DailyMed Label: Lanreotide Acetate

DailyMed Label: LANREOTIDE ACETATE

2024

DailyMed Prescription

LANREOTIDE ACETATE

LANREOTIDE ACETATE

Cipla USA Inc.

NDC: 69097-907

NDC: 69097-908

NDC: 69097-906

NDC: 69097-907

NDC: 69097-908

NDC: 69097-906

NDC: 69097-907

NDC: 69097-908

NDC: 69097-906

NDC: 69097-907

NDC: 69097-907

NDC: 69097-908

NDC: 69097-908

NDC: 69097-906

NDC: 69097-906

Lanreotide Injection 60 mg/0.2 mL, 90 mg/0.3 mL, and 120 mg/0.5 mL is a prolonged-release formulation for deep subcutaneous injection. It contains the drug substance lanreotide acetate, a synthetic octapeptide with a biological activity similar to naturally occurring somatostatin, water for injection and acetic acid (for pH adjustment). Lanreotide Injection is available as sterile, ready-to-use, single-dose prefilled syringes containing lanreotide acetate supersaturated bulk solution of 24.6% w/w lanreotide base.    Each syringe contains: LANREOTIDE ACETATE LANREOTIDE ACETATE LANREOTIDE ACETATE 60 mg/0.2 mL 90 mg/0.3 mL 120 mg/0.5 mL    Lanreotide acetate 89.9 mg 123.2 mg 156.6 mg    Acetic Acid q.s. q.s. q.s.    Water for injection 236.4 mg 324.1 mg 411.6 mg    Total Weight 328.9 mg 450.9 mg 572.8 mg Lanreotide acetate is a synthetic cyclical octapeptide analog of the natural hormone, somatostatin. Lanreotide acetate is chemically known as [cyclo S-S]-3-(2-naphthyl)-D-alanyl-L-cysteinyl-L- tyrosyl-D-tryptophyl-L-lysyl-L-valyl-L-cysteinyl-L-threoninamide, acetate salt. Its molecular weight is 1096.34 (base) and its amino acid sequence is: The Lanreotide Injection in the prefilled syringe is a white to pale yellow, semi-solid formulation. structure

Lanreotide Injection is a somatostatin analog indicated for: the long-term treatment of acromegalic patients who have had an inadequate response to or cannot be treated with surgery and/or radiotherapy. ( 1.1 )  the treatment of adult patients with unresectable, well- or moderately- differentiated, locally advanced or metastatic gastroenteropancreatic neuroendocrine tumors (GEP-NETs) to improve progression-free survival. ( 1.2 ) Lanreotide Injection is indicated for the long-term treatment of acromegalic patients who have had an inadequate response to surgery and/or radiotherapy, or for whom surgery and/or radiotherapy is not an option. The goal of treatment in acromegaly is to reduce growth hormone (GH) and insulin growth factor-1 (IGF-1) levels to normal. Lanreotide Injection is indicated for the treatment of adult patients with unresectable, well or moderately differentiated, locally advanced or metastatic gastroenteropancreatic neuroendocrine tumors (GEP-NETs) to improve progression-free survival.

Administration ( 2.1 ): For deep subcutaneous injection only.  Intended for administration by a healthcare provider.  Administer in the superior external quadrant of the buttock.  Alternate injection sites.  Recommended Dosage ( 2.1 ) Acromegaly: 90 mg every 4 weeks for 3 months. Adjust thereafter based on GH and/or IGF-1 levels. See full prescribing information for titration regimen.  GEP-NETs: 120 mg every 4 weeks.  Dosage Adjustment: See full prescribing information for dosage adjustment in patients with acromegaly and renal or hepatic impairment. ( 2.3 , 2.4 ) For deep subcutaneous injection only. Lanreotide Injection is intended for administration by a healthcare provider.  Refer to the Instructions For Use (IFU) for complete administration instructions with illustrations.  Preparation Remove Lanreotide Injection from the refrigerator 30 minutes prior to administration and allow to come to room temperature.  Keep pouch sealed until just prior to injection.  Product left in its sealed pouch at room temperature (not to exceed 104°F or 40°C) for up to 72 hours may be returned to the refrigerator for continued storage and use at a later time.  Prior to administration, inspect the Lanreotide Injection syringe visually for particulate matter and discoloration. Do not administer if particulate matter or discoloration is observed. The content of the prefilled syringe is a semi-solid phase having a gel-like appearance, with viscous characteristics and a color varying from white to pale yellow. The supersaturated solution can also contain micro bubbles that can clear up during injection. These differences are normal and do not interfere with the quality of the product.  Administration Slowly administer for 20 seconds as a deep subcutaneous injection in the superior external quadrant of the buttock.  Alternate the injection site between the right and left sides from one injection to the next. Acromegaly The recommended starting dosage of Lanreotide Injection is 90 mg given via the deep subcutaneous route, at 4-week intervals for 3 months. After 3 months, the dosage may be adjusted as follows: GH greater than 1 ng/mL to less than or equal to 2.5 ng/mL, IGF-1 normal, and clinical symptoms controlled: maintain Lanreotide Injection dosage at 90 mg every 4 weeks.  GH greater than 2.5 ng/mL, IGF-1 elevated, and/or clinical symptoms uncontrolled: increase Lanreotide Injection dosage to 120 mg every 4 weeks.  GH less than or equal to 1 ng/mL, IGF-1 normal, and clinical symptoms controlled: reduce Lanreotide Injection dosage to 60 mg every 4 weeks.  Thereafter, the dosage should be adjusted according to the response of the patient as judged by a reduction in serum GH and/or IGF-1 levels; and/or changes in symptoms of acromegaly. Patients who are controlled on Lanreotide Injection 60 or 90 mg may be considered for an extended dosing interval of Lanreotide Injection 120 mg every 6 or 8 weeks. GH and IGF-1 levels should be obtained 6 weeks after this change in dosing regimen to evaluate persistence of patient response. Continued monitoring of patient response with dosage adjustments for biochemical and clinical symptom control, as necessary, is recommended. Gastroenteropancreatic Neuroendocrine Tumors (GEP-NETs) The recommended dosage of Lanreotide Injection is 120 mg administered every 4 weeks by deep subcutaneous injection. Acromegaly The recommended starting dosage of Lanreotide Injection in acromegalic patients with moderate or severe renal impairment (creatinine clearance less than 60 mL/min) is 60 mg via the deep subcutaneous route at 4-week intervals for 3 months followed by dosage adjustment [see Dosage and Administration ( 2.2 ), Use in Specific Populations ( 8.6 )]. Acromegaly The recommended starting dosage of Lanreotide Injection in acromegalic patients with moderate or severe hepatic impairment (Child-Pugh Class B or C) is 60 mg via the deep subcutaneous route at 4-week intervals for 3 months followed by dosage adjustment [see Dosage and Administration ( 2.2 ), Use in Specific Populations ( 8.7 )].

