MESNA

6 ADVERSE REACTIONS The following are discussed in more detail in other sections of the labeling. • Hypersensitivity Reactions [see Warnings and Precautions (5.1) ] • Dermatological Toxicity [see Warnings and Precautions (5.2) ] • Benzyl Alcohol Toxicity [see Warnings and Precautions (5.3) ] • Laboratory Test Interferences [see Warnings and Precautions (5.4) ] • Use in Patients with a History of Adverse Reactions to Thiol Compounds [see Warnings and Precautions (5.5) ] The most common adverse reactions (> 10%) when mesna is given with ifosfamide are nausea, vomiting, constipation, leukopenia, fatigue, fever, anorexia, thrombocytopenia, anemia, granulocytopenia, diarrhea, asthenia, abdominal pain, headache, alopecia, and somnolence. ( 6.1 ) To report SUSPECTED ADVERSE REACTIONS, contact Baxter Healthcare at 1-866-888-2472, 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. Mesna adverse reaction data are available from four Phase 1 studies in which single intravenous doses of 600-1200 mg mesna injection without concurrent chemotherapy were administered to a total of 53 healthy volunteers and single oral doses of 600-2400 mg of MESNEX tablets were administered to a total of 82 healthy volunteers. The most frequently reported side effects (observed in two or more healthy volunteers) for healthy volunteers receiving single doses of mesna injection alone were headache, injection site reactions, flushing, dizziness, nausea, vomiting, somnolence, diarrhea, anorexia, fever, pharyngitis, hyperesthesia, influenza-like symptoms, and coughing. In two Phase 1 multiple-dose studies where healthy volunteers received MESNEX tablets alone or intravenous mesna followed by repeated doses of MESNEX tablets, flatulence and rhinitis were reported. In addition, constipation was reported by healthy volunteers who had received repeated doses of intravenous mesna. Additional adverse reactions in healthy volunteers receiving mesna alone included injection site reactions, abdominal pain/colic, epigastric pain/burning, mucosal irritation, lightheadedness, back pain, arthralgia, myalgia, conjunctivitis, nasal congestion, rigors, paresthesia, photophobia, fatigue, lymphadenopathy, extremity pain, malaise, chest pain, dysuria, pleuritic pain, dry mouth, dyspnea, and hyperhidrosis. In healthy volunteers, mesna was commonly associated with a rapid (within 24 hours) decrease in lymphocyte count, which was generally reversible within one week of administration. Because mesna is used in combination with ifosfamide or ifosfamide-containing chemotherapy regimens, it is difficult to distinguish the adverse reactions which may be due to mesna from those caused by the concomitantly administered cytotoxic agents. Adverse reactions reasonably associated with mesna administered intravenously and orally in four controlled studies in which patients received ifosfamide or ifosfamide-containing regimens are presented in Table 3. Table 3: Adverse Reactions in ≥5% of Patients Receiving Mesna in combination with Ifosfamide-containing Regimens Mesna Regimen Intravenous-Intravenous-Intravenous Intravenous dosing of ifosfamide and mesna followed by either intravenous or oral doses of MESNEX according to the applicable dosage schedule [see Dosage and Administration (2) ]. Intravenous-Oral-Oral N exposed 119 (100.0%) 119 (100%) Incidence of AEs 101 (84.9%) 106 (89.1%) Nausea 65 (54.6) 64 (53.8) Vomiting 35 (29.4) 45 (37.8) Constipation 28 (23.5) 21 (17.6) Leukopenia 25 (21.0) 21 (17.6) Fatigue 24 (20.2) 24 (20.2) Fever 24 (20.2) 18 (15.1) Anorexia 21 (17.6) 19 (16.0) Thrombocytopenia 21 (17.6) 16 (13.4) Anemia 20 (16.8) 21 (17.6) Granulocytopenia 16 (13.4) 15 (12.6) Asthenia 15 (12.6) 21 (17.6) Abdominal Pain 14 (11.8) 18 (15.1) Alopecia 12 (10.1) 13 (10.9) Dyspnea 11 (9.2) 11 (9.2) Chest Pain 10 (8.4) 11 (9.2) Hypokalemia 10 (8.4) 11 (9.2) Diarrhea 9 (7.6) 17 (14.3) Dizziness 9 (7.6) 5 (4.2) Headache 9 (7.6) 13 (10.9) Pain 9 (7.6) 10 (8.4) Sweating Increased 9 (7.6) 2 (1.7) Back Pain 8 (6.7) 6 (5.0) Hematuria 8 (6.7) 7 (5.9) Injection Site Reaction 8 (6.7) 10 (8.4) Edema 8 (6.7) 9 (7.6) Edema Peripheral 8 (6.7) 8 (6.7) Somnolence 8 (6.7) 12 (10.1) Anxiety 7 (5.9) 4 (3.4) Confusion 7 (5.9) 6 (5.0) Face Edema 6 (5.0) 5 (4.2) Insomnia 6 (5.0) 11 (9.2) Coughing 5 (4.2) 10 (8.4) Dyspepsia 4 (3.4) 6 (5.0) Hypotension 4 (3.4) 6 (5.0) Pallor 4 (3.4) 6 (5.0) Dehydration 3 (2.5) 7 (5.9) Pneumonia 2 (1.7) 8 (6.7) Tachycardia 1 (0.8) 7 (5.9) Flushing 1 (0.8) 6 (5.0) 6.2 Postmarketing Experience The following adverse reactions have been reported in the postmarketing experience of patients receiving mesna in combination with ifosfamide or similar drugs, making it difficult to distinguish the adverse reactions which may be due to mesna from those caused by the concomitantly administered cytotoxic agents. Because these reactions are reported from a population of unknown size, precise estimates of frequency cannot be made. Cardiovascular: Hypertension Gastrointestinal: Dysgeusia Hepatobiliary: Hepatitis Nervous System: Convulsion Respiratory: Hemoptysis

