Prescription Drugs

CLINICAL PHARMACOLOGY Mechanism Of Action Expression of programmed cell death ligand-1 (PD-L1) can be induced by inflammatory signals (e.g., IFN-gamma) and can be expressed on both tumor cells and tumor-associated immune cells in the tumor microenvironment. PD-L1 blocks T-cell function and activation through interaction with PD-1 and CD80 (B7.1). By binding to its receptors, PD-L1 reduces cytotoxic T-cell activity, proliferation, and cytokine production. Durvalumab is a human immunoglobulin G1 kappa (IgG1τ) monoclonal antibody that blocks the interaction of PD-L1 with PD-1 and CD80 (B7.1). Blockade of PD-L1/PD-1 and PD-L1/CD80 interactions releases the inhibition of immune responses, without inducing antibody dependent cell-mediated cytotoxicity (ADCC). PD-L1 blockade with durvalumab led to increased T-cell activation in vitro and decreased tumor size in co-engrafted human tumor and immune cell xenograft mouse models. Pharmacodynamics The exposure-response relationships for efficacy and safety are unknown. Cardiac Electrophysiology Durvalumab is unlikely to prolong the QT/QTc interval. Pharmacokinetics The pharmacokinetics of durvalumab was studied in 1324 patients with doses ranging from 0.1 mg/kg (0.01 times the approved recommended dosage) to 20 mg/kg (2 times the approved recommended dosage) administered once every two, three or four weeks. PK exposure increased more than dose-proportionally at doses less than 3 mg/kg (0.3 times the approved recommended dosage) and dose proportionally at doses greater than or equal to 3 mg/kg. Steady state was achieved at approximately 16 weeks. Distribution The geometric mean (% coefficient of variation [CV%]) steady state volume of distribution was 5.6 (17%) L. Elimination Durvalumab clearance decreases over time, with a mean maximal reduction (CV%) from baseline values of approximately 22.9% (46.3%) resulting in a geometric mean (CV%) steady state clearance (CLss) of 8.24 mL/h (37.3%); the decrease in CLss is not considered clinically relevant. The geometric mean (CV%) terminal half-life was approximately 17 (23.2%) days. Specific Populations Age (19-96 years), body weight (34-149 kg), sex, albumin levels, lactate dehydrogenase (LDH) levels, creatinine levels, soluble PD-L1, tumor type, race, mild renal impairment (creatinine clearance (CLcr) 60 to 89 mL/min), moderate renal impairment (CLcr 30 to 59 mL/min), mild hepatic impairment (bilirubin less than or equal to ULN and AST greater than ULN or bilirubin greater than 1.0 to 1.5 times ULN and any AST), or ECOG performance status had no clinically significant effect on the pharmacokinetics of durvalumab. The effect of severe renal impairment (CLcr 15 to 29 mL/min) or moderate hepatic impairment (bilirubin greater than 1.5 to 3.0 times ULN and any AST) or severe hepatic impairment (bilirubin greater than 3.0 times ULN and any AST) on the pharmacokinetics of durvalumab is unknown. Animal Toxicology And/Or Pharmacology In animal models, inhibition of PD-L1/PD-1 signaling increased the severity of some infections and enhanced inflammatory responses. M. tuberculosis-infected PD-1 knockout mice exhibit markedly decreased survival compared with wild-type controls, which correlated with increased bacterial proliferation and inflammatory responses in these animals. PD-L1 and PD-1 knockout mice have also shown decreased survival following infection with lymphocytic choriomeningitis virus. Clinical Studies Urothelial Carcinoma The efficacy of IMFINZI was evaluated in Study 1, the urothelial cancer cohort of a multicenter, multi-cohort, open-label clinical trial. In Study 1, 182 patients with locally advanced or metastatic urothelial carcinoma were enrolled. Patients had progressed while on or after a platinum-based therapy, including those who progressed within 12 months of receiving therapy in a neo-adjuvant or adjuvant setting. These patients had initiated durvalumab therapy at least 13 weeks prior to the data cut-off date. The trial excluded patients with a history of immunodeficiency; medical conditions that required systemic immunosuppression (not to exceed 10 mg/day of prednisone or equivalent); history of severe autoimmune disease; untreated CNS metastases; HIV; active tuberculosis, or hepatitis B or C infection. All patients received IMFINZI 10 mg/kg via intravenous infusion every 2 weeks for up to 12 months or until unacceptable toxicity or disease progression. Tumor assessments were performed at Weeks 6, 12 and 16, then every 8 weeks for the first year and every 12 weeks thereafter. The major efficacy outcome measures were confirmed Objective Response Rate (ORR) according to RECIST v1.1 as assessed by Blinded Independent Central Review (BICR), and duration of response (DoR). In Study 1, the median age was 67 years (range: 34 to 88), 72% were male, 64% were Caucasian. Sixty-six percent (66%) of patients had visceral metastasis (bone, liver, or lung), including 34% with liver metastasis. Lymph node only metastasis were present in 13% of patients. Sixty-six percent (66%) of patients had ECOG score of 1 and 41% of patients had a baseline creatinine clearance of < 60 mL/min. The Bellmunt risk score (which