Prescription Drugs

CLINICAL PHARMACOLOGY Virology Ganciclovir is a synthetic nucleoside analogue of 2'-deoxyguanosine that inhibits replication of herpes viruses both in vitro and in vivo. Sensitive human viruses include cytomegalovirus (CMV), herpes simplex virus -1 and -2 (HSV-1, HSV-2), Epstein-Barr virus (EBV) and varicella zoster virus (VZV). Clinical studies have been limited to assessment of efficacy in patients with CMV infection. Median effective inhibitory doses (ED50) of ganciclovir for human CMV isolates tested in vitro in several cell lines ranged from 0.2 to 3.0 µg/mL. The relationship between in vitrosensitivity of CMV to ganciclovir and clinical response has not been established. Ganciclovir inhibits mammalian cell proliferation in vitro at higher concentrations (10 to 60 µg/mL) with bone marrow colony forming cells being the most sensitive (ID50 ≥ 10 µg/mL) of those cell types tested. Emergence of viral resistance has been reported based on in vitro sensitivity testing of CMV isolates from patients receiving intravenous ganciclovir treatment. The prevalence of resistant isolates is unknown, and there is a possibility that some patients may be infected with strains of CMV resistant to ganciclovir. Therefore, the possibility of viral resistance should be considered in patients who show poor clinical response. Pharmacokinetics In a clinical trial of Vitrasert (ganciclovir) Implants, 26 patients (30 eyes) received a total of 39 primary implants and 12 exchange implants (performed 32 weeks after the implant was inserted or earlier if progression of CMV retinitis occurred). Because most of the exchanged implants were empty, the time the implant actually ran out of drug was unknown, and a precise in-vivo release rate could not be calculated. However, approximate in-vivo release rates could be determined for the exchanged implants, which ranged from 1.00 µg/h to more than 1.62 µg/h. In 14 implants (3 exchanged, 11 autopsy) in which the in-vivo release rate could accurately be calculated, the mean release rate was 1.40 µg/h, with a range from 0.5 to 2.88 µg/h. The mean vitreous drug levels in eight eyes (4 collected at the time of retinal detachment surgery; 2 collected from autopsy eyes within 6 hours of death and prior to fixation; 2 collected from implant exchanges) was 4.1 µg/mL.

CLINICAL PHARMACOLOGY Mechanism Of Action Ganciclovir is an antiviral drug with activity against CMV [see Microbiology]. Pharmacokinetics Absorption At the end of a 1-hour intravenous infusion of 5 mg/kg ganciclovir, total AUC ranged between 22.1 ± 3.2 (n=16) and 26.8 ± 6.1 mcg•hr/mL (n=16) and Cmax ranged between 8.27 ± 1.02 (n=16) and 9.0 ± 1.4 mcg/mL (n=16). Distribution The steady-state volume of distribution of ganciclovir after intravenous administration was 0.74 ± 0.15 L/kg (n=98). Ganciclovir diffuses across the placenta. Cerebrospinal fluid concentrations obtained 0.25 to 5.67 hours post-dose in 3 patients who received 2.5 mg/kg ganciclovir intravenously every 8 hours or every 12 hours ranged from 0.31 to 0.68 mcg/mL, representing 24% to 70% of the respective plasma concentrations. Binding to plasma proteins was 1% to 2% over ganciclovir concentrations of 0.5 and 51 mcg/mL. Elimination When administered intravenously, ganciclovir exhibits linear pharmacokinetics over the range of 1.6 to 5.0 mg/kg. Renal excretion of unchanged drug by glomerular filtration and active tubular secretion is the major route of elimination of ganciclovir. In patients with normal renal function, 91.3 ± 5.0% (n=4) of intravenously administered ganciclovir was recovered unmetabolized in the urine. Systemic clearance of intravenously administered ganciclovir was 3.52 ± 0.80 mL/min/kg (n=98) while renal clearance was 3.20 ± 0.80 mL/min/kg (n=47), accounting for 91 ± 11% of the systemic clearance (n=47). Half-life was 3.5 ± 0.9 hours (n=98) following intravenous administration. Specific Populations Pharmacokinetics in Patients with Renal Impairment The pharmacokinetics following intravenous administration of CYTOVENE-IV solution were evaluated in 10 immunocompromised patients with renal impairment who received doses ranging from 1.25 to 5.0 mg/kg. Decreased renal function results in decreased clearance of ganciclovir (Table 7). Table 7: Ganciclovir Pharmacokinetics in Patients with Renal Impairment Estimated Creatinine Clearance (mL/min) n Dose Clearance (mL/min) Mean ± SD Half-life (hours) Mean ± SD 50-79 4 3.2-5 mg/kg 128 + 63 4.6 ± 1.4 25-49 3 3-5 mg/kg 57 + 8 4.4 + 0.4 < 25 3 1.25-5 mg/kg 30 + 13 10.7 + 5.7 Plasma concentrations of ganciclovir are reduced by about 50% during a 4 hour hemodialysis session. Pharmacokinetics in Geriatric Patients The pharmacokinetic profiles of CYTOVENE-IV in patients 65 years of age and older have not been established. As ganciclovir is mainly renally excreted and since renal clearance decreases with age, a decrease in ganciclovir total body clearance and a prolongation of ganciclovir half-life can be anticipated in patients 65 years of age and older [see DOSAGE AND ADMINISTRATION, Use in Specific Populations]. Drug Interaction Studies Tables 8 and 9 provide a listing of established drug interaction studies with ganciclovir. Table 8 provides the effects of coadministered drug on ganciclovir plasma pharmacokinetic parameters, whereas Table 9 provides the effects of ganciclovir on plasma pharmacokinetic parameters of coadministered drug. Table 8: Results of Drug Interaction Studies with Ganciclovir: Effects of Coadministered Drug on Ganciclovir Pharmacokinetic Parameters Coadministered Drug Ganciclovir Dosage N Ganciclovir Pharmacokinetic (PK) Parameter Mycophenolate mofetil (MMF) 1.5 g single dose 5 mg/kg IV single dose 12 No effect on ganciclovir PK parameters observed (patients with normal renal function) Trimethoprim 200 mg once daily 1000 mg orally every 8 hours 12 No effect on ganciclovir PK parameters observed. Didanosine 200 mg every 12 hours simultaneously administered with ganciclovir 5 mg/kg IV twice daily 11 No effect on ganciclovir PK parameters observed 5 mg/kg IV once daily 11 No effect on ganciclovir PK parameters observed Probenecid 500 mg every 6 hours 1000 mg orally every 8 hours 10 AUC ↑ 53 ± 91% (range: -14% to 299%) Ganciclovir renal clearance ↓22 ± 20% (range: -54% to -4%) Table 9: Results of Drug Interaction Studies with Ganciclovir: Effects of Ganciclovir on Pharmacokinetic Parameters of Coadministered Drug Coadministered Drug Ganciclovir Dosage N Coadministered Drug Pharmacokinetic (PK) Parameter Oral cyclosporine at therapeutic doses 5 mg/kg infused over 1 hour every 12 hours 93 In a retrospective analysis of liver allograft recipients, there was no evidence of an effect on cyclosporine whole blood concentrations. Mycophenolate mofetil (MMF) 1.5 g single dose 5 mg/kg IV single dose 12 No PK interaction observed (patients with normal renal function) Trimethoprim 200 mg once daily 1000 mg orally every 8 hours 12 No effect on trimethoprim PK parameters observed. Didanosine 200 mg every 12 hours 5 mg/kg IV twice daily 11 AUC0-12 ↑70 ± 40% (range: 3% to 121%) Cmax↑49 ± 48% (range: -28% to 125%) Didanosine 200 mg every 12 hours 5 mg/kg IV once daily 11 AUC0-12 ↑50 ± 26% (range: 22% to 110%) Cmax ↑36 ± 36% (range: -27% to 94%) Microbiology Mechanism Of Action Ganciclovir is a synthetic analogue of 2'-deoxyguanosine, which inhibits replication of human CMV in cell culture and in vivo. In CMV-infected cells, ganciclovir is initially phosphorylated to ganciclovir monophosphate by the viral protein kinase, pUL97. Further phosphorylation occurs by cellular kinases to produce ganciclovir triphosphate, which is then slowly metabolized intracellularly. As the phosphorylation is largely dependent on the viral kinase, phosphorylation of ganciclovir occurs preferentially in virus-infected cells. The virustatic activity of ganciclovir is due to inhibition of the viral DNA polymerase, pUL54, by ganciclovir triphosphate. Antiviral Activity The quantitative relationship between the cell culture susceptibility of human herpes viruses to antivirals and clinical response to antiviral