Prescription Drugs

CLINICAL PHARMACOLOGY Mechanism Of Action Rucaparib is an inhibitor of poly (ADP-ribose) polymerase (PARP) enzymes, including PARP-1, PARP-2, and PARP-3, which play a role in DNA repair. In vitro studies have shown that rucaparib-induced cytotoxicity may involve inhibition of PARP enzymatic activity and increased formation of PARP-DNA complexes resulting in DNA damage, apoptosis, and cell death. Increased rucaparib-induced cytotoxicity was observed in tumor cell lines with deficiencies in BRCA½ and other DNA repair genes. Rucaparib has been shown to decrease tumor growth in mouse xenograft models of human cancer with or without deficiencies in BRCA. Pharmacodynamics The pharmacodynamic response of rucaparib has not been characterized. Cardiac Electrophysiology The effect of multiple doses of Rubraca on QTc interval was evaluated in an open-label single-arm study in 56 patients with solid tumors who were administered continuous doses of Rubraca ranging from 40 mg once daily (0.03 times the approved recommended dosage) to 840 mg twice daily (1.4 times the approved recommended dosage). The mean QTcF increase from baseline (90% confidence interval [CI]) in population pharmacokinetics estimated 95% percentile Cmax (3019 ng/mL) at steady state of 600 mg rucaparib twice daily was 14.9 msec (11.1-18.7 msec). Pharmacokinetics All pharmacokinetics of rucaparib were characterized in patients with cancer. Rucaparib demonstrated linear pharmacokinetics over a dose range from 240 to 840 mg twice daily with time-independence and dose-proportionality. The mean steady-state rucaparib Cmax was 1940 ng/mL (54% coefficient of variation [CV]) and AUC0-12h was 16900 h•ng/mL (54% CV) at the approved recommended dosage. Accumulation was 3.5 to 6.2 fold. Median terminal half-life (T½) was 17 hours following a single intravenous dose of 12 to 40 mg rucaparib. Absorption The median T max was 1.9 hours at the approved recommended dosage. The mean absolute bioavailability of rucaparib immediate-release tablet was 36% with a range from 30% to 45%. Following a high-fat meal, the Cmax was increased by 20% and AUC 0-24h was increased by 38%, and T max was delayed by  2.5 hours, as compared to dosing under fasted conditions [see DOSAGE AND ADMINISTRATION]. Distribution Rucaparib had a steady-state volume of distribution of 113 L to 262 L following a single intravenous dose of 12 mg to 40 mg rucaparib. In vitro, the protein binding of rucaparib was 70% in human plasma at therapeutic concentrations. Rucaparib preferentially distributed to red blood cells with a blood-to-plasma concentration ratio of 1.83. Elimination The mean terminal T ½ of rucaparib was 17 to 19 hours, following a single oral dose of 600 mg rucaparib. The apparent clearance ranged from 15.3 to 79.2 L/hour, following continuous 600 mg rucaparib orally twice daily. The clearance ranged from 13.9 to 18.4 L/hour, following a single intravenous dose of rucaparib 12 mg to 40 mg. Metabolism In vitro, rucaparib was metabolized primarily by CYP2D6 and to a lesser extent by CYP1A2 and CYP3A4. Specific Populations Age, Race, and Body Weight Based on population pharmacokinetic analyses, age, race, and body weight did not have a clinically significant effect on rucaparib exposure. Renal Impairment In patients who received Rubraca 600 mg twice daily, those with mild renal impairment (N=148; CLcr between 60 and 89 mL/min, as estimated by the Cockcroft-Gault method) and those with moderate renal impairment (N=72; CLcr between 30 and 59 mL/min) showed approximately 15% and 32% higher steady-state AUC, respectively, compared to patients with normal renal function (N=143; CLcr greater than or equal to 90 mL/min). The pharmacokinetic characteristics of rucaparib in patients with CLcr less than 30 mL/min or patients on dialysis are unknown. Hepatic Impairment Based on population pharmacokinetic analyses, no apparent pharmacokinetic difference was observed