Tamiflu (oseltamivir phosphate 45 mg) Dailymed

3dosage Forms And Strengths

Capsules: 30 mg, 45 mg, 75 mg

• 30-mg capsules (30 mg free base equivalent of the phosphate salt): light yellow hard gelatin capsules. "ROCHE" is printed in blue ink on the light yellow body and "30 mg" is printed in blue ink on the light yellow cap.
• 45-mg capsules (45 mg free base equivalent of the phosphate salt): grey hard gelatin capsules. "ROCHE" is printed in blue ink on the grey body and "45 mg" is printed in blue ink on the grey cap.
• 75-mg capsules (75 mg free base equivalent of the phosphate salt): grey/light yellow hard gelatin capsules. "ROCHE" is printed in blue ink on the grey body and "75 mg" is printed in blue ink on the light yellow cap.

For Oral Suspension: 6 mg/mL (final concentration when constituted)

• White powder blend for constitution to a white tutti-frutti–flavored suspension. After constitution, each bottle delivers a usable volume of 60 mL of oral suspension equivalent to 360 mg oseltamivir base (6 mg/mL).

• Capsules: 30 mg, 45 mg, 75 mg (3)
• Powder for oral suspension: 360 mg oseltamivir base (constituted to a final concentration of 6 mg/mL) (3)

4contraindications

TAMIFLU is contraindicated in patients with known serious hypersensitivity to oseltamivir or any component of the product. Severe allergic reactions have included anaphylaxis and serious skin reactions including toxic epidermal necrolysis, Stevens-Johnson Syndrome, and erythema multiforme [seeWarnings and Precautions (5.1)].


Patients with known serious hypersensitivity to oseltamivir or any of the components of TAMIFLU (4)

5warnings And Precautions

• Serious skin/hypersensitivity reactions: Discontinue TAMIFLU and initiate appropriate treatment if allergic-like reactions occur or are suspected. (5.1)
• Neuropsychiatric events: Patients with influenza, including those receiving TAMIFLU, particularly pediatric patients, may be at an increased risk of confusion or abnormal behavior early in their illness. Monitor for signs of abnormal behavior. (5.2)

5.1Serious Skin/Hypersensitivity Reactions

Cases of anaphylaxis and serious skin reactions including toxic epidermal necrolysis, Stevens-Johnson Syndrome, and erythema multiforme have been reported in postmarketing experience with TAMIFLU. TAMIFLU should be stopped and appropriate treatment instituted if an allergic-like reaction occurs or is suspected.

5.2Neuropsychiatric Events

Influenza can be associated with a variety of neurologic and behavioral symptoms that can include events such as hallucinations, delirium, and abnormal behavior, in some cases resulting in fatal outcomes. These events may occur in the setting of encephalitis or encephalopathy but can occur without obvious severe disease.

There have been postmarketing reports (mostly from Japan) of delirium and abnormal behavior leading to injury, and in some cases resulting in fatal outcomes, in patients with influenza who were receiving TAMIFLU. Because these events were reported voluntarily during clinical practice, estimates of frequency cannot be made but they appear to be uncommon based on TAMIFLU usage data. These events were reported primarily among pediatric patients and often had an abrupt onset and rapid resolution. The contribution of TAMIFLU to these events has not been established. Closely monitor patients with influenza for signs of abnormal behavior. If neuropsychiatric symptoms occur, evaluate the risks and benefits of continuing treatment for each patient.

5.3Bacterial Infections

Serious bacterial infections may begin with influenza-like symptoms or may coexist with or occur as complications during the course of influenza. TAMIFLU has not been shown to prevent such complications.

5.4Limitations of Populations Studied

Efficacy of TAMIFLU in the treatment of influenza in patients with chronic cardiac disease and/or respiratory disease has not been established. No difference in the incidence of complications was observed between the treatment and placebo groups in this population. No information is available regarding treatment of influenza in patients with any medical condition sufficiently severe or unstable to be considered at imminent risk of requiring hospitalization.

Efficacy of TAMIFLU for treatment or prophylaxis of influenza has not been established in immunocompromised patients.

6adverse Reactions

The following serious adverse reactions are discussed below and elsewhere in the labeling:

• Serious skin and hypersensitivity reactions [seeWarnings and Precautions (5.1)]
• Neuropsychiatric events [seeWarnings and Precautions (5.2)]

The most common adverse reactions are nausea and vomiting.


Most common adverse reactions (>1% and more common than with placebo):

• Treatment studies – Nausea, vomiting (6.1)
• Prophylaxis studies – Nausea, vomiting, diarrhea, abdominal pain (6.1)

To report SUSPECTED ADVERSE REACTIONS, contact Genentech at 1-888-835-2555 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch

6.1Clinical 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.

Treatment Studies in Adult Subjects

A total of 1171 subjects who participated in adult controlled clinical trials for the treatment of influenza were treated with TAMIFLU. The most frequently reported adverse events in these studies were nausea and vomiting. These events were generally of mild to moderate severity and usually occurred on the first 2 days of administration. Less than 1% of subjects discontinued prematurely from clinical trials due to nausea and vomiting.

Adverse events that occurred with an incidence of ≥1% in 1440 subjects taking placebo or TAMIFLU 75 mg twice daily in adult treatment studies are shown inTable 4. This summary includes 945 healthy young adults and 495 "at risk" subjects (elderly patients and patients with chronic cardiac or respiratory disease). Those events reported numerically more frequently in subjects taking TAMIFLU compared with placebo were nausea, vomiting, bronchitis, insomnia, and vertigo.

Prophylaxis Studies in Adult Subjects

A total of 4187 subjects (adolescents, healthy adults, and elderly) participated in prophylaxis studies, of whom 1790 received the recommended dose of 75 mg once daily for up to 6 weeks. Adverse events were qualitatively very similar to those seen in the treatment studies, despite a longer duration of dosing (seeTable 4). Events reported more frequently in subjects receiving TAMIFLU compared to subjects receiving placebo in prophylaxis studies, and more commonly than in treatment studies, were aches and pains, rhinorrhea, dyspepsia and upper respiratory tract infections. However, the difference in incidence between TAMIFLU and placebo for these events was less than 1%. There were no clinically relevant differences in the safety profile of the 942 elderly subjects who received TAMIFLU or placebo, compared with the younger population.

