USE IN SPECIFIC POPULATIONS SECTION.

8 USE IN SPECIFIC POPULATIONS. 8.1 Pregnancy. Pregnancy Category [see Contraindications (4)].Finasteride tablets is contraindicated for use in women who are or may become pregnant. Finasteride tablets is Type II -reductase inhibitor that prevents conversion of testosterone to -dihydrotestosterone (DHT), hormone necessary for normal development of male genitalia. In animal studies, finasteride caused abnormal development of external genitalia in male fet uses. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to the male fetu s.Abnormal male genital development is an expected consequence when conversion of testosterone to 5- dihydrotestosterone (DHT) is inhibited by -reductase inhibitors. These outcomes are similar to those reported in male infants with genetic -reductase deficiency. Women could be exposed to finasteride through contact with crushed or roken finasteride tablets or semen from male partner taking finasteride tablets. With regard to finasteride exposure th rough the skin, finasteride tablets are coated and will prevent skin contact with finasteride during norm al handling if the tablets have not been crushed or broken. Women who are pregnant or may beco me pregnant should not handle crushed or broken finasteride tablets because of possib le exposure of male fetus. If pregnant woman comes in contact with crushed or broken finasteride tablets, the contact area should be washed immediately with soap and water. With regard to potential finasteride xposure through semen, study has been conducted in men receiving finasteride tablets mg/day that measured finasteride concentrations in semen [see Clinical Pharmacology (12.3) ].In an embryo-fetal development study, pregnant rats received finasteride during the period of major organogenesis (gestation days to 17). At maternal doses of oral finasteride approximately to 684 times the recommended human dose (RHD) of mg/day (based on AUC at animal doses of 0.1 to 100 mg/kg/day) there was dose-dependent increase in hypospadias that occurred in 3.6 to 100% of male offspring. Exposure multiples were estimated using data from nonpregnant rats. Days 16 to 17 of gestation is critical period in male fetal rats for differentiation of the external genitalia. At oral maternal doses approximately 0.2 times the RHD (based on AUC at animal dose of 0.03 mg/kg/day), male offspring had decreased prostatic and seminal vesicular weights, delayed preputial separation and transient nipple development. Decreased anogenital distance occurred in male offspring of pregnant rats that received approximately 0.02 times the RHD (based on AUC at animal dose of 0.003 mg/kg/day). No abnormalities were observed in female offspring exposed to any dose of finasteride in utero. No developmental abnormalities were observed in the offspring of untreated females mated with finasteride-treated male rats that received approximately 488 times the RHD (based on AUC at animal dose of 80 mg/kg/day). Slightly decreased fertility was observed in male offspring after administration of about 20 times the RHD (based on AUC at animal dose of mg/kg/day) to female rats during late gestation and lactation. No effects on fertility were seen in female offspring under these conditions.No evidence of male external genital malformations or other abnormalities were observed in rabbit fetuses exposed to finasteride during the period of major organogenesis (gestation days to 18) at maternal doses up to 100 mg/kg/day (finasteride exposure levels were not measured in rabbits). However, this study may not have included the critical period for finasteride effects on development of male external genitalia in the rabbit.The fetal effects of maternal finasteride exposure during the period of embryonic and fetal development were evaluated in the rhesus monkey (gestation days 20 to 100), in species and development period more predictive of specific effects in humans than the studies in rats and rabbits. Intravenous administration of finasteride to pregnant monkeys at doses as high as 800 ng/day (estimated maximal blood concentration of 1.86 ng/mL or about 930 times the highest estimated exposure of pregnant women to finasteride from semen of men taking mg/day) resulted in no abnormalities in male fetuses. In confirmation of the relevance of the rhesus model for human fetal development, oral administration of dose of finasteride (2 mg/kg/day or approximately 120,000 times the highest estimated blood levels of finasteride from semen of men taking mg/day) to pregnant monkeys resulted in external genital abnormalities in male fetuses. No other abnormalities were observed in male fetuses and no finasteride- related abnormalities were observed in female fetuses at any dose.. 8.3 Nursing Mothers. Finasteride tablets is not indicated for use in women. It is not known whether finast eride is excreted in human milk.. 8.4 Pediatric Use. Finasteride tablets is not indicated or use in pediatric patients. Safety and effectiveness in pediatric patients have not been established.. 8.5 Geriatric Use. Clinical efficacy studies with finasteride tablets did not include subjects aged 65 and over. Based on the pharmacokinetics of finasteride mg, no dosage adjustment is necessary in the elderly for finasteride tablets see Clinical Phar macology 12.3)]. However the efficacy of finasteride tablets in the elderly has not been established.. 8.6 Hepatic Impairment. Caution should be exercised in the administration of finasteride tablets in those patients with liver function abnormalities, as finasteride is me tabolized extensively in the liver see Clinical Phar macology (12.3) ].. 8.7 Renal Impairment. No dosage adjustment is necessary in patients with renal impairment see Clinical Phar macology 12.3) ].

ADVERSE REACTIONS SECTION.