Injection: 60 mg/0.2 mL, 90 mg/0.3 mL, and 120 mg/0.5 mL sterile, single-dose, prefilled syringes fitted with an automatic needle guard. The prefilled syringes contain a white to pale yellow, semi-solid formulation. Injection: 60 mg/0.2 mL, 90 mg/0.3 mL, and 120 mg/0.5 mL single-dose prefilled syringes ( 3 )

Lanreotide Injection is contraindicated in patients with history of a hypersensitivity to lanreotide. Allergic reactions (including angioedema and anaphylaxis) have been reported following administration of lanreotide [see Adverse Reactions ( 6.3 )]. Hypersensitivity to lanreotide. ( 4 )

Cholelithiasis and Complications of Cholelithiasis: Monitor periodically. Discontinue if complications of cholelithiasis are suspected. Gallstones may occur; consider periodic monitoring. ( 5.1 )  Hyperglycemia and Hypoglycemia: Glucose monitoring is recommended and antidiabetic treatment adjusted accordingly. ( 5.2 , 7.1 ) Cardiovascular Abnormalities: Decrease in heart rate may occur. Use with caution in at-risk patients. ( 5.3 ) Thyroid Function Abnormalities: Decreases in thyroid function may occur; perform tests where clinically indicated. ( 5.4 ) Lanreotide Injection may reduce gallbladder motility and lead to gallstone formation; therefore, patients may need to be monitored periodically [see Adverse Reactions ( 6.1 ), Clinical Pharmacology ( 12.2 )] . There have been postmarketing reports of cholelithiasis (gallstones) resulting in complications, including cholecystitis, cholangitis, and pancreatitis, and requiring cholecystectomy in patients taking Lanreotide Injection. If complications of cholelithiasis are suspected, discontinue Lanreotide Injection and treat appropriately. Pharmacological studies in animals and humans show that lanreotide, like somatostatin and other somatostatin analogs, inhibits the secretion of insulin and glucagon. Hence, patients treated with Lanreotide Injection may experience hypoglycemia or hyperglycemia. Blood glucose levels should be monitored when lanreotide treatment is initiated, or when the dose is altered, and antidiabetic treatment should be adjusted accordingly [see Adverse Reactions ( 6.1 )]. The most common overall cardiac adverse reactions observed in three pooled Lanreotide Injection cardiac studies in patients with acromegaly were sinus bradycardia (12/217, 5.5%), bradycardia (6/217, 2.8%), and hypertension (12/217, 5.5%) [see Adverse Reactions ( 6.1 )]. In 81 patients with baseline heart rates of 60 beats per minute (bpm) or greater treated with Lanreotide Injection in Study 3, the incidence of heart rate less than 60 bpm was 23% (19/81) as compared to 16% (15/94) of placebo treated patients; 10 patients (12%) had documented heart rates less than 60 bpm on more than one visit. The incidence of documented episodes of heart rate less than 50 bpm as well as the incidence of bradycardia reported as an adverse event was 1% in each treatment group. Initiate appropriate medical management in patients who develop symptomatic bradycardia. In patients without underlying cardiac disease, Lanreotide Injection may lead to a decrease in heart rate without necessarily reaching the threshold of bradycardia. In patients suffering from cardiac disorders prior to Lanreotide Injection treatment, sinus bradycardia may occur. Care should be taken when initiating treatment with Lanreotide Injection in patients with bradycardia. Slight decreases in thyroid function have been seen during treatment with lanreotide in acromegalic patients, though clinical hypothyroidism is rare (less than 1%). Thyroid function tests are recommended where clinically indicated. Acromegaly: Serum GH and IGF-1 levels are useful markers of the disease and the effectiveness of treatment [see Dosage and Administration ( 2.2 )].

