ADVERSE REACTIONS SECTION.

6 ADVERSE REACTIONS The following adverse reactions are discussed in greater detail in other sections of the labeling: oMyelosuppression [see Warnings and Precautions (5.1)]oRenal failure [see Warnings and Precautions (5.2)]oBullous and exfoliative skin toxicity [see Warning and Precautions (5.3)]oInterstitial pneumonitis [see Warnings and Precautions (5.4)]oRadiation recall [see Warnings and Precautions (5.5)]. oMyelosuppression [see Warnings and Precautions (5.1)]. oRenal failure [see Warnings and Precautions (5.2)]. oBullous and exfoliative skin toxicity [see Warning and Precautions (5.3)]. oInterstitial pneumonitis [see Warnings and Precautions (5.4)]. oRadiation recall [see Warnings and Precautions (5.5)]. oThe most common adverse reactions (incidence >=20%) of Pemetrexed for Injection, when administered as single agent are fatigue, nausea, and anorexia. (6.1) oThe most common adverse reactions (incidence >=20%) of Pemetrexed for Injection when administered with cisplatin are vomiting, neutropenia, anemia, stomatitis/pharyngitis, thrombocytopenia, and constipation. (6.1) oThe most common adverse reactions (incidence >=20%) of Pemetrexed for Injection when administered in combination with pembrolizumab and platinum chemotherapy are fatigue/asthenia, nausea, constipation, diarrhea, decreased appetite, rash, vomiting, cough, dyspnea, and pyrexia. (6.1)To report SUSPECTED ADVERSE REACTIONS, contact Baxter Healthcare Corporation at 1-866-888-2472 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. oThe most common adverse reactions (incidence >=20%) of Pemetrexed for Injection, when administered as single agent are fatigue, nausea, and anorexia. (6.1) oThe most common adverse reactions (incidence >=20%) of Pemetrexed for Injection when administered with cisplatin are vomiting, neutropenia, anemia, stomatitis/pharyngitis, thrombocytopenia, and constipation. (6.1) oThe most common adverse reactions (incidence >=20%) of Pemetrexed for Injection when administered in combination with pembrolizumab and platinum chemotherapy are fatigue/asthenia, nausea, constipation, diarrhea, decreased appetite, rash, vomiting, cough, dyspnea, and pyrexia. (6.1). 6.1 Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reactions rates cannot be directly compared to rates in other clinical trials and may not reflect the rates observed in clinical practice. In clinical trials, the most common adverse reactions (incidence >=20%) of Pemetrexed for Injection, when administered as single agent, are fatigue, nausea, and anorexia. The most common adverse reactions (incidence >=20%) of Pemetrexed for Injection, when administered in combination with cisplatin are vomiting, neutropenia, anemia, stomatitis/pharyngitis, thrombocytopenia, and constipation. The most common adverse reactions (incidence >=20%) of Pemetrexed for Injection, when administered in combination with pembrolizumab and platinum chemotherapy, are fatigue/asthenia, nausea, constipation, diarrhea, decreased appetite, rash, vomiting, cough, dyspnea, and pyrexia. Non-Squamous NSCLCFirst-line Treatment of Metastatic Non-squamous NSCLC with Pembrolizumab and Platinum Chemotherapy The safety of Pemetrexed for Injection, in combination with pembrolizumab and investigators choice of platinum (either carboplatin or cisplatin), was investigated in Study KEYNOTE-189, multicenter, double-blind, randomized (2:1), active-controlled trial in patients with previously untreated, metastatic non-squamous NSCLC with no EGFR or ALK genomic tumor aberrations. total of 607 patients received Pemetrexed for Injection, pembrolizumab, and platinum every weeks for cycles followed by Pemetrexed for Injection and pembrolizumab (n=405), or placebo, Pemetrexed for Injection, and platinum every weeks for cycles followed by placebo and Pemetrexed for Injection (n=202). Patients with autoimmune disease that required systemic therapy within years of treatment; medical condition that required immunosuppression; or who had received more than 30 Gy of thoracic radiation within the prior 26 weeks were ineligible [see Clinical Studies (14.1)].The median duration of exposure to Pemetrexed for Injection was 7.2 months (range: day to 1.7 years). Seventy-two percent of patients received carboplatin. The study population characteristics were: median age of 64 years (range: 34 to 84), 49% age 65 years or older, 59% male, 94% White and 3% Asian, and 18% with history of brain metastases at baseline. Pemetrexed for Injection was discontinued for adverse reactions in 23% of patients in the Pemetrexed for Injection, pembrolizumab, and platinum arm. The most common adverse reactions resulting in discontinuation of Pemetrexed for Injection in this arm were acute kidney injury (3%) and pneumonitis (2%). Adverse reactions leading to interruption of Pemetrexed for Injection occurred in 49% of patients in the Pemetrexed for Injection, pembrolizumab, and platinum arm. The most common adverse reactions or laboratory abnormalities leading to interruption of Pemetrexed for Injection in this arm (>=2%) were neutropenia (12%), anemia (7%), asthenia (4%), pneumonia (4%), thrombocytopenia (4%), increased blood creatinine (3%), diarrhea (3%), and fatigue (3%). Table summarizes the adverse reactions that occurred in >=20% of patients treated with Pemetrexed for Injection, pembrolizumab, and platinum. Table 2: Adverse Reactions Occurring in >=20% of Patients in KEYNOTE-189Pemetrexed for InjectionPembrolizumabPlatinum Chemotherapyn=405PlaceboPemetrexed for InjectionPlatinum Chemotherapyn=202Adverse Reaction All GradesGraded per NCI CTCAE version 4.03. (%)Grade 3-4 (%)All Grades (%)Grade 3-4 (%)Gastrointestinal Disorders Nausea 563.5523.5 Constipation 351.0320.5 Diarrhea 315213.0 Vomiting 243.7233.0General Disorders and Administration Site Conditions FatigueIncludes asthenia and fatigue.5612586 Pyrexia 200.2150Metabolism and Nutrition Disorders Decreased appetite 281.5300.5Skin and Subcutaneous Tissue Disorders RashIncludes genital rash, rash, rash generalized, rash macular, rash maculo-papular, rash papular, rash pruritic, and rash pustular.252.0172.5Respiratory, Thoracic and Mediastinal Disorders Cough 210280 Dyspnea 213.7265Table summarizes the laboratory abnormalities that worsened from baseline in at least 20% of patients treated with Pemetrexed for Injection, pembrolizumab, and platinum.Table 3: Laboratory Abnormalities Worsened from Baseline in >=20% of Patients in KEYNOTE-189Pemetrexed for InjectionPembrolizumab Platinum ChemotherapyPlacebo Pemetrexed for Injection Platinum ChemotherapyLaboratory TestEach test incidence is based on the number of patients who had both baseline and at least one on-study laboratory measurement available: Pemetrexed for Injection/pembrolizumab/platinum chemotherapy (range: 381 to 401 patients) and placebo/Pemetrexed for Injection/platinum chemotherapy (range: 184 to 197 patients).All GradesGraded per NCI CTCAE version 4.03. %Grades 3-4%All Grades%Grades 3-4%Chemistry Hyperglycemia 639607 Increased ALT 473.8422.6 Increased AST 472.8401.0 Hypoalbuminemia 392.8391.1 Increased creatinine 374.2251.0 Hyponatremia 327236 Hypophosphatemia 30102814 Increased alkaline phosphatase 261.8292.1 Hypocalcemia 242.8170.5 Hyperkalemia 242.8193.1 Hypokalemia 215205Hematology Anemia 85178118 Lymphopenia 64226425 Neutropenia 48204119 Thrombocytopenia 3012298Initial Treatment in Combination with Cisplatin The safety of Pemetrexed for Injection was evaluated in Study JMDB, randomized (1:1), open-label, multicenter trial conducted in chemotherapy-naive patients with locally advanced or metastatic NSCLC. Patients received either Pemetrexed for Injection 500 mg/m2 intravenously and cisplatin 75 mg/m2 intravenously on Day of each 21-day cycle (n=839) or gemcitabine 1250 mg/m2 intravenously on Days and and cisplatin 75 mg/m2 intravenously on Day of each 21-day cycle (n=830). All patients were fully supplemented with folic acid and vitamin B12. Study JMDB excluded patients with an Eastern Cooperative Oncology Group Performance Status (ECOG PS of or greater), uncontrolled third-space fluid retention, inadequate bone marrow reserve and organ function, or calculated creatinine clearance less than 45 mL/min. Patients unable to stop using aspirin or other non-steroidal anti-inflammatory drugs or unable to take folic acid, vitamin B12 or corticosteroids were also excluded from the study.The data described below reflect exposure to Pemetrexed for Injection plus cisplatin in 839 patients in Study JMDB. Median age was 61 years (range 26-83 years); 70% of patients were men; 78% were White, 16% were Asian, 2.9% were Hispanic or Latino, 2.1% were Black or African American, and <1% were other ethnicities; 36% had an ECOG PS 0. Patients received median of cycles of Pemetrexed for Injection. Table provides the frequency and severity of adverse reactions that occurred in >=5% of 839 patients receiving Pemetrexed for Injection in combination with cisplatin in Study JMDB. Study JMDB was not designed to demonstrate statistically significant reduction in adverse reaction rates for Pemetrexed for Injection, as compared to the control arm, for any specified adverse reaction listed in Table 4.Table 4: Adverse Reactions Occurring in >=5% of Fully Vitamin-Supplemented Patients Receiving Pemetrexed for Injection in Combination with Cisplatin Chemotherapy in Study JMDBAdverse ReactionNCI CTCAE version 2.0.Pemetrexed for Injection/ Cisplatin(N=839)Gemcitabine/Cisplatin (N=830)All Grades (%)Grade 3-4 (%)All Grades (%)Grade 3-4 (%)All adverse reactions 90379153Laboratory Hematologic Anemia 3364610 Neutropenia 29153827 Thrombocytopenia 1042713Renal Elevated creatinine 10171Clinical Constitutional symptoms Fatigue 437455Gastrointestinal Nausea 567534 Vomiting 406366 Anorexia 272241 Constipation 211200 Stomatitis/pharyngitis 141120 Diarrhea 121132 Dyspepsia/heartburn 5060Neurology Sensory neuropathy 90121 Taste disturbance 8090Dermatology/Skin Alopecia 120211 Rash/Desquamation 7081The following additional adverse reactions of Pemetrexed for Injection were observed. Incidence 1% to <5% Body as Whole -- febrile neutropenia, infection, pyrexia General Disorders -- dehydration Metabolism and Nutrition -- increased AST, increased ALT Renal -- renal failure Eye Disorder -- conjunctivitis Incidence <1% Cardiovascular -- arrhythmia General Disorders -- chest pain Metabolism and Nutrition -- increased GGT Neurology -- motor neuropathyMaintenance Treatment Following First-line Non-Pemetrexed for Injection Containing Platinum-Based Chemotherapy In Study JMEN, the safety of Pemetrexed for Injection was evaluated in randomized (2:1), placebo-controlled, multicenter trial conducted in patients with non-progressive locally advanced or metastatic NSCLC following four cycles of first-line, platinum-based chemotherapy regimen. Patients received either Pemetrexed for Injection 500 mg/m2 or matching placebo intravenously every 21 days until disease progression or unacceptable toxicity. Patients in both study arms were fully supplemented with folic acid and vitamin B12. Study JMEN excluded patients with an ECOG PS of or greater, uncontrolled third-space fluid retention, inadequate bone marrow reserve and organ function, or calculated creatinine clearance less than 45 mL/min. Patients unable to stop using aspirin or other non-steroidal anti-inflammatory drugs or unable to take folic acid, vitamin B12 or corticosteroids were also excluded from the study. The data described below reflect exposure to Pemetrexed for Injection in 438 patients in Study JMEN. Median age was 61 years (range 26-83 years), 73% of patients were men; 65% were White, 31% were Asian, 2.9% were Hispanic or Latino, and <2% were other ethnicities; 39% had an ECOG PS 0. Patients received median of cycles of Pemetrexed for Injection and relative dose intensity of Pemetrexed for Injection of 96%. Approximately half the patients (48%) completed at least six, 21-day cycles and 23% completed ten or more 21-day cycles of Pemetrexed for Injection. Table provides the frequency and severity of adverse reactions reported in >=5% of the 438 Pemetrexed for Injection-treated patients in Study JMEN.Table 5: Adverse Reactions Occurring in >=5% of Patients Receiving Pemetrexed for Injection in Study JMENAdverse ReactionNCI CTCAE version 3.0.Pemetrexed for Injection (N=438)Placebo(N=218)All Grades (%)Grade 3-4 (%)All Grades (%)Grade 3-4 (%)All adverse reactions 6616374 Laboratory Hematologic Anemia 15361 Neutropenia 6300 Hepatic Increased ALT 10040 Increased AST 8040 Clinical Constitutional symptoms Fatigue 255111 Gastrointestinal Nausea 19161 Anorexia 19250 Vomiting 9010 Mucositis/stomatitis 7120 Diarrhea 5130 Infection 5220 Neurology Sensory neuropathy 9140 Dermatology/Skin Rash/desquamation 10030The requirement for transfusions (9.5% versus 3.2%), primarily red blood cell transfusions, and for erythropoiesis stimulating agents (5.9% versus 1.8%) were higher in the Pemetrexed for Injection arm compared to the placebo arm. The following additional adverse reactions were observed in patients who received Pemetrexed for Injection. Incidence 1% to <5% Dermatology/Skin -- alopecia, pruritus/itching Gastrointestinal -- constipation General Disorders -- edema, fever Hematologic -- thrombocytopenia Eye Disorder -- ocular surface disease (including conjunctivitis), increased lacrimation Incidence <1% Cardiovascular -- supraventricular arrhythmia Dermatology/Skin -- erythema multiforme General Disorders -- febrile neutropenia, allergic reaction/hypersensitivity Neurology -- motor neuropathy Renal -- renal failure Maintenance Treatment Following First-line Pemetrexed for Injection Plus Platinum Chemotherapy The safety of Pemetrexed for Injection was evaluated in PARAMOUNT, randomized (2:1), placebo-controlled study conducted in patients with non-squamous NSCLC with non-progressive (stable or responding disease) locally advanced or metastatic NSCLC following four cycles of Pemetrexed for Injection in combination with cisplatin as first-line therapy for NSCLC. Patients were randomized to receive Pemetrexed for Injection 500 mg/m2 or matching placebo intravenously on Day of each 21-day cycle until disease progression or unacceptable toxicity. Patients in both study arms received folic acid and vitamin B12 supplementation. PARAMOUNT excluded patients with an ECOG PS of or greater, uncontrolled third-space fluid retention, inadequate bone marrow reserve and organ function, or calculated creatinine clearance less than 45 mL/min. Patients unable to stop using aspirin or other non-steroidal anti-inflammatory drugs or unable to take folic acid, vitamin B12 or corticosteroids were also excluded from the study. The data described