CARCINOGENESIS & MUTAGENESIS & IMPAIRMENT OF FERTILITY SECTION.

13.1Carcinogenesis, Mutagenesis, Impairment of Fertility. Long-term animal carcinogenicity studies of pegcetacoplan have not been conducted.Pegcetacoplan was not mutagenic when tested in an in vitro bacterial reverse mutation (Ames) and was not genotoxic in an in vitro assay in human TK6 cells or in an in vivo micronucleus assay in mice.Effects of pegcetacoplan on fertility have not been studied in animals. There were no microscopic abnormalities in male or female reproductive organs in toxicity studies in rabbits and monkeys.

GERIATRIC USE SECTION.

8.5 Geriatric Use. Clinical studies of EMPAVELI did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between geriatric and younger patients.

HOW SUPPLIED SECTION.

16 HOW SUPPLIED/STORAGE AND HANDLING. How SuppliedEMPAVELI injection is clear, colorless to slightly yellowish aqueous solution for subcutaneous infusion supplied as 1,080 mg/20 mL (54 mg/mL) solution in 20-mL single-dose vials.EMPAVELI is available in 20-mL single-dose vials individually packaged in cartons that are supplied in 8-count convenience cartons. NDC 73606-010-01.. Storage and HandlingStore vials of EMPAVELI refrigerated at 2C to 8C (36F to 46F) in the original carton to protect from light. Do not use beyond the expiration date stamped on the carton.

IMMUNOGENICITY.

6.2 Immunogenicity. As with all therapeutic peptides, there is potential for immunogenicity. Immunogenicity data are highly dependent on the sensitivity and specificity of the assay. The available methodology and data on anti-pegcetacoplan antibody formation were not adequate to fully assess the incidence of anti-drug antibodies or their effect on pharmacokinetics, pharmacodynamics, safety, or effectiveness of pegcetacoplan.

INDICATIONS & USAGE SECTION.

1 INDICATIONS AND USAGE. EMPAVELI(TM) is indicated for the treatment of adult patients with paroxysmal nocturnal hemoglobinuria (PNH).. EMPAVELI is complement inhibitor indicated for the treatment of adult patients with paroxysmal nocturnal hemoglobinuria (PNH). (1).

ADVERSE REACTIONS SECTION.

6 ADVERSE REACTIONS. The following clinically significant adverse reactions are discussed in greater detail in other sections of the labeling:Serious Infections Caused by Encapsulated Bacteria [see Warnings and Precautions (5.1)] Infusion-Related Reactions [see Warnings and Precautions (5.3)] Serious Infections Caused by Encapsulated Bacteria [see Warnings and Precautions (5.1)] Infusion-Related Reactions [see Warnings and Precautions (5.3)] Most common adverse reactions in patients with PNH (incidence >=10%) were injection-site reactions, infections, diarrhea, abdominal pain, respiratory tract infection, viral infection, and fatigue. (6.1)To report SUSPECTED ADVERSE REACTIONS, contact Apellis Pharmaceuticals, Inc. at 1-833-866-3346 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.. 6.1 Clinical Trials Experience. Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.. Paroxysmal Nocturnal HemoglobinuriaThe data described below reflect the exposure of EMPAVELI in 80 adult patients with PNH who received EMPAVELI (n=41) or eculizumab (n=39) at the recommended dosing regimens for 16 weeks. Serious adverse events were reported in (17%) patients with PNH receiving EMPAVELI. The most common serious adverse reaction in patients treated with EMPAVELI was infections (5%). The most common adverse reactions (>=10%) with EMPAVELI were injection-site reactions, infections, diarrhea, abdominal pain, respiratory tract infection, viral infection, and fatigue.Table describes the adverse reactions that occurred in >=5% of patients treated with EMPAVELI in Study APL2-302.Table 1: Adverse Reactions Reported in >=5% of Patients Treated with EMPAVELIAdverse ReactionEMPAVELI(N=41)n (%)Eculizumab(N=39)n (%)General disorders and administration site conditionsInjection-site reactionThe following terms were combined: Abdominal pain includes: abdominal pain upper, abdominal discomfort, abdominal pain, abdominal pain lower, abdominal tenderness, epigastric discomfort Back pain includes: back pain, sciatica Chest pain includes: chest discomfort, non-cardiac chest pain, musculoskeletal chest pain, chest pain Fatigue includes: asthenia, lethargy, fatigue Infections include: oral herpes, bacterial infection, fungal infection, gastrointestinal infection, gastrointestinal viral infection, influenza-like illness, nasopharyngitis, pulpitis dental, rhinitis, tonsillitis, tonsillitis bacterial, vulvovaginal mycotic infection, hordeolum, sepsis, furuncle, otitis externa, viral respiratory tract infection, gastroenteritis, upper respiratory tract infection, bronchitis, ear infection, respiratory tract infection, rhinovirus infection, sinusitis, urinary tract infection Injection-site reaction includes: injection-site erythema, injection-site reaction, injection-site swelling, injection-site induration, injection-site bruising, injection-site pain, injection-site pruritus, vaccination-site reaction, administration-site swelling, injection-site hemorrhage, injection-site edema, injection-site warmth, administration-site pain, application-site pain, injection-site mass, injection-site rash, vaccination-site pain Respiratory tract infection includes: influenza-like illness, nasopharyngitis, rhinitis, tonsillitis, viral upper respiratory tract infection, upper respiratory tract infection, respiratory tract infection, sinusitis Systemic hypertension includes: hypertension Viral infection includes: oral herpes, gastrointestinal viral infection, viral upper respiratory tract infection, rhinovirus infection 16 (39)2 (5)Fatigue (12)9 (23)Chest pain (7)1 (3)Infections and infestationsInfections 12 (29)10 (26)Respiratory tract infection (15)5 (13)Viral Infection (12)3 (8)Gastrointestinal disordersDiarrhea9 (22)1 (3)Abdominal pain (20)4 (10)Musculoskeletal disordersBack pain (7)4 (10)Nervous system disordersHeadache3 (7)9 (23)Vascular disordersSystemic hypertension (7)1 (3). Clinically relevant adverse reactions in less than 5% of patients include:Intestinal ischemiaBiliary sepsisHypersensitivity pneumonitis. Intestinal ischemia. Biliary sepsis. Hypersensitivity pneumonitis. Description of Select Adverse Reactions. Injection-Site ReactionsInjection/infusion-site reactions (e.g., erythema, swelling, induration, pruritis, and pain) have been reported during Study APL2-302. These reactions were mild or moderate in severity.. DiarrheaNine cases of diarrhea have been reported during Study APL2-302. All cases were mild.. 6.2 Immunogenicity. As with all therapeutic peptides, there is potential for immunogenicity. Immunogenicity data are highly dependent on the sensitivity and specificity of the assay. The available methodology and data on anti-pegcetacoplan antibody formation were not adequate to fully assess the incidence of anti-drug antibodies or their effect on pharmacokinetics, pharmacodynamics, safety, or effectiveness of pegcetacoplan.

ANIMAL PHARMACOLOGY & OR TOXICOLOGY SECTION.

13.2 Animal Toxicology and/or Pharmacology. In toxicology studies in rabbits and cynomolgus monkeys, epithelial vacuolation and infiltrates of vacuolated macrophages were observed in multiple tissues, including the renal tubules, following daily subcutaneous doses of pegcetacoplan up to times the human dose. These findings are attributable to uptake of the PEG moieties of pegcetacoplan. Renal degeneration was observed microscopically in rabbits at exposures (Cmax and AUC) less than those for the human dose, and in monkeys at exposures approximately 2.7-fold those for the human dose. The clinical significance of these findings is uncertain.

BOXED WARNING SECTION.