therapy has not been established, and virus sensitivity testing has not been standardized. Sensitivity test results, expressed as the concentration of drug required to inhibit the growth of virus in cell culture by 50% (EC50), vary greatly depending upon a number of factors including the assay used. Thus the median concentration of ganciclovir that inhibits CMV replication (EC50 value) in cell culture (laboratory strains or clinical isolates) has ranged from 0.08 to 13.6 μM (0.02 to 3.48 mcg/mL). Ganciclovir inhibits mammalian cell proliferation (CC50 value) in cell culture at higher concentrations ranging from 118 to 2840 μM (30 to 725 mcg/mL). Bone marrow-derived colony-forming cells are more sensitive [CC50 value = 0.1 to 2.7 μM (0.028 to 0.7 mcg/mL)]. The relationship between the antiviral activity in cell culture and clinical response has not been established. Viral Resistance Cell Culture: CMV isolates with reduced susceptibility to ganciclovir have been selected in cell culture. Growth of CMV strains in the presence of ganciclovir resulted in the selection of amino acid substitutions in the viral protein kinase pUL97 and the viral DNA polymerase pUL54. In vivo: Viruses resistant to ganciclovir can arise after prolonged treatment or prophylaxis with ganciclovir by selection of substitutions in pUL97 and/or pUL54. Limited clinical data are available on the development of clinical resistance to ganciclovir and many pathways to resistance likely exist. In clinical isolates, seven canonical pUL97 substitutions, (M460V/I, H520Q, C592G, A594V, L595S, C603W) are the most frequently reported ganciclovir resistance-associated substitutions. These and other substitutions less frequently reported in the literature, or observed in clinical trials, are listed in Table 10. Table 10: Summary of Resistance-associated Amino Acid Substitutions Observed in the CMV of Patients Failing Ganciclovir Treatment or Prophylaxis pUL97 L405P, A440V, M460I/V/T/L, V466G/M, C518Y, H520Q, P521L, del 590-593, A591D/V, C592G, A594E/G/T/V/P, L595F/S/T/W, del 595, del 595-603, E596D/G/Y, K599E/M, del 600-601, del 597600, del 601-603, C603W/R/S/Y, C607F/S/Y, I610T, A613V pUL54 E315D, N408D/K/S, F412C/L/S, D413A/E/N, L501F/I, T503I, K513E/N/R, D515E, L516W, I521T, P522A/L/S, V526L, C539G, L545S/W, Q578H/L, D588E/N, G629S, S695T, I726T/V, E756K, L773V, V781I, V787L, L802M, A809V, T813S, T821I, A834P, G841A/S, D879G, A972V, del 981982, A987G Note: Many additional pathways to ganciclovir resistance likely exist CMV resistance to ganciclovir has been observed in individuals with AIDS and CMV retinitis who have never received ganciclovir therapy. Viral resistance has also been observed in patients receiving prolonged treatment for CMV retinitis with CYTOVENE-IV. In a controlled study of oral ganciclovir for prevention of AIDS-associated CMV disease, 364 individuals had one or more cultures performed after at least 90 days of ganciclovir treatment. Of these, 113 had at least one positive culture. The last available isolate from each subject was tested for reduced sensitivity, and 2 of 40 were found to be resistant to ganciclovir. These resistant isolates were associated with subsequent treatment failure for retinitis. The possibility of viral resistance should be considered in patients who show poor clinical response or experience persistent viral excretion during therapy. Cross-Resistance Cross-resistance has been reported for amino acid substitutions selected in cell culture by ganciclovir, cidofovir or foscarnet. In general, amino acid substitutions in pUL54 conferring cross-resistance to ganciclovir and cidofovir are located within the exonuclease domains and region V of the viral DNA polymerase. Whereas, amino acid substitutions conferring cross-resistance to foscarnet are diverse, but concentrate at and between regions II (codons 696-742) and III (codons 805-845). The amino acid substitutions that resulted in reduced susceptibility to ganciclovir and either cidofovir and/or foscarnet are summarized in Table 11. Table 11: Summary of pUL54 Amino Acid Substitutions with Cross-Resistance between Ganciclovir, Cidofovir, and/or Foscarnet Cross-resistant to cidofovir D301N, N408D/K, N410K, F412C/L/S/V, D413E/N, P488R, L501I, T503I, K513E/N, L516R/W, I521T, P522S/A, V526L, C539G/R, L545S/W, Q578H, D588N, I726T/V, E756K, L773V, V812L, T813S, A834P, G841A, del 981-982, A987G Cross-resistant to foscarnet F412C, Q578H/L, D588N, V715A/M, E756K, L773V, V781I, V787L, L802M, A809V, V812L, T813S, T821I, A834P, G841A/S, del 981-982 Clinical Studies Treatment Of CMV Retinitis In a retrospective, non-randomized, single-center analysis of 41 patients with AIDS and CMV retinitis diagnosed by ophthalmologic examination between August 1983 and April 1988, treatment with CYTOVENE-IV solution resulted in a delay in mean (median) time to first retinitis progression compared to untreated controls [105 (71) days from diagnosis vs 35 (29) days from diagnosis]. Patients in this series received induction treatment of CYTOVENE-IV 5 mg/kg twice daily for 14 to 21 days followed by maintenance treatment with either 5 mg/kg once daily, 7 days per week or 6 mg/kg once daily, 5 days per week. In a controlled, randomized study conducted between February 1989 and December 1990, immediate treatment with CYTOVENE-IV was compared to delayed treatment in 42 patients with AIDS and peripheral CMV retinitis; 35 of 42 patients (13 in the immediate-treatment group and 22 in the delayed-treatment group) were included in the analysis of time to retinitis progression. Based on masked assessment of fundus photographs, the mean [95% CI] and median [95% CI] times to progression of retinitis were 66 days [39, 94] and 50 days [40, 84], respectively, in the immediate-treatment group compared to 19 days [11, 27] and 13.5 days [8, 18], respectively, in the delayed-treatment group. Data from trials ICM 1653, ICM 1774, and AVI034, which were performed comparing CYTOVENE-IV to oral ganciclovir for treatment of CMV retinitis in patients with AIDS, are shown in Table 12, and Figures 1, 2, and 3, and are discussed below. Table 12: Population Characteristics in Studies ICM 1653, ICM 1774 and AVI 034 Demographics ICM 1653 (n=121) ICM 1774 (n=225) AVI 034 (n=159) Median age (years) 38 37 39 Range 24-62 22-56 23-62 Sex Males 116 (96%) 222 (99%) 148 (93%) Females 5 (4%) 3 (1%) 10 (6%) Ethnicity Asian 3 (3%) 5 (2%) 7 (4%) Black 11 (9%) 9 (4%) 3 (2%) Caucasian 98 (81%) 186 (83%) 140 (88%) Other 9 (7%) 25 (11%) 8 (5%) Median CD4 Count Range 9.5 7.0 10.0 0-141 0-80 0-320 Mean (SD) Observation Time (days) 107.9 (43.0) 97.6 (42.5) 80.9 (47.0) Trial ICM 1653: In this randomized, open-label, parallel group trial, conducted between March 1991 and November 1992, patients with AIDS and newly diagnosed CMV retinitis received a 3-week induction course of CYTOVENE-IV solution, 5 mg/kg twice daily for 14 days followed by 5 mg/kg once daily for 1 additional week. Following the 21-day intravenous induction course, patients with stable CMV retinitis were randomized to receive 20 weeks of maintenance treatment with either CYTOVENE-IV solution, 5 mg/kg once daily, or ganciclovir capsules, 500 mg 6 times daily (3000 mg/day). The study showed that the mean [95% CI] and median [95% CI] times to progression of CMV retinitis, as assessed by masked reading of fundus photographs, were 57 days [44, 70] and 29 days [28, 43], respectively, for patients on oral therapy compared to 62 days [50, 73] and 49 days [29, 61], respectively, for patients on intravenous therapy. The difference [95% CI] in the mean time to progression between the oral and intravenous therapies (oral -IV) was -5 days [-22, 12]. See Figure 1 for comparison of the proportion of patients remaining free of progression over time. Trial ICM 1774: In this three-arm, randomized, open-label, parallel group trial, conducted between June 1991 and August 1993, patients with AIDS and stable CMV retinitis following from 4 weeks to 4 months of treatment with CYTOVENE-IV solution were randomized to receive maintenance treatment with CYTOVENE-IV solution, 5 