Prescription Drugs

CLINICAL PHARMACOLOGY Mechanism Of Action Neratinib is a kinase inhibitor that irreversibly binds to Epidermal Growth Factor Receptor (EGFR), Human Epidermal Growth Factor Receptor 2 (HER2), and HER4. In vitro, neratinib reduces EGFR and HER2 autophosphorylation, downstream MAPK and AKT signaling pathways, and showed antitumor activity in EGFR and/or HER2 expressing carcinoma cell lines. Neratinib human metabolites M3, M6, M7 and M11 inhibited the activity of EGFR, HER2 and HER4 in vitro. In vivo, oral administration of neratinib inhibited tumor growth in mouse xenograft models with tumor cell lines expressing HER2 and EGFR. Pharmacodynamics Cardiac Electrophysiology The effect of NERLYNX on the QTc interval was evaluated in a randomized, placebo and positive controlled, double-blind, single-dose, crossover study in 60 healthy subjects. At 2.4fold the therapeutic exposures of NERLYNX, there was no clinically relevant effect on the QTc interval. Pharmacokinetics Neratinib exhibits a non-linear PK profile with less than dose proportional increase of AUC with the increasing daily dose over the range of 40 to 400 mg. Absorption The neratinib and major active metabolites M3, M6 and M7 peak concentrations are reached in the range of 2 to 8 hours after oral administration. Effect of Food The food-effect assessment was conducted in healthy volunteers who received NERLYNX 240 mg under fasting conditions and with high fat food (approximately 55% fat, 31% carbohydrate, and 14% protein) or standard breakfast (approximately 50% carbohydrate, 35% fat, and 15% protein). A high fat meal increased neratinib Cmax and AUCinf by 1.7-fold (90% CI: 1.1-2.7) and 2.2-fold (90% CI: 1.4-3.5), respectively. A standard breakfast increased the Cmax and AUCinf by 1.2-fold (90% CI: 0.97-1.42) and 1.1-fold (90% CI: 1.02-1.24), respectively. [See DOSAGE AND ADMINISTRATION] Distribution In patients, following multiple doses of NERLYNX, the mean (%CV) apparent volume of distribution at steady-state (Vss/F) was 6433 (19%) L. In vitro protein binding of neratinib in human plasma was greater than 99% and independent of concentration. Neratinib bound predominantly to human serum albumin and human alpha-1 acid glycoprotein. Elimination Following 7 days of daily 240 mg oral doses of NERLYNX in healthy subjects, the mean (%CV) plasma half-life of neratinib, M3, M6, and M7 was 14.6 (38%), 21.6 (77%), 13.8 (50%) and 10.4 (33%) hours, respectively. The mean elimination half-life of neratinib ranged from 7 to 17 hours following a single oral dose in patients. Following multiple doses of NERLYNX at once-daily 240 mg in cancer patients, the mean (%CV) CL/F after first dose and at steady state (day 21) were 216 (34%) and 281 (40%) L/hour, respectively. Metabolism Neratinib is metabolized primarily in the liver by CYP3A4 and to a lesser extent by flavincontaining monooxygenase (FMO). After oral administration of NERLYNX, neratinib represents the most prominent component in plasma. At steady state after 240 mg daily oral doses of NERLYNX in a healthy subject study (n=25), the systemic exposures (AUC) of the active metabolites M3, M6, M7 and M11were 15%, 33%, 22% and 4% of the systemic neratinib exposure (AUC) respectively. Excretion After oral administration of 200 mg (0.83 times of approved recommended dosage) radiolabeled neratinib oral formulation, fecal excretion accounted for approximately 97.1% and urinary excretion accounted for 1.13% of the total dose. Sixty-one percent of the excreted radioactivity was recovered within 96 hours and 98% was recovered after 10 days. Specific Populations Age, gender, race and renal function do not have a clinically significant effect on neratinib pharmacokinetics. Patients with Hepatic Impairment Neratinib is mainly metabolized in the liver. Single doses of 120 mg NERLYNX were evaluated in non-cancer patients with chronic hepatic impairment (n=6 each in Child Pugh Class A, B, and C) and in healthy subjects (n=9) with normal hepatic function. Neratinib exposures in the patients with Child Pugh Class A (mild impairment) and Child Pugh Class B (moderate impairment) were similar to that in normal healthy volunteers. Patients with severe hepatic impairment (Child Pugh Class C) had neratinib Cmax and AUC increased by 273% and 281%, respectively, as compared to the normal hepatic function controls. [see DOSAGE AND ADMINISTRATION and Use in Specific Populations]. Drug Interaction Studies Gastric Acid Reducing Agents: In a trial of 15 healthy subjects, administration of a single 240 mg dose of NERLYNX combined with a 30 mg lansoprazole dose at steady state decreased neratinib Cmax and AUC by 71% and 65%, respectively [See DOSAGE AND ADMINISTRATION and DRUG INTERACTIONS]. Strong and Moderate CYP3A4 Inhibitors: Concomitant use of ketoconazole (400 mg once-daily for 5 days), a strong inhibitor of CYP3A4, with a single oral 240 mg NERLYNX dose in healthy subjects (n=24) increased neratinib Cmax by 321% and AUC by 481%. The effect of moderate CYP3A4 inhibition has not been studied. Given neratinib is predominantly metabolized by the CYP3A4 pathway and had a significant exposure change with strong CYP3A4 inhibition, the potential impact on NERLYNX safety from concomitant use with moderate