazem AUC. When fosaprepitant was administered with diltiazem, the mean maximum decrease in diastolic blood pressure was significantly greater than that observed with diltiazem alone [24.3 ± 10.2 mm Hg with fosaprepitant versus 15.6 ± 4.1 mm Hg without fosaprepitant]. The mean maximumdecrease in systolic blood pressure was also greater after co-administration of diltiazem with fosaprepitant than administration of diltiazem alone [29.5 ± 7.9 mm Hg with fosaprepitant versus 23.8 ± 4.8 mm Hg without fosaprepitant]. Co-administration of fosaprepitant and diltiazem; however, did not result in any additional clinically significant changes in heart rate or PR interval, beyond those changes observed with diltiazem alone [see Drug Interactions ( 7.2 )]. Paroxetine : Coadministration of once daily doses of oral aprepitant 170 mg, with paroxetine 20 mg once daily, resulted in a decrease in AUC by approximately 25% and C max by approximately 20% of both aprepitant and paroxetine. This effect was not considered clinically important.

12.1 Mechanism of Action Fosaprepitant is a prodrugof aprepitant and accordingly, its antiemetic effectsare attributable to aprepitant. Aprepitant is a selectivehigh-affinity antagonist of human substanceP/neurokinin 1(NK1) receptors. Aprepitant has little or no affinity for serotonin (5-HT 3 ), dopamine, and corticosteroid receptors, the targets of existing therapiesfor chemotherapy-induced nausea and vomiting(CINV). Aprepitant has been shown in animal models to inhibit emesis induced by cytotoxicchemotherapeutic agents, such as cisplatin, via central actions. Animal and human Positron Emission Tomography (PET) studies with aprepitant have shown that it crosses the blood brain barrier and occupies brain NK 1 receptors. Animal and humanstudies have shown that aprepitant augmentsthe antiemetic activityof the 5-HT 3 -receptor antagonist ondansetron and the corticosteroid dexamethasone and inhibitsboth the acuteand delayed phasesof cisplatin-induced emesis.

12.2 Pharmacodynamics Cardiac Electrophysiology In a randomized, double-blind, positive-controlled, thorough QTc study, a single 200-mgdose of fosaprepitant (approximately 1.3 times the recommended dose) had no effect on the QTc interval.