mg/kg once daily, ganciclovir capsules, 500 mg 6 times daily, or ganciclovir capsules, 1000 mg three times daily for 20 weeks. The study showed that the mean [95% CI] and median [95% CI] times to progression of CMV retinitis, as assessed by masked reading of fundus photographs, were 54 days [48, 60] and 42 days [31, 54], respectively, for patients on oral therapy compared to 66 days [56, 76] and 54 days [41, 69], respectively, for patients on intravenous therapy. The difference [95% CI] in the mean time to progression between the oral and intravenous therapies (oral -IV) was -12 days [24, 0]. See Figure 2 for comparison of the proportion of patients remaining free of progression over time. Trial AVI 034: In this randomized, open-label, parallel group trial, conducted between June 1991 and February 1993, patients with AIDS and newly diagnosed (81%) or previously treated (19%) CMV retinitis who had tolerated 10 to 21 days of induction treatment with CYTOVENE-IV, 5 mg/kg twice daily, were randomized to receive 20 weeks of maintenance treatment with either ganciclovir capsules, 500 mg 6 times daily or CYTOVENE-IV solution, 5 mg/kg/day. The mean [95% CI] and median [95% CI] times to progression of CMV retinitis, as assessed by masked reading of fundus photographs, were 51 days [44, 57] and 41 days [31, 45], respectively, for patients on oral therapy compared to 62 days [52, 72] and 60 days [42, 83], respectively, for patients on intravenous therapy. The difference [95% CI] in the mean time to progression between the oral and intravenous therapies (oral -IV) was -11 days [-24, 1]. See Figure 3 for comparison of the proportion of patients remaining free of progression over time. Comparison of other CMV retinitis outcomes between oral and IV formulations (development of bilateral retinitis, progression into Zone 1, and deterioration of visual acuity), while not definitive, showed no marked differences between treatment groups in these studies. Because of low event rates among these endpoints, these studies are underpowered to rule out significant differences in these endpoints. Figure 1 : Trial ICM 1653: Time to Progression of CMV Retinitis Figure 2 : Trial ICM 1774: Time to Progression of CMV Retinitis Figure 3 : Trial AVI 034: Time to Progression of Retinitis Prevention Of CMV Disease In Transplant Recipients CYTOVENE-IV was evaluated in three randomized, controlled trials of prevention of CMV disease in organ transplant recipients. Trial ICM 1496: In a randomized, double-blind, placebo-controlled study of 149 heart transplant recipients at risk for CMV infection (CMV seropositive or a seronegative recipient of an organ from a CMV seropositive donor), there was a reduction in the overall incidence of CMV disease in patients treated with CYTOVENE-IV. Immediately post-transplant, patients received CYTOVENE-IV solution 5 mg/kg twice daily for 14 days followed by 6 mg/kg once daily for 5 days/week for an additional 14 days. Twelve of the 76 (16%) patients treated with CYTOVENE-IV vs 31 of the 73 (43%) placebo-treated patients developed CMV disease during the 120-day post-transplant observation period. No significant differences in hematologic toxicities were seen between the two treatment groups [see ADVERSE REACTIONS]. Trial ICM 1689: In a randomized, double-blind, placebo-controlled study of 72 bone marrow transplant recipients with asymptomatic CMV infection (CMV positive culture of urine, throat or blood) there was a reduction in the incidence of CMV disease in patients treated with CYTOVENE-IV following successful hematopoietic engraftment. Patients with virologic evidence of CMV infection received CYTOVENE-IV solution 5 mg/kg twice daily for 7 days followed by 5 mg/kg once daily through day 100 post-transplant. One of the 37 (3%) patients treated with CYTOVENE-IV vs 15 of the 35 (43%) placebo-treated patients developed CMV disease during the study. At 6 months post-transplant, there continued to be a reduction in the incidence of CMV disease in patients treated with CYTOVENE-IV. Six of 37 (16%) patients treated with CYTOVENE-IV vs 15 of the 35 (43%) placebo-treated patients developed disease through 6 months post-transplant. The overall rate of survival was higher in the group treated with CYTOVENE-IV, both at day 100 and day 180 post-transplant. Although the differences in hematologic toxicities were not statistically significant, the incidence of neutropenia was higher in the group treated with CYTOVENE-IV [see ADVERSE REACTIONS]. Trial ICM 1570: This was a randomized, unblinded study evaluated 40 allogeneic bone marrow transplant recipients at risk for CMV disease. Patients underwent bronchoscopy and bronchoalveolar lavage (BAL) on day 35 post-transplant. Patients with histologic, immunologic or virologic evidence of CMV infection in the lung were then randomized to observation or treatment with CYTOVENE-IV solution (5 mg/kg twice daily for 14 days followed by 5 mg/kg once daily 5 days/week until day 120). Four of 20 (20%) patients treated with CYTOVENE-IV and 14 of 20 (70%) control patients developed interstitial pneumonia. The incidence of CMV disease was lower in the group treated with CYTOVENE-IV, consistent with the results observed in ICM 1689.

VITRASERT® (ganciclovir) STERILE INTRAVITREAL IMPLANT WITH CYTOVENE® (ganciclovir, 4.5 mg) FOR INTRAVITREAL IMPLANTATION ONLY DESCRIPTION The Vitrasert Implant contains the antiviral drug ganciclovir. Each Vitrasert Implant contains a minimum of 4.5 mg ganciclovir. Each Vitrasert Implant contains a ganciclovir tablet which contains the inactive ingredient, magnesium stearate (0.25%). Each tablet is coated with polyvinyl alcohol and ethylene vinyl acetate polymers. The chemical name of ganciclovir is 9-[[2-hydroxy-1-(hydroxymethyl)ethoxy]methyl]guanine, and has the following structure: Ganciclovir is a white to off-white crystalline powder with a molecular formula of C9H13N5O4, and molecular weight of 255.23. Ganciclovir has a solubility of 4.3 mg/mL in water at 25°C.

Find Lowest Prices on CYTOVENE-IV (ganciclovir sodium) for Injection WARNING HEMATOLOGIC TOXICITY, IMPAIRMENT OF FERTILITY, FETAL TOXICITY, MUTAGENESIS AND CARCINOGENESIS Hematologic Toxicity: Granulocytopenia, anemia, thrombocytopenia, and pancytopenia have been reported in patients treated with CYTOVENE-IV [see WARNINGS AND PRECAUTIONS]. Impairment of Fertility: Based on animal data, CYTOVENE-IV may cause temporary or permanent inhibition of spermatogenesis in males and suppression of fertility in females [see WARNINGS AND PRECAUTIONS]. Fetal Toxicity: Based on animal data, CYTOVENE-IV has the potential to cause birth defects in humans [see WARNINGS AND PRECAUTIONS]. Mutagenesis and Carcinogenesis: Based on animal data, CYTOVENE-IV has the potential to cause cancers in humans [see WARNINGS AND PRECAUTIONS]. DESCRIPTION CYTOVENE-IV contains ganciclovir, in the form of the sodium salt for intravenous injection. Ganciclovir is a synthetic guanine derivative active against cytomegalovirus (CMV). Chemically, ganciclovir is 9-[[2-hydroxy-1-(hydroxymethyl)-ethoxy]methyl]guanine and ganciclovir sodium is 9-[[2hydroxy-1-(hydroxymethyl)-ethoxy]methyl]guanine, monosodium salt. The chemical structures of ganciclovir sodium and ganciclovir are: Ganciclovir is a white to off-white crystalline powder. Ganciclovir is a polar hydrophilic compound with a solubility of 2.6 mg/mL in water at 25°C and an n-octanol/water partition coefficient of 0.022. The pKas for ganciclovir are 2.2 and 9.4. CYTOVENE-IV (ganciclovir), formulated as monosodium salt, using sodium hydroxide as a salt forming agent, is a sterile white to off-white lyophilized powder. The lyophilized powder has an aqueous solubility of greater than 50 mg/mL at 25°C. At physiological pH, ganciclovir sodium exists as the un-ionized form with a solubility of approximately 6 mg/mL at 37°C. Each vial contains ganciclovir sodium equivalent to 500 mg ganciclovir. Inactive ingredients may include hydrochloric acid (QS) and sodium hydroxide (QS) added to adjust the pH. All doses in this package insert are specified in terms of ganciclovir.