includes ECOG score, baseline hemoglobin, and liver metastases) was 0 in 23%, 1 in 38%, 2 in 29%, and 3 in 9% of patients. Twenty percent (20%) of patients had disease progression following platinum-containing neo-adjuvant or adjuvant chemotherapy as their only prior line of therapy. Seventy percent (70%) of patients received prior cisplatin, 30% prior carboplatin and 35% received ≥ 2 prior lines of systemic therapy. Tumor specimens were evaluated prospectively for PD-L1 expression on tumor cells (TC) and immune cells (IC) at a central laboratory using the VENTANA PD-L1 (SP263) Assay. Of the 182 patients, 95 were classified as PD-L1 high (if ICs involve > 1% of the tumor area, TC ≥ 25% or IC ≥ 25%; if ICs involve ≤ 1% of the tumor area, TC ≥ 25% or IC=100%), 73 as PD-L1 low/negative (did not meet criterion for PD-L1 high), and samples for 14 patients were not evaluable. Table 4 summarizes the results in Study 1. The median follow-up time was 5.6 months. In 37 patients who had received only neoadjuvant or adjuvant therapy prior to study entry, nine patients (24%) responded. Among the total 31 responding patients, 14 patients (45%) had ongoing responses of 6 months or longer and five patients (16%) had ongoing responses of 12 months or longer. Table 4: Efficacy Results for Study 1 All Patients N = 182 PD-L1 High N = 95 PD-L1 Low/Negative N = 73 PD-L1 NE N = 14 Objective Response Rate by BICR n (%) (95% CI) 31 (17.0%) (11.9, 23.3) 25 (26.3%) (17.8, 36.4) 3 (4.1%) (0.9, 11.5) 3 (21.4%) (4.7, 50.8) Complete Response 5 3 1 1 Partial Response 26 22 2 2 Median Duration of Response months (range) NR (0.9+, 19.9+) NR (0.9+, 19.9+) 12.3 (1.9+, 12.3) NR (2.3+, 2.6+) BICR = Blinded Independent Central Review; NE = Not Evaluable; NR = Not Reached, + denotes a censored value

IMFINZI™ (durvalumab) Injection DESCRIPTION Durvalumab is a human immunoglobulin G1 kappa (IgG1τ) monoclonal antibody that blocks the interaction of programmed cell death ligand 1 (PD-L1) with the PD-1 and CD80 (B7.1) molecules. Durvalumab is produced by recombinant DNA technology in Chinese Hamster Ovary (CHO) cell suspension culture. IMFINZI (durvalumab) Injection for intravenous use is a sterile, preservative-free, clear to opalescent, colorless to slightly yellow solution, free from visible particles. Each 500 mg vial of IMFINZI contains 500 mg of durvalumab in 10 mL solution. Each mL contains durvalumab, 50 mg, L-histidine (2 mg), L-histidine hydrochloride monohydrate (2.7 mg), α,α-trehalose dihydrate (104 mg), Polysorbate 80 (0.2 mg), and Water for Injection, USP. Each 120 mg vial of IMFINZI contains 120 mg of durvalumab in 2.4 mL solution. Each mL contains durvalumab, 50 mg, L-histidine (2 mg), L-histidine hydrochloride monohydrate (2.7 mg), α,α-trehalose dihydrate (104 mg), Polysorbate 80 (0.2 mg), and Water for Injection, USP.

INDICATIONS IMFINZI is indicated for the treatment of patients with locally advanced or metastatic urothelial carcinoma who: have disease progression during or following platinum-containing chemotherapy. have disease progression within 12 months of neoadjuvant or adjuvant treatment with platinum-containing chemotherapy. This indication is approved under accelerated approval based on tumor response rate and duration of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials [see Clinical Studies]. DOSAGE AND ADMINISTRATION Recommended Dosing The recommended dose of IMFINZI is 10 mg/kg administered as an intravenous infusion over 60 minutes every 2 weeks until disease progression or unacceptable toxicity. Dose Modifications No dose reductions are recommended. Withhold and/or discontinue IMFINZI to manage adverse reactions as described in Table 1. Table 1: Recommended Treatment Modifications for IMFINZI Adverse Reactions Severitya IMFINZI Treatment Modification Corticosteroid Treatment Unless Otherwise Specified Pneumonitis [see WARNINGS AND PRECAUTIONS] Grade 2 Withhold doseb Initial dose of 1 mg/kg/day to 2 mg/kg/day prednisone or equivalent followed by a taper Grade 3 or 4 Permanently discontinue Initial dose of 1 mg/kg/day to 4 mg/kg/day prednisone or equivalent followed by a taper Hepatitis [see WARNINGS AND PRECAUTIONS] Grade 2 ALT or AST > 3-5xULN or total bilirubin > 1.5-3xULN Withhold doseb Initial dose of 1 mg/kg/day to 2 mg/kg/day prednisone or equivalent followed by a taper Grade 3 ALT or AST ≤ 8xULN or total bilirubin ≤ 5xULN Grade 3 ALT or AST > 8xULN or total bilirubin > 5xULN Permanently discontinue Concurrent ALT or AST > 3xULN and total bilirubin > 2xULN with no other cause Colitis or diarrhea [see WARNINGS AND PRECAUTIONS] Grade 2 Withhold doseb Initial dose of 1 mg/kg/day to 2 mg/kg/day prednisone or equivalent followed by a taper Grade 3 or 4 Permanently discontinue Hypothyroidism [see WARNINGS AND PRECAUTIONS] Grade 2-4 Initiate thyroid hormone replacement as clinically indicated Hyperthyroidism [see WARNINGS AND PRECAUTIONS] Grade 2-4 Withhold dose until clinically stable Symptomatic management Adrenal insufficiency, Hypophysitis/Hypopituitarism [see WARNINGS AND PRECAUTIONS] Grade 2-4 Withhold dose until clinically stable Initiate 1 to 2 mg/kg/day prednisone or equivalent followed by a taper and