Leuprolide

FENSOLVI for injectable suspension is a sterile polymeric matrix formulation of leuprolide acetate, a GnRH agonist, for subcutaneous use. It is designed to deliver leuprolide acetate at a controlled rate over a six-month therapeutic period. Leuprolide acetate is a synthetic nonapeptide analog of naturally occurring gonadotropin releasing hormone. The analog possesses greater potency than the natural hormone. The chemical name is 5-oxo-L-prolyl-L-histidyl-L-tryptophyl-L-seryl-L-tyrosyl-D-leucyl-L-leucyl-L-arginyl-N-ethyl-L-prolinamide acetate (salt) with the following structural formula: FENSOLVI is prefilled and supplied in two separate, sterile syringes whose contents are mixed immediately prior to administration. The two syringes are joined and the single dose product is mixed until it is homogenous. FENSOLVI is administered subcutaneously, where it forms a solid drug delivery depot. One syringe contains the ATRIGEL Delivery System and the other contains the leuprolide acetate. ATRIGEL is a polymeric (non-gelatin containing) delivery system consisting of a biodegradable poly(DL-lactide-co-glycolide) (PLG) polymer formulation dissolved in the biocompatible solvent, N-methyl-2-pyrrolidone (NMP). Refer to Table 3 for the delivery system composition and reconstituted product formulation for FENSOLVI product. Table 3: FENSOLVI Delivery System Composition and Reconstituted Product Formulation ATRIGEL Delivery System Syringe Polymer PLG Polymer description Copolymer with hexanediol Polymer DL-lactide to glycolide molar ratio 85:15 Reconstituted Product Polymer delivered 165 mg NMP delivered 165 mg Leuprolide acetate delivered 45 mg Approximate leuprolide free base equivalent 42 mg Approximate administered formulation weight 375 mg Approximate injection volume 0.375 mL formula

FENSOLVI is indicated for the treatment of pediatric patients 2 years of age and older with central precocious puberty (CPP). FENSOLVI is a gonadotropin releasing hormone (GnRH) agonist indicated for the treatment of pediatric patients 2 years of age and older with central precocious puberty.

For injectable suspension, 45 mg of leuprolide acetate supplied in a kit (NDC 62935-153-50) containing: Syringe A Tray Syringe B Tray Syringe A is prefilled with diluent for reconstitution (ATRIGEL Delivery System) Syringe B is prefilled with 45 mg lyophilized leuprolide acetate powder White plunger rod (To be used with Syringe B) Safety needle (18G x 5/8") Desiccant pack Desiccant pack Store refrigerated at 2 - 8 °C (35.6 – 46.4 °F). Once outside the refrigerator, this product may be stored in its original packaging at room temperature 15 – 30 °C (59 – 86 °F) for up to eight weeks prior to reconstitution and administration.

