REBETRON(tm)

Combination Therapy

containing

REBETOL(r) (ribavirin, USP) Capsules

and

INTRON(r) A (interferon alfa-2b, recombinant) Injection

PRODUCT INFORMATION

CONTRAINDICATIONS AND WARNINGS

Combination REBETOL/INTRON A therapy is contraindicated in females who are pregnant and in the male partners of females who are pregnant. Extreme care must be taken to avoid pregnancy during therapy and for 6 months after completion of treatment in female patients, and in female partners of male patients who are taking combination REBETOL/INTRON A therapy. Females of childbearing potential and males must use two reliable forms of effective contraception during treatment and during the 6-month posttreatment follow-up period. Significant teratogenic and/or embryocidal effects have been demonstrated for ribavirin in all animal species studied. See CONTRAINDICATIONS and WARNINGS.

REBETOL monotherapy is not effective for the treatment of chronic hepatitis C and should not be used for this indication. See WARNINGS.

Alpha interferons, including INTRON(r) A, cause or aggravate fatal or life-threatening neuropsychiatric, autoimmune, ischemic, and infectious disorders. Patients should be monitored closely with periodic clinical and laboratory evaluations. Patients with persistently severe or worsening signs or symptoms of these conditions should be withdrawn from therapy. In many but not all cases these disorders resolve after stopping INTRON A therapy. See WARNINGS, and ADVERSE REACTIONS.

DESCRIPTION

REBETOL(r) REBETOL is Schering Corporation's brand name for ribavirin, a nucleoside analog with antiviral activity. The chemical name of ribavirin is 1-ss-D-ribofuranosyl-1H-1,2,4-triazole-3-carboxamide and has the following structural formula:

NH2

OH OH

Ribavirin is a white, crystalline powder. It is freely soluble in water and slightly soluble in anhydrous alcohol. The empirical formula is C8H12N4O5 and the molecular weight is 244.21. REBETOL Capsules consist of a white powder in a white, opaque, gelatin capsule. Each capsule contains 200 mg ribavirin and the inactive ingredients microcrystalline cellulose, lactose monohydrate, croscarmellose sodium, and magnesium stearate. The capsule shell consists of gelatin, and titanium dioxide. The capsule is printed with edible blue pharmaceutical ink which is made of shellac, anhydrous ethyl alcohol, isopropyl alcohol, n-butyl alcohol, propylene glycol, ammonium hydroxide, and FD&C Blue #2 aluminum lake.

INTRON(r) A INTRON A is Schering Corporation's brand name for interferon alfa-2b, recombinant, a purified, sterile, recombinant interferon product. Interferon alfa-2b, recombinant has been classified as an alpha interferon and is a water-soluble protein composed of 165 amino acids with a molecular weight of 19,271 daltons produced by recombinant DNA techniques. It is obtained from the bacterial fermentation of a strain of Escherichia coli bearing a genetically engineered plasmid containing an interferon alfa-2b gene from human leukocytes. The fermentation is carried out in a defined nutrient medium containing the antibiotic tetracycline hydrochloride at a concentration of 5 to 10 mg/L; the presence of this antibiotic is not detectable in the final product. INTRON A Injection is a clear, colorless solution. The 3 million IU vial of INTRON A Injection contains 3 million IU of interferon alfa-2b, recombinant per 0.5 mL. The 18 million IU multidose vial of INTRON A Injection contains a total of 22.8 million IU of interferon alfa-2b, recombinant per 3.8 mL (3 million IU/0.5 mL) in order to provide the delivery of six 0.5 mL doses, each containing 3 million IU of INTRON A (for a label strength of 18 million IU). The 18 million IU INTRON A Injection multidose pen contains a total of 22.5 million IU of interferon alfa-2b, recombinant per 1.5 mL (3 million IU/0.2 mL) in order to provide the delivery of six 0.2-mL doses, each containing 3 million IU of INTRON A (for a label strength of 18 million IU). Each mL also contains 7.5 mg sodium chloride, 1.8 mg sodium phosphate dibasic, 1.3 mg sodium phosphate monobasic, 0.1 mg edetate disodium, 0.1 mg polysorbate 80, and 1.5 mg m-cresol as a preservative. Based on the specific activity of approximately 2.6 x 10 IU/mg protein as measured by HPLC assay, the corresponding quantities of interferon alfa-2b, recombinant in the vials and pen described above are approximately 0.012 mg, 0.088 mg, and 0.087 mg protein, respectively.

Mechanism of Action

Ribavirin/Interferon alfa-2b, recombinant

The mechanism of inhibition of hepatitis C virus (HCV) RNA by combination therapy with REBETOL and INTRON A has not been established.