4 CONTRAINDICATIONS Mesna is contraindicated in patients known to be hypersensitive to mesna or to any of the excipients [see Warnings and Precautions (5.1) ] . Known hypersensitivity to mesna or to any of the excipients in mesna, including benzyl alcohol. ( 4 )

11 DESCRIPTION Mesna is a detoxifying agent to inhibit the hemorrhagic cystitis induced by ifosfamide. The active ingredient, mesna, is a synthetic sulfhydryl compound designated as sodium-2-mercaptoethane sulfonate with a molecular formula of C 2 H 5 NaO 3 S 2 and a molecular weight of 164.18. Its structural formula is as follows: HS–CH 2 –CH 2 SO 3 –Na + Mesna injection is a sterile, nonpyrogenic, aqueous solution of clear and colorless appearance in clear glass multidose vials for intravenous administration. Mesna injection contains 100 mg/mL mesna, 0.25 mg/mL edetate disodium and sodium hydroxide for pH adjustment. Mesna injection multidose vials also contain 10.4 mg/mL of benzyl alcohol as a preservative. The solution has a pH range of 7.5-8.5. MESNEX tablets are white, oblong, scored biconvex film-coated tablets with the imprint M4. They contain 400 mg mesna. The excipients are calcium phosphate, cornstarch, hydroxypropylmethylcellulose, lactose, magnesium stearate, microcrystalline cellulose, polyethylene glycol, povidone, simethicone, and titanium dioxide.

2 DOSAGE AND ADMINISTRATION Mesna may be given on a fractionated dosing schedule of three bolus intravenous injections or a single bolus injection followed by two oral administrations of MESNEX tablets as outlined below. The dosing schedule should be repeated on each day that ifosfamide is administered. When the dosage of ifosfamide is adjusted, the ratio of mesna to ifosfamide should be maintained. ( 2 ) Intravenous Dosing Schedule: 0 Hours 4 Hours 8 Hours Ifosfamide 1.2 g/m 2 -- -- Mesna injection 240 mg/m 2 240 mg/m 2 240 mg/m 2 Intravenous and Oral Dosing Schedule: 0 Hours 2 Hours 6 Hours Ifosfamide 1.2 g/m 2 -- -- Mesna injection 240 mg/m 2 -- -- MESNEX tablets -- 480 mg/m 2 480 mg/m 2 Maintain sufficient urinary output, as required for ifosfamide treatment, and monitor urine for the presence of hematuria. ( 2.3 ) 2.1 Intravenous Dosing Mesna may be given on a fractionated dosing schedule of three bolus intravenous injections as outlined below. Mesna injection is given as intravenous bolus injections in a dosage equal to 20% of the ifosfamide dosage weight by weight (w/w) at the time of ifosfamide administration and 4 and 8 hours after each dose of ifosfamide. The total daily dose of mesna is 60% of the ifosfamide dose. The recommended dosing schedule is outlined below in Table 1. Table 1. Recommended Intravenous Dosing Schedule 0 Hours 4 Hours 8 Hours Ifosfamide 1.2 g/m 2 – – Mesna injection The dosing schedule should be repeated on each day that ifosfamide is administered. When the dosage of ifosfamide is increased or decreased, the ratio of mesna to ifosfamide should be maintained. 240 mg/m 2 240 mg/m 2 240 mg/m 2 2.2 Intravenous and Oral Dosing Mesna may be given on a fractionated dosing schedule of a single bolus injection followed by two oral administrations of MESNEX tablets as outlined below. Mesna injection is given as intravenous bolus injections in a dosage equal to 20% of the ifosfamide dosage (w/w) at the time of ifosfamide administration. MESNEX tablets are given orally in a dosage equal to 40% of the ifosfamide dose 2 and 6 hours after each dose of ifosfamide. The total daily dose of mesna is 100% of the ifosfamide dose. The recommended dosing schedule is outlined in Table 2. Table 2. Recommended Intravenous and Oral Dosing Schedule 0 Hours 2 Hours 6 Hours Ifosfamide 1.2 g/m 2 – – Mesna injection The dosing schedule should be repeated on each day that ifosfamide is administered. When the dosage of ifosfamide is increased or decreased, the ratio of mesna to ifosfamide should be maintained. 240 mg/m 2 – – MESNEX tablets – 480 mg/m 2 480 mg/m 2 The efficacy and safety of this ratio of intravenous mesna and oral MESNEX has not been established as being effective for daily doses of ifosfamide higher than 2 g/m 2 . Patients who vomit within two hours of taking oral MESNEX should repeat the dose or receive intravenous mesna. 2.3 Monitoring of Hematuria Maintain adequate hydration and sufficient urinary output, as required for ifosfamide treatment, and monitor urine for the presence of hematuria. If severe hematuria develops when mesna is given according to the recommended dosage schedule, dosage reductions or discontinuation of ifosfamide therapy may be required. 2.4 Preparation for Intravenous Administration and Stability Preparation Determine the volume of mesna injection for the intended dose. Dilute the volume of mesna injection for the dose in any of the following fluids to obtain a final concentration of 20 mg/mL: • 5% Dextrose Injection, USP • 5% Dextrose and 0.2% Sodium Chloride Injection, USP • 5% Dextrose and 0.33% Sodium Chloride Injection, USP • 5% Dextrose and 0.45% Sodium Chloride Injection, USP • 0.9% Sodium Chloride Injection, USP • Lactated Ringer’s Injection, USP Stability The mesna injection multidose vials may be stored and used for up to 8 days after initial puncture. Store diluted solutions at 25°C (77°F). Use diluted solutions within 24 hours. Do not mix mesna injection with epirubicin, cyclophosphamide, cisplatin, carboplatin, and nitrogen mustard. The benzyl alcohol contained in mesna injection vials can reduce the stability of ifosfamide. Ifosfamide and mesna may be mixed in the same bag provided the final concentration of ifosfamide does not exceed 50 mg/mL. Higher concentrations of ifosfamide may not be compatible with mesna and may reduce the stability of ifosfamide. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration whenever solution and container permit. Any solutions which are discolored, hazy, or contain visible particulate matter should not be used.