Must be administered by a healthcare professional. ( 2.1 ) The dose of FENSOLVI is 45 mg administered by subcutaneous injection once every six months. ( 2.1 ) Monitor response to FENSOLVI with a GnRH agonist stimulation test, basal serum luteinizing hormone (LH) levels or serum concentration of sex steroid levels at 1 to 2 months following initiation of therapy and as needed to confirm adequate suppression of pituitary gonadotropins, sex steroids, and progression of secondary sexual characteristics. ( 2.2 ) Measure height every 3 to 6 months and monitor bone age periodically. ( 2.2 ) See Full Prescribing Information for reconstitution and administration instructions. ( 2.3 , 2.4 ) 2.1 Dosing Information FENSOLVI must be administered by a healthcare professional. The dose of FENSOLVI is 45 mg administered by subcutaneous injection once every six months. Discontinue FENSOLVI treatment at the appropriate age of onset of puberty. 2.2 Monitoring Monitor response to FENSOLVI with a GnRH agonist stimulation test, basal serum luteinizing hormone (LH) levels or serum concentration of sex steroid levels at 1 to 2 months following initiation of therapy and as needed to confirm adequate suppression of pituitary gonadotropins, sex steroids, and progression of secondary sexual characteristics. Measure height (for calculation of growth velocity) every 3 to 6 months and monitor bone age periodically. Noncompliance with drug regimen or inadequate dosing may lead to gonadotropins and/or sex steroids increasing above prepubertal levels resulting in inadequate control of the pubertal process. If the dose of FENSOLVI is not adequate, switching to an alternative GnRH agonist for the treatment of CPP with the ability for dose adjustment may be necessary. 2.3 Reconstitution Instructions Use aseptic technique including gloves for reconstitution and administration. Allow the product to reach room temperature before reconstitution to allow for easier administration. Once reconstituted, the concentration is 45 mg/0.375 mL. Administer the product within 30 minutes or discard. FENSOLVI is packaged in a carton containing two trays and this package insert: Table 1: Contents of the Two Trays in the FENSOLVI Carton Syringe A Tray Syringe B Tray Syringe A is prefilled with diluent for reconstitution (ATRIGEL Delivery System) Syringe B is prefilled with 45 mg lyophilized leuprolide acetate powder White plunger rod (To be used with Syringe B) Safety needle (18G x 5/8") Desiccant pack Desiccant pack Follow the instructions below to prepare FENSOLVI: 1. On a clean field, open both trays by tearing off the foil from the corners and removing the contents. Discard the desiccant pack(s). Open the safety needle package by peeling back the paper tab. 2. Pull out (do not unscrew) the short blue plunger rod with attached gray stopper from Syringe B and discard. 3. Gently screw the white plunger rod into the remaining gray stopper in Syringe B. 4. Unscrew and discard the clear cap from Syringe A. 5. Remove and discard the gray rubber cap from Syringe B. 6. Join the two syringes together by pushing and gently screwing until secure. 7. Inject the liquid contents of Syringe A into the leuprolide acetate powder contained in Syringe B. Thoroughly mix the product for approximately 45 seconds by pushing the contents back and forth between both syringes to obtain a uniform suspension. When thoroughly mixed, the suspension will appear pale yellow. Note: Product must be mixed as described; shaking will not provide adequate mixing. 8. After mixing, hold the syringes vertically (upright) with Syringe B (wide syringe) on the bottom. The syringes should remain securely coupled. Draw all of the mixed product into Syringe B by depressing the Syringe A plunger and slightly withdrawing the Syringe B plunger. 9. Unscrew Syringe A to decouple the syringes while continuing to withdraw the Syringe B plunger. Note: Small air bubbles will remain in the formulation – this is acceptable. 10. Continue to hold Syringe B upright with the open end at the top. Hold back the white plunger on Syringe B to prevent loss of the product and attach the safety needle cartridge. Gently screw clockwise with approximately a three-quarter turn until the needle is secure. Do not overtighten, as the hub may become damaged resulting in leakage of the product during injection. The safety sheath may also be damaged if the needle is screwed with too much force. 11. (1) Move the safety sheath away from the needle and towards the syringe and (2) pull off the clear needle cartridge cover immediately prior to administration. Note: Should the needle hub appear to be damaged, or leak, do not use the product. If the needle hub is damaged or leakage is observed, use a new FENSOLVI carton. figure 1 figure 2 Figure 3 figure 4 figure 5 figure 6 figure 7 figure 8 figure 9 figure 10 step10 figure 12 2.4 Administration Instructions 1. Select a subcutaneous injection site on the abdomen, upper buttocks, or another location with adequate amounts of subcutaneous tissue that does not have excessive pigment, nodules, lesions, or hair. Avoid areas with brawny or fibrous subcutaneous tissue or locations that could be rubbed or compressed (i.e., by a belt or clothing waistband). Rotate injection sites with each injection. 2. Cleanse the injection-site area with an alcohol swab (not enclosed). 3. Using the thumb and forefinger, grab and bunch the area of skin around the injection site. 4. Using your dominant hand, insert the needle quickly at a 90° angle to the skin surface. The depth of penetration will depend on the amount and fullness of the subcutaneous tissue and the length of the needle. After the needle is inserted, release the skin. 5. Inject the drug using a slow, steady push and press down on the plunger until the syringe is empty. 6. Withdraw the needle quickly at the same 90° angle used for insertion. 7. Immediately following the withdrawal of the needle, activate the safety shield using a finger/thumb or flat surface and push until it completely covers the needle tip and locks into place. 8. An audible and tactile “click” verifies a locked position. 9. Check to confirm the safety sheath is fully engaged. Discard all components safely in an appropriate biohazard container. fig1 fig2 figure 2-4-3 figure 7 figure 2-4-5 figure 2-4-6

Hypersensitivity to GnRH, GnRH agonists or any of the components of FENSOLVI. Anaphylactic reactions to synthetic GnRH or GnRH agonists have been reported [see Adverse Reactions ( 6.2 )] . Pregnancy: FENSOLVI may cause fetal harm [see Use in Specific Populations ( 8.1 )] . Hypersensitivity reactions ( 4 ) Pregnancy ( 4 , 8.1 )