CYP3A4 inhibitors warrants consideration [see DRUG INTERACTIONS]. Strong and Moderate CYP3A4 Inducers: Concomitant use of rifampin, a strong inducer of CYP3A4, with a single oral 240 mg NERLYNX dose in healthy subjects (n=24) reduced neratinib Cmax by 76% and AUC by 87%. The AUC of active metabolites M6 and M7 were also reduced by 37-49% when compared to NERLYNX administered alone. The effect of moderate CYP3A4 induction has not been studied. Given neratinib is predominantly metabolized by the CYP3A4 pathway and had a significant exposure change with strong CYP3A4 induction, the potential impact on NERLYNX efficacy from concomitant use with moderate CYP3A4 inducers warrants consideration [see DRUG INTERACTIONS]. Effect of NERLYNX on P-gp Transporters: Concomitant use of digoxin (a single 0.5 mg oral dose), a P-gp substrate, with multiple oral doses of NERLYNX 240 mg in healthy subjects (n=18) increased the mean digoxin Cmax by 54% and AUC by 32% [see DRUG INTERACTIONS]. Clinical Studies Extended Adjuvant Treatment In Breast Cancer The safety and efficacy of NERLYNX were investigated in the ExteNET trial (NCT00878709), a multicenter, randomized, double-blind, placebo-controlled study of NERLYNX after adjuvant treatment with trastuzumab in women with HER2-positive breast cancer. A total of 2840 patients with early-stage HER2-positive breast cancer within two years of completing treatment with adjuvant trastuzumab was randomized to receive either NERLYNX (n=1420) or placebo (n=1420). Randomization was stratified by the following factors: hormone receptor status, nodal status (0, 1-3 vs 4 or more positive nodes) and whether trastuzumab was given sequentially versus concurrently with chemotherapy. NERLYNX 240 mg or placebo was given orally once daily for one year. The major efficacy outcome measure was invasive disease-free survival (iDFS) defined as the time between the date of randomization to the first occurrence of invasive recurrence (local/regional, ipsilateral, or contralateral breast cancer), distant recurrence, or death from any cause, with 2 years and 28 days of follow-up. Patient demographics and tumor characteristics were generally balanced between treatment arms. Patients had a median age of 52 years (range 23 to 83) and 12% of patients were 65 or older. The majority of patients were White (81%), and most patients (99.7%) had an ECOG performance status of 0 or 1. Fifty-seven percent (57%) had hormone receptor positive disease (defined as ER-positive and/or PgR-positive), 24% were node negative, 47% had one to three positive nodes and 30% had four or more positive nodes. Ten percent (10%) of patients had Stage I disease, 41% had Stage II disease and 31% had Stage III disease. The majority of patients (81%) were enrolled within one year of completion of trastuzumab treatment. Median time from the last adjuvant trastuzumab treatment to randomization was 4.4 months in the NERLYNX arm vs. 4.6 months in the placebo arm. Median duration of treatment was 11.6 months in the NERLYNX arm vs. 11.8 months in the placebo arm. The efficacy results from the ExteNET trial are summarized in Table 8 and Figure 1. Table 8: Efficacy iDFS Results for the ITT population Number of Events/ Total N (%) iDFS at 24 months1 (%, 95% CI) Stratified2 HR (95% CI) p-value3 NERLYNX Placebo NERLYNX Placebo 67/1420 (4.7) 106/1420 (7.5) 94.2 (92.6, 95.4) 91.9 (90.2, 93.2) 0.66 (0.49, 0.90) 0.008 HR=Hazard Ratio 1 Kaplan-Meier estimate 2 Stratified by prior trastuzumab (concurrent vs. sequential), nodal status (0-3 positive nodes vs. ≥ 4 positive nodes), and ER/PR status (positive vs. negative) 3 Stratified log-rank test Figure 1: iDFS in the ExteNET Trial -ITT Population Table 9: Subgroup Analyses1 Population Number of Events/ Total N (%) iDFS at 24 months2 (%, 95% CI) Unstratified HR (95% CI) NERLYNX Placebo NERLYNX Placebo Hormone Receptor Status Positive 29/816 (3.6) 63/815 (7.7) 95.6 (93.8, 96.9) 91.5 (89.2, 93.3) 0.49 (0.31, 0.75) Negative 38/604 (6.3) 43/605 (7.1) 92.2 (89.4, 94.3) 92.4 (89.8, 94.3) 0.93 (0.60, 1.43) Nodal Status Negative 7/335 (2.1) 11/336 (3.3) 97.2 (94.1, 98.7) 96.5 (93.7, 98.0) 0.72 (0.26, 1.83) 1-3 Positive Nodes 31/664 (4.7) 47/664 (7.1) 94.4 (92.2, 96.1) 92.4 (90.0, 94.2) 0.68 (0.43, 1.07) ≥ 4 Positive Nodes 29/421 (6.9) 48/420 (114) 91.4 (87.9, 94.0) 87.3 (83.4, 90.2) 0.62 (0.39, 0.97) Prior Trastuzumab Concurrent 49/884 (5.5) 66/886 (7.4) 93.2 (91.0, 94.8) 92.0 (89.9, 93.7) 0.80 (0.55, 1.16) Sequential 18/536 (3.4) 40/534 (7.5) 95.8 (93.4, 97.3) 91.6 (88.7, 93.8) 0.46 (0.26, 0.78) Completion of Prior Trastuzumab ≤ 1 year 58/1152 (5.0) 95/1145 (8.3) 93.8 (92.0, 95.2) 90.9 (89.0, 92.5) 0.63 (0.45, 0.88) 1-2 years 9/262 (3.4) 11/270 (4.1) 95.8 (92.0, 97.8) 95.7 (92.3, 97.6) 0.92 (0.37, 2.22) HR=Hazard Ratio 1 Exploratory analyses without adjusting multiple comparisons 2 Kaplan-Meier estimate Approximately 75% of patients were re-consented for extended follow-up beyond 24 months. Observations with missing data were censored at the last date of assessment. This exploratory analysis suggests that the iDFS results at 5 years are consistent with the 2-year iDFS results observed in ExteNET. At the time of the iDFS analysis, 2% of patients had died, and Overall Survival data were immature.

