Eliglustat

CERDELGA is indicated for the long-term treatment of adult patients with Gaucher disease type 1 (GD1) who are CYP2D6 extensive metabolizers (EMs), intermediate metabolizers (IMs), or poor metabolizers (PMs) as detected by an FDA-cleared test [see Dosage and Administration (2.1) ] . CERDELGA is a glucosylceramide synthase inhibitor indicated for the long-term treatment of adult patients with Gaucher disease type 1 who are CYP2D6 extensive metabolizers (EMs), intermediate metabolizers (IMs), or poor metabolizers (PMs) as detected by an FDA-cleared test. ( 1 ) Limitations of Use : CYP2D6 ultra-rapid metabolizers may not achieve adequate concentrations of CERDELGA to achieve a therapeutic effect. ( 1 ) A specific dosage cannot be recommended for CYP2D6 indeterminate metabolizers. ( 1 ) Limitations of Use : Patients who are CYP2D6 ultra-rapid metabolizers (URMs) may not achieve adequate concentrations of CERDELGA to achieve a therapeutic effect [see Clinical Studies (14) ] . A specific dosage cannot be recommended for those patients whose CYP2D6 genotype cannot be determined (indeterminate metabolizers) [see Clinical Studies (14) ] .

Capsules: 84 mg of eliglustat is in a capsule with a pearl blue-green opaque cap and pearl white opaque body imprinted with "GZ02" in black. Capsules: 84 mg eliglustat

CERDELGA is contraindicated in the following patients based on CYP2D6 metabolizer status due to the risk of cardiac arrhythmias from prolongation of the PR, QTc, and/or QRS cardiac intervals. EMs Taking a strong or moderate CYP2D6 inhibitor concomitantly with a strong or moderate CYP3A inhibitor. ( 4 , 5.1 , 7.1 , 12.3 ) Moderate or severe hepatic impairment. ( 4 , 5.1 , 8.7 , 12.3 ) Mild hepatic impairment taking a strong or moderate CYP2D6 inhibitor. ( 4 , 5.1 , 8.7 , 12.3 ) IMs Taking a strong or moderate CYP2D6 inhibitor concomitantly with a strong or moderate CYP3A inhibitor. ( 4 , 5.1 , 7.1 , 12.3 ) Taking a strong CYP3A inhibitor. ( 4 , 5.1 , 7.1 , 12.3 ) Any degree of hepatic impairment. ( 4 , 5.1 , 8.7 , 12.3 ) PMs Taking a strong CYP3A inhibitor ( 4 , 5.1 , 7.1 , 12.3 ) Any degree of hepatic impairment ( 4 , 5.1 , 8.7 , 12.3 ) EMs Taking a strong or moderate CYP2D6 inhibitor concomitantly with a strong or moderate CYP3A inhibitor [see Drug Interactions (7.1) ] Moderate or severe hepatic impairment [see Use in Specific Populations (8.7) ] Mild hepatic impairment and taking a strong or moderate CYP2D6 inhibitor [see Use in Specific Populations (8.7) ] IMs Taking a strong or moderate CYP2D6 inhibitor concomitantly with a strong or moderate CYP3A inhibitor [see Drug Interactions (7.1) ] Taking a strong CYP3A inhibitor [see Drug Interactions (7.1) ] Any degree of hepatic impairment [see Use in Specific Populations (8.7) ] PMs Taking a strong CYP3A inhibitor [see Drug Interactions (7.1) ] Any degree of hepatic impairment [see Use in Specific Populations (8.7) ]

ECG Changes and Potential for Cardiac Arrhythmias : Not recommended in patients with pre-existing cardiac disease, long QT syndrome, and concomitant use of Class IA and Class III antiarrhythmics. ( 5.1 ) 5.1 ECG Changes and Potential for Cardiac Arrhythmias CERDELGA is predicted to cause increases in ECG intervals (PR, QTc, and QRS) at substantially elevated eliglustat plasma concentrations and may increase the risk of cardiac arrhythmias. Use of CERDELGA is contraindicated, to be avoided, or requires dosage adjustment in patients taking CYP2D6 or CYP3A inhibitors, depending on CYP2D6 metabolizer status, type of inhibitor, or degree of hepatic impairment [see Dosage and Administration (2.3) , Contraindications (4) , Drug Interactions (7.1) ] . Use of CERDELGA in patients with pre-existing cardiac conditions has not been studied during clinical trials. Avoid use of CERDELGA in patients with: pre-existing cardiac disease (congestive heart failure, recent acute myocardial infarction, bradycardia, heart block, ventricular arrhythmia) long QT syndrome in combination with Class IA (e.g., quinidine, procainamide) or Class III (e.g., amiodarone, sotalol) antiarrhythmic medications [see Clinical Pharmacology (12.2) ]