CLINICAL PHARMACOLOGY

Pharmacokinetics

Interferon alfa-2b, recombinant Single- and multiple-dose pharmacokinetic properties of INTRON A (interferon alfa-2b, recombinant) are summarized in TABLE 1. Following a single 3 million IU (MIU) subcutaneous dose in 12 patients with chronic hepatitis C, mean (% CV *) serum concentrations peaked at 7 (44%) hours. Following 4 weeks of subcutaneous dosing with 3 MIU three times a week (TIW), interferon serum concentrations were undetectable predose. However, a twofold increase in bioavailability was noted upon multiple dosing of interferon; the reason for this is unknown. Mean half-life values following single- and multiple-dose administrations were 6.8 (24%) hours and 6.5 (29%) hours, respectively. Ribavirin Single- and multiple-dose pharmacokinetic properties in adults with chronic hepatitis C are summarized in TABLE 1. Ribavirin was rapidly and extensively absorbed following oral administration. However, due to first-pass metabolism, the absolute bioavailability averaged 64% (44%). There was a linear relationship between dose and AUCtf (AUC from time zero to last measurable concentration) following single doses of 200-1200 mg ribavirin. The relationship between dose and Cmax was curvilinear, tending to asymptote above single doses of 400-600 mg. Upon multiple oral dosing, based on AUC12hr, a sixfold accumulation of ribavirin was observed in plasma. Following oral dosing with 600 mg BID, steady-state was reached by approximately 4 weeks, with mean steady-state plasma concentrations of 2200 (37%) ng/mL. Upon discontinuation of dosing, the mean half-life was 298 (30%) hours, which probably reflects slow elimination from nonplasma compartments. Effect of Food on Absorption of Ribavirin Both AUCtf and Cmax increased by 70% when REBETOL Capsules were administered with a high-fat meal (841 kcal, 53.8 g fat, 31.6 g protein, and 57.4 g carbohydrate) in a single-dose pharmacokinetic study. There are insufficient data to address the clinical relevance of these results. Clinical efficacy studies were conducted without instructions with respect to food consumption. (See DOSAGE AND ADMINISTRATION.) Effect of Antacid on Absorption of Ribavirin Coadministration with an antacid containing magnesium, aluminum, and simethicone (MylantaO) resulted in a 14% decrease in mean ribavirin AUCtf. The clinical relevance of results from this single-dose study is unknown.

TABLE 1. Mean (% CV) Pharmacokinetic Parameters for INTRON A and REBETOL When Administered Individually to Adults with Chronic Hepatitis C

Parameter INTRON A (N=12) REBETOL (N=12) Single Dose 3 MIU Multiple Dose 3 MIU TIW Single Dose 600 mg Multiple Dose 600 mg BID T max (hr) 7 (44) 5 (37) 1.7 (46)

3 (60)

* IU/mL for INTRON A and ng/mL for REBETOL

* * IU.hr/mL for INTRON A and ng.hr/mL for REBETOL

+ data obtained from a single-dose pharmacokinetic study using 14C labeled ribavirin; N = 5

++

N = 6

* * * N = 11

Ribavirin transport into nonplasma compartments has been most extensively studied in red blood cells, and has been identified to be primarily via an es-type equilibrative nucleoside transporter. This type of transporter is present on virtually all cell types and may account for the extensive volume of distribution. Ribavirin does not bind to plasma proteins. Ribavirin has two pathways of metabolism: (i) a reversible phosphorylation pathway in nucleated cells; and (ii) a degradative pathway involving deribosylation and amide hydrolysis to yield a triazole carboxylic acid metabolite. Ribavirin and its triazole carboxamide and triazole carboxylic acid metabolites are excreted renally. After oral administration of 600 mg of 14C-ribavirin, approximately 61% and 12% of the radioactivity was eliminated in the urine and feces, respectively, in 336 hours. Unchanged ribavirin accounted for 17% of the administered dose. Results of in vitro studies using both human and rat liver microsome preparations indicated little or no cytochrome P450 enzyme-mediated metabolism of ribavirin, with minimal potential for P450 enzyme-based drug interactions. No pharmacokinetic interactions were noted between INTRON A Injection and REBETOL Capsules in a multiple-dose pharmacokinetic study.

Special Populations

Renal Dysfunction The pharmacokinetics of ribavirin were assessed after administration of a single oral dose (400 mg) of ribavirin to subjects with varying degrees of renal dysfunction. The mean AUCtf value was threefold greater in subjects with creatinine clearance values between 10 to 30 mL/min when compared to control subjects (creatinine clearance >90 mL/min). This appears to be due to reduction of apparent clearance in these patients. Ribavirin was not removed by hemodialysis. Patients with creatinine clearance < 50mL/min should not be treated with REBETOL (see WARNINGS). Hepatic Dysfunction The effect of hepatic dysfunction was assessed after a single oral dose of ribavirin (600 mg). The mean AUCtf values were not significantly different in subjects with mild, moderate, or severe hepatic dysfunction (Child-Pugh Classification A, B, or C), when compared to control subjects. However, the mean Cmax values increased with severity of hepatic dysfunction and was twofold greater in subjects with severe hepatic dysfunction when compared to control subjects.

Pediatric Patients Multiple-dose pharmacokinetic properties for REBETOL Capsules and INTRON A in pediatric patients with chronic hepatitis C between 5 and 16 years of age are summarized in Table 2. The pharmacokinetics of REBETOL and INTRON A (dose-normalized) are similar in adults and pediatric patients. Complete pharmacokinetic characteristics of REBETOL Oral Solution have not been determined in pediatric patients. Ribavirin Cmin values were similar following administration of REBETOL Oral Solution or REBETOL Capsules during 48 weeks of therapy in pediatric patients (3 to 16 years of age).

Table 2 Mean (% CV) Multiple-Dose Pharmacokinetic Parameters for INTRON A and REBETOL Capsules When Administered to Pediatric Patients With Chronic Hepatitis C

*AUC12 (ng.hr/ml) for REBETOL; AUC0-24 (IU.hr/ml) for INTRON A ND=not done

Elderly Patients

Pharmacokinetic evaluations for elderly subjects have not been performed.

Gender

There were no clinically significant pharmacokinetic differences noted in a single-dose study of eighteen male and eighteen female subjects.