NERLYNX (neratinib) Immediate Release, Film-coated Tablets DESCRIPTION NERLYNX (neratinib) immediate release, film-coated tablets for oral administration contain 40 mg of neratinib, equivalent to 48.31 mg neratinib maleate. Neratinib is a member of the 4-anilino quinolidine class of protein kinase inhibitors. The molecular formula for neratinib maleate is C30H29ClN6O3•C4H4O4 and the molecular weight is 673.11 Daltons. The chemical name is (E)N-{4-[3-chloro-4-(pyridin-2-yl methoxy)anilino]-3-cyano-7-ethoxyquinolin-6-yl}-4(dimethylamino)but-2-enamide maleate, and its structural formula is: Neratinib maleate is an off-white to yellow powder with pKas of 7.65 and 4.66. The solubility of neratinib maleate increases dramatically as neratinib becomes protonated at acidic pH. Neratinib maleate is sparingly soluble at pH 1.2 (32.90 mg/mL) and insoluble at approximate pH 5.0 and above (0.08 mg/mL or less). Inactive ingredients: Tablet Core: colloidal silicon dioxide, mannitol, microcrystalline cellulose, crospovidone, povidone, magnesium stearate & purified water. Coating: red film coat: polyvinyl alcohol, titanium dioxide, polyethylene glycol, talc, iron oxide red.

INDICATIONS NERLYNX is indicated for the extended adjuvant treatment of adult patients with early stage HER2-overexpressed/amplified breast cancer, to follow adjuvant trastuzumab based therapy [see Clinical Studies]. DOSAGE AND ADMINISTRATION Antidiarrheal Prophylaxis Antidiarrheal prophylaxis is recommended during the first 2 cycles (56 days) of treatment and should be initiated with the first dose of NERLYNX [see Dose Modifications and WARNINGS AND PRECAUTIONS]. Instruct patients to take loperamide as directed in Table 1, titrating to 1-2 bowel movements per day. Table 1: Loperamide Prophylaxis Time on NERLYNX Dose Frequency Weeks 1-2 (days 1 - 14) 4 mg Three times daily Weeks 3-8 (days 15 - 56) 4 mg Twice daily Weeks 9-52 (days 57 - 365) 4 mg As needed (not to exceed 16 mg per day) Additional antidiarrheal agents may be required to manage diarrhea in patients with loperamiderefractory diarrhea. NERLYNX dose interruptions and dose reductions may also be required to manage diarrhea [see Dose Modifications].   Recommended Dose And Schedule The recommended dose of NERLYNX is 240 mg (six tablets) given orally once daily with food, continuously for one year. Instruct patients to take NERLYNX at approximately the same time every day. NERLYNX tablets should be swallowed whole (tablets should not be chewed, crushed, or split prior to swallowing). If a patient misses a dose, do not replace missed dose, and instruct the patient to resume NERLYNX with the next scheduled daily dose. Dose Modifications Dose Modifications For Adverse Reactions NERLYNX dose modification is recommended based on individual safety and tolerability. Management of some adverse reactions may require dose interruption and/or dose reduction as shown in Table 2 to Table 5. Discontinue NERLYNX for patients who fail to recover to Grade 0-1 from treatment-related toxicity, for toxicities that result in a treatment delay > 3 weeks, or for patients that are unable to tolerate 120 mg daily. Additional clinical situations may result in dose adjustments as clinically indicated (e.g. intolerable toxicities, persistent Grade 2 adverse reactions, etc.). Table 2: NERLYNX Dose Modifications for Adverse Reactions Dose Level NERLYNX Dose Recommended starting dose 240 mg daily First dose reduction 200 mg daily Second dose reduction 160 mg daily Third dose reduction 120 mg daily Table 3: NERLYNX Dose Modifications and Management - General Toxicities1 Severity of Toxicity2 Action Grade 3 Hold NERLYNX until recovery to Grade ≤ 1 or baseline within 3 weeks of stopping treatment. Then resume NERLYNX at the next lower dose level. Grade 4 Discontinue NERLYNX permanently. 1 Refer to Table 4 and Table 5 below for management of diarrhea and hepatotoxicity 2 Per CTCAE v4.0 Dose Modifications For Diarrhea Diarrhea management requires the correct use of antidiarrheal medication, dietary changes, and appropriate dose modifications of NERLYNX. Guidelines for adjusting doses of NERLYNX in the setting of diarrhea are shown in Table 4. Table 4: Dose Modifications for Diarrhea Severity of Diarrhea1 Action Grade 1 diarrhea [increase of < 4 stools per day over baseline] Grade 2 diarrhea [increase of 4-6 stools per day over baseline] lasting < 5 days Grade 3 diarrhea [increase of ≥ 7 stools per day over baseline; incontinence; hospitalization indicated; limiting self-care activities of daily living] lasting < 2 days Adjust antidiarrheal treatment Diet modifications Fluid intake of ~2L should be maintained to avoid dehydration Once event resolves to ≤ Grade 1 or baseline, start loperamide 4 mg with each subsequent NERLYNX administration. Any grade with complicated features2 Grade 2 diarrhea lasting five days or longer3 Grade 3 diarrhea lasting longer than 2 days3 Interrupt NERLYNX treatment Diet modifications Fluid intake of ~2L should be maintained to avoid dehydration If diarrhea resolves to Grade 0-1 in one week or less, then resume NERLYNX treatment at the same dose. If diarrhea resolves to Grade 0-1 in longer than one week, then resume NERLYNX treatment at reduced dose (see Table 2). Once event resolves to ≤ Grade 1 or baseline, start loperamide 4 mg with each subsequent NERLYNX administration. Grade 4 diarrhea [Life-threatening consequences; urgent intervention indicated] Permanently discontinue NERLYNX treatment Diarrhea recurs to Grade 2 or higher at 120 mg per day Permanently