12.3 Pharmacokinetics Aprepitant after Fosaprepitant Administration Following administration of a single intravenous 150-mg dose of fosaprepitant, a prodrug of aprepitant administered as a 20-minute infusion to healthy subjects, the mean AUC 0-∞ of aprepitant was 37.4 (±14.8) mcg • hr/mL and the mean maximal aprepitant concentration (C max ) was 4.2 (±1.2) mcg/mL. Plasma concentrations of fosaprepitant are below the limits of quantification (10 ng/mL) within 30 minutes of the completion of infusion. Distribution Aprepitant is greater than 95% bound to plasma proteins. The mean apparent volume of distribution at steady state(Vd ss ) was approximately 70 L in humans.Aprepitant crossesthe blood brainbarrier in humans[see Clinical Pharmacology ( 12.1 )]. Elimination Metabolism Fosaprepitant is converted to aprepitant in in vitro incubations with human liver preparations and in S9 preparations from multiple other human tissues including kidney, lung and ileum. Thus, it appears that the conversion of fosaprepitant to aprepitant can occur in multiple extrahepatic tissues in addition to the liver.Aprepitant undergoes extensive metabolism. In vitro studies using human liver microsomes indicate that aprepitant is metabolized primarily by CYP3A4 with minor metabolism by CYP1A2 and CYP2C19. Metabolism is largely via oxidation at the morpholine ring and its side chains. No metabolism by CYP2D6, CYP2C9, or CYP2E1 was detected.In healthy young adults,aprepitant accounts for approximately 24% of the radioactivity in plasma over 72 hours following a single oral 300-mg dose of [ 14 C]-aprepitant, indicating a substantial presence of metabolites in the plasma. Seven metabolites of aprepitant, which are only weakly active, havebeen identified in human plasma. Excretion Following administration of a singleintravenous 100-mg dose of [ 14 C]-fosaprepitant to healthy subjects, 57% of the radioactivity was recovered in urine and 45% in feces.Aprepitant is eliminated primarilyby metabolism; aprepitant is not renally excreted. The apparent terminal half-liferanged from approximately 9 to 13 hours. Specific Populations Age: Geriatric Population Following oral administration of a single 125-mg dose of aprepitant on Day 1 and 80 mg once daily on Days 2 through 5, the AUC 0-24hr of aprepitant was 21% higher on Day 1 and 36% higher on Day 5 in elderly (65 years and older) relativeto younger adults.The C max was 10% higher on Day 1 and 24% higher on Day 5 in elderly relative to younger adults. These differences are not considered clinically meaningful [see Use in Specific Populations (8.5)]. Sex Following oral administration of a single dose of aprepitant, ranging from 40 mg to 375 mg, the AUC 0-24hr and C max are 9% and 17% higher in females as compared with males. The half-life of aprepitantis approximately 25% lower in femalesas compared with males and T max occursat approximately the same time. These differences are not considered clinically meaningful. Race/Ethnicity Following oral administration of a single dose of aprepitant, ranging from 40 mg to 375 mg, the AUC 0-24hr and C max are approximately 27% and 19% higher in Hispanicsas compared with Caucasians. The AUC 0-24hr and C max were 74% and 47% higher in Asians as compared to Caucasians. There was no difference in AUC 0-24hr or C max between Caucasians and Blacks.These differences are not considered clinicallymeaningful. Renal Impairment A single 240-mg oral dose of aprepitant was administered to patients with severe renal impairment (creatinine clearance less than 30 mL/min/1.73 m 2 as measured by 24-hour urinary creatinine clearance) and to patients with end stage renal disease(ESRD) requiring hemodialysis. In patients with severe renal impairment, the AUC 0-∞ of total aprepitant (unbound and protein bound) decreased by 21% and Cmax decreased by 32%, relative to healthy subjects (creatinine clearance greater than 80 mL/min estimated by Cockcroft-Gault method). In patients with ESRD undergoing hemodialysis, the AUC 0-∞ of total aprepitant decreased by 42% and C max decreased by 32%. Due to Hemodialysis conducted4 or 48 hours after dosing had no significant effect on the pharmacokineticsof aprepitant; less than 0.2% of the dose was recovered in the dialysate. Hepatic Impairment Fosaprepitant is metabolized in various extrahepatic tissues; therefore hepaticimpairment is not expected to alter the conversion of fosaprepitant to aprepitant.Following administration of a single 125-mg oral dose of aprepitant on Day 1 and 80 mg once daily on Days 2 and 3 to patients with mild hepatic impairment (Child-Pugh score 5 to 6), the AUC 0-24hr of aprepitant was 11% loweron Day 1 and 36% lower on Day 3, as comparedwith healthy subjectsgiven the same regimen. In patientswith moderate hepatic impairment (Child-Pugh score 7 to 9), the AUC 0-24hr of aprepitant was 10% higher on Day 1 and 18% higher on Day 3, as compared with healthy subjects given the same regimen. These differences in AUC 0-24hr are not considered clinically meaningful. There are no clinical or pharmacokinetic data in patientswith severe hepaticimpairment (Child-Pugh scoregreater than 9) [see Use in Specific Populations ( 8.6 )] Body Mass Index (BMI) For every 5 kg/m 2 increase in BMI, AUC 0-24hr and C max of aprepitant decrease by 9% and 10%. BMI of subjects in the analysis ranged from 18 kg/m 2 to 36 kg/m 2 . This change is not considered clinically meaningful. Pediatric use information is approved for Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.’s Emend (fosaprepitant) for injection. However, due to Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.’s marketing exclusivity rights, this drug product is not labeled with that pediatric information. Drug Interactions Studies Fosaprepitant, given as a single 150-mg dose, is a weak inhibitor of CYP3A4, with no evidence of inhibition or induction of CYP3A4 observed on Day 4. The weak inhibition of CYP3A4 continues for 2 days after single dose administration of fosaprepitant. Aprepitant is a substrate, an inhibitor, and an inducer of CYP3A4. Aprepitant is also an inducer of CYP2C9.Fosaprepitant or aprepitant is unlikely to interact with drugs that are substrates for the P­ glycoprotein transporter. Effects of Fosaprepitant/Aprepitant on the Pharmacokinetics of Other Drugs CYP3A4 Substrates Midazolam : Fosaprepitant 150 mg administered as a single intravenous dose on Day 1 increased the AUC 0-∞ of midazolam by approximately 1.8-fold on Day 1 and had no effect on Day 4 when midazolam was coadministered as a singleoral dose of 2 mg on Days 1 and 4. [see Drug interactions ( 7.1 )]. Corticosteroids : Dexamethasone: Fosaprepitant administered as a single 150 mg intravenous dose on Day 1 increased the AUC 0-24hr of dexamethasone, administered as a single 8-mg oral dose on Days 1, 2, and 3, by approximately 2-foldon Days 1 and 2 [see Dosageand Administration ( 2.1 ),Drug Interactions ( 7.1 )]. Methylprednisolone : When oral aprepitant as a 3-day regimen (125-mg/80-mg/80-mg) was administered with intravenous methylprednisolone 125 mg on Day 1 and oral methylprednisolone 40 mg on Days 2 and 3, the AUC of methylprednisolone was increased by 1.34-fold on Day 1 and by 2.5-fold on Day 3 [see Drug Interactions ( 7.1 )].Chemotherapeutic agents:Docetaxel: In a pharmacokinetic study, oral aprepitant administered as a 3-day regimen (125­ mg/80-mg/80-mg) did not influence the pharmacokinetics of docetaxel. Vinorelbine: In a pharmacokinetic study,oral aprepitant administered as a 3-day regimen (125­ mg/80-mg/80-mg) did not influence the pharmacokinetics of vinorelbine to a clinically significant degree.Oral contraceptives: When oral aprepitant was administered as a 3-day regimen (125-mg/80-mg/80­ mg) with ondansetron and dexamethasone, and coadministered with an oral contraceptive containing ethinyl estradiol and norethindrone, the trough concentrations of both ethinyl estradiol and norethindrone were reduced by as much as 64% for 3 weeks post-treatment [see Drug Interactions (7.1)]. CYP2C9 substrates (Warfarin, Tolbutamide ):Warfarin: A single125-mg dose of oral aprepitant was administered on Day 1 and 80 mg/day on Days 2 and 3 to subjects who were stabilized on chronic warfarin therapy. Although there was no effect of oral aprepitant on the plasma AUC of R(+) or S(-) warfarindetermined on Day 3, there was a 34% decrease in S(-) warfarin trough concentration accompanied by a 14% decrease in the prothrombin time (reported as International Normalized Ratio or INR) 5 days after completion of dosing with oral aprepitant [see Drug Interactions ( 7.1 )]. Tolbutamide : Oral aprepitant, when given as 125 mg on Day 1 and 80 mg/day on Days 2 and 3, decreased the AUC of tolbutamide by 23% on Day 4, 28% on Day 8, and 15% on Day 15, when a single dose of tolbutamide 500 mg was administered prior to the administration of the 3-day regimen of oral aprepitant and on Days 4, 8, and 15. This effectwas not considered clinically important. Other Drugs P-glycoprotein substrates: Aprepitant is unlikely to interact with drugs that are substrates for the P­ glycoprotein transporter, as demonstrated by the lack of interaction of oral aprepitant with digoxin in a clinical drug interaction study. 5-HT 3 antagonists: In clinicaldrug interaction studies,aprepitant did not have clinically important effects on the pharmacokinetics of ondansetron, granisetron, or hydrodolasetron (the active metabolite of dolasetron). Effect of Other Drugson the Pharmacokinetics of Fosaprepitant/Aprepitant Rifampin : When a single 375-mgdose of oral aprepitant was administered on Day 9 of a 14-day regimen of 600 mg/day of rifampin, a strong CYP3A4 inducer, the AUC of aprepitant decreased approximately 11-fold and the mean terminal half-life decreased approximately 3-fold [see Drug Interactions ( 7.2 )].. Ketoconazole: When a single 125-mg dose of oral aprepitant was administered on Day 5 of a 10-day regimen of 400 mg/day of ketoconazole, a strong CYP3A4 inhibitor, the AUC of aprepitant increased approximately 5-foldand the mean terminal half-life of aprepitant increased approximately 3-fold [see Drug Interactions (7.2)]. Diltiazem: In a study in 10 patients with mild to moderate hypertension, administration of 100 mg of fosaprepitant as an intravenous infusion with 120 mg of diltiazem, a moderate CYP3A4 inhibitor administered three times daily, resulted in a 1.5-fold increase in the aprepitant AUC and a1.4-fold increase in the diltiazem AUC. When fosaprepitant was administered with diltiazem, the mean maximum decrease in diastolic blood pressure was significantly greater than that observed with diltiazem alone [24.3 ± 10.2 mm Hg with fosaprepitant versus 15.6 ± 4.1 mm Hg without fosaprepitant]. The mean maximumdecrease in systolic blood pressure was also greater after co-administration of diltiazem with fosaprepitant than administration of diltiazem alone [29.5 ± 7.9 mm Hg with fosaprepitant versus 23.8 ± 4.8 mm Hg without fosaprepitant]. Co-administration of fosaprepitant and diltiazem; however, did not result in any additional clinically significant changes in heart rate or PR interval, beyond those changes observed with diltiazem alone [see Drug Interactions ( 7.2 )]. Paroxetine : Coadministration of once daily doses of oral aprepitant 170 mg, with paroxetine 20 mg once daily, resulted in a decrease in AUC by approximately 25% and C max by approximately 20% of both aprepitant and paroxetine. This effect was not considered clinically important.