WARNING: SERIOUS INFECTIONS CAUSED BY ENCAPSULATED BACTERIA. Meningococcal infections may occur in patients treated with EMPAVELI and may become rapidly life-threatening or fatal if not recognized and treated early. Use of EMPAVELI may predispose individuals to serious infections, especially those caused by encapsulated bacteria, such as Streptococcus pneumoniae, Neisseria meningitidis types A, C, W, Y, and B, and Haemophilus influenzae type [see Warnings and Precautions (5.1)].Comply with the most current Advisory Committee on Immunization Practices (ACIP) recommendations for vaccinations against encapsulated bacteria in patients with altered immunocompetence associated with complement deficiencies.Vaccinate patients against encapsulated bacteria as recommended at least weeks prior to administering the first dose of EMPAVELI unless the risks of delaying therapy with EMPAVELI outweigh the risk of developing serious infection. See Warnings and Precautions (5.1) for additional guidance on the management of the risk of serious infections.Vaccination reduces, but does not eliminate, the risk of serious infections. Monitor patients for early signs of serious infections and evaluate immediately if infection is suspected.EMPAVELI is available only through restricted program under Risk Evaluation and Mitigation Strategy (REMS). Under the EMPAVELI REMS, prescribers must enroll in the program [see Warnings and Precautions (5.2)]. Enrollment in the EMPAVELI REMS program and additional information are available by telephone: 1-888-343-7073 or at www.empavelirems.com.. Comply with the most current Advisory Committee on Immunization Practices (ACIP) recommendations for vaccinations against encapsulated bacteria in patients with altered immunocompetence associated with complement deficiencies.. Vaccinate patients against encapsulated bacteria as recommended at least weeks prior to administering the first dose of EMPAVELI unless the risks of delaying therapy with EMPAVELI outweigh the risk of developing serious infection. See Warnings and Precautions (5.1) for additional guidance on the management of the risk of serious infections.. Vaccination reduces, but does not eliminate, the risk of serious infections. Monitor patients for early signs of serious infections and evaluate immediately if infection is suspected.. WARNING: SERIOUS INFECTIONS CAUSED BY ENCAPSULATED BACTERIASee full prescribing information for complete boxed warning.Meningococcal infections may occur in patients treated with EMPAVELI and may become rapidly life-threatening or fatal if not recognized and treated early. Use of EMPAVELI may predispose individuals to serious infections, especially those caused by encapsulated bacteria, such as Streptococcus pneumoniae, Neisseria meningitidis types A, C, W, Y, and B, and Haemophilus influenzae type B. (5.1)Comply with the most current Advisory Committee on Immunization Practices (ACIP) recommendations for vaccinations against encapsulated bacteria. (5.1)Vaccinate patients against encapsulated bacteria as recommended at least weeks prior to administering the first dose of EMPAVELI unless the risks of delaying EMPAVELI therapy outweigh the risks of developing serious infection. See Warnings and Precautions (5.1) for additional guidance on managing the risk of serious infections.Vaccination reduces, but does not eliminate, the risk of serious infections. Monitor patients for early signs of serious infections and evaluate immediately if infection is suspected. (5.1)EMPAVELI is available only through restricted program under Risk Evaluation and Mitigation Strategy (REMS). Under the EMPAVELI REMS, prescribers must enroll in the program. (5.2). Comply with the most current Advisory Committee on Immunization Practices (ACIP) recommendations for vaccinations against encapsulated bacteria. (5.1). Vaccinate patients against encapsulated bacteria as recommended at least weeks prior to administering the first dose of EMPAVELI unless the risks of delaying EMPAVELI therapy outweigh the risks of developing serious infection. See Warnings and Precautions (5.1) for additional guidance on managing the risk of serious infections.. Vaccination reduces, but does not eliminate, the risk of serious infections. Monitor patients for early signs of serious infections and evaluate immediately if infection is suspected. (5.1).

CLINICAL PHARMACOLOGY SECTION.

12 CLINICAL PHARMACOLOGY. 12.1Mechanism of Action. Pegcetacoplan binds to complement protein C3 and its activation fragment C3b, thereby regulating the cleavage of C3 and the generation of downstream effectors of complement activation. In PNH, extravascular hemolysis (EVH) is facilitated by C3b opsonization while intravascular hemolysis (IVH) is mediated by the downstream membrane attack complex (MAC). Pegcetacoplan acts proximally in the complement cascade controlling both C3b-mediated EVH and terminal complement-mediated IVH.. 12.2 Pharmacodynamics. The mean C3 concentration increased from 0.94 g/L at baseline to 3.83 g/L at Week 16 in patients with PNH administered multiple doses of pegcetacoplan. The baseline percentage of PNH Type II III RBCs was 66.8%, which increased to 93.9% at Week 16. The mean percentage of PNH Type II III RBCs with C3 deposition was 17.7% at baseline and decreased to 0.20% at Week 16.. Cardiac ElectrophysiologyAt the recommended dose of EMPAVELI, no large mean increases in QTc interval (i.e., greater than 20 msec) were observed.. 12.3 Pharmacokinetics. Steady-state serum pegcetacoplan concentrations were achieved approximately to weeks following the first dose and mean (%CV) steady-state trough serum concentrations ranged between 655 (18.6%) to 706 (15.1%) mcg/mL in patients with PNH treated for 16 weeks. Exposure of pegcetacoplan increases proportionally over dosage range from 45 to 1,440 mg (0.04 to 1.33 times the approved recommended dose).. AbsorptionThe median Tmax of pegcetacoplan is between 108 and 144 hours (4.5 to 6.0 days).. DistributionThe mean (%CV) volume of distribution of pegcetacoplan is approximately 3.9 (35%) in patients with PNH.. EliminationThe estimated mean (CV%) of clearance (CL) is 0.37 L/day (28%) and median effective half-life of elimination (t1/2) is 8.0 days in patients with PNH.. MetabolismPegcetacoplan is expected to be metabolized into small peptides and amino acids by catabolic pathways.. Specific PopulationsThere were no clinically significant differences on the pharmacokinetics of pegcetacoplan based on age (19 to 81 years old), sex, race (Asian vs. non-Asian), renal impairment, and hepatic function as evaluated by total bilirubin (0.3-4.3 mg/dL), albumin (3.6-4.9 g/dL), aspartate aminotransferase (13-116 IU/L), or alanine aminotransferase (9-61 IU/L).

CLINICAL STUDIES SECTION.

14 CLINICAL STUDIES. 14.1Paroxysmal Nocturnal Hemoglobinuria. The efficacy and safety of EMPAVELI in patients with PNH were assessed in randomized, open-label, active comparator-controlled, 16-week Phase study (Study APL2-302; NCT03500549). The study enrolled patients with PNH who had been treated with stable dose of eculizumab for at least the previous months and with Hb levels less than 10.5 g/dL.Eligible patients entered 4-week run-in period during which they received EMPAVELI 1,080 mg subcutaneously twice weekly in addition to their current dose of eculizumab. Patients were then randomized in 1:1 ratio to receive either 1,080 mg of EMPAVELI twice weekly or their current dose of eculizumab through the duration of the 16-week randomized controlled period (RCP). If required, the dose of EMPAVELI could be adjusted to 1,080 mg every days. EMPAVELI was administered as subcutaneous infusion; the infusion time was approximately 20 to 40 minutes.Randomization was stratified based on the number of packed red blood cell (PRBC) transfusions within the 12 months prior to Day -28 (<4; >=4) and platelet count at screening (<100,000/mm3; >=100,000/mm3). Following completion of the RCP, all patients entered 32-week open-label period and received monotherapy with EMPAVELI. All patients who completed the 48-week period were eligible to enroll in separate long-term extension study.Patients were vaccinated against Streptococcus pneumoniae, Neisseria meningitidis types A, C, W, Y, and B, and Haemophilus influenzae type (Hib), either within years prior to Day or within weeks after starting treatment with EMPAVELI. Patients vaccinated after initiation of treatment with EMPAVELI received prophylactic treatment with appropriate antibiotics until weeks after vaccination. In addition, prophylactic antibiotic therapy was administered at the discretion of the investigator in accordance with local treatment guidelines for patients with PNH receiving treatment with complement inhibitor.A total of 80 patients were randomized to receive treatment, 41 to EMPAVELI and 39 to eculizumab. Demographics and baseline disease characteristics were generally well balanced between treatment groups (see Table 2). The median times from PNH diagnosis to Day -28 were 6.0 and 9.7 years, respectively, for EMPAVELI and eculizumab. The baseline mean total PNH RBC clone sizes (Type III) were 47% for EMPAVELI and 50% for eculizumab. Twenty-nine percent and 23% of patients had history of major adverse vascular events, and 37% and 26% had history of thrombosis for patients receiving EMPAVELI or eculizumab, respectively. Within 28 days prior to the first dose of EMPAVELI or eculizumab, respectively, 34% and 31% of subjects used anti-thrombotic agents (anti-platelet and/or anticoagulants). During Study APL2-302, 37% and 36% of subjects on EMPAVELI and eculizumab, respectively, used antithrombotic agents. total of 38 patients in the group treated with EMPAVELI and 39 patients in the eculizumab group completed the 16-week RCP and continued into the 32-week open-label period. Because of adverse events of hemolysis, patients were discontinued from the EMPAVELI group during the RCP. Two out of 41 patients in the EMPAVELI group needed the dose adjustment to 1,080 mg every days.Table 2: Patient Baseline Demographics and Characteristics in Study APL2-302ParameterStatisticsEMPAVELI(n=41)Eculizumab(n=39)Age (years)Mean (SD)50.2 (16.3)47.3 (15.8)Sex Femalen (%)27 (65.9)22 (56.4)Race Asiann (%)5 (12.2)7 (17.9) Black or African Americann (%)2 (4.9)0 Whiten (%)24 (58.5)25 (64.1) Othern (%)01 (2.6) Not reportedn (%)10 (24.4)6 (15.4)Ethnicity Hispanic or Latinon (%)2 (4.9)1 (2.6) Not Hispanic or Latinon (%)29 (70.7)32 (82.1) Not reportedn (%)10 (24.4)6 (15.4)Hemoglobin level (g/dL)Mean (SD)8.7 (1.1)8.7 (0.9)Absolute reticulocyte count (109 cells/L)Mean (SD)218 (75.0)216 (69.1)LDH level (U/L)Mean (SD)257.5 (97.7)308.6 (284.8)Number of transfusions in last 12 months prior to Day -28Mean (SD)6.1 (7.3)6.9 (7.7) <4n (%)20 (48.8)16 (41.0) >=4n (%)21 (51.2)23 (59.0)The efficacy of EMPAVELI was based on change from baseline to Week 16 (during RCP) in hemoglobin level. Baseline was defined as the average of measurements recorded prior to taking the first dose of EMPAVELI. Supportive efficacy data included transfusion avoidance, defined as the proportion of patients who did not require transfusion during the RCP, and change from baseline to Week 16 in absolute reticulocyte count (ARC).EMPAVELI was superior to eculizumab for the change from baseline in hemoglobin level at Week 16 (P<0.0001). The adjusted mean change from baseline in hemoglobin level was 2.37 g/dL in the group treated with EMPAVELI versus -1.47 g/dL in the eculizumab group (Figure 1), demonstrating an adjusted mean increase of 3.84 g/dL with EMPAVELI compared to eculizumab at Week 16 (95% CI, 2.33-5.34).Figure 1: Adjusted Mean (+- SE) Change from Baseline to Week 16 in Hemoglobin (g/dL)Treatment effect estimates from mixed model are shown. The mixed model contained the categorical effects of treatment, visit, treatment by visit interaction, and stratification factors (transfusion history and platelet count at screening), and the continuous covariate of baseline value. Non-inferiority was demonstrated in the endpoints of transfusion avoidance and change from baseline in ARC.The adjusted means, treatment differences, and confidence intervals (CIs) for additional efficacy results are shown in Table 3.Table 3: Additional Efficacy ResultsEMPAVELI(n=41)Eculizumab(n=39)Difference(95% CI)Transfusion avoidance, (%)35 (85%)6 (15%)63%Difference in percentages and 95% CI were based on the stratified Miettinen-Nurminen method. (48%, 77%)Change from baseline in ARC (109 cells/L), LSLS Least square mean (SE)SE Standard error -136 (6.5)28 (11.9)-164(-189.9, -137.3)Efficacy was generally similar across subgroups based on sex, race, and age.The results of the controlled trial of EMPAVELI in patients with PNH are supported by uncontrolled studies in patients with PNH who were not receiving complement inhibitor: Study APL2-202 (NCT03593200) and Study APL2-CP-PNH-204 (NCT02588833). These studies enrolled total of 24 patients with PNH who had PNH clone size of at least 10%, an LDH at least times the upper limit of normal, and at least transfusion in the 12 months prior to enrollment. In both studies, the treatment duration was approximately year. Increases in hemoglobin were observed in these trials.. Figure 1.

