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FDA Drug information

FYARRO

Read time: 5 mins
Marketing start date: 23 Dec 2024

Summary of product characteristics


Adverse Reactions

6 ADVERSE REACTIONS The following adverse reactions have been associated with FYARRO in clinical trials and are discussed in greater detail in other sections of the label [see Warnings and Precautions ( 5 )] . Stomatitis [see Warnings and Precautions ( 5.1 )] Myelosuppression [see Warnings and Precautions ( 5.2 )] Infections [see Warnings and Precautions ( 5.3 )] Hypokalemia [see Warnings and Precautions ( 5.4 )] Hyperglycemia [see Warnings and Precautions ( 5.5 )] Interstitial Lung Disease (ILD) / Non-Infectious Pneumonitis [see Warnings and Precautions ( 5.6 )] Hemorrhage [see Warnings and Precautions ( 5.7 )] Hypersensitivity [see Warnings and Precautions ( 5.8 )] The most common (≥30%) adverse reactions were stomatitis, fatigue, rash, infection, nausea, edema, diarrhea, musculoskeletal pain, decreased weight, decreased appetite, cough, vomiting, and dysgeusia. ( 6.1 ) The most common (≥6%) Grade 3 to 4 laboratory abnormalities were decreased lymphocytes, increased glucose, decreased potassium, decreased phosphate, decreased hemoglobin, and increased lipase. ( 6.1 ) To report SUSPECTED ADVERSE REACTIONS, contact Aadi Bioscience, Inc. at 1-888-BIO-AADI (888-246-2234) or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch . 6.1 Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety of FYARRO was assessed in a single-arm study (AMPECT). Thirty-four patients received FYARRO 100 mg/m 2 on Days 1 and 8 of 21-day cycles until disease progression or unacceptable toxicity [see Clinical Studies ( 14.1 )] . Among the 34 patients who received FYARRO, 16 (47%) were exposed for 6 months or longer and 7 (21%) were exposed for greater than 1 year. The median age of patients who received FYARRO was 59.5 years (range 27 to 78 years), 82% were female and Eastern Cooperative Oncology Group (ECOG) Performance Status was 0 (76%) or 1 (24%). Race was 71% White, 9% Black, 9% Asian, 3% Hawaiian/Pacific Islander and 9% Other/Not Reported. Ethnicity was 82% not Hispanic or Latino, 15% Hispanic or Latino, and 3% Not Reported. Serious adverse reactions occurred in 14 (41%) patients who received FYARRO. Serious adverse reactions in >5% of patients, including 4 (12%) patients with infection and 2 (6%) patients each with abdominal pain, dehydration, and upper gastrointestinal hemorrhage. Fatal adverse reactions occurred in 1 (2.9%) patient who received FYARRO and experienced upper gastrointestinal hemorrhage. Permanent discontinuation of FYARRO due to an adverse reaction occurred in 3 (9%) patients. Adverse reactions which resulted in permanent discontinuation of FYARRO included pneumonitis, anemia, and noninfective cystitis. Dosage interruptions of FYARRO due to an adverse reaction occurred in 22 (65%) patients. Adverse reactions which required dosage interruption in >5% of patients included stomatitis in 6 (18%) patients, pneumonitis in 5 (15%) patients, anemia in 3 (9%) patients, and dehydration, dermatitis acneiform, and thrombocytopenia in 2 (6%) patients each. Dose reductions of FYARRO due to an adverse reaction occurred in 12 (35%) patients. Adverse reactions which required dose reductions in >5% of patients included stomatitis and pneumonitis in 3 (9%) patients each. The most common adverse reactions (≥30%) were stomatitis in 27 (79%) patients, fatigue and rash in 23 (68%) patients each, infection in 20 (59%) patients, nausea and edema in 17 (50%) patients each, diarrhea, musculoskeletal pain and decreased weight in 16 (47%) patients each, decreased appetite in 15 (44%) patients, cough in 12 (35%) patients, and vomiting and dysgeusia in 11 (32%) patients each. The most common Grade 3 to 4 laboratory abnormalities (≥6%) were decreased lymphocytes in 7 (21%) patients, increased glucose and decreased potassium in 4 (12%) patients each, decreased phosphate in 3 (9%) patients, and decreased hemoglobin and increased lipase in 2 (6%) patients each. Table 4 summarizes the adverse reactions in AMPECT. Table 4. Adverse Reactions ≥10% in Patients with PEComa Who Received FYARRO in AMPECT FYARRO (N=34) Adverse Reaction All Grades (%) Grade 3 to 4 No Grade 4 reactions were reported (%) Gastrointestinal Stomatitis Includes stomatitis, aphthous ulcer, mouth ulceration, esophageal ulcer 79 18 Nausea 50 0 Diarrhea Includes diarrhea and enteritis 47 2.9 Vomiting 32 2.9 Abdominal Pain Includes abdominal pain, abdominal pain upper, and epigastric discomfort 29 6 Constipation 24 2.9 Dry Mouth 15 0 Hemorrhoids 12 0 General disorders Fatigue 68 2.9 Edema Includes face edema, generalized edema, edema, edema peripheral, and periorbital edema 50 2.9 Pyrexia 24 0 Skin and subcutaneous tissue disorders Rash Includes dermatitis acneiform, palmar-plantar erythrodysesthesia syndrome, rash, rash erythematous, rash macular, rash maculo-papular, rash papular, rash pruritic, and skin exfoliation 68 0 Alopecia 24 0 Pruritus 18 0 Dry Skin 12 0 Nail disorder 12 0 Infections Infections Includes all reported infections, including but not limited to, upper respiratory tract infection, urinary tract infection, sinusitis , skin infection, folliculitis, nasopharyngitis, pharyngitis, pharyngitis streptococcal, pneumonia, vaginal infection 59 12 Metabolism and nutrition Decreased appetite 44 0 Dehydration 15 6 Nervous system Dysgeusia 32 0 Headache 29 0 Peripheral neuropathy Includes dysesthesia, hypoesthesia, neuropathy peripheral, paresthesia, and peripheral sensory neuropathy 15 0 Dizziness Includes dizziness, dizziness postural, and vertigo 12 0 Investigations Weight decreased 47 0 Musculoskeletal and connective tissue disorders Musculoskeletal pain Includes arthralgia, back pain, musculoskeletal chest pain, myalgia, neck pain, non-cardiac chest pain, pain in extremity 47 2.9 Respiratory, thoracic, and mediastinal disorders Cough Includes cough, productive cough, and upper-airway cough syndrome 35 0 Pneumonitis 18 0 Dyspnea Includes dyspnea and dyspnea exertional 12 0 Vascular disorders Hypertension 29 2.9 Hemorrhage Includes epistaxis, hemorrhoidal hemorrhage, mouth hemorrhage, post procedural hemorrhage, and upper gastrointestinal hemorrhage. Includes one fatal adverse reaction of upper GI hemorrhage 24 2.9 Psychiatric disorders Insomnia 21 2.9 Eye disorders Vision blurred 12 0 Grading according to NCI CTCAE Version 4.03 Table 5 summarizes the laboratory abnormalities in AMPECT. Table 5. Laboratory Abnormalities ≥10% That Worsened from Baseline in Patients with PEComa who Received FYARRO in AMPECT FYARRO The denominator used to calculate the rate varied from 33 to 34 based on the number of patients with a baseline value and at least one post-treatment value. (N=34) Laboratory Abnormality Grading according to NCI CTCAE Version 4.03 All Grades (%) Grades 3 to 4 (%) Hematology Decreased lymphocytes 82 21 Decreased hemoglobin 68 6 Decreased leukocytes 41 0 Decreased neutrophils 35 0 Decreased platelets 35 0 Chemistry Increased creatinine 82 0 Increased triglycerides 52 0 Increased cholesterol 48 3 Increased alanine aminotransferase (ALT) 47 2.9 Decreased potassium 44 12 Decreased magnesium 42 0 Decreased albumin 35 2.9 Increased aspartate transaminase (AST) 32 2.9 Increased alkaline phosphatase 29 0 Decreased sodium 24 2.9 Decreased calcium 15 0 Decreased glucose 15 0 Decreased phosphate 15 9 Increased lipase 12 6 Increased glucose 12 12 Increased sodium 12 0 Clinically relevant adverse reactions occurring in <10% of patients included enteritis, edema, pancytopenia, acute kidney injury, and acute coronary syndrome.

