SPL PATIENT PACKAGE INSERT SECTION.

Patient Information. ZARXIO(R) (zar-zee-oh)(filgrastim-sndz)injectionWhat is ZARXIOZARXIO is man-made form of granulocyte colony-stimulating factor (G-CSF). G-CSF is substance produced by the body. It stimulates the growth of neutrophils, type of white blood cell important in the bodys fight against infection. Acute Radiation Syndrome: The effectiveness of filgrastim for this use was only studied in animals, because it could not be studied in people.Do not take ZARXIO if you have had serious allergic reaction to human G-CSFs such as filgrastim products or pegfilgrastim products.Before you take ZARXIO, tell your healthcare provider about all of your medical conditions, including if you:ohave sickle cell disorder.ohave kidney problems.oare receiving radiation therapy.oare allergic to latex. The needle cap on the prefilled syringe contains dry natural rubber (derived from latex). You should not give ZARXIO using the prefilled syringe if you have latex allergies. Ask your healthcare provider about using the vial if you have latex allergies. The vial stopper is not made with natural rubber latex.oare pregnant or plan to become pregnant. It is not known if ZARXIO will harm your unborn baby.oare breastfeeding or plan to breastfeed. It is not known if ZARXIO passes into your breast milk.Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements.How will receive ZARXIOoZARXIO injections can be given by healthcare provider by intravenous (IV) infusion or under your skin (subcutaneous injection). Your healthcare provider may decide subcutaneous injections can be given at home by you or your caregiver. If ZARXIO is given at home, see the detailed Instructions for Use that comes with your ZARXIO for information on how to prepare and inject dose of ZARXIO.oYou and your caregiver should be shown how to prepare and inject ZARXIO before you use it, by your healthcare provider.oYour healthcare provider will tell you how much ZARXIO to inject and when to inject it. Do not change your dose or stop ZARXIO unless your healthcare provider tells you to.oYou should not inject dose of ZARXIO less than 0.3 mL (180 mcg) from ZARXIO prefilled syringe. dose less than 0.3 mL cannot be accurately measured using the ZARXIO prefilled syringe. oIf you are receiving ZARXIO because you are also receiving chemotherapy, your dose of ZARXIO should be injected at least 24 hours before or 24 hours after your dose of chemotherapy. Your healthcare provider will do blood tests to monitor your white blood cell count, and if necessary, adjust your ZARXIO dose.oIf you are receiving ZARXIO because you have been suddenly (acutely) exposed to an amount of radiation that can affect your bone marrow (Acute Radiation Syndrome), you will need to have blood tests about every days during treatment with ZARXIO to check your white blood cell count.oIf you miss dose of ZARXIO, talk to your healthcare provider about when you should give your next dose.What are the possible side effects of ZARXIO ZARXIO may cause serious side effects, including:oSpleen rupture. Your spleen may become enlarged and can rupture. ruptured spleen can cause death. Call your healthcare provider right away if you have pain in the left upper stomach (abdomen) area or your left shoulder.oA serious lung problem called acute respiratory distress syndrome (ARDS). Call your healthcare provider or get emergency medical help right away if you have shortness of breath with or without fever, trouble breathing, or fast rate of breathing.oSerious allergic reactions. ZARXIO can cause serious allergic reactions. These reactions can cause rash over your whole body, shortness of breath, wheezing, dizziness, swelling around your mouth or eyes, fast heart rate, and sweating. If you have any of these symptoms, stop using ZARXIO and call your healthcare provider or get emergency medical help right away.oSickle cell crises. You may have serious sickle cell crisis, which could lead to death, if you have sickle cell disorder and receive ZARXIO. Call your healthcare provider right away if you have symptoms of sickle cell crisis such as pain or difficulty breathing.oKidney injury (glomerulonephritis). ZARXIO can cause kidney injury. Call your healthcare providerright away if you develop any of the following symptoms: oswelling of your face or anklesoblood in your urine or dark colored urine oyou urinate less than usual oCapillary leak syndrome. ZARXIO can cause fluid to leak from blood vessels into your bodys tissues. This condition is called Capillary Leak Syndrome (CLS). CLS can quickly cause you to have symptoms that may become life-threatening. Get emergency medical help right away if you develop any of the following symptoms:oswelling or puffiness and are urinating less than usualotrouble breathingoswelling of your stomach area (abdomen) and feeling of fullnessodizziness or feeling faintoa general feeling of tiredness oMyelodysplastic syndrome (MDS) and acute myeloid leukemia (AML).oZARXIO may increase the risk of developing precancerous condition called MDS or type of blood cancer called AML in people who were born with low white blood cell counts (congenital neutropenia).oIf you have breast cancer or lung cancer, when ZARXIO is used with chemotherapy and radiation therapy, or with radiation therapy only, you may have an increased risk of developing MDS or AML.oSymptoms of MDS and AML may include tiredness, fever, and easy bruising or bleeding.oCall your healthcare provider if you develop any of these symptoms during treatment with ZARXIO.oDecreased platelet count (thrombocytopenia). Your healthcare provider will check your blood during treatment with ZARXIO. Tell your healthcare provider if you have unusual bleeding or bruising during treatment with ZARXIO. This could be sign of decreased platelet counts, which may reduce the ability of your blood to clot.oIncreased white blood cell count (leukocytosis). Your healthcare provider will check your blood during treatment with ZARXIO.oInflammation of your blood vessels (cutaneous vasculitis). Tell your healthcare provider right away if you develop purple spots or redness of your skin.oInflammation of the aorta (aortitis). Inflammation of the aorta (the large blood vessel which transports blood from the heart to the body) has been reported in patients who received filgrastim products. Symptoms may include fever, abdominal pain, feeling tired, and back pain. Call your healthcare provider if you experience these symptoms. The most common side effects experienced in patients receiving ZARXIO include:oPatients with cancer receiving chemotherapy: fever, pain, rash, cough, and shortness of breathoPatients with acute myeloid leukemia receiving chemotherapy: pain, nose bleed, and rashoPatients with cancer receiving chemotherapy followed by bone marrow transplant: rashoPatients who are having their own blood cells collected: bone pain, fever, and headacheoPatients with severe chronic neutropenia: pain, decreased red blood cells, nose bleed, diarrhea, reduced sensation, and hair lossThese are not all the possible side effects of ZARXIO.Call your healthcare provider for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.How should store ZARXIOoStore ZARXIO in the refrigerator between 36F to 46F (2C to 8C).oDo not freeze. oStore ZARXIO in the original pack to protect it from light or physical damage. Do not leave ZARXIO in direct sunlight.oDo not shake ZARXIO.oTake ZARXIO out of the refrigerator 30 minutes before use and allow it to reach room temperature between 68F to 77F (20C to 25C) before preparing an injection.oIf not used right away,ZARXIO may be kept at room temperature for up to days. Throw away any ZARXIO that has been left at room temperature for longer than days.oAfter you inject your dose, throw away (dispose of) any unused ZARXIO left in the prefilled syringe or vial. Do not save unused ZARXIO in the prefilled syringe or vial for later use. Keep ZARXIO and all medicines out of the reach of children.General information about the safe and effective use of ZARXIO:Medicines are sometimes prescribed for purposes other than those listed in Patient Information leaflet. Do not use ZARXIO for condition for which it was not prescribed. Do not give ZARXIO to other people, even if they have the same symptoms that you have. It may harm them. You can ask your pharmacist or healthcare provider for information about ZARXIO that is written for healthcare professionals.What are the ingredients in ZARXIOActive ingredient: filgrastim-sndzInactive ingredients: glutamic acid, polysorbate 80, sodium hydroxide, sorbitol, water for injection Manufactured by: Sandoz Inc., Princeton, NJ 08540, US License No. 2003For more information visit www.zarxio.com or call 1-800-525-8747.This Patient Information has been approved by the U.S. Food and Drug Administration. Revised: 10/2024Instructions for UseZARXIO(R) (zar-zee-oh)(filgrastim-sndz)injectionSingle-Dose Prefilled SyringeImportant Information You Need to Know Before Injecting ZARXIO:oDo not inject yourself or someone else until you have been shown how to inject ZARXIO. Your healthcare provider will show you how to prepare and inject ZARXIO properly using the ZARXIO prefilled syringe with UltraSafe Passive(R) Needle Guard. Talk to your healthcare provider if you have any questions.oYou should not inject dose of ZARXIO less than 0.3 mL (180 mcg) from ZARXIO prefilled syringe. dose less than 0.3 mL cannot be accurately measured using the ZARXIO prefilled syringe.oDo not use the ZARXIO prefilled syringe if either the seal on the outer pack or the seal of the blister are broken.oKeep the ZARXIO prefilled syringe in the sealed pack until you are ready to use it.oThe needle cap on the prefilled syringe contains natural rubber (derived from latex). Do not handle the prefilled syringe if you are allergic to latex.oThe prefilled syringe has needle guard that will be activated to cover the needle after the injection is given. The needle guard will help prevent needle stick injuries to anyone who handles the prefilled syringe.oAvoid touching the syringe needle guard wings before use. Touching them may cause the syringe needle guard to be activated too early.oDo not remove the needle cap until just before you give the injection.oThrow away (dispose of) the used ZARXIO prefilled syringe right away after use. Do not re-use ZARXIO prefilled syringe. See Disposing of used ZARXIO prefilled syringes at the end of this Instructions for Use.oDo not use if the syringe has been dropped onto hard surface or dropped after removing the needle cap.Storing ZARXIOoStore ZARXIO in the refrigerator between 36F to 46F (2C to 8C).oProtect from freezing ZARXIO. If frozen, thaw in the refrigerator before use. Throw away (dispose of) if it has been frozen more than time.oStore ZARXIO in the original pack to protect it from light.oAvoid shaking ZARXIO.oTake ZARXIO out of the refrigerator 30 minutes before use and allow it to reach room temperature between 68F to 77F (20C to 25C) before preparing an injection.oIf not used right away, ZARXIO may be kept at room temperature for up to days. Throw away (dispose of) any ZARXIO that has been left at room temperature for longer than days.oAfter you inject your dose, throw away (dispose of) any unused ZARXIO left in the prefilled syringe. Do not save unused ZARXIO in the prefilled syringe for later use.Keep ZARXIO and all medicines out of the reach of children.About the ZARXIO prefilled syringe:oZARXIO prefilled syringes come in two strengths. Depending on your prescription, you will receive ZARXIO prefilled syringes that contain 300 mcg/0.5 mL or 480 mcg/0.8 mL of medicine. Your healthcare provider will determine the microgram (mcg) dose in milliliters (mL) that you will need to give based on your body weight. When you receive your ZARXIO prefilled syringes, always check to see that the:oname ZARXIO appears on the pack and prefilled syringe label.oexpiration date on the prefilled syringe label has not passed. You should not use prefilled syringe after the date on the label.ostrength of ZARXIO (number of mcg on the pack containing the prefilled syringe) is the same as what your healthcare provider prescribed.ZARXIO prefilled syringe parts (see Figure A). ZARXIO 300 mcg /0.5 mL prefilled syringe is shown as an example.Figure AWhat you need for your injection:Included in the pack:oA new ZARXIO prefilled syringeNot included in the pack (see Figure B): o1 Alcohol wipeo1 Cotton ball or gauzeoSharps disposal containero1 Adhesive bandageFigure BSee Disposing of used ZARXIO prefilled syringes at the end of this Instructions for Use.Preparing the ZARXIO prefilled syringeStep 1. Find clean, well-lit, flat work surface.Step 2. Take the pack containing the ZARXIO prefilled syringe out of the refrigerator and leave it unopened on your work surface for about 30 minutes so that it reaches room temperature.Step 3. Wash your hands well with soap and water.Step 4. Remove the ZARXIO prefilled syringe from the outer pack and take it out of the blister.Step 5. Check the expiration date. Do not use the ZARXIO prefilled syringe if the expiration date has passed.Step 6. Look through the viewing window on the ZARXIO prefilled syringe. The liquid inside should be clear. The color may be colorless to slightly yellow. You may see small air bubble in the liquid. This is normal. Do not use the prefilled syringe if the liquid contains visible particles, or if the liquid is cloudy or discolored. Return the ZARXIO prefilled syringe and the package it came in to your pharmacy.Step 7. Do not use ZARXIO prefilled syringe if it is broken. Return the broken prefilled syringe and the package it came in to your pharmacy.Step 8. Check to make sure that the plastic transparent needle guard is covering the barrel of the glass syringe. If the transparent needle guard is covering the needle cap (see Figure C) the needle guard has already been activated. Do not use the prefilled syringe. Get another prefilled syringe that has not been activated and is ready to use (see Figure D). Figure shows needle guard that has already been activated. Do not use ZARXIO prefilled syringe that has been activated. Figure Do Not UseFigure shows needle guard that has not yet been activated. The prefilled syringe is ready for use.Figure Ready to UseStep 9: Choose the injection site:oAreas of your body that you may use as injection sites include:othe front of your thighs (see Figure E)othe lower stomach-area (abdomen), but not the area inches around your navel (belly button) (see Figure E)oif caregiver is giving you the injectionupper outer arms (see Figure and Figure F)upper areas of the buttocks (see Figure F)oChoose different site each time you give yourself an injection.oDo not inject into areas where the skin is tender, bruised, red, scaly, or hard. Avoid areas with scars or stretch marks.Figure EFigure Step 10. Clean the injection site using circular motion with the alcohol wipe. Leave it to dry before injecting. Do not touch the cleaned area again before injecting.Giving your injection Step 11. Hold the prefilled syringe by the body (the clear plastic needle guard) with the needle pointing up (see Figure G). Holding the syringe with the needle pointing up helps to prevent medicine from leaking out of the needle. Carefully pull the needle cap straight off. Throw away the needle cap.Figure Step 12. Check the syringe for an air bubble. Gently tap the syringe body with your fingers until the air bubble rises to the top of the syringe (see Figure H). Slowly push the plunger up to push any air out of the syringe and stop when you see small drop start to appear at the needle tip (see Figure H). Figure HoYour healthcare provider has prescribed either full syringe dose or partial syringe dose of ZARXIO. If you are prescribed full dose, you will inject all of the medicine from your prefilled syringe. For full dose, go directly to Step 14. oIf you are prescribed partial dose of ZARXIO, start with Step 13. Step 13. Holding the syringe as shown, press slowly on the plunger to push out the excess medicine until the edge of the conical base of the plunger stopper lines up with the syringe marking for your prescribed dose. See Figure I, example for dose of 0.4 mL. Your dose may be different than the example shown.Be careful not to touch the needle guard wings before use. The needle guard may be activated too early.Check again to make sure the correct dose of ZARXIO is in the syringe.Call your healthcare provider if you have problems measuring or injecting your dose of ZARXIO.Figure Step 14. With one hand gently pinch the skin at the injection site. With your other hand insert the needle into your skin as shown (see Figure J). Push the needle all the way in to make sure that you inject your full dose.Figure Step 15. Hold the ZARXIO prefilled syringe as shown (see Figure K). Slowly press down on the plunger as far as it will go so that the plunger head is completely between the needle guard wings. Figure Step 16. Keep the plunger fully pressed down while you carefully pull the needle straight out from the injection site (see Figure L). Figure Step 17. Slowly release the plunger and allow the needle guard to automatically cover the exposed needle (see Figure M). Figure Step 18. There may be small amount of blood at the injections site. You can press cotton ball or gauze over the injection site and hold it for 10 seconds. Do not rub the injection site. You may cover the injection site with small adhesive bandage, if needed.Disposing of used ZARXIO prefilled syringesPut your used prefilled syringes in an FDA-cleared sharps disposal container right away after use (see Figure N). Do not throw away (dispose of) ZARXIO prefilled syringes in your household trash.Figure NIf you do not have an FDA-cleared sharps disposal container, you may use household container that is:omade of heavy-duty plastic,ocan be closed with tight-fitting, puncture-resistant lid, without sharps being able to come out,oupright and stable during use,oleak-resistant, andoproperly labeled to warn of hazardous waste inside the container.When your sharps disposal container is almost full, you will need to follow your community guidelines for the right way to dispose of your sharps disposal container. There may be state or local laws about how you should throw away used needles, syringes, and prefilled syringes. For more information about safe sharps disposal, and for specific information about sharps disposal in the state that you live in, go to the FDAs website at: http://www.fda.gov/safesharpsdisposal.Do not reuse the prefilled syringe.Do not recycle the syringe, or sharps disposal container or throw them into household trash.Important: Always keep the sharps disposal container out of the reach of children.This Instructions for Use has been approved by the U.S. Food and Drug Administration.Manufactured by: Sandoz Inc., Princeton, NJ 08540, US License No. 2003Revised: 08/2024Instructions for UseZARXIO(R) (zar-zee-oh) (filgrastim-sndz)InjectionSingle-Dose VialImportant Information You Need to Know Before Injecting ZARXIO:oDo not inject yourself or someone else until you have been shown how to inject ZARXIO. Your healthcare provider will show you how to prepare and inject ZARXIO properly using the ZARXIO vial and syringe. Talk to your healthcare provider if you have any questions.oDo not use the ZARXIO vial if either the seal on the outer pack or the cap of the vial is broken.oKeep the ZARXIO vial in the sealed pack until you are ready to use it.oThrow away (dispose of) the used ZARXIO vials, syringes, and needles right away after use. Do not re-use ZARXIO vials, syringes, or needles. See Disposing of used ZARXIO vials, syringes, and needles at the end of this Instructions for Use.oLatex-sensitive individuals: The vial stopper is not made with natural rubber latex. Storing ZARXIOoStore ZARXIO in the refrigerator between 36F to 46F (2C to 8C).oProtect ZARXIO from freezing. If frozen, thaw in the refrigerator before use. Throw away (dispose of) if it has been frozen more than time.oStore ZARXIO in the original pack to protect it from light.oAvoid shaking ZARXIO.oTake ZARXIO out of the refrigerator 30 minutes before use and allow it to reach room temperature between 68F to 77F (20C to 25C) before preparing an injection.oIf not used right away, ZARXIO may be kept at room temperature for up to days. Throw away (dispose of) any ZARXIO that has been left at room temperature for longer than days. oAfter you inject your dose, throw away (dispose of) any unused ZARXIO left in the vial. Do not save unused ZARXIO in the vial for later use.Keep ZARXIO and all medicines out of the reach of children.About the ZARXIO vial:oZARXIO vials come in two strengths. Depending on your prescription, you will receive ZARXIO vials that contain 300 mcg/mL or 480 mcg/1.6 mL of medicine. Your healthcare provider will determine the microgram (mcg) dose in milliliters (mL) that you will need to give based on your body weight.oWhen you receive your ZARXIO vials, always check to see that:othe name ZARXIO appears on the pack and vial label.othe expiration date on the vial label has not passed. You should not use vial after the date on the label.othe strength of ZARXIO (number of mcg on the pack containing the vial) is the same as what your healthcare provider prescribed.What you need for your injection:Included in the pack (see Figure A): oA new ZARXIO vialFigure ANot included in the pack (see Figure B): oNew disposable syringe and needleo2 Alcohol wipesoCotton ball or gauzeoSharps disposal containeroAdhesive bandageFigure BoOnly use the disposable syringes and needles that your healthcare provider prescribes.oOnly use the syringes and needles time. Discard (throw away) any used syringes and needles.oYou should only use syringe that is marked in tenths of milliliters (mL).oYour healthcare provider will show you how to measure the correct dose of ZARXIO. This dose will be measured in milliliters (mL).See Disposing of used ZARXIO vials, syringes, and needles at the end of this Instructions for Use.Preparing the ZARXIO injectionStep 1. Find clean, well-lit, flat work surface. Step 2. Take the ZARXIO vial out of the refrigerator and leave it unopened on your work surface for about 30 minutes so that it reaches room temperature. Step 3. Wash your hands well with soap and water. Step 4. Remove the ZARXIO vial from the outer pack. Step 5. Check the expiration date. Do not use the ZARXIO vial if the expiration date has passed. Step 6. Inspect the ZARXIO vial. The liquid inside should be clear. The color may be colorless to slightly yellow. Do not use the vial if the liquid contains visible particles, or if the liquid is cloudy or discolored. Return the ZARXIO vial and the package it came into your pharmacy. Step 7. Do not use ZARXIO vial if the cap is damaged. Return the vial with damaged cap and the package it came into your pharmacy. Step 8. Take the cap off the vial. Clean the rubber stopper with one alcohol wipe (see Figure C). Figure Step 9. Check the carton containing the syringe. If the carton has been opened or damaged, do not use that syringe. Dispose of (throw away) that syringe in the sharps disposal container. Step 10. Hold the syringe by the barrel with the needle cap pointing up (see Figure D). Carefully pull the needle cap straight off and away from your body. Throw away the needle cap into the sharps disposal container.Figure Step 11. Pull back on the plunger and draw air into the syringe that is the same amount (mL) as the dose of ZARXIO that your healthcare provider prescribed. Step 12. Keep the vial on the flat working surface and insert the needle straight down through the rubber stopper. Do not insert the needle through the rubber stopper more than time. Step 13. Push the plunger down and inject all the air from the syringe into the vial of ZARXIO (see Figure E).Figure Step 14. Keep the needle in the vial and turn the vial upside down (see Figure F). Make sure that the ZARXIO liquid is covering the tip of the needle.Figure Step 15. Keep the vial upside down and slowly pull back on the plunger to fill the syringe barrel with ZARXIO to the correct marking amount (mL) of medicine that matches the dose your healthcare provider prescribed. Step 16. Keep the needle in the vial and check for air bubbles in the syringe. If there are air bubbles, gently tap the syringe barrel with your finger until the air bubbles rise to the top (see Figure G). Slowly push the plunger up to push the air bubbles out of the syringe.Figure GStep 17. Keep the tip of the needle in the liquid and again pull the plunger back to the number on the syringe barrel that matches your dose. Check again for air bubbles. The air in the syringe will not hurt you, but too large an air bubble can reduce your dose of ZARXIO. If there are still air bubbles, repeat the steps above to remove them.Step 18. Check again to make sure that you have the correct dose in the syringe. It is important that you use the exact dose prescribed by your healthcare provider. Do not remove the needle from the vial. Lay the vial down on its side with the needle still in the vial.Step 19: Choose the injection site:oAreas of your body that you may use as injection sites include:the front of your thighs (see Figure H)the lower stomach-area (abdomen), but not the area inches around your navel (belly button) (see Figure H)if caregiver is giving you the injection upper outer arms (see Figure and Figure I)upper areas of the buttocks (see Figure I)oChoose different site each time you give yourself an injection.oDo not inject into areas where the skin is tender, bruised, red, scaly, or hard. Avoid areas with scars or stretch marks.Figure HFigure Step 20. Clean the injection site using circular motion with the alcohol wipe. Leave it to dry before injecting. Do not touch the cleaned area again before injecting.Giving your injection Step 21. Remove the prepared syringe and needle from the vial. Step 22. With one hand gently pinch the skin at the injection site. With your other hand insert the needle into your skin at 45 to 90 degree angle as shown (see Figure J). Push the needle all the way in to make sure that you inject your full dose. Figure Step 23. Hold the syringe as shown (see Figure K). Slowly press down on the plunger as far as it will go.Figure KStep 24. Keep the plunger fully pressed down while you carefully pull the needle straight out from the injection site.Step 25. There may be small amount of blood at the injection site. You can press cotton ball or gauze over the injection site and hold it for 10 seconds. Do not rub the injection site. You may cover the injection site with small adhesive bandage, if needed.Disposing of used ZARXIO vials, syringes, and needlesPut your used vials, syringes, and needles in an FDA-cleared sharps disposal container right away after use (see Figure L). Do not throw away (dispose of) vials, syringes, and needles in your household trash.Figure LIf you do not have an FDA-cleared sharps disposal container, you may use household container that is:omade of heavy-duty plastic,ocan be closed with tight-fitting, puncture-resistant lid, without sharps being able to come out,oupright and stable during use,oleak-resistant, andoproperly labeled to warn of hazardous waste inside the container.When your sharps disposal container is almost full, you will need to follow your community guidelines for the right way to dispose of your sharps disposal container. There may be state or local laws about how you should throw away used syringes and vials. For more information about safe sharps disposal, and for specific information about sharps disposal in the state that you live in, go to the FDAs website at: http://www.fda.gov/safesharpsdisposal.Do not reuse the vial or syringe.Do not recycle the vial, syringe, or sharps disposal container or throw them into household trash.Important: Always keep the sharps disposal container out of the reach of children.This Instructions for Use has been approved by the U.S. Food and Drug Administration.Manufactured by: Sandoz Inc., Princeton, NJ 08540, US License No. 2003 Approved: 08/2024. ohave sickle cell disorder.. ohave kidney problems.. oare receiving radiation therapy.. oare allergic to latex. The needle cap on the prefilled syringe contains dry natural rubber (derived from latex). You should not give ZARXIO using the prefilled syringe if you have latex allergies. Ask your healthcare provider about using the vial if you have latex allergies. The vial stopper is not made with natural rubber latex.. oare pregnant or plan to become pregnant. It is not known if ZARXIO will harm your unborn baby.. oare breastfeeding or plan to breastfeed. It is not known if ZARXIO passes into your breast milk.. oZARXIO injections can be given by healthcare provider by intravenous (IV) infusion or under your skin (subcutaneous injection). Your healthcare provider may decide subcutaneous injections can be given at home by you or your caregiver. If ZARXIO is given at home, see the detailed Instructions for Use that comes with your ZARXIO for information on how to prepare and inject dose of ZARXIO.. oYou and your caregiver should be shown how to prepare and inject ZARXIO before you use it, by your healthcare provider.. oYour healthcare provider will tell you how much ZARXIO to inject and when to inject it. Do not change your dose or stop ZARXIO unless your healthcare provider tells you to.. oYou should not inject dose of ZARXIO less than 0.3 mL (180 mcg) from ZARXIO prefilled syringe. dose less than 0.3 mL cannot be accurately measured using the ZARXIO prefilled syringe. oIf you are receiving ZARXIO because you are also receiving chemotherapy, your dose of ZARXIO should be injected at least 24 hours before or 24 hours after your dose of chemotherapy. Your healthcare provider will do blood tests to monitor your white blood cell count, and if necessary, adjust your ZARXIO dose.. oIf you are receiving ZARXIO because you have been suddenly (acutely) exposed to an amount of radiation that can affect your bone marrow (Acute Radiation Syndrome), you will need to have blood tests about every days during treatment with ZARXIO to check your white blood cell count.. oIf you miss dose of ZARXIO, talk to your healthcare provider about when you should give your next dose.. oSpleen rupture. Your spleen may become enlarged and can rupture. ruptured spleen can cause death. Call your healthcare provider right away if you have pain in the left upper stomach (abdomen) area or your left shoulder.. oA serious lung problem called acute respiratory distress syndrome (ARDS). Call your healthcare provider or get emergency medical help right away if you have shortness of breath with or without fever, trouble breathing, or fast rate of breathing.. oSerious allergic reactions. ZARXIO can cause serious allergic reactions. These reactions can cause rash over your whole body, shortness of breath, wheezing, dizziness, swelling around your mouth or eyes, fast heart rate, and sweating. If you have any of these symptoms, stop using ZARXIO and call your healthcare provider or get emergency medical help right away.. oSickle cell crises. You may have serious sickle cell crisis, which could lead to death, if you have sickle cell disorder and receive ZARXIO. Call your healthcare provider right away if you have symptoms of sickle cell crisis such as pain or difficulty breathing.. oKidney injury (glomerulonephritis). ZARXIO can cause kidney injury. Call your healthcare providerright away if you develop any of the following symptoms: oswelling of your face or anklesoblood in your urine or dark colored urine oyou urinate less than usual oswelling of your face or ankles. oblood in your urine or dark colored urine oyou urinate less than usual. oCapillary leak syndrome. ZARXIO can cause fluid to leak from blood vessels into your bodys tissues. This condition is called Capillary Leak Syndrome (CLS). CLS can quickly cause you to have symptoms that may become life-threatening. Get emergency medical help right away if you develop any of the following symptoms:oswelling or puffiness and are urinating less than usualotrouble breathingoswelling of your stomach area (abdomen) and feeling of fullnessodizziness or feeling faintoa general feeling of tiredness oswelling or puffiness and are urinating less than usual. otrouble breathing. oswelling of your stomach area (abdomen) and feeling of fullness. odizziness or feeling faint. oa general feeling of tiredness. oMyelodysplastic syndrome (MDS) and acute myeloid leukemia (AML).oZARXIO may increase the risk of developing precancerous condition called MDS or type of blood cancer called AML in people who were born with low white blood cell counts (congenital neutropenia).oIf you have breast cancer or lung cancer, when ZARXIO is used with chemotherapy and radiation therapy, or with radiation therapy only, you may have an increased risk of developing MDS or AML.oSymptoms of MDS and AML may include tiredness, fever, and easy bruising or bleeding.oCall your healthcare provider if you develop any of these symptoms during treatment with ZARXIO.. oZARXIO may increase the risk of developing precancerous condition called MDS or type of blood cancer called AML in people who were born with low white blood cell counts (congenital neutropenia).. oIf you have breast cancer or lung cancer, when ZARXIO is used with chemotherapy and radiation therapy, or with radiation therapy only, you may have an increased risk of developing MDS or AML.. oSymptoms of MDS and AML may include tiredness, fever, and easy bruising or bleeding.. oCall your healthcare provider if you develop any of these symptoms during treatment with ZARXIO.. oDecreased platelet count (thrombocytopenia). Your healthcare provider will check your blood during treatment with ZARXIO. Tell your healthcare provider if you have unusual bleeding or bruising during treatment with ZARXIO. This could be sign of decreased platelet counts, which may reduce the ability of your blood to clot.. oIncreased white blood cell count (leukocytosis). Your healthcare provider will check your blood during treatment with ZARXIO.. oInflammation of your blood vessels (cutaneous vasculitis). Tell your healthcare provider right away if you develop purple spots or redness of your skin.. oInflammation of the aorta (aortitis). Inflammation of the aorta (the large blood vessel which transports blood from the heart to the body) has been reported in patients who received filgrastim products. Symptoms may include fever, abdominal pain, feeling tired, and back pain. Call your healthcare provider if you experience these symptoms. oPatients with cancer receiving chemotherapy: fever, pain, rash, cough, and shortness of breath. oPatients with acute myeloid leukemia receiving chemotherapy: pain, nose bleed, and rash. oPatients with cancer receiving chemotherapy followed by bone marrow transplant: rash. oPatients who are having their own blood cells collected: bone pain, fever, and headache. oPatients with severe chronic neutropenia: pain, decreased red blood cells, nose bleed, diarrhea, reduced sensation, and hair loss. oStore ZARXIO in the refrigerator between 36F to 46F (2C to 8C).. oDo not freeze. oStore ZARXIO in the original pack to protect it from light or physical damage. Do not leave ZARXIO in direct sunlight.. oDo not shake ZARXIO.. oTake ZARXIO out of the refrigerator 30 minutes before use and allow it to reach room temperature between 68F to 77F (20C to 25C) before preparing an injection.. oIf not used right away,ZARXIO may be kept at room temperature for up to days. Throw away any ZARXIO that has been left at room temperature for longer than days.. oAfter you inject your dose, throw away (dispose of) any unused ZARXIO left in the prefilled syringe or vial. Do not save unused ZARXIO in the prefilled syringe or vial for later use. oDo not inject yourself or someone else until you have been shown how to inject ZARXIO. Your healthcare provider will show you how to prepare and inject ZARXIO properly using the ZARXIO prefilled syringe with UltraSafe Passive(R) Needle Guard. Talk to your healthcare provider if you have any questions.. oYou should not inject dose of ZARXIO less than 0.3 mL (180 mcg) from ZARXIO prefilled syringe. dose less than 0.3 mL cannot be accurately measured using the ZARXIO prefilled syringe.. oDo not use the ZARXIO prefilled syringe if either the seal on the outer pack or the seal of the blister are broken.. oKeep the ZARXIO prefilled syringe in the sealed pack until you are ready to use it.. oThe needle cap on the prefilled syringe contains natural rubber (derived from latex). Do not handle the prefilled syringe if you are allergic to latex.. oThe prefilled syringe has needle guard that will be activated to cover the needle after the injection is given. The needle guard will help prevent needle stick injuries to anyone who handles the prefilled syringe.. oAvoid touching the syringe needle guard wings before use. Touching them may cause the syringe needle guard to be activated too early.. oDo not remove the needle cap until just before you give the injection.. oThrow away (dispose of) the used ZARXIO prefilled syringe right away after use. Do not re-use ZARXIO prefilled syringe. See Disposing of used ZARXIO prefilled syringes at the end of this Instructions for Use.. oDo not use if the syringe has been dropped onto hard surface or dropped after removing the needle cap.. oStore ZARXIO in the refrigerator between 36F to 46F (2C to 8C).. oProtect from freezing ZARXIO. If frozen, thaw in the refrigerator before use. Throw away (dispose of) if it has been frozen more than time.. oStore ZARXIO in the original pack to protect it from light.. oAvoid shaking ZARXIO.. oTake ZARXIO out of the refrigerator 30 minutes before use and allow it to reach room temperature between 68F to 77F (20C to 25C) before preparing an injection.. oIf not used right away, ZARXIO may be kept at room temperature for up to days. Throw away (dispose of) any ZARXIO that has been left at room temperature for longer than days.. oAfter you inject your dose, throw away (dispose of) any unused ZARXIO left in the prefilled syringe. Do not save unused ZARXIO in the prefilled syringe for later use.. oZARXIO prefilled syringes come in two strengths. Depending on your prescription, you will receive ZARXIO prefilled syringes that contain 300 mcg/0.5 mL or 480 mcg/0.8 mL of medicine. Your healthcare provider will determine the microgram (mcg) dose in milliliters (mL) that you will need to give based on your body weight. When you receive your ZARXIO prefilled syringes, always check to see that the:oname ZARXIO appears on the pack and prefilled syringe label.oexpiration date on the prefilled syringe label has not passed. You should not use prefilled syringe after the date on the label.ostrength of ZARXIO (number of mcg on the pack containing the prefilled syringe) is the same as what your healthcare provider prescribed.. oname ZARXIO appears on the pack and prefilled syringe label.. oexpiration date on the prefilled syringe label has not passed. You should not use prefilled syringe after the date on the label.. ostrength of ZARXIO (number of mcg on the pack containing the prefilled syringe) is the same as what your healthcare provider prescribed.. oA new ZARXIO prefilled syringe. o1 Alcohol wipe. o1 Cotton ball or gauze. oSharps disposal container. o1 Adhesive bandage. oAreas of your body that you may use as injection sites include:othe front of your thighs (see Figure E)othe lower stomach-area (abdomen), but not the area inches around your navel (belly button) (see Figure E)oif caregiver is giving you the injectionupper outer arms (see Figure and Figure F)upper areas of the buttocks (see Figure F). othe front of your thighs (see Figure E). othe lower stomach-area (abdomen), but not the area inches around your navel (belly button) (see Figure E). oif caregiver is giving you the injection. upper outer arms (see Figure and Figure F). upper areas of the buttocks (see Figure F). oChoose different site each time you give yourself an injection.. oDo not inject into areas where the skin is tender, bruised, red, scaly, or hard. Avoid areas with scars or stretch marks.. Step 10. Clean the injection site using circular motion with the alcohol wipe. Leave it to dry before injecting. Do not touch the cleaned area again before injecting.. Step 11. Hold the prefilled syringe by the body (the clear plastic needle guard) with the needle pointing up (see Figure G). Holding the syringe with the needle pointing up helps to prevent medicine from leaking out of the needle. Carefully pull the needle cap straight off. Throw away the needle cap.. Step 12. Check the syringe for an air bubble. Gently tap the syringe body with your fingers until the air bubble rises to the top of the syringe (see Figure H). Slowly push the plunger up to push any air out of the syringe and stop when you see small drop start to appear at the needle tip (see Figure H). oYour healthcare provider has prescribed either full syringe dose or partial syringe dose of ZARXIO. If you are prescribed full dose, you will inject all of the medicine from your prefilled syringe. For full dose, go directly to Step 14. oIf you are prescribed partial dose of ZARXIO, start with Step 13.. Step 13. Holding the syringe as shown, press slowly on the plunger to push out the excess medicine until the edge of the conical base of the plunger stopper lines up with the syringe marking for your prescribed dose. See Figure I, example for dose of 0.4 mL. Your dose may be different than the example shown.. Step 14. With one hand gently pinch the skin at the injection site. With your other hand insert the needle into your skin as shown (see Figure J). Push the needle all the way in to make sure that you inject your full dose.. Step 15. Hold the ZARXIO prefilled syringe as shown (see Figure K). Slowly press down on the plunger as far as it will go so that the plunger head is completely between the needle guard wings. Step 16. Keep the plunger fully pressed down while you carefully pull the needle straight out from the injection site (see Figure L). Step 17. Slowly release the plunger and allow the needle guard to automatically cover the exposed needle (see Figure M). Step 18. There may be small amount of blood at the injections site. You can press cotton ball or gauze over the injection site and hold it for 10 seconds. Do not rub the injection site. You may cover the injection site with small adhesive bandage, if needed.. omade of heavy-duty plastic,. ocan be closed with tight-fitting, puncture-resistant lid, without sharps being able to come out,. oupright and stable during use,. oleak-resistant, and. oproperly labeled to warn of hazardous waste inside the container.. oDo not inject yourself or someone else until you have been shown how to inject ZARXIO. Your healthcare provider will show you how to prepare and inject ZARXIO properly using the ZARXIO vial and syringe. Talk to your healthcare provider if you have any questions.. oDo not use the ZARXIO vial if either the seal on the outer pack or the cap of the vial is broken.. oKeep the ZARXIO vial in the sealed pack until you are ready to use it.. oThrow away (dispose of) the used ZARXIO vials, syringes, and needles right away after use. Do not re-use ZARXIO vials, syringes, or needles. See Disposing of used ZARXIO vials, syringes, and needles at the end of this Instructions for Use.. oLatex-sensitive individuals: The vial stopper is not made with natural rubber latex. oStore ZARXIO in the refrigerator between 36F to 46F (2C to 8C).. oProtect ZARXIO from freezing. If frozen, thaw in the refrigerator before use. Throw away (dispose of) if it has been frozen more than time.. oStore ZARXIO in the original pack to protect it from light.. oAvoid shaking ZARXIO.. oTake ZARXIO out of the refrigerator 30 minutes before use and allow it to reach room temperature between 68F to 77F (20C to 25C) before preparing an injection.. oIf not used right away, ZARXIO may be kept at room temperature for up to days. Throw away (dispose of) any ZARXIO that has been left at room temperature for longer than days. oAfter you inject your dose, throw away (dispose of) any unused ZARXIO left in the vial. Do not save unused ZARXIO in the vial for later use.. oZARXIO vials come in two strengths. Depending on your prescription, you will receive ZARXIO vials that contain 300 mcg/mL or 480 mcg/1.6 mL of medicine. Your healthcare provider will determine the microgram (mcg) dose in milliliters (mL) that you will need to give based on your body weight.. oWhen you receive your ZARXIO vials, always check to see that:othe name ZARXIO appears on the pack and vial label.othe expiration date on the vial label has not passed. You should not use vial after the date on the label.othe strength of ZARXIO (number of mcg on the pack containing the vial) is the same as what your healthcare provider prescribed.. othe name ZARXIO appears on the pack and vial label.. othe expiration date on the vial label has not passed. You should not use vial after the date on the label.. othe strength of ZARXIO (number of mcg on the pack containing the vial) is the same as what your healthcare provider prescribed.. oA new ZARXIO vial. oNew disposable syringe and needle. o2 Alcohol wipes. oCotton ball or gauze. oSharps disposal container. oAdhesive bandage. oOnly use the disposable syringes and needles that your healthcare provider prescribes.. oOnly use the syringes and needles time. Discard (throw away) any used syringes and needles.. oYou should only use syringe that is marked in tenths of milliliters (mL).. oYour healthcare provider will show you how to measure the correct dose of ZARXIO. This dose will be measured in milliliters (mL).. Step 2. Take the ZARXIO vial out of the refrigerator and leave it unopened on your work surface for about 30 minutes so that it reaches room temperature.. Step 3. Wash your hands well with soap and water.. Step 4. Remove the ZARXIO vial from the outer pack.. Step 5. Check the expiration date. Do not use the ZARXIO vial if the expiration date has passed.. Step 6. Inspect the ZARXIO vial. The liquid inside should be clear. The color may be colorless to slightly yellow. Do not use the vial if the liquid contains visible particles, or if the liquid is cloudy or discolored. Return the ZARXIO vial and the package it came into your pharmacy.. Step 7. Do not use ZARXIO vial if the cap is damaged. Return the vial with damaged cap and the package it came into your pharmacy. Step 8. Take the cap off the vial. Clean the rubber stopper with one alcohol wipe (see Figure C). Step 9. Check the carton containing the syringe. If the carton has been opened or damaged, do not use that syringe. Dispose of (throw away) that syringe in the sharps disposal container. Step 10. Hold the syringe by the barrel with the needle cap pointing up (see Figure D). Carefully pull the needle cap straight off and away from your body. Throw away the needle cap into the sharps disposal container.. Step 11. Pull back on the plunger and draw air into the syringe that is the same amount (mL) as the dose of ZARXIO that your healthcare provider prescribed.. Step 12. Keep the vial on the flat working surface and insert the needle straight down through the rubber stopper. Do not insert the needle through the rubber stopper more than time.. Step 13. Push the plunger down and inject all the air from the syringe into the vial of ZARXIO (see Figure E).. Step 14. Keep the needle in the vial and turn the vial upside down (see Figure F). Make sure that the ZARXIO liquid is covering the tip of the needle.. Step 15. Keep the vial upside down and slowly pull back on the plunger to fill the syringe barrel with ZARXIO to the correct marking amount (mL) of medicine that matches the dose your healthcare provider prescribed.. Step 16. Keep the needle in the vial and check for air bubbles in the syringe. If there are air bubbles, gently tap the syringe barrel with your finger until the air bubbles rise to the top (see Figure G). Slowly push the plunger up to push the air bubbles out of the syringe.. oAreas of your body that you may use as injection sites include:the front of your thighs (see Figure H)the lower stomach-area (abdomen), but not the area inches around your navel (belly button) (see Figure H)if caregiver is giving you the injection upper outer arms (see Figure and Figure I)upper areas of the buttocks (see Figure I). the front of your thighs (see Figure H). the lower stomach-area (abdomen), but not the area inches around your navel (belly button) (see Figure H). if caregiver is giving you the injection upper outer arms (see Figure and Figure I)upper areas of the buttocks (see Figure I). upper outer arms (see Figure and Figure I). upper areas of the buttocks (see Figure I). oChoose different site each time you give yourself an injection.. oDo not inject into areas where the skin is tender, bruised, red, scaly, or hard. Avoid areas with scars or stretch marks.. Step 20. Clean the injection site using circular motion with the alcohol wipe. Leave it to dry before injecting. Do not touch the cleaned area again before injecting.. Step 21. Remove the prepared syringe and needle from the vial.. Step 22. With one hand gently pinch the skin at the injection site. With your other hand insert the needle into your skin at 45 to 90 degree angle as shown (see Figure J). Push the needle all the way in to make sure that you inject your full dose. Step 23. Hold the syringe as shown (see Figure K). Slowly press down on the plunger as far as it will go.. omade of heavy-duty plastic,. ocan be closed with tight-fitting, puncture-resistant lid, without sharps being able to come out,. oupright and stable during use,. oleak-resistant, and. oproperly labeled to warn of hazardous waste inside the container.. Fig-A. Fig-B. Fig-C. Fig-D. Fig-E. Fig-F. Fig-G. Fig-H. Fig-I. Fig-J. Fig-K. Fig-L. Fig-M. Fig-N. Fig-V-A. Fig-V-B1. Fig-V-B2. Fig-V-C. Fig-V-D1. Fig-V-D2. Fig-V-E. Fig-V-E. Fig-V-G. Fig-V-H. Fig-V-I. close-up of hand holding syringe Description automatically generated. drawing of syringe being used to make needle Description automatically generated. diagram of disposable cup Description automatically generated.

