Remimazolam Besylate

BYFAVO ® is indicated for the induction and maintenance of procedural sedation in adults undergoing procedures lasting 30 minutes or less. BYFAVO (remimazolam) for injection is a benzodiazepine indicated for the induction and maintenance of procedural sedation in adults undergoing procedures lasting 30 minutes or less. ( 1 )

Single-patient-use vial: Each glass, single-patient-use vial of BYFAVO (remimazolam) for injection contains 20 mg remimazolam white to off-white lyophilized powder, equivalent to 27.2 mg remimazolam besylate. Each glass, single-patient-use vial contains 20 mg BYFAVO (remimazolam) lyophilized powder for reconstitution, equivalent to 27.2 mg remimazolam besylate. ( 3 )

BYFAVO is contraindicated in patients with a history of severe hypersensitivity reaction to dextran 40 or products containing dextran 40 [see Warnings and Precautions (5.3) ]. Hypersensitivity to dextran 40. ( 4 )

Hypersensitivity Reactions : Hypersensitivity reactions including anaphylaxis may occur. ( 5.3 ) Neonatal Sedation and Withdrawal Syndrome : Receiving benzodiazepines during pregnancy can result in neonatal sedation and/or neonatal withdrawal. ( 5.4 , 8.1 ) Pediatric Neurotoxicity : In developing animals, exposures greater than 3 hours cause neurotoxicity. Weigh benefits against potential risks when considering elective procedures in children under 3 years old. ( 5.5 )

5.1 Personnel and Equipment for Monitoring and Resuscitation Clinically notable hypoxia, bradycardia, and hypotension were observed in Phase 3 studies of BYFAVO. Continuously monitor vital signs during sedation and through the recovery period. Only personnel trained in the administration of procedural sedation, and not involved in the conduct of the diagnostic or therapeutic procedure, should administer BYFAVO. Administering personnel must be trained in the detection and management of airway obstruction, hypoventilation, and apnea, including the maintenance of a patent airway, supportive ventilation, and cardiovascular resuscitation. Resuscitative drugs, and age- and size-appropriate equipment for bag/valve/mask assisted ventilation must be immediately available during administration of BYFAVO [see Dosage and Administration (2.1) ] . Consider the potential for worsened cardiorespiratory depression prior to using BYFAVO concomitantly with other drugs that have the same potential (e.g., opioid analgesics or other sedative-hypnotics) [see Drug Interactions (7.1) ]. Administer supplemental oxygen to sedated patients through the recovery period. A benzodiazepine reversal agent (flumazenil) should be immediately available during administration of BYFAVO [see Overdosage (10) ].

5.2 Risks from Concomitant Use with Opioid Analgesics and Other Sedative-Hypnotics Concomitant use of benzodiazepines, including BYFAVO, and opioid analgesics may result in profound sedation, respiratory depression, coma, and death [see Drug Interactions (7.1) ]. The sedative effect of intravenous BYFAVO can be accentuated by concomitantly administered CNS depressant medications, including other benzodiazepines and propofol. Titrate the dose of BYFAVO when administered with opioid analgesics and sedative-hypnotics to the desired clinical response. Continuously monitor sedated patients for hypotension, airway obstruction, hypoventilation, apnea, and oxygen desaturation. These cardiorespiratory effects may be more likely to occur in patients with obstructive sleep apnea, the elderly, and ASA III or IV patients.

5.3 Hypersensitivity Reactions BYFAVO contains dextran 40, which can cause hypersensitivity reactions, including rash, urticaria, pruritus, and anaphylaxis. BYFAVO is contraindicated in patients with a history of severe hypersensitivity reaction to dextran 40 or products containing dextran 40 [see Contraindications (4) , Adverse Reactions (6) ].

5.4 Neonatal Sedation and Withdrawal Syndrome Receiving benzodiazepines late in pregnancy can result in sedation (respiratory depression, lethargy, hypotonia) and/or withdrawal symptoms (hyperreflexia, irritability, restlessness, tremors, inconsolable crying, and feeding difficulties) in the neonate. Monitor neonates exposed to benzodiazepines, including BYFAVO, during pregnancy or labor for signs of sedation and monitor neonates exposed to benzodiazepines during pregnancy for signs of withdrawal and manage these neonates accordingly [see Use in Specific Populations (8.1) ].