discontinue NERLYNX treatment 1 Per CTCAE v4.0 2 Complicated features include dehydration, fever, hypotension, renal failure, or Grade 3 or 4 neutropenia 3 Despite being treated with optimal medical therapy Dose Modifications For Hepatic Impairment Reduce the NERLYNX starting dose to 80 mg in patients with severe hepatic impairment (Child Pugh C). No dose modifications are recommended for patients with mild to moderate hepatic impairment (Child Pugh A or B) [see Use in Specific Populations and CLINICAL PHARMACOLOGY]. Dose Modifications For Hepatotoxicity Guidelines for dose adjustment of NERLYNX in the event of liver toxicity are shown in Table 5. Patients who experience ≥ Grade 3 diarrhea requiring IV fluid treatment or any signs or symptoms of hepatotoxicity, such as worsening of fatigue, nausea, vomiting, right upper quadrant pain or tenderness, fever, rash, or eosinophilia, should be evaluated for changes in liver function tests. Fractionated bilirubin and prothrombin time should also be collected during hepatotoxicity evaluation [see WARNINGS AND PRECAUTIONS]. Table 5: Dose Modifications for Hepatotoxicity Severity of Hepatoxicity1 Action Grade 3 ALT ( > 5-20x ULN) OR Grade 3 bilirubin ( > 3-10x ULN) Hold NERLYNX until recovery to ≤ Grade 1 Evaluate alternative causes Resume NERLYNX at the next lower dose level if recovery to ≤ Grade 1 occurs within 3 weeks. If Grade 3 ALT or bilirubin occurs again despite one dose reduction, permanently discontinue NERLYNX Grade 4 ALT ( > 20x ULN) OR Grade 4 bilirubin ( > 10x ULN) Permanently discontinue NERLYNX Evaluate alternative causes 1 Per CTCAE v4.0 Concomitant Use With Gastric Acid Reducing Agents Proton pump inhibitors (PPI): Avoid concomitant use with NERLYNX [see DRUG INTERACTIONS]. H2-receptor antagonists: Avoid concomitant use with NERLYNX [see DRUG INTERACTIONS]. Antacids: Separate dosing of NERLYNX by 3 hours after antacids [see DRUG INTERACTIONS]. HOW SUPPLIED Dosage Forms And Strengths Tablets: 40 mg neratinib (equivalent to 48.31 mg of neratinib maleate). Film-coated, red, oval shaped and debossed with 'W104' on one side and plain on the other side. Storage And Handling NERLYNX 40 mg film-coated tablets are red, oval shaped and debossed with 'W104' on one side and plain on the other side. NERLYNX is available in: Bottles of 180 tablets: NDC 70437-240-18 Bottles of 126 tablets: NDC 70437-240-26 Store at controlled room temperature, 20°C to 25°C (68°F to 77°F); excursions permitted to 15-30°C (59-86°F) [see USP Controlled Room Temperature]. Distributed by: Puma Biotechnology, Inc. 10880 Wilshire Blvd., Suite 2150 Los Angeles, CA 90024-4106. Revised: Jul 2017

PATIENT INFORMATION NERLYNX (ner links) (neratinib) tablets What is the most important information I should know about NERLYNX? NERLYNX may cause serious side effects, including: Diarrhea. Diarrhea is a common side effect of NERLYNX, but it can also be severe. You may lose too much body salts and fluids, and get dehydrated. Your healthcare provider should prescribe the medicine loperamide for you during your first 2 months (56 days) of NERLYNX and then as needed. To help prevent or reduce diarrhea: You should start taking loperamide with your first dose of NERLYNX. Keep taking loperamide during the first 2 months (56 days) of NERLYNX treatment and then as needed. Your healthcare provider will tell you exactly how much and how often to take loperamide. Always take loperamide exactly as your healthcare provider tells you. While taking loperamide, you and your healthcare provider should try to keep the number of bowel movements that you have at 1 or 2 bowel movements each day. Tell your healthcare provider if you have more than 2 bowel movements in 1 day, or you have diarrhea that does not go away. Call your healthcare provider right away, as instructed, if you have severe diarrhea or if you have diarrhea along with weakness, dizziness, or fever. Your healthcare provider may also need to give you other medicines to manage diarrhea if loperamide does not work well enough. After 2 months (56 days) of treatment with NERLYNX, follow your healthcare provider's instructions about taking loperamide as needed to control diarrhea. Your healthcare provider may change your dose of NERLYNX, temporarily stop or completely stop NERLYNX if needed to manage your diarrhea. See “What are the possible side effects of NERLYNX?” for more information about side effects. What is NERLYNX? NERLYNX is a prescription medicine used to treat adults who have early-stage breast cancer, which: is HER2-positive and has previously been treated with the medicine trastuzumab. It is not known if NERLYNX is safe and effective in children. Before taking NERLYNX, tell your healthcare provider about all of your medical conditions, including if you: have liver problems. You may need a lower dose of NERLYNX. are pregnant or plan to become pregnant. NERLYNX can harm your unborn baby. If you are a female who can become pregnant: Your healthcare provider should do a pregnancy test before you start taking NERLYNX. You should use effective birth control (contraception) during treatment and for at least 1 month after your last dose of NERLYNX. Talk with your healthcare provider about forms of birth control that you can use during this time. Tell your healthcare provider right away if you become pregnant during treatment with NERLYNX. Males with female partners who can become pregnant should use effective birth control during treatment and for 3 months after the last dose of NERLYNX. are breastfeeding or plan to breastfeed. It is not known if NERLYNX passes into your breast milk. Do not breastfeed during treatment and for at least 1 month after your last dose of NERLYNX. Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. Especially tell your healthcare provider if you take medicines used to decrease stomach acid, called proton pump inhibitors or PPIs, and H-2 receptor antagonists. You should avoid taking these medicines during treatment with NERLYNX. How should I take NERLYNX? Take NERLYNX exactly as your healthcare provider tells you to take it. Your healthcare provider may change your dose of NERLYNX if needed. Take NERLYNX with food. Take NERLYNX at about the same time each day. If you take an antacid medicine, take NERLYNX 3 hours after the antacid medicine. NERLYNX is usually taken for 1 year. If you miss a dose of NERLYNX, skip that dose and take your next dose at your regular scheduled time. If you take too much NERLYNX, call your healthcare provider right away or go to the nearest hospital emergency room. What should I avoid during treatment with NERLYNX? You should avoid eating products that contain grapefruit during treatment with NERLYNX. What are the possible side effects of NERLYNX? NERLYNX may cause serious side effects, including: See “What is the most important information I should know about NERLYNX?” Liver problems. Changes in liver function tests are common with NERLYNX. Your healthcare provider should do blood tests before you begin treatment, monthly during the first 3 months, and then every 3 months as needed during treatment with NERLYNX. Your healthcare provider will stop your treatment with NERLYNX if your liver tests show severe problems. Call your healthcare provider right away if you get any of the following signs or symptoms of liver problems: tiredness nausea vomiting pain in the right upper stomach-area (abdomen) fever rash itching yellowing of your skin or whites of your eyes Common side effects of NERLYNX include: diarrhea nausea stomach-area (abdomen) pain tiredness vomiting rash dry or inflamed mouth, or mouth sores decreased appetite muscle spasms upset stomach nail problems including color change dry skin swelling of your stomach-area weight loss urinary tract infection These are not all the possible side effects of NERLYNX. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. How should I store NERLYNX? Store NERLYNX at room temperature between 68° to 77°F (20° to 25°C). Keep NERLYNX and all medicines out of the reach of children. General information about the safe and effective use of NERLYNX. Medicines are sometimes prescribed for purposes other than those listed in a Patient Information leaflet. Do not use NERLYNX for a condition for which it was not prescribed. Do not give NERLYNX to other people, even if they have the same symptoms that you have. It may harm them. You can ask your pharmacist or healthcare provider for information about NERLYNX that is written for health professionals. What are the ingredients in NERLYNX? Active ingredient: neratinib Inactive ingredients: Tablet Core: colloidal silicon dioxide, mannitol, microcrystalline cellulose, crospovidone, povidone, magnesium stearate & purified water. Coating: red film coat: polyvinyl alcohol, titanium dioxide, polyethylene glycol, talc, iron oxide red.

OVERDOSE There is no specific antidote, and the benefit of hemodialysis in the treatment of NERLYNX overdose is unknown. In the event of an overdose, administration should be withheld and general supportive measures undertaken. In the clinical trial setting, a limited number of patients reported overdose. The adverse reactions experienced by these patients were diarrhea, nausea, vomiting, and dehydration. The frequency and severity of gastrointestinal disorders (diarrhea, abdominal pain, nausea and vomiting) appear to be dose related. CONTRAINDICATIONS None.

SIDE EFFECTS The following clinically significant adverse reactions are described elsewhere in the labeling: Diarrhea [see WARNINGS AND PRECAUTIONS] Hepatotoxicity [see WARNINGS AND PRECAUTIONS] Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. ExteNET The data described below reflect exposure of NERLYNX as a single agent in ExteNET, a multicenter, randomized, double-blind, placebo-controlled study of NERLYNX within 2 years after completion of adjuvant treatment with trastuzumab-based therapy in women with HER2positive early-stage breast cancer. Patients who received NERLYNX in this trial were not required to receive any prophylaxis with antidiarrheal agents to prevent the NERLYNX-related diarrhea. The median duration of treatment was 11.6 months in the NERLYNX arm and 11.8 months in the placebo arm. The median age was 52 years (60% were ≥ 50 years old, 12% were ≥ 65 years old); 81% were Caucasian, 3% Black or African American, 14% Asian and 3% other. A total of 1408 patients were treated with NERLYNX. NERLYNX dose reduction due to an adverse reaction of any grade occurred in 31.2% of patients receiving NERLYNX compared to 2.6% of patients receiving placebo. Permanent discontinuation due to any adverse reaction was reported in 27.6% of NERLYNX-treated patients. The most common adverse reaction leading to discontinuation was diarrhea, accounting for 16.8% of NERLYNX-treated patients. The most common adverse reactions ( > 5%) were diarrhea, nausea, abdominal pain, fatigue, vomiting, rash, stomatitis, decreased appetite, muscle spasms, dyspepsia, AST or ALT increase, nail disorder, dry skin, abdominal distention, weight decreased and urinary