MYFORTIC - mycophenolic acid tablet, delayed release 
Novartis Pharmaceuticals Corporation

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Myfortic®
(mycophenolic acid*)
delayed-release tablets
*as mycophenolate sodium
Rx only
Prescribing Information

DESCRIPTION

Myfortic® (mycophenolic acid) delayed-release tablets are an enteric formulation of mycophenolate sodium that delivers the active moiety mycophenolic acid (MPA). Myfortic is an immunosuppressive agent. As the sodium salt, MPA is chemically designated as (E)-6-(4-hydroxy-6-methoxy-7-methyl-3-oxo-1,3-dihydroisobenzofuran-5-yl)-4-methylhex-4-enoic acid sodium salt.

Its empirical formula is C17H19O6Na. The molecular weight is 342.32 and the structural formula is

Myfortic, as the sodium salt, is a white to off-white, crystalline powder and is highly soluble in aqueous media at physiological pH and practically insoluble in 0.1 N hydrochloric acid.

Myfortic is available for oral use as delayed-release tablets containing either 180 mg or 360 mg of mycophenolic acid. Inactive ingredients include colloidal silicon dioxide, crospovidone, lactose anhydrous, magnesium stearate, povidone (K-30), and starch. The enteric coating of the tablet consists of hypromellose phthalate, titanium dioxide, iron oxide yellow, and indigotine (180 mg) or iron oxide red (360 mg).

CLINICAL PHARMACOLOGY

Mechanism of Action

MPA is an uncompetitive and reversible inhibitor of inosine monophosphate dehydrogenase (IMPDH), and therefore inhibits the de novo pathway of guanosine nucleotide synthesis without incorporation to DNA. Because T- and B-lymphocytes are critically dependent for their proliferation on de novo synthesis of purines, whereas other cell types can utilize salvage pathways, MPA has potent cytostatic effects on lymphocytes.

Mycophenolate sodium has been shown to prevent the occurrence of acute rejection in rat models of kidney and heart allotransplantation. Mycophenolate sodium also decreases antibody production in mice.

Pharmacokinetics

Absorption

In-vitro studies demonstrated that the enteric-coated Myfortic® (mycophenolic acid) tablet does not release MPA under acidic conditions (pH <5) as in the stomach but is highly soluble in neutral pH conditions as in the intestine. Following Myfortic oral administration without food in several pharmacokinetic studies conducted in renal transplant patients, consistent with its enteric-coated formulation, the median delay (Tlag) in the rise of MPA concentration ranged between 0.25 and 1.25 hours and the median time to maximum concentration (Tmax) of MPA ranged between 1.5 and 2.75 hours. In comparison, following the administration of mycophenolate mofetil, the median Tmax ranged between 0.5 and 1.0 hours. In stable renal transplant patients on cyclosporine, USP (MODIFIED) based immunosuppression, gastrointestinal absorption and absolute bioavailability of MPA following the administration of Myfortic delayed-release tablet was 93% and 72%, respectively. Myfortic pharmacokinetics is dose proportional over the dose range of 360 to 2160 mg.

Distribution

The mean (± SD) volume of distribution at steady state and elimination phase for MPA is 54 (± 25) L and 112 (± 48) L, respectively. MPA is highly protein bound to albumin, >98%. The protein binding of mycophenolic acid glucuronide (MPAG) is 82%. The free MPA concentration may increase under conditions of decreased protein binding (uremia, hepatic failure, and hypoalbuminemia).

Metabolism

MPA is metabolized principally by glucuronyl transferase to glucuronidated metabolites. The phenolic glucuronide of MPA, mycophenolic acid glucuronide (MPAG), is the predominant metabolite of MPA and does not manifest pharmacological activity. The acyl glucuronide is a minor metabolite and has comparable pharmacological activity to MPA. In stable renal transplant patients on cyclosporine, USP (MODIFIED) based immunosuppression, approximately 28% of the oral Myfortic dose was converted to MPAG by presystemic metabolism. The AUC ratio of MPA:MPAG:acyl glucuronide is approximately 1:24:0.28 at steady state. The mean clearance of MPA was 140 (± 30) mL/min.

Elimination

The majority of MPA dose administered is eliminated in the urine primarily as MPAG (>60%) and approximately 3% as unchanged MPA following Myfortic administration to stable renal transplant patients. The mean renal clearance of MPAG was 15.5 (± 5.9) mL/min. MPAG is also secreted in the bile and available for deconjugation by gut flora. MPA resulting from the deconjugation may then be reabsorbed and produce a second peak of MPA approximately 6–8 hours after Myfortic dosing. The mean elimination half-life of MPA and MPAG ranged between 8 and 16 hours, and 13 and 17 hours, respectively.

Food Effect

Compared to the fasting state, administration of Myfortic 720 mg with a high-fat meal (55 g fat, 1000 calories) had no effect on the systemic exposure (AUC) of MPA. However, there was a 33% decrease in the maximal concentration (Cmax), a 3.5-hour delay in the Tlag (range, -6 to 18 hours), and 5.0-hour delay in the Tmax (range, -9 to 20 hours) of MPA. To avoid the variability in MPA absorption between doses, Myfortic should be taken on an empty stomach (see DOSAGE AND ADMINISTRATION and PRECAUTIONS, Information for Patients).

Pharmacokinetics in Renal Transplant Patients

The mean pharmacokinetic parameters for MPA following the administration of Myfortic in renal transplant patients on cyclosporine, USP (MODIFIED) based immunosuppression are shown in Table 1. Single-dose Myfortic pharmacokinetics predicts multiple-dose pharmacokinetics. However, in the early posttransplant period, mean MPA AUC and Cmax were approximately one-half of those measured 6 months posttransplant.

After near equimolar dosing of Myfortic 720 mg BID and mycophenolate mofetil 1000 mg BID (739 mg as MPA) in both the single- and multiple-dose cross-over trials, mean systemic MPA exposure (AUC) was similar.

Table 1 Mean ± SD Pharmacokinetic Parameters for MPA Following the Oral Administration of Myfortic® to Renal Transplant Patients on Cyclosporine, USP (MODIFIED) Based Immunosuppression

Study Patient	Myfortic® Dosing	n	Dose (mg)	Tmax* (hr)	Cmax (µg/mL)	AUC0-12hr (µg*hr/mL)
Adult	Single	24	720	2 (0.8 – 8)	26.1 ± 12.0	66.5 ± 22.6**
Pediatric***	Single	10	450 /m2	2.5 (1.5 – 24)	36.3 ± 20.9	74.3 ± 22.5**
Adult	Multiple x 6 days, BID	10	720	2 (1.5 – 3.0)	37.0 ± 13.3	67.9 ± 20.3
Adult	Multiple x 28 days, BID	36	720	2.5 (1.5 – 8)	31.2 ± 18.1	71.2 ± 26.3
Adult	Chronic, multiple dose, BID
	2 weeks posttransplant	12	720	1.8 (1.0 – 5.3)	15.0 ± 10.7	28.6 ± 11.5
	3 months posttransplant	12	720	2 (0.5 – 2.5)	26.2 ± 12.7	52.3 ± 17.4
	6 months posttransplant	12	720	2 (0 – 3)	24.1 ± 9.6	57.2 ± 15.3
Adult	Chronic, multiple dose, BID	18	720	1.5 (0 – 6)	18.9 ± 7.9	57.4 ± 15.0
*median (range), ** AUC0-∞, *** age range of 5-16 years

Special Populations

Renal Insufficiency: No specific pharmacokinetic studies in individuals with renal impairment were conducted with Myfortic. However, based on studies of renal impairment with mycophenolate mofetil, MPA exposure is not expected to be appreciably increased over the range of normal to severely impaired renal function following Myfortic administration. In contrast, MPAG exposure would be increased markedly with decreased renal function; MPAG exposure being approximately 8-fold higher in the setting of anuria. Although dialysis may be used to remove the inactive metabolite MPAG, it would not be expected to remove clinically significant amounts of the active moiety MPA. This is in large part due to the high plasma protein binding of MPA.