5.5 Pediatric Neurotoxicity Published animal studies demonstrate that the administration of anesthetic and sedation drugs that block NMDA receptors and/or potentiate GABA activity increase neuronal apoptosis in the developing brain and result in long-term cognitive deficits when used for longer than 3 hours. The clinical significance of these findings is not clear. However, based on the available data, the window of vulnerability to these changes is believed to correlate with exposures in the third trimester of gestation through the first several months of life, but may extend out to approximately three years of age in humans [see Use in Specific Populations (8.1 , 8.4) , Nonclinical Pharmacology (13.2) ] . Some published studies in children suggest that similar deficits may occur after repeated or prolonged exposures to anesthetic agents early in life and may result in adverse cognitive or behavioral effects. These studies have substantial limitations, and it is not clear if the observed effects are due to the anesthetic/sedation drug administration or other factors such as the surgery or underlying illness. Anesthetic and sedation drugs are a necessary part of the care of children needing surgery, other procedures, or tests that cannot be delayed, and no specific medications have been shown to be safer than any other. Decisions regarding the timing of any elective procedures requiring anesthesia should take into consideration the benefits of the procedure weighed against the potential risks.

The following serious adverse reactions are discussed in greater detail in other sections: Neonatal Sedation and Withdrawal Syndrome [see Warnings and Precautions (5.4) , Use in Specific Populations (8.1) ] The most common adverse reactions (>10%) in patients receiving BYFAVO for procedural sedation are hypotension, hypertension, diastolic hypertension, systolic hypertension, hypoxia, and diastolic hypotension. ( 6 ) To report SUSPECTED ADVERSE REACTIONS, contact Acacia Pharma at 1-877-357-9237 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch

