Prescription Drugs

CLINICAL PHARMACOLOGY Mechanism Of Action The primary activity of insulin, including RYZODEG 70/30, is regulation of glucose metabolism. Insulin and its analogs lower blood glucose by stimulating peripheral glucose uptake, especially by skeletal muscle and fat, and by inhibiting hepatic glucose production. Insulin also inhibits lipolysis and proteolysis, and enhances protein synthesis. The insulin degludec component in RYZODEG 70/30 forms multi-hexamers when injected into the subcutaneous tissue resulting in a subcutanous insulin degludec depot. The protracted time action profile of RYZODEG 70/30 is predominantly due to delayed absorption of insulin degludec from the subcutaneous tissue to the systemic circulation and to a lesser extent due to binding of insulin-degludec to circulating albumin. Insulin aspart monomers are released rapidly into the circulation. Pharmacodynamics The pharmacodynamic profile of RYZODEG 70/30 reflects the action profiles of rapid-acting insulin aspart and long-acting insulin degludec. The pharmacodynamic profile for RYZODEG 70/30 given as single dose subcutaneous injections of 0.8 U/kg dose in a euglycemic clamp study in patients with type 1 diabetes, is shown in Figure 3. The mean maximum glucose lowering effect (GIRmax) of a 0.8 U/kg dose of RYZODEG 70/30 was 6.9 mg/kg/min, which was observed at a median of 2.3 hours post-dose. In patients with type 1 diabetes mellitus and type 2 diabetes mellitus, RYZODEG 70/30 has an onset of action that rapidly follows injection. Basal insulin degludec in RYZODEG 70/30 provides a glucose lowering effect over 24 hours upon once-daily administration. The duration of action of a single-dose of RYZODEG 70/30 may extend beyond 24 hours (Figure 3) due to the presence of the basal component, insulin degludec. Figure 3: GIR profile of RYZODEG 70/30 after single 0.8 U/kg dose administration in patients with type 1 diabetes mellitus The total and maximum glucose-lowering effect of RYZODEG 70/30 increases linearly with increasing doses from 0.4U/kg to 0.8U/kg in patients with type 1 diabetes mellitus and type 2 diabetes mellitus. Steady state background glucose lowering, attributable to the long-acting, insulin degludec component, will occur after 3 to 4 days of dose administration. However, the magnitude of the glucose-lowering effect at steady state is reduced in type 2 diabetic subjects in comparison to type 1 diabetic subjects given the same unit/kg RYZODEG 70/30 dose. Pharmacokinetics Absorption The concentration-time profile following a single subcutaneous dose of 0.4, 0.6, and 0.8 U/kg RYZODEG 70/30 in patients with type 1 diabetes mellitus and type 2 diabetes mellitus showed increased exposure with increasing dose for both components of RYZODEG 70/30 (insulin degludec and insulin aspart). Insulin aspart showed dose proportional increase in maximum concentration (Cmax) and slightly more than dose proportional increase in overall exposure AUC0-12h following single subcutaneous administration of RYZODEG 70/30 in patients with type 1 diabetes mellitus and type 2 diabetes mellitus. Insulin degludec showed dose proportional increase in Cmax and AUC0-120h following single subcutaneous administration of RYZODEG 70/30 in patients with type 1 diabetes mellitus and type 2 diabetes mellitus. The median onset of appearance for the insulin aspart component was 14 minutes after injection with a peak concentration after 72 minutes. Steady state serum concentrations of the insulin degludec component of RYZODEG 70/30 were reached after 3 to 4 days of dose administrations [see DOSAGE AND ADMINISTRATION]. Distribution The affinity of insulin degludec to serum albumin corresponds to a plasma protein binding of > 99% in human plasma. Insulin aspart has low binding to plasma proteins, < 10%, similar to regular human insulin. Elimination The half-life after subcutaneous administration is determined primarily by the rate of absorption from the subcutaneous tissue. The half-life of the basal component (insulin degludec) at steady state is approximately 25 hours independent of dose. Degradation of insulin degludec is similar to that of human insulin. All metabolites formed are inactive. Specific Populations As with other insulin preparations, RYZODEG 70/30 should always be titrated according to individual requirements. Geriatrics Pharmacokinetic and pharmacodynamic responses of RYZODEG 70/30 were investigated in 13 younger adult (18-35 years) and 15 geriatric ( ≥ 65 years) subjects with T1DM following two single s.c. dose administrations of 0.5 U/kg: one of RYZODEG 70/30 and one of NovoLog Mix 70/30. The total exposure of insulin aspart in RYZODEG 70/30 (based on AUCIAsp,0-12h,SD) tended to be higher in geriatric subjects than in younger adult subjects. The total exposure of insulin degludec in RYZODEG 70/30 (based on AUCIDeg,0-120h,SD) and the pharmacodynamic response to RYZODEG 70/30 (based on AUCGIR,0-24h) was similar in younger adult and geriatric subjects with T1DM, albeit higher between subjects variability among the geriatric subjects. Gender The effect of gender on the pharmacokinetics of the separate components of RYZODEG 70/30, insulin degludec and insulin aspart, was examined in across trial analyses of the pharmacokinetic and pharmacodynamic studies. Overall, there were no clinically relevant differences in the pharmacokinetic properties of insulin degludec or insulin aspart between female and male subjects. Obesity The effect of BMI on the pharmacokinetics of the separate components of RYZODEG 70/30, insulin degludec and insulin aspart, was explored in cross-trial analyses of the pharmacokinetic and pharmacodynamic studies. For subjects with type 1 diabetes, there was no relationship between exposure of insulin degludec and BMI. For subjects with type 1 and type 2 diabetes, a trend for decrease in glucose-lowering effect of insulin degludec with increasing BMI was observed. For insulin aspart, there was no relationship between BMI and exposure in subjects with T1DM or T2DM. Race and Ethnicity The effect of race and ethnic origin on the pharmacokinetics of RYZODEG 70/30 has not been studied. The basal component of RYZODEG 70/30, insulin degludec, has been studied in a pharmacokinetic and pharmacodynamic study in Black or African American subjects not of Hispanic or Latino origin (n=18), White subjects of Hispanic or Latino origin (n=22) and White subjects not of Hispanic or Latino origin (n=23) with type 2 diabetes mellitus. There were no statistically significant differences between the racial and ethnic groups investigated. Pregnancy The effect of pregnancy on the pharmacokinetics and pharmacodynamics of RYZODEG 70/30 has not been studied [see Use in Specific Populations]. Renal Impairment The effect of renal impairment on the pharmacokinetics of RYZODEG 70/30 has not been studied. The basal component of RYZODEG 70/30, insulin degludec, has been studied in a pharmacokinetic study in 32 subjects (n=4-8/group) with normal or impaired renal function/endstage renal disease following administration of a single subcutaneous dose (0.4 U/kg) of insulin degludec. Renal function was defined using creatinine clearance (Clcr) as follows: ≥ 90 mL/min (normal), 60-89 mL/min (mild), 30-59 mL/min (moderate) and < 30 mL/min (severe). Subjects requiring dialysis were classified as having end-stage renal disease (ESRD). Total (AUCIDeg,0- 120h,sD) and peak exposure of insulin degludec were on average about 10-25% and 13-27% higher, respectively in subjects with mild to severe renal impairment except subjects with ESRD who showed similar exposure as compared to subjects with normal renal function. No systematic trend was noted for this increase in exposure across different renal impairment subgroups. Hemodialysis did not affect clearance of insulin degludec (CL/FIDeg,SD) in subjects with ESRD. A single subcutaneous dose of 0.08 U/kg NOVOLOG (insulin aspart, the rapid-acting component of RYZODEG 70/30) was administered in a study to subjects with either normal, mild, moderate or severe (but not requiring hemodialysis) renal impairment. In