20191101

1

3 DOSAGE FORMS AND STRENGTHS Fosaprepitant for injection: 150 mg fosaprepitant, white to off white cake or powder in single-dose glass vial for reconstitution. Fosaprepitant for injection: 150 mg fosaprepitant, lyophilized cake or powder in single-dose vial for reconstitution ( 3 )

Fosaprepitant Fosaprepitant Fosaprepitant Dimeglumine Aprepitant Fosaprepitant Edetate Sodium Anhydrous Lactose Polysorbate 80 Sodium Hydroxide Hydrochloric Acid label carton structure

13.1 Carcinogenesis, Mutagenesis, Impairment Of Fertility Carcinogenesis Carcinogenicity studieswere conducted in Sprague-Dawley rats and in CD-1 mice for 2 years. In the rat carcinogenicity studies, animals were treated with oral doses ranging from 0.05 to 1,000 mg/kg twice daily. The highest dose produced systemic exposuresto aprepitant approximately equivalent to (female rats) or less than (male rats) the adulthuman exposure at the RHD of 150 mg. Treatment with aprepitant at doses of 5 to 1,000 mg/kg twicedaily caused an increase in the incidences of thyroid follicular cell adenomas and carcinomas in male rats. In female rats, it produced hepatocellular adenomas at 5 to 1,000 mg/kg twicedaily and hepatocellular carcinomas and thyroidfollicular cell adenomasat 125 to 1000mg/kg twice daily. In the mouse carcinogenicity studies,the animals were treated with oral doses ranging from 2.5 to 2,000 mg/kg/day. The highest dose produced a systemic exposureapproximately 2 times the adult human exposure at the RHD of 150 mg. Treatment with aprepitant produced skin fibrosarcomas at 125 and 500 mg/kg/day doses in male mice. Carcinogenicity studies were not conducted with fosaprepitant. Mutagenesis Aprepitant and fosaprepitant were not genotoxicin the Ames test, the human lymphoblastoid cell (TK6) mutagenesis test, the rat hepatocyte DNA strand break test, the Chinese hamster ovary (CHO) cell chromosome aberration test and the mouse micronucleustest. Impairment of Fertility Fosaprepitant, when administered intravenously, is rapidly convertedto aprepitant. In the fertilitystudies conducted with fosaprepitant and aprepitant, the highest systemic exposures to aprepitant were obtained following oral administration of aprepitant. Oral aprepitant did not affectthe fertility or general reproductive performance of male or female rats at doses up to the maximum feasible dose of 1,000 mg/kg twice daily (providingexposure in male rats lower than the exposure at the recommended adult human dose of 150 mg and exposurein female rats approximately equivalent to the adult human exposure).