ADVERSE REACTIONS SECTION.

6 ADVERSE REACTIONS. The following serious adverse reactions are discussed in greater detail in other sections of the labeling:oSplenic Rupture [see Warnings and Precautions (5.1)]oAcute Respiratory Distress Syndrome [see Warnings and Precautions (5.2)]oSerious Allergic Reactions [see Warnings and Precautions (5.3)]oSickle Cell Disorders [see Warnings and Precautions (5.4)]oGlomerulonephritis [see Warnings and Precautions (5.5)]oAlveolar Hemorrhage and Hemoptysis [see Warnings and Precautions (5.6)]oCapillary Leak Syndrome [see Warnings and Precautions (5.7)]oMyelodysplastic Syndrome [see Warnings and Precautions (5.8)]oAcute Myeloid Leukemia [see Warnings and Precautions (5.8)]oThrombocytopenia [see Warnings and Precautions (5.9)]oLeukocytosis [see Warnings and Precautions (5.10)]oCutaneous Vasculitis [see Warnings and Precautions (5.11)]oAortitis [see Warnings and Precautions (5.15)]. oSplenic Rupture [see Warnings and Precautions (5.1)]. oAcute Respiratory Distress Syndrome [see Warnings and Precautions (5.2)]. oSerious Allergic Reactions [see Warnings and Precautions (5.3)]. oSickle Cell Disorders [see Warnings and Precautions (5.4)]. oGlomerulonephritis [see Warnings and Precautions (5.5)]. oAlveolar Hemorrhage and Hemoptysis [see Warnings and Precautions (5.6)]. oCapillary Leak Syndrome [see Warnings and Precautions (5.7)]. oMyelodysplastic Syndrome [see Warnings and Precautions (5.8)]. oAcute Myeloid Leukemia [see Warnings and Precautions (5.8)]. oThrombocytopenia [see Warnings and Precautions (5.9)]. oLeukocytosis [see Warnings and Precautions (5.10)]. oCutaneous Vasculitis [see Warnings and Precautions (5.11)]. oAortitis [see Warnings and Precautions (5.15)]. Most common adverse reactions in patients:oWith nonmyeloid malignancies receiving myelosuppressive anti-cancer drugs (>= 5% difference in incidence compared to placebo) are pyrexia, pain, rash, cough, and dyspnea. (6.1)oWith AML (>= 2% difference in incidence) are pain, epistaxis and rash. (6.1)oWith nonmyeloid malignancies undergoing myeloablative chemotherapy followed by BMT (>= 5% difference in incidence) is rash. (6.1)oUndergoing peripheral blood progenitor cell mobilization and collection (>= 5% incidence) are bone pain, pyrexia and headache. (6.1)oWith severe chronic neutropenia (SCN) (>= 5% difference in incidence) are pain, anemia, epistaxis, diarrhea, hypoesthesia and alopecia. (6.1) Biosimilar means that the biological product is approved based on data demonstrating that it is highly similar to an FDA-approved biological product, known as reference product, and that there are no clinically meaningful differences between the biosimilar product and the reference product. Biosimilarity of ZARXIO has been demonstrated for the condition(s) of use (e.g., indication(s), dosing regimen(s), strength(s), dosage form(s), and route(s) of administration described in its Full Prescribing Information.To report SUSPECTED ADVERSE REACTIONS, contact Sandoz Inc. at 1-800-525-8747 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. oWith nonmyeloid malignancies receiving myelosuppressive anti-cancer drugs (>= 5% difference in incidence compared to placebo) are pyrexia, pain, rash, cough, and dyspnea. (6.1). oWith AML (>= 2% difference in incidence) are pain, epistaxis and rash. (6.1). oWith nonmyeloid malignancies undergoing myeloablative chemotherapy followed by BMT (>= 5% difference in incidence) is rash. (6.1). oUndergoing peripheral blood progenitor cell mobilization and collection (>= 5% incidence) are bone pain, pyrexia and headache. (6.1). oWith severe chronic neutropenia (SCN) (>= 5% difference in incidence) are pain, anemia, epistaxis, diarrhea, hypoesthesia and alopecia. (6.1). Biosimilar means that the biological product is approved based on data demonstrating that it is highly similar to an FDA-approved biological product, known as reference product, and that there are no clinically meaningful differences between the biosimilar product and the reference product. Biosimilarity of ZARXIO has been demonstrated for the condition(s) of use (e.g., indication(s), dosing regimen(s), strength(s), dosage form(s), and route(s) of administration described in its Full Prescribing Information.. 6.1 Clinical Trials Experience. Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of drug cannot be directly compared with rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice.Adverse Reactions in Patients with Cancer Receiving Myelosuppressive ChemotherapyThe following adverse reaction data in Table are from three randomized, placebo-controlled studies in patients with:osmall cell lung cancer receiving standard dose chemotherapy with cyclophosphamide, doxorubicin, and etoposide (Study 1)osmall cell lung cancer receiving ifosfamide, doxorubicin, and etoposide (Study 2), andonon-Hodgkins lymphoma (NHL) receiving doxorubicin, cyclophosphamide, vindesine, bleomycin, methylprednisolone, and methotrexate (ACVBP) or mitoxantrone, ifosfamide, mitoguazone, teniposide, methotrexate, folinic acid, methylprednisolone, and methotrexate (VIM3) (Study 3).A total of 451 patients were randomized to receive subcutaneous filgrastim 230 mcg/m2 (Study 1), 240 mcg/m2 (Study 2) or or mcg/kg/day (Study 3) (n=294) or placebo (n=157). The patients in these studies were median age 61 (range 29 to 78) years and 64% were male. The ethnicity was 95% Caucasian, 4% African American, and 1% Asian.Table 2. Adverse Reactions in Patients with Cancer Receiving Myelosuppressive Chemotherapy (With >= 5% Higher Incidence in Filgrastim Compared to Placebo)System Organ ClassPreferred TermFilgrastim(N=294)Placebo(N=157)Blood and lymphatic system disordersThrombocytopenia38%29%Gastrointestinal disordersNausea43%32%General disorders and administration site conditionsPyrexia48%29%Chest pain13%6%Pain12%6%Fatigue20%10%Musculoskeletal and connective tissue disordersBack pain15%8%Arthralgia9%2%Bone pain11%6%Pain in extremityPercent difference (Filgrastim Placebo) was 4%. 7%3%Nervous system disordersDizziness14%3%Respiratory, thoracic and mediastinal disordersCough14%8%Dyspnea13%8%Skin and subcutaneous tissue disordersRash14%5%InvestigationsBlood lactate dehydrogenase increased6%1%Blood alkaline phosphatase increased6%1%Adverse events with >= 5% higher incidence in filgrastim patients compared to placebo and associated with the sequelae of the underlying malignancy or cytotoxic chemotherapy delivered included anemia, constipation, diarrhea, oral pain, vomiting, asthenia, malaise, edema peripheral, hemoglobin decreased, decreased appetite, oropharyngeal pain, and alopecia.Adverse Reactions in Patients with Acute Myeloid LeukemiaAdverse reaction data below are from randomized, double-blind, placebo-controlled study in patients with AML (Study 4) who received an induction chemotherapy regimen of intravenous daunorubicin days 1, 2, and 3; cytosine arabinoside days to 7; and etoposide days to and up to additional courses of therapy (induction 2, and consolidation 1, 2) of intravenous daunorubicin, cytosine arabinoside, and etoposide. The safety population included 518 patients randomized to receive either mcg/kg/day filgrastim (n=257) or placebo (n=261). The median age was 54 (range 16 to 89) years and 54% were male.Adverse reactions with >= 2% higher incidence in filgrastim patients compared to placebo included epistaxis, back pain, pain in extremity, erythema, and rash maculo-papular.Adverse events with >= 2% higher incidence in filgrastim patients compared to placebo and associated with the sequelae of the underlying malignancy or cytotoxic chemotherapy included diarrhea, constipation, and transfusion reaction.Adverse Reactions in Patients with Cancer Undergoing Bone Marrow TransplantationThe following adverse reaction data are from one randomized, no treatment-controlled study in patients with acute lymphoblastic leukemia or lymphoblastic lymphoma receiving high-dose chemotherapy (cyclophosphamide or cytarabine, and melphalan) and total body irradiation (Study 5) and one randomized, no treatment-controlled study in patients with Hodgkins disease (HD) and NHL undergoing high-dose chemotherapy and autologous bone marrow transplantation (Study 6). Patients receiving autologous bone marrow transplantation only were included in the analysis. total of 100 patients received either 30 mcg/kg/day as 4-hour infusion (Study 5) or 10 mcg/kg/day or 30 mcg/kg/day as 24-hour infusion (Study 6) filgrastim (n=72), no treatment control or placebo (n=28). The median age was 30 (range 15 to 57) years, 57% were male.Adverse reactions with >= 5% higher incidence in filgrastim patients compared to patients receiving no filgrastim included rash and hypersensitivity.Adverse reactions in patients receiving intensive chemotherapy followed by autologous BMT with >= 5% higher incidence in filgrastim patients compared to patients receiving no filgrastim included thrombocytopenia, anemia, hypertension, sepsis, bronchitis, and insomnia.Adverse Reactions in Patients with Cancer Undergoing Autologous Peripheral Blood Progenitor Cell CollectionThe adverse reaction data in Table are from series of trials in patients with cancer undergoing mobilization of autologous peripheral blood progenitor cells for collection by leukapheresis. Patients (n=166) in all these trials underwent similar mobilization/collection regimen: filgrastim was administered for to days, in most cases the apheresis procedure occurred on days 5, 6, and 7. The dosage of filgrastim ranged between to 30 mcg/kg/day and was administered subcutaneously by injection or continuous infusion. The median age was 39 (range 15 to 67) years, and 48% were male.Table 3. Adverse Reactions in Patients with Cancer Undergoing Autologous PBPC in the Mobilization Phase (>= 5% Incidence in Filgrastim Patients)System Organ ClassPreferred TermMobilization Phase(N=166)Musculoskeletal and connective tissue disordersBone pain30%General disorders and administration site conditionsPyrexia16%InvestigationsBlood alkaline phosphatase increased11%Nervous system disordersHeadache10%Adverse Reactions in Patients with Severe Chronic NeutropeniaThe following adverse reaction data were identified in randomized, controlled study in patients with SCN receiving filgrastim (Study 7). 123 patients were randomized to 4-month observation period followed by subcutaneous filgrastim treatment or immediate subcutaneous filgrastim treatment. The median age was 12 years (range months to 76 years) and 46% were male. The dosage of filgrastim was determined by the category of neutropenia. Initial dosage of filgrastim:oIdiopathic neutropenia: 3.6 mcg/kg/dayoCyclic neutropenia: mcg/kg/dayoCongenital neutropenia: mcg/kg/day divided times per dayThe dosage was increased incrementally to 12 mcg/kg/day divided times per day if there was no response. Adverse reactions with >= 5% higher incidence in filgrastim patients compared to patients receiving no filgrastim included arthralgia, bone pain, back pain, muscle spasms, musculoskeletal pain, pain in extremity, splenomegaly, anemia, upper respiratory tract infection, and urinary tract infection (upper respiratory tract infection and urinary tract infection were higher in the filgrastim arm, total infection related events were lower in filgrastim-treated patients), epistaxis, chest pain, diarrhea, hypoesthesia, and alopecia.. osmall cell lung cancer receiving standard dose chemotherapy with cyclophosphamide, doxorubicin, and etoposide (Study 1). osmall cell lung cancer receiving ifosfamide, doxorubicin, and etoposide (Study 2), and. onon-Hodgkins lymphoma (NHL) receiving doxorubicin, cyclophosphamide, vindesine, bleomycin, methylprednisolone, and methotrexate (ACVBP) or mitoxantrone, ifosfamide, mitoguazone, teniposide, methotrexate, folinic acid, methylprednisolone, and methotrexate (VIM3) (Study 3).. oIdiopathic neutropenia: 3.6 mcg/kg/day. oCyclic neutropenia: mcg/kg/day. oCongenital neutropenia: mcg/kg/day divided times per day. 6.2 Postmarketing Experience. The following adverse reactions have been identified during post-approval use of filgrastim products. 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.osplenic rupture and splenomegaly (enlarged spleen) [see Warnings and Precautions (5.1)]oacute respiratory distress syndrome [see Warnings and Precautions (5.2)]oanaphylaxis [see Warnings and Precautions (5.3)]osickle cell disorders [see Warnings and Precautions (5.4)]oglomerulonephritis [see Warnings and Precautions (5.5)]oalveolar hemorrhage and hemoptysis [see Warnings and Precautions (5.6)]ocapillary leak syndrome [see Warnings and Precautions (5.7)]oleukocytosis [see Warnings and Precautions (5.10)]ocutaneous vasculitis [see Warnings and Precautions (5.11)]oSweets syndrome (acute febrile neutrophilic dermatosis)odecreased bone density and osteoporosis in pediatric patients receiving chronic treatment with filgrastim productsomyelodysplastic syndrome (MDS) and acute myeloid leukemia (AML) in patients with breast and lung cancer receiving chemotherapy and/or radiotherapy [see Warnings and Precautions (5.8)]oaortitis [see Warnings and Precautions (5.15)]oextramedullary hematopoiesis. osplenic rupture and splenomegaly (enlarged spleen) [see Warnings and Precautions (5.1)]. oacute respiratory distress syndrome [see Warnings and Precautions (5.2)]. oanaphylaxis [see Warnings and Precautions (5.3)]. osickle cell disorders [see Warnings and Precautions (5.4)]. oglomerulonephritis [see Warnings and Precautions (5.5)]. oalveolar hemorrhage and hemoptysis [see Warnings and Precautions (5.6)]. ocapillary leak syndrome [see Warnings and Precautions (5.7)]. oleukocytosis [see Warnings and Precautions (5.10)]. ocutaneous vasculitis [see Warnings and Precautions (5.11)]. oSweets syndrome (acute febrile neutrophilic dermatosis). odecreased bone density and osteoporosis in pediatric patients receiving chronic treatment with filgrastim products. omyelodysplastic syndrome (MDS) and acute myeloid leukemia (AML) in patients with breast and lung cancer receiving chemotherapy and/or radiotherapy [see Warnings and Precautions (5.8)]. oaortitis [see Warnings and Precautions (5.15)]. oextramedullary hematopoiesis.