this study, there was no apparent effect of creatinine clearance values on AUC and Cmax of insulin aspart. Hepatic Impairment The effect of hepatic impairment on the pharmacokinetics of RYZODEG 70/30 has not been studied. The basal component of RYZODEG 70/30, insulin degludec, has been studied in a pharmacokinetic study in 24 subjects (n=6/group) with normal or impaired hepatic function (mild, moderate, and severe hepatic impairment) following administration of a single subcutaneous dose (0.4 U/kg) of insulin degludec. No differences in the pharmacokinetics of insulin degludec were identified between healthy subjects and subjects with hepatic impairment [see Use in Specific Populations]. A single subcutaneous dose of 0.06 U/kg insulin aspart, the rapid-acting component of RYZODEG 70/30, was administered in an open-label, single-dose study of 24 subjects (n=6/group) with different degrees of hepatic impairment (mild, moderate, and severe). In this study, there was no correlation between the degree of hepatic failure and any insulin aspart pharmacokinetic parameter. Clinical Studies The efficacy of RYZODEG 70/30 administered once-daily with the main meal of the day in patients with type 1 diabetes and used with a mealtime insulin at remaining meals was evaluated in one randomized, open-label, treat-to-target, active-controlled trial. The efficacy of RYZODEG 70/30 administered once or twice daily with the main meal(s) in patients with type 2 diabetes when used with common oral anti-diabetic drugs was evaluated in four randomized, open-label, treat-to-target, active controlled trials. Patients treated with RYZODEG 70/30 achieved levels of glycemic control similar to those treated with LANTUS (insulin glargine U-100) and LEVEMIR (insulin detemir) and NOVOLOG MIX 70/30 (biphasic insulin aspart 70/30). Type 1 Diabetes - Adult Study A: RYZODEG 70/30 Administered with the Main Meal in Combination with a Rapid- Acting Insulin Analog at Remaining Meals The efficacy of RYZODEG 70/30 was evaluated in a 26-week randomized, open-label, multicenter trial in 548 patients with type 1 diabetes mellitus inadequately controlled on either a basal-bolus regimen or other insulin regimens at baseline. Patients were randomized to RYZODEG 70/30 once-daily administered at the main meal of the day or insulin detemir oncedaily at the evening meal or at bedtime. Insulin aspart was administered for the remaining insulin requiring meals. In patients randomized to detemir a second dose of insulin detemir could be added at breakfast after 8 weeks if glycemic control was inadequate. The mean age of the trial population was 41.3 years and mean duration of diabetes was 17.4 years. 49.6% were male. 90.3% were White, 2.9% Black or African American. 3.1% were Hispanic. 4.8 % of patients had eGFR < 60 mL/min/1.73m². The mean BMI was 26.4 kg/m². At week 26, the difference in HbA1c reduction from baseline between RYZODEG 70/30 and insulin detemir was - 0.05% with a 95% confidence interval of (-0.18%, 0.08%) and met the prespecified non-inferiority margin (0.4%). See Table 6. Table 6: Results at Week 26 in a Trial Comparing RYZODEG 70/30 to Insulin detemir in Patients with type 1 diabetes mellitus receiving Insulin aspart at mealtimes RYZODEG 70/30 + Insulin aspart Insulin detemir* + Insulin aspart N 366 182 HbA1c (%) Baseline 8.3 8.3 End of trial 7.6 7.6 Adjusted mean change from baseline ± -0.75 -0.7 Estimated treatment difference [95%CI] RYZODEG 70/30 v. Insulin detemir -0.05 [-0.18;0.08] Proportion Achieving HbA1c < 7% at Trial End 24.6% 20.3% FPG (mg/dL) Baseline 186 198 End of trial 156 155 Adjusted mean change from baseline -29.7 -33.8 Total Daily insulin dose** Baseline mean 56 U 56 U Mean dose after 26 weeks 69 U 79 U *Dosed once-daily or twice daily **Total daily insulin dose includes basal and bolus insulin doses ±The change from baseline to end of treatment visit in H bA1c was analysed using A N O V A with treatment, region, sex, and anti-diabetic treatment at screening as fixed effects, and age and baseline HbA1c as covariates. In Study A, there were 12.6% of subjects in RYZODEG 70/30 and 13.7% Insulin detemir arms for whom data was missing at the time of the HbA1c measurement. Type 2 Diabetes - Adult Study B: RYZODEG 70/30 Administered with the Main Meal as an Add-on to Metformin in Insulin Naive Patients The efficacy of RYZODEG 70/30 was evaluated in a 26-week randomized, open-label, multicenter trial in 529 insulin-naive patients with type 2 diabetes mellitus inadequately controlled on oral anti-diabetic drugs at baseline. Patients were randomized to RYZODEG 70/30 once-daily at breakfast or insulin glargine U-100 once-daily according to approved labeling. Metformin (Met) was administered in both arms. The mean age of the trial population was 56.9 years and mean duration of diabetes was 9.2 years. 49.3% were male. 72.4% were White, 6.4% Black or African American. 21.6% were Hispanic. 4.5% of patients had eGFR < 60 mL/min/1.73m². The mean BMI was 30.7 kg/m². At week 26, the difference in HbA1c reduction from baseline between RYZODEG 70/30 and insulin glargine U-100 was 0.03% with a 95% confidence interval of (-0.14%, 0.20%) and met the pre-specified non-inferiority margin (0.4%). See Table 7. Table 7: Results at Week 26 in a Trial Comparing RYZODEG 70/30 to Insulin glargine U- 100 in Insulin-naive Patients with type 2 diabetes mellitus RYZODEG 70/30 + Met Insulin glargine U-100 + Met N 266 263 HbA1c (%) Baseline 8.9 8.9 End of trial 7.2 7.2 Adjusted mean change from baseline ± -1.72 -1.75 Estimated treatment difference [95%CI] RYZODEG 70/30 v. Insulin glargine U-100 0.03 [-0.14;0.20] Proportion Achieving HbA1c < 7% at Trial End 45.9% 45.6% FPG (mg/dL) Baseline 183 187 End of trial 123 114 Adjusted mean change from baseline -63.3 -72.5 Post Prandial Glucose (mg/dL) Prandial increment at breakfast, baseline 61 65 Prandial increment at breakfast, end of trial 34 62 Adjusted mean change from baseline -27.2 -2.0 Estimated treatment difference [95%CI] RYZODEG 70/30 v. Insulin glargine U-100 -25.2 [-34.5; -15.9]1 Total Daily insulin dose Baseline mean 10 U 10 U Mean dose after 26 weeks 66 U 59 U 1p < 0.001, 1-sided p-value evaluated at 2.5% level for superiority ±The change from baseline to end of treatment visit in H bA1c was analysed using A N O V A with treatment, region, sex, and anti-diabetic treatment at screening as fixed effects, and age and baseline H bA 1c as covariates. In Study B, there were 17.7% of subjects in RYZODEG 70/30 and 12.9% Insulin glargine arms for whom data was missing at the time of the H bA1c measurement. Study C: RYZODEG 70/30 Administered with the Main Meal for Patients Inadequately Controlled on Once-Daily Basal Insulin and Oral Agents The efficacy of RYZODEG 70/30 was evaluated in a 26-week randomized, open-label, multicenter trial in 463 patients with type 2 diabetes mellitus inadequately controlled on basal insulin once-daily and oral antidiabetic drugs at baseline. Patients were randomized to RYZODEG 70/30 once-daily with either the evening meal or the largest meal of the day or insulin glargine U-100 once-daily according to approved labeling. The starting intervention insulin dose in units was determined by using the pre-trial basal insulin unit dose (1 to 1 unit conversion). The same oral anti-diabetic drugs were continued in both treatment arms which may have included any of the following used alone or in combination; Met, pioglitazone (Pio), DPP-4 inhibitors (DPP-4i) throughout the entire trial. The mean age of the trial population was 58.1 years and mean duration of diabetes was 11.5 years. 56.6% were male. 56.4% were White, 8.0% Black or African American. 4.5% were Hispanic. 