6.1 Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety of BYFAVO was evaluated in three prospective, randomized, double-blind, multicenter, parallel group clinical studies in 630 patients undergoing colonoscopy (two studies) or bronchoscopy (one study). Colonoscopy Study 1 and the bronchoscopy study evaluated American Society of Anesthesiologists (ASA) physical status I to III patients, and Colonoscopy Study 2 evaluated ASA III and IV patients. All three studies evaluated the safety of BYFAVO compared to placebo with midazolam rescue and an open-label midazolam treatment arm. Patients were administered a total dose ranging from 5 to 30 mg of BYFAVO. In these studies, the most common adverse reactions (incidence greater than 10%) following BYFAVO administration were hypotension, hypertension, diastolic hypertension, systolic hypertension, hypoxia, and diastolic hypotension. There were two patients who experienced an adverse reaction that led to discontinuation of study drug. One patient in the BYFAVO arm in the bronchoscopy study discontinued treatment due to bradycardia, hypertension, hypotension, hypoxia, and respiratory rate increase. One patient in the open-label midazolam arm in Colonoscopy Study 2 discontinued due to respiratory acidosis. No deaths were reported during the studies. Tables 1-3 provide a summary of the common adverse reactions observed in each of the three Phase 3 studies with BYFAVO. Table 1: Common Adverse Reactions in Colonoscopy Study 1 (Incidence >2%), ASA I to III Adverse Reaction BYFAVO N = 296 Placebo (with Midazolam Rescue 57/60 (95%) patients received midazolam rescue. ) N = 60 Midazolam N = 102 n (%) n (%) n (%) Hypotension Hypotension defined as a fall in systolic BP to ≤80 mmHg or in diastolic BP to ≤40 mmHg, or a fall in systolic or diastolic BP of 20% or more below baseline or necessitating medical intervention. 115 (39%) 25 (42%) 63 (62%) Hypertension Hypertension defined as an increase in systolic BP to ≥180 mmHg or in diastolic BP to ≥100 mmHg, or an increase of systolic or diastolic BP of 20% or more over baseline or necessitating medical intervention. 59 (20%) 17 (28%) 18 (18%) Bradycardia 33 (11%) 7 (12%) 16 (16%) Diastolic hypertension 29 (10%) 6 (10%) 9 (9%) Tachycardia 23 (8%) 7 (12%) 13 (13%) Diastolic hypotension 23 (8%) 4 (7%) 9 (9%) Systolic hypertension 16 (5%) 5 (8%) 6 (6%) Table 2: Common Adverse Reactions in Bronchoscopy Study (Incidence >2%) Adverse Reaction BYFAVO N = 303 Placebo (with Midazolam Rescue 57/59 (97%) patients received midazolam rescue. ) N = 59 Midazolam N = 69 n (%) n (%) n (%) Hypotension Hypotension defined as a fall in systolic BP to ≤80 mmHg or in diastolic BP to ≤40 mmHg, or a fall in systolic or diastolic BP of 20% or more below baseline or necessitating medical intervention. 99 (33%) 28 (47%) 23 (33%) Hypertension Hypertension defined as an increase in systolic BP to ≥180 mmHg or in diastolic BP to ≥100 mmHg, or an increase of systolic or diastolic BP of 20% or more over baseline or necessitating medical intervention. 85 (28%) 9 (15%) 19 (28%) Diastolic hypertension 77 (25%) 15 (25%) 16 (23%) Systolic hypertension 67 (22%) 13 (22%) 17 (25%) Hypoxia 66 (22%) 12 (20%) 13 (19%) Respiratory rate increased 43 (14%) 6 (10%) 10 (14%) Diastolic hypotension 41 (14%) 17 (29%) 16 (23%) Nausea 12 (4%) 2 (3%) 2 (3%) Bradycardia 11 (4%) 4 (7%) 4 (6%) Pyrexia 11 (4%) 1 (2%) 1 (1%) Headache 8 (3%) 0 (0%) 3 (4%) Table 3: Common Adverse Reactions in Colonoscopy Study 2 (Incidence >2%), ASA III and IV Adverse Reaction BYFAVO N = 31 Placebo (with Midazolam Rescue 16/16 (100%) patients received midazolam rescue. ) N = 16 Midazolam N = 30 n (%) n (%) n (%) Hypotension Hypotension defined as a fall in systolic BP to ≤80 mmHg or in diastolic BP to ≤40 mmHg, or a fall in systolic or diastolic BP of 20% or more below baseline or necessitating medical intervention. 