CARCINOGENESIS & MUTAGENESIS & IMPAIRMENT OF FERTILITY SECTION.

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility. The carcinogenic potential of filgrastim products has not been studied. Filgrastim failed to induce bacterial gene mutations in either the presence or absence of drug metabolizing enzyme system. Filgrastim had no observed effect on the fertility of male or female rats at doses up to 500 mcg/kg.

CLINICAL PHARMACOLOGY SECTION.

12 CLINICAL PHARMACOLOGY. 12.1 Mechanism of Action. Colony-stimulating factors are glycoproteins which act on hematopoietic cells by binding to specific cell surface receptors and stimulating proliferation, differentiation commitment, and some end-cell functional activation.Endogenous G-CSF is lineage-specific colony-stimulating factor that is produced by monocytes, fibroblasts, and endothelial cells. G-CSF regulates the production of neutrophils within the bone marrow and affects neutrophil progenitor proliferation, differentiation, and selected end-cell functions (including enhanced phagocytic ability, priming of the cellular metabolism associated with respiratory burst, antibody-dependent killing, and the increased expression of some cell surface antigens). G-CSF is not species-specific and has been shown to have minimal direct in vivo or in vitro effects on the production or activity of hematopoietic cell types other than the neutrophil lineage.. 12.2 Pharmacodynamics. In phase studies involving 96 patients with various nonmyeloid malignancies, administration of filgrastim resulted in dose-dependent increase in circulating neutrophil counts over the dose range of to 70 mcg/kg/day. This increase in neutrophil counts was observed whether filgrastim was administered intravenous (1 to 70 mcg/kg twice daily), subcutaneous (1 to mcg/kg once daily), or by continuous subcutaneous infusion (3 to 11 mcg/kg/day). With discontinuation of filgrastim therapy, neutrophil counts returned to baseline in most cases within days. Isolated neutrophils displayed normal phagocytic (measured by zymosan-stimulated chemiluminescence) and chemotactic (measured by migration under agarose using N-formyl-methionyl-leucyl-phenylalanine [fMLP] as the chemotaxin) activity in vitro. The absolute monocyte count was reported to increase in dose-dependent manner in most patients receiving filgrastim; however, the percentage of monocytes in the differential count remained within the normal range. Absolute counts of both eosinophils and basophils did not change and were within the normal range following administration of filgrastim. Increases in lymphocyte counts following filgrastim administration have been reported in some normal subjects and patients with cancer.White blood cell (WBC) differentials obtained during clinical trials have demonstrated shift towards earlier granulocyte progenitor cells (left shift), including the appearance of promyelocytes and myeloblasts, usually during neutrophil recovery following the chemotherapy-induced nadir. In addition, Dohle bodies, increased granulocyte granulation, and hypersegmented neutrophils have been observed. Such changes were transient and were not associated with clinical sequelae, nor were they necessarily associated with infection.. 12.3 Pharmacokinetics. Filgrastim products exhibit nonlinear pharmacokinetics. Clearance is dependent on filgrastim product concentration and neutrophil count: G-CSF receptor-mediated clearance is saturated by high concentration of filgrastim products and is diminished by neutropenia. In addition, filgrastim products are cleared by the kidney.Subcutaneous administration of 3.45 mcg/kg and 11.5 mcg/kg of filgrastim resulted in maximum serum concentrations of and 49 ng/mL, respectively, within to hours. After intravenous administration, the volume of distribution averaged 150 mL/kg and the elimination half-life was approximately 3.5 hours in both normal subjects and subjects with cancer. Clearance rates of filgrastim were approximately 0.5 to 0.7 mL/minute/kg. Single parenteral doses or daily intravenous doses, over 14-day period, resulted in comparable half-lives. The half-lives were similar for intravenous administration (231 minutes, following doses of 34.5 mcg/kg) and for subcutaneous administration (210 minutes, following filgrastim dosages of 3.45 mcg/kg). Continuous 24-hour intravenous infusions of 20 mcg/kg over an 11 to 20-day period produced steady-state serum concentrations of filgrastim with no evidence of drug accumulation over the time period investigated. The absolute bioavailability of filgrastim after subcutaneous administration is 60% to 70%.Specific PopulationsPatients Acutely Exposed to Myelosuppressive Doses of RadiationThe pharmacokinetics of filgrastim products are not available in patients acutely exposed to myelosuppressive doses of radiation. Based on limited pharmacokinetics data in irradiated non-human primates, the area under the time-concentration curve (AUC), reflecting the exposure to filgrastim in non-human primates at 10 mcg/kg dose of filgrastim, appears to be similar to that in humans at mcg/kg. Simulations conducted using the population pharmacokinetic model indicates that the exposures to filgrastim at filgrastim dose of 10 mcg/kg in patients acutely exposed to myelosuppressive doses of radiation are expected to exceed the exposures at dose of 10 mcg/kg in irradiated non-human primates.Pediatric PatientsThe pharmacokinetics of filgrastim in pediatric patients after chemotherapy are similar to those in adult patients receiving the same weight-normalized doses, suggesting no age-related differences in the pharmacokinetics of filgrastim products [see Use in Specific Populations (8.4)].Renal ImpairmentIn study with healthy volunteers, subjects with moderate renal impairment, and subjects with end stage renal disease (n=4 per group), higher serum concentrations were observed in subjects with end-stage renal disease. However, dose adjustment in patients with renal impairment is not necessary.Hepatic ImpairmentPharmacokinetics and pharmacodynamics of filgrastim are similar between subjects with hepatic impairment and healthy subjects (n=12/group). The study included 10 subjects with mild hepatic impairment (Child-Pugh Class A) and subjects with moderate hepatic impairment (Child-Pugh Class B). Therefore, dose adjustment for ZARXIO in patients with hepatic impairment is not necessary.. 12.6 Immunogenicity The observed incidence of anti-drug antibodies is highly dependent on the sensitivity and specificity of the assay. Differences in assay methods preclude meaningful comparisons of the incidence of anti-drug antibodies in the studies described below with the incidence of anti-drug antibodies in other studies, including those of filgrastim or of other filgrastim products. While available data suggest that small proportion of patients developed binding antibodies to filgrastim products, the nature and specificity of these antibodies has not been adequately studied. In clinical studies using filgrastim, the incidence of antibodies binding to filgrastim was 3% (11/333). In these 11 patients, no evidence of neutralizing response was observed using cell based bioassay. Because of the low occurrence of anti-drug antibodies, the effect of these antibodies on the pharmacokinetics, pharmacodynamics, safety, and/or effectiveness of filgrastim products is unknown.Cytopenias resulting from an antibody response to exogenous growth factors have been reported on rare occasions in patients treated with other recombinant growth factors.

CLINICAL STUDIES SECTION.