Contraindications

4 CONTRAINDICATIONS FYARRO is contraindicated in patients with a history of severe hypersensitivity to sirolimus, other rapamycin derivatives, or albumin [see Warnings and Precautions ( 5.8 )] . History of severe hypersensitivity to sirolimus, other rapamycin derivatives, or albumin. ( 4 )

Description

11 DESCRIPTION FYARRO (sirolimus protein-bound particles for injectable suspension) (albumin-bound) is sirolimus formulated as albumin-bound nanoparticles. The active ingredient in FYARRO is sirolimus bound to albumin which exists in the nanoparticles in a non-crystalline, amorphous state. Sirolimus is a mechanistic target of rapamycin kinase (mTOR) inhibitor. Sirolimus is a macrocyclic lactone produced by Streptomyces hygroscopicus . The chemical name of sirolimus is [3S[3R*[S*(1R*,3S*,4S*)),6S*,7E,9S*,10S*,12S*,14R*,15E,17E,19E,21R*,23R*,26S*, 27S*,3 4aR*]]- 9,10,12,13,14,21,22,23,24,25,26,27,32,33,34,34a-Hexadecahydro-9,27-dihydroxy 3-[2-(4-hydroxy-3- methoxycyclohexyl)-1-methylethyl]-10,21-dimethoxy-6,8,12,14,20,26-hexamethyl-23,27-epoxy-3H- pyrido[2,1-c][1,4]oxaazacyclohentriacontine-1,5,11,28,29(4H,6H,31H)-pentone. Its empirical formula is C 51 H 79 NO 13 , and the molecular weight is 914.2. The structural formula of sirolimus is illustrated as follows: Sirolimus is a white to off-white crystalline powder and is insoluble in water but freely soluble in benzyl alcohol, chloroform, acetone, and acetonitrile. FYARRO is supplied as a white to yellow, sterile, lyophilized powder for reconstitution with 20 mL of 0.9% Sodium Chloride Injection, USP prior to intravenous infusion. Each single-dose vial contains 100 mg of sirolimus (bound to human albumin) and approximately 850 mg of human albumin (containing sodium caprylate and sodium acetyltryptophanate). Each milliliter (mL) of reconstituted suspension contains 5 mg sirolimus formulated as albumin-bound particles. The structural formula of sirolimus