Hepatic Insufficiency: No specific pharmacokinetic studies in individuals with hepatic impairment were conducted with Myfortic. In a single dose (mycophenolate mofetil 1000 mg) study of 18 volunteers with alcoholic cirrhosis and 6 healthy volunteers, hepatic MPA glucuronidation processes appeared to be relatively unaffected by hepatic parenchymal disease when the pharmacokinetic parameters of healthy volunteers and alcoholic cirrhosis patients within this study were compared. However, it should be noted that for unexplained reasons, the healthy volunteers in this study had about a 50% lower AUC compared to healthy volunteers in other studies, thus making comparison between volunteers with alcoholic cirrhosis and health volunteers difficult. Effects of hepatic disease on this process probably depend on the particular disease. Hepatic disease, such as primary biliary cirrhosis, with other etiologies may show a different effect.

Pediatrics: Limited data are available on the use of Myfortic at a dose of 450 mg/m2 body surface area in children. The mean MPA pharmacokinetic parameters for stable pediatric renal transplant patients, 5–16 years, on cyclosporine, USP (MODIFIED) are shown in Table 1. At the same dose administered based on body surface area, the respective mean Cmax and AUC of MPA determined in children were higher by 33% and 18% than those determined for adults. The clinical impact of the increase in MPA exposure is not known.

Gender: There are no significant gender differences in Myfortic pharmacokinetics.

Elderly: Pharmacokinetics in the elderly have not been formally studied.

CLINICAL STUDIES

The safety and efficacy of Myfortic® (mycophenolic acid) in combination with cyclosporine, USP (MODIFIED) and corticosteroids for the prevention of organ rejection was assessed in two multicenter, randomized, double-blind trials in de novo and maintenance renal transplant patients compared to mycophenolate mofetil.

The de novo study was conducted in 423 renal transplant patients (ages 18-75 years) in Austria, Canada, Germany, Hungary, Italy, Norway, Spain, UK and USA. Cadaveric donor specimens accounted for 84% of randomized patients. Patients were administered either Myfortic 1.44 g/day or mycophenolate mofetil 2 g/day within 48 hours posttransplant for 12 months in combination with cyclosporine, USP (MODIFIED) and corticosteroids. Forty-one percent of patients received antibody therapy as induction treatment. Treatment failure was defined as the first occurrence of biopsy-proven acute rejection, graft loss, death or lost to follow-up at 6 months. The incidence of treatment failure was similar in Myfortic- and mycophenolate mofetil-treated patients at 6 and 12 months (Table 2). The cumulative incidence of graft loss, death and lost to follow-up at 12 months is also given in Table 2.

Table 2 Treatment Failure in de novo Renal Transplant Patients (Percent of Patients) at 6 and 12 Months of Treatment when Administered in Combination with Cyclosporine* and Corticosteroids

	Myfortic® 1.44 g/day (n=213)	mycophenolate mofetil 2 g/day (n=210)
6 Months	n (%)	n (%)
Treatment failure#	55 (25.8)	55 (26.2)
Biopsy-proven acute rejection	46 (21.6)	48 (22.9)
Graft loss	7 (3.3)	9 (4.3)
Death	1 (0.5)	2 (1.0)
Lost to follow-up**	3 (1.4)	0
12 Months	n (%)	n (%)
Graft loss or death or lost to follow-up***	20 (9.4)	18 (8.6)
Treatment failure	61 (28.6)	59 (28.1)
Biopsy-proven acute rejection	48 (22.5)	51 (24.3)
Graft loss	9 (4.2)	9 (4.3)
Death	2 (0.9)	5 (2.4)
Lost to follow-up**	5 (2.3)	0
*USP (MODIFIED) **Lost to follow-up indicates patients who were lost to follow-up without prior biopsy-proven acute rejection, graft loss or death ***Lost to follow-up indicates patients who were lost to follow-up without prior graft loss or death (9 Myfortic patients and 4 mycophenolate mofetil patients) #95% confidence interval of the difference in treatment failure at 6 months (Myfortic – mycophenolate mofetil) is (-8.7%, 8.0%).

The maintenance study was conducted in 322 renal transplant patients (ages 18–75 years), who were at least 6 months posttransplant receiving 2 g/day mycophenolate mofetil in combination with cyclosporine USP (MODIFIED), with or without corticosteroids for at least two weeks prior to entry in the study. Patients were randomized to Myfortic 1.44 g/day or mycophenolate mofetil 2 g/day for 12 months. The study was conducted in Austria, Belgium, Canada, Germany, Italy, Spain, and USA. Treatment failure was defined as the first occurrence of biopsy-proven acute rejection, graft loss, death, or lost to follow-up at 6 and 12 months. The incidences of treatment failure at 6 and 12 months were similar between Myfortic- and mycophenolate mofetil-treated patients (Table 3). The cumulative incidence of graft loss, death and lost to follow-up at 12 months is also given in Table 3.

Table 3 Treatment Failure in Maintenance Transplant Patients (Percent of Patients) at 6 and 12 Months of Treatment when Administered in Combination with Cyclosporine* and with or without Corticosteroids

	Myfortic® 1.44 g/day (n = 159)	mycophenolate mofetil 2 g/day (n = 163)
6 Months	n (%)	n (%)
Treatment failure#	7 (4.4)	11 (6.7)
Biopsy-proven acute rejection	2 (1.3)	2 (1.2)
Graft loss	0	1 (0.6)
Death	0	1 (0.6)
Lost to follow-up**	5 (3.1)	7 (4.3)
12 Months	n (%)	n (%)
Graft loss or death or lost to follow-up***	10 (6.3)	17 (10.4)
Treatment failure	12 (7.5)	20 (12.3)
Biopsy-proven acute rejection	2 (1.3)	5 (3.1)
Graft loss	0	1 (0.6)
Death	2 (1.3)	4 (2.5)
Lost to follow-up**	8 (5.0)	10 (6.1)
*USP (MODIFIED) **Lost to follow-up indicates patients who were lost to follow-up without prior biopsy-proven acute rejection, graft loss, or death ***Lost to follow-up indicates patients who were lost to follow-up without prior graft loss or death (8 Myfortic patients and 12 mycophenolate mofetil patients) #95% confidence interval of the difference in treatment failure at 6 months (Myfortic – mycophenolate mofetil) is (-7.4%, 2.7%).

The safety and efficacy of Myfortic has not been studied in hepatic or cardiac transplant trials.