8.3% of patients had eGFR < 60 mL/min/1.73m². The mean BMI was 30.1 kg/m². At week 26, the difference in HbA1c reduction from baseline between RYZODEG 70/30 and insulin glargine U-100 was -0.03% with a 95% confidence interval of (-0.20%, 0.14%) and met the pre-specified non-inferiority margin (0.4%). See Table 8. Table 8: Results at Week 26 in a Trial Comparing RYZODEG 70/30 to Insulin glargine U- 100 in Patients with type 2 diabetes mellitus RYZODEG 70/30 + Met ± Pio ± DPP-4i Insulin glargine U-100 + Met ± Pio ± DPP-4i N 230 233 HbA1c (%) Baseline 8.3 8.4 End of trial 7.3 7.4 Adjusted mean change from baseline ± -1.00 -0.97 Estimated treatment difference [95%CI] RYZODEG 70/30 v. Insulin glargine U-100 -0.03 [-0.20;0.14] Proportion Achieving HbAic < 7% at Trial End 40.0% 36.5% FPG (mg/dL) Baseline 144 141 End of trial 114 108 Adjusted mean change from baseline -28.9 -34.9 Post Prandial Glucose (mg/dL) Prandial increment at dinner, baseline 48 55 Prandial increment at dinner, end of trial 22 46 Adjusted mean change from baseline -32.3 -8.3 Estimated treatment difference [95%CI] RYZODEG 70/30 v. Insulin glargine U-100 -23.9 [-34.7;-13.0]1 Total Daily insulin dose Baseline mean 28 U 31 U Mean dose after 26 weeks 60 U 60 U p < 0.001, 1-sided p-value evaluated at 2.5% level for superiority ± The change from baseline to end of treatment visit in H bA 1c was analysed using A N O V A with treatment, region, sex, and anti-diabetic treatment at screening as fixed effects, and age and baseline HbA1c as covariates. In Study C, there were 14.8 % of subjects in RYZODEG 70/30 and 12% Insulin glargine arms for whom data was missing at the time of the HbA1c measurement. Type 2 Diabetes - Adult, BID Study D: RYZODEG 70/30 Administered with the Main Meal for Patients Inadequately Controlled on Once-Daily or Twice-Daily Pre-Mix or Self-mixed Insulin The efficacy of RYZODEG 70/30 was evaluated in a 26-week randomized, open-label, multicenter trial in 446 patients with type 2 diabetes mellitus inadequately controlled on once or twice daily premixed or self-mixed insulin with or without background oral anti-diabetic agents. Patients were randomized to RYZODEG 70/30 or biphasic insulin aspart 70/30, both administered twice daily before the breakfast and main evening meals. Subjects on premixed insulin twice daily initiated trial insulin at the same dose as their premixed insulin (1 to 1 unit conversion). Subjects on a self-mixed regimen transfer to trial insulin at doses corresponding to their respective self-mixed pre-meal dose. Subjects previously receiving premixed or self-mixed insulin once-daily were to divide their dose into 2 equal doses. Patients continued on pre-trial oral background therapies which may have included any of the following used alone or in combination; Met, Pio, DPP-4i throughout the entire trial. The mean age of the trial population was 58.7 years and mean duration of diabetes was 13.0 years. 55.6% were male. 52.5% were White, 0.2% Black or African American. 0.4% were Hispanic. 14.3% of patients had eGFR < 60 mL/min/1.73m². The mean BMI was 29.3 kg/m². At week 26, the difference in HbA1c reduction from baseline between RYZODEG 70/30 and biphasic insulin aspart 70/30 was -0.03% with a 95% confidence interval of (-0.18%, 0.13%) and met the pre-specified non-inferiority margin (0.4%). See Table 9. Table 9: Results at Week 26 in a Trial Comparing RYZODEG 70/30 to Biphasic insulin aspart 70/30 in Patients with type 2 diabetes mellitus RYZODEG 70/30 ± Met ± Pio ± DPP-4i Biphasic insulin aspart 70/30 ± Met ± Pio ± DPP-4i N 224 222 HbA1c (%) Baseline 8.3 8.4 End of trial 7.1 7.1 Adjusted mean change from baseline ± -1.31 -1.29 Estimated treatment difference [95%CI] RYZODEG 70/30 v. Biphasic insulin aspart 70/30 -0.03 [-0.18;0.13] Proportion Achieving HbA1c < 7% at Trial End 50.4% 48.6% FPG (mg/dL) Baseline 160 155 End of trial 104 123 Adjusted mean change from baseline -50.4 -29.8 Total Daily insulin dose Baseline mean 54 U 51 U Mean dose after 26 weeks 90 U 98 U ±The change from baseline to end of treatment visit in H bA 1c was analysed using A N O V A with treatment, region, sex, and anti-diabetic treatment at screening as fixed effects, and age and baseline H bA 1c as covariates. In Study D, there were 12.1 % of subjects in R YZODEG 70/30 and 15.3% Biphasic insulin aspart 70/30 arms for whom data was missing at the time of the H bA 1c measurement. Study E : RYZODEG 70/30 Administered with Any Main Meal for Patients Inadequately Controlled on Basal Insulin, Pre-Mix or Self-mixed Insulin The efficacy of RYZODEG 70/30 was evaluated in a 26-week randomized, open-label, multicenter trial in 422 patients with type 2 diabetes mellitus inadequately controlled on basal insulin, premixed or self-mixed insulin in a once or twice daily insulin with or without background Met. Patients were randomized to RYZODEG 70/30 or biphasic insulin aspart 70/30, both administered twice daily at the breakfast and main evening meal. Subjects on oncedaily insulin split the total dose of their previous insulin treatment into 2 equal doses of trial insulin for twice daily administration. Subjects on twice daily insulin transferred their doses on a unit-to-unit basis to the trial insulin. Patients on Met continued Met at their pre-trial dose. The mean age of the trial population was 59.8 years and mean duration of diabetes was 16.3 years. 54.5% were male. All patients were Asian. 17.2% of patients had eGFR < 60 mL/min/1.73m². The mean BMI was approximately 25.4 kg/m². At week 26, the difference in HbA1c reduction from baseline between RYZODEG 70/30 and biphasic insulin aspart 70/30 was 0.05% with a 95% confidence interval of (-0.10%, 0.20%) and met the pre-specified non-inferiority margin (0.4%). See Table 10. Table 10: Results at Week 26 in a Trial Comparing RYZODEG 70/30 to Biphasic insulin aspart 70/30 in Asian Patients with type 2 diabetes mellitus RYZODEG 70/30 ± Met Biphasic insulin aspart 70/30 ± Met N 280 142 HbA1c (%) Baseline 8.4 8.4 End of trial 7.1 7.0 Adjusted mean change from baseline ± -1.39 -1.44 Estimated treatment difference [95%CI] RYZODEG 70/30 v. Biphasic insulin aspart 70/30 0.05 [-0.10;0.20] Proportion Achieving HbA1c < 7% at Trial End 48.2% 49.3% FPG (mg/dL) Baseline 143 143 End of trial 97 116 Adjusted mean change from baseline -45.3 -26.2 Total Daily insulin dose Baseline mean 37 U 37 U Mean dose after 26 weeks 55 U 68 U ±The change from baseline to end of treatment visit in H bA 1c was analysed using A N O V A with treatment, region, sex, and anti-diabetic treatment at screening as fixed effects, and age and baseline H bA 1c as covariates. In Study E, there were 12.1 % of subjects in R YZODEG 70/30 and 10.6% Biphasic insulin aspart 70/30 arms for whom data was missing at the time of the H bA 1c measurement.

RYZODEG®70/30 (insulin degludec and insulin aspart) Injection DESCRIPTION RYZODEG 70/30 (insulin degludec and insulin aspart injection) is a human insulin analog solution containing 70% insulin degludec and 30% insulin aspart for subcutaneous injection. It consists of insulin degludec, a long-acting insulin, and insulin aspart, a rapid-acting insulin both of which function as parenteral blood-glucose-lowering agents [see CLINICAL PHARMACOLOGY]. Insulin degludec differs from human insulin in that the amino acid threonine in position B30 has been omitted and a side-chain consisting of glutamic acid and a C16 fatty acid has been attached (chemical name: LysB29(Ns-hexadecandioyl-y-Glu) des(B30) human insulin) and is produced by recombinant DNA technology utilizing Saccharomyces cerevisiae. Insulin degludec has a molecular formula of C274H411N65O81S6 and a molecular weight of 6103.97. Figure 1: Structural formula of insulin degludec Insulin aspart is homologous with regular human insulin with the exception of a single substitution of the amino acid proline by aspartic acid in position B28, and is produced by recombinant DNA technology utilizing Saccharomyces cerevisiae. Insulin aspart has a molecular formula of C256H381N65O79S6 and a molecular weight of 5825.8. Figure 2: Structural formula of insulin aspart RYZODEG 70/30 is a sterile, aqueous, clear, and colorless solution and contains a total of 100 Units of insulin degludec and insulin aspart mixture per mL, glycerol 19 mg/mL, metacresol 1.72 mg/mL, phenol 1.50 mg/mL, sodium chloride 0.58 mg/mL, zinc 27.4 mcg/mL and water for injection. RYZODEG 70/30 has a pH of approximately 7.4. Hydrochloric acid or sodium hydroxide may be added to adjust pH.