Most common adverse reactions (≥10%) are: fatigue, headache, nausea, diarrhea, back pain, pain in extremities, and upper abdominal pain. ( 6.1 ) To report SUSPECTED ADVERSE REACTIONS, contact Genzyme Corporation at 1-800-745-4447 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 most common adverse reactions to CERDELGA (occurring in ≥10% of the 126 GD1 patients treated with CERDELGA across Trials 1 and 2) were fatigue, headache, nausea, diarrhea, back pain, pain in extremities, and upper abdominal pain. The adverse reaction profile of CERDELGA is based on two controlled studies, Trials 1 and 2 [see Clinical Studies (14.1 , 14.2) ] . Table 3 presents the profile from the 9-month double-blind, randomized, placebo-controlled trial of 40 treatment-naive patients (Trial 1). Patients were between the ages of 16 and 63 on the date of the first dose of study drug, and included 20 males and 20 females. Table 3: Adverse Reactions Occurring in ≥10% of Treatment-Naive GD1 Patients and More Frequently than Placebo (Trial 1) CERDELGA (N=20) Placebo (N=20) Adverse Reaction Patients n (%) Patients n (%) Arthralgia 9 (45) 2 (10) Headache 8 (40) 6 (30) Migraine 2 (10) 0 (0) Flatulence 2 (10) 1 (5) Nausea 2 (10) 1 (5) Oropharyngeal pain 2 (10) 1 (5) Table 4 presents the profile from the 12-month open-label, randomized, imiglucerase-controlled trial of 159 treated patients switching from enzyme replacement therapy (ERT) (Trial 2). Patients were between the ages of 18 and 69 on the date of the first dose of CERDELGA, and included 87 females and 72 males. Table 4: Adverse Reactions Occurring in ≥5% of GD1 Patients Switching from Enzyme Replacement Therapy to CERDELGA and More Frequently than Imiglucerase (Trial 2) Trial 2 was not designed to support comparative claims for CERDELGA for the adverse reactions reported in this table. CERDELGA (N=106) Imiglucerase (N=53) Adverse Reaction Patients n (%) Patients n (%) Fatigue 15 (14) 1 (2) Headache 14 (13) 1 (2) Nausea 13 (12) 0 (0) Diarrhea 13 (12) 2 (4) Back pain 13 (12) 3 (6) Pain in extremity 12 (11) 1 (2) Upper abdominal pain 11 (10) 0 (0) Dizziness 9 (8) 0 (0) Asthenia 9 (8) 0 (0) Cough 7 (7) 2 (4) Dyspepsia 7 (7) 1 (2) Gastroesophageal reflux disease 7 (7) 0 (0) Constipation 5 (5) 0 (0) Palpitations 5 (5) 0 (0) Rash 5 (5) 0 (0) In a separate uncontrolled study, with up to 4 years of treatment in 26 naive GD1 patients, the types and incidences of adverse reactions were similar to Trials 1 and 2.