In this section of the label, numbers in parenthesis indicate % coefficient of variation.

Description of Clinical Studies

Previously Untreated Patients Adults with compensated chronic hepatitis C and detectable HCV RNA (assessed by a central laboratory using a research-based RT- PCR assay) who were previously untreated with alpha interferon therapy were enrolled into two multicenter, double-blind trials (US and International) and randomized to receive REBETOL Capsules 1200 mg/day (1000 mg/day for patients weighing PS75 kg) plus INTRON A Injection 3 MIU TIW or INTRON A Injection plus placebo for 24 or 48 weeks followed by 24 weeks of off-therapy follow-up. The International study did not contain a 24-week INTRON A plus placebo treatment arm. The US study enrolled 912 patients who, at baseline, were 67% male, 89% caucasian with a mean Knodell HAI score (I+II+III) of 7.5, and 72% genotype 1. The International study, conducted in

Europe, Israel, Canada, and Australia, enrolled 799 patients (65% male, 95% caucasian, mean Knodell score 6.8, and 58% genotype 1).

Study results are summarized in TABLE 3.

TABLE 3. Virologic and Histologic Responses: Previously Untreated Patients *

Number (%) of Patients.

1. Defined as HCV RNA below limit of detection using a research based RT-PCR assay at end of treatment and during follow-up period.

2. Defined as posttreatment (end of follow-up) minus pretreatment liver biopsy Knodell HAI score (I+II+III) improvement of >2 points.

Of patients who had not achieved HCV RNA below the limit of detection of the research based assay by week 24 of REBETOL/INTRON A treatment, less than 5% responded to an additional 24 weeks of combination treatment. Among patients with HCV genotype 1 treated with REBETOL/INTRON A therapy who achieved HCV RNA below the detection limit of the research-based assay by 24 weeks, those randomized to 48 weeks of treatment had higher virologic responses compared to those in the 24-week treatment group. There was no observed increase in response rates for patients with HCV nongenotype 1 randomized to REBETOL/INTRON A therapy for 48 weeks compared to 24 weeks.

Relapse Patients Patients with compensated chronic hepatitis C and detectable HCV RNA (assessed by a central laboratory using a research based RT-PCR assay) who had relapsed following one or two courses of interferon therapy (defined as abnormal serum ALT levels) were enrolled into two multicenter, double-blind trials (US and International) and randomized to receive REBETOL 1200 mg/day (1000 mg/day for patients weighing PS75 kg) plus INTRON A 3 MIU TIW or INTRON A plus placebo for 24 weeks followed by 24 weeks of off-therapy follow-up. The US study enrolled 153 patients who, at baseline, were 67% male, 92% caucasian with a mean Knodell HAI score (I+II+III) of 6.8, and 58% genotype 1. The International study, conducted in Europe, Israel, Canada, and Australia, enrolled 192 patients (64% male, 95% caucasian, mean Knodell score 6.6, and 56% genotype 1). Study results are summarized in TABLE 4.

TABLE 4. Virologic and Histologic Responses: Relapse Patients *

Number (%) of Patients.

1. Defined as HCV RNA below limit of detection using a research based RT-PCR assay at end of treatment and during follow-up period.

2. Defined as posttreatment (end of follow-up) minus pretreatment liver biopsy Knodell HAI score (I+II+III) improvement of >2 points.

Virologic and histologic responses were similar among male and female patients in both the previously untreated and relapse studies. Pediatric Patients Pediatric patients 3 to 16 years of age with compensated chronic hepatitis C and detectable HCV RNA (assessed by a central laboratory using a research-based RT-PCR assay) were treated with REBETOL 15 mg/kg per day plus INTRON A 3 MIU/m2 TIW for 48 weeks followed by 24 weeks of off-therapy follow-up. A total of 118 patients received treatment who were 57% male, 80% Caucasian, and 78% genotype 1. Patients <5 years of age received REBETOL Oral Solution and those >=5 years of age received either REBETOL Oral Solution or Capsules. Study results are summarized in Table 5.

Table 5: Virologic Response: Previously Untreated Pediatric Patients *

Genotype non-1 (n=26) 21 (81)

*Number (%) of patients

1. Defined as HCV RNA below limit of detection using a research based RT-PCR assay at end of treatment and during follow-up period.

Patients with viral genotype 1, regardless of viral load, had a lower response rate to INTRON A/REBETOL combination therapy compared to patients with genotype non-1, 36% versus 81%. Patients with both poor prognostic factors (genotype 1 and high viral load) had a response rate of 26% (13/50).

CONTRAINDICATIONS

Combination REBETOL/INTRON A therapy must not be used by females who are pregnant or by males whose female partners are pregnant. Extreme care must be taken to avoid pregnancy in female patients and in female partners of male patients taking combination REBETOL/INTRON A therapy. Combination REBETOL/INTRON A therapy should not be initiated until a report of a negative pregnancy test has been obtained immediately prior to initiation of therapy. Females of childbearing potential and males must use two forms of effective contraception during treatment and during the 6 months after treatment has been concluded. Significant teratogenic and/or embryocidal effects have been demonstrated for ribavirin in all animal species in which adequate studies have been conducted. These effects occurred at doses as low as one twentieth of the recommended human dose of REBETOL Capsules. If pregnancy occurs in a patient or partner of a patient during treatment or during the 6 months after treatment stops, physicians are encouraged to report such cases by calling (800) 727-7064. See boxed CONTRAINDICATIONS AND WARNINGS. See WARNINGS. REBETOL Capsules in combination with INTRON A Injection is contraindicated in patients with a history of hypersensitivity to ribavirin and/or alpha interferon or any component of the capsule and/or injection. Patients with autoimmune hepatitis must not be treated with combination REBETOL/INTRON A therapy.