INDICATIONS RYZODEG 70/30 is indicated to improve glycemic control in adults with diabetes mellitus. Limitations of Use RYZODEG 70/30 is not recommended for the treatment of diabetic ketoacidosis DOSAGE AND ADMINISTRATION Important Administration Instructions Always check insulin label before administration [see WARNINGS AND PRECAUTIONS]. Inspect visually for particulate matter and discoloration. Only use RYZODEG 70/30 if the solution appears clear and colorless. Train patients on proper use and injection technique before initiating RYZODEG 70/30. Training reduces the risk of administration errors such as needle sticks and incomplete dosing. Inject RYZODEG 70/30 subcutaneously into the thigh, upper arm, or abdomen. Rotate injection sites within the same region from one injection to the next to reduce the risk of lipodystrophy [see ADVERSE REACTIONS]. DO NOT administer RYZODEG 70/30 intravenously, intramuscularly, or in an insulin infusion pump. DO NOT dilute or mix RYZODEG 70/30 with any other insulin products or solutions. General Dosing Instructions Inject RYZODEG 70/30 subcutaneously once or twice daily with any main meal. Administer a rapid- or a short-acting insulin at other meals if needed. Patients with type 1 diabetes, will generally require a rapid- or short-acting insulin at meals when RYZODEG 70/30 is not administered for optimal glucose control. Individualize and titrate the dose of RYZODEG 70/30 based on the patient's metabolic needs, blood glucose monitoring results, and glycemic control goal [see WARNINGS AND PRECAUTIONS]. Adjust the RYZODEG 70/30 dose according to blood glucose measurements before breakfast (fasting). The recommended time between dose increases is 3 to 4 days. Dose adjustments may be needed with changes in physical activity, changes in meal patterns (i.e., macronutrient content or timing of food intake), changes in renal or hepatic function or during acute illness to minimize the risk of hypoglycemia or hyperglycemia [see WARNINGS AND PRECAUTIONS]. If a dose of RYZODEG 70/30 is missed, the next dose should be taken with the next main meal of that day and thereafter resume the usual dosing schedule. Patients should not take an extra dose to make up for a missed dose. Starting Dose In Insulin-Naive Patients Type 1 Diabetes Mellitus The recommended starting dose of RYZODEG 70/30 in insulin-naive patients with type 1 diabetes is approximately one-third to one-half of the total daily insulin dose. The remainder of the total daily insulin dose should be administered as a short- or rapid-acting insulin divided between each daily meal. As a general rule, 0.2 to 0.4 units of insulin per kilogram of body weight can be used to calculate the initial total daily insulin dose in insulin-naive patients with type 1 diabetes. Type 2 Diabetes Mellitus The recommended starting dose of RYZODEG 70/30 in insulin-naive patients with type 2 diabetes mellitus is 10 units once daily. Starting Dose In Patients With Type 1 Or Type 2 Diabetes On A Once Or Twice Daily Premix Or Self-mix Insulin Alone Or As Part of A Regimen Of Multiple Daily Injections Start RYZODEG 70/30 at the same unit dose and injection schedule as the premix or self-mix insulin. In patients also using short- or rapid-acting insulin at mealtimes continue the short- or rapid-acting insulin at the same dose for meals NOT covered by RYZODEG 70/30. Starting Dose In Patients With Type 1 Or Type 2 Diabetes On A Once Or Twice Daily Basal Insulin Alone Or As Part Of A Regimen Of Multiple Daily Injections In patient with type 2 diabetes switching from a regimen that includes only a once- or twice-daily basal insulin, start RYZODEG 70/30 at the same unit dose and injection schedule. For patients switching from once-daily basal insulin to once-daily RYZODEG 70/30, monitor blood glucose after starting therapy due to the rapid-acting insulin component [see WARNINGS AND PRECAUTIONS]. In patients switching from a multiple daily injections regimen that includes a basal and short- or rapid-acting insulin at mealtimes, start RYZODEG 70/30 once daily with the main meal at the same unit dose as the basal insulin. Continue the short- or rapid-acting insulin at the same dose for meals NOT covered by RYZODEG 70/30. HOW SUPPLIED Dosage Forms And Strengths RYZODEG 70/30 is available as a clear and colorless solution for injection in: 100 units/mL (U-100): 3 mL FlexTouch disposable prefilled pen Storage And Handling RYZODEG 70/30 is as a clear, and colorless solution available as a 3mL FlexTouch disposable prefilled pen (see Table 11). Table 11 : Presentations of RYZODEG 70/30 RYZODEG 70/30 Total volume Concentration Total units available in presentation NDC number Max dose per injection Dose increment Packag Size U-100 FlexTouch 3 mL 100 units/mL 300 Units 0169-2770-15 80 Units 1 Unit 5 pens/p Recommended Storage Unused RYZODEG 70/30 should be stored between 36° to 46°F (2° and 8°C). Do not store in the freezer or directly adjacent to the refrigerator cooling element. Do not freeze. Do not use RYZODEG 70/30 if it has been frozen. Unopened FlexTouch disposable prefilled pen: Not in-use (unopened) RYZODEG 70/30 disposable prefilled pen should be stored in a refrigerator 36° to 46°F (2° and 8°C ). Discard after expiration date. Open (In-Use) FlexTouch disposable prefilled pen: The in-use RYZODEG 70/30 FlexTouch pen should NOT be refrigerated but should be kept at room temperature, below 30°C (86°F) away from direct heat and light. The opened (in-use) RYZODEG 70/30 FlexTouch pen may be used for up to 28 days (4 weeks) after being opened, if it is kept at room temperature. The storage conditions are summarized in Table 12: Table 12: Storage Conditions for RYZODEG 70/30 FlexTouch Not in-use (unopened) Refrigerated (36°F - 46°F [2°C - 8°C]) Not in-use (unopened) Room Temperature (below 86°F [30°C]) In-use (opened) Room Temperature (below 86°F [30°C]) 3 mL RYZODEG 70/30 U100 FlexTouch Until expiration date 28 days (4 weeks) 28 days (4 weeks) (Do not refrigerate) Manufactured by: Novo Nordisk A/S, DK-2880 Bagsvaerd, Denmark. For information about RYZODEG 70/30 contact: Novo Nordisk Inc.800 Scudders Mill Road, Plainsboro, NJ 08536, 1-800-727-6500. www.novonordi sk-us.com. Revised: Sep 2015

PATIENT INFORMATION RYZODEG® 70/30 (RY-zoh-deg) (insulin degludec and insulin aspart injection) Do not share your RYZODEG 70/30 FlexTouch delivery device with other people, even if the needle has been changed. You may give other people a serious infection, or get a serious infection from them. What is RYZODEG 70/30? RYZODEG 70/30 is a man-made insulin that is used to control high blood sugar in adults with diabetes mellitus. RYZODEG 70/30 is not for people with diabetic ketoacidosis (increased ketones in the blood or urine). It is not known if RYZODEG 70/30 is safe and effective in children under 18 years of age. Who should not take RYZODEG 70/30? Do not take RYZODEG 70/30 if you: are having an episode of low blood sugar (hypoglycemia). have an allergy to RYZODEG 70/30 or any of the ingredients in RYZODEG 70/30. Before taking RYZODEG 70/30, tell your healthcare provider about all your medical conditions including, if you are: pregnant, planning to become pregnant, or are breastfeeding. taking new prescription or over-the-counter medicines, vitamins, or herbal supplements. Before you start taking RYZODEG 70/30, talk to your healthcare provider about low blood sugar and how to manage it. How should I take RYZODEG 70/30? Read the Instructions for Use that come with your RYZODEG 70/30. Take RYZODEG 70/30 exactly as your healthcare provider tells you to. RYZODEG 70/30 starts acting fast. Inject RYZODEG 70/30 with your meal. If you take RYZODEG 70/30 1 time each day, take your dose with any main meal. If you take RYZODEG 70/30 2 times each day, take your dose with your 2 largest meals. Know the type and strength of insulin you take. Do not change the type of insulin you take unless your healthcare provider tells you to. The amount of insulin and the best time for you to take your insulin may need to change if you take different types of insulin. If you miss or are delayed in taking a dose of RYZODEG 70/30: Take your next dose with your next main meal on the same day and continue with your regular dosing schedule. Do not take an extra dose. Check your blood sugar levels. Ask your healthcare provider what your blood sugars should be and when you should check your blood sugar levels. Do not reuse or share needles with other people. You may give other people a serious infection or get a serious infection from them. Never inject RYZODEG 70/30 into a vein or muscle. Never use a syringe to remove RYZODEG 70/30 from the FlexTouch pen. What should I avoid while taking RYZODEG 70/30? While taking RYZODEG 70/30 do not: Drive or operate heavy machinery, until you know how RYZODEG 70/30 affects you. Drink alcohol or use prescription or over-the-counter medicines that contain alcohol. What are the possible side effects of RYZODEG 70/30? RYZODEG 70/30 may cause serious side effects that can lead to death, including: Low blood sugar (hypoglycemia). Signs and symptoms that may indicate low blood sugar include: dizziness or light-headedness blurred vision anxiety, irritability, or mood changes sweating slurred speech hunger confusion shakiness headache fast heart beat Low potassium in your blood (hypokalemia). Heart failure. Taking certain diabetes pills called thiazolidinediones or “TZDs” with RYZODEG 70/30 may cause heart failure in some people. This can happen even if you have never had heart failure or heart problems before. If you already have heart failure, it may get worse while you take TZDs with RYZODEG 70/30. Your healthcare provider should monitor you closely while you are taking TZDs with RYZODEG 70/30. Tell your healthcare provider if you have any new or worse symptoms of heart failure including shortness of breath, swelling of your ankles or feet, tiredness, sudden weight gain. Treatment with TZDs and RYZODEG 70/30 may need to be adjusted or stopped by your healthcare provider if you have new or worse heart failure. Your insulin dose may need to change because of: change in level of physical activity or exercise increased stress change in diet weight gain or loss illness Common side effects of RYZODEG 70/30 may include: serious allergic reactions (whole body reactions), reactions at the injection site, skin thickening or pits at the injection site (lipodystrophy), itching, rash, swelling of your hands and feet, and weight gain. Get emergency medical help if you have: trouble breathing, shortness of breath, fast heartbeat, swelling of your face, tongue, or throat, sweating, extreme drowsiness, dizziness, confusion. These are not all the possible side effects of RYZODEG 70/30. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. General information about the safe and effective use of RYZODEG 70/30. Medicines are sometimes prescribed for purposes other than those listed in a Patient Information leaflet. You can ask your pharmacist or healthcare provider for information about RYZODEG 70/30 that is written for health professionals. Do not use RYZODEG 70/30 for a condition for which it was not prescribed. Do not give RYZODEG 70/30 to other people, even if they have the same symptoms that you have. It may harm them. What are the ingredients in RYZODEG 70/30? Active Ingredient: 70% insulin degludec and 30% insulin aspart Inactive Ingredients: zinc, metacresol, glycerol, phenol, sodium chloride, and water for injection. Hydrochloric acid or sodium hydroxide may be added. Instructions for Use RYZODEG®70/30 (RY-zoh-deg) FlexTouch®Pen 100 units/mL (insulin degludec and insulin aspart injection) Do not share your RYZODEG 70/30 FlexTouch Pen with other people, even if the needle is changed. You may give other people a serious infection, or get a serious infection from them. RYZODEG 70/30 FlexTouch Pen 100 units/mL (“Pen”) is a prefilled disposable pen containing 300 units of RYZODEG 70/30 (insulin degludec and insulin aspart injection) 100 units/mL insulin. You can inject from 1 to 80 units in a single injection. The units can be increased by 1 unit at a time. This Pen is not recommended for use by the blind or visually impaired without the assistance of a person trained in the proper use of the product. Supplies you will need to give your RYZODEG 70/30 injection: RYZODEG 70/30 FlexTouch Pen a new NovoFine or NovoTwist needle alcohol swab a sharps container for throwing away used Pens and needles. See “After your injection” at the end of these instructions. Preparing your RYZODEG 70/30 FlexTouch Pen: Wash your hands with soap and water. Before you start to prepare your injection, check the RYZODEG 70/30 FlexTouch Pen label to make sure you are taking the right type of insulin. This is especially important if you take more than 1 type of insulin. RYZODEG 70/30 should look clear and colorless. Do not use RYZODEG 70/30 if it is cloudy or colored. Do not use RYZODEG 70/30 past the expiration date printed on the label or 28 days after you start using the Pen. Always use a new needle for each injection to help ensure sterility and prevent blocked needles. Do not reuse or share needles with another person. You may give other people a serious infection, or get a serious infection from them. Figure A Step 1: Pull Pen cap straight off (See Figure B). Figure B Step 2: Check the liquid in the Pen (See Figure C). RYZODEG 70/30 should look clear and  colorless. Do not use it if it looks cloudy or colored. Figure C Step 3: Select a new needle. Pull off the paper tab from the outer needle cap (See Figure D). Figure D Step 4: Push the capped needle straight onto the Pen and twist the needle on until it is tight (See Figure E). Figure E Step 5: Pull off the outer needle cap. Do not throw it away (See Figure F). Figure F Step 6: Pull off the inner needle cap and throw it away (See Figure G). Figure G Priming your RYZODEG 70/30 FlexTouch Pen: Step 7: Turn the dose selector to select 2 units (See Figure H). 2 units selected Figure H Step 8: Hold the Pen with the needle pointing up. Tap the top of the Pen gently a few times to let any air bubbles rise to the top (See Figure I). Figure I Step 9: Hold the Pen with the needle pointing up. Press and hold in the dose button until the dose counter shows “0”. The “0” must line up with the dose pointer. A drop of insulin should be seen at the needle tip (See Figure J). If you do not see a drop of insulin, repeat steps 7 to 9, no more than 6 times. If you still do not see a drop of insulin, change the needle and repeat steps 7 to 9. Figure J Selecting your dose: Step 10: Check to make sure the dose selector is set at 0. Turn the dose selector to select the number of units you need to inject. The dose pointer should line up with your dose (See Figure K). If you select the wrong dose, you can turn the dose selector forwards or backwards to the correct dose. The even numbers are printed on the dial. The odd numbers are shown as lines. Figure K The RYZODEG 70/30 FlexTouch Pen insulin scale will show you how much insulin is left in your Pen (See Figure L). Example Approx. 200 units left Figure L To see how much insulin is left in your RYZODEG 70/30 FlexTouch Pen: Turn the dose selector until it stops. The dose counter will line up with the number of units of insulin that is left in your Pen. If the dose counter shows 80, there are at least 80 units left in your Pen. If the dose counter shows less than 80, the number shown in the dose counter is the number of units left in your Pen. Giving your injection: Inject your RYZODEG 70/30 exactly as your healthcare provider has shown you. Your healthcare provider should tell you if you need to pinch the skin before injecting. RYZODEG 70/30 can be injected under the skin (subcutaneously) of your upper legs (thighs), upper arms, or stomach area (abdomen). Change (rotate) your injection sites within the area you choose for each dose. Do not use the same injection site for each injection. Step 11: Choose your injection site and wipe the skin with an alcohol swab (See Figure M). Let the injection site dry before you inject your dose. Figure M Step 12: Insert the needle into your skin (See Figure N). Make sure you can see the dose counter. Do not cover it with your fingers, this can stop your injection. Figure N Step 13: Press and hold down the dose button until the dose counter shows “0” (See Figure O). The “0” must line up with the dose pointer. You may then hear or feel a click. Figure O Keep the needle in your skin after the dose counter has returned to “0” and slowly count to 6 (See Figure P). When the dose counter returns to “0”, you will not get your full dose until 6 seconds later. If the needle is removed before you count to 6, you may see a stream of insulin coming from the needle tip. If you see a stream of insulin coming from the needle tip you will not get your full dose. If this happens you should check your blood sugar levels more often because you may need more insulin. Figure P Step 14: Pull the needle out of your skin (See Figure Q). If you see blood after you take the needle out of your skin, press the injection site lightly with a piece of gauze or an alcohol swab. Do not rub the area. Figure Q Step 15: Carefully remove the needle from the Pen and throw it away (See Figure R). Do not recap the needle. Recapping the needle can lead to needle stick injury. Figure R If you do not have a sharps container, carefully slip the needle into the outer needle cap (See Figure S). Safely remove the needle and throw it away as soon as you can. Figure S Do not store the Pen with the needle attached. Storing without the needle attached helps prevent leaking, blocking of the needle, and air from entering the Pen. Step 16 Replace the Pen cap by pushing it straight on (See Figure T). Figure T After your injection: Put your used RYZODEG 70/30 FlexTouch Pen and needles in a FDA-cleared sharps disposal container right away after use. Do not throw away (dispose of) loose needles and Pens in your household trash. If you do not have a FDA-cleared sharps disposal container, you may use a household container that is: made of a heavy-duty plastic can be closed with a tight-fitting, puncture-resistant lid, without sharps being able to come out upright and stable during use leak-resistant properly labeled to warn of hazardous waste inside the container When your sharps disposal container is almost full, you will need to follow your community guidelines for the right way to dispose of your sharps disposal container. There may be state or local laws about how you should throw away used needles and syringes. Do not reuse or share needles or syringes with another person. For more information about the safe sharps disposal, and for specific information about sharps disposal in the state that you live in, go to the FDA's website at: http://www.fda.gov/safesharpsdisposal. Do not dispose of your used sharps disposal container in your household trash unless your community guidelines permit this. Do not recycle your used sharps disposal container. How should I store my RYZODEG 70/30 FlexTouch Pen? Before use: Store unused RYZODEG 70/30 FlexTouch Pens in the refrigerator at 36°F to 46°F (2°C to 8°C). Do not freeze RYZODEG 70/30. Do not use RYZODEG 70/30 if it has been frozen. Unused Pens may be used until the expiration date printed on the label, if kept in the refrigerator. Pen in use: Store the Pen you are currently using out of the refrigerator below 86°F. Keep RYZODEG 70/30 away from heat or light. The RYZODEG 70/30 FlexTouch Pen you are using should be thrown away after 28 days, even if it still has insulin left in it and the expiration date has not passed. General Information about the safe and effective use of RYZODEG 70/30. Keep RYZODEG 70/30 FlexTouch Pens and needles out of the reach of children. Always use a new needle for each injection. Do not share RYZODEG 70/30 FlexTouch Pens or needles with other people. You may give other people a serious infection, or get a serious infection from them. This Instructions for Use has been approved by the U.S. Food and Drug Administration.