13 NONCLINICAL TOXICOLOGY 13.1 Carcinogenesis, Mutagenesis, Impairment Of Fertility Carcinogenesis Carcinogenicity studieswere conducted in Sprague-Dawley rats and in CD-1 mice for 2 years. In the rat carcinogenicity studies, animals were treated with oral doses ranging from 0.05 to 1,000 mg/kg twice daily. The highest dose produced systemic exposuresto aprepitant approximately equivalent to (female rats) or less than (male rats) the adulthuman exposure at the RHD of 150 mg. Treatment with aprepitant at doses of 5 to 1,000 mg/kg twicedaily caused an increase in the incidences of thyroid follicular cell adenomas and carcinomas in male rats. In female rats, it produced hepatocellular adenomas at 5 to 1,000 mg/kg twicedaily and hepatocellular carcinomas and thyroidfollicular cell adenomasat 125 to 1000mg/kg twice daily. In the mouse carcinogenicity studies,the animals were treated with oral doses ranging from 2.5 to 2,000 mg/kg/day. The highest dose produced a systemic exposureapproximately 2 times the adult human exposure at the RHD of 150 mg. Treatment with aprepitant produced skin fibrosarcomas at 125 and 500 mg/kg/day doses in male mice. Carcinogenicity studies were not conducted with fosaprepitant. Mutagenesis Aprepitant and fosaprepitant were not genotoxicin the Ames test, the human lymphoblastoid cell (TK6) mutagenesis test, the rat hepatocyte DNA strand break test, the Chinese hamster ovary (CHO) cell chromosome aberration test and the mouse micronucleustest. Impairment of Fertility Fosaprepitant, when administered intravenously, is rapidly convertedto aprepitant. In the fertilitystudies conducted with fosaprepitant and aprepitant, the highest systemic exposures to aprepitant were obtained following oral administration of aprepitant. Oral aprepitant did not affectthe fertility or general reproductive performance of male or female rats at doses up to the maximum feasible dose of 1,000 mg/kg twice daily (providingexposure in male rats lower than the exposure at the recommended adult human dose of 150 mg and exposurein female rats approximately equivalent to the adult human exposure).

ANDA209965

Fosaprepitant

Fosaprepitant

16714-120

HUMAN PRESCRIPTION DRUG

INTRAVENOUS

PACKAGE LABEL PRINCIPAL DISPLAY PANEL SECTION Vial Label:

17 PATIENT COUNSELING INFORMATION Advise the patient to read the FDAapproved patientlabeling (Patient Information). Hypersensitivity Advise patientsthat hypersensitivity reactions, including anaphylaxis and anaphylactic shock, have been reported in patients taking fosaprepitant. Advisepatients to seek immediate medical attention if they experience signs or symptoms of a hypersensitivity reaction, such as hives, rash and itching, skin peeling or sores, flushing, difficulty in breathingor swallowing, or dizziness, rapid or weak heartbeat or feeling faint [see warnings and precautions ( 5.2 )]. Infusion Site Reactions Advise patients to seek medical attention if they experience new or worsening signs or symptoms of an infusion site reaction, such as erythema, edema, pain, necrosis, vasculitis, or thrombophlebitis at or near the infusion site [see Warnings and Precautions ( 5.3 )]. Drug Interactions Advise patients to discuss all medications they are taking, including other prescription, non­ prescription medication or herbal products[see Contraindications (4 ), Warnings and Precautions ( 5.1 )]. Warfarin: Instruct patientson chronic warfarintherapy to follow instructions from their healthcare provider regarding blood draws to monitor their INR during the 2-week period, particularly at 7 to 10 days, followinginitiation of fosaprepitant with each chemotherapy cycle [see Warningsand Precautions ( 5.4 )]. Hormonal Contraceptives: Advise patients that administration of fosaprepitant may reduce the efficacy of hormonal contraceptives. Instruct patients to use effectivealternative or back-upmethods of contraception (such as condomsand spermicides) during treatment with fosaprepitant and for 1 month following administration of fosaprepitant [see Warnings and Precautions ( 5.5 ),Use in Specific Populations ( 8.3 )]. Mfd. for: Northstar Rx LLC Memphis, TN 38141 Mfd. by: MSN Laboratories Pvt. Ltd, Telangana - 509 228 , India. Issued: 1119

