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Physicians office Resource 2022 | Issue 1

Resources for You, Your Patients, & Your Practice

PLANNING FOR NEW INSTRUMENTS AND NEW TESTS PAGE 18

IDENTIFYING MIS-C WITH RISK PREDICTION MODEL PAGE 28

HOW CAN YOU PREVENT ANTIMICROBIAL RESISTANCE? PAGE 37

ACCURATE FLU TESTING MADE EASY PUBLISHED BY Medical Education Resources, LLC PUBLISHER Aaron R. Medaris amedaris@physiciansofficeresource.com

CEO Andrew C. Nimmo acnimmo@physiciansofficeresource.com

PRESIDENT John D. Pasquale

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TRAVEL EDITOR Brandi L. Brower EDITORIAL BOARD Michael Paquin, FHIMSS Barry Craig, MLT (NCA), CLC STAFF WRITER Dylan J. Chadwick

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CREATIVE DIRECTOR PRODUCTION MANAGER Jessica Elmer

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sekisuidiagnostics.com 2022 · ISSUE 1 | 3

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TABLE OF CONTENTS

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PLANNING FOR NEW INSTRUMENTS AND NEW TESTS

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PAGE 18

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HOW CAN YOU PREVENT ANTIMICROBIAL RESISTANCE?

IDENTIFYING MIS-C WITH RISK PREDICTION MODEL

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NOW APPROVED FOR ADULT PATIENTS WITH WALDENSTRÖM’S MACROGLOBULINEMIA (WM) 1

THE BTK INHIBITOR THAT DELIVERS POWERFUL AND CONSISTENT RESPONSES BRUKINSA® (zanubrutinib) is a kinase inhibitor indicated for the treatment of adult patients with Waldenström’s macroglobulinemia.

Ibrutinib

BRUKINSA

The first and only head-to-head trial of BTK inhibitors in WM

A global, randomized Phase 3 trial in WM across a range of patients*1 • Treatment-naïve

• Relapsed/refractory

• MYD88MUT (CXCR4WT, CXCR4WHIM)

• MYD88WT

Powerful Responses Across WM Patients While the primary endpoint of superiority did not reach statistical significance, numerically higher VGPR/CR rates were achieved in the BRUKINSA treatment arm.1

24-hour inhibition of BTK was maintained at 100% in PBMCs and 94% to 100% in lymph nodes when taken at the recommended total daily dose of 320 mg. The clinical significance of 100% inhibition has not been established. 1,2

All patients1 IWWM-6 criteria† (Cohort 1)

IMPORTANT SAFETY INFORMATION WARNINGS AND PRECAUTIONS Hemorrhage Fatal and serious hemorrhagic events have occurred in patients with hematological malignancies treated with BRUKINSA monotherapy. Grade 3 or higher hemorrhage events including intracranial and gastrointestinal hemorrhage, hematuria and hemothorax have been reported in 3.4% of patients treated with BRUKINSA monotherapy. Hemorrhage events of any grade occurred in 35% of patients treated with BRUKINSA monotherapy. Bleeding events have occurred in patients with and without concomitant antiplatelet or anticoagulation therapy. Co-administration of BRUKINSA with antiplatelet or anticoagulant medications may further increase the risk of hemorrhag Monitor for signs and symptoms of bleeding. Discontinue BRUKINSA if intracranial hemorrhage of any grade occurs. Consider the benefit-risk of withholding BRUKINSA for 3-7 days pre- and post-surgery depending upon the type of surgery and the risk of bleeding. Infections Fatal and serious infections (including bacterial, viral, or fungal) and opportunistic infections have occurred in patients with hematological malignancies treated with BRUKINSA monotherapy. Grade 3 or higher infections occurred in 27% of patients, most commonly pneumonia. Infections due to hepatitis B virus (HBV) reactivation have occurred. Consider prophylaxis for herpes simplex virus, pneumocystis jiroveci pneumonia and other infections according to standard of care in patients who are at increased risk for infections. Monitor and evaluate patients for fever or other signs and symptoms of infection and treat appropriately.

All patients1

Cytopenias Grade 3 or 4 cytopenias, including neutropenia (26%), thrombocytopenia (11%) and anemia (8%) based on laboratory measurements, were reported in patients treated with BRUKINSA monotherapy. Grade 4 neutropenia occurred in 13% of patients, and Grade 4 thrombocytopenia occurred in 3.6% of patients. Monitor complete blood counts regularly during treatment and interrupt treatment, reduce the dose or discontinue treatment as warranted. Treat using growth factor or transfusions, as needed. Second Primary Malignancies Second primary malignancies, including non-skin carcinoma, have occurred in 14% of patients treated with BRUKINSA monotherapy. The most frequent second primary malignancy was non-melanoma skin cancer reported in 8% of patients. Other second primary malignancies included malignant solid tumors (4.0%), melanoma (1.7%) and hematologic malignancies (1.2%). Advise patients to use sun protection, and monitor patients for the development of second primary malignancies. Cardiac Arrhythmias Atrial fibrillation and atrial flutter were reported in 3.2% of patients treated with BRUKINSA monotherapy. Patients with cardiac risk factors, hypertension and acute infections may be at increased risk. Grade 3 or higher events were reported in 1.1% of patients treated with BRUKINSA monotherapy. Monitor signs and symptoms for atrial fibrillation and atrial flutter and manage as appropriate. Embryo-Fetal Toxicity Based on findings in animals, BRUKINSA can cause fetal harm when administered to a pregnant woman. Administration of zanubrutinib to pregnant rats during the period of organogenesis caused embryo-fetal

BRUKINSA

toxicity including malformations at exposures that were 5 times higher than those reported in patients at the recommended dose of 160 mg twice daily. Advise women to avoid becoming pregnant while taking BRUKINSA and for 1 week after the last dose. Advise men to avoid fathering a child during treatment and for 1 week after the last dose. 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 a fetus.

ADVERSE REACTIONS The most common adverse reactions, including laboratory abnormalities, in ≥ 30% of patients who received BRUKINSA (N=847) included decreased neutrophil count (54%), upper respiratory tract infection (47%), decreased platelet count (41%), hemorrhage (35%), decreased lymphocyte count (31%), rash (31%) and musculoskeletal pain (30%).

DRUG INTERACTIONS

78 % % 16 62 %

(n=102)

CR+VGPR+PR‡

(95% CI: 68, 85)

VGPR/CR‡

Modiﬁed IWWM-6 criteria† (Cohort 1)

Ibrutinib

78 % % 7 71 %

(n=99)

CR+VGPR+PR

(95% CI: 68, 86)

VGPR/CR

BRUKINSA

78 % % 28 49 %

(n=102)

CR+VGPR+PR‡

(95% CI: 68, 85)

VGPR/CR‡

Ibrutinib

78 % % 19 59 %

(n=99)

CR+VGPR+PR

(95% CI: 68, 86)

VGPR/CR

Median follow-up time was 19.4 months.3 The prespecified efficacy outcome measure of VGPR/CR was assessed by IRC.1

Safety in WM is consistent with the established BRUKINSA profile1

CYP3A Inhibitors: When BRUKINSA is co-administered with a strong CYP3A inhibitor, reduce BRUKINSA dose to 80 mg once daily. For co-administration with a moderate CYP3A inhibitor, reduce BRUKINSA dose to 80 mg twice daily.

Serious adverse reactions, including fatal events, have occurred with BRUKINSA, including hemorrhage, infections, cytopenias, second primary malignancies, and cardiac arrhythmias. The most common adverse reactions (≥30%) include neutrophil count decreased, upper respiratory tract infection, platelet count decreased, hemorrhage, lymphocyte count decreased, rash, and musculoskeletal pain.

CYP3A Inducers: Avoid co-administration with moderate or strong CYP3A inducers.

*Patients were enrolled from the United States, Europe, and Australia/New Zealand. †IWWM-6 criteria (Owen et al, 2013) requires complete resolution of extramedullary disease (EMD) if present at baseline for VGPR to be assessed. Modified IWWM-6 criteria (Treon, 2015) requires a reduction in EMD if present at baseline for VGPR to be assessed.4,5 ‡ There were no CRs in either treatment arm.

SPECIFIC POPULATIONS Hepatic Impairment: The recommended dose of BRUKINSA for patients with severe hepatic impairment is 80 mg orally twice daily.

Please see Brief Summary of full Prescribing Information on following pages.

BTK=Bruton’s tyrosine kinase; CI=confidence interval; CR=complete response; IRC=independent review committee; IWWM-6=6th International Workshop on Waldenström’s Macroglobulinemia; MUT=mutated; ORR=overall response rate; PBMCs=peripheral blood mononuclear cells; PR=partial response; VGPR=very good partial response; WHIM=WHIM syndrome-like somatic mutation; WT=wild type.

References: 1. BRUKINSA. Package insert. BeiGene, Ltd; 2021. 2. Tam C, Trotman J, Opat S, et al. Phase 1 study of the selective BTK inhibitor zanubrutinib in B-cell malignancies and safety and efficacy evaluation in CLL. Blood. 2019;134(11):851-859. 3. Tam CS, Opat S, D’Sa S, et al. A randomized phase 3 trial of zanubrutinib vs ibrutinib in symptomatic Waldenström macroglobulinemia: the ASPEN study. Blood. 2020;136(18):2038-2050. 4. Owen RG, Kyle RA, Stone MJ, et al. Response assessment in Waldenström macroglobulinemia: update from the VIth International Workshop. Br J Haematol. 2013;160(2):171-176. 5. Treon SP. How I treat Waldenström macroglobulinemia. Blood. 2015;126(6):721-732. BRUKINSA and BeiGene are registered trademarks owned by BeiGene, Ltd. © BeiGene, Ltd. 2021 All Rights Reserved. 0821-BRU-PRC-032-r1 10/2021

LEARN MORE AT BRUKINSA.com

BRIEF SUMMARY OF PRESCRIBING INFORMATION FOR BRUKINSA® (zanubrutinib) SEE PACKAGE INSERT FOR FULL PRESCRIBING INFORMATION 1 INDICATIONS AND USAGE 1.1 Mantle Cell Lymphoma BRUKINSA is indicated for the treatment of adult patients with mantle cell lymphoma (MCL) who have received at least one prior therapy. This indication is approved under accelerated approval based on overall response rate [see Clinical Studies (14.1)]. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial. 1.2 Waldenström’s Macroglobulinemia BRUKINSA is indicated for the treatment of adult patients with Waldenström’s macroglobulinemia (WM). 1.3 Marginal Zone Lymphoma BRUKINSA is indicated for the treatment of adult patients with relapsed or refractory marginal zone lymphoma (MZL) who have received at least one anti-CD20-based regimen.

Fatal events within 30 days of the last dose of BRUKINSA occurred in 8 (7%) of 118 patients with MCL. Fatal cases included pneumonia in 2 patients and cerebral hemorrhage in one patient. Serious adverse reactions were reported in 36 patients (31%). The most frequent serious adverse reactions that occurred were pneumonia (11%) and hemorrhage (5%). Of the 118 patients with MCL treated with BRUKINSA, 8 (7%) patients discontinued treatment due to adverse reactions in the trials. The most frequent adverse reaction leading to treatment discontinuation was pneumonia (3.4%). One (0.8%) patient experienced an adverse reaction leading to dose reduction (hepatitis B).

Body System

Blood and lymphatic system disorders

5 WARNINGS AND PRECAUTIONS

Monitor for signs and symptoms of bleeding. Discontinue BRUKINSA if intracranial hemorrhage of any grade occurs. Consider the benefit-risk of withholding BRUKINSA for 3-7 days pre- and post-surgery depending upon the type of surgery and the risk of bleeding. 5.2 Infections Fatal and serious infections (including bacterial, viral, or fungal) and opportunistic infections have occurred in patients with hematological malignancies treated with BRUKINSA monotherapy. Grade 3 or higher infections occurred in 27% of patients, most commonly pneumonia. Infections due to hepatitis B virus (HBV) reactivation have occurred. Consider prophylaxis for herpes simplex virus, pneumocystis jiroveci pneumonia, and other infections according to standard of care in patients who are at increased risk for infections. Monitor and evaluate patients for fever or other signs and symptoms of infection and treat appropriately. 5.3 Cytopenias Grade 3 or 4 cytopenias, including neutropenia (26%), thrombocytopenia (11%) and anemia (8%) based on laboratory measurements, developed in patients treated with BRUKINSA monotherapy [see Adverse Reactions (6.1)]. Grade 4 neutropenia occurred in 13% of patients, and Grade 4 thrombocytopenia occurred in 3.6% of patients. Monitor complete blood counts regularly during treatment and interrupt treatment, reduce the dose, or discontinue treatment as warranted [see Dosage and Administration (2.4)]. Treat using growth factor or transfusions, as needed. 5.4 Second Primary Malignancies Second primary malignancies, including non-skin carcinoma, have occurred in 14% of patients treated with BRUKINSA monotherapy. The most frequent second primary malignancy was non-melanoma skin cancer reported in 8% of patients. Other second primary malignancies included malignant solid tumors (4.0%), melanoma (1.7%) and hematologic malignancies (1.2%). Advise patients to use sun protection and monitor patients for the development of second primary malignancies. 5.5 Cardiac Arrhythmias Atrial fibrillation and atrial flutter were reported in 3.2% of patients treated with BRUKINSA monotherapy. Patients with cardiac risk factors, hypertension and acute infections may be at increased risk. Grade 3 or higher events were reported in 1.1% of patients treated with BRUKINSA monotherapy. Monitor signs and symptoms for atrial fibrillation and atrial flutter and manage as appropriate [see Dosage and Administration (2.4)]. 5.6 Embryo-Fetal Toxicity Based on findings in animals, BRUKINSA can cause fetal harm when administered to a pregnant woman. Administration of zanubrutinib to pregnant rats during the period of organogenesis caused embryo-fetal toxicity, including malformations at exposures that were 5 times higher than those reported in patients at the recommended dose of 160 mg twice daily. Advise women to avoid becoming pregnant while taking BRUKINSA and for 1 week after the last dose. Advise men to avoid fathering a child during treatment and for 1 week after the last dose. 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 a fetus [see Use in Specific Populations (8.1)]. 6 ADVERSE REACTIONS The following clinically significant adverse reactions are discussed in more detail in other sections of the labeling: • Hemorrhage [see Warnings and Precautions (5.1)] • Infections [see Warnings and Precautions (5.2)]

Adverse Reaction

Percent of Patients (N=118) All Grades Grade 3 or % Higher % 38 15

Neutropenia and Neutrophil count decreased Thrombocytopenia and Platelet count decreased

Leukopenia and White blood count decreased

Anemia and Hemoglobin decreased Upper respiratory tract infection

Pneumonia§

10^

Urinary tract infection

0.8

RashII

Bruising*

Diarrhea

0.8

Constipation

Hypertension

3.4

Hemorrhage

3.4

Musculoskeletal and connective tissue disorders

Musculoskeletal pain‡

3.4

Metabolism and nutrition disorders

Hypokalemia

1.7

Respiratory, thoracic and mediastinal disorders

Cough

Infections and infestations

Skin and subcutaneous tissue disorders Gastrointestinal disorders Vascular disorders

†

Other clinically significant adverse reactions that occurred in < 10% of patients with mantle cell lymphoma include major hemorrhage (defined as ≥ Grade 3 hemorrhage or CNS hemorrhage of any grade) (5%), hyperuricemia (6%) and headache (4.2%). Table 4: Selected Laboratory Abnormalities* (> 20%) in Patients with MCL in Studies BGB-3111-206 and BGB-3111-AU-003

Hematologic abnormalities Neutrophils decreased Platelets decreased Hemoglobin decreased Lymphocytosis† Chemistry abnormalities Blood uric acid increased ALT increased Bilirubin increased

Percent of Patients (N=118) All Grades (%) Grade 3 or 4 (%) 45 40 27 41

20 7 6 16

29 28 24

2.6 0.9 0.9

* Based on laboratory measurements. † Asymptomatic lymphocytosis is a known effect of BTK inhibition.

• Second Primary Malignancies [see Warnings and Precautions (5.4)]

Waldenström’s Macroglobulinemia (WM)

• Cardiac Arrhythmias [see Warnings and Precautions (5.5)]

The safety of BRUKINSA was investigated in two cohorts of Study BGB-3111-302 (ASPEN). Cohort 1 included 199 patients with MYD88 mutation (MYD88MUT) WM, randomized to and treated with either BRUKINSA (101 patients) or ibrutinib (98 patients). The trial also included a non-randomized arm, Cohort 2, with 26 wild type MYD88 (MYD88WT) WM patients and 2 patients with unknown MYD88 status [see Clinical Studies (14.2)].