INDICATIONS The Vitrasert (ganciclovir) Implant is indicated for the treatment of CMV retinitis in patients with acquired immunodeficiency syndrome (AIDS). The diagnosis of CMV retinitis is ophthalmologic and should be made by indirect ophthalmoscopy. Other conditions in the differential diagnosis of CMV retinitis include candidiasis, toxoplasmosis, histoplasmosis, retinal scars, and cotton wool spots, any of which may produce a retinal appearance similar to CMV. For this reason, it is essential that the diagnosis of CMV be established by a physician familiar with the retinal presentation of these conditions. The Vitrasert (ganciclovir) Implant is for intravitreal implantation only. Clinical Trials In a randomized, controlled parallel group trial conducted between May 1993 and December 1994, treatment with the Vitrasert (ganciclovir) Implant was compared to treatment with intravenous ganciclovir (Cytovene-IV; Roche) in 188 patients with AIDS and newly diagnosed CMV retinitis. Patients randomized to the Cytovene-IV treatment group received Cytovene-IV solution at induction doses (5 mg/kg twice daily) for 14 days, followed by maintenance dosing (5 mg/kg once daily). Based on masked assessment of fundus photographs, the median time to progression was approximately 210 days for the Vitrasert (ganciclovir) Implant treatment group compared to approximately 120 days for the intravenous ganciclovir treatment group. DOSAGE AND ADMINISTRATION Each Vitrasert Implant contains a minimum of 4.5 mg of ganciclovir, and is designed to release the drug over a 5 to 8 month period of time. Following depletion of ganciclovir from the Vitrasert (ganciclovir) Implant, as evidenced by progression of retinitis, the Vitrasert (ganciclovir) Implant may be removed and replaced. Handling and Disposal Caution should be exercised in handling of the Vitrasert (ganciclovir) Implant in order to avoid damage to the polymer coating on the implant, which may result in an increased rate of drug release from the implant. Thus, the Vitrasert (ganciclovir) Implant should be handled only by the suture tab. Aseptic technique should be maintained at all times prior to and during the surgical implantation procedure. Because the Vitrasert Implant contains ganciclovir, which shares some of the properties of anti-tumor agents (i.e., carcinogenicity and mutagenicity), consideration should be given to handling and disposal of the Vitrasert (ganciclovir) Implant according to guidelines issued for antineoplastic drugs. HOW SUPPLIED The Vitrasert (ganciclovir) Implant is supplied in individual unit boxes in a sterile Tyvek package (NDC 24208-412-01). Store at controlled room temperature, 15 - 30°C (59 - 86°F). Protect from freezing, excessive heat and light. Revised August 2005. Manufactured for: Bausch & Lomb Incorporated, Rochester, NY 14609 USA. (800) 338-2020. Manufactured by: AMP, Inc. Irvine, CA 92618, USA. FDA Rev date: 4/18/2000

INDICATIONS Treatment Of CMV Retinitis CYTOVENE-IV is indicated for the treatment of cytomegalovirus (CMV) retinitis in immunocompromised adult patients, including patients with acquired immunodeficiency syndrome (AIDS) [see Clinical Studies]. Prevention Of CMV Disease In Transplant Recipients CYTOVENE-IV is indicated for the prevention of CMV disease in adult transplant recipients at risk for CMV disease [see Clinical Studies]. DOSAGE AND ADMINISTRATION Important Dosing And Administration Information To avoid phlebitis/pain at the infusion site, CYTOVENE-IV must only be administered by intravenous infusion over 1 hour, preferably via plastic cannula, into a vein with adequate blood flow to permit rapid dilution and distribution. Do not administer CYTOVENE-IV by rapid or bolus intravenous injection which may increase toxicity as a result of excessive plasma levels. The recommended dosage and infusion rate for CYTOVENE-IV should not be exceeded. Do not administer the reconstituted CYTOVENE-IV solution intramuscularly or subcutaneously because it may result in severe tissue irritation due to high pH (11). Administration of CYTOVENE-IV should be accompanied by adequate hydration. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. Testing Before And During Treatment Females of reproductive potential should undergo pregnancy testing before initiation of treatment with CYTOVENEIV [see WARNINGS AND PRECAUTIONS, Use in Specific Populations]. Complete blood counts with differential and platelet counts should be performed frequently, especially in patients in whom CYTOVENE-IV or other nucleoside analogues have previously resulted in cytopenias, or in whom absolute neutrophil counts are less than 1000 cells/μL at the beginning of treatment [see WARNINGS AND PRECAUTIONS]. All patients should be monitored for renal function before and during treatment with CYTOVENE-IV and dose should be adjusted as needed [see DOSAGE AND ADMINISTRATION, WARNINGS AND PRECAUTIONS]. Patients with CMV retinitis should have frequent ophthalmological examinations during treatment with CYTOVENEIV solution to monitor disease status and for other retinal abnormalities [see ADVERSE REACTIONS]. Recommended Dosage For Treatment Of CMV Retinitis In Adult Patients With Normal Renal Function Induction Dosage: The recommended initial dosage of CYTOVENE-IV for patients with normal renal function is 5 mg/kg (given intravenously at a constant rate over 1 hour) every 12 hours for 14 to 21 days. Maintenance Dosage: Following induction treatment, the recommended maintenance dosage of CYTOVENE-IV is 5 mg/kg (given intravenously at a constant rate over 1 hour) once daily for 7 days per week, or 6 mg/kg once daily for 5 days per week. Recommended Dosage For The Prevention Of CMV Disease In Adult Transplant Recipients With Normal Renal Function Induction Dosage: The recommended initial dosage of CYTOVENE-IV for patients with normal renal function is 5 mg/kg (given intravenously at a constant rate over 1 hour) every 12 hours for 7 to 14 days. Maintenance Dosage: Following induction, the recommended maintenance dosage of CYTOVENE-IV is 5 mg/kg (given intravenously at a constant rate over 1 hour) once daily for 7 days per week, or 6 mg/kg once daily for 5 days per week until 100 to 120 days post-transplantation. Recommended Dosage In Adult Patients With Renal Impairment For patients with impairment of renal function, refer to Table 1 for recommended doses of CYTOVENE-IV for induction and maintenance dosage for treatment of CMV retinitis and prevention of CMV disease in transplant recipients. Carefully monitor serum creatinine or creatinine clearance before and during treatment to allow for dosage adjustments in patients with impaired renal function. Table 1: Recommended Induction and Maintenance Dosage for Adult Patients with Renal Impairment Creatinine Clearance* (mL/min) CYTOVENE-IV Induction Dose (mg/kg) Dosing Interval (hours) for Induction CYTOVENE-IV Maintenance Dose (mg/kg) Dosing Interval (hours) for Maintenance Greater than or equal to70 5 12 5 24 50-69 2.5 12 2.5 24 25-49 2.5 24 1.25 24 10-24 1.25 24 0.625 24 Lessthan10 1.25 3 times per week, following hemodialysis 0.625 3 times per week, following hemodialysis * Creatinine clearance can be related to serum creatinine by the formulas given below. Creatinine clearance for males = (140 -age [yrs]) (body wt [kg])/(72) (serum creatinine [mg/dL]) Creatinine clearance for females = 0.85 x male value Patients Undergoing Hemodialysis Induction dosing for CYTOVENE-IV in patients undergoing hemodialysis should not exceed 1.25 mg/kg 3 times per week; and maintenance dosing should not exceed 0.625 mg/kg 3 times per week following each hemodialysis session. CYTOVENE-IV should be given shortly after completion of the hemodialysis session, since hemodialysis has been shown to reduce plasma levels by approximately 50% [see CLINICAL PHARMACOLOGY]. Preparation Of CYTOVENE-IV CYTOVENE-IV must be reconstituted and diluted under the supervision of a healthcare provider and administered as intravenous infusion. Each 10 mL clear glass vial contains ganciclovir sodium equivalent to 500 mg of ganciclovir. Wearing disposable gloves is recommended during reconstitution and when wiping the outer surface of the vial and the table after reconstitution. The contents of the vial should be prepared for administration in the following manner: 1. Reconstitution Instructions: Reconstitute lyophilized CYTOVENE-IV by injecting 10 mL of Sterile Water for Injection, USP, into the vial. Do not use bacteriostatic water for injection containing parabens. It is incompatible with CYTOVENEIV and may cause precipitation. Gently swirl the vial in order to ensure complete wetting of the product. Continue swirling until a clear reconstituted solution is obtained. Visually inspect the reconstituted solution for particulate matter and discoloration prior to proceeding with infusion. Discard the vial if particulate matter or discoloration is observed. Reconstituted solution in the vial is stable at room temperature (25°C) for 12 hours. Do not refrigerate or freeze. 