Arikayce Suspension
FDA Label NDC 71558-590

ARIKAYCE has been associated with an increased risk of respiratory adverse reactions including, hypersensitivity pneumonitis, hemoptysis, bronchospasm, exacerbation of underlying pulmonary disease that have led to hospitalizations in some cases [see Warnings and Precautions (5.1, 5.2, 5.3, 5.4)].

LIMITED POPULATION: ARIKAYCE^® is indicated in adults, who have limited or no alternative treatment options, for the treatment of Mycobacterium avium complex (MAC) lung disease as part of a combination antibacterial drug regimen in patients who do not achieve negative sputum cultures after a minimum of 6 consecutive months of a multidrug background regimen therapy. As only limited clinical safety and effectiveness data for ARIKAYCE are currently available, reserve ARIKAYCE for use in adults who have limited or no alternative treatment options. This drug is indicated for use in a limited and specific population of patients.

This indication is approved under accelerated approval based on achieving sputum culture conversion (defined as 3 consecutive negative monthly sputum cultures) by Month 6. Clinical benefit has not yet been established [see Clinical Studies (14)]. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials.

Limitation of Use:

ARIKAYCE has only been studied in patients with refractory MAC lung disease defined as patients who did not achieve negative sputum cultures after a minimum of 6 consecutive months of a multidrug background regimen therapy. The use of ARIKAYCE is not recommended for patients with non-refractory MAC lung disease.

Overview of Clinical Trials for Safety Evaluation

Within the refractory NTM clinical program, 388 patients that participated in three clinical trials were treated with ARIKAYCE at the dose of 590 mg/day (median duration of exposure to ARIKAYCE was 169 days).

Trial 1 (NCT#02344004) was an open-label, randomized (2:1), multi-center Phase 3 trial in patients with refractory Mycobacterium avium complex (MAC) lung disease. Patients were randomized to either 8 months of ARIKAYCE plus a background regimen (n=223) or background regimen alone (n=112).

Trial 2 (NCT#02628600) was a single-arm extension of Trial 1 for refractory MAC lung disease patients that failed to achieve negative sputum cultures after 6 months of treatment or had a relapse or recurrence by Month 6 from either study arm of Trial 1. A total of 133 patients (n=74 from the prior background regimen alone arm of Trial 1, and n=59 from the prior ARIKAYCE plus background regimen arm in Trial 1) participated in the trial.

Trial 3 (NCT#01315236) was a double-blind, randomized, placebo-controlled Phase 2 study in patients with refractory nontuberculous mycobacterial (NTM) lung disease caused by MAC and Mycobacterium abscessus. Patients were randomized to either ARIKAYCE plus background regimen or an inhaled diluted empty liposome placebo plus background regimen for 84 days.

Across all clinical trials of patients with and without refractory NTM lung infection, 802 patients were exposed to multiple doses of ARIKAYCE.

Adverse Reactions Leading to Treatment Discontinuation

In the three NTM studies, there was a higher incidence of premature discontinuation of ARIKAYCE. In Trial 1, 33.5% discontinued ARIKAYCE prematurely; most were due to adverse reactions (17.4%) and withdrawal by subject (9.4%). In the comparator arm 8% of subjects discontinued theirbackground regimen, with 0.9% due to adverse reactions and 5.4% due to withdrawal by subject. In Trial 2 (the single-arm extension of Trial 1), 20.3% of patients starting on ARIKAYCE discontinued prematurely with 14.9% discontinuing due to adverse reactions. In Trial 3, all 9 (20.5%) premature discontinuations occurred in the ARIKAYCE plus background regimen-treated patients and there were no premature discontinuations in the placebo plus background regimen arm.

Serious Adverse Reactions in Trials 1 and 3

In the two randomized trials (Trial 1 and Trial 3), there were more serious adverse reactions (SARs) reported in the ARIKAYCE-treated arm as compared to the respective control arm. In Trial 1, 20.2% of patients treated with ARIKAYCE plus background regimen reported SAR as compared to 16.1% of patients treated with background regimen alone. In addition, in Trial 1 [2 to 1 randomization, ARIKAYCE plus background regimen versus background regimen alone], there were 82 hospitalizations in 41 patients (18.4%) treated with ARIKAYCE plus background regimen compared to 23 hospitalizations in 15 patients (13.4%) treated with background regimen alone. The most common SARs and reasons for hospitalization in the ARIKAYCE plus background regimen arm were related to exacerbation of underlying pulmonary disease and lower respiratory tract infections, such as pneumonia.

In Trial 3, 18.2% of patients treated with ARIKAYCE plus background regimen reported SARs compared to 8.9% of patients treated with background regimen plus inhaled placebo.