INDICATIONS AND USAGE

Myfortic® (mycophenolic acid) delayed-release tablets are indicated for the prophylaxis of organ rejection in patients receiving allogeneic renal transplants, administered in combination with cyclosporine and corticosteroids.

CONTRAINDICATIONS

Myfortic® (mycophenolic acid) is contraindicated in patients with a hypersensitivity to mycophenolate sodium, mycophenolic acid, mycophenolate mofetil, or to any of its excipients.

WARNINGS (SEE BOXED WARNING)

Lymphoma and Other Malignancies

Patients receiving immunosuppressive regimens involving combinations of drugs, including Myfortic® (mycophenolic acid), as part of an immunosuppressive regimen are at increased risk of developing lymphomas and other malignancies, particularly of the skin (see ADVERSE REACTIONS). The risk appears to be related to the intensity and duration of immunosuppression rather than to the use of any specific agent.

The rates for lymphoproliferative disease or lymphoma in Myfortic-treated patients were comparable to the mycophenolate mofetil group in the de novo and maintenance studies (see ADVERSE REACTIONS). As usual for patients with increased risk for skin cancer, exposure to sunlight and UV light should be limited by wearing protective clothing and using a sunscreen with a high protection factor.

Infections

Oversuppression of the immune system can also increase susceptibility to infection, including opportunistic infections, fatal infections, and sepsis. Fatal infections can occur in patients receiving immunosuppressive therapy (see ADVERSE REACTIONS).

Latent Viral Infections

Immunosuppressed patients are at increased risk for opportunistic infections, including activation of latent viral infections. These include cases of progressive multifocal leukoencephalopathy (PML) and BK virus-associated nephropathy (BKVAN) which have been observed in patients receiving immunosuppressants, including Myfortic.

Cases of progressive multifocal leukoencephalopathy (PML), sometimes fatal, have been reported in patients treated with mycophenolate mofetil (MMF). Hemiparesis, apathy, confusion, cognitive deficiencies and ataxia were the most frequent clinical features observed. Mycophenolate mofetil (MMF) is metabolized to mycophenolic acid (MPA), the active ingredient in Myfortic and the active form of the drug. The reported cases generally had risk factors for PML, including treatment with immunosuppressant therapies and impairment of immune functions. In immunosuppressed patients, physicians should consider PML in the differential diagnosis in patients reporting neurological symptoms and consultation with a neurologist should be considered as clinically indicated. Consideration should be given to reducing the amount of immunosuppression in patients who develop PML. In transplant patients, physicians should also consider the risk that reduced immunosuppression represents to the graft.

BKVAN is associated with serious outcomes, including deteriorating renal function and renal graft loss (see ADVERSE REACTIONS, Postmarketing Experience). Patient monitoring may help detect patients at risk for BK virus-associated nephropathy. Reduction in immunosuppression should be considered for patients who develop evidence of BK virus-associated nephropathy.

Pure Red Cell Aplasia

Cases of pure red cell aplasia (PRCA) have been reported in patients treated with mycophenolate mofetil (MMF) in combination with other immunosuppressive agents. MMF is metabolized to mycophenolic acid (MPA), the active ingredient in Myfortic and the active form of the drug. The mechanism for MMF induced PRCA is unknown; the relative contribution of other immunosuppressants and their combinations in an immunosuppressive regimen are also unknown. In some cases PRCA was found to be reversible with dose reduction or cessation of MMF therapy. In transplant patients, however, reduced immunosuppression may place the graft at risk. Changes to Myfortic therapy should only be undertaken under appropriate supervision in transplant recipients in order to minimize the risk of graft rejection (see ADVERSE REACTIONS, Postmarketing Experience).

Concomitant Use

Myfortic has been administered in combination with the following agents in clinical trials: antithymocyte/lymphocyte immunoglobulin, muromonab-CD3, basiliximab, daclizumab, cyclosporine, and corticosteroids. The efficacy and safety of Myfortic in combination with other immunosuppression agents have not been determined.

Pregnancy: Teratogenic Effects: Pregnancy Category D

Mycophenolate mofetil (MMF) can cause fetal harm when administered to a pregnant woman. Following oral or IV administration, MMF is metabolized to mycophenolic acid (MPA), the active ingredient in Myfortic and the active form of the drug. Use of Myfortic during pregnancy is associated with an increased risk of first trimester pregnancy loss and an increased risk of congenital malformations, especially external ear and other facial abnormalities including cleft lip and palate, and anomalies of the distal limbs, heart, esophagus, and kidney. In the National Transplantation Pregnancy Registry (NTPR), there were data on 33 MMF-exposed pregnancies in 24 transplant patients; there were 15 spontaneous abortions (45%) and 18 live-born infants. Four of these 18 infants had structural malformations (22%). In postmarketing data (collected from 1995 to 2007) on 77 women exposed to systemic MMF during pregnancy, 25 had spontaneous abortions and 14 had a malformed infant or fetus. Six of 14 malformed offspring had ear abnormalities. Because these postmarketing data are reported voluntarily, it is not always possible to reliably estimate the frequency of particular adverse outcomes. These malformations are similar to findings in animal reproductive toxicology studies. For comparison, the background rate for congenital anomalies in the United States is about 3%, and NTPR data show a rate of 4-5% among babies born to organ transplant patients using other immunosuppressive drugs.

In a teratology study performed with mycophenolate sodium in rats, at a dose as low as 1 mg/kg, malformations in the offspring were observed, including anophthalmia, exencephaly and umbilical hernia. The systemic exposure at this dose represents 0.05 times the clinical exposure at the dose of 1.44 g/day Myfortic. In teratology studies in rabbits, fetal resorptions and malformations occurred from 80 mg/kg/day, in the absence of maternal toxicity (dose levels are equivalent to about 0.8 times the recommended clinical dose, corrected for BSA). There are no relevant qualitative or quantitative differences in the teratogenic potential of mycophenolate sodium and mycophenolate mofetil.

If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to the fetus. In certain situations, the patient and her healthcare practitioner may decide that the maternal benefits outweigh the risks to the fetus. Women using Myfortic at any time during pregnancy should be encouraged to enroll in the National Transplantation Pregnancy Registry.

Pregnancy Exposure Prevention

Women of childbearing potential should have a negative serum or urine pregnancy test with a sensitivity of at least 25 mIU/mL within 1 week prior to beginning therapy. Myfortic therapy should not be initiated until a negative pregnancy test report is obtained.

Women of childbearing potential (including pubertal girls and perimenopausal women) taking Myfortic must receive contraceptive counseling and use effective contraception. The patient should begin using her two chosen methods of contraception 4 weeks prior to starting Myfortic therapy, unless abstinence is the chosen method. She should continue contraceptive use during therapy and for 6 weeks after stopping Myfortic. Patients should be aware that Myfortic reduces blood levels of the hormones in the oral contraceptive pill and could theoretically reduce its effectiveness (see PRECAUTIONS, Information for Patients and PRECAUTIONS, Drug Interactions, Oral Contraceptives).

 

Patients receiving Myfortic should be monitored for neutropenia (see PRECAUTIONS, Laboratory Tests). The development of neutropenia may be related to Myfortic itself, concomitant medications, viral infections, or some combination of these events. If neutropenia develops (ANC <1.3×103/µL), dosing with Myfortic should be interrupted or the dose reduced, appropriate diagnostic tests performed, and the patient managed appropriately (see DOSAGE AND ADMINISTRATION).