The following adverse reactions to Lanreotide Injection are discussed in greater detail in other sections of the labeling:

Cyclosporine: Lanreotide Injection may decrease the absorption of cyclosporine. Dosage adjustment of cyclosporine may be needed. ( 7.2 ) Bromocriptine: Lanreotide Injection may increase the absorption of bromocriptine. ( 7.3 )  Bradycardia-Inducing Drugs (e.g., beta-blockers): Lanreotide Injection may decrease heart rate. Dosage adjustment of the coadministered drug may be necessary. ( 7.3 ) Lanreotide, like somatostatin and other somatostatin analogs, inhibits the secretion of insulin and glucagon. Therefore, blood glucose levels should be monitored when Lanreotide Injection treatment is initiated or when the dose is altered, and antidiabetic treatment should be adjusted accordingly [see Warnings and Precautions ( 5.2 )]. Concomitant administration of cyclosporine with Lanreotide Injection may decrease the absorption of cyclosporine, and therefore, may necessitate adjustment of cyclosporine dose to maintain therapeutic drug concentrations. [see Clinical Pharmacology ( 12.3 )] Limited published data indicate that concomitant administration of a somatostatin analog and bromocriptine may increase the absorption of bromocriptine [see Clinical Pharmacology ( 12.3 )] . Concomitant administration of bradycardia-inducing drugs (e.g., beta-blockers) may have an additive effect on the reduction of heart rate associated with lanreotide. Dosage adjustments of concomitant drugs may be necessary. The limited published data available indicate that somatostatin analogs may decrease the metabolic clearance of compounds known to be metabolized by cytochrome P450 enzymes, which may be due to the suppression of growth hormone. Since it cannot be excluded that Lanreotide Injection may have this effect, avoid other drugs mainly metabolized by CYP3A4 and which have a low therapeutic index (e.g., quinidine, terfenadine). Drugs metabolized by the liver may be metabolized more slowly during Lanreotide Injection treatment and dose reductions of the concomitantly administered medications should be considered [see Clinical Pharmacology ( 12.3 )] .

Lactation: Advise women not to breastfeed during treatment and for 6 months after the last dose. ( 8.2 ) Risk Summary Limited available data based on postmarketing case reports with Lanreotide Injection use in pregnant women are not sufficient to determine a drug-associated risk of adverse developmental outcomes. In animal reproduction studies, decreased embryo/fetal survival was observed in pregnant rats and rabbits at subcutaneous doses 5- and 2-times the maximum recommended human dose (MRHD) of 120 mg, respectively (see Data) . The estimated background risk of major birth defects and miscarriage for the indicated populations is unknown. All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively. Data Animal Data A reproductive study in pregnant rats given 30 mg/kg of lanreotide by subcutaneous injection every 2 weeks (5 times the human dose, based on body surface area comparisons) resulted in decreased embryo/fetal survival. A study in pregnant rabbits given subcutaneous injections of 0.45 mg/kg/day (2 times the human therapeutic exposures at the maximum recommended dose of 120 mg, based on comparisons of relative body surface area) shows decreased fetal survival and increased fetal skeletal/ soft tissue abnormalities. Risk Summary There is no information available on the presence of lanreotide in human milk, the effects of the drug on the breastfed infant, or the effects of the drug on milk production. Studies show that lanreotide acetate administered subcutaneously passes into the milk of lactating rats; however, due to specifies- specific differences in lactation physiology, animal data may not reliably predict drug levels in human milk . Because of the potential for serious adverse reactions in breastfed infants from Lanreotide Injection, including effects on glucose metabolism and bradycardia, advise women not to breastfeed during treatment with Lanreotide Injection and for 6 months (6 half-lives) following the last dose. Infertility Females Based on results from animal studies conducted in female rats, Lanreotide Injection may reduce fertility in females of reproductive potential [see Nonclinical Toxicology ( 13.1 )]. The safety and effectiveness of Lanreotide Injection in pediatric patients have not been established. No overall differences in safety or effectiveness were observed between elderly patients with acromegaly compared with younger patients and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out. Studies 3 and 4, conducted in patients with neuroendocrine tumors, did not include sufficient numbers of patients aged 65 and over to determine whether they respond differently from younger patients. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy. Acromegaly Lanreotide has been studied in patients with end-stage renal function on dialysis, but has not been studied in patients with mild, moderate, or severe renal impairment. It is recommended that patients with moderate or severe renal impairment receive a starting dose of lanreotide of 60 mg. Caution should be exercised when considering patients with moderate or severe renal impairment for an extended dosing interval of Lanreotide Injection 120 mg every 6 or 8 weeks [see Dosage and Administration ( 2.1 ) and Clinical Pharmacology ( 12.3 )] . Neuroendocrine Tumors (NET) – Gastroenteropancreatic Neuroendocrine Tumors No effect was observed in total clearance of lanreotide in patients with mild to moderate renal impairment receiving Lanreotide Injection 120 mg. Patients with severe renal impairment were not studied [see Clinical Pharmacology ( 12.3 )] . Acromegaly It is recommended that patients with moderate or severe hepatic impairment receive a starting dose of lanreotide of 60 mg. Caution should be exercised when considering patients with moderate or severe hepatic impairment for an extended dosing interval of Lanreotide Injection 120 mg every 6 or 8 weeks [see Dosage and Administration ( 2.1 ) and Clinical Pharmacology ( 12.3 )] . Neuroendocrine Tumors (NET) – Gastroenteropancreatic Neuroendocrine Tumors Lanreotide Injection has not been studied in patients with hepatic impairment.