Dosage And Administration

2 DOSAGE AND ADMINISTRATION The recommended dosage of FYARRO is 100 mg/m 2 administered as an IV infusion over 30 minutes on Days 1 and 8 of each 21-day cycle until disease progression or unacceptable toxicity. ( 2.1 ) 2.1 Recommended Dosage The recommended dosage of FYARRO is 100 mg/m2 administered as an intravenous infusion over 30 minutes on Days 1 and 8 of each 21-day cycle until disease progression or unacceptable toxicity. 2.2 Dosage Modifications for Adverse Reactions Table 1 lists the recommended dose reductions of FYARRO for adverse reactions. Table 1. Recommended dose reductions of FYARRO for adverse reactions. Dose Reduction Dose First Dose Reduction 75 mg/m 2 (25% reduction from 100 mg/m 2 ) Second Dose Reduction 56 mg/m 2 (25% reduction from 75 mg/m 2 ) Third Dose Reduction Permanently discontinue FYARRO in patients who are unable to tolerate FYARRO after three dose reductions. 45 mg/m 2 (20% reduction from 56 mg/m 2 ) Table 2 lists the recommended dosage modifications of FYARRO for adverse reactions. Table 2. Recommended FYARRO Dosage Modifications for Adverse Reactions Adverse Reaction Severity Severity based on Common Terminology Criteria for Adverse Events Version 4.03. Dosage Modifications Stomatitis [see Warnings and Precautions ( 5.1 )] Grade 2 or 3 Withhold FYARRO until Grade ≤1. Restart at the same dose for first occurrence. If recurs, restart at reduced dose level. Grade 4 Permanently discontinue FYARRO. Anemia [see Warnings and Precautions ( 5.2 )] Grade 2 Withhold FYARRO until Hb ≥8 g/dL. Restart at the same dose level. Grade ≥3 Withhold FYARRO until Hb ≥8 g/dL. Restart at the same dose level. If recurs, resume at reduced dose level. Thrombocytopenia [see Warnings and Precautions ( 5.2 )] Grade 2 Withhold FYARRO until platelet count >100×10 9 /L. Restart at the same dose level. Grade ≥3 Withhold FYARRO until platelet count >100×10 9 /L. Restart at reduced dose level. Neutropenia [see Warnings and Precautions ( 5.2 )] Grade 2 or 3 Withhold FYARRO until absolute neutrophil count ≥1.5×10 9 /L. Restart at the same dose level. Grade 4 Withhold FYARRO until absolute neutrophil count ≥1.5×10 9 /L. Restart at reduced dose level. Infections [see Warnings and Precautions ( 5.3 )] Grade 3 Withhold FYARRO until resolved. Restart at reduced dose level. If recurs, permanently discontinue FYARRO. Grade 4 Withhold FYARRO until resolved. Restart at reduced dose level or permanently discontinue FYARRO. Hypokalemia [see Warnings and Precautions ( 5.4 )] Grade 2 Withhold FYARRO until Grade ≤1. Restart at the same dose level. If recurs, restart at reduced dose level. Grade ≥3 Withhold FYARRO until Grade ≤1. Restart at reduced dose level. If recurs, permanently discontinue FYARRO. Hyperglycemia [see Warnings and Precautions ( 5.5 )] Grade ≥3 Withhold FYARRO until Grade ≤2. Restart at reduced dose level. Interstitial Lung Disease / Non- Infectious Pneumonitis [see Warnings and Precautions ( 5.6 )] Grade 2 Withhold FYARRO for up to 3 weeks until Grade ≤1. Restart at reduced dose level. If not resolved to Grade ≤1 within 3 weeks, permanently discontinue FYARRO. If recurs, permanently discontinue FYARRO. Grade ≥3 Permanently discontinue FYARRO. Hemorrhage [see Warnings and Precautions ( 5.7 )] Grade 2 or 3 Withhold FYARRO until Grade ≤1. Resume at reduced dose. If recurs, permanently discontinue FYARRO. Grade 4 Permanently discontinue FYARRO. Other Adverse Reactions [see Adverse Reactions ( 6.1 )] Grade 3 Withhold FYARRO until Grade ≤1. Restart at the same dose level. If recurs, restart at reduced dose level. Grade 4 Permanently discontinue FYARRO. 2.3 Dosage Modifications for Concomitant Use with CYP3A4 and/or P-gp Inhibitors and Inducers Reduce the dosage of FYARRO to 56 mg/m 2 when used concomitantly with a moderate or weak cytochrome P-450 3A4 (CYP3A4) inhibitor. Avoid concomitant use with drugs that are strong CYP3A4 and/or P-glycoprotein (P-gp) inhibitors and inducers and with grapefruit and grapefruit juice [see Drug Interactions ( 7.1 ), Clinical Pharmacology ( 12.3 )]. 2.4 Patients with Hepatic Impairment The recommended dosage modification of FYARRO in patients with mild or moderate hepatic impairment is described in Table 3 [see Use in Specific Populations ( 8.6 ), Clinical Pharmacology ( 12.3 )] . Closely monitor patients with hepatic impairment for increased toxicity. Avoid use in patients with severe hepatic impairment [see Use in Specific Populations ( 8.6 )] . Table 3. Recommended FYARRO Dosage in Patients with Mild or Moderate Hepatic Impairment Hepatic Impairment (based on NCI criteria) Dosage Mild (total bilirubin ≤ULN, AST >ULN or total bilirubin >1 to 1.5×ULN, any AST) 75 mg/m 2 Moderate (total bilirubin >1.5 to 3.0×ULN, any AST) 56 mg/m 2 2.5 Preparation and Administration FYARRO is a hazardous drug. Follow applicable special handling and disposal procedures. 1 FYARRO is supplied as a sterile lyophilized powder for reconstitution before use. READ ENTIRE PREPARATION INSTRUCTIONS PRIOR TO RECONSTITUTION. Preparation: 1. Aseptically, reconstitute each vial by injecting 20 mL of 0.9% Sodium Chloride Injection, USP. 2. Slowly inject the 20 mL of 0.9% Sodium Chloride Injection, USP, over a minimum of 1 minute, using the sterile syringe to direct the solution flow onto the INSIDE WALL OF THE VIAL. 3. DO NOT INJECT the 0.9% Sodium Chloride Injection, USP, directly on to the lyophilized powder, which has a cake-like appearance, as this will result in foaming. 4. Once the injection is complete, allow the vial to sit for a minimum of 5 minutes to ensure proper wetting of the lyophilized powder. 5. Gently swirl and/or invert the vial slowly for at least 2 minutes until complete dissolution of any powder occurs. Avoid shaking the vial to prevent the generation of foam. 6 . If foaming or clumping occurs, let suspension stand for at least 15 minutes until foam subsides. If foaming or clumping is present after one hour, do not use the reconstituted suspension. Each mL of the reconstituted formulation will contain 5 mg sirolimus. The reconstituted suspension should be milky and homogenous without visible particulates. If particulates or settling are visible, the vial should be gently inverted again to ensure complete resuspension prior to use. Discard the reconstituted suspension if precipitates are observed. Discard any unused portion. 7. Transfer the volume of FYARRO required for the calculated dose into an empty sterile PVC or polyolefin infusion bag for administration without further dilution. The use of medical devices containing silicone oil as a lubricant (e.g., syringes and intravenous bags) to reconstitute and administer FYARRO may result in the formation of proteinaceous strands. Visually inspect reconstituted FYARRO suspension in the infusion bag prior to administration. Discard reconstituted suspension if particulate matter, proteinaceous strands, or discoloration are observed. Administration: Administer the reconstituted FYARRO suspension intravenously over 30 minutes. image of proper solution flow onto the INSIDE WALL OF THE VIAL 2.6 Stability Unopened vials of FYARRO are stable until the date indicated on the package when stored between 2°C to 8°C (36°F to 46°F) in the original package. Neither freezing nor thawing adversely affects the stability of the product. Stability of Reconstituted Suspension in the Vial Reconstituted FYARRO in the vial should be used immediately but may be refrigerated at 2°C to 8°C (36°F to 46°F) for a maximum of 6 hours stored in the original carton to protect it from light. Discard any unused portion. Stability of Reconstituted Suspension in the Infusion Bag The suspension for infusion when prepared as recommended in an infusion bag should be used immediately but may be refrigerated at 2°C to 8°C (36°F to 46°F) and protected from light for a maximum of 9 hours. The total maximum combined refrigerated storage time of reconstituted FYARRO in the vial and in the infusion bag is 15 hours. This may be followed by storage in the infusion bag at ambient temperature (approximately 25°C) and lighting conditions for a maximum of 4 hours. Discard any unused portion.