Common Adverse Reactions

The incidence of adverse reactions in Trial 1 are displayed in Table 1. Only those adverse reactions with a rate of at least 5% in the ARIKAYCE plus background regimen group and greater than the background regimen alone group, are shown.

Selected adverse drug reactions that occurred in <5% of patients and at higher frequency in ARIKAYCE-treated patients in Trial 1 are presented in Table 2.

Refer to Table 1 and Table 2 for the incidence rate of hypersensitivity pneumonitis, bronchospasm, cough, dysphonia, exacerbation of underlying disease, hemoptysis, ototoxicity, upper airway irritation, and neuromuscular disorders [see Warnings and Precautions (5.1, 5.2, 5.3, 5.4, 5.5, 5.6)]

Risk Summary

There are no data on ARIKAYCE use in pregnant women to evaluate for any drug-associated risk of major birth defects, miscarriage or adverse maternal or fetal outcomes. Although systemic absorption of amikacin following oral inhalation is expected to be low [see Clinical Pharmacology (12.3)], systemic exposure to aminoglycoside antibacterial drugs, including ARIKAYCE, may be associated with total, irreversible, bilateral congenital deafness when administered to pregnant women [see Warnings and Precautions (5.8)]. Advise pregnant women of the potential risk to a fetus.

Animal reproductive toxicology studies have not been conducted with inhaled amikacin. Subcutaneous administration of amikacin to pregnant rats (up to 100 mg/kg/day) and mice (up to 400 mg/kg/day) during organogenesis was not associated with fetal malformations. Ototoxicity was not adequately evaluated in offspring in animal studies.

The estimated background risk of major birth defects and miscarriage for the indicated populations is unknown. All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively.

Data

Animal Data

No animal reproductive toxicology studies have been conducted with ARIKAYCE or non-liposomal amikacin administered by inhalation.

Amikacin was subcutaneously administered to pregnant rats (Gestation Days 8-14) and mice (Gestation Days 7-13) at doses of 25, 100, or 400 mg/kg to assess developmental toxicity. These doses did not cause fetal visceral or skeletal malformations in mice. The high dose was excessively maternally toxic in rats (nephrotoxicity and mortality were observed), precluding the evaluation of offspring at this dose. Fetal malformations were not observed at the low or mid dose in rats. Postnatal development of the rats and mice exposed to these doses of amikacin in utero did not differ significantly from control.

Ototoxicity was not adequately evaluated in offspring in animal developmental toxicology studies.

Risk Summary

There is no information regarding the presence of ARIKAYCE in human milk, the effects on the breastfed infant, or the effects on milk production after administration of ARIKAYCE by inhalation. Although limited published data on other routes of administration of amikacin indicate that amikacin is present in human milk, systemic absorption of ARIKAYCE following inhaled administration is expected to be low [see Clinical Pharmacology (12.3)]. The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for ARIKAYCE and any potential adverse effects on the breastfed child from ARIKAYCE or from the underlying maternal condition.

Sputum Concentrations

Following once daily inhalation of 590 mg ARIKAYCE in Mycobacterium avium complex (MAC) patients, sputum concentrations at 1 to 4 hours post-inhalation were 1720, 884, and 1300 mcg/g at 1, 3, and 6 months, respectively. High variability in amikacin concentrations were observed (CV% >100%). After 48 to 72 hours post-inhalation, amikacin sputum concentrations decreased to approximately 5% of those at 1 to 4 hours post-inhalation.

Serum Concentrations

Following 3 months of once daily inhalation of 590 mg ARIKAYCE in MAC patients, the mean serum AUC_0-24 was 23.5 mcg*hr/mL (range: 8.0 to 46.5 mcg*hr/mL; n=12) and the mean serum C_max was 2.8 mcg/mL (range: 1.0 to 4.4 µg/mL; n=12). The maximum C_max and AUC_0-24 were below the mean C_max of approximately 76 mcg/mL and AUC_0-24 of 154 mcg*hr/mL observed for intravenous administration of amikacin sulfate for injection at the approved dosage of 15 mg/kg once daily in healthy adults.

Absorption

The bioavailability of ARIKAYCE is expected to vary primarily from individual differences in nebulizer efficiency and airway pathology.

Distribution

The protein binding of amikacin in serum is ≤ 10%.

Elimination

Following inhalation of ARIKAYCE in MAC patients, the apparent serum half-life of amikacin ranged from approximately 5.9 to 19.5 hrs.

Metabolism

Amikacin does not undergo appreciable metabolism.