in 34 patients with mild hepatic impairment (total bilirubin less than or equal to ULN and AST greater than ULN, or total bilirubin between 1.0 to 1.5 time ULN and any AST) who received Rubraca 600 mg twice daily as compared to patients with normal hepatic function (N=337). The pharmacokinetic characteristics of rucaparib in patients with moderate to severe hepatic impairment (total bilirubin greater than 1.5 times ULN) are unknown. CYP Enzyme Polymorphism Based on population pharmacokinetic analyses, steady-state concentrations following rucaparib 600 mg twice daily did not differ significantly across CYP2D6 or CYP1A2 genotype subgroups. Drug Interaction Studies Effects of Other Drugs on Rucaparib In vitro, rucaparib had a low metabolic turnover rate in human liver microsomes, and was metabolized primarily by CYP2D6 and to a lesser extent by CYP1A2 and CYP3A4. In vitro, rucaparib was shown to be a substrate of P-gp and BCRP, but not a substrate of renal uptake transporters OAT1, OAT3, and OCT2, or hepatic transporters OATP1B1 and OATP1B3. Concomitant treatment with proton pump inhibitors has no clinically meaningful change in steady-state exposures. Effect of Rucaparib on Other Drugs Effect of rucaparib on other drugs has not been studied in humans. Rucaparib reversibly inhibited CYP1A2, CYP2C19, CYP2C9, and CYP3A, and to a lesser extent CYP2C8, CYP2D6, and UGT1A1. Rucaparib induced CYP1A2, and down regulated CYP2B6 and CYP3A4 in human hepatocytes at clinically relevant exposures. Rucaparib was a potent inhibitor of MATE1 and MATE2-K, and a moderate inhibitor of OCT1. Weak inhibition was observed at ultra-therapeutic concentration (300 μM) of rucaparib for MRP4, OATP1B1, OATP1B3, OAT1, and OAT3. No inhibition was observed for MRP2, MRP3, or BSEP. Rucaparib was an inhibitor of BCRP and P-gp efflux transporters with IC50 of 55 μM and 283 μM, respectively. Clinical Studies The efficacy of Rubraca was investigated in 106 patients in two multicenter, single-arm, open-label clinical trials, Study 1 and Study 2, in patients with advanced BRCA-mutant ovarian cancer who had progressed after 2 or more prior chemotherapies. All 106 patients received Rubraca 600 mg orally twice daily as monotherapy until disease progression or unacceptable toxicity. Objective response rate (ORR) and duration of response (DOR) were assessed by the investigator and independent radiology review (IRR) according to Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1. The median age of the patients was 59 years (range 33 to 84), the majority were Caucasian (78%), and 100% had an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1. All patients had received at least two prior platinum-based chemotherapies and 43% had received 3 or more prior lines of chemotherapy. There were 18/106 patients (17%) who had deleterious BRCA mutations detected in tumor tissue and not in whole blood specimens. Tumor BRCA mutation status was verified retrospectively in 96% (64/67) of the patients for whom a tumor tissue sample was available by the companion diagnostic FoundationFocus CDx BRCA ™ test, which is FDA approved for selection of patients for Rubraca treatment. Efficacy results are summarized in Table 4. Table 4: Overall Response and Duration of Response in Patients with BRCA-mutant Ovarian Cancer Who Received 2 or More Chemotherapies in Study 1 and Study 2 Investigator-assessed N=106 Objective Response Rate (95% CI) 54% (44, 64) Complete Response 9% Partial Response 45% Median DOR in months (95% CI) 9.2 (6.6 ,11.6) Response assessment by independent radiology review was 42% (95% CI [32, 52]), with a median DOR of 6.7 months (95% CI [5.5, 11.1]). Investigator-assessed ORR was 66% (52/79; 95% CI [54, 76]) in platinum-sensitive patients, 25% (5/20; 95% CI [9, 49]) in platinum-resistant patients, and 0% (0/7; 95% CI [0, 41]) in platinum-refractory patients. ORR was similar for patients with a BRCA1 gene mutation or BRCA2 gene mutation.