hormone replacement as clinically indicated Type 1 Diabetes Mellitus [see WARNINGS AND PRECAUTIONS] Grade 2-4 Withhold dose until clinically stable Initiate treatment with insulin as clinically indicated Nephritis [see WARNINGS AND PRECAUTIONS] Grade 2 Creatinine > 1.5-3x ULN Withhold doseb Initial dose of 1 mg/kg/day to 2 mg/kg/day prednisone or equivalent followed by a taper Grade 3 Creatinine > 3-6x Permanently discontinue ULN Grade 4 Creatinine > 6x ULN Rash or dermatitis [see WARNINGS AND PRECAUTIONS] Grade 2 for > 1 week Withhold doseb Consider initial dose of 1 mg/kg/day to 2 mg/kg/day prednisone or equivalent followed by a taper Grade 3 Grade 4 Permanently discontinue Infection [see WARNINGS AND PRECAUTIONS] Grade 3 or 4 Withhold dose Symptomatic management; treat with anti-infectives for suspected or confirmed infections Infusion-related reactions [see WARNINGS AND PRECAUTIONS] Grade 1 or 2 Interrupt or slow the rate of infusion Consider pre-medications with subsequent doses Grade 3 or 4 Permanently discontinue Other Grade 3 Withhold doseb Symptomatic management Grade 4 Permanently discontinue Consider initial dose of 1 mg/kg/day to 4 mg/kg/day prednisone or equivalent followed by taper a Common Terminology Criteria for Adverse Events, version 4.03. ALT: alanine aminotransferase; AST: aspartate aminotransferase; ULN: upper limit of normal. b Based on severity of the adverse reactions, IMFINZI should be withheld and corticosteroids administered. Consider increasing dose of corticosteroids and/or other systemic immunosuppressants if there is worsening or no improvement. Corticosteroid taper should be initiated when adverse reaction improves to < Grade 1 and should be continued over at least 1 month. For adverse reactions that do not result in permanent discontinuation, resume treatment when adverse reaction returns to ≤ Grade 1 and the corticosteroid dose has been reduced to < 10 mg prednisone or equivalent per day. Preparation And Administration Preparation Visually inspect drug product for particulate matter and discoloration. IMFINZI is clear to opalescent, colorless to slightly yellow solution, free from visible particles. Discard the vial if the solution is cloudy, discolored, or visible particles are observed. Do not shake the vial. Withdraw the required volume from the vial(s) of IMFINZI and transfer into an intravenous bag containing 0.9% Sodium Chloride Injection, USP or 5% Dextrose Injection, USP. Mix diluted solution by gentle inversion. Do not shake the solution. The final concentration of the diluted solution should be between 1 mg/mL and 15 mg/mL. Discard partially used or empty vials of IMFINZI. Storage Of Infusion Solution IMFINZI does not contain a preservative. Administer infusion solution immediately once prepared. If infusion solution is not administered immediately and needs to be stored, the total time from vial puncture to the start of the administration should not exceed: 24 hours in a refrigerator at 2°C to 8°C (36°F to 46°F) 4 hours at room temperature up to 25°C (77°F) Do not freeze. Do not shake. Administration Administer infusion solution intravenously over 60 minutes through an intravenous line containing a sterile, low-protein binding 0.2 or 0.22 micron in-line filter. Do not co-administer other drugs through the same infusion line. HOW SUPPLIED Dosage Forms And Strengths Injection: 120 mg/2.4mL (50 mg/mL) and 500 mg/10mL (50 mg/mL) clear to opalescent, colorless to slightly yellow solution in a single-dose vial. Storage And Handling IMFINZI (durvalumab) Injection is a clear to opalescent, colorless to slightly yellow solution supplied in a carton containing one single-dose vial either as: 500 mg/10 mL (NDC 0310-4611-50) 120 mg/2.4 mL (NDC 0310-4500-12) Store in a refrigerator at 2°C to 8°C (36°F to 46°F) in original carton to protect from light. Do not freeze. Do not shake. Manufactured for: AstraZeneca Pharmaceuticals LP, Wilmington, DE 19850 By: AstraZeneca UK Limited 1 Francis Crick Ave. Cambridge, England CB2 0AA US License No. 2043 IMFINZI is a trademark of AstraZeneca group of companies. For more information, call 1-800-236-9933 or go to www.IMFINZI.com. Revised: Apr 2017

PATIENT INFORMATION IMFINZI™ (durvalumab) Injection What is the most important information I should know about IMFINZI? IMFINZI is a medicine that may treat a type of cancer in the bladder and urinary tract by working with your immune system. In some patients IMFINZI can cause the immune system to attack normal organs and tissues and can affect the way they work. These problems can sometimes become serious or life-threatening and can lead to death. Call or see your healthcare provider right away if you develop any symptoms of the following problems or these symptoms get worse: Lung problems (pneumonitis). Signs and symptoms of pneumonitis may include: new or worsening cough shortness of breath chest pain Liver problems (hepatitis). Signs and symptoms of hepatitis may include: yellowing of your skin or the whites of your eyes severe nausea or vomiting pain on the right side of your stomach area (abdomen) drowsiness dark urine (tea colored) bleeding or bruising more easily than normal feeling less