LABOR & DELIVERY SECTION.

8.2 Lactation. Risk Summary It is not known whether this drug is excreted in human milk. Teriflunomide was detected in rat milk following single oral dose. The developmental and health benefits of breastfeeding should be considered along with the mothers clinical need for teriflunomide tablets and any potential adverse effects on the breastfed infant from teriflunomide tablets or from the underlying maternal condition.

MECHANISM OF ACTION SECTION.

12.1 Mechanism of Action. Teriflunomide, an immunomodulatory agent with anti-inflammatory properties, inhibits dihydroorotate dehydrogenase, mitochondrial enzyme involved in de novo pyrimidine synthesis. The exact mechanism by which teriflunomide exerts its therapeutic effect in multiple sclerosis is unknown but may involve reduction in the number of activated lymphocytes in CNS.

ADVERSE REACTIONS SECTION.

6 ADVERSE REACTIONS. The following serious adverse reactions are described elsewhere in the prescribing information: Hepatotoxicity [see Contraindications (4) and Warnings and Precautions (5.1)] Bone Marrow Effects/Immunosuppression Potential/Infections [see Warnings and Precautions (5.4)] Hypersensitivity and Serious Skin Reactions [see Contraindications (4) and Warnings and Precautions (5.5)] Peripheral Neuropathy [see Warnings and Precautions (5.6)] Increased Blood Pressure [see Warnings and Precautions (5.7)] Respiratory Effects [see Warnings and Precautions (5.8)] Most common adverse reactions (>=10% and >=2% greater than placebo): headache, diarrhea, nausea, alopecia, increase in ALT (6) To report SUSPECTED ADVERSE REACTIONS, contact 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 drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice. total of 2,047 patients receiving teriflunomide tablets (7 mg or 14 mg once daily) constituted the safety population in the pooled analysis of placebo controlled studies in patients with relapsing forms of multiple sclerosis; of these, 71% were female. The average age was 37 years.Table lists adverse reactions in placebo-controlled trials with rates that were at least 2% for teriflunomide tablets patients and also at least 2% above the rate in placebo patients. The most common were headache, an increase in ALT, diarrhea, alopecia, and nausea. The adverse reaction most commonly associated with discontinuation was an increase in ALT (3.3%, 2.6%, and 2.3% of all patients in the teriflunomide tablets mg, teriflunomide tablets 14 mg, and placebo treatment arms, respectively). Table 1. Adverse Reactions in Pooled Placebo-Controlled Studies in Patients with Relapsing Forms of Multiple SclerosisAdverse ReactionTeriflunomide Tablets mg (N=1,045) Teriflunomide Tablets 14 mg (N=1,002) Placebo (N=997) Headache 18% 16% 15% Increase in Alanine aminotransferase 13% 15% 9% Diarrhea 13% 14% 8% Alopecia 10% 13% 5% Nausea 8% 11% 7% Paresthesia 8% 9% 7% Arthralgia 8% 6% 5% Neutropenia 4% 6% 2% Hypertension 3% 4% 2% Cardiovascular Deaths Four cardiovascular deaths, including three sudden deaths, and one myocardial infarction in patient with history of hyperlipidemia and hypertension were reported among approximately 2,600 patients exposed to teriflunomide tablets in the premarketing database. These cardiovascular deaths occurred during uncontrolled extension studies, one to nine years after initiation of treatment. relationship between teriflunomide tablets and cardiovascular death has not been established. Acute Renal Failure In placebo-controlled studies, creatinine values increased more than 100% over baseline in 8/1,045 (0.8%) patients in the mg teriflunomide tablets group and 6/1,002 (0.6%) patients in the 14 mg teriflunomide tablets group versus 4/997 (0.4%) patients in the placebo group. These elevations were transient. Some elevations were accompanied by hyperkalemia. Teriflunomide tablets may cause acute uric acid nephropathy with transient acute renal failure because teriflunomide tablets increases renal uric acid clearance. HypophosphatemiaIn clinical trials, 18% of teriflunomide tablets-treated patients had hypophosphatemia with serum phosphorus levels of at least 0.6 mmol/L, compared to 7% of placebo-treated patients; 4% of teriflunomide tablets-treated patients had hypophosphatemia with serum phosphorus levels at least 0.3 mmol/L but less than 0.6 mmol/L, compared to 0.8% of placebo-treated patients. No patient in any treatment group had serum phosphorus below 0.3 mmol/L.. 6.2 Postmarketing Experience. The following adverse reactions have been identified during postapproval use of teriflunomide tablets. Because these reactions are reported voluntarily from population of uncertain size, it is not always possible to reliably estimate their frequency or establish causal relationship to drug exposure. Hypersensitivity reactions, some of which were severe, such as anaphylaxis and angioedema [see Warnings and Precautions (5.5)] Severe skin reactions, including toxic epidermal necrolysis and Stevens-Johnson syndrome [see Warnings and Precautions (5.5)] Thrombocytopenia [see Warnings and Precautions (5.4)] Interstitial lung disease [see Warnings and Precautions (5.8)] Pancreatitis.

BOXED WARNING SECTION.

WARNING: HEPATOTOXICITY and RISK OF TERATOGENICITY. Hepatotoxicity Severe liver injury including fatal liver failure has been reported in patients treated with leflunomide, which is indicated for rheumatoid arthritis. similar risk would be expected for teriflunomide because recommended doses of teriflunomide and leflunomide result in similar range of plasma concentrations of teriflunomide. Concomitant use of teriflunomide tablets with other potentially hepatotoxic drugs may increase the risk of severe liver injury. Obtain transaminase and bilirubin levels within months before initiation of teriflunomide tablets therapy. Monitor ALT levels at least monthly for six months after starting teriflunomide tablets [see Warnings and Precautions (5.1)]. If drug induced liver injury is suspected, discontinue teriflunomide tablets and start an accelerated elimination procedure with cholestyramine or charcoal [see Warnings and Precautions (5.3)]. Teriflunomide tablets are contraindicated in patients with severe hepatic impairment [see Contraindications (4)]. Patients with pre-existing liver disease may be at increased risk of developing elevated serum transaminases when taking teriflunomide tablets. Risk of Teratogenicity Teriflunomide tablets are contraindicated for use in pregnant women and in women of reproductive potential who are not using effective contraception because of the potential for fetal harm. Teratogenicity and embryolethality occurred in animals at plasma teriflunomide exposures lower than that in humans. Exclude pregnancy before the start of treatment with teriflunomide tablets in females of reproductive potential. Advise females of reproductive potential to use effective contraception during teriflunomide tablets treatment and during an accelerated drug elimination procedure after teriflunomide tablets treatment. Stop teriflunomide tablets and use an accelerated drug elimination procedure if the patient becomes pregnant [see Contraindications (4), Warnings and Precautions (5.2, 5.3), Use in Specific Populations (8.1), and Clinical Pharmacology (12.3)]. WARNING: HEPATOTOXICITY and RISK OF TERATOGENICITY See full prescribing information for complete boxed warning HepatotoxicitySevere liver injury including fatal liver failure has been reported in patients treated with leflunomide, which is indicated for rheumatoid arthritis. similar risk would be expected for teriflunomide because recommended doses of teriflunomide and leflunomide result in similar range of plasma concentrations of teriflunomide. Obtain transaminase and bilirubin levels within months before initiation of teriflunomide tablets and monitor ALT levels at least monthly for six months (5.1). If drug induced liver injury is suspected, discontinue teriflunomide tablets and start accelerated elimination procedure (5.3). Risk of Teratogenicity Teratogenicity and embryolethality occurred in animals administered teriflunomide (5.2, 8.1). Exclude pregnancy prior to initiating teriflunomide tablets therapy (4, 5.2, 8.1). Advise use of effective contraception in females of reproductive potential during treatment and during an accelerated drug elimination procedure (4, 5.2, 5.3, 8.1). Stop teriflunomide tablets and use an accelerated drug elimination procedure if the patient becomes pregnant (5.2, 5.3, 8.1).

CARCINOGENESIS & MUTAGENESIS & IMPAIRMENT OF FERTILITY SECTION.

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility. Carcinogenesis No evidence of carcinogenicity was observed in lifetime carcinogenicity bioassays in mouse and rat. In mouse, teriflunomide was administered orally at doses up to 12 mg/kg/day for up to 95 to 104 weeks; plasma teriflunomide exposures (AUC) at the highest dose tested are approximately times that in humans at the maximum recommended human dose (MRHD, 14 mg /day). In rat, teriflunomide was administered orally at doses up to mg/kg/day for up to 97 to 104 weeks; plasma teriflunomide AUCs at the highest doses tested are less than that in humans at the MRHD.Mutagenesis Teriflunomide was negative in the in vitro bacterial reverse mutation (Ames) assay, the in vitro HPRT assay, and in in vivo micronucleus and chromosomal aberration assays. Teriflunomide was positive in an in vitro chromosomal aberration assay in human lymphocytes, with and without metabolic activation. Addition of uridine (to supplement the pyrimidine pool) reduced the magnitude of the clastogenic effect; however, teriflunomide was positive in the in vitro chromosomal aberration assay, even in the presence of uridine. 4-Trifluoromethylaniline (4-TFMA), minor metabolite of teriflunomide, was positive in the in vitro bacterial reverse mutation (Ames) assay, the in vitro HPRT assay, and the in vitro chromosomal aberration assay in mammalian cells. 4-TFMA was negative in in vivo micronucleus and chromosomal aberration assays. Impairment of Fertility Oral administration of teriflunomide (0, 1, 3, 10 mg/kg/day) to male rats prior to and during mating (to untreated females) resulted in no adverse effects on fertility; however, reduced epididymal sperm count was observed at the mid and high doses tested. The no-effect dose for reproductive toxicity in male rats (1 mg/kg) is less than the MRHD on mg/m2 basis. Oral administration of teriflunomide (0, 0.84, 2.6, 8.6 mg/kg/day) to female rats, prior to and during mating (to untreated males) and continuing to gestation day 6, resulted in embryolethality, reduced fetal body weight, and/or malformations at all doses tested. Due to marked embryolethality at the highest dose tested, no fetuses were available for evaluation. The lowest dose tested is less than the MRHD on mg/m2 basis.

CLINICAL PHARMACOLOGY SECTION.