Table 4 Most Frequent Adverse Events in Studies in Naturally Acquired Influenza in Subjects 13 Years of Age and Older

	Treatment				Prophylaxis
Adverse Event	Placebo N=716		TAMIFLU75 mg twice dailyN=724		Placebo/No Prophylaxis N=1688		TAMIFLU75 mg once dailyN=1790
Nausea (without vomiting)	40	(6%)	72	(10%)	56	(3%)	129	(7%)
Vomiting	21	(3%)	68	(9%)	16	(1%)	39	(2%)
Diarrhea	70	(10%)	48	(7%)	40	(2%)	50	(3%)
Bronchitis	15	(2%)	17	(2%)	22	(1%)	15	(1%)
Abdominal pain	16	(2%)	16	(2%)	25	(1%)	37	(2%)
Dizziness	25	(3%)	15	(2%)	21	(1%)	24	(1%)
Headache	14	(2%)	13	(2%)	306	(18%)	326	(18%)
Cough	12	(2%)	9	(1%)	119	(7%)	94	(5%)
Insomnia	6	(1%)	8	(1%)	15	(1%)	22	(1%)
Vertigo	4	(1%)	7	(1%)	4	(<1%)	4	(<1%)
Fatigue	7	(1%)	7	(1%)	163	(10%)	139	(8%)

Additional adverse events occurring in <1% of patients receiving TAMIFLU for treatment included unstable angina, anemia, pseudomembranous colitis, humerus fracture, pneumonia, pyrexia, and peritonsillar abscess.

Treatment Studies in Pediatric Subjects

A total of 1032 pediatric subjects aged 1 to 12 years (including 698 otherwise healthy pediatric subjects aged 1 to 12 years and 334 asthmatic pediatric subjects aged 6 to 12 years) participated in controlled clinical trials of TAMIFLU given for the treatment of influenza. A total of 515 pediatric subjects received treatment with TAMIFLU for oral suspension.

Adverse events occurring in ≥1% of pediatric subjects receiving TAMIFLU treatment are uled inTable 5. The most frequently reported adverse event was vomiting. Other events reported more frequently by pediatric subjects treated with TAMIFLU included abdominal pain, epistaxis, ear disorder, and conjunctivitis. These events generally occurred once and resolved despite continued dosing resulting in discontinuation of drug in 8 out of 515 (2%) cases.

The adverse event profile in adolescents is similar to that described for adult subjects and pediatric subjects aged 1 to 12 years.

Prophylaxis Studies in Pediatric Subjects

Pediatric subjects aged 1 to 12 years participated in a postexposure prophylaxis study in households, both as index cases (n=134) and as contacts (n=222). Gastrointestinal events were the most frequent, particularly vomiting. In a separate 6-week, uncontrolled, pediatric seasonal prophylaxis study (n=49), the adverse events noted were consistent with those previously observed (seeTable 5).

Table 5 Most Frequent Adverse Events Occurring in Children Aged 1 to 12 Years in Studies in Naturally Acquired Influenza

	Treatment Trials				Household Prophylaxis Trial
Adverse Event	Placebo N=517		TAMIFLU2 mg/kg twice dailyN=515		No ProphylaxisUnit dose = age-based dosing of 30 mg, 45 mg, or 60 mg N=87		Prophylaxis with TAMIFLU once daily N=99
Vomiting	48	(9%)	77	(15%)	2	(2%)	10	(10%)
Diarrhea	55	(11%)	49	(10%)	-		1	(1%)
Otitis media	58	(11%)	45	(9%)	2	(2%)	2	(2%)
Abdominal pain	20	(4%)	24	(5%)	-		3	(3%)
Asthma (including aggravated)	19	(4%)	18	(3%)	1	(1%)	1	(1%)
Nausea	22	(4%)	17	(3%)	1	(1%)	4	(4%)
Epistaxis	13	(3%)	16	(3%)	-		1	(1%)
Pneumonia	17	(3%)	10	(2%)	2	(2%)	-
Ear disorder	6	(1%)	9	(2%)	-		-
Sinusitis	13	(3%)	9	(2%)	-		-
Bronchitis	11	(2%)	8	(2%)	2	(2%)	-
Conjunctivitis	2	(<1%)	5	(1%)	-		-
Dermatitis	10	(2%)	5	(1%)	-		-
Lymphadenopathy	8	(2%)	5	(1%)	-		-
Tympanic membrane disorder	6	(1%)	5	(1%)	-		-

Prophylaxis Study in Immunocompromised Subjects

In a 12-week seasonal prophylaxis study in 475 immunocompromised subjects, including 18 pediatric subjects 1 to 12 years of age, the safety profile in the 238 subjects receiving TAMIFLU was consistent with that previously observed in other TAMIFLU prophylaxis clinical trials.

6.2Postmarketing Experience

The following adverse reactions have been identified during postapproval use of TAMIFLU. Because these reactions are reported voluntarily from a population of uncertain size, it is not possible to reliably estimate their frequency or establish a causal relationship to TAMIFLU exposure.

Body as a Whole: Swelling of the face or tongue, allergy, anaphylactic/anaphylactoid reactions, hypothermia

Dermatologic: Rash, dermatitis, urticaria, eczema, toxic epidermal necrolysis, Stevens-Johnson Syndrome, erythema multiforme [seeWarnings and Precautions (5.1)]

Digestive: Hepatitis, liver function tests abnormal

Cardiac: Arrhythmia

Gastrointestinal disorders: Gastrointestinal bleeding, hemorrhagic colitis

Neurologic: Seizure

Metabolic: Aggravation of diabetes

Psychiatric: Abnormal behavior, delirium, including symptoms such as hallucinations, agitation, anxiety, altered level of consciousness, confusion, nightmares, delusions [seeWarnings and Precautions (5.2)]

7drug Interactions

Live attenuated influenza vaccine, intranasal (7):

• Do not administer until 48 hours following cessation of TAMIFLU.
• Do not administer TAMIFLU until 2 weeks following administration of the live attenuated influenza vaccine, unless medically indicated.

Influenza Vaccines

The concurrent use of TAMIFLU with live attenuated influenza vaccine (LAIV) intranasal has not been evaluated. However, because of the potential for interference between these products, LAIV should not be administered within 2 weeks before or 48 hours after administration of TAMIFLU, unless medically indicated. The concern about possible interference arises from the potential for antiviral drugs to inhibit replication of live vaccine virus. Trivalent inactivated influenza vaccine can be administered at any time relative to use of TAMIFLU.