6 ADVERSE REACTIONS. The most common adverse reactions, reported in >=1% of patients treated ith finasteride tablets and greater than in patients treated ith placebo are: decreased libido, ere ctile ysfunction and ejaculation disorder (6.1). To report SUSPECTED ADVERSE REACTIONS, contact Ascend Laboratories, LLC at 1-877-ASC-RX01 (877-272-7901) or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. 6.1 Clinical Trials Experience. Because clinical trials are condu cted 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 obse rved in clinical practice.Clinical Studies for finasteride tablets mg in the Treatment of Male Pattern Hair Loss In three controlled clinical trials for finasteride tablets of 12-month duration, 1.4% of patients taking finasteride tablets (n=945) were discontinued due to adverse experiences that were considered to be possibly, probably or definitely drug-related (1.6% for placebo; n=934).Clinical adverse experiences that were reported as possibly, probably or definitely drug-related in >1% of patients treated with finasteride tablets or placebo are presented in Table 1.T ABLE 1: Drug-Related Ad verse Experiences for Finasteride tablets mg (finasteride mg) inYear ( %)M ALE ATTERN AIR LOSS Finasteride N=945 Placebo N=934 Decreased Libido 1.8 1.3 Erectile ysfunction 1.3 0.7 Ejaculation Disorder (Decreased Volu me of Ejaculate) 1.2 (0.8) 0.7 (0.4) Discontinuation due todrug-related sexual adverse experiences 1.2 0.9 Integrated analysis of clinical adverse experiences showed that during treatment with finasteride tablets, 36 (3.8%) of 945 men had reported one or more of these adverse experiences as compared to 20 (2.1%) of 934 men treated with placebo (p=0.04). Resolution occurred in men who discontinued therapy with finasteride tablets due to these side effects and in most of those who continued therapy. The incidence of each of the above adverse experiences decreased to <0.3% by the fifth year of treatment with finasteride tablets.In study of finasteride mg daily in healthy men, median decrease in ejaculate volume of 0.3 mL (-11%) compared with 0.2 mL (-8%) for placebo was observed after 48 weeks of treatment. Two other studies showed that finasteride at times the dosage of finasteride tablets (5 mg daily) produced significant median decreases of approximately .5 mL (-25%) compared to placebo in ejaculate volume, but this was reversible after discontinuation of treatment.In the clinical studies with finasteride tablets, the incidences for breast tenderness and enlargement, hypersensitivity reactions, and testicu lar pain in finasteride-treated patients were not different from those in patients treated with placebo. Controlled Clinical Trials and Long-Term Open Extension Studies for finasteride tablets mg (finasteride mg) and AVODART (dutasteride) in the Treat ment of Benign Prostatic yperplasia In the finasteride tablets mg Long-Term Efficacy and Safety Study (PLESS), 4-year controlled clinical study, 3040 patients between the ages of 45 and 78 with symptomatic BPH and an enlarged prostate were evaluated for safety over period of years (1524 on finasteride tablets, mg /day and 1516 on placebo). 3.7% (57 patients) treated with finasteride tablets mg and 2.1% (32 patients) treated with placebo discontinued therapy as result of adverse reactions related to se xual function, which are the most frequently reported adverse reactions.Table presents the only clinical adverse react ions considered possibly, probably or definitely drug related by the investigator, for which the incidence on finasteride tablets mg was >1% and greater than placebo over the years of the study. In years to of the study, there was no significant difference between treatment groups in the incidences of impoten ce, decreased libido and ejaculation disorder.TABLE 2: Drug-Related Adverse Experiences for Finasteride tablets mg BENIGN PROSTATIC HYPERPLASIA Year (%)Years 2, and (%)Finasteride mgPlaceboFinasteride mgPlaceboImpotence 8.1 3.7 5.1 5.1 Decreased Libido 6.4 3.4 2.6 2.6 Decreased Volume of Ejaculate 3.7 0.8 1.5 0.5 Ejaculation Disorder 0.8 0.1 0.2 0.1 Breast Enlargement 0.5 0.1 1.8 1.1 Breast Tenderness 0.4 0.1 0.7 0.3 Rash 0.5 0.2 0.5 0.1 Combined Years to 4N 1524 and 1516, finasteride vs placebo, respectivelyThe adverse experience profiles in the 1-year, pla cebo-controlled, Phase III BPH studies and the 5-year open extensions with finasteride tablets mg and PLESS were similar.There is no evidence of increased sexual adverse experiences with ncreased duration of treatment with finasteride tablets mg. New reports of drug-related sexual adverse experiences decreased with duration of therapy.During the 4- to 6-year placebo- and comparator- controlled Medical Therapy of Prostatic Symptoms (MTOPS) study that enrolled 3047 men, there were cases of breast cancer in men treated with finasteride tablets but no cases in men not treated with finasteride tablets. During the 4-year placebo-controlled PLESS study that enrolled 3040 men, there were cases of breast cancer in placebo-treated men, but no cases were reported in men treated with finasteride tablets.During the 7-year placebo-controlled Prostate Cancer Prevention Trial (PCPT) that enrolled 18,882 men, there was case of breast cancer in men treated ith finasteride tablets, and case of breast cancer in men treated with placebo. The relationship between long-t erm use of finasteride and male breast neoplasia is currently unknown.The PCPT trial was 7-year randomized, double- blind, placebo-controlled trial that enrolled 18,882 healthy men >=55 years of age with normal digital rectal examination and PSA <=3.0 ng/mL. Men received either finasteride tablets mg (finasteride mg) or lacebo daily. Patients were evaluated annually with PSA and digital rectal exams. Biopsies were performed or elevated PSA, an abnormal digital rectal exam, or the end of study. The incidence of Gleason score to 10 prostate cancer was higher in men treated with finasteride (1.8%) than in those treated with placebo (1.1%). In 4-year placebo -controlled clinical trial with another -reductase inhibitor [AVODART (dutaster ide)], similar results for Gleason score to 10 prostate cancer were observed (1% dutasteride vs 0.5% placebo). The clinical significance of these findings with respect to use of finasteride tablets by men is unknown.No clinical benefit has been demonstrated in patients with prostate cancer treated with finasteride tablets. Finasteride tablets is not approved to reduce the risk of developing prostate cancer.. 6.2 Postmarketing Experience. The following adverse reactions have been identified during post approval use of finasteride tablets. Because these reactions are reported voluntarily from population of uncertain size, it is not always possible to reliably estimate their frequency or establi sh causal relationship to drug exposure:Hypersensitivity Reaction: hypersensitivity reactions such as rash, pruritus, urticaria, and angioedema (including swelling of the lips, tongue, throat, and face);Reproductive System: sexual dysfunction that continued after discontinuation of treatment, including erectile dysfunction, libido disorders, ejaculation disorders, and orgasm disorders; male infertility and/or poor seminal quality (normalization or improvement of seminal quality has been reported after discontinuation of finasteride); testicular pain. [See Adverse Reactions (6.1).] Neoplasms: male breast cancer;Breast disorders: breast tenderness and enlargement;Nervous System/Psychiatric: depression.

