Prescription Drugs

CLINICAL PHARMACOLOGY Mechanism Of Action OSPHENA is an estrogen agonist/antagonist with tissue selective effects. Its biological actions are mediated through binding to estrogen receptors. This binding results in activation of estrogenic pathways in some tissues (agonism) and blockade of estrogenic pathways in others (antagonism). Pharmacokinetics Absorption Following a single oral administration of OSPHENA 60 mg tablet in postmenopausal women under fasted condition, peak median serum concentrations was reached at approximately 2 hours (range: 1 to 8 hours) post-dose (see Figure 2). Mean ospemifene Cmax and AUC0-inf were 533 ng/mL and 4165 ngEhr/mL, respectively. After a single oral administration of OSPHENA 60 mg tablet in postmenopausal women with a high fat/high calorie (860 kcal) meal, Cmax was reached at approximately 2.5 hours (range: 1 to 6 hours) post-dose. Mean ospemifene Cmax and AUC0-inf were 1198 ng/mL and 7521 ngEhr/mL, respectively. The absolute bioavailability of ospemifene was not evaluated. Ospemifene exhibits less than dose-proportional pharmacokinetics from 25 to 200 mg with ospemifene capsule formulation. Accumulation of ospemifene with respect to AUC0-inf was approximately 2 after twelve weeks of daily administration. Steady-state was reached after nine days of ospemifene administration. Figure 2: Mean serum concentration profile of ospemifene following a single oral administration of OSPHENA 60 mg tablet in postmenopausal women under fed (N=28) and fasted (N=91) conditions Food Effect In general, food increased the bioavailability of ospemifene by approximately 2-3 fold. In a cross-study comparison, single dose OSPHENA 60 mg tablet administered with a high fat/high calorie meal (860 kcal) in postmenopausal women increased Cmax and AUC0-inf by 2.3- and 1.7-fold, respectively, compared to fasted condition. Elimination half-life and time to maximum concentration (Tmax) were unchanged in the presence of food. In two food effect studies in healthy males using different ospemifene tablet formulations Cmax and AUC0-inf increased by 2.3- and 1.8-fold, respectively, with a low fat/low calorie meal (300 kcal) and increased by 3.6- and 2.7-fold, respectively, with a high fat/high calorie meal (860 kcal), compared to fasted condition. OSPHENA should be taken with food [see DOSAGE AND ADMINISTRATION]. Distribution OSPHENA is highly (>99 percent) bound to serum proteins. The apparent volume of distribution is 448 L. Metabolism In vitro experiments with human liver microsomes indicated that ospemifene primarily undergoes metabolism via CYP3A4, CYP2C9 and CYP2C19. The major metabolite was 4-hydroxyospemifene. The apparent total body clearance is 9.16 L/hr using a population approach. Excretion The apparent terminal half-life of ospemifene in postmenopausal women is approximately 26 hours. Following an oral administration of ospemifene, approximately 75% and 7% of the dose was excreted in feces and urine, respectively. Less than 0.2% of the ospemifene dose was excreted unchanged in urine. Use In Specific Populations Pediatric The pharmacokinetics of ospemifene in pediatric patients has not been evaluated [see Use In Specific Populations]. Geriatric No differences in ospemifene pharmacokinetics were detected with regard to age (range 40 to 80 years) [see Use In Specific Populations]. Race Race did not have clinically relevant effect on ospemifene pharmacokinetics. Renal Impairment In women with severe renal impairment (CrCL <30 mL/min), the Cmax and AUC0-inf for ospemifene following a single 60 mg dose administered with a high fat/high calorie meal were lower by 21% and higher by 20%, respectively [see Use In Specific Populations]. Hepatic Impairment In women with mild hepatic impairment (Child-Pugh Class A), the Cmax and AUC0-inf for ospemifene following a single 60 mg dose administered with a high fat/high calorie meal were lower by 21% and 9.1%, respectively, compared to women with normal hepatic function. In women with moderate hepatic impairment (Child-Pugh Class B), the Cmax and AUC0-inf for ospemifene following a single 60 mg dose administered with a high fat/high calorie meal were higher by 1% and 29%, respectively, compared to women with normal hepatic function. The effect of severe hepatic impairment on the pharmacokinetics of ospemifene has not been evaluated [see WARNINGS AND PRECAUTIONS and Use In Specific Populations]. Drug Interactions Ospemifene is metabolized primarily by CYP3A4 and CYP2C9. CYP2C19 and other pathways contribute to the metabolism of ospemifene. In order of decreasing