Patient Information Fosaprepitant (FOS a PREP i tant) for Injection Read this patientinformation before you start receivingfosaprepitant for injection and each time you are scheduled to receive fosaprepitant for injection. There may be new information. This information does not take the place of talking with your healthcare provider about your medical condition or treatment. What is fosaprepitant for injection? Fosaprepitant for injection is a prescription medicine used with other medicines that treat nausea and vomiting in patients 18 years of age and older to prevent nausea and vomiting caused by certain anti-cancer (chemotherapy) medicines. Fosaprepitant for injection is not used to treat nausea and vomiting that you already have. It is not known if fosaprepitant for injection is safe and effective in children less than 6 months of age. Who should not recieve fosaprepitant for injection? Do not receive fosaprepitant for injection if you: are allergic to fosaprepitant, aprepitant, or any of the ingredients in fosaprepitant for injection. See the end of this leaflet for a complete list of the ingredients in fosaprepitant for injection.are taking pimozide (ORAP ® ) What should I tell my healthcare provider before receiving fosaprepitant for injection? Before receiving fosaprepitant for injection, tell your healthcare provider if you: have liver problems are pregnant or plan to become pregnant. It is not known if fosaprepitant for injection can harm your unborn baby. Women who use birth control medicines containing hormones to prevent pregnancy (birth control pills, skin patches, implants, and certain IUDs) should also use a backup method of birth control that does not contain hormones, such as condoms and spermicides, during treatment with fosaprepitant for injection and for 1 month after receiving fosaprepitant for injection. are breastfeeding or plan to breastfeed. It is not known if fosaprepitant for injection passes into your breast milk. Talk to your healthcare provider about the best way to feed your baby if you receive fosaprepitant for injection. Tell your healthcare provider about all the medicinesyou take , including prescription and over-the-counter medicines, vitamins, and herbal supplements.Fosaprepitant for injection may affect the way other medicines work, and other medicines may affect the way fosaprepitant for injection works, causing serious side effects.Know the medicines you take. Keep a list of them to show your healthcare provider or pharmacist when you get a new medicine. How will I receive fosaprepitant for injection? Adults 18 years of age and older :Fosaprepitant for injection will be given on Day 1 of chemotherapy treatment. It will be given to you by intravenous (IV) infusion in your vein about 50 to 60 minutes before you start your chemotherapy treatment.If you take the blood thinner medicine warfarin sodium (COUMADIN ® , JANTOVEN ®) , your healthcare provider may do blood tests after you receive fosaprepitant for injection to check your blood clotting. What are the possible side effectsof fosaprepitant for injection? Fosaprepitant for injection may cause serious side effects, including: Serious allergic reactions. Allergic reactions can happen with fosaprepitant for injection and may be serious. Tell your doctor or nurse right away if you have hives, rash, itching, flushing or redness of your face or skin, trouble breathing or swallowing, dizziness, a rapid or weak heartbeat, or you feel faint during or soon after you receive fosaprepitant for injection, as you may need emergency medical care. Severe skin reactions, which may include rash, skin peeling, or sores, may occur. Infusion site reactions (ISR) at or near the infusion site have happened with fosaprepitant for injection. Most severe ISR have happened with a certain type of chemotherapy medicine that can burn or blister your skin (vesicant) with side effects, including pain, swelling and redness. Death of skin tissue (necrosis) has happened in some people getting this type of chemotherapy medicine. Most ISR can happen with the first, second, or third dose and some can last up to 2 weeks or longer. Tell your healthcare provider right away if you get any infusion site side effects. In adults, the most common side effects of fosaprepitant for injection include: tiredness feeling weak or numb in your arms and legs diarrhea painful, difficult, or changes in your digestion (dyspepsia) low white blood cell and red blood cell counts urinary tract infection weakness pain in your arms and legs Tell your healthcare provider if you have any side effect that bothers you or that does not go away. These are not all of the possible side effects of fosaprepitant for injection. For more information ask your healthcare provider or pharmacist. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. General information about the safe and effective use of fosaprepitant for injection? If you would like more information about fosaprepitant for injection, talk with your healthcare provider. You can ask your healthcare provider or pharmacist for information about fosaprepitant for injection that is written for health professionals. For more information about fosaprepitant for injection call 1-844-375-6847. What are the ingredients in fosaprepitant for injection? Active ingredient : fosaprepitant dimeglumine Inactive ingredients : edetate disodium, lactose anhydrous, polysorbate 80, sodium hydroxide and/ or hydrochloric acid (for pH adjustment).The brands listed are trademarks or registered trademarks of their respective owners and are not affiliated with and do not endorse MSN Pharmaceuticals Inc. Pediatric use information is approved for Merck Sharp & Dohme Corp., a subsidiary of Merck & Co.,Inc.’s Emend (fosaprepitant) for injection. However, due to Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.’s marketing exclusivity rights, this drug product is not labeled with that pediatric information This Patient Information has been approved by the U.S. Food and Drug Administration. Mfd. for: Northstar Rx LLC Memphis, TN 38141 Mfd. by: MSN Laboratories Pvt. Ltd, Telangana - 509 228 , India. Issued: 1119

