Zinbryta

Overdose

No information provided.

Contraindications

ZINBRYTA is contraindicated in patients with:

• Pre-existing hepatic disease or hepatic impairment, including ALT or AST at least 2 times the ULN, because ZINBRYTA could exacerbate existing liver dysfunction.
• A history of autoimmune hepatitis or other autoimmune condition involving the liver.
• A history of hypersensitivity to daclizumab or any other components of the formulation. Use in such patients may result in anaphylaxis or life-threatening multi-organ hypersensitivity.

Undesirable effects

The following serious adverse reactions are described elsewhere in labeling:

• Hepatic Injury
• Immune-Mediated Disorders
• Acute Hypersensitivity
• Infections
• Depression and Suicide

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of ZINBRYTA cannot be directly compared with rates in clinical trials of other drugs and may not reflect the rates observed in practice.

In all controlled and uncontrolled trials performed in patients with relapsing multiple sclerosis, 2236 patients received ZINBRYTA for a total of 5214 person-years. Of these patients, 1576 received ZINBRYTA for at least 1 year, 1259 for at least 2 years, and 888 for at least 3 years. In the controlled studies, approximately 67% were female, 92% were Caucasian, and the mean age was 36 years at study entry.

In the active-controlled study (Study 1), 919 patients received ZINBRYTA (150 mg SQ, every 4 weeks) and 922 patients received AVONEX (interferon beta-1a 30 mcg IM, weekly) for a minimum of 2 years and up to 3 years, with 1952 person-years of exposure to ZINBRYTA; the median length of treatment was approximately 27 months. The adverse reactions from Study 1 are presented in Table 2.

In the placebo-controlled study (Study 2), 417 patients received ZINBRYTA with 423 person-years of exposure, of which 208 received 150 mg, and 204 received placebo every 4 weeks for up to 1 year; the median length of treatment was approximately 11 months. The adverse reactions from Study 2 are presented in Table 3.

The most common adverse reactions (incidence at least 5% and at least 2% higher incidence than comparator) that occurred in ZINBRYTA-treated patients were nasopharyngitis, upper respiratory tract infection, rash, influenza, dermatitis, oropharyngeal pain, bronchitis, eczema, and lymphadenopathy compared with AVONEX; and upper respiratory tract infection, depression, rash, pharyngitis, and increased alanine aminotransferase (ALT) compared with placebo.

The most common adverse reactions leading to discontinuation in up to 5% of patients treated with ZINBRYTA were hepatic events including elevations of serum transaminases and cutaneous events.

Patients were excluded from the clinical studies for abnormal laboratory values including hemoglobin, complete blood count with differential, serum transaminases, or serum creatinine. Patients were excluded if they had a history of seizure disorder or of having a seizure within 6 months of beginning the study, or suicidal ideation or severe depression within 3 months of beginning the study. During Study 1, concomitant use of ZINBRYTA with the hepatotoxic drugs valproic acid, carbamazepine, lamotrigine, phenytoin, isoniazid, and propylthiouracil was not permitted except in patients already receiving the drugs at the time of study entry.

In clinical studies, serum chemistry was evaluated at baseline and monthly. Hematology was evaluated at baseline, monthly for 6 months, and then every 3 months. Thyroid function was measured at baseline and every 6 months.

Table 2: Adverse Reactions in Adults with RMS with an Incidence at Least 2% More for ZINBRYTA 150 mg SQ Every 4 Weeks than AVONEX 30 mcg IM Once Weekly (Study 1)

Table 3: Adverse Reactions in Adults with RMS with an Incidence at Least 2% More for ZINBRYTA 150 mg SQ Every 4 Weeks than Placebo (Study 2)

Other clinically relevant adverse reactions observed at <2% difference included abnormal liver function test, decreased lymphocyte count, diarrhea, dry skin, erythema, folliculitis, increased hepatic enzyme, laryngitis, lymphadenitis, pneumonia, pruritus, psoriasis, respiratory tract infection, skin exfoliation, toxic skin eruption, and viral infection.

In Study 1, seizures occurred in 1% of ZINBRYTA-treated patients, compared with 0.3% of AVONEX-treated patients. In Study 2, no seizures occurred in either treatment group.

Types of immune-mediated or autoimmune conditions that were observed in 2 or more ZINBRYTA-treated patients include type I diabetes, celiac disease, autoimmune thyroiditis, immune hemolytic anemia, thrombocytopenia, pancreatitis, glomerulonephritis, sarcoidosis, rheumatoid arthritis, thyroiditis, and sialadenitis. The relationship of these events to ZINBRYTA is unknown.