The data in the WARNINGS AND PRECAUTIONS reflect exposure to BRUKINSA in seven clinical trials, administered as a single agent at 160 mg twice daily in 730 patients, at 320 mg once daily in 105 patients, and at 40 mg to 160 mg once daily (0.125 to 0.5 times the recommended dosage) in 12 patients. Among 847 patients receiving BRUKINSA, 73% were exposed for at least 1 year, 57% were exposed for at least 2 years and 26% were exposed for at least 3 years. In this pooled safety population, the most common adverse reactions, including laboratory abnormalities, in ≥ 30% of patients included neutrophil count decreased (54%), upper respiratory tract infection (47%), platelet count decreased (41%), hemorrhage (35%), lymphocyte count decreased (31%), rash (31%) and musculoskeletal pain (30%). Mantle Cell Lymphoma (MCL) The safety of BRUKINSA was evaluated in 118 patients with MCL who received at least one prior therapy in two single-arm clinical trials, BGB-3111-206 [NCT03206970] and BGB-3111-AU-003 [NCT02343120] [see Clinical Studies (14.1)]. The median age of patients who received BRUKINSA in studies BGB-3111-206 and BGB-3111-AU-003 was 62 years (range: 34 to 86), 75% were male, 75% were Asian, 21% were White, and 94% had an ECOG performance status of 0 to 1. Patients had a median of 2 prior lines of therapy (range: 1 to 4). The BGB-3111-206 trial required a platelet count ≥ 75 x 109/L and an absolute neutrophil count ≥ 1 x 109/L independent of growth factor support, hepatic enzymes ≤ 2.5 x upper limit of normal, total bilirubin ≤ 1.5 x ULN. The BGB-3111-AU-003 trial required a platelet count ≥ 50 x 109/L and an absolute neutrophil count ≥ 1 x 109/L independent of growth factor support, hepatic enzymes ≤ 3 x upper limit of normal, total bilirubin ≤ 1.5 x ULN. Both trials required a CLcr ≥ 30 mL/min. Both trials excluded patients with prior allogeneic hematopoietic stem cell transplant, exposure to a BTK inhibitor, known infection with HIV and serologic evidence of active hepatitis B or hepatitis C infection and patients requiring strong CYP3A inhibitors or strong CYP3A inducers. Patients received BRUKINSA 160 mg twice daily or 320 mg once daily. Among patients receiving BRUKINSA, 79% were exposed for 6 months or longer, and 68% were exposed for greater than one year.

General disorders and administration site conditions

Musculoskeletal and connective tissue disorders Nervous system disorders Respiratory, thoracic and mediastinal disorders

^ Includes fatal adverse reaction. * Bruising includes all related terms containing bruise, bruising, contusion, ecchymosis. † Hemorrhage includes all related terms containing hemorrhage, hematoma. ‡ Musculoskeletal pain includes musculoskeletal pain, musculoskeletal discomfort, myalgia, back pain, arthralgia, arthritis. § Pneumonia includes pneumonia, pneumonia fungal, pneumonia cryptococcal, pneumonia streptococcal, atypical pneumonia, lung infection, lower respiratory tract infection, lower respiratory tract infection bacterial, lower respiratory tract infection viral. II Rash includes all related terms containing rash. ¶ Upper respiratory tract infection includes upper respiratory tract infection, upper respiratory tract infection viral.

Laboratory Parameter

Gastrointestinal disorders

Skin and subcutaneous tissue disorders

• Cytopenias [see Warnings and Precautions (5.3)]

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.

Infections and infestations

Table 3: Adverse Reactions (≥ 10%) in Patients Receiving BRUKINSA in BGB-3111-206 and BGB-3111-AU-003 Trials

4 CONTRAINDICATIONS: None.

Bleeding events have occurred in patients with and without concomitant antiplatelet or anticoagulation therapy. Co-administration of BRUKINSA with antiplatelet or anticoagulant medications may further increase the risk of hemorrhage.

Body System

Table 3 summarizes the adverse reactions in BGB-3111-206 and BGB-3111-AU-003.

This indication is approved under accelerated approval based on overall response rate [see Clinical Studies (14.3)]. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial.

5.1 Hemorrhage Fatal and serious hemorrhagic events have occurred in patients with hematological malignancies treated with BRUKINSA monotherapy. Grade 3 or higher hemorrhage including intracranial and gastrointestinal hemorrhage, hematuria and hemothorax have been reported in 3.4% of patients treated with BRUKINSA monotherapy. Hemorrhage events of any grade, excluding purpura and petechiae, occurred in 35% of patients.

Table 5 summarizes the adverse reactions in Cohort 1 in ASPEN. Table 5: Adverse Reactions (≥ 10%) Occurring in Patients with WM Who Received BRUKINSA in Cohort 1

Among patients who received BRUKINSA, 93% were exposed for 6 months or longer, and 89% were exposed for greater than 1 year. In Cohort 1 of the ASPEN study safety population (N=101), the median age of patients who received BRUKINSA was 70 years (45-87 years old); 67% were male, 86% were White, 4% were Asian and 10% were not reported (unknown race). In Cohort 2 of the ASPEN study safety population (N=28), the median age of patients who received BRUKINSA was 72 (39-87 years old); 50% were male, 96% were White and 4% were not reported (unknown race). In Cohort 1, serious adverse reactions occurred in 44% of patients who received BRUKINSA. Serious adverse reactions in > 2% of patients included influenza (3%), pneumonia (4%), neutropenia and neutrophil count decreased (3%), hemorrhage (4%), pyrexia (3%) and febrile neutropenia (3%). In Cohort 2, serious adverse reactions occurred in 39% of patients. Serious adverse reactions in > 2 patients included pneumonia (14%).

Vascular disorders

Adverse Reaction

Upper respiratory tract infection¶

BRUKINSA (N=101) All Grades Grade 3 (%) or 4 (%) 44 0

Pneumonia§ Urinary tract infection Diarrhea Nausea Constipation Vomiting Fatigue# Pyrexia Edema peripheral Bruising* Rashll Pruritus Musculoskeletal pain‡ Muscle spasms Headache Dizziness Cough Dyspnea Hemorrhage† Hypertension

12 11 22 18 16 12 31 16 12 20 29 11 45 10 18 13 16 14 42 14

4 0 3 0 0 0 1 4 0 0 0 1 9 0 1 1 0 0 4 9

Ibrutinib (N=98) All Grades Grade 3 (%) or 4 (%) 40 2 26 13 34 13 7 14 25 13 20 34 32 6 39 28 14 12 18 7 43 19

10 2 2 1 0 1 1 2 0 0 0 0 1 1 1 0 0 0 9 14

* Bruising includes all related terms containing “bruise,” “contusion,” or “ecchymosis.” † Hemorrhage includes epistaxis, hematuria, conjunctival hemorrhage, hematoma, rectal hemorrhage, periorbital hemorrhage, mouth hemorrhage, post procedural hemorrhage, hemoptysis, skin hemorrhage, hemorrhoidal hemorrhage, ear hemorrhage, eye hemorrhage, hemorrhagic diathesis, periorbital hematoma, subdural hemorrhage, wound hemorrhage, gastric hemorrhage, lower gastrointestinal hemorrhage, spontaneous hematoma, traumatic hematoma, traumatic intracranial hemorrhage, tumor hemorrhage, retinal hemorrhage, hematochezia, diarrhea hemorrhagic, hemorrhage, melena, post procedural hematoma, subdural hematoma, anal hemorrhage, hemorrhagic disorder, pericardial hemorrhage, postmenopausal hemorrhage, stoma site hemorrhage, subarachnoid hemorrhage. # Fatigue includes asthenia, fatigue, lethargy. ‡ Musculoskeletal pain includes back pain, arthralgia, pain in extremity, musculoskeletal pain, myalgia, bone pain, spinal pain, musculoskeletal chest pain, neck pain, arthritis, musculoskeletal discomfort. § Pneumonia includes lower respiratory tract infection, lung infiltration, pneumonia, pneumonia aspiration, pneumonia viral. ll Rash includes all related terms rash, maculo-papular rash, erythema, rash erythematous, drug eruption, dermatitis allergic, dermatitis atopic, rash pruritic, dermatitis, photodermatosis, dermatitis acneiform, stasis dermatitis, vasculitic rash, eyelid rash, urticaria, skin toxicity. ¶ Upper respiratory tract infection includes upper respiratory tract infection, laryngitis, nasopharyngitis, sinusitis, rhinitis, viral upper respiratory tract infection, pharyngitis, rhinovirus infection, upper respiratory tract congestion. Clinically relevant adverse reactions in < 10% of patients who received BRUKINSA included localized infection, atrial fibrillation or atrial flutter and hematuria. Table 6 summarizes the laboratory abnormalities in ASPEN.

Table 6: Select Laboratory Abnormalities* (≥ 20%) That Worsened from Baseline in Patients with WM Who Received BRUKINSA in Cohort 1 Laboratory Abnormality

BRUKINSA1 All Grades (%) Grade 3 or 4 (%)

Hematologic Abnormalities Neutrophils decreased Platelets decreased Hemoglobin decreased

Ibrutinib1 All Grades (%) Grade 3 or 4 (%)

50 35 20

24 8 7

34 39 20

9 5 7

Bilirubin increased

1.0

Calcium decreased

2.0

Creatinine increased

1.0

Glucose increased

2.3

Potassium increased

2.0

Urate increased

3.2

Phosphate decreased

3.1

Chemistry Abnormalities

* Based on laboratory measurements. 1 The denominator used to calculate the rate varied from 86 to 101 based on the number of patients with a baseline value and at least one post-treatment value.

Marginal Zone Lymphoma The safety of BRUKINSA was evaluated in 88 patients with previously treated MZL in two single-arm clinical studies, BGB-3111-214 and BGB-3111-AU-003 [see Clinical Studies (14.3)]. The trials required an absolute neutrophil count ≥ 1 x 109/L, platelet count ≥ 50 or ≥ 75 x 109/L and adequate hepatic function and excluded patients requiring a strong CYP3A inhibitor or inducer. Patients received BRUKINSA 160 mg twice daily (97%) or 320 mg once daily (3%). The median age in both studies combined was 70 years (range: 37 to 95), 52% were male, 64% were Caucasian and 19% were Asian. Most patients (92%) had an ECOG performance status of 0 to 1. Eighty percent received BRUKINSA for 6 months or longer, and 67% received treatment for more than one year. Two fatal adverse reactions (2.3%) occurred within 30 days of the last dose of BRUKINSA, including myocardial infarction and a Covid-19 related death. Serious adverse reactions occurred in 40% of patients. The most frequent serious adverse reactions were pyrexia (8%) and pneumonia (7%). Adverse reactions lead to treatment discontinuation in 6% of patients, dose reduction in 2.3%, and dose interruption in 34%. The leading cause of dose modification was respiratory tract infections (13%). Table 7 summarizes selected adverse reactions in BGB-3111-214 and BGB-3111-AU-003. Table 7: Adverse Reactions Occurring in ≥ 10% Patients with MZL Who Received BRUKINSA Body System

Permanent discontinuation of BRUKINSA due to an adverse reaction occurred in 2% of patients in Cohort 1 and included hemorrhage (1 patient), neutropenia and neutrophil count decreased (1 patient); in Cohort 2, permanent discontinuation of BRUKINSA due to an adverse reaction occurred in 7% of patients and included subdural hemorrhage (1 patient) and diarrhea (1 patient).

Infections and infestations

Dosage interruptions of BRUKINSA due to an adverse reaction occurred in 32% of patients in Cohort 1 and in 29% in Cohort 2. Adverse reactions which required dosage interruption in > 2% of patients included neutropenia, vomiting, hemorrhage, thrombocytopenia and pneumonia in Cohort 1. Adverse reactions leading to dosage interruption in > 2 patients in Cohort 2 included pneumonia and pyrexia.

Gastrointestinal disorders

Dose reductions of BRUKINSA due to an adverse reaction occurred in 11% of patients in Cohort 1 and in 7% in Cohort 2. Adverse reactions which required dose reductions in > 2% of patients included neutropenia in Cohort 1. Adverse reaction leading to dose reduction occurred in 2 patients in Cohort 2 (each with one event: diarrhea and pneumonia).

Skin and subcutaneous tissue disorders Musculoskeletal and connective tissue disorders Vascular disorders General disorders Respiratory, thoracic and mediastinal disorders

Adverse Reaction

Upper respiratory tract infectionsa Urinary tract infectionb Pneumoniac† Diarrhead Abdominal paine Nausea Bruisingf Rashg Musculoskeletal painh Hemorrhagei Fatiguej Coughk

* Includes 2 fatal events of COVID-19 pneumonia. Upper respiratory tract infections includes upper respiratory tract infection, nasopharyngitis, sinusitis, tonsillitis, rhinitis, viral upper respiratory tract infection. b Urinary tract infection includes urinary tract infection, cystitis, Escherichia urinary tract infection, pyelonephritis, cystitis. c Pneumonia includes COVID-19 pneumonia, pneumonia, bronchopulmonary aspergillosis, lower respiratory tract infection, organizing pneumonia. d Diarrhea includes diarrhea and diarrhea hemorrhagic. e Abdominal pain includes abdominal pain, abdominal pain upper, abdominal discomfort. f Bruising includes contusion, ecchymosis, increased tendency to bruise, post procedural contusion. g Rash includes rash, rash maculo-papular, rash pruritic, dermatitis, dermatitis allergic, dermatitis atopic, dermatitis contact, drug reaction with eosinophilia and systemic symptoms, erythema, photosensitivity reaction, rash erythematous, rash papular, seborrheic dermatitis. h Musculoskeletal pain includes back pain, arthralgia, musculoskeletal pain, myalgia, pain in extremity, musculoskeletal chest pain, bone pain, musculoskeletal discomfort, neck pain. i Hemorrhage includes epistaxis, hematuria, hemorrhoidal hemorrhage, hematoma, hemoptysis, conjunctival hemorrhage, diarrhea hemorrhagic, hemorrhage urinary tract, mouth hemorrhage, pulmonary hematoma, subcutaneous hematoma, gingival bleeding, melena, upper gastrointestinal hemorrhage. j Fatigue includes fatigue, lethargy, asthenia. k Cough includes cough and productive cough. a

BRUKINSA (N=88) All Grades Grade 3 % or 4 (%) 26 3.4 11 2.3 10 6 25 3.4 14 2.3 13 0 24 0 21 0 27 1.1 23 1.1 21 2.3 10 0

Clinically relevant adverse reactions in < 10% of patients who received BRUKINSA included peripheral neuropathy, second primary malignancies, dizziness, edema, headache, petechiae, purpura and atrial fibrillation or flutter. Table 8 summarizes selected laboratory abnormalities. Table 8: Select Laboratory Abnormalities (≥ 20%) That Worsened from Baseline in Patients with MZL Laboratory Abnormality1 Hematologic abnormalities Neutrophils decreased Platelets decreased Lymphocytes decreased Hemoglobin decreased Chemistry abnormalities Glucose increased Creatinine increased Phosphate decreased Calcium decreased ALT increased

BRUKINSA All Grades (%)

Grade 3 or 4 (%)