2. Infusion Instructions: Based on patient weight, the appropriate volume of the reconstituted solution (ganciclovir concentration 50 mg/mL) should be removed from the vial and added to an acceptable infusion fluid (typically 100 mL) for delivery over the course of 1 hour. Infusion concentrations greater than 10 mg/mL are not recommended. The following infusion fluids have been determined to be chemically and physically compatible with CYTOVENE-IV solution: 0.9% Sodium Chloride, 5% Dextrose, Ringer's Injection and Lactated Ringer's Injection, USP. CYTOVENE-IV, when reconstituted with Sterile Water for Injection (non-bacteriostatic) and further diluted with 0.9% sodium chloride injection or other acceptable infusion fluid as specified above, should be used within 24 hours of dilution to reduce the risk of bacterial contamination. The diluted infusion solution should be refrigerated (2°C to 8°C). Do not freeze. Handling And Disposal Caution should be exercised in the handling and preparation of solutions of CYTOVENE-IV. Solutions of CYTOVENE-IV are alkaline (pH 11). Avoid direct contact of the skin or mucous membranes with CYTOVENE-IV solution. If such contact occurs, wash thoroughly with soap and water; rinse eyes thoroughly with plain water. Wearing disposable gloves is recommended. Because ganciclovir shares some of the properties of antitumor agents (i.e., carcinogenicity and mutagenicity), consideration should be given to handling and disposal according to guidelines issued for antineoplastic drugs1 [see HOW SUPPLIED/Storage and Handling]. HOW SUPPLIED Dosage Forms And Strengths For injection: Single dose vial containing 500 mg of ganciclovir as a sterile lyophilized white to off-white powder for reconstitution with 10 mL of preservative-free Sterile Water for Injection, USP for intravenous use [see DOSAGE AND ADMINISTRATION]. Storage And Handling CYTOVENE-IV (ganciclovir sodium) for injection is supplied in 10 mL sterile vials, each containing ganciclovir sodium equivalent to 500 mg of ganciclovir as a white to off-white powder. CYTOVENE-IV is supplied in cartons of 5 vials (NDC 0004-6940-04). Storage Store at 25°C (77°F); excursions permitted to 15° to 30°C (59° to 86°F) [See USP Controlled Room Temperature]. Store reconstituted solution in the vial at 25°C (77°F) for no longer than 12 hours. Do not refrigerate or freeze. Store diluted infusion solution under refrigeration at 2° to 8°C (36° to 46°F) for no longer than 24 hours. Do not freeze. REFERENCES 1. “OSHA Hazardous Drugs.” OSHA. http://www.osha.gov/SLTC/hazardousdrugs/index.html. Distributed by: Genentech USA, Inc. A Member of the Roche Group1, DNA Way, South San Francisco, CA 94080-4990. Revised: Jul 2017

PATIENT INFORMATION The Vitrasert (ganciclovir) Implant is not a cure for CMV retinitis, and some immunocompromised patients may continue to experience progression of retinitis with the Vitrasert (ganciclovir) Implant. Patients should be advised to have ophthalmologic follow-up examinations of both eyes at appropriate intervals following implantation of the Vitrasert (ganciclovir) Implant. As with any surgical procedure, there is risk involved. Potential complications accompanying intraocular surgery to place the Vitrasert (ganciclovir) Implant into the vitreous cavity may include, but are not limited to, the following: intraocular infection or inflammation, detachment of the retina, and formation of cataract in the natural crystalline lens. Following implantation of the Vitrasert (ganciclovir) Implant, nearly all patients will experience an immediate and temporary decrease in visual acuity in the implanted eye which lasts for approximately two to four weeks post-operatively. This decrease in visual acuity is likely a result of the surgical implant procedure. The Vitrasert (ganciclovir) Implant only treats eyes in which it has been implanted. Additionally, because CMV is a systemic disease, patients should be monitored for extraocular CMV infections (e.g., pneumonitis, colitis) in the body. Patients should be advised that ganciclovir has caused decreased sperm production in animals and may cause infertility in humans. Women of childbearing potential should be advised that ganciclovir causes birth defects in animals and should not be used during pregnancy. Patients should be advised that ganciclovir has caused tumors in animals. Although there is no information from human studies, ganciclovir should be considered a potential carcinogen.

PATIENT INFORMATION Hematologic Toxicity Inform patients that CYTOVENE-IV may cause hematologic toxicity including granulocytopenia (neutropenia), anemia, and thrombocytopenia. Inform patients that their blood counts and platelet counts should be closely monitored while on treatment [see WARNINGS AND PRECAUTIONS]. Impairment Of Renal Function Inform patients that CYTOVENE-IV has been associated with decreased renal function and that serum creatinine or creatinine clearance should be monitored while on treatment to allow for dosage adjustment in patients with renal impairment [see WARNINGS AND PRECAUTIONS]. Impairment Of Fertility Inform patients that CYTOVENE-IV may cause temporary or permanent infertility in humans [see WARNINGS AND PRECAUTIONS, Use in Specific Populations]. Pregnancy And Contraception Advise female patients to use effective contraception during and for at least 30 days following treatment with CYTOVENE-IV. Similarly, advise men to practice barrier contraception during and for at least 90 days following treatment with CYTOVENE-IV [see WARNINGS AND PRECAUTIONS, Use in Specific Populations]. Carcinogenicity Inform patients that CYTOVENE-IV should be considered a potential carcinogen [see WARNINGS AND PRECAUTIONS]. Drug Interactions Inform patients that CYTOVENE-IV may interact with other drugs. Advise patients to report to their healthcare provider the use of any other medication [see DRUG INTERACTIONS]. Impairment Of Cognitive Ability Based on the adverse reaction profile, ganciclovir may affect cognitive abilities including on the ability to drive and operate machinery as seizures, dizziness, and/or confusion have been reported with the use of CYOVENE-IV [see ADVERSE REACTION]. Ophthalmological Examination In Patients With CMV Retinitis Inform patients that CYTOVENE-IV is not a cure for CMV retinitis, and they may continue to experience progression of retinitis during or following treatment. Advise patients to have frequent ophthalmological follow-up examinations while being treated with CYTOVENE-IV. Some patients may require more frequent ophthalmological follow-up [see DOSAGE AND ADMINISTRATION, ADVERSE REACTIONS]. Lactation Advise nursing mothers not to breastfeed if they are receiving CYTOVENE-IV because of the potential for serious adverse events in nursing infants and because HIV can be passed to the baby in breast milk [see Use in Specific Populations].

OVERDOSE No information provided. CONTRAINDICATIONS The Vitrasert (ganciclovir) Implant is contraindicated in patients with hypersensitivity to ganciclovir or acyclovir, and in patients with any contraindications for intraocular surgery, such as external infection or severe thrombocytopenia.

OVERDOSE Reports of adverse reactions after overdoses with CYTOVENE-IV, some with fatal outcomes, have been received from clinical trials and during post-marketing experience. One or more of the following adverse reactions has been reported with overdoses: Hematological toxicity: myelosuppression including pancytopenia, leukopenia, neutropenia, granulocytopenia, thrombocytopenia, bone marrow failure Hepatotoxicity: hepatitis, liver function disorder Renal toxicity: worsening of hematuria in a patient with pre-existing renal impairment, acute renal failure, elevated creatinine Gastrointestinal toxicity: abdominal pain, diarrhea, vomiting Neurotoxicity: seizures Since ganciclovir is dialyzable, dialysis may be useful in reducing serum concentrations in patients who have received an overdose of CYTOVENE-IV [see CLINICAL PHARMACOLOGY]. Adequate hydration should be maintained. The use of hematopoietic growth factors should be considered in patients with cytopenias [see WARNINGS AND PRECAUTIONS]. CONTRAINDICATIONS CYTOVENE-IV is contraindicated in patients who have experienced a clinically significant hypersensitivity reaction (e.g., anaphylaxis) to ganciclovir, valganciclovir, or any component of the formulation.

SIDE EFFECTS During clinical trials, the most frequent adverse events seen in patients treated with the Vitrasert (ganciclovir) Implant involved the eye. During the first two months following implantation, visual acuity loss of 3 lines or more, vitreous hemorrhage, and retinal detachments occurred in approximately 10-20% of patients. Cataract formation/lens opacities, macular abnormalities, intraocular pressure spikes, optic disk/nerve changes, hyphemas and uveitis occurred in approximately 1-5%. Adverse events with an incidence of less than 1% were: retinopathy, anterior chamber cell and flare, synechia, hemorrhage (other than vitreous), cotton wool spots, keratopathy, astigmatism, endophthalmitis, microangiopathy, sclerosis, choroiditis, chemosis, phthisis bulbi, angle closure glaucoma with anterior chamber shallowing, vitreous detachment, vitreous traction, hypotony, severe post-operative inflammation, retinal tear, retinal hole, corneal dellen, choroidal folds, pellet extrusion from scleral wound, and gliosis. DRUG INTERACTIONS No drug interactions have been observed with the Vitrasert (ganciclovir) Implant. There is limited experience with use of retinal tamponades in conjunction with the Vitrasert (ganciclovir) Implant.