In controlled studies, 1 ZINBRYTA-treated woman developed breast cancer compared with none in the AVONEX-treated group. Across all controlled and open-label clinical studies, 8 of 1485 (0.5%) ZINBRYTA-treated women developed breast cancer, and 1 of 751 (0.1%) ZINBRYTA-treated men developed breast cancer. It is unclear whether this represents an incidence increase over background rate.

As with all therapeutic proteins, there is potential for immunogenicity. In Study 1, patients were tested for anti-drug (daclizumab) antibodies at Week 4 and approximately every 3 months thereafter. Anti-drug antibodies and neutralizing antibodies were observed in 19% (175/913) and 8% (71/913) of patients, respectively. Anti-drug antibody responses were transient in 12% (110/913) of patients and persistent in 7% (65/913) of patients. Anti-drug and neutralizing antibody responses predominantly occurred during the first year of treatment, and their frequency declined with continued ZINBRYTA treatment.

In patients with neutralizing antibodies, daclizumab clearance was increased on average by 19%. There was no apparent correlation of anti-drug antibody or neutralizing antibody development to clinical response, adverse reactions, or pharmacodynamic profile of ZINBRYTA.

The detection of antibody formation is highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, comparison of the incidence of antibodies to daclizumab with the incidence of antibodies to other products may be misleading.

Therapeutic indications

ZINBRYTA is indicated for the treatment of adult patients with relapsing forms of multiple sclerosis (MS). Because of its safety profile, the use of ZINBRYTA should generally be reserved for patients who have had an inadequate response to two or more drugs indicated for the treatment of MS.

Pharmacodynamic properties

During ZINBRYTA treatment, mean cell counts for the major immune subsets (T, B, and NK cells) remained within normal ranges. Total lymphocyte, T and B cell counts decreased less than 10% from baseline during the first year of treatment. Total lymphocyte counts returned to baseline levels approximately 8-12 weeks after the last dose of ZINBRYTA (150 mg).

Pharmacokinetic properties

The pharmacokinetics of ZINBRYTA are similar for healthy volunteers and patients with multiple sclerosis (MS).

Following a single subcutaneous injection of ZINBRYTA, the maximum concentration occurred between 5 and 7 days. At steady state, daclizumab mean maximum serum concentration (Cmax) was 30 μg/mL, minimum serum concentration (Cmin) was 15 μg/mL, and area under the serum concentration-time curve over the dosing interval (AUCtau) values were approximately 640 μg-days per mL. The absolute bioavailability of 150 mg subcutaneous daclizumab was approximately 90%.

After administration of ZINBRYTA 150 mg subcutaneously every 4 weeks, serum daclizumab concentrations reached steady state by the fourth dose. Daclizumab accumulated to a level approximately 2.5-fold compared with a single dose.

The coefficient of variation between individual patients was approximately 35-40% for exposure (Cmax and AUC) and 27-51% for clearance and volume of distribution.

In multiple sclerosis patients taking 150 mg subcutaneous doses of ZINBRYTA every 4 weeks, the estimated steady-state volume of distribution of daclizumab was approximately 6.34 liters.

Because it is a protein, daclizumab is expected to undergo catabolism to peptides and amino acids in the same manner as endogenous IgG proteins without renal elimination. The estimated clearance of daclizumab is 0.212 liters per day with an elimination half-life of 21 days. Daclizumab clearance in patients who developed neutralizing antibodies was 19% higher.

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Fertility, pregnancy and lactation

There are no adequate data on the developmental risk associated with use of ZINBRYTA in pregnant women.

Administration of ZINBRYTA to monkeys during gestation resulted in embryofetal death and reduced fetal growth at maternal exposures greater than 30 times that expected clinically. 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. The background risk of major birth defects and miscarriage for the indicated population is unknown.

Animal Data

In monkeys administered ZINBRYTA (0, 10, 50, or 200 mg/kg) weekly by subcutaneous injection during organogenesis (gestation days 20 through 50), there was a decrease in fetal body weight and crown-rump length, and an increase in embryofetal death at the highest dose tested. Plasma exposure (AUC) at the no-effect dose of 50 mg/kg was approximately 30 times that in humans at the recommended human dose (RHD) of 150 mg.

In monkeys administered ZINBRYTA (50 mg/kg) weekly by subcutaneous injection from gestation day 50 to birth, there were no effects on pre-or postnatal development for up to 6 months after birth. Plasma exposure (AUC) at the administered dose was 55 times that in humans at the RHD.