RUBRACA™ (rucaparib) Tablets DESCRIPTION Rucaparib is an inhibitor of the mammalian polyadenosine 5'-diphosphoribose polymerase (PARP) enzyme. The chemical name is 8-fluoro-2-{4-[(methylamino)methyl]phenyl}-1,3,4,5-tetrahydro-6H-azepino[5,4,3-cd]indol-6-one ((1S,4R)-7,7dimethyl-2-oxobicyclo[2.2.1]hept-1-yl)methanesulfonic acid salt. The chemical formula of rucaparib camsylate is C19H18FN3O•C10H16O4S and the relative molecular mass is 555.67 Daltons. The chemical structure of rucaparib camsylate is shown below: Rucaparib camsylate is a white to pale yellow powder; formulated into a tablet for oral use. Rucaparib shows pH-independent low solubility of approximately 1 mg/mL across the physiological pH range. Rubraca (rucaparib) tablets contain rucaparib camsylate as the active ingredient. Each 200 mg tablet contains 344 mg rucaparib camsylate equivalent to 200 mg rucaparib free base. Each 300 mg tablet contains 516 mg rucaparib camsylate equivalent to 300 mg rucaparib free base. The inactive ingredients in Rubraca tablets include: microcrystalline cellulose, sodium starch glycolate, colloidal silicon dioxide, and magnesium stearate. The cosmetic blue film coating for 200 mg tablets and cosmetic yellow film coating for 300 mg tablets is Opadry II containing polyvinyl alcohol, titanium dioxide, polyethylene glycol/macrogol, and talc. The coating is colorized as blue using brilliant blue aluminum lake and indigo carmine aluminum lake, or yellow using yellow iron oxide.

INDICATIONS Rubraca™ is indicated as monotherapy for the treatment of patients with deleterious BRCA mutation (germline and/or somatic) associated advanced ovarian cancer who have been treated with two or more chemotherapies. Select patients for therapy based on an FDA-approved companion diagnostic for Rubraca [see DOSAGE AND ADMINISTRATION]. This indication is approved under accelerated approval based on objective response rate and duration of response [see Clinical Studies]. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials. DOSAGE AND ADMINISTRATION Patient Selection Select patients for the treatment of advanced ovarian cancer with Rubraca based on the presence of a deleterious BRCA mutation (germline and/or somatic)[see INDICATIONS AND USAGE and Clinical Studies]. Information on the FDA-approved test for the detection of a tumor BRCA mutation in patients with ovarian cancer is available at: http://www.fda.gov/CompanionDiagnostics. Recommended Dose The recommended dose of Rubraca is 600 mg (two 300 mg tablets) taken orally twice daily with or without food. Continue treatment until disease progression or unacceptable toxicity. If a patient misses a dose of Rubraca, instruct the patient to take the next dose at its scheduled time. Vomited doses should not be replaced. Dose Modifications For Adverse Reactions To manage adverse reactions, consider interruption of treatment or dose reduction. Recommended dose reductions are indicated in Table 1. Table 1:  Recommended Dose Adjustments Dose Reduction Dose Starting Dose 600 mg twice daily (two 300 mg tablets) First Dose Reduction 500 mg twice daily (one 300 mg tablet and one 200 mg tablet) Second Dose Reduction 400 mg twice daily (two 200 mg tablets) Third Dose Reduction 300 mg twice daily (one 300 mg tablet) HOW SUPPLIED Dosage Forms And Strengths Tablets (200 mg): blue, round, immediate-release, film-coated, debossed with “C2”. Tablets (300 mg): yellow, oval, immediate-release, film-coated, debossed with “C3”. Storage And Handling Rubraca is available as 200 mg and 300 mg tablets. 200 mg Tablets Blue, round, and debossed with “C2” on one side Supplied in bottles of 60 tablets (NDC: 69660-201-91) 300 mg Tablets Yellow, oval, and debossed with “C3” on one side Supplied in bottles of 60 tablets (NDC: 69660-203-91) Storage Store at 20°C to 25°C (68°F to 77°F); excursions permitted to 15°C to 30°C (59°F to 86°F) [see USP Controlled Room Temperature]. Distributed by: Clovis Oncology, Inc. Boulder, Colorado 80301. For more information, go to www.Rubraca.com or call 1-844-258-7662. Revised: December 2016

PATIENT INFORMATION Rubraca™ (roo-brah'-kah) (rucaparib) Tablets What is the most important information I should know about Rubraca? Rubraca may cause serious side effects including: Bone marrow problems called Myelodysplastic Syndrome (MDS) or a type of cancer of the blood called Acute Myeloid Leukemia (AML). Some people who have ovarian cancer and who have received previous treatment with chemotherapy or certain other medicines for their cancer have developed MDS or AML during or after treatment with Rubraca. MDS or AML may lead to death. If you develop MDS or AML, your healthcare provider will stop treatment with Rubraca. Symptoms of low blood cell counts are common during treatment with Rubraca, but can be a sign of serious problems, including MDS or AML. Tell your healthcare provider if you have any of the following symptoms during treatment with Rubraca: weakness weight loss fever frequent infections blood in urine or stool shortness of breath feeling very tired