ADVERSE REACTIONS SECTION.

6 ADVERSE REACTIONS. The following clinically significant adverse reactions are described elsewhere in the labeling:Myelosuppression [see Warnings and Precautions (5.1)] Mucositis [see Warnings and Precautions (5.2)] Dermatologic Reactions [see Warnings and Precautions (5.3)] Tumor Lysis Syndrome [see Warnings and Precautions (5.4)] Hepatic Toxicity [see Warnings and Precautions (5.5)] Myelosuppression [see Warnings and Precautions (5.1)] Mucositis [see Warnings and Precautions (5.2)] Dermatologic Reactions [see Warnings and Precautions (5.3)] Tumor Lysis Syndrome [see Warnings and Precautions (5.4)] Hepatic Toxicity [see Warnings and Precautions (5.5)] Most common adverse reactions (>35%) are mucositis, thrombocytopenia, nausea, and fatigue. (6.1)To report SUSPECTED ADVERSE REACTIONS, contact Fresenius Kabi USA, LLC at 1-800-551-7176 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. 6.1 Clinical Trials Experience. Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice.. Peripheral T-cell LymphomaThe safety of Pralatrexate injection was evaluated in Study PDX-008 [see Clinical Studies (14)]. Patients received Pralatrexate injection 30 mg/m2 once weekly for weeks in 7-week cycles. The median duration of treatment was 70 days (range: day to 1.5 years). The majority of patients (69%, = 77) remained at the target dose for the duration of treatment. Overall, 85% of scheduled doses were administered.Forty-four percent of patients (n 49) experienced serious adverse event while on study or within 30 days after their last dose of Pralatrexate injection. The most common serious adverse events (> 3%), regardless of causality, were pyrexia, mucositis, sepsis, febrile neutropenia, dehydration, dyspnea, and thrombocytopenia. One death from cardiopulmonary arrest in patient with mucositis and febrile neutropenia was reported in this trial. Across clinical trials, deaths from mucositis, febrile neutropenia, sepsis, and pancytopenia occurred in 1.2% of patients who received doses ranging from 30 mg/m2 to 325 mg/m2.Twenty-three percent of patients (n 25) discontinued treatment with Pralatrexate injection due to adverse reactions. The most frequent adverse reactions reported as the reason for discontinuation of treatment were mucositis (6%) and thrombocytopenia (5%).The most common adverse reactions (> 35%) were mucositis, thrombocytopenia, nausea, and fatigue.Table summarizes the adverse reactions in Study PDX-008.Table Adverse Reactions in (>= 10%) in Patients Who Received Pralatrexate Injection in Study PDX-008a Mucositis includes stomatitis or mucosal inflammation of the gastrointestinal and genitourinary tracts.b Five patients with platelets 10,000/mcL.c Liver function test abnormal includes increased ALT, increased AST, and increased transaminasesPralatrexate InjectionN=111All Grades (%)Grade (%)Grade (%)Any Adverse Reaction1004331 Mucositisa 70174 Thrombocytopeniab 411419b Nausea4040 Fatigue3652 Anemia34152 Constipation3300 Pyrexia3211 Edema3010 Cough2810 Epistaxis2600 Vomiting2520 Neutropenia24137 Diarrhea2120 Dyspnea1970 Anorexia1530 Hypokalemia1541 Rash1500 Pruritus1420 Pharyngolaryngeal pain1410 Liver function test abnormalc 1350 Abdominal pain1240 Pain in extremity1200 Back pain1130 Leukopenia1134 Night sweats1100 Asthenia1010 Upper respiratory tract infection1010 Tachycardia1000. 6.2 Postmarketing Experience. The following adverse reactions have been identified during postapproval use of Pralatrexate 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.Dermatologic Reactions: Toxic epidermal necrolysis.

CARCINOGENESIS & MUTAGENESIS & IMPAIRMENT OF FERTILITY SECTION.

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility. CarcinogenesisCarcinogenicity studies have not been performed with pralatrexate.. MutagenesisPralatrexate did not cause mutations in the Ames test or the Chinese hamster ovary cell chromosome aberration assay. Nevertheless, these tests do not reliably predict genotoxicity for this class of compounds. Pralatrexate did not cause mutations in the mouse micronucleus assay.. Impairment of FertilityNo fertility studies have been performed.

CLINICAL PHARMACOLOGY SECTION.

12 CLINICAL PHARMACOLOGY. 12.1 Mechanism of Action. Pralatrexate is folate analog metabolic inhibitor that competitively inhibits dihydrofolate reductase. It is also competitive inhibitor for polyglutamylation by the enzyme folylpolyglutamyl synthetase. This inhibition results in the depletion of thymidine and other biological molecules the synthesis of which depends on single carbon transfer.. 12.2 Pharmacodynamics. Pralatrexate exposure-response relationship and the time course of pharmacodynamics responses are unknown.. 12.3 Pharmacokinetics. Pralatrexate is racemic mixture of S- and R-diastereomers. The pharmacokinetics of pralatrexate at the recommended dosage of 30 mg/m2 once weekly have been evaluated in 10 patients with PTCL. Pralatrexate total systemic exposure (AUC) and maximum plasma concentration (Cmax) increased proportionally over dose range 30 to 325 mg/m2 (10.8 times the approved recommended dosage). No accumulation of pralatrexate was observed.. DistributionSteady-state volume of distribution of pralatrexate S- and R-diastereomers is 105 and 37 L, respectively. Protein binding of pralatrexate is approximately 67% in vitro.. EliminationThe total systemic clearance of pralatrexate diastereomers was 417 mL/min (S-diastereomer) and 191 mL/min (R-diastereomer). The terminal elimination half-life of pralatrexate was 12-18 hours (coefficient of variance [CV] 62-120%).. MetabolismPralatrexate is not significantly metabolized by CYP450 isozymes or glucuronidases in vitro.. ExcretionFollowing single dose of Pralatrexate injection 30 mg/m2, approximately 34% of the pralatrexate dose was excreted unchanged into urine. Following radiolabeled pralatrexate dose, 39% (CV 28%) of the dose was recovered in urine as unchanged pralatrexate and 34% (CV 88%) in feces as unchanged pralatrexate and/or any metabolites. 10% (CV 95%) of the dose was exhaled over 24 hours.. Specific PopulationsNo clinically meaningful effect on the pharmacokinetics of pralatrexate was observed based on sex.The effect of hepatic impairment on the pharmacokinetics of pralatrexate has not been studied.. Patients with Renal ImpairmentFollowing administration of single dose of Pralatrexate injection, mean exposures of the pralatrexate S-diastereomer and R-diastereomer were comparable in patients with mild to moderate (eGFR 30 to 59 mL/min/1.73 m2 based on MDRD) renal impairment as compared with severe (eGFR 15 to 29 mL/min/1.73 m2) renal impairment. The mean fraction of the administered dose excreted as unchanged diastereomers in urine (fe) decreased with declining renal function [see Use in Specific Populations (8.6)].. Drug Interaction Studies. Clinical StudiesCoadministration of probenecid (an inhibitor of multidrug resistance-associated protein [MRP2] in vitro) resulted in delayed clearance of pralatrexate.. In Vitro StudiesCytochrome P450 (CYP) Enzymes: Pralatrexate does not induce or inhibit CYP enzymes.Transporter Systems: Pralatrexate is substrate for BCRP, MRP2, MRP3, and OATP1B3, but is not substrate of P-gp, OATP1B1, OCT2, OAT1, or OAT3.Pralatrexate inhibits MRP2 and MRP3, but does not inhibit P-gp, BCRP, OCT2, OAT1, OAT3, OATP1B1, or OATP1B3. MRP3 is transporter that may affect the transport of etoposide and teniposide.

