FDA Label for Edaravone

1 Indications And Usage

Edaravone injection is indicated for the treatment of amyotrophic lateral sclerosis (ALS).

2.1 Dosage Information

The recommended dosage of edaravone injection is an intravenous infusion of 60 mg administered over a 60-minute period according to the following schedule:

• •An initial treatment cycle with daily dosing for 14 days, followed by a 14-day drug-free period
• •Subsequent treatment cycles with daily dosing for 10 days out of 14-day periods, followed by 14-day drug-free periods

2.2 Preparation And Administration Information For Edaravone Injection

Edaravone injection is for intravenous infusion only.

Preparation

Do not use if the yellow oxygen indicator has turned green or blue before opening the package. Once the overwrap package is opened, use within 24 hours. Discard unused portion [see How Supplied/Storage and Handling (16.1,16.2)].

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.

Administration

Administer each 60 mg dose of edaravone injection as two consecutive 30 mg intravenous infusion bags over a total of 60 minutes (infusion rate approximately 1 mg per minute [3.33 mL per minute]).

Promptly discontinue the infusion upon the first observation of any signs or symptoms consistent with a hypersensitivity reaction [see Warnings and Precautions (5.1,5.2)].

Other medications should not be injected into the infusion bag or mixed with edaravone injection.

2.4 Switching From Edaravone Injection To Radicava Ors

Patients treated with 60 mg of edaravone injection intravenous infusion may be switched to 105 mg (5 mL) Radicava ORS using the same dosing frequency.

3 Dosage Forms And Strengths

Edaravone injection is supplied for intravenous infusion in a single-dose polypropylene bag containing 30 mg of edaravone in 100 mL of clear, colorless, and free from visible particle aqueous solution.

4 Contraindications

Edaravone injection is contraindicated in patients with a history of hypersensitivity to edaravone or any of the inactive ingredients in this product. Hypersensitivity reactions and anaphylactic reactions have occurred [see Warnings and Precautions (5.1,5.2)].

5.1 Hypersensitivity Reactions

Hypersensitivity reactions (redness, wheals, and erythema multiforme) and cases of anaphylaxis (urticaria, decreased blood pressure, and dyspnea) have been reported in spontaneous postmarketing reports with edaravone injection.

Patients should be monitored carefully for hypersensitivity reactions. If hypersensitivity reactions occur, discontinue edaravone injection, treat per standard of care, and monitor until the condition resolves [see Contraindications (4)].

5.2 Sulfite Allergic Reactions

Edaravone injection contains sodium bisulfite, a sulfite that may cause allergic type reactions, including anaphylactic symptoms and life-threatening or less severe asthmatic episodes in susceptible people. The overall prevalence of sulfite sensitivity in the general population is unknown. Sulfite sensitivity occurs more frequently in asthmatic than non-asthmatic people.

6 Adverse Reactions

The following serious adverse reactions are described elsewhere in the labeling:

• •Hypersensitivity Reactions [see Warnings and Precautions (5.1)]
• •Sulfite Allergic Reactions [see Warnings and Precautions (5.2)]

6.1 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.

In randomized, placebo-controlled trials, 184 patients with ALS were administered edaravone injection 60 mg in treatment cycles for 6 months. The population consisted of Japanese patients who had a median age of 60 years (range 29-75) and were 59% male. Most (93%) of these patients were living independently at the time of screening.

Most Common Adverse Reactions Observed During Clinical Studies

Table 2 lists the adverse reactions that occurred in ≥ 2% of patients in the edaravone injection-treated group and that occurred at least 2% more frequently than in the placebo-treated group in randomized placebo-controlled ALS trials. The most common adverse reactions that occurred in ≥10% of edaravone injection-treated patients were contusion, gait disturbance, and headache.

Table 2: Adverse Reactions from Pooled Placebo-Controlled Trials^* that Occurred in ≥ 2% of Edaravone Injection-Treated Patients and ≥ 2% More Frequently than in Placebo Patients

* Pooled placebo-controlled studies include two additional studies with 231 additional patients, all using the same treatment regimen [see Clinical Studies (14)].

6.2 Postmarketing Experience

The following adverse reactions have been identified during post-approval use of edaravone injection. 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.

Skin and subcutaneous tissue disorders: Hypersensitivity reactions and anaphylaxis. [see Warnings and Precautions (5.1, 5.2)].

8.1 Pregnancy

Risk Summary

There are no adequate data on the developmental risk associated with the use of edaravone injection in pregnant women. In animal studies, administration of edaravone to pregnant rats and rabbits resulted in adverse developmental effects (increased mortality, decreased growth, delayed sexual development, and altered behavior) at clinically relevant doses. Most of these effects occurred at doses that were also associated with maternal toxicity (see Animal Data).

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. The background risk for major birth defects and miscarriage in patients with ALS is unknown.