bruising or bleeding more easily Your healthcare provider will do blood tests to check your blood cell counts: before treatment with Rubraca. every month during treatment with Rubraca. weekly if you have low blood cell counts for a long time. Your healthcare provider may stop treatment with Rubraca until your blood cell counts improve. See “What are possible side effects of Rubraca?” for more information about side effects. What is Rubraca? Rubraca is a prescription medicine used to treat people with advanced ovarian cancer who: have certain “BRCA” gene mutations, either inherited (germline) or acquired (somatic), and have received previous treatment with 2 or more prior chemotherapy medicines for their cancer. Your healthcare provider will perform a test to make sure Rubraca is right for you. It is not known if Rubraca is safe and effective in children. What should I tell my healthcare provider before taking Rubraca? Before you take Rubraca, tell your healthcare provider about all of your medical conditions, including if you: are pregnant or plan to become pregnant. Rubraca can harm your unborn baby and may cause loss of pregnancy (miscarriage). You should not become pregnant during treatment with Rubraca. If you are able to become pregnant, your healthcare provider may do a pregnancy test before you start treatment with Rubraca. Females who are able to become pregnant should use effective birth control during treatment and for 6 months after the last dose of Rubraca. Talk to your healthcare provider about birth control methods that may be right for you. Tell your healthcare provider right away if you become pregnant. are breastfeeding or plan to breastfeed. It is not known if Rubraca passes into your breast milk. Do not breastfeed during treatment and for 2 weeks after the last dose of Rubraca. Tell your healthcare provider about all the medicines you take, including prescription and over-the counter medicines, vitamins, and herbal supplements. How should I take Rubraca? Take Rubraca exactly as your healthcare provider tells you. Your healthcare provider may temporarily stop treatment with Rubraca or change your dose of Rubraca if you have side effects. Do not change your dose or stop taking Rubraca unless your healthcare provider tells you to. Take Rubraca 2 times a day. Each dose should be taken about 12 hours apart. Take Rubraca with or without food. If you miss a dose of Rubraca, take your next dose at your usual scheduled time. Do not take an extra dose to make up for a missed dose. If you vomit after taking a dose of Rubraca, do not take an extra dose. Take your next dose at your usual time. If you take too much Rubraca, call your healthcare provider or go to the nearest emergency room right away. What should I avoid while taking Rubraca? Avoid spending time in sunlight. Rubraca can make your skin sensitive to the sun (photosensitivity). You may sunburn more easily during treatment with Rubraca. You should wear a hat and clothes that cover your skin and use sunscreen to help protect against sunburn if you have to be in the sunlight. What are the possible side effects of Rubraca? Rubraca may cause serious side effects. See “What is the most important information I should know about Rubraca?” The most common side effects of Rubraca include: nausea fatigue vomiting stomach-area pain changes in how food tastes constipation decreased appetite diarrhea shortness of breath decrease in hemoglobin (anemia) low blood cell counts changes in liver or kidney function blood tests increased cholesterol levels These are not all of the possible side effects of Rubraca. For more information, ask your healthcare provider or pharmacist. Call your healthcare provider for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. How should I store Rubraca? Store Rubraca at room temperature between 68°F to 77°F (20°C to 25°C). Keep Rubraca and all medicines out of the reach of children. General information about the safe and effective use of Rubraca Medicines are sometimes prescribed for purposes other than those listed in a Patient Information leaflet. Do not use Rubraca for a condition for which it was not prescribed. Do not give it to other people, even if they have the same symptoms you have. It may harm them. You can ask your healthcare provider or pharmacist for more information about Rubraca. What are the ingredients in Rubraca? Active ingredient: rucaparib Inactive ingredients: microcrystalline cellulose, sodium starch glycolate, colloidal silicon dioxide, magnesium stearate. The film coating contains polyvinyl alcohol, titanium dioxide, polyethylene glycol/macrogol, and talc. The blue film coating contains brilliant blue aluminum lake and indigo carmine aluminum lake. The yellow film coating contains yellow iron oxide.

OVERDOSE There is no specific treatment in the event of Rubraca overdose, and symptoms of overdose are not established. In the event of suspected overdose, physicians should follow general supportive measures and should treat symptomatically. CONTRAINDICATIONS None.