CLINICAL STUDIES SECTION.

14 CLINICAL STUDIES. The efficacy of Pralatrexate injection was evaluated in Study PDX-008, an open-label, single-arm, multi-center, international trial that enrolled patients with relapsed or refractory PTCL. One hundred and eleven patients received Pralatrexate injection 30 mg/m2 intravenously over to minutes once weekly by for weeks in 7-week cycles until disease progression or unacceptable toxicity. Of the 111 patients treated, 109 patients were evaluable for efficacy. Evaluable patients had histologically confirmed PTCL by independent central review using the Revised European American Lymphoma (REAL) World Health Organization (WHO) disease classification, and relapsed or refractory disease after at least one prior treatment.The major efficacy outcome measure was overall response rate (complete response, complete response unconfirmed, and partial response) as assessed by International Workshop Criteria (IWC). An additional efficacy outcome measure was duration of response. Response assessments were scheduled at the end of cycle and then every other cycle (every 14 weeks). Duration of response was measured from the first day of documented response to disease progression or death. Response and disease progression were evaluated by independent central review using the IWC.The median age was 59 years (range: 21 to 85); 68% were male; 72% were White, 13% were Black, 8% were Hispanic and 5% were Asian. Patients had baseline Eastern Cooperative Oncology Group (ECOG) performance status of (39%), (44%), or (17%). The median time from initial diagnosis to study entry was 1.3 years (range 24 days to 26.8 years). The median number of prior systemic therapies was (range to 12). Approximately 24% of patients (n 27) did not have evidence of response to any previous therapy. Approximately 63% of patients (n 70) did not have evidence of response to their most recent prior therapy before entering the study.Efficacy results are provided in Table 5.Table Efficacy Results for Study PDX-008 per Independent Central Review (IWC)Fourteen patients went off treatment in cycle 1; patients were unevaluable for response by IWC due to insufficient materials provided to central review.CR Complete Response, CRu Complete Response unconfirmed, PR Partial ResponseEvaluable Patients(N=109)N (%)95% CIMedian Duration of ResponseRange of Duration of ResponseOverall ResponseCR+CRu+PR29 (27)19, 36287 days (9.4 months)1-503 daysCR/CRu9 (8)PR20 (18)Responses >= 14 weeks CR+CRu+PR13 (12)7, 20Not Reached98-503 daysCR/CRu7 (6)PR6 (6)The initial response assessment was scheduled at the end of cycle 1. Of the responders, 66% responded within cycle 1. The median time to first response was 45 days (range 37-349 days).

CLINICAL TRIALS EXPERIENCE SECTION.

6.1 Clinical Trials Experience. Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice.. Peripheral T-cell LymphomaThe safety of Pralatrexate injection was evaluated in Study PDX-008 [see Clinical Studies (14)]. Patients received Pralatrexate injection 30 mg/m2 once weekly for weeks in 7-week cycles. The median duration of treatment was 70 days (range: day to 1.5 years). The majority of patients (69%, = 77) remained at the target dose for the duration of treatment. Overall, 85% of scheduled doses were administered.Forty-four percent of patients (n 49) experienced serious adverse event while on study or within 30 days after their last dose of Pralatrexate injection. The most common serious adverse events (> 3%), regardless of causality, were pyrexia, mucositis, sepsis, febrile neutropenia, dehydration, dyspnea, and thrombocytopenia. One death from cardiopulmonary arrest in patient with mucositis and febrile neutropenia was reported in this trial. Across clinical trials, deaths from mucositis, febrile neutropenia, sepsis, and pancytopenia occurred in 1.2% of patients who received doses ranging from 30 mg/m2 to 325 mg/m2.Twenty-three percent of patients (n 25) discontinued treatment with Pralatrexate injection due to adverse reactions. The most frequent adverse reactions reported as the reason for discontinuation of treatment were mucositis (6%) and thrombocytopenia (5%).The most common adverse reactions (> 35%) were mucositis, thrombocytopenia, nausea, and fatigue.Table summarizes the adverse reactions in Study PDX-008.Table Adverse Reactions in (>= 10%) in Patients Who Received Pralatrexate Injection in Study PDX-008a Mucositis includes stomatitis or mucosal inflammation of the gastrointestinal and genitourinary tracts.b Five patients with platelets 10,000/mcL.c Liver function test abnormal includes increased ALT, increased AST, and increased transaminasesPralatrexate InjectionN=111All Grades (%)Grade (%)Grade (%)Any Adverse Reaction1004331 Mucositisa 70174 Thrombocytopeniab 411419b Nausea4040 Fatigue3652 Anemia34152 Constipation3300 Pyrexia3211 Edema3010 Cough2810 Epistaxis2600 Vomiting2520 Neutropenia24137 Diarrhea2120 Dyspnea1970 Anorexia1530 Hypokalemia1541 Rash1500 Pruritus1420 Pharyngolaryngeal pain1410 Liver function test abnormalc 1350 Abdominal pain1240 Pain in extremity1200 Back pain1130 Leukopenia1134 Night sweats1100 Asthenia1010 Upper respiratory tract infection1010 Tachycardia1000.

CONTRAINDICATIONS SECTION.

4 CONTRAINDICATIONS. None. None. (4).

DESCRIPTION SECTION.