14 CLINICAL STUDIES 14.1 Prevention of Nausea and Vomiting Associated with HEC in Adults In a randomized, parallel,double-blind, active-controlled study, fosaprepitant for injection 150 mg as a single intravenous infusion(N=1147) was comparedto a 3-day oral aprepitant regimen (N=1175) in patientsreceiving a HEC regimen that included cisplatin (≥70 mg/m 2 ). All patients in both groups received dexamethasone and ondansetron (see Table 11). Patient demographics were similar betweenthe two treatment groups. Of the total 2322 patients, 63% were men, 56% White,26% Asian, 3% American Indian/Alaska Native,2% Black, 13% Multi-Racial, and 33% Hispanic/Latino ethnicity. Patient ages ranged from 19 to 86 years of age, with a mean age of 56 years.Other concomitant chemotherapy agents commonly administered were fluorouracil (17%),gemcitabine (16%), paclitaxel (15%), and etoposide (12%). T a ble 11: Treatment Regimens in Adult HEC Trial* Day 1 Day 2 Day 3 Day 4 Fosaprepitant Regimen Fosaprepitant for injection 150 mg intravenously over 20 to 30 minutes approximately 30 minutes priorto chemotherapy none none none Oral dexamethasone † 12 mg 8 mg 8 mg twice daily 8 mg twice daily Ondansetron Ondansetron ‡ none none none Oral Aprepitant Regimen Aprepitant capsules 125 mg 80 mg 80 mg none Oral dexamethasone § 12 mg 8 mg 8 mg 8 mg Ondansetron Ondansetron ‡ none none none * fosaprepitant for injection placebo, aprepitant capsules placebo and dexamethasone placebo (in the evenings on Days 3 and 4) were used to maintain blinding. † Dexamethasone was administered 30 minutes prior to chemotherapy treatment on Day 1 and in the morning on Days 2 through 4. Dexamethasone was also administered in the evenings on Days 3 and 4. The 12 mg dose of dexamethasone on Day 1 and the 8 mg once daily dose on Day 2 reflects a dosage adjustment to account for a drug interaction with the fosaprepitant for injection regimen [see Clinical Pharmacology ( 12.3 )]. ‡Ondansetron 32 mg intravenous was used in the clinical trials of fosaprepitant. Although this dose was used in clinical trials, this is no longer the currently recommended dose. Refer to the ondansetron prescribing information for the current recommended dose. § Dexamethasone was administered 30 minutes prior to chemotherapy treatment on Day 1 and in the morning on Days 2 through 4. The 12 mg dose of dexamethasone on Day 1 and the 8 mg once daily dose on Days 2 through 4 reflects a dosage adjustment to account for a drug interaction with the oral aprepitant regimen [see Clinical Pharmacology( 12.3 )]. The efficacy of fosaprepitant for injection was evaluated based on the primary and secondary endpoints listed in Table 12 and was shown to be non-inferior to that of the 3-day oral aprepitant regimen with regard to complete response in each of the evaluated phases. The pre-specified non-inferiority margin for complete response in the overall phase was 7%. The pre-specified non-inferiority margin for complete response in the delayedphase was 7.3%. Thepre-specified non-inferiority margin for no vomiting in the overall phase was 8.2%. T a ble 12 Percent of Adult Patients Receiving HEC Responding by Treatment Group and Phase — Cycle 1 ENDPOINTS Fosaprepitant for Injection Regimen (N = 1106) * % Oral Ap repitant Regimen (N = 1134) * % Difference† (95% CI) PRIMARY ENDPOINT Complete Response ‡ Overall § 71.9 72.3 -0.4 (-4.1, 3.3) SECONDARYENDPOINTS Complete Response ‡ Delayedphase ¶ 74.3 74.2 0.1 (-3.5, 3.7) No Vomiting Overall § 72.9 74.6 -1.7 (-5.3, 2.0) * N: Number of patients included in the primary analysis of completeresponse. † Difference and Confidence interval (CI) were calculated using the method proposed by Miettinen and Nurminen and adjusted for Gender. ‡ Complete Response = no vomiting and no use of rescue therapy. § Overall = 0 to 120 hours post-initiation of cisplatin chemotherapy. ¶ Delayed phase = 25 to 120 hours post-initiation of cisplatin chemotherapy. 14.2 Prevention of Nausea and Vomiting Associated with MEC in Adults In a randomized, parallel, double-blind, active comparator-controlled study, fosaprepitant for injection 150 mg as a single intravenous infusion (N=502) in combination with ondansetron and dexamethasone (fosaprepitant dimeglumine regimen) was compared with ondansetron and dexamethasone alone (standard therapy) (N=498) (see Table 13) in patients receiving a MEC regimen. Patient demographics were similar between the two treatment groups. Of the total 1,000 patients included in the efficacy analysis, 41% were men, 84% White, 4% Asian, 1% American Indian/Alaska Native, 2% Black, 10% Multi-Racial, and 19% Hispanic/Latino ethnicity. Patient ages ranged from 23 to 88 years of age, with a mean age of 60 years. The most commonly administered MEC chemotherapeutic agents were carboplatin (51%), oxaliplatin (24%), and cyclophosphamide (12%). Table 13 Treatment Regimens in Adult MEC Trial * Day 1 Day 2 Day 3 Fosaprepitant Regimen Fosaprepitant for Injection 150 mg intravenously over 20 to 30 minutes approximately 30 minutes prior to chemotherapy none none Oral Dexamethasone † 12 mg none none Oral Ondansetron ‡ 8 mg for 2 doses none none Standard Therapy Oral Dexamethasone 20 mg none none Oral Ondansetron ‡ 8 mg for 2 doses 8 mg twice daily 8 mg twice daily * Fosaprepitant for injection placebo and dexamethasone placebo (on Day 1) were used to maintain blinding. † Dexamethasone was administered 30 minutes prior to chemotherapy treatment on Day 1. The 12 mg dose reflects a dosage adjustment to account for a drug interaction with the Fosaprepitant for injection regimen [see Clinical Pharmacology ( 12.3 )]. ‡ The first ondansetron dose was administered 30 to 60 minutes prior to chemotherapy treatment on Day 1 and the second dose was administered 8 hours after first ondansetron dose. The primary endpoint was complete response (defined as no vomiting and no rescue therapy) in the delayed phase (25 to 120 hours) of chemotherapy-induced nausea and vomiting. The results by treatment group are shown in Table 14. Table 14 Percent of Adult Patients Receiving MEC Responding by Treatment Group ENDPOINTS Fosaprepitant for Injection Regimen (N = 502)* % Standard Therapy Regimen ( N = 498)* % P-Value Treatment Difference (95% CI) PRIMARYENDPOINT Complete Response † Delayed phase ‡ 78.9 68.5 <0.001 10.4 (5.1, 15.9) *N: Number of patients included in the intention to treat population. † Complete Response = no vomiting and no use of rescue therapy. ‡ Delayed phase = 25 to 120 hours post-initiation of chemotherapy.