CLINICAL TRIALS EXPERIENCE SECTION.

6.1 Clinical Trials Experience. Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.. Paroxysmal Nocturnal HemoglobinuriaThe data described below reflect the exposure of EMPAVELI in 80 adult patients with PNH who received EMPAVELI (n=41) or eculizumab (n=39) at the recommended dosing regimens for 16 weeks. Serious adverse events were reported in (17%) patients with PNH receiving EMPAVELI. The most common serious adverse reaction in patients treated with EMPAVELI was infections (5%). The most common adverse reactions (>=10%) with EMPAVELI were injection-site reactions, infections, diarrhea, abdominal pain, respiratory tract infection, viral infection, and fatigue.Table describes the adverse reactions that occurred in >=5% of patients treated with EMPAVELI in Study APL2-302.Table 1: Adverse Reactions Reported in >=5% of Patients Treated with EMPAVELIAdverse ReactionEMPAVELI(N=41)n (%)Eculizumab(N=39)n (%)General disorders and administration site conditionsInjection-site reactionThe following terms were combined: Abdominal pain includes: abdominal pain upper, abdominal discomfort, abdominal pain, abdominal pain lower, abdominal tenderness, epigastric discomfort Back pain includes: back pain, sciatica Chest pain includes: chest discomfort, non-cardiac chest pain, musculoskeletal chest pain, chest pain Fatigue includes: asthenia, lethargy, fatigue Infections include: oral herpes, bacterial infection, fungal infection, gastrointestinal infection, gastrointestinal viral infection, influenza-like illness, nasopharyngitis, pulpitis dental, rhinitis, tonsillitis, tonsillitis bacterial, vulvovaginal mycotic infection, hordeolum, sepsis, furuncle, otitis externa, viral respiratory tract infection, gastroenteritis, upper respiratory tract infection, bronchitis, ear infection, respiratory tract infection, rhinovirus infection, sinusitis, urinary tract infection Injection-site reaction includes: injection-site erythema, injection-site reaction, injection-site swelling, injection-site induration, injection-site bruising, injection-site pain, injection-site pruritus, vaccination-site reaction, administration-site swelling, injection-site hemorrhage, injection-site edema, injection-site warmth, administration-site pain, application-site pain, injection-site mass, injection-site rash, vaccination-site pain Respiratory tract infection includes: influenza-like illness, nasopharyngitis, rhinitis, tonsillitis, viral upper respiratory tract infection, upper respiratory tract infection, respiratory tract infection, sinusitis Systemic hypertension includes: hypertension Viral infection includes: oral herpes, gastrointestinal viral infection, viral upper respiratory tract infection, rhinovirus infection 16 (39)2 (5)Fatigue (12)9 (23)Chest pain (7)1 (3)Infections and infestationsInfections 12 (29)10 (26)Respiratory tract infection (15)5 (13)Viral Infection (12)3 (8)Gastrointestinal disordersDiarrhea9 (22)1 (3)Abdominal pain (20)4 (10)Musculoskeletal disordersBack pain (7)4 (10)Nervous system disordersHeadache3 (7)9 (23)Vascular disordersSystemic hypertension (7)1 (3). Clinically relevant adverse reactions in less than 5% of patients include:Intestinal ischemiaBiliary sepsisHypersensitivity pneumonitis. Intestinal ischemia. Biliary sepsis. Hypersensitivity pneumonitis. Description of Select Adverse Reactions. Injection-Site ReactionsInjection/infusion-site reactions (e.g., erythema, swelling, induration, pruritis, and pain) have been reported during Study APL2-302. These reactions were mild or moderate in severity.. DiarrheaNine cases of diarrhea have been reported during Study APL2-302. All cases were mild.

CONTRAINDICATIONS SECTION.

4 CONTRAINDICATIONS. EMPAVELI is contraindicated in:Patients with hypersensitivity to pegcetacoplan or to any of the excipients.Patients who are not currently vaccinated against certain encapsulated bacteria, unless the risks of delaying EMPAVELI treatment outweigh the risks of developing bacterial infection with an encapsulated organism [see Warnings and Precautions (5.1)].Patients with unresolved serious infection caused by encapsulated bacteria including Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae.. Patients with hypersensitivity to pegcetacoplan or to any of the excipients.. Patients who are not currently vaccinated against certain encapsulated bacteria, unless the risks of delaying EMPAVELI treatment outweigh the risks of developing bacterial infection with an encapsulated organism [see Warnings and Precautions (5.1)].. Patients with unresolved serious infection caused by encapsulated bacteria including Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae.. EMPAVELI is contraindicated in:Patients with hypersensitivity to pegcetacoplan or any of the excipients. (4)Patients who are not currently vaccinated against certain encapsulated bacteria unless the risks of delaying EMPAVELI treatment outweigh the risks of developing serious bacterial infection with an encapsulated organism. (4, 5.1)Patients with unresolved serious infection caused by encapsulated bacteria. (4). Patients with hypersensitivity to pegcetacoplan or any of the excipients. (4). Patients who are not currently vaccinated against certain encapsulated bacteria unless the risks of delaying EMPAVELI treatment outweigh the risks of developing serious bacterial infection with an encapsulated organism. (4, 5.1). Patients with unresolved serious infection caused by encapsulated bacteria. (4).

DESCRIPTION SECTION.

11 DESCRIPTION. EMPAVELI contains pegcetacoplan, complement inhibitor. Pegcetacoplan is symmetrical molecule comprised of two identical pentadecapeptides covalently bound to the ends of linear 40-kiloDalton (kDa) PEG molecule. The peptide portions of pegcetacoplan contain 1-methyl-L-tryptophan (Trp(Me)) in position and amino(ethoxyethoxy)acetic acid (AEEA) in position 14.The molecular weight of pegcetacoplan is approximately 43.5 kDa. The molecular formula is C1970H3848N50O947S4. The structure of pegcetacoplan is shown below.EMPAVELI injection is sterile, clear, colorless to slightly yellowish aqueous solution for subcutaneous use and is supplied in 20-mL single-dose vial. Each mL of solution contains 54 mg of pegcetacoplan, 41 mg of sorbitol, 0.384 mg of glacial acetic acid, 0.490 mg of sodium acetate trihydrate, and Water for Injection USP. EMPAVELI may also contain sodium hydroxide and/or additional glacial acetic acid for adjustment to target pH of 5.0.. Chemical Structure.

DOSAGE & ADMINISTRATION SECTION.