Excretion

Systemically absorbed amikacin following ARIKAYCE administration is eliminated principally via glomerular filtration. On average, 7.42% (ranging from 0.72 to 22.60%; n=14) of the total ARIKAYCE dose was excreted in urine as unchanged drug compared to 94% following intravenous administration of amikacin sulfate for injection. Unabsorbed amikacin, following ARIKAYCE inhalation, is probably eliminated primarily by cellular turnover and expectoration.

Drug Interaction Studies

No clinical drug interaction studies have been conducted with ARIKAYCE [see Drug Interactions (7)].

Mechanism of Action

Amikacin is a polycationic, semisynthetic, bactericidal aminoglycoside. Amikacin enters the bacterial cell by binding to negatively charged components of the bacterial cell wall disrupting the overall architecture of the cell wall. The primary mechanism of action is the disruption and inhibition of protein synthesis in the target bacteria by binding to the 30S ribosomal subunit.

Resistance

The mechanism of resistance to amikacin in mycobacteria has been linked to mutations in the rrs gene of the 16S rRNA. In clinical trials, MAC isolates developing an amikacin MIC of > 64 mcg/mL after baseline were observed in a higher proportion of subjects treated with ARIKAYCE [see Clinical Studies (14)].

Interaction with Other Antimicrobials

There has been no in vitro signal for antagonism between amikacin and other antimicrobials against MAC based on fractional inhibitory concentration (FIC) and macrophage survival assays. In select instances, some degree of synergy between amikacin and other agents has been observed, as for example, synergy between aminoglycosides, including amikacin, and the beta-lactam class has been documented.

Important Instructions for Administration of ARIKAYCE

Instruct patients to read the Instructions for Use before starting ARIKAYCE. Instruct patients to only use the Lamira™ Nebulizer System to administer ARIKAYCE. Advise the patient or caregiver not use the Lamira Nebulizer System with any other medicine.

Hypersensitivity Pneumonitis and Bronchospasm (Difficulty Breathing)

Advise patients to inform their healthcare provider if they experience shortness of breath or wheezing after administration of ARIKAYCE. Advise patients with a history of reactive airway disease, asthma, or bronchospasm, to administer ARIKAYCE after using a short-acting bronchodilator [see Warnings and Precautions (5.1, 5.3)].

Hemoptysis or Cough

Advise patients to inform their healthcare provider if they cough up blood or experience episodic cough either during or after ARIKAYCE administration particularly in the first month after starting ARIKAYCE [see Warnings and Precautions (5.2) and Adverse Reactions (6.1)].

Exacerbations of Underlying Pulmonary Disease

Advise patients to inform their healthcare provider if they experience worsening of their lung disease after starting ARIKAYCE [see Warnings and Precautions (5.4)].

Dysphonia or Difficulty Speaking

Advise patients to inform their healthcare provider if they have difficulty speaking. Difficulty speaking or loss of ability to speak has been reported with ARIKAYCE [see Adverse Reactions (6.1)].

Ototoxicity (Ringing in the Ears)

Advise patients to inform their healthcare provider if they experience ringing in the ears, dizziness, or any changes in hearing because ARIKAYCE has been associated with hearing loss [see Warnings and Precautions (5.5)].

Advise the patient not to operate heavy machinery or do dangerous activities while inhaling ARIKAYCE through the Lamira Nebulizer System because ARIKAYCE can cause symptoms such as dizziness or respiratory symptoms.

Nephrotoxicity or Kidney Damage

Advise patients to inform their health care provider if they have kidney problems because kidney damage has been reported with aminoglycosides [see Warnings and Precautions (5.6)].

Neuromuscular Blockade

Advise patients to inform their healthcare provider of known neuromuscular disease (e.g., myasthenia gravis) [see Warnings and Precautions (5.7)].

Embryo-fetal Toxicity

Advise pregnant women that aminoglycosides, including ARIKAYCE, may cause irreversible congenital deafness when administered during pregnancy [see Warnings and Precautions (5.8) and Use in Special Populations (8.1)].

Manufactured for:

Insmed^®, Bridgewater, NJ 08807

Insmed^® and, ARIKAYCE^® are trademarks of Insmed Incorporated. Lamira™ is a trademark of PARI Pharma GmbH.

© Insmed Incorporated. All rights reserved. 2010 7,718,189; 2012 8,226,975; 2014 8,632,804, 8,642,075, 8,679,532 and 8,802,137; 2017 9,566,234 and 9,827,317 and 2018 9,895,385

ARIKAYCE is for oral inhalation use only. Administer by nebulization only with the Lamira™ Nebulizer System. Refer to the Instructions for Use for full administration information on use of ARIKAYCE with the Lamira Nebulizer System.

Instruct patients using a bronchodilator (‘reliever’) to first use the bronchodilator following the bronchodilator leaflet for use information before using ARIKAYCE.