8.5 Geriatric Use Of the 1649 adult cancer patients treated with intravenous fosaprepitant in HEC and MEC clinical studies, 27% were aged 65 and over, while 5% were aged 75 and over. Other reported clinical experience with fosaprepitant has not identified differences in responses between elderly and younger patients. In general, use caution when dosing elderly patients as they have a greater frequency of decreased hepatic, renal or cardiac function and concomitant disease or other drug therapy [see Clinical Pharmacology (12.3) ].

8.2 Lactation Risk Summary Lactation studies have not been conducted to assess the presence of aprepitant in human milk, the effects on the breastfed infant,or the effects on milk production. Aprepitant is present in rat milk. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for fosaprepitant and any potential adverse effects on the breastfed infant from fosaprepitant or from the underlying maternal condition.

8.3 Females and Males of Reproductive Potential Contraception Upon administration of fosaprepitant, the efficacy of hormonal contraceptives may be reduced. Advise females of reproductive potential using hormonal contraceptives to use an effective alternative or back-up non-hormonal contraceptive (such as condoms and spermicides) during treatment with fosaprepitant and for 1 month following the last dose [see Drug Interactions (7.1) ,Clinical Pharmacology (12.3) ] .

8.4 Pediatric Use The safety and effectiveness of fosaprepitant dimeglumine for the prevention of nausea and vomiting associated with HEC or MEC have not been established in patients less than 6 months of age. Juvenile Animal Toxicity Data In juvenile dogs treated with fosaprepitant, changes in reproductive organs were observed. In juvenile rats treated with aprepitant, slight changes in sexual maturation were observed without an effect on reproduction. No effects on neurobehavior, sensory and motor function, or learning and memory were observed in rats. In a toxicity study in juvenile dogs treated with fosaprepitant from postnatal day 14 (equivalent to a newborn human) to day 42 (approximately equivalent to a 2 year old human), decreased testicular weight and Leydig cell size were seen in the males at 6 mg/kg/day and increased uterine weight, hypertrophy of the uterus and cervix, and edema of vaginal tissues were seen in females from 4 mg/kg/day. A study was also conducted in young rats to evaluate the effects of aprepitant on growth and on neurobehavioral and sexual development. Rats were treated at oral doses up to the maximum feasible dose of 1000 mg/kg twice daily from the early postnatal period (Postnatal Day 10 (equivalent to a newborn human) through Postnatal Day 58 (approximately equivalent to a 15 year old human)). Slight changes in the onset of sexual maturation were observed in female and male rats; however, there were no effects on mating, fertility, embryonic-fetal survival, or histomorphology of the reproductive organs. There were no effects in neurobehavioral tests of sensory function, motor function, and learning and memory. Pediatric use information is approved for Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.’s Emend (fosaprepitant) for injection. However, due to Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.’s marketing exclusivity rights, this drug product is not labeled with that pediatric information.

8.1 Pregnancy Risk Summary There are insufficient data on use of fosaprepitant in pregnant women to inform a drug associated risk. In animal reproduction studies, no adverse developmental effects were observed in rats or rabbits exposed during the period of organogenesis to systemic drug levels (AUC) approximately equivalent to the exposure at the recommended human dose (RHD) of 150 mg [seeData] . The estimated background risk of major birth defects and miscarriage for the indicated populations is unknown. In the U.S. general population, the estimated background risk of majorbirth defects and miscarriage in clinically recognized pregnancies is 2 to 4% and 15 to 20%, respectively. Data Animal Data In embryofetal development studies in rats and rabbits, aprepitant was administered during the period of organogenesis at oral dosesup to 1,000 mg/kg twicedaily (rats) and up to the maximum tolerated dose of 25 mg/kg/day (rabbits). No embryofetal lethality or malformations were observed at any dose level in eitherspecies. The exposures(AUC) in pregnantrats at 1,000 mg/kg twice daily and in pregnant rabbits at 25 mg/kg/day were approximately equivalent to the exposure at the RHD of 150 mg. Aprepitant crosses the placenta in rats and rabbits.