11 DESCRIPTION. Pralatrexate is dihydrofolate reductase inhibitor. Pralatrexate has the chemical name (2S)-2[[4-[(1RS)-1-[(2, 4-diaminopteridin-6-yl)methyl]but-3- ynyl]benzoyl]amino]pentanedioic acid. The molecular formula is C23H23N7O5 and the molecular weight is 477.48 g/mol. Pralatrexate is 1:1 racemic mixture of S- and R- diastereomers at the C10 position (indicated with ). The structural formula is as follows:Pralatrexate is an off-white to yellow solid. It is soluble in aqueous solutions at pH 6.5 or higher. Pralatrexate is practically insoluble in chloroform and ethanol. The pKa values are 3.25, 4.76, and 6.17.Pralatrexate Injection is supplied as preservative-free, sterile, isotonic, non-pyrogenic clear yellow aqueous solution contained in clear glass single-dose vial (Type I) for intravenous use. Each mL of solution contains 20 mg of pralatrexate, sufficient sodium chloride to achieve an isotonic (280-300 mOsm) solution, and sufficient sodium hydroxide, and hydrochloric acid if needed, to adjust and maintain the pH at 7.5-8.5. Pralatrexate Injection is supplied as either 20 mg (1 mL) or 40 mg (2 mL) single-dose vials at concentration of 20 mg/mL.. Structural Formula.

DOSAGE & ADMINISTRATION SECTION.

2 DOSAGE AND ADMINISTRATION. Supplement patients with vitamin B12 mg intramuscularly every 8-10 weeks starting 10 weeks before the first dose and folic acid to 1.25 mg orally once daily starting 10 days before the first dose. (2.1)The recommended dosage of Pralatrexate injection is 30 mg/m2 intravenously over to minutes once weekly for weeks in 7-week cycles. (2.1)For patients with severe renal impairment (GFR 15 to 29 mL/min/1.73 m2), reduce the Pralatrexate injection dose to 15 mg/m2 (2.1).. Supplement patients with vitamin B12 mg intramuscularly every 8-10 weeks starting 10 weeks before the first dose and folic acid to 1.25 mg orally once daily starting 10 days before the first dose. (2.1). The recommended dosage of Pralatrexate injection is 30 mg/m2 intravenously over to minutes once weekly for weeks in 7-week cycles. (2.1). For patients with severe renal impairment (GFR 15 to 29 mL/min/1.73 m2), reduce the Pralatrexate injection dose to 15 mg/m2 (2.1).. 2.1 Important Dosing Information. Pretreatment Vitamin Supplementation. Folic AcidInstruct patients to take folic acid to 1.25 mg orally once daily beginning 10 days before the first dose of Pralatrexate injection. Continue folic acid during treatment with Pralatrexate injection and for 30 days after the last dose [see Warnings and Precautions (5.1, 5.2)]. Vitamin B12Administer vitamin B12 mg intramuscularly within 10 weeks prior to the first dose of Pralatrexate injection and every 8-10 weeks thereafter. Subsequent vitamin B12 injections may be given the same day as treatment with Pralatrexate injection [see Warnings and Precautions (5.1, 5.2)]. 2.2 Recommended Dosage. The recommended dosage of Pralatrexate injection is 30 mg/m2 intravenously over 3-5 minutes once weekly for weeks in 7-week cycles until progressive disease or unacceptable toxicity.. 2.3 Dosage Modifications for Renal Impairment and End Stage Renal Disease. Severe renal impairment (eGFR 15 to 29 mL/min/1.73 m2 by MDRD): Reduce the Pralatrexate injection dose to 15 mg/m2 [see Use in Specific Populations (8.6)].End stage renal disease (ESRD: eGFR less than 15 mL/min/1.73 m2 by MDRD) with or without dialysis: Avoid administration. If the potential benefit of administration justifies the potential risk, monitor renal function and reduce the Pralatrexate injection dose based on adverse reactions [see Warnings and Precautions (5.6), Use in Specific Populations (8.6)].. Severe renal impairment (eGFR 15 to 29 mL/min/1.73 m2 by MDRD): Reduce the Pralatrexate injection dose to 15 mg/m2 [see Use in Specific Populations (8.6)].. End stage renal disease (ESRD: eGFR less than 15 mL/min/1.73 m2 by MDRD) with or without dialysis: Avoid administration. If the potential benefit of administration justifies the potential risk, monitor renal function and reduce the Pralatrexate injection dose based on adverse reactions [see Warnings and Precautions (5.6), Use in Specific Populations (8.6)].. 2.4 Monitoring and Dosage Modifications for Adverse Reactions. MonitoringMonitor complete blood cell counts and severity of mucositis at baseline and weekly. Perform serum chemistry tests, including renal and hepatic function, prior to the start of the first and fourth dose of each cycle.. Recommended Dosage ModificationsDo not administer Pralatrexate injection until:Mucositis Grade or less.Platelet of 100,000/mcL or greater for first dose and 50,000/mcL or greater for all subsequent doses.Absolute neutrophil count (ANC) of 1,000/mcL or greater.Dosage modifications for adverse reactions are provided in Tables 1, 2, and 3.Table Pralatrexate Injection Dosage Modifications for Mucositisa Based National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE version 3.0)Mucositis Gradeaon Day of TreatmentActionRecommended Dose upon Recovery to Grade or 1PatientsWithoutSevere Renal ImpairmentPatients with Severe Renal ImpairmentGrade 2Omit doseContinue prior doseContinue prior doseGrade recurrenceOmit dose20 mg/m2 10 mg/m2 Grade 3Omit dose20 mg/m2 10 mg/m2 Grade 4Stop therapyTable Pralatrexate Injection Dosage Modifications for MyelosuppressionG-CSF=granulocyte colony-stimulating factor; GM-CSF=granulocyte macrophage colony-stimulating factorBlood Count on Day of TreatmentDuration of ToxicityActionRecommended Dose Upon RecoveryPatientsWithoutSevere Renal ImpairmentPatients with Severe Renal ImpairmentPlatelet less than 50,000/mcL1 weekOmit doseContinue prior doseContinue prior dose2 weeksOmit dose20 mg/m2 10 mg/m2 weeksStop therapyANC 500 to 1,000/mcL and no fever1 weekOmit doseContinue prior doseContinue prior doseANC 500 to 1,000/mcL with fever or ANC less than 500/mcL1 weekOmit dose, give G-CSF or GM-CSFContinue prior dose with G-CSF or GM-CSFContinue prior dose with G-CSF or GM-CSF2 weeks or recurrenceOmit dose, give G-CSF or GM-CSF20 mg/m2 with G-CSF or GM-CSF10 mg/m2 with G-CSF or GM-CSF3 weeks or2nd recurrenceStop therapyTable Pralatrexate Injection Dosage Modifications for All Other Adverse Reactionsa Based on NCI CTCAE version 3.0Toxicity Gradeaon Day of TreatmentActionRecommended Dose upon Recovery to Grade or LowerPatientsWithoutSevere Renal ImpairmentPatients with Severe Renal ImpairmentGrade 3Omit dose20 mg/m2 10 mg/m2 Grade 4Stop therapy. Mucositis Grade or less.. Platelet of 100,000/mcL or greater for first dose and 50,000/mcL or greater for all subsequent doses.. Absolute neutrophil count (ANC) of 1,000/mcL or greater.. 2.5 Preparation and Administration. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. Do not use any vials exhibiting particulate matter or discoloration.Pralatrexate injection is hazardous drug. Follow applicable special handling and disposal procedures.1 If Pralatrexate injection comes in contact with the skin, immediately and thoroughly wash with soap and water. If Pralatrexate injection comes in contact with mucous membranes, flush thoroughly with water.Aseptically withdraw the calculated dose from the appropriate number of vial(s) into syringe for immediate use. Do not dilute Pralatrexate injection.Administer undiluted Pralatrexate injection intravenously over 3-5 minutes via the side port of free-flowing 0.9% Sodium Chloride Injection.After withdrawal of dose, discard vial(s) including any unused portion.