Overall Drug Interaction Profile for Oseltamivir

Information derived from pharmacology and pharmacokinetic studies of oseltamivir suggests that clinically significant drug interactions are unlikely.

Oseltamivir is extensively converted to oseltamivir carboxylate by esterases, located predominantly in the liver. Drug interactions involving competition for esterases have not been extensively reported in literature. Low protein binding of oseltamivir and oseltamivir carboxylate suggests that the probability of drug displacement interactions is low.

In vitro studies demonstrate that neither oseltamivir nor oseltamivir carboxylate is a good substrate for P450 mixed-function oxidases or for glucuronyl transferases.

Clinically important drug interactions involving competition for renal tubular secretion are unlikely due to the known safety margin for most of these drugs, the elimination characteristics of oseltamivir carboxylate (glomerular filtration and anionic tubular secretion) and the excretion capacity of these pathways. Coadministration of probenecid results in an approximate two-fold increase in exposure to oseltamivir carboxylate due to a decrease in active anionic tubular secretion in the kidney. However, due to the safety margin of oseltamivir carboxylate, no dose adjustments are required when coadministering with probenecid.

No pharmacokinetic interactions have been observed when coadministering oseltamivir with amoxicillin, acetaminophen, aspirin, cimetidine, antacids (magnesium and aluminum hydroxides and calcium carbonates), or warfarin.

8use In Specific Populations

• Pregnancy: No data in pregnant women. Use only if clearly needed. (8.1)
• Nursing mothers: Caution should be exercised when administered to a nursing woman. (8.3).
• Pediatric use: Safety and efficacy not established in patients less than 1 year old. (8.4)

8.1Pregnancy

TERATOGENIC EFFECTS SECTION

Pregnancy Category C

There are insufficient human data upon which to base an evaluation of risk of TAMIFLU to the pregnant woman or developing fetus. Studies for effects on embryo-fetal development were conducted in rats (50, 250, and 1500 mg/kg/day) and rabbits (50, 150, and 500 mg/kg/day) by the oral route. Relative exposures at these doses were, respectively, 2, 13, and 100 times human exposure in the rat and 4, 8, and 50 times human exposure in the rabbit. Pharmacokinetic studies indicated that fetal exposure was seen in both species. In the rat study, minimal maternal toxicity was reported in the 1500 mg/kg/day group. In the rabbit study, slight and marked maternal toxicities were observed, respectively, in the 150 and 500 mg/kg/day groups. There was a dose-dependent increase in the incidence rates of a variety of minor skeletal abnormalities and variants in the exposed offspring in these studies. However, the individual incidence rate of each skeletal abnormality or variant remained within the background rates of occurrence in the species studied.

Because animal reproductive studies may not be predictive of human response and there are no adequate and well-controlled studies in pregnant women, TAMIFLU should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

8.3Nursing Mothers

In lactating rats, oseltamivir and oseltamivir carboxylate are excreted in the milk. It is not known whether oseltamivir or oseltamivir carboxylate is excreted in human milk. TAMIFLU should, therefore, be used only if the potential benefit for the lactating mother justifies the potential risk to the breast-fed infant.

8.4Pediatric Use

The safety and efficacy of TAMIFLU in pediatric patients younger than 1 year of age have not been studied. TAMIFLU is not indicated for either treatment or prophylaxis of influenza in pediatric patients younger than 1 year of age because of the unknown clinical significance of nonclinical animal toxicology data for human infants [seeNonclinical Toxicology (13.2)].

8.5Geriatric Use

Of the total number of subjects in clinical studies of TAMIFLU for the treatment of influenza, 19% were 65 and over, while 7% were 75 and over. Of the total number of patients in clinical studies of TAMIFLU for the prophylaxis of influenza, 25% were 65 and over, while 18% were 75 and over. No overall differences in safety or effectiveness were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and younger subjects.

The safety of TAMIFLU in geriatric subjects has been established in clinical studies that enrolled 741 subjects (374 received placebo and 362 received TAMIFLU). Some seasonal variability was noted in the clinical efficacy outcomes [seeClinical Studies (14.1)].

Safety and efficacy have been demonstrated in elderly residents of nursing homes who took TAMIFLU for up to 42 days for the prevention of influenza. Many of these individuals had cardiac and/or respiratory disease, and most had received vaccine that season [seeClinical Studies (14.2)].

8.6Renal Impairment

Dose adjustment is recommended for patients with a serum creatinine clearance between 10 and 30 mL/min [seeDosage and Administration (2.4)andClinical Pharmacology (12.3)]. No recommended dosing regimens are available for patients with end-stage renal disease undergoing routine hemodialysis or continuous peritoneal dialysis treatment.

8.7Hepatic Impairment

No dosage adjustment is required in patients with mild to moderate hepatic impairment. The safety and pharmacokinetics in patients with severe hepatic impairment have not been evaluated [seeDosage and Administration (2.5)andClinical Pharmacology (12.3)].

10overdosage

At present, there has been no experience with overdose. Single doses of up to 1000 mg of TAMIFLU have been associated with nausea and/or vomiting.

11description

TAMIFLU (oseltamivir phosphate) is available as capsules containing 30 mg, 45 mg, or 75 mg oseltamivir for oral use, in the form of oseltamivir phosphate, and as a powder for oral suspension, which when constituted with water as directed contains 6 mg/mL oseltamivir base. In addition to the active ingredient, each capsule contains pregelatinized starch, talc, povidone K30, croscarmellose sodium, and sodium stearyl fumarate. The 30 mg capsule shell contains gelatin, titanium dioxide, yellow iron oxide, and red iron oxide. The 45 mg capsule shell contains gelatin, titanium dioxide, and black iron oxide. The 75 mg capsule shell contains gelatin, titanium dioxide, yellow iron oxide, black iron oxide, and red iron oxide. Each capsule is printed with blue ink, which includes FD&C Blue No. 2 as the colorant. In addition to the active ingredient, the powder for oral suspension contains sorbitol, monosodium citrate, xanthan gum, titanium dioxide, tutti-frutti flavoring, sodium benzoate, and saccharin sodium.