Lanreotide Injection is supplied in strengths of 60 mg/0.2 mL, 90 mg/0.3 mL, and 120 mg/0.5 mL as a white to pale yellow, semi-solid formulation in a single, sterile, prefilled, ready-to-use, polypropylene syringe (fitted with an automatic needle guard) fitted with a 20 mm needle covered by a sheath. Each prefilled syringe is sealed in a laminated pouch and packed in a carton. NDC 69097-907-67 60 mg/0.2 mL, sterile, prefilled syringe NDC 69097-908-67 90 mg/0.3 mL, sterile, prefilled syringe NDC 69097-906-67 120 mg/0.5 mL, sterile, prefilled syringe Storage and Handling Store Lanreotide Injection in the refrigerator at 2°C to 8°C (36°F to 46°F). Protect from light. Store in the original package.

Lanreotide, the active component of Lanreotide acetate is an octapeptide analog of natural somatostatin. The mechanism of action of lanreotide is believed to be similar to that of natural somatostatin. Lanreotide has a high affinity for human somatostatin receptors (SSTR) 2 and 5 and a reduced binding affinity for human SSTR1, 3, and 4. Activity at human SSTR2 and 5 is the primary mechanism believed responsible for GH inhibition. Like somatostatin, lanreotide is an inhibitor of various endocrine, neuroendocrine, exocrine, and paracrine functions. The primary pharmacodynamic effect of lanreotide is a reduction of GH and/or IGF-1 levels enabling normalization of levels in acromegalic patients [see Clinical Studies ( 14.1 )] . In acromegalic patients, lanreotide reduces GH levels in a dose-dependent way. After a single injection of Lanreotide acetate, plasma GH levels fall rapidly and are maintained for at least 28 days. Lanreotide inhibits the basal secretion of motilin, gastric inhibitory peptide, and pancreatic polypeptide, but has no significant effect on the secretion of secretin. Lanreotide inhibits postprandial secretion of pancreatic polypeptide, gastrin, and cholecystokinin (CCK). In healthy subjects, lanreotide produces a reduction and a delay in postprandial insulin secretion, resulting in transient, mild glucose intolerance. Lanreotide inhibits meal-stimulated pancreatic secretions, and reduces duodenal bicarbonate and amylase concentrations, and produces a transient reduction in gastric acidity. Lanreotide has been shown to inhibit gallbladder contractility and bile secretion in healthy subjects  [see Warnings and Precautions ( 5.1 )] . In healthy subjects, lanreotide inhibits meal-induced increases in superior mesenteric artery and portal venous blood flow, but has no effect on basal or meal-stimulated renal blood flow. Lanreotide has no effect on renal plasma flow or renal vascular resistance. However, a transient decrease in glomerular filtration rate (GFR) and filtration fraction has been observed after a single injection of lanreotide. In healthy subjects, non-significant reductions in glucagon levels were seen after lanreotide administration. In diabetic non-acromegalic subjects receiving a continuous infusion (21-day) of lanreotide, serum glucose concentrations were temporarily decreased by 20% to 30% after the start and end of the infusion. Serum glucose concentrations returned to normal levels within 24 hours. A significant decrease in insulin concentrations was recorded between baseline and Day 1 only [see Warnings and Precautions ( 5.2 )] . Lanreotide inhibits the nocturnal increase in thyroid-stimulating hormone (TSH) seen in healthy subjects. Lanreotide reduces prolactin levels in acromegalic patients treated on a long-term basis [see Warnings and Precautions ( 5.4 )] . Lanreotide acetate is thought to form a drug depot at the injection site due to the interaction of the formulation with physiological fluids. The most likely mechanism of drug release is a passive diffusion of the precipitated drug from the depot towards the surrounding tissues, followed by the absorption to the bloodstream. After a single, deep subcutaneous administration, the mean absolute bioavailability of Lanreotide acetate in healthy subjects was 73.4, 69.0, and 78.4% for the 60 mg, 90 mg, and 120 mg doses, respectively. Mean C max values ranged from 4.3 to 8.4 ng/mL during the first day. Single-dose linearity was demonstrated with respect to AUC and C max , and showed high inter-subject variability. Lanreotide acetate showed sustained release of lanreotide with a half-life of 23 to 30 days. Mean serum concentrations were > 1 ng/mL throughout 28 days at 90 mg and 120 mg and > 0.9 ng/mL at 60 mg. In studies evaluating excretion, <5% of lanreotide was excreted in urine and less than 0.5% was recovered unchanged in feces, indicative of some biliary excretion. Acromegaly In a repeat-dose administration pharmacokinetics (PK) study in acromegalic patients, rapid initial release was seen giving peak levels during the first day after administration. At doses of Lanreotide acetate between 60 and 120 mg, linear pharmacokinetics were observed in acromegalic patients. At steady state, mean C max values were 3.8 ± 0.5, 5.7 ± 1.7, and 7.7 ± 2.5 ng/mL, increasing linearly with dose. The mean accumulation ratio index was 2.7, which is in line with the range of values for the half-life of Lanreotide acetate. The steady- state trough serum lanreotide concentrations in patients receiving Lanreotide acetate every 28 days were 1.8 ± 0.3; 2.5 ± 0.9 and 3.8 ± 1.0 ng/mL at 60 mg, 90 mg, and 120 mg doses, respectively. A limited initial burst effect and a low peak-to-trough fluctuation (81% to 108%) of the serum concentration at the plateau were observed. For the same doses, similar values were obtained in clinical studies after at least four administrations (2.3 ± 0.9, 3.2 ± 1.1, and 4.0 ± 1.4 ng/mL, respectively). Pharmacokinetic data from studies evaluating extended dosing use of Lanreotide Injection 120 mg demonstrated mean steady-state, C min values between 1.6 and 2.3 ng/mL for the 8- and 6-week treatment interval, respectively. Gastroenteropancreatic Neuroendocrine Tumors In patients with GEP-NETs treated with Lanreotide Injection 120 mg every 4 weeks, steady state concentrations were reached after 4 to 5 injections and the mean trough serum lanreotide concentrations at steady state ranged from 5.3 to 8.6 ng/mL. Specific Populations Lanreotide Injection has not been studied in specific populations. However, the pharmacokinetics of lanreotide in renal impaired, hepatic impaired, and geriatric subjects were evaluated after IV administration of lanreotide immediate release formulation (IRF) at 7 mcg/kg dose. Geriatric Studies in healthy elderly subjects showed an 85% increase in half-life and a 65% increase in mean residence time (MRT) of lanreotide compared to those seen in healthy young subjects; however, there was no change in either AUC or C max of lanreotide in elderly as compared to healthy young subjects. Age has no effect on clearance of lanreotide based on population PK analysis in patients with GEP-NET which included 122 patients aged 65 to 85 years with neuroendocrine tumors. Renal Impairment An approximate 2-fold decrease in total serum clearance of lanreotide, with a consequent 2 fold increase in half-life and AUC was observed. Patients with acromegaly and with moderate to severe renal impairment should begin treatment with Lanreotide Injection 60 mg. Caution should be exercised when considering patients with moderate or severe renal impairment for an extended dosing interval of Lanreotide Injection 120 mg every 6 or 8 weeks. Mild (CLcr 60-89 mL/min) or moderate (CLcr 30-59 mL/min) renal impairment has no effect on clearance of lanreotide in patients with GEP-NET based on population PK analysis which included 106 patients with mild and 59 patients with moderate renal impairment treated with Lanreotide Injection. GEP-NET patients with severe renal impairment (CLcr < 30 mL/min) were not studied. Hepatic Impairment In subjects with moderate to severe hepatic impairment, a 30% reduction in clearance of lanreotide was observed. Patients with acromegaly and with moderate to severe hepatic impairment should begin treatment with Lanreotide Injection 60 mg. Caution should be exercised when considering patients with moderate or severe hepatic impairment for an extended dosing interval of Lanreotide Injection 120 mg every 6 or 8 weeks. The effect of hepatic impairment on clearance of lanreotide has not been studied in patients with GEP-NET.