potency, ospemifene was suggested to be a weak inhibitor for CYP2B6, CYP2C9, CYP2C19, CYP2C8, CYP2D6 and CYP3A4 in in vitro studies. Ospemifene is not a significant P-glycoprotein substrate in vitro; no in vivo transporter study was conducted. Effect Of Co-Administered Drugs On The Pharmacokinetics Of Ospemifene Fluconazole (CYP3A4/CYP2C9/CYP2C19 Inhibitor) Fluconazole (a moderate CYP3A / strong CYP2C9 / moderate CYP2C19 inhibitor) 400 mg was given on Day 1 followed by 200 mg on Days 2 to 5 under fasted condition. On Day 5 approximately one hour after fluconazole administration, ospemifene 60 mg was administered after breakfast (two slices of bread with ham, cheese, a few slices of cucumber and/or tomatoes, and juice). Fluconazole 200 mg was taken for three additional days under fasted condition. Multiple doses of fluconazole in fourteen postmenopausal women increased the Cmax and AUC0-inf of ospemifene by 1.7- and 2.7-fold, respectively [see DRUG INTERACTIONS]. Rifampin (CYP3A4/CYP2C9/CYP2C19 Inducer) Rifampin 600 mg was given once daily for 5 consecutive days (given at least one hour before or two hours after a meal) in the late afternoon. On Day 6 after an overnight fast, ospemifene 60 mg was administered in the morning after under fed condition (two slices of bread with ham, cheese, a few slices of cucumber and/or tomatoes, and juice). Multiple doses of rifampin 600 mg in twelve postmenopausal women reduced Cmax and AUC0-inf of ospemifene by 51% and 58%, respectively. Rifampin and other inducers of CYP3A4 are expected to decrease the systemic exposure of ospemifene [see DRUG INTERACTIONS]. Ketoconazole (CYP3A4 Inhibitor) Ketoconazole 400 mg was given once daily for 4 consecutive days after breakfast. On Day 5 after an overnight fast, ketoconazole 400 mg and ospemifene 60 mg were co-administered under fed condition (two slices of bread with ham, cheese, a few slices of cucumber and/or tomatoes, and juice). Ketoconazole administration once daily continued for an additional 3 days (Days 6 to 8). Coadministration of a single 60 mg dose of ospemifene and multiple doses of ketoconazole in twelve postmenopausal women increased Cmax and AUC0-inf by 1.5- and 1.4-fold, respectively [see DRUG INTERACTIONS]. Omeprazole (CYP2C19 Inhibitor) Omeprazole (a moderate CYP2C19 inhibitor) 40 mg was given for 5 days. On Day 5, approximately one hour after omeprazole administration, ospemifene 60 mg was administered after breakfast (two slices of bread with ham, cheese, a few slices of cucumber and/or tomatoes, and juice). Multiple doses of omeprazole in fourteen postmenopausal women increased Cmax and AUC0-inf by 1.20- and 1.17-fold, respectively. Effect Of Ospemifene On The Pharmacokinetics Of The Co-Administered Drug Warfarin Ospemifene 60 mg was given after a light breakfast (two slices of bread with ham and cheese and juice) once daily for 12 days in sixteen postmenopausal women who were determined to be rapid metabolizers of CYP2C9 (CYP2C9*1/*1 or CYP2C9*1/*2). On Day 8, a single dose of warfarin 10 mg and vitamin K 10 mg were administered one hour after a light breakfast. The geometric mean ratio (90% CI) for Swarfarin with and without ospemifene for Cmax and AUC0-inf were 0.97 (0.92-1.02) and 0.96 (0.91- 1.02), respectively. Multiple doses of ospemifene did not significantly affect the pharmacokinetics of a single dose of warfarin. No study was conducted with multiple doses of warfarin. Omeprazole Ospemifene 60 mg was administered once daily for 7 days after a light meal in the late afternoon in fourteen postmenopausal women. On Day 8 after an overnight fast, a single 20 mg dose of omeprazole was administered in the morning of at least 10 hrs; ospemifene was not given on Day 8. The geometric mean ratios for the metabolic index (omeprazole/5-hydroxyomeprazole) at the concentration at the 3 hr time point and for AUC0-8hr was 0.97 with and without ospemifene. It is unclear if ospemifene will affect the pharmacokinetics of drugs metabolized by CYP2C19 due to the significant time gap between ospemifene and omeprazole administration. Bupropion Ospemifene 60 mg was administered once daily for seven consecutive days after the evening meal in sixteen postmenopausal women (not homozygous for CYP2B6*6). On the Day 8 after overnight fast, a single 150 mg dose of sustained release bupropion was administered in morning under fasted condition. The geometric mean ratio (90% CI) for bupropion with and without ospemifene for Cmax and AUC0-inf were 0.82 (0.75-0.91) and 0.81 (0.77-0.86), respectively. The geometric mean ratio (90% CI) for hydroxybupropion, an active