Qualitative and quantitative composition

Injection: 150 mg/mL solution in a single-dose prefilled autoinjector.

Injection: 150 mg/mL solution in a single-dose prefilled syringe.

ZINBRYTA is a sterile, preservative-free, colorless to slightly yellow, clear to slightly opalescent solution.

ZINBRYTA injection is a sterile, colorless to slightly yellow, clear to slightly opalescent solution for subcutaneous injection. ZINBRYTA is provided in a 29 gauge, 0.5 inch staked (preaffixed) needle syringe with a rubber plunger stopper and rigid needle shield that are not made with natural rubber latex.

Two presentations are provided for ZINBRYTA injection, a single-dose prefilled autoinjector and a single-dose prefilled syringe.

The ZINBRYTA PEN is available in a carton containing a single-dose prefilled disposable autoinjector, which contains a syringe providing 1 mL of 150 mg/mL of daclizumab. The NDC is 0074-0034-01.

The ZINBRYTA prefilled syringe is available in a carton containing a single-dose prefilled disposable syringe providing 1 mL of 150 mg/mL of daclizumab. The NDC is 0074-0033-01.

Store in a refrigerator between 2°C to 8°C (36°F to 46°F) in the original carton to protect from light. Do not freeze or expose to temperatures above 30°C (86°F). Discard if frozen.

If refrigeration is unavailable, ZINBRYTA may be stored protected from light up to 30°C (86°F) for a period up to 30 days. Do not place ZINBRYTA back into the refrigerator after allowing it to warm to room temperature. Discard after 30 days without refrigeration.

Dispose in a sharps container or other hard plastic or metal sealable container. Always follow local regulations for disposal.

Manufactured by: Biogen Inc., Cambridge, MA 02142. Revised: May 2017

Special warnings and precautions for use

Included as part of the PRECAUTIONS section.

ZINBRYTA can cause life-threatening severe liver injury, including liver failure and autoimmune hepatitis. In controlled studies, serious drug-related hepatic injury occurred in 0.7% of ZINBRYTA-treated patients compared with 0.4% of AVONEX-treated patients (Study 1) and in 1.0% of ZINBRYTA-treated patients compared with no injury in placebo patients (Study 2). Across all clinical studies (controlled and open-label), serious drug-related hepatic injury occurred in 1% of ZINBRYTA-treated patients, with monthly monitoring of transaminases and total bilirubin. The incidence of discontinuation due to drug related hepatic injury was 5% in ZINBRYTA-treated patients and 4% in AVONEX-treated patients.

Across all clinical studies (controlled and open-label), 0.3% of ZINBRYTA-treated patients developed autoimmune hepatitis. One fatal case of autoimmune hepatitis occurred in a patient re-initiating ZINBRYTA after a planned 6 month treatment interruption period. This patient subsequently received two doses of ZINBRYTA in the presence of persisting alanine aminotransferase levels (ALT) more than 5 times the upper limit of normal (ULN).

The incidence of increases in hepatic transaminases was greater in patients taking ZINBRYTA than in those taking AVONEX or placebo. The incidence of ALT or AST elevations above 5 times the ULN was 6% in ZINBRYTA-treated patients compared with 3% in AVONEX-treated patients (Study 1) and 4% in ZINBRYTA-treated patients compared with 1% in patients on placebo (Study 2). Less than 1% of ZINBRYTA-treated patients had ALT or AST greater than 20 times the ULN. Elevations of hepatic transaminases of at least 3 times the ULN combined with elevated bilirubin at least 2 times the ULN and alkaline phosphatase less than 2 times the ULN occurred in 0.7% of ZINBRYTA-treated patients compared with 0.1% of AVONEX-treated patients. In clinical trials, serum transaminase elevations occurred during treatment and up to 4 months after the last dose of ZINBRYTA.

Prior to starting treatment with ZINBRYTA, obtain serum transaminases (ALT and AST) and total bilirubin levels.

Test transaminase levels and total bilirubin monthly and assess before the next dose of ZINBRYTA. Follow transaminase levels and total bilirubin monthly for 6 months after the last dose of ZINBRYTA.

Treatment modifications are recommended based on serum transaminase and total bilirubin values.

If a patient develops clinical signs or symptoms suggestive of hepatic dysfunction (e.g., unexplained nausea, vomiting, abdominal pain, fatigue, anorexia, or jaundice and/or dark urine), promptly measure serum transaminases and total bilirubin and interrupt or discontinue treatment with ZINBRYTA, as appropriate.