CARCINOGENESIS & MUTAGENESIS & IMPAIRMENT OF FERTILITY SECTION.

13.1 Carcinogenesis Mutagenesis Impairment Of Fertility. No evidence of tumorigenic effect was observed in 24-month study in Sprague-Dawley rats receiving doses of finasteride up to 160 mg/kg/day in males and 320 mg/kg/day in females. These doses produced respective systemic exposure in rats of 888 and 2192 times those observed in man receiving the recommended human dose of mg/day. All exposure calculations were based on calculated AU C(0-24 hr)for animals and mean AU C(0-24 hr) for man (0.05 ugohr/mL).In 19-month carcinogenicity study in CD-1 mice, statistically significant (p<0.05) increase in the incidence of testicular Leydig cell adenomas as observed at 1824 times the human exposure (250 mg/kg/day). In mice at 184 times the human exposure, estimated (25 mg/kg/day) and in rats at 312 times the human exposure (>40 mg/kg/day) an increase in the incidence of Leydig cell hyperplasia was observed. positive correlation between the proliferative changes in the Leydig cells and an increase in serum LH levels (2- to 3-fold above control) has been demonstrated in both rodent species treated with high doses of finasteride. No drug-related Leydig cell changes were seen in either rats or dogs treated with finasteride for year at 240 and 2800 times (20 mg/kg/day and 45 mg/kg/day, respectively), or in mice treated for 19 months at 18.4 times the human exposure, estimated (2.5 mg/kg/day).No evidence of mutagenicity was observed in an in vi tro bacterial mutagenesis assay, mammalian cell mutagenesis assay, or in an in vi tro alkaline elution assay. In an in vi tro chromosome aberration assay, using Chinese hamster ovary cells, there was slight increase in chromosome aberrations. In an in vivo chromosome aberration assay in mice, no treatment-related increase in chromosome aberration was observed with finasteride at the maximum tol erated dose of 250 mg/kg/day (1824 times the human exposure) as determined in the carcinogenicity studies. In sexually mature male rabbits treated with finasteride at 4344 times the human exposure (80 mg/kg/day) for up to 12 weeks, no effect on fertility, sperm count, or ejaculate volume was seen. In sexually mature male rats treated with 488 times the human exposure (80 mg/kg/day), there were no significant effects on fertility after or 12 weeks of treatment; however, when treatment was continued for up to 24 or 30 weeks, there was an apparent decrease in fertility, fecundity, and an associated significant decrease in the weights of the seminal vesicles and rostate. All these effects were reversible within weeks of discontinuation of treatment. No drug-rel ated effect on testes or on mating performance has been seen in rats or rabbits. This de crease in fertility in finasteride-treated rats is secondary to its effect on accessory sex organs (prostate and seminal vesicles) resulting in failure to form seminal plug. The seminal plug is essential for normal fertility in rats but is not relevant in man.

CLINICAL PHARMACOLOGY SECTION.