Standard lifetime carcinogenicity bioassays were conducted in mice and rats. Mice were given daily subcutaneous doses of lanreotide at 0.5, 1.5, 5, 10, and 30 mg/kg for 104 weeks. Cutaneous and subcutaneous tumors of fibrous connective tissues at the injection sites were observed at the high dose of 30 mg/kg/day. Fibrosarcomas in both genders and malignant fibrous histiocytomas were observed in males at 30 mg/kg/day resulting in exposures 3 times higher than the clinical therapeutic exposure at the maximum therapeutic dose of 120 mg given by monthly subcutaneous injection based on the AUC values. Rats were given daily subcutaneous doses of lanreotide at 0.1, 0.2, and 0.5 mg/ kg for 104 weeks. Increased cutaneous and subcutaneous tumors of fibrous connective tissues at the injection sites were observed at the dose of 0.5 mg/kg/day resulting in exposures less than the clinical therapeutic exposure at 120 mg given by monthly subcutaneous injection. The increased incidence of injection site tumors in rodents is likely related to the increased dosing frequency (daily) in animals compared to monthly dosing in humans and therefore may not be clinically relevant. Lanreotide was not genotoxic in tests for gene mutations in a bacterial mutagenicity (Ames) assay, or mouse lymphoma cell assay with or without metabolic activation. Lanreotide was not genotoxic in tests for the detection of chromosomal aberrations in a human lymphocyte and in vivo mouse micronucleus assay. In a fertility study conducted with lanreotide in rats, reduced female fecundity was observed at estimated exposure corresponding to approximately 10-fold the plasma exposure at the MRHD of 120 mg. The fertility of male rats was unaffected by the treatment up to an estimated exposure corresponding to approximately 11-fold the plasma exposure at the MRHD of 120 mg.