43 33 32 26

15 10 8 6

54 34 27 23 22

4.6 1.1 2.3 0 1.1

The denominator used to calculate the rate varied from 87 to 88 based on the number of patients with a baseline value and at least one post-treatment value. 7 DRUG INTERACTIONS 7.1 Effect of Other Drugs on BRUKINSA Table 9: Drug Interactions that Affect Zanubrutinib Moderate and Strong CYP3A Inhibitors Clinical Impact • Co-administration with a moderate or strong CYP3A inhibitor increases zanubrutinib Cmax and AUC [see Clinical Pharmacology (12.3)] which may increase the risk of BRUKINSA toxicities. Prevention or • Reduce BRUKINSA dosage when co-administered with moderate or strong CYP3A inhibitors management [see Dosage and Administration (2.3)]. Moderate and Strong CYP3A Inducers Clinical Impact • Co-administration with a moderate or strong CYP3A inducer decreases zanubrutinib Cmax and AUC [see Clinical Pharmacology (12.3)] which may reduce BRUKINSA efficacy. Prevention or • Avoid co-administration of BRUKINSA with moderate or strong CYP3A inducers management [see Dosage and Administration (2.3)]. 8 USE IN SPECIFIC POPULATIONS 8.1 Pregnancy Risk Summary Based on findings in animals, BRUKINSA can cause fetal harm when administered to pregnant women. There are no available data on BRUKINSA use in pregnant women to evaluate for a drug-associated risk of major birth defects, miscarriage or adverse maternal or fetal outcomes. In animal reproduction studies, oral administration of zanubrutinib to pregnant rats during the period of organogenesis was associated with fetal heart malformation at approximately 5-fold human exposures (see Data). Women should be advised to avoid pregnancy while taking BRUKINSA. If BRUKINSA is used during pregnancy, or if the patient becomes pregnant while taking BRUKINSA, the patient should be apprised of the potential hazard to the fetus. The estimated 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. Data Animal Data Embryo-fetal development toxicity studies were conducted in both rats and rabbits. Zanubrutinib was administered orally to pregnant rats during the period of organogenesis at doses of 30, 75, and 150 mg/kg/day. Malformations in the heart (2- or 3-chambered hearts) were noted at all dose levels in the absence of maternal toxicity. The dose of 30 mg/kg/day is approximately 5 times the exposure (AUC) in patients receiving the recommended dose of 160 mg twice daily. Administration of zanubrutinib to pregnant rabbits during the period of organogenesis at 30, 70, and 150 mg/kg/day resulted in post-implantation loss at the highest dose. The dose of 150 mg/kg is approximately 32 times the exposure (AUC) in patients at the recommended dose and was associated with maternal toxicity. In a pre- and post-natal developmental toxicity study, zanubrutinib was administered orally to rats at doses of 30, 75, and 150 mg/kg/day from implantation through weaning. The offspring from the middle and high dose groups had decreased body weights preweaning, and all dose groups had adverse ocular findings (e.g., cataract, protruding eye). The dose of 30 mg/kg/ day is approximately 5 times the AUC in patients receiving the recommended dose. 8.2 Lactation Risk Summary There are no data on the presence of zanubrutinib or its metabolites in human milk, the effects on the breastfed child, or the effects on milk production. Because of the potential for serious adverse reactions from BRUKINSA in a breastfed child, advise lactating women not to breastfeed during treatment with BRUKINSA and for two weeks following the last dose. 8.3 Females and Males of Reproductive Potential Pregnancy Testing Pregnancy testing is recommended for females of reproductive potential prior to initiating BRUKINSA therapy. Contraception Females BRUKINSA can cause embryo-fetal harm when administered to pregnant women [see Use in Specific Populations (8.1)]. Advise female patients of reproductive potential to use effective contraception during treatment with BRUKINSA and for 1 week following the last dose of BRUKINSA. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be informed of the potential hazard to a fetus. Males Advise men to avoid fathering a child while receiving BRUKINSA and for 1 week following the last dose of BRUKINSA. 8.4 Pediatric Use Safety and effectiveness in pediatric patients have not been established. 8.5 Geriatric Use Of the 847 patients in clinical studies with BRUKINSA, 53% were ≥ 65 years of age, and 20% were ≥ 75 years of age. No overall differences in safety or effectiveness were observed between younger and older patients. 8.6 Renal Impairment No dosage modification is recommended in patients with mild, moderate, or severe renal impairment (CLcr ≥ 15 mL/min, estimated by Cockcroft-Gault). Monitor for BRUKINSA adverse reactions in patients on dialysis [see Clinical Pharmacology (12.3)]. 8.7 Hepatic Impairment Dosage modification of BRUKINSA is recommended in patients with severe hepatic impairment [see Dosage and Administration (2.2)]. The safety of BRUKINSA has not been evaluated in patients with severe hepatic impairment. No dosage modification is recommended in patients with mild to moderate hepatic impairment. Monitor for BRUKINSA adverse reactions in patients with hepatic impairment [see Clinical Pharmacology (12.3)]. Distributed and Marketed by: BeiGene USA, Inc. 2955 Campus Drive, Suite 200 San Mateo, CA 94403 BRUKINSA® is a registered trademark owned by BeiGene, Ltd. © BeiGene, Ltd. 2021 All Rights Reserved. 0721-BRU-PRC-027 09/2021

BIOFIRE® FILMARRAY® TORCH From BioFire

The BioFire® FilmArray® Torch is a fully integrated, random, and continuous access system designed to meet your laboratory’s syndromic infectious disease testing needs. The BioFire Torch offers a radically reduced benchtop footprint, saving precious space in the lab, and its scalability meets high throughput demands. BioFire® FilmArray® Link Software automatically uploads patient results. Fully compatible with all CLIA Moderate BioFire® FilmArray® Panels, the BioFire Torch helps you maximize efficiency and productivity.

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View Brochures, Videos & More at POR.io Enter Number 1112 in the Search Area

Round up SARS-CoV-2 and 18 other pathogens. The new BioFire Respiratory 2.1-EZ (RP2.1-EZ) Panel (EUA) covers SARS-CoV-2 detection and so much more. ®

ACUCY INFLUENZA A&B TEST

From Sekisui Diagnostics

The Acucy™ Influenza A&B Test is for the rapid, qualitative detection of influenza A and B viral nucleoprotein antigens from both nasal and nasopharyngeal swabs. Utilizing the Acucy™ Reader in either the point-of-care or laboratory setting, workflow flexibility is achieved with both Read Now and Walk Away features. The combination provides clinicians with standardized and definitive result interpretation.

View Brochures, Videos & More at POR.io Enter Number 1113 in the Search Area

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OSOM ULTRA PLUS FLU A&B TEST From Sekisui Diagnostics 1114 Stronger Clinical Performance Takes Lateral Flow Testing To The Next Level. Providing superior rapid results at the point-of-care. Fast, easy, cost effective so you can test and treat in one visit.

Right now, SARS-CoV-2 is everyone’s top suspect, but many other respiratory bugs can cause similar, overlapping symptoms. Testing for just SARS-CoV-2 or influenza could mean running the risk of missing the real culprit, leading to missed infections, or even coinfections. Additionally, many rapid diagnostic tests sacrifice accuracy for speed, with sensitivities oftentimes ranging from 50–70%.2 Now you can test for 18 common respiratory pathogens in your clinic, including SARS-CoV-2 in patients suspected of a COVID-19 infection with syndromic testing from the BioFire RP2.1-EZ Panel— now available under an FDA Emergency Use Authorization (EUA).1,3 Syndromic testing means all it takes is one test and about 45 minutes to round up SARS-CoV-2—and all the other usual respiratory suspects. What's your frontline solution for respiratory season and beyond?

1115

BioFire RP2.1-EZ Panel (EUA) Overall 97.1% sensitivity and 99.3% specificity (prospective specimens)4 SARS-CoV-2 98.0% sensitivity and 100% specificity (archived specimens)5 SARS-CoV-2 100% PPA and 100% NPA (contrived specimens)6

To learn more, visit biofiredx.com

• High Performance- Equivalent or exceeding the performance of reader devices, without the need for an instrument • Results in 10 minutes • OSOM® Custom Care- Exceptional Support/Training by licensed medical technologists and experienced healthcare professionals • Made in the USA

View Brochures, Videos & More at POR.io Enter Number 1114 in the Search Area

14 | PHYSICIANS OFFICE RESOURCE

1. This test has not been FDA cleared or approved. This test has been authorized by FDA under an EUA for use by authorized laboratories. This test has been authorized only for the detection and differentiation of nucleic acid of SARS-CoV-2 from multiple respiratory viral and bacterial organisms. This test is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of invitro diagnostics for detection and/or diagnosis of COVID-19 under Section 564(b)(1) of the Federal Food, Drug, and Cosmetic Act, 21 U.S.C. § 360bbb-3(b)(1), unless the authorization is terminated or revoked sooner. 2. http://www.cdc.gov/flu/professionals/diagnosis/rapidlab.htm 3. For use with the CLIA-waived BioFire® FilmArray® 2.0 EZ configuration. 4. Based on the prospective portion of the clinical study for the BioFire® FilmArray® Respiratory 2 (RP2) Panel. 5. Based on the archived specimen study in the BioFire Respiratory 2.1 (RP2.1) Panel EUA submission 6. Based on the contrived specimen study in the BioFire Respiratory 2.1 (RP2.1) Panel EUA submission.

BFR0001-0517-02

PRODUCT FOCUS

FLU AND RESPIRATORY

PRODUCT FOCUS

STREP TESTS 1116

Why You Should Be Doing Spirometry

OSOM® ULTRA STREP A TEST From Sekisui Diagnostics

The OSOM® Ultra Strep A test is a color immunochromatographic assay intended for the qualitative detection of Group A Streptococcus antigen directly from throat swab specimens. Shown to be not statistically different than single swab culture. Sensitivity 95.7% and 100% Specificity. Includes two additional test sticks for External QC. CLIA Waived..

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1120

View Brochures, Videos & More at POR.io Enter Number 1116 in the Search Area

TOXICOLOGY TOXICOLOGY URINE DRUG SCREENING REAGENTS From Abbott

1121 1117

Prescription drug misuse and illicit drug abuse is a growing public health challenge in this country. Building a test profile that covers highly misused drugs has never been so vital. With over 20 relevant assays to choose from Abbott’s suite of Immunalysis reagents allows you to easily screen for relevant substances. Our complete line of assays, calibrators, and controls enables you to implement an efficient drug screening program in office.

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TOXICOLOGY SCREENING SIMPLIFIED ABBOTT’S IMMTOX 270 BENCHTOP ANALYZER NOW WITH 14 ASSAYS CLIA CATEGORIZED AS MODERATE COMPLEXITY From Abbott

The ImmTox270 benchtop analyzer offers comprehensive toxicology screening solutions for physician offices, treatment centers and independent laboratories. Broad test menu with over 20 assays to choose from including 14 that are now available as moderately complex.

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16 | PHYSICIANS OFFICE RESOURCE

With complete laboratory solutions from consultation to licensure, and compliance the Abbott Clinical Laboratory Solutions team has you covered.

View Brochures, Videos & More at POR.io Enter Number 1118 in the Search Area

It’s Important - Spirometry is the gold standard for the diagnosis and management of both asthma and COPD. It’s Good Medicine - Your patients are correctly diagnosed and treated more accurately and conveniently in your office. The earlier you detect the disease; the easier you can treat it. It’s Easy - A spirometry test takes less than five minutes to perform. It’s Good Business - Office spirometry is third party reimbursable and will pay for itself within the first year of purchase. It’s Safe - The SpiroSafe filter is single use viral/bacterial filters that helps to protect your patients and staff. It is >99% effective against viral and bacterial cross-contamination. Why Micro Direct? - Micro Direct’s spirometry experts will help you choose the right spirometer and then FULLY support your staff from training on how to use the spirometer through billing questions; and all Micro Direct spirometers are backed by a 30-day money back guarantee.

Micro Direct, Inc. 803 Webster Street Lewiston, ME 04240 1-888-287-8556 sales@mdspiro.com

www.mdspiro.com

1122

Whether planning a new, start-up laboratory operation, or performing an analysis of placement instruments, or add or delete tests), it is important to do a realistic assessment not only of what you want to offer your ordering physicians, but what you can realistical-

PLANNING FOR NEW INSTRUMENTS AND NEW TESTS

ly offer. The laboratory’s test menu should be aligned as closely as possible with physician expectations and needs, as well as the laboratory’s operational capabilities. By strengthening relationships with ordering physicians, laboratories can more accurately forecast future service needs and make the best decisions as to test menu, instrumentation, and staffing, including which tests to outsource or maintain in-house10.

Begin this process by: Reviewing Basic Information about the Current / Proposed Laboratory Operation The first step in the planning process for adding new tests and new instrumentation begins with asking the following baseline questions regarding the present or proposed laboratory operation: • What is your present test menu? Present instrumentation? Present staffing levels? • What medical specialties are represented by your ordering physicians? (an important determinant of what tests will be requested, as well as patient demographics) • Do you anticipate changes in the number of client physicians served? New specialties added? New populations served?

BY IRWIN Z. ROTHENBERG, MBA, MS, CLS(ASCP), TECHNICAL WRITER /QUALITY ADVISOR, COLA RESOURCES, INC.

• What are your current or anticipated test volumes / demand for specific tests? • What is the complexity of testing already performed or planned? (waived vs. non-waived, with attendant regulatory requirements, including personnel) • What are your present hours of operation with attendant staffing levels / type and volume of testing performed per shift / commitment for turn-around times? • What are your anticipated operating and capital budgets? (important determinant for changes to instrumentation

18 | PHYSICIANS OFFICE RESOURCE

and level of automation; as well as staffing expertise) • Is adequate workspace available to accommodate all phases of new patient testing from specimen collection to test result reporting? The answers to these questions provide guidance for any changes to the test menu, which will be a driver for decisions on whether to acquire new or replacement instruments. The next step forward is to perform a Cost/Benefit analysis of your present operation, and of the proposed changes to the test systems to determine economic and logistical feasibility. Determine the Feasibility of Adding New Tests: Perform a Cost / Benefit Analysis1 It is by taking into account the internal as well as external factors in the laboratory environment, that the decisions made will have the best chance of success. Below are items to consider for your cost/benefit analysis: • Instrument capacity for current or proposed test menu (is it “right-sized” for test volume and level of staffing) • Instrument cost (purchase or lease) • Reagent cost (are you obligated to purchase reagents from a particular manufacturer?) • Reagent life (expiration dates: days, weeks, months before/after opening packages)

2022 · ISSUE 1 | 19

FEATURE

current testing, (providing input for decisions on whether or not to purchase new or re-

FEATURE

• Storage requirements for reagents (do you need to buy a new refrigerator or freezer?) • Frequency and expense of Quality Controls, Calibration, and Maintenance • Tests run singly or in batch-mode • Comparison of in-house testing with reference laboratory charges and turn-around time • Complexity of present and proposed testing. • Staffing requirements: number, training expenses; qualifications and experience beyond present staffing; continuing education • Proficiency Testing requirements • Facility space, ventilation, electrical needs; hazardous disposal requirements • Time and involvement of the Lab Director, and the Technical Consultant • Document storage requirements / LIS capability • Adjusting the front office staffing to handle additional pre and post analytical paperwork and communications Additional strategies to determine the appropriateness of testing offered, and the instrumentation needed2. • Analyze test mix and outsource demanded but low-volume tests. Only outsource these tests if you can provide the test results a lower cost and with a better turnaround time. • Project test demand and costs to determine which tests to perform in house. Conversely, analysis of send-out volumes may indicate opportunities to bring certain tests in-house. • Partner with reference laboratories. Reference laboratories can provide valuable support in the form of financial analysis, methodology assessment, and provision of clinical samples to help make in-sourceversus-outsource decisions and to establish and increase on-site test volumes. Consider external factors as well3 Consider what is going on in the laboratory industry today, noting trends both locally and across the country and seeing if these factors may affect your laboratory: • What will be the impact of changes in reimbursement / payment mechanisms? • What is the current market for your laboratory services? Estimating market size and location is a critical component to determine market opportunity. These estimates will drive financial outcomes. • If you are part of an organization that has adopted the concept of value-based medical care, and it now part of an Accountable Care Organization (ACO), or accepts “bundled payments”, your expenses will come under increased pressure to be held down and

20 | PHYSICIANS OFFICE RESOURCE

minimized. You may be encouraged to outsource more than originally planned. • The well-documented staffing shortage may be a factor in your area; consider your local situation if planning to increase testing, add shifts, and new pre-analytic services. Of course, providing the highest level of service for your patients may justify costs associated with the above considerations, but it is vital to ensure that your instrumentation can handle the changes in projected demand in terms of test volume capacity, variety of tests offered, operating times and staffing. This may require considering more automation. Automation has long been regarded as an important means for clinical laboratories to achieve greater operational efficiency, test accuracy, method standardization, total data handling and reduced turnaround time; in short, an improved quality of patient care. The development of new generations of automated standalone and bench top equipment has made automation a more viable option for labs of all sizes—and in many cases, a necessary option for labs seeking to remain competitive in today’s marketplace4.

Solid & Glass Door Refrigerators From 1 to 15 Cu.ft.

B. Set priorities for automation based on realistic budget limitations Once you have taken care of the above, and determined your needs, start getting quotes on systems needed. Budget negotiations will begin, with sets of reality checks on what is doable and what is not. Decisions should be based on priorities set in advance. C. A few more points to remember Always choose a vendor who can provide prompt, affordable service to minimize any downtime. Remember the data management involved. There are different sets of tools for data processing, data mining and data visualization, and you need to think about how you are going to track and analyze this data. Finally, create an infrastructure that can be easily modified or expanded for other applications.

Refrigeration designed and purpose-built for pharmacy, medication, and vaccination applications to support meeting CDC/VFC vaccine storage guidelines

+/-1ºC variation derived from the maximum deviation of an NTC sensor in a 1 oz. vial located nearest the champer geometric center during a 24 hour test period

1123

Advanced Temperature Control & Durable Performance

• Intelligent microprocessor digital temperature controller • Adjustable operating control range from +2 to +8ºC • Digital display of the min/max temperature in Celsius or Fahrenheit • Password protected control parameters beyond setpoitn • Optimized forced air cooling for excellent stability & uniformity with rapid recovery • Open door and high/low temperature alarms • Factory installed lock conveniently located towards the top of each unit • $GMXVWDEOH VKHOYLQJ FDQ EH VSDFHG LQ óµ LQWHUYDOV IRU IOH[LEOH VWRUDJH

Pharma-Vac Refrigerators Accucold ARS1PV ARG1PV ARS3PV ARG3PV ARS6PV ARG6PV ARS8PV ARG8PV ARS12PV ARG12PV ARS15PV ARG15PV

Steps in Determining the Right Automation for Your Laboratory5 A. Questions to ask when deciding how much automation is needed The amount of automation needed depends on the type and size of your laboratory. If all you are looking for is increased throughput and you don’t really have to deal with diverse assays and readouts, then you might want to think about modular components. So, with a few nonintegrated pieces of equipment, you can get the throughput you need without a huge investment, or additional space required.