Patients with prolonged elevations of serum transaminases should be evaluated for other possible causes, such as infection, and a specialist should evaluate the patient. Discontinue ZINBRYTA if autoimmune hepatitis is suspected. Treatment of autoimmune hepatitis with systemic corticosteroids and other immunosuppressant drugs may be required. Some patients may need long-term immunosuppression.

Caution should be used when using hepatotoxic drugs, including non-prescription products, concomitantly with ZINBRYTA. Also, carefully consider the need for the use of herbal products or dietary supplements that can cause hepatotoxicity.

Treatment with ZINBRYTA increases the risk of immune-mediated disorders, including autoimmune disorders such as autoimmune hepatitis. Across all clinical studies (controlled and open-label), immune-mediated disorders occurred in 28% of patients on ZINBRYTA, the most common of which were skin reactions and lymphadenopathy. In the active-control study (Study 1), immune-mediated disorders were observed in 32% of ZINBRYTA-treated patients compared with 12% for AVONEX-treated patients. In Study 1, serious immune-mediated disorders were observed in 4% of patients treated with ZINBRYTA compared with less than 1% for AVONEX-treated patients. In the placebo-control study (Study 2), immune-mediated disorders were observed in 13% of ZINBRYTA-treated patients compared with 7% of placebo-treated patients. In Study 2, serious immune-mediated disorders were observed in 0.5% of ZINBRYTA-treated patients and in 0.5% of placebo-treated patients. In some cases, patients had concurrent or sequential occurring disorders while taking ZINBRYTA.

Some patients required invasive procedures for diagnosis (e.g., colonoscopy, liver biopsy, kidney biopsy, lung biopsy), hospitalization for fluid replacement or blood transfusion, or prolonged treatment with systemic corticosteroids or immunosuppressant drugs. Some of these events did not resolve after stopping ZINBRYTA during study follow-up.

Prescribers should be vigilant regarding emergent immune-mediated disorders. For suspected immune-mediated disorders, ensure adequate evaluation to confirm etiology or to exclude other causes. If a patient develops a serious immune-mediated disorder, consider stopping ZINBRYTA and refer the patient to an appropriate specialist for further evaluation and treatment.

ZINBRYTA causes skin reactions. In clinical trials, skin reactions occurred in 37% of ZINBRYTA-treated patients compared with 19% of AVONEX-treated patients (Study 1) and in 18% of ZINBRYTA-treated patients compared with 13% of patients on placebo (Study 2). Skin reactions occurred at any time during treatment with ZINBRYTA. Rashes occurred in 11% of ZINBRYTA-treated patients compared to 4% of AVONEX-treated patients, and in 7% of ZINBRYTA-treated patients compared to 3% of patients on placebo. Dermatitis occurred more frequently in ZINBRYTA-treated patients compared to AVONEX-treated patients or to patients on placebo, and eczema was observed more frequently in ZINBRYTA-treated patients compared to AVONEX-treated patients. Psoriatic conditions occurred in 2% of ZINBRYTA-treated patients compared with 0.3% of AVONEX-treated patients. Photosensitivity also occurred.

Serious skin reactions occurred in 2% of patients treated with ZINBRYTA compared with 0.1% of patients on AVONEX (Study 1) and in 1% of patients treated with ZINBRYTA compared with none treated with placebo (Study 2). One death resulted from infectious complications following a serious cutaneous reaction. In patients with a history of skin conditions, including eczema or psoriasis, use of ZINBRYTA may exacerbate those conditions. Treatment of skin reactions included treatment with topical or systemic steroids or immunosuppressant drugs, including tacrolimus. In clinical trials, discontinuation because of skin reactions was 4% in ZINBRYTA-treated patients. Rashes took a mean of 3 months to resolve, some were unresolved at the time of the last evaluation.

If a patient develops a serious diffuse or inflammatory rash, it is recommended that a dermatologist evaluate the patient before the next dose of ZINBRYTA. Discontinuation of ZINBRYTA may be appropriate.