14 CLINICAL STUDIES. 14.1 Patients with Cancer Receiving Myelosuppressive Chemotherapy. The safety and efficacy of filgrastim to decrease the incidence of infection, as manifested by febrile neutropenia, in patients with nonmyeloid malignancies receiving myelosuppressive anti-cancer drugs were established in randomized, double-blind, placebo-controlled trial conducted in patients with small cell lung cancer (Study 1).In Study 1, patients received up to cycles of intravenous chemotherapy including intravenous cyclophosphamide and doxorubicin on day 1; and etoposide on days 1, 2, and of 21 day cycles. Patients were randomized to receive filgrastim (n=99) at dose of 230 mcg/m2 (4 to mcg/kg/day) or placebo (n=111). Study drug was administered subcutaneously daily beginning on day 4, for maximum of 14 days. total of 210 patients were evaluable for efficacy and 207 were evaluable for safety. The demographic and disease characteristics were balanced between arms with median age of 62 (range 31 to 80) years; 64% males; 89% Caucasian; 72% extensive disease and 28% limited disease.The main efficacy endpoint was the incidence of febrile neutropenia. Febrile neutropenia was defined as an ANC 1,000/mm3 and temperature 38.2C. Treatment with filgrastim resulted in clinically and statistically significant reduction in the incidence of infection, as manifested by febrile neutropenia, 40% for filgrastim-treated patients and 76% for placebo-treated patients (p 0.001). There were also statistically significant reductions in the incidence and overall duration of infection manifested by febrile neutropenia; the incidence, severity and duration of severe neutropenia (ANC 500/mm3); the incidence and overall duration of hospital admissions; and the number of reported days of antibiotic use.. 14.2 Patients with Acute Myeloid Leukemia Receiving Induction or Consolidation Chemotherapy. The safety and efficacy of filgrastim to reduce the time to neutrophil recovery and the duration of fever, following induction or consolidation chemotherapy treatment of patients with acute myeloid leukemia (AML) was established in randomized, double-blind, placebo-controlled, multi-center trial in patients with newly diagnosed, de novo AML (Study 4).In Study the initial induction therapy consisted of intravenous daunorubicin days 1, 2, and 3; cytosine arabinoside days to 7; and etoposide days to 5. Patients were randomized to receive subcutaneous filgrastim (n=259) at dose of mcg/kg/day or placebo (n=262) from 24 hours after the last dose of chemotherapy until neutrophil recovery (ANC >=1,000/mm3 for consecutive days or >= 10,000/mm3 for day) or for maximum of 35 days. The demographic and disease characteristics were balanced between arms with median age of 54 (range 16 to 89) years; 54% males; initial white blood cell count (65% <25,000 /mm3 and 27% 100,000/mm3); 29% unfavorable cytogenetics.The main efficacy endpoint was median duration of severe neutropenia defined as neutrophil count 500/mm3. Treatment with filgrastim resulted in clinically and statistically significant reduction in median number of days of severe neutropenia, filgrastim-treated patients 14 days, placebo-treated patients 19 days (p=0.0001: difference of days (95% CI: -6.0, -4.0)). There was reduction in the median duration of intravenous antibiotic use, filgrastim-treated patients: 15 days versus placebo-treated patients: 18.5 days; reduction in the median duration of hospitalization, filgrastim-treated patients: 20 days versus placebo-treated patients: 25 days.There were no statistically significant differences between the filgrastim and the placebo groups in complete remission rate (69% filgrastim, 68% placebo), median time to progression of all randomized patients (165 days filgrastim, 186 days placebo), or median overall survival (380 days filgrastim, 425 days placebo).. 14.3 Patients with Cancer Undergoing Bone Marrow Transplantation. The safety and efficacy of filgrastim to reduce the duration of neutropenia in patients with nonmyeloid malignancies undergoing myeloablative chemotherapy followed by autologous bone marrow transplantation was evaluated in randomized controlled trials of patients with lymphoma (Study and Study 9). The safety and efficacy of filgrastim to reduce the duration of neutropenia in patients undergoing myeloablative chemotherapy followed by allogeneic bone marrow transplantation was evaluated in randomized placebo-controlled trial (Study 10).In Study 6, patients with Hodgkins disease received preparative regimen of intravenous cyclophosphamide, etoposide, and BCNU (CVP), and patients with non-Hodgkins lymphoma received intravenous BCNU, etoposide, cytosine arabinoside and melphalan (BEAM). There were 54 patients randomized 1:1:1 to control, filgrastim 10 mcg/kg/day, and filgrastim 30 mcg/kg/day as 24-hour continuous infusion starting 24-hours after bone marrow infusion for maximum of 28 days. The median age was 33 (range 17 to 57) years; 56% males; 69% Hodgkins disease and 31% non-Hodgkins lymphoma.The main efficacy endpoint was duration of severe neutropenia ANC 500/mm3. statistically significant reduction in the median number of days of severe neutropenia (ANC 500/mm3) occurred in the filgrastim-treated groups versus the control group (23 days in the control group, 11 days in the 10 mcg/kg/day group, and 14 days in the 30 mcg/kg/day group [11 days in the combined treatment groups, p=0.004]).In Study 9, patients with Hodgkins disease and non-Hodgkins lymphoma received preparative regimen of intravenous cyclophosphamide, etoposide, and BCNU (CVP). There were 43 evaluable patients randomized to continuous subcutaneous infusion filgrastim 10 mcg/kg/day (n=19), filgrastim 30 mcg/kg/day (n=10) and no treatment (n=14) starting the day after marrow infusion for maximum of 28 days. The median age was 33 (range 17 to 56) years; 67% males; 28% Hodgkins disease and 72% non-Hodgkins lymphoma.The main efficacy endpoint was duration of severe neutropenia. There was statistically significant reduction in the median number of days of severe neutropenia (ANC 500/mm3) in the filgrastim-treated groups versus the control group (21.5 days in the control group versus 10 days in the filgrastim-treated groups, < 0.001). The number of days of febrile neutropenia was also reduced significantly in this study (13.5 days in the control group versus days in the filgrastim-treated groups, < 0.0001).In Study 10, 70 patients scheduled to undergo bone marrow transplantation for multiple underlying conditions using multiple preparative regimens were randomized to receive filgrastim 300 mcg/m2/day (n=33) or placebo (n=37) days through 28 after marrow infusion. The median age was 18 (range to 45) years, 56% males. The underlying disease was: 67% hematologic malignancy, 24% aplastic anemia, 9% other. statistically significant reduction in the median number of days of severe neutropenia occurred in the treated group versus the control group (19 days in the control group and 15 days in the treatment group, < 0.001) and time to recovery of ANC to >= 500/mm3 (21 days in the control group and 16 days in the treatment group, < 0.001).. 14.4 Patients Undergoing Autologous Peripheral Blood Progenitor Cell Collection and Therapy. The safety and efficacy of filgrastim to mobilize autologous peripheral blood progenitor cells for collection by leukapheresis was supported by the experience in uncontrolled trials, and randomized trial comparing hematopoietic stem cell rescue using filgrastim-mobilized autologous peripheral blood progenitor cells to autologous bone marrow (Study 11). Patients in all these trials underwent similar mobilization/collection regimen: filgrastim was administered for to days, in most cases the apheresis procedure occurred on days 5, 6, and 7. The dose of filgrastim ranged between 10 to 24 mcg/kg/day and was administered subcutaneously by injection or continuous intravenous infusion.Engraftment was evaluated in 64 patients who underwent transplantation using filgrastim-mobilized autologous hematopoietic progenitor cells in uncontrolled trials. Two of the 64 patients (3%) did not achieve the criteria for engraftment as defined by platelet count >= 20,000/mm3 by day 28. In clinical trials of filgrastim for the mobilization of hematopoietic progenitor cells, filgrastim was administered to patients at doses between to 24 mcg/kg/day after reinfusion of the collected cells until sustainable ANC (>= 500/mm3) was reached. The rate of engraftment of these cells in the absence of filgrastim post transplantation has not been studied.Study 11 was randomized, unblinded study of patients with Hodgkins disease or non-Hodgkins lymphoma undergoing myeloablative chemotherapy, 27 patients received filgrastim-mobilized autologous hematopoietic progenitor cells and 31 patients received autologous bone marrow. The preparative regimen was intravenous BCNU, etoposide, cytosine arabinoside and melphalan (BEAM). Patients received daily filgrastim 24 hours after stem cell infusion at dose of mcg/kg/day. The median age was 33 (range to 59) years; 64% males; 57% Hodgkins disease and 43% non-Hodgkins lymphoma. The main efficacy endpoint was number of days of platelet transfusions. Patients randomized to filgrastim-mobilized autologous peripheral blood progenitor cells compared to autologous bone marrow had significantly fewer days of platelet transfusions (median vs 10 days).. 14.5 Patients with Severe Chronic Neutropenia. The safety and efficacy of filgrastim to reduce the incidence and duration of sequelae of neutropenia (that is fever, infections, oropharyngeal ulcers) in symptomatic adult and pediatric patients with congenital neutropenia, cyclic neutropenia, or idiopathic neutropenia was established in randomized controlled trial conducted in patients with severe neutropenia (Study 7).Patients eligible for Study had history of severe chronic neutropenia documented with an ANC 500/mm3 on three occasions during 6-month period, or in patients with cyclic neutropenia consecutive days of ANC 500/mm3 per cycle. In addition, patients must have experienced clinically significant infection during the previous 12 months. Patients were randomized to 4-month observation period followed by filgrastim treatment or immediate filgrastim treatment. The median age was 12 years (range months to 76 years); 46% males; 34% idiopathic, 17% cyclic and 49% congenital neutropenia. Filgrastim was administered subcutaneously. The dose of filgrastim was determined by the category of neutropenia.Initial dose of filgrastim:oIdiopathic neutropenia: 3.6 mcg/kg/dayoCyclic neutropenia: mcg/kg/dayoCongenital neutropenia: mcg/kg/day divided times per dayThe dose was increased incrementally to 12 mcg/kg/day divided times per day if there was no response.The main efficacy endpoint was response to filgrastim treatment. ANC response from baseline (< 500/mm3) was defined as follows:oComplete response: median ANC 1,500/mm3 oPartial response: median ANC >= 500/mm3 and <= 1,500/mm3 with minimum increase of 100%oNo response: median ANC 500/mm3 There were 112 of 123 patients who demonstrated complete or partial response to filgrastim treatment.Additional efficacy endpoints included comparison between patients randomized to months of observation and patients receiving filgrastim of the following parameters:oincidence of infectionoincidence of feveroduration of feveroincidence, duration, and severity of oropharyngeal ulcersonumber of days of antibiotic useThe incidence for each of these clinical parameters was lower in the filgrastim arm compared to the control arm for cohorts in each of the major diagnostic categories. An analysis of variance showed no significant interaction between treatment and diagnosis, suggesting that efficacy did not differ substantially in the different diseases. Although filgrastim substantially reduced neutropenia in all patient groups, in patients with cyclic neutropenia, cycling persisted but the period of neutropenia was shortened to day.. oIdiopathic neutropenia: 3.6 mcg/kg/day. oCyclic neutropenia: mcg/kg/day. oCongenital neutropenia: mcg/kg/day divided times per day. oComplete response: median ANC 1,500/mm3 oPartial response: median ANC >= 500/mm3 and <= 1,500/mm3 with minimum increase of 100%. oNo response: median ANC 500/mm3 oincidence of infection. oincidence of fever. oduration of fever. oincidence, duration, and severity of oropharyngeal ulcers. onumber of days of antibiotic use. 14.6 Patients Acutely Exposed to Myelosuppressive Doses of Radiation (Hematopoietic Syndrome of Acute Radiation Syndrome) Efficacy studies of filgrastim products could not be conducted in humans with acute radiation syndrome for ethical and feasibility reasons. Approval of this indication was based on efficacy studies conducted in animals and data supporting the use of filgrastim for other approved indications [see Dosage and Administration (2.1 to 2.4)].Because of the uncertainty associated with extrapolating animal efficacy data to humans, the selection of human dose for ZARXIO is aimed at providing exposures to filgrastim that exceed those observed in animal efficacy studies. The 10 mcg/kg daily dose is selected for humans exposed to myelosuppressive doses of radiation because the exposure associated with such dose is expected to exceed the exposure associated with 10 mcg/kg dose in non-human primates [see Clinical Pharmacology (12.3)]. The safety of filgrastim at daily dose of 10 mcg/kg has been assessed on the basis of clinical experience in approved indications.The efficacy of filgrastim was studied in randomized, blinded, placebo-controlled study in non-human primate model of radiation injury. The planned sample size was 62 animals, but the study was stopped at the interim analysis with 46 animals because efficacy was established. Rhesus macaques were randomized to control (n 22) or treated (n 24) group. Animals were exposed to total body irradiation of 7.4 +- 0.15 Gy delivered at 0.8 +- 0.03 Gy/min, representing dose that would be lethal in 50% of animals by 60 days of follow-up (LD50/60). Starting on day after irradiation, animals received daily subcutaneous injections of placebo (5% dextrose in water) or filgrastim (10 mcg/kg/day). Blinded treatment was stopped when one of the following criteria was met: ANC >= 1,000/mm3 for consecutive days, or ANC >= 10,000/mm3 for more than consecutive days within study day to 5, or ANC >= 10,000/mm3 any time after study day 5. Animals received medical management consisting of intravenous fluids, antibiotics, blood transfusions, and other support as required.Filgrastim significantly (at 0.023 level of significance) reduced 60-day mortality in the irradiated non-human primates: 21% mortality (5/24) in the filgrastim group compared to 59% mortality (13/22) in the control group.

CONTRAINDICATIONS SECTION.

4 CONTRAINDICATIONS. ZARXIO is contraindicated in patients with history of serious allergic reactions to human granulocyte colony-stimulating factors such as filgrastim products or pegfilgrastim products [see Warnings and Precautions 5.3)].. Patients with history of serious allergic reactions to human granulocyte colony-stimulating factors such as filgrastim products or pegfilgrastim products. (4).

DESCRIPTION SECTION.

11 DESCRIPTION. Filgrastim-sndz is 175 amino acid human granulocyte colony-stimulating factor (G-CSF) manufactured by recombinant DNA technology.Filgrastim-sndz is produced by Escherichia coli (E coli) bacteria into which has been inserted the human granulocyte colony-stimulating factor gene. Filgrastim-sndz has molecular weight of 18,800 daltons. The protein has an amino acid sequence that is identical to the natural sequence predicted from human DNA sequence analysis, except for the addition of an N-terminal methionine necessary for expression in coli. Because filgrastim-sndz is produced in coli, the product is non-glycosylated and thus differs from G-CSF isolated from human cell.ZARXIO (filgrastim-sndz) injection is sterile, clear, colorless to slightly yellowish, preservative-free liquid containing filgrastim-sndz at specific activity of x 108 U/mg (as measured by proliferation assay). The product is available in single-dose vials and single-dose prefilled syringes for subcutaneous or intravenous use. The single-dose vials contain either 300 mcg/mL or 480 mcg/1.6 mL of filgrastim-sndz. The single-dose prefilled syringes contain either 300 mcg/0.5 mL or 480 mcg/0.8 mL of filgrastim-sndz. The ZARXIO drug product has pH of 4.4. See Table below for product composition of each single-dose vial and prefilled syringe.Table 4. Product Composition300 mcg/mL Vial480 mcg/1.6 mL Vial300 mcg/0.5 mLSyringe480 mcg/0.8 mLSyringeFilgrastim-sndz300 mcg480 mcg300 mcg480 mcgGlutamic Acid1.471 mg2.354 mg0.736 mg1.178 mgPolysorbate 800.04 mg0.064 mg0.02 mg0.032 mgSorbitol50 mg80 mg25 mg40 mgSodium hydroxideq.s.q.s.q.s.q.s.Water for Injection USP q.s. adad mLad 1.6 mLad 0.5 mLad 0.8 mLq.s.: quantity sufficient to make.

DOSAGE & ADMINISTRATION SECTION.