2 DOSAGE AND ADMINISTRATION. Recommended dosage is 1,080 mg by subcutaneous infusion twice weekly via commercially available pump. (2.2)See Full Prescribing Information for instructions on preparation and administration. (2.2, 2.3). Recommended dosage is 1,080 mg by subcutaneous infusion twice weekly via commercially available pump. (2.2). See Full Prescribing Information for instructions on preparation and administration. (2.2, 2.3). 2.1Recommended Vaccination and Prophylaxis. Vaccinate patients against encapsulated bacteria, including Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae type at least weeks prior to initiation of EMPAVELI therapy according to current ACIP guidelines [see Warnings and Precautions (5.1)].Provide weeks of antibacterial drug prophylaxis to patients if EMPAVELI must be initiated immediately and vaccines are administered less than weeks before starting therapy with EMPAVELI.Healthcare professionals who prescribe EMPAVELI must enroll in the REMS for EMPAVELI [see Warnings and Precautions (5.2)].. 2.2Dosage. The recommended dose of EMPAVELI is 1,080 mg by subcutaneous infusion twice weekly via commercially available infusion pump with reservoir of at least 20 mL.. Dosage for patients switching to EMPAVELI from C5 inhibitorsTo reduce the risk of hemolysis with abrupt treatment discontinuation:For patients switching from eculizumab, initiate EMPAVELI while continuing eculizumab at its current dose. After weeks, discontinue eculizumab before continuing on monotherapy with EMPAVELI.For patients switching from ravulizumab, initiate EMPAVELI no more than weeks after the last dose of ravulizumab.. For patients switching from eculizumab, initiate EMPAVELI while continuing eculizumab at its current dose. After weeks, discontinue eculizumab before continuing on monotherapy with EMPAVELI.. For patients switching from ravulizumab, initiate EMPAVELI no more than weeks after the last dose of ravulizumab.. Dose AdjustmentFor lactate dehydrogenase (LDH) levels greater than x the upper limit of normal (ULN), adjust the dosing regimen to 1,080 mg every three days.In the event of dose increase, monitor LDH twice weekly for at least weeks.. For lactate dehydrogenase (LDH) levels greater than x the upper limit of normal (ULN), adjust the dosing regimen to 1,080 mg every three days.. In the event of dose increase, monitor LDH twice weekly for at least weeks.. Missed DoseAdminister EMPAVELI as soon as possible after missed dose. Resume the regular dosing schedule following administration of the missed dose.. Administer EMPAVELI as soon as possible after missed dose. Resume the regular dosing schedule following administration of the missed dose.. 2.3Administration. EMPAVELI is for subcutaneous infusion using an infusion pump.EMPAVELI is intended for use under the guidance of healthcare professional. After proper training in subcutaneous infusion, patient may self-administer, or the patients caregiver may administer EMPAVELI, if healthcare provider determines that it is appropriate.Refer to the EMPAVELI Instructions for Use and the infusion pump manufacturers instructions for full preparation and administration information.Use aseptic technique when preparing and administering EMPAVELI.Prior to use, allow EMPAVELI to reach room temperature for approximately 30 minutes. Keep the vial in the carton until ready for use to protect from light.Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. EMPAVELI is clear, colorless to slightly yellowish solution. Do not use if the liquid looks cloudy, contains particles, or is dark yellow.Use needleless transfer device (such as vial adapter) or transfer needle to fill the syringe.Rotate infusion sites (i.e., abdomen, thighs, hips, upper arms) from one infusion to the next. Do not infuse where the skin is tender, bruised, red, or hard. Avoid infusing into tattoos, scars, or stretch marks.If multi-infusion sets are needed, ensure the infusion sites are at least inches apart.The typical infusion time is approximately 30 minutes (if using two infusion sites) or approximately 60 minutes (if using one infusion site).Discard any unused portion.. Refer to the EMPAVELI Instructions for Use and the infusion pump manufacturers instructions for full preparation and administration information.. Use aseptic technique when preparing and administering EMPAVELI.. Prior to use, allow EMPAVELI to reach room temperature for approximately 30 minutes. Keep the vial in the carton until ready for use to protect from light.. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. EMPAVELI is clear, colorless to slightly yellowish solution. Do not use if the liquid looks cloudy, contains particles, or is dark yellow.. Use needleless transfer device (such as vial adapter) or transfer needle to fill the syringe.. Rotate infusion sites (i.e., abdomen, thighs, hips, upper arms) from one infusion to the next. Do not infuse where the skin is tender, bruised, red, or hard. Avoid infusing into tattoos, scars, or stretch marks.. If multi-infusion sets are needed, ensure the infusion sites are at least inches apart.. The typical infusion time is approximately 30 minutes (if using two infusion sites) or approximately 60 minutes (if using one infusion site).. Discard any unused portion.

DOSAGE FORMS & STRENGTHS SECTION.

3 DOSAGE FORMS AND STRENGTHS. Injection: 1,080 mg/20 mL (54 mg/mL) clear, colorless to slightly yellowish solution in single-dose vial.. Injection: 1,080 mg/20 mL (54 mg/mL) in single-dose vial. (3). Injection: 1,080 mg/20 mL (54 mg/mL) in single-dose vial. (3).

FEMALES & MALES OF REPRODUCTIVE POTENTIAL SECTION.

8.3 Females and Males of Reproductive Potential. Contraception. FemalesEMPAVELI may cause embryo-fetal harm when administered to pregnant women [see Use in Specific Populations (8.1)]. Pregnancy testing is recommended for females of reproductive potential prior to treatment with EMPAVELI. Advise female patients of reproductive potential to use effective contraception during treatment with EMPAVELI and for 40 days after the last dose.

INFORMATION FOR PATIENTS SECTION.

17 PATIENT COUNSELING INFORMATION. Advise the patient to read the FDA-approved patient labeling (Medication Guide and Instructions for Use).. Serious Infections Caused by Encapsulated BacteriaAdvise patients of the risk of serious infection. Inform patients that they are required to receive vaccinations against encapsulated bacteria at least weeks prior to receiving the first dose of EMPAVELI if they have not been previously vaccinated. They are required to be revaccinated according to current medical guidelines for encapsulated bacteria while on EMPAVELI therapy. Inform patients that vaccination may not prevent serious infection and strongly advise patients to seek immediate medical attention if these signs or symptoms occur. These signs and symptoms include the following:fever with or without shivers or the chillsfever and rashshortness of breathextreme pain or discomfortheadache with nausea or vomitinghigh heart rateheadache and feverheadache with stiff neck or stiff backconfusionmuscle aches with flu-like symptomsclammy skineyes sensitive to lightInform patients that they will be given Patient Safety Card for EMPAVELI that they should carry with them at all times. This card describes symptoms which, if experienced, should prompt the patient to seek immediate medical evaluation.. fever with or without shivers or the chills. fever and rash. shortness of breath. extreme pain or discomfort. headache with nausea or vomiting. high heart rate. headache and fever. headache with stiff neck or stiff back. confusion. muscle aches with flu-like symptoms. clammy skin. eyes sensitive to light. Anaphylaxis and infusion-related reactionsAdvise patients of the risk of anaphylaxis and infusion-related reactions. Inform patients that anaphylaxis is life-threatening and strongly advise patients to seek immediate medical attention if these signs or symptoms occur. These signs and symptoms include the following:difficulty breathing including shortness of breath and wheezingswollen tongue or throatfeeling faintrapid heart rateskin reactions, including hives and itchingnausea or vomitingconfusion and anxietydizziness or fainting. difficulty breathing including shortness of breath and wheezing. swollen tongue or throat. feeling faint. rapid heart rate. skin reactions, including hives and itching. nausea or vomiting. confusion and anxiety. dizziness or fainting. DiscontinuationInform patients with PNH that they may develop hemolysis due to PNH when EMPAVELI is discontinued and that they will be monitored by their healthcare professional for at least weeks following discontinuation of EMPAVELI.Inform patients who discontinue EMPAVELI to keep the Patient Safety Card with them for months after the last dose of EMPAVELI, because the increased risk of serious infection persists for several weeks following discontinuation of EMPAVELI.

INSTRUCTIONS FOR USE SECTION.