WARNINGS

Pregnancy

Category X, may cause birth defects. See boxed CONTRAINDICATIONS AND WARNINGS. See CONTRAINDICATIONS.

Anemia

HEMOLYTIC ANEMIA (HEMOGLOBIN <10 G/DL) WAS OBSERVED IN APPROXIMATELY 10% OF REBETOL/INTRON A-TREATED PATIENTS IN CLINICAL TRIALS (SEE ADVERSE REACTIONS LABORATORY VALUES - HEMOGLOBIN). ANEMIA OCCURRED WITHIN 1 - 2 WEEKS OF INITIATION OF RIBAVIRIN THERAPY. BECAUSE OF THIS INITIAL ACUTE DROP IN HEMOGLOBIN, IT IS ADVISED THAT COMPLETE BLOOD COUNTS (CBC) SHOULD BE OBTAINED PRETREATMENT AND AT WEEK 2 AND WEEK 4 OF THERAPY OR MORE FREQUENTLY IF CLINICALLY INDICATED. PATIENTS SHOULD THEN BE FOLLOWED AS CLINICALLY APPROPRIATE.

The anemia associated with REBETOL/INTRON A therapy may result in deterioration of cardiac function and/or exacerbation of the symptoms of coronary disease. Patients should be assessed before initiation of therapy and should be appropriately monitored during therapy. If there is any deterioration of cardiovascular status, therapy should be suspended or discontinued. (See DOSAGE AND ADMINISTRATION.) Because cardiac disease may be worsened by drug induced anemia, patients with a history of significant or unstable cardiac disease should not use combination REBETOL/INTRON A therapy. (See ADVERSE REACTIONS.) Similarly, patients with hemoglobinopathies (eg, thalassemia, sickle-cell anemia) should not be treated with combination REBETOL/INTRON A therapy.

Psychiatric

Severe psychiatric adverse events, including depression, psychoses, aggressive behavior, hallucinations, violent behavior (suicidal ideation, suicidal attempts, suicides) and rare instances of homicidal ideation have occurred during combination Rebetol/Intron A therapy, both in patients with and without a previous psychiatric disorder. Rebetol/Intron A therapy should be used with extreme caution in patients with a history of pre-existing psychiatric disorders, and all patients should be carefully monitored for evidence of depression and other psychiatric symptoms. Suspension of Rebetol/Intron A therapy should be considered if psychiatric intervention and/or dose reduction is unsuccessful in controlling psychiatric symptoms. In severe cases, therapy should be stopped immediately and psychiatric intervention sought. ADVERSE REACTIONS

Suicidal ideation or attempts occurred more frequently among pediatric patients, primarily adolescents, compared to adult patients (2.4% versus 1%) during treatment and off-therapy follow-up. (See

.)

Bone marrow toxicity:

INTRON A therapy suppresses bone marrow function and may result in severe cytopenias including very rare events of aplastic anemia. It is advised that complete blood counts (CBC) be obtained pre- treatment and monitored routinely during therapy (see PRECAUTIONS: Laboratory Tests). INTRON A therapy should be discontinued in patients who develop severe decreases in neutrophil (<0.5 x 109/L) or platelet counts (<25 x 109/L) (see DOSAGE AND ADMINISTRATION: Guidelines for Dose Modifications).

Pulmonary

Pulmonary symptoms, including dyspnea, pulmonary infiltrates, pneumonitis and pneumonia, have been reported during therapy with REBETOL/INTRON A; occasional cases of fatal pneumonia have occurred. In addition, sarcoidosis or the exacerbation of sarcoidosis has been reported. . If there is evidence of pulmonary infiltrates or pulmonary function impairment, the patient should be closely monitored, and, if appropriate, combination REBETOL/INTRON A treatment should be discontinued.

Other

*

REBETOL Capsule monotherapy is not effective for the treatment of chronic hepatitis C and should not be used for this indication.

*

Fatal and nonfatal pancreatitis has been observed in patients treated with REBETOL/INTRON A therapy. REBETOL/INTRON A therapy should be suspended in patients with signs and symptoms of pancreatitis and discontinued in patients with confirmed pancreatitis.

*

Combination REBETOL/INTRON A therapy should not be used in patients with creatinine clearance

<50 mL/min.

*

Diabetes mellitus and hyperglycemia have been observed in patients treated with INTRON A.

*

Ophthalmologic disorders have been reported with treatment with alpha interferons (including INTRON A therapy). Investigators using alpha interferons have reported the occurrence of retinal

hemorrhages, cotton wool spots, and retinal artery or vein obstruction in rare instances. Any patient complaining of loss of visual acuity or visual field should have an eye examination. Because these ocular events may occur in conjunction with other disease states, a visual exam prior to initiation of combination REBETOL/INTRON A therapy is recommended in patients with diabetes mellitus or hypertension.

*

Acute serious hypersensitivity reactions (eg, urticaria, angioedema, bronchoconstriction, anaphylaxis) have been observed in INTRON A-treated patients; if such an acute reaction develops, combination REBETOL/INTRON A therapy should be discontinued immediately and appropriate medical therapy instituted.

*

Combination REBETOL/INTRON A therapy should be discontinued for patients developing thyroid abnormalities during treatment whose thyroid function cannot be controlled by medication.