1 INDICATIONS AND USAGE Mesna is indicated as a prophylactic agent in reducing the incidence of ifosfamide-induced hemorrhagic cystitis. Limitation of Use: Mesna is not indicated to reduce the risk of hematuria due to other pathological conditions such as thrombocytopenia. Mesna is a cytoprotective agent indicated as a prophylactic agent in reducing the incidence of ifosfamide-induced hemorrhagic cystitis. ( 1 ) Limitation of Use: Mesna is not indicated to reduce the risk of hematuria due to other pathological conditions such as thrombocytopenia. ( 1 )

10 OVERDOSAGE There is no known antidote for mesna. In a clinical trial, 11 patients received intravenous mesna 10 mg/kg to 66 mg/kg per day for 3 to 5 days. Patients also received ifosfamide or cyclophosphamide. Adverse reactions included nausea, vomiting, diarrhea and fever. An increased rate of these adverse reactions has also been found in oxazaphosphorine-treated patients receiving ≥80 mg mesna per kg per day intravenously compared with patients receiving lower doses or hydration treatment only. Postmarketing, administration of 4.5 g to 6.9 g of mesna resulted in hypersensitivity reactions including mild hypotension, shortness of breath, asthma exacerbation, rash, and flushing.

7 DRUG INTERACTIONS No clinical drug interaction studies have been conducted with mesna.

12 CLINICAL PHARMACOLOGY 12.1 Mechanism of Action Mesna reacts chemically with the urotoxic ifosfamide metabolites, acrolein and 4-hydroxy-ifosfamide, resulting in their detoxification. The first step in the detoxification process is the binding of mesna to 4‑hydroxy-ifosfamide forming a non-urotoxic 4-sulfoethylthioifosfamide. Mesna also binds to the double bonds of acrolein and to other urotoxic metabolites and inhibits their effects on the bladder. 12.3 Pharmacokinetics Absorption Following oral administration, peak plasma concentrations were reached within 1.5 to 4 hours and 3 to 7 hours for free mesna and total mesna (mesna plus dimesna and mixed disulfides), respectively. Oral bioavailability averaged 58% (range 45 to 71%) for free mesna and 89% (range 74 to 104%) for total mesna based on plasma AUC data from 8 healthy volunteers who received 1200 mg oral or intravenous doses. Food does not affect the urinary availability of orally administered mesna. Distribution Mean apparent volume of distribution (V d ) for mesna is 0.652 ± 0.242 L/kg after intravenous administration which suggests distribution to total body water (plasma, extracellular fluid, and intracellular water). Metabolism Analogous to the physiological cysteine-cystine system, mesna is rapidly oxidized to its major metabolite, mesna disulfide (dimesna). Plasma concentrations of mesna exceed those of dimesna after oral or intravenous administration. Excretion Following intravenous administration of a single 800 mg dose, approximately 32% and 33% of the administered dose was eliminated in the urine in 24 hours as mesna and dimesna, respectively. Mean plasma elimination half-lives of mesna and dimesna are 0.36 hours and 1.17 hours, respectively. Mesna has a plasma clearance of 1.23 L/h/kg.