hungry than usual Intestinal problems (colitis). Signs and symptoms of colitis may include: diarrhea or more bowel movements than usual stools that are black, tarry, sticky, or have blood or mucus severe stomach area (abdomen) pain or tenderness Hormone gland problems (especially the thyroid, adrenals, pituitary and pancreas). Signs and symptoms that your hormone glands are not working properly may include: headaches that will not go away or unusual headaches extreme tiredness weight gain or weight loss dizziness or fainting feeling more hungry or thirsty than usual hair loss feeling cold constipation your voice gets deeper urinating more often than usual nausea or vomiting stomach area (abdomen) pain changes in mood or behavior, such as decreased sex drive, irritability, or forgetfulness Kidney problems, including nephritis and kidney failure. Signs of kidney problems may include: decrease in the amount of urine blood in your urine swelling in your ankles loss of appetite Skin problems. Signs of these problems may include: rash itching skin blistering Problems in other organs. Signs and symptoms may include: neck stiffness headache confusion fever changes in mood or behavior blurry vision, double vision, or other vision problems eye pain or redness Severe Infections. Signs and symptoms may include: fever cough frequent urination pain when urinating flu-like symptoms Severe infusion reactions. Signs and symptoms of severe infusion reactions may include: chills or shaking itching or rash flushing shortness of breath or wheezing dizziness fever feel like passing out back or neck pain facial swelling Getting medical treatment right away may help keep these problems from becoming more serious. Your healthcare provider will check you for these problems during your treatment with IMFINZI. Your healthcare provider may treat you with corticosteroid or hormone replacement medicines. Your healthcare provider may delay or completely stop treatment with IMFINZI, if you have severe side effects. What is IMFINZI? IMFINZI is a prescription medicine used to treat a type of cancer in the bladder and urinary tract called urothelial carcinoma. IMFINZI may be used when your urothelial carcinoma: has spread or cannot be removed by surgery and, you have tried chemotherapy that contains platinum, and it did not work or is no longer working. It is not known if IMFINZI is safe and effective in children. Before you receive IMFINZI, tell your healthcare provider about all of your medical conditions, including if you: have immune system problems such as Crohn's disease, ulcerative colitis, or lupus have had an organ transplant have lung or breathing problems have liver problems are being treated for an infection are pregnant or plan to become pregnant. IMFINZI can harm your unborn baby. If you are able to become pregnant, you should use an effective method of birth control during your treatment and for at least 3 months after the last dose of IMFINZI. Talk to your healthcare provider about birth control methods that you can use during this time. Tell your healthcare provider right away if you become pregnant during treatment with IMFINZI. are breastfeeding or plan to breastfeed. It is not known if IMFINZI passes into your breast milk. Do not breastfeed during treatment and for at least 3 months after the last dose of IMFINZI. Tell your healthcare provider about all the medicines you take, including prescription and over-thecounter medicines, vitamins, and herbal supplements. How will I receive IMFINZI? Your healthcare provider will give you IMFINZI into your vein through an intravenous (IV) line over 60 minutes. IMFINZI is usually given every 2 weeks. Your healthcare provider will decide how many treatments you need. Your healthcare provider will test your blood to check you for certain side effects. If you miss any appointments, call your healthcare provider as soon as possible to reschedule your appointment. What are the possible side effects of IMFINZI? IMFINZI can cause serious side effects, including: See “What is the most important information I should know about IMFINZI?” The most common side effects of IMFINZI include: feeling tired muscle and/or bone pain constipation decreased appetite nausea swelling urinary tract infection Tell your healthcare provider if you have any side effect that bothers you or that does not go away. These are not all the possible side effects of IMFINZI. Ask your healthcare provider or pharmacist for more information. Call your healthcare provider for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. General information about the safe and effective use of IMFINZI. Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. If you would like more information about IMFINZI, talk with your healthcare provider. You can ask your healthcare provider for information about IMFINZI that is written for health professionals. What are the ingredients in IMFINZI? Active ingredient: durvalumab Inactive ingredients: L-histidine, L-histidine hydrochloride monohydrate, α,α-trehalose dihydrate, polysorbate 80, water for injection, USP.

OVERDOSE There is no information on overdose with IMFINZI. CONTRAINDICATIONS None.