18 (58%) 11 (69%) 17 (57%) Hypertension Hypertension defined as an increase in systolic BP to ≥180 mmHg or in diastolic BP to ≥100 mmHg, or an increase of systolic or diastolic BP of 20% or more over baseline or necessitating medical intervention. 13 (42%) 6 (38%) 13 (43%) Respiratory acidosis 6 (19%) 2 (13%) 8 (27%) Diastolic hypertension 3 (10%) 0 (0%) 0 (0%) Systolic hypertension 2 (6%) 0 (0%) 0 (0%) Bradycardia 1 (3%) 1 (6%) 4 (13%) Respiratory rate decreased 1 (3%) 1 (6%) 2 (7%) Diastolic hypotension 1 (3%) 1 (6%) 0 (0%) Blood pressure diastolic increased 1 (3%) 0 (0%) 0 (0%) Blood pressure increased 1 (3%) 0 (0%) 0 (0%) Blood pressure systolic increased 1 (3%) 0 (0%) 0 (0%) Upper respiratory tract infection 1 (3%) 0 (0%) 0 (0%) Adverse reaction data from Colonoscopy Study 1 and the bronchoscopy study analyzed according to the cumulative dose of concomitant fentanyl (<100 mcg, 100-150 mcg and >150 mcg) suggest an increase in some adverse reactions with increasing fentanyl dose, such as hypotension, hypertension, bradycardia, hypoxia, and increased respiratory rate (see Table 4 and Table 5 ). There were too few patients in each fentanyl stratum in Colonoscopy Study 2 to perform this analysis. Table 4: Common Adverse Reactions Incidence >2% of patients. in Colonoscopy Study 1 by Cumulative Fentanyl Dose BYFAVO Placebo (with Midazolam Rescue 57/60 (95%) patients received midazolam rescue. ) Midazolam Fentanyl dose (mcg) <100 100-150 >150 <100 100-150 >150 <100 100-150 >150 N = 148 N = 146 N = 2 N = 9 N = 43 N = 8 N = 31 N = 62 N = 9 Adverse Reaction n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) Hypotension Hypotension defined as a fall in systolic BP to ≤80 mmHg or in diastolic BP to ≤40 mmHg, or a fall in systolic or diastolic BP of 20% or more below baseline or necessitating medical intervention. 49 (33%) 64 (44%) 2 (100%) 5 (56%) 17 (40%) 3 (38%) 18 (58%) 36 (58%) 9 (100%) Hypertension Hypertension defined as an increase in systolic BP to ≥180 mmHg or in diastolic BP to ≥100 mmHg, or an increase of systolic or diastolic BP of 20% or more over baseline or necessitating medical intervention. 24 (16%) 35 (24%) 0 (0%) 1 (11%) 14 (33%) 2 (25%) 3 (10%) 12 (19%) 3 (33%) Bradycardia 12 (8%) 20 (14%) 1 (50%) 0 (0%) 5 (12%) 2 (25%) 1 (3%) 13 (21%) 2 (22%) Diastolic hypertension 9 (6%) 20 (14%) 0 (0%) 0 (0%) 3 (7%) 3 (38%) 2 (6%) 7 (11%) 0 (0%) Tachycardia 10 (7%) 12 (8%) 1 (50%) 0 (0%) 6 (14%) 1 (13%) 2 (6%) 8 (13%) 3 (33%) Diastolic hypotension 10 (7%) 13 (9%) 0 (0%) 0 (0%) 3 (7%) 1 (13%) 3 (10%) 4 (6%) 2 (22%) Systolic hypertension 5 (3%) 11 (8%) 0 (0%) 0 (0%) 3 (7%) 2 (25%) 4 (13%) 2 (3%) 0 (0%) Table 5: Common Adverse Reactions Incidence >2% of patients. in Bronchoscopy Study by Cumulative Fentanyl Dose BYFAVO Placebo (with Midazolam Rescue 57/59 (97%) patients received midazolam rescue. ) Midazolam Fentanyl dose (mcg) <100 100-150 >150 <100 100-150 >150 <100 100-150 >150 N = 215 N = 63 N = 25 N = 26 N = 18 N = 15 N = 29 N = 27 N = 13 Adverse Reaction n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) Hypotension Hypotension defined as a fall in systolic BP to ≤ 80 mmHg or in diastolic BP to ≤40 mmHg, or a fall in systolic or diastolic BP of 20% or more below baseline or necessitating medical intervention. […]