DOSAGE FORMS & STRENGTHS SECTION.

3 DOSAGE FORMS AND STRENGTHS. Injection: 40 mg/2 mL (20 mg/mL) and 20 mg/mL clear yellow sterile solution in single-dose vial. Injection: 20 mg/1 mL or 40 mg/2 mL in single-dose vial (3).

DRUG INTERACTIONS SECTION.

7 DRUG INTERACTIONS. Avoid coadministration with probenecid or nonsteroidal anti-inflammatory drugs. If coadministration is unavoidable, monitor for increased risk of adverse reactions. (7.1). Avoid coadministration with probenecid or nonsteroidal anti-inflammatory drugs. If coadministration is unavoidable, monitor for increased risk of adverse reactions. (7.1). 7.1 Effects of Other Drugs on Pralatrexate Injection. Coadministration of Pralatrexate injection with probenecid increased pralatrexate plasma concentrations [see Clinical Pharmacology (12.3)], which may increase the risk of adverse reactions. Avoid coadministration with probenecid or nonsteroidal anti-inflammatory drugs. If coadministration is unavoidable, monitor for increased risk of adverse reactions.

GERIATRIC USE SECTION.

8.5 Geriatric Use. In the Study PDX-008, 36% of patients (n 40) were 65 years of age and over. No overall differences in efficacy and safety were observed in patients based on age (< 65 years compared with >= 65 years). Due to the contribution of renal excretion to overall clearance of pralatrexate (approximately 34%), age-related decline in renal function may lead to reduction in clearance and commensurate increase in plasma exposure. In general, dose selection for an elderly patient should be cautious, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy. Since elderly patients may be at higher risk, monitor more closely. Omit dose and subsequently adjust or discontinue therapy for adverse reactions [see Dosage and Administration (2.4)].

HOW SUPPLIED SECTION.

16 HOW SUPPLIED/STORAGE AND HANDLING. Pralatrexate Injection is available in single-dose clear glass vials containing pralatrexate at concentration of 20 mg/mL as preservative-free, sterile, clear yellow solution individually packaged for intravenous use in the following presentations:Product CodeUnit of SaleStrength550101NDC 65219-550-0120 mg/1 mL552102NDC 65219-552-0240 mg/2 mLStore refrigerated at 2-8C (36-46F) [see USP Controlled Cold Temperature] in original carton to protect from light.Pralatrexate Injection is hazardous drug. Follow applicable special handling and disposal procedures.1.

INDICATIONS & USAGE SECTION.

1 INDICATIONS AND USAGE. Pralatrexate injection is indicated for the treatment of patients with relapsed or refractory peripheral T-cell lymphoma (PTCL).This indication is approved under accelerated approval based on overall response rate [see Clinical Studies (14)]. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trial(s).. Pralatrexate injection is dihydrofolate reductase inhibitor indicated for the treatment of patients with relapsed or refractory peripheral T-cell lymphoma (PTCL).This indication is approved under accelerated approval based on overall response rate. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trial(s). (1).

INFORMATION FOR PATIENTS SECTION.

17 PATIENT COUNSELING INFORMATION. Advise the patient to read the FDA-approved patient labeling (Patient Information).. Folic Acid and Vitamin B12SupplementationAdvise patients treated with Pralatrexate injection to take folic acid and vitamin B12 to reduce the risk of possible side effects [see Dosage and Administration (2.1)]. MyelosuppressionInform patients of the risk of myelosuppression and to immediately contact their healthcare provider should any signs of infection develop, including fever. Inform patients to contact their healthcare provider if bleeding or symptoms of anemia occur [see Warnings and Precautions (5.1)]. MucositisInform patients of the signs and symptoms of mucositis. Instruct patients on ways to reduce the risk of its development, and on ways to maintain nutrition and control discomfort from mucositis if it occurs [see Warnings and Precautions (5.2)].. Dermatologic ReactionsAdvise patients about the risks for and the signs and symptoms of dermatologic reactions. Instruct patients to immediately notify their healthcare provider if any skin reactions occur [see Warnings and Precautions (5.3)]. Tumor Lysis SyndromeInform patients about the risk of and the signs and symptoms of tumor lysis syndrome. Patients should be instructed to notify their healthcare provider if they experience these symptoms [see Warnings and Precautions (5.4)]. Concomitant MedicationsPatients should be instructed to inform their healthcare provider if they are taking any concomitant medications including prescription drugs (such as trimethoprim/sulfamethoxazole and probenecid) and nonprescription drugs (such as nonsteroidal anti-inflammatory drugs) [see Drug Interactions (7.1)]. Embryo-Fetal ToxicityAdvise pregnant women and females of reproductive potential of the potential risk to fetus. Advise females or reproductive potential to inform their healthcare provider of known or suspected pregnancy [see Warnings and Precautions (5.7) and Use in Specific Populations (8.1)].Advise females patients of reproductive potential to use effective contraception during treatment with Pralatrexate injection and for months after the final dose [see Use in Specific Populations (8.3)].Advise males with female partners of reproductive potential to use effective contraception during treatment with Pralatrexate injection and for at least months after the final dose [see Use in Specific Populations (8.3)] LactationAdvise females women not to breastfeed during treatment with Pralatrexate injection and for week after the final dose [see Use in Specific Populations (8.2)].Manufactured for:Lake Zurich, IL 60047www.fresenius-kabi.com/usMade in Germany451756. Fresenius Kabi Logo.

LACTATION SECTION.