Indications And Usage

1 INDICATIONS AND USAGE FYARRO ™ is indicated for the treatment of adult patients with locally advanced unresectable or metastatic malignant perivascular epithelioid cell tumor (PEComa). FYARRO is an mTOR inhibitor indicated for the treatment of adult patients with locally advanced unresectable or metastatic malignant perivascular epithelioid cell tumor (PEComa). ( 1 )

Adverse Reactions Table

Table 4. Adverse Reactions ≥10% in Patients with PEComa Who Received FYARRO in AMPECT
FYARRO (N=34)
Adverse ReactionAll Grades (%)Grade 3 to 4No Grade 4 reactions were reported (%)
Gastrointestinal
StomatitisIncludes stomatitis, aphthous ulcer, mouth ulceration, esophageal ulcer7918
Nausea500
DiarrheaIncludes diarrhea and enteritis472.9
Vomiting322.9
Abdominal PainIncludes abdominal pain, abdominal pain upper, and epigastric discomfort296
Constipation242.9
Dry Mouth150
Hemorrhoids120
General disorders
Fatigue682.9
EdemaIncludes face edema, generalized edema, edema, edema peripheral, and periorbital edema502.9
Pyrexia240
Skin and subcutaneous tissue disorders
RashIncludes dermatitis acneiform, palmar-plantar erythrodysesthesia syndrome, rash, rash erythematous, rash macular, rash maculo-papular, rash papular, rash pruritic, and skin exfoliation680
Alopecia240
Pruritus180
Dry Skin120
Nail disorder120
Infections
InfectionsIncludes all reported infections, including but not limited to, upper respiratory tract infection, urinary tract infection, sinusitis , skin infection, folliculitis, nasopharyngitis, pharyngitis, pharyngitis streptococcal, pneumonia, vaginal infection5912
Metabolism and nutrition
Decreased appetite440
Dehydration156
Nervous system
Dysgeusia320
Headache290
Peripheral neuropathyIncludes dysesthesia, hypoesthesia, neuropathy peripheral, paresthesia, and peripheral sensory neuropathy150
DizzinessIncludes dizziness, dizziness postural, and vertigo120
Investigations
Weight decreased470
Musculoskeletal and connective tissue disorders
Musculoskeletal painIncludes arthralgia, back pain, musculoskeletal chest pain, myalgia, neck pain, non-cardiac chest pain, pain in extremity472.9
Respiratory, thoracic, and mediastinal disorders
CoughIncludes cough, productive cough, and upper-airway cough syndrome350
Pneumonitis180
DyspneaIncludes dyspnea and dyspnea exertional120
Vascular disorders
Hypertension292.9
HemorrhageIncludes epistaxis, hemorrhoidal hemorrhage, mouth hemorrhage, post procedural hemorrhage, and upper gastrointestinal hemorrhage. Includes one fatal adverse reaction of upper GI hemorrhage242.9
Psychiatric disorders
Insomnia212.9
Eye disorders
Vision blurred120
Grading according to NCI CTCAE Version 4.03

Drug Interactions

7 DRUG INTERACTIONS Strong CYP3A4 and/or P-gp Inhibitors or Inducers : Avoid concomitant use. ( 2.3 , 7.1 ) Moderate or Weak CYP3A4 Inhibitors : Reduce FYARRO dose. ( 2.3 , 7.1 ) 7.1 Effects of Other Drugs on FYARRO CYP3A4 and/or P-gp Inhibitors or Inducers CYP3A4 and/or P-gp inhibitors may increase sirolimus concentrations, which may increase the risk of FYARRO adverse reactions. CYP3A4 and/or P-gp inducers may decrease sirolimus concentrations, which may reduce FYARRO effectiveness. Strong CYP3A4 and/or P-gp Inhibitors or Inducers: Avoid concomitant use of FYARRO with strong CYP3A4 and/or P-gp inhibitors or strong CYP3A4 and/or P-gp inducers [see Dosage and Administration ( 2.3 ), Clinical Pharmacology ( 12.3 )] . Grapefruit or Grapefruit Juice: Avoid concomitant use of FYARRO with grapefruit or grapefruit juice. Moderate or Weak CYP3A4 Inhibitors: Reduce the dosage of FYARRO when used concomitantly with a moderate or weak CYP3A4 inhibitor [see Dosage and Administration ( 2.3 ), Clinical Pharmacology ( 12.3 )] . Moderate or Weak CYP3A4 Inducers: Use of FYARRO may result in decreased effectiveness.

Clinical Pharmacology

12 CLINICAL PHARMACOLOGY 12.1 Mechanism of Action Sirolimus in FYARRO is an inhibitor of mechanistic target of rapamycin kinase (mTOR, previously known as mammalian target of rapamycin). mTOR, a serine threonine kinase, is downstream of the PI3K/AKT pathway, controls key cellular processes such as cell survival, growth, and proliferation, and is commonly dysregulated in several human cancers. In cells, sirolimus binds to the immunophilin, FK Binding Protein-12 (FKBP-12), to generate an immunosuppressive complex. The sirolimus-FKBP-12 complex binds to and inhibits activation of the mechanistic target of rapamycin complex 1 (mTORC1). Inhibition of mTOR by sirolimus has been shown to reduce cell proliferation, angiogenesis, and glucose uptake in in vitro and in vivo studies. In a nonclinical study in athymic mice bearing human tumor xenografts, intravenous administration of FYARRO resulted in higher tumor accumulation of sirolimus, inhibition of an mTOR target in the tumor, and tumor growth inhibition compared to administration of an oral formulation of sirolimus at the same weekly total dose. 12.2 Pharmacodynamics Sirolimus exposure-response relationship has not been fully characterized. Cardiac Electrophysiology The effect of FYARRO on the QTc interval has not been adequately characterized. 12.3 Pharmacokinetics Absorption Following administration of FYARRO at the recommended dosage, the estimated mean (%CV) C max and AUC 0-inf of sirolimus in patients with advanced solid tumors were 2590 ng/mL (30% CV) and 22100 ng∙h/mL (50% CV), respectively. Distribution The protein binding of sirolimus is >99%, primarily to serum albumin in vitro . Elimination The mean elimination half-life of sirolimus is approximately 59 hours (41% CV). Metabolism Sirolimus is metabolized by CYP3A4. Excretion Following a single radiolabeled sirolimus oral dose to human subjects, 91% and 2% of the radioactivity was recovered in feces and urine, respectively. Specific Populations There were no clinically significant differences in the pharmacokinetics of sirolimus based on age (18 to 78 years), sex, mild or moderate renal impairment (creatinine clearance 30 to 89 mL/min). The effect of race, severe renal impairment, and hepatic impairment on the pharmacokinetics of sirolimus is unknown. Drug Interaction Studies No studies evaluating the drug interaction potential of FYARRO have been conducted. Sirolimus is a substrate for both CYP3A4 and P-gp.

Mechanism Of Action

12.1 Mechanism of Action Sirolimus in FYARRO is an inhibitor of mechanistic target of rapamycin kinase (mTOR, previously known as mammalian target of rapamycin). mTOR, a serine threonine kinase, is downstream of the PI3K/AKT pathway, controls key cellular processes such as cell survival, growth, and proliferation, and is commonly dysregulated in several human cancers. In cells, sirolimus binds to the immunophilin, FK Binding Protein-12 (FKBP-12), to generate an immunosuppressive complex. The sirolimus-FKBP-12 complex binds to and inhibits activation of the mechanistic target of rapamycin complex 1 (mTORC1). Inhibition of mTOR by sirolimus has been shown to reduce cell proliferation, angiogenesis, and glucose uptake in in vitro and in vivo studies. In a nonclinical study in athymic mice bearing human tumor xenografts, intravenous administration of FYARRO resulted in higher tumor accumulation of sirolimus, inhibition of an mTOR target in the tumor, and tumor growth inhibition compared to administration of an oral formulation of sirolimus at the same weekly total dose.