Refrigerators & Freezers From 23 to 49 Cu.ft.

Capacity 1 cu.ft. 1 cu.ft. 3 cu.ft. 3 cu.ft. 6 cu.ft. 6 cu.ft. 8 cu.ft. 8 cu.ft. 12 cu.ft. 12 cu.ft. 15 cu.ft. 15 cu.ft.

Height 21.5” 21.5” 33.75” 33.75” 32.5” 32.5” 50” 50” 61.75” 61.75” 72” 72”

Width 17.5” 17.5” 18.5” 18.5” 23.5” 23.5” 23.38” 23.38” 23.38” 23.38” 23.5” 23.5”

Depth 19.5” 20” 19” 19.5” 24.5” 25” 24.5” 25” 24.5” 25” 24.5” 25”

Door White Glass White Glass White Glass White Glass White Glass White Glass

790*, $936.00 $949.00 $1,089.00 $1,102.00 $1,235.00 $1,266.00 $1,654.00 $1,667.00 $2,139.00 $2,152.00 $2,321.00 $2,334.00

Height 83.75 83.75 83.75 83.75

Width 27.5 27.5 55.25 55.25

Depth 31 31 31 31

Door (1) Stainless (1) Glass (2) Stainless (2) Glass

790*, $2,789.00 $3,114.00 $4,674.00 $5,031.00

Height 83.75 83.75

Width 27.5 55.25

Depth 31 31

Door (1) Stainless (2) Stainless

790*, $3,205.00 $5,194.00

Pharma-Lab Refrigerators Accucold ARS23ML ARG23ML ARS49ML ARG49ML

Capacity 23 cu.ft. 23 cu.ft. 49 cu.ft. 49 cu.ft.

Pharma-Lab Freezers Accucold AFS23ML AFS49ML

Capacity 23 cu.ft. 49 cu.ft.

Choosing the Right Sized Unit Below are a few handy steps for determining the ideal Accucold refrigerator size for your clinic:

Estimate the maximum number of doses of publicly-provided vaccine and privately purchased vaccine that will be in your refrigerator.

Refrigerator: Public Vaccine

Add the number of doses on hand (current inventory) from your last order form. ________________

Match your maximum doses with the minimum cubic feet needed to safely store your vaccine

Max. Doses

Minimum Cubic Ft.

2,000+ doses

may need more than one refrigerator

1000-2000

40 cu.ft 36 cu.ft 21-23 cu.ft

Private Vaccine

+ ________________

900-1000 801-900

Total doses

= ________________

701-800

17-19.5 cu.ft

Multiply (max inventory) Maximum doses

x 1.25 = ________________

400-700

11-16.7 cu.ft

100-399

4.9-6.1 cu.ft

One of the ways that laboratories can use their resources more effectively is to strengthen their relationships with physicians. These relationships are vital as strategic assets, and, as the demands on physicians continue to multiply, they will increasingly rely on their laboratory partners for diagnostic support. Physicians increasingly seek a diagnostic resource that can meet all of their testing needs7.

The key role of competent management in accomplishing these goals9 Effective laboratory planning requires competent management. It is through the application of management skills that you can implement change with minimal disruption. Competent laboratory management includes effective communication with the staff; providing key information and direction for the continuing future development of the laboratory; and encouraging involvement in the development of strategic plans. 22 | PHYSICIANS OFFICE RESOURCE

2 R. Saunders and A. Westerink. Sidebar: The Strategic Value of laboratory Outreach. Nov 1, 2014. http://www. hfma.org/Content.aspx?id=25853 3 Strategic Planning For The Clinical laboratory. Martha Robbins and Associates. Clinical laboratory Consulting. http://www.labconsultant.com/strategic.htm 4 G Tufel Right-Sizing Laboratory Automation. Clinical Lab Products. December 17, 2014. http://www.clpmag.com/2014/12/right-sizing-laboratory-automation/ 5 M. Ferrer. Ask the Expert: How to Automate Your Lab to Best Fit Your Needs. Lab Manager. January 2011. http://www.labmanager.com/ask-the-expert/2011/01/ ask-the-expert-how-to-automate-your-lab-to-best-fityour-needs 6 K Huey. Starting a New Lab: How to Develop a Budget and Buy Equipment. American Physiological Society (APS). http://www.the-aps.org/mm/Careers/Mentor/Managing-a-Lab-and-Personnel/Early-Career-Professionals/Setting-Up-a-Laboratory/Developing-a-Budget-and-Buying-Equipment 7 R. Saunders and A. Westerink. Sidebar: The Strategic Value of laboratory Outreach. Nov 1, 2014. http://www. hfma.org/Content.aspx?id=25853 8 Dr. Curtis Hanson and Elizabeth Plumhoff. MAYO CLINIC: Test Utilization and the Clinical Laboratory. May 2012. http://www.mayomedicallaboratories.com/ articles/communique/2012/05.html 9 How To become A Good Lab Manager by Elizabeth Sandquist. ASBMB Today. October 2013. 10 R. Saunders and A. Westerink. Sidebar: The Strategic Value of laboratory Outreach. Nov 1, 2014. http://www. hfma.org/Content.aspx?id=25853

1124

EHENS PR I M

An important step in this process is to work with client physicians on a program of proper test utilization to encourage the most efficient and relevant use of the testing offered.

1 The Cost Effective Laboratory: The Changing Landscape of Laboratory Testing. Laboratory Testing Matters. August 2015. http://www.labtestingmatters. org/the-cost-effective-laboratory-the-changing-landscape-of-laboratory-testing/

To efficiently manage laboratory test utilization requires both ensuring adequate utilization of needed tests in some patients and discouraging superfluous tests in other patients8.

Endnotes

Laboratories are discovering that they are well positioned to provide medical guidance and direction for clinicians who are trying to maneuver their way through the increasingly complex world of laboratory testing.

TRANSFORM PATIENT SATISFACTION AND PRACTICE EFFICIENCY.

Recognize the strategic importance of physician / laboratory relationships

POINT OF CARE

E. Consider purchasing a service contract6 A service contract can include many services beyond a general warranty, such as software updates, calibration, certification, preventative maintenance, priority service, and/or additional discounts on upgrades. Service contracts can be costly, and you can either discuss options with colleagues or make your own informed decision. Several reasons why you may choose to purchase a service contract could include reduced hassles if your equipment breaks, faster/priority repairs and a predictable expense in your budget. If a piece of equipment is critical to your work, you use it frequently, and major repairs are very expensive, a service contract may be worthwhile. In terms of budget, you will know exactly what you are going to pay in advance and will not be blindsided with a major “surprise” expense.

Successful management can motivate staff to provide feedback about their workload; instruments and kits used; make suggestions for improvement of, and changes to, their test menu; and provide information about interactions with other offices, departments, physicians, and patients. These types of information play an important role when developing strategies for cost containment, automation, growth, re-alignment, and even repositioning of the lab in the community.

FEATURE

D. Plan for downtime for routine maintenance and equipment breakdown

AVA I L A

CLIA Waived Tests: CMP, BMP, Lipid Panel, Lipid Panel Plus, General Chemistry, Kidney Check, Renal Panel, MetLyte 8 and Electrolytes

1125

Fast—Results in minutes, accelerating patient care decisions. Accurate—Lab-accurate results for a wide range of tests.* Versatile—Comprehensive CLIA-waived menu available. Simple—Intuitive function to improve operational efficiency. Convenient—Have test results during office visit, increasing patient satisfaction.

To learn more, contact your Abbott Point of Care representative at 888-893-0335, your distribution representative, or visit www.pointofcare.abbott *2016 Proficiency Testing Results, American Proficiency Institute, www.api-pt.com [Piccolo Xpress]. See cartridge information at www.pointofcare.abbott [i-STAT]. i-STAT Part No: 04J60-20 Waived Kit, 04J48-50 Moderately Complex Kit, 06F20-20 Waived Analyzer, 04P75-03 Moderately Complex Analyzer Piccolo Xpress Part No: 07P05-50 Piccolo Xpress with 3YR Serv, 07P05-51 Piccolo Xpress with 5YR Serv ©Abbott Point of Care Inc. 400 College Road East, Princeton, NJ 08540 www.pointofcare.abbott For in vitro diagnostic use only. This material is intended for a U.S. audience only. i-STAT is a trademark of Abbott. 3032.REV1 07/20 POR Ad - Abbott POC i-Stat/Piccolo Piccolo Xpress is a registered trademark of Abaxis, Inc. and distributed by Abbott Point of Care. Abaxis 888-3355 Rev A

For your patients with previously treated, unresectable locally advanced or metastatic cholangiocarcinoma (CCA) with an FGFR2 fusion or rearrangement

Take in the power of PEMAZYRE PEMAZYRE is the first FDA-approved therapy for the treatment of adults with previously treated, unresectable locally advanced or metastatic cholangiocarcinoma with a fibroblast growth factor receptor 2 (FGFR2) fusion or other rearrangement as detected by an FDA-approved test. This indication is approved under accelerated approval based on overall response rate and duration of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial(s). The major efficacy outcomes were evaluated in 107 patients with an FGFR2 fusion or non-fusion rearrangement* in a multicenter, open-label, single-arm study of 146 total patients with locally advanced unresectable or metastatic cholangiocarcinoma who had received ≥1 previous line of systemic therapy.1,†

Patients receiving PEMAZYRE achieved durable responses Median DoR was

9.1 months

Patients with DoR: • ≥6 months: 63% (n=24)

1, ‡

• ≥12 months: 18% (n=7)

Clinical response rates of PEMAZYRE1 100 Percent of Patients

INDICATIONS AND USAGE

FGFR, fibroblast growth factor receptor.

ORR: the primary endpoint2

2.8% CR 33 % PR

36% ORR (95% CI, 27%–45%)

20 0 Efficacy evaluable population (N=107) Note: Data are from IRC per RECIST v1.1, and CR and PR are confirmed.

Median time to response was 2.7 months (range, 0.7–6.9 months)

*Determined by a clinical trial assay performed at a central laboratory. † Patients received PEMAZYRE in 21-day cycles at a dosage of 13.5 mg orally once daily for 14 consecutive days, followed by 7 days off therapy, until disease progression or unacceptable toxicity occurred. The major efficacy outcome measures were ORR and DoR, as determined by IRC according to RECIST v1.1. ‡ 95% CI, 6.0-14.5 months and was calculated using the Brookmeyer and Crowley’s method.1 CI, confidence interval; DoR, duration of response; IRC, independent review committee; ORR, overall response rate; RECIST, Response Evaluation Criteria in Solid Tumors.

Molecular profiling is necessary to detect FGFR2 fusions or rearrangements A next-generation sequencing assay, such as FoundationOne® CDx, meets the following criteria to detect FGFR2 fusions3-6: • Specifically detects FGFR2 fusions (distinct from FGFR2 mutations) • Detects FGFR2 fusions with a wide range of fusion partners (whether known or unknown)

Learn more about testing and treating your appropriate patients. Visit hcp.PEMAZYRE.com

IMPORTANT SAFETY INFORMATION Ocular Toxicity Retinal Pigment Epithelial Detachment (RPED): PEMAZYRE can cause RPED, which may cause symptoms such as blurred vision, visual floaters, or photopsia. Clinical trials of PEMAZYRE did not conduct routine monitoring including optical coherence tomography (OCT) to detect asymptomatic RPED; therefore, the incidence of asymptomatic RPED with PEMAZYRE is unknown.

Among 466 patients who received PEMAZYRE across clinical trials, RPED occurred in 6% of patients, including Grade 3-4 RPED in 0.6%. The median time to first onset of RPED was 62 days. RPED led to dose interruption of PEMAZYRE in 1.7% of patients, and dose reduction and permanent discontinuation in 0.4% and in 0.4% of patients, respectively. RPED resolved continued

Please see Important Safety Information for PEMAZYRE continued on the adjacent page.

IMPORTANT SAFETY INFORMATION (CONTINUED) or improved to Grade 1 levels in 87.5% of patients who required dosage modification of PEMAZYRE for RPED. Perform a comprehensive ophthalmological examination including OCT prior to initiation of PEMAZYRE and every 2 months for the first 6 months and every 3 months thereafter during treatment. For onset of visual symptoms, refer patients for ophthalmologic evaluation urgently, with follow-up every 3 weeks until resolution or discontinuation of PEMAZYRE. Modify the dose or permanently discontinue PEMAZYRE as recommended in the prescribing information for PEMAZYRE. Dry Eye: Among 466 patients who received PEMAZYRE across clinical trials, dry eye occurred in 27% of patients, including Grade 3-4 in 0.6% of patients. Treat patients with ocular demulcents as needed.

Hyperphosphatemia and Soft Tissue Mineralization PEMAZYRE can cause hyperphosphatemia leading to soft tissue mineralization, cutaneous calcification, calcinosis, and non-uremic calciphylaxis. Increases in phosphate levels are a pharmacodynamic effect of PEMAZYRE. Among 466 patients who received PEMAZYRE across clinical trials, hyperphosphatemia was reported in 92% of patients based on laboratory values above the upper limit of normal. The median time to onset of hyperphosphatemia was 8 days (range 1-169). Phosphate lowering therapy was required in 29% of patients receiving PEMAZYRE. Monitor for hyperphosphatemia and initiate a low phosphate diet when serum phosphate level is >5.5 mg/dL. For serum phosphate levels >7 mg/dL, initiate phosphate lowering therapy and withhold, reduce the dose, or permanently discontinue PEMAZYRE based on duration and severity of hyperphosphatemia as recommended in the prescribing information.

Embryo-Fetal Toxicity Based on findings in an animal study and its mechanism of action, PEMAZYRE can cause fetal harm when administered to a pregnant woman. Oral administration of pemigatinib to pregnant rats during the period of organogenesis caused fetal malformations, fetal growth retardation, and embryo-fetal death at maternal exposures lower than the human exposure based on area under the curve (AUC) at the clinical dose of 13.5 mg. Advise pregnant women of the potential risk to the fetus. Advise female patients of reproductive potential to use effective contraception during treatment with PEMAZYRE and for 1 week after the final dose. Advise males with female partners of reproductive potential to use effective contraception during treatment with PEMAZYRE and for 1 week after the final dose.

Adverse Reactions Serious adverse reactions occurred in 45% of patients receiving PEMAZYRE. Serious adverse reactions in ≥2% of patients who received PEMAZYRE included abdominal pain, pyrexia, cholangitis, pleural effusion, acute kidney injury, cholangitis infective, failure to thrive, hypercalcemia, hyponatremia, small intestinal obstruction, and urinary tract infection. Fatal adverse reactions occurred in 4.1% of patients, including failure to thrive, bile duct obstruction, cholangitis, sepsis, and pleural effusion. Permanent discontinuation due to an adverse reaction occurred in 9% of patients who received PEMAZYRE. Adverse reactions requiring permanent discontinuation in ≥1% of patients included intestinal obstruction and acute kidney injury. Dosage interruptions due to an adverse reaction occurred in 43% of patients who received PEMAZYRE. Adverse reactions requiring dosage interruption in ≥1% of patients included

stomatitis, palmar-plantar erythrodysesthesia syndrome, arthralgia, fatigue, abdominal pain, AST increased, asthenia, pyrexia, ALT increased, cholangitis, small intestinal obstruction, alkaline phosphatase increased, diarrhea, hyperbilirubinemia, electrocardiogram QT prolonged, decreased appetite, dehydration, hypercalcemia, hyperphosphatemia, hypophosphatemia, back pain, pain in extremity, syncope, acute kidney injury, onychomadesis, and hypotension. Dose reductions due to an adverse reaction occurred in 14% of patients who received PEMAZYRE. Adverse reactions requiring dosage reductions in ≥1% of patients who received PEMAZYRE included stomatitis, arthralgia, palmar-plantar erythrodysesthesia syndrome, asthenia, and onychomadesis. Clinically relevant adverse reactions occurring in ≤10% of patients included fractures (2.1%). In all patients treated with pemigatinib, 1.3% experienced pathologic fractures (which included patients with and without cholangiocarcinoma [N=466]). Soft tissue mineralization, including cutaneous calcification, calcinosis, and non-uremic calciphylaxis associated with hyperphosphatemia were observed with PEMAZYRE treatment. Within the first 21-day cycle of PEMAZYRE dosing, serum creatinine increased (mean increase of 0.2 mg/dL) and reached steady state by Day 8, and then decreased during the 7 days off therapy. Consider alternative markers of renal function if persistent elevations in serum creatinine are observed. The most common adverse reactions (incidence ≥20%) were hyperphosphatemia (60%), alopecia (49%), diarrhea (47%), nail toxicity (43%), fatigue (42%), dysgeusia (40%), nausea (40%), constipation (35%), stomatitis (35%), dry eye (35%), dry mouth (34%), decreased appetite (33%), vomiting (27%), arthralgia (25%), abdominal pain (23%), hypophosphatemia (23%), back pain (20%), and dry skin (20%).