Oseltamivir phosphate is a white crystalline solid with the chemical name (3R,4R,5S)-4-acetylamino-5-amino-3(1-ethylpropoxy)-1-cyclohexene-1-carboxylic acid, ethyl ester, phosphate (1:1). The chemical formula is C₁₆H₂₈N₂O₄ (free base). The molecular weight is 312.4 for oseltamivir free base and 410.4 for oseltamivir phosphate salt. The structural formula is as follows:

12clinical Pharmacology

12.1Mechanism of Action

Oseltamivir is an antiviral drug [seeClinical Pharmacology (12.4)].

12.3Pharmacokinetics

Absorption and Bioavailability

Oseltamivir is readily absorbed from the gastrointestinal tract after oral administration of oseltamivir phosphate and is extensively converted predominantly by hepatic esterases to oseltamivir carboxylate. At least 75% of an oral dose reaches the systemic circulation as oseltamivir carboxylate. Exposure to oseltamivir is less than 5% of the total exposure after oral dosing (seeTable 6).

Table 6 Mean (% CV) Pharmacokinetic Parameters of Oseltamivir and Oseltamivir Carboxylate Following Multiple Dosing of 75 mg Capsules Twice Daily (n=20)

Parameter	Oseltamivir	Oseltamivir Carboxylate
Cmax (ng/mL)	65 (26)	348 (18)
AUC0-12h (ng∙h/mL)	112 (25)	2719 (20)

Plasma concentrations of oseltamivir carboxylate are proportional to doses up to 500 mg given twice daily.

Coadministration with food has no significant effect on the peak plasma concentration (551 ng/mL under fasted conditions and 441 ng/mL under fed conditions) and the area under the plasma concentration time curve (6218 ng∙h/mL under fasted conditions and 6069 ng∙h/mL under fed conditions) of oseltamivir carboxylate.

Distribution

The volume of distribution (V_ss) of oseltamivir carboxylate, following intravenous administration in 24 subjects, ranged between 23 and 26 liters.

The binding of oseltamivir carboxylate to human plasma protein is low (3%). The binding of oseltamivir to human plasma protein is 42%, which is insufficient to cause significant displacement-based drug interactions.

Metabolism

Oseltamivir is extensively converted to oseltamivir carboxylate by esterases located predominantly in the liver. Neither oseltamivir nor oseltamivir carboxylate is a substrate for, or inhibitor of, cytochrome P450 isoforms.

Elimination

Absorbed oseltamivir is primarily (>90%) eliminated by conversion to oseltamivir carboxylate. Plasma concentrations of oseltamivir declined with a half-life of 1 to 3 hours in most subjects after oral administration. Oseltamivir carboxylate is not further metabolized and is eliminated in the urine. Plasma concentrations of oseltamivir carboxylate declined with a half-life of 6 to 10 hours in most subjects after oral administration. Oseltamivir carboxylate is eliminated entirely (>99%) by renal excretion. Renal clearance (18.8 L/h) exceeds glomerular filtration rate (7.5 L/h), indicating that tubular secretion occurs in addition to glomerular filtration. Less than 20% of an oral radiolabeled dose is eliminated in feces.

Special Populations

Renal Impairment

Administration of 100 mg of oseltamivir phosphate twice daily for 5 days to patients with various degrees of renal impairment showed that exposure to oseltamivir carboxylate is inversely proportional to declining renal function. Oseltamivir carboxylate exposures in patients with normal and impaired renal function administered various dose regimens of oseltamivir are described inTable 7.

Table 7 Oseltamivir Carboxylate Exposures in Patients With Normal and Reduced Serum Creatinine Clearance

Parameter	Normal Renal Function			Impaired Renal Function
	75 mgonce daily	75 mgtwice daily	150 mgtwice daily	Creatinine Clearance<10 mL/min		Creatinine Clearance>10 and <30 mL/min
				CAPD	Hemodialysis	75 mgdaily	75 mgalternate days	30 mgdaily
				30 mgweekly	30 mg alternateHD cycle
Cmax	259Observed values. All other values are predicted.	348	705	766	850	1638	1175	655
Cmin	39	138	288	62	48	864	209	346
AUC48	7476	10876	21864	17381	12429	62636	21999	25054

Hepatic Impairment

In clinical studies oseltamivir carboxylate exposure was not altered in patients with mild or moderate hepatic impairment [seeDosage and Administration (2.5)andUse in Specific Populations (8.7)].

Pediatric Patients

The pharmacokinetics of oseltamivir and oseltamivir carboxylate have been evaluated in a single-dose pharmacokinetic study in pediatric patients aged 5 to 16 years (n=18) and in a small number of pediatric patients aged 3 to 12 years (n=5) enrolled in a clinical trial. Younger pediatric patients cleared both the prodrug and the active metabolite faster than adult patients resulting in a lower exposure for a given mg/kg dose. For oseltamivir carboxylate, apparent total clearance decreases linearly with increasing age (up to 12 years). The pharmacokinetics of oseltamivir in pediatric patients over 12 years of age are similar to those in adult patients.

Geriatric Patients

Exposure to oseltamivir carboxylate at steady-state was 25% to 35% higher in geriatric patients (age range 65 to 78 years) compared to young adults given comparable doses of oseltamivir. Half-lives observed in the geriatric patients were similar to those seen in young adults. Based on drug exposure and tolerability, dose adjustments are not required for geriatric patients for either treatment or prophylaxis [seeDosage and Administration (2.6)].

12.4Microbiology

MECHANISM OF ACTION SECTION

Mechanism of Action

Oseltamivir phosphate is an ethyl ester prodrug requiring ester hydrolysis for conversion to the active form, oseltamivir carboxylate. Oseltamivir carboxylate is an inhibitor of influenza virus neuraminidase affecting release of viral particles.

Antiviral Activity

The antiviral activity and neuraminidase inhibitory activity of oseltamivir carboxylate against laboratory strains and clinical isolates of influenza virus was determined in cell culture and biochemical assays. The concentrations of oseltamivir carboxylate required for inhibition of influenza virus in cell culture were highly variable depending on the assay method used and the virus tested. The 50% and 90% effective concentrations (EC₅₀ and EC₉₀) were in the range of 0.0008 µM to >35 µM and 0.004 µM to >100 µM, respectively (1 µM=0.284 µg/mL). The median IC₅₀ values of oseltamivir against influenza A/H1N1, influenza A/H3N2, and influenza B clinical isolates were 2.5 nM (range 0.93-4.16 nM, N=74), 0.96 nM (range 0.13-7.95 nM, N=774), and 60 nM (20-285 nM, N=256), respectively, in a neuraminidase assay with a fluorescently labeled MUNANA substrate. The relationship between the antiviral activity in cell culture, inhibitory activity in the neuraminidase assay, and the inhibition of influenza virus replication in humans has not been established.