12.1 Mechanism of Action Mesna reacts chemically with the urotoxic ifosfamide metabolites, acrolein and 4-hydroxy-ifosfamide, resulting in their detoxification. The first step in the detoxification process is the binding of mesna to 4‑hydroxy-ifosfamide forming a non-urotoxic 4-sulfoethylthioifosfamide. Mesna also binds to the double bonds of acrolein and to other urotoxic metabolites and inhibits their effects on the bladder.

12.3 Pharmacokinetics Absorption Following oral administration, peak plasma concentrations were reached within 1.5 to 4 hours and 3 to 7 hours for free mesna and total mesna (mesna plus dimesna and mixed disulfides), respectively. Oral bioavailability averaged 58% (range 45 to 71%) for free mesna and 89% (range 74 to 104%) for total mesna based on plasma AUC data from 8 healthy volunteers who received 1200 mg oral or intravenous doses. Food does not affect the urinary availability of orally administered mesna. Distribution Mean apparent volume of distribution (V d ) for mesna is 0.652 ± 0.242 L/kg after intravenous administration which suggests distribution to total body water (plasma, extracellular fluid, and intracellular water). Metabolism Analogous to the physiological cysteine-cystine system, mesna is rapidly oxidized to its major metabolite, mesna disulfide (dimesna). Plasma concentrations of mesna exceed those of dimesna after oral or intravenous administration. Excretion Following intravenous administration of a single 800 mg dose, approximately 32% and 33% of the administered dose was eliminated in the urine in 24 hours as mesna and dimesna, respectively. Mean plasma elimination half-lives of mesna and dimesna are 0.36 hours and 1.17 hours, respectively. Mesna has a plasma clearance of 1.23 L/h/kg.

20181217

12

3 DOSAGE FORMS AND STRENGTHS • Mesna injection: 1 g Multidose Vial, 100 mg/mL • MESNEX (mesna) tablets: 400 mg film-coated tablets with functional score • Injection: 1g (100 mg/mL) Multidose vials ( 3 ) • Tablets: 400 mg with functional score ( 3 )

MESNA MESNA MESNA 2-MERCAPTOETHANESULFONIC ACID EDETATE DISODIUM SODIUM HYDROXIDE BENZYL ALCOHOL

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility No long-term studies in animals have been performed to evaluate the carcinogenic potential of mesna. Mesna was not genotoxic in the in vitro Ames bacterial mutagenicity assay, the in vitro mammalian lymphocyte chromosomal aberration assay or the in vivo mouse micronucleus assay. No studies on male or female fertility were conducted. No signs of male or female reproductive organ toxicity were seen in 6-month oral rat studies (≤2000 mg/kg/day) or 29-week oral dog studies (520 mg/kg/day) at doses approximately 10-fold higher than the maximum recommended human dose on a body surface area basis.

13 NONCLINICAL TOXICOLOGY 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility No long-term studies in animals have been performed to evaluate the carcinogenic potential of mesna. Mesna was not genotoxic in the in vitro Ames bacterial mutagenicity assay, the in vitro mammalian lymphocyte chromosomal aberration assay or the in vivo mouse micronucleus assay. No studies on male or female fertility were conducted. No signs of male or female reproductive organ toxicity were seen in 6-month oral rat studies (≤2000 mg/kg/day) or 29-week oral dog studies (520 mg/kg/day) at doses approximately 10-fold higher than the maximum recommended human dose on a body surface area basis.