SIDE EFFECTS The following serious adverse reactions are discussed in greater detail in other sections of the labeling: Hematologic Toxicity [see WARNINGS AND PRECAUTIONS] Renal Impairment [see WARNINGS AND PRECAUTIONS] Impairment of Fertility [see WARNINGS AND PRECAUTIONS] Fetal Toxicity [see WARNINGS AND PRECAUTIONS] Mutagenesis and Carcinogenesis [see WARNINGS AND PRECAUTIONS] Clinical Trial Experience In Adult Patients 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 rates observed in practice. The most common adverse reactions and laboratory abnormalities reported in at least 20% of patients were pyrexia, diarrhea, leukopenia, nausea, anemia, asthenia, headache, cough, decreased appetite, dyspnea, abdominal pain, sepsis, hyperhidrosis, and blood creatinine increased. Selected adverse reactions that occurred during clinical trials of CYTOVENE-IV are summarized below, according to the participating study patient population. Adverse Reactions In Patients With CMV Retinitis Three controlled, randomized, phase 3 trials comparing CYTOVENE-IV and ganciclovir capsules for maintenance treatment of CMV retinitis have been completed. During these trials, CYTOVENE-IV or ganciclovir capsules were prematurely discontinued in 9% of subjects because of adverse reactions. Selected adverse reactions and laboratory abnormalities reported during the conduct of these controlled trials are summarized in Table 2 and Table 3, respectively [see Clinical Studies]. Table 2: Pooled Selected Adverse Reactions Reported in > 5% of Subjects Comparing CYTOVENE-IV to Ganciclovir Capsules for Maintenance Treatment of CMV Retinitis Adverse Reaction Maintenance Treatment Studies CYTOVENE-IV (n=179) Ganciclovir Capsules (n=326) Pyrexia 48% 38% Diarrhea 44% 41% Leukopenia 41% 29% Anemia 25% 19% Total catheter events 22% 6% Catheter infection 9% 4% Catheter sepsis 8% 1% Other catheter related events 5% 1% Sepsis 15% 4% Decreased appetite 14% 15% Vomiting 13% 13% Infection 13% 9% Hyperhidrosis 12% 11% Chills 10% 7% Neuropathy peripheral 9% 8% Thrombocytopenia 6% 6% Pruritus 5% 6% Retinal Detachment Retinal detachment has been observed in subjects with CMV retinitis both before and after initiation of therapy with ganciclovir. Its relationship to therapy with ganciclovir is unknown. Retinal detachment occurred in 11% of patients treated with CYTOVENE-IV and in 8% of patients treated with ganciclovir capsules. Table 3: Selected Laboratory Abnormalities in Trials for Treatment of CMV Retinitis Laboratory Abnormalities CMV Retinitis Treatment* CYTOVENE-IV† 5 mg/kg/day (N=175) % Ganciclovir Capsules‡ 3000 mg/day (N=320) % Neutropenia with Absolute Neutrophil Count (ANC) per μL: < 500 25% 18% 500 - < 749 14% 17% 750 - < 1000 26% 19% Anemia with Hemoglobin (g/dL): < 6.5 g/dL 5% 2% 6.5 - < 8.0 16% 10% 8.0 - < 9.5 26% 25% Serum Creatinine (mg/dL): > 2.5 2% 1% >1.5 - < 2.5 14% 12% * Pooled data from Treatment Studies: ICM 1653, ICM 1774 and AVI 034 † Mean time on therapy = 103 days, including allowed re-induction treatment periods ‡ Mean time on therapy = 91 days, including allowed re-induction treatment periods Adverse Reactions In Transplant Recipients There have been three controlled clinical trials of CYTOVENE-IV for the prevention of CMV disease in transplant recipients. Selected laboratory abnormalities are summarized in Tables 4 and 5 below. Table 4 shows the frequency of neutropenia and thrombocytopenia and Table 5 shows the frequency of elevated serum creatinine values observed in these trials [see Clinical Studies]. Table 4: Laboratory Abnormalities in Controlled Trials - Transplant Recipients who Received CYTOVENE-IV, Placebo or Control CYTOVENE-IV Heart Allograft* Bone Marrow Allograft† CYTOVENE-IV (n=76) Placebo (n=73) CYTOVENE-IV (n=57) Control (n=55) Neutropenia Absolute Neutrophil Count (ANC) per μL < 500 4% 3% 12% 6% 500-1000 3% 8% 29% 17% Total ANC ≤ 1000/μL 7% 11% 41% 23% Thrombocytopenia Platelet count per μL < 25,000 3% 1% 32% 28% 25,000-50,000 5% 3% 25% 37% Total Platelet Count < 50,000/μL 8% 4% 57% 65% Table 5: Serum Creatinine Levels in Controlled Trials -Transplant Recipients who Received CYTOVENE-IV or Placebo Serum Creatinine Levels (mg/dL) Heart Allograft ICM 1496 Bone Marrow Allograft ICM 1570 Bone Marrow Allograft ICM 1689 CYTOVENE-IV (n=76) Placebo (n=73) CYTOVENE-IV (n=20) Control (n=20) CYTOVENE-IV (n=37) Placebo (n=35) > 2.5 mg/dL 18% 4% 20% 0% 0% 0% > 1.5 - < 2.5 58% 69% 50% 35% 43% 44% Other Adverse Reactions In Clinical Trials In Patients With CMV Retinitis And In Transplant Recipients Adverse drug reactions with CYTOVENE-IV or ganciclovir capsules in controlled clinical studies in either subjects with AIDS or transplant recipients are listed below [see Clinical Studies]. All these events occurred in at least 3 subjects. Blood and lymphatic disorders: pancytopenia, bone marrow failure Cardiac disorders: arrhythmias Ear and labyrinth disorders: tinnitus, ear pain, deafness Eye disorders: visual impairment, vitreous disorders, eye pain, conjunctivitis, macular edema Gastrointestinal disorders: nausea, abdominal pain, dyspepsia, flatulence, constipation, mouth ulceration, dysphagia, abdominal distention, pancreatitis, gastrointestinal perforation, eructation, dry mouth General disorders and administration site conditions: fatigue, injection site inflammation, edema, pain, malaise, asthenia, chest pain, multiple organ failure Immune system disorders: hypersensitivity Infections and infestations: candida infections including oral candidiasis, upper respiratory infection, influenza, urinary tract infections, cellulitis Investigations: blood alkaline phosphatase increased, hepatic function abnormal, aspartate aminotransferase increased, alanine aminotransferase increased, creatinine clearance decreased Metabolism and nutrition disorders: weight decreased Musculoskeletal and connective tissue disorders: back pain, myalgia, arthralgia, muscle spasms, leg cramps, myasthenia Nervous system disorders: headache, insomnia, dizziness, paresthesia, hypoaesthesia, seizures, somnolence, dysgeusia (taste disturbance), tremor Psychiatric disorders: depression, confusional state, anxiety, agitation, psychotic disorder, thinking abnormal, abnormal dreams Renal and urinary disorders: kidney failure, renal function abnormal, urinary frequency, hematuria Respiratory, thoracic and mediastinal disorders: cough, dyspnea Skin and subcutaneous tissues disorders: dermatitis, alopecia, dry skin, urticaria, rash Vascular disorders: hypotension, hypertension, phlebitis, vasodilation Postmarketing Experience The following adverse reactions have been identified during post-approval use of CYTOVENE-IV or ganciclovir capsules. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Blood and lymphatic disorders: hemolytic anemia, agranulocytosis, granulocytopenia Cardiac disorders: cardiac arrest, conduction disorder, torsade de pointes, ventricular tachycardia Congenital, familial and genetic disorders: congenital anomaly Endocrine disorders: inappropriate antidiuretic hormone secretion Eye disorders: cataracts, dry eyes Gastrointestinal disorders: intestinal ulcer Hepatobiliary disorders: cholelithiasis, cholestasis, hepatic failure, hepatitis Immune system disorders: anaphylactic reaction, allergic reaction, vasculitis Investigations: blood triglycerides increased Metabolism and nutrition disorders: acidosis, hypercalcemia, hyponatremia Musculoskeletal and connective tissue disorders: arthritis, rhabdomyolysis Nervous system disorders: dysesthesia, dysphasia, extrapyramidal disorder, facial paralysis, amnesia, anosmia, myelopathy, cerebrovascular accident, third cranial nerve paralysis, aphasia, encephalopathy, intracranial hypertension Psychiatric disorders: irritability, hallucinations Renal and urinary disorders: renal tubular disorder, hemolytic uremic syndrome Reproductive system and breast disorders: infertility, testicular hypotrophy Respiratory, thoracic and mediastinal disorders: bronchospasm, pulmonary fibrosis Skin and subcutaneous tissues disorders: exfoliative dermatitis, Stevens-Johnson syndrome Vascular disorders: peripheral ischemia DRUG INTERACTIONS Drug-drug interaction studies were conducted in patients with normal renal function. Patients with impaired renal function may have increased concentrations of ganciclovir and the coadministered drug following concomitant administration of CYOTVENE-IV and drugs excreted by the same pathway as ganciclovir. Therefore, these patients should be closely monitored for toxicity of ganciclovir and the coadministered drug. Established and other potentially significant drug interactions conducted with ganciclovir are listed in Table 6 [see CLINICAL PHARMACOLOGY]. Table 6: Established and Other Potentially Significant Drug Interactions with Ganciclovir Name of the Concomitant Drug Change in the Concentration of Ganciclovir or Concomitant Drug Clinical Comment Imipenem-cilastatin Unknown Coadministration with imipenem-cilastatin is not recommended because generalized seizures have been reported in patients who received ganciclovir and imipenem-cilastatin. Cyclosporine or amphotericin B Unknown Monitor renal function when CYTOVENE IV is coadministered with cyclosporine or amphotericin B because of potential increase in serum creatinine [see WARNINGS AND PRECAUTIONS]. Mycophenolate mofetil (MMF) ↔Ganciclovir (in patients with normal renal function) ↔MMF (in patients with normal renal function) Based on increased risk, patients should be monitored for hematological and renal toxicity. Other drugs associated with myelosuppresion or nephrotoxicity (e.g., dapsone, doxorubicin, flucytosine, hydroxyurea, pentamidine, tacrolimus, trimethoprim/ sulfamethoxazole, vinblastine, vincristine and zidovudine) Unknown Because of potential for higher toxicity, coadministration with CYTOVENE-IV should be considered only if the potential benefits are judged to outweigh the risks. Didanosine ↔Ganciclovir ↑Didanosine Patients should be closely monitored for didanosine toxicity (e.g., pancreatitis). Probenecid ↑ Ganciclovir CYTOVENE-IV dose may need to be reduced. Monitor for evidence of ganciclovir toxicity.