SIDE EFFECTS The following adverse reactions are also discussed elsewhere: Hypoglycemia [see WARNINGS AND PRECAUTIONS] Hypersensitivity and allergic reactions [see WARNINGS AND PRECAUTIONS] Hypokalemia [see WARNINGS AND PRECAUTIONS] Clinical Trial 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 of RYZODEG 70/30 in subjects with type 1 diabetes or type 2 diabetes was evaluated in five treat-to-target trials of 6-12 month duration [see Clinical Studies]. The data in Table 1 reflect the exposure of 362 patients with type 1 diabetes to RYZODEG 70/30, with a mean exposure duration to RYZODEG 70/30 of 43 weeks. The mean age was 41 years and 1% were older than 75 years. Fifty-two percent were male, 91% were White, 3% were Black or African American and 3% were Hispanic. The mean body mass index (BMI) was 26 kg/m². The mean duration of diabetes was 17 years and the mean HbA1c at baseline was 8.3%. A history of neuropathy, ophthalmopathy, nephropathy and cardiovascular disease at baseline was reported in 19%, 25%, 6% and 4% respectively. The mean eGFR at baseline was 88 mL/min/1.73 m² and 6% of patients had an eGFR less than 60 mL/min/1.73 m². The data in Table 2 reflect the exposure of 998 patients with type 2 diabetes to RYZODEG 70/30 with a mean exposure duration to RYZODEG 70/30 of 24 weeks. The mean age was 58 years and 3% were older than 75 years. Fifty-four percent were male, 44% were White, 4% were Black or African American and 6% were Hispanic. The mean BMI was 29 kg/m². The mean duration of diabetes was 12 years and the mean HbA1c at baseline was 8.5%. A history of neuropathy, ophthalmopathy, nephropathy and cardiovascular disease at baseline was reported for 15%, 21%, 10% and 1% respectively. At baseline, the mean eGFR was 84 mL/min/1.73 m² and 11% of patients had an eGFR less than 60 mL/min/1.73 m . Common adverse reactions (excluding hypoglycemia) occurring in RYZODEG 70/30-treated subjects during clinical trials in patients with type 1 diabetes mellitus and type 2 diabetes mellitus are listed in Table 1 and Table 2, respectively. Common adverse reactions were defined as reactions occurring in ≥ 5% of the population studied. Hypoglycemia is not shown in these tables but discussed in a dedicated subsection below. Table 1: Adverse Reactions Occurring in ≥ 5% of RYZODEG 70/30-Treated Patients with Type 1 Diabetes Mellitus Adverse Reaction RYZODEG 70/30 (N=362) Nasopharyngitis 24.6 % Headache 9.7 % Upper respiratory tract infection 9.1 % Influenza 6.9 % Table 2: Adverse Reactions Occurring in ≥ 5% of RYZODEG 70/30-Treated Patients with Type 2 Diabetes Mellitus Adverse Reaction RYZODEG 70/30 (N=998) Nasopharyngitis 11.1 % Upper respiratory tract infection 5.7 % Headache 5.6 % Hypoglycemia Hypoglycemia is the most commonly observed adverse reaction in patients using insulin, including RYZODEG 70/30 [see WARNINGS AND PRECAUTIONS]. The rates of reported hypoglycemia depend on the definition of hypoglycemia used, diabetes type, insulin dose, intensity of glucose control, background therapies, and other intrinsic and extrinsic patient factors. For these reasons, comparing rates of hypoglycemia in clinical trials for RYZODEG 70/30 with the incidence of hypoglycemia for other products may be misleading and also, may not be representative of hypoglycemia rates that occur in clinical practice. Rates of hypoglycemia by trial are shown in Table 3 for type 1 diabetes and Table 4 for type 2 diabetes for patients treated with RYZODEG 70/30 [see Clinical Studies]. Severe hypoglycemia was defined as an episode requiring assistance of another person to actively administer carbohydrate, glucagon, or other resuscitative actions. A Novo Nordisk hypoglycemia episode was defined as a severe hypoglycemia episode or an episode where a laboratory or a self-measured glucose calibrated to plasma was less than 56 mg/dL or where a whole blood glucose was less than 50 mg/dL (i.e., with or without the presence of hypoglycemic symptoms). Table 3: Percent (%) of Patients with Type 1 Diabetes Experiencing at Least One Episode of Severe Hypoglycemia or Novo Nordisk Hypoglycemia§ on RYZODEG 70/30 in Adult Clinical Trials Study A RYZODEG 70/30 OD* + INSULIN ASPART BID**, 52 weeks (N=362) Severe hypoglycemia Percent of patients 13.3% Novo Nordisk hypoglycemia§ Percent of patients 95.0% *OD: once daily **BID: twice daily §Novo Nordisk hypoglycemia : a severe hypoglycemia episode or an episode where a laboratory or a self-measured glucose calibrated to plasma was less than 56 mg/dL or where a whole blood glucose was less than 50 mg/dL (i.e., with or without the presence of hypoglycemic symptoms). Table 4: Percent (%) of Patients with Type 2 Diabetes Experiencing at Least One Episode of Severe Hypoglycemia or Novo Nordisk Hypoglycemia§ on RYZODEG 70/30 in Adult Clinical Trials Study B RYZODEG 70/30 OD* insulin naive, previously on 2 or more OADs*** (N=265) Study C RYZODEG 70/30 OD* previously on basal insulin OD and 1 or more OADs*** (N=230) Study D RYZODEG 70/30 BID** previously on OD*/BID premix/self-mix, ±OADs*** (N=224) Study E RYZODEG 70/30 BID** previously on OD*/BID basal/ premix/ self-mix, ±OADs*** (N=279) Severe hypoglycemia Percent of patients 0.4% 0% 3.1% 1.4% Novo Nordisk hypoglycemia Percent of patients 49.8% 52.6% 66.1% 73.5% *OD: once daily **BID: twice daily ***OAD: oral anti-diabetic agent §Novo Nordisk hypoglycemia: a severe hypoglycemia episode or an episode where a laboratory or a self-measured glucose calibrated to plasma was less than 56 mg/dL or where a whole blood glucose was less than 50 mg/dL (i.e., with or without the presence of hypoglycemic symptoms). Allergic Reactions Severe, life-threatening, generalized allergy, including anaphylaxis, generalized skin reactions, angioedema, bronchospasm, hypotension, and shock may occur with any insulin, including RYZODEG 70/30 and may be life threatening [see WARNINGS AND PRECAUTIONS].  Hypersensitivity (manifested with swelling of tongue and lips, diarrhea, nausea, tiredness and itching) and urticaria were reported in 0.5% of patients treated with RYZODEG 70/30. Lipodystrophy Long-term use of insulin, including RYZODEG 70/30, can cause lipodystrophy at the site of repeated insulin injections. Lipodystrophy includes lipohypertrophy (thickening of adipose tissue) and lipoatrophy (thinning of adipose tissue), and may affect insulin absorption. Rotate insulin injection sites within the same region to reduce the risk of lipodystrophy [see DOSAGE AND ADMINISTRATION]. In the clinical program, lipodystrophy was reported in 0.1% of patients treated with RYZODEG 70/30. Injection Site Reactions Patients taking RYZODEG 70/30 may experience injection site reactions, including injection site hematoma, pain, hemorrhage, erythema, nodules, swelling, discoloration, pruritis, warmth, and injection site mass. In the clinical program, injection site reactions occurred in 2.0% of patients treated with RYZODEG 70/30. Weight Gain Weight gain can occur with insulin therapy, including RYZODEG 70/30, and has been attributed to the anabolic effects of insulin. In the clinical program, patients with type 1 diabetes treated with RYZODEG 70/30 gained an average of 2.8 kg and patients with type 2 diabetes treated with RYZODEG 70/30 gained an average of 1.6 kg. Peripheral Edema Insulin, including RYZODEG 70/30, may cause sodium retention and edema. In the clinical program, peripheral edema, occurred in 2.2% of patients with type 1 diabetes mellitus and 1.8% of patients with type 2 diabetes mellitus treated with RYZODEG 70/30. Immunogenicity As with all therapeutic proteins, insulin administration may cause anti-insulin antibodies to form. The detection of antibody formation is highly dependent on the sensitivity and specificity of the assay and may be influenced by several factors such as: assay methodology, sample handling, timing of sample collection, concomitant medication, and underlying disease. For these reasons, comparison of the incidence of antibodies to RYZODEG 70/30 with the incidence of antibodies in other studies or to other products, may be misleading. In studies of type 1 diabetes patients, 95.9% of patients who received RYZODEG 70/30 once daily were positive for anti-insulin antibodies (AIA) at least once during the studies, including 89% that were positive at baseline, while 13% of these patients were positive for anti-IAsp antibodies at least once during the studies, including 6.4% who were positive at baseline. In studies of type 2 diabetes patients, 67.5% of patients who received RYZODEG 70/30 once daily were positive for AIA at least once during the studies, including 45.4% that were positive at baseline, while 17.1% of these patients were positive for anti-IAsp antibodies at least once during the studies, including 12.3% who were positive at baseline. The antibody incidence rates for type 2 diabetes may be underreported due to potential assay interference by endogenous insulin in samples in these patients. The presence of antibodies that affect clinical efficacy may necessitate dose adjustments to correct for tendencies toward hyper- or hypoglycemia. The incidence of anti-insulin degludec antibodies has not been established. DRUG INTERACTIONS Table 5 includes clinically significant drug interactions with RYZODEG 70/30. Table 5: Clinically Significant Drug Interactions with RYZODEG 70/30 Drugs That May Increase the Risk of Hypoglycemia Drugs: Antidiabetic agents, ACE inhibitors, angiotensin II receptor blocking agents, disopyramide, fibrates, fluoxetine, monoamine oxidase inhibitors, pentoxifylline, pramlintide, propoxyphene, salicylates, somatostatin analogs (e.g., octreotide), and sulfonamide antibiotics, GLP-1 receptor agonists, DPP-4 inhibitors, SGLT-2 inhibitors. Intervention: Dose reductions and increased frequency of glucose monitoring may be required when RYZODEG 70/30 is co-administered with these drugs. Drugs That May Decrease the Blood Glucose Lowering Effect of RYZODEG 70/30 Drugs: Atypical antipsychotics (e.g., olanzapine and clozapine), corticosteroids, danazol, diuretics, estrogens, glucagon, isoniazid, niacin, oral contraceptives, phenothiazines, progestogens (e.g., in oral contraceptives), protease inhibitors, somatropin, sympathomimetic agents (e.g., albuterol, epinephrine, terbutaline), and thyroid hormones. Intervention: Dose increases and increased frequency of glucose monitoring may be required when RYZODEG 70/30 is co-administered with these drugs. Drugs That May Increase or Decrease the Blood Glucose Lowering Effect of RYZODEG 70/30 Drugs: Alcohol, beta-blockers, clonidine, and lithium salts. Pentamidine may cause hypoglycemia, which may sometimes be followed by hyperglycemia. Intervention: Dose adjustment and increased frequency of glucose monitoring may be required when RYZODEG 70/30 is co-administered with these drugs. Drugs That May Blunt Signs and Symptoms of Hypoglycemia Drugs: Beta-blockers, clonidine, guanethidine, and reserpine. Intervention: Increased frequency of glucose monitoring may be required when RYZODEG 70/30 is co-administered with these drugs.