below reflect exposure to Pemetrexed for Injection in 333 patients in PARAMOUNT. Median age was 61 years (range 32 to 83 years); 58% of patients were men; 94% were White, 4.8% were Asian, and <1% were Black or African American; 36% had an ECOG PS 0. The median number of maintenance cycles was for Pemetrexed for Injection and placebo arms. Dose reductions for adverse reactions occurred in 3.3% of patients in the Pemetrexed for Injection arm and 0.6% in the placebo arm. Dose delays for adverse reactions occurred in 22% of patients in the Pemetrexed for Injection arm and 16% in the placebo arm. Table provides the frequency and severity of adverse reactions reported in >=5% of the 333 Pemetrexed for Injection-treated patients in PARAMOUNT.Table 6: Adverse Reactions Occurring in >=5% of Patients Receiving Pemetrexed for Injection in PARAMOUNTAdverse ReactionNCI CTCAE version 3.0.Pemetrexed for Injection (N=333)Placebo(N=167)All Grades (%)Grade 3-4 (%)All Grades (%)Grades 3-4 (%)All adverse reactions 5317344.8 Laboratory Hematologic Anemia 154.84.80.6 Neutropenia 93.90.60Clinical Constitutional symptoms Fatigue 184.5110.6 Gastrointestinal Nausea 120.32.40 Vomiting 601.80 Mucositis/stomatitis 50.32.40 General disorders Edema 503.60The requirement for red blood cell (13% versus 4.8%) and platelet (1.5% versus 0.6%) transfusions, erythropoiesis stimulating agents (12% versus 7%), and granulocyte colony stimulating factors (6% versus 0%) were higher in the Pemetrexed for Injection arm compared to the placebo arm. The following additional Grade or adverse reactions were observed more frequently in the Pemetrexed for Injection arm. Incidence 1% to <5% Blood/Bone Marrow -- thrombocytopenia General Disorders -- febrile neutropenia Incidence <1% Cardiovascular -- ventricular tachycardia, syncope General Disorders -- pain Gastrointestinal -- gastrointestinal obstruction Neurologic -- depression Renal -- renal failure Vascular -- pulmonary embolismTreatment of Recurrent Disease After Prior ChemotherapyThe safety of Pemetrexed for Injection was evaluated in Study JMEI, randomized (1:1), open-label, active-controlled trial conducted in patients who had progressed following platinum-based chemotherapy. Patients received Pemetrexed for Injection 500 mg/m2 intravenously or docetaxel 75 mg/m2 intravenously on Day of each 21-day cycle. All patients on the Pemetrexed for Injection arm received folic acid and vitamin B12 supplementation. Study JMEI excluded patients with an ECOG PS of or greater, uncontrolled third-space fluid retention, inadequate bone marrow reserve and organ function, or calculated creatinine clearance less than 45 mL/min. Patients unable to discontinue aspirin or other non-steroidal anti-inflammatory drugs or unable to take folic acid, vitamin B12 or corticosteroids were also excluded from the study. The data described below reflect exposure to Pemetrexed for Injection in 265 patients in Study JMEI. Median age was 58 years (range 22 to 87 years); 73% of patients were men; 70% were White, 24% were Asian, 2.6% were Black or African American, 1.8% were Hispanic or Latino, and <2% were other ethnicities; 19% had an ECOG PS 0. Table provides the frequency and severity of adverse reactions reported in >=5% of the 265 Pemetrexed for Injection-treated patients in Study JMEI. Study JMEI is not designed to demonstrate statistically significant reduction in adverse reaction rates for Pemetrexed for Injection, as compared to the control arm, for any specified adverse reaction listed in the Table below.Table 7: Adverse Reactions Occurring in >=5% of Fully Supplemented Patients Receiving Pemetrexed for Injection in Study JMEIAdverse ReactionNCI CTCAE version 2.0.Pemetrexed for Injection (N=265)Docetaxel(N=276)All Grades (%)Grades 3-4 (%)All Grade (%)Grades 3-4 (%) Laboratory Hematologic Anemia 194224 Neutropenia 1154540 Thrombocytopenia 8210 Hepatic Increased ALT 8210 Increased AST 7110 Clinical Gastrointestinal Nausea 313172 Anorexia 222243 Vomiting 162121 Stomatitis/pharyngitis 151171 Diarrhea 130243 Constipation 6040 Constitutional symptoms Fatigue 345365 Fever 8080 Dermatology/Skin Rash/desquamation 14060 Pruritus 7020 Alopecia 61382The following additional adverse reactions were observed in patients assigned to receive Pemetrexed for Injection. Incidence 1% to <5% Body as Whole -- abdominal pain, allergic reaction/hypersensitivity, febrile neutropenia, infection Dermatology/Skin -- erythema multiforme Neurology -- motor neuropathy, sensory neuropathy Incidence <1% Cardiovascular -- supraventricular arrhythmias Renal -- renal failure Mesothelioma The safety of Pemetrexed for Injection was evaluated in Study JMCH, randomized (1:1), single-blind study conducted in patients with MPM who had received no prior chemotherapy for MPM. Patients received Pemetrexed for Injection 500 mg/m2 intravenously in combination with cisplatin 75 mg/m2 intravenously on Day of each 21-day cycle or cisplatin 75 mg/m2 intravenously on Day of each 21-day cycle administered until disease progression or unacceptable toxicity. Safety was assessed in 226 patients who received at least one dose of Pemetrexed for Injection in combination with cisplatin and 222 patients who received at least one dose of cisplatin alone. Among 226 patients who received Pemetrexed for Injection in combination with cisplatin, 74% (n=168) received full supplementation with folic acid and vitamin B12 during study therapy, 14% (n=32) were never supplemented, and 12% (n=26) were partially supplemented. Study JMCH excluded patients with Karnofsky Performance Scale (KPS) of less than 70, inadequate bone marrow reserve and organ function, or calculated creatinine clearance less than 45 mL/min. Patients unable to stop using aspirin or other non-steroidal anti-inflammatory drugs were also excluded from the study. The data described below reflect exposure to Pemetrexed for Injection in 168 patients that were fully supplemented with folic acid and vitamin B12. Median age was 60 years (range 19 to 85 years); 82% were men; 92% were White, 5% were Hispanic or Latino, 3.0% were Asian, and <1% were other ethnicities; 54% had KPS of 90-100. The median number of treatment cycles administered was in the Pemetrexed for Injection/cisplatin fully supplemented group and in the Pemetrexed for Injection/cisplatin never supplemented group. Patients receiving Pemetrexed for Injection in the fully supplemented group had relative dose intensity of 93% of the protocol-specified Pemetrexed for Injection dose intensity. The most common adverse reaction resulting in dose delay was neutropenia. Table provides the frequency and severity of adverse reactions >=5% in the subgroup of Pemetrexed for Injection-treated patients who were fully vitamin supplemented in Study JMCH. Study JMCH was not designed to demonstrate statistically significant reduction in adverse reaction rates for Pemetrexed for Injection, as compared to the control arm, for any specified adverse reaction listed in the table below.Table 8: Adverse Reactions Occurring in >=5% of Fully Supplemented Subgroup of Patients Receiving Pemetrexed for Injection/Cisplatin in Study JMCHIn Study JMCH, 226 patients received at least one dose of Pemetrexed for Injection in combination with cisplatin and 222 patients received at least one dose of cisplatin. Table provides the ADRs for subgroup of patients treated with Pemetrexed for Injection in combination with cisplatin (168 patients) or cisplatin alone (163 patients) who received full supplementation with folic acid and vitamin B12 during study therapy. Adverse ReactionNCI CTCAE version 2.0.Pemetrexed for Injection/cisplatin(N=168)Cisplatin(N=163)All Grades (%)Grade 3-4 (%)All Grades (%)Grade 3-4 (%) Laboratory Hematologic Neutropenia 5623133 Anemia 264100 Thrombocytopenia 23590 Renal Elevated creatinine 111101 Decreased creatinine clearance 161182 Clinical Eye Disorder Conjunctivitis 5010 Gastrointestinal Nausea 8212776 Vomiting 5711504 Stomatitis/pharyngitis 23360 Anorexia 201141 Diarrhea 17480 Constipation 12171 Dyspepsia 5110 Constitutional Symptoms Fatigue 4810429 Metabolism and Nutrition Dehydration 7411 Neurology Sensory neuropathy 100101 Taste disturbance 8060 Dermatology/Skin Rash 16150 Alopecia 11060The following additional adverse reactions were observed in patients receiving Pemetrexed for Injection plus cisplatin: Incidence 1% to <5% Body as Whole -- febrile neutropenia, infection, pyrexia Dermatology/Skin -- urticaria General Disorders -- chest pain Metabolism and Nutrition -- increased AST, increased ALT, increased GGT Renal -- renal failure Incidence <1% Cardiovascular -- arrhythmia Neurology -- motor neuropathy Exploratory Subgroup Analyses based on Vitamin Supplementation Table provides the results of exploratory analyses of the frequency and severity of NCI CTCAE Grade or adverse reactions reported in more Pemetrexed for Injection-treated patients who did not receive vitamin supplementation (never supplemented) as compared with those who received vitamin supplementation with daily folic acid and vitamin B12 from the time of enrollment in Study JMCH (fully-supplemented). Table 9: Exploratory Subgroup Analysis of Selected Grade 3/4 Adverse Reactions Occurring in Patients Receiving Pemetrexed for Injection in Combination with Cisplatin with or without Full Vitamin Supplementation in Study JMCHNCI CTCAE version 2.0. Grade 3-4 Adverse Reactions Fully Supplemented Patients N=168 (%)Never Supplemented PatientsN=32 (%)Neutropenia 2338Thrombocytopenia 59Vomiting 1131Febrile neutropenia 19Infection with Grade 3/4 neutropenia 06Diarrhea 49The following adverse reactions occurred more frequently in patients who were fully vitamin supplemented than in patients who were never supplemented: ohypertension (11% versus 3%), ochest pain (8% versus 6%), othrombosis/embolism (6% versus 3%). Additional Experience Across Clinical Trials Sepsis, with or without neutropenia, including fatal cases: 1%Severe esophagitis, resulting in hospitalization: <1%. Nausea Constipation Diarrhea Vomiting FatigueIncludes asthenia and fatigue.. Pyrexia Decreased appetite RashIncludes genital rash, rash, rash generalized, rash macular, rash maculo-papular, rash papular, rash pruritic, and rash pustular.. Cough Dyspnea Hyperglycemia Increased ALT Increased AST Hypoalbuminemia Increased creatinine Hyponatremia Hypophosphatemia Increased alkaline phosphatase Hypocalcemia Hyperkalemia Hypokalemia Anemia Lymphopenia Neutropenia Thrombocytopenia Anemia Neutropenia Thrombocytopenia Elevated creatinine Fatigue Nausea Vomiting Anorexia Constipation Stomatitis/pharyngitis Diarrhea Dyspepsia/heartburn Sensory neuropathy Taste disturbance Alopecia Rash/Desquamation Incidence 1% to <5% Body as Whole -- febrile neutropenia, infection, pyrexia General Disorders -- dehydration Metabolism and Nutrition -- increased AST, increased ALT Renal -- renal failure Eye Disorder -- conjunctivitis Incidence <1% Cardiovascular -- arrhythmia General Disorders -- chest pain Metabolism and Nutrition -- increased GGT Neurology -- motor neuropathy. Laboratory. Hematologic. Anemia Neutropenia Hepatic. Increased ALT Increased AST Clinical. Constitutional symptoms. Fatigue Gastrointestinal. Nausea Anorexia Vomiting Mucositis/stomatitis Diarrhea Infection Neurology. Sensory neuropathy Dermatology/Skin. Rash/desquamation Incidence 1% to <5% Dermatology/Skin -- alopecia, pruritus/itching Gastrointestinal -- constipation General Disorders -- edema, fever Hematologic -- thrombocytopenia Eye Disorder -- ocular surface disease (including conjunctivitis), increased lacrimation Incidence <1% Cardiovascular -- supraventricular arrhythmia Dermatology/Skin -- erythema multiforme General Disorders -- febrile neutropenia, allergic reaction/hypersensitivity Neurology -- motor neuropathy Renal -- renal failure Laboratory Hematologic Anemia Neutropenia Constitutional symptoms Fatigue Gastrointestinal Nausea Vomiting Mucositis/stomatitis General disorders Edema Incidence 1% to <5% Blood/Bone Marrow -- thrombocytopenia General Disorders -- febrile neutropenia Incidence <1% Cardiovascular -- ventricular tachycardia, syncope General Disorders -- pain Gastrointestinal -- gastrointestinal obstruction Neurologic -- depression Renal -- renal failure Vascular -- pulmonary embolism. Laboratory Hematologic Anemia Neutropenia Thrombocytopenia Hepatic Increased ALT Increased AST Clinical Gastrointestinal Nausea Anorexia Vomiting Stomatitis/pharyngitis Diarrhea Constipation Constitutional symptoms Fatigue Fever Dermatology/Skin Rash/desquamation Pruritus Alopecia Incidence 1% to <5% Body as Whole -- abdominal pain, allergic reaction/hypersensitivity, febrile neutropenia, infection Dermatology/Skin -- erythema multiforme Neurology -- motor neuropathy, sensory neuropathy Incidence <1% Cardiovascular -- supraventricular arrhythmias Renal -- renal failure Laboratory Hematologic Neutropenia Anemia Thrombocytopenia Renal Elevated creatinine Decreased creatinine clearance Clinical Eye Disorder Conjunctivitis Gastrointestinal Nausea Vomiting Stomatitis/pharyngitis Anorexia Diarrhea Constipation Dyspepsia Constitutional Symptoms Fatigue Metabolism and Nutrition Dehydration Neurology Sensory neuropathy Taste disturbance Dermatology/Skin Rash Alopecia Incidence 1% to <5% Body as Whole -- febrile neutropenia, infection, pyrexia Dermatology/Skin -- urticaria General Disorders -- chest pain Metabolism and Nutrition -- increased AST, increased ALT, increased GGT Renal -- renal failure Incidence <1% Cardiovascular -- arrhythmia Neurology -- motor neuropathy ohypertension (11% versus 3%), ochest pain (8% versus 6%), othrombosis/embolism (6% versus 3%). Sepsis, with or without neutropenia, including fatal cases: 1%Severe esophagitis, resulting in hospitalization: <1%. 6.2 Postmarketing Experience The following adverse reactions have been identified during post-approval use of Pemetrexed for Injection. 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. Blood and Lymphatic System -- immune-mediated hemolytic anemia Gastrointestinal -- colitis, pancreatitis General Disorders and Administration Site Conditions -- edema Injury, poisoning, and procedural complications -- radiation recall Respiratory -- interstitial pneumonitis Skin -- Serious and fatal bullous skin conditions, Stevens-Johnson syndrome, and toxic epidermal necrolysis. Blood and Lymphatic System -- immune-mediated hemolytic anemia Gastrointestinal -- colitis, pancreatitis General Disorders and Administration Site Conditions -- edema Injury, poisoning, and procedural complications -- radiation recall Respiratory -- interstitial pneumonitis Skin -- Serious and fatal bullous skin conditions, Stevens-Johnson syndrome, and toxic epidermal necrolysis.