Drug Interactions Avoid concomitant use of strong and moderate CYP3A inhibitors with PEMAZYRE. Reduce the dose of PEMAZYRE if concomitant use with a strong or moderate CYP3A inhibitor cannot be avoided. Avoid concomitant use of strong and moderate CYP3A inducers with PEMAZYRE.

Special Populations Advise lactating women not to breastfeed during treatment with PEMAZYRE and for 1 week after the final dose. Reduce the recommended dose of PEMAZYRE for patients with severe renal impairment as described in the prescribing information. Reduce the recommended dose of PEMAZYRE for patients with severe hepatic impairment as described in the prescribing information. Please see the Brief Summary of Prescribing Information on the following pages. References: 1. PEMAZYRE (pemigatinib) Prescribing Information. Incyte Corporation. 2. Abou-Alfa GK, Sahai V, Hollebecque A, et al. Lancet Oncol. 2020;21(5):671-684. 3. Lowery MA, Ptashkin R, Jordan E, et al. Clin Cancer Res. 2018;24(17):4154-4161. 4. Javle MM, Murugesan K, Shroff RT, et al. J Clin Oncol. 2019;37(15 suppl):4087. 5. Hollebecque A, de Bono JS, Plummer R, et al. Ann Oncol. 2019;30(suppl 1):mdz029. 6. Frampton GM, Fichtenholtz A, Otto GA, et al. Nat Biotechnol. 2013;31(11):1023-1031.

BRIEF SUMMARY: For Full Prescribing Information, see package insert. INDICATIONS AND USAGE PEMAZYRE is indicated for the treatment of adults with previously treated, unresectable locally advanced or metastatic cholangiocarcinoma with a fibroblast growth factor receptor 2 (FGFR2) fusion or other rearrangement as detected by an FDA-approved test [see Dosage and Administration (2.1) in Full Prescribing Information]. This indication is approved under accelerated approval based on overall response rate and duration of response [see Clinical Studies (14.1) in Full Prescribing Information]. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial(s). CONTRAINDICATIONS None. WARNINGS AND PRECAUTIONS Ocular Toxicity Retinal Pigment Epithelial Detachment (RPED) PEMAZYRE can cause RPED, which may cause symptoms such as blurred vision, visual floaters, or photopsia. Clinical trials of PEMAZYRE did not conduct routine monitoring including optical coherence tomography (OCT) to detect asymptomatic RPED; therefore, the incidence of asymptomatic RPED with PEMAZYRE is unknown. Among 466 patients who received PEMAZYRE across clinical trials, RPED occurred in 6% of patients, including Grade 3-4 RPED in 0.6%. The median time to first onset of RPED was 62 days. RPED led to dose interruption of PEMAZYRE in 1.7% of patients, and dose reduction and permanent discontinuation in 0.4% and in 0.4% of patients, respectively. RPED resolved or improved to Grade 1 levels in 87.5% of patients who required dosage modification of PEMAZYRE for RPED. Perform a comprehensive ophthalmological examination including OCT prior to initiation of PEMAZYRE and every 2 months for the first 6 months and every 3 months thereafter during treatment. For onset of visual symptoms, refer patients for ophthalmologic evaluation urgently, with follow-up every 3 weeks until resolution or discontinuation of PEMAZYRE. Modify the dose or permanently discontinue PEMAZYRE as recommended [see Dosage and Administration (2.3) in Full Prescribing Information]. Dry Eye Among 466 patients who received PEMAZYRE across clinical trials, dry eye occurred in 27% of patients, including Grade 3-4 in 0.6% of patients. Treat patients with ocular demulcents as needed. Hyperphosphatemia and Soft Tissue Mineralization PEMAZYRE can cause hyperphosphatemia leading to soft tissue mineralization, cutaneous calcification, calcinosis, and non-uremic calciphylaxis. Increases in phosphate levels are a pharmacodynamic effect of PEMAZYRE [see Clinical Pharmacology (12.2) in Full Prescribing Information]. Among 466 patients who received PEMAZYRE across clinical trials, hyperphosphatemia was reported in 92% of patients based on laboratory values above the upper limit of normal. The median time to onset of hyperphosphatemia was 8 days (range 1-169). Phosphate lowering therapy was required in 29% of patients receiving PEMAZYRE. Monitor for hyperphosphatemia and initiate a low phosphate diet when serum phosphate level is > 5.5 mg/dL. For serum phosphate levels > 7 mg/dL, initiate phosphate lowering therapy and withhold, reduce the dose, or permanently discontinue PEMAZYRE based on duration and severity of hyperphosphatemia [see Dosage and Administration (2.3) in Full Prescribing Information]. Embryo-Fetal Toxicity Based on findings in an animal study and its mechanism of action, PEMAZYRE can cause fetal harm when administered to a pregnant woman. Oral administration of pemigatinib to pregnant rats during the period of organogenesis caused fetal malformations, fetal growth retardation, and embryo-fetal death at maternal exposures lower than the human exposure based on area under the curve (AUC) at the clinical dose of 13.5 mg. Advise pregnant women of the potential risk to the fetus. Advise female patients of reproductive potential to use effective contraception during treatment with PEMAZYRE and for 1 week after the final dose. Advise males with female partners of reproductive potential to use effective contraception during treatment with PEMAZYRE and for 1 week after the final dose [see Use in Specific Populations (8.1, 8.3) in Full Prescribing Information]. ADVERSE REACTIONS The following adverse reactions are discussed elsewhere in the labeling: • Ocular Toxicity [see Warnings and Precautions (5.1) in Full Prescribing Information] • Hyperphosphatemia and Soft Tissue Mineralization [see Warnings and Precautions (5.2) in Full Prescribing Information]. 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 PEMAZYRE was evaluated in FIGHT-202, which included 146 patients with previously treated, locally advanced or metastatic cholangiocarcinoma [see Clinical Studies (14.1) in Full Prescribing Information]. Patients were treated orally with PEMAZYRE 13.5 mg once daily for 14 days on followed by 7 days off therapy until disease progression or unacceptable toxicity. The median duration of

treatment was 181 days (range: 7 to 730 days). The median age of PEMAZYREtreated patients was 59 years (range 26-78), 58% were females, and 71% were White. Serious adverse reactions occurred in 45% of patients receiving PEMAZYRE. Serious adverse reactions in ≥ 2% of patients who received PEMAZYRE included abdominal pain, pyrexia, cholangitis, pleural effusion, acute kidney injury, cholangitis infective, failure to thrive, hypercalcemia, hyponatremia, small intestinal obstruction, and urinary tract infection. Fatal adverse reactions occurred in 4.1% of patients, including failure to thrive, bile duct obstruction, cholangitis, sepsis, and pleural effusion. Permanent discontinuation due to an adverse reaction occurred in 9% of patients who received PEMAZYRE. Adverse reactions requiring permanent discontinuation in ≥ 1% of patients included intestinal obstruction and acute kidney injury. Dosage interruptions due to an adverse reaction occurred in 43% of patients who received PEMAZYRE. Adverse reactions requiring dosage interruption in ≥ 1% of patients included stomatitis, palmar-plantar erythrodysesthesia syndrome, arthralgia, fatigue, abdominal pain, AST increased, asthenia, pyrexia, ALT increased, cholangitis, small intestinal obstruction, alkaline phosphatase increased, diarrhea, hyperbilirubinemia, electrocardiogram QT prolonged, decreased appetite, dehydration, hypercalcemia, hyperphosphatemia, hypophosphatemia, back pain, pain in extremity, syncope, acute kidney injury, onychomadesis, and hypotension. Dose reductions due to an adverse reaction occurred in 14% of patients who received PEMAZYRE. Adverse reactions requiring dosage reductions in ≥ 1% of patients who received PEMAZYRE included stomatitis, arthralgia, palmar-plantar erythrodysesthesia syndrome, asthenia, and onychomadesis. Table 1 summarizes the adverse reactions in FIGHT-202. Table 2 summarizes laboratory abnormalities in FIGHT-202.

Table 1: Adverse Reactions (≥ 15%) in Patients Receiving PEMAZYRE in FIGHT-202 PEMAZYRE N=146 All Gradesa Grades ≥ 3* Adverse Reaction (%) (%) Metabolism and nutrition disorders 60

Decreased appetite

1.4

Hypophosphatemiac

Dehydration

3.4

Alopecia

Nail toxicityd

2.1

Dry skin

0.7

Palmar-plantar erythrodysesthesia syndrome

4.1

Diarrhea

2.7

Nausea

Constipation

Stomatitis

Hyperphosphatemiab

Table 1 continued.

Adverse Reaction

PEMAZYRE N=146 All Gradesa Grades ≥ 3* (%) (%)

Infections and infestations Urinary tract infection

2.7

2.1

Investigations Weight loss

*Only Grades 3 – 4 were identified. a Graded per NCI CTCAE 4.03. b Includes hyperphosphatemia and blood phosphorous increased; graded based on clinical severity and medical interventions taken according to the “investigations-other, specify” category in NCI CTCAE v4.03. c Includes hypophosphatemia and blood phosphorous decreased. d Includes nail toxicity, nail disorder, nail discoloration, nail dystrophy, nail hypertrophy, nail ridging, nail infection, onychalgia, onychoclasis, onycholysis, onychomadesis, onychomycosis, and paronychia. e Includes dry eye, keratitis, lacrimation increased, pinguecula, and punctate keratitis.

Clinically relevant adverse reactions occurring in ≤ 10% of patients included fractures (2.1%). In all patients treated with pemigatinib, 1.3% experienced pathologic fractures (which included patients with and without cholangiocarcinoma [N=466]). Soft tissue mineralization, including cutaneous calcification, calcinosis, and non-uremic calciphylaxis associated with hyperphosphatemia were observed with PEMAZYRE treatment.

Table 2: Select Laboratory Abnormalities (≥ 10%) Worsening from Baseline in Patients Receiving PEMAZYRE in FIGHT-202 a PEMAZYRE N=146 Grades ≥ 3 All Gradesb Laboratory Abnormality (%) (%) Hematology Decreased hemoglobin

Decreased lymphocytes

6 8

Decreased platelets

3.4

Increased leukocytes

0.7

Decreased leukocytes

1.4

Chemistry

Skin and subcutaneous tissue disorders

Increased phosphatec

Decreased phosphate

Increased alanine aminotransferase

4.1

Increased aspartate aminotransferase

Increased calcium

4.1

Increased alkaline phosphatase

Increased creatinined

1.4

2.1

Decreased sodium

0.7

Increased glucose

0.7

Decreased albumin

Dry mouth

Increased urate

Vomiting

1.4

Increased bilirubin

Abdominal pain

4.8

Decreased potassium

Decreased calcium

2.7

Gastrointestinal disorders

General disorders Fatigue

4.8

Increased potassium

2.1

Edema peripheral

0.7

Decreased glucose

1.4

Nervous system disorders Dysgeusia

Headache

0.7

Eye disorders Dry eyee

Musculoskeletal and connective tissue disorders Arthralgia

Back pain

2.7

Pain in extremity

2.1

Table 1 continued above.

The denominator used to calculate the rate varied from 142-146 based on the number of patients with a baseline value and at least one post-treatment value. b Graded per NCI CTCAE 4.03. c Based on CTCAE 5.0 grading. d Graded based on comparison to upper limit of normal. a

Increased Creatinine Within the first 21-day cycle of PEMAZYRE dosing, serum creatinine increased (mean increase of 0.2 mg/dL) and reached steady state by Day 8, and then decreased during the 7 days off therapy. Consider alternative markers of renal function if persistent elevations in serum creatinine are observed [see Clinical Pharmacology (12.3) in Full Prescribing Information]. DRUG INTERACTIONS Effect of Other Drugs on PEMAZYRE Strong and Moderate CYP3A Inducers Concomitant use of PEMAZYRE with a strong or moderate CYP3A inducer decreases pemigatinib plasma concentrations, [see Clinical Pharmacology (12.3) in Full Prescribing Information] which may reduce the efficacy

of PEMAZYRE. Avoid concomitant use of strong and moderate CYP3A inducers with PEMAZYRE. Strong and Moderate CYP3A Inhibitors Concomitant use of a strong or moderate CYP3A inhibitor with PEMAZYRE increases pemigatinib plasma concentrations, [see Clinical Pharmacology (12.3) in Full Prescribing Information] which may increase the incidence and severity of adverse reactions. Avoid concomitant use of strong and moderate CYP3A inhibitors with PEMAZYRE. Reduce PEMAZYRE dosage if concomitant use of strong and moderate CYP3A inhibitors cannot be avoided [see Dosage and Administration (2.4) in Full Prescribing Information]. USE IN SPECIFIC POPULATIONS Pregnancy Risk Summary Based on findings in an animal study and its mechanism of action, PEMAZYRE can cause fetal harm or loss of pregnancy when administered to a pregnant woman [see Clinical Pharmacology (12.1) in Full Prescribing Information]. There are no available data on the use of PEMAZYRE in pregnant women. Oral administration of pemigatinib to pregnant rats during the period of organogenesis at maternal plasma exposures below the human exposure at the clinical dose of 13.5 mg resulted in fetal malformations, fetal growth retardation, and embryo-fetal death (see Data). Advise pregnant women of the potential risk to a fetus. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively. Data Animal Data Once daily oral administration of pemigatinib to pregnant rats during the period of organogenesis resulted in 100% embryofetal mortality due to post-implantation loss at doses ≥ 0.3 mg/kg (approximately 0.6 times the human exposure based on AUC at the clinical dose of 13.5 mg). Fetal survival was unaffected at 0.1 mg/kg per day; however, once daily oral administration of pemigatinib at the 0.1 mg/kg dose level (approximately 0.2 times the human exposure based on AUC at the clinical dose of 13.5 mg) resulted in reduced mean fetal body weight and an increase in fetal skeletal and visceral malformations, major blood vessel variations, and reduced ossification. Lactation Risk Summary There are no data on the presence of pemigatinib or its metabolites in human milk or their effects on either the breastfed child or on milk production. Because of the potential for serious adverse reactions in breastfed children from PEMAZYRE, advise women not to breastfeed during treatment and for 1 week after the final dose. Females and Males of Reproductive Potential Pregnancy Testing Verify pregnancy status of females of reproductive potential prior to initiating PEMAZYRE [see Use in Specific Populations (8.1) in Full Prescribing Information]. Contraception PEMAZYRE can cause fetal harm when administered to pregnant women [see Use in Specific Populations (8.1) in Full Prescribing Information]. Females Advise females of reproductive potential to use effective contraception during treatment with PEMAZYRE and for 1 week after the final dose. Males Advise males with female partners of reproductive potential to use effective contraception during treatment with PEMAZYRE and for 1 week after the final dose. Pediatric Use The safety and effectiveness of PEMAZYRE have not been established in pediatric patients. Animal Toxicity Data In 4- or 13-week repeat-dose toxicology studies in rats and non-human primates, animals displayed toxicities in bone and teeth at pemigatinib exposures lower than the human exposure at the clinical dose of 13.5 mg. Physeal and cartilage dysplasia were present in multiple bones in both species, and tooth (incisor) abnormalities (complete loss of ameloblasts with associated secondary changes) occurred in rats. Six weeks after cessation of dosing, these findings did not show complete evidence of recovery, and additional tooth-related findings (mal-aligned, whitened, broken, and trimmed/thinned incisors) developed in the 13-week study. Geriatric Use In FIGHT-202, 32% of patients were 65 years and older, and 8% of patients were 75 years and older. No overall differences in safety or effectiveness were observed between these patients and younger patients. Renal Impairment Reduce the recommended dosage of PEMAZYRE for patients with severe renal impairment (eGFR 15 to 29 mL/min/1.73 m2, estimated by Modification of Diet in Renal Disease [MDRD] equation) [see Dosage and Administration (2.5) and Clinical Pharmacology (12.3) in Full Prescribing Information]. No dosage adjustment is recommended for patients with mild or moderate renal impairment (eGFR 30 to 89 mL/min/1.73 m2). No dosage adjustment is recommended for patients with end-stage renal disease (eGFR < 15 mL/min/1.73 m2) who are receiving intermittent hemodialysis. [see Clinical Pharmacology (12.3) in Full Prescribing Information]. Hepatic Impairment Reduce the recommended dosage of PEMAZYRE for patients with severe hepatic impairment (total bilirubin > 3 × ULN with any AST) [see Dosage and Administration (2.6) and Clinical Pharmacology (12.3) in Full Prescribing Information]. No dosage adjustment is recommended for patients with mild (total bilirubin > upper limit of normal [ULN] to 1.5 × ULN or AST > ULN) or moderate (total bilirubin >1.5–3 × ULN with any AST) hepatic impairment [see Clinical Pharmacology (12.3) in Full Prescribing Information]. PEMAZYRE is a registered trademark of Incyte Corporation. U.S. Patent Nos. 9,611,267 and 10,131,667 © 2020-2021 Incyte Corporation. All rights reserved. Issued: February 2021 PLR-PEM-00009