Resistance

Influenza A virus isolates with reduced susceptibility to oseltamivir carboxylate have been recovered by serial passage of virus in cell culture in the presence of increasing concentrations of oseltamivir carboxylate, from clinical isolates collected during treatment with oseltamivir, and from viral isolates sampled during community surveillance studies. Reduced susceptibility of influenza virus to inhibition by oseltamivir carboxylate may be conferred by amino acid substitutions in the viral neuraminidase and/or hemagglutinin proteins. Changes in the viral neuraminidase that have been associated with reduced susceptibility to oseltamivir carboxylate are summarized inTable 8. Hemagglutinin substitutions associated with oseltamivir resistance include A28T and R124M in influenza A H3N2 and H154Q in H1N9, a reassortant human/avian virus.

Table 8 Neuraminidase Amino Acid Substitutions Observed in Oseltamivir Treatment Studies or Community Surveillance

Amino Acid Substitution	Influenza Type/Sub-type	Source
Catalytic Residues
R292K	A N2	Roche clinical trials, publication, surveillanceSubstitutions identified by surveillance data only; population and use of TAMIFLU are unknown
Framework Residues
H275Y	A N1	Roche clinical trials, publication, surveillance
N294S	A N1, N2	Publications
E119V	A N2	Roche clinical trials, publication, surveillance
SASG245-248 deletion	A N2	Roche clinical trial
I222V	A N2	Publication
I222T	B	Publication
D198N	B	Publication, surveillance
D198E	B	Surveillance
R371K	B	Surveillance
G402S	B	Publication

Selection of influenza A viruses resistant to oseltamivir can occur at higher frequencies in children. The incidence of oseltamivir treatment-associated resistance in pediatric treatment studies has been detected at rates of 27% to 37% and 3% to 18% (3/11 to 7/19 and 1/34 to 9/50 post-treatment isolates, respectively) for influenza A/H1N1 and influenza A/H3N2, respectively. The frequency of resistance selection to oseltamivir and the prevalence of such resistant virus vary seasonally and geographically.

Circulating seasonal influenza strains expressing neuraminidase resistance-associated substitutions have been observed in individuals who have not received oseltamivir treatment. The oseltamivir resistance-associated substitution H275Y was found in >99% of US circulating 2008 H1N1 influenza isolates. The 2009 H1N1 influenza ("swine flu") was almost uniformly susceptible to oseltamivir. Prescribers should consider available information from the CDC on influenza drug susceptibility patterns and treatment effects when deciding whether to use TAMIFLU.

Cross-resistance

Cross-resistance between oseltamivir and zanamivir has been observed in neuraminidase biochemical assays. The H275Y (N1 numbering) or N294S (N2 numbering) oseltamivir resistance-associated substitutions observed in the N1 neuraminidase subtype, and the E119V or N294S oseltamivir resistance-associated substitutions observed in the N2 subtype (N2 numbering), are associated with reduced susceptibility to oseltamivir but not zanamivir. The Q136K and K150T zanamivir resistance-associated substitutions observed in N1 neuraminidase, or the S250G zanamivir resistance-associated substitutions observed in influenza B, confer reduced susceptibility to zanamivir but not oseltamivir. The R292K oseltamivir resistance-associated substitution observed in N2, and the I222T, D198E/N, R371K, or G402S oseltamivir resistance-associated substitutions observed in influenza B neuraminidase, confer reduced susceptibility to both oseltamivir and zanamivir. In general, amino acid substitutions at neuraminidase catalytic residues confer cross-resistance to other neuraminidase inhibitors while substitutions at framework residues may or may not confer cross-resistance.

No single amino acid substitution has been identified that could confer cross-resistance between the neuraminidase inhibitor class (oseltamivir, zanamivir) and the M2 ion channel inhibitor class (amantadine, rimantadine). However, a virus may carry a neuraminidase inhibitor associated substitution in neuraminidase and an M2 ion channel inhibitor associated substitution in M2 and may therefore be resistant to both classes of inhibitors. The clinical relevance of phenotypic cross-resistance evaluations has not been established.

Immune Response

No influenza vaccine/oseltamivir interaction study has been conducted. In studies of naturally acquired and experimental influenza, treatment with TAMIFLU did not impair normal humoral antibody response to infection.

13nonclinical Toxicology

13.1Carcinogenesis, Mutagenesis, Impairment of Fertility

In 2-year carcinogenicity studies in mice and rats given daily oral doses of the prodrug oseltamivir phosphate up to 400 mg/kg and 500 mg/kg, respectively, the prodrug and the active form oseltamivir carboxylate induced no statistically significant increases in tumors over controls. The mean maximum daily exposures to the prodrug in mice and rats were approximately 130- and 320-fold, respectively, greater than those in humans at the proposed clinical dose based on AUC comparisons. The respective safety margins of the exposures to the active oseltamivir carboxylate were 15- and 50-fold.

Oseltamivir was found to be non-mutagenic in the Ames test and the human lymphocyte chromosome assay with and without enzymatic activation and negative in the mouse micronucleus test. It was found to be positive in a Syrian Hamster Embryo (SHE) cell transformation test. Oseltamivir carboxylate was non-mutagenic in the Ames test and the L5178Y mouse lymphoma assay with and without enzymatic activation and negative in the SHE cell transformation test.

In a fertility and early embryonic development study in rats, doses of oseltamivir at 50, 250, and 1500 mg/kg/day were administered to females for 2 weeks before mating, during mating and until day 6 of pregnancy. Males were dosed for 4 weeks before mating, during mating, and for 2 weeks after mating. There were no effects on fertility, mating performance or early embryonic development at any dose level. The highest dose was approximately 100 times the human systemic exposure (AUC_0-24h) of oseltamivir carboxylate.

13.2Animal Toxicology and/or Pharmacology

Single, oral administration of ≥657 mg/kg oseltamivir resulted in toxicity, including death, in juvenile 7 day old rats, but had no effect on adult rats. No toxicity was observed after repeated administration of up to 500 mg/kg oseltamivir to developing juvenile rats 7 to 21 days old. This 500 mg/kg dose was approximately 280 and 14 times the human systemic exposure (AUC_0-24h) of oseltamivir and oseltamivir carboxylate, respectively. Clinical relevance of the juvenile rat study finding for young infants is unknown.