PRECAUTIONS

Exacerbation of autoimmune disease has been reported in patients receiving alpha interferon therapy (including INTRON A therapy). REBETOL/INTRON A therapy should be used with caution in patients with other autoimmune disorders. There have been reports of interferon, including INTRON A (interferon alfa-2b, recombinant) exacerbating pre-existing psoriasis; therefore, combination REBETOL/INTRON A therapy should be used in these patients only if the potential benefit justifies the potential risk. The safety and efficacy of REBETOL/INTRON A therapy has not been established in liver or other organ transplant patients, decompensated hepatitis C patients, patients who are nonresponders to interferon therapy, or patients coinfected with HBV or HIV. The safety and efficacy of REBETOL Capsule monotherapy for the treatment of HIV infection, adenovirus, early RSV infection, parainfluenza, or influenza have not been established and REBETOL Capsules should not be used for these indications. There is no information regarding the use of REBETOL Capsules with other interferons.

Triglycerides(see WARNINGS - Other).

: Elevated triglyceride levels have been observed in patients treated with interferon including REBETOL/INTRON A therapy. Elevated triglyceride levels should be managed as clinically appropriate. Severe hypertriglyceridemia (triglycerides >1000 mg/dL) may result in pancreatitis. Discontinuation of REBETOL/INTRON A therapy should be considered for patients with persistently elevated triglycerides (triglycerides >1000 mg/dL) associated with symptoms of potential pancreatitis, such as abdominal pain, nausea, or vomiting

Drug Interactions

Nucleoside Analogs:

Administration of nucleoside analogues has resulted in fatal and nonfatal lactic acidosis. Coadministration of ribavirin and nucleoside analogues should be undertaken with caution and only if the potential benefit outweighs the potential risks.

Information for Patients

Combination REBETOL/INTRON A therapy must not be used by females who are pregnant or by males whose female partners are pregnant. Extreme care must be taken to avoid pregnancy in female patients and in female partners of male patients taking combination REBETOL/INTRON A therapy. Combination REBETOL/INTRON A therapy should not be initiated until a report of a negative pregnancy test has been obtained immediately prior to initiation of therapy. Patients must perform a pregnancy test monthly during therapy and for 6 months posttherapy. Females of childbearing potential must be counseled about use of effective contraception (two reliable forms) prior to initiating therapy. Patients (male and female) must be advised of the teratogenic/embryocidal risks and must be instructed to practice effective contraception during combination REBETOL/INTRON A therapy and for 6 months posttherapy. Patients (male and female) should be

advised to notify the physician immediately in the event of a pregnancy. (See CONTRAINDICATIONS.) If pregnancy does occur during treatment or during 6 months posttherapy, the patient must be advised of the significant teratogenic risk of REBETOL therapy to the fetus. Patients, or partners of patients, should immediately report any pregnancy that occurs during treatment or within 6 months after treatment cessation to their physician. Physicians are encouraged to report such cases by calling (800) 727-7064. Patients receiving combination REBETOL/INTRON A treatment should be directed in its appropriate use, informed of the benefits and risks associated with treatment, and referred to the patient MEDICATION GUIDE. There are no data evaluating whether REBETOL/INTRON A therapy will prevent transmission of infection to others. Also, it is not known if treatment with REBETOL/INTRON A therapy will cure hepatitis C or prevent cirrhosis, liver failure, or liver cancer that may be the result of infection with the hepatitis C virus. If home use is prescribed, a puncture-resistant container for the disposal of used syringes and needles should be supplied to the patient. Patients should be thoroughly instructed in the importance of proper disposal and cautioned against any reuse of needles and syringes. The full container should be disposed of according to the directions provided by the physician (see MEDICATION GUIDE). To avoid possible transmission of disease, do not share your multidose pen with anyone; it is for you and you alone. The most common adverse experiences occurring with combination REBETOL/INTRON A therapy are "flu-like" symptoms, such as headache, fatigue, myalgia, and fever (see ADVERSE REACTIONS) and appear to decrease in severity as treatment continues. Some of these "flu-like" symptoms may be minimized by bedtime administration of INTRON A therapy. Antipyretics should be considered to prevent or partially alleviate the fever and headache. Another common adverse experience associated with INTRON A therapy is thinning of the hair. Patients should be advised that laboratory evaluations are required prior to starting therapy and periodically thereafter (see Laboratory Tests). It is advised that patients be well hydrated, especially during the initial stages of treatment. .

Laboratory Tests

The following laboratory tests are recommended for all patients on combination REBETOL/INTRON A therapy, prior to beginning treatment and then periodically thereafter.

*Standard hematologic tests - including hemoglobin (pretreatment, week 2 and week 4of therapy, and as clinically appropriate [see WARNINGS]), complete and differential white blood cell counts, and platelet count. *Blood chemistries - liver function tests and TSH. *Pregnancy - including monthly monitoring for females of childbearing potential.

Carcinogenesis and Mutagenesis

Carcinogenicity studies with interferon alfa-2b, recombinant have not been performed because neutralizing activity appears in the serum after multiple dosing in all of the animal species tested.