CARCINOGENESIS & MUTAGENESIS & IMPAIRMENT OF FERTILITY SECTION.

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility No carcinogenicity studies have been conducted with pemetrexed. Pemetrexed was clastogenic in an in vivo micronucleus assay in mouse bone marrow but was not mutagenic in multiple in vitro tests (Ames assay, Chinese Hamster Ovary cell assay). Pemetrexed administered intraperitoneally at doses of >=0.1 mg/kg/day to male mice (approximately 0.006 times the recommended human dose based on BSA) resulted in reduced fertility, hypospermia, and testicular atrophy.

CLINICAL PHARMACOLOGY SECTION.

12 CLINICAL PHARMACOLOGY 12.1 Mechanism of Action Pemetrexed for Injection is folate analog metabolic inhibitor that disrupts folate-dependent metabolic processes essential for cell replication. In vitro studies show that pemetrexed inhibits thymidylate synthase (TS), dihydrofolate reductase, and glycinamide ribonucleotide formyltransferase (GARFT), which are folate-dependent enzymes involved in the de novo biosynthesis of thymidine and purine nucleotides. Pemetrexed is taken into cells by membrane carriers such as the reduced folate carrier and membrane folate binding protein transport systems. Once in the cell, pemetrexed is converted to polyglutamate forms by the enzyme folylpolyglutamate synthetase. The polyglutamate forms are retained in cells and are inhibitors of TS and GARFT.. 12.2 Pharmacodynamics Pemetrexed inhibited the in vitro growth of mesothelioma cell lines (MSTO-211H, NCI-H2052) and showed synergistic effects when combined with cisplatin. Based on population pharmacodynamic analyses, the depth of the absolute neutrophil counts (ANC) nadir correlates with the systemic exposure to pemetrexed and supplementation with folic acid and vitamin B12. There is no cumulative effect of pemetrexed exposure on ANC nadir over multiple treatment cycles. 12.3 Pharmacokinetics AbsorptionThe pharmacokinetics of pemetrexed when Pemetrexed for Injection was administered as single agent in doses ranging from 0.2 to 838 mg/m2 infused over 10-minute period have been evaluated in 426 cancer patients with variety of solid tumors. Pemetrexed total systemic exposure (AUC) and maximum plasma concentration (Cmax) increased proportionally with increase of dose. The pharmacokinetics of pemetrexed did not change over multiple treatment cycles. DistributionPemetrexed has steady-state volume of distribution of 16.1 liters. In vitro studies indicated that pemetrexed is 81% bound to plasma proteins. EliminationThe total systemic clearance of pemetrexed is 91.8 mL/min and the elimination half-life of pemetrexed is 3.5 hours in patients with normal renal function (creatinine clearance of 90 mL/min). As renal function decreases, the clearance of pemetrexed decreases and exposure (AUC) of pemetrexed increases. MetabolismPemetrexed is not metabolized to an appreciable extent. Excretion Pemetrexed is primarily eliminated in the urine, with 70% to 90% of the dose recovered unchanged within the first 24 hours following administration. In vitro studies indicated that pemetrexed is substrate of OAT3 (organic anion transporter 3), transporter that is involved in the active secretion of pemetrexed. Specific PopulationsAge (26 to 80 years) and sex had no clinically meaningful effect on the systemic exposure of pemetrexed based on population pharmacokinetic analyses. Racial Groups The pharmacokinetics of pemetrexed were similar in Whites and Blacks or African Americans. Insufficient data are available for other ethnic groups.Patients with Hepatic ImpairmentPemetrexed has not been formally studied in patients with hepatic impairment. No effect of elevated AST, ALT, or total bilirubin on the PK of pemetrexed was observed in clinical studies. Patients with Renal ImpairmentPharmacokinetic analyses of pemetrexed included 127 patients with impaired renal function. Plasma clearance of pemetrexed decreases as renal function decreases, with resultant increase in systemic exposure. Patients with creatinine clearances of 45, 50, and 80 mL/min had 65%, 54%, and 13% increases, respectively in systemic exposure (AUC) compared to patients with creatinine clearance of 100 mL/min [see Dosage and Administration (2.3) and Warnings and Precautions (5.2)]. Third-Space FluidThe pemetrexed plasma concentrations in patients with various solid tumors with stable, mild to moderate third-space fluid were comparable to those observed in patients without third space fluid collections. The effect of severe third space fluid on pharmacokinetics is not known. Drug Interaction StudiesDrugs Inhibiting OAT3 TransporterIbuprofen, an OAT3 inhibitor, administered at 400 mg four times day decreased the clearance of pemetrexed and increased its exposure (AUC) by approximately 20% in patients with normal renal function (creatinine clearance >80 mL/min). In Vitro Studies Pemetrexed is substrate for OAT3. Ibuprofen, an OAT3 inhibitor inhibited the uptake of pemetrexed in OAT3-expressing cell cultures with an average [Iu]/IC50 ratio of 0.38. In vitro data predict that at clinically relevant concentrations, other NSAIDs (naproxen, diclofenac, celecoxib) would not inhibit the uptake of pemetrexed by OAT3 and would not increase the AUC of pemetrexed to clinically significant extent. [see Drug Interactions (7)]. Pemetrexed is substrate for OAT4. In vitro, ibuprofen and other NSAIDs (naproxen, diclofenac, celecoxib) are not inhibitors of OAT4 at clinically relevant concentrations. AspirinAspirin, administered in low to moderate doses (325 mg every hours), does not affect the pharmacokinetics of pemetrexed. CisplatinCisplatin does not affect the pharmacokinetics of pemetrexed and the pharmacokinetics of total platinum are unaltered by pemetrexed. Vitamins Neither folic acid nor vitamin B12 affect the pharmacokinetics of pemetrexed. Drugs Metabolized by Cytochrome P450 Enzymes In vitro studies suggest that pemetrexed does not inhibit the clearance of drugs metabolized by CYP3A, CYP2D6, CYP2C9, and CYP1A2.

CLINICAL STUDIES SECTION.