metabolite formed via CYP2B6, with and without ospemifene for Cmax and AUC0-inf were 1.16 (1.09-1.24) and 0.98 (0.92-1.04), respectively. Clinical Stuides The effectiveness and safety of OSPHENA on moderate to severe symptoms of vulvar and vaginal atrophy in postmenopausal women were examined in three placebo-controlled clinical trials (two 12- week efficacy trials and one 52-week long-term safety trial). In the three placebo-controlled trials, a total of 787 women received placebo and 1102 women received 60 mg OSPHENA. The first clinical trial was a 12-week, randomized, double-blind, placebo-controlled, parallel-group study that enrolled 826 generally healthy postmenopausal women between 41 to 81 years of age (mean 59 years of age) who at baseline had ≤5 percent superficial cells on a vaginal smear, a vaginal pH >5.0, and who identified at least one moderate to severe vaginal symptom that was considered the most bothersome to her (vaginal dryness, pain during intercourse [dyspareunia], or vaginal irritation/itching). Treatment groups included 30 mg OSPHENA (n=282), 60 mg OSPHENA (n=276), and placebo (n=268). All women were assessed for improvement in the mean change from Baseline to Week 12 for the coprimary efficacy variables of: most bothersome symptom (MBS) of vulvar and vaginal atrophy (defined as the individual moderate to severe symptom that was identified by the woman as most bothersome at baseline), percentage of vaginal superficial and vaginal parabasal cells on a vaginal smear, and vaginal pH. Following completion of 12-weeks, women with an intact uterus were allowed to enroll in a 40- week double-blind extension study, and women without an intact uterus were allowed to enroll in a 52- week open-label extension study. The second clinical trial was a 12-week, randomized, double-blind, placebo-controlled, parallel-group study that enrolled 919 generally healthy postmenopausal women between 41 to 79 years of age (mean 59 years of age) who at baseline had ≤5 percent superficial cells on a vaginal smear, a vaginal pH >5.0, and who identified either moderate to severe vaginal dryness (dryness cohort) or moderate to severe dyspareunia (dyspareunia cohort) as most bothersome to her at baseline. Treatment groups included 60 mg OSPHENA (n=463) and placebo (n=456). Primary endpoints and study conduct were similar to those in Trial 1. The third clinical trial was a 52-week, randomized, double-blind, placebo-controlled, long-term safety study that enrolled 426 generally healthy postmenopausal women between 49 to 79 years of age (mean 62 years of age) with an intact uterus. Treatment groups included 60 mg OSPHENA (n=363) and placebo (n=63). Effects On Dyspareunia In the 1 and 2 clinical trial, the modified intent-to-treat population of women treated st nd with OSPHENA when compared to placebo, demonstrated a statistically significant improvement (least square mean change from Baseline to Week 12) in the moderate to severe most bothersome symptom (MBS) of dyspareunia (1st trial p=0.0012, 2nd trial p<0.0001). See Table 2. A statistically significant increase in the proportion of superficial cells and a corresponding statistically significant decrease in the proportion of parabasal cells on a vaginal smear was also demonstrated (p<0.0001 for both). The mean reduction in vaginal pH between baseline and Week 12 was also statistically significant (p<0.0001). Table 2: Week 12 Effects on Dyspareunia (the Woman's Self-Identified Most Bothersome Moderate to Severe Symptom of Vulvar and Vaginal Atrophy at Baseline). Mean Change in Severity at Week 12 with Last Observation Carried Forward (LOCF), Modified Intent-to-Treat Population 1st Clinical Trial Results Most Bothersome Moderate to Severe Symptom at Baseline OSPHENA 60 mg (N=110) Placebo (N=113) Dyspareunia Baseline Mean (SD) 2.7 (0.44) 2.7 (0.45) LS Mean Change from Baseline (SE) -1.39 (0.11) -0.89 (0.11) p-value vs. placebo 0.0012 - 2nd Clinical Trial Results Most Bothersome Moderate to Severe Symptom at Baseline OSPHENA 60 mg (N=301) Placebo (N=297) Dyspareunia Baseline Mean (SD) 2.7 (0.47) 2.7 (0.47) LS Mean Change from Baseline (SE) -1.55 (0.06) -1.19 (0.07) p-value vs. placebo <0.0001 - Definitions: LOCF = last observation carried forward; SD = standard deviation; SE = standard error; LS = least square *The modified intent-to-treat population (mITT) included only women in the ITT population who at baseline met the inclusion criteria of ≤5 percent superficial cells on a vaginal smear, a vaginal pH > 5.0, and who identified moderate or severe dyspareunia as her most bothersome vaginal symptom.