SIDE EFFECTS The following serious adverse reactions are discussed elsewhere in the labeling: Myelodysplastic Syndrome/Acute Myeloid Leukemia [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. Rubraca 600 mg twice daily as monotherapy, has been studied in 377 patients with ovarian cancer treated in two open-label, single arm trials. In these patients, the median age was 62 years (range 31 to 86), 100% had an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1, 38% had BRCA-mutated ovarian cancer, 45% had received 3 or more prior lines of chemotherapy, and the median time since ovarian cancer diagnosis was 43 months (range 6 to 197). Adverse reactions led to dose reduction or interruption in 62% of patients, most frequently from anemia (27%), and fatigue/asthenia (22%). Adverse reactions led to dose discontinuation in 10% of patients, most frequently from fatigue/asthenia (2%). The median duration of treatment was 5.5 months (range 0.1 to 28.0). Table 2 and Table 3 summarize the common adverse reactions and abnormal laboratory findings, respectively, observed in patients treated with Rubraca. Table 2: Adverse Reactions Reported in ≥ 20% of Patients with Ovarian Cancer Treated with Rubraca 600 mg Twice Daily Adverse Reaction All Ovarian Cancer Patients (N = 377) % Gradesa 1-4 Grades 3-4 Gastrointestinal Disorders Nausea 77 5 Vomiting 46 4 Constipation 40 2 Diarrhea 34 2 Abdominal Pain 32 3 General Disorders Asthenia/Fatigue 77 11 Blood and Lymphatic System Disorders Anemia 44 25 Thrombocytopenia 21 5 Nervous System Disorders Dysgeusia 39 0.3 Metabolism and Nutrition Disorders Decreased appetite 39 3 Respiratory, Thoracic, and Mediastinal Disorders Dyspnea 21 0.5 a National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE version 4.03) The following adverse reactions have been identified in < 20% of the 377 patients treated with Rubraca 600 mg twice daily: dizziness (17%), neutropenia (15%), rash (includes rash, rash erythematous, rash maculopapular and dermatitis) (13%), pyrexia (11%), photosensitivity reaction (10%), pruritus (includes pruritus and pruritus generalized) (9%), Palmarplantar erythrodysaesthesia syndrome (2%), and febrile neutropenia (1%). Table 3: Laboratory Abnormalities Reported in ≥ 35% of Patients with Ovarian Cancer Treated with Rubraca 600 mg Twice Daily Laboratory Parameter All Patients with Ovarian Cancer (N = 377) % Grade 1-4 a Grade 3-4 Clinical Chemistry Increase in creatinine 92 1 Increase in ALTb 74 13 Increase in ASTb 73 5 Increase in cholesterol 40 2 Hematologic Decrease in hemoglobin 67 23 Decrease in lymphocytes 45 7 Decrease in platelets 39 6 Decrease in absolute neutrophil count 35 10 a At least one worsening shift in CTCAE grade and by maximum shift from baseline. b Increase in ALT/AST led to treatment discontinuation in 0.3% of patients (1/377). DRUG INTERACTIONS No information provided.

WARNINGS Included as part of the PRECAUTIONS section. PRECAUTIONS Myelodysplastic Syndrome/Acute Myeloid Leukemia Myelodysplastic syndrome (MDS)/Acute Myeloid Leukemia (AML) was reported in 2 of 377 (0.5%) patients with ovarian cancer treated with Rubraca. The duration of Rubraca treatment prior to the diagnosis of MDS/AML was 57 days and 539 days. Both patients received prior treatment with platinum and other DNA damaging agents. In addition, AML was reported in 2 ( < 1%) patients with ovarian cancer enrolled in a blinded, randomized trial evaluating Rubraca versus placebo. One case of AML was fatal. The duration of treatment prior to the diagnosis of AML was 107 days and 427 days. Both patients had received prior treatment with platinum and other DNA damaging agents. Monitor complete blood count testing at baseline and monthly thereafter. Do not start Rubraca until patients have recovered from hematological toxicity caused by previous chemotherapy ( ≤ Grade 1). For prolonged hematological toxicities, interrupt Rubraca and monitor blood counts weekly until recovery. If the levels have not recovered to Grade 1 or less after 4 weeks, refer the patient to a hematologist for further investigations, including bone marrow analysis and blood sample for cytogenetics. If MDS/AML is confirmed, discontinue Rubraca. Embryo-Fetal Toxicity Rubraca can cause fetal harm when administered to a pregnant woman based on its mechanism of action and findings from animal studies. In an animal reproduction study, administration of rucaparib to pregnant rats during organogenesis resulted in embryo-fetal death at maternal exposure that were 0.04 times the AUC in patients receiving the recommended dose of 600 mg twice daily. Apprise pregnant women of the potential risk to a fetus. Advise females of reproductive potential to use effective contraception during treatment and