14 CLINICAL STUDIES 14.1 Non-Squamous NSCLC Initial Treatment in Combination with Pembrolizumab and Platinum The efficacy of Pemetrexed for Injection in combination with pembrolizumab and platinum chemotherapy was investigated in Study KEYNOTE-189 (NCT02578680), randomized, multicenter, double-blind, active-controlled trial conducted in patients with metastatic non-squamous NSCLC, regardless of PD-L1 tumor expression status, who had not previously received systemic therapy for metastatic disease and in whom there were no EGFR or ALK genomic tumor aberrations. Patients with autoimmune disease that required systemic therapy within years of treatment; medical condition that required immunosuppression; or who had received more than 30 Gy of thoracic radiation within the prior 26 weeks were ineligible. Randomization was stratified by smoking status (never versus former/current), choice of platinum (cisplatin versus carboplatin), and tumor PD-L1 status (TPS <1% [negative] versus TPS >=1%). Patients were randomized (2:1) to one of the following treatment arms: oPemetrexed for Injection 500 mg/m2, pembrolizumab 200 mg, and investigators choice of cisplatin 75 mg/m2 or carboplatin AUC mg/mL/min intravenously on Day of each 21-day cycle for cycles followed by Pemetrexed for Injection 500 mg/m2 and pembrolizumab 200 mg intravenously every weeks. Pemetrexed for Injection was administered after pembrolizumab and prior to platinum chemotherapy on Day 1. oPlacebo, Pemetrexed for Injection 500 mg/m2, and investigators choice of cisplatin 75 mg/m2 or carboplatin AUC mg/mL/min intravenously on Day of each 21-day cycle for cycles followed by placebo and Pemetrexed for Injection 500 mg/m2 intravenously every weeks. Treatment with Pemetrexed for Injection continued until RECIST v1.1 (modified to follow maximum of 10 target lesions and maximum of target lesions per organ)-defined progression of disease as determined by the investigator or unacceptable toxicity. Patients randomized to placebo, Pemetrexed for Injection, and platinum chemotherapy were offered pembrolizumab as single agent at the time of disease progression.Assessment of tumor status was performed at Week 6, Week 12, and then every weeks thereafter. The main efficacy outcome measures were OS and PFS as assessed by BICR RECIST v1.1, modified to follow maximum of 10 target lesions and maximum of five target lesions per organ. Additional efficacy outcome measures were ORR and duration of response, as assessed by the BICR according to RECIST v1.1, modified to follow maximum of 10 target lesions and maximum of target lesions per organ. total of 616 patients were randomized: 410 patients to the Pemetrexed for Injection, pembrolizumab, and platinum chemotherapy arm and 206 to the placebo, Pemetrexed for Injection, and platinum chemotherapy arm. The study population characteristics were: median age of 64 years (range: 34 to 84); 49% age 65 or older; 59% male; 94% White and 3% Asian; 56% ECOG performance status of 1; and 18% with history of brain metastases. Thirty-one percent had tumor PD-L1 expression TPS <1%. Seventy-two percent received carboplatin and 12% were never smokers. total of 85 patients in the placebo, Pemetrexed for Injection, and chemotherapy arm received an anti-PD-1/PD-L1 monoclonal antibody at the time of disease progression.The trial demonstrated statistically significant improvement in OS and PFS for patients randomized to Pemetrexed for Injection in combination with pembrolizumab and platinum chemotherapy compared with placebo, Pemetrexed for Injection, and platinum chemotherapy (see Table 10 and Figure 1).Table 10: Efficacy Results of KEYNOTE-189Endpoint Pemetrexed for Injection Pembrolizumab Platinum Chemotherapyn=410Placebo Pemetrexed for Injection Platinum Chemotherapyn=206OS Number (%) of patients with event 127 (31%)108 (52%) Median in months (95% CI) NR(NR, NR)11.3(8.7, 15.1) Hazard ratioBased on the stratified Cox proportional hazard model. (95% CI) 0.49 (0.38, 0.64) p-valueBased on stratified log-rank test.<0.0001PFS Number of patients with event (%) 244 (60%)166 (81%) Median in months (95% CI) 8.8 (7.6, 9.2)4.9 (4.7, 5.5) Hazard ratio (95% CI) 0.52 (0.43, 0.64) p-value<0.0001ORR Overall response rateResponse: Best objective response as confirmed complete response or partial response.(95% CI) 48% (43, 53)19% (14, 25) Complete response 0.5%0.5% Partial response 47%18% p-valueBased on Miettinen and Nurminen method stratified by PD-L1 status, platinum chemotherapy and smoking status.NR not reached <0.0001Duration of Response Median in months (range) 11.2 (1.1+, 18.0+)7.8 (2.1+, 16.4+)Figure 1: Kaplan-Meier Curve for Overall Survival in KEYNOTE-189Initial Treatment in Combination with CisplatinThe efficacy of Pemetrexed for Injection was evaluated in Study JMDB (NCT00087711), multi-center, randomized (1:1), open-label study conducted in 1725 chemotherapy-naive patients with Stage IIIb/IV NSCLC. Patients were randomized to receive Pemetrexed for Injection with cisplatin or gemcitabine with cisplatin. Randomization was stratified by Eastern Cooperative Oncology Group Performance Status (ECOG PS versus 1), gender, disease stage, basis for pathological diagnosis (histopathological/cytopathological), history of brain metastases, and investigative center. Pemetrexed for Injection was administered intravenously over 10 minutes at dose of 500 mg/m2 on Day of each 21-day cycle. Cisplatin was administered intravenously at dose of 75 mg/m2 approximately 30 minutes after Pemetrexed for Injection administration on Day of each cycle, gemcitabine was administered at dose of 1250 mg/m2 on Day and Day 8, and cisplatin was administered intravenously at dose of 75 mg/m2 approximately 30 minutes after administration of gemcitabine, on Day of each 21-day cycle. Treatment was administered up to total of cycles; patients in both arms received folic acid, vitamin B12, and dexamethasone [see Dosage and Administration (2.4)]. The primary efficacy outcome measure was overall survival. total of 1725 patients were enrolled with 862 patients randomized to Pemetrexed for Injection in combination with cisplatin and 863 patients to gemcitabine in combination with cisplatin. The median age was 61 years (range 26-83 years), 70% were male, 78% were White, 17% were Asian, 2.9% were Hispanic or Latino, and 2.1% were Black or African American, and <1% were other ethnicities. Among patients for whom ECOG PS (n=1722) and smoking history (n=1516) were collected, 65% had an ECOG PS of 1, 36% had an ECOG PS of 0, and 84% were smokers. For tumor characteristics, 73% had non-squamous NSCLC and 27% had squamous NSCLC; 76% had Stage IV disease. Among 1252 patients with non-squamous NSCLC histology, 68% had diagnosis of adenocarcinoma, 12% had large cell histology and 20% had other histologic subtypes. Efficacy results in Study JMDB are presented in Table 11 and Figure 2.Table 11: Efficacy Results in Study JMDBEfficacy Parameter Pemetrexed for Injectionplus Cisplatin (N=862)Gemcitabine plus Cisplatin(N=863)Overall Survival Median (months) (95% CI) 10.3(9.8-11.2)10.3(9.6-10.9) Hazard ratio (HR)Unadjusted for multiple comparisons.Adjusted for gender, stage, basis of diagnosis, and performance status.(95% CI) 0.94(0.84-1.05)Progression-Free Survival Median (months)(95% CI) 4.8(4.6-5.3)5.1(4.6-5.5) Hazard ratio (HR)a,b (95% CI) 1.04(0.94-1.15)Overall Response Rate (95% CI) 27.1%(24.2-30.1)24.7%(21.8-27.6)Figure 2: Kaplan-Meier Curves for Overall Survival in Study JMDBIn pre-specified analyses assessing the impact of NSCLC histology on overall survival, clinically relevant differences in survival according to histology were observed. These subgroup analyses are shown in Table 12 and Figure and 4. This difference in treatment effect for Pemetrexed for Injection based on histology demonstrating lack of efficacy in squamous cell histology was also observed in Studies JMEN and JMEI. Table 12: Overall Survival in NSCLC Histologic Subgroups in Study JMDBHistologic Subgroups Pemetrexed for Injectionplus Cisplatin (N=862)Gemcitabine plus Cisplatin(N=863)Non-squamous NSCLC (N=1252) Median (months) (95% CI) 11.0(10.1-12.5)10.1(9.3-10.9) HRUnadjusted for multiple comparisons.Adjusted for ECOG PS, gender, disease stage, and basis for pathological diagnosis (histopathological/cytopathological).(95% CI) 0.84(0.74-0.96)Adenocarcinoma (N=847) Median (months) (95% CI) 12.6 (10.7-13.6)10.9 (10.2-11.9) HR(95% CI) 0.84 (0.71-0.99)Large Cell (N=153) Median (months) (95% CI) 10.4 (8.6-14.1)6.7 (5.5-9.0) HR(95% CI) 0.67 (0.48-0.96)Non-squamous, not otherwise specified (N=252) Median (months) (95% CI) 8.6 (6.8-10.2)9.2 (8.1-10.6) HR(95% CI) 1.08 (0.81-1.45)Squamous Cell (N=473) Median (months) (95% CI) 9.4 (8.4-10.2)10.8 (9.5-12.1) HR(95% CI) 1.23 (1.00-1.51)Figure 3: Kaplan-Meier Curves for Overall Survival in Non-squamous NSCLC in Study JMDBFigure 4: Kaplan-Meier Curves for Overall Survival in Squamous NSCLC in Study JMDBMaintenance Treatment Following First-line Non-Pemetrexed for Injection Containing Platinum-Based ChemotherapyThe efficacy of Pemetrexed for Injection as maintenance therapy following first-line platinum-based chemotherapy was evaluated in Study JMEN (NCT00102804), multicenter, randomized (2:1), double-blind, placebo-controlled study conducted in 663 patients with Stage IIIb/IV NSCLC who did not progress after four cycles of platinum-based chemotherapy. Patients were randomized to receive Pemetrexed for Injection 500 mg/m2 intravenously every 21 days or placebo until disease progression or intolerable toxicity. Patients in both study arms received folic acid, vitamin B12, and dexamethasone [see Dosage and Administration (2.4)]. Randomization was carried out using minimization approach [Pocock and Simon (1975)] using the following factors: gender, ECOG PS (0 versus 1), response to prior chemotherapy (complete or partial response versus stable disease), history of brain metastases (yes versus no), non-platinum component of induction therapy (docetaxel versus gemcitabine versus paclitaxel), and disease stage (IIIb versus IV). The major efficacy outcome measures were progression-free survival based on assessment by independent review and overall survival; both were measured from the date of randomization in Study JMEN. total of 663 patients were enrolled with 441 patients randomized to Pemetrexed for Injection and 222 patients randomized to placebo. The median age was 61 years (range 26-83 years); 73% were male; 65% were White, 32% were Asian, 2.9% were Hispanic or Latino, and <2% were other ethnicities; 60% had an ECOG PS of 1; and 73% were current or former smokers. Median time from initiation of platinum-based chemotherapy to randomization was 3.3 months (range 1.6 to 5.1 months) and 49% of the population achieved partial or complete response to first-line, platinum-based chemotherapy. With regard to tumor characteristics, 81% had Stage IV disease, 73% had non-squamous NSCLC and 27% had squamous NSCLC. Among the 481 patients with non-squamous NSCLC, 68% had adenocarcinoma, 4% had large cell, and 28% had other histologies. Efficacy results are presented in Table 13 and Figure 5.Table 13: Efficacy Results in Study JMENEfficacy Parameter Pemetrexed for InjectionPlaceboOverall survival N=441N=222 Median (months) (95% CI) 13.4(11.9-15.9)10.6(8.7-12.0) Hazard ratioHazard ratios are adjusted for multiplicity but not for stratification variables.(95% CI) 0.79(0.65-0.95) p-value p=0.012Progression-free survival per independent reviewN=387N=194 Median (months) (95% CI) 4.0(3.1-4.4)2.0(1.5-2.8) Hazard ratio(95% CI) 0.60(0.49-0.73) p-value p<0.00001Figure 5: Kaplan-Meier Curves for Overall Survival in Study JMENThe results of pre-specified subgroup analyses by NSCLC histology are presented in Table 14 and and 7. Table 14: Efficacy Results in Study JMEN by Histologic SubgroupOverall SurvivalProgression-Free Survival Per Independent ReviewEfficacy ParameterPemetrexed for Injection(N=441)Placebo(N=222)Pemetrexed for Injection (N=387)Placebo (N=194)Non-squamous NSCLC (n=481) Median (months) 15.510.34.41.8 HRHazard ratios are not adjusted for multiplicity0.700.47 (95% CI) (0.56-0.88)(0.37-0.60)Adenocarcinoma (n=328) Median (months) 16.811.54.62.7 HR0.730.51 (95% CI) (0.56-0.96)(0.38-0.68)Large cell carcinoma (n=20) Median (months) 8.47.94.51.5 HR0.980.40 (95% CI) (0.36-2.65)(0.12-1.29)OtherPrimary diagnosis of NSCLC not specified as adenocarcinoma, large cell carcinoma, or squamous cell carcinoma. (n=133) Median (months) 11.37.74.11.6 HR0.610.44 (95% CI) (0.40-0.94)(0.28-0.68)Squamous cell NSCLC (n=182) Median (months) 9.910.82.42.5 HR1.071.03 (95% CI) (0.77-1.50)(0.71-1.49)Figure 6: Kaplan-Meier Curves for Overall Survival in Non-squamous NSCLC in Study JMENFigure 7: Kaplan-Meier Curves for Overall Survival in Squamous NSCLC in Study JMENMaintenance Treatment Following First-line Pemetrexed for Injection Plus Platinum Chemotherapy The efficacy of Pemetrexed for Injection as maintenance therapy following first-line platinum-based chemotherapy was also evaluated in PARAMOUNT (NCT00789373), multi-center, randomized (2:1), double-blind, placebo-controlled study conducted in patients with Stage IIIb/IV non-squamous NSCLC who had completed four cycles of Pemetrexed for Injection in combination with cisplatin and achieved complete response (CR) or partial response (PR) or stable disease (SD). Patients were required to have an ECOG PS of or 1. Patients were randomized to receive Pemetrexed for Injection 500 mg/m2 intravenously every 21 days or placebo until disease progression. Randomization was stratified by response to Pemetrexed for Injection in combination with cisplatin induction therapy (CR or PR versus SD), disease stage (IIIb versus IV), and ECOG PS (0 versus 1). Patients in both arms received folic acid, vitamin B12, and dexamethasone. The main efficacy outcome measure was investigator-assessed progression-free survival (PFS) and an additional efficacy outcome measure was overall survival (OS); PFS and OS were measured from the time of randomizationA total of 539 patients were enrolled with 359 patients randomized to Pemetrexed for Injection and 180 patients randomized to placebo. The median age was 61 years (range 32 to 83 years); 58% were male; 95% were White, 4.5% were Asian, and <1% were Black or African American; 67% had an ECOG PS of 1; 78% were current or former smokers; and 43% of the population achieved partial or complete response to first-line, platinum-based chemotherapy. With regard to tumor characteristics, 91% had Stage IV disease, 87% had adenocarcinoma, 7% had large cell, and 6% had other histologies. Efficacy results for PARAMOUNT are presented in Table 15 and Figure 8. Table 15: Efficacy Results in PARAMOUNTEfficacy Parameter Pemetrexed for Injection (N=359)Placebo(N=180)Overall survival Median (months) (95% CI) 13.9(12.8-16.0)11.0(10.0-12.5)Hazard ratio (HR)Hazard ratios are adjusted for multiplicity but not for stratification variables. (95% CI) 0.78(0.64-0.96)p-value p=0.02Progression-free survivalBased on investigators assessment.Median (months) (95% CI) 4.1(3.2-4.6)2.8(2.6-3.1)Hazard ratio (HR) (95% CI) 0.62(0.49-0.79)p-value p<0.0001Figure 8: Kaplan-Meier Curves for Overall Survival in PARAMOUNTTreatment of Recurrent Disease After Prior Chemotherapy The efficacy of Pemetrexed for Injection was evaluated in Study JMEI (NCT00004881), multicenter, randomized (1:1), open-label study conducted in patients with Stage III or IV NSCLC that had recurred or progressed following one prior chemotherapy regimen for advanced disease. Patients were randomized to receive Pemetrexed for Injection 500 mg/m2 intravenously or docetaxel 75 mg/m2 as 1-hour intravenous infusion once every 21 days. Patients randomized to Pemetrexed for Injection also received folic acid and vitamin B12. The study was designed to show that overall survival with Pemetrexed for Injection was non-inferior to docetaxel, as the major efficacy outcome measure, and that overall survival was superior for patients randomized to Pemetrexed for Injection compared to docetaxel, as secondary outcome measure. total of 571 patients were enrolled with 283 patients randomized to Pemetrexed for Injection and 288 patients randomized to docetaxel. The median age was 58 years (range 22 to 87 years); 72% were male; 71% were White, 24% were Asian, 2.8% were Black or African American, 1.8% were Hispanic or Latino, and <2% were other ethnicities; 88% had an ECOG PS of or 1. With regard to tumor characteristics, 75% had Stage IV disease; 53% had adenocarcinoma, 30% had squamous histology; 8% large cell; and 9% had other histologic subtypes of NSCLC.The efficacy results in the overall population and in subgroup analyses based on histologic subtype are provided in Tables 16 and 17, respectively. Study JMEI did not show an improvement in overall survival in the intent-to-treat population. In subgroup analyses, there was no evidence of treatment effect on survival in patients with squamous NSCLC; the absence of treatment effect in patients with NSCLC of squamous histology was also observed Studies JMDB and JMEN [see Clinical Studies (14.1)]. Table 16: Efficacy Results in Study JMEIEfficacy ParameterPemetrexed for Injection (N=283)Docetaxel(N=288)Overall survival Median (months) (95% CI) 8.3 (7.0-9.4)7.9(6.3-9.2) Hazard ratioHazard ratios are not adjusted for multiplicity or for stratification variables.(95% CI) 0.99(0.82-1.20)Progression-free survival Median (months)(95% CI)2.9(2.4-3.1)2.9(2.7-3.4) Hazard ratioa(95% CI) 0.97(0.82-1.16) Overall response rate (95% CI) 8.5%(5.2-11.7)8.3%(5.1-11.5)Table 17: Exploratory Efficacy Analyses by Histologic Subgroup in Study JMEIHistologic SubgroupsPemetrexed for Injection(N=283)Docetaxel(N=288)Non-squamous NSCLC (N=399) Median (months) (95% CI) 9.3(7.8-9.7)8.0(6.3-9.3) HRHazard ratio unadjusted for multiple comparisons.(95% CI) 0.89(0.71-1.13)Adenocarcinoma (N=301) Median (months) (95% CI) 9.0(7.6-9.6)9.2(7.5-11.3) HR(95% CI)1.09(0.83-1.44)Large Cell (N=47) Median (months) (95% CI) 12.8(5.8-14.0)4.5(2.3-9.1) HR(95% CI)0.38(0.18-0.78)OtherPrimary diagnosis of NSCLC not specified as adenocarcinoma, large cell carcinoma, or squamous cell carcinoma. (N=51) Median (months) (95% CI) 9.4(6.0-10.1)7.9(4.0-8.9) HR(95% CI) 0.62(0.32-1.23)Squamous NSCLC (N=172) Median (months) (95% CI) 6.2(4.9-8.0)7.4(5.6-9.5) HR(95% CI)1.32(0.93-1.86). oPemetrexed for Injection 500 mg/m2, pembrolizumab 200 mg, and investigators choice of cisplatin 75 mg/m2 or carboplatin AUC mg/mL/min intravenously on Day of each 21-day cycle for cycles followed by Pemetrexed for Injection 500 mg/m2 and pembrolizumab 200 mg intravenously every weeks. Pemetrexed for Injection was administered after pembrolizumab and prior to platinum chemotherapy on Day 1. oPlacebo, Pemetrexed for Injection 500 mg/m2, and investigators choice of cisplatin 75 mg/m2 or carboplatin AUC mg/mL/min intravenously on Day of each 21-day cycle for cycles followed by placebo and Pemetrexed for Injection 500 mg/m2 intravenously every weeks. Number (%) of patients with event Median in months (95% CI) Hazard ratioBased on the stratified Cox proportional hazard model. (95% CI) p-valueBased on stratified log-rank test.. Number of patients with event (%) Median in months (95% CI) Hazard ratio (95% CI) p-value. Overall response rateResponse: Best objective response as confirmed complete response or partial response.(95% CI) Complete response Partial response p-valueBased on Miettinen and Nurminen method stratified by PD-L1 status, platinum chemotherapy and smoking status.NR not reached Median in months (range) Median (months) (95% CI) Hazard ratio (HR)Unadjusted for multiple comparisons.Adjusted for gender, stage, basis of diagnosis, and performance status.(95% CI) Median (months)(95% CI) Hazard ratio (HR)a,b (95% CI) Median (months) (95% CI) HRUnadjusted for multiple comparisons.Adjusted for ECOG PS, gender, disease stage, and basis for pathological diagnosis (histopathological/cytopathological).(95% CI) Median (months) (95% CI) HR(95% CI) Median (months) (95% CI) HR(95% CI) Median (months) (95% CI) HR(95% CI) Median (months) (95% CI) HR(95% CI) Median (months) (95% CI) Hazard ratioHazard ratios are adjusted for multiplicity but not for stratification variables.(95% CI) p-value Median (months) (95% CI) Hazard ratio(95% CI) p-value Median (months) HRHazard ratios are not adjusted for multiplicity. (95% CI) Median (months) HR. (95% CI) Median (months) HR. (95% CI) Median (months) HR. (95% CI) Median (months) HR. (95% CI) Median (months) (95% CI) Hazard ratioHazard ratios are not adjusted for multiplicity or for stratification variables.(95% CI) Median (months)(95% CI). Hazard ratioa(95% CI) Overall response rate (95% CI) Median (months) (95% CI) HRHazard ratio unadjusted for multiple comparisons.(95% CI) Median (months) (95% CI) HR(95% CI). Median (months) (95% CI) HR(95% CI). Median (months) (95% CI) HR(95% CI) Median (months) (95% CI) HR(95% CI). Figure 1. Figure 2. Figure 3. Figure 4. Figure 5. Figure 6. Figure 7. Figure 8. 14.2 Mesothelioma The efficacy of Pemetrexed for Injection was evaluated in Study JMCH (NCT00005636), multicenter, randomized (1:1), single-blind study conducted in patients with MPM who had received no prior chemotherapy. Patients were randomized (n=456) to receive Pemetrexed for Injection 500 mg/m2 intravenously over 10 minutes followed 30 minutes later by cisplatin 75 mg/m2 intravenously over two hours on Day of each 21-day cycle or to receive cisplatin 75 mg/m2 intravenously over hours on Day of each 21-day cycle; treatment continued until disease progression or intolerable toxicity. The study was modified after randomization and treatment of 117 patients to require that all patients receive folic acid 350 mcg to 1000 mcg daily beginning to weeks prior to the first dose of Pemetrexed for Injection and continuing until to weeks after the last dose, vitamin B12 1000 mcg intramuscularly to weeks prior to first dose of Pemetrexed for Injection and every weeks thereafter, and dexamethasone mg orally, twice daily, for days starting the day prior to each Pemetrexed for Injection dose. Randomization was stratified by multiple baseline variables including KPS, histologic subtype (epithelial, mixed, sarcomatoid, other), and gender. The major efficacy outcome measure was overall survival and additional efficacy outcome measures were time to disease progression, overall response rate, and response duration. total of 448 patients received at least one dose of protocol-specified therapy; 226 patients were randomized to and received at least one dose of Pemetrexed for Injection plus cisplatin, and 222 patients were randomized to and received cisplatin. Among the 226 patients who received cisplatin with Pemetrexed for Injection, 74% received full supplementation with folic acid and vitamin B12 during study therapy, 14% were never supplemented, and 12% were partially supplemented. Across the study population, the median age was 61 years (range: 20 to 86 years); 81% were male; 92% were White, 5% were Hispanic or Latino, 3.1% were Asian, and <1% were other ethnicities; and 54% had baseline KPS score of 90-100% and 46% had KPS score of 70-80%. With regard to tumor characteristics, 46% had Stage IV disease, 31% Stage III, 15% Stage II, and 7% Stage disease at baseline; the histologic subtype of mesothelioma was epithelial in 68% of patients, mixed in 16%, sarcomatoid in 10% and other histologic subtypes in 6%. The baseline demographics and tumor characteristics of the subgroup of fully supplemented patients was similar to the overall study population. The efficacy results from Study JMCH are summarized in and Figure 9. Table 18: Efficacy Results in Study JMCHEfficacy Parameter All Randomized and Treated Patients (N=448)Fully Supplemented Patients (N=331)Pemetrexed for Injection/Cisplatin (N=226)Cisplatin (N=222)Pemetrexed for Injection/Cisplatin (N=168)Cisplatin (N=163)Median overall survival (months) 12.19.313.310.0(95% CI) (10.0-14.4)(7.8-10.7)(11.4-14.9)(8.4-11.9)Hazard ratioHazard ratios are not adjusted for stratification variables. 0.770.75Log rank p-value 0.020NANot pre-specified analysis. Figure 9: Kaplan-Meier Curves for Overall Survival in Study JMCHBased upon prospectively defined criteria (modified Southwest Oncology Group methodology) the objective tumor response rate for Pemetrexed for Injection plus cisplatin was greater than the objective tumor response rate for cisplatin alone. There was also improvement in lung function (forced vital capacity) in the Pemetrexed for Injection plus cisplatin arm compared to the control arm. Figure 9.

CONTRAINDICATIONS SECTION.

4 CONTRAINDICATIONS Pemetrexed for Injection is contraindicated in patients with history of severe hypersensitivity reaction to pemetrexed [see Adverse Reactions (6.1)]. History of severe hypersensitivity reaction to pemetrexed. (4).

DESCRIPTION SECTION.

11 DESCRIPTION Pemetrexed for Injection is folate analog metabolic inhibitor. The drug substance, pemetrexed disodium heptahydrate, has the chemical name L-glutamic acid, N-[4-[2-(2-amino-4,7-dihydro-4-oxo-1H-pyrrolo[2,3-d]pyrimidin-5-yl)ethyl]benzoyl]-, disodium salt, heptahydrate with molecular formula of C20H19N5Na2O6o7H2O and molecular weight of 597.49. The structural formula is as follows:Pemetrexed for Injection is sterile white-to-light yellow or green-yellow lyophilized powder in single-dose vials to be reconstituted for intravenous infusion. Each 100-mg vial of Pemetrexed for Injection contains 100 mg pemetrexed (equivalent to 139.8 mg pemetrexed disodium heptahydrate) and 106 mg mannitol. Each 500-mg vial of Pemetrexed for Injection contains 500 mg pemetrexed (equivalent to 699 mg pemetrexed disodium heptahydrate) and 500 mg mannitol. Hydrochloric acid and/or sodium hydroxide may have been added to adjust pH.. Pemetrexed Structural Formula.

DOSAGE & ADMINISTRATION SECTION.