WARNINGS CMV retinitis may be associated with CMV disease elsewhere in the body. The Vitrasert (ganciclovir) Implant provides localized therapy limited to the implanted eye. The Vitrasert (ganciclovir) Implant does not provide treatment for systemic CMV disease. Patients should be monitored for extraocular CMV disease. As with any surgical procedure, there is risk involved. Potential complications accompanying intraocular surgery to place the Vitrasert (ganciclovir) Implant into the vitreous cavity may include, but are not limited to, the following: vitreous loss, vitreous hemorrhage, cataract formation, retinal detachment, uveitis, endophthalmitis, and decrease in visual acuity. Following implantation of the Vitrasert (ganciclovir) Implant, nearly all patients will experience an immediate and temporary decrease in visual acuity in the implanted eye which lasts for approximately two to four weeks post-operatively. This decrease in visual acuity is likely a result of the surgical implant procedure. PRECAUTIONS General As with all intraocular surgery, sterility of the surgical field and the Vitrasert (ganciclovir) Implant should be rigorously maintained. The Vitrasert (ganciclovir) Implant should be handled only by the suture tab in order to avoid damaging the polymer coatings since this could affect release rate of ganciclovir inside the eye. The Vitrasert (ganciclovir) Implant should not be resterilized by any method. A high level of surgical skill is required for implantation of the Vitrasert (ganciclovir) Implant. A surgeon should have observed or assisted in surgical implantation of the Vitrasert (ganciclovir) Implant prior to attempting the procedure. Carcinogenesis, Mutagenesis Ganciclovir was carcinogenic in the mouse at oral doses of 20 and 1000 mg/kg/day. At the dose of 1000 mg/kg/day there was a significant increase in the incidence of tumors of the preputial gland in males, forestomach (nonglandular mucosa) in males and females, and reproductive tissues (ovaries, uterus, mammary gland, clitoral gland, and vagina) and liver in females. At the dose of 20 mg/kg/day, a slightly increased incidence of tumors was noted in the preputial and harderian glands in males, forestomach in males and females, and liver in females. Except for histiocytic sarcoma of the liver, ganciclovir-induced tumors were generally of epithelial or vascular origin. Although the preputial and clitoral glands, forestomach, and harderian glands of mice do not have human counterparts, ganciclovir should be considered a potential carcinogen in humans. Ganciclovir increased mutations in mouse lymphoma cells and DNA damage in human lymphocytes in vitro at concentrations between 50-500 and 250-2000 µg/mL, respectively. In the mouse micronucleus assay, ganciclovir was clastogenic at doses of 150 and 500 mg/kg (IV) (2.8 - 10x human exposure based on AUC) but not 50 mg/kg (exposure approximately comparable to the human based on AUC). Ganciclovir was not mutagenic in the Ames Salmonella assay at concentrations of 500-5000 µg/mL. Impairment of Fertility Ganciclovir caused decreased mating behavior, decreased fertility, and an increased incidence of embryolethality in female mice following intravenous doses of 90 mg/kg/day. Ganciclovir caused decreased fertility in male mice and hypospermatogenesis in mice and dogs following daily oral or intravenous administration of doses ranging from 0.2 - 10 mg/kg. Pregnancy: Teratogenic Effects: Pregnancy Category C Ganciclovir has been shown to be embryotoxic in rabbits and mice following intravenous administration and teratogenic in rabbits. Fetal resorptions were present in at least 85% of rabbits and mice administered 60 mg/kg/day and 108 mg/kg/day, respectively. Effects observed in rabbits included: fetal growth retardation, embryolethality, teratogenicity, and/or maternal toxicity. Teratogenic changes included cleft palate, anophthalmia/microphthalmia, aplastic organs (kidney and pancreas), hydrocephaly, and brachygnathia. In mice, effects observed were maternal/fetal toxicity and embryolethality. Daily intravenous doses of 90 mg/kg administered to female mice prior to mating, during gestation, and during lactation caused hypoplasia of the testes and seminal vesicles in the month-old male offspring, as well as pathologic changes in the nonglandular region of the stomach (see Carcinogenesis, Mutagenesis subsection). Although each Vitrasert Implant contains from 4.5 to 6.4 mg of ganciclovir, which is released locally in the vitreous, there are no adequate and well-controlled studies in pregnant women on the effects of the Vitrasert (ganciclovir) Implant. Therefore, the Vitrasert (ganciclovir) Implant should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Nursing Mothers It is not known whether ganciclovir from the Vitrasert (ganciclovir) Implant is excreted in human milk. Daily intravenous doses of 90 mg/kg administered to female mice prior to mating, during gestation, and during lactation caused hypoplasia of the testes and seminal vesicles in the month-old male offspring, as well as pathologic changes in the non-glandular region of the stomach. Because many drugs are excreted in human milk and, because carcinogenicity and teratogenicity effects occurred in animals treated with ganciclovir, mothers should be instructed to discontinue nursing if they have a Vitrasert (ganciclovir) Implant. Pediatric Use Safety and effectiveness in pediatric patients below 9 years of age have not been established.

WARNINGS Included as part of the PRECAUTIONS section. PRECAUTIONS Hematologic Toxicity Granulocytopenia (neutropenia), anemia, thrombocytopenia and pancytopenia, have been observed in patients treated with CYTOVENE-IV. The frequency and severity of these events vary widely in different patient populations [see ADVERSE REACTIONS]. CYTOVENE-IV is not recommended if the absolute neutrophil count is less than 500 cells/μL, hemoglobin is less than 8 g/dL, or the platelet count is less than 25,000 cells/μL. CYTOVENE-IV should also be used with caution in patients with pre-existing cytopenias and in patients receiving myelosuppressive drugs or irradiation. Granulocytopenia (neutropenia) usually occurs during the first or second week of treatment but may occur at any time during treatment. Cell counts usually begin to recover within 3 to 7 days after discontinuing drug. Colony-stimulating factors have been shown to increase neutrophil and white blood cell counts in patients receiving CYTOVENE-IV solution for treatment of CMV retinitis. Due to the frequency of neutropenia, anemia and thrombocytopenia in patients receiving CYTOVENE-IV, complete blood counts with differential and platelet counts should be performed frequently in all patients, especially in patients with renal impairment and in patients in whom ganciclovir or other nucleoside analogues have previously resulted in leukopenia, or in whom neutrophil counts are less than 1000 cells/μL at the beginning of treatment [see DOSAGE AND ADMINISTRATION]. Renal Impairment CYTOVENE-IV should be used with caution in patients with impaired renal function because the half-life and plasma/serum concentrations of ganciclovir will be increased due to reduced renal clearance. If renal function is impaired, dosage adjustments are recommended [see DOSAGE AND ADMINISTRATION, Use in Specific Populations]. Increased serum creatinine levels have been reported in elderly patients and in transplant recipients receiving concomitant nephrotoxic medications (i.e., cyclosporine and amphotericin B). Monitoring renal function during therapy with CYTOVENE-IV is essential, especially for elderly patients and those patients receiving concomitant agents that may cause nephrotoxicity [see DOSAGE AND ADMINISTRATION, DRUG INTERACTIONS, Use in Specific Populations]. Impairment Of Fertility Based on animal data, CYTOVENE-IV at the recommended human dose (RHD) may cause temporary or permanent inhibition of spermatogenesis in males, and may cause suppression of fertility in females. Advise patients that fertility may be impaired with the use of CYTOVENE-IV [see Use in Specific Populations, Nonclinical Toxicology]. Fetal Toxicity CYTOVENE-IV may cause fetal toxicity when administered to pregnant women based on findings in animal studies. Systemic exposure of ganciclovir in animals at approximately 2 times the RHD caused fetal growth retardation, embryolethality, teratogenicity, and/or maternal toxicity. Teratogenic changes in animals included cleft palate, anophthalmia/microphthalmia, aplastic organs (kidney and pancreas), hydrocephaly and brachygnathia. Women of childbearing potential should be advised to use effective contraception during treatment and for at least 30 days following treatment with CYTOVENE-IV. Similarly, men should be advised to practice barrier contraception during and for at least 90 days following treatment with CYTOVENE-IV [see Use in Specific Populations, Nonclinical Toxicology]. Mutagenesis And Carcinogenesis Animal data indicate that ganciclovir is mutagenic and carcinogenic. CYTOVENE-IV should therefore be considered a potential carcinogen in humans [see DOSAGE AND ADMINISTRATION, Nonclinical Toxicology]. Nonclinical Toxicology Carcinogenesis, Mutagenesis, Impairment