Find Lowest Prices on OSPHENA® (ospemifene) Tablets, for Oral Use WARNING ENDOMETRIAL CANCER AND CARDIOVASCULAR DISORDERS Endometrial Cancer OSPHENA is an estrogen agonist/antagonist with tissues elective effects. In the endometrium, OSPHENA has estrogen agonistic effects. There is an increased risk of endometrial cancer in a woman with a uterus who uses unopposed estrogens. Adding a progestin to estrogen therapy reduces the risk of endometrial hyperplasia, which may be a precursor to endometrial cancer. Adequate diagnostic measures, including directed and random endometrial sampling when indicated, should be undertaken to rule out malignancy in postmenopausal women with undiagnosed persistent or recurring abnormal genital bleeding [see WARNINGS AND PRECAUTIONS]. Cardiovascular Disorders There is a reported increased risk of stroke and deep vein thrombosis (DVT) in postmenopausal women (50 to 79 years of age) who received daily oral conjugated estrogens (CE) [0.625 mg]-alone therapy over 7.1 years as part of the Women's Health Initiative (WHI) [see WARNINGS AND PRECAUTIONS]. In the clinical trials for OSPHENA (duration of treatment up to 15 months ), the incidence rates of thromboembolic and hemorrhagic stroke were 0.72 and 1.45 per thous and women, respectively in OSPHENA 60 mg treatment group and 1.04 and 0 in placebo [see WARNINGS AND PRECAUTIONS]. The incidence of DVT was 1.45 per thous and women in OSPHENA 60 mg treatment group and 1.04 per thous and women in placebo [see WARNINGS AND PRECAUTIONS]. OSPHENA should be prescribed for the shortest duration consistent with treatment goals and risks for the individual woman. DESCRIPTION OSPHENA is an estrogen agonist/antagonist. The chemical structure of ospemifene is shown in Figure 1. Figure 1: Chemical structure The chemical designation is Z-2-[4-(4-chloro-1,2-diphenylbut-1-enyl)phenoxy]ethanol, and has the empirical formula C24H23ClO2, which corresponds to a molecular weight of 378.9. Ospemifene is a white to off-white crystalline powder that is insoluble in water and soluble in ethanol. Each OSPHENA tablet contains 60 mg of ospemifene. Inactive ingredients include colloidal silicon dioxide, hypromellose, lactose monohydrate, magnesium stearate, mannitol, microcrystalline cellulose, polyethylene glycol, povidone, pregelatinized starch, sodium starch glycolate, titanium dioxide, and triacetin.

INDICATIONS OSPHENA is indicated for the treatment of moderate to severe dyspareunia, a symptom of vulvar and vaginal atrophy, due to menopause. DOSAGE AND ADMINISTRATION OSPHENA is an estrogen agonist/antagonist which has agonistic effects on the endometrium. Generally, when a product with estrogen agonistic effects on the endometrium is prescribed for a postmenopausal woman with a uterus, a progestin should be considered to reduce the risk of endometrial cancer. A woman without a uterus does not need a progestin [see WARNINGS AND PRECAUTIONS]. Use of OSPHENA should be for the shortest duration consistent with treatment goals and risks for the individual woman. Postmenopausal women should be re-evaluated periodically as clinically appropriate to determine if treatment is still necessary. Treatment Of Moderate To Severe Dyspareunia, A Symptom Of Vulvar And Vaginal Atrophy, Due To Menopause Take one 60 mg tablet with food once daily. HOW SUPPLIED Dosage Forms And Strengths OSPHENA tablets are white to off-white, oval, biconvex, film coated tablets containing 60 mg of ospemifene and engraved with "60" on one side. OSPHENA tablets are white to off-white, oval, biconvex, film coated tablets containing 60 mg of ospemifene and engraved with "60" on one side. They are available as follows: NDC 59630-580-90 Bottle of 90 tablets NDC 59630-580-30 Blister pack of 30 tablets containing 2 blister cards of 15 tablets each Storage And Handling Store at 20° to 25°C (68° to 77°F); excursions permitted to 15° to 30°C (59° to 86°F) [see USP Controlled Room Temperature]. Manufactured by: Penn Pharmaceutical Services Ltd. 23-24 Tafarnauback Industrial Estate Tredegar, Gwent, South Wales NP22 3AA, United Kingdom Made in UK. Revised: Aug 2015.