12 CLINICAL PHARMACOLOGY. 12.1 Mechanism of Action. Teriflunomide, an immunomodulatory agent with anti-inflammatory properties, inhibits dihydroorotate dehydrogenase, mitochondrial enzyme involved in de novo pyrimidine synthesis. The exact mechanism by which teriflunomide exerts its therapeutic effect in multiple sclerosis is unknown but may involve reduction in the number of activated lymphocytes in CNS.. 12.2 Pharmacodynamics. Potential to prolong the QT intervalIn placebo controlled thorough QT study performed in healthy subjects, there was no evidence that teriflunomide caused QT interval prolongation of clinical significance (i.e., the upper bound of the 90% confidence interval for the largest placebo-adjusted, baseline-corrected QTc was below 10 ms). 12.3 Pharmacokinetics. Teriflunomide is the principal active metabolite of leflunomide and is responsible for leflunomides activity in vivo. At recommended doses, teriflunomide and leflunomide result in similar range of plasma concentrations of teriflunomide. Based on population analysis of teriflunomide in healthy volunteers and MS patients, median t1/2 was approximately 18 and 19 days after repeated doses of mg and 14 mg respectively. It takes approximately months respectively to reach steady-state concentrations. The estimated AUC accumulation ratio is approximately 30 after repeated doses of or 14 mg. AbsorptionMedian time to reach maximum plasma concentrations is between to hours post dose following oral administration of teriflunomide. Food does not have clinically relevant effect on teriflunomide pharmacokinetics. Distribution Teriflunomide is extensively bound to plasma protein (>99%) and is mainly distributed in plasma. The volume of distribution is 11 after single intravenous (IV) administration. Metabolism Teriflunomide is the major circulating moiety detected in plasma. The primary biotransformation pathway to minor metabolites of teriflunomide is hydrolysis, with oxidation being minor pathway. Secondary pathways involve oxidation, N-acetylation and sulfate conjugation. Elimination Teriflunomide is eliminated mainly through direct biliary excretion of unchanged drug as well as renal excretion of metabolites. Over 21 days, 60.1% of the administered dose is excreted via feces (37.5%) and urine (22.6%). After an accelerated elimination procedure with cholestyramine, an additional 23.1% was recovered (mostly in feces). After single IV administration, the total body clearance of teriflunomide is 30.5 mL/h. Drug Interaction Studies Teriflunomide is not metabolized by Cytochrome P450 or flavin monoamine oxidase enzymes. The Potential Effect of Teriflunomide Tablets on Other Drugs CYP2C8 Substrates There was an increase in mean repaglinide Cmax and AUC (1.7-and 2.4-fold, respectively) following repeated doses of teriflunomide and single dose of 0.25 mg repaglinide, suggesting that teriflunomide is an inhibitor of CYP2C8 in vivo. The magnitude of interaction could be higher at the recommended repaglinide dose [see Drug Interactions (7)].. CYP1A2 Substrates Repeated doses of teriflunomide decreased mean Cmax and AUC of caffeine by 18% and 55%, respectively, suggesting that teriflunomide may be weak inducer of CYP1A2 in vivo[see Drug Interactions (7)]. . OAT3 Substrates There was an increase in mean cefaclor Cmax and AUC (1.43-and 1.54-fold, respectively), following repeated doses of teriflunomide, suggesting that teriflunomide is an inhibitor of organic anion transporter (OAT3) in vivo [see Drug Interactions (7)]. BCRP and OATP1B1/1B3 Substrates There was an increase in mean rosuvastatin Cmax and AUC (2.65-and 2.51-fold, respectively), following repeated doses of teriflunomide, suggesting that teriflunomide is an inhibitor of BCRP transporter and organic anion transporting polypeptide 1B1 and 1B3 (OATP1B1/1B3) [see Drug Interactions (7)]. Oral Contraceptives There was an increase in mean ethinylestradiol Cmax and AUC0-24 (1.58-and 1.54-fold, respectively) and levonorgestrel Cmax and AUC0-24 (1.33-and 1.41-fold, respectively) following repeated doses of teriflunomide [see Drug Interactions (7)]. Teriflunomide did not affect the pharmacokinetics of bupropion (a CYP2B6 substrate), midazolam (a CYP3A4 substrate), S-warfarin (a CYP2C9 substrate), omeprazole (a CYP2C19 substrate), and metoprolol (a CYP2D6 substrate). The Potential Effect of Other Drugs on Teriflunomide Tablets Potent CYP and transporter inducers: Rifampin did not affect the pharmacokinetics of teriflunomide. Specific populations Hepatic Impairment Mild and moderate hepatic impairment had no impact on the pharmacokinetics of teriflunomide. The pharmacokinetics of teriflunomide in severe hepatic impairment has not been evaluated [see Contraindications (4), Warnings and Precautions (5.1), and Use in Specific Populations (8.6)]. Renal Impairment Severe renal impairment had no impact on the pharmacokinetics of teriflunomide [see Use in Specific Populations (8.7)]. Gender In population analysis, the clearance rate for teriflunomide is 23% less in females than in males. Race Effect of race on the pharmacokinetics of teriflunomide cannot be adequately assessed due to low number of non-white patients in the clinical trials.

CLINICAL STUDIES SECTION.

14 CLINICAL STUDIES. Four randomized, controlled, double-blind clinical trials established the efficacy of teriflunomide tablets in patients with relapsing forms of multiple sclerosis. Study was double-blind, placebo-controlled clinical trial that evaluated once daily doses of teriflunomide tablets mg and teriflunomide tablets 14 mg for up to 26 months in patients with relapsing forms of multiple sclerosis. Patients were required to have diagnosis of multiple sclerosis exhibiting relapsing clinical course, with or without progression, and to have experienced at least one relapse over the year preceding the trial or at least two relapses over the two years preceding the trial. Patients were required not to have received interferon-beta for at least four months, or any other multiple sclerosis medication for at least six months before entering the study, nor were these medications permitted during the study. Neurological evaluations were to be performed at screening, every 12 weeks until week 108, and after suspected relapses. MRI was to be performed at screening, and at Week 24, 48, 72, and 108. The primary endpoint was the annualized relapse rate (ARR).In Study 1, 1,088 patients were randomized to receive teriflunomide tablets mg (n=366), teriflunomide tablets 14 mg (n=359), or placebo (n=363). At entry, patients had an Expanded Disability Status Scale (EDSS) score <=5.5. Patients had mean age of 38 years, mean disease duration of years, and mean EDSS at baseline of 2.7. total of 91% of patients had relapsing remitting multiple sclerosis, and 9% had progressive form of multiple sclerosis with relapses. The mean duration of treatment was 635, 627, and 631 days for teriflunomide tablets mg, teriflunomide tablets 14 mg, and placebo, respectively. The percentage of patients who completed the study treatment period was 75%, 73%, and 71% for teriflunomide tablets mg, teriflunomide tablets 14 mg, and placebo, respectively. There was statistically significant reduction in ARR for patients who received teriflunomide tablets mg or teriflunomide tablets 14 mg, compared to patients who received placebo (see Table 2). There was consistent reduction of the ARR noted in subgroups defined by sex, age group, prior multiple sclerosis therapy, and baseline disease activity. There was statistically significant reduction in the relative risk of disability progression at week 108 sustained for 12 weeks (as measured by at least 1-point increase from baseline EDSS <= 5.5 or 0.5 point increase for those with baseline EDSS 5.5) in the teriflunomide tablets 14 mg group compared to placebo (see Table and Figure 1). The effect of teriflunomide tablets on several magnetic resonance imaging (MRI) variables, including the total lesion volume of T2 and hypointense T1 lesions, was assessed in Study 1. The change in total lesion volume from baseline was significantly lower in the teriflunomide tablets mg and teriflunomide tablets 14 mg groups than in the placebo group. Patients in both teriflunomide tablets groups had significantly fewer gadolinium-enhancing lesions per T1-weighted scan than those in the placebo group (see Table 2). Table 2. Clinical and MRI Results of Study Teriflunomide Tablets mg N=365 Teriflunomide Tablets 14 mg N=358 Placebo N=363 Clinical Endpoints Annualized relapse rate 0.37 (p 0.0002) 0.369 (p 0.0005) 0.539 Relative risk reduction 31% 31% Percent of patients remaining relapse-free at week 108 53.7% 56.5% 45.6% Percent disability progression at week 108 21.7% (p 0.084) 20.2% (p 0.028) 27.3% Hazard ratio 0.76 0.7 MRI Endpoints Median change from baseline in Total lesion volume1 (mL) at week 108 0.755 (p= 0.0317)2 0.345 (p 0.0003)2 1.127 Mean number of Gd-enhancing T1-lesions per scan 0.57 (p 0.0001) 0.261 (p 0.0001) 1.331 Total lesion volume: sum of T2 and hypointense T1 lesion volume in mL p-values based on cubic root transformed data for total lesion volumeFigure 1. Kaplan-Meier plot of time to disability progression sustained for 12 weeks (Study 1) Study was double-blind, placebo-controlled clinical trial that evaluated once daily doses of teriflunomide tablets mg and teriflunomide tablets 14 mg for up to 40 months in patients with relapsing forms of multiple sclerosis. Patients were required to have diagnosis of multiple sclerosis exhibiting relapsing clinical course and to have experienced at least one relapse over the year preceding the trial, or at least two relapses over the two years preceding the trial. Patients were required not to have received any multiple sclerosis medication for at least three months before entering the trial, nor were these medications permitted during the trial. Neurological evaluations were to be performed at screening, every 12 weeks until completion, and after every suspected relapse. The primary end point was the ARR. total of 1,165 patients received teriflunomide tablets mg (n=407), teriflunomide tablets 14 mg (n=370), or placebo (n=388). Patients had mean age of 38 years, mean disease duration of years, and mean EDSS at baseline of 2.7. total of 98% of patients had relapsing remitting multiple sclerosis, and 2% had progressive form of multiple sclerosis with relapses. The mean duration of treatment was 552, 567, and 571 days for teriflunomide tablets mg, teriflunomide tablets 14 mg, and placebo, respectively. The percentage of patients who completed the study treatment period was 67%, 66%, and 68% for teriflunomide tablets mg, teriflunomide tablets 14 mg, and placebo, respectively.There was statistically significant reduction in the ARR for patients who received teriflunomide tablets mg or teriflunomide tablets 14 mg compared to patients who received placebo (see Table 3). There was consistent reduction of the ARR noted in subgroups defined by sex, age group, prior multiple sclerosis therapy, and baseline disease activity. There was statistically significant reduction in the relative risk of disability progression at week 108 sustained for 12 weeks (as measured by at least 1-point increase from baseline EDSS <= 5.5 or 0.5 point increase for those with baseline EDSS 5.5) in the teriflunomide tablets 14 mg group compared to placebo (See Table and Figure 2). Table 3. Clinical Results of Study Teriflunomide Tablets mg N=407 Teriflunomide Tablets 14 mg N=370 Placebo N=388 Clinical Endpoints Annualized relapse rate 0.389 (p 0.0183) 0.319 (p 0.0001) 0.501 Relative risk reduction 22% 36% Percent of patients remaining relapse-free at week 108 58.2% 57.1% 46.8% Percent disability progression at week 108 21.1% (p 0.762) 15.8% (p 0.044) 19.7% Hazard ratio 0.96 0.69 Figure 2. Kaplan-Meier plot of time to disability progression sustained for 12 weeks (Study ) Study was double-blind, placebo-controlled clinical trial that evaluated once daily doses of teriflunomide tablets mg and teriflunomide tablets 14 mg for up to 108 weeks in patients with relapsing multiple sclerosis. Patients were required to have had first clinical event consistent with acute demyelination occurring within 90 days of randomization with or more T2 lesions at least mm in diameter that were characteristic of multiple sclerosis. total of 614 patients received teriflunomide tablets mg (n=203), teriflunomide tablets 14 mg (n=214), or placebo (n=197). Patients had mean age of 32 years, EDSS at baseline of 1.7, and mean disease duration of two months. The proportion of patients free of relapse was greater in the teriflunomide tablets mg (70.5%, < 0.05) and teriflunomide tablets 14 mg (72.2%, < 0.05) groups than in the placebo group (61.7%). The effect of teriflunomide tablets on MRI activity was also demonstrated in Study 4, randomized, double-blind, placebo-controlled clinical trial of multiple sclerosis patients with relapse. In Study 4, MRI was to be performed at baseline, weeks, 12 weeks, 18 weeks, 24 weeks, 30 weeks, and 36 weeks after treatment initiation. total of 179 patients were randomized to teriflunomide tablets mg (n=61), teriflunomide tablets 14 mg (n=57), or placebo (n= 61). Baseline demographics were consistent across treatment groups. The primary endpoint was the average number of unique active lesions/MRI scan during treatment. The mean number of unique active lesions per brain MRI scan during the 36-week treatment period was lower in patients treated with teriflunomide tablets mg (1.06) and teriflunomide tablets 14 mg (0.98) as compared to placebo (2.69), the difference being statistically significant for both (p=0.0234 and p=0.0052, respectively).. Figure 1. fIG2.