BY SEKISUI DIAGNOSTICS

In 2019, the World Health Organization declared antibacterial resistance one of the top 10 threats to global health. As deadly as it has already proven to be, COVID-19 could result in even more health-related disruptions in the future. Several studies estimate that 70% to 97% of hospitalized patients with COVID-19 received antibiotic therapy. Here’s the problem: Increased antibiotic usage accelerates antibiotic resistance. The irony is, SARS-CoV-2 is a virus with respiratory symptoms, and no antibiotic is yet available against it. Inappropriate prescribing could have been avoided with diagnostic testing for influenza, Respiratory Syncytial Virus, group A strep, etc., prior to prescription and treatment. COVID-19 pandemic reminds us of the value of infectious diseases diagnostics. Even though economic value of infectious diseases diagnostics is not always easily quantifiable, diagnostics play a valuable and critical role in effective patient care. Diagnostics helps to determine the disease etiology, influence treatment modalities, and enable public health surveillance. Moreover, advances in Point-Of-Care (POC) testing have further improved patient care. Antimicrobial resistance Microbes are survivors. To paraphrase German philosopher Friedrich Nietzsche, what doesn’t kill them makes them stronger. When exposed to conditions that inhibit growth, such as antibiotics, microbes make changes that help them survive. Those that acquire resistance can multiply rapidly and spread the resistance to other microbes. Per Rodney Rohde, PhD, professor, and chair for the Clinical Laboratory Science (CLS) Program in the College of Health Professions at Texas State University, COVID-19 pandemic can worsen the threat posed by antimicrobial resistance. In 2019, the World Health Organization declared antibacterial resistance one of the top 10 threats to global health. Left unchecked, drug-resistant diseases could cause 10 million deaths each year by 2050, warns the UN Ad hoc Interagency Coordinating Group on Antimicrobial Resistance. In the United States, antibiotic-resistant bacteria and fungi cause more than 2.8 million infections and 35,000 deaths each year— nearly twice as many annual deaths from antibiotic resistance as reported in 2013. The Centers for 28 | PHYSICIANS OFFICE RESOURCE

Disease Control and Prevention’s 2019 AR Threats Report includes two new urgent threats: drug-resistant Candida auris and Carbapenem-resistant Acinetobacter. These were added to three identified in 2013: Carbapenem-resistant Enterobacteriaceae (CRE), Neisseria gonorrhoeae, and Clostridioides difficile. Enter COVID-19 COVID has exacerbated the threat. In 2020, the World Health Organization reported on a study that showed that while 72% of COVID-19 patients received antibiotics, only 8% demonstrated bacterial or fungal co-infections. WHO also reported that early in the pandemic, azithromycin was widely used with hydroxychloroquine in the mistaken belief it could quell the virus. Azithromycin has since been shown to have no effect on SARS-CoV-2. Another factor exacerbating antibiotic resistance has been the upswing in telehealth during the pandemic. Studies have shown that antibiotics are prescribed for a broader set of symptoms in the absence of physical examinations or laboratory tests -- e.g., telehealth. Hospital admissions increase the risk of healthcare-associated infections and the transmission of multidrug-resistant organisms. Disruptions to health services during the pandemic also led to interruptions to treatments, such as for tuberculosis and human immunodeficiency virus, which can lead to selection for drug resistance. Similarly, disruptions to vaccination services increase the risk of infection, potentially leading to an overuse of antimicrobials. The widespread use of biocidal agents for environmental and personal disinfection represents another threat. Low-level exposure to biocidal agents can select for drug-resistant strains and enhance the risk of cross-resistance to antibiotics, particularly those that treat Gram-negative bacteria. What now? Outsmarting microbes will never be easy. After all, they’ve been at it for a long time. Researchers believe that Enterococci bacteria – which cause thousands of multidrug-resistant infections in patients each year – were carried onto land in the guts of the world’s first terrestrial animals 425 million years ago. Still, efforts are being made to slow down the growth of antibiotic resistance. For the duration of the current pandemic, the World Health Organization recommends: 2022 · ISSUE 1 | 29

FEATURE

HOW CAN YOU PREVENT ANTIMICROBIAL RESISTANCE?

FEATURE

1. Training health workers to identify signs and symptoms of severe COVID-19 and those of bacterial or fungal disease; evaluate the need for medical devices that increase the chances of health care-associated infections; and implement strict infection prevention and control measures.

• Explore phage therapy. Bacteriophages (phages) are viruses that selectively infect and kill bacteria. Phage therapy has been used to treat patients with severe, multi-drug-resistant infections under compassionate use conditions with promising results. However, knowledge gaps have hindered its development in the U.S.

2. Ensuring the regular supply of quality-assured antimicrobials, including antiretroviral and tuberculosis drugs, and vaccines.

Diagnostics an essential component The need for antibiotic stewardship programs has never been more urgent. The UK’s National Institute for Health and Care Excellence (NICE) defines such programs as “an organizational or healthcare-system-wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness.” They emphasize education and training about antimicrobial resistance, providing regular feedback to prescribers, and integrating audits into existing quality improvement programs.

3. Reducing the turnaround time of COVID-19 testing by improving testing methods and expanding testing facilities, especially for presumed patients, to reduce the urge to initiate antibiotics. 4. Exercising caution in the use of biocides for environmental and personal disinfection, and prioritizing biocidal agents with a low selection pressure for antibiotic resistance. In the long run Government agencies, academic institutions, and nonprofit and industry groups around the world are sharing their expertise and aligning clinical trials and resources to tackle the growing problem. For example, the Antibacterial Resistance Leadership Group, funded by the U.S. National Institute of Allergy and Infectious Diseases (NIAID) is collaborating with groups in 19 countries and has initiated more than 40 clinical studies at 130 sites. In 2019, the UN Interagency Coordination Group on Antimicrobial Resistance recommended countries support awareness programs for prudent use of antimicrobials by professionals in human, animal and plant health; invest in research and development for new technologies to combat antimicrobial resistance; and urgently phase out the use of critically important antimicrobials as growth promoters in agriculture. In 2020, NIAID proposed a four-pronged approach to the challenge: • Support research into promising therapeutics. For example, the Institute is funding research projects to develop models to predict the potency of therapeutics based on an understanding of how molecules enter and leave Gram-negative pathogens. • Optimize existing antibiotics, that is, developing regimens of older antibiotics to more effectively treat infections and suppress the emergence of resistance. • Develop microbiome-based approaches. For example, NIAID scientists collaborated with researchers in Thai land on a project that showed that Bacillus -- a “good” bacterium commonly found in probiotic digestive supplements -- helps eliminate Staphylococcus aureus.

30 | PHYSICIANS OFFICE RESOURCE

Bionet CardioTouch 3000: $1,495.00 Schiller FT-1: $2,530.00 Burdick ELI 280: $4,294.00 Welch Allyn CP150 w/ Interp: $3,645.00

In the U.S., the National Action Plan for Combating Antibiotic-Resistant Bacteria, 2020-2025 recognizes the importance of rapid and innovative diagnostics as a tool to ensure appropriate antimicrobial use. Specifically, the authors call for researchers to: • Develop new or enhance existing diagnostics that use isolates and primary samples to determine the presence, severity, or antimicrobial susceptibility or resistance of bacterial or fungal infections and to identify appropriate treatment. • Stimulate research to better understand the appropriate use of diagnostics to determine the presence, severity, or antimicrobial susceptibility or resistance of bacterial or fungal infections in human and veterinary care. • Develop evidence-based guidance to promote the appropriate use of new diagnostics and to improve the use of existing diagnostics that determine the presence, severity, or antimicrobial susceptibility or resistance of bacterial or fungal infections in human clinical care.

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The Adview 2 is still the only truly modular diagnostic station that grows with your needs. Start with blood pressure and choose temperature or pulse oximetry option at the time of purchase.

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Coaxial Ophth, Fiber Optic Oto, Speucla Dispenser, Aneroid BP, Wall Transformer and Wall Board without Thermometer: $979.00 1134 with Thermometer: $1,416.00

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To summarize • Detect, respond to, and contain emerging resistance • Prevent and stop spread of resistant infections in health care and community settings. • Improve antibiotic use.

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In addition to the above, Point-of-Care (POC) testing can play a crucial role in antibiotic stewardship. A study in a UK hospital demonstrated that a point-of-care test (POCT) for viral respiratory infections reduced the number of inappropriate hospital admissions and antibiotic prescriptions. With advancement in POC testing and conscious efforts towards antibiotic stewardship we can prevent antimicrobial resistance.

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I N P O S T- P L AT I N U M , P O S T– P D - ( L )1 l a /m U C PAT I E N T S

IN CISPL ATIN-INELIGIBLE , POST–PD -(L)1 la/mUC PATIENTS 1

I N P O S T- P L AT I N U M , P O S T– P D - ( L )1 l a /m U C PAT I E N T S

N P O S T- P-(L)1 L AT I la/mUC NUM, PO S T– P D - ( L )1 l a /m U C PAT I E N T S IN CISPL ATIN-INELIGIBLE ,I POST–PD PATIENTS

PADCEV DELIVERED CLINICALLY MEANINGFUL RESPONSE1,3

PADCEV® SIGNIFICANTLY IMPROVED OS vs CHEMOTHERAPY1 PADCEV SIGNIFICANTLY IMPROVED OS vs CHEMOTHERAPY

100

OS (%)

Median OS

9.0 months Median OS

PADCEV Chemotherapy

(95% CI: 8.1, 10.7) 6 9

0 301

257 250

3 257

222 198

6 222

12 Time (Months)

95% CI: 39.8%, 61.3%)

130 101

130

63 12 Time 51 (Months) 63

718 6

21 2

24 0

0 0

*The EV-301 trial evaluated PADCEV vs investigator’s-choice chemotherapy multicenter, phase 3 trial of 608 patients with 307 250 198 101 51 29 6 in a randomized, 2 0 locally*The advanced urothelial cancer who had previously received platinum-containing chemotherapy and apatients PD-1 orwith PD-L1 EV-301 or trialmetastatic evaluated PADCEV vs investigator’s-choice chemotherapy in a randomized, multicenter, phase 3 trial of 608 inhibitor. Patients wereorrandomized 1:1 to either 1.25 mg/kg ofpreviously PADCEV via IV infusion over 30 minutes on days 1, 8, and 15 of every 28-day locally advanced metastatic urothelial cancer who had received platinum-containing chemotherapy and a PD-1 or PD-L1 2 2 2 cycle, or docetaxel at 75 mg/m , paclitaxel 1751.25 mg/m , orofvinflunine at IV 320 mg/m inhibitor. Patients were randomized 1:1 to at either mg/kg PADCEV via infusion over 30 minutes on days 1, 8, and 15 of every 28-day 2 2 on daycycle, 1 of every 21-day at cycle. For both arms, treatment untilat 320 mg/m2 or docetaxel 75 mg/m , paclitaxel at 175 mg/mcontinued , or vinflunine radiographic toxicity.1,2 on day 1disease of everyprogression 21-day cycle.or Forunacceptable both arms, treatment continued until † Basedradiographic on log-rank disease test. Stratification were toxicity.1,2 progressionfactors or unacceptable † 1 on log-rank test. Stratification factors were ECOG Based PS, region and liver metastasis. ECOG PS, region and liver metastasis.1

IMPORTANT SAFETY INFORMATION IMPORTANT SAFETY INFORMATION WARNING: SERIOUS REACTIONS BOXEDBOXED WARNING: SERIOUS SKINSKIN REACTIONS