2 DOSAGE AND ADMINISTRATION. oPatients with cancer receiving myelosuppressive chemotherapy or induction and/or consolidation chemotherapy for AMLoRecommended starting dose is mcg/kg/day subcutaneous injection, short intravenous infusion (15 to 30 minutes), or continuous intravenous infusion. See Full Prescribing Information for recommended dosage adjustments and timing of administration (2.1) oPatients with cancer undergoing bone marrow transplantationo10 mcg/kg/day given as an intravenous infusion no longer than 24 hours. See Full Prescribing Information for recommended dosage adjustments and timing of administration. (2.2)oPatients undergoing autologous peripheral blood progenitor cell collection and therapyo10 mcg/kg/day subcutaneous injection (2.3)oAdminister for at least days before first leukapheresis procedure and continue until last leukapheresis (2.3)oPatients with congenital neutropeniaoRecommended starting dose is mcg/kg subcutaneous injection twice daily (2.4)oPatients with cyclic or idiopathic neutropeniaoRecommended starting dose is mcg/kg subcutaneous injection daily (2.4)oPatients acutely exposed to myelosuppressive doses of radiationo10 mcg/kg/day subcutaneous injection (2.5)oDirect administration of less than 0.3 mL (180 mcg) is not recommended due to potential for dosing errors (2.6). oPatients with cancer receiving myelosuppressive chemotherapy or induction and/or consolidation chemotherapy for AMLoRecommended starting dose is mcg/kg/day subcutaneous injection, short intravenous infusion (15 to 30 minutes), or continuous intravenous infusion. See Full Prescribing Information for recommended dosage adjustments and timing of administration (2.1) oRecommended starting dose is mcg/kg/day subcutaneous injection, short intravenous infusion (15 to 30 minutes), or continuous intravenous infusion. See Full Prescribing Information for recommended dosage adjustments and timing of administration (2.1) oPatients with cancer undergoing bone marrow transplantationo10 mcg/kg/day given as an intravenous infusion no longer than 24 hours. See Full Prescribing Information for recommended dosage adjustments and timing of administration. (2.2). o10 mcg/kg/day given as an intravenous infusion no longer than 24 hours. See Full Prescribing Information for recommended dosage adjustments and timing of administration. (2.2). oPatients undergoing autologous peripheral blood progenitor cell collection and therapyo10 mcg/kg/day subcutaneous injection (2.3)oAdminister for at least days before first leukapheresis procedure and continue until last leukapheresis (2.3). o10 mcg/kg/day subcutaneous injection (2.3). oAdminister for at least days before first leukapheresis procedure and continue until last leukapheresis (2.3). oPatients with congenital neutropeniaoRecommended starting dose is mcg/kg subcutaneous injection twice daily (2.4). oRecommended starting dose is mcg/kg subcutaneous injection twice daily (2.4). oPatients with cyclic or idiopathic neutropeniaoRecommended starting dose is mcg/kg subcutaneous injection daily (2.4). oRecommended starting dose is mcg/kg subcutaneous injection daily (2.4). oPatients acutely exposed to myelosuppressive doses of radiation. o10 mcg/kg/day subcutaneous injection (2.5). oDirect administration of less than 0.3 mL (180 mcg) is not recommended due to potential for dosing errors (2.6). 2.1 Dosage in Patients with Cancer Receiving Myelosuppressive Chemotherapy or Induction and/or Consolidation Chemotherapy for AML. The recommended starting dosage of ZARXIO is mcg/kg/day, administered as single daily injection by subcutaneous injection, by short intravenous infusion (15 to 30 minutes), or by continuous intravenous infusion. Obtain complete blood count (CBC) and platelet count before instituting ZARXIO therapy and monitor twice weekly during therapy. Consider dose escalation in increments of mcg/kg for each chemotherapy cycle, according to the duration and severity of the absolute neutrophil count (ANC) nadir. Recommend stopping ZARXIO if the ANC increases beyond 10,000/mm3 [see Warnings and Precautions 5.10)].Administer ZARXIO at least 24 hours after cytotoxic chemotherapy. Do not administer ZARXIO within the 24-hour period prior to chemotherapy [see Warnings and Precautions 5.13 )]. transient increase in neutrophil count is typically seen to days after initiation of ZARXIO therapy. Therefore, to ensure sustained therapeutic response, administer ZARXIO daily for up to weeks or until the ANC has reached 10,000/mm3 following the expected chemotherapy-induced neutrophil nadir. The duration of ZARXIO therapy needed to attenuate chemotherapy-induced neutropenia may be dependent on the myelosuppressive potential of the chemotherapy regimen employed.. 2.2 Dosage in Patients with Cancer Undergoing Bone Marrow Transplantation. The recommended dosage of ZARXIO following bone marrow transplantation (BMT) is 10 mcg/kg/day given as an intravenous infusion no longer than 24 hours. Administer the first dose of ZARXIO at least 24 hours after cytotoxic chemotherapy and at least 24 hours after bone marrow infusion. Monitor CBCs and platelet counts frequently following marrow transplantation.During the period of neutrophil recovery, titrate the daily dosage of ZARXIO against the neutrophil response (see Table 1).Table 1. Recommended Dosage Adjustments During Neutrophil Recovery in Patients with Cancer Following BMTAbsolute Neutrophil CountZARXIO Dosage AdjustmentWhen ANC greater than 1,000/mm3 for consecutive daysReduce to mcg/kg/dayIf ANC decreases to less than 1,000/mm3 at any time during the mcg/kg/day administration, increase ZARXIO to 10 mcg/kg/day, and then follow the above steps. Then, if ANC remains greater than 1,000/mm3 for more consecutive daysDiscontinue ZARXIOThen, if ANC decreases to less than 1,000/mm3 Resume at mcg/kg/day. 2.3 Dosage in Patients Undergoing Autologous Peripheral Blood Progenitor Cell Collection and Therapy. The recommended dosage of ZARXIO for the mobilization of autologous peripheral blood progenitor cells (PBPC) is 10 mcg/kg/day given by subcutaneous injection. Administer ZARXIO for at least days before the first leukapheresis procedure and continue until the last leukapheresis. Although the optimal duration of ZARXIO administration and leukapheresis schedule have not been established, administration of filgrastim for to days with leukaphereses on days 5, 6, and was found to be safe and effective [see Clinical Studies 14.4)]. Monitor neutrophil counts after days of ZARXIO, and discontinue ZARXIO if the white blood cell (WBC) count rises to greater than 100,000/mm3.. 2.4 Dosage in Patients with Severe Chronic Neutropenia. Prior to starting ZARXIO in patients with suspected chronic neutropenia, confirm the diagnosis of severe chronic neutropenia (SCN) by evaluating serial CBCs with differential and platelet counts, and evaluating bone marrow morphology and karyotype. The use of ZARXIO prior to confirmation of correct diagnosis of SCN may impair diagnostic efforts and may thus impair or delay evaluation and treatment of an underlying condition, other than SCN, causing the neutropenia.The recommended starting dosage in patients with Congenital Neutropenia is mcg/kg as twice daily subcutaneous injection and the recommended starting dosage in patients with Idiopathic or Cyclic Neutropenia is mcg/kg as single daily subcutaneous injection.Dosage Adjustments in Patients with Severe Chronic NeutropeniaChronic daily administration is required to maintain clinical benefit. Individualize the dosage based on the patients clinical course as well as ANC. In the SCN postmarketing surveillance study, the reported median daily doses of filgrastim were: mcg/kg (congenital neutropenia), 2.1 mcg/kg (cyclic neutropenia), and 1.2 mcg/kg (idiopathic neutropenia). In rare instances, patients with congenital neutropenia have required doses of filgrastim greater than or equal to 100 mcg/kg/day.Monitor CBCs for Dosage AdjustmentsDuring the initial weeks of ZARXIO therapy and during the weeks following any dosage adjustment, monitor CBCs with differential and platelet counts. Once patient is clinically stable, monitor CBCs with differential and platelet counts monthly during the first year of treatment. Thereafter, if the patient is clinically stable, less frequent routine monitoring is recommended.. 2.5 Dosage in Patients Acutely Exposed to Myelosuppressive Doses of Radiation (Hematopoietic Syndrome of Acute Radiation Syndrome) The recommended dosage of ZARXIO is 10 mcg/kg as single daily subcutaneous injection for patients exposed to myelosuppressive doses of radiation. Administer ZARXIO as soon as possible after suspected or confirmed exposure to radiation doses greater than gray (Gy).Estimate patients absorbed radiation dose (i.e., level of radiation exposure) based on information from public health authorities, biodosimetry if available, or clinical findings such as time to onset of vomiting or lymphocyte depletion kinetics.Obtain baseline CBC and then serial CBCs approximately every third day until the ANC remains greater than 1,000/mm3 for consecutive CBCs. Do not delay administration of ZARXIO if CBC is not readily available.Continue administration of ZARXIO until the ANC remains greater than 1,000/mm3 for consecutive CBCs or exceeds 10,000/mm3 after radiation-induced nadir.. 2.6 Important Administration Instructions. ZARXIO (for subcutaneous use or intravenous use) is supplied in single-dose vials and in single-dose prefilled syringes [see Dosage Forms and Strengths (3)]. Administration Instructions for Subcutaneous InjectionInject ZARXIO subcutaneously in the outer area of upper arms, abdomen, thighs, or upper outer areas of the buttock. If patients or caregivers are to administer ZARXIO, instruct them in appropriate injection technique and ask them to follow the subcutaneous injection procedures in the Instructions for Use for prefilled syringe with BD UltraSafe Passive (R) Needle Guard or for the vial. If the patient or caregiver misses dose of ZARXIO, instruct them to contact their healthcare provider.Patients who will self-administer and caregivers who will administer to the patient may benefit from training by healthcare professional. Training should aim to demonstrate to those patients and caregivers how to measure the dose of ZARXIO, and the focus should be on ensuring that patient or caregiver can successfully perform all of the steps in the Instructions for Use for the vial or prefilled syringe with BD UltraSafe Passive(R) Needle Guard. If patient or caregiver is not able to demonstrate that they can measure the dose and administer the product successfully, you should consider whether the patient is an appropriate candidate for self-administration of ZARXIO prefilled syringe or whether the patient would benefit from the ZARXIO vial presentation. If patient or caregiver experiences difficulty measuring the required dose, especially if it is other than the entire content of the ZARXIO prefilled syringe, use of the ZARXIO vial may be considered [see Instructions for Use].Instructions for the Prefilled SyringeZARXIO prefilled syringe with BD UltraSafe Passive(R) Needle Guard is not designed to allow for direct administration of doses of less than 0.3 mL (180 mcg). The spring-mechanism of the needle guard apparatus affixed to the prefilled syringe interferes with the visibility of the graduation markings on the syringe barrel corresponding to 0.1 mL and 0.2 mL. The visibility of these markings is necessary to accurately measure doses of ZARXIO less than 0.3 mL (180 mcg) for direct administration to patients. Thus, the direct administration to patients requiring doses of less than 0.3 mL (180 mcg) is not recommended due to the potential for dosing errors. If less than 0.3 mL is needed the ZARXIO single-dose vial should be used. Persons with latex allergies should not administer the ZARXIO prefilled syringe, because the needle cap contains natural rubber latex (derived from latex). For latex sensitive individuals the ZARXIO vial should be considered as the vial stopper is not made with natural rubber latex. Prior to use, remove the prefilled syringe from the refrigerator and allow ZARXIO to reach room temperature [between 20C to 25C (68F to 77F)] for minimum of 30 minutes. If not used immediately, the prefilled syringe may be stored at room temperature for up to days. Discard any prefilled syringe left at room temperature for greater than days. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit (the solution is clear and colorless to slightly yellowish). Do not administer ZARXIO if particulates or discoloration are observed.Discard unused portion of ZARXIO in prefilled syringes. Do not save unused drug for later administration.Instructions for the Single-dose vialPrior to use, remove the vial from the refrigerator and allow ZARXIO to reach room temperature for minimum of 30 minutes. If not used immediately, the vial may be stored at room temperature for up to days. Discard any vial left at room temperature for greater than days. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit (the solution is clear and colorless to slightly yellowish). Do not administer ZARXIO if particulates or discoloration are observed.Discard the unused portion of ZARXIO in single-dose vial and do not re-enter the vial. Do not save unused drug for later administration.Administration Instructions for DilutionIf required for intravenous administration, ZARXIO may be diluted in 5% Dextrose Injection, USP to concentrations between mcg/mL and 15 mcg/mL. ZARXIO diluted to concentrations from mcg/mL to 15 mcg/mL should be protected from adsorption to plastic materials by the addition of Albumin (Human) to final concentration of mg/mL. When diluted in 5% Dextrose Injection, USP or 5% Dextrose plus Albumin (Human), ZARXIO is compatible with glass, polyvinylchloride, polyolefin, and polypropylene.Do not dilute with Sodium Chloride Injection at any time because the product may precipitate.Diluted ZARXIO solution from ZARXIO prefilled syringe can be stored at room temperature [between 20 to 25 (68 to 77)] for up to 24 hours. This 24-hour time period includes the time during room temperature storage of the infusion solution and the duration of the infusion.Diluted ZARXIO solution from ZARXIO vial can be stored refrigerated [2C to 8C (36F to 46F)] for up to 24 hours or at room temperature [between 20 to 25 (68 to 77)] for up to hours, including the time during room temperature storage of the infusion solution and the duration of the infusion.

DOSAGE FORMS & STRENGTHS SECTION.

3 DOSAGE FORMS AND STRENGTHS. ZARXIO is clear, colorless to slightly yellowish solution available as: Vial:oInjection: 300 mcg/mL in single-dose vialoInjection: 480 mcg/1.6 mL (300 mcg/mL) in single-dose vial Prefilled Syringe:oInjection: 300 mcg/0.5 mL in single-dose prefilled syringeoInjection: 480 mcg/0.8 mL in single-dose prefilled syringe ZARXIO is clear, colorless to slightly yellowish solution available as:. Vial:. oInjection: 300 mcg/mL in single-dose vial. oInjection: 480 mcg/1.6 mL (300 mcg/mL) in single-dose vial. Prefilled Syringe:. oInjection: 300 mcg/0.5 mL in single-dose prefilled syringe. oInjection: 480 mcg/0.8 mL in single-dose prefilled syringe. VialoInjection: 300 mcg/mL in single-dose-vial (3)oInjection: 480 mcg/1.6 mL (300 mcg/mL) in single-dose-vial (3)Prefilled SyringeoInjection: 300 mcg/0.5 mL in single-dose prefilled syringe with BD UltraSafe Passive(R) Needle Guard (3)oInjection: 480 mcg/0.8 mL in single-dose prefilled syringe with BD UltraSafe Passive(R) Needle Guard (3). Vial. oInjection: 300 mcg/mL in single-dose-vial (3). oInjection: 480 mcg/1.6 mL (300 mcg/mL) in single-dose-vial (3). oInjection: 300 mcg/0.5 mL in single-dose prefilled syringe with BD UltraSafe Passive(R) Needle Guard (3). oInjection: 480 mcg/0.8 mL in single-dose prefilled syringe with BD UltraSafe Passive(R) Needle Guard (3).

GERIATRIC USE SECTION.

8.5 Geriatric Use. Among 855 subjects enrolled in randomized, placebo-controlled trials of filgrastim treated-patients receiving myelosuppressive chemotherapy, there were 232 subjects age 65 or older, and 22 subjects age 75 or older. No overall differences in safety or effectiveness were observed between these subjects and younger subjects. Clinical studies of filgrastim in other approved indications (i.e., BMT recipients, PBPC mobilization, and SCN) did not include sufficient numbers of subjects aged 65 and older to determine whether elderly subjects respond differently from younger subjects.

HOW SUPPLIED SECTION.

16 HOW SUPPLIED/STORAGE AND HANDLING. ZARXIO injection is clear, colorless to slightly yellowish, preservative-free solution supplied as:Vial:The vial is supplied in carton containing one single-dose vial providing:o300 mcg/mL of filgrastim-sndz solution (NDC 61314-246-71)o480 mcg/1.6 (300 mcg/mL) mL of filgrastim-sndz solution (NDC 61314-266-73)Latex sensitive individuals: The vial stopper is not made with natural rubber latex.Prefilled syringe (BD UltraSafe Passive(R) Needle Guard):Single-dose prefilled syringe containing 300 mcg/0.5 mL of filgrastim-sndz solution.oPack of prefilled syringe (NDC 61314-318-01)oPack of 10 (multipack) prefilled syringes (NDC 61314-318-10)Single-dose prefilled syringe containing 480 mcg/0.8 mL of filgrastim-sndz solution.oPack of prefilled syringe (NDC 61314-326-01)oPack of 10 (multipack) prefilled syringes (NDC 61314-326-10)Latex-sensitive individuals: The removable needle cap of ZARXIO prefilled syringe contains natural rubber latex which may cause allergic reaction. The safe use of ZARXIO in latex-sensitive individuals has not been studied.Storage:Store ZARXIO in the refrigerator at 2C to 8C (36F to 46F) in the original pack to protect from light. Do not leave ZARXIO in direct sunlight. Avoid shaking. Avoid freezing; if frozen, thaw in the refrigerator before administration. Discard ZARXIO if frozen more than once.. o300 mcg/mL of filgrastim-sndz solution (NDC 61314-246-71). o480 mcg/1.6 (300 mcg/mL) mL of filgrastim-sndz solution (NDC 61314-266-73). oPack of prefilled syringe (NDC 61314-318-01). oPack of 10 (multipack) prefilled syringes (NDC 61314-318-10). oPack of prefilled syringe (NDC 61314-326-01). oPack of 10 (multipack) prefilled syringes (NDC 61314-326-10).

INDICATIONS & USAGE SECTION.

1 INDICATIONS AND USAGE. ZARXIO is leukocyte growth factor indicated tooDecrease the incidence of infection, as manifested by febrile neutropenia, in patients with nonmyeloid malignancies receiving myelosuppressive anti-cancer drugs associated with significant incidence of severe neutropenia with fever (1.1)oReduce the time to neutrophil recovery and the duration of fever, following induction or consolidation chemotherapy treatment of patients with acute myeloid leukemia (AML) (1.2)oReduce the duration of neutropenia and neutropenia-related clinical sequelae, e.g., febrile neutropenia, in patients with nonmyeloid malignancies undergoing myeloablative chemotherapy followed by bone marrow transplantation (BMT) (1.3)oMobilize autologous hematopoietic progenitor cells into the peripheral blood for collection by leukapheresis (1.4)oReduce the incidence and duration of sequelae of severe neutropenia (e.g., fever, infections, oropharyngeal ulcers) in symptomatic patients with congenital neutropenia, cyclic neutropenia, or idiopathic neutropenia (1.5)oIncrease survival in patients acutely exposed to myelosuppressive doses of radiation (Hematopoietic Syndrome of Acute Radiation Syndrome) (1.6). oDecrease the incidence of infection, as manifested by febrile neutropenia, in patients with nonmyeloid malignancies receiving myelosuppressive anti-cancer drugs associated with significant incidence of severe neutropenia with fever (1.1). oReduce the time to neutrophil recovery and the duration of fever, following induction or consolidation chemotherapy treatment of patients with acute myeloid leukemia (AML) (1.2). oReduce the duration of neutropenia and neutropenia-related clinical sequelae, e.g., febrile neutropenia, in patients with nonmyeloid malignancies undergoing myeloablative chemotherapy followed by bone marrow transplantation (BMT) (1.3). oMobilize autologous hematopoietic progenitor cells into the peripheral blood for collection by leukapheresis (1.4). oReduce the incidence and duration of sequelae of severe neutropenia (e.g., fever, infections, oropharyngeal ulcers) in symptomatic patients with congenital neutropenia, cyclic neutropenia, or idiopathic neutropenia (1.5). oIncrease survival in patients acutely exposed to myelosuppressive doses of radiation (Hematopoietic Syndrome of Acute Radiation Syndrome) (1.6). 1.1 Patients with Cancer Receiving Myelosuppressive Chemotherapy. ZARXIO is indicated to decrease the incidence of infection, as manifested by febrile neutropenia, in patients with nonmyeloid malignancies receiving myelosuppressive anti-cancer drugs associated with significant incidence of severe neutropenia with fever [see Clinical Studies 14.1 )].. 1.2 Patients with Acute Myeloid Leukemia Receiving Induction or Consolidation Chemotherapy. ZARXIO is indicated for reducing the time to neutrophil recovery and the duration of fever, following induction or consolidation chemotherapy treatment of patients with acute myeloid leukemia (AML) [see Clinical Studies 14.2)].. 1.3 Patients with Cancer Undergoing Bone Marrow Transplantation. ZARXIO is indicated to reduce the duration of neutropenia and neutropenia-related clinical sequelae, e.g., febrile neutropenia, in patients with nonmyeloid malignancies undergoing myeloablative chemotherapy followed by bone marrow transplantation [see Clinical Studies (14.3)]. 1.4 Patients Undergoing Autologous Peripheral Blood Progenitor Cell Collection and Therapy. ZARXIO is indicated for the mobilization of autologous hematopoietic progenitor cells into the peripheral blood for collection by leukapheresis [see Clinical Studies (14.4)].. 1.5 Patients with Severe Chronic Neutropenia. ZARXIO is indicated for chronic administration to reduce the incidence and duration of sequelae of neutropenia (e.g., fever, infections, oropharyngeal ulcers) in symptomatic patients with congenital neutropenia, cyclic neutropenia, or idiopathic neutropenia [see Clinical Studies 14.5)].. 1.6 Patients Acutely Exposed to Myelosuppressive Doses of Radiation (Hematopoietic Syndrome of Acute Radiation Syndrome) ZARXIO is indicated to increase survival in patients acutely exposed to myelosuppressive doses of radiation [see Clinical Studies 14.6)].

INFORMATION FOR PATIENTS SECTION.