Pre-treatment with short-acting selective beta-2 agonists should be considered for patients with known hyperreactive airway disease, chronic obstructive pulmonary disease, asthma, or bronchospasm [see Warnings and Precautions (5.3)].

The recommended dosage of ARIKAYCE in adults is once daily inhalation of the contents of one 590 mg/8.4 mL ARIKAYCE vial (590 mg of amikacin) using the Lamira Nebulizer System.

Administer ARIKAYCE with the Lamira Nebulizer System only. ARIKAYCE should be at room temperature before use. Prior to opening, shake the ARIKAYCE vial well for at least 10 to 15 seconds until the contents appear uniform and well mixed. The ARIKAYCE vial is opened by flipping up the plastic top of the vial then pulling downward to loosen the metal ring. The metal ring and the rubber stopper should be removed carefully. The contents of the ARIKAYCE vial can then be poured into the medication reservoir of the nebulizer handset.

If a daily dose of ARIKAYCE is missed, administer the next dose the next day. Do NOT double the dose to make up for the missed dose.

ARIKAYCE is supplied as a sterile, white, milky, aqueous, liposome suspension for oral inhalation in a unit-dose glass vial containing amikacin 590 mg/8.4 mL (equivalent to amikacin sulfate 623 mg/8.4 mL).

ARIKAYCE is contraindicated in patients with a known hypersensitivity to any aminoglycoside.

Hypersensitivity pneumonitis has been reported with the use of ARIKAYCE in the clinical trials. Hypersensitivity pneumonitis (reported as allergic alveolitis, pneumonitis, interstitial lung disease, allergic reaction to ARIKAYCE) was reported at a higher frequency in patients treated with ARIKAYCE plus a background regimen (3.1 %) compared to patients treated with a background regimen alone (0%). Most patients with hypersensitivity pneumonitis discontinued treatment with ARIKAYCE and received treatment with corticosteroids [see Adverse Reactions (6.1)]. If hypersensitivity pneumonitis occurs, discontinue ARIKAYCE and manage the patient as medically appropriate.

Hemoptysis has been reported with the use of ARIKAYCE in the clinical trials. Hemoptysis was reported at a higher frequency in patients treated with ARIKAYCE plus a background regimen (17.9 %) compared to patients treated with a background regimen alone (12.5 %) [see Adverse Reactions (6.1)]. If hemoptysis occurs, manage the patients as medically appropriate.

Bronchospasm has been reported with the use of ARIKAYCE in the clinical trials. Bronchospasm (reported as asthma, bronchial hyperreactivity, bronchospasm, dyspnea, dyspnea exertional, prolonged expiration, throat tightness, wheezing) was reported at a higher frequency in patients treated with ARIKAYCE plus a background regimen (28.7 %) compared to patients treated with a background regimen alone (10.7 %) [see Adverse Reactions (6.1)]. If bronchospasm occurs during the use of ARIKAYCE treat the patients as medically appropriate.

Exacerbations of underlying pulmonary disease has been reported with the use of ARIKAYCE in the clinical trials. Exacerbations of underlying pulmonary disease (reported as chronic obstructive pulmonary disease, infective exacerbation of chronic obstructive pulmonary disease, infective exacerbation of bronchiectasis) have been reported at a higher frequency in patients treated with ARIKAYCE plus a background regimen (14.8 %) compared to patients treated with background regimen alone (9.8 %) [see Adverse Reactions (6.1)]. If exacerbations of underlying pulmonary disease occurs during the use of ARIKAYCE, treat the patients as medically appropriate.

Ototoxicity has been reported with the use of ARIKAYCE in the clinical trials. Ototoxicity (including deafness, dizziness, presyncope, tinnitus, and vertigo) were reported with a higher frequency in patients treated with ARIKAYCE plus a background regimen (17 %) compared to patients treated with background regimen alone (9.8 %). This was primarily driven by tinnitus (7.6% in ARIKAYCE plus background regimen vs. 0.9% in the background regimen alone arm) and dizziness (6.3% in ARIKAYCE plus background regimen vs. 2.7% in the background regimen alone arm). [see Adverse Reactions (6.1)].

Closely monitor patients with known or suspected auditory or vestibular dysfunction during treatment with ARIKAYCE. If ototoxicity occurs, manage the patient as medically appropriate, including potentially discontinuing ARIKAYCE.

Nephrotoxicity was observed during the clinical trials of ARIKAYCE in patients with MAC lung disease but not at a higher frequency than the background regimen alone [see Adverse Reactions (6.1)]. Nephrotoxicity has been associated with the aminoglycosides. Close monitoring of patients with known or suspected renal dysfunction may be needed when prescribing ARIKAYCE.