Data

Animal Data

In rats, intravenous administration of edaravone (0, 3, 30, or 300 mg/kg/day) throughout the period of organogenesis resulted in reduced fetal weight at all doses. In dams allowed to deliver naturally, offspring weight was reduced at the highest dose tested. Maternal toxicity was also observed at the highest dose tested. There were no adverse effects on reproductive function in the offspring. A no-effect dose for embryofetal developmental toxicity was not identified; the low dose is less than the recommended human dose of 60 mg for edaravone injection, on a body surface area (mg/m²) basis.

In rabbits, intravenous administration of edaravone (0, 3, 20, or 100 mg/kg/day) throughout the period of organogenesis resulted in embryofetal death at the highest dose tested, which was associated with maternal toxicity. The higher no-effect dose for embryofetal developmental toxicity is approximately 6 times the recommended human dose (RHD) for edaravone injection on a body surface area (mg/m²) basis.

The effects on offspring of edaravone (0, 3, 20, or 200 mg/kg/day), administered by intravenous injection to rats from GD 17 throughout lactation, were assessed in two studies. In the first study, offspring mortality was observed at the high dose and increased activity was observed at the mid and high doses. In the second study, there was an increase in stillbirths, offspring mortality, and delayed physical development (vaginal opening) at the highest dose tested. Reproduction function in offspring was not affected in either study. Maternal toxicity was evident in both studies at all but the lowest dose tested. The no-effect dose for developmental toxicity (3 mg/kg/day) is less than the RHD on a mg/m² basis.

8.2 Lactation

Risk Summary

There are no data on the presence of edaravone in human milk, the effects on the breastfed infant, or the effects of the drug on milk production. Edaravone and its metabolites are excreted in the milk of lactating rats. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for edaravone injection and any potential adverse effects on the breastfed infant from edaravone injection or from the underlying maternal condition.

8.4 Pediatric Use

Safety and effectiveness of edaravone injection in pediatric patients have not been established.

8.5 Geriatric Use

Of the 184 patients with ALS who received edaravone injection in 3 placebo-controlled clinical trials, a total of 53 patients were 65 years of age and older, including 2 patients 75 years of age and older. No overall differences in safety or effectiveness were observed between these patients and younger patients, but greater sensitivity of some older individuals cannot be ruled out.

11 Description

The active ingredient in edaravone injection is edaravone, which is a member of the substituted 2-pyrazolin-5-one class. The chemical name of edaravone is [3-methyl-1-phenyl-2-pyrazolin-5-one].

Molecular formula: C₁₀H₁₀N₂O

Molecular weight: 174.20

Chemical structure:

chem-structure - edaravone 01

Edaravone is a white to yellowish powder with a melting point of 129.7°C. It is freely soluble in acetic acid, methanol, or ethanol and slightly soluble in water or diethyl ether.

Edaravone injection is a clear, colorless, and free from visible particle liquid provided as a sterile solution.

Edaravone injection is supplied for intravenous infusion in a polypropylene bag containing 30 mg edaravone in 100 mL isotonic, sterile, aqueous solution, which is further over-wrapped on the front with transparent Aten film and on the back with four-layer formable film as secondary packaging. The over-wrapped package also contains an oxygen absorber and oxygen indicator to minimize oxidation.

Each bag contains the following inactive ingredients: L-cysteine hydrochloride hydrate (10 mg), sodium bisulfite (20 mg). Sodium chloride is added for isotonicity and phosphoric acid and sodium hydroxide are added to adjust to pH 4.

12.1 Mechanism Of Action

The mechanism by which edaravone injection exerts its therapeutic effect in patients with ALS is unknown.

12.2 Pharmacodynamics

Cardiac Electrophysiology

At exposures at least 5 times higher than that of the recommended dose of edaravone injection, edaravone does not prolong the QT interval to any clinically relevant extent.

12.3 Pharmacokinetics

Edaravone injection is administered by IV infusion. The maximum plasma concentration (C_max) of edaravone was reached by the end of infusion. There was a trend of more than dose-proportional increase in area under the concentration-time curve (AUC) and C_max of edaravone. With multiple-dose administration, edaravone does not accumulate in plasma.

Distribution

Edaravone is bound to human serum proteins (92%), mainly to albumin, with no concentration dependence in the range of 0.1 to 50 micromol/L. Edaravone has a mean volume of distribution after intravenous administration of 63.1 L.

Elimination

The mean terminal elimination half-life of edaravone is approximately 4.5 to 9 hours. The half-lives of its metabolites are 3 to 6 hours. Following intravenous administration, the total clearance of edaravone is estimated to be 35.9 L/h.