12 CLINICAL PHARMACOLOGY. 12.1 Mechanism of Action. Finasteride is competitive and specific inhibitor of Type II 5-reductase, an intracellular enzyme that converts the androgen testosterone into DHT. Two disti nct isozymes are found in mice, rats, monkeys, and humans: Type and II. Each of these isozymes is diff erentially expressed in tissues and developmental stages. In humans, Type 5 -reductase is predominant in the sebaceous glands of most regions of skin, including scalp, and liver. Type 5 -reductase is responsible for approximately one-third of circulating DHT. The Type II -reductase isozyme is primarily found in prostate, seminal vesicles, epididymides, and hair follicles as well as liver, and is responsible for two-thirds of circulating DHT.In humans, the mechanism of action of finasteride is based on its preferential inhibition of the Type II isozyme. Using native tissues (scalp and prostate), in vitro binding studies examining the potential of finasteride to inhibit either isozyme revealed 100-fold selectivity for the human Type II -reductase over Type isozyme (IC50=500 and 4.2 nM for Type and II, respectively). For both isozymes, the inhibition by finasteride is accompanied by reduct ion of the inhibitor to dihydrofinasteride and adduct formation with NADP+. The turnover for the enzyme complex is slow (t1/2 approximately 30 days for the Type II enzyme complex and 14 days for the Type complex). Inhibition of Type II -reductase blocks the peripheral conversion of testosterone to DHT, res ulting in significant decreases in serum and tissue DHT concentrations.In men with male pattern hair loss (androgenetic alopecia), the balding scalp contains miniaturized hair follicles and increased amounts of DHT compared with hairy scalp. Administration of finasteride decreases scalp and serum DHT concentrations in these men. The relative contributions of these reductions to the treatment effect of finasteride have not been defined. By this mechanism, finasteride appears to interrupt key factor in the development of androgenetic alopecia in those patients genetically predisposed.. 12.2 Pharmacodynamics. Finasteride produces rapid reduction in serum DHT concentration, reaching 65% suppression within 24 hours of oral dosing with 1-mg tablet. Mean cir culating levels of testosterone and estradiol were increased by approximately 15% as compared to bas eline, but these remained within the physiologic range.Finasteride has no affinity for the androgen receptor and has no androgenic, antiandrogenic, estrogenic, antiestrogenic, or progestational effects. In studies with finasteride, no clinically meaningful changes in luteinizing hormone (LH), follicle-stimulating hormone (FSH) or prolactin were detected. In healthy volunteers, treatment with finasteride did not alt er the response of LH and FSH to gonadotropin-releasing hormone indicating that the hypothalamic-pituitary-testicular axis was not affected. Finasteride had no effect on circulating levels of cortisol, thyroid-sti mulating hormone, or thyroxine, nor did it affect the plasma lipid profile (e.g., total cholesterol, low-density lipoproteins, igh-density lipoproteins and triglycerides) or bone mineral density.. 12.3 Pharmacokinetics. AbsorptionIn study in 15 healthy young male subjects, the mean bioavailability of finasteride 1-mg tablets was 65% (range 26 to 170%), based on the ratio of area under the curve (AUC) relative to an intravenous (IV) reference dose. At steady state following dosing with mg/day (n=12), maximum finasteride plasma concentration averaged 9.2 ng/mL (range, 4.9 to 13.7 ng/mL) and was reached to hours postdose; AUC(0-24 hr) was 53 ngohr/mL (range, 20 to 154 ngohr/mL). Bioav ailability of finasteride was not affected by food.DistributionMean steady-state volume of distribution was 76 liters (range, 44 to 96 liters; n=15). Approximately 90% of circulating finasteride is bound to plasma proteins. There is slow accumulation phase for finasteride after multiple dosing.Finasteride has been found to cross the blood-brain barrier.Semen levels have been measured in 35 men taking finast eride mg/day for weeks. In 60% (21 of 35) of the samples, finasteride levels were undetectab le (<0.2 ng/mL). The mean finasteride level was 0.26 ng/mL and the highest level measured was 1.52 ng /mL. Using the highest semen level measured and assuming 100% absorption from 5-mL ejaculate per day, human exposure through vaginal absorption would be up to 7.6 ng per day, which is 650-fold less than the dose of finasteride (5 ug) that had no effect on circulating DHT levels in men. [See Use in Specific Populations (8.1 .] MetabolismFinasteride is extensively metabolized in the live r, primarily via the cytochrome P450 3A4 enzyme subfamily. Two metabolites, the t-butyl side chain monohydroxylated and monocarboxylic acid metabolites, have been identified that possess no more than 20% of the 5-reductase inhibitory activity of finasteride. Excre tionFollowing intravenous infusion in healthy young subje cts (n=15), mean plasma clearance of finasteride was 165 mL/min (range, 70 to 279 mL/min). Mean terminal half-life in plasma was 4.5 hours (range, 3.3 to 13.4 hours; n=12). Following an oral dose of 14C-finasteride in man (n=6), mean of 39% (range, 32 to 46%) of the dose was excreted in the urine in the form of metabolites; 57% (range, 51 to 64%) was excreted in the fe ce s.Mean terminal half-life is approximately to hours in men 18 to 60 years of age and hours in men more than 70 years of age.TABLE 3: Mean (SD) Pharmacokinetic Parameters in Healthy Men (ages 18 to 26) Mean (+-SD)n=15 Bioavailability 65% (26 to 170%) Clearance (mL/min) 165 (55) Volume of Distribution (L) 76 (14) RangeTABLE 4: Mean (SD) Noncompartmental Pharmacokinetic Parameters After Multiple Doses of mg/day in Healthy Men (ages 19 to 42) Mean (+-SD) (n=12)AUC (ng.hr/mL) 53 (33.8) Peak Concentration (ng/mL) 9.2 (2.6) Time to Peak (hours) 1.3 (0.5) Half-Life (hours) 4.5 (1.6) First-dose values; all other parameters are last-dose valuesRenal mpair mentNo dosage adjustment is necessary in patients with renal impairment. In patients with chronic renal impairment, with creatinine clearances ranging rom 9.0 to 55 mL/min, AUC, maximum plasma concentration, half-life, and protein binding after single dose of 14C-finasteride were similar to those obtained in healthy volunteers. Urinary excretion of metabolites was decreased in patients with renal impairment. This decrease was associated with an increase in fecal excretion of metabolites. Plasma concentrations of metabolites were significantly higher in patients ith renal impairment (based on 60% increase in total radioactivity AUC). However, ifnasteride has been tolerated in men with normal renal function receiving up to 80 mg/day for 12 weeks where exposure of these patien ts to metabolites would presumably be much greater.Hepatic mpair mentThe effect of hepatic impairment on finasteride pharmacokinetics has not been studied. Caution should be used in the administration of finasteride tablets in patien ts with liver function abnormalities, as finasteride is metabolized extensively in the liver.

CLINICAL STUDIES SECTION.