ZINBRYTA increases the incidence of lymphadenopathy. In controlled studies, lymphadenopathy or lymphadenitis occurred in 6% of ZINBRYTA-treated patients compared with 1% of AVONEX-treated patients (Study 1) and in 2% of ZINBRYTA-treated patients compared with 1% of placebo-treated patients (Study 2). Onset of lymphadenopathy or lymphadenitis occurred throughout the treatment period. Serious events related to lymphadenopathy or lymphadenitis included infections, benign salivary neoplasm, skin reactions, thrombocytopenia, and interstitial lung changes. The majority of cases resolved with or without continued treatment with ZINBRYTA and took a mean of 3 months to resolve. Lymphadenopathy resulted in discontinuation in 0.6 % of ZINBRYTA-treated patients.

Some patients with lymphadenopathy underwent diagnostic biopsy. In the event that lymph node biopsy is considered, full diagnostic evaluation should be conducted by a specialist.

An increased incidence of serious colitis (less than 1%) was reported in patients treated with ZINBRYTA compared with none for patients treated with AVONEX or placebo in clinical trials. Consider referring patients who develop symptoms of colitis (e.g., abdominal pain, fever, prolonged diarrhea) to a specialist.

A wide variety of other immune-mediated disorders, some serious, have occurred infrequently with the use of ZINBRYTA. These include single organ or systemic multi-organ inflammatory reactions. Many events occurred in only one patient, and the relationship to ZINBRYTA is unknown. Some required treatment with systemic corticosteroids. Some required several months for resolution after the last dose of ZINBRYTA.

For suspected immune-mediated disorders, ensure adequate evaluation to confirm etiology or to exclude other causes. If a patient develops a serious immune-mediated disorder, consider stopping ZINBRYTA and refer the patient to an appropriate specialist for further evaluation and treatment.

ZINBRYTA is available only through a restricted program under a Risk Evaluation and Mitigation Strategy (REMS) called the ZINBRYTA REMS Program, because of the risks of hepatic injury including autoimmune hepatitis, and other immune-mediated disorders.

Notable requirements of the ZINBRYTA REMS Program include the following:

• Prescribers must be certified with the program by enrolling and completing training.
• Patients must enroll in the program and comply with ongoing monitoring requirements.
• Pharmacies must be certified with the program and must only dispense to patients who are authorized to receive ZINBRYTA.

Further information, including a list of qualified pharmacies/distributors, is available at 1-800-456-2255

ZINBRYTA can cause anaphylaxis, angioedema, and urticaria after the first dose or at any time during treatment. Discontinue and do not re-start ZINBRYTA if anaphylaxis or other allergic reactions occur.

ZINBRYTA increases the risk for infections. In controlled trials, infections occurred in 65% of ZINBRYTA-treated patients compared with 57% of AVONEX-treated patients (Study 1) and in 50% of ZINBRYTA-treated patients compared with 44% of patients taking placebo (Study 2). Serious infections occurred in 4% of ZINBRYTA-treated patients compared with 2% of AVONEX-treated patients (Study 1) and in 3% of ZINBRYTA-treated patients compared with none on placebo (Study 2).

The most common types of infections observed were upper respiratory tract infections, urinary tract infections and viral infections.

In clinical trials, cases of tuberculosis occurred in countries where tuberculosis is endemic. Evaluate high-risk patients for tuberculosis infection prior to initiating treatment with ZINBRYTA. For patients testing positive for tuberculosis, treat by standard medical practice prior to therapy with ZINBRYTA.

Avoid initiating ZINBRYTA in patients with severe active infection until the infection is fully controlled. If serious infection develops, consider withholding treatment with ZINBRYTA until the infection resolves.

The safety of immunization with live viral vaccines during treatment with ZINBRYTA has not been studied. Vaccination with live vaccines is not recommended during treatment and up to 4 months after discontinuation of ZINBRYTA.

Depression-related events occurred more frequently in patients receiving ZINBRYTA than in patients receiving AVONEX or placebo. In controlled trials, depression-related events occurred in 10% of ZINBRYTA-treated patients compared with 8% of AVONEX-treated patients (Study 1) and in 7% of ZINBRYTA-treated patients compared with 2% of patients taking placebo (Study 2). In Study 1, serious events related to depression, including suicidal ideation or suicide attempt, occurred in 0.4% of ZINBRYTA-treated patients and in 0.7% of AVONEX-treated patients. None occurred in Study 2 (placebo-controlled).

Administer ZINBRYTA with caution to patients with previous or current depressive disorders. Advise patients and/or caregivers to immediately report any symptoms of new or worsening depression and/or suicidal ideation to their healthcare provider.

If a patient develops severe depression and/or suicidal ideation, consider discontinuation of ZINBRYTA.