100 80 60 40 20

hyperglycemia patientswith with higher body mass index hyperglycemiaincreased increased consistently consistently ininpatients higher body mass index and baselineA1C. A1C.Five Fivepercent percent (5%) patients required andininpatients patientswith withhigher higher baseline (5%) of of patients required initiationofofinsulin insulintherapy therapy for TheThe median timetime to to initiation for treatment treatmentofofhyperglycemia. hyperglycemia. median • PADCEV can severe cause severe and cutaneous fatal cutaneous adverse reactions including onset • PADCEV can cause and fatal adverse reactions including onsetofofhyperglycemia hyperglycemia was 0.6 20.3). Hyperglycemia led led 0.6 months months(range: (range:0.1 0.1toto 20.3). Hyperglycemia Stevens-Johnson syndrome (SJS)Toxic and Toxic Epidermal Necrolysis (TEN), which toto discontinuationof ofPADCEV PADCEV in monitor blood glucose Stevens-Johnson syndrome (SJS) and Epidermal Necrolysis (TEN), which discontinuation in0.6% 0.6%ofofpatients. patients.Closely Closely monitor blood glucose predominantly thecycle first cycle of treatment, occur later. levels levelsininpatients patientswith, with, or or at at risk oror hyperglycemia. If blood occurredoccurred predominantly duringduring the first of treatment, but but maymay occur later. risk for, for,diabetes diabetesmellitus mellitus hyperglycemia. If blood • monitor Closely monitor patients forreactions. skin reactions. glucoseisiselevated elevated(>250 (>250 mg/dL), mg/dL), withhold • Closely patients for skin glucose withholdPADCEV. PADCEV. • Immediately withhold PADCEV and consider referral for specialized care for Pneumonitis Severe, life-threatening or fatal pneumonitis occurred in patients • Immediately withhold PADCEV and consider referral for specialized care for Pneumonitis Severe, life-threatening or fatal pneumonitis occurred in patients suspected or severe skin reactions. treated with PADCEV. In clinical trials, 3.1% of the 680 patients treated with PADCEV suspected SJS or SJS TENor orTEN severe skin reactions. with PADCEV. In clinical trials, 3.1% the 680 with PADCEV • Permanently discontinue PADCEV in patients with confirmed SJS or TEN; or treated had pneumonitis of any grade and 0.7% hadof Grade 3-4. patients In clinicaltreated trials, the median • Permanently discontinue PADCEV in patients with confirmed SJS or TEN; or had pneumonitis of any gradewas and2.9 0.7% had Grade 3-4. In6). clinical trials, the median Grade 4 or recurrent Grade 3 skin reactions. time to onset of pneumonitis months (range: 0.6 to Monitor patients for Grade 4 or recurrent Grade 3 skin reactions. time to onset of pneumonitis was months (range: 0.6hypoxia, to 6). Monitor patients for signs and symptoms indicative of2.9 pneumonitis, such as cough, dyspnea INDICATION signs and symptoms indicative of pneumonitis, such as hypoxia, cough, dyspnea INDICATION PADCEV is indicated for the treatment of adult patients with locally advanced or or interstitial infiltrates on radiologic exams. Evaluate and exclude infectious, interstitial infiltrates on radiologic exams. Evaluate and exclude infectious, and other causes for such signs and symptoms through appropriate PADCEVmetastatic is indicated for the cancer treatment ofwho: adult patients with locally advanced or orneoplastic urothelial (mUC) neoplastic and other causes for for such signs who anddevelop symptoms through appropriate investigations. Withhold PADCEV patients persistent or recurrent metastatic urothelial cancer (mUC)a programmed who: • have previously received death receptor-1 (PD-1) or investigations. Withhold for patients develop persistent recurrent Grade 2 pneumonitis and PADCEV consider dose reduction.who Permanently discontinueor PADCEV programmed death-ligand 1 (PD-L1) inhibitor and platinum-containing • have previously received a programmed death receptor-1 (PD-1) or in all2patients with Grade 3 or 4 pneumonitis. Grade pneumonitis and consider dose reduction. Permanently discontinue PADCEV chemotherapy, or 1 (PD-L1) inhibitor and platinum-containing programmed death-ligand occurred in 52% of the 680 patients treated with in Peripheral all patientsneuropathy with Grade(PN) 3 or 4 pneumonitis. • are ineligible chemotherapy, or for cisplatin-containing chemotherapy and have previously PADCEV inneuropathy clinical trials, including 39% with 7% with treated muscularwith Peripheral (PN) occurred insensory 52% ofneuropathy, the 680 patients received or more prior lineschemotherapy of therapy. • are ineligible forone cisplatin-containing and have previously weakness and 6%trials, with motor neuropathy; 4% experienced Grade 7% 3-4with reactions. PADCEV in clinical including 39% with sensory neuropathy, muscular received one or more prior lines of therapy. WARNINGS AND PRECAUTIONS PN occurred treated with PADCEV or withoutGrade pre-existing PN. weakness and in 6%patients with motor neuropathy; 4%with experienced 3-4 reactions. Skin reactions Severe cutaneous adverse reactions, including fatal cases of SJS or The median time to onset of Grade ≥2 PN was 4.6 months (range: 0.1 to 15.8 PN. WARNINGS AND PRECAUTIONS PN occurred in patients treated with PADCEV with or without pre-existing TEN, occurred in patients treated with PADCEV. SJS and TEN occurred predominantly months). Neuropathy led to treatment discontinuation in 5% of patients. Monitor Skin reactions Severe adversebut reactions, including fatalreactions cases of SJS or The median time to onset of Grade ≥2 PN was 4.6 months (range: 0.1 to 15.8 during the firstcutaneous cycle of treatment may occur later. Skin occurred patients for symptoms of new or worsening peripheral neuropathy and consider TEN, occurred patients treated with PADCEV. and TEN occurred predominantly Neuropathy treatment in occurs. 5% of patients. Monitor in 55%inof the 680 patients treated withSJS PADCEV in clinical trials. Twenty-three months). dose interruption or led dosetoreduction ofdiscontinuation PADCEV when PN Permanently during the first cycle of treatment but may occur later. Skin reactions occurred for symptoms new orwho worsening peripheral percent (23%) of patients had maculo-papular rash and 33% had pruritus. Grade patients discontinue PADCEV in of patients develop Grade ≥3 PN.neuropathy and consider in 55% of patients treated withofPADCEV in clinicalmaculo-papular trials. Twenty-three interruption dose reduction when PN occurs. 3-4the skin680 reactions occurred in 13% patients, including rash, rash dose Ocular disorders or were reported in 40%ofofPADCEV the 384 patients treated withPermanently PADCEV percent erythematous, (23%) of patients maculo-papular rash and 33% had pruritus. Gradeand discontinue rashhad or drug eruption, symmetrical drug-related intertriginous PADCEV in patients who develop ≥3 PN. The majority of in clinical trials in which ophthalmologic examsGrade were scheduled. 3-4 skinflexural reactions occurred(SDRIFE), in 13% of patients,bullous, including maculo-papular rash Ocular exanthema dermatitis dermatitis exfoliative,rash, and palmarwere reported 40%included of the 384 patients treated with thesedisorders events involved the corneainand events associated with dryPADCEV eye erythematous, rash or drug eruption, symmetrical intertriginous and plantar erythrodysesthesia. In clinical trials, thedrug-related median time to onset of severe skin in such as keratitis, vision, increased lacrimation, limbal stem of clinical trials in blurred which ophthalmologic exams wereconjunctivitis, scheduled. The majority reactions was 0.6 months (range: bullous, 0.1 to 6.4). Among patients experiencing a skin these flexural exanthema (SDRIFE), dermatitis dermatitis exfoliative, and palmarcell deficiency, and keratopathy. Dryand eyeincluded symptomsevents occurred in 34% of with patients, events involved the cornea associated dry eye reaction leading to dose interruption then restarted plantar erythrodysesthesia. In clinical trials, who the median time toPADCEV onset of(n=59), severe24% skin of such andas blurred vision occurred in 13% of patients, during treatment with PADCEV. keratitis, blurred vision, increased lacrimation, conjunctivitis, limbal stem patients restarting at the same dose and 16% of patients restarting at a reduced dose The median time tokeratopathy. onset to symptomatic disorder was 1.6inmonths reactions was 0.6 months (range: 0.1 to 6.4). Among patients experiencing a skin cell deficiency, and Dry eye ocular symptoms occurred 34% of(range: patients, recurrent severe skin reactions. Skin reactions led (n=59), to discontinuation 0 to 19.1 months). Monitor patients for ocular disorders. Consider artificial tears reactionexperienced leading to dose interruption who then restarted PADCEV 24% of and blurred vision occurred in 13% of patients, during treatment with PADCEV. PADCEVat in the 2.6% of patients. Monitor throughout treatment formedian prophylaxis of dry eyes and ophthalmologic evaluation if ocular symptoms patients of restarting same dose and 16% ofpatients patientsclosely restarting at a reduced dosefor The time to onset to symptomatic ocular disorder was 1.6 months (range: skin reactions. topical corticosteroids and antihistamines, as clinically occur or do not resolve. Consider treatment with ophthalmic topical steroids, if experienced recurrent Consider severe skin reactions. Skin reactions led to discontinuation 19.1 months). Monitor patients for ocular disorders. Consider artificial tears indicated. Withhold PADCEV and refer for specialized care for suspected SJS or TEN 0 to indicated after an ophthalmic exam. Consider dose interruption or dose reduction of PADCEV in 2.6% of patients. Monitor patients closely throughout treatment for for prophylaxis of dry eyes and ophthalmologic evaluation if ocular symptoms or for severe (Grade 3) skin reactions. Permanently discontinue PADCEV in patients of PADCEV for symptomatic ocular disorders. skin reactions. Consider topical antihistamines, asreactions. clinically occur or do not resolve. Consider treatment with ophthalmic topical steroids, if with confirmed SJS or TEN,corticosteroids or for Grade 4 orand recurrent Grade 3 skin Infusion site extravasation Skin and soft tissue reactions secondary to indicated. Withhold PADCEV and refer for specialized care for suspected SJS or TEN indicated after an ophthalmic exam.after Consider dose interruption or dose reduction Hyperglycemia and diabetic ketoacidosis (DKA), including fatal events, occurred extravasation have been observed administration of PADCEV. Of the 680 or for severe (Gradewith 3) skin Permanently discontinue in patients in patients and reactions. without pre-existing diabetes mellitus,PADCEV treated with PADCEV. ofpatients, PADCEV1.6% for symptomatic ocular disorders. of patients experienced skin and soft tissue reactions, including with confirmed TEN, orhemoglobin for Grade A1C 4 or ≥8% recurrent Grade 3 from skin reactions. PatientsSJS withor baseline were excluded clinical trials. In Infusion extravasation and soft tissue reactions 0.3% whosite experienced Grade 3-4Skin reactions. Reactions may be delayed.secondary Erythema, to Hyperglycemia and14% diabetic (DKA), including events, occurred extravasation clinical trials, of theketoacidosis 680 patients treated with PADCEVfatal developed hyperglycemia; have been observed after administration of PADCEV. Ofafter the 680 swelling, increased temperature, and pain worsened until 2-7 days 7%with of patients developed Grade 3-4diabetes hyperglycemia. The incidence Grade 3-4 patients, in patients and without pre-existing mellitus, treated withofPADCEV. extravasation resolved within 1-4 weeks of peak. Two patients (0.3%) developed 1.6%and of patients experienced skin and soft tissue reactions, including Patients with baseline hemoglobin A1C ≥8% were excluded from clinical trials. In 0.3% who experienced Grade 3-4 reactions. Reactions may be delayed. Erythema,

CR: 22%

(n=20/89)

PR: 28%

(n=25/89)

Median % OS PR: 28 (n=25/89) 12.9 months

(95% CI: 10.6, 15.2) Major efficacy outcome measure: Median DOR§|| was 13.8 months with PADCEV (95% CI: 6.4, NE)1 OS Major efficacyMedian outcome measure: Median DOR§||

30%

reduction in the risk of death vs chemotherapy (N=608; HR=0.70; 95% CI: 0.56, 0.89; P=0.0014)

9.0 months

was 13.8 months with PADCEV (95% CI: 6.4, NE)1 (95% CI: 8.1, 10.7)

PADCEV (n=301) Chemotherapy (n=307)

The EV-201 trial (Cohort 2) was a single-arm, multicenter trial of 89 patients with locally advanced or metastatic 3 6 9 12 15 18 21 24 0 of urothelial cancer who Number had previously received a PD-1 or PD-L1 inhibitor and were cisplatin ineligible. Patients received

‡ 33 15 29

(n=45/89; 95% CI: 39.8%, 61.3%) (n=45/89;

P=0.0014)

(N=608; HR=0.70; 95% CI: 0.56, 0.89; P=0.0014)

(95% CI: 10.6, 15.2)

9.0 months

PADCEV 3 (n=301) Chemotherapy (n=307)

PADCEVNumber 301 of Chemotherapy Subjects 307

12.9 months

MAJOR EFFICACY OUTCOME MEASURE:

† MAJOR EFFICACY OUTCOME CONFIRMED ORR BY BICR1,3,4 MEASURE: OS

51 %

ORR

(95% CI: 8.1, 10.7)

PADCEV (n=301) Chemotherapy (n=307) 20

ORR

in the risk (N=608; HR=0.70; of death vs 95% CI: 0.56, 0.89; chemotherapy

(95% CI: 10.6, 15.2)

Number of Subjects

12.9 months Median OS

100

30%

Median OS

In the EV-201‡ trial (Cohort 2)In the EV-301* MAJOR EFFICACY OUTCOME MEASURE: trial 1,3,4 1,3 ® ORRRESPONSE BY BICR PADCEV DELIVERED CLINICALLY MEANINGFUL SIGNIFICANTLY IMPROVED OS vs CHEMOTHERAPY1 PADCEVCONFIRMED

reduction in the%risk of death vs reduction chemotherapy

MAJOR EFFICACY OUTCOME MEASURE: OS†

OS (%)

In the EV-301* trial MAJOR EFFICACY OUTCOME MEASURE: OS† ®

In the EV-201‡ trial (Cohort 2)

In the EV-301* trial

Time (Months) Subjects The EV-201 trial (Cohort 2) was a single-arm, multicenter trial ofon 89days patients locally advanced or metastatic 1.25 mg/kg of PADCEV via IV infusion over257 30 minutes 1, 8, with and 15 28-day cycle and continued PADCEV 222 130 63 of every 33 7 2 0 301 urothelial cancer who had previously received a PD-1 or PD-L1 inhibitor and were cisplatin ineligible. 29 Patients received Chemotherapy 307progression 250 or unacceptable 198 101 51 major efficacy 6 2 0 to receive treatment until disease toxicity. The outcome measures, 1.25 mg/kg of PADCEV via IV infusion over 30 minutes on days 1, 8, and 15 of every 28-day cycle and continued confirmed ORR DOR,progression were assessed by BICR using RECIST v1.1. efficacy ORR consisted of confirmed and *The EV-301 trial evaluated PADCEV investigator’s-choice chemotherapy in aCR randomized, multicenter, phase 3 trial of 608 patients with to receive treatment untiland disease or unacceptable toxicity. Thevsmajor outcome measures, PR. CR as the disappearance of allor target and nontarget lesions. PR was defined as a ≥30% locally advanced metastatic urothelial cancer had previously platinum-containing chemotherapy and a PD-1 or PD-L1 confirmed ORRwas anddefined DOR, were assessed by BICR using RECIST v1.1. ORR consisted ofwho confirmed CR andreceived in the sumdisappearance of diameters lesions, taking as reference the baseline sum of diameters. inhibitor. Patients randomized 1:1 toPR either 1.25 mg/kg of PADCEV via IV infusion over 30 minutes on days 1, 8, and 15 of every 28-day PR. CRdecrease was defined as the ofofalltarget target andwere nontarget lesions. was defined as a ≥30% 1,4,52 2 Median duration follow-up was 13.4as months. cycle, or docetaxel at 75 mg/m ,the paclitaxel 175 mg/m , or vinflunine at 320 mg/m2 decrease in the sum of diameters of of target lesions, taking reference baselineatsum of diameters. 1,4,5 of response, Kaplan-Meier of duration as the time from first response onestimate day 1 of every 21-day cycle. For defined both arms, treatment continued until Median duration§of follow-up was 13.4 months. § radiographic progression or unacceptable toxicity.1,2by BICR.4,6 to date of progression or death dueastothe any cause, Kaplan-Meier estimate of duration of disease response, defined time fromwas first assessed response † 4,6 Based||on test. Stratification factors were to date of progression orlog-rank death to any cause, was by BICR. Based ondue patients (n=45) withassessed a response by BICR.1 || ECOG region and with liver ametastasis. Based on PS, patients (n=45) response by1 BICR.1