PATIENT INFORMATION OSPHENA® (os fee' nah) (ospemifene) Tablets Read this Patient Information before you start taking OSPHENA and each time you get a refill. There may be new information. This information does not take the place of talking to your healthcare provider about your medical condition or your treatment. What is the most important information I should know about OSPHENA ? OSPHENA is a medicine that works like estrogen in the lining of the uterus (womb), but can work differently in other parts of the body. Taking estrogen-alone or OSPHENA may increase your chance of getting cancer of the lining of the uterus (womb). Vaginal bleeding after menopause may be a warning sign of cancer of the lining of the uterus (womb). Your healthcare provider should check any unusual vaginal bleeding to find out the cause. Tell your healthcare provider right away if you have any unusual vaginal bleeding while you are taking OSPHENA. OSPHENA may increase your chance of getting strokes and blood clots. You and your healthcare provider should talk regularly about whether you still need treatment with OSPHENA. What is OSPHENA? OSPHENA is an oral prescription medicine that contains ospemifene. What is OSPHENA used for? OSPHENA is used after menopause for women with or without a uterus to: Treat moderate to severe pain during sexual intercourse due to changes in and around your vagina. Who should not take OSPHENA? Do not start taking OSPHENA if you: have unusual vaginal bleeding Vaginal bleeding after menopause may be a warning sign of cancer of the lining of the uterus (womb). Your healthcare provider should check any unusual vaginal bleeding to find out the cause. currently have or have had certain cancers Estrogen may increase the chances of getting certain types of cancers, such as cancer of the lining of the uterus. If you have or have had cancer, talk with your healthcare provider about whether you should take OSPHENA. currently have or have had blood clots had a stroke or heart attack are allergic to OSPHENA or any of its ingredients : See the list of ingredients in OSPHENA at the end of this leaflet. think you may be pregnant OSPHENA is not for pregnant women. If you think you may be pregnant, you should have a pregnancy test and know the results. Do not take OSPHENA if the test is positive and talk to your healthcare provider. What should I tell my healthcare provider before taking OSPHENA? Before you take OSPHENA, tell your healthcare provider if you: have any unusual vaginal bleeding Vaginal bleeding after menopause may be a warning sign of cancer of the lining of the uterus (womb). Your healthcare provider should check any unusual vaginal bleeding to find out the cause. have any other medical conditions Such as severe liver problems. are going to have surgery or will be on bed rest Your healthcare provider will let you know if you need to stop taking OSPHENA. are breast feeding It is not known if OSPHENA can pass into your breast milk. Tell your healthcare provider about all medicines you take, including prescription and nonprescription medicines, vitamins, and herbal supplements. Some medicines may affect how OSPHENA works. OSPHENA may also affect how other medicines work. Keep a list of your medicines and show it to your healthcare provider and pharmacist each time you get a new medicine. How should I take OSPHENA? Take OSPHENA exactly how your healthcare provider tells you to take it. Take OSPHENA by mouth 1 time each day with food. You and your healthcare provider should talk regularly (every 3 to 6 months) about the dose you are taking and whether or not you still need treatment with OSPHENA. What are the possible side effects of OSPHENA? See "What is the most important information I should know about OSPHENA?" Serious, but less common side effects include: stroke blood clots cancer of the lining of the uterus (womb) Call your healthcare provider right away if you get any of the following warning signs or any other unusual symptoms that concern you: unusual vaginal bleeding changes in vision or speech sudden new severe headaches severe pains in your chest or legs with or without shortness of breath, weakness and fatigue Less serious, but common side effects include: hot flushes or flashes vaginal discharge muscle spasms increased sweating These are not all the possible side effects of OSPHENA. For more information, ask your healthcare provider or pharmacist. Tell your healthcare provider about any side effects that bother you or does not go away. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800- FDA-1088. What can I do to lower my chances of a serious side effect with OSPHENA? Talk with your healthcare provider regularly about whether you should continue taking OSPHENA. If you have a uterus, talk with your healthcare provider about whether the addition of a progestin is right for you. See your healthcare provider right away if you develop vaginal bleeding while taking OSPHENA. Have a pelvic exam, breast exam and mammogram (breast x-ray) every year unless your healthcare provider tells you something else. If members of your family have had breast cancer or if you have ever had breast lumps or an abnormal mammogram (breast x-ray), you may need to have breast exams more often. If you have high blood pressure, high cholesterol (fat in the blood), diabetes, are overweight, or use tobacco, you may have a higher chance of getting heart disease. Tell your healthcare provider if you are going to have surgery or will be on bed rest. Ask your healthcare provider for ways to lower your chances of getting heart disease. How should I store OSPHENA? Store OSPHENA at room temperature between 68°F to 77°F (20°C to 25°C). Keep OSPHENA and all medicines out of the reach of children. General information about the safe and effective use of OSPHENA. Medicines are sometimes prescribed for conditions that are not mentioned in patient information leaflets. Do not take OSPHENA for conditions for which it was not prescribed. Do not give OSPHENA to other people, even if they have the same symptoms you have. It may harm them. This leaflet summarizes the most important information about OSPHENA. If you would like more information, talk with your healthcare provider or pharmacist. You can ask your healthcare provider or pharmacist for more information about OSPHENA that is written for health professionals. For more information, go to www.osphena.com or call Shionogi Inc. at 1-855-OSPHENA (1-855-677- 4362). What are the ingredients in OSPHENA? Active Ingredient: ospemifene Inactive ingredients: colloidal silicon dioxide, hypromellose, lactose monohydrate, magnesium stearate, mannitol, microcrystalline cellulose, polyethylene glycol, povidone, pregelatinized starch, sodium starch glycolate, titanium dioxide, and triacetin. This Patient Information has been approved by the U.S. Food and Drug Administration.