SIDE EFFECTS The following adverse reactions are discussed in greater detail in other sections of the labeling. Immune-Mediated Pneumonitis [see WARNINGS AND PRECAUTIONS]. Immune-Mediated Hepatitis [see WARNINGS AND PRECAUTIONS]. Immune-Mediated Colitis [see WARNINGS AND PRECAUTIONS]. Immune-Mediated Endocrinopathies [see WARNINGS AND PRECAUTIONS]. Other Immune-Mediated Adverse Reactions [see WARNINGS AND PRECAUTIONS]. Infection [see WARNINGS AND PRECAUTIONS]. Infusion-Related Reactions [see WARNINGS AND PRECAUTIONS]. Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety data described in Table 2 reflect exposure to IMFINZI in 182 patients with locally advanced or metastatic urothelial carcinoma in Study 1 whose disease has progressed during or after one standard platinum-based regimen. Patients received 10 mg/kg IMFINZI via intravenous infusion every 2 weeks [see Clinical Studies]. The median duration of exposure was 10.2 weeks (range: 0.14, 52.4). Thirty-one percent (31%) of patients had a drug delay or interruption for an adverse reaction. The most common ( > 2%) were liver injury (4.9%), urinary tract infection (3.3%), acute kidney injury (3.3%), and musculoskeletal pain (2.7%). The most common adverse reactions ( ≥ 15%) were fatigue (39%), musculoskeletal pain (24%), constipation (21%), decreased appetite (19%), nausea (16%), peripheral edema (15%) and urinary tract infection (15%). The most common Grade 3 or 4 adverse reactions ( ≥ 3%) were fatigue, urinary tract infection, musculoskeletal pain, abdominal pain, dehydration, and general physical health deterioration. Eight patients (4.4%) who were treated with IMFINZI experienced Grade 5 adverse events of cardiorespiratory arrest, general physical health deterioration, sepsis, ileus, pneumonitis, or immune- mediated hepatitis. Three additional patients were experiencing infection and disease progression at the time of death. IMFINZI was discontinued for adverse reactions in 3.3% of patients. Serious adverse reactions occurred in 46% of patients. The most frequent serious adverse reactions ( > 2%) were acute kidney injury (4.9%), urinary tract infection (4.4%), musculoskeletal pain (4.4%), liver injury (3.3%), general physical health deterioration (3.3%), sepsis, abdominal pain, pyrexia/tumor associated fever (2.7% each). Immune-mediated adverse reactions requiring systemic corticosteroids or hormone replacement therapy occurred in 8.2% (15/182) patients, including 5.5% (10/182) patients who required systemic corticosteroid therapy and 2.7% (5/182) patients who required only hormone replacement therapy. Seven patients (3.8%) received an oral prednisone dose equivalent to > 40 mg daily for an immune-mediated adverse reaction [see WARNINGS AND PRECAUTIONS]. Table 2 summarizes the adverse reactions that occurred in ≥ 10% of patients, while Table 3 summarizes the Grade 3 -4 selected laboratory abnormalities that occurred in ≥ 1% of patients treated with IMFINZI in Study 1. Table 2: Adverse Reactions in ≥ 10% of Patients in UC Cohort Study 1 Adverse Reaction IMFINZI N=182 All Grades (%) Grades 3 - 4 (%) All Adverse Reactions 96 43 Gastrointestinal Disorders Constipation 21 1 Nausea 16 2 Abdominal pain1 14 3 Diarrhea/Colitis 13 1 General Disorders and Administration Fatigue2 39 6 Peripheral edema3 15 2 Pyrexia/Tumor associated fever 14 1 Infections Urinary tract infection4 15 4 Metabolism and Nutrition Disorders Decreased appetite/Hypophagia 19 1 Musculoskeletal and Connective Tissue Disorders Musculoskeletal pain5 24 4 Respiratory, Thoracic, and MediastinaDisorders Dyspnea/Exertional Dyspnea 13 2 Cough/Productive Cough 10 0 Skin and Subcutaneous Tissue Disorders Rash6 11 1 1 Includes abdominal pain upper, abdominal pain lower and flank pain 2 Includes asthenia, lethargy, and malaise 3 Includes edema, localized edema, edema peripheral, lymphedema, peripheral swelling, scrotal edema, and scrotal swelling 4 Includes cystitis, candiduria and urosepsis 5 Includes back pain, musculoskeletal chest pain, musculoskeletal pain and discomfort, myalgia, and neck pain 6 Includes dermatitis, dermatitis acneiform, dermatitis psoriasiform, psoriasis, rash maculo-papular, rash pruritic,  rash papular, rash pustular, skin toxicity, eczema, erythema, erythema multiforme, rash erythematous, acne, and  lichen planus Table 3: Grade 3-4 Laboratory Abnormalities Worsened from Baseline Occurring in ≥ 1% Patients in UC Cohort Study 1 Laboratory Test Grade 3 - 4 % Hyponatremia 12 Lymphopenia 11 Anemia 8 Increased alkaline phosphatase 4 Hypermagnesemia 4 Hypercalcemia 3 Hyperglycemia 3 Increased AST 2 Increased ALT 1 Hyperbilirubinemia 1 Increased creatinine 1 Neutropenia 1 Hyperkalemia 1 Hypokalemia 1 Hypoalbuminemia 1 Immunogenicity As with all therapeutic proteins, there is a potential for immunogenicity. The detection of antibody formation is highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, comparison of the incidence of antibodies to IMFINZI to the incidence of antibodies to other products may be misleading. Due to the limitations in assay performance, the incidence of antibody development in patients receiving IMFINZI has not been adequately determined. Of 1124 patients who were treated with IMFINZI 10 mg/kg every 2 weeks and evaluable for the presence of anti-drug antibodies (ADAs), 3.3% patients tested positive for treatment-emergent ADAs. The clinical significance of anti-durvalumab antibodies is unknown. DRUG INTERACTIONS No information provided.