8 USE IN SPECIFIC POPULATIONS 8.1 Pregnancy Risk Summary There are insufficient data on use of fosaprepitant in pregnant women to inform a drug associated risk. In animal reproduction studies, no adverse developmental effects were observed in rats or rabbits exposed during the period of organogenesis to systemic drug levels (AUC) approximately equivalent to the exposure at the recommended human dose (RHD) of 150 mg [seeData] . The estimated background risk of major birth defects and miscarriage for the indicated populations is unknown. In the U.S. general population, the estimated background risk of majorbirth defects and miscarriage in clinically recognized pregnancies is 2 to 4% and 15 to 20%, respectively. Data Animal Data In embryofetal development studies in rats and rabbits, aprepitant was administered during the period of organogenesis at oral dosesup to 1,000 mg/kg twicedaily (rats) and up to the maximum tolerated dose of 25 mg/kg/day (rabbits). No embryofetal lethality or malformations were observed at any dose level in eitherspecies. The exposures(AUC) in pregnantrats at 1,000 mg/kg twice daily and in pregnant rabbits at 25 mg/kg/day were approximately equivalent to the exposure at the RHD of 150 mg. Aprepitant crosses the placenta in rats and rabbits. 8.2 Lactation Risk Summary Lactation studies have not been conducted to assess the presence of aprepitant in human milk, the effects on the breastfed infant,or the effects on milk production. Aprepitant is present in rat milk. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for fosaprepitant and any potential adverse effects on the breastfed infant from fosaprepitant or from the underlying maternal condition. 8.3 Females and Males of Reproductive Potential Contraception Upon administration of fosaprepitant, the efficacy of hormonal contraceptives may be reduced. Advise females of reproductive potential using hormonal contraceptives to use an effective alternative or back-up non-hormonal contraceptive (such as condoms and spermicides) during treatment with fosaprepitant and for 1 month following the last dose [see Drug Interactions (7.1) ,Clinical Pharmacology (12.3) ] . 8.4 Pediatric Use The safety and effectiveness of fosaprepitant dimeglumine for the prevention of nausea and vomiting associated with HEC or MEC have not been established in patients less than 6 months of age. Juvenile Animal Toxicity Data In juvenile dogs treated with fosaprepitant, changes in reproductive organs were observed. In juvenile rats treated with aprepitant, slight changes in sexual maturation were observed without an effect on reproduction. No effects on neurobehavior, sensory and motor function, or learning and memory were observed in rats. In a toxicity study in juvenile dogs treated with fosaprepitant from postnatal day 14 (equivalent to a newborn human) to day 42 (approximately equivalent to a 2 year old human), decreased testicular weight and Leydig cell size were seen in the males at 6 mg/kg/day and increased uterine weight, hypertrophy of the uterus and cervix, and edema of vaginal tissues were seen in females from 4 mg/kg/day. A study was also conducted in young rats to evaluate the effects of aprepitant on growth and on neurobehavioral and sexual development. Rats were treated at oral doses up to the maximum feasible dose of 1000 mg/kg twice daily from the early postnatal period (Postnatal Day 10 (equivalent to a newborn human) through Postnatal Day 58 (approximately equivalent to a 15 year old human)). Slight changes in the onset of sexual maturation were observed in female and male rats; however, there were no effects on mating, fertility, embryonic-fetal survival, or histomorphology of the reproductive organs. There were no effects in neurobehavioral tests of sensory function, motor function, and learning and memory. Pediatric use information is approved for Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.’s Emend (fosaprepitant) for injection. However, due to Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.’s marketing exclusivity rights, this drug product is not labeled with that pediatric information. 8.5 Geriatric Use Of the 1649 adult cancer patients treated with intravenous fosaprepitant in HEC and MEC clinical studies, 27% were aged 65 and over, while 5% were aged 75 and over. Other reported clinical experience with fosaprepitant has not identified differences in responses between elderly and younger patients. In general, use caution when dosing elderly patients as they have a greater frequency of decreased hepatic, renal or cardiac function and concomitant disease or other drug therapy [see Clinical Pharmacology (12.3) ]. 8.6 Patients with Hepatic Impairment The pharmacokinetics of aprepitant in patients with mild and moderate hepatic impairment were similar to those of healthy subjects with normal hepatic function.No dosage adjustment is necessary for patients with mild to moderatehepatic impairment (Child-Pugh score 5 to 9). Thereare no clinical or pharmacokinetic data in patientswith severe hepaticimpairment (Child-Pugh score greater than 9). Therefore, additional monitoring for adverse reactions in these patients may be warranted when fosaprepitant is administered [see Clinical Pharmacology (12.3) ] .

16 HOW SUPPLIED/STORAGE AND HANDLING No.120 —Single-dose glass vial containing 150 mg of fosaprepitant as a white to off white lyophilized cake or powder for reconstitution. Supplied as follows: NDC- 16714-120-01 1 vial per carton