SIDE EFFECTS The following serious adverse reactions are discussed elsewhere in the labeling: Cardiovascular Disorders [see BOX WARNING, WARNINGS AND PRECAUTIONS] Malignant Neoplasms [see BOX WARNING, WARNINGS AND PRECAUTIONS] Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety of OSPHENA has been assessed in nine phase 2/3 trials (N=1892) with doses ranging from 5 to 90 mg per day. The duration of treatment in these studies ranged from 6 weeks to 15 months. Most women (N=1370) had a treatment period of at least 12 weeks, 409 had at least 52 weeks (1 year) of exposure. The incidence rates of thromboembolic and hemorrhagic stroke were 0.72 per thousand women (1 reported case of thromboembolic stroke) and 1.45 per thousand women (2 reported cases of hemorrhagic stroke), respectively in OSPHENA 60 mg treatment group and 1.04 and 0 per thousand women, respectively in placebo. The incidence of deep vein thrombosis (DVT) was 1.45 per thousand women in OSPHENA 60 mg treatment group (2 reported cases of DVT) and 1.04 (1 case of DVT) in placebo. Table 1 lists adverse reactions occurring more frequently in the OSPHENA 60 mg treatment group than in placebo and at a frequency ≥1%. Table 1: Adverse Reactions Reported More Common in the OSPHENA Treatment Group (60 mg Once Daily) and at Frequency ≥1.0% in the Double- Blind, Controlled Clinical Trials with OSPHENA vs . Placebo Ospemifene 60 mg (N=1242) % Placebo (N=958) % Vascular Disorders Hot flush 7.5 2.6 Reproductive System and Breast Disorders Vaginal discharge 3.8 0.3 Genital discharge 1.3 0.1 Musculoskeletal and Connective Tissue Disorders Muscle spasms 3.2 0.9 Skin and Subcutaneous Tissue Disorders Hyperhidrosis 1.6 0.6 Postmarketing Experience The following adverse reactions have been identified during post-approval use of ospemifene. Because these reactions are reported voluntarily from a population of uncertain size, it is not possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Immune System Disorders: allergic conditions including hypersensitivity, angioedema Skin and Subcutaneous Tissue Disorders: rash, rash erythematous, rash generalized, pruritus, urticaria DRUG INTERACTIONS OSPHENA is primarily metabolized by CYP3A4 and CYP2C9. CYP2C19 and other pathways contribute to the metabolism of ospemifene. Estrogens And Estrogen Agonist/Antagonist OSPHENA should not be used concomitantly with estrogens and estrogen agonists/antagonists. The safety of concomitant use of OSPHENA with estrogens and estrogen agonists/antagonists has not been studied. Fluconazole Fluconazole, a moderate CYP3A / strong CYP2C9 / moderate CYP2C19 inhibitor, should not be used with OSPHENA. Fluconazole increases the systemic exposure of ospemifene by 2.7-fold. Administration of fluconazole with ospemifene may increase the risk of OSPHENA-related adverse reactions [see CLINICAL PHARMACOLOGY]. Rifampin Rifampin, a strong CYP3A4 / moderate CYP2C9 / moderate CYP2C19 inducer, decreases the systemic exposure of ospemifene by 58%. Therefore, co-administration of OSPHENA with drugs such as rifampin which induce CYP3A4, CYP2C9 and/or CYP2C19 activity would be expected to decrease the systemic exposure of ospemifene, which may decrease the clinical effect [see CLINICAL PHARMACOLOGY]. Ketoconazole Ketoconazole, a strong CYP3A4 inhibitor increases the systemic exposure of ospemifene by 1.4-fold. Administration of ketoconazole chronically with ospemifene may increase the risk of OSPHENArelated adverse reactions [see CLINICAL PHARMACOLOGY]. Warfarin Repeated administration of ospemifene had no effect on the pharmacokinetics of a single 10 mg dose of warfarin. No study was conducted with multiple doses of warfarin. The effect of ospemifene on clotting time such as the International Normalized Ratio (INR) or prothrombin time (PT) was not studied [see CLINICAL PHARMACOLOGY]. Highly Protein-Bound Drugs Ospemifene is more than 99% bound to serum proteins and might affect the protein binding of other drugs. Use of OSPHENA with other drug products that are highly protein bound may lead to increased exposure of either that drug or ospemifene [see CLINICAL PHARMACOLOGY]. Multiple Enzyme Inhibition Co-administration of OSPHENA with a drug known to inhibit CYP3A4 and CYP2C9 isoenzymes may increase the risk of OSPHENA-related adverse reactions.