2 DOSAGE AND ADMINISTRATION oThe recommended dose of Pemetrexed for Injection administered with pembrolizumab and platinum chemotherapy in patients with creatinine clearance (calculated by Cockcroft-Gault equation) of 45 mL/min or greater is 500 mg/m2 as an intravenous infusion over 10 minutes, administered after pembrolizumab and prior to platinum chemotherapy, on Day of each 21-day cycle. (2.1) oThe recommended dose of Pemetrexed for Injection, administered as single agent or with cisplatin, in patients with creatinine clearance of 45 mL/minute or greater is 500 mg/m2 as an intravenous infusion over 10 minutes on Day of each 21-day cycle. (2.1, 2.2) oInitiate folic acid 400 mcg to 1000 mcg orally, once daily, beginning days prior to the first dose of Pemetrexed for Injection and continue until 21 days after the last dose of Pemetrexed for Injection. (2.4) oAdminister vitamin B12, mg intramuscularly, week prior to the first dose of Pemetrexed for Injection and every cycles. (2.4) oAdminister dexamethasone mg orally, twice daily the day before, the day of, and the day after Pemetrexed for Injection administration. (2.4). oThe recommended dose of Pemetrexed for Injection administered with pembrolizumab and platinum chemotherapy in patients with creatinine clearance (calculated by Cockcroft-Gault equation) of 45 mL/min or greater is 500 mg/m2 as an intravenous infusion over 10 minutes, administered after pembrolizumab and prior to platinum chemotherapy, on Day of each 21-day cycle. (2.1) oThe recommended dose of Pemetrexed for Injection, administered as single agent or with cisplatin, in patients with creatinine clearance of 45 mL/minute or greater is 500 mg/m2 as an intravenous infusion over 10 minutes on Day of each 21-day cycle. (2.1, 2.2) oInitiate folic acid 400 mcg to 1000 mcg orally, once daily, beginning days prior to the first dose of Pemetrexed for Injection and continue until 21 days after the last dose of Pemetrexed for Injection. (2.4) oAdminister vitamin B12, mg intramuscularly, week prior to the first dose of Pemetrexed for Injection and every cycles. (2.4) oAdminister dexamethasone mg orally, twice daily the day before, the day of, and the day after Pemetrexed for Injection administration. (2.4). 2.1 Recommended Dosage for Non-Squamous NSCLC oThe recommended dose of Pemetrexed for Injection when administered with pembrolizumab and platinum chemotherapy for the initial treatment of metastatic non-squamous NSCLC in patients with creatinine clearance (calculated by Cockcroft-Gault equation) of 45 mL/min or greater is 500 mg/m2 as an intravenous infusion over 10 minutes administered after pembrolizumab and prior to carboplatin or cisplatin on Day of each 21-day cycle for cycles. Following completion of platinum-based therapy, treatment with Pemetrexed for Injection with or without pembrolizumab is administered until disease progression or unacceptable toxicity. Please refer to the full prescribing information for pembrolizumab and for carboplatin or cisplatin. oThe recommended dose of Pemetrexed for Injection when administered with cisplatin for initial treatment of locally advanced or metastatic non-squamous NSCLC in patients with creatinine clearance (calculated by Cockcroft-Gault equation) of 45 mL/min or greater is 500 mg/m2 as an intravenous infusion over 10 minutes administered prior to cisplatin on Day of each 21-day cycle for up to six cycles in the absence of disease progression or unacceptable toxicity. oThe recommended dose of Pemetrexed for Injection for maintenance treatment of non-squamous NSCLC in patients with creatinine clearance (calculated by Cockcroft-Gault equation) of 45 mL/min or greater is 500 mg/m2 as an intravenous infusion over 10 minutes on Day of each 21-day cycle until disease progression or unacceptable toxicity after four cycles of platinum-based first-line chemotherapy. oThe recommended dose of Pemetrexed for Injection for treatment of recurrent non-squamous NSCLC in patients with creatinine clearance (calculated by Cockcroft-Gault equation) of 45 mL/min or greater is 500 mg/m2 as an intravenous infusion over 10 minutes on Day of each 21-day cycle until disease progression or unacceptable toxicity.. oThe recommended dose of Pemetrexed for Injection when administered with pembrolizumab and platinum chemotherapy for the initial treatment of metastatic non-squamous NSCLC in patients with creatinine clearance (calculated by Cockcroft-Gault equation) of 45 mL/min or greater is 500 mg/m2 as an intravenous infusion over 10 minutes administered after pembrolizumab and prior to carboplatin or cisplatin on Day of each 21-day cycle for cycles. Following completion of platinum-based therapy, treatment with Pemetrexed for Injection with or without pembrolizumab is administered until disease progression or unacceptable toxicity. Please refer to the full prescribing information for pembrolizumab and for carboplatin or cisplatin. oThe recommended dose of Pemetrexed for Injection when administered with cisplatin for initial treatment of locally advanced or metastatic non-squamous NSCLC in patients with creatinine clearance (calculated by Cockcroft-Gault equation) of 45 mL/min or greater is 500 mg/m2 as an intravenous infusion over 10 minutes administered prior to cisplatin on Day of each 21-day cycle for up to six cycles in the absence of disease progression or unacceptable toxicity. oThe recommended dose of Pemetrexed for Injection for maintenance treatment of non-squamous NSCLC in patients with creatinine clearance (calculated by Cockcroft-Gault equation) of 45 mL/min or greater is 500 mg/m2 as an intravenous infusion over 10 minutes on Day of each 21-day cycle until disease progression or unacceptable toxicity after four cycles of platinum-based first-line chemotherapy. oThe recommended dose of Pemetrexed for Injection for treatment of recurrent non-squamous NSCLC in patients with creatinine clearance (calculated by Cockcroft-Gault equation) of 45 mL/min or greater is 500 mg/m2 as an intravenous infusion over 10 minutes on Day of each 21-day cycle until disease progression or unacceptable toxicity.. 2.2 Recommended Dosage for Mesothelioma oThe recommended dose of Pemetrexed for Injection when administered with cisplatin in patients with creatinine clearance (calculated by Cockcroft-Gault equation) of 45 mL/min or greater is 500 mg/m2 as an intravenous infusion over 10 minutes on Day of each 21-day cycle until disease progression or unacceptable toxicity.. oThe recommended dose of Pemetrexed for Injection when administered with cisplatin in patients with creatinine clearance (calculated by Cockcroft-Gault equation) of 45 mL/min or greater is 500 mg/m2 as an intravenous infusion over 10 minutes on Day of each 21-day cycle until disease progression or unacceptable toxicity.. 2.3 Renal Impairment oPemetrexed for Injection dosing recommendations are provided for patients with creatinine clearance (calculated by Cockcroft-Gault equation) of 45 mL/min or greater [see Dosage and Administration (2.1, 2.2)]. There is no recommended dose for patients whose creatinine clearance is less than 45 mL/min [see Use in Specific Populations (8.6)].. oPemetrexed for Injection dosing recommendations are provided for patients with creatinine clearance (calculated by Cockcroft-Gault equation) of 45 mL/min or greater [see Dosage and Administration (2.1, 2.2)]. There is no recommended dose for patients whose creatinine clearance is less than 45 mL/min [see Use in Specific Populations (8.6)].. 2.4 Premedication and Concomitant Medications to Mitigate Toxicity Vitamin SupplementationoInitiate folic acid 400 mcg to 1000 mcg orally once daily, beginning days before the first dose of Pemetrexed for Injection and continuing until 21 days after the last dose of Pemetrexed for Injection [see Warnings and Precautions (5.1)]. oAdminister vitamin B12, mg intramuscularly, week prior to the first dose of Pemetrexed for Injection and every cycles thereafter. Subsequent vitamin B12 injections may be given the same day as treatment with Pemetrexed for Injection [see Warnings and Precautions (5.1)]. Do not substitute oral vitamin B12 for intramuscular vitamin B12. CorticosteroidsoAdminister dexamethasone mg orally twice daily for three consecutive days, beginning the day before each Pemetrexed for Injection administration. oInitiate folic acid 400 mcg to 1000 mcg orally once daily, beginning days before the first dose of Pemetrexed for Injection and continuing until 21 days after the last dose of Pemetrexed for Injection [see Warnings and Precautions (5.1)]. oAdminister vitamin B12, mg intramuscularly, week prior to the first dose of Pemetrexed for Injection and every cycles thereafter. Subsequent vitamin B12 injections may be given the same day as treatment with Pemetrexed for Injection [see Warnings and Precautions (5.1)]. Do not substitute oral vitamin B12 for intramuscular vitamin B12. oAdminister dexamethasone mg orally twice daily for three consecutive days, beginning the day before each Pemetrexed for Injection administration. 2.5 Dosage Modification of Ibuprofen in Patients with Mild to Moderate Renal Impairment Receiving Pemetrexed for Injection In patients with creatinine clearances between 45 mL/min and 79 mL/min, modify administration of ibuprofen as follows [see Warnings and Precautions (5.6), Drug Interactions (7) and Clinical Pharmacology (12.3)]: oAvoid administration of ibuprofen for days before, the day of, and days following administration of Pemetrexed for Injection. oMonitor patients more frequently for myelosuppression, renal, and gastrointestinal toxicity, if concomitant administration of ibuprofen cannot be avoided.. oAvoid administration of ibuprofen for days before, the day of, and days following administration of Pemetrexed for Injection. oMonitor patients more frequently for myelosuppression, renal, and gastrointestinal toxicity, if concomitant administration of ibuprofen cannot be avoided.. 2.6 Dosage Modifications for Adverse Reactions Obtain complete blood count on Days 1, 8, and 15 of each cycle. Assess creatinine clearance prior to each cycle. Do not administer Pemetrexed for Injection if the creatinine clearance is less than 45 mL/min. Delay initiation of the next cycle of Pemetrexed for Injection until: orecovery of non-hematologic toxicity to Grade 0-2, oabsolute neutrophil count (ANC) is 1500 cells/mm3 or higher, and oplatelet count is 100,000 cells/mm3 or higher. Upon recovery, modify the dosage of Pemetrexed for Injection in the next cycle as specified in Table 1. For dosing modifications for cisplatin, carboplatin, or pembrolizumab, refer to their prescribing information. Table 1: Recommended Dosage Modifications for Adverse ReactionsNational Cancer Institute Common Toxicity Criteria for Adverse Events version (NCI CTCAE v2). Toxicity in Most Recent Treatment Cycle Pemetrexed for Injection Dose Modification for Next CycleMyelosuppressive toxicity [see Warnings and Precautions (5.1)] ANC less than 500/mm3and platelets greater than or equal to 50,000/mm3 OR Platelet count less than 50,000/mm3 without bleeding.75% of previous dose Platelet count less than 50,000/mm3 with bleeding50% of previous dose Recurrent Grade or myelosuppression after dose reductionsDiscontinue Non-hematologic toxicity Any Grade or toxicities EXCEPT mucositis or neurologic toxicity OR Diarrhea requiring hospitalization 75% of previous dose Grade or mucositis 50% of previous dose Renal toxicity [see Warnings and Precautions (5.2)]Withhold until creatinine clearance is 45 mL/min or greater Grade or neurologic toxicity Permanently discontinue Recurrent Grade or non-hematologic toxicity after dose reductionsPermanently discontinue Severe and life-threatening Skin Toxicity [see Warnings and Precautions (5.3)]Permanently discontinue Interstitial Pneumonitis [see Warnings and Precautions (5.4)]Permanently discontinue. orecovery of non-hematologic toxicity to Grade 0-2, oabsolute neutrophil count (ANC) is 1500 cells/mm3 or higher, and oplatelet count is 100,000 cells/mm3 or higher. ANC less than 500/mm3and platelets greater than or equal to 50,000/mm3 OR. Platelet count less than 50,000/mm3 without bleeding.. Platelet count less than 50,000/mm3 with bleeding. Recurrent Grade or myelosuppression after dose reductions. Any Grade or toxicities EXCEPT mucositis or neurologic toxicity OR. Diarrhea requiring hospitalization Grade or mucositis Renal toxicity [see Warnings and Precautions (5.2)]. Grade or neurologic toxicity Recurrent Grade or non-hematologic toxicity after dose reductions. Severe and life-threatening Skin Toxicity [see Warnings and Precautions (5.3)]. Interstitial Pneumonitis [see Warnings and Precautions (5.4)]. 2.7 Preparation for Administration oPemetrexed for Injection is cytotoxic drug. Follow applicable special handling and disposal procedures.1oCalculate the dose of Pemetrexed for Injection and determine the number of vials needed. oReconstitute Pemetrexed for Injection to achieve concentration of 25 mg/mL as follows: oReconstitute each 100-mg vial with 4.2 mL of 0.9% Sodium Chloride Injection, USP (preservative-free)oReconstitute each 500-mg vial with 20 mL of 0.9% Sodium Chloride Injection, USP (preservative-free) oDo not use calcium-containing solutions for reconstitution. oGently swirl each vial until the powder is completely dissolved. The resulting solution is clear and ranges in color from colorless to yellow or green-yellow. FURTHER DILUTION IS REQUIRED prior to administration. oStore reconstituted, preservative-free product under refrigerated conditions [2-8C (36-46F)] for no longer than 24 hours from the time of reconstitution. Discard vial after 24 hours. oInspect reconstituted product visually for particulate matter and discoloration prior to further dilution. If particulate matter is observed, discard vial. oWithdraw the calculated dose of Pemetrexed for Injection from the vial(s) and discard vial with any unused portion.oFurther dilute Pemetrexed for Injection with 0.9% Sodium Chloride Injection (preservative-free) to achieve total volume of 100 mL for intravenous infusion. oStore diluted, reconstituted product under refrigerated conditions [2-8C (36-46F)] for no more than 24 hours from the time of reconstitution. Discard after 24 hours.. oPemetrexed for Injection is cytotoxic drug. Follow applicable special handling and disposal procedures.1. oCalculate the dose of Pemetrexed for Injection and determine the number of vials needed. oReconstitute Pemetrexed for Injection to achieve concentration of 25 mg/mL as follows: oReconstitute each 100-mg vial with 4.2 mL of 0.9% Sodium Chloride Injection, USP (preservative-free)oReconstitute each 500-mg vial with 20 mL of 0.9% Sodium Chloride Injection, USP (preservative-free) oDo not use calcium-containing solutions for reconstitution. oReconstitute each 100-mg vial with 4.2 mL of 0.9% Sodium Chloride Injection, USP (preservative-free). oReconstitute each 500-mg vial with 20 mL of 0.9% Sodium Chloride Injection, USP (preservative-free) oDo not use calcium-containing solutions for reconstitution. oGently swirl each vial until the powder is completely dissolved. The resulting solution is clear and ranges in color from colorless to yellow or green-yellow. FURTHER DILUTION IS REQUIRED prior to administration. oStore reconstituted, preservative-free product under refrigerated conditions [2-8C (36-46F)] for no longer than 24 hours from the time of reconstitution. Discard vial after 24 hours. oInspect reconstituted product visually for particulate matter and discoloration prior to further dilution. If particulate matter is observed, discard vial. oWithdraw the calculated dose of Pemetrexed for Injection from the vial(s) and discard vial with any unused portion.. oFurther dilute Pemetrexed for Injection with 0.9% Sodium Chloride Injection (preservative-free) to achieve total volume of 100 mL for intravenous infusion. oStore diluted, reconstituted product under refrigerated conditions [2-8C (36-46F)] for no more than 24 hours from the time of reconstitution. Discard after 24 hours.

DOSAGE FORMS & STRENGTHS SECTION.

3 DOSAGE FORMS AND STRENGTHS For injection: 100 mg or 500 mg pemetrexed as white to light-yellow or green-yellow lyophilized powder in single-dose vials for reconstitution.. For Injection: 100 mg or 500 mg lyophilized powder in single-dose vial (3).

DRUG INTERACTIONS SECTION.

7 DRUG INTERACTIONS Effects of Ibuprofen on PemetrexedIbuprofen increases exposure (AUC) of pemetrexed [see Clinical Pharmacology (12.3)]. In patients with creatinine clearance between 45 mL/min and 79 mL/min: oAvoid administration of ibuprofen for days before, the day of, and days following administration of Pemetrexed for Injection [see Dosage and Administration (2.5)]. oMonitor patients more frequently for myelosuppression, renal, and gastrointestinal toxicity, if concomitant administration of ibuprofen cannot be avoided. oAvoid administration of ibuprofen for days before, the day of, and days following administration of Pemetrexed for Injection [see Dosage and Administration (2.5)]. oMonitor patients more frequently for myelosuppression, renal, and gastrointestinal toxicity, if concomitant administration of ibuprofen cannot be avoided. Ibuprofen increased risk of Pemetrexed for Injection toxicity in patients with mild to moderate renal impairment. Modify the ibuprofen dosage as recommended for patients with creatinine clearance between 45 mL/min and 79 mL/min. (2.5, 5.6, 7).

FEMALES & MALES OF REPRODUCTIVE POTENTIAL SECTION.