Advise the patient to read the FDA-approved patient labeling (Medication Guide). Symptoms After Initial FENSOLVI Administration Inform patients and caregivers that during the early phase of therapy with FENSOLVI, gonadotropins and sex steroids rise above baseline because of the initial stimulatory effect of the drug. Therefore, an increase in clinical signs and symptoms of puberty may be observed . Instruct patients and caregivers to notify the physician if these symptoms continue beyond the second month after FENSOLVI administration [see Warnings and Precautions ( 5.1 )]. Psychiatric Events Inform patients and caregivers that psychiatric events have been reported in patients taking GnRH agonists, including leuprolide acetate. Events include emotional lability, such as crying, irritability, impatience, anger, and aggression. Instruct patients and caregivers to monitor for development or worsening of psychiatric symptoms including depression during treatment with FENSOLVI [see Warnings and Precautions ( 5.2 )] . Convulsions Inform patients and caregivers that reports of convulsions have been observed in patients receiving GnRH agonists, including leuprolide acetate. Patients with a history of seizures, epilepsy, cerebrovascular disorders, central nervous system anomalies or tumors, and patients on concomitant medications that have been associated with convulsions may be at increased risk [see Warnings and Precautions ( 5.3 )] . Pseudotumor Cerebri (Idiopathic Intracranial Hypertension) Inform patients and caregivers that reports of pseudotumor cerebri (idiopathic intracranial hypertension) have been observed in pediatric patients receiving GnRH agonists, including leuprolide acetate. Advise patients and caregivers to monitor for headache, and vision issues such as blurred vision, double vision, loss of vision, pain behind the eye or pain with eye movement, ringing in the ears, dizziness, and nausea. Advise patients and caregivers to contact their healthcare provider if the patient develops any these symptoms. [see Warnings and Precautions ( 5.4 )] . Injection Site Reactions Inform patients and caregivers that injection site related adverse reactions may occur such as transient burning/stinging, pain, bruising, and redness. Advise patients to contact their healthcare provider if they experience rash or severe injection site reactions [see Adverse Reactions ( 6.1 )]. Pregnancy FENSOLVI is contraindicated in pregnancy. If the patient becomes pregnant while taking the drug, the patient should be informed of the potential risk to the fetus [see Use in Specific Populations ( 8.1 )]. Compliance with the Dosing Schedule Inform caregivers about the importance of adherence to the FENSOLVI dosing schedule of one injection every 24 weeks [see Dosage and Administration ( 2.1 , 2.2 )]. Rx only Revised 04/2022 Manufactured by: Tolmar, Inc. Fort Collins, CO 80526 for Tolmar International Ltd. Dublin 2, Ireland D02 T380 Distributed by: Tolmar Pharmaceuticals, Inc. Fort Collins, CO 80526 ©2020 Tolmar Pharmaceuticals, Inc. All rights reserved. FENSOLVI, ATRIGEL, Tolmar, and associated logos, are trademarks of the Tolmar group. 04006141 Rev. 2 04/22

No pharmacokinetic drug-drug interaction studies have been conducted with FENSOLVI.

Two-year carcinogenicity studies were conducted with leuprolide acetate in rats and mice. In rats, a dose-related increase of benign pituitary hyperplasia and benign pituitary adenomas was noted at 24 months when the drug was administered subcutaneously at high daily doses (0.6 to 4 mg/kg). There was a significant but not dose-related increase of pancreatic islet-cell adenomas in females and of testicular interstitial cell adenomas in males (highest incidence in the low dose group). In mice, no leuprolide acetate-induced tumors or pituitary abnormalities were observed at a dose as high as 60 mg/kg for two years. Patients have been treated with leuprolide acetate for up to three years with doses as high as 10 mg/day and for two years with doses as high as 20 mg/day without demonstrable pituitary abnormalities. No carcinogenicity studies have been conducted with FENSOLVI. Mutagenicity studies have been performed with leuprolide acetate using bacterial and mammalian systems. These studies provided no evidence of a mutagenic potential.