14 CLINICAL STUDIES. 14.1 Studies in MenThe efficacy of finasteride tablets was demonstrated in men (88% Caucasian) with mild to moderate androgenetic alopecia (male pattern hair loss) between 18 and 41 years of age. In order to prevent seborrheic dermatitis which might confound the assess ment of hair growth in these studies, all men, whether treated with finasteride or placebo, were nstructed to use specified, medicated, tar-based shampoo (Neutrogena T/Gel(R) Shampoo) during the first years of the studies.There were three double-blind, randomized, placebo- controlled studies of 12-month duration. The two primary endpoints were hair count and patient self-assessment; the two secondary endpoints were investigator assessment and ratings of photographs. In addition, information was collected regarding sexual function (based on self-administered que stionnaire) and non-scalp body hair growth. The three studies were conducted in 1879 men with mild to moderate, but not complete, hair loss. Two of the studies enrolled men with predominantly mild to moderate vertex hair loss (n=1553). The third enrolled men having mild to moderate hair loss in the anterior mid-scalp area with or without vertex balding (n=326).Studies in Men with Vertex Baldness Of the men who completed the first 12 months of the two vertex baldness trials, 1215 elected to continue in double-blind, placebo-controlled, 12-month xtension studies. There were 547 men receiving finasteride tablets for both the initial study and first extension periods (up to years of treatment) and 60 men receiving placebo for the same periods. The extension studies were continued for additional years, with 323 men on finasteride tablets and 23 on placebo ente ring the fifth year of the study.In order to evaluate the effect of discontinuation of therapy, there were 65 men who received finasteride tablets for the initial 12 months followed by placebo in the first 12-month extension period. Some of these men continued in additional extension studies and were witched back to treatment with finasteride tablets with 32 men entering the fifth year of the study. Lastly, there were 543 men who received placebo for the initial 12 months followed by finasteride tablets in the first 12-month extension period. Some of these men continued in additional extension studies receiving finasteride tablets with 290 men entering the fifth year of the study (see Figure below).Hair counts were assessed by photog raphic enlargements of representati ve area of active hair loss. In these two studies in men with vertex baldness, signif icant increases in hair count were demonstrated at and 12 months in men treated with finasteride tablets, while significant hair loss from baseline was demonstrated in those treated with placebo. At 12 months there was 107-hair difference from placebo (p<0.001, finasteride tablets [n=679] vs placebo [n=672]) within 1-inch diameter circle (5.1 cm2). Hair count was maintained in those men taking finasteride tablets for up to years, resulting in 138-hair difference between treatment groups (p<0.001, finasteride tablets [n=433] vs placebo [n=47]) within the same area. In men treated with finasteride tablets the maximum impro vement in hair count compared to baseline was achieved during the first years. Although the initial improvement was followed by slow decline, hair count was maintained above baseline throughout the years of the studies. Furthermore, because the decline in the placebo group was more rapid, the difference between treatment groups also continued to increase throughout the studies, resulting in 277 -hair difference (p<0.001, finasteride tablets [n=219] vs placebo [n=15]) at years (see Figure below).Patients who switched from placebo to finasteride tablets (n =425) had decrease in hair count at the end of the initial 12-month placebo period, followed by an increase in hair count after year of treatment with finasteride tablets. This increase in hair count was less (56 hairs above original baseline) than the increase (91 hairs above original baseline) observed after year of treatment in men initially randomized to finasteride tablets. Although the increase in hair count, relative to when therapy was initiated, was comparable between these two groups, higher absolute hair count was achieved in patients who were started on treatment with finasteride tablets in the initial study. This advantage was maintained through the remaining years of the studies. change of treatment from finasteride tablets to placebo (n=48) at the end of the initial 12 months resulted in reversal of the increase in hair count 12 months later, at 24 months (see Figure below).At 12 months, 58% of men in the placebo group had urther hair loss (defined as any decrease in hair count from baseline), compared with 14% of men treated with finasteride tablets. In men treated for up to years, 72% of men in the pla cebo group demonstrated hair loss, compa red with 17% of men treated with finasteride tablets. At years, 100% of men in the lacebo group demonstrated hair loss, compared with 35% of men treated with finasteride tablets. Figure 1Patient self-assessment was obtained at each clinic visit from self-administered questionnaire, which included questions on their perception of hair growth, hair loss, and appearance. This self-assessment demonstrated an increase in amount of hair, dec rease in hair loss, and improvement in appearance in men treated with finasteride tablets. Overall improvement compared with placebo was seen as early as months (p<0.05), with improve ment maintained over years.Investigator assessment was based on 7-point scale valuating increases or decreases in scalp hair at each patient visit. This assessment showed significantly greater increases in hair growth in men treated with finasteride tablets compared with placebo as early as months (p<0.001). At 12 months, the investigators rated 65% of men treated with finasteride tablets as having increased hair growth compared with 37% in the placebo group. At years, the investigators rated 80% of men treated with finasteride tablets as having increased hair growth compared with 47% of men treated with placebo. At years, the investigators rated 77% of men treated with finasteride tablets as having inc reased hair growth, compared with 15% of men treated with placebo.An independent panel rated standardized photographs of the head in blinded fashion based on increases or decreases in scalp hair using the same 7-point scale as the investigator assessment. At 12 months, 48% of men treated with finasteride tablets mg had an increase as compared with 7% of men treated with placebo. At years, an increase in hair growth was demonstrated in 66% of men treated with finasteride tablets, compared with 7% of men treated with placebo. At years, 48% of men treated with finasteride tablets demonstrated an increase in hair growth, 42% were rated as having no change (no further visible progression of hair loss from baseline) and 10% were rated as having lost hair when compared to baseline. In comparison, 6% of men treated with placebo demonstrated an increase in hair growth, 19% were rated as having no change and 75% were rated as having lost hair when compared to baseline.A 48-week, placebo-controlled study designed to assess by phototrichogram the effect of finasteride tablets on total and actively growing (anagen) scalp hairs in vertex baldness enrolled 212 men with androgenetic alopecia. At baseline and 48 weeks, total and anagen hair counts were obtained in 1-cm2 target area of the scalp. Men treated with finasteride tablets showed increases from baseline in total and anagen hair counts of hairs and 18 hairs, respectively, whereas men treated with placebo had decreases of 10 hairs and hairs, respectively. These changes in hair counts resulted in between-group difference of 17 hairs in total hair count (p<0.001) and 27 hairs in anagen hair count (p<0.001), and an improvement in the proportion of anagen hairs from 62% at basel ine to 68% for men treated with finasteride tablets.Other Results in Vertex Baldness Studies sexual function questionnaire was self-administered by patients participating in the two vertex baldness trials to detect more subtle changes in sexual function. At Month 12, statistically significant differences in favor of placebo were found in of domains (se xual interest, erections, and perception of sexual problems). However, no significant difference was seen in the question on overall satisfaction with sex life.In one of the two vertex baldness studies, patients were questioned on non-scalp body hair growth. finasteride tablets did not appear to affect non-scalp body hair.Study in Men with Hair Loss in the Anterior Mid-Scalp Area study of 12-month duration, designed to assess the efficacy of finasteride tablets in men with hair loss in the anterior mid-scalp area, also demonstrated significant increases in hair count compared with placebo. Increases in hair count were accompanied by imp rovements in patient sel f-assessment, investigator assessment, and ratings based on standardized photograph s. Hair counts were obtained in the anterior mid-scalp area, and did not include the area of textporal recession or the anterior hairline.Summary of Clinical Studies in Men Clinical studies were conducted in men aged 18 to 41 with mild to moderate degrees of androgenetic alopecia. All men treated with finasteride tablets or placebo received tar-based shampoo (Neutrogena T/Gel(R) Shampoo) during the first years of the studies. Clini cal improvement was seen as early as months in the patients treated with finasteride tablets and led to net increase in scalp hair count and hair regrowth. In clinical studies for up to years, treatment with finasteride tablets slowed the further progression of hair loss observed in the placebo group. In general, the difference between treatment groups continued to increase throughout the years of the studies.Ethnic Anal ysis of Clinical Data from Men In combined analysis of the two studies on ver tex baldness, mean hair count changes from baseline were 91 vs -19 hairs (Finasteride tablets vs placebo) among Caucasians (n=1185), 49 vs -27 hairs among Blacks (n=84), 53 vs -38 hairs among Asians n=17), 67 vs hairs among Hispanics (n=45) and 67 vs -15 hairs among other ethnic groups (n=20). Patient self-assessment showed improvement across racial groups with finasteride tablets treatment, except for satisfaction of the frontal hairline and vertex in Black men, who were satisfied overall. 14.2 Study in WomenIn study involving 137 postmenopausal women with androgenetic alopecia who were treated with finasteride tablets (n=67) or placebo (n=70) for 12 month s, effectiveness could not be demonstrated. There was no improvement in hair counts, patient self-assessment, investigator assessment, or ratings of standardized photographs in the women treated with finasteride tablets when compared with the placebo group[ see Indications and Usage (1)]. finasteride-figure1.