See Full Prescribing Information for a list of clinically significant drug interactions. ( 7.1 , 7.2 )

7.1 Effect of Other Drugs on CERDELGA Coadministration of CERDELGA with: CYP2D6 or CYP3A inhibitors may increase eliglustat concentrations which may increase the risk of cardiac arrhythmias from prolongation of the PR, QTc, and/or QRS cardiac interval [see Warnings and Precautions (5.1) , Clinical Pharmacology (12.3) ] . strong CYP3A inducers decrease eliglustat concentrations which may reduce CERDELGA efficacy [see Clinical Pharmacology (12.3) ] . See Table 5 for prevention and management of interactions with drugs affecting CERDELGA. Use of CERDELGA is contraindicated, to be avoided, or may require dosage adjustment depending on the concomitant drug and CYP2D6 metabolizer status [see Dosage and Administration (2.2 , 2.3) , Contraindications (4) , Drug Interactions (7.1) ] . Table 5: Prevention and Management Strategies of Drug Interactions Affecting CERDELGA Based on CYP2D6 Metabolizer Status and Concomitant Interacting Drug Concomitant Drug(s) CYP2D6 Metabolizer Status EMs IMs PMs CYP2D6 Inhibitor Strong Reduce frequency of CERDELGA 84 mg to once daily Continue CERDELGA 84 mg once daily No effect of CYP2D6 inhibitor due to little or no CYP2D6 activity in CYP2D6 PMs. Moderate Weak Continue CERDELGA 84 mg twice daily CYP3A Inhibitor Strong Reduce frequency of CERDELGA 84 mg to once daily Contraindicated Moderate Avoid coadministration Weak Continue CERDELGA 84 mg twice daily Avoid coadministration CYP2D6 Inhibitor Concomitantly with a strong CYP3A Inhibitor Strong Contraindicated Moderate CYP2D6 Inhibitor Concomitantly with a moderate CYP3A Inhibitor Strong Contraindicated Avoid coadministration Moderate CYP3A Inducer Strong Avoid coadministration

7.2 Effect of CERDELGA on Other Drugs See Table 6 for clinically relevant interactions affecting P-gp or CYP2D6 substrates when coadministered with CERDELGA. Table 6: Prevention and Management Strategies of Drug Interactions Affecting Other Drugs Substrates for P-gp or CYP2D6 Clinical Impact Coadministration of CERDELGA may increase concentrations of drugs that are substrates for P-gp or CYP2D6 [see Clinical Pharmacology (12.3) ] and may increase the risk of toxicity of these drugs. Prevention or Management Digoxin Monitor serum digoxin concentrations before initiating CERDELGA. Reduce digoxin dose by 30% and continue monitoring. Other P-gp substrates or CYP2D6 substrates Monitor therapeutic drug concentrations, as indicated, or consider reducing the dosage of the concomitant drug and titrate to clinical effect.

8.1 Pregnancy Risk Summary Available data on CERDELGA use in pregnant women includes 20 pregnancies that occurred during the clinical development program and a small number of post-marketing case reports. These data are not sufficient to assess drug-associated risks major birth defects, miscarriage, or adverse maternal or fetal outcomes. In animal reproduction studies in pregnant rats administered oral eliglustat during organogenesis, a spectrum of various developmental abnormalities were observed at doses 6 times the recommended human dose. No adverse developmental outcomes were observed with oral administration of eliglustat to pregnant rabbits at dose levels 10 times the recommended human dose [see Data ] . The estimated background risk of major birth defects and miscarriage in 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 Disease-associated maternal and/or embryo/fetal risk Women with Gaucher disease type 1 have an increased risk of spontaneous abortion, especially if disease symptoms are not treated and controlled pre-conception and during a pregnancy. Pregnancy may exacerbate existing Gaucher disease type 1 symptoms or result in new disease manifestations. Gaucher disease type 1 manifestations may lead to adverse pregnancy outcomes including, hepatosplenomegaly which can interfere with the normal growth of a pregnancy and thrombocytopenia which can lead to increased bleeding and possible hemorrhage. Data Animal data Reproduction studies have been performed in pregnant rats at oral doses up to 120 mg/kg/day (about 6 times the recommended human dose based on body surface area) and in pregnant rabbits at oral doses up to 100 mg/kg/day (about 10 times the recommended human dose based on body surface area) following administration of eliglustat during the period of organogenesis (gestation days 6 to 17 in the rat and 6 to 18 in the rabbit). In rats, at 120 mg/kg/day (about 6 times the recommended human dose based on body surface area), eliglustat increased the number of late resorptions, dead fetuses and post implantation loss, reduced fetal body weight, and caused fetal cerebral variations (dilated cerebral ventricles), fetal skeletal variations (poor bone ossification) and fetal skeletal malformations (abnormal number of ribs or lumbar vertebra). Eliglustat-related effects on fetal rats were observed in association with signs of maternal toxicity. Eliglustat did not cause fetal harm in rabbits at oral doses up to 100 mg/kg/day (about 10 times the recommended human dose based on body surface area). Mild maternal toxicity was observed at the 100 mg/kg/day dose. In a pre and postnatal development study in rats (dosed daily from gestation day 6 to postpartum day 21), eliglustat did not show any significant adverse effects on pre and postnatal development at doses up to 100 mg/kg/day (about 5 times the recommended human dose based on body surface area).