8.3 Females and Males of Reproductive Potential ContraceptionFemales Pemetrexed for Injection can cause fetal harm when administered to pregnant woman [see Use in Specific Populations (8.1)]. Because of the potential for genotoxicity, advise females of reproductive potential to use effective contraception during treatment with Pemetrexed for Injection for at least months after the final dose of Pemetrexed for Injection. Males Because of the potential for genotoxicity, advise males with female partners of reproductive potential to use effective contraception during treatment with Pemetrexed for Injection and for months after the final dose [see Nonclinical Toxicology (13.1)]. InfertilityMales Pemetrexed for Injection may impair fertility in males of reproductive potential. It is not known whether these effects on fertility are reversible [see Nonclinical Toxicology (13.1)].

GERIATRIC USE SECTION.

8.5 Geriatric Use Of the 3,946 patients enrolled in clinical studies of Pemetrexed for Injection, 34% were 65 and over and 4% were 75 and over. No overall differences in effectiveness were observed between these patients and younger patients. The incidences of Grade 3-4 anemia, fatigue, thrombocytopenia, hypertension, and neutropenia were higher in patients 65 years of age and older as compared to younger patients: in at least one of five randomized clinical trials. [see Adverse Reactions (6.1) and Clinical Studies (14.1, 14.2)].

HOW SUPPLIED SECTION.

16 HOW SUPPLIED/STORAGE AND HANDLING How SuppliedPemetrexed for Injection is white-to-light yellow or green-yellow lyophilized powder supplied in single-dose vials for reconstitution for intravenous infusion. NDC 0338-0720-01: Carton containing one (1) single-dose vial of 100 mg pemetrexed. NDC 0338-0722-01: Carton containing one (1) single-dose vial of 500 mg pemetrexed. Storage and HandlingStore at 25C (77F); excursions permitted to 15-30C (59-86F) [see USP Controlled Room Temperature]. Pemetrexed for Injection is cytotoxic drug. Follow applicable special handling and disposal procedures.1.

INDICATIONS & USAGE SECTION.

1 INDICATIONS AND USAGE Pemetrexed for Injection is folate analog metabolic inhibitor indicated: oin combination with pembrolizumab and platinum chemotherapy, for the initial treatment of patients with metastatic non-squamous NSCLC, with no EGFR or ALK genomic tumor aberrations. (1.1) oin combination with cisplatin for the initial treatment of patients with locally advanced or metastatic, non-squamous, non-small cell lung cancer (NSCLC). (1.1) oas single agent for the maintenance treatment of patients with locally advanced or metastatic, non-squamous NSCLC whose disease has not progressed after four cycles of platinum-based first-line chemotherapy. (1.1) oas single agent for the treatment of patients with recurrent, metastatic non-squamous, NSCLC after prior chemotherapy. (1.1) Limitations of Use: Pemetrexed for Injection is not indicated for the treatment of patients with squamous cell, non-small cell lung cancer. (1.1) oinitial treatment, in combination with cisplatin, of patients with malignant pleural mesothelioma whose disease is unresectable or who are otherwise not candidates for curative surgery. (1.2). oin combination with pembrolizumab and platinum chemotherapy, for the initial treatment of patients with metastatic non-squamous NSCLC, with no EGFR or ALK genomic tumor aberrations. (1.1) oin combination with cisplatin for the initial treatment of patients with locally advanced or metastatic, non-squamous, non-small cell lung cancer (NSCLC). (1.1) oas single agent for the maintenance treatment of patients with locally advanced or metastatic, non-squamous NSCLC whose disease has not progressed after four cycles of platinum-based first-line chemotherapy. (1.1) oas single agent for the treatment of patients with recurrent, metastatic non-squamous, NSCLC after prior chemotherapy. (1.1) Limitations of Use: Pemetrexed for Injection is not indicated for the treatment of patients with squamous cell, non-small cell lung cancer. (1.1) oinitial treatment, in combination with cisplatin, of patients with malignant pleural mesothelioma whose disease is unresectable or who are otherwise not candidates for curative surgery. (1.2). 1.1 Non-Squamous Non-Small Cell Lung Cancer (NSCLC) Pemetrexed for Injection is indicated: oin combination with pembrolizumab and platinum chemotherapy, for the initial treatment of patients with metastatic non-squamous NSCLC, with no EGFR or ALK genomic tumor aberrations. oin combination with cisplatin for the initial treatment of patients with locally advanced or metastatic, non-squamous, non-small cell lung cancer (NSCLC). oas single agent for the maintenance treatment of patients with locally advanced or metastatic, non-squamous NSCLC whose disease has not progressed after four cycles of platinum-based first-line chemotherapy. oas single agent for the treatment of patients with recurrent, metastatic non-squamous, NSCLC after prior chemotherapy. Limitations of Use: Pemetrexed for Injection is not indicated for the treatment of patients with squamous cell, non-small cell lung cancer [see Clinical Studies (14.1)]. oin combination with pembrolizumab and platinum chemotherapy, for the initial treatment of patients with metastatic non-squamous NSCLC, with no EGFR or ALK genomic tumor aberrations. oin combination with cisplatin for the initial treatment of patients with locally advanced or metastatic, non-squamous, non-small cell lung cancer (NSCLC). oas single agent for the maintenance treatment of patients with locally advanced or metastatic, non-squamous NSCLC whose disease has not progressed after four cycles of platinum-based first-line chemotherapy. oas single agent for the treatment of patients with recurrent, metastatic non-squamous, NSCLC after prior chemotherapy. Limitations of Use: Pemetrexed for Injection is not indicated for the treatment of patients with squamous cell, non-small cell lung cancer [see Clinical Studies (14.1)]. 1.2 Mesothelioma Pemetrexed for Injection is indicated, in combination with cisplatin, for the initial treatment of patients with malignant pleural mesothelioma whose disease is unresectable or who are otherwise not candidates for curative surgery.

INFORMATION FOR PATIENTS SECTION.

17 PATIENT COUNSELING INFORMATION Advise the patient to read the FDA-approved patient labeling (Patient Information). Premedication and Concomitant Medication: Instruct patients to take folic acid as directed and to keep appointments for vitamin B12 injections to reduce the risk of treatment-related toxicity. Instruct patients of the requirement to take corticosteroids to reduce the risks of treatment-related toxicity [see Dosage and Administration (2.4) and Warnings and Precautions (5.1)]. Myelosuppression: Inform patients of the risk of low blood cell counts and instruct them to immediately contact their physician for signs of infection, fever, bleeding, or symptoms of anemia [see Warnings and Precautions (5.1)]. Renal Failure: Inform patients of the risks of renal failure, which may be exacerbated in patients with dehydration arising from severe vomiting or diarrhea. Instruct patients to immediately contact their healthcare provider for decrease in urine output [see Warnings and Precautions (5.2)]. Bullous and Exfoliative Skin Disorders: Inform patients of the risks of severe and exfoliative skin disorders. Instruct patients to immediately contact their healthcare provider for development of bullous lesions or exfoliation in the skin or mucous membranes [see Warnings and Precautions (5.3)]. Interstitial Pneumonitis: Inform patients of the risks of pneumonitis. Instruct patients to immediately contact their healthcare provider for development of dyspnea or persistent cough [see Warnings and Precautions (5.4)]. Radiation Recall: Inform patients who have received prior radiation of the risks of radiation recall. Instruct patients to immediately contact their healthcare provider for development of inflammation or blisters in an area that was previously irradiated [see Warnings and Precautions (5.5)]. Increased Risk of Toxicity with Ibuprofen in Patients with Renal Impairment: Advise patients with mild to moderate renal impairment of the risks associated with concomitant ibuprofen use and instruct them to avoid use of all ibuprofen containing products for days before, the day of, and days following administration of Pemetrexed for Injection [see Dosage and Administration (2.5), Warnings and Precautions (5.6), and Drug Interactions (7)]. Embryo-Fetal Toxicity: Advise females of reproductive potential and males with female partners of reproductive potential of the potential risk to fetus [see Warnings and Precautions (5.7) and Use in Specific Populations (8.1)]. Advise females of reproductive potential to use effective contraception during treatment with Pemetrexed for Injection and for months after the final dose. Advise females to inform their prescriber of known or suspected pregnancy. Advise males with female partners of reproductive potential to use effective contraception during treatment with Pemetrexed for Injection and for months after the final dose [see Warnings and Precautions (5.7) and Use in Specific Populations (8.3)]. Lactation: Advise women not to breastfeed during treatment with Pemetrexed for Injection and for week after the final dose [see Use in Specific Populations (8.2)].Manufactured for: Baxter Healthcare Corporation Deerfield, IL 60015 USAMade in GermanyHA-30-01-980Baxter is registered trademark of Baxter International Inc.Revised: 10/2021PATIENT INFORMATIONPemetrexed for InjectionWhat is Pemetrexed for Injection Pemetrexed for Injection is prescription medicine used to treat: oa kind of lung cancer called non-squamous non-small cell lung cancer (NSCLC). Pemetrexed for Injection is used: oas the first treatment in combination with pembrolizumab and platinum chemotherapy when your lung cancer with no abnormal EGFR or ALK gene has spread (advanced NSCLC). oas the first treatment in combination with cisplatin when your lung cancer has spread (advanced NSCLC). oalone as maintenance treatment after you have received cycles of chemotherapy that contains platinum for first treatment of your advanced NSCLC and your cancer has not progressed. oalone when your lung cancer has returned or spread after prior chemotherapy. oa kind of cancer called malignant pleural mesothelioma. This cancer affects the lining of the lungs and chest wall. Pemetrexed for Injection is used in combination with cisplatin as the first treatment for malignant pleural mesothelioma that cannot be removed by surgery or you are not able to have surgery. It is not known if Pemetrexed for Injection is safe and effective in children. Do not take Pemetrexed for Injection: if you have had severe allergic reaction to any medicine that contains pemetrexed.Before taking Pemetrexed for Injection, tell your healthcare provider about all of your medical conditions, including if you: ohave kidney problems. ohave had radiation therapy. oare pregnant or plan to become pregnant. Pemetrexed for Injection can harm your unborn baby. oFemales who are able to become pregnant should use effective birth control (contraception) during treatment with Pemetrexed for Injection and for months after the final dose. Tell your healthcare provider right away if you become pregnant or think you are pregnant during treatment with Pemetrexed for Injection. oMales with female partners who are able to become pregnant should use effective birth control (contraception) during treatment with Pemetrexed for Injection and for months after the final dose. oAre breastfeeding or plan to breastfeed. It is not known if Pemetrexed for Injection passes into breast milk. Do not breastfeed during treatment with Pemetrexed for Injection and for week after the final dose. Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. Tell your healthcare provider if you have kidney problems and take medicine that contains ibuprofen. You should avoid taking ibuprofen for days before, the day of, and days after receiving treatment with Pemetrexed for Injection. How is Pemetrexed for Injection given oIt is very important to take folic acid and vitamin B12 during your treatment with Pemetrexed for Injection to lower your risk of harmful side effects.oTake folic acid exactly as prescribed by your healthcare provider time day, beginning days (1 week) before your first dose of Pemetrexed for Injection and continue taking folic acid until 21 days (3 weeks) after your last dose of Pemetrexed for Injection. oYour healthcare provider will give you vitamin B12 injections during treatment with Pemetrexed for Injection. You will get your first vitamin B12 injection days (1 week) before your first dose of Pemetrexed for Injection, and then every cycles. oYour healthcare provider will prescribe medicine called corticosteroid for you to take times day for days, beginning the day before each treatment with Pemetrexed for Injection. oPemetrexed for Injection is given to you by intravenous (IV) infusion into your vein. The infusion is given over 10 minutes. oPemetrexed for Injection is usually given once every 21 days (3 weeks). What are the possible side effects of Pemetrexed for InjectionPemetrexed for Injection can cause serious side effects, including: oLow blood cell counts. Low blood cell counts can be severe, including low white blood cell counts (neutropenia), low platelet counts (thrombocytopenia), and low red blood cell counts (anemia). Your healthcare provider will do blood test to check your blood cell counts regularly during your treatment with Pemetrexed for Injection. Tell your healthcare provider right away if you have any signs of infection, fever, bleeding, or severe tiredness during your treatment with Pemetrexed for Injection.oKidney problems, including kidney failure. Pemetrexed for Injection can cause severe kidney problems that can lead to death. Severe vomiting or diarrhea can lead to loss of fluids (dehydration) which may cause kidney problems to become worse. Tell your healthcare provider right away if you have decrease in amount of urine. oSevere skin reactions. Severe skin reactions that may lead to death can happen with Pemetrexed for Injection. Tell your healthcare provider right away if you develop blisters, skin sores, skin peeling, or painful sores, or ulcers in your mouth, nose, throat or genital area. oLung problems (pneumonitis). Pemetrexed for Injection can cause serious lung problems that can lead to death. Tell your healthcare provider right away if you get any new or worsening symptoms of shortness of breath, cough, or fever. oRadiation recall. Radiation recall is skin reaction that can happen in people who have received radiation treatment in the past and are treated with Pemetrexed for Injection. Tell your healthcare provider if you get swelling, blistering, or rash that looks like sunburn in an area that was previously treated with radiation. The most common side effects of Pemetrexed for Injection when given alone are: otirednessonauseaoloss of appetiteThe most common side effects of Pemetrexed for Injection when given with cisplatin are:ovomitingolow white blood cell counts (neutropenia)oswelling or sores in your mouth or sore throatolow platelet counts (thrombocytopenia)oconstipationolow red blood cell counts (anemia)The most common side effects of Pemetrexed for Injection when given with pembrolizumab and platinum chemotherapy are: otiredness/weaknessonauseaoconstipationodiarrheaoloss of appetiteorashovomitingocoughoshortness of breathofeverPemetrexed for Injection may cause fertility problems in males. This may affect your ability to father child. It is not known if these effects are reversible. Talk to your healthcare provider if this is concern for you. Your healthcare provider will do blood test to check for side effects during treatment with Pemetrexed for Injection. Your healthcare provider may change your dose of Pemetrexed for Injection, delay treatment, or stop treatment if you have certain side effects. Tell your healthcare provider if you have any side effect that bothers you or that does not go away. These are not all the side effects of Pemetrexed for Injection. For more information, ask your healthcare provider or pharmacist. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.General information about the safe and effective use of Pemetrexed for Injection. Medicines are sometimes prescribed for purposes other than those listed in Patient Information leaflet. You can ask your pharmacist or healthcare provider for information about Pemetrexed for Injection that is written for health professionals. What are the ingredients in Pemetrexed for Injection Active ingredient: pemetrexed Inactive ingredients: mannitol, hydrochloric acid and/or sodium hydroxide may have been added to adjust pH.Manufactured for:Baxter Healthcare CorporationDeerfield, IL 60015 USA This Patient Information has been approved by the U.S. Food and Drug Administration. Revised: October 2021. oa kind of lung cancer called non-squamous non-small cell lung cancer (NSCLC). Pemetrexed for Injection is used: oas the first treatment in combination with pembrolizumab and platinum chemotherapy when your lung cancer with no abnormal EGFR or ALK gene has spread (advanced NSCLC). oas the first treatment in combination with cisplatin when your lung cancer has spread (advanced NSCLC). oalone as maintenance treatment after you have received cycles of chemotherapy that contains platinum for first treatment of your advanced NSCLC and your cancer has not progressed. oalone when your lung cancer has returned or spread after prior chemotherapy. oas the first treatment in combination with pembrolizumab and platinum chemotherapy when your lung cancer with no abnormal EGFR or ALK gene has spread (advanced NSCLC). oas the first treatment in combination with cisplatin when your lung cancer has spread (advanced NSCLC). oalone as maintenance treatment after you have received cycles of chemotherapy that contains platinum for first treatment of your advanced NSCLC and your cancer has not progressed. oalone when your lung cancer has returned or spread after prior chemotherapy. oa kind of cancer called malignant pleural mesothelioma. This cancer affects the lining of the lungs and chest wall. Pemetrexed for Injection is used in combination with cisplatin as the first treatment for malignant pleural mesothelioma that cannot be removed by surgery or you are not able to have surgery. ohave kidney problems. ohave had radiation therapy. oare pregnant or plan to become pregnant. Pemetrexed for Injection can harm your unborn baby. oFemales who are able to become pregnant should use effective birth control (contraception) during treatment with Pemetrexed for Injection and for months after the final dose. Tell your healthcare provider right away if you become pregnant or think you are pregnant during treatment with Pemetrexed for Injection. oMales with female partners who are able to become pregnant should use effective birth control (contraception) during treatment with Pemetrexed for Injection and for months after the final dose. oFemales who are able to become pregnant should use effective birth control (contraception) during treatment with Pemetrexed for Injection and for months after the final dose. Tell your healthcare provider right away if you become pregnant or think you are pregnant during treatment with Pemetrexed for Injection. oMales with female partners who are able to become pregnant should use effective birth control (contraception) during treatment with Pemetrexed for Injection and for months after the final dose. oAre breastfeeding or plan to breastfeed. It is not known if Pemetrexed for Injection passes into breast milk. Do not breastfeed during treatment with Pemetrexed for Injection and for week after the final dose. oIt is very important to take folic acid and vitamin B12 during your treatment with Pemetrexed for Injection to lower your risk of harmful side effects.oTake folic acid exactly as prescribed by your healthcare provider time day, beginning days (1 week) before your first dose of Pemetrexed for Injection and continue taking folic acid until 21 days (3 weeks) after your last dose of Pemetrexed for Injection. oYour healthcare provider will give you vitamin B12 injections during treatment with Pemetrexed for Injection. You will get your first vitamin B12 injection days (1 week) before your first dose of Pemetrexed for Injection, and then every cycles. oTake folic acid exactly as prescribed by your healthcare provider time day, beginning days (1 week) before your first dose of Pemetrexed for Injection and continue taking folic acid until 21 days (3 weeks) after your last dose of Pemetrexed for Injection. oYour healthcare provider will give you vitamin B12 injections during treatment with Pemetrexed for Injection. You will get your first vitamin B12 injection days (1 week) before your first dose of Pemetrexed for Injection, and then every cycles. oYour healthcare provider will prescribe medicine called corticosteroid for you to take times day for days, beginning the day before each treatment with Pemetrexed for Injection. oPemetrexed for Injection is given to you by intravenous (IV) infusion into your vein. The infusion is given over 10 minutes. oPemetrexed for Injection is usually given once every 21 days (3 weeks). oLow blood cell counts. Low blood cell counts can be severe, including low white blood cell counts (neutropenia), low platelet counts (thrombocytopenia), and low red blood cell counts (anemia). Your healthcare provider will do blood test to check your blood cell counts regularly during your treatment with Pemetrexed for Injection. Tell your healthcare provider right away if you have any signs of infection, fever, bleeding, or severe tiredness during your treatment with Pemetrexed for Injection.. oKidney problems, including kidney failure. Pemetrexed for Injection can cause severe kidney problems that can lead to death. Severe vomiting or diarrhea can lead to loss of fluids (dehydration) which may cause kidney problems to become worse. Tell your healthcare provider right away if you have decrease in amount of urine. oSevere skin reactions. Severe skin reactions that may lead to death can happen with Pemetrexed for Injection. Tell your healthcare provider right away if you develop blisters, skin sores, skin peeling, or painful sores, or ulcers in your mouth, nose, throat or genital area. oLung problems (pneumonitis). Pemetrexed for Injection can cause serious lung problems that can lead to death. Tell your healthcare provider right away if you get any new or worsening symptoms of shortness of breath, cough, or fever. oRadiation recall. Radiation recall is skin reaction that can happen in people who have received radiation treatment in the past and are treated with Pemetrexed for Injection. Tell your healthcare provider if you get swelling, blistering, or rash that looks like sunburn in an area that was previously treated with radiation. otiredness. onausea. oloss of appetite. ovomiting. olow white blood cell counts (neutropenia). oswelling or sores in your mouth or sore throat. olow platelet counts (thrombocytopenia). oconstipation. olow red blood cell counts (anemia). otiredness/weakness. onausea. oconstipation. odiarrhea. oloss of appetite. orash. ovomiting. ocough. oshortness of breath. ofever. Baxter Logo. Baxter Logo.