Pharmacodynamics

12.2 Pharmacodynamics Sirolimus exposure-response relationship has not been fully characterized. Cardiac Electrophysiology The effect of FYARRO on the QTc interval has not been adequately characterized.

Pharmacokinetics

12.3 Pharmacokinetics Absorption Following administration of FYARRO at the recommended dosage, the estimated mean (%CV) C max and AUC 0-inf of sirolimus in patients with advanced solid tumors were 2590 ng/mL (30% CV) and 22100 ng∙h/mL (50% CV), respectively. Distribution The protein binding of sirolimus is >99%, primarily to serum albumin in vitro . Elimination The mean elimination half-life of sirolimus is approximately 59 hours (41% CV). Metabolism Sirolimus is metabolized by CYP3A4. Excretion Following a single radiolabeled sirolimus oral dose to human subjects, 91% and 2% of the radioactivity was recovered in feces and urine, respectively. Specific Populations There were no clinically significant differences in the pharmacokinetics of sirolimus based on age (18 to 78 years), sex, mild or moderate renal impairment (creatinine clearance 30 to 89 mL/min). The effect of race, severe renal impairment, and hepatic impairment on the pharmacokinetics of sirolimus is unknown. Drug Interaction Studies No studies evaluating the drug interaction potential of FYARRO have been conducted. Sirolimus is a substrate for both CYP3A4 and P-gp.

Effective Time

20211206

Version

5

Dosage And Administration Table

Table 1. Recommended dose reductions of FYARRO for adverse reactions.
Dose ReductionDose
First Dose Reduction75 mg/m2 (25% reduction from 100 mg/m2)
Second Dose Reduction56 mg/m2 (25% reduction from 75 mg/m2)
Third Dose ReductionPermanently discontinue FYARRO in patients who are unable to tolerate FYARRO after three dose reductions.45 mg/m2 (20% reduction from 56 mg/m2)

Dosage Forms And Strengths

3 DOSAGE FORMS AND STRENGTHS For injectable suspension: white to yellow, sterile lyophilized powder containing 100 mg of sirolimus formulated as albumin-bound particles in single-dose vial for reconstitution. For injectable suspension: lyophilized powder containing 100 mg of sirolimus formulated as albumin-bound particles in single-dose vial for reconstitution. ( 3 )

Spl Product Data Elements

FYARRO Sirolimus SIROLIMUS SIROLIMUS ALBUMIN HUMAN white to yellow

Carcinogenesis And Mutagenesis And Impairment Of Fertility

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility No carcinogenicity, mutagenesis, or fertility studies were conducted with FYARRO. Carcinogenicity studies have been conducted in mice and rats with an oral formulation of sirolimus. In an 86-week female mouse study, there was a statistically significant increase in malignant lymphoma at all dose levels compared with controls. In a second mouse study, hepatocellular adenoma and carcinoma in males were considered sirolimus-related. In a 104-week rat study, there were no significant findings. Sirolimus was not genotoxic in an in vitro bacterial reverse mutation assay, a Chinese hamster ovary cell chromosomal aberration assay, a mouse lymphoma cell forward mutation assay, or an in vivo mouse micronucleus assay. When female rats were treated by gavage with an oral formulation of sirolimus and mated to untreated males, female fertility was decreased at 0.5 mg/kg due to decreased implantation. In addition, reduced ovary and uterus weight were observed. The NOAEL for female rat fertility was 0.1 mg/kg. When male rats were treated by gavage with an oral formulation of sirolimus and mated to untreated females, male fertility was decreased at 2 mg/kg. Atrophy of testes, epididymides, prostate, seminiferous tubules, and reduced sperm counts were observed. The NOAEL for male rat fertility was 0.5 mg/kg. Testicular tubular degeneration was also seen in a 4-week intravenous study of sirolimus in monkeys at 0.1 mg/kg.

Nonclinical Toxicology

13 NONCLINICAL TOXICOLOGY 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility No carcinogenicity, mutagenesis, or fertility studies were conducted with FYARRO. Carcinogenicity studies have been conducted in mice and rats with an oral formulation of sirolimus. In an 86-week female mouse study, there was a statistically significant increase in malignant lymphoma at all dose levels compared with controls. In a second mouse study, hepatocellular adenoma and carcinoma in males were considered sirolimus-related. In a 104-week rat study, there were no significant findings. Sirolimus was not genotoxic in an in vitro bacterial reverse mutation assay, a Chinese hamster ovary cell chromosomal aberration assay, a mouse lymphoma cell forward mutation assay, or an in vivo mouse micronucleus assay. When female rats were treated by gavage with an oral formulation of sirolimus and mated to untreated males, female fertility was decreased at 0.5 mg/kg due to decreased implantation. In addition, reduced ovary and uterus weight were observed. The NOAEL for female rat fertility was 0.1 mg/kg. When male rats were treated by gavage with an oral formulation of sirolimus and mated to untreated females, male fertility was decreased at 2 mg/kg. Atrophy of testes, epididymides, prostate, seminiferous tubules, and reduced sperm counts were observed. The NOAEL for male rat fertility was 0.5 mg/kg. Testicular tubular degeneration was also seen in a 4-week intravenous study of sirolimus in monkeys at 0.1 mg/kg.

Application Number

NDA213312

Brand Name

FYARRO

Generic Name

Sirolimus

Product Ndc

80803-153

Product Type

HUMAN PRESCRIPTION DRUG

Route

INTRAVENOUS

Package Label Principal Display Panel

PRINCIPAL DISPLAY PANEL NDC 80803-153-50 Rx Only Fyarro ™ sirolimus protein-bound particles for injectable suspension (albumin-bound) 100 mg per vial For intravenous infusion Single-dose vial Discard any unused portion. Principal display panel - Carton