INSTRUCTIONS FOR USEEMPAVELI(TM) (em-puh-vel-ee)(pegcetacoplan)Injection, for subcutaneous use Important InformationRead this Instructions for Use before you start using EMPAVELI and each time you get refill. There may be new information. This information does not take the place of talking to your healthcare provider about your medical condition or treatment. Your healthcare provider should show you or your caregiver how to infuse EMPAVELI the right way before you use it for the first time. Ask your healthcare provider about any instructions you do not understand.How should store EMPAVELIStore vials of EMPAVELI in the refrigerator between 36F to 46F (2C to 8C) in the original carton to protect from light.Do not use EMPAVELI past the expiration date stamped on the carton.Keep EMPAVELI and all medicines out of the reach of children.Step 1Prepare for infusionBefore you start:Find well-lit, flat work surface area, like table.Remove single vial carton from the refrigerator. Keep the vial in the carton at room temperature and allow it to warm up for about 30 minutes.Do not try to speed up the warming process.Gather your supplies (See Figure A):Infusion pump and manufacturers instructions (not shown)Compatible syringe for your infusion pumpTransfer needle ORNeedleless transfer device to draw up the medicine from the vialInfusion set (not shown; varies according to device manufacturers instructions)Infusion tubingSharps containerAlcohol wipesGauze and tape, or transparent dressing Figure A: SuppliesClean your work surface well using an alcohol wipe.Wash your hands well with soap and water. Dry your hands.Step 2Check the vial and liquidRemove the vial from the carton. Carefully look at the liquid in the vial of EMPAVELI.EMPAVELI is clear, colorless to slightly yellowish liquid. Check for particles or color changes (See Figure B). Do not use the vial if:The liquid looks cloudy, contains particles, or is dark yellow.The protective flip cap is missing or damaged.The expiration date on the label has passed.Figure BStep 3Prepare and fill syringeRemove the protective flip cap from the vial to show the middle part of the gray rubber stopper of the EMPAVELI vial (See Figure C). Throw away the cap.Clean the stopper with new alcohol wipe and allow the stopper to dry.Figure COption 1: If using needleless transfer device (such as vial adapter), follow the instructions provided by the device manufacturer.OR Option 2: If transfer is done using transfer needle and syringe, follow the instructions below:Attach sterile transfer needle to sterile syringe.Pull back the plunger to the 20-mL mark to fill the syringe with air (See Figure D).Push the air-filled syringe with transfer needle attached through the center of the vial stopper.The tip of the transfer needle should not be in the solution to avoid creating bubbles (See Figure E).Gently push the air from the syringe into the vial. This will inject the air from the syringe into the vial. Figure DFigure ETurn the vial upside down and insert the needle in the solution (See Figure F).Figure FWith the transfer needle tip in the solution, slowly pull the plunger to fill the syringe with all the EMPAVELI liquid (See Figure G).Remove the filled syringe and the transfer needle from the vial.Figure GRemove the transfer needle by using one hand to slide the needle into the needle cap and scoop upwards to cover the needle (See Figure H).Figure HOnce the needle is covered, push the needle cap towards the syringe to fully attach it with one hand to prevent an accidental stick with the needle (See Figure I).Figure ITwist off and remove the transfer needle (See Figure J).Figure JStep 4Prepare infusion pump and tubingGather the infusion pump supplies and follow the device manufacturers instructions to prepare the pump and tubing.Step 5Prepare the infusion site(s)Select an area on your abdomen, thighs, hips, or upper arms for the infusion(s) (See Figure K). Avoid the following infusion areas: Do not infuse into areas where the skin is tender, bruised, red, or hard.Avoid infusing into tattoos, scars, or stretch marks. Figure KUse different site(s) from the last time you infused EMPAVELI. If there are multiple infusion sites, they should be at least inches apart. Change (rotate) infusion sites in between each infusion (See Figure L).Figure LClean the skin at each infusion site(s) with new alcohol wipe, starting at the center of each infusion site and working outward in circular motion (See Figure M).Let the skin dry.Figure MStep 6Insert and secure the infusion needle(s)Pinch the skin between your thumb and forefinger around the infusion site (where you plan to insert the needle).Insert the needle into the skin (See Figure N).Figure NSecure the needle(s) using gauze and tape or transparent dressing placed over the infusion site(s) (See Figure O).Figure OStep 7Start infusionFollow the device manufacturers instructions to start the infusion.Start the infusion right away after drawing EMPAVELI into the syringe.EMPAVELI infusion takes about 30 minutes (if using infusion sites) or about 60 minutes (if using infusion site) to complete.Step 8Complete infusionFollow the device manufacturers instructions to complete the infusion.Step 9Record infusionRecord your treatment as directed by your healthcare provider.Step 10Clean upAfter the infusion is complete, remove the dressing and slowly take out the needle(s). Cover the infusion site with new dressing.Remove the infusion set from the pump and throw it away into the sharps container (See Figure P).Clean and store the infusion pump according to the device manufacturers instructions.Step 11Dispose of (throw away) used needles and syringes and EMPAVELI infusion tubing.Put the used needles, syringes, and EMPAVELI infusion tubing in an FDA-cleared sharps disposal container right away after use (See Figure P). Do not throw away the used needles, syringes, and EMPAVELI infusion tubing in your household trash.If you do not have an FDA-cleared sharps disposal container, you may use household container that is:made of heavy-duty plastic,can be closed with tight-fitting, puncture-resistant lid, without sharps being able to come out,upright and stable during use,leak-resistant, andproperly 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 and 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 recycle your used sharps disposal container.Figure PCall 1-866-692-7527 to speak with an Apellis representative.Manufactured For:Apellis Pharmaceuticals, Inc. 100 Fifth Avenue Waltham, MA 02451 Copyright (C) 2021 Apellis Pharmaceuticals, Inc. All rights reserved. EMPAVELI is trademark of Apellis Pharmaceuticals, Inc.This Instructions for Use has been approved by the U.S. Food and Drug Administration.Issued 05/2021EMP-IFU-14May2021-2.0. Store vials of EMPAVELI in the refrigerator between 36F to 46F (2C to 8C) in the original carton to protect from light.. Do not use EMPAVELI past the expiration date stamped on the carton.. Find well-lit, flat work surface area, like table.. Remove single vial carton from the refrigerator. Keep the vial in the carton at room temperature and allow it to warm up for about 30 minutes.. Do not try to speed up the warming process.. Infusion pump and manufacturers instructions (not shown). Compatible syringe for your infusion pump. Transfer needle OR. Needleless transfer device to draw up the medicine from the vial. Infusion set (not shown; varies according to device manufacturers instructions). Infusion tubing. Sharps container. Alcohol wipes. Gauze and tape, or transparent dressing. Remove the vial from the carton. Carefully look at the liquid in the vial of EMPAVELI.EMPAVELI is clear, colorless to slightly yellowish liquid. Check for particles or color changes (See Figure B). EMPAVELI is clear, colorless to slightly yellowish liquid. Check for particles or color changes (See Figure B).. The liquid looks cloudy, contains particles, or is dark yellow.. The protective flip cap is missing or damaged.. The expiration date on the label has passed.. Remove the protective flip cap from the vial to show the middle part of the gray rubber stopper of the EMPAVELI vial (See Figure C). Throw away the cap.. Clean the stopper with new alcohol wipe and allow the stopper to dry.. Attach sterile transfer needle to sterile syringe.. Pull back the plunger to the 20-mL mark to fill the syringe with air (See Figure D).. Push the air-filled syringe with transfer needle attached through the center of the vial stopper.. The tip of the transfer needle should not be in the solution to avoid creating bubbles (See Figure E).. Gently push the air from the syringe into the vial. This will inject the air from the syringe into the vial.. Turn the vial upside down and insert the needle in the solution (See Figure F).. With the transfer needle tip in the solution, slowly pull the plunger to fill the syringe with all the EMPAVELI liquid (See Figure G).. Remove the filled syringe and the transfer needle from the vial.. Remove the transfer needle by using one hand to slide the needle into the needle cap and scoop upwards to cover the needle (See Figure H).. Once the needle is covered, push the needle cap towards the syringe to fully attach it with one hand to prevent an accidental stick with the needle (See Figure I).. Twist off and remove the transfer needle (See Figure J).. Gather the infusion pump supplies and follow the device manufacturers instructions to prepare the pump and tubing.. Select an area on your abdomen, thighs, hips, or upper arms for the infusion(s) (See Figure K). Avoid the following infusion areas: Do not infuse into areas where the skin is tender, bruised, red, or hard.Avoid infusing into tattoos, scars, or stretch marks. Do not infuse into areas where the skin is tender, bruised, red, or hard.. Avoid infusing into tattoos, scars, or stretch marks.. Use different site(s) from the last time you infused EMPAVELI. If there are multiple infusion sites, they should be at least inches apart. Change (rotate) infusion sites in between each infusion (See Figure L).. Clean the skin at each infusion site(s) with new alcohol wipe, starting at the center of each infusion site and working outward in circular motion (See Figure M).. Let the skin dry.. Pinch the skin between your thumb and forefinger around the infusion site (where you plan to insert the needle).. Insert the needle into the skin (See Figure N).. Secure the needle(s) using gauze and tape or transparent dressing placed over the infusion site(s) (See Figure O).. Follow the device manufacturers instructions to start the infusion.. Start the infusion right away after drawing EMPAVELI into the syringe.. EMPAVELI infusion takes about 30 minutes (if using infusion sites) or about 60 minutes (if using infusion site) to complete.. Follow the device manufacturers instructions to complete the infusion.. Record your treatment as directed by your healthcare provider.. After the infusion is complete, remove the dressing and slowly take out the needle(s). Cover the infusion site with new dressing.. Remove the infusion set from the pump and throw it away into the sharps container (See Figure P).. Clean and store the infusion pump according to the device manufacturers instructions.. Put the used needles, syringes, and EMPAVELI infusion tubing in an FDA-cleared sharps disposal container right away after use (See Figure P). Do not throw away the used needles, syringes, and EMPAVELI infusion tubing in your household trash.. If you do not have an FDA-cleared sharps disposal container, you may use household container that is:made of heavy-duty plastic,can be closed with tight-fitting, puncture-resistant lid, without sharps being able to come out,upright and stable during use,leak-resistant, andproperly labeled to warn of hazardous waste inside the container. made of heavy-duty plastic,. can be closed with tight-fitting, puncture-resistant lid, without sharps being able to come out,. upright and stable during use,. leak-resistant, and. properly 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 and 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 recycle your used sharps disposal container.. Figure A. Figure B. Figure C. Figure D. Figure E. Figure F. Figure G. Figure H. Figure I. Figure J. Figure K. Figure L. Figure M. Figure N. Figure O. Figure P.