The effect of Lanreotide Injection on reducing GH and IGF-levels and control of symptoms in patients with acromegaly was studied in 2 long-term, multiple-dose, randomized, multicenter studies. Study 1 This 1-year study included a 4-week, double-blind, placebo-controlled phase; a 16-week single-blind, fixed-dose phase; and a 32-week, open-label, dose-titration phase. Patients with active acromegaly, based on biochemical tests and medical history, entered a 12-week washout period if there was previous treatment with a somatostatin analog or a dopaminergic agonist. Upon entry, patients were randomly allocated to receive a single, deep subcutaneous injection of Lanreotide Injection 60, 90, or 120 mg or placebo. Four weeks later, patients entered a fixed-dose phase where they received 4 injections of Lanreotide Injection followed by a dose-titration phase of 8 injections for a total of 13 injections over 52 weeks (including the placebo phase). Injections were given at 4-week intervals. During the dose-titration phase of the study, the dose was titrated twice (every fourth injection), as needed, according to individual GH and IGF-1 levels. A total of 108 patients (51 males, 57 females) were enrolled in the initial placebo-controlled phase of the study. Half (54/108) of the patients had never been treated with a somatostatin analog or dopamine agonist, or had stopped treatment for at least 3 months prior to their participation in the study and were required to have a mean GH level greater than 5 ng/mL at their first visit. The other half of the patients had received prior treatment with a somatostatin analog or a dopamine agonist before study entry and at study entry were required to have a mean GH concentration greater than 3 ng/mL and at least a 100% increase in mean GH concentration after washout of medication. One hundred and seven (107) patients completed the placebo-controlled phase, 105 patients completed the fixed-dose phase, and 99 patients completed the dose-titration phase. Patients not completing withdrew due to adverse events (5) or lack of efficacy (4). In the double-blind phase of Study 1, a total of 52 (63%) of the 83 lanreotide-treated patients had a greater than 50% decrease in mean GH from baseline to Week 4, including 52%, 44%, and 90% of patients in the 60, 90, and 120 mg groups, respectively, compared to placebo (0%, 0/25). In the fixed- dose phase at Week 16, 72% of all 107 lanreotide-treated patients had a decrease from baseline in mean GH of greater than 50%, including 68% (23/34), 64% (23/36), and 84% (31/37) of patients in the 60, 90, and 120 mg lanreotide treatment groups, respectively. Efficacy achieved in the first 16 weeks was maintained for the duration of the study (see Table 4). Table 4: Overall Efficacy Results Based on GH and IGF-1 Levels by Treatment Phase in Study 1 1  n=105,  2 n=102,  3 Age-adjusted *Last Observation Carried Forward Baseline N=107 Before Titration 1 (16 weeks) N=107 Before Titration 2 (32 weeks) N=105 Last Value Available* N=107 GH ≤5.0 ng/mL Number of Responders (%) 20 (19%) 72 (67%) 76 (72%) 74 (69%) ≤2.5 ng/mL Number of Responders (%) 0 (0%) 52 (49%) 59 (56%) 55 (51%) ≤1.0 ng/mL Number of Responders (%) 0 (0%) 15 (14%) 18 (17%) 17 (16%) Median GH ng/mL 10.27 2.53 2.20 2.43 GH Reduction Median % Reduction - 75.5 78.2 75.5 IGF-1 Normal 3 Number of Responders (%) 9 (8%) 58 (54%) 57 (54%) 62 (58%) Median IGF-1 ng/mL 775.0 332.0 1 316.5 2 326.0 IGF-1 Reduction Median % Reduction - 52.3 1 54.5 2 55.4 IGF-1 Normal 3  + GH ≤2.5 ng/mL Number of Responders (%) 0 (0%) 41 (38%) 46 (44%) 44 (41%) Study 2 This was a 48-week, open-label, uncontrolled, multicenter study that enrolled patients who had an IGF- 1 concentration 1.3 times or greater than the upper limit of the normal age- adjusted range. Patients receiving treatment with a somatostatin analog (other than Lanreotide Injection) or a dopaminergic agonist had to attain this IGF-1 concentration after a washout period of up to 3 months. Patients were initially enrolled in a 4-month, fixed-dose phase where they received 4 deep subcutaneous injections of Lanreotide Injection 90 mg, at 4-week intervals. Patients then entered a dose-titration phase where the dose of Lanreotide Injection was adjusted based on GH and IGF-1 levels at the beginning of the dose-titration phase and, if necessary, again after another 4 injections. Patients titrated up to the maximum dose (120 mg) were not allowed to titrate down again. A total of 63 