Patients receiving Myfortic should be instructed to immediately report any evidence of infection, unexpected bruising, bleeding, or any other manifestation of bone marrow suppression.

PRECAUTIONS

General

Gastrointestinal bleeding (requiring hospitalization) has been reported in de novo renal transplant patients (1.0%) and maintenance patients (1.3%) treated with Myfortic® (mycophenolic acid) (up to 12 months). Intestinal perforations, gastrointestinal hemorrhage, gastric ulcers and duodenal ulcers have rarely been observed. Most patients receiving Myfortic were also receiving other drugs known to be associated with these complications. Patients with active peptic ulcer disease were excluded from enrollment in studies with Myfortic. Because MPA derivatives have been associated with an increased incidence of digestive system adverse events, including infrequent cases of gastrointestinal tract ulceration, hemorrhage, and perforation, Myfortic should be administered with caution in patients with active serious digestive system disease (see ADVERSE REACTIONS).

Subjects with severe chronic renal impairment (GFR <25 mL/min/1.73 m2) may present higher plasma MPA and MPAG AUCs relative to subjects with lesser degrees of renal impairment or normal healthy volunteers. No data are available on the safety of long-term exposure to these levels of MPAG.

In the de novo study, 18.3% of Myfortic patients versus 16.7% in the mycophenolate mofetil group experienced delayed graft function (DGF). Although patients with DGF experienced a higher incidence of certain adverse events (anemia, leukopenia, and hyperkalemia) than patients without DGF, these events in DGF patients were not more frequent in patients receiving Myfortic compared to mycophenolate mofetil. No dose adjustment is recommended for these patients; however, such patients should be carefully observed (see CLINICAL PHARMACOLOGY and DOSAGE AND ADMINISTRATION).

In view of the significant reduction in the AUC of MPA by cholestyramine when administered with mycophenolate mofetil, caution should be used in the concomitant administration of Myfortic with drugs that interfere with enterohepatic recirculation because of the potential to reduce the efficacy (see PRECAUTIONS, Drug Interactions).

On theoretical grounds, because Myfortic is an IMPDH Inhibitor, it should be avoided in patients with rare hereditary deficiency of hypoxanthine-guanine phosphoribosyl-transferase (HGPRT) such as Lesch-Nyhan and Kelley-Seegmiller syndrome.

During treatment with Myfortic, the use of live attenuated vaccines should be avoided and patients should be advised that vaccinations may be less effective (see PRECAUTIONS, Drug Interactions, Live Vaccines).

Information for Patients

• It is recommended that Myfortic be administered on an empty stomach, one hour before or two hours after food intake (see DOSAGE AND ADMINISTRATION).
  
• In order to maintain the integrity of the enteric coating of the tablet, patients should be instructed not to crush, chew, or cut Myfortic tablets and to swallow the tablets whole.
  
• Give patients complete dosage instructions and inform them about the increased risk of lymphoproliferative disease and certain other malignancies.
  
• Inform patients that they need repeated appropriate laboratory tests while they are taking Myfortic.
  
• Inform women of childbearing potential that use of Myfortic in pregnancy is associated with an increased risk of first trimester pregnancy loss and an increased risk of birth defects, and that they must use effective contraception.
  
• Discuss pregnancy plans with female patients of childbearing potential.
  
• Any female of childbearing potential must use highly effective (two methods) contraception 4 weeks prior to starting Myfortic therapy and continue contraception until 6 weeks after stopping Myfortic treatment, unless abstinence is the chosen method (see WARNINGS, Pregnancy).
  
• A patient who is planning a pregnancy should not use Myfortic unless she can not be successfully treated with other immunosuppressant drugs. Risks and benefits of Myfortic and alternative immunosuppressants should be discussed with the patient.

Laboratory Tests

Complete blood count should be performed weekly during the first month, twice monthly for the second and the third month of treatment, then monthly through the first year. If neutropenia develops (ANC <1.3×103/µL), dosing with Myfortic should be interrupted or the dose reduced, appropriate tests performed, and the patient managed accordingly (see WARNINGS).

Drug Interactions

The following drug interaction studies have been conducted with Myfortic:

Antacids: Absorption of a single dose of Myfortic was decreased when administered to 12 stable renal transplant patients also taking magnesium-aluminum-containing antacids (30 mL): the mean Cmax and AUC(0-t) values for MPA were 25% and 37% lower, respectively, than when Myfortic was administered alone under fasting conditions. It is recommended that Myfortic and antacids not be administered simultaneously.

Cyclosporine: When studied in stable renal transplant patients, cyclosporine, USP (MODIFIED) pharmacokinetics were unaffected by steady-state dosing of Myfortic.

The following recommendations are derived from drug interaction studies conducted following the administration of mycophenolate mofetil:

Acyclovir/Ganciclovir: May be taken with Myfortic; however, during the period of treatment, physicians should monitor blood cell counts. Both acyclovir/ganciclovir and MPAG concentrations are increased in the presence of renal impairment, their coexistence may compete for tubular secretion and further increase in the concentrations of the two.

Azathioprine/Mycophenolate Mofetil: Given that azathioprine and mycophenolate mofetil inhibit purine metabolism, it is recommended that Myfortic not be administered concomitantly with azathioprine or mycophenolate mofetil.

Cholestyramine and Drugs that Bind Bile Acids: These drugs interrupt enterohepatic recirculation and reduce MPA exposure when coadministered with mycophenolate mofetil. Therefore, do not administer Myfortic with cholestyramine or other agents that may interfere with enterohepatic recirculation or drugs that may bind bile acids, for example bile acid sequestrates or oral activated charcoal, because of the potential to reduce the efficacy of Myfortic.

Oral Contraceptives: Given the different metabolism of Myfortic and oral contraceptives, no drug interaction between these two classes of drug is expected. However, in a drug-drug interaction study, mean levonorgesterol AUC was decreased by 15% when coadministered with mycophenolate mofetil. Therefore, it is recommended that oral contraceptives are coadministered with Myfortic with caution and additional birth control methods be considered (see PRECAUTIONS, Pregnancy).

Live Vaccines: During treatment with Myfortic, the use of live attenuated vaccines should be avoided and patients should be advised that vaccinations may be less effective. Influenza vaccination may be of value. Prescribers should refer to national guidelines for influenza vaccination (see PRECAUTIONS, General).

Drugs that alter the gastrointestinal flora may interact with Myfortic by disrupting enterohepatic recirculation. Interference of MPAG hydrolysis may lead to less MPA available for absorption.

Carcinogenesis, Mutagenesis, Impairment of Fertility

In a 104-week oral carcinogenicity study in rats, mycophenolate sodium was not tumorigenic at daily doses up to 9 mg/kg, the highest dose tested. This dose resulted in approximately 0.6-1.2 times the systemic exposure (based upon plasma AUC) observed in renal transplant patients at the recommended dose of 1.44 g/day. Similar results were observed in a parallel study in rats performed with mycophenolate mofetil. In a 104-week oral carcinogenicity study in mice, mycophenolate mofetil was not tumorigenic at a daily dose level as high as 180 mg/kg (which corresponds to 0.6 times the proposed mycophenolate sodium therapeutic dose based upon body surface area).