LACTATION SECTION.

8.2 Lactation. Risk SummaryIt is not known whether pegcetacoplan is secreted in human milk or whether there is potential for absorption and harm to the infant. There are no data on the effects of pegcetacoplan on milk production. Pegcetacoplan is present in milk of lactating monkeys (see Animal Data). Since many medicinal products are secreted into human milk, and because of the potential for serious adverse reaction in breastfeeding child, breastfeeding should be discontinued during treatment and for 40 days after the last dose.. Data. Animal DataPegcetacoplan was detectable in milk of lactating monkeys at less than 1% concentration of serum levels but was not detectable in the serum of nursing infants.

MECHANISM OF ACTION SECTION.

12.1Mechanism of Action. Pegcetacoplan binds to complement protein C3 and its activation fragment C3b, thereby regulating the cleavage of C3 and the generation of downstream effectors of complement activation. In PNH, extravascular hemolysis (EVH) is facilitated by C3b opsonization while intravascular hemolysis (IVH) is mediated by the downstream membrane attack complex (MAC). Pegcetacoplan acts proximally in the complement cascade controlling both C3b-mediated EVH and terminal complement-mediated IVH.

NONCLINICAL TOXICOLOGY SECTION.

13 NONCLINICAL TOXICOLOGY. 13.1Carcinogenesis, Mutagenesis, Impairment of Fertility. Long-term animal carcinogenicity studies of pegcetacoplan have not been conducted.Pegcetacoplan was not mutagenic when tested in an in vitro bacterial reverse mutation (Ames) and was not genotoxic in an in vitro assay in human TK6 cells or in an in vivo micronucleus assay in mice.Effects of pegcetacoplan on fertility have not been studied in animals. There were no microscopic abnormalities in male or female reproductive organs in toxicity studies in rabbits and monkeys.. 13.2 Animal Toxicology and/or Pharmacology. In toxicology studies in rabbits and cynomolgus monkeys, epithelial vacuolation and infiltrates of vacuolated macrophages were observed in multiple tissues, including the renal tubules, following daily subcutaneous doses of pegcetacoplan up to times the human dose. These findings are attributable to uptake of the PEG moieties of pegcetacoplan. Renal degeneration was observed microscopically in rabbits at exposures (Cmax and AUC) less than those for the human dose, and in monkeys at exposures approximately 2.7-fold those for the human dose. The clinical significance of these findings is uncertain.

PACKAGE LABEL.PRINCIPAL DISPLAY PANEL.

PRINCIPAL DISPLAY PANEL 1,080 mg/20 mL Vial Carton. NDC 73606-010-01EMPAVELI(TM)(pegcetacoplan)Injection1,080 mg/20 mL(54 mg/mL)For Subcutaneous Infusion OnlyDispense the enclosed Medication Guide to each patient.One 20 mL Single-Dose Vial. Discard unused portion.Rx onlyApellis. PRINCIPAL DISPLAY PANEL 1,080 mg/20 mL Vial Carton.

PEDIATRIC USE SECTION.

8.4 Pediatric Use. Safety and effectiveness have not been established.

PHARMACODYNAMICS SECTION.

12.2 Pharmacodynamics. The mean C3 concentration increased from 0.94 g/L at baseline to 3.83 g/L at Week 16 in patients with PNH administered multiple doses of pegcetacoplan. The baseline percentage of PNH Type II III RBCs was 66.8%, which increased to 93.9% at Week 16. The mean percentage of PNH Type II III RBCs with C3 deposition was 17.7% at baseline and decreased to 0.20% at Week 16.. Cardiac ElectrophysiologyAt the recommended dose of EMPAVELI, no large mean increases in QTc interval (i.e., greater than 20 msec) were observed.

PHARMACOKINETICS SECTION.

12.3 Pharmacokinetics. Steady-state serum pegcetacoplan concentrations were achieved approximately to weeks following the first dose and mean (%CV) steady-state trough serum concentrations ranged between 655 (18.6%) to 706 (15.1%) mcg/mL in patients with PNH treated for 16 weeks. Exposure of pegcetacoplan increases proportionally over dosage range from 45 to 1,440 mg (0.04 to 1.33 times the approved recommended dose).. AbsorptionThe median Tmax of pegcetacoplan is between 108 and 144 hours (4.5 to 6.0 days).. DistributionThe mean (%CV) volume of distribution of pegcetacoplan is approximately 3.9 (35%) in patients with PNH.. EliminationThe estimated mean (CV%) of clearance (CL) is 0.37 L/day (28%) and median effective half-life of elimination (t1/2) is 8.0 days in patients with PNH.. MetabolismPegcetacoplan is expected to be metabolized into small peptides and amino acids by catabolic pathways.. Specific PopulationsThere were no clinically significant differences on the pharmacokinetics of pegcetacoplan based on age (19 to 81 years old), sex, race (Asian vs. non-Asian), renal impairment, and hepatic function as evaluated by total bilirubin (0.3-4.3 mg/dL), albumin (3.6-4.9 g/dL), aspartate aminotransferase (13-116 IU/L), or alanine aminotransferase (9-61 IU/L).

PREGNANCY SECTION.

8.1 Pregnancy. Risk SummaryThere are insufficient data on EMPAVELI use in pregnant women to inform drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. There are risks to the mother and fetus associated with untreated PNH in pregnancy (see Clinical Considerations). The use of EMPAVELI may be considered following an assessment of the risks and benefits.Treatment of pregnant cynomolgus monkeys with pegcetacoplan at subcutaneous dose of 28 mg/kg/day (2.9 times human exposure based on AUC) from the gestation period through parturition resulted in statistically significant increase in abortions or stillbirths compared to controls (see Data).The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have background risk of major birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriages in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.. Clinical Considerations. Disease-associated maternal and/or fetal/neonatal riskPNH in pregnancy is associated with adverse maternal outcomes, including worsening cytopenias, thrombotic events, infections, bleeding, miscarriages and increased maternal mortality, and adverse fetal outcomes, including fetal death and premature delivery.. Data. Animal DataAnimal reproduction studies with pegcetacoplan were conducted in cynomolgus monkeys. Pegcetacoplan treatment of pregnant cynomolgus monkeys at subcutaneous dose of 28 mg/kg/day (2.9 times human exposure based on AUC) from the gestation period through parturition resulted in statistically significant increase in abortions and stillbirths compared to controls. No increase in abortions or stillbirths occurred at dose of mg/kg/day (1.3 times human exposure based on AUC). No maternal toxicity or teratogenic effects were observed in offspring delivered at term. No developmental effects were observed in infants up to months postpartum. Systemic exposure to pegcetacoplan of less than 1% of maternal levels was detected in fetuses from monkeys treated with 28 mg/kg/day from the period of organogenesis through the second trimester.

SPL MEDGUIDE SECTION.