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

Inform the patient of the risk of severe hepatic injury associated with ZINBRYTA. Advise patients of the symptoms of hepatic dysfunction, and instruct patients to report such symptoms to their health care provider immediately.

Discuss with the patient the importance of measuring hepatic laboratory values and having them evaluated by the health care provider monthly while taking ZINBRYTA and for up to 6 months after the last dose of ZINBRYTA.

Discuss with the patient the risk of concomitant use of other hepatotoxic medications, over the counter medications, herbal products, or dietary supplements.

Inform the patient that they will be given a ZINBRYTA Patient Wallet Card that they should carry with them at all times. This card describes symptoms which, if experienced, should prompt the patient to immediately seek medical evaluation.

Advise the patient to show the ZINBRYTA Patient Wallet Card to other treating health care providers.

Advise patients that ZINBRYTA can cause their immune system to attack healthy cells in their body and that this can affect any organ system.

Skin Reactions

Advise patients that ZINBRYTA can cause dermatologic reactions that can range from mild rashes to serious reactions that could require treatment with other medications or result in hospitalization. Instruct patients to seek immediate medical attention if dermatologic reactions occur.

Lymphadenopathy

Inform patients that ZINBRYTA may cause lymphadenopathy that can range from mild events that can resolve on their own to serious lymphadenopathy that may require invasive procedures for diagnosis. Inform patients of the symptoms and instruct patients to contact their health care provider if they develop lymphadenopathy.

Non-Infectious Colitis

Inform patients that ZINBRYTA may cause gastrointestinal reactions that may be serious and could require treatment. Advise patients of the symptoms of colitis and instruct patients to promptly contact their healthcare provider if they experience these symptoms.

ZINBRYTA is available only through a restricted program called the ZINBRYTA REMS Program. Inform the patient of the following notable requirements:

• Patients must enroll in the program and comply with ongoing monitoring requirements.

ZINBRYTA is available only from certified pharmacies participating in the program. Therefore, provide patients with the telephone number and website for information on how to obtain the product.

Advise patients of the symptoms of allergic reactions and anaphylaxis, and instruct patients to seek immediate medical attention if these symptoms occur.

Inform patients that they may be more likely to get infections when taking ZINBRYTA, and that they should contact their health care provider if they develop symptoms of infection.

Advise patients of the symptoms of depression and suicidal ideation as they have occurred with the use of ZINBRYTA and instruct patients to report symptoms of depression or thoughts of suicide to their health care provider immediately.

Provide appropriate instruction for methods of self-injection, including careful review of the ZINBRYTA Instructions for Use. Instruct the patient in the use of aseptic technique when administering ZINBRYTA.

Inform the patient that a health care provider should show them or their caregiver how to inject ZINBRYTA before administering the first dose. Tell the patient not to re-use needles, pens or syringes, and instruct the patient on safe disposal procedures. Inform the patient to dispose of used needles, pens and syringes in a puncture-resistant container.

The carcinogenic potential of ZINBRYTA has not been assessed.

Genetic toxicology studies of ZINBRYTA have not been conducted.

ZINBRYTA (0, 10, 50, or 200 mg/kg) administered biweekly by subcutaneous injection to monkeys had no adverse effect on male (sperm motility, concentration, and morphology or testosterone levels) or female (estrus cycle length or estradiol/progesterone patterns) fertility endpoints. At the highest dose tested, plasma exposures (AUC) in males and females were 100 and 85 times, respectively, that at the recommended human dose (RHD) of 150 mg.

There are no adequate data on the developmental risk associated with use of ZINBRYTA in pregnant women.

Administration of ZINBRYTA to monkeys during gestation resulted in embryofetal death and reduced fetal growth at maternal exposures greater than 30 times that expected clinically. 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. The background risk of major birth defects and miscarriage for the indicated population is unknown.

Animal Data

In monkeys administered ZINBRYTA (0, 10, 50, or 200 mg/kg) weekly by subcutaneous injection during organogenesis (gestation days 20 through 50), there was a decrease in fetal body weight and crown-rump length, and an increase in embryofetal death at the highest dose tested. Plasma exposure (AUC) at the no-effect dose of 50 mg/kg was approximately 30 times that in humans at the recommended human dose (RHD) of 150 mg.

In monkeys administered ZINBRYTA (50 mg/kg) weekly by subcutaneous injection from gestation day 50 to birth, there were no effects on pre-or postnatal development for up to 6 months after birth. Plasma exposure (AUC) at the administered dose was 55 times that in humans at the RHD.

