BYNFEZIA Pen (Page 3 of 5)

8.2 Lactation

R isk Summary

There is no information available on the presence of octreotide in human milk, the effects of the drug on the breastfed infant, or the effects of the drug on milk production. Studies show that octreotide administered subcutaneously passes into the milk of lactating rats (see Data). When a drug is present in animal milk, it is likely that the drug will be present in human milk. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for BYNFEZIA Pen, and any potential adverse effects on the breastfed child from BYNFEZIA Pen or from the underlying maternal condition.

D ata

Following a subcutaneous dose (1 mg/kg) of octreotide to lactating rats, transfer of octreotide into milk was observed at a low concentration compared to plasma (milk/plasma ratio of 0.009).

8.3 Females and Males of Reproductive Potential

Discuss the potential for unintended pregnancy with premenopausal women as the therapeutic benefits of a reduction in GH levels and normalization of IGF-1 concentration in acromegalic females treated with octreotide may lead to improved fertility.

8.4 Pediatric Use

Safety and efficacy of BYNFEZIA Pen in pediatric patients have not been established.
In post-marketing reports, serious adverse reactions, including hypoxia, necrotizing enterocolitis, and death, have been reported with octreotide injection use in pediatric patients, most notably in children under 2 years of age.

8.5 Geriatric Use

Clinical studies of octreotide did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.

8.6 Renal Impairment

In patients on dialysis, the half-life of octreotide may increase, necessitating adjustment of the maintenance dosage [see Clinical Pharmacology (12.3)].

10 OVERDOSAGE

A limited number of accidental overdoses of octreotide in adults have been reported. The doses ranged from 2,400 mcg/day to 6,000 mcg/day administered by continuous infusion or subcutaneously 1,500 mcg three times a day. Adverse reactions in some patients included arrhythmia, hypotension, cardiac arrest, brain hypoxia, pancreatitis, hepatitis steatosis, hepatomegaly, lactic acidosis, flushing, diarrhea, lethargy, weakness, and weight loss.

If overdose occurs, contact Poison Control (1-800-222-1222) for latest recommendations.

11 DESCRIPTION

BYNFEZIA Pen (octreotide acetate) injection is a sterile, clear, colorless solution of octreotide, acetate in buffered lactic acid solution. BYNFEZIA Pen is somatostatin analogue. Octreotide acetate is chemically known as L-Cysteinamide, D-phenylalanyl-L-cysteinyl-L-phenylalanyl-D-tryptophyl-L-lysyl-L-threonyl-N-[2-hydroxy-1-(hydroxymethyl)propyl]-, cyclic (2→7)-disulfide; [R-(R*, R*)] acetate salt. It is a long-acting octapeptide with pharmacologic actions mimicking those of the natural hormone somatostatin.

The molecular weight of octreotide acetate is 1019.3 (free peptide, C49 H66 N10 O10 S2 ) and its amino acid sequence is:

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(click image for full-size original)

BYNFEZIA Pen (octreotide acetate) injection is available as disposable single-patient-use pen with a deliverable volume of 2.8 mL.

Each milliliter of BYNFEZIA Pen contains 2,500 mcg octreotide (present as octreotide acetate, USP), 3.4 mg lactic acid USP, 22.5 mg mannitol USP, 5 mg phenol USP, and Water for Injection USP. The pH of the solution is adjusted to 4.2 ± 0.3 by the addition of aqueous sodium bicarbonate solution.

12 CLINICAL PHARMACOLOGY

12.1 Mechanism of Action

BYNFEZIA Pen (octreotide acetate) exerts pharmacologic actions similar to the natural hormone, somatostatin. It is an even more potent inhibitor of growth hormone, glucagon, and insulin than somatostatin. Like somatostatin, it also suppresses LH response to GnRH, decreases splanchnic blood flow, and inhibits release of serotonin, gastrin, vasoactive intestinal peptide, secretin, motilin, and pancreatic polypeptide.

By virtue of these pharmacological actions, octreotide has been used to treat the symptoms associated with metastatic carcinoid tumors (flushing and diarrhea), and VIP secreting adenomas (watery diarrhea).

12.2 Pharmacodynamics

Octreotide substantially reduces growth hormone and/or IGF-I levels in patients with acromegaly.

Single doses of octreotide have been shown to inhibit gallbladder contractility and to decrease bile secretion in normal volunteers. In clinical trials the incidence of gallstone or biliary sludge formation was markedly increased [see Warnings and Precautions (5.1)].

Octreotide may suppress secretion of thyroid stimulating hormone (TSH) [see Warnings and Precautions (5.3)].

12.3 Pharmacokinetics

Absorption

After subcutaneous injection, octreotide is absorbed and completely from the injection site. Peak concentrations of 5.2 ng/mL (100 mcg dose) were reached 0.4 hours after dosing. Peak concentrations and area under the curve values were dose proportional after subcutaneous single doses up to 500 mcg and after subcutaneous multiple doses up to 500 mcg three times a day (1,500 mcg/day).

Distribution

In healthy volunteers the distribution of octreotide from plasma was rapid (tα1/2 = 0.2 h), the volume of distribution (Vdss ) was estimated to be 13.6 L, and the total body clearance ranged from 7 L/hr to 10 L/hr. In blood, the distribution into the erythrocytes was found to be negligible and about 65% was bound in the plasma in a concentration-independent manner. Binding was mainly to lipoprotein and, to a lesser extent, to albumin.

Elimination

The elimination of octreotide from plasma had an apparent half-life of 1.7 to 1.9 hours compared with 1-3 minutes with the natural hormone. The duration of action of octreotide injection is variable but extends up to 12 hours depending upon the type of tumor. About 32% of the dose is excreted unchanged into the urine.

In patients with acromegaly, the pharmacokinetics differ somewhat from those in healthy volunteers. A mean peak concentration of 2.8 ng/mL (100 mcg dose) was reached in 0.7 hours after subcutaneous dosing. The volume of distribution (Vdss ) was estimated to be 21.6 ± 8.5 L and the total body clearance was increased to 18 L/hr. The mean percent of the drug bound was 41.2%. The disposition and elimination half-lives were similar to normals.

Specific Populations

Geriatric Patients

In an elderly population, dose adjustments may be necessary due to a significant increase in the half-life (46%) and a significant decrease in the clearance (26%) of the drug [see Use in Specific Populations (8.5)].

Patients with Renal Impairment

In patients with renal impairment the elimination of octreotide from plasma was prolonged and total body clearance reduced. In mild renal impairment (ClCR 40-60 mL/min) octreotide t1/2 was 2.4 hours and total body clearance was 8.8 L/hr, in moderate impairment (ClCR 10-39 mL/min) t1/2 was 3.0 hours and total body clearance 7.3 L/hr, and in severely renally impaired patients not requiring dialysis (ClCR <10 mL/min) t1/2 was 3.1 hours and total body clearance was 7.6 L/hr. In patients with severe renal failure requiring dialysis, total body clearance was reduced to about half that found in healthy subjects (from approximately 10 L/hr to 4.5 L/hr) [see Use in Specific Populations (8.6)].

Patients with Hepatic Impairment

Patients with liver cirrhosis showed prolonged elimination of drug, with octreotide t1/2 increasing to 3.7 hr and total body clearance decreasing to 5.9 L/hr, whereas patients with fatty liver disease showed t1/2 increased to 3.4 hr and total body clearance of 8.2 L/hr.

Drug Interaction Studies

Limited published data indicate that somatostatin analogs may decrease the metabolic clearance of compounds known to be metabolized by cytochrome P450 enzymes [see Drug Interactions (7.5)].

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