14clinical Studies

14.1Treatment of Influenza

Adult Subjects

Two placebo-controlled double-blind clinical trials were conducted: one in the U.S. and one outside the U.S. Subjects were eligible for these trials if they had fever >100ºF, accompanied by at least one respiratory symptom (cough, nasal symptoms, or sore throat) and at least one systemic symptom (myalgia, chills/sweats, malaise, fatigue, or headache) and influenza virus was known to be circulating in the community. In addition, all subjects enrolled in the trials were allowed to take fever-reducing medications.

Of 1355 subjects enrolled in these two trials, 849 (63%) subjects were influenza-infected (age range 18 to 65 years; median age 34 years; 52% male; 90% Caucasian; 31% smokers). Of the 849 influenza-infected subjects, 95% were infected with influenza A, 3% with influenza B, and 2% with influenza of unknown type.

TAMIFLU was started within 40 hours of onset of symptoms. Subjects participating in the trials were required to self-assess the influenza-associated symptoms as "none," "mild," "moderate," or "severe." Time to improvement was calculated from the time of treatment initiation to the time when all symptoms (nasal congestion, sore throat, cough, aches, fatigue, headaches, and chills/sweats) were assessed as "none" or "mild." In both studies, at the recommended dose of TAMIFLU 75 mg twice daily for 5 days, there was a 1.3 day reduction in the median time to improvement in influenza-infected subjects receiving TAMIFLU compared to subjects receiving placebo. Subgroup analyses of these studies by gender showed no differences in the treatment effect of TAMIFLU in men and women.

In the treatment of influenza, no increased efficacy was demonstrated in subjects receiving treatment of 150 mg TAMIFLU twice daily for 5 days.

Geriatric Subjects

Three double-blind placebo-controlled treatment trials were conducted in subjects ≥65 years of age in three consecutive seasons. The enrollment criteria were similar to that of adult trials with the exception of fever being defined as >97.5°F. Of 741 subjects enrolled, 476 (65%) subjects were influenza-infected. Of the 476 influenza-infected subjects, 95% were infected with influenza type A and 5% with influenza type B.

In the pooled analysis, at the recommended dose of TAMIFLU 75 mg twice daily for 5 days, there was a 1-day reduction in the median time to improvement in influenza-infected subjects receiving TAMIFLU compared to those receiving placebo (p=NS). However, the magnitude of treatment effect varied between studies.

Pediatric Subjects

One double-blind placebo-controlled treatment trial was conducted in pediatric subjects aged 1 to 12 years (median age 5 years), who had fever (>100°F) plus one respiratory symptom (cough or coryza) when influenza virus was known to be circulating in the community. Of 698 subjects enrolled in this trial, 452 (65%) were influenza-infected (50% male; 68% Caucasian). Of the 452 influenza-infected subjects, 67% were infected with influenza A and 33% with influenza B.

The primary endpoint in this study was the time to freedom from illness, a composite endpoint that required 4 individual conditions to be met. These were: alleviation of cough, alleviation of coryza, resolution of fever, and parental opinion of a return to normal health and activity. TAMIFLU treatment of 2 mg/kg twice daily, started within 48 hours of onset of symptoms, significantly reduced the total composite time to freedom from illness by 1.5 days compared to placebo. Subgroup analyses of this study by gender showed no differences in the treatment effect of TAMIFLU in male and female pediatric subjects.

14.2Prophylaxis of Influenza

Adult Subjects

The efficacy of TAMIFLU in preventing naturally occurring influenza illness has been demonstrated in three seasonal prophylaxis studies and a postexposure prophylaxis study in households. The primary efficacy parameter for all these studies was the incidence of laboratory-confirmed clinical influenza. Laboratory-confirmed clinical influenza was defined as oral temperature ≥99.0°F/37.2°C plus at least one respiratory symptom (cough, sore throat, nasal congestion) and at least one constitutional symptom (aches and pain, fatigue, headache, chills/sweats), all recorded within 24 hours, plus either a positive virus isolation or a four-fold increase in virus antibody titers from baseline.

In a pooled analysis of two seasonal prophylaxis studies in healthy unvaccinated adults (aged 13 to 65 years), TAMIFLU 75 mg once daily taken for 42 days during a community outbreak reduced the incidence of laboratory-confirmed clinical influenza from 5% (25/519) for the placebo group to 1% (6/520) for the TAMIFLU group.

In a seasonal prophylaxis study in elderly residents of skilled nursing homes, TAMIFLU 75 mg once daily taken for 42 days reduced the incidence of laboratory-confirmed clinical influenza from 4% (12/272) for the placebo group to <1% (1/276) for the TAMIFLU group. About 80% of this elderly population were vaccinated, 14% of subjects had chronic airway obstructive disorders, and 43% had cardiac disorders.

In a study of postexposure prophylaxis in household contacts (aged ≥13 years) of an index case, TAMIFLU 75 mg once daily administered within 2 days of onset of symptoms in the index case and continued for 7 days reduced the incidence of laboratory-confirmed clinical influenza from 12% (24/200) in the placebo group to 1% (2/205) for the TAMIFLU group. Index cases did not receive TAMIFLU in the study.

Pediatric Subjects

The efficacy of TAMIFLU in preventing naturally occurring influenza illness has been demonstrated in a randomized, open-label, postexposure prophylaxis study in households that included children aged 1 to 12 years, both as index cases and as family contacts. All index cases in this study received treatment. The primary efficacy parameter for this study was the incidence of laboratory-confirmed clinical influenza in the household. Laboratory-confirmed clinical influenza was defined as oral temperature ≥100°F/37.8°C plus cough and/or coryza recorded within 48 hours, plus either a positive virus isolation or a four-fold or greater increase in virus antibody titers from baseline or at illness visits. Among household contacts 1 to 12 years of age not already shedding virus at baseline, TAMIFLU for oral suspension 30 mg to 60 mg taken once daily for 10 days reduced the incidence of laboratory-confirmed clinical influenza from 17% (18/106) in the group not receiving prophylaxis to 3% (3/95) in the group receiving prophylaxis.