WARNINGS Included as part of the "PRECAUTIONS" Section PRECAUTIONS Cardiovascular Disorders Risk factors for cardiovascular disorders, arterial vascular disease (for example, hypertension, diabetes mellitus, tobacco use, hypercholesterolemia, and obesity) and/or venous thromboembolism (VTE) (for example, personal history or family history of VTE, obesity, and systemic lupus erythematosus), should be managed appropriately. Stroke In the WHI estrogen-alone substudy, a statistically significant increased risk of stroke was reported in women 50 to 79 years of age receiving daily CE (0.625 mg)-alone compared to women in the same age group receiving placebo (45 versus 33 per ten thousand women-years). The increase in risk was demonstrated in year 1 and persisted. In the clinical trials for OSPHENA (duration of treatment up to 15 months), the incidence rates of thromboembolic and hemorrhagic stroke were 0.72 and 1.45 per thousand women, respectively in OSPHENA 60 mg treatment group and 1.04 and 0 per thousand women in placebo. Should thromboembolic or hemorrhagic stroke occur or be suspected, OSPHENA should be discontinued immediately. Coronary Heart Disease In the WHI estrogen-alone substudy, no overall effect on coronary heart disease (CHD) events (defined as nonfatal MI, silent MI, or CHD death) was reported in women receiving estrogen-alone compared to placebo. In the OSPHENA clinical trials, a single MI occurred in a woman receiving 60 mg of ospemifene. Venous Thromboembolism In the WHI estrogen-alone substudy, the risk of VTE (DVT and PE), was increased for women receiving daily CE (0.625 mg)-alone compared to placebo (30 versus 22 per ten thousand womenyears), although only the increased risk of DVT reached statistical significance (23 versus 15 per ten thousand women-years). The increase in VTE risk was demonstrated during the first 2 years. In the OSPHENA clinical trials, the incidence of DVT was 1.45 per thousand women in OSPHENA 60 mg treatment group and 1.04 per thousand women in placebo. Should a VTE occur or be suspected, OSPHENA should be discontinued immediately. If feasible, OSPHENA should be discontinued at least 4 to 6 weeks before surgery of the type associated with an increased risk of thromboembolism, or during periods of prolonged immobilization. Malignant Neoplasms Endometrial Cancer OSPHENA is an estrogen agonist/antagonist with tissue selective effects. In the endometrium, OSPHENA has agonistic effects. In the OSPHENA clinical trials (60 mg treatment group), no cases of endometrial cancer were seen with exposure up to 52 weeks. There was a single case of simple hyperplasia without atypia. Endometrial thickening equal to 5 mm or greater was seen in the OSPHENA treatment groups at a rate of 60.1 per thousand women vs. 21.2 per thousand women for placebo. The incidence of any type of proliferative (weakly plus active plus disordered) endometrium was 86.1 per thousand women in OSPHENA vs. 13.3 per thousand women for placebo. Uterine polyps occurred at an incidence of 5.9 per thousand women vs. 1.8 per thousand women for placebo. An increased risk of endometrial cancer has been reported with the use of unopposed estrogen therapy in a woman with a uterus. The reported endometrial cancer risk among unopposed estrogen users is about 2 to 12 times greater than in non-users, and appears dependent on duration of treatment and on estrogen dose. Most studies show no significant increased risk associated with the use of estrogens for less than 1 year. The greatest risk appears to be associated with prolonged use, with increased risks of 15- to 24-fold for 5 to 10 years or more. This risk has been shown to persist for at least 8 to 15 years after estrogen therapy is discontinued. Adding a progestin to postmenopausal estrogen therapy has been shown to reduce the risk of endometrial hyperplasia, which may be a precursor to endometrial cancer. There are, however, possible risks that may be associated with the use of progestins with estrogens compared to estrogen-alone regimens. These include an increased risk of breast cancer. The use of progestins with OSPHENA therapy was not evaluated in the clinical trials. Clinical surveillance of all women using OSPHENA is important. Adequate diagnostic measures, including directed or random endometrial sampling when indicated, should be undertaken to rule out malignancy in postmenopausal women with undiagnosed persistent or recurring abnormal genital bleeding. Breast Cancer OSPHENA 60 mg has not been adequately studied in women with breast cancer; therefore, it should not be used in women with known or suspected breast cancer or with a history of breast cancer. Severe Hepatic Impairment OSPHENA should not be used in women with severe hepatic impairment [see Use In Specific Populations and CLINICAL PHARMACOLOGY]. Patient Counseling Information See FDA-approved patient labeling (PATIENT INFORMATION) Hypersensitivity Reactions Inform postmenopausal women who have had hypersensitivity reactions to OSPHENA, such as angioedema, urticaria, rash, pruritus, that they should not take OSPHENA [see CONTRAINDICATIONS]. Vaginal Bleeding Inform postmenopausal women of the importance of reporting unusual vaginal bleeding to their