Of Fertility Carcinogenesis, Mutagenesis Ganciclovir was carcinogenic in mice at the same mean drug exposure in humans as at the RHD (5 mg/kg). At the dose of 1000 mg/kg/day (1.4 times the exposure at the RHD), there was a significant increase in the incidence of tumors of the preputial gland in males, forestomach (nonglandular mucosa) in males and females, and reproductive tissues (ovaries, uterus, mammary gland, clitoral gland and vagina) and liver in females. At the dose of 20 mg/kg/day (0.1 times the exposure at the RHD), a slightly increased incidence of tumors was noted in the preputial and harderian glands in males, forestomach in males and females, and liver in females. No carcinogenic effect was observed in mice administered ganciclovir at 1 mg/kg/day (exposure estimated as 0.01 times the RHD). Except for histiocytic sarcoma of the liver, ganciclovir-induced tumors were generally of epithelial or vascular origin. Although the preputial and clitoral glands, forestomach and harderian glands of mice do not have human counterparts, ganciclovir should be considered a potential carcinogen in humans. Ganciclovir increased mutations in mouse lymphoma cells and DNA damage in human lymphocytes in vitro at concentrations between 50 to 500 and 250 to 2000 μg/mL, respectively. In the mouse micronucleus assay, ganciclovir was clastogenic at doses of 150 and 500 mg/kg (2.8 to 10 times the exposure at the RHD) but not at doses of 50 mg/kg (exposure approximately comparable to the RHD). Ganciclovir was not mutagenic in the Ames Salmonella assay at concentrations of 500 to 5000 μg/mL. Impairment Of Fertility Ganciclovir caused decreased mating behavior, decreased fertility, and an increased incidence of embryolethality in female mice following doses of 90 mg/kg/day (exposures approximately 1.7 times the RHD). Ganciclovir caused decreased fertility in male mice and hypospermatogenesis in mice and dogs following daily oral or intravenous administration of doses ranging from 0.2 to 10 mg/kg. Systemic drug exposure (AUC) at the lowest dose showing toxicity in each species ranged from 0.03 to 0.1 times the exposure at the RHD. Use In Specific Populations Pregnancy Risk Summary In animal studies, ganciclovir caused maternal and fetal toxicity and embryo-fetal mortality in pregnant mice and rabbits as well as teratogenicity in rabbits at exposures two times the exposure at the recommended human dose (RHD) [see Data]. Although placental transfer of ganciclovir has been shown to occur based on ex vivo experiments with human placenta and in at least one case report in a pregnant woman, no adequate human data are available to establish whether CYTOVENE-IV poses a risk to pregnancy outcomes. The background risk of major birth defects and miscarriage for the indicated populations is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in the clinically recognized pregnancies is 2-4% and 15-20%, respectively. Clinical Considerations Disease-Associated Maternal And/Or Embryo-Fetal Risk Most maternal CMV infections are asymptomatic or they may be associated with a self-limited mononucleosis-like syndrome. However, in immunocompromised patients (i.e., transplant patients or patients with AIDS), CMV infections may be symptomatic and may result in significant maternal morbidity and mortality. The transmission of CMV to the fetus is a result of maternal viremia and transplacental infection. Perinatal infection can also occur from exposure of the neonate to CMV shedding in the genital tract. Approximately 10% of children with congenital CMV infection are symptomatic at birth. Mortality in symptomatic infants is about 10% and approximately 50-90% of symptomatic surviving newborns experience significant morbidity, including mental retardation, sensorineural hearing loss, microcephaly, seizures, and other medical problems. The risk of congenital CMV infection resulting from primary maternal CMV infection may be higher and of greater severity than that resulting from maternal reactivation of CMV infection. Data Animal Data Daily intravenous doses of ganciclovir were administered to pregnant mice (108 mg/kg/day) and rabbits (60 mg/kg/day), and also to female mice (90 mg/kg) prior to mating, during gestation, and during lactation. Fetal resorptions were present in at least 85% of rabbits and mice. Additional effects observed in rabbits included fetal growth retardation, embryolethality, teratogenicity, and/or maternal toxicity. Teratogenic changes included cleft palate, anophthalmia/microphthalmia, aplastic organs (kidney and pancreas), hydrocephaly, and brachygnathia. In pre/postnatal development studies in mice, there were maternal/fetal toxicity and embryolethality which included fetal effects of hypoplasia of the testes and seminal vesicles in the male offspring, as well as pathologic changes in the nonglandular region of the stomach. The systemic exposure (AUC) of ganciclovir during these studies was approximately 2 times (pregnant mice and rabbits) and 1.7 times (pre/postnatal mice) the exposure in humans at the RHD [see Nonclinical Toxicology]. Lactation Risk Summary No data are available regarding the presence of ganciclovir in human milk, the effects on the breastfed infant, or the effects on milk production. When ganciclovir was administered to lactating rats, ganciclovir was present in milk [see Data]. Advise nursing mothers that breastfeeding is not recommended during treatment with CYTOVENE-IV because of the potential for serious adverse reactions in nursing infants. Furthermore, the Centers for Disease Control and Prevention recommends that HIV-infected mothers not breastfeed their infants to avoid potential postnatal transmission of HIV [see WARNINGS AND PRECAUTIONS, Nonclinical Toxicology]. Data Animal Data Ganciclovir administered intravenously (at 0.13 mg/h) to lactating rats (on lactation day 15) resulted in passive transfer into milk. The milk-to-serum ratio for ganciclovir at steady state was 1.6 ± 0.33. Females And Males Of Reproductive Potential Pregnancy Testing Females of reproductive potential should undergo pregnancy testing before initiation of treatment with CYTOVENE-IV [see DOSAGE AND ADMINISTRATION, Use in Specific Populations]. Contraception Females Because of the mutagenic and teratogenic potential of CYTOVENE-IV, females of reproductive potential should be advised to use effective contraception during treatment and for at least 30 days following treatment with CYTOVENE-IV [see WARNINGS AND PRECAUTIONS, Nonclinical Toxicology]. Males Because of its mutagenic potential, males should be advised to practice barrier contraception during and for at least 90 days following treatment with CYTOVENE-IV [see WARNINGS AND PRECAUTIONS, Nonclinical Toxicology]. Infertility CYTOVENE-IV at the recommended doses may cause temporary or permanent female and male infertility [see WARNINGS AND PRECAUTIONS, Nonclinical Toxicology]. Pediatric Use Safety and efficacy of CYTOVENE IV have not been established in pediatric patients. A total of 120 pediatric patients with serious CMV infections participated in clinical trials. Granulocytopenia and thrombocytopenia were the most common adverse reactions. The pharmacokinetic characteristics of ganciclovir after administration of CYTOVENE-IV were studied in 27 neonates (aged 2 to 49 days) and 10 pediatric patients, aged 9 months to 12 years. In neonates, the pharmacokinetic parameters after ganciclovir intravenous doses of 4 mg/kg (n=14) and 6 mg/kg (n=13) were Cmax 5.5 ± 1.6 and 7.0 ± 1.6 mcg/mL, systemic clearance 3.14 ± 1.75 and 3.56 ± 1.27 mL/min/kg, and t½ of 2.4 hours (harmonic mean) for both doses, respectively. In pediatric patients 9 months to 12 years of age, the pharmacokinetic characteristics of ganciclovir were the same after single and multiple (every 12 hours) intravenous doses (5 mg/kg). The steady-state volume of distribution was 0.64 ± 0.22 L/kg, Cmax was 7.9 ± 3.9 mcg/mL, systemic clearance was 4.7 ± 2.2 mL/min/kg, and t½ was 2.4 ± 0.7 hours. Although the pharmacokinetics of CYTOVENE-IV in pediatric patients were similar to those observed in adults, the safety and efficacy of ganciclovir at these exposures in pediatric patients have not been established. Geriatric Use Clinical studies of CYTOVENE-IV did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. In general, dose selection for an elderly patient should be cautious, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy. CYTOVENE-IV is known to be substantially excreted by the kidney, and the risk of toxic reactions to this drug may be greater in patients with impaired renal function. Because renal clearance decreases with age, CYTOVENE-IV should be administered to elderly patients with special consideration of their renal status. Renal function should be monitored and dosage adjustments should be made accordingly [see DOSAGE AND ADMINISTRATION, WARNINGS AND PRECAUTIONS, Use in Specific Populations]. Renal Impairment Dose reduction is recommended when administering CYTOVENE-IV to patients with renal impairment [see DOSAGE AND ADMINISTRATION, and WARNINGS AND PRECAUTIONS]. Hepatic Impairment The safety and efficacy of CYTOVENE-IV have not been studied in patients with hepatic impairment.