LACTATION SECTION.

8.2 Lactation Risk SummaryThere is no information regarding the presence of pemetrexed or its metabolites in human milk, the effects on the breastfed infant, or the effects on milk production. Because of the potential for serious adverse reactions in breastfed infants from Pemetrexed for Injection, advise women not to breastfeed during treatment with Pemetrexed for Injection and for one week after last dose.

MECHANISM OF ACTION SECTION.

12.1 Mechanism of Action Pemetrexed for Injection is folate analog metabolic inhibitor that disrupts folate-dependent metabolic processes essential for cell replication. In vitro studies show that pemetrexed inhibits thymidylate synthase (TS), dihydrofolate reductase, and glycinamide ribonucleotide formyltransferase (GARFT), which are folate-dependent enzymes involved in the de novo biosynthesis of thymidine and purine nucleotides. Pemetrexed is taken into cells by membrane carriers such as the reduced folate carrier and membrane folate binding protein transport systems. Once in the cell, pemetrexed is converted to polyglutamate forms by the enzyme folylpolyglutamate synthetase. The polyglutamate forms are retained in cells and are inhibitors of TS and GARFT.

NONCLINICAL TOXICOLOGY SECTION.

13 NONCLINICAL TOXICOLOGY 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility No carcinogenicity studies have been conducted with pemetrexed. Pemetrexed was clastogenic in an in vivo micronucleus assay in mouse bone marrow but was not mutagenic in multiple in vitro tests (Ames assay, Chinese Hamster Ovary cell assay). Pemetrexed administered intraperitoneally at doses of >=0.1 mg/kg/day to male mice (approximately 0.006 times the recommended human dose based on BSA) resulted in reduced fertility, hypospermia, and testicular atrophy.

OVERDOSAGE SECTION.

10 OVERDOSAGE No drugs are approved for the treatment of Pemetrexed for Injection overdose. Based on animal studies, administration of leucovorin may mitigate the toxicities of Pemetrexed for Injection overdosage. It is not known whether pemetrexed is dialyzable.

PACKAGE LABEL.PRINCIPAL DISPLAY PANEL.

PACKAGE/LABEL PRINCIPAL DISPLAY PANEL Container LabelLOT/EXP:Single-Dose Vial Rx only NDC 0338-0720-01Pemetrexedfor Injection, USP100 mg per vialFor intravenous use only.Discard unused portion.Baxter LogoCaution: Cytotoxic Agent Each vial contains pemetrexed disodiumequivalent to 100 mg pemetrexed, 106 mg ofmannitol. Hydrochloric acid and/or sodiumhydroxide may have been added to adjust pH.Storage: Store powder at 25C (77F);excursions permitted to 15-30C (59-86F)[see USP Controlled Room Temperature].See accompanying literature for storage ofreconstituted and infusion solutions.Manufactured for: Baxter Healthcare Corporation, Deerfield, IL 60015 USA. Product of Germany. Barcode (01)003033807200192D BarcodeUSA HA-65-01-837 55Carton LabelPemetrexedfor Injection, USP100 mg per vialBarcode(01) 20303380720013Baxter is registered trademark ofBaxter International Inc.GTIN:SN:LOT:EXP:Single-Dose Vial NDC 0338-0720-01Pemetrexedfor Injection, USP100 mg per vialBarcodeHA-80-02-962USAPemetrexedfor Injection, USPEach vial contains Pemetrexeddisodium equivalent to 100 mgpemetrexed, 106 mg of mannitol.Hydrochloric acid and/or sodiumhydroxide may have been added toadjust pH. To Reconstitute: Add 4.2 mL of 0.9%Sodium Chloride Injection(preservative free) to make solutioncontaining 25 mg/mL pemetrexed.Reconstituted solution must befurther diluted before use (seeaccompanying literature).Administer infusion solution within24 hours after initial reconstitution.Discard unused portion.See accompanying literature fordosage.C475Single-Dose Vial NDC 0338-0720-01Pemetrexed for Injection, USP100 mg per vialFor intravenous use only. Rx only Baxter Logo2335B0115BarcodePemetrexed for Injection, USPStorage: Store powder at 25C(77F); excursions permitted to15-30C (59-86F) [see USPControlled Room Temperature].Store reconstituted and infusionsolutions at refrigerated, 2-8C(36-46F).Caution: Cytotoxic AgentManufactured for: Baxter Healthcare Corporation Deerfield, IL 60015 USAProduct of GermanyContainer LabelLOT/EXP:Single-Dose VialRx onlyNDC 0338-0722-01Pemetrexedfor Injection, USP500 mg per vialFor intravenous use only.Discard unused portion.Baxter LogoCaution: Cytotoxic Agent Each vial contains pemetrexed disodium equivalent to 500 mg pemetrexed, 500 mg of mannitol. Hydrochloric acid and/or sodium hydroxide may have been added to adjust pH.Storage: Store powder at 25C (77F);excursions permitted to 15-30C (59-86F) [see USP Controlled Room Temperature]. See accompanying literature for storage of reconstituted and infusion solutions.Manufactured for: Baxter Healthcare Corporation, Deerfield, IL 60015 USA. Product of Germany. Barcode (01)003033807220132D BarcodeUSA HA-65-01-838 57Carton LabelPemetrexedfor Injection, USP500 mg per vialBarcode(01) 20303380722017Baxter is registered trademark ofBaxter International Inc.GTIN:SN:LOT:EXP:Single-Dose Vial NDC 0338-0722-01Pemetrexedfor Injection, USP500 mg per vialBarcodeHA-80-02-963USAPemetrexedfor Injection, USPEach vial contains Pemetrexed disodium equivalent to 500 mg pemetrexed, 500 mg of mannitol. Hydrochloric acid and/or sodiumhydroxide may have been added to adjust pH.To Reconstitute: Add 20 mL of 0.9% Sodium Chloride Injection (preservative free) to make solution containing 25 mg/mL pemetrexed.Reconstituted solution must be further diluted before use (see accompanying literature).Administer infusion solution within 24 hours after initial reconstitution. Discard unused portion. See accompanying literature for dosage.C477Single-Dose Vial NDC 0338-0722-01Pemetrexed for Injection, USP500 mg per vialFor intravenous use only. Rx only Baxter Logo2335B0115BarcodePemetrexed for Injection, USPStorage: Store powder at 25C (77F); excursions permitted to 15-30C (59-86F) [see USP Controlled Room Temperature].Store reconstituted and infusion solutions at refrigerated, 2-8C (36-46F).Caution: Cytotoxic AgentManufactured for: Baxter Healthcare Corporation Deerfield, IL 60015 USAProduct of Germany. Pemetrexed Representative Container Label 0338-0720-01. Pemetrexed Representative Carton Label 0338-0720-01. Pemetrexed Representative Container Label 0338-0722-01. Pemetrexed Representative Carton Label 0338-0722-01.

PEDIATRIC USE SECTION.

8.4 Pediatric Use The safety and effectiveness of Pemetrexed for Injection in pediatric patients have not been established. The safety and pharmacokinetics of Pemetrexed for Injection were evaluated in two clinical studies conducted in pediatric patients with recurrent solid tumors. Pemetrexed for Injection was administered at doses ranging from 400 to 2480 mg/m2 intravenously over 10 minutes on Day of 21-day cycle to 32 pediatric patients with recurrent solid tumors in dose-finding study. The maximum tolerated dose (MTD) was determined to be 1910 mg/m2 (60 mg/kg for patients <12 months old). Pemetrexed for Injection was administered at the MTD every 21 days in an activity-estimating study enrolling 72 patients with relapsed or refractory osteosarcoma, Ewing sarcoma/peripheral primitive neural ectodermal tumor (PNET), rhabdomyosarcoma, neuroblastoma, ependymoma, medulloblastoma/supratentorial PNET, or non-brainstem high grade glioma. Patients in both studies received concomitant vitamin B12 and folic acid supplementation and dexamethasone. No tumor responses were observed. Adverse reactions observed in pediatric patients were similar to those observed in adults. Single-dose pharmacokinetics of Pemetrexed for Injection administered at doses ranging from 400 to 2480 mg/m2 were evaluated in 22 patients (13 males and females) age to 18 years (average age 12 years). Pemetrexed exposure (AUC and Cmax) appeared to increase proportionally with dose. Average clearance (2.30 L/h/m2) and half-life (2.3 hours) were similar in pediatric patients compared to adults.

PHARMACODYNAMICS SECTION.

12.2 Pharmacodynamics Pemetrexed inhibited the in vitro growth of mesothelioma cell lines (MSTO-211H, NCI-H2052) and showed synergistic effects when combined with cisplatin. Based on population pharmacodynamic analyses, the depth of the absolute neutrophil counts (ANC) nadir correlates with the systemic exposure to pemetrexed and supplementation with folic acid and vitamin B12. There is no cumulative effect of pemetrexed exposure on ANC nadir over multiple treatment cycles.

PHARMACOKINETICS SECTION.

12.3 Pharmacokinetics AbsorptionThe pharmacokinetics of pemetrexed when Pemetrexed for Injection was administered as single agent in doses ranging from 0.2 to 838 mg/m2 infused over 10-minute period have been evaluated in 426 cancer patients with variety of solid tumors. Pemetrexed total systemic exposure (AUC) and maximum plasma concentration (Cmax) increased proportionally with increase of dose. The pharmacokinetics of pemetrexed did not change over multiple treatment cycles. DistributionPemetrexed has steady-state volume of distribution of 16.1 liters. In vitro studies indicated that pemetrexed is 81% bound to plasma proteins. EliminationThe total systemic clearance of pemetrexed is 91.8 mL/min and the elimination half-life of pemetrexed is 3.5 hours in patients with normal renal function (creatinine clearance of 90 mL/min). As renal function decreases, the clearance of pemetrexed decreases and exposure (AUC) of pemetrexed increases. MetabolismPemetrexed is not metabolized to an appreciable extent. Excretion Pemetrexed is primarily eliminated in the urine, with 70% to 90% of the dose recovered unchanged within the first 24 hours following administration. In vitro studies indicated that pemetrexed is substrate of OAT3 (organic anion transporter 3), transporter that is involved in the active secretion of pemetrexed. Specific PopulationsAge (26 to 80 years) and sex had no clinically meaningful effect on the systemic exposure of pemetrexed based on population pharmacokinetic analyses. Racial Groups The pharmacokinetics of pemetrexed were similar in Whites and Blacks or African Americans. Insufficient data are available for other ethnic groups.Patients with Hepatic ImpairmentPemetrexed has not been formally studied in patients with hepatic impairment. No effect of elevated AST, ALT, or total bilirubin on the PK of pemetrexed was observed in clinical studies. Patients with Renal ImpairmentPharmacokinetic analyses of pemetrexed included 127 patients with impaired renal function. Plasma clearance of pemetrexed decreases as renal function decreases, with resultant increase in systemic exposure. Patients with creatinine clearances of 45, 50, and 80 mL/min had 65%, 54%, and 13% increases, respectively in systemic exposure (AUC) compared to patients with creatinine clearance of 100 mL/min [see Dosage and Administration (2.3) and Warnings and Precautions (5.2)]. Third-Space FluidThe pemetrexed plasma concentrations in patients with various solid tumors with stable, mild to moderate third-space fluid were comparable to those observed in patients without third space fluid collections. The effect of severe third space fluid on pharmacokinetics is not known. Drug Interaction StudiesDrugs Inhibiting OAT3 TransporterIbuprofen, an OAT3 inhibitor, administered at 400 mg four times day decreased the clearance of pemetrexed and increased its exposure (AUC) by approximately 20% in patients with normal renal function (creatinine clearance >80 mL/min). In Vitro Studies Pemetrexed is substrate for OAT3. Ibuprofen, an OAT3 inhibitor inhibited the uptake of pemetrexed in OAT3-expressing cell cultures with an average [Iu]/IC50 ratio of 0.38. In vitro data predict that at clinically relevant concentrations, other NSAIDs (naproxen, diclofenac, celecoxib) would not inhibit the uptake of pemetrexed by OAT3 and would not increase the AUC of pemetrexed to clinically significant extent. [see Drug Interactions (7)]. Pemetrexed is substrate for OAT4. In vitro, ibuprofen and other NSAIDs (naproxen, diclofenac, celecoxib) are not inhibitors of OAT4 at clinically relevant concentrations. AspirinAspirin, administered in low to moderate doses (325 mg every hours), does not affect the pharmacokinetics of pemetrexed. CisplatinCisplatin does not affect the pharmacokinetics of pemetrexed and the pharmacokinetics of total platinum are unaltered by pemetrexed. Vitamins Neither folic acid nor vitamin B12 affect the pharmacokinetics of pemetrexed. Drugs Metabolized by Cytochrome P450 Enzymes In vitro studies suggest that pemetrexed does not inhibit the clearance of drugs metabolized by CYP3A, CYP2D6, CYP2C9, and CYP1A2.