Metabolism

Edaravone is metabolized to a sulfate conjugate and a glucuronide conjugate, which are not pharmacologically active. The glucuronide conjugation of edaravone involves multiple uridine diphosphate glucuronosyltransferase (UGT) isoforms (UGT1A1, UGT1A6, UGT1A7, UGT1A8, UGT1A9, UGT1A10, UGT2B7, and UGT2B17). In human plasma, edaravone is mainly detected as the sulfate conjugate, which is presumed to be formed by sulfotransferases.

Excretion

In Japanese and Caucasian healthy volunteer studies, edaravone was excreted mainly in the urine as its glucuronide conjugate (60-80% of the dose up to 48 hours). Approximately 6-8% of the dose was recovered in the urine as the sulfate conjugate, and <1% of the dose was recovered in the urine as the unchanged drug. In vitro studies suggest that the sulfate conjugate of edaravone is hydrolyzed back to edaravone, which is then converted to the glucuronide conjugate in the kidney before excretion into the urine.

Specific Populations

Geriatric Patients

No age effect on edaravone pharmacokinetics has been found [see Use in Specific Populations (8.5)].

Patients with Renal Impairment

Following single IV infusion of 30 mg edaravone (half the recommended dosage of edaravone injection) over 60 minutes, mean C_max and AUC_0-∞ of unchanged edaravone were 1.15-and 1.20-fold greater in the subjects with mild renal impairment (eGFR 60-89 mL/min/1.73m²) and were 1.25-and 1.29-fold greater in the subjects with moderate renal impairment (eGFR 30-59 mL/min/1.73m²) when compared to subjects with normal renal function, respectively. These changes in exposures are not considered to be clinically significant and therefore no dosage adjustments are necessary in patients with mild to moderate renal impairment. The effects of severe renal impairment on the pharmacokinetics of edaravone have not been studied.

Patients with Hepatic Impairment

Following single IV infusion of 30 mg edaravone (half of the recommended dose of edaravone injection) over 60 minutes, mean C_max and AUC_0-∞ of unchanged edaravone were 1.20-and 1.07-fold greater in the subjects with mild hepatic impairment (Child-Pugh score 5 or 6), were 1.24-and 1.14-fold greater in the subjects with moderate hepatic impairment (Child-Pugh score 7 to 9), and were 1.20-and 1.19-fold greater in the subjects with severe hepatic impairment (Child-Pugh score 10 to 14) when compared to subjects with normal hepatic function, respectively. These changes in exposures are not considered to be clinically significant and therefore no dosage adjustments are necessary in patients with hepatic impairment.

Male and Female Patients

No gender effect on edaravone pharmacokinetics has been found.

Racial or Ethnic Groups

There were no significant racial differences in Cmax and AUC of edaravone between Japanese and Caucasian subjects.

Drug Interaction Studies

The pharmacokinetics of edaravone is not expected to be significantly affected by inhibitors of cytochrome P450 (CYP) enzymes, UGTs, or major transporters.

In vitro studies demonstrated that, at the recommended dosage, edaravone and its metabolites are not expected to significantly inhibit CYP enzymes (CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6, and CYP3A), conjugating enzymes UGT1A1 and UGT2B7, or other transporters (P-gp, OATP1B1, OATP1B3, OAT1, OCT2, MATE1, and MATE2-K) in humans. Edaravone and its metabolites are not expected to induce CYP1A2, or CYP2B6, at the recommended dosage of edaravone.

In vitro data indicated that edaravone was not a substrate of OATP1B1 or OATP1B3.

13.1 Carcinogenesis, Mutagenesis, Impairment Of Fertility

Carcinogenesis

Carcinogenicity studies of edaravone using the intravenous route have not been conducted.

Mutagenesis

Edaravone was negative in in vitro (bacterial reverse mutation and Chinese hamster lung chromosomal aberration) and in vivo (mouse micronucleus) assays.

Impairment of Fertility

Intravenous administration of edaravone (0, 3, 20, or 200 mg/kg) prior to and throughout mating in male and female rats and continuing in females to gestation day 7 had no effect on fertility; however, disruption of the estrus cycle and mating behavior was observed at the highest dose tested. No effects on reproductive function were observed at the lower doses, which are up to approximately 3 times the RHD for edaravone injection (60 mg) on a body surface area (mg/m²) basis.

14 Clinical Studies

The efficacy of edaravone injection for the treatment of ALS was established in a 6-month, randomized, placebo-controlled, double-blind study conducted in Japanese patients with ALS who were living independently and met the following criteria at screening:

• 1.Functionality retained most activities of daily living (defined as scores of 2 points or better on each individual item of the ALS Functional Rating Scale – Revised [ALSFRS-R; described below])
• 2.Normal respiratory function (defined as percent-predicted forced vital capacity values of [%FVC] ≥ 80%)
• 3.Definite or Probable ALS based on El Escorial revised criteria
• 4.Disease duration of 2 years or less

The study enrolled 69 patients in the edaravone injection arm and 68 in the placebo arm. Baseline characteristics were similar between these groups, with over 90% of patients in each group being treated with riluzole.