There are no data on the presence of daclizumab in human milk, the effects on the breastfed child, or the effects of the drug on milk production. Daclizumab was excreted in the milk of ZINBRYTA-treated monkeys.

The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for ZINBRYTA and any potential adverse effects on the breastfed child from ZINBRYTA or from the underlying maternal condition.

Safety and effectiveness of ZINBRYTA in patients less than 17 years old have not been established. Use of ZINBRYTA is not recommended in pediatric patients due to the risks of hepatic injury and immune-mediated disorders.

Clinical studies of ZINBRYTA did not include a sufficient number of patients aged 65 and over to determine whether they respond differently than younger patients.

Clinical trials did not include patients with ALT or AST more than two times the ULN. Patients with signs and symptoms of hepatic impairment may be at increased risk for hepatotoxicity from ZINBRYTA.

Dosage (Posology) and method of administration

The recommended dosage of ZINBRYTA is 150 milligrams injected subcutaneously once monthly.

Instruct patients to inject a missed dose as soon as possible but no more than two weeks late. After two weeks, skip the missed dose and take the next dose on schedule. Administer only one dose at a time.

ZINBRYTA is for subcutaneous use only.

Train patients in the proper technique for self-administering subcutaneous injections using the prefilled autoinjector or syringe.

Thirty minutes prior to injection, remove ZINBRYTA from the refrigerator to allow the drug to warm to room temperature. Do not use external heat sources such as hot water to warm ZINBRYTA. Do not place ZINBRYTA back into the refrigerator after allowing it to warm to room temperature.

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. ZINBRYTA is a colorless to slightly yellow, clear to slightly opalescent solution. Do not use ZINBRYTA if it is cloudy or there are visible particles.

Sites for injection include the thigh, abdomen, and back of the upper arm.

Use each prefilled autoinjector or syringe one time and then place in a sharps disposal container for disposal according to community guidelines.

Prior to initiating ZINBRYTA, obtain and evaluate the following:

• Serum transaminases (alanine aminotransferase (ALT) and aspartate aminotransferase  (AST)) and total bilirubin levels. Initiation of ZINBRYTA is contraindicated in patients with pre-existing hepatic disease or hepatic impairment including ALT or AST at least 2 times the  ULN.

• Evaluate patients at high risk for tuberculosis infection prior to initiating treatment with ZINBRYTA. For patients testing positive for tuberculosis, treat tuberculosis by standard medical practice prior to therapy with ZINBRYTA.
• Avoid initiating ZINBRYTA in patients with tuberculosis or other severe active infection.
• Prior to initiation of ZINBRYTA, screen patients for Hepatitis B and C. ZINBRYTA is contraindicated in patients with pre-existing hepatic disease.

Because vaccination with live vaccines is not recommended during treatment and up to 4 months after discontinuation of treatment, consider any necessary immunization with live vaccines prior to treatment with ZINBRYTA.

Conduct the following laboratory tests at periodic intervals to monitor for early signs of potentially serious adverse effects:

Test transaminase levels and total bilirubin monthly and assess before the next dose of ZINBRYTA. Follow transaminase levels and total bilirubin monthly for 6 months after the last dose of ZINBRYTA. As shown in Table 1, interruption or discontinuation of ZINBRYTA therapy is recommended for management of certain liver test abnormalities.

Table 1: ZINBRYTA Treatment Modification for Liver Test Abnormalities

Interaction with other medicinal products and other forms of interaction

The following serious adverse reactions are described elsewhere in labeling:

• Hepatic Injury
• Immune-Mediated Disorders
• Acute Hypersensitivity
• Infections
• Depression and Suicide

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of ZINBRYTA cannot be directly compared with rates in clinical trials of other drugs and may not reflect the rates observed in practice.

In all controlled and uncontrolled trials performed in patients with relapsing multiple sclerosis, 2236 patients received ZINBRYTA for a total of 5214 person-years. Of these patients, 1576 received ZINBRYTA for at least 1 year, 1259 for at least 2 years, and 888 for at least 3 years. In the controlled studies, approximately 67% were female, 92% were Caucasian, and the mean age was 36 years at study entry.

In the active-controlled study (Study 1), 919 patients received ZINBRYTA (150 mg SQ, every 4 weeks) and 922 patients received AVONEX (interferon beta-1a 30 mcg IM, weekly) for a minimum of 2 years and up to 3 years, with 1952 person-years of exposure to ZINBRYTA; the median length of treatment was approximately 27 months. The adverse reactions from Study 1 are presented in Table 2.