The genotoxic potential of mycophenolate sodium was determined in five assays. Mycophenolate sodium was genotoxic in the mouse lymphoma/thymidine kinase assay, the micronucleus test in V79 Chinese hamster cells, and the in-vivo mouse micronucleus assay. Mycophenolate sodium was not genotoxic in the bacterial mutation assay (Salmonella typhimurium TA 1535, 97a, 98, 100, & 102) or the chromosomal aberration assay in human lymphocytes. Mycophenolate mofetil generated similar genotoxic activity. The genotoxic activity of MPA is probably due to the depletion of the nucleotide pool required for DNA synthesis as a result of the pharmacodynamic mode of action of MPA (inhibition of nucleotide synthesis).

Mycophenolate sodium had no effect on male rat fertility at daily oral doses as high as 18 mg/kg and exhibited no testicular or spermatogenic effects at daily oral doses of 20 mg/kg for 13 weeks (approximately two-fold the therapeutic systemic exposure of MPA). No effects on female fertility were seen up to a daily dose of 20 mg/kg, which was approximately three-fold higher than the recommended therapeutic dose based upon systemic exposure.

Pregnancy

Teratogenic Effects: Pregnancy Category D. (See WARNINGS.)

Nursing Mothers

It is not known whether MPA is excreted in human milk. Because of the potential for serious adverse reactions in nursing infants from MPA, a decision should be made whether to discontinue the drug or to discontinue nursing while on treatment or within 6 weeks after stopping therapy, taking into account the importance of the drug to the mother.

Pediatric Use

De novo Renal Transplant

The safety and effectiveness of Myfortic in de novo pediatric renal transplant patients have not been established.

Stable Renal Transplant

There are no pharmacokinetic data available for pediatric patients <5 years. The safety and effectiveness of Myfortic have been established in the age group 5-16 years in stable pediatric renal transplant patients. Use of Myfortic in this age group is supported by evidence from adequate and well-controlled studies of Myfortic in stable adult renal transplant patients. Limited pharmacokinetic data are available for stable pediatric renal transplant patients in the age group 5-16 years. Pediatric doses for patients with BSA <1.19 m2 cannot be accurately administered using currently available formulations of Myfortic tablets (see CLINICAL PHARMACOLOGY, Special Populations and DOSAGE AND ADMINISTRATION).

Geriatric Use

Patients ≥65 years may generally be at increased risk of adverse drug reactions due to immunosuppression. Clinical studies of Myfortic did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. 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, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.

ADVERSE REACTIONS

The incidence of adverse events for Myfortic® (mycophenolic acid) was determined in randomized, comparative, active-controlled, double-blind, double-dummy trials in prevention of acute rejection in de novo and maintenance kidney transplant patients.

The principal adverse reactions associated with the administration of Myfortic include constipation, nausea, and urinary tract infection in de novo patients and nausea, diarrhea and nasopharyngitis in maintenance patients.

Adverse events reported in ≥20% of patients receiving Myfortic or mycophenolate mofetil in the 12-month de novo renal study and maintenance renal study, when used in combination with cyclosporine, USP (MODIFIED) and corticosteroids, are listed in Table 4. Adverse event rates were similar between Myfortic and mycophenolate mofetil in both de novo and maintenance patients.

Table 4 Adverse Events (%) in Controlled de novo and Maintenance Renal Studies Reported in ≥20% of Patients

	de novo Renal Study		Maintenance Renal Study
	Myfortic®  1.44 g/day (n=213)	mycophenolate mofetil 2 g/day (n=210)	Myfortic® 1.44 g/day (n=159)	mycophenolate mofetil 2 g/day (n=163)
Blood and Lymphatic System Disorders
Anemia	21.6	21.9	–	–
Leukopenia	19.2	20.5	–	–
Gastrointestinal System Disorders
Constipation	38.0	39.5	–	–
Nausea	29.1	27.1	24.5	19.0
Diarrhea	23.5	24.8	21.4	24.5
Vomiting	23.0	20.0	–	–
Dyspepsia	22.5	19.0	–	–
Infections and Infestations
Urinary Tract Infection	29.1	33.3	–	–
CMV Infection	20.2	18.1	–	–
Nervous System Disorder
Insomnia	23.5	23.8	–	–
Surgical and Medical Procedure
Postoperative Pain	23.9	18.6	–	–

Table 5 summarizes the incidence of opportunistic infections in de novo and maintenance transplant patients, which were similar in both treatment groups.

Table 5 Viral and Fungal Infections (%) Reported Over 0-12 Months

	de novo Renal Study		Maintenance Renal Study
	Myfortic® 1.44 g/day (n = 213)	mycophenolate mofetil 2 g/day (n = 210)	Myfortic® 1.44 g/day (n = 159)	mycophenolate mofetil 2 g/day (n = 163)
	(%)	(%)	(%)	(%)
Any Cytomegalovirus	21.6	20.5	1.9	1.8
- Cytomegalovirus Disease	4.7	4.3	0	0.6
Herpes Simplex	8.0	6.2	1.3	2.5
Herpes Zoster	4.7	3.8	1.9	3.1
Any Fungal Infection	10.8	11.9	2.5	1.8
- Candida NOS	5.6	6.2	0	1.8
- Candida Albicans	2.3	3.8	0.6	0

The following opportunistic infections occurred rarely in the above controlled trials: aspergillus and cryptococcus.

The incidence of malignancies and lymphoma is consistent with that reported in the literature for this patient population. Lymphoma developed in 2 de novo patients (0.9%), (one diagnosed 9 days after treatment initiation) and in 2 maintenance patients (1.3%) (one was AIDS-related), receiving Myfortic with other immunosuppressive agents in the 12-month controlled clinical trials. Nonmelanoma skin carcinoma occurred in 0.9% de novo and 1.8% maintenance patients. Other types of malignancy occurred in 0.5% de novo and 0.6% maintenance patients.

The following adverse events were reported between 3% to <20% incidence in de novo and maintenance patients treated with Myfortic in combination with cyclosporine and corticosteroids are listed in Table 6.

Table 6 Adverse Events Reported in 3% to <20% of Patients Treated with Myfortic® in Combination with Cyclosporine* and Corticosteroids