Information For Patients

17 PATIENT COUNSELING INFORMATION Stomatitis Advise patients of the risk of stomatitis [see Warnings and Precautions ( 5.1 )] . Myelosuppression Advise patients of the risk of myelosuppression and the need to monitor blood counts periodically during therapy [see Warnings and Precautions ( 5.2 )] . Infections Advise patients that they are more susceptible to infections and that they should immediately report any signs or symptoms of infection to their healthcare provider [see Warnings and Precautions ( 5.3 )] . Hypokalemia Advise patients of the risk of hypokalemia and the need to monitor potassium periodically during therapy [see Warnings and Precautions ( 5.4 )] . Hyperglycemia Advise patients of the risk of hyperglycemia and the need to monitor glucose periodically during therapy [see Warnings and Precautions ( 5.5 )] . Interstitial Lung Disease / Non-Infectious Pneumonitis Advise patients of the risk of developing non-infectious pneumonitis and to immediately report any new or worsening respiratory symptoms to their healthcare provider [see Warnings and Precautions ( 5.6 )] . Hemorrhage Advise patients of the risk of hemorrhage. Instruct patients to report signs of bleeding, and to seek immediate medical attention for signs or symptoms of severe bleeding [see Warnings and Precautions ( 5.7 )] . Hypersensitivity Reactions Advise patients of the risk of clinically significant hypersensitivity reactions and to promptly contact their healthcare provider or seek emergency care for signs of hypersensitivity reaction including rash, itching, hives, difficulty breathing or swallowing, flushing, chest pain, or dizziness [see Contraindications ( 4 ), Warnings and Precautions ( 5.8 )] . Embryo-Fetal Toxicity Advise females of reproductive potential of the potential risk to a fetus and to inform their healthcare provider of a known or suspected pregnancy [see Warnings and Precautions ( 5.9 )] . Advise females of reproductive potential to use effective contraception during treatment and for 12 weeks after the last dose [see Use in Specific Populations ( 8.1 , 8.3 )] . Advise males with female partners of reproductive potential to use effective contraception during treatment and for 12 weeks after the last dose [see Warnings and Precautions ( 5.9 ), Use in Specific Populations ( 8.3 )] . Infertility Advise males and females of reproductive potential of the potential risk for impaired fertility [see Warnings and Precautions ( 5.10 ), Use in Specific Populations ( 8.3 )] . Immunizations Advise patients that vaccinations may be less effective while being treated with FYARRO. Advise patients to avoid the use of live vaccines, and close contact with those who have received live vaccines, while on FYARRO [see Warnings and Precautions ( 5.11 )] . Lactation Advise women not to breastfeed during treatment with FYARRO and for 2 weeks after the last dose [see Use in Specific Populations ( 8.2 )] . Drug Interactions Advise patients to inform their healthcare provider about all concomitant medications, including prescription medicine, over the counter drugs, vitamins, and herbal products [see Drug Interactions ( 7 )] . Inform patients to avoid grapefruit and grapefruit juice while taking FYARRO. This product's label may have been updated. For current full prescribing information, please visit www.aadibio.com. Manufactured for Aadi Bioscience, Inc., Pacific Palisades, CA 90272. FYARRO is a trademark of Aadi Bioscience, Inc. Patent: www.aadibio.com/patents/

Clinical Studies

6.1 Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety of FYARRO was assessed in a single-arm study (AMPECT). Thirty-four patients received FYARRO 100 mg/m 2 on Days 1 and 8 of 21-day cycles until disease progression or unacceptable toxicity [see Clinical Studies ( 14.1 )] . Among the 34 patients who received FYARRO, 16 (47%) were exposed for 6 months or longer and 7 (21%) were exposed for greater than 1 year. The median age of patients who received FYARRO was 59.5 years (range 27 to 78 years), 82% were female and Eastern Cooperative Oncology Group (ECOG) Performance Status was 0 (76%) or 1 (24%). Race was 71% White, 9% Black, 9% Asian, 3% Hawaiian/Pacific Islander and 9% Other/Not Reported. Ethnicity was 82% not Hispanic or Latino, 15% Hispanic or Latino, and 3% Not Reported. Serious adverse reactions occurred in 14 (41%) patients who received FYARRO. Serious adverse reactions in >5% of patients, including 4 (12%) patients with infection and 2 (6%) patients each with abdominal pain, dehydration, and upper gastrointestinal hemorrhage. Fatal adverse reactions occurred in 1 (2.9%) patient who received FYARRO and experienced upper gastrointestinal hemorrhage. Permanent discontinuation of FYARRO due to an adverse reaction occurred in 3 (9%) patients. Adverse reactions which resulted in permanent discontinuation of FYARRO included pneumonitis, anemia, and noninfective cystitis. Dosage interruptions of FYARRO due to an adverse reaction occurred in 22 (65%) patients. Adverse reactions which required dosage interruption in >5% of patients included stomatitis in 6 (18%) patients, pneumonitis in 5 (15%) patients, anemia in 3 (9%) patients, and dehydration, dermatitis acneiform, and thrombocytopenia in 2 (6%) patients each. Dose reductions of FYARRO due to an adverse reaction occurred in 12 (35%) patients. Adverse reactions which required dose reductions in >5% of patients included stomatitis and pneumonitis in 3 (9%) patients each. The most common adverse reactions (≥30%) were stomatitis in 27 (79%) patients, fatigue and rash in 23 (68%) patients each, infection in 20 (59%) patients, nausea and edema in 17 (50%) patients each, diarrhea, musculoskeletal pain and decreased weight in 16 (47%) patients each, decreased appetite in 15 (44%) patients, cough in 12 (35%) patients, and vomiting and dysgeusia in 11 (32%) patients each. The most common Grade 3 to 4 laboratory abnormalities (≥6%) were decreased lymphocytes in 7 (21%) patients, increased glucose and decreased potassium in 4 (12%) patients each, decreased phosphate in 3 (9%) patients, and decreased hemoglobin and increased lipase in 2 (6%) patients each. Table 4 summarizes the adverse reactions in AMPECT. Table 4. Adverse Reactions ≥10% in Patients with PEComa Who Received FYARRO in AMPECT FYARRO (N=34) Adverse Reaction All Grades (%) Grade 3 to 4 No Grade 4 reactions were reported (%) Gastrointestinal Stomatitis Includes stomatitis, aphthous ulcer, mouth ulceration, esophageal ulcer 79 18 Nausea 50 0 Diarrhea Includes diarrhea and enteritis 47 2.9 Vomiting 32 2.9 Abdominal Pain Includes abdominal pain, abdominal pain upper, and epigastric discomfort 29 6 Constipation 24 2.9 Dry Mouth 15 0 Hemorrhoids 12 0 General disorders Fatigue 68 2.9 Edema Includes face edema, generalized edema, edema, edema peripheral, and periorbital edema 50 2.9 Pyrexia 24 0 Skin and subcutaneous tissue disorders Rash Includes dermatitis acneiform, palmar-plantar erythrodysesthesia syndrome, rash, rash erythematous, rash macular, rash maculo-papular, rash papular, rash pruritic, and skin exfoliation 68 0 Alopecia 24 0 Pruritus 18 0 Dry Skin 12 0 Nail disorder 12 0 Infections Infections Includes all reported infections, including but not limited to, upper respiratory tract infection, urinary tract infection, sinusitis , skin infection, folliculitis, nasopharyngitis, pharyngitis, pharyngitis streptococcal, pneumonia, vaginal infection 59 12 Metabolism and nutrition Decreased appetite 44 0 Dehydration 15 6 Nervous system Dysgeusia 32 0 Headache 29 0 Peripheral neuropathy Includes dysesthesia, hypoesthesia, neuropathy peripheral, paresthesia, and peripheral sensory neuropathy 15 0 Dizziness Includes dizziness, dizziness postural, and vertigo 12 0 Investigations Weight decreased 47 0 Musculoskeletal and connective tissue disorders Musculoskeletal pain Includes arthralgia, back pain, musculoskeletal chest pain, myalgia, neck pain, non-cardiac chest pain, pain in extremity 47 2.9 Respiratory, thoracic, and mediastinal disorders Cough Includes cough, productive cough, and upper-airway cough syndrome 35 0 Pneumonitis 18 0 Dyspnea Includes dyspnea and dyspnea exertional 12 0 Vascular disorders Hypertension 29 2.9 Hemorrhage Includes epistaxis, hemorrhoidal hemorrhage, mouth hemorrhage, post procedural hemorrhage, and upper gastrointestinal hemorrhage. Includes one fatal adverse reaction of upper GI hemorrhage 24 2.9 Psychiatric disorders Insomnia 21 2.9 Eye disorders Vision blurred 12 0 Grading according to NCI CTCAE Version 4.03 Table 5 summarizes the laboratory abnormalities in AMPECT. Table 5. Laboratory Abnormalities ≥10% That Worsened from Baseline in Patients with PEComa who Received FYARRO in AMPECT FYARRO The denominator used to calculate the rate varied from 33 to 34 based on the number of patients with a baseline value and at least one post-treatment value. (N=34) Laboratory Abnormality Grading according to NCI CTCAE Version 4.03 All Grades (%) Grades 3 to 4 (%) Hematology Decreased lymphocytes 82 21 Decreased hemoglobin 68 6 Decreased leukocytes 41 0 Decreased neutrophils 35 0 Decreased platelets 35 0 Chemistry Increased creatinine 82 0 Increased triglycerides 52 0 Increased cholesterol 48 3 Increased alanine aminotransferase (ALT) 47 2.9 Decreased potassium 44 12 Decreased magnesium 42 0 Decreased albumin 35 2.9 Increased aspartate transaminase (AST) 32 2.9 Increased alkaline phosphatase 29 0 Decreased sodium 24 2.9 Decreased calcium 15 0 Decreased glucose 15 0 Decreased phosphate 15 9 Increased lipase 12 6 Increased glucose 12 12 Increased sodium 12 0 Clinically relevant adverse reactions occurring in <10% of patients included enteritis, edema, pancytopenia, acute kidney injury, and acute coronary syndrome.