8.2 Lactation. Risk SummaryThere is no data on the presence of pralatrexate in human milk or its effects on the breastfed child or milk production. Because of the potential for serious adverse reactions in breastfed child, advise women not to breastfeed during treatment with Pralatrexate injection and for week after the last dose.

MECHANISM OF ACTION SECTION.

12.1 Mechanism of Action. Pralatrexate is folate analog metabolic inhibitor that competitively inhibits dihydrofolate reductase. It is also competitive inhibitor for polyglutamylation by the enzyme folylpolyglutamyl synthetase. This inhibition results in the depletion of thymidine and other biological molecules the synthesis of which depends on single carbon transfer.

NONCLINICAL TOXICOLOGY SECTION.

13 NONCLINICAL TOXICOLOGY. 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility. CarcinogenesisCarcinogenicity studies have not been performed with pralatrexate.. MutagenesisPralatrexate did not cause mutations in the Ames test or the Chinese hamster ovary cell chromosome aberration assay. Nevertheless, these tests do not reliably predict genotoxicity for this class of compounds. Pralatrexate did not cause mutations in the mouse micronucleus assay.. Impairment of FertilityNo fertility studies have been performed.

OVERDOSAGE SECTION.

10 OVERDOSAGE. No specific information is available on the treatment of overdosage of Pralatrexate injection. If an overdose occurs, general supportive measures should be instituted as deemed necessary by the treating healthcare provider. Based on Pralatrexate injections mechanism of action, consider the prompt administration of leucovorin.

PACKAGE LABEL.PRINCIPAL DISPLAY PANEL.

PRINCIPAL DISPLAY PANEL Pralatrexate Injection 20 mg/mL CartonNDC 65219-550-01PralatrexateInjection20 mg/mLFor intravenous useRx only1 mL. PRINCIPAL DISPLAY PANEL Pralatrexate Injection 20 mg/mL Carton.

PEDIATRIC USE SECTION.

8.4 Pediatric Use. The safety and effectiveness of Pralatrexate injection in pediatric patients have not been established.

PHARMACODYNAMICS SECTION.

12.2 Pharmacodynamics. Pralatrexate exposure-response relationship and the time course of pharmacodynamics responses are unknown.

PHARMACOKINETICS SECTION.

12.3 Pharmacokinetics. Pralatrexate is racemic mixture of S- and R-diastereomers. The pharmacokinetics of pralatrexate at the recommended dosage of 30 mg/m2 once weekly have been evaluated in 10 patients with PTCL. Pralatrexate total systemic exposure (AUC) and maximum plasma concentration (Cmax) increased proportionally over dose range 30 to 325 mg/m2 (10.8 times the approved recommended dosage). No accumulation of pralatrexate was observed.. DistributionSteady-state volume of distribution of pralatrexate S- and R-diastereomers is 105 and 37 L, respectively. Protein binding of pralatrexate is approximately 67% in vitro.. EliminationThe total systemic clearance of pralatrexate diastereomers was 417 mL/min (S-diastereomer) and 191 mL/min (R-diastereomer). The terminal elimination half-life of pralatrexate was 12-18 hours (coefficient of variance [CV] 62-120%).. MetabolismPralatrexate is not significantly metabolized by CYP450 isozymes or glucuronidases in vitro.. ExcretionFollowing single dose of Pralatrexate injection 30 mg/m2, approximately 34% of the pralatrexate dose was excreted unchanged into urine. Following radiolabeled pralatrexate dose, 39% (CV 28%) of the dose was recovered in urine as unchanged pralatrexate and 34% (CV 88%) in feces as unchanged pralatrexate and/or any metabolites. 10% (CV 95%) of the dose was exhaled over 24 hours.. Specific PopulationsNo clinically meaningful effect on the pharmacokinetics of pralatrexate was observed based on sex.The effect of hepatic impairment on the pharmacokinetics of pralatrexate has not been studied.. Patients with Renal ImpairmentFollowing administration of single dose of Pralatrexate injection, mean exposures of the pralatrexate S-diastereomer and R-diastereomer were comparable in patients with mild to moderate (eGFR 30 to 59 mL/min/1.73 m2 based on MDRD) renal impairment as compared with severe (eGFR 15 to 29 mL/min/1.73 m2) renal impairment. The mean fraction of the administered dose excreted as unchanged diastereomers in urine (fe) decreased with declining renal function [see Use in Specific Populations (8.6)].. Drug Interaction Studies. Clinical StudiesCoadministration of probenecid (an inhibitor of multidrug resistance-associated protein [MRP2] in vitro) resulted in delayed clearance of pralatrexate.. In Vitro StudiesCytochrome P450 (CYP) Enzymes: Pralatrexate does not induce or inhibit CYP enzymes.Transporter Systems: Pralatrexate is substrate for BCRP, MRP2, MRP3, and OATP1B3, but is not substrate of P-gp, OATP1B1, OCT2, OAT1, or OAT3.Pralatrexate inhibits MRP2 and MRP3, but does not inhibit P-gp, BCRP, OCT2, OAT1, OAT3, OATP1B1, or OATP1B3. MRP3 is transporter that may affect the transport of etoposide and teniposide.

PREGNANCY SECTION.

8.1 Pregnancy. Risk SummaryBased on findings from animal studies and its mechanism of action [see Clinical Pharmacology (12.1)], Pralatrexate injection can cause fetal harm when administered to pregnant woman. There are insufficient data on Pralatrexate injection use in pregnant women to evaluate for drug- associated risk. Pralatrexate injection was embryotoxic and fetotoxic in rats and rabbits when administered during organogenesis at doses about 1.2% (0.012 times) of the clinical dose on mg/m2 basis. Advise pregnant women of the potential risk to fetus.The estimated background risk of major birth defects and miscarriage for the indicated population(s) is unknown. All pregnancies have background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively.. Data. Animal DataPralatrexate was embryotoxic and fetotoxic in rats at intravenous doses of 0.06 mg/kg/day (0.36 mg/m2/day or about 1.2% of the clinical dose on mg/m2 basis) given on gestation days through 20. Treatment with pralatrexate caused dose-dependent decrease in fetal viability manifested as an increase in late, early, and total resorptions. There was also dosedependent increase in post-implantation loss. In rabbits, intravenous doses of 0.03 mg/kg/day (0.36 mg/m2/day) or greater given on gestation days through 21 also caused abortion and fetal lethality. This toxicity manifested as early and total resorptions, post-implantation loss, and decrease in the total number of live fetuses.

REFERENCES SECTION.

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

RENAL IMPAIRMENT SUBSECTION.