Patients with neuromuscular disorders were not enrolled in ARIKAYCE clinical trials. Patients with known or suspected neuromuscular disorders, such as myasthenia gravis, should be closely monitored since aminoglycosides may aggravate muscle weakness by blocking the release of acetylcholine at neuromuscular junctions.

Aminoglycosides can cause fetal harm when administered to a pregnant woman. Aminoglycosides, including ARIKAYCE, may be associated with total, irreversible, bilateral congenital deafness in pediatric patients exposed in utero. Patients who use ARIKAYCE during pregnancy, or become pregnant while taking ARIKAYCE should be apprised of the potential hazard to the fetus [see Use in Specific Populations (8.1)].

The following clinically significant adverse reactions are described in greater detail in other sections of labeling:

• Hypersensitivity pneumonitis [see Boxed Warning and Warnings and Precautions (5.1)]
• Hemoptysis [see Boxed Warning and Warnings and Precautions (5.2)]
• Bronchospasm [see Boxed Warning and Warnings and Precautions (5.3)]
• Exacerbation of Underlying Pulmonary Disease [see Boxed Warning and Warnings and Precautions (5.4)]
• Ototoxicity [see Warnings and Precautions (5.5)]
• Nephrotoxicity [see Warnings and Precautions (5.6)]
• Neuromuscular Blockade [see Warnings and Precautions (5.7)]

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.

Avoid concomitant use of ARIKAYCE with medications associated with neurotoxicity, nephrotoxicity, and ototoxicity.

Some diuretics can enhance aminoglycoside toxicity by altering aminoglycoside concentrations in serum and tissue. Avoid concomitant use of ARIKAYCE with ethacrynic acid, furosemide, urea, or intravenous mannitol.

Safety and effectiveness of ARIKAYCE in pediatric patients below 18 years of age have not been established.

In the NTM clinical trials, of the total number of patients receiving ARIKAYCE, 196 (50.5%) were ≥ 65 years and 55 (14.2%) were ≥ 75 years. No overall differences in safety and effectiveness were observed between elderly subjects and younger subjects. Because elderly patients are more likely to have decreased renal function, it may be useful to monitor renal function [see Warnings and Precautions (5.6)].

ARIKAYCE has not been studied in patients with hepatic impairment. No dose adjustments based on hepatic impairment are required since amikacin is not hepatically metabolized [see Clinical Pharmacology (12.3)].

ARIKAYCE has not been studied in patients with renal impairment. Given the low systemic exposure to amikacin following administration of ARIKAYCE, clinically relevant accumulation of amikacin is unlikely to occur in patients with renal impairment. However, renal function should be monitored in patients with known or suspected renal impairment, including elderly patients with potential age-related decreases in renal function [see Warnings and Precautions (5.6), Use in Specific Populations (8.5)].

Adverse reactions specifically associated with overdose of ARIKAYCE have not been identified. Acute toxicity should be treated with immediate withdrawal of ARIKAYCE, and baseline tests of renal function should be undertaken.

Hemodialysis may be helpful in removing amikacin from the body.

In all cases of suspected overdosage, physicians should contact the Regional Poison Control Center for information about effective treatment. In the case of any overdosage, the possibility of drug interactions with alterations in drug disposition should be considered.

The active ingredient in ARIKAYCE (amikacin liposome inhalation suspension) is amikacin sulfate USP, an aminoglycoside antibacterial. Its chemical name is D-Streptamine, O-3-amino-3-deoxy-α-D-glucopyranosyl-(1→6)-O-[6-amino-6-deoxy-α-D-glucopyranosyl-(1→4)]-N¹-(4-amino-2-hydroxy-1-oxobutyl)-2-deoxy-, (S)-, sulfate (1:2) salt with a chemical formula of C₂₂H₄₃N₅O₁₃∙2H₂SO₄ with a molecular weight of 781.76. Its structural formula is:

Chemical Structure (Arikayce 01)

ARIKAYCE is a white milky suspension consisting of amikacin sulfate encapsulated in liposomes and is supplied in a unit-dose 10 mL clear glass vial containing amikacin 590 mg/8.4 mL (equivalent to amikacin sulfate 623 mg/8.4 mL) as a sterile aqueous liposomal suspension for oral inhalation. ARIKAYCE consists of amikacin sulfate encapsulated in liposomes at a targeted concentration of 70 mg amikacin/mL with the pH range of 6.1 to 7.1 and lipid to amikacin weight ratio in the range of 0.60 to 0.79. The inactive ingredients are cholesterol, dipalmitoylphosphatidylcholine (DPPC), sodium chloride, sodium hydroxide (for pH adjustment), and water for injection.