Adequate studies to assess the carcinogenic potential of ribavirin in animals have not been conducted. However, ribavirin is a nucleoside analog that has produced positive findings in multiple in vitro and animal in vivo genotoxicity assays, and should be considered a potential carcinogen. Further studies to assess the carcinogenic potential of ribavirin in animals are ongoing. Mutagenicity studies have demonstrated that interferon alfa-2b, recombinant is not mutagenic. Ribavirin demonstrated increased incidences of mutation and cell transformation in multiple genotoxicity assays. Ribavirin was active in the Balb/3T3 In Vitro Cell Transformation Assay. Mutagenic activity was observed in the mouse lymphoma assay, and at doses of 20-200 mg/kg (estimated human equivalent of 1.67 - 16.7 mg/kg, based on body surface area adjustment for a 60 kg adult; 0.1 - 1 X the maximum recommended human 24-hour dose of ribavirin) in a mouse micronucleus assay. A dominant lethal assay in rats was negative, indicating that if mutations occurred in rats they were not transmitted through male gametes.

Impairment of Fertility

No reproductive toxicology studies have been performed using interferon alfa-2b, recombinant in combination with ribavirin. However, evidence provided below for interferon alfa-2b, recombinant and ribavirin when administered alone indicate that both agents have adverse effects on reproduction. It should be assumed that the effects produced by either agent alone will also be caused by the combination of the two agents. Interferons may impair human fertility. In studies of interferon alfa-2b recombinant administration in nonhuman primates, menstrual cycle abnormalities have been observed. Decreases in serum estradiol and progesterone concentrations have been reported in females treated with human leukocyte interferon. In addition, ribavirin demonstrated significant embryocidal and/or teratogenic effects at doses well below the recommended human dose in all animal species in which adequate studies have been conducted.

Fertile females and partners of fertile females should not receive combination REBETOL/INTRON A therapy unless the patient and his/her partner are using effective contraception (two reliable forms). Based on a multiple dose half-life (t1/2 ) of ribavirin of 12 days, effective contraception must be utilized for 6 months posttherapy (eg, 15 half-lives of clearance for ribavirin). Combination REBETOL/INTRON A therapy should be used with caution in fertile males. In studies in mice to evaluate the time course and reversibility of ribavirin-induced testicular degeneration at doses of 15 to 150 mg/kg/day (estimated human equivalent of 1.25 - 12.5 mg/kg/day, based on body surface area adjustment for a 60 kg adult; 0.1 - 0.8 X the maximum human 24-hour dose of ribavirin) administered for 3 or 6 months, abnormalities in sperm occurred. Upon cessation of treatment, essentially total recovery from ribavirin-induced testicular toxicity was apparent within 1 or 2 spermatogenesis cycles.

Animal Toxicology

Long-term studies in the mouse and rat (18 - 24 months; doses of 20 - 75 and 10 -

40 mg/kg/day, respectively [estimated human equivalent doses of 1.67 - 6.25 and 1.43 - 5.71 mg/kg/day, respectively, based on body surface area adjustment for a 60 kg adult; approximately 0.1 - 0.4 X the maximum human 24-hour dose of ribavirin]) have demonstrated a relationship between chronic ribavirin exposure and increased incidences of vascular lesions (microscopic hemorrhages) in mice. In rats, retinal degeneration occurred in controls, but the incidence was increased in ribavirin- treated rats. Pregnancy Category X (see CONTRAINDICATIONS) Interferon alfa-2b, recombinant has been shown to have abortifacient effects in Macaca mulatta (rhesus monkeys) at 15 and 30 million IU/kg (estimated human equivalent of 5 and 10 million IU/kg, based on body surface area adjustment for a 60 kg adult). There are no adequate and well-controlled studies in pregnant females. Ribavirin produced significant embryocidal and/or teratogenic effects in all animal species in which adequate studies have been conducted. Malformations of the skull, palate, eye, jaw, limbs, skeleton, and gastrointestinal tract were noted. The incidence and severity of teratogenic effects increased with escalation of the drug dose. Survival of fetuses and offspring was reduced. In conventional embryotoxicity/teratogenicity studies in rats and rabbits, observed no effect dose levels were well below those for proposed clinical use (0.3 mg/kg/day for both the rat and rabbit; approximately 0.06 X the recommended human 24-hour dose of ribavirin). No maternal toxicity or effects on offspring were observed in a peri/postnatal toxicity study in rats dosed orally at up to 1 mg/kg/day (estimated human equivalent dose of 0.17 mg/kg based on body surface area adjustment for a 60 kg adult; approximately 0.01 X the maximum recommended human 24-hour dose of ribavirin).

Treatment and Posttreatment: Potential Risk to the Fetus

Ribavirin is known to accumulate in intracellular components from where it is cleared very slowly. It is not known whether ribavirin contained in sperm will exert a potential teratogenic effect upon fertilization of the ova. In a study in rats, it was concluded that dominant lethality was not induced by ribavirin at doses up to 200 mg/kg for 5 days (estimated human equivalent doses of 7.14 - 28.6 mg/kg, based on body surface area adjustment for a 60 kg adult; up to 1.7 X the maximum recommended human dose of ribavirin). However, because of the potential human teratogenic effects of ribavirin, male patients should be advised to take every precaution to avoid risk of pregnancy for their female partners.

Females of childbearing potential should not receive combination REBETOL/INTRON A therapy unless they are using effective contraception (two reliable forms) during the therapy period. In addition, effective contraception should be utilized for 6 months posttherapy based on a multiple dose half-life (t1/2 ) of ribavirin of 12 days. Male patients and their female partners must practice effective contraception (two reliable forms) during treatment with combination REBETOL/INTRON A therapy and for the 6-month posttherapy period (eg, 15 half-lives for ribavirin clearance from the body). If pregnancy occurs in a patient or partner of a patient during treatment or during the 6 months after treatment cessation, physicians are encouraged to report such cases by calling (800) 727-7064. Nursing Mothers It is not known whether REBETOL and INTRON A are excreted in human milk. However, studies in mice have shown that mouse interferons are excreted into the milk. Because of the potential for serious adverse reactions from the drugs in nursing infants, a decision should be made whether to discontinue nursing or to discontinue combination REBETOL/INTRON A therapy, taking into account the importance of the therapy to the mother.