NDA019884

MESNA

MESNA

10019-953

HUMAN PRESCRIPTION DRUG

INTRAVENOUS

PACKAGE/LABEL PRINCIPAL DISPLAY PANEL Container Label - 1g Multidose Vial NDC 10019-953-62 Mesna Injection 1g/vial FOR INTRAVEOUS USE 1 Multidose Vial Rx only Baxter Logo Manufactured by Baxter Healthcare Corporation Deerfield, IL 60015 USA LOT/EXP: JMXXX MM.JJJJ Each vial contains 1 gram of mesna in 10 mL water. 1% benzyl alcohol is added as a preservative. See insert for dosing information. Store at 20° -25° C (68° -77° F) [see USP Contolled Room Temperature]. Barcode (01)00310019953625 USA HA-65-01-565 C 32 Carton Label- 1g Multidose Vial NDC 10019-953-01 Mesna Injection 1g/vial Rx only FOR INTRAVENOUS USE 1 Multidose Vial Baxter Logo Manufactured by: Baxter Healthcare Corporation Deerfield, IL 60015 USA (01) 00310019953014 (21) XXXXXXXXXXXX (17) JJMMTT (10) JMXXXA Mesna Injection 1g/vial Barcode HA-80-02-155 USA Fragile: Handle with care. Store at 20° -25° C (68° - 77°), excursions permitted to 15° - 30° C (59° - 86°) [see USP Controlled Room Temperature]. Baxter Logo Manufactured by: Baxter Healthcare Corporation Deerfield, IL 60015 USA C 202 NDC 10019 953 01 Mesna Injection 1g/vial Rx only FOR INTRAVENOUS USE 1 Multidose Vial Baxter Logo Manufactured by: Baxter Healthcare Corporation Deerfield, IL 60015 USA LOT/EXP: JMXXXXA MMJJJJ 2639B3993 Barcode Folding Box Can Be Recycled Each vial contains 1 g mesna in 10 mL water. Mesna Injection is a sterile and nonpyrogenic solution containing 10% sodium-2-mercaptoethane sulfonate (mesna) in water for injection with 0.025% edetate disodium and sodium hydroxide to adjust pH to 7.5 to 8.5. 1% benzyl alcohol is added as a preservative. Dosage : See package insert for directions for use. Should not be prescribed without thorough knowledge of dose, indications and toxicology as contained in accompanying literature. Carton Label - 10 Multidose Vials NDC 10019-953-02 Mesna Injection 1 g FOR INTRAVENOUS USE 10 Multidose Vials Baxter Logo Manufactured By: Baxter Healthcare Corporation Deerfield, IL 60015 USA NDC 10019-953-02 Mesna Injection 1 g Rx Only Each vial contains 1 g mesna in 10mL water. Mesna Injection is a sterile and nonpyrogenic solution containing 10% sodium-2-mercaptoethane sulfonate (mesna) in water for injection with 0.025% edetate disodium and sodium hydroxide to adjust pH to 7.5 to 8.5. 1% benzyl alcohol is added as a preservative. Dosage: See package insert for directions for use. Should not be prescribed without thorough knowledge of dose, indications and toxicology as contained in accompanying literature. Fragile: Handle with care. Store at 20° -25° C (68° -77°), excursions permitted to 15° - 30° C (59° -86°) [see USP Controlled Room Temperature]. HA-80-01-629 USA NDC 10019-953-02 Mesna Injection 1g FOR INTRAVENOUS USE 10 Multidose Vials n 3 10019 95302 1 639B3992 LOT: EXP: NDC 10019-953-02 Mesna Injection 1g Rx only FOR INTRAVENOUS USE 10 Multidose Vials Baxter Logo Manufactured by: Baxter Healthcare Corporation Deerfield, IL 60015 USA Folding Box Logo Can Be Recycled NDC 10019-953-02 Mesna Injection 1g FOR INTRAVENOUS USE 10 Multidose Vials Mesna Representative Container Label NDC 10019-953-62 Mesna Representative Carton Label NDC 1009-953-01 1 of 2 Mesna Representative Carton Label NDC 1009-953-01 2 of 2 Mesna Representative Carton Label - panel 1 Mesna Representative Carton Label - panel 2 Mesna Representative Carton Label - panel 3 Mesna Representative Carton Label - panel 4