ARIKAYCE is administered only using a Lamira Nebulizer System [see Dosage and Administration (2.1)]. Like all other nebulized treatments, the amount delivered to the lungs will depend upon patient factors. Under standardized in vitro testing per USP<1601> adult breathing pattern (500 mL tidal volume, 15 breaths per minute, and inhalation: exhalation ratio of 1:1), the mean delivered dose from the mouthpiece was approximately 312 mg of amikacin sulfate (53% of label claim). The mass median aerodynamic diameter (MMAD) of the nebulized aerosol droplets is about 4.7 µm (4.1 – 5.3 µm) as determined using the Next Generation Impactor (NGI) method. A percentage of the amikacin in the liposome is released by the nebulization process, thus nebulized ARIKAYCE delivers a combination of free and liposomal amikacin.

ARIKAYCE is an antibacterial drug [see Microbiology (12.4)].

ARIKAYCE exposure-response relationships and the time course of pharmacodynamic response are unknown.

In a 2-year inhalation carcinogenicity study, rats were exposed to ARIKAYCE for 15-25, 50-70, or 155-170 minutes per day for 96-104 weeks. These provided approximate inhaled doses of 5, 15, and 45 mg/kg/day. Squamous cell carcinoma was observed in the lungs of 2 of 120 rats administered the highest dose tested. Maximum serum AUC levels of amikacin in the rats at steady state were approximately 1.3, 2.8, and 7.6 mcg∙hr/mL at the low, mid, and high doses, respectively, compared with 23.5 mcg∙hr/mL (8.0 to 46.5 mcg∙hr/mL) measured in humans. The squamous cell carcinomas may be the result of a high lung burden of particulates from ARIKAYCE in the rat lung. The relevance of the lung tumor findings with regards to humans receiving ARIKAYCE is unknown.

No evidence of mutagenicity or genotoxicity was observed in a battery of in vitro and in vivo genotoxicity studies with a liposome-encapsulated amikacin formulation similar to ARIKAYCE (in vitro microbial mutagenesis test, in vitro mouse lymphoma mutation assay, in vitro chromosomal aberration study, and an in vivo micronucleus study in rats).

No fertility studies were conducted with ARIKAYCE. Intraperitoneal administration of amikacin to male and female rats at doses up to 200 mg/kg/day prior to mating through Day 7 of gestation were not associated with impairment of fertility or adverse effects on early embryonic development.

To provide information about chronic dosing of ARIKAYCE to another animal species, a 9-month inhalation toxicology study was conducted in dogs. Foamy alveolar macrophages associated with clearance of the inhaled product were present at dose-related incidence and severity, but they were not associated with inflammation, tissue hyperplasia, or the presence of preneoplastic or neoplastic changes. Dogs were exposed to ARIKAYCE for up to 90 minutes per day, providing inhaled amikacin doses of approximately 5, 10, and 30 mg/kg/day.

Trial 1 (NCT#02344004) was an open-label, randomized (2:1), multi-center trial in patients with refractory Mycobacterium avium complex (MAC) lung disease as confirmed by at least 2 sputum culture results. Patients were considered to have refractory MAC lung disease if they did not achieve negative sputum cultures after a minimum duration of 6 consecutive months of background regimen therapy that was either ongoing or stopped no more than 12 months before the screening visit. Patients were randomized to either ARIKAYCE plus a background regimen or background regimen alone. The surrogate endpoint for assessing efficacy was based on achieving culture conversion (3 consecutive monthly negative sputum cultures) by Month 6. The date of conversion was defined as the date of the first of the 3 negative monthly cultures, which had to be achieved by Month 4 in order to meet the endpoint by Month 6.

A total of 336 patients were randomized (ARIKAYCE plus background regimen, n=224; background regimen alone, n=112) (ITT population), with a mean age of 64.7 years and there was a higher percentage of females (69.3%) than males (30.7%) in the study. At the time of enrollment, of the 336 subjects in the ITT population, 302 (89.9%) were either on a guideline-based regimen for MAC or off guideline-based therapy for MAC for less than 3 months while 34 (10.1%) were off treatment for 3 to 12 months prior to enrollment. At screening, patients were stratified by smoking status (current smoker or not) and by whether patients were on treatment or off treatment for at least 3 months. Most patients at screening were not current smokers (89.3%) and had underlying bronchiectasis (62.5%). At baseline, background regimens included a macrolide (91.9%), a rifamycin (85.7%), or ethambutol (80.3%). Overall, 54.9% of subjects were receiving a triple background regimen of a macrolide, a rifamycin and ethambutol.