WARNINGS Included as part of the PRECAUTIONS section. PRECAUTIONS Immune-Mediated Pneumonitis Immune-mediated pneumonitis or interstitial lung disease occurred in patients receiving IMFINZI. Monitor patients for signs and symptoms of pneumonitis. Evaluate patients with suspected pneumonitis with radiographic imaging and manage with treatment modifications and corticosteroids [see DOSAGE AND ADMINISTRATION]. In Study 1 (n=182), one patient (0.5%) died from immune-mediated pneumonitis. In the combined safety database (n=1414), of patients treated with IMFINZI 10 mg/kg every 2 weeks, immune-mediated pneumonitis occurred in 32 (2.3%) patients including fatal pneumonitis in one (0.1%) patient and Grade 3-4 in six (0.4%) patients. The median time to onset was 55.5 days (range: 24-423 days). Seventeen  (1.2%) patients received high-dose corticosteroid treatment (at least 40 mg prednisone or equivalent per day). IMFINZI was interrupted in 12 patients and discontinued in five (0.4%) patients. Resolution occurred in 18 (1.3%) patients. Immune-Mediated Hepatitis Immune-mediated hepatitis occurred in patients receiving IMFINZI. Monitor patients for abnormal liver tests each cycle during treatment with IMFINZI. Manage immune-mediated hepatitis with treatment modifications and corticosteroids [see DOSAGE AND ADMINISTRATION]. In Study 1, one (0.5%) patient died from immune-mediated hepatitis. An additional two (1.1%) patients experienced immune-mediated hepatitis, including Grade 3 in one (0.5%) patient. In the combined safety database, immune-mediated hepatitis occurred in 16 (1.1%) patients including fatal hepatitis in one ( < 0.1%) patient and Grade 3 in nine (0.6%) patients. The median time to onset was 51.5 days (range: 15-312 days). Twelve (0.8%) of the 16 patients received high-dose corticosteroid treatment. One patient also received mycophenolate treatment. IMFINZI was interrupted in five (0.3%) patients and discontinued in three (0.2%) patients. Resolution occurred in nine (0.6%) patients. In the combined safety database, Grade 3 or 4 elevations in ALT occurred in 40/1342 (3.0%) of patients, AST in 58/1336 (4.3%), and total bilirubin in 37/1341 (2.8%) of patients. Immune-Mediated Colitis Immune-mediated colitis or diarrhea occurred in patients receiving IMFINZI. Monitor patients for signs and symptoms of colitis or diarrhea and manage with treatment modifications, anti-diarrheal agents, and corticosteroids [see DOSAGE AND ADMINISTRATION]. In Study 1, colitis or diarrhea occurred in 23 (12.6%) patients including Grade 3 or 4 diarrhea in two (1.1%) patients. No patients in Study 1 received systemic corticosteroids or immunosuppressants for diarrhea or colitis. In the combined safety database, immune-mediated colitis or diarrhea occurred in 18 (1.3%) patients including Grade 4 in one ( < 0.1%) and Grade 3 in four (0.3%) patients. The median time to onset was 73 days (range: 13-345 days). Of these patients, one ( < 0.1%) had Grade 4 and four (0.3%) had Grade 3 immune-mediated colitis or diarrhea. Ten (0.7%) of the 18 patients received high-dose corticosteroid treatment. Two (0.1%) patients received non-steroidal immunosuppressants. IMFINZI was interrupted in five (0.4%) patients and discontinued in six (0.4%) patients. Resolution occurred in 11 (0.8%) patients. Immune-Mediated Endocrinopathies Immune-related thyroid disorders, adrenal insufficiency, type 1 diabetes mellitus and hypophysitis/hypopituitarism have occurred in patients receiving IMFINZI. Monitor patients for clinical signs and symptoms of endocrinopathies. Thyroid Disorders Monitor thyroid function prior to and periodically during treatment with IMFINZI. Asymptomatic patients with abnormal thyroid function tests can receive IMFINZI. Manage patients with abnormal thyroid function tests with hormone replacement (if indicated) and treatment modifications [see DOSAGE AND ADMINISTRATION]. In the Study 1, hypothyroidism or thyroiditis leading to hypothyroidism occurred in ten (5.5%) patients. All patients had Grade 1-2 hypothyroidism. The median time to first onset was 42 days (range: 15-239). Thyroid stimulating hormone (TSH) was elevated and above the patient's baseline in 25 (15.3%) of 163 patients with a follow-up measurement. In Study 1, hyperthyroidism or thyroiditis leading to hyperthyroidism occurred in nine (4.9%) patients. All patients had Grade 1-2 hyperthyroidism. The median time to first onset was 43 days (range: 14-71). Thyroid stimulating hormone (TSH) was decreased and below the patient's baseline in 26 (16%) of 163 patients with a follow-up measurement. In the combined safety database, hypothyroidism occurred in 136 (9.6%) patients, while hyperthyroidism occurred in 81 (5.7%) patients. Thyroiditis occurred in ten patients, including Grade 3 in one patient who had a myocardial infarction. In nine patients with thyroiditis, transient hyperthyroidism preceded hypothyroidism. Treatment with a beta-blocker and/or thioamide was administered for hyperthyroidism in five of these patients. Adrenal Insufficiency Monitor patients for clinical signs and symptoms of adrenal insufficiency. Administer corticosteroids and hormone replacement as clinically indicated [see DOSAGE AND ADMINISTRATION]. In Study 1, adrenal insufficiency occurred in one (0.5%) patient (Grade 1). In the combined safety database, adrenal insufficiency occurred in 13 (0.9%) patients, including Grade 3 in two (0.1%) patients. Seven (0.5%) of these patients were treated