8.6 Renal Impairment. No dosage modification is recommended for patients with mild or moderate renal impairment (eGFR 30 to 59 mL/min/1.73 m2 based on MDRD). For patients with severe renal impairment (eGFR 15 to 29 mL/min/1.73 m2), reduce the recommended dose of Pralatrexate injection [see Dosage and Administration (2.3)].Serious adverse drug reactions, including TEN and mucositis, have been reported in patients with ESRD undergoing dialysis. Avoid the use of Pralatrexate injection in patients with ESRD with or without dialysis. If the potential benefit of administration justifies the potential risk, monitor renal function and reduce the Pralatrexate injection dose based on adverse reactions [see Dosage and Administration (2.3), Warnings and Precautions (5.6)].

SPL PATIENT PACKAGE INSERT SECTION.

This Patient Information has been approved by the U.S. Food and Drug Administration.Revised: 09/2022Patient InformationPralatrexate Injection(PRA-luh-TREK-sayt)What is Pralatrexate injectionPralatrexate injection is prescription used to treat people with type of cancer called peripheral T-cell lymphoma (PTCL) that does not go away, gets worse, or comes back after use of another cancer treatment.It is not known if Pralatrexate injection is safe and effective in children.Before you receive Pralatrexate injection, tell your healthcare provider about all of your medical conditions, including if you:have kidney problems, including end-stage renal disease (ESRD)are pregnant or plan to become pregnant. Pralatrexate injection can harm your unborn baby. Females who are able to become pregnant: Your healthcare provider may do pregnancy test before you start treatment with Pralatrexate injection.You should use effective birth control (contraception) during treatment with Pralatrexate injection and for months after the last dose. Talk to your healthcare provider about the best birth control methods you can use during this time.Tell your healthcare provider if you become pregnant or think you maybe pregnant during treatment with Pralatrexate injection. Males with female partners who are able to become pregnant should use effective birth control during treatment with Pralatrexate injection and for months after the last dose of Pralatrexate injection. are breastfeeding or plan to breastfeed. It is not known if Pralatrexate injection passes into your breast milk. Do not breastfeed during treatment with Pralatrexate injection and for week after the last dose. Talk to your healthcare provider about the best way to feed your baby during treatment with Pralatrexate injection.Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. Some medicines may affect how Pralatrexate injection works.Especially tell your healthcare provider if you take:sulfamethoxazole trimethoprimnon-steroidal anti-inflammatory (NSAIDs) medicinesprobenecidKnow the medicines you take. Keep list of them and show it to your healthcare provider or pharmacist each time you start new medicine.How will receive Pralatrexate injectionPralatrexate injection will be given to you by your healthcare provider as an intravenous (IV) injection into your vein over to minutes.Pralatrexate injection is usually given in cycles, one time each week for weeks, with no treatment on the 7th week.Your healthcare provider will treat you with folic acid and vitamin B12 before and during your treatment with Pralatrexate injection to help reduce the risk of possible side effects.You will take folic acid by mouth for 10 days before your first dose of Pralatrexate injection. Continue taking folic acid during treatment with Pralatrexate injection and for 30 days after the last dose.Your healthcare provider will give you vitamin B12 injection into your muscle (intramuscular). You will get your first vitamin B12 injection 10 weeks before your first dose of Pralatrexate injection and every to 10 weeks during treatment with Pralatrexate injection.Your healthcare provider will do blood tests before and during treatment with Pralatrexate injection.Your healthcare provider may stop treatment, delay treatment, or change your dose of Pralatrexate injection based on results of your blood tests and if you have certain side effects.What are the possible side effects of Pralatrexate injectionPralatrexate injection may cause serious side effects, including:Low blood cell counts: Your healthcare provider will do blood tests to check your blood cell counts before and during treatment with Pralatrexate injection. Tell your healthcare provider right away if you develop any signs of infection, fever, bleeding or tiredness during treatment with Pralatrexate injection. Redness and sores of the mucous membrane lining of the mouth, lips,throat, digestive tract, and genitals (mucositis). Mucositis is common with Pralatrexate injection and can be severe. Tell your healthcare provider if you develop redness or painful sores in your mouth or throat, or have trouble speaking, eating or drinking. Your healthcare provider will tell you about ways to reduce your risk of getting mucositis, and how to maintain nutrition and help control the discomfort from mucositis.Severe skin reactions. Pralatrexate injection can cause severe skin reactions that may lead to death. In people with lymphoma, severe skin reactions may happen on and under your skin. Tell your healthcare provider right away if you develop any of the following skin reactions:rashpeeling and loss of skinsoresblisters Tumor Lysis Syndrome (TLS). TLS is caused by the fast breakdown of certain types of cancer cells. Your healthcare provider may do blood tests to check you for TLS and treat you if needed.Liver problems. Your healthcare provider will monitor you for liver problems during treatment with Pralatrexate injection.Increased risk of serious reactions in people with kidney problems. People with severe kidney problems may have greater risk for increased serious reactions during treatment with Pralatrexate injection.The most common side effects of Pralatrexate injection include: low platelet blood counts, nausea, and tiredness.These are not all of the possible side effects of Pralatrexate injection.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 Pralatrexate injection.Medicines are sometimes prescribed for purposes other than those listed in Patient Information leaflet. This Patient Information leaflet summarizes the most important information about Pralatrexate injection. If you would like more information, talk with your healthcare provider. You can ask your healthcare provider or pharmacist for information about Pralatrexate injection that is written for health professionals.What are the ingredients in Pralatrexate injectionActive ingredient: pralatrexate Inactive ingredients: sodium chloride, sodium hydroxide, and hydrochloric acid.Manufactured for: Lake Zurich, IL 60047www.fresenius-kabi.com/usMade in Germany451757. have kidney problems, including end-stage renal disease (ESRD). are pregnant or plan to become pregnant. Pralatrexate injection can harm your unborn baby. Females who are able to become pregnant: Your healthcare provider may do pregnancy test before you start treatment with Pralatrexate injection.You should use effective birth control (contraception) during treatment with Pralatrexate injection and for months after the last dose. Talk to your healthcare provider about the best birth control methods you can use during this time.Tell your healthcare provider if you become pregnant or think you maybe pregnant during treatment with Pralatrexate injection. Males with female partners who are able to become pregnant should use effective birth control during treatment with Pralatrexate injection and for months after the last dose of Pralatrexate injection. Your healthcare provider may do pregnancy test before you start treatment with Pralatrexate injection.. You should use effective birth control (contraception) during treatment with Pralatrexate injection and for months after the last dose. Talk to your healthcare provider about the best birth control methods you can use during this time.. Tell your healthcare provider if you become pregnant or think you maybe pregnant during treatment with Pralatrexate injection.. are breastfeeding or plan to breastfeed. It is not known if Pralatrexate injection passes into your breast milk. Do not breastfeed during treatment with Pralatrexate injection and for week after the last dose. Talk to your healthcare provider about the best way to feed your baby during treatment with Pralatrexate injection.. sulfamethoxazole trimethoprim. non-steroidal anti-inflammatory (NSAIDs) medicines. probenecid. Pralatrexate injection will be given to you by your healthcare provider as an intravenous (IV) injection into your vein over to minutes.. Pralatrexate injection is usually given in cycles, one time each week for weeks, with no treatment on the 7th week.. Your healthcare provider will treat you with folic acid and vitamin B12 before and during your treatment with Pralatrexate injection to help reduce the risk of possible side effects.You will take folic acid by mouth for 10 days before your first dose of Pralatrexate injection. Continue taking folic acid during treatment with Pralatrexate injection and for 30 days after the last dose.Your healthcare provider will give you vitamin B12 injection into your muscle (intramuscular). You will get your first vitamin B12 injection 10 weeks before your first dose of Pralatrexate injection and every to 10 weeks during treatment with Pralatrexate injection.. You will take folic acid by mouth for 10 days before your first dose of Pralatrexate injection. Continue taking folic acid during treatment with Pralatrexate injection and for 30 days after the last dose.. Your healthcare provider will give you vitamin B12 injection into your muscle (intramuscular). You will get your first vitamin B12 injection 10 weeks before your first dose of Pralatrexate injection and every to 10 weeks during treatment with Pralatrexate injection.. Your healthcare provider will do blood tests before and during treatment with Pralatrexate injection.. Low blood cell counts: Your healthcare provider will do blood tests to check your blood cell counts before and during treatment with Pralatrexate injection. Tell your healthcare provider right away if you develop any signs of infection, fever, bleeding or tiredness during treatment with Pralatrexate injection. Redness and sores of the mucous membrane lining of the mouth, lips,throat, digestive tract, and genitals (mucositis). Mucositis is common with Pralatrexate injection and can be severe. Tell your healthcare provider if you develop redness or painful sores in your mouth or throat, or have trouble speaking, eating or drinking. Your healthcare provider will tell you about ways to reduce your risk of getting mucositis, and how to maintain nutrition and help control the discomfort from mucositis.. Severe skin reactions. Pralatrexate injection can cause severe skin reactions that may lead to death. In people with lymphoma, severe skin reactions may happen on and under your skin. Tell your healthcare provider right away if you develop any of the following skin reactions:rashpeeling and loss of skinsoresblisters rash. peeling and loss of skin. sores. blisters. Tumor Lysis Syndrome (TLS). TLS is caused by the fast breakdown of certain types of cancer cells. Your healthcare provider may do blood tests to check you for TLS and treat you if needed.. Liver problems. Your healthcare provider will monitor you for liver problems during treatment with Pralatrexate injection.. Increased risk of serious reactions in people with kidney problems. People with severe kidney problems may have greater risk for increased serious reactions during treatment with Pralatrexate injection.. Fresenius Kabi Logo.