healthcare providers as soon as possible [see WARNINGS AND PRECAUTIONS]. Hot Flashes Or Flushes OSPHENA may initiate or increase the occurrence of hot flashes in some women [see ADVERSE REACTIONS]. Nonclinical Toxicology Carcinogenesis, Mutagenesis, Impairment Of Fertility Carcinogenesis In a 2-year carcinogenicity study in female mice, ospemifene administration of 100, 400 or 1500 mg/kg/day was well tolerated. No evaluation for carcinogenicity was conducted in male mice. There was significant increase in adrenal subcapsular cell adenomas at 4 and 5 times the human exposure based on AUC, and adrenal cortical tumors at 5 times the human exposure. In the ovary, an increase in sex cord/stromal tumors, tubulostromal tumors, granulosa cell tumors, and luteomas were also seen. These findings occurred at doses 2 to 5 times the human exposure based on AUC, and are probably related to estrogenic/antiestrogenic effect of ospemifene in mice. In a 2-year carcinogenicity study in rats, ospemifene administration of 10, 50, or 300 mg/kg/day was well tolerated. A significant increase in thymomas was recorded for males and thymomas for females at all ospemifene dose levels, or 0.3 to 1.2 times the human exposure based on AUC. In the liver, an increase in hepatocellular tumors were recorded at for females at all ospemifene dose levels. Mutagenesis Ospemifene was not genotoxic in vitro in the Ames test in strains of Salmonella typhimurium or at the thymidine kinase (tk) locus of mouse lymphoma L5178Y cells in the absence and in the presence of a metabolic activator system. In in vivo testing, ospemifene was not genotoxic in a standard mouse bone marrow micronucleus test or in a determination of DNA adducts in the liver of rats. Impairment Of Fertility The effect of ospemifene on fertility was not directly evaluated. In female rats and monkeys, decreases in ovarian and uterine weights, decreased corpora lutea number, increased ovarian cysts, uterine atrophy, and disrupted cycles were observed when given repeated daily oral doses. In male rats, atrophy of the prostate and seminal vesicles was noted. The effects on reproductive organs observed in animals are consistent with the estrogen receptor activity of ospemifene and potential for impairment of fertility. Use In Specific Populations Pregnancy Teratogenic Effects Pregnancy Category X [see CONTRAINDICATIONS]. Risk Summary Based on animal data, OSPHENA is likely to increase the risk of adverse outcomes during pregnancy and labor. Adverse findings at maternally toxic doses included embryofetal lethality in rats and rabbits, and neonatal mortality and difficult labor in rats. The reproductive effects observed are consistent with and are considered to be related to estrogen receptor activity of OSPHENA. Animal Data The effects of OSPHENA on embryo-fetal development were studied in rats (0.1, 1 or 4 mg/kg/day) and rabbits (3, 10, or 30 mg/kg/day) when treated from implantation through organogenesis. In rabbits, there was an increase in the incidence of total resorptions at 30 mg/kg/day (10 times the human exposure based on surface area mg/m2 ). Drug-induced malformations were not observed in either rats or rabbits. The effects of OSPHENA on pre-and postnatal development were studied in pregnant rats (0.01, 0.05, and 0.25 mg/kg/day) treated from implantation through lactation. Pregnant rats given 0.05 or 0.25 mg/kg/day OSPHENA (0.8% to 4% the human exposure based on surface area mg/m2 ), had a significantly prolonged and difficult gestation, increased post-implantation loss, increased number of dead pups at birth, and an increased incidence of postnatal loss. OSPHENA did not induce adverse effects in the surviving offspring of pregnant rats at drug exposures up to 4% the human exposure. Nursing Mothers It is not known whether OSPHENA is excreted in human breast milk. In a nonclinical study, ospemifene was excreted in rat milk and detected at concentrations higher than that in maternal plasma. Pediatric Use OSPHENA is not indicated in children. Clinical studies have not been conducted in the pediatric population. Geriatric Use Of the 1892 OSPHENA-treated women enrolled in the nine phase 2/3 trials of OSPHENA, >19 percent were 65 years of age or older. No clinically meaningful differences in safety or effectiveness were observed between these women and younger women less than 65 years of age. Renal Impairment The pharmacokinetics of ospemifene in women with severe renal impairment (CrCL <30 mL/min) was similar to those in women with normal renal function [see CLINICAL PHARMACOLOGY]. No dose adjustment of OSPHENA is required in women with renal impairment. Hepatic Impairment The pharmacokinetics of ospemifene has not been studied in women with severe hepatic impairment (Child-Pugh Class C); therefore, OSPHENA should not be used in women with severe hepatic impairment [see WARNINGS AND PRECAUTIONS , and CLINICAL PHARMACOLOGY]. No clinically important pharmacokinetic differences with OSPHENA were observed between women with mild to moderate hepatic impairment and healthy women [see CLINICAL PHARMACOLOGY]. No dose adjustment of OSPHENA is required in women with mild (Child-Pugh Class A) or moderate (Child-Pugh Class B) hepatic impairment.