Clinical Studies Table

Table 4. Adverse Reactions ≥10% in Patients with PEComa Who Received FYARRO in AMPECT
FYARRO (N=34)
Adverse ReactionAll Grades (%)Grade 3 to 4No Grade 4 reactions were reported (%)
Gastrointestinal
StomatitisIncludes stomatitis, aphthous ulcer, mouth ulceration, esophageal ulcer7918
Nausea500
DiarrheaIncludes diarrhea and enteritis472.9
Vomiting322.9
Abdominal PainIncludes abdominal pain, abdominal pain upper, and epigastric discomfort296
Constipation242.9
Dry Mouth150
Hemorrhoids120
General disorders
Fatigue682.9
EdemaIncludes face edema, generalized edema, edema, edema peripheral, and periorbital edema502.9
Pyrexia240
Skin and subcutaneous tissue disorders
RashIncludes dermatitis acneiform, palmar-plantar erythrodysesthesia syndrome, rash, rash erythematous, rash macular, rash maculo-papular, rash papular, rash pruritic, and skin exfoliation680
Alopecia240
Pruritus180
Dry Skin120
Nail disorder120
Infections
InfectionsIncludes all reported infections, including but not limited to, upper respiratory tract infection, urinary tract infection, sinusitis , skin infection, folliculitis, nasopharyngitis, pharyngitis, pharyngitis streptococcal, pneumonia, vaginal infection5912
Metabolism and nutrition
Decreased appetite440
Dehydration156
Nervous system
Dysgeusia320
Headache290
Peripheral neuropathyIncludes dysesthesia, hypoesthesia, neuropathy peripheral, paresthesia, and peripheral sensory neuropathy150
DizzinessIncludes dizziness, dizziness postural, and vertigo120
Investigations
Weight decreased470
Musculoskeletal and connective tissue disorders
Musculoskeletal painIncludes arthralgia, back pain, musculoskeletal chest pain, myalgia, neck pain, non-cardiac chest pain, pain in extremity472.9
Respiratory, thoracic, and mediastinal disorders
CoughIncludes cough, productive cough, and upper-airway cough syndrome350
Pneumonitis180
DyspneaIncludes dyspnea and dyspnea exertional120
Vascular disorders
Hypertension292.9
HemorrhageIncludes epistaxis, hemorrhoidal hemorrhage, mouth hemorrhage, post procedural hemorrhage, and upper gastrointestinal hemorrhage. Includes one fatal adverse reaction of upper GI hemorrhage242.9
Psychiatric disorders
Insomnia212.9
Eye disorders
Vision blurred120
Grading according to NCI CTCAE Version 4.03

References

15 REFERENCES 1. OSHA Hazardous Drugs. OSHA. https://www.osha.gov/SLTC/hazardousdrugs/index.html.

Geriatric Use

8.5 Geriatric Use Of the 34 patients treated with FYARRO, 44% were 65 years of age and older, and 6% were 75 years of age and older. Clinical studies of FYARRO did not include sufficient numbers of patients aged 65 and over to determine whether they respond differently from younger patients.