The proportion of patients achieving culture conversion (3 consecutive monthly negative sputum cultures) by Month 6 was significantly (p<0.0001) greater for ARIKAYCE plus background regimen (65/224, 29.0%) compared to background regimen alone (10/112, 8.9%). An analysis of sustained sputum culture conversion through Month 6 (defined as consecutive negative sputum cultures with no positive culture on solid media or no more than 2 consecutive positive cultures in liquid media following achieving initial culture conversion) showed that 3 subjects in each treatment arm who initially achieved culture conversion did not have sustained sputum culture conversion through Month 6. Thus, 27.7% (62/224) of ARIKAYCE plus background regimen patients and 6.3% (7/112) of background regimen alone patients had sustained sputum culture conversion through Month 6.

Image (Arikayce 02)

In Trial 1, 23/224 (10.3%) of patients had MAC isolates that developed MIC of > 64 mcg/mL while receiving treatment with ARIKAYCE. In the background regimen alone arm, 4/112 (3.6%) of patients had MAC isolates that developed amikacin MIC of > 64 mcg/mL.

Additional endpoints to assess the clinical benefit of ARIKAYCE, for example, change from baseline in six-minute walk test distance and the Saint George's Respiratory Questionnaire, did not demonstrate clinical benefit by Month 6.

ARIKAYCE (amikacin liposome inhalation suspension), 590 mg/8.4 mL, is supplied in a sterile, unit-dose 10-mL glass vial. The product is dispensed as a 28-vial kit.

Each carton contains a 28-day supply of medication (28 vials). In addition to the ARIKAYCE vials in the carton, one Lamira Nebulizer Handset and four Lamira Aerosol Heads are provided.

NDC 71558-590-28

The Lamira Nebulizer System contains a controller, a spare Aerosol Head, a spare Handset, Power Cord and accessories.

Store ARIKAYCE vials refrigerated at 2°C to 8°C (36°F to 46°F) until expiration date on vial. Do not freeze. Once expired, discard any unused drug.

ARIKAYCE can be stored at room temperature up to 25°C (77°F) for up to 4 weeks. Once at room temperature, any unused drug must be discarded at the end of 4 weeks.

Advise the patient to read the FDA-approved patient labeling (Medication Guide and Patient Instructions for Use).

ARIKAYCE^® LIMITED POPULATION
(amikacin liposome inhalation suspension)

For oral inhalation use
Lamira™ Nebulizer System

Before using your Lamira Nebulizer System, be sure you read and understand the detailed information in the full Instructions for Use that comes with the Lamira Nebulizer System. This will provide more complete information about how to put together (assemble), prepare, use, clean, and disinfect your Lamira Nebulizer System. If you do not understand any part of the instructions, contact Arikares Support at 1-833-ARIKARE (1-833-274-5273) before using the Lamira Nebulizer System.

• Plug the A/C Power Supply into the Controller.
• Plug the A/C Power Supply into the wall outlet.

Do not insert the A/C Power into the front of the Controller.

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Gather your ARIKAYCE medicine. The ARIKAYCE 28-day kit contains:

1 ARIKAYCE Quick Start Guide 1 Instructions for Use insert 1 Full Prescribing Information insert 1 Lamira Nebulizer Handset 4 Lamira Aerosol Heads (1 in each weekly box) 28 vials (1 vial each day) of ARIKAYCE (7 in each weekly box)

Check to make sure you have all the necessary parts for your Lamira Nebulizer System:

Figure (Arikayce 03)

Spare Lamira Nebulizer Handset:

Figure (Arikayce 04)

You will also need the following supplies that do not come in your ARIKAYCE 28-day kit that will help you care for your Lamira Nebulizer System:

Clear liquid soap for cleaning the Handset and Aerosol Head Distilled water for disinfecting the Handset and Aerosol Head

Choose your power supply and get it ready.

Figure (Arikayce 05)

or

Figure (Arikayce 06)

Cleaning and Disinfecting

Clean and disinfect your Handset and Aerosol Head before you use it for the first time, and immediately after each use.

When you receive your Handset and Aerosol Head, they will not be sterile. Cleaning and disinfecting your Handset and Aerosol Head is important to reduce the risk of infection, illness, and contamination.

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Figure (Arikayce 07)
Figure (Arikayce 08)
Figure (Arikayce 09)
Clean all Handset parts by adding a few drops of clear liquid dish soap and warm tap water to a clean tub or bowl. Cover the Handset parts in the warm soapy water and soak for 5 minutes, shaking them periodically. Then rinse them thoroughly under warm running tap water.	Figure (Arikayce 10)
Be sure your Handset and Aerosol Head are clean before you disinfect. Boil the Handset parts, including the Aerosol Head, in a clean pot of distilled water for a full 5 minutes.	Figure (Arikayce 11)
Air dry on a lint-free towel. When fully dry, wrap up the parts in a lint-free towel for storage. You can put them together again just before taking your next treatment.	Figure (Arikayce 12)

Assembling Your Handset

a.

a1.

a2.

b.