SPL UNCLASSIFIED SECTION.

2.1 Important Dosing Information. Pretreatment Vitamin Supplementation. Folic AcidInstruct patients to take folic acid to 1.25 mg orally once daily beginning 10 days before the first dose of Pralatrexate injection. Continue folic acid during treatment with Pralatrexate injection and for 30 days after the last dose [see Warnings and Precautions (5.1, 5.2)]. Vitamin B12Administer vitamin B12 mg intramuscularly within 10 weeks prior to the first dose of Pralatrexate injection and every 8-10 weeks thereafter. Subsequent vitamin B12 injections may be given the same day as treatment with Pralatrexate injection [see Warnings and Precautions (5.1, 5.2)].

USE IN SPECIFIC POPULATIONS SECTION.

8 USE IN SPECIFIC POPULATIONS. Lactation: Advise not to breastfeed. (8.2). Lactation: Advise not to breastfeed. (8.2). 8.1 Pregnancy. Risk SummaryBased on findings from animal studies and its mechanism of action [see Clinical Pharmacology (12.1)], Pralatrexate injection can cause fetal harm when administered to pregnant woman. There are insufficient data on Pralatrexate injection use in pregnant women to evaluate for drug- associated risk. Pralatrexate injection was embryotoxic and fetotoxic in rats and rabbits when administered during organogenesis at doses about 1.2% (0.012 times) of the clinical dose on mg/m2 basis. Advise pregnant women of the potential risk to fetus.The estimated background risk of major birth defects and miscarriage for the indicated population(s) is unknown. All pregnancies have background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively.. Data. Animal DataPralatrexate was embryotoxic and fetotoxic in rats at intravenous doses of 0.06 mg/kg/day (0.36 mg/m2/day or about 1.2% of the clinical dose on mg/m2 basis) given on gestation days through 20. Treatment with pralatrexate caused dose-dependent decrease in fetal viability manifested as an increase in late, early, and total resorptions. There was also dosedependent increase in post-implantation loss. In rabbits, intravenous doses of 0.03 mg/kg/day (0.36 mg/m2/day) or greater given on gestation days through 21 also caused abortion and fetal lethality. This toxicity manifested as early and total resorptions, post-implantation loss, and decrease in the total number of live fetuses.. 8.2 Lactation. Risk SummaryThere is no data on the presence of pralatrexate in human milk or its effects on the breastfed child or milk production. Because of the potential for serious adverse reactions in breastfed child, advise women not to breastfeed during treatment with Pralatrexate injection and for week after the last dose.. 8.3 Females and Males of Reproductive Potential. Pralatrexate injection can cause fetal harm when administered to pregnant woman [see Use in Specific Populations (8.1 )].. Pregnancy TestingVerify pregnancy status in females of reproductive potential prior to initiation of Pralatrexate injection.. Contraception. FemalesAdvise females of reproductive potential to use effective contraception during treatment with Pralatrexate injection and for months following the last dose.. MalesAdvise males with female partners of reproductive potential to use effective contraception during treatment with Pralatrexate injection and for months following the last dose.. 8.4 Pediatric Use. The safety and effectiveness of Pralatrexate injection in pediatric patients have not been established.. 8.5 Geriatric Use. In the Study PDX-008, 36% of patients (n 40) were 65 years of age and over. No overall differences in efficacy and safety were observed in patients based on age (< 65 years compared with >= 65 years). Due to the contribution of renal excretion to overall clearance of pralatrexate (approximately 34%), age-related decline in renal function may lead to reduction in clearance and commensurate increase in plasma exposure. In general, dose selection for an elderly patient should be cautious, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy. Since elderly patients may be at higher risk, monitor more closely. Omit dose and subsequently adjust or discontinue therapy for adverse reactions [see Dosage and Administration (2.4)]. 8.6 Renal Impairment. No dosage modification is recommended for patients with mild or moderate renal impairment (eGFR 30 to 59 mL/min/1.73 m2 based on MDRD). For patients with severe renal impairment (eGFR 15 to 29 mL/min/1.73 m2), reduce the recommended dose of Pralatrexate injection [see Dosage and Administration (2.3)].Serious adverse drug reactions, including TEN and mucositis, have been reported in patients with ESRD undergoing dialysis. Avoid the use of Pralatrexate injection in patients with ESRD with or without dialysis. If the potential benefit of administration justifies the potential risk, monitor renal function and reduce the Pralatrexate injection dose based on adverse reactions [see Dosage and Administration (2.3), Warnings and Precautions (5.6)].