CONTRAINDICATIONS SECTION.

4 CONTRAINDICATIONS. Teriflunomide tablet is contraindicated in/with: Patients with severe hepatic impairment [see Warnings and Precautions (5.1)]. Pregnant women and females of reproductive potential not using effective contraception. Teriflunomide tablet may cause fetal harm [see Warnings and Precautions (5.2, and 5.3) and Use in Specific Populations (8.1)]. Patients with history of hypersensitivity reaction to teriflunomide, leflunomide, or to any of the inactive ingredients in teriflunomide tablet. Reactions have included anaphylaxis, angioedema, and serious skin reactions [see Warnings and Precautions (5.5)]. Coadministration with leflunomide [see Clinical Pharmacology (12.3)]. o Severe hepatic impairment (4, 5.1) Pregnancy (4, 5.2, 8.1) Hypersensitivity (4, 5.5) Current leflunomide treatment (4).

DESCRIPTION SECTION.

11 DESCRIPTION. Teriflunomide is an oral de novo pyrimidine synthesis inhibitor of the DHO-DH enzyme, with the chemical name (Z)-2-Cyano-3-hydroxy-but-2-enoic acid-(4-trifluoromethylphenyl)-amide. Its molecular weight is 270.21, and the empirical formula is C12H9F3N2O2 with the following chemical structure: Teriflunomide is white to off-white powder that is soluble in N, - Dimethyl formamide and practically insoluble in water. Teriflunomide is formulated as film-coated tablets for oral administration. Teriflunomide tablets contain mg or 14 mg of teriflunomide and the following inactive ingredients: lactose monohydrate, corn starch, sodium starch glycolate, hydroxypropyl cellulose, microcrystalline cellulose, colloidal silicon dioxide, and magnesium stearate. The film coating for the 14 mg tablet is made of hypromellose, titanium dioxide, talc, polyethylene glycol 8000, talc, and FD&C Blue2 Aluminium Lake. In addition to these, the mg tablet film coating includes iron oxide yellow.. Structure.

DOSAGE & ADMINISTRATION SECTION.

2 DOSAGE AND ADMINISTRATION. The recommended dose of teriflunomide tablet is mg or 14 mg orally once daily. Teriflunomide tablets can be taken with or without food. Monitoring to assess safety Obtain transaminase and bilirubin levels within months before initiation of teriflunomide tablets therapy. Monitor ALT levels at least monthly for six months after starting teriflunomide tablets [see Warnings and Precautions (5.1)]. Obtain complete blood cell count (CBC) within months before the initiation of treatment with teriflunomide tablets. Further monitoring should be based on signs and symptoms of infection [see Warnings and Precautions (5.4)]. Prior to initiating teriflunomide tablets, screen patients for latent tuberculosis infection with tuberculin skin test or blood test for mycobacterium tuberculosis infection [see Warnings and Precautions (5.4)]. Exclude pregnancy prior to initiation of treatment with teriflunomide tablets in females of reproductive potential [see Warnings and Precautions (5.2)]. Check blood pressure before start of teriflunomide tablets treatment and periodically thereafter [see Warnings and Precautions (5.7)]. 7 mg or 14 mg orally once daily, with or without food. (2).

DOSAGE FORMS & STRENGTHS SECTION.

3 DOSAGE FORMS AND STRENGTHS. Teriflunomide tablets are available as mg and 14 mg tablets. The mg tablet is very light greenish-bluish grey to pale greenish-blue, hexagonal film-coated tablet debossed with L on one side and 597 on other side. Each tablet contains mg of teriflunomide.The 14 mg tablet is pale blue to pastel blue, pentagonal film-coated tablet debossed with L on one side and 598 on other side. Each tablet contains 14 mg of teriflunomide. 7 mg and 14 mg film-coated tablets (3).

DRUG INTERACTIONS SECTION.

7 DRUG INTERACTIONS. Effect of teriflunomide tablets on CYP2C8 substrates Teriflunomide is an inhibitor of CYP2C8 in vivo. In patients taking teriflunomide tablets, exposure of drugs metabolized by CYP2C8 (e.g., paclitaxel, pioglitazone, repaglinide, rosiglitazone) may be increased. Monitor these patients and adjust the dose of the concomitant drug(s) metabolized by CYP2C8 as required [see Clinical Pharmacology (12.3)]. Effect of teriflunomide tablets on warfarin Coadministration of teriflunomide tablets with warfarin requires close monitoring of the international normalized ratio (INR) because teriflunomide tablets may decrease peak INR by approximately 25%. Effect of teriflunomide tablets on oral contraceptives Teriflunomide tablets may increase the systemic exposures of ethinylestradiol and levonorgestrel. Consideration should be given to the type or dose of contraceptives used in combination with teriflunomide tablets [see Clinical Pharmacology (12.3)]. Effect of teriflunomide tablets on CYP1A2 substrates Teriflunomide may be weak inducer of CYP1A2 in vivo. In patients taking teriflunomide tablets, exposure of drugs metabolized by CYP1A2 (e.g., alosetron, duloxetine, theophylline, tizanidine) may be reduced. Monitor these patients and adjust the dose of the concomitant drug(s) metabolized by CYP1A2 as required [see Clinical Pharmacology (12.3)]. Effect of teriflunomide tablets on organic anion transporter (OAT3) substrates Teriflunomide inhibits the activity of OAT3 in vivo. In patients taking teriflunomide tablets, exposure of drugs which are OAT3 substrates (e.g., cefaclor, cimetidine, ciprofloxacin, penicillin G, ketoprofen, furosemide, methotrexate, zidovudine) may be increased. Monitor these patients and adjust the dose of the concomitant drug(s) which are OAT3 substrates as required [see Clinical Pharmacology (12.3)]. Effect of teriflunomide tablets on BCRP and organic anion transporting polypeptide B1 and B3 (OATP1B1/1B3) substrates Teriflunomide inhibits the activity of BCRP and OATP1B1/1B3 in vivo. For patient taking teriflunomide tablets, the dose of rosuvastatin should not exceed 10 mg once daily. For other substrates of BCRP (e.g., mitoxantrone) and drugs in the OATP family (e.g., methotrexate, rifampin), especially HMG-Co reductase inhibitors (e.g., atorvastatin, nateglinide, pravastatin, repaglinide, and simvastatin), consider reducing the dose of these drugs and monitor patients closely for signs and symptoms of increased exposures to the drugs while patients are taking teriflunomide tablets [see Clinical Pharmacology (12.3)]. o Drugs metabolized by CYP2C8 and OAT3 transporters: Monitor patients because teriflunomide may increase exposure of these drugs (7) Teriflunomide may increase exposure of ethinylestradiol and levonorgestrel. Choose an appropriate oral contraceptive (7) Drugs metabolized by CYP1A2: Monitor patients because teriflunomide may decrease exposure of these drugs (7) Warfarin: Monitor INR as teriflunomide may decrease INR (7) Drugs metabolized by BCRP and OATP1B1/B3 transporters: Monitor patients because teriflunomide may increase exposure of these drugs (7) Rosuvastatin: The dose of rosuvastatin should not exceed 10 mg once daily in patients taking teriflunomide tablets (7).

GERIATRIC USE SECTION.

8.5 Geriatric Use. Clinical studies of teriflunomide tablets did not include patients over 65 years old.

HOW SUPPLIED SECTION.

16 HOW SUPPLIED/STORAGE AND HANDLING. Teriflunomide tablets are available as mg and 14 mg tablets.The mg tablet is pale blue to pastel blue, hexagonal film-coated tablet debossed with L on one side and 597 on other side. Each tablet contains mg of teriflunomide. Teriflunomide tablets mg are supplied as: NDC 46708-313-14 Carton of 28 tablets containing wallet composed of folded blister cards of 14 tablets per blister card NDC 46708-313-30 Bottle of 30 tablets with child-resistant closureThe 14 mg tablet is pale blue to pastel blue, pentagonal film-coated tablet debossed with L on one side and 598 on other side. Each tablet contains 14 mg of teriflunomide.Teriflunomide tablets 14 mg are supplied as: NDC 46708-314-14 Carton of 28 tablets containing wallet composed of folded blister cards of 14 tablets per blister card NDC 46708-314-30 Bottle of 30 tablets with child-resistant closure NDC 46708-314-91 Bottle of 1,000 tablets Store at 25C (77F); excursions permitted to 15 to 30C (59 to 86F) [see USP Controlled Room Temperature].