with systemic corticosteroids. Type 1 Diabetes Mellitus Monitor patients for hyperglycemia or other signs and symptoms of diabetes. Initiate insulin for type 1 diabetes mellitus and manage patients with treatment modifications [see DOSAGE AND ADMINISTRATION]. New onset type 1 diabetes mellitus without an alternative etiology occurred in one patient ( < 0.1%) in the combined safety database. Hypophysitis Monitor for signs and symptoms of hypophysitis or hypopituitarism. Administer corticosteroids and hormone replacement as clinically indicated [see DOSAGE AND ADMINISTRATION]. Hypopituitarism leading to adrenal insufficiency and diabetes insipidus occurred in one patient ( < 0.1%) in the combined safety database. Other Immune-Mediated Adverse Reactions IMFINZI has caused immune-mediated rash. Other immune-related adverse reactions, including aseptic meningitis, hemolytic anemia, immune thrombocytopenic purpura, myocarditis, myositis, nephritis, and ocular inflammatory toxicity including uveitis and keratitis, have occurred in ≤ 1.0% of patients treated with IMFINZI. Immune-mediated Rash Monitor for signs and symptoms of rash [see DOSAGE AND ADMINISTRATION]. In Study 1, 20 (11.0%) of patients developed rash including Grade 3 rash in one (0.5%) patient. In the combined safety database, 220 (15.6%) patients developed rash and four (0.3%) patients developed vitiligo. Systemic corticosteroids were administered in 17 (1.2%) patients. The rash resolved in 133 (9.4%) patients. Immune Thrombocytopenic Purpura Monitor patients for signs and symptoms of immune thrombocytopenic purpura [see DOSAGE AND ADMINISTRATION]. In the combined safety database, immune thrombocytopenic purpura led to death in one ( < 0.1%) patient. The patient received high-dose corticosteroids, human immunoglobulin, and rituximab. Nephritis Monitor patients for abnormal renal function tests prior to and each cycle during treatment with IMFINZI and manage with treatment modifications and corticosteroids [see DOSAGE AND ADMINISTRATION]. In Study 1, one patient received systemic corticosteroids for immune-mediated nephritis. In the combined safety database, immune-mediated nephritis occurred in three (0.2%) patients including Grade 3 in two (0.1%) patients. All three patients received high-dose corticosteroids treatment. IMFINZI was discontinued in all three patients. Resolution occurred in all three patients. Infection Severe infections, including sepsis, necrotizing fasciitis, and osteomyelitis, occurred in patients receiving IMFINZI. Monitor patients for signs and symptoms of infection and treat with anti-infectives for suspected or confirmed infections. Withhold IMFINZI for ≥ Grade 3 infection [see DOSAGE AND ADMINISTRATION and ADVERSE REACTIONS]. In Study 1, infections occurred in 54 (29.7%) patients. Grade 3 or 4 infection occurred in eleven (6.0%) patients, while five (2.7%) patients were experiencing infection at the time of death. Urinary tract infections were the most common cause of Grade 3 or higher infection, occurring in eight (4.4%) patients. In the combined safety database, infections occurred in 531 (37.6%) patients. Infusion-Related Reactions Severe infusion-related reactions have been reported in patients receiving IMFINZI. Monitor for signs and symptoms of an infusion-related reaction. Interrupt or slow the rate of infusion in patients with mild or moderate infusion reactions. Permanently discontinue IMFINZI in patients with Grade 3 or 4 infusion reactions [see DOSAGE AND ADMINISTRATION]. Infusion related reactions occurred in three (1.6%) patients in Study 1 and 26 (1.8%) patients in the combined safety database. There were five (0.4%) Grade 3 and no Grade 4 or 5 reactions. Four (0.3%) patients developed urticaria within 48 hours of dosing. Embryo-Fetal Toxicity Based on its mechanism of action and data from animal studies, IMFINZI can cause fetal harm when administered to a pregnant woman. In animal reproduction studies, administration of durvalumab to cynomolgus monkeys from the onset of organogenesis through delivery resulted in increased premature delivery, fetal loss and premature neonatal death. Advise pregnant women of the potential risk to a fetus. Advise females of reproductive potential to use effective contraception during treatment with IMFINZI and for at least 3 months after the last dose of IMFINZI [see Use in Specific Populations]. Patient Counseling Information Advise the patient to read the FDA-approved patient labeling (Medication Guide). Inform patients of the risk of immune-mediated adverse reactions that may require corticosteroid treatment and interruption or discontinuation of IMFINZI, including: Pneumonitis: Advise patients to contact their healthcare provider immediately for any new or worsening cough, chest pain, or shortness of breath [see WARNINGS AND PRECAUTIONS]. Hepatitis: Advise patients to contact their healthcare provider immediately for jaundice, severe nausea or vomiting, pain on the right side of abdomen, lethargy, or easy bruising or bleeding [see WARNINGS AND PRECAUTIONS]. Colitis: Advise patients to contact their healthcare provider immediately for diarrhea, blood or mucus in stools, or severe abdominal pain [see WARNINGS AND PRECAUTIONS]. Endocrinopathies: Advise patients to contact their healthcare provider immediately for signs or symptoms of hypothyroidism, hyperthyroidism, adrenal insufficiency, hypophysitis or type 1 diabetes mellitus [see WARNINGS AND PRECAUTIONS]. Other