This Medication Guide has been approved by the U.S. Food and Drug Administration.Issued 05/2021 MEDICATION GUIDEEMPAVELI(TM) (em-puh-vel-ee)(pegcetacoplan) injection, for subcutaneous useWhat is the most important information should know about EMPAVELIEMPAVELI is medicine that can affect your immune system. EMPAVELI can lower the ability of your immune system to fight infections.EMPAVELI may increase your chance of getting serious and life-threatening meningococcal infections. Meningococcal infections may quickly become life-threatening and cause death if not recognized and treated early.EMPAVELI may also increase the risk of getting serious infections. People who take EMPAVELI may have an increased risk of getting infections caused by Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae type B. Serious infections may quickly become life-threatening and cause death if not recognized and treated early.You must be vaccinated against these bacteria at least weeks before your first dose of EMPAVELI if you have not already had these vaccines.If your healthcare provider decides that urgent treatment with EMPAVELI is needed, you should receive the required vaccinations as soon as possible.If you have not been vaccinated and EMPAVELI therapy must be initiated immediately, you should also receive weeks of antibiotics with your vaccinations.If you have been vaccinated against these bacteria in the past, you might need additional vaccinations before starting EMPAVELI. Your healthcare provider will decide if you need additional vaccinations.Vaccines reduce the risk of serious infections, but do not prevent all serious infections. Call your healthcare provider or get emergency medical care right away if you get any of these signs and symptoms of serious infection: fever with or without shivers or the chillsfever and rashshortness of breathextreme pain or discomfortheadache with nausea or vomitinghigh heart rateheadache and feverheadache with stiff neck or stiff backconfusionmuscle aches with flu-like symptomsclammy skineyes sensitive to lightYour healthcare provider will give you Patient Safety Card about the risk of serious infections. Carry it with you at all times during treatment and for months after your last EMPAVELI dose. Your risk of serious infections may continue for several weeks after your last dose of EMPAVELI. It is important to show this card to any healthcare provider who treats you. This will help them diagnose and treat you quickly. EMPAVELI is only available through program called the EMPAVELI REMS. Before you can take EMPAVELI, your healthcare provider must:enroll in the EMPAVELI REMS program.counsel you about the risk of serious infections caused by certain bacteria.give you information about the symptoms of serious infections.give you Patient Safety Card about your risk of serious infections, as discussed above.make sure that you are vaccinated. What is EMPAVELIEMPAVELI is prescription medicine used to treat adults with disease called paroxysmal nocturnal hemoglobinuria (PNH).It is not known if EMPAVELI is safe and effective in children.Do not take EMPAVELI if you:are allergic to pegcetacoplan or any of the ingredients in EMPAVELI. See the end of this Medication Guide for complete list of ingredients in EMPAVELI.have not been vaccinated against Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae type B, unless your healthcare provider decides that urgent treatment with EMPAVELI is needed. See What is the most important information should know about EMPAVELI have serious Streptococcus pneumoniae, Neisseria meningitidis, or Haemophilus influenzae type infection.Before you take EMPAVELI, tell your healthcare provider about all of your medical conditions, including if you:have an infection or fever.are pregnant or plan to become pregnant. EMPAVELI may harm your unborn baby. Females who are able to become pregnant should have pregnancy test before starting treatment with EMPAVELI.Females who are able to become pregnant should use an effective method of birth control (contraception) during treatment with EMPAVELI and for 40 days after the final dose. are breastfeeding or plan to breastfeed. It is not known if EMPAVELI passes into your breast milk. You should not breastfeed during treatment with EMPAVELI and for 40 days after the final dose.Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. EMPAVELI and other medicines can affect each other, causing side effects.Know the medicines you take and the vaccines you receive. Keep list of them to show your healthcare provider and pharmacist when you get new medicine.How should take EMPAVELISee the detailed Instructions for Use that comes with your EMPAVELI for information about how to prepare and infuse your dose of EMPAVELI.Your healthcare provider should show you how to prepare and infuse EMPAVELI before you use it for the first time.Use EMPAVELI exactly as your healthcare provider tells you. Your healthcare provider will tell you how much EMPAVELI to infuse and how often to infuse EMPAVELI. Do not infuse more or less than your healthcare provider tells you to.EMPAVELI is given by infusion under the skin (subcutaneously) into your stomach (abdomen), back of upper arms, hips, or thighs using an infusion pump.EMPAVELI is given by an infusion times each week. If there is an increase in your LDH, an enzyme in your blood, your healthcare provider may tell you to take EMPAVELI every days.If you are changing treatment from eculizumab to EMPAVELI, you should continue eculizumab for weeks after your first dose of EMPAVELI. After weeks, you should stop treatment with eculizumab.If you are changing treatment from ravulizumab to EMPAVELI, you should take your starting dose of EMPAVELI no more than weeks after your last dose of ravulizumab.If you have PNH and you stop taking EMPAVELI, your healthcare provider will need to monitor you closely for at least weeks after stopping EMPAVELI. Stopping treatment with EMPAVELI may cause breakdown of red blood cells due to PNH.Symptoms or problems that can happen due to red blood cell breakdown include:decreased hemoglobin level in your bloodblood in your urineshortness of breathtrouble swallowingtirednesspain in the stomach (abdomen)blood clotserectile dysfunction (ED)If you miss dose of EMPAVELI, take the missed dose as soon as possible. Take your next dose at your regularly scheduled time.What are the possible side effects of EMPAVELIEMPAVELI can cause serious side effects including:See What is the most important information should know about EMPAVELI Allergic reactions. Allergic reactions can happen during your EMPAVELI infusion. Stop your EMPAVELI infusion and tell your healthcare provider or get emergency medical care right away if you get any of these symptoms during your EMPAVELI infusion:chest paintrouble breathing or shortness of breathswelling of your face, tongue, or throatfeel faint or pass out The most common side effects in people with PNH treated with EMPAVELI include injection-site reactions, infections, diarrhea, pain in the stomach (abdomen), respiratory tract infection, viral infection, and tiredness.Tell your healthcare provider about any side effect that bothers you or that does not go away. These are not all of the possible side effects of EMPAVELI. For more information, ask your healthcare provider or pharmacist.Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.How should store EMPAVELIStore vials of EMPAVELI in the refrigerator between 36F to 46F (2C to 8C) in the original carton to protect from light.Do not use EMPAVELI past the expiration date stamped on the carton.Keep EMPAVELI and all medicines out of the reach of children.General information about the safe and effective use of EMPAVELI.Medicines are sometimes prescribed for purposes other than those listed in Medication Guide. Do not use EMPAVELI for condition for which it was not prescribed. Do not give EMPAVELI 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 EMPAVELI that is written for health professionals.What are the ingredients in EMPAVELIActive ingredient: pegcetacoplan Inactive ingredients: sorbitol, glacial acetic acid, sodium acetate trihydrate, Water for Injection USP. EMPAVELI may also contain sodium hydroxide and/or additional glacial acetic acid for pH adjustment. Manufactured for: Apellis Pharmaceuticals, Inc. 100 Fifth Avenue Waltham, MA 02451For patent information: www.apellis.com/productpatentCopyright (C) 2021 Apellis Pharmaceuticals, Inc. All rights reserved.EMPAVELI is trademark of Apellis Pharmaceuticals, Inc.For more information, go to www.EMPAVELI.com or call 1-866-692-7527EMP-MG-14May2021-1.0. EMPAVELI may increase your chance of getting serious and life-threatening meningococcal infections. Meningococcal infections may quickly become life-threatening and cause death if not recognized and treated early.. EMPAVELI may also increase the risk of getting serious infections. People who take EMPAVELI may have an increased risk of getting infections caused by Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae type B. Serious infections may quickly become life-threatening and cause death if not recognized and treated early.You must be vaccinated against these bacteria at least weeks before your first dose of EMPAVELI if you have not already had these vaccines.If your healthcare provider decides that urgent treatment with EMPAVELI is needed, you should receive the required vaccinations as soon as possible.If you have not been vaccinated and EMPAVELI therapy must be initiated immediately, you should also receive weeks of antibiotics with your vaccinations.If you have been vaccinated against these bacteria in the past, you might need additional vaccinations before starting EMPAVELI. Your healthcare provider will decide if you need additional vaccinations.Vaccines reduce the risk of serious infections, but do not prevent all serious infections. Call your healthcare provider or get emergency medical care right away if you get any of these signs and symptoms of serious infection: You must be vaccinated against these bacteria at least weeks before your first dose of EMPAVELI if you have not already had these vaccines.. If your healthcare provider decides that urgent treatment with EMPAVELI is needed, you should receive the required vaccinations as soon as possible.. If you have not been vaccinated and EMPAVELI therapy must be initiated immediately, you should also receive weeks of antibiotics with your vaccinations.. If you have been vaccinated against these bacteria in the past, you might need additional vaccinations before starting EMPAVELI. Your healthcare provider will decide if you need additional vaccinations.. Vaccines reduce the risk of serious infections, but do not prevent all serious infections. Call your healthcare provider or get emergency medical care right away if you get any of these signs and symptoms of serious infection:. fever with or without shivers or the chills. fever and rash. shortness of breath. extreme pain or discomfort. headache with nausea or vomiting. high heart rate. headache and fever. headache with stiff neck or stiff back. confusion. muscle aches with flu-like symptoms. clammy skin. eyes sensitive to light. enroll in the EMPAVELI REMS program.. counsel you about the risk of serious infections caused by certain bacteria.. give you information about the symptoms of serious infections.. give you Patient Safety Card about your risk of serious infections, as discussed above.. make sure that you are vaccinated.. are allergic to pegcetacoplan or any of the ingredients in EMPAVELI. See the end of this Medication Guide for complete list of ingredients in EMPAVELI.. have not been vaccinated against Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae type B, unless your healthcare provider decides that urgent treatment with EMPAVELI is needed. See What is the most important information should know about EMPAVELI have serious Streptococcus pneumoniae, Neisseria meningitidis, or Haemophilus influenzae type infection.. have an infection or fever.. are pregnant or plan to become pregnant. EMPAVELI may harm your unborn baby. Females who are able to become pregnant should have pregnancy test before starting treatment with EMPAVELI.Females who are able to become pregnant should use an effective method of birth control (contraception) during treatment with EMPAVELI and for 40 days after the final dose. Females who are able to become pregnant should use an effective method of birth control (contraception) during treatment with EMPAVELI and for 40 days after the final dose.. are breastfeeding or plan to breastfeed. It is not known if EMPAVELI passes into your breast milk. You should not breastfeed during treatment with EMPAVELI and for 40 days after the final dose.. See the detailed Instructions for Use that comes with your EMPAVELI for information about how to prepare and infuse your dose of EMPAVELI.. Your healthcare provider should show you how to prepare and infuse EMPAVELI before you use it for the first time.. Use EMPAVELI exactly as your healthcare provider tells you. Your healthcare provider will tell you how much EMPAVELI to infuse and how often to infuse EMPAVELI. Do not infuse more or less than your healthcare provider tells you to.. EMPAVELI is given by infusion under the skin (subcutaneously) into your stomach (abdomen), back of upper arms, hips, or thighs using an infusion pump.. EMPAVELI is given by an infusion times each week. If there is an increase in your LDH, an enzyme in your blood, your healthcare provider may tell you to take EMPAVELI every days.. If you are changing treatment from eculizumab to EMPAVELI, you should continue eculizumab for weeks after your first dose of EMPAVELI. After weeks, you should stop treatment with eculizumab.. If you are changing treatment from ravulizumab to EMPAVELI, you should take your starting dose of EMPAVELI no more than weeks after your last dose of ravulizumab.. If you have PNH and you stop taking EMPAVELI, your healthcare provider will need to monitor you closely for at least weeks after stopping EMPAVELI. Stopping treatment with EMPAVELI may cause breakdown of red blood cells due to PNH.Symptoms or problems that can happen due to red blood cell breakdown include:. decreased hemoglobin level in your blood. blood in your urine. shortness of breath. trouble swallowing. tiredness. pain in the stomach (abdomen). blood clots. erectile dysfunction (ED). See What is the most important information should know about EMPAVELI Allergic reactions. Allergic reactions can happen during your EMPAVELI infusion. Stop your EMPAVELI infusion and tell your healthcare provider or get emergency medical care right away if you get any of these symptoms during your EMPAVELI infusion:chest paintrouble breathing or shortness of breathswelling of your face, tongue, or throatfeel faint or pass out chest pain. trouble breathing or shortness of breath. swelling of your face, tongue, or throat. feel faint or pass out. Store vials of EMPAVELI in the refrigerator between 36F to 46F (2C to 8C) in the original carton to protect from light.. Do not use EMPAVELI past the expiration date stamped on the carton.