Warnings and Precautions, Benzyl Alcohol Toxicity (5.3) 12/2018

17 PATIENT COUNSELING INFORMATION See FDA-approved patient labeling (Patient Information). Hypersensitivity • Advise the patient to discontinue mesna and seek immediate medical attention if any signs or symptoms of a hypersensitivity reaction, including systemic anaphylactic reactions occur [see Warnings and Precautions (5.1) ]. Dosing Instructions • Advise the patient to take mesna at the exact time and in the exact amount as prescribed. Advise the patient to contact their healthcare provider if they vomit within 2 hours of taking oral MESNEX, or if they miss a dose of oral MESNEX [see Dosage and Administration (2.2) ]. Hemorrhagic Cystitis • Mesna does not prevent hemorrhagic cystitis in all patients nor does it prevent or alleviate any of the other adverse reactions or toxicities associated with ifosfamide. • Advise the patient to report to their healthcare provider if his/her urine has turned a pink or red color [see Dosage and Administration (2.3) ]. Dermatologic Toxicity • Advise the patient that Stevens-Johnson syndrome, toxic epidermal necrolysis, and drug rash with eosinophilia and systemic symptoms and bullous and ulcerative skin and mucosal reactions have occurred with mesna. Advise the patient to report to their healthcare provider if signs and symptoms of these syndromes occur [see Warnings and Precautions (5.2) ]. Benzyl Alcohol Toxicity • Advise patients that serious adverse reactions are associated with the benzyl alcohol found in mesna and other medications in premature neonates and low-birth weight infants [see Warnings and Precautions (5.3) and Use in Specific Populations (8.4) ]. Embryo-Fetal Toxicity • Mesna is used in combination with ifosfamide. Ifosfamide or other cytotoxic agents can cause fetal harm when administered to a pregnant woman. Inform female patients of the risk to a fetus and potential loss of the pregnancy. Advise females to inform their healthcare provider if they are pregnant or become pregnant [see Use in Specific Populations (8.1) ]. Contraception • Advise females of reproductive potential to use effective contraception during treatment with mesna in combination with ifosamide and for 6 months after the last dose [see Use in Specific Populations (8.3) ] . • Advise male patients with female partners of reproductive potential to use effective contraception during treatment with mesna in combination with ifosamide and for 3 months after the last dose [see Use in Specific Populations (8.3) ]. Lactation • Advise lactating women not to breastfeed during treatment with mesna or ifosfamide and for 1 week after the last dose [see Use in Specific Populations (8.2) ] . Baxter Logo Mesna injection manufactured by: MESNEX (mesna) tablets manufactured for: Baxter Healthcare Corporation Deerfield, IL 60015 USA For Product Inquiry 1800 ANA DRUG (1-800-262-3784) Made in Germany Baxter and Mesnex are registered trademarks of Baxter International Inc. Material No. HA-30-01-815 ______________________________________________________________________________________________________________________________ Patient Information MESNEX (MES-nex) (mesna) tablets Mesna injection What is the most important information I should know about mesna? Mesna can cause serious allergic reactions and skin reactions. These serious reactions can happen the first time you are treated with mesna or after several months of treatment with mesna. Stop treatment with mesna and go to the nearest hospital emergency room right away if you develop any of the symptoms listed below: • fever • swelling of your face, lips, mouth, or tongue • trouble breathing or wheezing • itching • burning • skin rash or hives • skin redness or swelling • skin blisters or peeling • feel lightheaded or faint • feel like your heart is racing • nausea • vomiting • joint or muscle aches • mouth sores See “ What are the possible side effects of mesna? ” for more information about side effects. What is mesna? Mesna is a prescription medicine used to reduce the risk of inflammation and bleeding of the bladder (hemorrhagic cystitis) in people who receive ifosfamide (a medicine used to treat cancer). Mesna is not for use to reduce the risk of blood in the urine (hematuria) due to other medical conditions. Do not take MESNEX tablets or receive mesna by intravenous (IV) infusion if you are allergic to mesna or any of the ingredients in mesna. See the end of this leaflet for a complete list of ingredients in mesna. Before you take or receive mesna, tell your healthcare provider about all of your medical conditions, including if you: • are allergic to any medicines • are pregnant or plan to become pregnant. Females who are able to become pregnant: o Your healthcare provider will verify if you are pregnant or not before you start treatment with mesna and ifosfamide. o You should use effective birth control (contraception) during treatment with mesna and ifosfamide and for 6 months after the last dose. o Tell your healthcare provider if you become pregnant during treatment with mesna and ifosfamide. Males with female partners who are able to become pregnant should use effective birth control during treatment with mesna and ifosfamide and for 3 months after the last dose. You should also read the ifosfamide Prescribing Information for important pregnancy, contraception, and infertility information. • are breastfeeding or plan to breastfeed. It is not known if mesna passes into your breast milk. Do not breastfeed during treatment and for 1 week after the last dose of mesna or ifosfamide. Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. How will I receive mesna? • Mesna is given on the same day that you receive ifosfamide. • Mesna can be given by an intravenous (IV) infusion into a vein or tablets taken by mouth. • You will receive mesna in one of two ways: o Mesna intravenous (IV) infusion into a vein at the time you receive ifosfamide and 4 and 8 hours after you receive ifosfamide, OR o Mesna intravenous (IV) infusion into a vein at the time you receive ifosfamide and MESNEX tablets taken by mouth 2 and 6 hours after you receive ifosfamide. • Take MESNEX tablets at the exact times and the exact dose your healthcare provider tells you to take it. • During treatment with mesna intravenous (IV) infusion or MESNEX tablets, you should drink 4 to 8 cups of liquid (1 to 2 liters) each day. • Tell your healthcare provider if you: o vomit within 2 hours of taking MESNEX tablets by mouth o miss a dose of MESNEX tablets o have pink or red colored urine What are the possible side effects of mesna? Mesna may cause serious side effects, including: See “What is the most important information I should know about mesna?” • Mesna that is given by intravenous (IV) infusion contains the preservative benzyl alcohol. Benzyl alcohol has been shown to cause serious side effects and death in premature newborns and low-birth weight babies. Avoid use of mesna injection in premature newborns and low birth weight infants. MESNEX tablets do not contain benzyl alcohol. The most common side effects of mesna when given with ifosfamide include: These are not all the possible side effects of mesna. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. How should I store MESNEX tablets? • Store MESNEX tablets at room temperature between 68°F to 77°F (20°C to 25°C). Keep mesna and all medicines out of the reach of children. General information about the safe and effective use of mesna. Medicines are sometimes prescribed for purposes other than those listed in a Patient Information leaflet. Do not use mesna for a condition for which it was not prescribed. Do not give mesna to other people, even if they have the same symptoms that you have. It may harm them. You can ask your pharmacist or healthcare provider for information about mesna that is written for health professionals. What are the ingredients in mesna? Active ingredient: mesna Inactive ingredients: Mesna injection: edetate disodium, sodium hydroxide, and benzyl alcohol as a preservative. MESNEX tablets: calcium phosphate, cornstarch, hydroxypropylmethylcellulose, lactose, magnesium stearate, microcrystalline cellulose, polyethylene glycol, povidone, simethicone, and titanium dioxide. Manufactured by: Baxter Healthcare Corporation, Deerfield, IL 60015 USA Made in Germany Baxter and Mesnex are registered trademarks of Baxter International Inc. For more information, call 1-800-262-3784. This Patient Information has been approved by the U.S. Food and Drug Administration. Revised: 12 2018