tract infection. The most frequently reported Grade 3 or 4 adverse reactions were diarrhea, vomiting, nausea, and abdominal pain. Serious adverse reactions in the NERLYNX arm included diarrhea (1.6%), vomiting (0.9%), dehydration (0.6%), cellulitis (0.4%), renal failure (0.4%), erysipelas (0.4%), alanine aminotransferase increased (0.3%), aspartate aminotransferase increased (0.3%), nausea (0.3%), fatigue (0.2%), and abdominal pain (0.2%). Table 6 summarizes the adverse reactions in ExteNET. Table 6: Adverse Reactions Reported in ≥ 2% of NERLYNX-Treated Patients in ExteNET System Organ Class (Preferred Term) NERLYNX n=1408 Placebo n=1408 All Grades (%) Grade 3 (%) Grade 4 (%) All Grades (%) Grade 3 (%) Grade 4 (%) Gastrointestinal Disorders Diarrhea 95 40 0.1 35 2 0 Nausea 43 2 0 22 0.1 0 Abdominal pain1 36 2 0 15 0.4 0 Vomiting 26 3 0 8 0.4 0 Stomatitis2 14 0.6 0 6 0.1 0 Dyspepsia 10 0.4 0 4 0 0 Abdominal distension 5 0.3 0 3 0 0 Dry mouth 3 0.1 0 2 0 0 General Disorders and Administration Site Conditions Fatigue 27 2 0 20 0.4 0 Hepatobiliary Disorders Alanine aminotransferase increased 9 1 0.2 3 0.2 0 Aspartate aminotransferase increased 7 0.5 0.2 3 0.3 0 Infections and Infestations Urinary tract infection 5 0.1 0 2 0 0 Investigations Weight decreased 5 0.1 0 0.5 0 0 Metabolism and Nutrition Disorders Decreased appetite 12 0.2 0 3 0 0 Dehydration 4 0.9 0.1 0.4 0.1 0 Musculoskeletal and Connective Tissue Disorders Muscle spasms 11 0.1 0 3 0.1 0 Respiratory, Thoracic and Mediastinal Disorders Epistaxis 5 0 0 1 0.1 0 Skin and Subcutaneous Tissue Disorders Rash3 18 0.6 0 9 0 0 Dry skin 6 0 0 2 0 0 Nail Disorder4 8 0.3 0 2 0 0 Skin fissures 2 0.1 0 0.1 0 0 1 Includes abdominal pain, abdominal pain upper, and abdominal pain lower 2 Includes stomatitis, aphthous stomatitis, mouth ulceration, oral mucosal blistering, mucosal inflammation, oropharyngeal pain, oral pain, glossodynia, glossitis, and cheilitis 3 Includes rash, rash erythematous, rash follicular, rash generalized, rash pruritic, rash pustular, rash maculopapular, rash papular, dermatitis, dermatitis acneiform, and toxic skin eruption 4 Includes nail disorder, paronychia, onychoclasis, nail discoloration, nail toxicity, nail growth abnormal, and nail dystrophy DRUG INTERACTIONS Effect of Other Drugs On NERLYNX Table 7 includes drug interactions that affect the pharmacokinetics of neratinib. Table 7: Drug Interactions that Affect Neratinib Gastric Acid Reducing Agents Clinical Impact Concomitant use of NERLYNX with a proton pump inhibitor (PPI, lansoprazole) resulted in a decrease of neratinib Cmax by 71% and AUC by 65% [see CLINICAL PHARMACOLOGY]. Concomitant use with other pH lowering agents was not studied but a decrease in neratinib AUC is also considered likely. Decreased neratinib AUC may reduce NERLYNX activity. Prevention or Management PPIs Avoid concomitant use [see DOSAGE AND ADMINISTRATION]. H2-receptor antagonists Avoid concomitant use [see DOSAGE AND ADMINISTRATION]. Antacids Separate NERLYNX dosing by 3 hours after antacids [see DOSAGE AND ADMINISTRATION]. Strong and Moderate CYP3A4 Inhibitors Clinical Impact Concomitant use of NERLYNX with a strong CYP3A4 inhibitor (ketoconazole) increased neratinib Cmax by 321% and AUC by 481% [see CLINICAL PHARMACOLOGY]. Concomitant use of NERLYNX with other strong or moderate CYP3A4 inhibitors may increase neratinib concentrations. Increased neratinib concentrations may increase the risk of toxicity. Prevention or Management Avoid concomitant use of NERLYNX with strong or moderate CYP3A4 inhibitors. Examples1 Strong CYP3A4 inhibitors: boceprevir, clarithromycin, cobicistat, conivaptan, danoprevir and ritonavir, diltiazem, elvitegravir and ritonavir, grapefruit juice, idelalisib, indinavir and ritonavir, itraconazole, ketoconazole, lopinavir and ritonavir, nefazodone, nelfinavir, paritaprevir and ritonavir and (ombitasvir and/or dasabuvir), posaconazole, ritonavir, saquinavir and ritonavir, tipranavir and ritonavir, troleandomycin, voriconazole Moderate CYP3A4 inhibitors: aprepitant, cimetidine, ciprofloxacin, clotrimazole, crizotinib, cyclosporine, dronedarone, erythromycin, fluconazole, fluvoxamine, imatinib, tofisopam, verapamil Strong or Moderate CYP3A4 Inducers Clinical Impact Concomitant use of NERLYNX with a strong CYP3A4 inducer (rifampin) reduced neratinib Cmax by 76% and AUC by 87% [see CLINICAL PHARMACOLOGY]. Concomitant use of NERLYNX with other strong or moderate CYP3A4 inducers may decrease NERLYNX concentrations. Decreased neratinib AUC may reduce NERLYNX activity. Prevention or Management Avoid concomitant use of NERLYNX with strong or moderate CYP3A4 inducers. Examples1 Strong CYP3A4 inducers: carbamazepine, enzalutamide, mitotane, phenytoin, rifampin, St. John’s wort Moderate CYP3A4 inducers: bosentan, efavirenz, etravirine, modafinil 1 These examples are a guide and not considered a comprehensive list of all possible drugs that may fit this category. The healthcare provider should consult appropriate references for comprehensive information. Effect Of NERLYNX On Other Drugs P-glycoprotein (P-gp) Substrates Concomitant use of NERLYNX with digoxin, a P-gp substrate, increased digoxin concentrations [see CLINICAL PHARMACOLOGY]. Increased concentrations of digoxin may lead to increased risk of adverse reactions including cardiac toxicity. Refer to the digoxin prescribing information for dosage adjustment recommendations due to drug interactions. NERLYNX may inhibit the transport of other P-gp substrates (e.g., dabigatran, fexofenadine).