patients (38 males, 25 females) entered the fixed-dose phase of the trial and 57 patients completed 48 weeks of treatment. Six patients withdrew due to adverse reactions (3), other reasons (2), or lack of efficacy (1). After 48 weeks of treatment with Lanreotide Injection at 4-week intervals, 43% (27/63) of the acromegalic patients in this study achieved normal age-adjusted IGF-1 concentrations. Mean IGF-1 concentrations after treatment completion were 1.3 ± 0.7 times the upper limit of normal compared to  2.5 ± 1.1 times the upper limit of normal at baseline. The reduction in IGF-1 concentrations over time correlated with a corresponding marked decrease in mean GH concentrations. The proportion of patients with mean GH concentrations less than 2.5 ng/ mL increased significantly from 35% to 77% after the fixed- dose phase and 85% at the end of the study. At the end of treatment, 24/63 (38%) of patients had both normal IGF-1 concentrations and a GH concentration of less than or equal to 2.5 ng/mL (see Table 5) and 17/63 patients (27%) had both normal IGF-1 concentrations and a GH concentration of less than 1 ng/mL. Table 5: Overall Efficacy Results Based on GH and IGF-1 Levels by Treatment Phase in Study 2 1  Age-adjusted,  2 N= 62, * Last Observation Carried Forward Baseline N=63 Before Titration 1 (12 wks) N=63 Before Titration 2 (28 wks) N=59 Last Value Available* N=63 IGF-1 Normal 1 Number of Responders (%) 0 (0%) 17 (27%) 22 (37%) 27 (43%) Median IGF-1 ng/mL 689.0 382.0 334.0 317.0 IGF-1 Reduction Median % Reduction - 41.0 51.0 50.3 GH ≤5.0 ng/mL Number of Responders (%) 40 (64%) 59 (94%) 57 (97%) 62 (98%) ≤2.5 ng/mL Number of Responders (%) 21 (33%) 47 (75%) 47 (80%) 54 (86%) ≤1.0 ng/mL Number of Responders (%) 8 (13%) 19 (30%) 18 (31%) 28 (44%) Median GH ng/Ml 3.71 1.65 1.48 1.13 GH Reduction Median % Reduction - 63.2 66.7 78.6 2 IGF-1 normal 1  + GH ≤2.5 ng/mL Number of Responders (%) 0 (0%) 14 (22%) 20 (34%) 24 (38%) Examination of age and gender subgroups did not identify differences in response to Lanreotide Injection among these subgroups. The limited number of patients in the different racial subgroups did not raise any concerns regarding efficacy of Lanreotide Injection in these subgroups. The efficacy of Lanreotide Injection was established in a multicenter, randomized, double-blind, placebo-controlled trial of 204 patients with unresectable, well or moderately differentiated, metastatic or locally advanced, gastroenteropancreatic neuroendocrine tumors. Patients were required to have non-functioning tumors without hormone-related symptoms. Patients were randomized 1:1 to receive Lanreotide Injection 120 mg (n=101) or placebo (n=103) every 4 weeks until disease progression, unacceptable toxicity, or a maximum of 96 weeks of treatment. Randomization was stratified by the presence or absence of prior therapy and by the presence or absence of disease progression within 6 months of enrollment. The major efficacy outcome measure was progression-free survival (PFS), defined as time to disease progression as assessed by central independent radiological review using the Response Evaluation Criteria in Solid Tumors (RECIST 1.0) or death. The median patient age was 63 years (range 30 to 92 years) and 95% were Caucasian. Disease progression was present in nine of 204 patients (4.4%) in the 6 months prior to enrollment and 29 patients (14%) received prior chemotherapy. Ninety-one patients (45%) had primary sites of disease in the pancreas, with the remainder originating in the midgut (35%), hindgut (7%), or unknown primary location (13%). The majority (69%) of the study population had grade 1 tumors. Baseline prognostic characteristics were similar between arms with one exception; there were 39% of patients in the Lanreotide Injection arm and 27% of patients in the placebo arm who had hepatic involvement by tumor of greater than 25%. Patients on the Lanreotide Injection arm had a statistically significant improvement in PFS compared to patients receiving placebo (see Table 6 and Figure 1). Table 6: Efficacy Results in Study 3 1  NE = not reached at 22 months 2  Hazard Ratio is derived from a Cox stratified proportional hazards model LANREOTIDE ACETATE Placebo n=101 n=103       Number of Events (%) 32 (31.7%) 60 (58.3%)       Median PFS (months)(95% CI) NE1 (NE, NE) 16.6 (11.2, 22.1)       HR (95% CI) 0.47 (0.30, 0.73) 2       Log-rank p-value <0.001 Figure 1: Kaplan-Meier Curves of Progression-Free Survival Figure 1