Edaravone injection was administered as an intravenous infusion of 60 mg given over a 60-minute period according to the following schedule:

• •An initial treatment cycle with daily dosing for 14 days, followed by a 14-day drug-free period (Cycle 1)
• •Subsequent treatment cycles with daily dosing for 10 days out of 14-day periods, followed by 14-day drug-free periods (Cycles 2-6).

The primary efficacy endpoint was a comparison of the change between treatment arms in the ALSFRS-R total scores from baseline to Week 24. The ALSFRS-R scale consists of 12 questions that evaluate the fine motor, gross motor, bulbar, and respiratory function of patients with ALS (speech, salivation, swallowing, handwriting, cutting food, dressing/hygiene, turning in bed, walking, climbing stairs, dyspnea, orthopnea, and respiratory insufficiency). Each item is scored from 0-4, with higher scores representing greater functional ability. The decline in ALSFRS-R scores from baseline was significantly less in the edaravone injection-treated patients as compared to placebo (see Table 3). The distribution of change in ALSFRS-R scores from baseline to Week 24 by percent of patients is shown in Figure 1.

Table 3: Analysis of Change from Baseline to Week 24 in ALSFRS-R Scores

Treatment	Change from Baseline LS Mean ± SE (95% CI)	Treatment Difference (Edaravone Injection – placebo [95% CI])	p-value
Edaravone Injection	−5.01±0.64	2.49 (0.99, 3.98)	0.0013
Placebo	−7.50±0.66

Figure 1: Distribution of Change from Baseline to Week 24 in ALSFRS-R Scores

figure-1 - edaravone 02

16.1 How Supplied

Edaravone Injection is supplied as a 30 mg/100 mL (0.3 mg/mL) clear, colorless, and free from visible particle sterile solution for intravenous infusion in single-dose polypropylene bags, each over-wrapped on the front with transparent Aten film and on the back with four-layer formable film as secondary packaging containing an oxygen absorber and oxygen indicator, which should be yellow to reflect appropriate oxygen levels [see Dosage and Administration (2.2) and How Supplied/Storage and Handling (16.2)].

These are supplied in cartons as listed below.

•  NDC 0781-3527-94 30 mg/100 mL (0.3 mg/mL) Single-Dose bag
•  NDC 0781-3527-20 2 bags per carton

16.2 Storage And Handling

Store edaravone injection at 20° to 25°C (68° to 77°F); excursions permitted to 15° to 30°C (59° to 86°F) [see USP Controlled Room Temperature]. Protect from light. Store in overwrapped package to protect from oxygen degradation until time of use. The yellow oxygen indicator will turn green or blue if the oxygen has exceeded acceptable levels. Once the overwrap package is opened, use within 24 hours.

17 Patient Counseling Information

Advise the patients to read the FDA-approved patient labeling (Patient Information).

Hypersensitivity Reactions

Advise patients to seek immediate medical care if they experience signs or symptoms of a hypersensitivity reaction [see Warnings and Precautions (5.1)].

Sulfite Allergic Reactions

Advise patients about potential for sulfite sensitivity. Inform patients that edaravone injection contains sodium bisulfite, which may cause allergic type reactions including anaphylactic symptoms and life-threatening or less severe asthmatic episodes, and to seek immediate medical care if they experience these signs or symptoms [see Warnings and Precautions (5.2)].

Pregnancy and Breastfeeding

Advise patients to notify their healthcare provider if they become pregnant or intend to become pregnant during edaravone injection therapy [see Use in Specific Populations (8.1)].

Advise patients to notify their healthcare provider if they intend to breastfeed or are breastfeeding an infant [see Use in Specific Populations (8.2)].

Manufactured by InfoRLife SA for Sandoz Inc., Princeton, NJ 08540

RADICAVA ORS^® is a registered trademark of Mitsubishi Tanabe Pharma Corporation.

Patient Information

Edaravone Injection for Intravenous Infusion

(e-DAR-a-vone)

•  This Patient Information has been approved by the U.S. Food and Drug Administration Revised: 10/2023

Package/Label Principal Display Panel

NDC 0781-3527-20

Edaravone Injection

30 mg/100 mL (0.3 mg/mL)

For Intravenous Infusion

(Infuse each 30 mg/100 mL bag over a period of 30 minutes)

Sterile Solution

Single-dose - Discard unused portion

Rx Only

Each 100 mL single-dose bag contains:

Active: 30 mg edaravone

Inactive: L-cysteine hydrochloride hydrate (10 mg), sodium bisulfite (20 mg). Sodium chloride is added for isotonicity and phosphoric acid and sodium hydroxide are added to adjust to pH 4.

100 mL x 2 Bags

SANDOZ

carton - edaravone 03