INDICATIONS & USAGE SECTION.

1 INDICATIONS AND USAGE. Teriflunomide tablets are indicated for the treatment of patients with relapsing forms of multiple sclerosis. Teriflunomide tablet is pyrimidine synthesis inhibitor indicated for the treatment of patients with relapsing forms of multiple sclerosis (1).

INFORMATION FOR PATIENTS SECTION.

17 PATIENT COUNSELING INFORMATION. Advise the patient to read the FDA-approved patient labeling (Medication Guide). Medication Guide is required for distribution with teriflunomide tablets. Hepatotoxicity Inform patients that teriflunomide tablets may increase liver enzymes and that their liver enzymes will be checked before starting teriflunomide tablets and for at least months while they are taking teriflunomide tablets. Advise patients that they should contact their physician if they have any unexplained nausea, vomiting, abdominal pain, fatigue, anorexia, or jaundice and/or dark urine. Importance of Preventing Pregnancy. Inform patients that based on animal studies, teriflunomide tablets may cause fetal harm. Advise females of reproductive potential of the need for effective contraception during teriflunomide tablets treatment and until completion of an accelerated elimination procedure. Advise them that an accelerated elimination procedure can be used at any time after the discontinuation of teriflunomide tablets. Instruct the patient that if she suspects or confirms pregnancy, she should immediately inform her physician. Instruct men taking teriflunomide tablets and not wishing to father child to use effective contraception to minimize any possible risk to the fetus; their female partners should also use effective contraception.. Advise men wishing to father child to discontinue use of teriflunomide tablets and undergo an accelerated elimination procedure. Availability of an Accelerated Elimination Procedure Advise patients that teriflunomide tablets may stay in the blood for up to years after the last dose and that an accelerated elimination procedure may be used if needed. Risk of Infections Inform patients that they may develop lowering of their white blood cell counts and that their blood counts will be checked before starting teriflunomide tablets. Inform patients that they may be more likely to get infections when taking teriflunomide tablets and that they should contact their physician if they develop symptoms of infection, particularly in case of fever. Advise patients that the use of some vaccines should be avoided during treatment with teriflunomide tablets and for at least months after discontinuation. Serious Allergic ReactionsAdvise patients to discontinue teriflunomide tablets and seek immediate medical attention if any signs or symptoms of hypersensitivity reaction occur [see Contraindications (4) and Warnings and Precautions (5.5)]. Signs and symptoms include dyspnea, urticaria, and angioedema including lips, eyes, throat, and tongue or skin rash.Peripheral Neuropathy Inform patients that they may develop peripheral neuropathy. Advise patients that they should contact their physician if they develop symptoms of peripheral neuropathy, such as numbness or tingling of hands or feet. Increased Blood Pressure Inform patients that teriflunomide tablets may increase blood pressure. LactationInform patients that it is not known whether this drug is present in human milk. Advise patients, if they are considering breastfeeding, to discuss this with their healthcare provider to decide if they will take teriflunomide tablets or breastfeed. Advise patients that they should not do both.

NONCLINICAL TOXICOLOGY SECTION.

13 NONCLINICAL TOXICOLOGY. 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility. Carcinogenesis No evidence of carcinogenicity was observed in lifetime carcinogenicity bioassays in mouse and rat. In mouse, teriflunomide was administered orally at doses up to 12 mg/kg/day for up to 95 to 104 weeks; plasma teriflunomide exposures (AUC) at the highest dose tested are approximately times that in humans at the maximum recommended human dose (MRHD, 14 mg /day). In rat, teriflunomide was administered orally at doses up to mg/kg/day for up to 97 to 104 weeks; plasma teriflunomide AUCs at the highest doses tested are less than that in humans at the MRHD.Mutagenesis Teriflunomide was negative in the in vitro bacterial reverse mutation (Ames) assay, the in vitro HPRT assay, and in in vivo micronucleus and chromosomal aberration assays. Teriflunomide was positive in an in vitro chromosomal aberration assay in human lymphocytes, with and without metabolic activation. Addition of uridine (to supplement the pyrimidine pool) reduced the magnitude of the clastogenic effect; however, teriflunomide was positive in the in vitro chromosomal aberration assay, even in the presence of uridine. 4-Trifluoromethylaniline (4-TFMA), minor metabolite of teriflunomide, was positive in the in vitro bacterial reverse mutation (Ames) assay, the in vitro HPRT assay, and the in vitro chromosomal aberration assay in mammalian cells. 4-TFMA was negative in in vivo micronucleus and chromosomal aberration assays. Impairment of Fertility Oral administration of teriflunomide (0, 1, 3, 10 mg/kg/day) to male rats prior to and during mating (to untreated females) resulted in no adverse effects on fertility; however, reduced epididymal sperm count was observed at the mid and high doses tested. The no-effect dose for reproductive toxicity in male rats (1 mg/kg) is less than the MRHD on mg/m2 basis. Oral administration of teriflunomide (0, 0.84, 2.6, 8.6 mg/kg/day) to female rats, prior to and during mating (to untreated males) and continuing to gestation day 6, resulted in embryolethality, reduced fetal body weight, and/or malformations at all doses tested. Due to marked embryolethality at the highest dose tested, no fetuses were available for evaluation. The lowest dose tested is less than the MRHD on mg/m2 basis.

NURSING MOTHERS SECTION.

8.3 Females and Males of Reproductive Potential. Pregnancy Testing Exclude pregnancy prior to initiation of treatment with teriflunomide tablets in females of reproductive potential. Advise females to notify their healthcare provider immediately if pregnancy occurs or is suspected during treatment [see Warnings and Precautions (5.2, 5.3) and Use in Specific Populations (8.1)]. Contraception Females Females of reproductive potential should use effective contraception while taking teriflunomide tablets. If teriflunomide tablet is discontinued, use of contraception should be continued until is it verified that plasma concentrations of teriflunomide are less than 0.02 mg/L (0.02 mcg/mL). Females of reproductive potential who wish to become pregnant should undergo an accelerated elimination procedure. Effective contraception should be used until it is verified that plasma concentrations of teriflunomide are less than 0.02 mg/L (0.02 mcg/mL) [see Warnings and Precautions (5.3)]. Males Teriflunomide is detected in human semen. Animal studies to specifically evaluate the risk of male-mediated fetal toxicity have not been conducted. To minimize any possible risk, men not wishing to father child and their female partners should use effective contraception. Men wishing to father child should discontinue use of teriflunomide tablets and either undergo an accelerated elimination procedure or wait until verification that the plasma teriflunomide concentration is less than 0.02 mg/L (0.02 mcg/mL) [see Warnings and Precautions (5.3)]. InfertilityAdministration of teriflunomide to male rats resulted in no adverse effects on fertility. However, reduced epididymal sperm count was observed [see Nonclinical Toxicology (13.1)]. Effects of teriflunomide tablets on fertility in humans have not been evaluated.

OVERDOSAGE SECTION.

10 OVERDOSAGE. There is no experience regarding teriflunomide overdose or intoxication in humans. Teriflunomide 70 mg daily up to 14 days was well tolerated by healthy subjects. In the event of clinically significant overdose or toxicity, cholestyramine or activated charcoal is recommended to accelerate elimination [see Warnings and Precautions (5.3)].

PACKAGE LABEL.PRINCIPAL DISPLAY PANEL.

PACKAGE LABEL.PRINCIPAL DISPLAY PANEL 7 mg. NDC 46708-313-14 Teriflunomide Tablets mg per Tablet Rx only PHARMACIST: Dispense the accompanying Medication Guide to each patient. 28 Tablets Alembic 28 tablets.

PEDIATRIC USE SECTION.

8.4 Pediatric Use. Safety and effectiveness in pediatric patients have not been established.

PHARMACODYNAMICS SECTION.

12.2 Pharmacodynamics. Potential to prolong the QT intervalIn placebo controlled thorough QT study performed in healthy subjects, there was no evidence that teriflunomide caused QT interval prolongation of clinical significance (i.e., the upper bound of the 90% confidence interval for the largest placebo-adjusted, baseline-corrected QTc was below 10 ms).

PHARMACOKINETICS SECTION.