17 PATIENT COUNSELING INFORMATION. Advise the patient to read the FDA-approved patient labeling (Patient Information and Instructions for Use). Review the steps for direct patient administration with patients and caregivers. Training by the healthcare provider should aim to ensure that patients and caregivers can successfully perform all of the steps in the Instructions for Use of ZARXIO vial and prefilled syringe, including showing the patient or caregiver how to measure the required dose, particularly if patient is on dose other than the entire prefilled syringe. If patient or caregiver is not able to demonstrate that they can measure the dose and administer the product successfully, you should consider whether the patient is an appropriate candidate for self-administration of ZARXIO or whether the patient would benefit from different ZARXIO presentation.Advise patients of the following risks and potential risks with ZARXIO:oRupture or enlargement of the spleen may occur. Symptoms include left upper quadrant abdominal pain or left shoulder pain. Advise patients to report pain in these areas to their physician immediately [see Warnings and Precautions (5.1)].oDyspnea, with or without fever, progressing to Acute Respiratory Distress Syndrome, may occur. Advise patients to report dyspnea to their physician immediately [see Warnings and Precautions (5.2)].oSerious allergic reactions may occur, which may be signaled by rash, facial edema, wheezing, dyspnea, hypotension, or tachycardia. Advise patients to seek immediate medical attention if signs or symptoms of hypersensitivity reaction occur [see Warnings and Precautions (5.3)].oIn patients with sickle cell disease, sickle cell crisis and death have occurred. Discuss potential risks and benefits for patients with sickle cell disease prior to the administration of human granulocyte colony-stimulating factors [see Warnings and Precautions (5.4)].oGlomerulonephritis may occur. Symptoms include swelling of the face or ankles, dark colored urine or blood in the urine, or decrease in urine production. Advise patients to report signs or symptoms of glomerulonephritis to their physician immediately [see Warnings and Precautions (5.5)].oThere may be an increased risk of Myelodysplastic Syndrome and/or Acute Myeloid Leukemia in patients with congenital neutropenia who receive filgrastim products and in patients with breast and lung cancer who receive filgrastim products in conjunction with chemotherapy and/or radiation therapy. Symptoms of MDS and AML may include tiredness, fever, and easy bruising or bleeding. Advise patients to report to their physician signs and symptoms of MDS/AML [see Warnings and Precautions (5.8)].oCutaneous vasculitis may occur, which may be signaled by purpura or erythema. Advise patients to report signs or symptoms of vasculitis to their physician immediately [see Warnings and Precautions (5.11)].oAortitis may occur. Symptoms may include fever, abdominal pain, malaise, back pain, and increased inflammatory markers. Advise patients to report signs and symptoms of aortitis to their physician immediately [see Warnings and Precautions (5.15)]. Advise patients acutely exposed to myelosuppressive doses of radiation (Hematopoietic Syndrome of Acute Radiation Syndrome) that efficacy studies of filgrastim products for this indication could not be conducted in humans for ethical and feasibility reasons and that, therefore, approval of this use was based on efficacy studies conducted in animals [see Clinical Studies (14.6)].Instruct patients who self-administer ZARXIO using the prefilled syringe or single-dose vial of the: oImportance of following the applicable Instructions for Use. oDangers of reusing needles, syringes or unused portions of single-dose vials.oImportance of following local requirements for proper disposal of used syringes, needles, and unused vials. oImportance of informing the healthcare provider if difficulty occurs when measuring or administering partial contents of the ZARXIO prefilled syringe. If difficulties occur, use of the ZARXIO vial may be considered.oDifference in product concentration of the ZARXIO prefilled syringe in comparison to the ZARXIO vial. When switching patients from the ZARXIO prefilled syringe to the ZARXIO vial, or vice versa, ensure that patients understand the correct volume to be administered since the concentration of ZARXIO differs between the prefilled syringe and the vial.ZARXIO(R) (filgrastim-sndz)UltraSafe and UltraSafe Passive are registered trademarks of Safety Syringes, Inc. BD is registered trademark of Becton, Dickinson and Company.Manufactured by:Sandoz Inc., Princeton, NJ 08540US License No. 2003. oRupture or enlargement of the spleen may occur. Symptoms include left upper quadrant abdominal pain or left shoulder pain. Advise patients to report pain in these areas to their physician immediately [see Warnings and Precautions (5.1)].. oDyspnea, with or without fever, progressing to Acute Respiratory Distress Syndrome, may occur. Advise patients to report dyspnea to their physician immediately [see Warnings and Precautions (5.2)].. oSerious allergic reactions may occur, which may be signaled by rash, facial edema, wheezing, dyspnea, hypotension, or tachycardia. Advise patients to seek immediate medical attention if signs or symptoms of hypersensitivity reaction occur [see Warnings and Precautions (5.3)].. oIn patients with sickle cell disease, sickle cell crisis and death have occurred. Discuss potential risks and benefits for patients with sickle cell disease prior to the administration of human granulocyte colony-stimulating factors [see Warnings and Precautions (5.4)].. oGlomerulonephritis may occur. Symptoms include swelling of the face or ankles, dark colored urine or blood in the urine, or decrease in urine production. Advise patients to report signs or symptoms of glomerulonephritis to their physician immediately [see Warnings and Precautions (5.5)].. oThere may be an increased risk of Myelodysplastic Syndrome and/or Acute Myeloid Leukemia in patients with congenital neutropenia who receive filgrastim products and in patients with breast and lung cancer who receive filgrastim products in conjunction with chemotherapy and/or radiation therapy. Symptoms of MDS and AML may include tiredness, fever, and easy bruising or bleeding. Advise patients to report to their physician signs and symptoms of MDS/AML [see Warnings and Precautions (5.8)].. oCutaneous vasculitis may occur, which may be signaled by purpura or erythema. Advise patients to report signs or symptoms of vasculitis to their physician immediately [see Warnings and Precautions (5.11)].. oAortitis may occur. Symptoms may include fever, abdominal pain, malaise, back pain, and increased inflammatory markers. Advise patients to report signs and symptoms of aortitis to their physician immediately [see Warnings and Precautions (5.15)].. Advise patients acutely exposed to myelosuppressive doses of radiation (Hematopoietic Syndrome of Acute Radiation Syndrome) that efficacy studies of filgrastim products for this indication could not be conducted in humans for ethical and feasibility reasons and that, therefore, approval of this use was based on efficacy studies conducted in animals [see Clinical Studies (14.6)].. oImportance of following the applicable Instructions for Use. oDangers of reusing needles, syringes or unused portions of single-dose vials.. oImportance of following local requirements for proper disposal of used syringes, needles, and unused vials. oImportance of informing the healthcare provider if difficulty occurs when measuring or administering partial contents of the ZARXIO prefilled syringe. If difficulties occur, use of the ZARXIO vial may be considered.. oDifference in product concentration of the ZARXIO prefilled syringe in comparison to the ZARXIO vial. When switching patients from the ZARXIO prefilled syringe to the ZARXIO vial, or vice versa, ensure that patients understand the correct volume to be administered since the concentration of ZARXIO differs between the prefilled syringe and the vial.

LACTATION SECTION.

8.2 Lactation Risk Summary There is published literature documenting transfer of filgrastim into human milk. There are few case reports describing the use of filgrastim in breastfeeding mothers with no adverse effects noted in the infants. There are no data on the effects of filgrastim products on milk production. Other filgrastim products are secreted poorly into breast milk, and filgrastim products are not absorbed orally by neonates. The developmental and health benefits of breastfeeding should be considered along with the mothers clinical need for ZARXIO and any potential adverse effects on the breastfed child from ZARXIO or from the underlying maternal condition.

MECHANISM OF ACTION SECTION.

12.1 Mechanism of Action. Colony-stimulating factors are glycoproteins which act on hematopoietic cells by binding to specific cell surface receptors and stimulating proliferation, differentiation commitment, and some end-cell functional activation.Endogenous G-CSF is lineage-specific colony-stimulating factor that is produced by monocytes, fibroblasts, and endothelial cells. G-CSF regulates the production of neutrophils within the bone marrow and affects neutrophil progenitor proliferation, differentiation, and selected end-cell functions (including enhanced phagocytic ability, priming of the cellular metabolism associated with respiratory burst, antibody-dependent killing, and the increased expression of some cell surface antigens). G-CSF is not species-specific and has been shown to have minimal direct in vivo or in vitro effects on the production or activity of hematopoietic cell types other than the neutrophil lineage.

NONCLINICAL TOXICOLOGY SECTION.

13 NONCLINICAL TOXICOLOGY. 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility. The carcinogenic potential of filgrastim products has not been studied. Filgrastim failed to induce bacterial gene mutations in either the presence or absence of drug metabolizing enzyme system. Filgrastim had no observed effect on the fertility of male or female rats at doses up to 500 mcg/kg.. 13.2 Animal Toxicology and Pharmacology. Filgrastim was administered to monkeys, dogs, hamsters, rats, and mice as part of nonclinical toxicology program, which included studies up to 1-year duration.In the repeated-dose studies, changes observed were attributable to the expected pharmacological actions of filgrastim (i.e., dose-dependent increases in white blood cell counts, increased circulating segmented neutrophils, and increased myeloid: erythroid ratio in bone marrow). Histopathologic examination of the liver and spleen revealed evidence of ongoing extramedullary granulopoiesis, and dose-related increases in spleen weight were seen in all species. These changes all reversed after discontinuation of treatment.

OVERDOSAGE SECTION.

10 OVERDOSAGE. The maximum tolerated dose of filgrastim products has not been determined. In filgrastim clinical trials of patients with cancer receiving myelosuppressive chemotherapy, WBC counts 100,000/mm3 have been reported in less than 5% of patients, but were not associated with any reported adverse clinical effects. Patients in the BMT studies received up to 138 mcg/kg/day without toxic effects, although there was flattening of the dose response curve above daily doses of greater than 10 mcg/kg/day.

PACKAGE LABEL.PRINCIPAL DISPLAY PANEL.

300 mcg Carton. Zarxio(R) (filgrastim-sndz)InjectionFor Subcutaneous Use orIntravenous Use OnlySingle-Dose Only1 prefilled syringe with needle guard300 mcg/0.5 mLNDC 61314-318-01A recombinant Granulocyte Colony-Stimulating Factor (rG-CSF)derived from Coli. No Preservative.Refrigerate. Protect from freezing.Caution: Contains Natural Rubber LatexWhich May Cause Allergic Reaction.Rx onlySANDOZ. 300mcg-label.

PEDIATRIC USE SECTION.

8.4 Pediatric Use. ZARXIO prefilled syringe with BD UltraSafe Passive(R) Needle Guard may not accurately measure volumes less than 0.3 mL due to the needle spring mechanism design. Therefore, the direct administration of volume less than 0.3 mL using ZARXIO prefilled syringe is not recommended due to the potential for dosing errors. For direct administration of doses less than 0.3 mL (180 mcg) use ZARXIO single-dose vial.In patients with cancer receiving myelosuppressive chemotherapy, 15 pediatric patients median age 2.6 (range 1.2 to 9.4) years with neuroblastoma were treated with myelosuppressive chemotherapy (cyclophosphamide, cisplatin, doxorubicin, and etoposide) followed by subcutaneous filgrastim at doses of 5, 10, or 15 mcg/kg/day for 10 days (n=5/dose) (Study 8). The pharmacokinetics of filgrastim in pediatric patients after chemotherapy are similar to those in adults receiving the same weight-normalized doses, suggesting no age-related differences in the pharmacokinetics of filgrastim. In this population, filgrastim was well tolerated. There was one report of palpable splenomegaly and one report of hepatosplenomegaly associated with filgrastim therapy; however, the only consistently reported adverse event was musculoskeletal pain, which is no different from the experience in the adult population.The safety and effectiveness of ZARXIO have been established in pediatric patients with SCN [see Clinical Studies (14.5)]. In phase study (Study 7) to assess the safety and efficacy of filgrastim in the treatment of SCN, 123 patients with median age of 12 years (range months to 76 years) were studied. Of the 123 patients, 12 were infants (7 months to years of age), 49 were children (2 to 12 years of age), and were adolescents (12 to 16 years of age). Additional information is available from SCN postmarketing surveillance study, which includes long-term follow-up of patients in the clinical studies and information from additional patients who entered directly into the postmarketing surveillance study. Of the 731 patients in the surveillance study, 429 were pediatric patients 18 years of age (range 0.9 to 17) [see Indications and Usage (1.5), Dosage and Administration 2.6 ), and Clinical Studies (14.5)].Long-term follow-up data from the postmarketing surveillance study suggest that height and weight are not adversely affected in patients who received up to years of filgrastim treatment. Limited data from patients who were followed in the phase study for 1.5 years did not suggest alterations in sexual maturation or endocrine function.Pediatric patients with congenital types of neutropenia (Kostmanns syndrome, congenital agranulocytosis, or Schwachman-Diamond syndrome) have developed cytogenetic abnormalities and have undergone transformation to MDS and AML while receiving chronic filgrastim treatment. The relationship of these events to filgrastim product administration is unknown [see Warnings and Precautions (5.8) and Adverse Reactions (6)].The use of ZARXIO to increase survival in pediatric patients acutely exposed to myelosuppressive doses of radiation is based on studies of filgrastim conducted in animals and clinical data supporting the use of filgrastim in other approved indications [see Dosage and Administration (2.1 to 2.4) and Clinical Studies (14.6)].

PHARMACODYNAMICS SECTION.

12.2 Pharmacodynamics. In phase studies involving 96 patients with various nonmyeloid malignancies, administration of filgrastim resulted in dose-dependent increase in circulating neutrophil counts over the dose range of to 70 mcg/kg/day. This increase in neutrophil counts was observed whether filgrastim was administered intravenous (1 to 70 mcg/kg twice daily), subcutaneous (1 to mcg/kg once daily), or by continuous subcutaneous infusion (3 to 11 mcg/kg/day). With discontinuation of filgrastim therapy, neutrophil counts returned to baseline in most cases within days. Isolated neutrophils displayed normal phagocytic (measured by zymosan-stimulated chemiluminescence) and chemotactic (measured by migration under agarose using N-formyl-methionyl-leucyl-phenylalanine [fMLP] as the chemotaxin) activity in vitro. The absolute monocyte count was reported to increase in dose-dependent manner in most patients receiving filgrastim; however, the percentage of monocytes in the differential count remained within the normal range. Absolute counts of both eosinophils and basophils did not change and were within the normal range following administration of filgrastim. Increases in lymphocyte counts following filgrastim administration have been reported in some normal subjects and patients with cancer.White blood cell (WBC) differentials obtained during clinical trials have demonstrated shift towards earlier granulocyte progenitor cells (left shift), including the appearance of promyelocytes and myeloblasts, usually during neutrophil recovery following the chemotherapy-induced nadir. In addition, Dohle bodies, increased granulocyte granulation, and hypersegmented neutrophils have been observed. Such changes were transient and were not associated with clinical sequelae, nor were they necessarily associated with infection.

PHARMACOKINETICS SECTION.

12.3 Pharmacokinetics. Filgrastim products exhibit nonlinear pharmacokinetics. Clearance is dependent on filgrastim product concentration and neutrophil count: G-CSF receptor-mediated clearance is saturated by high concentration of filgrastim products and is diminished by neutropenia. In addition, filgrastim products are cleared by the kidney.Subcutaneous administration of 3.45 mcg/kg and 11.5 mcg/kg of filgrastim resulted in maximum serum concentrations of and 49 ng/mL, respectively, within to hours. After intravenous administration, the volume of distribution averaged 150 mL/kg and the elimination half-life was approximately 3.5 hours in both normal subjects and subjects with cancer. Clearance rates of filgrastim were approximately 0.5 to 0.7 mL/minute/kg. Single parenteral doses or daily intravenous doses, over 14-day period, resulted in comparable half-lives. The half-lives were similar for intravenous administration (231 minutes, following doses of 34.5 mcg/kg) and for subcutaneous administration (210 minutes, following filgrastim dosages of 3.45 mcg/kg). Continuous 24-hour intravenous infusions of 20 mcg/kg over an 11 to 20-day period produced steady-state serum concentrations of filgrastim with no evidence of drug accumulation over the time period investigated. The absolute bioavailability of filgrastim after subcutaneous administration is 60% to 70%.Specific PopulationsPatients Acutely Exposed to Myelosuppressive Doses of RadiationThe pharmacokinetics of filgrastim products are not available in patients acutely exposed to myelosuppressive doses of radiation. Based on limited pharmacokinetics data in irradiated non-human primates, the area under the time-concentration curve (AUC), reflecting the exposure to filgrastim in non-human primates at 10 mcg/kg dose of filgrastim, appears to be similar to that in humans at mcg/kg. Simulations conducted using the population pharmacokinetic model indicates that the exposures to filgrastim at filgrastim dose of 10 mcg/kg in patients acutely exposed to myelosuppressive doses of radiation are expected to exceed the exposures at dose of 10 mcg/kg in irradiated non-human primates.Pediatric PatientsThe pharmacokinetics of filgrastim in pediatric patients after chemotherapy are similar to those in adult patients receiving the same weight-normalized doses, suggesting no age-related differences in the pharmacokinetics of filgrastim products [see Use in Specific Populations (8.4)].Renal ImpairmentIn study with healthy volunteers, subjects with moderate renal impairment, and subjects with end stage renal disease (n=4 per group), higher serum concentrations were observed in subjects with end-stage renal disease. However, dose adjustment in patients with renal impairment is not necessary.Hepatic ImpairmentPharmacokinetics and pharmacodynamics of filgrastim are similar between subjects with hepatic impairment and healthy subjects (n=12/group). The study included 10 subjects with mild hepatic impairment (Child-Pugh Class A) and subjects with moderate hepatic impairment (Child-Pugh Class B). Therefore, dose adjustment for ZARXIO in patients with hepatic impairment is not necessary.

PREGNANCY SECTION.