WARNINGS Included as part of the PRECAUTIONS section. PRECAUTIONS Never Share A RYZODEG 70/30 FlexTouch Pen Between Patients RYZODEG 70/30 FlexTouch disposable prefilled pen should never be shared between patients, even if the needle is changed. Sharing poses a risk for transmission of blood-borne pathogens. Hyperglycemia Or Hypoglycemia With Changes In Insulin Regimen Changes in insulin, manufacturer, type, or method of administration may affect glycemic control and predispose to hypoglycemia or hyperglycemia. These changes should be made cautiously and only under medical supervision and the frequency of blood glucose monitoring should be increased. For patients with type 2 diabetes, adjustments in concomitant oral anti-diabetic treatment may be needed. When converting from other insulin therapies to RYZODEG 70/30 follow dosing recommendations [see DOSAGE AND ADMINISTRATION]. Hypoglycemia Hypoglycemia is the most common adverse reaction of insulin, including RYZODEG 70/30 [see ADVERSE REACTIONS]. Severe hypoglycemia can cause seizures, may be life-threatening or cause death. Hypoglycemia can impair concentration ability and reaction time; this may place an individual and others at risk in situations where these abilities are important (e.g., driving or operating other machinery). RYZODEG 70/30, or any insulin, should not be used during episodes of hypoglycemia [see CONTRAINDICATIONS]. Hypoglycemia can happen suddenly and symptoms may differ in each individual and change over time in the same individual. Symptomatic awareness of hypoglycemia may be less pronounced in patients with longstanding diabetes, in patients with diabetic nerve disease, in patients using medications that block the sympathetic nervous system (e.g., beta-blockers) )[see DRUG INTERACTIONS, or in patients who experience recurrent hypoglycemia. Risk Factors for Hypoglycemia The risk of hypoglycemia generally increases with intensity of glycemic control. The risk of hypoglycemia after an injection is related to the duration of action of the insulin [see CLINICAL PHARMACOLOGY] and, in general, is highest when the glucose lowering effect of the insulin is maximal. As with all insulin preparations, the glucose lowering effect time course of RYZODEG 70/30 may vary in different individuals or at different times in the same individual and depends on many conditions, including the area of injection as well as the injection site blood supply and temperature. Other factors which may increase the risk of hypoglycemia include changes in meal pattern (e.g., macronutrient content or timing of meals), changes in level of physical activity, or changes to coadministered medication [see DRUG INTERACTIONS]. Patients with renal or hepatic impairment may be at higher risk of hypoglycemia [see Use in Specific Populations]. Risk Mitigation Strategies for Hypoglycemia Patients and caregivers must be educated to recognize and manage hypoglycemia. Selfmonitoring of blood glucose plays an essential role in the prevention and management of hypoglycemia. In patients at higher risk for hypoglycemia and patients who have reduced symptomatic awareness of hypoglycemia, increased frequency of blood glucose monitoring is recommended. Hypoglycemia Due To Medication Errors Accidental mix-ups between insulin products have been reported. To avoid medication errors between RYZODEG 70/30 and other insulins, instruct patients to always check the insulin label before each injection. Do not transfer RYZODEG 70/30 from the RYZODEG 70/30 pen to a syringe. The markings on the insulin syringe will not measure the dose correctly and can result in overdosage and severe hypoglycemia [see DOSAGE AND ADMINISTRATION and Hypoglycemia above]. Hypersensitivity And Allergic Reactions Severe, life-threatening, generalized allergy, including anaphylaxis, can occur with insulin products, including RYZODEG 70/30. If hypersensitivity reactions occur, discontinue RYZODEG 70/30; treat per standard of care and monitor until symptoms and signs resolve. RYZODEG 70/30 is contraindicated in patients who have had hypersensitivity reactions to insulin degludec, insulin aspart, or one of the excipients [see CONTRAINDICATIONS]. Hypokalemia All insulin products, including RYZODEG 70/30, cause a shift in potassium from the extracellular to intracellular space, possibly leading to hypokalemia. Untreated hypokalemia may cause respiratory paralysis, ventricular arrhythmia, and death. Monitor potassium levels in patients at risk for hypokalemia if indicated (e.g., patients using potassium-lowering medications, patients taking medications sensitive to potassium concentrations). Fluid Retention And Congestive Heart Failure With Concomitant Use Of A PPAR Gamma Agonist Thiazolidinediones (TZDs), which are peroxisome proliferator-activated receptor (PPAR)- gamma agonists can cause dose related fluid retention, particularly when used in combination with insulin. Fluid retention may lead to or exacerbate congestive heart failure. Patients treated with insulin, including RYZODEG 70/30 and a PPAR-gamma agonist should be observed for signs and symptoms of congestive heart failure. If congestive heart failure develops, it should be managed according to current standards of care and discontinuation or dose reduction of the PPAR-gamma agonist must be considered. Patient Counseling Information See FDA-Approved Patient Labeling (Patient Information and Instructions for Use) Never Share a RYZODEG 70/30 FlexTouch Pen Device Between Patients Advise patients that they should never share a RYZODEG 70/30 FlexTouch pen device with another person, even if the needle is changed, because doing so carries a risk for transmission of blood-borne pathogens [see WARNINGS AND PRECAUTIONS]. Hyperglycemia or Hypoglycemia Inform patients that hypoglycemia is the most common adverse reaction with insulin. Inform patients of the symptoms of hypoglycemia. Inform patients that the ability to concentrate and react may be impaired as a result of hypoglycemia. This may present a risk in situations where these abilities are especially important, such as driving or operating other machinery. Advise patients who have frequent hypoglycemia or reduced or absent warning signs of hypoglycemia to use caution when driving or operating machinery. Advise patients that changes in insulin regimen can predispose to hyper- or hypoglycemia. Advise patients that changes in insulin regimen should be made under close medical supervision [see WARNINGS AND PRECAUTIONS]. Medication errors Inform patients to always check the insulin label before each injection [see WARNINGS AND PRECAUTIONS]. Instruct patients that when injecting RYZODEG 70/30, they must press and hold down the dose button until the dose counter shows 0 and then keep the needle in the skin and count slowly to 6. When the dose counter returns to 0, the prescribed dose is not completely delivered until 6 seconds later. If the needle is removed earlier, they may see a stream of insulin coming from the needle tip. If so, the full dose will not be delivered, (a possible under-dose may occur by as much as 20%), and they should increase the frequency of checking their blood glucose levels and possible additional insulin administration may be necessary. If 0 does not appear in the dose counter after continuously pressing the dose button, the patient may have used a blocked needle. In this case they would not have received any insulin—even though the dose counter has moved from the original dose that was set. If the patient did have a blocked or damaged needle, instruct them to change the needle as described in Step 15 of the Instructions for Use and repeat all steps in the IFU starting with a new needle and the section Preparing your RYZODEG 70/30 FlexTouch Pen. Make sure the patient selects the full dose needed. If patients routinely do not hold the needle under the skin as recommended, the patient may need to slightly increase the dialed insulin dose to achieve the patient's glycemic targets. Instruct patients to not re-use needles. A new needle must be attached before each injection. Reuse of needles increases the risk of blocked needles which may cause under-dosing or overdosing. Instruct Patients to never use a syringe to remove RYZODEG 70/30 from the FlexTouch disposable insulin prefilled pen. Administration RYZODEG 70/30 must only be used if the solution is clear and colorless with no particles visible. Patients must be advised that RYZODEG 70/30 must NOT be diluted or mixed with any other insulin or solution [see DOSAGE AND ADMINISTRATION]. Management of Hypoglycemia and Handling of Special Situations Patients should be instructed on self-management procedures including glucose monitoring, proper injection technique, and management of hypoglycemia and hyperglycemia. Patients must be instructed on handling of special situations such as intercurrent conditions (illness, stress, or emotional disturbances), an inadequate or skipped insulin dose, inadvertent administration of an increased insulin dose, inadequate food intake, and skipped meals [see WARNINGS AND PRECAUTIONS]. Refer patients to the RYZODEG 70/30 “Patient Information” for additional information about the potential side effects of insulin therapy, including lipodystrophy (and the need to rotate injection sites within the same body region), weight gain, allergic reactions, and hypoglycemia. Women of Reproductive Potential Advise patients to inform their health care professional if they are pregnant or are contemplating pregnancy. Nonclinical Toxicology Carcinogenesis, Mutagenesis, Impairment