14 CLINICAL STUDIES 14.1 Intravenous Mesna Hemorrhagic cystitis produced by ifosfamide is dose dependent (Table 4). At a dose of 1.2 g/m 2 ifosfamide administered daily for 5 days, 16 to 26% of the patients who received conventional uroprophylaxis (high fluid intake, alkalinization of the urine, and the administration of diuretics) developed hematuria (>50 RBC per hpf or macrohematuria) (Studies 1, 2, and 3). In contrast, none of the patients who received mesna injection together with this dose of ifosfamide developed hematuria (Studies 3 and 4). In two randomized studies, (Studies 5 and 6), higher doses of ifosfamide, from 2 g/m 2 to 4 g/m 2 administered for 3 to 5 days, produced hematuria in 31 to 100% of the patients. When mesna was administered together with these doses of ifosfamide, the incidence of hematuria was less than 7%. Table 4. Percent of Mesna Patients Developing Hematuria (≥50 RBC/hpf or macrohematuria) Study Conventional Uroprophylaxis (number of patients) Standard Mesna Intravenous Regimen (number of patients) Uncontrolled Studies Ifosfamide dose 1.2 g/m 2 d x 5 Study 1 16% (7/44) - Study 2 26% (11/43) - Study 3 18% (7/38) 0% (0/21) Study 4 - 0% (0/32) Controlled Studies Ifosfamide dose 2 g/m 2 to 4 g/m 2 d x 3 to 5 Study 5 31% (14/46) 6% (3/46) Study 6 100% (7/7) 0% (0/8) 14.2 Oral MESNEX Clinical studies comparing recommended intravenous and oral MESNEX dosing regimens demonstrated incidences of grade 3 to 4 hematuria of <5%. Study 7 was an open label, randomized, two-way crossover study comparing three intravenous doses with an initial intravenous dose followed by two oral doses of MESNEX in patients with cancer treated with ifosfamide at a dose of 1.2 g/m 2 to 2.0 g/m 2 for 3 to 5 days. Study 8 was a randomized, multicenter study in cancer patients receiving ifosfamide at 2.0 g/m 2 for 5 days. In both studies, development of grade 3 or 4 hematuria was the primary efficacy endpoint. The percent of patients developing hematuria in each of these studies is presented in Table 5. Table 5. Percent of MESNEX Patients Developing Grade 3 or 4 Hematuria MESNEX Dosing Regimen Study Standard Intravenous Regimen (number of patients) Intravenous + Oral Regimen (number of patients) Study 7 0% (0/30) 3.6% (1/28) Study 8 3.7% (1/27) 4.3% (1/23)

8.5 Geriatric Use Clinical studies of mesna did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. In general, dose selection for an elderly patient should be cautious, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy. The ratio of ifosfamide to mesna should remain unchanged.

8.4 Pediatric Use Mesna injection contains the preservative benzyl alcohol which has been associated with serious adverse reactions and death when administered intravenously to premature neonates and low birth weight infants . Avoid use of mesna injection in premature neonates and low-birth weight infants [see Warnings and Precautions (5.3) ] .

8.1 Pregnancy Risk Summary Mesna is used in combination with ifosfamide or other cytotoxic agents. Ifosfamide can cause fetal harm when administered to a pregnant woman. Refer to the ifosfamide prescribing information for more information on use during pregnancy. Mesna injection contains the preservative benzyl alcohol. Because benzyl alcohol is rapidly metabolized by a pregnant woman, benzyl alcohol exposure in the fetus is unlikely [see Warnings and Precautions (5.3) and Use in Specific Populations (8.4) ]. The estimated background risk of major birth defects and miscarriage for the indicated populations are unknown. All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. 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 Mesna is used in combination with ifosfamide or other cytotoxic agents. Ifosfamide can cause fetal harm including embryo-fetal lethality. Refer to the ifosfamide prescribing information for more information on use during pregnancy. In embryo-fetal development studies, oral administration of mesna to pregnant rats (500, 1000, 1500, and 2000 mg/kg) and rabbits (500 and 1000 mg/kg) during the period of organogenesis revealed no adverse developmental outcomes at doses approximately 10 times the maximum recommended total daily human equivalent dose based on body surface area.