Pediatric Use

Suicidal ideation or attempts occurred more frequently among pediatric patients primarily adolescents, compared to adult patients (2.4% versus 1%) during treatment and off therapy follow-up (see WARNINGS). WARNINGS

As in adult patients, pediatric patients experienced other psychiatric adverse events (e.g., depression, emotional lability, somnolence), anemia, and neutropenia (see

). During a 48-week course of therapy there was a decrease in the rate of linear growth (mean percentile assignment decrease of 9 %) and a decrease in the rate of weight gain (mean percentile assignment decrease of 13 %). A general reversal of these trends was noted during the 24- week post-treatment period.

Injection site disorders, fever, anorexia, vomiting, and emotional lability occurred more frequently in pediatric patients compared to adult patients. Conversely, pediatric patients experienced less fatigue, dyspepsia, arthralgia, insomnia, irritability, impaired concentration, dyspnea, and pruritis compared to adult patients.

Geriatric Use WARNINGS

Clinical studies of REBETRON Combination Therapy did not include sufficient numbers of subjects aged 65 and over to determine if they respond differently from younger subjects. In clinical trials, elderly subjects had a higher frequency of anemia (67%) than did younger patients (28%) (see

).

In general, REBETOL (ribavirin) should be administered to elderly patients cautiously, starting at the lower end of the dosing range, reflecting the greater frequency of decreased renal, hepatic and/or cardiac function, and of concomitant disease or other drug therapy. REBETOL (ribavirin) is known to be substantially excreted by the kidney, and the risk of adverse reactions to ribavirin may be greater in patients with impaired renal function. Because elderly patients often have decreased renal function, care should be taken in dose selection. Renal function should be monitored and dosage adjustments of ribavirin should be made accordingly (see DOSAGE AND ADMINISTRATION: Guidelines for Dose Modification). REBETOL should not be used in elderly patients with creatinine clearance <50mL/min (see WARNINGS). REBETRON Combination Therapy should be used very cautiously in elderly patients with a history of psychiatric disorders (see WARNINGS).

OVERDOSAGE

There is limited experience with overdosage. Acute ingestion of up to 20 grams of REBETOL Capsules, INTRON A ingestion of up to 120 million units, and subcutaneous doses of INTRON A up to 10 times the recommended doses have been reported. Primary effects that have been observed are increased incidence and severity of the adverse events related to the therapeutic use of INTRON A and REBETOL. However, hepatic enzyme abnormalities, renal failure, hemorrhage, and myocardial infarction have been reported with administration of single subcutaneous doses of INTRON A that exceed dosing recommendations. There is no specific antidote for INTRON A or REBETOL, and hemodialysis and peritoneal dialysis are not effective for treatment of overdose of either agent.

DOSAGE AND ADMINISTRATION

INTRON A Injection should be administered subcutaneously and REBETOL Capsules should be administered orally. REBETOL may be administered without regard to food, but should be administered in a consistent manner. (See CLINICAL PHARMACOLOGY.)

Adults

The recommended dose of REBETOL Capsules depends on the patient's body weight. The recommended doses of REBETOL and INTRON A for adults are given in TABLE 8. The recommended duration of treatment for patients previously untreated with interferon is 24 to 48 weeks. The duration of treatment should be individualized to the patient depending on baseline disease characteristics, response to therapy, and tolerability of the regimen (see Description of Clinical Studies and ADVERSE REACTIONS). After 24 weeks of treatment virologic response should be assessed. Treatment discontinuation should be considered in any patient who has not achieved an HCV-RNA below the limit of detection of the assay by 24 weeks. There are no safety and efficacy data on treatment for longer than 48 weeks in the previously untreated patient population. In patients who relapse following interferon therapy, the recommended duration of treatment is 24 weeks. There are no safety and efficacy data on treatment for longer than 24 weeks in the relapse patient population.

Pediatrics

The recommended dose of REBETOL is 15 mg/kg per day orally (divided dose AM and PM). For children weighing PS25 kg or who cannot swallow capsules, REBETOL Oral Solution is supplied in a concentration of 40 mg/mL. For children weighing >25 kg, either the Oral Solution or 200-mg capsule may be administered Refer to Table 12 for dosing recommendations for the 200-mg capsule to achieve the recommended dose. The recommended duration of treatment is 48 weeks for pediatric patients with genotype 1. After 24 weeks of treatment virologic response should be assessed. Treatment discontinuation should be considered in any patient who has not achieved an HCV RNA below the limit of detection of the assay by this time. The recommended duration of treatment for pediatric patients with genotype 2/3 is 24 weeks. There are no safety and efficacy data on treatment for longer than 48 weeks in pediatrics. (see TABLE 9).

Under no circumstances should REBETOL capsules be opened, crushed or broken (see Contraindications and Warnings).