NONCLINICAL TOXICOLOGY SECTION.

13 NONCLINICAL TOXICOLOGY. 13.1 Carcinogenesis Mutagenesis Impairment Of Fertility. No evidence of tumorigenic effect was observed in 24-month study in Sprague-Dawley rats receiving doses of finasteride up to 160 mg/kg/day in males and 320 mg/kg/day in females. These doses produced respective systemic exposure in rats of 888 and 2192 times those observed in man receiving the recommended human dose of mg/day. All exposure calculations were based on calculated AU C(0-24 hr)for animals and mean AU C(0-24 hr) for man (0.05 ugohr/mL).In 19-month carcinogenicity study in CD-1 mice, statistically significant (p<0.05) increase in the incidence of testicular Leydig cell adenomas as observed at 1824 times the human exposure (250 mg/kg/day). In mice at 184 times the human exposure, estimated (25 mg/kg/day) and in rats at 312 times the human exposure (>40 mg/kg/day) an increase in the incidence of Leydig cell hyperplasia was observed. positive correlation between the proliferative changes in the Leydig cells and an increase in serum LH levels (2- to 3-fold above control) has been demonstrated in both rodent species treated with high doses of finasteride. No drug-related Leydig cell changes were seen in either rats or dogs treated with finasteride for year at 240 and 2800 times (20 mg/kg/day and 45 mg/kg/day, respectively), or in mice treated for 19 months at 18.4 times the human exposure, estimated (2.5 mg/kg/day).No evidence of mutagenicity was observed in an in vi tro bacterial mutagenesis assay, mammalian cell mutagenesis assay, or in an in vi tro alkaline elution assay. In an in vi tro chromosome aberration assay, using Chinese hamster ovary cells, there was slight increase in chromosome aberrations. In an in vivo chromosome aberration assay in mice, no treatment-related increase in chromosome aberration was observed with finasteride at the maximum tol erated dose of 250 mg/kg/day (1824 times the human exposure) as determined in the carcinogenicity studies. In sexually mature male rabbits treated with finasteride at 4344 times the human exposure (80 mg/kg/day) for up to 12 weeks, no effect on fertility, sperm count, or ejaculate volume was seen. In sexually mature male rats treated with 488 times the human exposure (80 mg/kg/day), there were no significant effects on fertility after or 12 weeks of treatment; however, when treatment was continued for up to 24 or 30 weeks, there was an apparent decrease in fertility, fecundity, and an associated significant decrease in the weights of the seminal vesicles and rostate. All these effects were reversible within weeks of discontinuation of treatment. No drug-rel ated effect on testes or on mating performance has been seen in rats or rabbits. This de crease in fertility in finasteride-treated rats is secondary to its effect on accessory sex organs (prostate and seminal vesicles) resulting in failure to form seminal plug. The seminal plug is essential for normal fertility in rats but is not relevant in man.

PHARMACOKINETICS SECTION.