12.3 Pharmacokinetics. Teriflunomide is the principal active metabolite of leflunomide and is responsible for leflunomides activity in vivo. At recommended doses, teriflunomide and leflunomide result in similar range of plasma concentrations of teriflunomide. Based on population analysis of teriflunomide in healthy volunteers and MS patients, median t1/2 was approximately 18 and 19 days after repeated doses of mg and 14 mg respectively. It takes approximately months respectively to reach steady-state concentrations. The estimated AUC accumulation ratio is approximately 30 after repeated doses of or 14 mg. AbsorptionMedian time to reach maximum plasma concentrations is between to hours post dose following oral administration of teriflunomide. Food does not have clinically relevant effect on teriflunomide pharmacokinetics. Distribution Teriflunomide is extensively bound to plasma protein (>99%) and is mainly distributed in plasma. The volume of distribution is 11 after single intravenous (IV) administration. Metabolism Teriflunomide is the major circulating moiety detected in plasma. The primary biotransformation pathway to minor metabolites of teriflunomide is hydrolysis, with oxidation being minor pathway. Secondary pathways involve oxidation, N-acetylation and sulfate conjugation. Elimination Teriflunomide is eliminated mainly through direct biliary excretion of unchanged drug as well as renal excretion of metabolites. Over 21 days, 60.1% of the administered dose is excreted via feces (37.5%) and urine (22.6%). After an accelerated elimination procedure with cholestyramine, an additional 23.1% was recovered (mostly in feces). After single IV administration, the total body clearance of teriflunomide is 30.5 mL/h. Drug Interaction Studies Teriflunomide is not metabolized by Cytochrome P450 or flavin monoamine oxidase enzymes. The Potential Effect of Teriflunomide Tablets on Other Drugs CYP2C8 Substrates There was an increase in mean repaglinide Cmax and AUC (1.7-and 2.4-fold, respectively) following repeated doses of teriflunomide and single dose of 0.25 mg repaglinide, suggesting that teriflunomide is an inhibitor of CYP2C8 in vivo. The magnitude of interaction could be higher at the recommended repaglinide dose [see Drug Interactions (7)].. CYP1A2 Substrates Repeated doses of teriflunomide decreased mean Cmax and AUC of caffeine by 18% and 55%, respectively, suggesting that teriflunomide may be weak inducer of CYP1A2 in vivo[see Drug Interactions (7)]. . OAT3 Substrates There was an increase in mean cefaclor Cmax and AUC (1.43-and 1.54-fold, respectively), following repeated doses of teriflunomide, suggesting that teriflunomide is an inhibitor of organic anion transporter (OAT3) in vivo [see Drug Interactions (7)]. BCRP and OATP1B1/1B3 Substrates There was an increase in mean rosuvastatin Cmax and AUC (2.65-and 2.51-fold, respectively), following repeated doses of teriflunomide, suggesting that teriflunomide is an inhibitor of BCRP transporter and organic anion transporting polypeptide 1B1 and 1B3 (OATP1B1/1B3) [see Drug Interactions (7)]. Oral Contraceptives There was an increase in mean ethinylestradiol Cmax and AUC0-24 (1.58-and 1.54-fold, respectively) and levonorgestrel Cmax and AUC0-24 (1.33-and 1.41-fold, respectively) following repeated doses of teriflunomide [see Drug Interactions (7)]. Teriflunomide did not affect the pharmacokinetics of bupropion (a CYP2B6 substrate), midazolam (a CYP3A4 substrate), S-warfarin (a CYP2C9 substrate), omeprazole (a CYP2C19 substrate), and metoprolol (a CYP2D6 substrate). The Potential Effect of Other Drugs on Teriflunomide Tablets Potent CYP and transporter inducers: Rifampin did not affect the pharmacokinetics of teriflunomide. Specific populations Hepatic Impairment Mild and moderate hepatic impairment had no impact on the pharmacokinetics of teriflunomide. The pharmacokinetics of teriflunomide in severe hepatic impairment has not been evaluated [see Contraindications (4), Warnings and Precautions (5.1), and Use in Specific Populations (8.6)]. Renal Impairment Severe renal impairment had no impact on the pharmacokinetics of teriflunomide [see Use in Specific Populations (8.7)]. Gender In population analysis, the clearance rate for teriflunomide is 23% less in females than in males. Race Effect of race on the pharmacokinetics of teriflunomide cannot be adequately assessed due to low number of non-white patients in the clinical trials.

PREGNANCY SECTION.

8.1 Pregnancy. Risk Summary Teriflunomide tablets are contraindicated for use in pregnant women and females of reproductive potential not using effective contraception because of the potential for fetal harm based on animal data. Human data are not available at this time to inform the presence or absence of drug-associated risk with the use of teriflunomide tablets during pregnancy.In animal reproduction studies in rat and rabbits, oral administration of teriflunomide during organogenesis caused teratogenicity and embryolethality at plasma exposures (AUC) lower than that at the maximum human recommended dose (MHRD) of 14 mg/day [see Data]. In the US general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively. The background risk of major birth defects and miscarriage in the indicated population is unknown. Clinical Considerations Women who wish to become pregnant should discontinue use of teriflunomide tablets and undergo an accelerated elimination procedure to decrease the plasma concentration of teriflunomide to less than 0.02 mg/L (0.02 mcg/mL). Effective contraception should be used until is it verified that plasma concentrations of teriflunomide are less than 0.02 mg/L (0.02 mcg/mL) [see Warnings and Precautions (5.3)]. Human plasma concentrations of teriflunomide less than 0.02 mg/L (0.02 mcg/mL) are expected to have minimal embryofetal risk [see Contraindications (4) and Warnings and Precautions (5.3)]. If the patient becomes pregnant while taking this drug, stop treatment with teriflunomide tablets, inform the patient of the potential risk to the fetus, and perform the accelerated drug elimination procedure to achieve plasma concentrations of less than 0.02 mg/L (0.02 mcg/mL) [see Warnings and Precautions (5.3) and Clinical Pharmacology (12.3)]. Refer the patient to an obstetrician/gynecologist, preferably experienced in reproductive toxicity, for further evaluation and counseling [see Warnings and Precautions (5.2, 5.3)]. Data Animal Data When teriflunomide (oral doses of 1, 3, or 10 mg/kg/day) was administered to pregnant rats throughout the period of organogenesis, high incidences of fetal malformation (primarily craniofacial, and axial and appendicular skeletal defects) and embryofetal death were observed at doses not associated with maternal toxicity. Adverse effects on embryofetal development were observed following dosing at various stages throughout organogenesis. Maternal plasma exposure at the no-effect level (1 mg/kg/day) for embryofetal developmental toxicity in rats was less than that in humans at the maximum recommended human dose (MRHD, 14 mg/day). Administration of teriflunomide (oral doses of 1, 3.5, or 12 mg/kg/day) to pregnant rabbits throughout organogenesis resulted in high incidences of fetal malformation (primarily craniofacial, and axial and appendicular skeletal defects) and embryofetal death at doses associated with minimal maternal toxicity. Maternal plasma exposure at the no-effect dose (1 mg/kg/day) for embryofetal developmental toxicity in rabbits was less than that in humans at the MRHD. In studies in which teriflunomide (oral doses of 0.05, 0.1, 0.3, 0.6, or mg/kg/day) was administered to rats during gestation and lactation, decreased growth, eye and skin abnormalities, and high incidences of malformation (limb defects) and postnatal death were observed in the offspring at doses not associated with maternal toxicity. Maternal plasma exposure at the no-effect dose for pre-and postnatal developmental toxicity in rats (0.1 mg/kg/day) was less than that in humans at the MRHD. In animal reproduction studies of leflunomide, embryolethality and teratogenic effects were observed in pregnant rat and rabbit at or below clinically relevant plasma teriflunomide exposures (AUC). In published reproduction studies in pregnant mice, leflunomide was embryolethal and increased the incidence of malformations (craniofacial, axial skeletal, heart and great vessel). Supplementation with exogenous uridine reduced the teratogenic effects in pregnant mice, suggesting that the mode of action (inhibition of mitochondrial enzyme dihydroorotate dehydrogenase) is the same for therapeutic efficacy and developmental toxicity. At recommended doses in humans, teriflunomide and leflunomide result in similar range of plasma concentrations of teriflunomide.

RECENT MAJOR CHANGES SECTION.

Boxed Warning, Risk of Teratogenicity 11/2016 Dosage and Administration (2) 11/2016 Contraindications, Hypersensitivity (4) 06/2016Warnings and Precautions, Teratogenicity (5.2) 11/2016 Warnings and Precautions, Bone Marrow Effects/ Immunosuppression Potential/Infections (5.4) 06/2016Warnings and Precautions, Hypersensitivity and Serious Skin Reactions (5.5) 06/2016Warnings and Precautions, Respiratory Effects (5.8) 06/2016.

SPL MEDGUIDE SECTION.