Dose Modifications (TABLE 10)

In clinical trials, approximately 26% of patients required modification of their dose of REBETOL Capsules, INTRON A Injection, or both agents. If severe adverse reactions or laboratory abnormalities develop during combination REBETOL/INTRON A therapy the dose should be modified, or discontinued if appropriate, until the adverse reactions abate. If intolerance persists after dose adjustment, REBETOL/INTRON A therapy should be discontinued. REBETOL/INTRON A therapy should be administered with caution to patients with pre- existing cardiac disease. Patients should be assessed before commencement of therapy and should be appropriately monitored during therapy. If there is any deterioration of cardiovascular status, therapy should be stopped. (See WARNINGS.) For patients with a history of stable cardiovascular disease, a permanent dose reduction is required if the hemoglobin decreases by 32 g/dL during any 4-week period. In addition, for these cardiac history patients, if the hemoglobin remains <12 g/dL after 4 weeks on a reduced dose, the patient should discontinue combination REBETOL/INTRON A therapy. It is recommended that a patient whose hemoglobin level falls below 10 g/dL have his/her REBETOL dose reduced to 600 mg daily (1 x 200 mg capsule AM, 2 x 200 mg capsules PM) for adults and 7.5 mg/kg per day (divided dose AM and PM) for pediatric patients. A patient whose hemoglobin level falls below 8.5 g/dL should be permanently discontinued from REBETOL/INTRON A therapy. (See WARNINGS.) It is recommended that a patient who experiences moderate depression (persistent low mood, loss of interest, poor self image, and/or hopelessness) have his/her INTRON A dose temporarily reduced and/or be considered for medical therapy. A patient experiencing severe depression or suicidal ideation/attempt should be discontinued from REBETOL/INTRON A therapy and followed closely with appropriate medical management. (See WARNINGS.)

TABLE 10. Guidelines for Dose Modifications

Dose Reduction * REBETOL - Adults 600 mg daily Pediatrics: half the dose INTRON A - Adults 1.5 million IU TIW Pediatrics: 1.5 million IU/m2 TIW Permanent Discontinuation of Treatment REBETOL and INTRON A Hemoglobin <10 g/dL (REBETOL) <8.5 g/dL

Cardiac History Patients only.

2 g/dL decrease during any 4-

week period during treatment

(REBETOL/INTRON A)

Cardiac History Patients only.

<12 g/dL after 4 weeks of dose reduction

White blood count <1.5 x 109/L (INTRON A) <1.0 x 109/L Neutrophil count <0.75 x 109/L (INTRON A) <0.5 x 109/L Platelet count Adults: <50 x 109/L (INTRON A) Pediatrics: <80 x 109/L Adults: <25 x 109/L Pediatrics: <50 x 109/L

(INTRON A)

*

Study medication to be dose reduced is shown in parenthesis

Administration of INTRON A Injection

At the discretion of the physician, the patient may self-administer the INTRON A. (See illustrated MEDICATION GUIDE for instructions.) The Intron A Injection is supplied as a clear and colorless solution. The appropriate INTRON A dose should be withdrawn from the vial or set on the multidose pen and injected subcutaneously. The INTRON A Injection supplied with the B-D Safety Lok(tm) syringes contain a plastic sleeve to be pulled over the needle after use. The syringe locks with an audible click when the green stripe on the safety sleeve covers the red stripe on the needle. After administration of INTRON A Injection, it is essential to follow the procedure for proper disposal of syringes and needles. (See MEDICATION GUIDE for detailed instructions.) Vial/Pen Label Strength Fill Volume Concentration 3 million IU vial 0.5 mL 3 million IU/0.5 mL 18 million IU multidose vial+ 3.8 mL 3 million IU/0.5 mL 18 million IU multidose pen++ 1.5 mL 3 million IU/0.2 mL

+

This is a multidose vial which contains a total of 22.8 million IU of interferon alfa-2b, recombinant per 3.8 mL in order to provide the delivery of six 0.5- mL doses, each containing 3 million IU of interferon alfa-2b, recombinant (for a label strength of 18 million IU).

++

This is a multidose pen which contains a total of 22.5 million IU of interferon alfa-2b, recombinant per 1.5 mL in order to provide the delivery of six 0.2-mL doses, each containing 3 million IU of interferon alfa-2b, recombinant (for a label strength of 18 million IU).

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. INTRON A Injection may be administered using either sterilized glass or plastic disposable syringes. Stability INTRON A Injection provided in vials is stable at 35degC (95degF) for up to 7 days and at 30degC (86degF) for up to 14 days. INTRON A Injection provided in a multidose pen is stable at 30degC (86degF) for up to 2 days. The solution is clear and colorless.

HOW SUPPLIED

REBETOL 200-mg Capsules are white, opaque capsules with REBETOL, 200 mg, and the Schering Corporation logo imprinted on the capsule shell; the capsules are packaged in a bottle. INTRON A Injection is a clear, colorless solution packaged in single dose and multidose vials, and a multidose pen. INTRON A Injection and REBETOL Capsules are available in the following combination package presentations:

STORAGE CONDITIONS

Store the REBETOL Capsules plus INTRON A Injection combination package refrigerated between 2degC and 8degC (36deg and 46deg F).

When separated, the individual bottle of REBETOL Capsules should be stored refrigerated between 2deg and 8degC (36deg and 46degF) or at 25degC (77degF); excursions are permitted between 15deg and 30degC (59deg and 86degF).

When separated, the individual vials of INTRON A Injection and the INTRON A Multidose Pen should be stored refrigerated between 2deg and 8degC (36deg and 46degF).

Schering Corporation Kenilworth, NJ 07033 USA Copyright (c) 1998, Schering Corporation. All rights reserved.