Immunocompromised Subjects

A double-blind, placebo-controlled study was conducted for seasonal prophylaxis of influenza in 475 immunocompromised subjects (including 18 pediatric subjects 1 to 12 years of age) who had received solid organ (n=388; liver, kidney, liver and kidney) or hematopoietic stem cell transplants (n=87). Median time since transplant for solid organ transplant recipients was 1105 days for the placebo group and 1379 days for the oseltamivir group. Median time since transplant for hematopoietic stem cell transplant recipients was 424 days for the placebo group and 367 days for the oseltamivir group. Approximately 40% of subjects received influenza vaccine prior to entering the study. The primary efficacy endpoint for this study was the incidence of confirmed, clinical influenza, defined as oral temperature >99.0^°F/37.2^°C plus cough and/or coryza, all recorded within 24 hours, plus either a positive virus culture or a four-fold increase in virus antibody titers from baseline. The incidence of confirmed clinical influenza was 3% (7/238) in the group not receiving TAMIFLU compared with 2% (5/237) in the group receiving TAMIFLU; this difference was not statistically significant. A secondary analysis was performed using the same clinical symptoms and RT-PCR for laboratory confirmation of influenza. Among subjects who were not already shedding virus at baseline, the incidence of RT-PCR-confirmed clinical influenza was 3% (7/231) in the group not receiving TAMIFLU and <1% (1/232) in the group receiving TAMIFLU.

16how Supplied/storage And Handling

TAMIFLU Capsules

45-mg capsules (45 mg free base equivalent of the phosphate salt): grey hard gelatin capsules. "ROCHE" is printed in blue ink on the grey body and "45 mg" is printed in blue ink on the grey cap. Available in buler packages of 10 (NDC 54868-6083-0).

75-mg capsules (75 mg free base equivalent of the phosphate salt): grey/light yellow hard gelatin capsules. "ROCHE" is printed in blue ink on the grey body and "75 mg" is printed in blue ink on the light yellow cap. Available in buler packages of 10 (NDC 54868-4476-0).

STORAGE AND HANDLING SECTION

Storage

Store the capsules at 25°C (77°F); excursions permitted to 15° to 30°C (59° to 86°F) [See USP Controlled Room Temperature].

TAMIFLU for Oral Suspension

Supplied as a white powder blend in a glass bottle. After constitution, the powder blend produces a white tutti-frutti–flavored oral suspension. After constitution with 55 mL of water, each bottle delivers a usable volume of 60 mL of oral suspension equivalent to 360 mg oseltamivir base (6 mg/mL). Each bottle is supplied with a bottle adapter and a 10 mL oral dispenser (NDC 54868-6315-0).

STORAGE AND HANDLING SECTION

Storage

Store dry powder at 25°C (77°F); excursions permitted to 15° to 30°C (59° to 86°F) [See USP Controlled Room Temperature].

Store constituted suspension under refrigeration for up to 17 days at 2° to 8°C (36° to 46°F). Do not freeze. Alternatively, store constituted suspension for up to 10 days at 25°C (77°F); excursions permitted to 15° to 30°C (59° to 86°F) [See USP Controlled Room Temperature].

17patient Counseling Information

SeeFDA-approved Patient Labeling (Patient Information)

17.1Information for Patients

Patients and/or caregivers should be advised of the risk of severe allergic reactions (including anaphylaxis) or serious skin reactions and should stop TAMIFLU and seek immediate medical attention if an allergic-like reaction occurs or is suspected.

Patients and/or caregivers should be advised of the risk of neuropsychiatric events in patients with influenza and should contact their physician if they experience signs of abnormal behavior while receiving TAMIFLU. Their physician will determine if TAMIFLU treatment should be continued.

Instruct patients to begin treatment with TAMIFLU as soon as possible from the first appearance of flu symptoms. Similarly, prevention should begin as soon as possible after exposure, at the recommendation of a physician.

Instruct patients to take any missed doses as soon as they remember, except if it is near the next scheduled dose (within 2 hours), and then continue to take TAMIFLU at the usual times.

TAMIFLU is not a substitute for a flu vaccination. Patients should continue receiving an annual flu vaccination according to guidelines on immunization practices.

A bottle of TAMIFLU for oral suspension contains approximately 11 g sorbitol. One dose of 75 mg TAMIFLU for oral suspension delivers 2 g sorbitol. For patients with hereditary fructose intolerance, this is above the daily maximum limit of sorbitol and may cause dyspepsia and diarrhea.

Distributed by:

Genentech USA, Inc. A Member of the Roche Group1 DNA WaySouth San Francisco, CA 94080-4990

Licensor:

Gilead Sciences, Inc.Foster City, California 94404

TUCOS_640796_PI_2011_03(K)

© 2011 Genentech, Inc. All rights reserved.



Additional bar code labeling applied by:Physicians Total Care, Inc.Tulsa, Oklahoma        74146

Spl Patient Package Insert Section

Patient InformationTAMIFLU^® (oseltamivir phosphate)

This leaflet contains important information about TAMIFLU (TAM-ih-flew). Read it well before you begin treatment. This information does not take the place of talking with your healthcare professional about your medical condition or your treatment. This leaflet does not ul all the benefits and risks of TAMIFLU. If you have any questions about TAMIFLU, ask your healthcare professional. Only your healthcare professional can determine if TAMIFLU is right for you.

What is TAMIFLU?

TAMIFLU attacks the influenza virus and stops it from spreading inside your body. TAMIFLU treats flu at its source, by attacking the virus that causes the flu, rather than simply masking symptoms.

TAMIFLU is for treating adults and children age 1 and older with the flu whose flu symptoms started within the last day or two. TAMIFLU can also reduce the chance of getting the flu in people age 1 and older who have a higher chance of getting the flu because they spend time with someone who has the flu. TAMIFLU can also reduce the chance of getting the flu if there is a flu outbreak in the community.

What is "Flu"?

"The flu" is an infection caused by the influenza virus. Flu symptoms include fever (usually 100ºF to 103ºF in adults, and sometimes higher in children) and problems such as cough, sore throat, runny or stuffy nose, headaches, muscle aches, fever, and extreme tiredness. Many people use the term "flu" to mean any combination of these symptoms, such as the common cold, but true influenza infection is often worse and may last longer than a cold.

Flu outbreaks happen about once a year, usually in the winter, when the influenza virus spreads widely in the community. Outside of those outbreaks, only a very tiny number of respiratory infections are caused by the influenza virus.

Should I get a flu shot?

TAMIFLU is not a substitute for a flu vaccination. You should continue to get a flu vaccination every year, according to your healthcare professional's advice.

Who should not take TAMIFLU?