8.2 Lactation Risk Summary There are no human data available on the presence of eliglustat in human milk, the effects on the breastfed infant, or the effects on milk production. Eliglustat and its metabolites were present in the milk of lactating rats [see Data ] . When a drug is present in animal milk, it is likely that the drug will be present in human milk. The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for CERDELGA and any potential adverse effects on the breastfed child from CERDELGA or from the underlying maternal condition. Data In a milk excretion study in the rat, a single oral dose of 30 mg/kg [ 14 C]-labeled eliglustat was administered to lactating female rats at day 11 postpartum. Approximately 0.23% of the administered radioactivity was excreted into the milk within 24 hours of dose administration. The concentration in the milk at 24 hours post dose was 16.3-fold higher than the plasma concentration.

8.4 Pediatric Use Safety and effectiveness in pediatric patients have not been established.

8.5 Geriatric Use Clinical studies of CERDELGA did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Clinical experience has not identified differences in responses between the elderly and younger patients.

8.6 Renal Impairment Use CERDELGA in patients with renal impairment based on the patient's CYP2D6 metabolizer status [see Clinical Pharmacology (12.3) ] . EMs Avoid CERDELGA in patients with end-stage renal disease (ESRD) (estimated creatinine clearance (eCLcr) less than 15 mL/min not on dialysis or requiring dialysis). No dosage adjustment is recommended in patients with mild, moderate, or severe renal impairment (eCLcr at least 15 mL/min). IMs and PMs Avoid CERDELGA in patients with any degree of renal impairment.

8.7 Hepatic Impairment Use CERDELGA in patients with hepatic impairment based on CYP2D6 metabolizer status and concomitant use of CYP2D6 or CYP3A inhibitors [see Clinical Pharmacology (12.3) ] . EMs CERDELGA is contraindicated in patients with [see Contraindications (4) ] : severe (Child-Pugh Class C) hepatic impairment moderate (Child-Pugh Class B) hepatic impairment mild (Child-Pugh Class A) hepatic impairment taking a strong or moderate CYP2D6 inhibitor Reduce dosage frequency of CERDELGA 84 mg to once daily [see Dosage and Administration (2.3) ] in patients with mild hepatic impairment taking: a weak CYP2D6 inhibitor a strong, moderate, or weak CYP3A inhibitor No dosage adjustment is recommended in patients with mild hepatic impairment, unless otherwise specified above. IMs and PMs CERDELGA is contraindicated in patients with any degree of hepatic impairment [see Contraindications (4) ] .

Gaucher disease is caused by a deficiency of the lysosomal enzyme acid β-glucosidase. Acid β-glucosidase catalyzes the conversion of the sphingolipid glucocerebroside into glucose and ceramide. The enzymatic deficiency causes an accumulation of glucosylceramide (GL-1) primarily in the lysosomal compartment of macrophages, giving rise to foam cells or "Gaucher cells." The clinical features of this lysosomal storage disorder (LSD) are reflective of the accumulation of Gaucher cells in the reticuloendothelial system (liver, spleen, bone marrow, and other organs). The accumulation of Gaucher cells in the liver, spleen, and bone marrow leads to organomegaly and skeletal disease. Presence of Gaucher cells in the bone marrow and spleen leads to clinically significant anemia and thrombocytopenia. CERDELGA is a specific inhibitor of glucosylceramide synthase (IC 50 =10 ng/mL) and acts as a substrate reduction therapy for GD1 by reducing the production of GL-1. By reducing GL-1 production, CERDELGA alleviates the accumulation of GL-1 in the target organs.