	de novo Renal Study	Maintenance Renal Study
Blood and Lymphatic Disorders	Lymphocele, thrombocytopenia	Leukopenia, anemia
Cardiac Disorder	Tachycardia	–
Eye Disorder	Vision blurred	–
Endocrine Disorders	Cushingoid, hirsutism	–
Gastrointestinal Disorders	Abdominal pain upper, flatulence, abdominal distension, sore throat, abdominal pain lower, abdominal pain, gingival hyperplasia, loose stool	Vomiting, dyspepsia, abdominal pain, constipation, gastroesophageal reflux disease, loose stool, flatulence, abdominal pain upper
General Disorders and Administration Site Conditions	Edema, edema lower limb, pyrexia, pain, fatigue, edema peripheral, chest pain	Fatigue, pyrexia, edema, chest pain, peripheral edema
Infections and Infestations	Nasopharyngitis, herpes simplex, upper respiratory tract infection, oral candidiasis, herpes zoster, sinusitis, wound infection, implant infection, pneumonia	Nasopharyngitis, upper respiratory tract infection, urinary tract infection, influenza, sinusitis
Injury, Poisoning, and Procedural Complications	Drug toxicity	Postprocedural pain
Investigations	Blood creatinine increased hemoglobin decrease, blood pressure increased, liver function tests abnormal	Blood creatinine increase, weight increase
Metabolism and Nutrition Disorders	Hypocalcemia, hyperuricemia, hyperlipidemia, hypokalemia, hypophosphatemia hypercholesterolemia, hyperkalemia, hypomagnesemia, diabetes mellitus, hyperphosphatemia, dehydration, fluid overload, hyperglycemia, hypercalcemia	Dehydration, hypokalemia, hypercholesterolemia
Musculoskeletal and Connective Tissue Disorders	Back pain, arthralgia, pain in limb, muscle cramps, myalgia	Arthralgia, pain in limb, back pain, muscle cramps, peripheral swelling, myalgia
Nervous System Disorders	Tremor, headache, dizziness (excluding vertigo)	Headache, dizziness
Psychiatric Disorders	Anxiety	Insomnia, depression
Renal and Urinary Disorders	Renal tubular necrosis, renal impairment, dysuria, hematuria, hydronephrosis, bladder spasm, urinary retention	–
Respiratory, Thoracic and Mediastinal Disorders	Cough, dyspnea, dyspnea exertional	Cough, dyspnea, pharyngolaryngeal pain, sinus congestion
Skin and Subcutaneous Tissue Disorders	Acne, pruritus	Rash, contusion
Surgical and Medical Procedures	Complications of transplant surgery, postoperative complications, postoperative wound complication	–
Vascular Disorders	Hypertension, hypertension aggravated, hypotension	Hypertension
* USP (MODIFIED)

The following additional adverse reactions have been associated with the exposure to MPA when administered as a sodium salt or as mofetil ester:

Gastrointestinal: Colitis (sometimes caused by CMV), pancreatitis, esophagitis, intestinal perforation, gastrointestinal hemorrhage, gastric ulcers, duodenal ulcers, and ileus (see PRECAUTIONS).

Resistance Mechanism Disorders: Serious life-threatening infections such as meningitis and infectious endocarditis have been reported occasionally and there is evidence of a higher frequency of certain types of serious infections such as tuberculosis and atypical mycobacterial infection.

Respiratory: Interstitial lung disorders, including fatal pulmonary fibrosis, have been reported rarely with MPA administration and should be considered in the differential diagnosis of pulmonary symptoms ranging from dyspnea to respiratory failure in posttransplant patients receiving MPA derivatives.

Postmarketing Experience

• Cases of progressive multifocal leukoencephalopathy (PML), sometimes fatal, have been reported in patients treated with mycophenolate mofetil (MMF). Mycophenolate mofetil (MMF) is metabolized to mycophenolic acid (MPA), the active ingredient in Myfortic and the active form of the drug (see WARNINGS, Latent Viral Infections).
  
• BK virus-associated nephropathy has been observed in patients receiving immunosuppressants, including Myfortic. This infection is associated with serious outcomes, including deteriorating renal function and renal graft loss (see WARNINGS, Latent Viral Infections).
  
• Congenital malformations have been reported in offspring of patients exposed to mycophenolate mofetil (MMF) during pregnancy (see WARNINGS, Pregnancy).
  
• Cases of pure red cell aplasia (PRCA) have been reported in patients treated with mycophenolate mofetil in combination with other immunosuppressive agents (see WARNINGS).

OVERDOSAGE

Signs and Symptoms

There has been no reported experience of acute overdose of Myfortic® (mycophenolic acid) in humans.

Possible signs and symptoms of acute overdose could include the following: hematological abnormalities such as leukopenia and neutropenia, and gastrointestinal symptoms such as abdominal pain, diarrhea, nausea and vomiting, and dyspepsia.

Treatment and Management

General supportive measures and symptomatic treatment should be followed in all cases of overdosage. Although dialysis may be used to remove the inactive metabolite MPAG, it would not be expected to remove clinically significant amounts of the active moiety MPA due to the 98% plasma protein binding of MPA. By interfering with enterohepatic circulation of MPA, activated charcoal or bile acid sequestrants, such as cholestyramine, may reduce the systemic MPA exposure.

DOSAGE AND ADMINISTRATION

The recommended dose of Myfortic® (mycophenolic acid) is 720 mg administered twice daily (1440 mg total daily dose) on an empty stomach, one hour before or two hours after food intake (see CLINICAL PHARMACOLOGY, Food Effect).

Myfortic delayed-release tablets and mycophenolate mofetil tablets and capsules should not be used interchangeably without physician supervision because the rate of absorption following the administration of these two products is not equivalent.

Patients are to be instructed that Myfortic tablets should not be crushed, chewed, or cut prior to ingesting. The tablets should be swallowed whole in order to maintain the integrity of the enteric coating.

Pediatric: Based on a pharmacokinetic study conducted in stable renal pediatric transplant patients, the recommended dose of Myfortic in stable pediatric patients is 400 mg/m2 body surface area (BSA) administered twice daily (up to a maximum dose of 720 mg administered twice daily). Patients with a BSA of 1.19 to 1.58 m2 may be dosed either with three Myfortic 180 mg tablets or one 180 mg tablet plus one 360 mg tablet twice daily (1080 mg daily dose). Patients with a BSA of >1.58 m2 may be dosed either with four Myfortic 180 mg tablets or two Myfortic 360 mg tablets twice daily (1440 mg daily dose). Pediatric doses for patients with BSA <1.19 m2 cannot be accurately administered using currently available formulations of Myfortic tablets.

Geriatrics: The maximum recommended dose is 720 mg administered twice daily.

Treatment During Rejection Episodes

Renal transplant rejection does not lead to changes in MPA pharmacokinetics; dosage reduction or interruption of Myfortic is not required.

Patients with Renal Impairment

No dose adjustments are needed in patients experiencing delayed renal graft function postoperatively. Patients with severe chronic renal impairment (GFR <25 mL/min/1.73 m2 BSA) should be carefully followed for potential adverse reactions due to increase in free MPA and total MPAG concentrations (see CLINICAL PHARMACOLOGY, Pharmacokinetics: Special Populations).

Patients with Hepatic Impairment

No dose adjustments are needed for renal transplant patients with hepatic parenchymal disease. However, it is not known whether dosage adjustments are needed for hepatic disease with other etiologies (see CLINICAL PHARMACOLOGY, Pharmacokinetics).

HOW SUPPLIED

Myfortic® (mycophenolic acid) delayed-release tablets

360 mg tablet: Pale orange-red film-coated ovaloid tablet with imprint (debossing) “CT” on one side, containing 360 mg mycophenolic acid formulated as a sodium salt.

Bottles of 120…………………………………………………………………NDC 0078-0386-66

180 mg tablet: Lime green film-coated round tablet with bevelled edges and the imprint (debossing) “C” on one side, containing 180 mg mycophenolic acid formulated as a sodium salt.

Bottles of 120…………………………………………………………………NDC 0078-0385-66

Storage

Store at 25°C (77°F); excursions permitted to 15-30°C (59-86°F) [see USP Controlled Room Temperature]. Protect from moisture.

Dispense in a tight container (USP).