Do not take TAMIFLU if you are allergic to the main ingredient, oseltamivir phosphate, or to any other ingredients of TAMIFLU. Before starting treatment, make sure your healthcare professional knows if you take any other medicines, or are pregnant, planning to become pregnant, or breastfeeding. TAMIFLU is normally not recommended for use during pregnancy or nursing, as the effects on the unborn child or nursing infant are unknown. TAMIFLU is not recommended for use in children younger than 1 year of age.

Tell your healthcare professional if you have any type of kidney disease, heart disease, respiratory disease, or any serious health condition.

TAMIFLU for Oral Suspension contains sorbitol. Sorbitol may cause upset stomach and diarrhea in patients with a family history of fructose intolerance.

How should I take TAMIFLU?

It is important that you begin your treatment with TAMIFLU as soon as possible from the first appearance of your flu symptoms or soon after you are exposed to the flu. If you feel worse or develop new symptoms during treatment with TAMIFLU, or if your flu symptoms do not start to get better, you should contact your healthcare professional.

If you have the flu: Take TAMIFLU twice a day for 5 days, once in the morning and once in the evening. You should complete the entire treatment of 10 doses (capsules or suspension), even if you feel better.

To prevent the flu: If someone in your home has the flu, take TAMIFLU once a day for 10 days or for as long as prescribed. You can take TAMIFLU for up to 6 weeks if you are exposed to the flu because of an outbreak in your community. Follow your healthcare professional's advice on how long to take TAMIFLU.

You can take TAMIFLU with food or without food. There is less chance of stomach upset if you take it with a light snack, milk, or a meal.

If you are taking TAMIFLU for Oral Suspension, your pharmacist will give you a dosing dispenser to measure the proper amount of Oral Suspension for your dose. Follow your healthcare professional's instructions on how to measure the proper dose for you. Review the instructions below on how to use the dispenser and ask your pharmacist if you have any questions. If you lose or damage the dispenser and cannot use it, contact your healthcare professional or pharmacist for advice on the proper dose.

If TAMIFLU for Oral Suspension is not available, your healthcare provider may instruct you to open TAMIFLU Capsules and mix the contents with sweetened liquids such as regular or sugar-free chocolate syrup, corn syrup, caramel topping, or light brown sugar (dissolved in water). Please follow the dosing instructions below.

If you forget to take your medicine, take the missed dose as soon as you remember, except if it is 2 hours or less before your next dose. Then continue to take TAMIFLU at the usual times. Do not take 2 doses at a time to make up for a missed dose. If you miss several doses, tell your healthcare professional and follow the advice given to you.

What are the possible side effects of TAMIFLU?

The most common side effects of TAMIFLU are nausea and vomiting. These are usually mild to moderate. They usually happen in the first 2 days of treatment. Taking TAMIFLU with food may reduce the chance of getting these side effects.

If you develop an allergic reaction or severe rash, stop taking TAMIFLU and contact your healthcare professional.

People with the flu, particularly children and adolescents, may be at an increased risk of seizures, confusion, or abnormal behavior early during their illness. These events may occur shortly after beginning TAMIFLU or may occur when flu is not treated. These events are uncommon but may result in accidental injury to the patient. Therefore, patients should be observed for signs of unusual behavior and a healthcare professional should be contacted immediately if the patient shows any signs of unusual behavior.

Before taking TAMIFLU, please let your healthcare provider know if you have received nasally administered influenza virus vaccine during the past two weeks.

If you notice any side effects not mentioned in this leaflet, or if you have any concerns about the side effects you get, tell your healthcare professional.

How and where should I store TAMIFLU?

TAMIFLU Capsules should be stored at room temperature, 77°F (25°C) and kept in a dry place. Keep this medication out of reach of children.

TAMIFLU for Oral Suspension should be stored under refrigeration for up to 17 days at 36° to 46°F (2° to 8°C). Do not freeze. Alternatively, store at room temperature for up to 10 days. Discard any unused portion when you are finished with your prescribed dosing of TAMIFLU.

General advice about prescription medicines:

Medicines are sometimes prescribed for conditions that are not mentioned in patient information leaflets. Do not use TAMIFLU for a condition for which it was not prescribed. Do not give TAMIFLU to other people, even if they have the same symptoms you have. It may not be right for them.

This leaflet summarizes the most important information about TAMIFLU. If you would like more information, talk with your healthcare professional. You can ask your pharmacist or healthcare professional for information about TAMIFLU that is written for health professionals.

DOSING INSTRUCTIONS FOR PATIENTS:

How Do I Prepare a Dose of TAMIFLU for Oral Suspension?

Please follow instructions carefully to ensure proper dosing of the oral suspension.

• Shake closed bottle well for about 5 seconds before each use.
• Remove child-resistant cap.
• Before inserting the tip of the oral dispenser into bottle adapter, push the plunger completely down toward the tip of the oral dispenser. Insert tip firmly into opening of the bottle adapter.
• Turn the entire unit (bottle and oral dispenser) upside down.
• Pull the plunger out slowly until the desired amount of medication is withdrawn into the oral dispenser (see figure). The 12.5 mL (75 mg) dose is obtained by filling the dispenser twice, once to the 10 mL graduation, and a second fill to the 2.5 mL graduation.

• Turn the entire unit right side up and remove the oral dispenser slowly from the bottle.
• Dispense directly into mouth. Do not mix with any liquid prior to dispensing.
• Close bottle with child-resistant cap after each use.
• Disassemble oral dispenser, rinse under running tap water and air dry prior to next use.

If Directed by My Healthcare Provider, How Do I Mix the Contents of TAMIFLU Capsules with Sweetened Liquids?

Please follow instructions carefully to ensure proper dosing.

• Holding one capsule over a small bowl, carefully pull the capsule open and pour the complete contents of the capsule into the bowl.
• Add to the capsule contents a small amount of a sweetened liquid such as chocolate syrup (regular or sugar-free), corn syrup, caramel topping, or light brown sugar (dissolved in water) that the child will consume completely.
• Stir the mixture and give the entire dose to the child.

Distributed by:

Genentech USA, Inc. A Member of the Roche Group1 DNA WaySouth San Francisco, CA 94080-4990

Licensor:

Gilead Sciences, Inc.Foster City, California 94404

TUCOS_640796_PPI_2011_03(K)

Rev. March 2011

© 2011 Genentech, Inc. All rights reserved.