for 6 months following the last dose of Rubraca [see Use in Specific Populations and CLINICAL PHARMACOLOGY]. Patient Counseling Information Advise the patient to read the FDA-approved patient labeling (PATIENT INFORMATION). MDS/AML Advise patients to contact their healthcare provider if they experience weakness, feeling tired, fever, weight loss, frequent infections, bruising, bleeding easily, breathlessness, blood in urine or stool, and/or laboratory findings of low blood cell counts, or a need for blood transfusions. These may be signs of hematological toxicity or a more serious uncommon bone marrow problem called 'myelodysplastic syndrome' (MDS) or 'acute myeloid leukemia' (AML) which have been reported in patients treated with Rubraca [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 6 months after receiving the last dose of Rubraca [see WARNINGS AND PRECAUTIONS and Use in Specific Populations]. Photosensitivity Advise patients to use appropriate sun protection due to the increased susceptibility to sunburn while taking Rubraca [see ADVERSE REACTIONS]. Lactation Advise females not to breastfeed during treatment and for 2 weeks after the last dose of Rubraca [see Use in Specific Populations]. Dosing Instructions Instruct patients to take Rubraca orally twice daily with or without food. Doses should be taken approximately 12 hours apart. Advise patients that if a dose of Rubraca is missed or if the patient vomits after taking a dose of Rubraca, patients should not take an extra dose, but take the next dose at the regular time [see DOSAGE AND ADMINISTRATION]. Use In Specific Populations Pregnancy Risk Summary Based on findings from animal studies and its mechanism of action, Rubraca can cause fetal harm when administered to pregnant women. There are no available data in pregnant women to inform the drug-associated risk. In an animal reproduction study, administration of rucaparib to pregnant rats during organogenesis resulted in embryo-fetal death at maternal exposure that were 0.04 times the AUC 0-24h in patients receiving the recommended dose of 600 mg twice daily [see Data]. Apprise pregnant women of the potential risk to a fetus. The background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively. Data Animal Data In a dose range-finding embryo-fetal development study, pregnant rats received oral doses of 50, 150, 500, or 1000 mg/kg/day of rucaparib during the period of organogenesis. Post-implantation loss (100% early resorptions) was observed in all animals at doses greater than or equal to 50 mg/kg/day (with maternal systemic exposures approximately 0.04 times the human exposure at the recommended dose based on AUC 0-24h ). Lactation Risk Summary There is no information regarding the presence of rucaparib in human milk, or on its effects on milk production or the breast-fed infant. Because of the potential for serious adverse reactions in breast-fed infants from Rubraca, advise lactating women not to breastfeed during treatment with Rubraca and for 2 weeks after the final dose. 8.3 Females and Males of Reproductive Potential Pregnancy Testing Pregnancy testing is recommended for females of reproductive potential prior to initiating Rubraca. Contraception Females Rubraca 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 and for 6 months following the final dose of Rubraca. Pediatric Use The safety and effectiveness of Rubraca in pediatric patients have not been established. Geriatric Use One hundred and sixty (42%) of the 377 ovarian cancer patients in clinical trials of Rubraca were 65 years of age or older. No overall differences in safety were observed between these patients and younger patients, but greater sensitivity of some older individuals cannot be ruled out. The effectiveness of Rubraca in patients with BRCA-mutant ovarian cancer who were 65 years of age or older could not be assessed due to the small number of patients (N=38). Hepatic Impairment No starting dose adjustment is recommended for patients with mild hepatic impairment (total bilirubin less than or equal to upper limit of normal [ULN] and AST greater than ULN, or total bilirubin between 1.0 to 1.5 times ULN and any AST). No recommendation of starting dose adjustment is available for patients with moderate to severe hepatic impairment (total bilirubin greater than 1.5 times ULN) due to a lack of data [See CLINICAL PHARMACOLOGY]. Renal Impairment No starting dose adjustment is recommended for patients with mild to moderate renal impairment (creatinine clearance [CLcr] between 30 and 89 mL/min, as estimated by the Cockcroft-Gault method). There is no recommended starting dose for patients with CLcr less than 30 mL/min or patients on dialysis due to a lack of data [See CLINICAL PHARMACOLOGY].