7.1 Opioid Analgesics and Other Sedative-Hypnotics The sedative effect of intravenous BYFAVO can be accentuated by concomitantly administered CNS depressant medications, including opioid analgesics, other benzodiazepines, and propofol. Continuously monitor vital signs during sedation and through the recovery period. Titrate the dose of BYFAVO when administered with opioid analgesics and sedative-hypnotics to the desired clinical response [see Warnings and Precautions (5.2) ].

Lactation : A lactating woman may pump and discard breast milk for 5 hours after treatment with BYFAVO. ( 8.2 ) Pediatric Use : BYFAVO should not be used in patients less than 18 years of age. ( 8.4 ) Geriatric Use : Sedating drugs, such as BYFAVO, may cause confusion and over-sedation in the elderly; elderly patients generally should be observed closely. ( 8.5 ) Severe Hepatic Impairment : In patients with severe hepatic impairment the dose of BYFAVO should be carefully titrated to effect. Depending on the overall status of the patient, reduced doses might be indicated. ( 8.6 , 12.3 )

8.1 Pregnancy Risk Summary Neonates born to mothers using benzodiazepines late in pregnancy have been reported to experience symptoms of sedation and/or neonatal withdrawal [see Warnings and Precautions (5.4) , Clinical Considerations ]. Available data from published observational studies of pregnant women exposed to benzodiazepines do not report a clear association with benzodiazepines and major birth defects (see Data ). In animal studies, reduced fetal weights but no evidence of malformations or embryofetal lethality were noted in a study in which pregnant rabbits were treated intravenously with 4 times the maximum recommended human dose (MRHD) of 30 mg during organogenesis. Adequate rodent reproductive and developmental toxicology studies have not been completed to fully evaluate the effects of BYFAVO. Published studies in pregnant primates demonstrate that the administration of anesthetic and sedation drugs that block NMDA receptors and/or potentiate GABA activity during the period of peak brain development increases neuronal apoptosis in the developing brain of the offspring when used for longer than 3 hours. There are no data on pregnancy exposures in primates corresponding to periods prior to the third trimester in humans (see Data ) . The background risk of major birth defects and miscarriage for the indicated population 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. Clinical Considerations Fetal/Neonatal Adverse Reactions Benzodiazepines cross the placenta and may produce respiratory depression, hypotonia, and sedation in neonates. Monitor neonates exposed to BYFAVO during pregnancy or labor for signs of sedation, respiratory depression, hypotonia, and feeding problems. Monitor neonates exposed to BYFAVO during pregnancy for signs of withdrawal. Manage these neonates accordingly [see Warnings and Precautions (5.4) ]. Data Human Data Published data from observational studies on the use of benzodiazepines during pregnancy do not report a clear association with benzodiazepines and major birth defects. Although early studies reported an increased risk of congenital malformations with diazepam and chlordiazepoxide, there was no consistent pattern noted. In addition, the majority of more recent case-control and cohort studies of benzodiazepine use during pregnancy, which were adjusted for confounding exposures to alcohol, tobacco, and other medications, have not confirmed these findings. Animal Data Reduced fetal weights but no evidence of malformation or embryofetal lethality were noted in a study in which pregnant rabbits were treated intravenously with 5 mg/kg remimazolam (approximately 4 times the MRHD of 30 mg/day based on AUC) from Gestation Day 6 to 20 in the presence of maternal toxicity (reduced food intake and body weights). In a study that did not test exposures comparable to the MRHD of 30 mg/day over the full period of organogenesis, there was an increase in early resorptions (embryolethality) but no evidence of malformations when female rats were treated from Gestation Day 6 through 17 with up to 30 mg/kg remimazolam via intravenous bolus (approximately 0.3 times the MRHD based on AUC by the end of the dosing interval) in the presence of maternal toxicity (convulsion in one mid dose and one high dose dam). In a pre- and postnatal development study that did not test exposures comparable to the MRHD of 30 mg/day over the full treatment period, there were no adverse effects on survival or development of offspring when pregnant rats were treated with up to 30 mg/kg remimazolam (<0.3 times the MRHD by the end of the gestational period) by intravenous bolus injection from Gestation Day 6 through Lactation Day 20 with minimal evidence of maternal toxicity (sedation). No evidence of adverse effects on physical development, a functional observational battery of behavioral assessments, or fertility were noted in pups born to pregnant rabbits that were treated by intravenous infusion of up to 20 mg/kg/day remimazolam (approximately 19 times the MRHD based on AUC) from 14 days prior to mating until Lactation Day 30 despite the presence of maternal toxicity (sedation, convulsions, and mortality). Learning and memory of the first-generation offspring was not evaluated in this study. In a published study in primates, administration of an anesthetic dose of ketamine for 24 hours on Gestation Day 122 increased neuronal apoptosis in the developing brain of the fetus. In other published studies, administration of either isoflurane or propofol for 5 hours on Gestation Day 120 resulted in increased neuronal and oligodendrocyte apoptosis in the developing brain of the offspring. With respect to brain development, this time period corresponds to the third trimester of gestation in the human. The clinical significance of these findings is not clear; however, studies in juvenile animals suggest neuroapoptosis correlates with long-term cognitive deficits [see Warnings and Precautions (5.4 , 5.5) , Use in Specific Populations (8.4) , Nonclinical Toxicology (13.2) ].

8.2 Lactation Risk Summary There are reports of sedation, poor feeding, and poor weight gain in infants exposed to benzodiazepines through breast milk. There are no data on the effects of remimazolam in human milk, the effects on the breastfed infant or the effects on milk production. Remimazolam is present in animal milk (see Data ) . When a drug is present in animal milk, it is likely that it will be present in human milk. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for BYFAVO and any potential adverse effects on the breastfed child from BYFAVO or from the underlying maternal condition. Clinical Considerations Infants exposed to BYFAVO through breast milk should be monitored for sedation, poor feeding, and poor weight gain. A lactating woman may consider interrupting breastfeeding and pumping and discarding breast milk during treatment and for 5 hours (approximately 5 elimination half-lives) after BYFAVO administration in order to minimize drug exposure to a breastfed infant. Data In rabbits administered daily intravenous infusions of remimazolam at 12.5 and 20 mg/kg/day from 14 days before mating until Lactation Day 30, remimazolam and the metabolite CNS7054 were present in milk samples obtained after the end of an infusion on Day 10 or 11 of lactation. Remimazolam was not quantifiable in plasma samples obtained from rabbit kits taken in the morning on Day 10 or 11 of lactation. However, metabolite CNS7054 was present at low levels in 2 of the 5 kits sampled.

8.4 Pediatric Use Safety and effectiveness in pediatric patients have not been established. No studies are available in any pediatric population and extrapolation of adult effectiveness data to the pediatric population is not possible. […]

BYFAVO is a benzodiazepine. BYFAVO binds to brain benzodiazepine sites (gamma amino butyric acid type A [GABA A ] receptors), while its carboxylic acid metabolite (CNS7054) has a 300 times lower affinity for the receptor. BYFAVO, like other benzodiazepines, did not show clear selectivity between subtypes of the GABA A receptor.