WARNINGS Included as part of the PRECAUTIONS section. PRECAUTIONS Diarrhea Severe diarrhea and sequelae, such as dehydration, hypotension, and renal failure, have been reported during treatment with NERLYNX. Diarrhea was reported in 95% of NERLYNX-treated patients in ExteNET, a randomized placebo controlled trial. In the NERLYNX arm, Grade 3 diarrhea occurred in 40% and Grade 4 diarrhea occurred in 0.1% of patients. The majority of patients (93%) had diarrhea in the first month of treatment, the median time to first onset of Grade ≥ 3 diarrhea was 8 days (range, 1-350), and the median cumulative duration of Grade ≥ 3 diarrhea was 5 days (range, 1-139) [see ADVERSE REACTIONS]. Antidiarrheal prophylaxis with loperamide has been shown to lower the incidence and severity of diarrhea. Instruct patients to initiate antidiarrheal prophylaxis with loperamide along with the first dose of NERLYNX and continue during the first two cycles (56 days) of treatment [see DOSAGE AND ADMINISTRATION]. Monitor patients for diarrhea and treat with additional antidiarrheals as needed. When severe diarrhea with dehydration occurs, administer fluid and electrolytes as needed, interrupt NERLYNX, and reduce subsequent doses [see DOSAGE AND ADMINISTRATION]. Perform stool cultures as clinically indicated to exclude infectious causes of Grade 3 or 4 diarrhea or diarrhea of any grade with complicating features (dehydration, fever, neutropenia). Hepatotoxicity NERLYNX has been associated with hepatotoxicity characterized by increased liver enzymes. In ExteNET, 9.7% of patients experienced an alanine aminotransferase (ALT) increase ≥ 2 x ULN, 5.1% of patients experienced an aspartate aminotransferase (AST) increase ≥ 2 x ULN, and 1.7% of patients experienced an AST or ALT elevation > 5 x ULN ( ≥ Grade 3). Hepatotoxicity or increases in liver transaminases led to drug discontinuation in 1.7% of NERLYNX-treated patients. Total bilirubin, AST, ALT, and alkaline phosphatase should be measured prior to starting treatment with NERLYNX monthly for the first 3 months of treatment, then every 3 months while on treatment and as clinically indicated. These tests should also be performed in patients experiencing Grade 3 diarrhea or any signs or symptoms of hepatotoxicity, such as worsening of fatigue, nausea, vomiting, right upper quadrant tenderness, fever, rash, or eosinophilia [see DOSAGE AND ADMINISTRATION and ADVERSE REACTIONS]. Embryo-Fetal Toxicity Based on findings from animal studies and its mechanism of action, NERLYNX can cause fetal harm when administered to a pregnant woman. In animal reproduction studies, administration of neratinib to pregnant rabbits during organogenesis caused abortions, embryo-fetal death and fetal abnormalities in rabbits at maternal AUCs approximately 0.2 times the AUC in patients receiving the recommended dose. Advise pregnant women of the potential risk to a fetus. Advise females of reproductive potential to use effective contraception during treatment and for at least 1 month after the last dose. [see Use in Specific Populations and CLINICAL PHARMACOLOGY]. Patient Counseling Information Advise the patient to read the FDA-approved patient labeling (PATIENT INFORMATION). Diarrhea Inform patients that NERLYNX has been associated with diarrhea which may be severe in some cases. Instruct patients to maintain 1-2 bowel movements per day and on how to use anti-diarrheal treatment regimens. Advise patients to inform their healthcare provider immediately if severe ( ≥ Grade 3) diarrhea or diarrhea associated with weakness, dizziness, or fever occurs during treatment with NERLYNX [see DOSAGE AND ADMINISTRATION and WARNINGS AND PRECAUTIONS]. Hepatotoxicity Inform patients that NERLYNX has been associated with hepatotoxicity which may be severe in some cases. Inform patients that they should report signs and symptoms of liver dysfunction to their healthcare provider immediately [see WARNINGS AND PRECAUTIONS]. Embryo-Fetal Toxicity Advise females to inform their healthcare provider if they are pregnant or become pregnant. Inform female patients of the risk to a fetus and potential loss of the pregnancy [see Use in Specific Populations]. Advise females of reproductive potential to use effective contraception during treatment and for 1 month after receiving the last dose of NERLYNX [see WARNINGS AND PRECAUTIONS and Use in Specific Populations]. Advise lactating women not to breastfeed during treatment with NERLYNX and for at least 1 month after the last dose [see Use in Specific Populations]. Drug Interactions NERLYNX may interact with many drugs; therefore, advise patients to report to their healthcare provider the use of any other prescription or nonprescription medication or herbal products [see DOSAGE AND ADMINISTRATION and CLINICAL PHARMACOLOGY]. NERLYNX may interact with gastric acid reducing agents. Advise patients to avoid concomitant use of proton pump inhibitors or H2-receptor antagonists. Advise patients to separate the dosing of NERLYNX by 3 hours after antacid medicine [see DOSAGE AND ADMINISTRATION and DRUG INTERACTIONS]. NERLYNX may interact with grapefruit. Advise patients to avoid taking NERLYNX with grapefruit products [see DRUG INTERACTIONS]. Dosing and Administration Instruct patients to take NERLYNX with food at approximately the same time each day consecutively for one year. If a patient misses a dose, instruct the patient not to replace the missed dose, and to resume NERLYNX with the next scheduled daily dose [see DOSAGE AND ADMINISTRATION Nonclinical Toxicology Carcinogenesis, Mutagenesis, Impairment Of Fertility Neratinib was not carcinogenic in a 26-week study in Tg.rasH2 transgenic mice when administered daily by oral gavage at doses up to 50 mg/kg/day in males and 125 mg/kg/day in females. Neratinib was not mutagenic in an in vitro bacterial reverse mutation (AMES) assay or clastogenic in an in vitro human lymphocyte chromosomal aberration assay or an in vivo rat bone marrow micronucleus assay. In a fertility