Medication Guide. Teriflunomide (ter floo noe mide) TabletsRead this Medication Guide before you start using teriflunomide tablets and each time you get refill. There may be new information. This information does not take the place of talking with your doctor about your medical condition or your treatment.What is the most important information should know about teriflunomide tablets Teriflunomide tablets may cause serious side effects, including: Liver problems: Teriflunomide tablets may cause serious liver problems that may lead to death. Your risk of liver problems may be higher if you take other medicines that also affect your liver. Your doctor should do blood tests to check your liver: within months before you start taking teriflunomide tablets time month for months after you start taking teriflunomide tablets Call your doctor right away if you have any of the following symptoms of liver problems: nausea vomiting stomach pain loss of appetite tiredness your skin or the whites of your eyes turn yellow dark urine Harm to your unborn baby: Teriflunomide tablets may cause harm to your unborn baby. Do not take teriflunomide tablets if you are pregnant. Do not take teriflunomide tablets unless you are using effective birth control. If you are female, you should have pregnancy test before you start taking teriflunomide tablets. Use effective birth control during your treatment with teriflunomide tablets. After stopping teriflunomide tablets, continue using effective birth control until you have blood tests to make sure your blood levels of teriflunomide tablets are low enough. If you become pregnant while taking teriflunomide tablets or within years after you stop taking it, tell your doctor right away. For men taking teriflunomide tablets: If your female partner plans to become pregnant, you should stop taking teriflunomide tablets and ask your doctor how to quickly lower the levels of teriflunomide tablets in your blood. If your female partner does not plan to become pregnant, you and your female partner should use effective birth control during your treatment with teriflunomide tablets. Teriflunomide tablets remains in your blood after you stop taking it, so continue using effective birth control until Teriflunomide tablets blood levels have been checked and they are low enough. Teriflunomide tablets may stay in your blood for up to years after you stop taking it. Your doctor can prescribe medicine to help lower your blood levels of teriflunomide tablets more quickly. Talk to your doctor if you want more information about this. What is teriflunomide tablet Teriflunomide tablet is prescription medicine used to treat relapsing forms of multiple sclerosis (MS). Teriflunomide tablet can decrease the number of MS flare-ups (relapses). Teriflunomide tablet does not cure MS, but it can help slow down the physical problems that MS causes. It is not known if teriflunomide tablets are safe and effective in children. Who should not take teriflunomide tablets Do not take teriflunomide tablet if you: you have had an allergic reaction to teriflunomide tablet or medicine called leflunomidehave severe liver problems are pregnant or are of childbearing age and not using effective birth control take medicine called leflunomide What should tell my doctor before taking teriflunomide tablets Before you take teriflunomide tablets, tell your doctor if you: have liver or kidney problems have fever or infection, or you are unable to fight infections have numbness or tingling in your hands or feet that is different from your MS symptoms have diabetes have had serious skin problems when taking other medicines have breathing problems have high blood pressure are breastfeeding or plan to breastfeed. It is not known if teriflunomide passes into your breast milk. You and your doctor should decide if you will take teriflunomide tablets or breastfeed. You should not do both. Tell your doctor about all the medicines you take,including prescription and non-prescription medicines, vitamins, and herbal supplements.Using teriflunomide tablets and other medicines may affect each other causing serious side effects. Teriflunomide tablets may affect the way other medicines work, and other medicines may affect how teriflunomide tablets works. Especially tell your doctor if you take medicines that could raise your chance of getting infections, including medicines used to treat cancer or to control your immune system. Ask your doctor or pharmacist for list of these medicines if you are not sure. Know the medicines you take. Keep list of them to show your doctor or pharmacist when you get new medicine. How should take teriflunomide tablets Take teriflunomide tablets exactly as your doctor tells you to take it. Take teriflunomide tablets time each day. Take teriflunomide tablets with or without food. What are possible side effects of teriflunomide tablets Teriflunomide tablets may cause serious side effects, including: See What is the most important information should know about teriflunomide tablets decreases in your white blood cell count. Your white blood cell counts should be checked before you start taking teriflunomide tablets. When you have low white blood cell count you: may have more frequent infections. You should have skin test for TB (tuberculosis) before you start taking teriflunomide tablets. Tell your doctor if you have any of these symptoms of an infection: fever tiredness body aches chills nausea vomiting should not receive certain vaccinations during your treatment with teriflunomide tablets and for months after your treatment with teriflunomide tablets ends.numbness or tingling in your hands or feet that is different from your MS symptoms. You have greater chance of getting peripheral neuropathy if you: are over 60 years of age take certain medicines that affect your nervous system have diabetes Tell your doctor if you have numbness or tingling in your hands or feet that is different from your MS. allergic reactions, including serious skin problems. Tell your doctor if you have difficulty breathing, itching, swelling on any part of your body including in your lips, eyes, throat or tongue, or any skin problems such as rash or redness and peeling. new or worsening breathing problems. Tell your doctor if you have shortness of breath or coughing with or without fever. high blood pressure. Your doctor should check your blood pressure before you start taking teriflunomide tablets and while you are taking teriflunomide tablets. The most common side effects of teriflunomide tablets include: headache diarrhea nausea hair thinning or loss (alopecia) increases in the results of blood tests to check your liver function Tell your doctor if you have any side effect that bothers you or that does not go away.These are not all the possible side effects of teriflunomide tablets. For more information, ask your doctor or pharmacist. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-332-1088. How should store teriflunomide tablets Store teriflunomide tablets 25C (77F); excursions permitted to 15 to 30C (59 to 86F) [see USP Controlled Room Temperature]. Keep teriflunomide tablets and all medicines out of reach of children. Bottles of 30s count comes in child-resistant package.General information about the safe and effective use of teriflunomide tablets. Medicines are sometimes prescribed for purposes other than those listed in Medication Guide. Do not use teriflunomide tablets for condition for which it was not prescribed. Do not give teriflunomide tablets to other people, even if they have the same symptoms you have. It may harm them.This Medication Guide summarizes the most important information about teriflunomide tablets. If you would like more information, talk with your doctor. You can ask your doctor or pharmacist for information about teriflunomide tablets that is written for healthcare professionals. What are the ingredients in teriflunomide tablets Active ingredient: teriflunomide Inactive ingredients in mg and 14 mg tablets: lactose monohydrate, corn starch, sodium starch glycolate, hydroxypropyl cellulose, microcrystalline cellulose, colloidal silicon dioxide, and magnesium stearate. The film coating for the 14 mg tablet is made of hypromellose, titanium dioxide, talc, polyethylene glycol 8000, talc, and FD&C Blue2 Aluminium Lake.In addition, the mg tablets also contain iron oxide yellow. This Medication Guide has been approved by the U.S. Food and Drug Administration. Manufactured by: Alembic Pharmaceuticals Limited (Formulation Division), Village Panelav, P. O. Tajpura, Near Baska, Taluka-Halol, Panchmahal 389350, Gujarat, India.Revised: 06/2022. Liver problems: Teriflunomide tablets may cause serious liver problems that may lead to death. Your risk of liver problems may be higher if you take other medicines that also affect your liver. Your doctor should do blood tests to check your liver: within months before you start taking teriflunomide tablets time month for months after you start taking teriflunomide tablets within months before you start taking teriflunomide tablets 1 time month for months after you start taking teriflunomide tablets nausea vomiting stomach pain loss of appetite tiredness your skin or the whites of your eyes turn yellow dark urine Harm to your unborn baby: Teriflunomide tablets may cause harm to your unborn baby. Do not take teriflunomide tablets if you are pregnant. Do not take teriflunomide tablets unless you are using effective birth control. If you are female, you should have pregnancy test before you start taking teriflunomide tablets. Use effective birth control during your treatment with teriflunomide tablets. After stopping teriflunomide tablets, continue using effective birth control until you have blood tests to make sure your blood levels of teriflunomide tablets are low enough. If you become pregnant while taking teriflunomide tablets or within years after you stop taking it, tell your doctor right away. If you are female, you should have pregnancy test before you start taking teriflunomide tablets. Use effective birth control during your treatment with teriflunomide tablets. After stopping teriflunomide tablets, continue using effective birth control until you have blood tests to make sure your blood levels of teriflunomide tablets are low enough. If you become pregnant while taking teriflunomide tablets or within years after you stop taking it, tell your doctor right away. For men taking teriflunomide tablets: If your female partner plans to become pregnant, you should stop taking teriflunomide tablets and ask your doctor how to quickly lower the levels of teriflunomide tablets in your blood. If your female partner does not plan to become pregnant, you and your female partner should use effective birth control during your treatment with teriflunomide tablets. Teriflunomide tablets remains in your blood after you stop taking it, so continue using effective birth control until Teriflunomide tablets blood levels have been checked and they are low enough. If your female partner plans to become pregnant, you should stop taking teriflunomide tablets and ask your doctor how to quickly lower the levels of teriflunomide tablets in your blood. If your female partner does not plan to become pregnant, you and your female partner should use effective birth control during your treatment with teriflunomide tablets. Teriflunomide tablets remains in your blood after you stop taking it, so continue using effective birth control until Teriflunomide tablets blood levels have been checked and they are low enough. If your female partner plans to become pregnant, you should stop taking teriflunomide tablets and ask your doctor how to quickly lower the levels of teriflunomide tablets in your blood. If your female partner does not plan to become pregnant, you and your female partner should use effective birth control during your treatment with teriflunomide tablets. Teriflunomide tablets remains in your blood after you stop taking it, so continue using effective birth control until Teriflunomide tablets blood levels have been checked and they are low enough. have severe liver problems are pregnant or are of childbearing age and not using effective birth control take medicine called leflunomide have liver or kidney problems have fever or infection, or you are unable to fight infections have numbness or tingling in your hands or feet that is different from your MS symptoms have diabetes have had serious skin problems when taking other medicines have breathing problems have high blood pressure are breastfeeding or plan to breastfeed. It is not known if teriflunomide passes into your breast milk. You and your doctor should decide if you will take teriflunomide tablets or breastfeed. You should not do both. Take teriflunomide tablets exactly as your doctor tells you to take it. Take teriflunomide tablets time each day. Take teriflunomide tablets with or without food. See What is the most important information should know about teriflunomide tablets decreases in your white blood cell count. Your white blood cell counts should be checked before you start taking teriflunomide tablets. When you have low white blood cell count you: may have more frequent infections. You should have skin test for TB (tuberculosis) before you start taking teriflunomide tablets. Tell your doctor if you have any of these symptoms of an infection: fever tiredness body aches chills nausea vomiting should not receive certain vaccinations during your treatment with teriflunomide tablets and for months after your treatment with teriflunomide tablets ends.numbness or tingling in your hands or feet that is different from your MS symptoms. You have greater chance of getting peripheral neuropathy if you: are over 60 years of age take certain medicines that affect your nervous system have diabetes may have more frequent infections. You should have skin test for TB (tuberculosis) before you start taking teriflunomide tablets. Tell your doctor if you have any of these symptoms of an infection: fever tiredness body aches chills nausea vomiting should not receive certain vaccinations during your treatment with teriflunomide tablets and for months after your treatment with teriflunomide tablets ends.. fever tiredness body aches chills nausea vomiting should not receive certain vaccinations during your treatment with teriflunomide tablets and for months after your treatment with teriflunomide tablets ends.. numbness or tingling in your hands or feet that is different from your MS symptoms. You have greater chance of getting peripheral neuropathy if you: are over 60 years of age take certain medicines that affect your nervous system have diabetes are over 60 years of age take certain medicines that affect your nervous system have diabetes new or worsening breathing problems. Tell your doctor if you have shortness of breath or coughing with or without fever. high blood pressure. Your doctor should check your blood pressure before you start taking teriflunomide tablets and while you are taking teriflunomide tablets. headache diarrhea nausea hair thinning or loss (alopecia) increases in the results of blood tests to check your liver function.

SPL UNCLASSIFIED SECTION.

5.1 Hepatotoxicity. Severe liver injury including fatal liver failure and dysfunction has been reported in some patients treated with leflunomide, which is indicated for rheumatoid arthritis. similar risk would be expected for teriflunomide because recommended doses of teriflunomide and leflunomide result in similar range of plasma concentrations of teriflunomide. Patients with pre-existing liver disease may be at increased risk of developing elevated serum transaminases when taking teriflunomide tablets. Patients with pre-existing acute or chronic liver disease, or those with serum alanine aminotransferase (ALT) greater than two times the upper limit of normal (ULN) before initiating treatment, should not normally be treated with teriflunomide tablets. Teriflunomide tablets are contraindicated in patients with severe hepatic impairment [see Contraindications (4)]. In placebo-controlled trials, ALT greater than three times the ULN occurred in 61/1,045 (5.8%) and 62/1,002 (6.2%) of patients receiving teriflunomide tablets mg and 14 mg, respectively, and 38/997 (3.8%) of patients receiving placebo, during the treatment period. These elevations occurred mostly within the first year of treatment. Half of the cases returned to normal without drug discontinuation. In clinical trials, if ALT elevation was greater than three times the ULN on two consecutive tests, teriflunomide tablet was discontinued and patients underwent an accelerated elimination procedure [see Warnings and Precautions (5.3)]. Of the patients who underwent discontinuation and accelerated elimination in controlled trials, half returned to normal or near normal values within months. One patient in the controlled trials developed ALT 32 times the ULN and jaundice months after initiation of teriflunomide tablets 14 mg treatment. The patient was hospitalized for weeks and recovered after plasmapheresis and cholestyramine accelerated elimination procedure. Teriflunomide tablets-induced liver injury in this patient could not be ruled out. Obtain serum transaminase and bilirubin levels within months before initiation of teriflunomide tablets therapy. Monitor ALT levels at least monthly for six months after starting teriflunomide tablets. Consider additional monitoring when teriflunomide tablets are given with other potentially hepatotoxic drugs. Consider discontinuing teriflunomide tablets if serum transaminase increase (greater than three times the ULN) is confirmed. Monitor serum transaminase and bilirubin on teriflunomide tablets therapy, particularly in patients who develop symptoms suggestive of hepatic dysfunction, such as unexplained nausea, vomiting, abdominal pain, fatigue, anorexia, or jaundice and/or dark urine. If liver injury is suspected to be teriflunomide tablets-induced, discontinue teriflunomide tablets and start an accelerated elimination procedure [see Warnings and Precautions (5.3)] and monitor liver tests weekly until normalized. If teriflunomide tablets-induced liver injury is unlikely because some other probable cause has been found, resumption of teriflunomide tablets therapy may be considered.