SPL UNCLASSIFIED SECTION.

2.1Recommended Vaccination and Prophylaxis. Vaccinate patients against encapsulated bacteria, including Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae type at least weeks prior to initiation of EMPAVELI therapy according to current ACIP guidelines [see Warnings and Precautions (5.1)].Provide weeks of antibacterial drug prophylaxis to patients if EMPAVELI must be initiated immediately and vaccines are administered less than weeks before starting therapy with EMPAVELI.Healthcare professionals who prescribe EMPAVELI must enroll in the REMS for EMPAVELI [see Warnings and Precautions (5.2)].

STORAGE AND HANDLING SECTION.

Storage and HandlingStore vials of EMPAVELI refrigerated at 2C to 8C (36F to 46F) in the original carton to protect from light. Do not use beyond the expiration date stamped on the carton.

USE IN SPECIFIC POPULATIONS SECTION.

8 USE IN SPECIFIC POPULATIONS. 8.1 Pregnancy. Risk SummaryThere are insufficient data on EMPAVELI use in pregnant women to inform drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. There are risks to the mother and fetus associated with untreated PNH in pregnancy (see Clinical Considerations). The use of EMPAVELI may be considered following an assessment of the risks and benefits.Treatment of pregnant cynomolgus monkeys with pegcetacoplan at subcutaneous dose of 28 mg/kg/day (2.9 times human exposure based on AUC) from the gestation period through parturition resulted in statistically significant increase in abortions or stillbirths compared to controls (see Data).The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have background risk of major birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriages in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.. Clinical Considerations. Disease-associated maternal and/or fetal/neonatal riskPNH in pregnancy is associated with adverse maternal outcomes, including worsening cytopenias, thrombotic events, infections, bleeding, miscarriages and increased maternal mortality, and adverse fetal outcomes, including fetal death and premature delivery.. Data. Animal DataAnimal reproduction studies with pegcetacoplan were conducted in cynomolgus monkeys. Pegcetacoplan treatment of pregnant cynomolgus monkeys at subcutaneous dose of 28 mg/kg/day (2.9 times human exposure based on AUC) from the gestation period through parturition resulted in statistically significant increase in abortions and stillbirths compared to controls. No increase in abortions or stillbirths occurred at dose of mg/kg/day (1.3 times human exposure based on AUC). No maternal toxicity or teratogenic effects were observed in offspring delivered at term. No developmental effects were observed in infants up to months postpartum. Systemic exposure to pegcetacoplan of less than 1% of maternal levels was detected in fetuses from monkeys treated with 28 mg/kg/day from the period of organogenesis through the second trimester.. 8.2 Lactation. Risk SummaryIt is not known whether pegcetacoplan is secreted in human milk or whether there is potential for absorption and harm to the infant. There are no data on the effects of pegcetacoplan on milk production. Pegcetacoplan is present in milk of lactating monkeys (see Animal Data). Since many medicinal products are secreted into human milk, and because of the potential for serious adverse reaction in breastfeeding child, breastfeeding should be discontinued during treatment and for 40 days after the last dose.. Data. Animal DataPegcetacoplan was detectable in milk of lactating monkeys at less than 1% concentration of serum levels but was not detectable in the serum of nursing infants.. 8.3 Females and Males of Reproductive Potential. Contraception. FemalesEMPAVELI may cause embryo-fetal harm when administered to pregnant women [see Use in Specific Populations (8.1)]. Pregnancy testing is recommended for females of reproductive potential prior to treatment with EMPAVELI. Advise female patients of reproductive potential to use effective contraception during treatment with EMPAVELI and for 40 days after the last dose.. 8.4 Pediatric Use. Safety and effectiveness have not been established.. 8.5 Geriatric Use. Clinical studies of EMPAVELI did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between geriatric and younger patients.

WARNINGS AND PRECAUTIONS SECTION.

5 WARNINGS AND PRECAUTIONS. Use caution when administering EMPAVELI to patients with:Serious infections caused by encapsulated bacteria. (5.1)Infusion-Related Reactions: Monitor patients for infusion-related reactions and institute appropriate medical management as needed. (5.3)Interference with Laboratory Tests: Use of silica reagents in coagulation panels may result in artificially prolonged activated partial thromboplastin time (aPTT). (5.5). Serious infections caused by encapsulated bacteria. (5.1). Infusion-Related Reactions: Monitor patients for infusion-related reactions and institute appropriate medical management as needed. (5.3). Interference with Laboratory Tests: Use of silica reagents in coagulation panels may result in artificially prolonged activated partial thromboplastin time (aPTT). (5.5). 5.1Serious Infections Caused by Encapsulated Bacteria. The use of EMPAVELI may predispose individuals to serious, life-threatening, or fatal infections caused by encapsulated bacteria including Streptococcus pneumoniae, Neisseria meningitidis types A, C, W, Y, and B, and Haemophilus influenzae type (Hib). To reduce the risk of infection, all patients must be vaccinated against these bacteria according to the most current ACIP recommendations for patients with altered immunocompetence associated with complement deficiencies. Revaccinate patients in accordance with ACIP recommendations considering the duration of therapy with EMPAVELI.For patients without known history of vaccination, administer required vaccines at least weeks prior to receiving the first dose of EMPAVELI. If immediate therapy with EMPAVELI is indicated, administer required vaccine as soon as possible and provide patients with weeks of antibacterial drug prophylaxis.Closely monitor patients for early signs and symptoms of serious infection and evaluate patients immediately if an infection is suspected. Promptly treat known infections. Serious infection may become rapidly life-threatening or fatal if not recognized and treated early. Consider discontinuation of EMPAVELI in patients who are undergoing treatment for serious infections.. 5.2EMPAVELI REMS. Because of the risk of serious infections, EMPAVELI is available only through restricted program under REMS. Under the EMPAVELI REMS, prescribers must enroll in the program.Prescribers must counsel patients about the risk of serious infection, provide the patients with the REMS educational materials, and ensure patients are vaccinated against encapsulated bacteria.Enrollment in the EMPAVELI REMS and additional information are available by telephone: 1-888-343-7073 or at www.empavelirems.com.. 5.3Infusion-Related Reactions. Systemic hypersensitivity reactions (e.g., facial swelling, rash, urticaria) have occurred in patients treated with EMPAVELI. One patient (less than 1% in clinical studies) experienced serious allergic reaction which resolved after treatment with antihistamines. If severe hypersensitivity reaction (including anaphylaxis) occurs, discontinue EMPAVELI infusion immediately, institute appropriate treatment, per standard of care, and monitor until signs and symptoms are resolved.. 5.4Monitoring PNH Manifestations after Discontinuation of EMPAVELI. After discontinuing treatment with EMPAVELI, closely monitor for signs and symptoms of hemolysis, identified by elevated LDH levels along with sudden decrease in PNH clone size or hemoglobin, or reappearance of symptoms such as fatigue, hemoglobinuria, abdominal pain, dyspnea, major adverse vascular events (including thrombosis), dysphagia, or erectile dysfunction. Monitor any patient who discontinues EMPAVELI for at least weeks to detect hemolysis and other reactions. If hemolysis, including elevated LDH, occurs after discontinuation of EMPAVELI, consider restarting treatment with EMPAVELI.. 5.5Interference with Laboratory Tests. There may be interference between silica reagents in coagulation panels and EMPAVELI that results in artificially prolonged activated partial thromboplastin time (aPTT); therefore, avoid the use of silica reagents in coagulation panels.