study in rats, neratinib administration up to 12 mg/kg/day (approximately 0.5 times the maximum recommended dose of 240 mg/day in patients on a mg/m² basis) caused no effects on mating or the ability of animals to become pregnant. In repeat-dose toxicity studies in dogs with oral administration of neratinib daily for up to 39 weeks, tubular hypoplasia of the testes was observed at ≥ 0.5 mg/kg/day. This finding was observed at AUCs that were approximately 0.4 times the AUC in patients at the maximum recommended dose of 240 mg. Use In Specific Populations Pregnancy Risk Summary Based on findings from animal studies and the mechanism of action, NERLYNX can cause fetal harm when administered to a pregnant woman [see CLINICAL PHARMACOLOGY]. There are no available data in pregnant women to inform the drug-associated risk. In animal reproduction studies, administration of neratinib to pregnant rabbits during organogenesis resulted in abortions, embryo-fetal death and fetal abnormalities in rabbits at maternal exposures (AUC) approximately 0.2 times exposures in patients at the recommended dose (see Data). Advise pregnant women of the potential risk to a fetus. The background risk of major birth defects and miscarriage for the indicated population is unknown. However, the background risk of major birth defects is 2-4% and of miscarriage is 1520% of clinically recognized pregnancies in the U.S. general population. Data Animal Data In a fertility and early embryonic development study in female rats, neratinib was administered orally for 15 days before mating to Day 7 of pregnancy, which did not cause embryonic toxicity at doses up to 12 mg/kg/day in the presence of maternal toxicity. A dose of 12 mg/kg/day in rats is approximately 0.5 times the maximum recommended dose of 240 mg/day in patients on a mg/m² basis. In an embryo-fetal development study in rats, pregnant animals received oral doses of neratinib up to 15 mg/kg/day during the period of organogenesis. No effects on embryo-fetal development or survival were observed. Maternal toxicity was evident at 15 mg/kg/day (approximately 0.6 times the AUC in patients receiving the maximum recommended dose of 240 mg/day). In an embryo-fetal development study in rabbits, pregnant animals received oral doses of neratinib up to 9 mg/kg/day during the period of organogenesis. Administration of neratinib at doses ≥ 6 mg/kg/day resulted in maternal toxicity, abortions and embryo-fetal death (increased resorptions). Neratinib administration resulted in increased incidence of fetal gross external (domed head), soft tissue (dilation of the brain ventricles and ventricular septal defect), and skeletal (misshapen anterior fontanelles and enlarged anterior and/or posterior fontanelles) abnormalities at ≥ 3 mg/kg/day. The AUC(0-t) at 6 mg/kg/day and 9 mg/kg/day in rabbits were approximately 0.5 and 0.8 times, respectively, the AUCs in patients receiving the maximum recommended dose of 240 mg/day. In a peri and postnatal development study in rats, oral administration of neratinib from gestation day 7 until lactation day 20 resulted in maternal toxicity at ≥ 10 mg/kg/day (approximately 0.4 times the maximum recommended dose of 240 mg/day in patients on a mg/m² basis) including decreased body weights, body weight gains, and food consumption. Effects on long-term memory were observed in male offspring at maternal doses ≥ 5 mg/kg/day (approximately 0.2 times the maximum recommended dose of 240 mg/day in patients on a mg/m² basis). Lactation Risk Summary No data are available regarding the presence of neratinib or its metabolites in human milk or its effects on the breastfed infant or on milk production. Because of the potential for serious adverse reactions in breastfed infants from NERLYNX, advise lactating women not to breastfeed while taking NERLYNX and for at least 1 month after the last dose. Females And Males Of Reproductive Potential Pregnancy Based on animal studies, NERLYNX can cause fetal harm when administered to a pregnant woman [see Use in Specific Populations]. Females of reproductive potential should have a pregnancy test prior to starting treatment with NERLYNX. Contraception Females Based on animal studies, NERLYNX can cause fetal harm when administered to a pregnant woman [see Use in Specific Populations]. Advise females of reproductive potential to use effective contraception during treatment with NERLYNX and for at least 1 month after the last dose. Males Based on findings in animal reproduction studies, advise male patients with female partners of reproductive potential to use effective contraception during treatment and for 3 months after the last dose of NERLYNX [see Use in Specific Populations]. Pediatric Use The safety and efficacy of NERLYNX in pediatric patients has not been established. Geriatric Use In the ExteNET trial, the mean age was 52 years in the NERLYNX arm; 1236 patients were < 65 years, 172 patients were ≥ 65 years, of whom 25 patients were 75 years or older. There was a higher frequency of treatment discontinuations due to adverse reactions in the ≥ 65 years age group than in the < 65 years age group; in the NERLYNX arm, the percentages were 44.8% compared with 25.2%, respectively, and in the placebo arm 6.4% and 5.3%, respectively. The incidence of serious adverse reactions in the NERLYNX arm vs. placebo arm was 7.0% vs. 5.7% ( < 65 years-old) and 9.9% vs. 8.1% ( ≥ 65 years-old). The serious adverse reactions most frequently reported in the ≥ 65 years-old group were vomiting (2.3%), diarrhea (1.7%), renal failure (1.7%), and dehydration (1.2%). Hepatic Impairment No dose modifications are recommended for patients with mild to moderate hepatic impairment (Child Pugh A or B). Patients with severe, pre-existing hepatic impairment (Child Pugh Class C) experienced a reduction in neratinib clearance and an increase in Cmax and AUC. Reduce the NERLYNX dosage for patients with severe hepatic impairment. [see DOSAGE AND ADMINISTRATION and CLINICAL PHARMACOLOGY].