Pediatric Use

8.4 Pediatric Use The safety and efficacy of FYARRO in pediatric patients have not been established.

Pregnancy

8.1 Pregnancy Risk Summary Based on animal studies and the mechanism of action, FYARRO can cause fetal harm when administered to a pregnant woman [see Clinical Pharmacology ( 12.1 )] . Although there are no data on the use of FYARRO in pregnant women, there are limited data on the use of sirolimus during pregnancy. In animal studies, oral sirolimus was embryo/fetotoxic in rats [see Data ] at sub-therapeutic doses. Advise pregnant women of the potential risk to a fetus. The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively. Data Animal Data Reproductive studies in animals have not been performed with FYARRO. Studies with an oral formulation of sirolimus have shown that it crosses the placenta and is toxic to the conceptus. In rat embryo-fetal development studies, pregnant rats were administered an oral formulation of sirolimus during the period of organogenesis (Gestational Day 6-15). Sirolimus produced embryo-fetal lethality at 0.5 mg/kg and reduced fetal weight at 1 mg/kg. The no observed adverse effect level (NOAEL) for fetal toxicity in rats was 0.1 mg/kg. Maternal toxicity (weight loss) was observed at 2 mg/kg. The NOAEL for maternal toxicity was 1 mg/kg. In rabbit embryo-fetal development studies, pregnant rabbits were administered an oral formulation of sirolimus during the period of organogenesis (Gestational Day 6-18). There were no effects on embryo-fetal development at doses up to 0.05 mg/kg; however, at doses of 0.05 mg/kg and above, the ability to sustain a pregnancy was impaired (i.e., embryo-fetal abortion or early resorption). Maternal toxicity (decreased body weight) was observed at 0.05 mg/kg. The NOAEL for maternal toxicity was 0.025 mg/kg. In a pre- and post-natal development study in rats, pregnant females were dosed with an oral formation of sirolimus during gestation and lactation (Gestational Day 6 through Lactation Day 20). An increased incidence of dead pups occurred at 0.5 mg/kg, resulting in reduced live litter size. At 0.1 mg/kg, there were no adverse effects on offspring. Sirolimus did not cause maternal toxicity or affect developmental parameters in the surviving offspring (e.g., morphological development, motor activity, learning, or fertility assessment) at 0.5 mg/kg, the highest oral dose tested.

Use In Specific Populations

8 USE IN SPECIFIC POPULATIONS Hepatic Impairment : Reduce the dose of FYARRO in patients with mild or moderate hepatic impairment. Avoid use in patients with severe hepatic impairment. ( 2.4 , 8.6 ) Lactation : Advise not to breastfeed. ( 8.2 ) Females and Males of Reproductive Potential : May impair fertility in females and males. ( 5.9 , 5.10 , 8.3 ) 8.1 Pregnancy Risk Summary Based on animal studies and the mechanism of action, FYARRO can cause fetal harm when administered to a pregnant woman [see Clinical Pharmacology ( 12.1 )] . Although there are no data on the use of FYARRO in pregnant women, there are limited data on the use of sirolimus during pregnancy. In animal studies, oral sirolimus was embryo/fetotoxic in rats [see Data ] at sub-therapeutic doses. Advise pregnant women of the potential risk to a fetus. The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively. Data Animal Data Reproductive studies in animals have not been performed with FYARRO. Studies with an oral formulation of sirolimus have shown that it crosses the placenta and is toxic to the conceptus. In rat embryo-fetal development studies, pregnant rats were administered an oral formulation of sirolimus during the period of organogenesis (Gestational Day 6-15). Sirolimus produced embryo-fetal lethality at 0.5 mg/kg and reduced fetal weight at 1 mg/kg. The no observed adverse effect level (NOAEL) for fetal toxicity in rats was 0.1 mg/kg. Maternal toxicity (weight loss) was observed at 2 mg/kg. The NOAEL for maternal toxicity was 1 mg/kg. In rabbit embryo-fetal development studies, pregnant rabbits were administered an oral formulation of sirolimus during the period of organogenesis (Gestational Day 6-18). There were no effects on embryo-fetal development at doses up to 0.05 mg/kg; however, at doses of 0.05 mg/kg and above, the ability to sustain a pregnancy was impaired (i.e., embryo-fetal abortion or early resorption). Maternal toxicity (decreased body weight) was observed at 0.05 mg/kg. The NOAEL for maternal toxicity was 0.025 mg/kg. In a pre- and post-natal development study in rats, pregnant females were dosed with an oral formation of sirolimus during gestation and lactation (Gestational Day 6 through Lactation Day 20). An increased incidence of dead pups occurred at 0.5 mg/kg, resulting in reduced live litter size. At 0.1 mg/kg, there were no adverse effects on offspring. Sirolimus did not cause maternal toxicity or affect developmental parameters in the surviving offspring (e.g., morphological development, motor activity, learning, or fertility assessment) at 0.5 mg/kg, the highest oral dose tested. 8.2 Lactation Risk Summary There are no data on the presence of FYARRO in human milk or its effects on the breastfed child or on milk production. It is not known whether sirolimus is present in human milk. There are no data on its effects on the breastfed infant or milk production. The pharmacokinetic and safety profiles of sirolimus in infants are not known. Sirolimus is present in the milk of lactating rats. There is potential for serious adverse effects from sirolimus in breastfed infants based on mechanism of action [see Clinical Pharmacology ( 12.1 )] . Because of the potential for serious adverse reactions in breastfed infants from FYARRO, advise women not to breastfeed during treatment with FYARRO and for 2 weeks after the last dose. 8.3 Females and Males of Reproductive Potential FYARRO can cause fetal harm when administered to a pregnant woman [see Warnings and Precautions ( 5.9 ), Use in Specific Populations ( 8.1 )] . Pregnancy Testing Verify pregnancy status of females of reproductive potential prior to initiating FYARRO. Contraception Females Advise females of reproductive potential to use effective contraception during treatment with FYARRO and for 12 weeks after the last dose. Males Advise males with female partners of reproductive potential to use effective contraception during treatment with FYARRO and for 12 weeks after the last dose. Infertility Although there are no data on the impact of FYARRO on fertility, based on available clinical findings with oral formulation of sirolimus and findings in animals, male and female fertility may be compromised by the treatment with FYARRO [see Warnings and Precautions ( 5.10 ), Nonclinical Toxicology ( 13.1 )] . Ovarian cysts and menstrual disorders (including amenorrhea and menorrhagia) have been reported in females with the use of oral formulation of sirolimus. Azoospermia has been reported in males with the use of oral formulation sirolimus and has been reversible upon discontinuation in most cases. 8.4 Pediatric Use The safety and efficacy of FYARRO in pediatric patients have not been established. 8.5 Geriatric Use Of the 34 patients treated with FYARRO, 44% were 65 years of age and older, and 6% were 75 years of age and older. Clinical studies of FYARRO did not include sufficient numbers of patients aged 65 and over to determine whether they respond differently from younger patients. 8.6 Hepatic Impairment FYARRO is not recommended for use in patients with severe hepatic impairment. Reduce FYARRO dosage in patients with mild or moderate hepatic impairment [see Dosage and Administration ( 2.4 ), Clinical Pharmacology ( 12.3 )] .

How Supplied

16 HOW SUPPLIED/STORAGE AND HANDLING FYARRO (sirolimus protein-bound particles for injectable suspension) (albumin-bound) is a white to yellow, sterile lyophilized powder supplied as: NDC 80803-153-50, 100 mg of sirolimus in a single-dose vial. Each carton contains 1 vial. Store the vials in the original cartons at 2° to 8°C [USP Refrigerated Temperature] (36° to 46°F). Retain in the original package to protect from light. FYARRO is a hazardous drug. Follow applicable special handling and disposal procedures. 1

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