WARNINGS AND PRECAUTIONS SECTION.

5 WARNINGS AND PRECAUTIONS. Myelosuppression: Monitor complete blood counts and omit and/or reduce dose based on ANC and platelet count. (2.4, 5.1)Mucositis:Monitor at least weekly. Omit and/or reduce dose for grade or higher mucositis. (2.4, 5.2)Dermatologic reactions: Reactions, including fatal reactions, occurred and may be progressive and increase in severity with further treatment. Monitor closely and withhold or discontinue Pralatrexate injection based on severity. (2.4, 5.3)Tumor lysis syndrome: Monitor patients who are increased risk and treat promptly. (5.4)Hepatic toxicity: Monitor for liver function tests. Omit until recovery, adjust or discontinue therapy based on severity. (2.4, 5.5)Risk of increased toxicity with renal impairment: Avoid Pralatrexate injection in patients with end stage renal disease with or without dialysis. If the potential benefit of administration justifies the potential risk, monitor renal function and reduce the Pralatrexate injection dose based on adverse reactions. (2.3, 2.4, 5.6)Embryo-fetal toxicity: Can cause fetal harm. Advise patients of the potential risk to fetus and to use an effective method of contraception. (5.7, 8.1, 8.3). Myelosuppression: Monitor complete blood counts and omit and/or reduce dose based on ANC and platelet count. (2.4, 5.1). Mucositis:Monitor at least weekly. Omit and/or reduce dose for grade or higher mucositis. (2.4, 5.2). Dermatologic reactions: Reactions, including fatal reactions, occurred and may be progressive and increase in severity with further treatment. Monitor closely and withhold or discontinue Pralatrexate injection based on severity. (2.4, 5.3). Tumor lysis syndrome: Monitor patients who are increased risk and treat promptly. (5.4). Hepatic toxicity: Monitor for liver function tests. Omit until recovery, adjust or discontinue therapy based on severity. (2.4, 5.5). Risk of increased toxicity with renal impairment: Avoid Pralatrexate injection in patients with end stage renal disease with or without dialysis. If the potential benefit of administration justifies the potential risk, monitor renal function and reduce the Pralatrexate injection dose based on adverse reactions. (2.3, 2.4, 5.6). Embryo-fetal toxicity: Can cause fetal harm. Advise patients of the potential risk to fetus and to use an effective method of contraception. (5.7, 8.1, 8.3). 5.1 Myelosuppression. Pralatrexate injection can cause myelosuppression, manifested by thrombocytopenia, neutropenia, and/or anemia.Administer vitamin B12 and instruct patients to take folic acid to reduce the risk of treatment-related myelosuppression [see Dosage and Administration (2.1)]. Monitor complete blood counts and omit and/or reduce the dose based on ANC and platelet count prior to each dose [see Dosage and Administration (2.4)].. 5.2 Mucositis. Pralatrexate injection can cause mucositis [see Adverse Reactions (6.1)].Administer vitamin B12 and instruct patients to take folic acid to reduce the risk of mucositis [see Dosage and Administration (2.1)]. Monitor for mucositis weekly and omit and/or reduce the dose for grade or higher mucositis [see Dosage and Administration (2.4)]. 5.3 Dermatologic Reactions. Pralatrexate injection can cause severe dermatologic reactions, which may result in death. These dermatologic reactions have been reported in clinical studies (2.1% of 663 patients) and post marketing experience, and have included skin exfoliation, ulceration, and toxic epidermal necrolysis (TEN) [see Adverse Reactions (6.1, 6.2)]. They may be progressive and increase in severity with further treatment and may involve skin and subcutaneous sites of known lymphoma.Monitor closely for dermatologic reactions. Withhold or discontinue Pralatrexate injection based on severity [see Dosage and Administration (2.4)]. 5.4 Tumor Lysis Syndrome. Pralatrexate injection can cause tumor lysis syndrome (TLS). Monitor patients who are at increased risk of TLS and treat promptly.. 5.5 Hepatic Toxicity. Pralatrexate injection can cause hepatic toxicity and liver function test abnormalities [see Adverse Reactions (6.1)]. Persistent liver function test abnormalities may be indicators of hepatic toxicity and require dose modification or discontinuation.Monitor liver function tests. Omit dose until recovery, adjust or discontinue therapy based on the severity of the hepatic toxicity [see Dosage and Administration (2.4)]. 5.6 Risk of Increased Toxicity with Renal Impairment. Patients with severe renal impairment (eGFR 15 to 30 mL/min/1.73 m2 based on MDRD) may be at greater risk for increased exposure and adverse reactions. Reduce Pralatrexate injection dosage in patients with severe renal impairment [see Dosage and Administration (2.3)].Serious adverse reactions, including TEN and mucositis, were reported in patients with end stage renal disease (ESRD) undergoing dialysis who were administered Pralatrexate injection. Avoid Pralatrexate injection in patients with ESRD with or without dialysis. If the potential benefit of administration justifies the potential risk, monitor renal function and reduce the Pralatrexate injection dose based on adverse reactions [see Dosage and Administration (2.3)].. 5.7 Embryo-Fetal Toxicity. Based on findings in animals and its mechanism of action, Pralatrexate injection can cause fetal harm when administered to pregnant woman. Pralatrexate injection was embryotoxic and fetotoxic in rats and rabbits. Advise pregnant women of the potential risk to fetus. Advise females of reproductive potential to use effective contraception during treatment with Pralatrexate injection and for months after the last dose. Advise males with female partners of reproductive potential to use effective contraception during treatment with Pralatrexate injection and for months after the last dose [see Use in Specific Populations (8.1, 8.3)].