In the placebo-controlled study (Study 2), 417 patients received ZINBRYTA with 423 person-years of exposure, of which 208 received 150 mg, and 204 received placebo every 4 weeks for up to 1 year; the median length of treatment was approximately 11 months. The adverse reactions from Study 2 are presented in Table 3.

The most common adverse reactions (incidence at least 5% and at least 2% higher incidence than comparator) that occurred in ZINBRYTA-treated patients were nasopharyngitis, upper respiratory tract infection, rash, influenza, dermatitis, oropharyngeal pain, bronchitis, eczema, and lymphadenopathy compared with AVONEX; and upper respiratory tract infection, depression, rash, pharyngitis, and increased alanine aminotransferase (ALT) compared with placebo.

The most common adverse reactions leading to discontinuation in up to 5% of patients treated with ZINBRYTA were hepatic events including elevations of serum transaminases and cutaneous events.

Patients were excluded from the clinical studies for abnormal laboratory values including hemoglobin, complete blood count with differential, serum transaminases, or serum creatinine. Patients were excluded if they had a history of seizure disorder or of having a seizure within 6 months of beginning the study, or suicidal ideation or severe depression within 3 months of beginning the study. During Study 1, concomitant use of ZINBRYTA with the hepatotoxic drugs valproic acid, carbamazepine, lamotrigine, phenytoin, isoniazid, and propylthiouracil was not permitted except in patients already receiving the drugs at the time of study entry.

In clinical studies, serum chemistry was evaluated at baseline and monthly. Hematology was evaluated at baseline, monthly for 6 months, and then every 3 months. Thyroid function was measured at baseline and every 6 months.

Table 2: Adverse Reactions in Adults with RMS with an Incidence at Least 2% More for ZINBRYTA 150 mg SQ Every 4 Weeks than AVONEX 30 mcg IM Once Weekly (Study 1)

Table 3: Adverse Reactions in Adults with RMS with an Incidence at Least 2% More for ZINBRYTA 150 mg SQ Every 4 Weeks than Placebo (Study 2)

Other clinically relevant adverse reactions observed at <2% difference included abnormal liver function test, decreased lymphocyte count, diarrhea, dry skin, erythema, folliculitis, increased hepatic enzyme, laryngitis, lymphadenitis, pneumonia, pruritus, psoriasis, respiratory tract infection, skin exfoliation, toxic skin eruption, and viral infection.

In Study 1, seizures occurred in 1% of ZINBRYTA-treated patients, compared with 0.3% of AVONEX-treated patients. In Study 2, no seizures occurred in either treatment group.

Types of immune-mediated or autoimmune conditions that were observed in 2 or more ZINBRYTA-treated patients include type I diabetes, celiac disease, autoimmune thyroiditis, immune hemolytic anemia, thrombocytopenia, pancreatitis, glomerulonephritis, sarcoidosis, rheumatoid arthritis, thyroiditis, and sialadenitis. The relationship of these events to ZINBRYTA is unknown.

In controlled studies, 1 ZINBRYTA-treated woman developed breast cancer compared with none in the AVONEX-treated group. Across all controlled and open-label clinical studies, 8 of 1485 (0.5%) ZINBRYTA-treated women developed breast cancer, and 1 of 751 (0.1%) ZINBRYTA-treated men developed breast cancer. It is unclear whether this represents an incidence increase over background rate.

As with all therapeutic proteins, there is potential for immunogenicity. In Study 1, patients were tested for anti-drug (daclizumab) antibodies at Week 4 and approximately every 3 months thereafter. Anti-drug antibodies and neutralizing antibodies were observed in 19% (175/913) and 8% (71/913) of patients, respectively. Anti-drug antibody responses were transient in 12% (110/913) of patients and persistent in 7% (65/913) of patients. Anti-drug and neutralizing antibody responses predominantly occurred during the first year of treatment, and their frequency declined with continued ZINBRYTA treatment.

In patients with neutralizing antibodies, daclizumab clearance was increased on average by 19%. There was no apparent correlation of anti-drug antibody or neutralizing antibody development to clinical response, adverse reactions, or pharmacodynamic profile of ZINBRYTA.

The detection of antibody formation is highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, comparison of the incidence of antibodies to daclizumab with the incidence of antibodies to other products may be misleading.

Caution should be used when using hepatotoxic drugs, including non-prescription products, concomitantly with ZINBRYTA. Carefully consider the need for the use of herbal products or dietary supplements that can cause hepatotoxicity.