8.1 Pregnancy Risk Summary Available data from published studies, including several observational studies of pregnancy outcomes in women exposed to filgrastim products and those who were unexposed, have not established an association with filgrastim product use during pregnancy and major birth defects, miscarriage, or adverse maternal or fetal outcomes (see Data). Reports in the scientific literature have described transplacental passage of filgrastim in pregnant women when administered <= 30 hours prior to preterm delivery (<= 30 weeks gestation). In animal reproduction studies, effects of filgrastim on prenatal development have been studied in rats and rabbits. No malformations were observed in either species. No maternal or fetal effects were observed in pregnant rats at doses up to 58 times the human doses. Filgrastim has been shown to have adverse effects in pregnant rabbits at doses to 10 times higher than the human doses (see Data). The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risks of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15- 20%, respectively. Data Human Data Several observational studies based on the Severe Chronic Neutropenia International Registry (SCNIR) described pregnancy outcomes in women with severe chronic neutropenia (SCN) who were exposed to filgrastim products during pregnancy and women with SCN who were unexposed. No major differences were seen between treated and untreated women with respect to pregnancy outcome (including miscarriage and preterm labor), newborn complications (including birth weight), and infections. Methodological limitations of these studies include small sample size and lack of generalizability due to the underlying maternal condition. Animal Data Effects of filgrastim on prenatal development have been studied in rats and rabbits. No malformations were observed in either species. Filgrastim has been shown to have adverse effects in pregnant rabbits at doses to 10 times higher than the human doses. In pregnant rabbits showing signs of maternal toxicity, reduced embryo-fetal survival (at 20 and 80 mcg/kg/day) and increased abortions (at 80 mcg/kg/day) were observed. In pregnant rats, no maternal or fetal effects were observed at doses up to 575 mcg/kg/day, which is approximately 58 times higher than the human dose of 10 mcg/kg/day.Offspring of rats administered filgrastim during the peri-natal and lactation periods exhibited delay in external differentiation and growth retardation (>= 20 mcg/kg/day) and slightly reduced survival rate (100 mcg/kg/day).

RECENT MAJOR CHANGES SECTION.

Indications and Usage: Patients Acutely Exposed to Myelosuppressive Doses of Radiation (Hematopoietic Syndrome of Acute Radiation Syndrome) (1.6)10/2024Dosage and Administration: Dosage in Patients Acutely Exposed to Myelosuppressive Doses of Radiation (Hematopoietic Syndrome of Acute Radiation Syndrome) (2.5)10/2024Dosage and Administration: Important Administration Instructions (2.6)08/2024.

SPL UNCLASSIFIED SECTION.

1.1 Patients with Cancer Receiving Myelosuppressive Chemotherapy. ZARXIO is indicated to decrease the incidence of infection, as manifested by febrile neutropenia, in patients with nonmyeloid malignancies receiving myelosuppressive anti-cancer drugs associated with significant incidence of severe neutropenia with fever [see Clinical Studies 14.1 )].

USE IN SPECIFIC POPULATIONS SECTION.

8 USE IN SPECIFIC POPULATIONS. 8.1 Pregnancy Risk Summary Available data from published studies, including several observational studies of pregnancy outcomes in women exposed to filgrastim products and those who were unexposed, have not established an association with filgrastim product use during pregnancy and major birth defects, miscarriage, or adverse maternal or fetal outcomes (see Data). Reports in the scientific literature have described transplacental passage of filgrastim in pregnant women when administered <= 30 hours prior to preterm delivery (<= 30 weeks gestation). In animal reproduction studies, effects of filgrastim on prenatal development have been studied in rats and rabbits. No malformations were observed in either species. No maternal or fetal effects were observed in pregnant rats at doses up to 58 times the human doses. Filgrastim has been shown to have adverse effects in pregnant rabbits at doses to 10 times higher than the human doses (see Data). The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risks of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15- 20%, respectively. Data Human Data Several observational studies based on the Severe Chronic Neutropenia International Registry (SCNIR) described pregnancy outcomes in women with severe chronic neutropenia (SCN) who were exposed to filgrastim products during pregnancy and women with SCN who were unexposed. No major differences were seen between treated and untreated women with respect to pregnancy outcome (including miscarriage and preterm labor), newborn complications (including birth weight), and infections. Methodological limitations of these studies include small sample size and lack of generalizability due to the underlying maternal condition. Animal Data Effects of filgrastim on prenatal development have been studied in rats and rabbits. No malformations were observed in either species. Filgrastim has been shown to have adverse effects in pregnant rabbits at doses to 10 times higher than the human doses. In pregnant rabbits showing signs of maternal toxicity, reduced embryo-fetal survival (at 20 and 80 mcg/kg/day) and increased abortions (at 80 mcg/kg/day) were observed. In pregnant rats, no maternal or fetal effects were observed at doses up to 575 mcg/kg/day, which is approximately 58 times higher than the human dose of 10 mcg/kg/day.Offspring of rats administered filgrastim during the peri-natal and lactation periods exhibited delay in external differentiation and growth retardation (>= 20 mcg/kg/day) and slightly reduced survival rate (100 mcg/kg/day).. 8.2 Lactation Risk Summary There is published literature documenting transfer of filgrastim into human milk. There are few case reports describing the use of filgrastim in breastfeeding mothers with no adverse effects noted in the infants. There are no data on the effects of filgrastim products on milk production. Other filgrastim products are secreted poorly into breast milk, and filgrastim products are not absorbed orally by neonates. The developmental and health benefits of breastfeeding should be considered along with the mothers clinical need for ZARXIO and any potential adverse effects on the breastfed child from ZARXIO or from the underlying maternal condition.. 8.4 Pediatric Use. ZARXIO prefilled syringe with BD UltraSafe Passive(R) Needle Guard may not accurately measure volumes less than 0.3 mL due to the needle spring mechanism design. Therefore, the direct administration of volume less than 0.3 mL using ZARXIO prefilled syringe is not recommended due to the potential for dosing errors. For direct administration of doses less than 0.3 mL (180 mcg) use ZARXIO single-dose vial.In patients with cancer receiving myelosuppressive chemotherapy, 15 pediatric patients median age 2.6 (range 1.2 to 9.4) years with neuroblastoma were treated with myelosuppressive chemotherapy (cyclophosphamide, cisplatin, doxorubicin, and etoposide) followed by subcutaneous filgrastim at doses of 5, 10, or 15 mcg/kg/day for 10 days (n=5/dose) (Study 8). The pharmacokinetics of filgrastim in pediatric patients after chemotherapy are similar to those in adults receiving the same weight-normalized doses, suggesting no age-related differences in the pharmacokinetics of filgrastim. In this population, filgrastim was well tolerated. There was one report of palpable splenomegaly and one report of hepatosplenomegaly associated with filgrastim therapy; however, the only consistently reported adverse event was musculoskeletal pain, which is no different from the experience in the adult population.The safety and effectiveness of ZARXIO have been established in pediatric patients with SCN [see Clinical Studies (14.5)]. In phase study (Study 7) to assess the safety and efficacy of filgrastim in the treatment of SCN, 123 patients with median age of 12 years (range months to 76 years) were studied. Of the 123 patients, 12 were infants (7 months to years of age), 49 were children (2 to 12 years of age), and were adolescents (12 to 16 years of age). Additional information is available from SCN postmarketing surveillance study, which includes long-term follow-up of patients in the clinical studies and information from additional patients who entered directly into the postmarketing surveillance study. Of the 731 patients in the surveillance study, 429 were pediatric patients 18 years of age (range 0.9 to 17) [see Indications and Usage (1.5), Dosage and Administration 2.6 ), and Clinical Studies (14.5)].Long-term follow-up data from the postmarketing surveillance study suggest that height and weight are not adversely affected in patients who received up to years of filgrastim treatment. Limited data from patients who were followed in the phase study for 1.5 years did not suggest alterations in sexual maturation or endocrine function.Pediatric patients with congenital types of neutropenia (Kostmanns syndrome, congenital agranulocytosis, or Schwachman-Diamond syndrome) have developed cytogenetic abnormalities and have undergone transformation to MDS and AML while receiving chronic filgrastim treatment. The relationship of these events to filgrastim product administration is unknown [see Warnings and Precautions (5.8) and Adverse Reactions (6)].The use of ZARXIO to increase survival in pediatric patients acutely exposed to myelosuppressive doses of radiation is based on studies of filgrastim conducted in animals and clinical data supporting the use of filgrastim in other approved indications [see Dosage and Administration (2.1 to 2.4) and Clinical Studies (14.6)].. 8.5 Geriatric Use. Among 855 subjects enrolled in randomized, placebo-controlled trials of filgrastim treated-patients receiving myelosuppressive chemotherapy, there were 232 subjects age 65 or older, and 22 subjects age 75 or older. No overall differences in safety or effectiveness were observed between these subjects and younger subjects. Clinical studies of filgrastim in other approved indications (i.e., BMT recipients, PBPC mobilization, and SCN) did not include sufficient numbers of subjects aged 65 and older to determine whether elderly subjects respond differently from younger subjects.

WARNINGS AND PRECAUTIONS SECTION.

5 WARNINGS AND PRECAUTIONS. oFatal splenic rupture: Evaluate patients who report left upper abdominal or shoulder pain for an enlarged spleen or splenic rupture. (5.1)oAcute respiratory distress syndrome (ARDS): Evaluate patients who develop fever and lung infiltrates or respiratory distress for ARDS. Discontinue ZARXIO in patients with ARDS. (5.2)oSerious allergic reactions, including anaphylaxis: Permanently discontinue ZARXIO in patients with serious allergic reactions. (5.3)oFatal sickle cell crises: Discontinue ZARXIO if sickle cell crisis occurs. (5.4)oGlomerulonephritis: Evaluate and consider dose-reduction or interruption of ZARXIO if causality is likely. (5.5)oMyelodysplastic Syndrome (MDS) and Acute Myeloid Leukemia (AML): Monitor patients with breast and lung cancer using ZARXIO in conjunction with chemotherapy and/or radiotherapy for signs and symptoms of MDS/AML. (5.8)oThrombocytopenia: Monitor platelet counts. (5.9). oFatal splenic rupture: Evaluate patients who report left upper abdominal or shoulder pain for an enlarged spleen or splenic rupture. (5.1). oAcute respiratory distress syndrome (ARDS): Evaluate patients who develop fever and lung infiltrates or respiratory distress for ARDS. Discontinue ZARXIO in patients with ARDS. (5.2). oSerious allergic reactions, including anaphylaxis: Permanently discontinue ZARXIO in patients with serious allergic reactions. (5.3). oFatal sickle cell crises: Discontinue ZARXIO if sickle cell crisis occurs. (5.4). oGlomerulonephritis: Evaluate and consider dose-reduction or interruption of ZARXIO if causality is likely. (5.5). oMyelodysplastic Syndrome (MDS) and Acute Myeloid Leukemia (AML): Monitor patients with breast and lung cancer using ZARXIO in conjunction with chemotherapy and/or radiotherapy for signs and symptoms of MDS/AML. (5.8). oThrombocytopenia: Monitor platelet counts. (5.9). 5.1 Splenic Rupture. Splenic rupture, including fatal cases, has been reported following the administration of filgrastim products. Evaluate patients who report left upper abdominal or shoulder pain for an enlarged spleen or splenic rupture.. 5.2 Acute Respiratory Distress Syndrome. Acute respiratory distress syndrome (ARDS) has been reported in patients receiving filgrastim products. Evaluate patients who develop fever and lung infiltrates or respiratory distress for ARDS. Discontinue ZARXIO in patients with ARDS.. 5.3 Serious Allergic Reactions. Serious allergic reactions, including anaphylaxis, have been reported in patients receiving filgrastim products. The majority of reported events occurred upon initial exposure. Provide symptomatic treatment for allergic reactions. Allergic reactions, including anaphylaxis, in patients receiving filgrastim products can recur within days after the discontinuation of initial anti-allergic treatment. Permanently discontinue ZARXIO in patients with serious allergic reactions. ZARXIO is contraindicated in patients with history of serious allergic reactions to human granulocyte colony-stimulating factors such as filgrastim products or pegfilgrastim products.. 5.4 Sickle Cell Disorders. Severe and sometimes fatal sickle cell crises can occur in patients with sickle cell disorders receiving filgrastim products. Discontinue ZARXIO if sickle cell crisis occurs. 5.5 Glomerulonephritis. Glomerulonephritis has occurred in patients receiving filgrastim products. The diagnoses were based upon azotemia, hematuria (microscopic and macroscopic), proteinuria, and renal biopsy. Generally, events of glomerulonephritis resolved after dose-reduction or discontinuation of filgrastim products. If glomerulonephritis is suspected, evaluate for cause. If causality is likely, consider dose-reduction or interruption of ZARXIO.. 5.6 Alveolar Hemorrhage and Hemoptysis. Alveolar hemorrhage manifesting as pulmonary infiltrates and hemoptysis requiring hospitalization have been reported in healthy donors treated with filgrastim products undergoing peripheral blood progenitor cell (PBPC) collection mobilization. Hemoptysis resolved with discontinuation of filgrastim products. The use of ZARXIO for PBPC mobilization in healthy donors is not an approved indication.. 5.7 Capillary Leak Syndrome. Capillary leak syndrome (CLS) has been reported after G-CSF administration, including filgrastim products, and is characterized by hypotension, hypoalbuminemia, edema and hemoconcentration. Episodes vary in frequency, severity and may be life-threatening if treatment is delayed. Patients who develop symptoms of capillary leak syndrome should be closely monitored and receive standard symptomatic treatment, which may include need for intensive care.. 5.8 Myelodysplastic Syndrome (MDS) and Acute Myeloid Leukemia (AML). Patients with Severe Chronic NeutropeniaConfirm the diagnosis of SCN before initiating ZARXIO therapy. MDS and AML have been reported to occur in the natural history of congenital neutropenia without cytokine therapy. Cytogenetic abnormalities, transformation to MDS, and AML have also been observed in patients treated with filgrastim products for SCN. Based on available data including postmarketing surveillance study, the risk of developing MDS and AML appears to be confined to the subset of patients with congenital neutropenia. Abnormal cytogenetics and MDS have been associated with the eventual development of myeloid leukemia. The effect of filgrastim products on the development of abnormal cytogenetics and the effect of continued filgrastim products administration in patients with abnormal cytogenetics or MDS are unknown. Monitor patients for signs and symptoms of MDS/AML in these settings. If patient with SCN develops abnormal cytogenetics or myelodysplasia, the risks and benefits of continuing ZARXIO should be carefully considered.Patients with Breast and Lung CancerMDS and AML have been associated with the use of filgrastim products in conjunction with chemotherapy and/or radiotherapy in patients with breast and lung cancer. Monitor patients for signs and symptoms of MDS/AML in these settings.. 5.9 Thrombocytopenia. Thrombocytopenia has been reported in patients receiving filgrastim products. Monitor platelet counts.. 5.10 Leukocytosis. Patients with Cancer Receiving Myelosuppressive ChemotherapyWhite blood cell counts of 100,000/mm3 or greater were observed in approximately 2% of patients receiving filgrastim at dosages above mcg/kg/day. In patients with cancer receiving ZARXIO as an adjunct to myelosuppressive chemotherapy, to avoid the potential risks of excessive leukocytosis, it is recommended that ZARXIO therapy be discontinued if the ANC surpasses 10,000/mm3 after the chemotherapy-induced ANC nadir has occurred. Monitor CBCs at least twice weekly during therapy. Dosages of ZARXIO that increase the ANC beyond 10,000/mm3 may not result in any additional clinical benefit. In patients with cancer receiving myelosuppressive chemotherapy, discontinuation of filgrastim therapy usually resulted in 50% decrease in circulating neutrophils within to days, with return to pretreatment levels in to days.Peripheral Blood Progenitor Cell Collection and TherapyDuring the period of administration of ZARXIO for PBPC mobilization in patients with cancer, discontinue ZARXIO if the leukocyte count rises to 100,000/mm3.. 5.11 Cutaneous Vasculitis. Cutaneous vasculitis has been reported in patients treated with filgrastim products. In most cases, the severity of cutaneous vasculitis was moderate or severe. Most of the reports involved patients with SCN receiving long-term filgrastim therapy. Hold ZARXIO therapy in patients with cutaneous vasculitis. ZARXIO may be started at reduced dose when the symptoms resolve and the ANC has decreased.. 5.12 Potential Effect on Malignant Cells. ZARXIO is growth factor that primarily stimulates neutrophils. The granulocyte colony-stimulating factor (G-CSF) receptor through which ZARXIO acts has also been found on tumor cell lines. The possibility that ZARXIO acts as growth factor for any tumor type cannot be excluded. The safety of filgrastim products in chronic myeloid leukemia (CML) and myelodysplasia has not been established.When ZARXIO is used to mobilize PBPC, tumor cells may be released from the marrow and subsequently collected in the leukapheresis product. The effect of reinfusion of tumor cells has not been well studied, and the limited data available are inconclusive.. 5.13 Simultaneous Use with Chemotherapy and Radiation Therapy Not Recommended. The safety and efficacy of ZARXIO given simultaneously with cytotoxic chemotherapy have not been established. Because of the potential sensitivity of rapidly dividing myeloid cells to cytotoxic chemotherapy, do not use ZARXIO in the period 24 hours before through 24 hours after the administration of cytotoxic chemotherapy [see Dosage and Administration (2.2)].The safety and efficacy of ZARXIO have not been evaluated in patients receiving concurrent radiation therapy. Avoid the simultaneous use of ZARXIO with chemotherapy and radiation therapy.. 5.14 Nuclear Imaging. Increased hematopoietic activity of the bone marrow in response to growth factor therapy has been associated with transient positive bone-imaging changes. This should be considered when interpreting bone-imaging results.. 5.15 Aortitis Aortitis has been reported in patients receiving filgrastim products. It may occur as early as the first week after start of therapy. Manifestations may include generalized signs and symptoms such as fever, abdominal pain, malaise, back pain, and increased inflammatory markers (e.g., c-reactive protein and white blood cell count). Consider aortitis in patients who develop these signs and symptoms without known etiology. Discontinue ZARXIO if aortitis is suspected.