Handling

Tablets should not be crushed or cut.

REV: OCTOBER 2009                                                             T2009-106

Manufactured by:

Novartis Pharma Stein AG

Stein, Switzerland

Distributed by:

Novartis Pharmaceuticals Corporation

East Hanover, New Jersey 07936

© Novartis

MEDICATION GUIDE

MYFORTIC® (my-for-tic)
(mycophenolic acid)
delayed-release tablets

Read the Medication Guide that comes with Myfortic before you start taking it and each time you get a refill. There may be new information. This Medication Guide does not take the place of talking with your healthcare provider about your medical condition or treatment. If you have any questions about Myfortic, ask your healthcare provider.

What is the most important information I should know about Myfortic?

Myfortic can cause serious side effects including:

• Possible loss of pregnancy and higher risk of birth defects. Women who take Myfortic during pregnancy, have a higher risk of losing a pregnancy (miscarriage) during the first three months (first trimester), and a higher risk that their baby will be born with birth defects.

If you are a female and are able to become pregnant:

• Your healthcare provider must talk with you about effective birth control methods (contraceptive counseling).
  
• You should have a negative pregnancy test within 1 week before starting Myfortic therapy.
  
• You must use two different types of effective birth control at the same time, for 4 weeks before you start taking Myfortic, during your entire Myfortic therapy, and for 6 weeks after stopping Myfortic, unless you choose to avoid sexual intercourse completely (abstinence). Myfortic decreases blood levels of the hormones in the birth control pills that you take by mouth. Birth control pills may not work as well while you are taking Myfortic, and you could get pregnant.
  
• If you plan to become pregnant, talk with your healthcare provider. Your healthcare provider will decide if other medicines to prevent rejection may be right for you. In certain situations, you and your doctor may decide that taking Myfortic is more important to your health than the possible risks to your unborn baby.
  
• If you get pregnant while taking Myfortic, do not stop taking Myfortic. Call your healthcare provider right away. You and your healthcare provider should report any cases of pregnancy to:
  • FDA MedWatch at 1-800-FDA-1088
    
  • Novartis Drug Safety at 1-888-669-6682

Talk to your healthcare provider about joining the National Transplantation Pregnancy Registry at: 1-877-955-6877.

• Increased risk of getting serious infections. Myfortic weakens the body’s immune system and affects your ability to fight infections. Serious infections can happen with Myfortic and can lead to death. Types of infections can include:
  • Viral infections. Certain viruses can live in your body and cause active infections when your immune system is weak. Viral infections that can happen with Myfortic include:
    • Shingles, other herpes infections, and cytomegalovirus (CMV). CMV can cause serious tissue and blood infections. 
      
    • BK virus. BK virus can affect how your kidney works and cause your transplanted kidney to fail.
    
    
  • A brain infection called Progressive Multifocal Leukoencephalopathy (PML). In some patients Myfortic may cause an infection of the brain that may cause death. You are at risk for this brain infection because you have a weakened immune system. You should tell your healthcare provider right away if you have any of the following symptoms:
    • Weakness on one side of the body
      
    • You do not care about things that you usually care about (apathy)
      
    • You are confused or have problems thinking
      
    • You can not control your muscles
    
    
  • Fungal infections. Yeast and other types of fungal infections can happen with Myfortic and cause serious tissue and blood infections. See “What are the possible side effects of Myfortic?”

Call your healthcare provider right away if you have any of these signs and symptoms of infection:

• Temperature of 100.5°F or greater
  
• Cold symptoms, such as a runny nose or sore throat
  
• Flu symptoms, such as an upset stomach, stomach pain, vomiting or diarrhea
  
• Earache or headache
  
• Pain during urination or you need to urinate often
  
• White patches in the mouth or throat
  
• Unexpected bruising or bleeding
  
• Cuts, scrapes or incisions that are red, warm and oozing pus

• Increased risk of getting certain cancers. People who take Myfortic have a higher risk of getting lymphoma, and other cancers, especially skin cancer. Tell your healthcare provider if you have:
  • unexplained fever, tiredness that does not go away, weight loss, or lymph node swelling
    
  • a brown or black skin lesion with uneven borders, or one part of the lesion does not look like other parts
    
  • a change in the size or color of a mole
    
  • a new skin lesion or bump
    
  • any other changes to your health

See the section “What are the possible side effects of Myfortic?” for other serious side effects.

What is Myfortic?

Myfortic is a prescription medicine given to prevent rejection (antirejection medicine) in people who have received a kidney transplant. Rejection is when the body’s immune system senses the new organ as “foreign” and attacks it.

Myfortic is used with other medicines containing cyclosporine (Sandimmune®, Gengraf®, and Neoral®) and corticosteroids. These medicines work together to help prevent rejection to your transplanted kidney.

Myfortic can be used to prevent rejection in children who are 5 years or older and are stable after having a kidney transplant. It is not known if Myfortic is safe and works in children younger than 5 years. It is not known how Myfortic works in children who have just received a new kidney transplant.

Who should not take Myfortic?

Do not take Myfortic if you are allergic to mycophenolic acid, mycophenolate sodium, mycophenolate mofetil, or any of the ingredients in Myfortic. See the end of this Medication Guide for a complete list of ingredients in Myfortic.

What should I tell my healthcare provider before I start taking Myfortic?

Tell your healthcare provider about all of your medical conditions, including if you:

• have any digestive problems, such as ulcers
  
• plan to receive any vaccines. You should not receive live vaccines while you take Myfortic. Some vaccines may not work as well during treatment with Myfortic.
  
• have Lesch-Nyhan or Kelley-Seegmiller syndrome or another rare inherited deficiency of hypoxanthine-guanine phosphoribosyl-transferase (HGPRT). You should not take Myfortic if you have one of these disorders.
  
• are pregnant or planning to become pregnant. See “What is the most important information I should know about Myfortic.
  
• are breastfeeding. It is not known if Myfortic passes into breast milk. You and your healthcare provider will decide if you will stop taking Myfortic or breast-feed. You should not do both without first talking to your healthcare provider.

Tell your healthcare provider about all the medicines you take, including prescription and nonprescription medicines, vitamins, and herbal supplements. Some medicines may affect the way Myfortic works and Myfortic may affect how some medicines work. Especially tell your doctor if you take:

• birth control pills (oral contraceptives). See “What is the most important information I should know about Myfortic?”
  
• antacids that contain aluminum or magnesium. Myfortic and antacids should not be taken at the same time.
  
• acyclovir (Zovirax®), Ganciclovir (Cytovene® IV, Valcyte®)
  
• azathioprine (Azasan®, Imuran®)
  
• cholestyramine (Questran® Light, Questran®, Locholest Light, Prevalite®)

Know the medicines you take. Keep a list of your medicines with you to show your healthcare provider and pharmacist when you get a new medicine. Do not take any new medicine without talking to your healthcare provider.

How should I take Myfortic?

• Take Myfortic exactly as prescribed. Your healthcare provider will tell you how much Myfortic to take.
  
• Do not stop taking or change your dose of Myfortic without talking to your healthcare provider.
  
• Take Myfortic on an empty stomach, either 1 hour before or 2 hours after a meal.
  