USE IN SPECIFIC POPULATIONS SECTION.

8 USE IN SPECIFIC POPULATIONS. 8.1 Pregnancy. Risk Summary Teriflunomide tablets are contraindicated for use in pregnant women and females of reproductive potential not using effective contraception because of the potential for fetal harm based on animal data. Human data are not available at this time to inform the presence or absence of drug-associated risk with the use of teriflunomide tablets during pregnancy.In animal reproduction studies in rat and rabbits, oral administration of teriflunomide during organogenesis caused teratogenicity and embryolethality at plasma exposures (AUC) lower than that at the maximum human recommended dose (MHRD) of 14 mg/day [see Data]. In the US general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively. The background risk of major birth defects and miscarriage in the indicated population is unknown. Clinical Considerations Women who wish to become pregnant should discontinue use of teriflunomide tablets and undergo an accelerated elimination procedure to decrease the plasma concentration of teriflunomide to less than 0.02 mg/L (0.02 mcg/mL). Effective contraception should be used until is it verified that plasma concentrations of teriflunomide are less than 0.02 mg/L (0.02 mcg/mL) [see Warnings and Precautions (5.3)]. Human plasma concentrations of teriflunomide less than 0.02 mg/L (0.02 mcg/mL) are expected to have minimal embryofetal risk [see Contraindications (4) and Warnings and Precautions (5.3)]. If the patient becomes pregnant while taking this drug, stop treatment with teriflunomide tablets, inform the patient of the potential risk to the fetus, and perform the accelerated drug elimination procedure to achieve plasma concentrations of less than 0.02 mg/L (0.02 mcg/mL) [see Warnings and Precautions (5.3) and Clinical Pharmacology (12.3)]. Refer the patient to an obstetrician/gynecologist, preferably experienced in reproductive toxicity, for further evaluation and counseling [see Warnings and Precautions (5.2, 5.3)]. Data Animal Data When teriflunomide (oral doses of 1, 3, or 10 mg/kg/day) was administered to pregnant rats throughout the period of organogenesis, high incidences of fetal malformation (primarily craniofacial, and axial and appendicular skeletal defects) and embryofetal death were observed at doses not associated with maternal toxicity. Adverse effects on embryofetal development were observed following dosing at various stages throughout organogenesis. Maternal plasma exposure at the no-effect level (1 mg/kg/day) for embryofetal developmental toxicity in rats was less than that in humans at the maximum recommended human dose (MRHD, 14 mg/day). Administration of teriflunomide (oral doses of 1, 3.5, or 12 mg/kg/day) to pregnant rabbits throughout organogenesis resulted in high incidences of fetal malformation (primarily craniofacial, and axial and appendicular skeletal defects) and embryofetal death at doses associated with minimal maternal toxicity. Maternal plasma exposure at the no-effect dose (1 mg/kg/day) for embryofetal developmental toxicity in rabbits was less than that in humans at the MRHD. In studies in which teriflunomide (oral doses of 0.05, 0.1, 0.3, 0.6, or mg/kg/day) was administered to rats during gestation and lactation, decreased growth, eye and skin abnormalities, and high incidences of malformation (limb defects) and postnatal death were observed in the offspring at doses not associated with maternal toxicity. Maternal plasma exposure at the no-effect dose for pre-and postnatal developmental toxicity in rats (0.1 mg/kg/day) was less than that in humans at the MRHD. In animal reproduction studies of leflunomide, embryolethality and teratogenic effects were observed in pregnant rat and rabbit at or below clinically relevant plasma teriflunomide exposures (AUC). In published reproduction studies in pregnant mice, leflunomide was embryolethal and increased the incidence of malformations (craniofacial, axial skeletal, heart and great vessel). Supplementation with exogenous uridine reduced the teratogenic effects in pregnant mice, suggesting that the mode of action (inhibition of mitochondrial enzyme dihydroorotate dehydrogenase) is the same for therapeutic efficacy and developmental toxicity. At recommended doses in humans, teriflunomide and leflunomide result in similar range of plasma concentrations of teriflunomide.. 8.2 Lactation. Risk Summary It is not known whether this drug is excreted in human milk. Teriflunomide was detected in rat milk following single oral dose. The developmental and health benefits of breastfeeding should be considered along with the mothers clinical need for teriflunomide tablets and any potential adverse effects on the breastfed infant from teriflunomide tablets or from the underlying maternal condition.. 8.3 Females and Males of Reproductive Potential. Pregnancy Testing Exclude pregnancy prior to initiation of treatment with teriflunomide tablets in females of reproductive potential. Advise females to notify their healthcare provider immediately if pregnancy occurs or is suspected during treatment [see Warnings and Precautions (5.2, 5.3) and Use in Specific Populations (8.1)]. Contraception Females Females of reproductive potential should use effective contraception while taking teriflunomide tablets. If teriflunomide tablet is discontinued, use of contraception should be continued until is it verified that plasma concentrations of teriflunomide are less than 0.02 mg/L (0.02 mcg/mL). Females of reproductive potential who wish to become pregnant should undergo an accelerated elimination procedure. Effective contraception should be used until it is verified that plasma concentrations of teriflunomide are less than 0.02 mg/L (0.02 mcg/mL) [see Warnings and Precautions (5.3)]. Males Teriflunomide is detected in human semen. Animal studies to specifically evaluate the risk of male-mediated fetal toxicity have not been conducted. To minimize any possible risk, men not wishing to father child and their female partners should use effective contraception. Men wishing to father child should discontinue use of teriflunomide tablets and either undergo an accelerated elimination procedure or wait until verification that the plasma teriflunomide concentration is less than 0.02 mg/L (0.02 mcg/mL) [see Warnings and Precautions (5.3)]. InfertilityAdministration of teriflunomide to male rats resulted in no adverse effects on fertility. However, reduced epididymal sperm count was observed [see Nonclinical Toxicology (13.1)]. Effects of teriflunomide tablets on fertility in humans have not been evaluated.. 8.4 Pediatric Use. Safety and effectiveness in pediatric patients have not been established. 8.5 Geriatric Use. Clinical studies of teriflunomide tablets did not include patients over 65 years old. 8.6 Hepatic Impairment. No dosage adjustment is necessary for patients with mild and moderate hepatic impairment. The pharmacokinetics of teriflunomide in severe hepatic impairment has not been evaluated. Teriflunomide tablets are contraindicated in patients with severe hepatic impairment [see Contraindications (4), Warnings and Precautions (5.1), and Clinical Pharmacology (12.3)]. 8.7 Renal Impairment. No dosage adjustment is necessary for patients with mild, moderate, and severe renal impairment [see Clinical Pharmacology (12.3)].

WARNINGS AND PRECAUTIONS SECTION.