12.3 Pharmacokinetics. AbsorptionIn study in 15 healthy young male subjects, the mean bioavailability of finasteride 1-mg tablets was 65% (range 26 to 170%), based on the ratio of area under the curve (AUC) relative to an intravenous (IV) reference dose. At steady state following dosing with mg/day (n=12), maximum finasteride plasma concentration averaged 9.2 ng/mL (range, 4.9 to 13.7 ng/mL) and was reached to hours postdose; AUC(0-24 hr) was 53 ngohr/mL (range, 20 to 154 ngohr/mL). Bioav ailability of finasteride was not affected by food.DistributionMean steady-state volume of distribution was 76 liters (range, 44 to 96 liters; n=15). Approximately 90% of circulating finasteride is bound to plasma proteins. There is slow accumulation phase for finasteride after multiple dosing.Finasteride has been found to cross the blood-brain barrier.Semen levels have been measured in 35 men taking finast eride mg/day for weeks. In 60% (21 of 35) of the samples, finasteride levels were undetectab le (<0.2 ng/mL). The mean finasteride level was 0.26 ng/mL and the highest level measured was 1.52 ng /mL. Using the highest semen level measured and assuming 100% absorption from 5-mL ejaculate per day, human exposure through vaginal absorption would be up to 7.6 ng per day, which is 650-fold less than the dose of finasteride (5 ug) that had no effect on circulating DHT levels in men. [See Use in Specific Populations (8.1 .] MetabolismFinasteride is extensively metabolized in the live r, primarily via the cytochrome P450 3A4 enzyme subfamily. Two metabolites, the t-butyl side chain monohydroxylated and monocarboxylic acid metabolites, have been identified that possess no more than 20% of the 5-reductase inhibitory activity of finasteride. Excre tionFollowing intravenous infusion in healthy young subje cts (n=15), mean plasma clearance of finasteride was 165 mL/min (range, 70 to 279 mL/min). Mean terminal half-life in plasma was 4.5 hours (range, 3.3 to 13.4 hours; n=12). Following an oral dose of 14C-finasteride in man (n=6), mean of 39% (range, 32 to 46%) of the dose was excreted in the urine in the form of metabolites; 57% (range, 51 to 64%) was excreted in the fe ce s.Mean terminal half-life is approximately to hours in men 18 to 60 years of age and hours in men more than 70 years of age.TABLE 3: Mean (SD) Pharmacokinetic Parameters in Healthy Men (ages 18 to 26) Mean (+-SD)n=15 Bioavailability 65% (26 to 170%) Clearance (mL/min) 165 (55) Volume of Distribution (L) 76 (14) RangeTABLE 4: Mean (SD) Noncompartmental Pharmacokinetic Parameters After Multiple Doses of mg/day in Healthy Men (ages 19 to 42) Mean (+-SD) (n=12)AUC (ng.hr/mL) 53 (33.8) Peak Concentration (ng/mL) 9.2 (2.6) Time to Peak (hours) 1.3 (0.5) Half-Life (hours) 4.5 (1.6) First-dose values; all other parameters are last-dose valuesRenal mpair mentNo dosage adjustment is necessary in patients with renal impairment. In patients with chronic renal impairment, with creatinine clearances ranging rom 9.0 to 55 mL/min, AUC, maximum plasma concentration, half-life, and protein binding after single dose of 14C-finasteride were similar to those obtained in healthy volunteers. Urinary excretion of metabolites was decreased in patients with renal impairment. This decrease was associated with an increase in fecal excretion of metabolites. Plasma concentrations of metabolites were significantly higher in patients ith renal impairment (based on 60% increase in total radioactivity AUC). However, ifnasteride has been tolerated in men with normal renal function receiving up to 80 mg/day for 12 weeks where exposure of these patien ts to metabolites would presumably be much greater.Hepatic mpair mentThe effect of hepatic impairment on finasteride pharmacokinetics has not been studied. Caution should be used in the administration of finasteride tablets in patien ts with liver function abnormalities, as finasteride is metabolized extensively in the liver.

PREGNANCY SECTION.

8.1 Pregnancy. Pregnancy Category [see Contraindications (4)].Finasteride tablets is contraindicated for use in women who are or may become pregnant. Finasteride tablets is Type II -reductase inhibitor that prevents conversion of testosterone to -dihydrotestosterone (DHT), hormone necessary for normal development of male genitalia. In animal studies, finasteride caused abnormal development of external genitalia in male fet uses. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to the male fetu s.Abnormal male genital development is an expected consequence when conversion of testosterone to 5- dihydrotestosterone (DHT) is inhibited by -reductase inhibitors. These outcomes are similar to those reported in male infants with genetic -reductase deficiency. Women could be exposed to finasteride through contact with crushed or roken finasteride tablets or semen from male partner taking finasteride tablets. With regard to finasteride exposure th rough the skin, finasteride tablets are coated and will prevent skin contact with finasteride during norm al handling if the tablets have not been crushed or broken. Women who are pregnant or may beco me pregnant should not handle crushed or broken finasteride tablets because of possib le exposure of male fetus. If pregnant woman comes in contact with crushed or broken finasteride tablets, the contact area should be washed immediately with soap and water. With regard to potential finasteride xposure through semen, study has been conducted in men receiving finasteride tablets mg/day that measured finasteride concentrations in semen [see Clinical Pharmacology (12.3) ].In an embryo-fetal development study, pregnant rats received finasteride during the period of major organogenesis (gestation days to 17). At maternal doses of oral finasteride approximately to 684 times the recommended human dose (RHD) of mg/day (based on AUC at animal doses of 0.1 to 100 mg/kg/day) there was dose-dependent increase in hypospadias that occurred in 3.6 to 100% of male offspring. Exposure multiples were estimated using data from nonpregnant rats. Days 16 to 17 of gestation is critical period in male fetal rats for differentiation of the external genitalia. At oral maternal doses approximately 0.2 times the RHD (based on AUC at animal dose of 0.03 mg/kg/day), male offspring had decreased prostatic and seminal vesicular weights, delayed preputial separation and transient nipple development. Decreased anogenital distance occurred in male offspring of pregnant rats that received approximately 0.02 times the RHD (based on AUC at animal dose of 0.003 mg/kg/day). No abnormalities were observed in female offspring exposed to any dose of finasteride in utero. No developmental abnormalities were observed in the offspring of untreated females mated with finasteride-treated male rats that received approximately 488 times the RHD (based on AUC at animal dose of 80 mg/kg/day). Slightly decreased fertility was observed in male offspring after administration of about 20 times the RHD (based on AUC at animal dose of mg/kg/day) to female rats during late gestation and lactation. No effects on fertility were seen in female offspring under these conditions.No evidence of male external genital malformations or other abnormalities were observed in rabbit fetuses exposed to finasteride during the period of major organogenesis (gestation days to 18) at maternal doses up to 100 mg/kg/day (finasteride exposure levels were not measured in rabbits). However, this study may not have included the critical period for finasteride effects on development of male external genitalia in the rabbit.The fetal effects of maternal finasteride exposure during the period of embryonic and fetal development were evaluated in the rhesus monkey (gestation days 20 to 100), in species and development period more predictive of specific effects in humans than the studies in rats and rabbits. Intravenous administration of finasteride to pregnant monkeys at doses as high as 800 ng/day (estimated maximal blood concentration of 1.86 ng/mL or about 930 times the highest estimated exposure of pregnant women to finasteride from semen of men taking mg/day) resulted in no abnormalities in male fetuses. In confirmation of the relevance of the rhesus model for human fetal development, oral administration of dose of finasteride (2 mg/kg/day or approximately 120,000 times the highest estimated blood levels of finasteride from semen of men taking mg/day) to pregnant monkeys resulted in external genital abnormalities in male fetuses. No other abnormalities were observed in male fetuses and no finasteride- related abnormalities were observed in female fetuses at any dose.