Risk Summary FENSOLVI is contraindicated in pregnancy [see Contraindications ( 4 )] . FENSOLVI may cause fetal harm based on findings from animal studies and the drug’s mechanism of action [see Clinical Pharmacology ( 12.1 )]. The available data from published clinical studies and case reports and from the pharmacovigilance database on exposure to leuprolide acetate during pregnancy are insufficient to assess the risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. Based on animal reproduction studies, leuprolide acetate may be associated with an increased risk of pregnancy complications, including early pregnancy loss and fetal harm. In animal reproduction studies, subcutaneous administration of leuprolide acetate to rabbits during the period of organogenesis caused embryo-fetal toxicity, decreased fetal weights and a dose-dependent increase in major fetal abnormalities in animals at doses less than the recommended human dose based on body surface area using an estimated daily dose. A similar rat study also showed increased fetal mortality and decreased fetal weights but no major fetal abnormalities at doses less than the recommended human dose based on body surface area using an estimated daily dose (see Data) . The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. In the US 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 When administered on day 6 of pregnancy at test dosages of 0.00024 mg/kg, 0.0024 mg/kg, and 0.024 mg/kg (1/3255 to 1/33 of the human dose) to rabbits, leuprolide acetate produced a dose-related increase in major fetal abnormalities. Similar studies in rats failed to demonstrate an increase in fetal malformations. There was increased fetal mortality and decreased fetal weights with the two higher doses of leuprolide acetate in rabbits and with the highest dose (0.024 mg/kg) in rats.

The safety and effectiveness of FENSOLVI for the treatment of CPP has been established in pediatric patients 2 years of age and older. Use of FENSOLVI for this indication is supported by evidence from an adequate and uncontrolled open-label, single-arm study of 64 pediatric patients with CPP with an age range of 4 to 9 years [see Clinical Studies ( 14 )] . The safety and effectiveness of FENSOLVI have not been established in pediatric patients less than 2 years old.

The following serious adverse reactions are described here and elsewhere in the label: Initial rise in gonadotropin and sex steroid levels [see Warnings and Precautions ( 5.1 )] . Psychiatric Events [see Warnings and Precautions ( 5.2 )] . Convulsions [see Warnings and Precautions ( 5.3 )] . Pseudotumor Cerebri (Idiopathic Intracranial Hypertension) [ see Warnings and Precautions ( 5.4 )] The most common adverse reactions (≥5%) were: injection site pain, nasopharyngitis, pyrexia, headache, cough, abdominal pain, injection site erythema, nausea, constipation, vomiting, upper respiratory tract infection, bronchospasm, productive cough, and hot flush. ( 6.1 ) To report SUSPECTED ADVERSE REACTIONS, contact Tolmar Pharmaceuticals, Inc. at 1-844-4TOLMAR (1-844-486-5627) or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch . 6.1 Clinical Trials Experience Because clinical studies 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. FENSOLVI was evaluated in an uncontrolled, open-label, single-arm clinical trial in which 64 pediatric patients with CPP received at least one dose of FENSOLVI. The age ranged from 4 to 9 years at start of treatment; 62 patients were female and 2 were male; 53% White; 23% Black; 8% American Indian or Alaska Native; 5% Asian; 2% Native Hawaiian or Other Pacific Islander. 56% of the subjects self-identified as Hispanic or Latino ethnicity. Adverse reactions that occurred in ≥ 5% of patients are shown in Table 2. Table 2: Adverse Reactions Occurring in ≥ 5% of Patients Treated with FENSOLVI in an Open-Label, Single-Arm Trial Adverse Reactions % of Patients (N=64) Injection site pain 31 Nasopharyngitis 22 Pyrexia 17 Headache 16 Cough 13 Abdominal pain 9 Injection site erythema 9 Nausea 8 Constipation 6 Vomiting 6 Upper respiratory tract infection 6 Bronchospasm 6 Productive cough 6 Hot flush 5 Other Adverse Reactions: Psychiatric Emotional disorder (2%) and irritability (2%) 6.2 Postmarketing Experience The following adverse reactions have been identifed during postapproval use of leuprolide acetate or FENSOLVI. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Allergic Reactions: anaphylactic, rash, urticaria, and photosensitivity reactions. General : chest pain, weight increase, weight decrease, decreased appetite, fatigue. Laboratory Abnormalities: decreased WBC. Metabolic : diabetes mellitus. Musculoskeletal and Connective Tissue : arthralgia, epiphysiolysis, muscle spasms, myalgia. Neurologic: neuropathy peripheral, convulsion, paralysis, insomnia, pseudotumor cerebri (idiopathic intracranial hypertension). Psychiatric: emotional lability, such as crying, irritability, impatience, anger and aggression. Depression, including rare reports of suicidal ideation and attempt. Many, but not all, of these patients had a history of psychiatric illness or other comorbidities with an increased risk of depression. Skin and Subcutaneous Tissue : injection site reactions including induration and abscess, flushing, hyperhidrosis. Reproductive System: vaginal bleeding, breast enlargement. Vascular : hypertension, hypotension. Respiratory: dyspnea.

No specific antidotes for FENSOLVI are known. Contact Poison Control (1-800-222-1222) for latest recommendations.