Patient Information Lanreotide (lan-REE-oh-tide) (lanreotide) injection Read this Patient Information before you receive your first Lanreotide Injection and before each injection. There may be new information. This information does not take the place of talking with your healthcare provider about your medical condition or your treatment. What is Lanreotide injection? Lanreotide injection is a prescription medicine used for: the long-term treatment of people with acromegaly when: surgery or radiotherapy have not worked well enough or they are not able to have surgery or radiotherapy. the treatment of adults with a type of cancer known as neuroendocrine tumors, from the gastrointestinal tract or the pancreas (GEP-NETs) that has spread or cannot be removed by surgery. It is not known if Lanreotide injection is safe and effective in children. Who should not receive Lanreotide injection? Do not receive Lanreotide injection if  you are allergic to lanreotide. What should I tell my healthcareproviderbeforereceivingLanreotideInjection? Before you receive Lanreotide Injection, tell your healthcare provider about all of your medical conditions, including if you: have gallbladder problems have diabetes have heart problems have thyroid problems have kidney problems have liver problems are pregnant or plan to become pregnant. It is not known if Lanreotide injection will harm your unborn baby are breastfeeding or plan to breastfeed. It is not known if Lanreotide Injection passes into your breast milk. You should not breastfeed if you receive Lanreotide Injection and for 6 months after your last dose of Lanreotide Injection are a female who can become pregnant. Lanreotide Injection may affect fertility in females and may affect your ability to become pregnant. Talk to your healthcare provider if this is a concern for you Tell your healthcare provider about all the medicines you take , including prescription and over-the-counter medicines, vitamins, and herbal supplements. Lanreotide Injection and other medicines may affect each other, causing side effects. Lanreotide Injection may affect the way other medicines work, and other medicines may affect how Lanreotide Injection works. Your dose of Lanreotide Injection or your other medicines may need to be changed. Especially tell your healthcare provider if you take: insulin or other diabetes medicines cyclosporine (Gengraf, Neoral, or Sandimmune) medicines that lower your heart rate such as beta blockers How will I receive Lanreotide injection? You will receive a Lanreotide Injection every 4 weeks in your healthcare provider’s office Your healthcare provider may change your dose of Lanreotide Injection or the length of time between your injections. Your healthcare provider will tell you how long you need to receive Lanreotide Injection Lanreotide Injection is injected deep under the skin of the upper outer area of your buttock. Your injection site should change (alternate) between your right and left buttock from one injection of Lanreotide Injection to the next During your treatment with Lanreotide Injection for acromegaly, your healthcare provider may do certain blood tests to see if Lanreotide Injection is working What should I avoid while receiving Lanreotide injection? Lanreotide injection can cause dizziness. If you have dizziness, do not drive a car or operate machinery. What are the possible side effects of Lanreotide Injection? Lanreotide Injection may cause serious side effects, including: Gallstones (cholelithiasis) and complications that can happen if you have gallstones. Gallstones are a serious but common side effect in people who take Lanreotide Injection and have acromegaly and GEP-NET. Your healthcare provider may check your gallbladder before and during treatment with Lanreotide Injection. Possible complications of gallstones include inflammation and infection of the gall bladder, and pancreatitis. Tell your healthcare provider if you get any symptoms of gallstones, including:      ⚬ sudden pain in your upper right stomach area (abdomen)      ⚬ yellowing of your skin and whites of your eyes      ⚬ nausea         ⚬ sudden pain in your right shoulder between your shoulder blades      ⚬ fever with chills Changes in your blood sugar  (high blood sugar or low blood sugar). If you have diabetes, test your blood sugar as your healthcare provider tells you to. Your healthcare provider may change your dose of diabetes medicine especially when you first start receiving Lanreotide Injection or if your dose of Lanreotide Injection changes. High blood sugar is a common side effect in people with GEP-NET.     Tell your healthcare provider right away if you have any signs or symptoms of high blood sugar or low blood sugar. Signs and symptoms of high blood sugar may include:      ⚬ increased thirst      ⚬ increased appetite      ⚬ nausea         ⚬ weakness or tiredness      ⚬ urinating more often than normal      ⚬ your breath smells like fruit Signs and symptoms of low blood sugar may include:       ⚬ dizziness or lightheadedness      ⚬ blurred vision      ⚬ fast heartbeat      ⚬ sweating      ⚬ slurred speech      ⚬ irritability or mood changes      ⚬ confusion      ⚬ shakiness      ⚬ hunger      ⚬ headache Slow heart rate.  Tell your healthcare provider right away if you have slowing of your heart rate or if you have symptoms of a slow heart rate, including:      ⚬ dizziness or lightheadedness      ⚬ fainting or near-fainting      ⚬ chest pain      ⚬ shortness of breath      ⚬ confusion or memory problems      ⚬ weakness, extreme tiredness High blood pressure. High blood pressure can happen in people who receive Lanreotide Injection and is a common side effect in people with GEP-NET. Changes in thyroid function.  Lanreotide Injection can cause the thyroid gland to not make enough thyroid hormones that the body needs (hypothyroidism) in people who have acromegaly. Tell your healthcare provider if you have signs and symptoms of low thyroid hormones levels, including:      ⚬ fatigue      ⚬ weight gain      ⚬ a puffy face      ⚬ being cold all of the time      ⚬ constipation      ⚬ dry skin      ⚬ thinning, dry hair      ⚬ decreased sweating      ⚬ depression The most common side effects of Lanreotide Injection in people with acromegaly include:      • diarrhea      • stomach area (abdominal) pain      • nausea      • pain, itching, or a lump at the injection site The most common side effects of Lanreotide Injection in people with GEP-NETinclude:      • stomach area (abdominal) pain      • muscle and joint aches      • vomiting      • headache      • pain, itching, or a lump at the injection site Tell your healthcare provider right away if you have signs of an allergic reaction after receiving Lanreotide Injection, including:      • swelling of your face, lips, mouth or tongue      • breathing problems      • fainting, dizziness, feeling lightheaded (low blood pressure)      • itching      • flushing or redness of your skin      • rash      • hives These are not all the possible side effects of Lanreotide Injection. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. General information about the safe and effective use of Lanreotide Injection. Medicines are sometimes prescribed for purposes other than those listed in a Patient Information leaflet. Do not receive Lanreotide Injection for a condition for which it was not prescribed. You can ask your healthcare provider for information about Lanreotide Injection that is written for health professionals. What are the ingredients in Lanreotide Injection? Active ingredient:  lanreotide acetate Inactive ingredients:  water for injection and acetic acid (for pH adjustment) Manufactured by: Pharmathen International S.A., Rodopi, Greece Manufactured for: Cipla USA, Inc., 10 Independence Boulevard, Suite 300, Warren, NJ 07059 For more information, go to www.ciplausa.com or call Cipla Ltd. at 1-866-604-3268 Issued: 04/2024 This Patient Information has been approved by the U.S. Food and Drug Administration. SAP Code: 99349731

Rx Only NDC 69097-907-67 Lanreotide Injection 60 mg*/0.2 mL For deep subcutaneous injection For Single dose only. Discard unused portion. Lanreotide Injection should be administered by a healthcare professional. Leave at room temperature for 30 minutes before administration. Cipla Carton Label Pouch Label Pouch Sticker Label Syringe Label Rx Only NDC 69097-908-67 Lanreotide Injection 90 mg*/0.3 mL For deep subcutaneous injection For Single dose only. Discard unused portion. Lanreotide Injection should be administered by a healthcare professional. Leave at room temperature for 30 minutes before administration. Cipla Carton Label Pouch Label Pouch Sticker Label Syringe Label Rx Only NDC 69097-906-67 Lanreotide Injection 120 mg*/0.5 mL For deep subcutaneous injection For Single dose only. Discard unused portion. Lanreotide Injection should be administered by a healthcare professional. Leave at room temperature for 30 minutes before administration. Cipla Carton Label Pouch Label Pouch Sticker Label Syringe Label carton label_60mg pouch label_60mg pouch sticker label_60mg syringe label_60mg carton label_90mg pouch label_90mg pouch sticker label_90mg syringe label_90mg carton label_120mg pouch label_120mg pouch sticker label_120mg syringe label_120mg