WARNINGS AND PRECAUTIONS SECTION.

5 WARNINGS AND PRECAUTIONS. Finasteride tablets is not indicated for use in women or pediatric patients 5.1 5.4 ).Women should not handle crushed or broken finasteride tablets when they are pregnant or may potentially be pregnant due to potential risk to male fetus (5.1 8.1 16 ).Finasteride tablets causes decrease in serum PSA levels. Any confirmed increase in PSA while on finasteride tablets may signal the presence of prostate cancer and should be evaluated, even if those values are still ithin the normal range for men not taking 5-reductase inhibitor 5 2 ).5-reductase inhibitors may increase the risk of high grade prostate cancer 5 3 6 1 ).. Finasteride tablets is not indicated for use in women or pediatric patients 5.1 5.4 ).. Women should not handle crushed or broken finasteride tablets when they are pregnant or may potentially be pregnant due to potential risk to male fetus (5.1 8.1 16 ).. Finasteride tablets causes decrease in serum PSA levels. Any confirmed increase in PSA while on finasteride tablets may signal the presence of prostate cancer and should be evaluated, even if those values are still ithin the normal range for men not taking 5-reductase inhibitor 5 2 ).. 5-reductase inhibitors may increase the risk of high grade prostate cancer 5 3 6 1 ).. 5.1 Exposure of Women-Risk to Male Fetus. Finasteride tablets is not indicated for use in women. Women should not handle crushed or broken finasteride tablets when they are pregnant or may potentially be pregnant because of the possibility of absorption of finasteride and the subsequent potential risk to male fetus. Finasteride Tablets are coated and will prevent contact with the active ingredient during normal handling, provided that the tablets have not been broken or crushed [ See Indications and Usage (1), Contraindicat ions (4), Use in Specific Populations (8.1), How Supplied Storage and Handling 16 and Patient Counseling Infor mation (17.1).] 5.2 Effects on Prostate Specific Antigen (PSA). In clinical studies with finasteride tablets mg (finasteride, mg) in men 18 to 41 years of age, the mean value of serum prostate specific antigen (PSA) decreased from 0.7 ng/mL at ba seline to 0.5 ng/mL at Month 12. Further, in clinical studies with finasteride tablets mg (fina steride, mg) when used in older men who have benign prostatic hyperplasia (BPH), PSA levels are decreased by approxi mately 50%. Other studies with finasteride tablets mg showed it may al so cau se de crea ses in serum PSA in the pre sen ce of pro state can cer. The se findings should be taken into account for proper interpretation of serum PSA when evaluating men treated with fina steride. Any confirmed increa se rom the lowest PSA value while on finasteride tablets may signal the presence of prostate cancer and should be evaluated, even if PSA levels are still within the normal range for men not taking 5 -reductase inhibitor. Non-compl iance to therapy with finasteride tablets may also affe ct PSA te st re sult s. 5.3 Increased Risk of High-Grade Prostate Cancer with 5a-Reductase Inhibitors. Men aged 55 and over with normal digital rectal examination and PSA <=3.0 ng/mL at baseline taking finasteride mg/day (5 times the dose of finasteride tablets) in the 7-year Prostate Cancer Prevention Trial (PCPT) had an increased risk of Gleason score to 10 prost ate cancer (finasteride 1.8% vs placebo 1.1%). [See Adverse Reactions (6.1).] Similar results were observed in 4-year placebo-controlled clinical trial with another 5-reductase inhibitor (dutasteride, AVODART) (1% dutasteride vs 0.5% placebo). 5- reductase inhibitors may increase the risk of development of high-grade prostate cancer. Whether the effect of 5-reductase inhibitors to reduce prostate volume, or study-related factors, impacted the results of these studies has not been established.. 5.4 Pediatric Patients. Finasteride Tablets is not indicated for use in pediatric patients see Use in Specific Populations (8.4).