Immune-Mediated Adverse Reactions: Advise patients to contact their healthcare provider immediately for signs or symptoms of rash, nephritis, aseptic meningitis, thrombocytopenic purpura, myocarditis, hemolytic anemia, myositis, uveitis and keratitis [see WARNINGS AND PRECAUTIONS]. Infection: Advise patients to contact their healthcare provider immediately for infection [see WARNINGS AND PRECAUTIONS]. Infusion-Related Reactions: Advise patients to contact their healthcare provider immediately for signs or symptoms of infusion-related reactions [see WARNINGS AND PRECAUTIONS]. Embryo-Fetal Toxicity: Advise females of reproductive potential that IMFINZI can cause harm to a fetus and to inform their healthcare provider of a known or suspected pregnancy [see WARNINGS AND PRECAUTIONS and Use in Specific Populations]. Advise females of reproductive potential to use effective contraception during treatment and for at least 3 months after the last dose of IMFINZI [see Use in Specific Populations]. Lactation: Advise female patients not to breastfeed while taking IMFINZI and for at least 3 months after the last dose [see WARNINGS AND PRECAUTIONS and Use in Specific Populations]. Nonclinical Toxicology Carcinogenesis, Mutagenesis, Impairment Of Fertility The carcinogenic and genotoxic potential of durvalumab have not been evaluated. Animal fertility studies have not been conducted with durvalumab. In repeat-dose toxicology studies with durvalumab in sexually mature cynomolgus monkeys of up to 3 months duration, there were no notable effects on the male and female reproductive organs. Use In Specific Populations Pregnancy Risk summary Based on its mechanism of action and data from animal studies, IMFINZI can cause fetal harm when administered to a pregnant woman [see CLINICAL PHARMACOLOGY]. There are no data on the use of IMFINZI in pregnant women. In animal reproduction studies, administration of durvalumab to pregnant cynomolgus monkeys from the confirmation of pregnancy through delivery resulted in increased in premature delivery, fetal loss and premature neonatal death (see Data). Human immunoglobulin G1 (IgG1) is known to cross the placental barrier; therefore, durvalumab has the potential to be transmitted from the mother to the developing fetus. Apprise pregnant women of the potential risk to a fetus. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively. Data Animal Data As reported in the literature, the PD-1/PD-L1 pathway plays a central role in preserving pregnancy by maintaining maternal immune tolerance to the fetus. In mouse allogeneic pregnancy models, disruption of PD-L1 signaling was shown to result in an increase in fetal loss. The effects of durvalumab on prenatal and postnatal development were evaluated in reproduction studies in cynomolgus monkeys. Durvalumab was administered from the confirmation of pregnancy through delivery at exposure levels approximately 6 to 20 times higher than those observed at the clinical dose of 10 mg/kg of durvalumab (based on AUC). Administration of durvalumab resulted in premature delivery, fetal loss (abortion and stillbirth) and increase in neonatal deaths. Durvalumab was detected in infant serum on postpartum Day 1, indicating the presence of placental transfer of durvalumab. Based on its mechanism of action, fetal exposure to durvalumab may increase the risk of developing immune-mediated disorders or altering the normal immune response and immune-mediated disorders have been reported in PD-1 knockout mice. Lactation Risk Summary There is no information regarding the presence of durvalumab in human milk, the effects on the breastfed infant, or the effects on milk production. Human IgG1 is excreted in human milk. Durvalumab was present in the milk of lactating cynomolgus monkeys and was associated with premature neonatal death (see Data). Because of the potential for adverse reactions in breastfed infants from durvalumab, advise a lactating woman not to breastfeed during treatment with IMFINZI and for at least 3 months after the last dose. Data In lactating cynomolgus monkeys, durvalumab was present in breast milk at about 0.15% of maternal serum concentrations after administration of durvalumab from the confirmation of pregnancy through delivery at exposure levels approximately 6 to 20 times higher than those observed at the clinical dose of 10 mg/kg of durvalumab (based on AUC). Administration of durvalumab resulted in premature neonatal death. Females And Males Of Reproductive Potential Contraception Females Based on its mechanism of action, IMFINZI can cause fetal harm when administered to a pregnant woman [see Use in Specific Populations]. Advise females of reproductive potential to use effective contraception during treatment with IMFINZI, and for at least 3 months following the last dose of IMFINZI. Pediatric Use The safety and effectiveness of IMFINZI have not been established in pediatric patients. Geriatric Use Of the 182 patients treated with IMFINZI, 112 patients were 65 years or older and 34 patients were 75 years or older. The overall response rate in patients 65 years or older was 15.2% (17/112) and was 11.8% (4/34) in patients 75 years or older. Grade 3 or 4 adverse reactions occurred in 38% (42/112) of patients 65 years or older and 35% (12/34) of patients 75 years or older. Study results in patients > 65 years of age and particularly in those > 75 years of age should be viewed with caution given the small number of patients.