Of Fertility Standard 2-year carcinogenicity studies in animals have not been performed to evaluate the carcinogenic potential of insulin degludec/aspart RYZODEG 70/30. In a 52-week study including human insulin (NPH insulin) as comparator, Sprague-Dawley rats were dosed subcutaneously with insulin degludec, the basal component of insulin degludec/aspart RYZODEG 70/30 at 3.3, 6.7, and 10 U/kg/day resulting in 5 times the human exposure (AUC) when compared to a human subcutaneous dose of 1.08 U/kg/day RYZODEG 70/30. Human insulin was dosed at 6.7 U/kg/day. No treatment-related increases in incidences of hyperplasia, benign or malignant tumors were recorded in female mammary glands from rats dosed with insulin degludec and no treatment related changes in the female mammary gland cell proliferation were found using BrdU incorporation. Further, no treatment related changes in the occurrence of hyperplastic or neoplastic lesions were seen in other tissues in animals dosed with insulin degludec when compared to vehicle or human insulin. In 52-week studies, Sprague-Dawley rats were dosed subcutaneously with insulin aspart, the rapid-acting component of insulin degludec/aspart RYZODEG 70/30, at 10, 50, and 200 U/kg/day (approximately 2, 8, and 32 times the human subcutaneous dose of 1.0 U/kg/day, based on U/body surface area, respectively). At a dose of 200 U/kg/day, insulin aspart increased the incidence of mammary gland tumors in females when compared to untreated controls. The incidence of mammary tumors found with insulin aspart was not significantly different from that found with regular human insulin. The relevance of these findings to humans is not known. Genotoxicity testing of insulin degludec was not performed. Insulin aspart was not genotoxic in the following tests: Ames test, mouse lymphoma cell forward gene mutation test, human peripheral blood lymphocyte chromosome aberration test, in vivo micronucleus test in mice, and ex vivo UDS test in rat liver hepatocytes. In a combined fertility and embryo-fetal study in male and female rats, treatment with insulin degludec up to 21 U/kg/day (approximately 5 times the human subcutaneous dose of 0.75 U/kg/day, based on U/body surface area) prior to mating and in female rats during gestation had no effect on mating performance. In fertility studies with insulin aspart (NOVOLOG) in male and female rats, at subcutaneous doses up to 200 U/kg/day (approximately 32 times the human subcutaneous dose, based on U/body surface area), no direct adverse effects on male and female fertility, or general reproductive performance of animals was observed. Use In Specific Populations Pregnancy Pregnancy Category C There are no adequate well-controlled clinical studies of the use of insulin degludec/insulin aspart in pregnant women. Patients should be advised to discuss with their health care provider if they intend to or if they become pregnant. Because animal reproduction studies are not always predictive of human response, insulin degludec/insulin aspart should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. It is essential for patients with diabetes or a history of gestational diabetes to maintain good metabolic control before conception and throughout pregnancy. Insulin requirements may decrease during the first trimester, generally increase during the second and third trimesters, and rapidly decline after delivery. Careful monitoring of glucose control is essential in these patients. An open-label, randomized study compared the safety and efficacy of NOVOLOG (insulin aspart, the rapid-acting component of RYZODEG 70/30) versus human insulin in the treatment of pregnant women with Type 1 diabetes (322 exposed pregnancies (insulin aspart: 157, human insulin: 165). Two-thirds of the enrolled patients were already pregnant when they entered the study. Since only one-third of the patients enrolled before conception, the study was not large enough to evaluate the risk of congenital malformations. Mean HbA1c of ~ 6% was observed in both groups during pregnancy, and there was no significant difference in the incidence of maternal hypoglycemia. Subcutaneous reproduction and teratology studies have been performed with insulin degludec/insulin aspart, and human insulin (NPH) as a comparator in rats. In these studies, insulin degludec/insulin aspart was given to rats during organogenesis. The effect of insulin degludec/insulin aspart was consistent with those observed with human insulin as both caused visceral/skeletal abnormalities in rats at dose of 30 U/kg/day (approximately 8 times the human subcutaneous dose of 1.08 U/kg/day based on U/body surface area). Subcutaneous reproduction and teratology studies have been performed with insulin degludec (basal component of insulin degludec/insulin aspart), and human insulin (NPH) as a comparator in rats and rabbits. In these studies, insulin was given to female rats before mating throughout pregnancy until weaning, and to rabbits during organogenesis. The effect of insulin degludec was consistent with those observed with human insulin as both caused pre- and post-implantation losses and visceral/skeletal abnormalities in rats at an insulin degludec dose of 21 U/kg/day (approximately 5 times the human exposure (AUC) at a human subcutaneous dose of 0.75 U/kg/day) and in rabbits at a dose of 3.3 U/kg/day (approximately 10 times the human exposure (AUC) at a human subcutaneous dose of 0.75 U/kg/day). The effects are probably secondary to maternal hypoglycemia. Subcutaneous reproduction and teratology studies have been performed with NOVOLOG (insulin aspart, the rapid-acting component of RYZODEG 70/30) and regular human insulin in rats and rabbits. In these studies, insulin aspart was given to female rats before mating, during mating, and throughout pregnancy, and to rabbits during organogenesis. The effects of insulin aspart did not differ from those observed with subcutaneous regular human insulin. Insulin aspart, like human insulin, caused pre- and post-implantation losses and visceral/skeletal abnormalities in rats at a dose of 200 U/kg/day (approximately 32 times the human subcutaneous dose of 1.0 U/kg/day, based on U/body surface area) and in rabbits at a dose of 10 U/kg/day (approximately three times the human subcutaneous dose of 1.0 U/kg/day, based on U/body surface area). The effects are probably secondary to maternal hypoglycemia at high doses. No significant effects were observed in rats at a dose of 50 U/kg/day and in rabbits at a dose of 3 U/kg/day. These doses are approximately 8 times the human subcutaneous dose of 1.0 U/kg/day for rats and equal to the human subcutaneous dose of 1.0 U/kg/day for rabbits, based on U/body surface area. Nursing Mothers It is unknown whether insulin degludec/aspart is excreted in human milk. Because many drugs, including human insulin, are excreted in human milk, caution should be exercised when insulin degludec/aspartis administered to a nursing mother. Women with diabetes who are lactating may require adjustments in insulin dose, meal plan, or both. In rats, the basal component of insulin degludec/aspart, insulin degludec, was secreted in milk and the concentration in milk was lower than in plasma. Pediatric Use The safety and efficacy of RYZODEG 70/30 in children and adolescents under the age of 18 years have not been established. Geriatric Use In clinical studies [see Clinical Studies] a total of 9 (2.5%) of the 362 RYZODEG 70/30- treated patients with type 1 diabetes were 65 years or older and 4 (1.1%) were 75 years and older. A total of 256 (25.7%) of the 998 RYZODEG 70/30-treated patients with type 2 diabetes were 65 years or older and 32 (3.2%) were 75 years and older. Differences in safety or effectiveness were not suggested in subgroup analyses comparing subjects older than 65 years to younger subjects. Nevertheless, greater caution should be exercised when RYZODEG 70/30 is administered to geriatric patients since greater sensitivity of some older individuals to the effects of RYZODEG 70/30 cannot be ruled out. The initial dosing, dose increments, and maintenance dosage should be conservative to avoid hypoglycemia. Hypoglycemia may be more difficult to recognize in the elderly. Renal Impairment In clinical studies [see Clinical Studies] a total of 18 (5%) of the 362 RYZODEG 70/30- treated patients with type 1 diabetes had an eGFR less than 60 mL/min/1.73 m or less and 1(0.3%) had an eGFR less than 30 mL/min/1.73 m² or less. A total of 111 (11%) of the 998 RYZODEG 70/30-treated patients with type 2 diabetes had an eGFR less than 60 mL/min/1.73 m² and no subjects had an eGFR less than 30 mL/min/1.73 m². No differences in the pharmacokinetics of the individual components of RYZODEG 70/30, insulin degludec or insulin aspart, were identified in separate studies comparing healthy subjects and subjects with renal impairment [see CLINICAL PHARMACOLOGY]. However, as with all insulin products, glucose monitoring should be intensified and the RYZODEG 70/30 dosage adjusted on an individual basis in patients with renal impairment. Hepatic Impairment No differences in the pharmacokinetics of the individual components of RYZODEG 70/30, insulin degludec or insulin aspart, were identified in separate studies comparing healthy subjects and subjects with hepatic impairment (mild, moderate, and severe hepatic impairment) [see CLINICAL PHARMACOLOGY]. However, as with all insulin products, glucose monitoring should be intensified and the RYZODEG 70/30 dosage adjusted on an individual basis in patients with hepatic impairment.