5 WARNINGS AND PRECAUTIONS. Elimination of teriflunomide tablets can be accelerated by administration of cholestyramine or activated charcoal for 11 days (5.3) Teriflunomide tablets may decrease WBC. recent CBC should be available before starting teriflunomide tablets. Monitor for signs and symptoms of infection. Consider suspending treatment with teriflunomide tablets in case of serious infection. Do not start teriflunomide tablets in patients with active infections (5.4) Stop teriflunomide tablets if patient has anaphylaxis, angioedema, Stevens-Johnson syndrome, toxic epidermal necrolysis; initiate rapid elimination (5.3, 5.5) If patient develops symptoms consistent with peripheral neuropathy, evaluate patient and consider discontinuing teriflunomide tablets (5.6) Teriflunomide tablets may increase blood pressure. Measure blood pressure at treatment initiation and monitor blood pressure during treatment (5.7). 5.1 Hepatotoxicity. Severe liver injury including fatal liver failure and dysfunction has been reported in some patients treated with leflunomide, which is indicated for rheumatoid arthritis. similar risk would be expected for teriflunomide because recommended doses of teriflunomide and leflunomide result in similar range of plasma concentrations of teriflunomide. Patients with pre-existing liver disease may be at increased risk of developing elevated serum transaminases when taking teriflunomide tablets. Patients with pre-existing acute or chronic liver disease, or those with serum alanine aminotransferase (ALT) greater than two times the upper limit of normal (ULN) before initiating treatment, should not normally be treated with teriflunomide tablets. Teriflunomide tablets are contraindicated in patients with severe hepatic impairment [see Contraindications (4)]. In placebo-controlled trials, ALT greater than three times the ULN occurred in 61/1,045 (5.8%) and 62/1,002 (6.2%) of patients receiving teriflunomide tablets mg and 14 mg, respectively, and 38/997 (3.8%) of patients receiving placebo, during the treatment period. These elevations occurred mostly within the first year of treatment. Half of the cases returned to normal without drug discontinuation. In clinical trials, if ALT elevation was greater than three times the ULN on two consecutive tests, teriflunomide tablet was discontinued and patients underwent an accelerated elimination procedure [see Warnings and Precautions (5.3)]. Of the patients who underwent discontinuation and accelerated elimination in controlled trials, half returned to normal or near normal values within months. One patient in the controlled trials developed ALT 32 times the ULN and jaundice months after initiation of teriflunomide tablets 14 mg treatment. The patient was hospitalized for weeks and recovered after plasmapheresis and cholestyramine accelerated elimination procedure. Teriflunomide tablets-induced liver injury in this patient could not be ruled out. Obtain serum transaminase and bilirubin levels within months before initiation of teriflunomide tablets therapy. Monitor ALT levels at least monthly for six months after starting teriflunomide tablets. Consider additional monitoring when teriflunomide tablets are given with other potentially hepatotoxic drugs. Consider discontinuing teriflunomide tablets if serum transaminase increase (greater than three times the ULN) is confirmed. Monitor serum transaminase and bilirubin on teriflunomide tablets therapy, particularly in patients who develop symptoms suggestive of hepatic dysfunction, such as unexplained nausea, vomiting, abdominal pain, fatigue, anorexia, or jaundice and/or dark urine. If liver injury is suspected to be teriflunomide tablets-induced, discontinue teriflunomide tablets and start an accelerated elimination procedure [see Warnings and Precautions (5.3)] and monitor liver tests weekly until normalized. If teriflunomide tablets-induced liver injury is unlikely because some other probable cause has been found, resumption of teriflunomide tablets therapy may be considered.. 5.2 Teratogenecity. Teriflunomide tablets may cause fetal harm when administered to pregnant woman. Teratogenicity and embryo-fetal lethality occurred in animal reproduction studies in multiple animal species at plasma teriflunomide exposures similar to or lower than that in humans at the maximum human recommended dose (MHRD) of 14 mg/day [see Use in Specific Populations (8.1)]. Teriflunomide tablets are contraindicated for use in pregnant women and females of reproductive potential not using effective contraception [see Contraindications (4) and Warnings and Precautions (5.3)]. 5.3 Procedure for Accelerated Elimination of Teriflunomide. Teriflunomide is eliminated slowly from the plasma [see Clinical Pharmacology (12.3)]. Without an accelerated elimination procedure, it takes on average months to reach plasma concentrations less than 0.02 mg/L, although because of individual variations in drug clearance it may take as long as years. An accelerated elimination procedure could be used at any time after discontinuation of teriflunomide tablets. Elimination can be accelerated by either of the following procedures: Administration of cholestyramine g every hours for 11 days. If cholestyramine g three times day is not well tolerated, cholestyramine g three times day can be used. Administration of 50 oral activated charcoal powder every 12 hours for 11 days. If either elimination procedure is poorly tolerated, treatment days do not need to be consecutive unless there is need to lower teriflunomide plasma concentration rapidly. At the end of 11 days, both regimens successfully accelerated teriflunomide elimination, leading to more than 98% decrease in teriflunomide plasma concentrations. Use of the accelerated elimination procedure may potentially result in return of disease activity if the patient had been responding to teriflunomide tablets treatment.. 5.4 Bone Marrow Effects/Immunosuppression Potential/Infections. Bone Marrow Effects mean decrease compared to baseline in white blood cell (WBC) count of approximately 15% (mainly neutrophils and lymphocytes) and in platelet count of approximately 10% was observed in placebo-controlled trials with mg and 14 mg of teriflunomide tablets. The decrease in mean WBC count occurred during the first weeks and WBC count remained low during treatment. In placebo-controlled studies, neutrophil count 1.5x109/L was observed in 12% and 16% of patients receiving teriflunomide tablets mg and 14 mg, respectively, compared with 7% of patients receiving placebo; lymphocyte count <0.8x109/L was observed in 10% and 12% of patients receiving teriflunomide tablets mg and 14 mg, respectively, compared with 6% of patients receiving placebo. No cases of serious pancytopenia were reported in premarketing clinical trials of teriflunomide tablets but rare cases of pancytopenia and agranulocytosis, have been reported in the postmarketing setting with leflunomide. similar risk would be expected for teriflunomide tablets [see Clinical Pharmacology (12.3)]. Cases of thrombocytopenia with teriflunomide tablets, including rare cases with platelet counts less than 50,000/mm3, have been reported in the postmarketing setting. Obtain complete blood cell count (CBC) within months before the initiation of treatment with teriflunomide tablets. Further monitoring should be based on signs and symptoms suggestive of bone marrow suppression. Risk of Infection Tuberculosis Screening Patients with active acute or chronic infections should not start treatment until the infection(s) is resolved. If patient develops serious infection consider suspending treatment with teriflunomide tablets and using an accelerated elimination procedure. Reassess the benefits and risks prior to resumption of therapy. Instruct patients receiving teriflunomide tablets to report symptoms of infections to physician. Teriflunomide tablets are not recommended for patients with severe immunodeficiency, bone marrow disease, or severe, uncontrolled infections. Medications like teriflunomide tablets that have immunosuppression potential may cause patients to be more susceptible to infections, including opportunistic infections. In placebo-controlled studies of teriflunomide tablets, no overall increase in the risk of serious infections was observed with teriflunomide tablets mg (2.2%) or 14 mg (2.7%) compared to placebo (2.2%). However, one fatal case of klebsiella pneumonia sepsis occurred in patient taking teriflunomide tablets 14 mg for 1.7 years. Fatal infections have been reported in the postmarketing setting in patients receiving leflunomide, especially Pneumocystis jiroveci pneumonia and aspergillosis. Most of the reports were confounded by concomitant immunosuppressant therapy and/or comorbid illness which, in addition to rheumatoid disease, may predispose patients to infection. In clinical studies with teriflunomide tablets, cytomegalovirus hepatitis reactivation has been observed. In clinical studies with teriflunomide tablets, cases of tuberculosis have been observed. Prior to initiating teriflunomide tablets, screen patients for latent tuberculosis infection with tuberculin skin test or with blood test for mycobacterium tuberculosis infection. Teriflunomide tablet has not been studied in patients with positive tuberculosis screen, and the safety of teriflunomide tablets in individuals with latent tuberculosis infection is unknown. For patients testing positive in tuberculosis screening, treat by standard medical practice prior to therapy with teriflunomide tablets.Vaccination No clinical data are available on the efficacy and safety of live vaccinations in patients taking teriflunomide tablets. Vaccination with live vaccines is not recommended. The long half-life of teriflunomide tablets should be considered when contemplating administration of live vaccine after stopping teriflunomide tablets. Malignancy The risk of malignancy, particularly lymphoproliferative disorders, is increased with the use of some immunosuppressive medications. There is potential for immunosuppression with teriflunomide tablets. No apparent increase in the incidence of malignancies and lymphoproliferative disorders was reported in the teriflunomide tablets clinical trials, but larger and longer-term studies would be needed to determine whether there is an increased risk of malignancy or lymphoproliferative disorders with teriflunomide tablets. 5.5 Hypersensitivity and Serious Skin Reactions. Teriflunomide tablets can cause anaphylaxis and severe allergic reactions [see Contraindications (4)]. Signs and symptoms have included dyspnea, urticaria, and angioedema including lips, eyes, throat, and tongue. Cases of serious skin reactions, including cases of Stevens-Johnson syndrome (SJS) and fatal case of toxic epidermal necrolysis (TEN), have been reported with teriflunomide tablets. In patients treated with leflunomide, the parent compound, very rare cases of Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) have also been reported. Inform patients of the signs and symptoms of anaphylaxis and angioedema and signs and symptoms that may signal serious skin reaction. Inform patients that fever associated with signs of other organ system involvement (e.g., rash, lymphadenopathy, or hepatic dysfunction) may be drug-related. Instruct patients to discontinue teriflunomide tablets and seek immediate medical care should these signs and symptoms occur. Discontinue teriflunomide tablets, unless the reactions are clearly not drug-related, and begin an accelerated elimination procedure immediately [see Warnings and Precautions (5.3)]. In such cases, patients should not be re-exposed to teriflunomide [see Contraindications (4)]. 5.6 Peripheral Neuropathy. In placebo-controlled studies, peripheral neuropathy, including both polyneuropathy and mononeuropathy (e.g., carpal tunnel syndrome), occurred more frequently in patients taking teriflunomide tablets than in patients taking placebo. The incidence of peripheral neuropathy confirmed by nerve conduction studies was 1.4% (13 patients) and 1.9% (17 patients) of patients receiving mg and 14 mg of teriflunomide tablets, respectively, compared with 0.4% receiving placebo (4 patients). Treatment was discontinued in 0.7% (8 patients) with confirmed peripheral neuropathy (3 patients receiving teriflunomide tablets mg and patients receiving teriflunomide tablets 14 mg). Five of them recovered following treatment discontinuation. Not all cases of peripheral neuropathy resolved with continued treatment. Peripheral neuropathy also occurred in patients receiving leflunomide. Age older than 60 years, concomitant neurotoxic medications, and diabetes may increase the risk for peripheral neuropathy. If patient taking teriflunomide tablets develops symptoms consistent with peripheral neuropathy, such as bilateral numbness or tingling of hands or feet, consider discontinuing teriflunomide tablets therapy and performing an accelerated elimination procedure [see Warnings and Precautions (5.3)]. 5.7 Increased Blood Pressure. In placebo-controlled studies, the mean change from baseline to the end of study in systolic blood pressure was +2.3 mmHg and +2.7 mmHg for teriflunomide tablets mg and 14 mg, respectively, and -0.6 mmHg for placebo. The change from baseline in diastolic blood pressure was +1.4 mmHg and +1.9 mmHg for teriflunomide tablets mg and 14 mg, respectively, and -0.3 mmHg for placebo. Hypertension was an adverse reaction in 3.1% and 4.3% of patients treated with mg or 14 mg of teriflunomide tablets compared with 1.8% for placebo. Check blood pressure before start of teriflunomide tablets treatment and periodically thereafter. Elevated blood pressure should be appropriately managed during treatment with teriflunomide tablets.. 5.8 Respiratory Effects. Interstitial lung disease, including acute interstitial pneumonitis, has been reported with teriflunomide tablets in the postmarketing setting.Interstitial lung disease and worsening of pre-existing interstitial lung disease have been reported during treatment with leflunomide. Interstitial lung disease may be fatal and may occur acutely at any time during therapy with variable clinical presentation. New onset or worsening pulmonary symptoms, such as cough and dyspnea, with or without associated fever, may be reason for discontinuation of therapy and for further investigation as appropriate. If discontinuation of the drug is necessary, consider initiation of an accelerated elimination procedure [see Warnings and Precautions (5.3)]. 5.9 Concomitant Use with Immunosuppressive or Immunomodulating Therapies. Coadministration with antineoplastic, or immunosuppressive therapies used for treatment of multiple sclerosis has not been evaluated. Safety studies in which teriflunomide tablets was concomitantly administered with other immune modulating therapies for up to one year (interferon beta, glatiramer acetate) did not reveal any specific safety concerns. The long term safety of these combinations in the treatment of multiple sclerosis has not been established. In any situation in which the decision is made to switch from teriflunomide tablets to another agent with known potential for hematologic suppression, it would be prudent to monitor for hematologic toxicity, because there will be overlap of systemic exposure to both compounds. Use of an accelerated elimination procedure may decrease this risk, but may also potentially result in return of disease activity if the patient had been responding to teriflunomide tablets treatment [see Warnings and Precautions (5.3)].