PREGNANCY SECTION.

8.1 Pregnancy Risk SummaryBased on findings from animal studies and its mechanism of action, Pemetrexed for Injection can cause fetal harm when administered to pregnant woman [see Clinical Pharmacology (12.1)]. There are no available data on Pemetrexed for Injection use in pregnant women. In animal reproduction studies, intravenous administration of pemetrexed to pregnant mice during the period of organogenesis was teratogenic, resulting in developmental delays and malformations at doses lower than the recommended human dose of 500 mg/m2[see Data]. Advise pregnant women of the potential risk to fetus [see Use in Special Populations (8.3)]. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is to 4% and 15 to 20%, respectively. DataAnimal Data Pemetrexed was teratogenic in mice. Daily dosing of pemetrexed by intravenous injection to pregnant mice during the period of organogenesis increased the incidence of fetal malformations (cleft palate; protruding tongue; enlarged or misshaped kidney; and fused lumbar vertebra) at doses (based on BSA) 0.03 times the human dose of 500 mg/m2. At doses, based on BSA, greater than or equal to 0.0012 times the 500 mg/m2 human dose, pemetrexed administration resulted in dose-dependent increases in developmental delays (incomplete ossification of talus and skull bone; and decreased fetal weight).

REFERENCES SECTION.

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

SPL UNCLASSIFIED SECTION.

1.1 Non-Squamous Non-Small Cell Lung Cancer (NSCLC) Pemetrexed for Injection is indicated: oin combination with pembrolizumab and platinum chemotherapy, for the initial treatment of patients with metastatic non-squamous NSCLC, with no EGFR or ALK genomic tumor aberrations. oin combination with cisplatin for the initial treatment of patients with locally advanced or metastatic, non-squamous, non-small cell lung cancer (NSCLC). oas single agent for the maintenance treatment of patients with locally advanced or metastatic, non-squamous NSCLC whose disease has not progressed after four cycles of platinum-based first-line chemotherapy. oas single agent for the treatment of patients with recurrent, metastatic non-squamous, NSCLC after prior chemotherapy. Limitations of Use: Pemetrexed for Injection is not indicated for the treatment of patients with squamous cell, non-small cell lung cancer [see Clinical Studies (14.1)]. oin combination with pembrolizumab and platinum chemotherapy, for the initial treatment of patients with metastatic non-squamous NSCLC, with no EGFR or ALK genomic tumor aberrations. oin combination with cisplatin for the initial treatment of patients with locally advanced or metastatic, non-squamous, non-small cell lung cancer (NSCLC). oas single agent for the maintenance treatment of patients with locally advanced or metastatic, non-squamous NSCLC whose disease has not progressed after four cycles of platinum-based first-line chemotherapy. oas single agent for the treatment of patients with recurrent, metastatic non-squamous, NSCLC after prior chemotherapy. Limitations of Use: Pemetrexed for Injection is not indicated for the treatment of patients with squamous cell, non-small cell lung cancer [see Clinical Studies (14.1)].

USE IN SPECIFIC POPULATIONS SECTION.

8 USE IN SPECIFIC POPULATIONS Lactation: Advise not to breastfeed. (8.2). 8.1 Pregnancy Risk SummaryBased on findings from animal studies and its mechanism of action, Pemetrexed for Injection can cause fetal harm when administered to pregnant woman [see Clinical Pharmacology (12.1)]. There are no available data on Pemetrexed for Injection use in pregnant women. In animal reproduction studies, intravenous administration of pemetrexed to pregnant mice during the period of organogenesis was teratogenic, resulting in developmental delays and malformations at doses lower than the recommended human dose of 500 mg/m2[see Data]. Advise pregnant women of the potential risk to fetus [see Use in Special Populations (8.3)]. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is to 4% and 15 to 20%, respectively. DataAnimal Data Pemetrexed was teratogenic in mice. Daily dosing of pemetrexed by intravenous injection to pregnant mice during the period of organogenesis increased the incidence of fetal malformations (cleft palate; protruding tongue; enlarged or misshaped kidney; and fused lumbar vertebra) at doses (based on BSA) 0.03 times the human dose of 500 mg/m2. At doses, based on BSA, greater than or equal to 0.0012 times the 500 mg/m2 human dose, pemetrexed administration resulted in dose-dependent increases in developmental delays (incomplete ossification of talus and skull bone; and decreased fetal weight). 8.2 Lactation Risk SummaryThere is no information regarding the presence of pemetrexed or its metabolites in human milk, the effects on the breastfed infant, or the effects on milk production. Because of the potential for serious adverse reactions in breastfed infants from Pemetrexed for Injection, advise women not to breastfeed during treatment with Pemetrexed for Injection and for one week after last dose.. 8.3 Females and Males of Reproductive Potential ContraceptionFemales Pemetrexed for Injection can cause fetal harm when administered to pregnant woman [see Use in Specific Populations (8.1)]. Because of the potential for genotoxicity, advise females of reproductive potential to use effective contraception during treatment with Pemetrexed for Injection for at least months after the final dose of Pemetrexed for Injection. Males Because of the potential for genotoxicity, advise males with female partners of reproductive potential to use effective contraception during treatment with Pemetrexed for Injection and for months after the final dose [see Nonclinical Toxicology (13.1)]. InfertilityMales Pemetrexed for Injection may impair fertility in males of reproductive potential. It is not known whether these effects on fertility are reversible [see Nonclinical Toxicology (13.1)].. 8.4 Pediatric Use The safety and effectiveness of Pemetrexed for Injection in pediatric patients have not been established. The safety and pharmacokinetics of Pemetrexed for Injection were evaluated in two clinical studies conducted in pediatric patients with recurrent solid tumors. Pemetrexed for Injection was administered at doses ranging from 400 to 2480 mg/m2 intravenously over 10 minutes on Day of 21-day cycle to 32 pediatric patients with recurrent solid tumors in dose-finding study. The maximum tolerated dose (MTD) was determined to be 1910 mg/m2 (60 mg/kg for patients <12 months old). Pemetrexed for Injection was administered at the MTD every 21 days in an activity-estimating study enrolling 72 patients with relapsed or refractory osteosarcoma, Ewing sarcoma/peripheral primitive neural ectodermal tumor (PNET), rhabdomyosarcoma, neuroblastoma, ependymoma, medulloblastoma/supratentorial PNET, or non-brainstem high grade glioma. Patients in both studies received concomitant vitamin B12 and folic acid supplementation and dexamethasone. No tumor responses were observed. Adverse reactions observed in pediatric patients were similar to those observed in adults. Single-dose pharmacokinetics of Pemetrexed for Injection administered at doses ranging from 400 to 2480 mg/m2 were evaluated in 22 patients (13 males and females) age to 18 years (average age 12 years). Pemetrexed exposure (AUC and Cmax) appeared to increase proportionally with dose. Average clearance (2.30 L/h/m2) and half-life (2.3 hours) were similar in pediatric patients compared to adults.. 8.5 Geriatric Use Of the 3,946 patients enrolled in clinical studies of Pemetrexed for Injection, 34% were 65 and over and 4% were 75 and over. No overall differences in effectiveness were observed between these patients and younger patients. The incidences of Grade 3-4 anemia, fatigue, thrombocytopenia, hypertension, and neutropenia were higher in patients 65 years of age and older as compared to younger patients: in at least one of five randomized clinical trials. [see Adverse Reactions (6.1) and Clinical Studies (14.1, 14.2)]. 8.6 Patients with Renal Impairment Pemetrexed for Injection is primarily excreted by the kidneys. Decreased renal function results in reduced clearance and greater exposure (AUC) to Pemetrexed for Injection compared with patients with normal renal function [Warnings and Precautions (5.2, 5.6) and Clinical Pharmacology (12.3)]. No dose is recommended for patients with creatinine clearance less than 45 mL/min [see Dosage and Administration (2.3)].

WARNINGS AND PRECAUTIONS SECTION.

5 WARNINGS AND PRECAUTIONS oMyelosuppression: Can cause severe bone marrow suppression resulting in cytopenia and an increased risk of infection. Do not administer Pemetrexed for Injection when the absolute neutrophil count is less than 1500 cells/mm3 and platelets are less than 100,000 cells/mm3. Initiate supplementation with oral folic acid and intramuscular vitamin B12 to reduce the severity of hematologic and gastrointestinal toxicity of Pemetrexed for Injection. (2.4, 5.1). oRenal Failure: Can cause severe, and sometimes fatal, renal failure. Do not administer when creatinine clearance is less than 45 mL/min. (2.3, 5.2) oBullous and Exfoliative Skin Toxicity: Permanently discontinue for severe and life-threatening bullous, blistering or exfoliating skin toxicity. (5.3) oInterstitial Pneumonitis: Withhold for acute onset of new or progressive unexplained pulmonary symptoms. Permanently discontinue if pneumonitis is confirmed. (5.4) oRadiation Recall: Can occur in patients who received radiation weeks to years previously; permanently discontinue for signs of radiation recall. (5.5) oEmbryo-Fetal Toxicity: Can cause fetal harm. Advise patients of the potential risk to fetus and to use effective contraception. (5.7, 8.1, 8.3). oMyelosuppression: Can cause severe bone marrow suppression resulting in cytopenia and an increased risk of infection. Do not administer Pemetrexed for Injection when the absolute neutrophil count is less than 1500 cells/mm3 and platelets are less than 100,000 cells/mm3. Initiate supplementation with oral folic acid and intramuscular vitamin B12 to reduce the severity of hematologic and gastrointestinal toxicity of Pemetrexed for Injection. (2.4, 5.1). oRenal Failure: Can cause severe, and sometimes fatal, renal failure. Do not administer when creatinine clearance is less than 45 mL/min. (2.3, 5.2) oBullous and Exfoliative Skin Toxicity: Permanently discontinue for severe and life-threatening bullous, blistering or exfoliating skin toxicity. (5.3) oInterstitial Pneumonitis: Withhold for acute onset of new or progressive unexplained pulmonary symptoms. Permanently discontinue if pneumonitis is confirmed. (5.4) oRadiation Recall: Can occur in patients who received radiation weeks to years previously; permanently discontinue for signs of radiation recall. (5.5) oEmbryo-Fetal Toxicity: Can cause fetal harm. Advise patients of the potential risk to fetus and to use effective contraception. (5.7, 8.1, 8.3). 5.1 Myelosuppression and Increased Risk of Myelosuppression without Vitamin Supplementation Pemetrexed for Injection can cause severe myelosuppression resulting in requirement for transfusions and which may lead to neutropenic infection. The risk of myelosuppression is increased in patients who do not receive vitamin supplementation. In Study JMCH, incidences of Grade 3-4 neutropenia (38% versus 23%), thrombocytopenia (9% versus 5%), febrile neutropenia (9% versus 0.6%), and neutropenic infection (6% versus 0) were higher in patients who received Pemetrexed for Injection plus cisplatin without vitamin supplementation as compared to patients who were fully supplemented with folic acid and vitamin B12 prior to and throughout Pemetrexed for Injection plus cisplatin treatment. Initiate supplementation with oral folic acid and intramuscular vitamin B12 prior to the first dose of Pemetrexed for Injection; continue vitamin supplementation during treatment and for 21 days after the last dose of Pemetrexed for Injection to reduce the severity of hematologic and gastrointestinal toxicity of Pemetrexed for Injection [see Dosage and Administration (2.4)]. Obtain complete blood count at the beginning of each cycle. Do not administer Pemetrexed for Injection until the ANC is at least 1500 cells/mm3 and platelet count is at least 100,000 cells/mm3. Permanently reduce Pemetrexed for Injection in patients with an ANC of less than 500 cells/mm3 or platelet count of less than 50,000 cells/mm3 in previous cycles [see Dosage and Administration (2.6)]. In Studies JMDB and JMCH, among patients who received vitamin supplementation, incidence of Grade 3-4 neutropenia was 15% and 23%, the incidence of Grade 3-4 anemia was 6% and 4%, and incidence of Grade 3-4 thrombocytopenia was 4% and 5%, respectively. In Study JMCH, 18% of patients in the Pemetrexed for Injection arm required red blood cell transfusions compared to 7% of patients in the cisplatin arm [see Adverse Reactions (6.1)]. In Studies JMEN, PARAMOUNT, and JMEI, where all patients received vitamin supplementation, incidence of Grade 3-4 neutropenia ranged from 3% to 5%, and incidence of Grade 3-4 anemia ranged from 3% to 5%. 5.2 Renal Failure Pemetrexed for Injection can cause severe, and sometimes fatal, renal toxicity. The incidences of renal failure in clinical studies in which patients received Pemetrexed for Injection with cisplatin were: 2.1% in Study JMDB and 2.2% in Study JMCH. The incidence of renal failure in clinical studies in which patients received Pemetrexed for Injection as single agent ranged from 0.4% to 0.6% (Studies JMEN, PARAMOUNT, and JMEI [see Adverse Reactions (6.1)]. Determine creatinine clearance before each dose and periodically monitor renal function during treatment with Pemetrexed for Injection. Withhold Pemetrexed for Injection in patients with creatinine clearance of less than 45 mL/minute [see Dosage and Administration (2.3)]. 5.3 Bullous and Exfoliative Skin Toxicity Serious and sometimes fatal, bullous, blistering and exfoliative skin toxicity, including cases suggestive of Stevens-Johnson Syndrome/Toxic epidermal necrolysis can occur with Pemetrexed for Injection. Permanently discontinue Pemetrexed for Injection for severe and life-threatening bullous, blistering or exfoliating skin toxicity.. 5.4 Interstitial Pneumonitis Serious interstitial pneumonitis, including fatal cases, can occur with Pemetrexed for Injection treatment. Withhold Pemetrexed for Injection for acute onset of new or progressive unexplained pulmonary symptoms such as dyspnea, cough, or fever pending diagnostic evaluation. If pneumonitis is confirmed, permanently discontinue Pemetrexed for Injection. 5.5 Radiation Recall Radiation recall can occur with Pemetrexed for Injection in patients who have received radiation weeks to years previously. Monitor patients for inflammation or blistering in areas of previous radiation treatment. Permanently discontinue Pemetrexed for Injection for signs of radiation recall. 5.6 Increased Risk of Toxicity with Ibuprofen in Patients with Renal Impairment Exposure to Pemetrexed for Injection is increased in patients with mild to moderate renal impairment who take concomitant ibuprofen, increasing the risks of adverse reactions of Pemetrexed for Injection. In patients with creatinine clearances between 45 mL/min and 79 mL/min, avoid administration of ibuprofen for days before, the day of, and days following administration of Pemetrexed for Injection. If concomitant ibuprofen use cannot be avoided, monitor patients more frequently for Pemetrexed for Injection adverse reactions, including myelosuppression, renal, and gastrointestinal toxicity [see Dosage and Administration (2.5), Drug Interactions (7), and Clinical Pharmacology (12.3)].. 5.7 Embryo-Fetal Toxicity Based on findings from animal studies and its mechanism of action, Pemetrexed for Injection can cause fetal harm when administered to pregnant woman. In animal reproduction studies, intravenous administration of pemetrexed to pregnant mice during the period of organogenesis was teratogenic, resulting in developmental delays and increased malformations at doses lower than the recommended human dose of 500 mg/m2. Advise pregnant women of the potential risk to the fetus. Advise females of reproductive potential to use effective contraception during treatment with Pemetrexed for Injection and for months after the final dose. Advise males with female partners of reproductive potential to use effective contraception during treatment with Pemetrexed for Injection and for months after the final dose [see Use in Specific Populations (8.1, 8.3) and Clinical Pharmacology (12.1)].