Step 1: Wash your hands with soap and water, and dry them well.	Figure (Arikayce 13)
Step 2: Insert the Blue Valve. Open the Handset by gently pulling up on the tab of the Medication Reservoir. Insert the Blue Valve so that it rests on top of the Aerosol Chamber with the 2 valve flaps facing down.	Figure (Arikayce 14)
Step 3: Insert the Aerosol Head.
Grasp the Aerosol Head by the 2 flexible plastic tabs on each side. Be sure the text "For amikacin liposome inhalation suspension" is facing toward you and is at the top of the Aerosol Head. Squeeze the 2 flexible plastic tabs together while inserting the Aerosol Head into the Medication Reservoir. Close the Handset when you are done. Do not touch the silver part of the Aerosol Head at any time. After the Aerosol Head has been used 7 times, throw away (dispose of) and replace with a new one during the cleaning process.	Figure (Arikayce 15)
Step 4: Attach the Mouthpiece to your Handset with the Blue Flap facing up.	Figure (Arikayce 16)
Step 5: Finally, attach the Handset to the Controller.
Figure (Arikayce 17)

Taking ARIKAYCE

Your ARIKAYCE should be at room temperature before use to make sure that your Lamira Nebulizer System operates properly. Do not use other medicines in your Handset.

Bring ARIKAYCE to room temperature by removing it from the refrigerator at least 45 minutes before use. Do not use if your ARIKAYCE has been frozen.

Step 1: Get your ARIKAYCE ready. Place the Handset on a clean, flat, stable surface. Shake the ARIKAYCE vial well for at least 10 to 15 seconds, until the medicine looks the same throughout and well mixed.	Figure (Arikayce 18)
How to open the ARIKAYCE vial
Lift the orange cap from the vial.	Figure (Arikayce 19)
Grip the metal ring on top of the vial and pull it down gently until 1 side breaks away from the vial.	Figure (Arikayce 20)
Pull the metal band from around the vial top in a circular motion until it comes off completely.	Figure (Arikayce 21)
Carefully remove the rubber stopper.	Figure (Arikayce 22)
Open the vial and pour the ARIKAYCE into the Medication Reservoir. Attach the Medication Cap.	Figure (Arikayce 23)
Step 2: Sit in a relaxed, upright position.
Press and hold down on the On/Off button for a few seconds to turn the Lamira on. Mist will begin to flow.	Figure (Arikayce 24)
Step 3: Insert the Mouthpiece and take slow, deep breaths. Then, breathe normally in and out through the Mouthpiece until your treatment is complete. Treatment should take about 14 minutes but could take up to 20 minutes. Be sure to hold the Handset level throughout the treatment.	Figure (Arikayce 25)
Step 4: Check that your treatment has ended.
The Lamira will beep 2 times. The LED light will flash red 2 times. A Checkmark will briefly appear on the screen. The Controller will automatically shut off. Remove the Medication Cap and check the Medication Reservoir to make sure that no more than a few drops of ARIKAYCE remains. If ARIKAYCE remains, replace the Medication Cap, press the On/Off button, and complete your dose.	Figure (Arikayce 26)
For any issues you may have with your Lamira Nebulizer System, see Section K –Troubleshooting of the full Instructions for Use that comes with your medicine.

Cleaning your Lamira Handset and Aerosol Head After Use

• Rinse, clean, and disinfect handset right away after each use to reduce infection, illness, and contamination.
• Disinfect the Handset and Aerosol Head every day.
• See "Cleaning and Disinfecting" at the beginning of the Instructions for Use on how to properly clean and disinfect your handset and aerosol head.

This Instructions for Use has been approved by the U.S. Food and Drug Administration.
Issued: 09/2018

1-833-ARIKARE
(1-833-274-5273)

Contains 28 sterile unit-dose vials
Each vial contains amikacin 590 mg/8.4 mL
(equivalent to amikacin 623 mg/8.4 mL)

For oral inhalation only

ARIKAYCE^®
(amikacin liposome
inhalation suspension)
590 mg/8.4 mL vials

Limited Population*

Insmed^®

Attention Patients:
Store refrigerated until expiration date on vial. Do not freeze. Once expired,
discard any unused medicine. ARIKAYCE can be stored at room temperature
up to 25°C (77°F) for up to 4 weeks. Once at room temperature, any unused
medicine must be discarded at the end of 4 weeks.

*See the full prescribing information for ARIKAYCE
for information about the limited population

ARIKAYCE.COM

Principal Display Panel (8.4 mL Vial Carton)