8 USE IN SPECIFIC POPULATIONS • Pregnancy: Mesna in combination with ifosfamide can cause fetal harm. Advise patients of potential risk to a fetus. ( 8.1 ) • Lactation: Do not breastfeed. ( 8.2 ) • Females and Males of Reproductive Potential: Advise patients to use effective contraception. Verify pregnancy status prior to initiation of mesna in combination with ifosfamide. ( 8.3 ) • Pediatric use: In premature neonates and low-birth weight infants, avoid use of benzyl alcohol-containing solutions. ( 8.4 ) • Geriatric use: Dose selection should be cautious. ( 8.5 ) 8.1 Pregnancy Risk Summary Mesna is used in combination with ifosfamide or other cytotoxic agents. Ifosfamide can cause fetal harm when administered to a pregnant woman. Refer to the ifosfamide prescribing information for more information on use during pregnancy. Mesna injection contains the preservative benzyl alcohol. Because benzyl alcohol is rapidly metabolized by a pregnant woman, benzyl alcohol exposure in the fetus is unlikely [see Warnings and Precautions (5.3) and Use in Specific Populations (8.4) ]. The estimated background risk of major birth defects and miscarriage for the indicated populations are unknown. All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. 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 Mesna is used in combination with ifosfamide or other cytotoxic agents. Ifosfamide can cause fetal harm including embryo-fetal lethality. Refer to the ifosfamide prescribing information for more information on use during pregnancy. In embryo-fetal development studies, oral administration of mesna to pregnant rats (500, 1000, 1500, and 2000 mg/kg) and rabbits (500 and 1000 mg/kg) during the period of organogenesis revealed no adverse developmental outcomes at doses approximately 10 times the maximum recommended total daily human equivalent dose based on body surface area. 8.2 Lactation Risk Summary Mesna is used in combination with ifosfamide or other cytotoxic agents. Ifosfamide is excreted in breast milk. Refer to the ifosfamide prescribing information for more information on use during lactation. There are no data on the presence of mesna in human or animal milk, the effect on the breastfed child, or the effect on milk production. Mesna injection contains the preservative benzyl alcohol. Because benzyl alcohol is rapidly metabolized by a lactating woman, benzyl alcohol exposure in the breastfed infant is unlikely. However, adverse reactions have occurred in premature neonates and low birth weight infants who received intravenously administered benzyl alcohol-containing drugs [see Warnings and Precautions (5.3) and Use in Specific Populations (8.4) ]. Because of the potential for serious adverse reactions in a breastfed child, advise lactating women not to breastfeed during treatment and for 1 week after the last dose of mesna or ifosfamide. 8.3 Females and Males of Reproductive Potential MESNEX is used in combination with ifosfamide or other cytotoxic agents. Ifosfamide can cause fetal harm when administered to a pregnant woman. Refer to the ifosfamide prescribing information for more information on contraception and effects on fertility. Pregnancy Testing Verify the pregnancy status of females of reproductive potential prior to initiation of mesna in combination with ifosfamide. Contraception Females Advise females of reproductive potential to use effective contraception during treatment with mesna in combination with ifosfamide and for 6 months after the last dose. Males Advise males with female partners of reproductive potential to use effective contraception during treatment with mesna in combination with ifosfamide and for 3 months after the last dose. 8.4 Pediatric Use Mesna injection contains the preservative benzyl alcohol which has been associated with serious adverse reactions and death when administered intravenously to premature neonates and low birth weight infants . Avoid use of mesna injection in premature neonates and low-birth weight infants [see Warnings and Precautions (5.3) ] . 8.5 Geriatric Use Clinical studies of mesna did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. In general, dose selection for an elderly patient should be cautious, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy. The ratio of ifosfamide to mesna should remain unchanged. 8.6 Use in Patients with Renal Impairment No clinical studies were conducted to evaluate the effect of renal impairment on the pharmacokinetics of mesna. 8.7 Use in Patients with Hepatic Impairment No clinical studies were conducted to evaluate the effect of hepatic impairment on the pharmacokinetics of mesna.

16 HOW SUPPLIED/STORAGE AND HANDLING Mesna injection 100 mg/mL • NDC 10019-953-01 1 g Multidose Vial, Box of 1 vial of 10 mL • NDC 10019-953-02 1 g Multidose Vial, Box of 10 vials of 10 mL Store at 20°C to 25°C (68°F to 77°F), excursions permitted to 15°C to 30°C (59°F to 86°F) [see USP Controlled Room Temperature]. If mesna is co-administered with ifosfamide, refer to the ifosfamide prescribing information for safe handling instructions. MESNEX (mesna) tablets • NDC 67108-3565-9 400 mg scored tablets packaged in box of 10 tablets Store at 20°C to 25°C (68°F to 77°F), excursions permitted to 15°C to 30°C (59°F to 86°F) [see USP Controlled Room Temperature].