• Swallow Myfortic whole. Do not crush, chew, or cut Myfortic. The Myfortic tablets have a coating so that the medicine will pass through your stomach and dissolve in your intestine.
  • If you forget to take Myfortic, take it as soon as you remember and then take your next dose at its regular time. If it is almost time for your next dose, skip the missed dose. Do not take two doses at the same time. Call your healthcare provider or pharmacist if you are not sure what to do.
    
  • If you take more than the prescribed dose of Myfortic, call your healthcare provider right away.
    
  • Do not change (substitute) between using Myfortic delayed-release tablets and mycophenolate mofetil tablets, capsules, or oral suspension for one another unless your healthcare provider tells you to. These medicines are absorbed differently. This may affect the amount of medicine in your blood.
    
  • Be sure to keep all appointments at your transplant clinic. During these visits, your healthcare provider may perform regular blood tests.

What should I avoid while taking Myfortic?

Avoid pregnancy. See “What is the most important information I should know about Myfortic?”

• Limit the amount of time you spend in sunlight. Avoid using tanning beds and sunlamps. People who take Myfortic have a higher risk of getting skin cancer. See “What is the most important information I should know about Myfortic?” Wear protective clothing when you are in the sun and use a sunscreen with a high sun protection factor (SPF 30 and above). This is especially important if your skin is fair (light colored) or you have a family history of skin cancer.
  
• Elderly patients 65 years of age or older may have more side effects with Myfortic because of a weaker immune system.

What are the possible side effects of Myfortic?

Myfortic can cause serious side effects.

See "What is the most important information I should know about Myfortic?"

Stomach and intestinal bleeding can happen in people who take Myfortic. Bleeding can be severe and you may have to be hospitalized for treatment.

The most common side effects of taking Myfortic include:

In people with a new transplant:

• low blood cell counts
  • red blood cells
    
  • white blood cells
    
  • platelets
  
  
• constipation
  
• nausea
  
• diarrhea
  
• vomiting
  
• urinary tract infections
  
• stomach upset

In people who take Myfortic for a long time (long-term) after transplant:

• low blood cell counts
  • red blood cells
    
  • white blood cells
  
  
• nausea
  
• diarrhea
  
• sore throat

Your healthcare provider will do blood tests before you start taking Myfortic and during treatment with Myfortic to check your blood cell counts. Tell your healthcare provider right away if you have any signs of infection (see “What is the most important information I should know about Myfortic?”), or any unexpected bruising or bleeding. Also, tell your healthcare provider if you have unusual tiredness, dizziness or fainting.

These are not all the possible side effects of Myfortic. Your healthcare provider may be able to help you manage these side effects.

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

How should I store Myfortic?

• Store Myfortic tablets at room temperature, 59° to 86°F (15° to 30°C). Myfortic does not need to be refrigerated.
  
• Keep the container tightly closed. Store Myfortic in a dry place.
  
• Keep Myfortic and all medicines out of the reach of children.

General information about Myfortic

Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Do not use Myfortic for a condition for which it was not prescribed. Do not give Myfortic to other people, even if they have the same symptoms you have. It may harm them.

This Medication Guide summarizes the most important information about Myfortic. If you would like more information, talk with your doctor. You can ask your doctor or pharmacist for information about Myfortic that is written for healthcare professionals. You can also call 1-888-669-6682 or visit the Myfortic website at www.myfortic.com.

What are the ingredients in Myfortic?

Active ingredient: mycophenolic acid (as mycophenolate sodium)

Inactive ingredients: colloidal silicon dioxide, crospovidone, lactose anhydrous, magnesium stearate, povidone (K-30), and starch. The enteric coating of the tablet consists of hypromellose phthalate, titanium dioxide, iron oxide yellow, and indigotine (for the 180-mg tablet) or iron oxide red (for the 360-mg tablet)

This Medication Guide has been approved by the U.S. Food and Drug Administration.

Sandimmune and Neoral are registered trademarks of Novartis Pharmaceuticals Corporation.

Any other trademarks in this document are the property of their respective owners.

REV: OCTOBER 2009                                                             T2009-107

Manufactured by:

Novartis Pharma Stein AG

Stein, Switzerland

Distributed by:

Novartis Pharmaceuticals Corporation

East Hanover, New Jersey 07936

© Novartis

PRINCIPAL DISPLAY PANEL

Package Label – 180 mg

Rx Only             NDC 0078-0385-66

Myfortic®

(mycophenolic acid*)

delayed-release tablets

*as mycophenolate sodium

Dispense the accompanying Medication Guide to each patient.

120 Tablets

PRINCIPAL DISPLAY PANEL

Package Label – 360 mg

Rx Only             NDC 0078-0386-66

Myfortic®

(mycophenolic acid*)

delayed-release tablets

*as mycophenolate sodium

Dispense the accompanying Medication Guide to each patient.

120 Tablets

MYFORTIC  mycophenolic acid   tablet, delayed release

Product Information Product Type HUMAN PRESCRIPTION DRUG NDC Product Code (Source) 0078-0386 Route of Administration ORAL DEA Schedule

Active Ingredient/Active Moiety Ingredient Name Basis of Strength Strength MYCOPHENOLIC ACID (MYCOPHENOLIC ACID) MYCOPHENOLIC ACID 360 mg

Inactive Ingredients Ingredient Name Strength SILICON DIOXIDE   CROSPOVIDONE   HYPROMELLOSE   FERRIC OXIDE RED   FERRIC OXIDE YELLOW   ANHYDROUS LACTOSE   MAGNESIUM STEARATE   POVIDONE K30   STARCH, CORN   TITANIUM DIOXIDE

Product Characteristics Color ORANGE (pale orange-red) Score no score Shape OVAL (ovaloid) Size 18mm Flavor Imprint Code CT Contains

Packaging # NDC Package Description Multilevel Packaging 1 0078-0386-66 120 TABLET In 1 BOTTLE None

Marketing Information
Marketing Category	Application Number or Monograph Citation	Marketing Start Date	Marketing End Date
NDA	NDA050791	02/27/2004

MYFORTIC  mycophenolic acid   tablet, delayed release

Product Information Product Type HUMAN PRESCRIPTION DRUG NDC Product Code (Source) 0078-0385 Route of Administration ORAL DEA Schedule

Active Ingredient/Active Moiety Ingredient Name Basis of Strength Strength MYCOPHENOLIC ACID (MYCOPHENOLIC ACID) MYCOPHENOLIC ACID 180 mg

Inactive Ingredients Ingredient Name Strength SILICON DIOXIDE   CROSPOVIDONE   HYPROMELLOSE   FD&C BLUE NO. 2   FERRIC OXIDE YELLOW   ANHYDROUS LACTOSE   MAGNESIUM STEARATE   POVIDONE K30   STARCH, CORN   TITANIUM DIOXIDE

Product Characteristics Color GREEN (lime green) Score no score Shape ROUND Size 10mm Flavor Imprint Code C Contains

Packaging # NDC Package Description Multilevel Packaging 1 0078-0385-66 120 TABLET In 1 BOTTLE None

Marketing Information
Marketing Category	Application Number or Monograph Citation	Marketing Start Date	Marketing End Date
NDA	NDA050791	02/27/2004

Labeler - Novartis Pharmaceuticals Corporation (002147023)

Revised: 10/2009Novartis Pharmaceuticals Corporation