‡

extravasation reactions with secondary cellulitis, bullae, or exfoliation. Ensure pneumonitis (1.1% each). Adverse reactions leading tooccurred discontinuation occurred in extravasation reactions with secondary cellulitis, bullae, or exfoliation. Ensure pneumonitis hyperglycemia (1.1% each). Adverse increased reactions consistently leading intopatients discontinuation with higher body in mass index IMPORTANT SAFETY INFORMATION adequate access to PADCEV starting and PADCEV andformonitor possible 20% ofpatients patients; most common (≥2%) was PN (7%). adequate venousvenous access prior to prior starting monitor possiblefor 20% of patients; and in the most common withthe higher (≥2%) baseline was PN A1C. (7%). Five Adverse percent reactions (5%) ofAdverse patients leading reactions required leading BOXED SERIOUS SKIN REACTIONS extravasation duringWARNING: administration. If extravasation occurs, stop the infusion dose interruption initiation of insulinintherapy 60% offorpatients; treatment theof hyperglycemia. common The median were time(≥3%) to were extravasation during administration. If extravasation occurs, stop thetoinfusion to dose occurred interruption occurred in 60% ofmost patients; the(≥3%) most common PADCEV cause severe and fatal cutaneous adverse reactionsPN including and monitor for adverse reactions. (19%), rash onset (9%), of fatigue hyperglycemia was 0.6(5%), months AST (range: increased 0.1and to 20.3). hyperglycemia Hyperglycemia led and•monitor forcan adverse reactions. PN (19%), rash(8%), (9%),diarrhea fatigue (8%), diarrhea (5%), AST increased and hyperglycemia Stevens-Johnson (SJS) and Toxic Epidermal Necrolysis Embryo-fetal toxicitytoxicity PADCEVsyndrome can cause fetal harm when administered to (TEN), (3% which each). to discontinuation reactions leading ofreactions PADCEV to dose inleading reduction 0.6% ofto patients. occurred Closely in 49%monitor of patients; blood glucose Embryo-fetal PADCEV can cause fetal harm when administered to Adverse (3% each). Adverse dose reduction occurred in 49% of patients; occurred predominantly during the but occur later.common a pregnant woman. Advise patients of the potential risk of to treatment, therisk fetus. theAdvise most were PN (19%), rash (11%) andmellitus fatigue Clinically levelsmost in(≥3%) patients with, or at risk for,PN diabetes or(7%). hyperglycemia. bloodClinically a pregnant woman. Advise patients offirst thecycle potential toAdvise themay fetus. the common (≥3%) were (19%), rash (11%) and fatigueIf(7%). • Closely monitor patients fortoskin femalefemale patients of reproductive potential usereactions. effective during relevant adverse reactions (<15%) include vomiting (13%), AST increased glucose isadverse elevated (>250 mg/dL), withhold PADCEV. patients of reproductive potential to usecontraception effective contraception during reactions (<15%) include vomiting (13%),(12%), AST increased (12%), • Immediately PADCEV and referral for specialized care for relevant PADCEV treatment and forwithhold 2and months after the lastconsider dose. Advise male patients lipase increased Pneumonitis (11%), ALT Severe, increased life-threatening (10%), pneumonitis or fatal pneumonitis (4%) and infusion occurred siteinand patients PADCEV treatment for 2 months after the last dose. Advise male patients lipase increased (11%), ALT increased (10%), pneumonitis (4%) infusion site suspected SJS or TEN orpotential severe skin reactions. with female partners of reproductive to use effective contraception extravasation treated (1%). with PADCEV. In clinical trials, 3.1% of the 680 patients treated with PADCEV with female partners of reproductive potential to use effective contraception extravasation (1%). • Permanently discontinue in after patients confirmed SJS or TEN; or had pneumonitis of any grade and 0.7% had Grade 3-4. In clinical trials, the median during treatment with PADCEV and forPADCEV 4 months the with last dose. duringGrade treatment with PADCEV forreactions. 4 months after the last dose.DRUG INTERACTIONS 4 or recurrent Grade and 3 skin timedrugs to onset pneumonitis 2.9and months (range: 0.6 to 6). Monitor patients for DRUG INTERACTIONS ADVERSE REACTIONS Effects of other onofPADCEV (Dualwas P-gp Strong CYP3A4 Inhibitors) signs and indicative of pneumonitis, such as Strong hypoxia, cough, dyspnea ADVERSE REACTIONS ofsymptoms other drugs on strong PADCEV (Dual P-gp and CYP3A4 Inhibitors) INDICATION Most Common Adverse Reactions, Including Laboratory Abnormalities (≥20%) ConcomitantEffects use with a dual P-gp and CYP3A4 inhibitors may increase or interstitial infiltrates on radiologic exams. Evaluate and exclude infectious, Most Common Adverse Reactions, Including Laboratory Abnormalities (≥20%) Concomitant use with a dual P-gp and strong CYP3A4 inhibitors may increase PADCEV is indicated for the treatment of adult patients with locally advanced or Rash, aspartate aminotransferase (AST) increased, glucose increased, creatinine unconjugated monomethyl auristatin E exposure, which may increase the incidence neoplastic and other causesmonitor for suchpatients signs and through appropriate metastatic urothelial cancer (mUC) who: Rash, aspartate aminotransferase (AST) increased, glucose increased, monomethyl auristatin E exposure, maywhen increase the incidence increased, fatigue, PN, lymphocytes decreased, alopecia, decreased appetite, creatinine or severity ofunconjugated PADCEV toxicities. Closely forsymptoms signswhich of toxicity investigations. Withhold PADCEV forand patients who develop persistent or recurrent • decreased, have fatigue, previously received a programmed deathalopecia, receptor-1 (PD-1) orappetite, increased, PN, lymphocytes decreased, decreased or severity of PADCEV toxicities. Closely monitor patients for signs of toxicity when hemoglobin diarrhea, sodium decreased, nausea, pruritus, phosphate PADCEV is given concomitantly with dual P-gp strong CYP3A4 inhibitors. Grade 2 pneumonitis and consider dose reduction. Permanently discontinue PADCEV programmed death-ligand 1sodium (PD-L1)decreased, inhibitor and platinum-containing decreased, dysgeusia, alanine aminotransferase (ALT) increased, anemia, hemoglobin decreased, diarrhea, nausea, pruritus, phosphate PADCEV is given with dual P-gp and strong CYP3A4 inhibitors. SPECIFIC inPOPULATIONS all patients with concomitantly Grade 3 or 4 pneumonitis. chemotherapy, or alanine albumin decreased, neutrophils decreased, urate increased, lipase decreased, dysgeusia, aminotransferase (ALT)increased, increased,Lactation anemia, Advise Peripheral lactating neuropathy women not (PN) to breastfeed occurred in during 52%treatment of the 680with patients PADCEV treated with SPECIFIC POPULATIONS • are ineligible for cisplatin-containing chemotherapy and have previously platelets decreased, weightneutrophils decreased and dry skin. urate increased, lipase increased, albumin decreased, decreased, and for at least PADCEV 3 weeks in clinical after the trials, last including dose. 39%not withtosensory neuropathy, with muscular Lactation Advise lactating women breastfeed during7% treatment with PADCEV received one or more prior lines of therapy. EV-301 Study: 296 patients previously treated with PD-1/L1 platelets decreased, weight decreased andadry skin. inhibitor and Hepatic impairment weakness Avoid and 6% the with use of motor PADCEV neuropathy; in patients 4%with experienced moderate Grade or severe 3-4 reactions. and for at least 3 weeks after the last dose. platinum-based chemotherapy. WARNINGS PRECAUTIONS EV-301 Study: 296AND patients previously treated with a PD-1/L1 inhibitor and hepatic impairment. PN occurred in patientsAvoid treated withinor withoutwith pre-existing PN.or severe Hepatic impairment thewith use PADCEV of PADCEV patients moderate Serious adverse reactions occurred in 47%adverse of patients treated with PADCEV; Skin reactions Severe cutaneous reactions, including fatal casesPlease of SJSsee or additional platinum-based chemotherapy. The median Important time to onset Safety of Information Grade ≥2 PNand wasBrief 4.6 months Summary (range: of full 0.1 to 15.8 hepatic impairment. the most common (≥2%) were urinary tract infection, acute kidney injury TEN, occurred patients treated within PADCEV. and TENtreated occurred predominantly Serious adversein reactions occurred 47% ofSJS patients with PADCEV; months). Information, Neuropathy including ledBOXED to treatment WARNING, discontinuation on adjacent in pages. 5% of patients. Monitor (7% each)during and pneumonia (5%). adverse occurred in reactions 3% of Prescribing see additional Safety Information and Brief the first cycle ofFatal treatment butreactions may occur later. Skin occurred patients for symptoms ofImportant new or worsening peripheral neuropathy and Summary consider of full theincluding most common (≥2%) were urinary tract infection, acute kidney injury Please BICR=blinded independent central review; CI=confidence interval; CR=complete response; patients, multiorgan dysfunction (1.0%), hepatic dysfunction, septic Prescribing Information, including BOXED WARNING, on adjacent pages. in 55% of the 680 patients treated with PADCEV in clinical trials. Twenty-three dose interruption or dose reduction of PADCEV when PN occurs. Permanently DOR=duration of response; HR=hazard ratio; IV=intravenous; la=locally advanced; each) and pneumonia (5%). Fatalabscess adverse reactions occurred in 3% of shock,(7% hyperglycemia, andmaculo-papular pelvic (0.3% each). Adverse percent (23%)pneumonitis ofmultiorgan patients had rashhepatic and 33% had pruritus. Grade BICR=blinded mUC=metastatic urothelial cancer;inNE=not evaluable; ORR=objective response independent central review; CI=confidence interval; rate; CR=complete response; discontinue PADCEV patients who develop Grade ≥3 PN. patients, including dysfunction (1.0%), dysfunction, septic reactions leading to discontinuation occurred in 17% of patients; the most PD-(L)1=programmed death receptor-1 orIV=intravenous; programmed death3-4 skin reactions occurred in 13% of patients, including maculo-papularOS=overall rash, rash survival; DOR=duration ofwere response; HR=hazard ratio; la=locally advanced; Ocular disorders reported in 40% of the 384 patients treated with PADCEV shock, hyperglycemia, and pelvic abscess (0.3% each).ligand Adverse common (≥2%) were PN (5%) rasheruption, (4%). Adverse reactions leading to intertriginous dose 1; PR=partial response; RECIST=Response Evaluation Criteria in Solid Tumors. mUC=metastatic urothelial cancer; NE=not ORR=objective response rate; erythematous, rashand orpneumonitis drug symmetrical drug-related and in clinical trials in which ophthalmologic examsevaluable; were scheduled. The majority of reactions leading to discontinuation occurred in 17% of patients; the most interruption occurred in 61%(SDRIFE), of patients; the most common (≥4%)exfoliative, were PN and References: 1. PADCEV [package insert]. Northbrook, IL: Astellas Pharma US, Inc. 2.death Powles T,receptor-1 Rosenberg JE, Sonpavde OS=overall survival; PD-(L)1=programmed or with programmed deathflexural exanthema dermatitis bullous, dermatitis palmarthese events involved the cornea and included events associated dry eye GP, et al. Enfortumab vedotin in previously treated advanced urothelial carcinoma. N Engl J Med 2021;384(12):1125-35. were PN (5%) rash (4%).the Adverse reactions leading to dose (23%),common rash (11%)(≥2%) and fatigue (9%). Adverse reactions leading to dose ligand PR=partial response; RECIST=Response Evaluation Criteria in Solid Tumors. plantar erythrodysesthesia. Inand clinical trials, median timereduction to onset of severe skin 3. Seagen Inc. andsuch Astellas. PADCEV. Datablurred on File. 4. Yu EY, Petrylak DP, O’Donnell PH, et al. Enfortumab vedotin after as1; keratitis, vision, increased lacrimation, conjunctivitis, limbal stem occurred inreactions 34% of patients; theinmost common were PN (10%), rashexperiencing (8%), interruption occurred 61% of patients; theAmong most common (≥4%) PD-1 were PN inhibitors References: 1. PADCEV [package insert]. Northbrook, IL: Astellas Pharma US, Inc. 2. 34% Powlesof T, Rosenberg or in cisplatin-ineligible patients with advanced urothelial carcinoma (EV-201): ain multicentre, was 0.6 months (range: 0.1(≥2%) to 6.4). patients a PD-L1 skin cell deficiency, and keratopathy. Dry eye symptoms occurred patients,JE, Sonpavde single-arm, phase 2 trial. Lancet Oncol 2021;22(6):872-82. 5. Eisenhauer EA, Therasse P, Bogaerts J, et New 2021;384(12):1125-35. GP, et al. Enfortumab vedotin in previously treated advanced urothelial carcinoma. N Englal.J Med decreased appetite and fatigue (3%interruption each). adverse reactions (23%), rash (11%) and fatigue (9%).Clinically Adverse reactions leading to dose reduction reaction leading to dose whorelevant then restarted PADCEV (n=59), 24% of and blurred vision occurred in 13% of patients, during treatment with PADCEV.vedotin after response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). Eur JDP, Cancer 2009;45(2):2283. Seagen Inc. and Astellas. PADCEV. Data on File. 4. Yu EY, Petrylak O’Donnell PH, et al. Enfortumab (<15%)occurred include vomiting increased (12%), inrestarting 34% of(14%), patients; the mostand common (≥2%) were PN(10%), (10%), rash 47. 6.(8%), Supplement to: Yu Petrylak DP,to O’Donnell PH, et al. Enfortumab vedotin after PD-1urothelial or PD-L1 inhibitors in (EV-201): patients at theAST same dose 16% ofhyperglycemia patients restarting at a reduced dose PD-1 orEY, PD-L1 inhibitors in cisplatin-ineligible patients with advanced carcinoma a multicentre, The median time onset to symptomatic ocular disorder wasphase 1.6 months (range: cisplatin-ineligiblesingle-arm, patients with advanced urothelial carcinoma (EV-201): a multicentre, single-arm,EA, 2 trial.P, Bogaerts J, et al. New ALT increased (9%), pneumonitis (3%) and siteSkin extravasation (0.7%). phase 2 trial. Lancet Oncol 2021;22(6):872-82. 5. Eisenhauer Therasse decreased appetite and fatigue (3%infusion each). Clinically relevant adverse reactions experienced recurrent severe skin reactions. reactions led to discontinuation 0 to 19.1 months). Monitor for ocular disorders. Consider artificial Lancet Oncol 2021;22(6):872-82. response evaluation criteria in solidpatients tumours: revised RECIST guideline (version 1.1). Eur J Cancertears 2009;45(2):228EV-201, Cohort 2 Study: 89 patients previously treated with a PD-1/L1 of PADCEV 2.6% of patients. patients closely treatment for 47. (<15%) includeinvomiting (14%),Monitor AST increased (12%),throughout hyperglycemia (10%), for6.prophylaxis ofYudry eyes and evaluation if ocular symptoms Supplement to: EY, Petrylak DP, ophthalmologic O’Donnell PH, et al. Enfortumab vedotin after PD-1 or PD-L1 inhibitors in inhibitor not eligible forpneumonitis platinum-based skin reactions. Consider topical corticosteroids andsite antihistamines, as clinically withConsider advanced urothelial carcinoma (EV-201): a multicentre, single-arm,ifphase 2 trial. ALTand increased (9%), (3%)chemotherapy. and infusion extravasation (0.7%). cisplatin-ineligible occur or do notpatients resolve. treatment with ophthalmic topical steroids, Serious adverse reactions occurred in 39% of patients treated with PADCEV; Lancet Oncol 2021;22(6):872-82. indicated. Withhold PADCEV refer forpreviously specialized care for suspected SJS or TEN indicated after an ophthalmic exam. Consider dose interruption or dose reduction EV-201, Cohort 2 Study: 89and patients treated with the most common (≥3%) were pneumonia, sepsis and diarrhea (5% each).PADCEV Fatala PD-1/L1 or for severe (Grade 3) skin reactions. Permanently discontinue in patients of PADCEV for symptomatic ocular disorders. inhibitor and not eligible for platinum-based chemotherapy. adverse reactions occurred in 8% of patients, including acute kidney injury with confirmed SJS or TEN, or for Grade 4 orofrecurrent Grade 3 skin reactions. adverse reactions occurred in 39% patients treated with PADCEV; Infusion site extravasation Skin and soft tissue reactions secondary to (2.2%),Serious metabolic acidosis, sepsis, multiorgan dysfunction, pneumonia and diabetic ketoacidosissepsis (DKA),and including fatal(5% events, occurred the Hyperglycemia most common and (≥3%) were pneumonia, diarrhea each). Fatal extravasation have been observed after administration of PADCEV. Of the 680 in patients with and without pre-existing diabetes mellitus, treated with PADCEV. patients, 1.6% of patients experienced skin and soft tissue reactions, including adverse reactions occurred in 8% of patients, including acute kidney injury Patients baseline hemoglobin A1C ≥8% were excluded © 2021 Astellas Pharma with US, Inc. and Seagen Inc. All rights reserved. 081-0281-PM 07/21 from clinical trials. In 0.3% who experienced Grade 3-4 reactions. Reactions may be delayed. Erythema, (2.2%), metabolic acidosis, multiorgan dysfunction, and PADCEV® andclinical the PADCEV device jointly owned by Agensys, Inc., and Seagen Inc.pneumonia trials, 14%are oftrademarks the 680sepsis, patients treated with PADCEV developed hyperglycemia; swelling, increased temperature, and pain worsened until 2-7 days after Astellas and the flying star logo are registered trademarks of Astellas Pharma Inc. Visit 7% of patients developed Grade 3-4 hyperglycemia. The incidence of Grade 3-4PADCEVhcp.com extravasation and resolved within 1-4 weeks of peak. Two patients (0.3%) developed Seagen and the Seagen logo are registered trademarks of Seagen Inc. © 2021 Astellas Pharma US, Inc. and Seagen Inc. All rights reserved. 081-0281-PM 07/21

after extravasation and resolved within 1-4 weeks of peak. Two patients (0.3%) developed extravasation reactions with secondary cellulitis, bullae, or exfoliation. Ensure adequate venous access prior to starting PADCEV and monitor for possible extravasation during administration. If extravasation occurs, stop the infusion and monitor for adverse reactions.

Table 2. Recommended Dose Reduction Schedule Dose Level

PADCEV® (enfortumab vedotin-ejfv) for injection, for intravenous use The following is a brief summary of the full Prescribing Information. Please see the package insert for full prescribing information including BOXED WARNING. WARNING: SERIOUS SKIN REACTIONS • PADCEV can cause severe and fatal cutaneous adverse reactions including StevensJohnson syndrome (SJS) and Toxic Epidermal Necrolysis (TEN), which occurred predominantly during the first cycle of treatment, but may occur later. • Closely monitor patients for skin reactions. • Immediately withhold PADCEV and consider referral for specialized care for suspected SJS or TEN or severe skin reactions. • Permanently discontinue PADCEV in patients with confirmed SJS or TEN; or Grade 4 or recurrent Grade 3 skin reactions INDICATIONS AND USAGE PADCEV® is indicated for the treatment of adult patients with locally advanced or metastatic urothelial cancer (mUC) who: • have previously received a programmed death receptor-1 (PD-1) or programmed deathligand 1 (PD-L1) inhibitor and platinum-containing chemotherapy, or • are ineligible for cisplatin-containing chemotherapy and have previously received one or more prior lines of therapy. DOSAGE AND ADMINISTRATION Recommended Dosage The recommended dose of PADCEV is 1.25 mg/kg (up to a maximum of 125 mg for patients ≥ 100 kg) administered as an intravenous infusion over 30 minutes on Days 1, 8 and 15 of a 28-day cycle until disease progression or unacceptable toxicity. Dose Modifications Adverse Reaction

Peripheral Neuropathy

Other nonhematologic toxicity

Suspected SJS or TEN

Immediately withhold, consult a specialist to confirm the diagnosis. If not SJS/TEN, see Grade 3 skin reactions.

Confirmed SJS or TEN; Grade 4 or recurrent Grade 3 skin reactions

Permanently discontinue.

Grade 3 (severe) skin reactions

Withhold until Grade ≤ 1, then resume treatment at the same dose level or consider dose reduction by one dose level.

Blood glucose > 250 mg/dL

Withhold until elevated blood glucose has improved to ≤ 250 mg/dL, then resume treatment at the same dose level.

Grade 2

Withhold until Grade ≤ 1 for persistent or recurrent Grade 2 pneumonitis, consider dose reduction by one dose level.

Grade ≥ 3

Permanently discontinue.

Grade 2

Withhold until Grade ≤ 1, then resume treatment at the same dose level (if first occurrence). For a recurrence, withhold until Grade ≤ 1, then resume treatment reduced by one dose level.

Grade ≥ 3

Permanently discontinue.

Grade 3

Withhold until Grade ≤ 1, then resume treatment at the same dose level or consider dose reduction by one dose level.

Grade 4

Permanently discontinue.

Grade 3, or Grade 2 thrombocytopenia

Withhold until Grade ≤ 1, then resume treatment at the same dose level or consider dose reduction by one dose level.

Grade 4

Withhold until Grade ≤ 1, then reduce dose by one dose level or discontinue treatment.

Hematologic toxicity

*Grade 1 is mild, Grade 2 is moderate, Grade 3 is severe, Grade 4 is life-threatening.

1.0 mg/kg up to 100 mg

Second dose reduction

0.75 mg/kg up to 75 mg

Third dose reduction

0.5 mg/kg up to 50 mg

WARNINGS AND PRECAUTIONS Skin Reactions Severe cutaneous adverse reactions, including fatal cases of SJS or TEN occurred in patients treated with PADCEV. SJS and TEN occurred predominantly during the first cycle of treatment but may occur later. Skin reactions occurred in 55% of the 680 patients treated with PADCEV in clinical trials. Twenty-three percent (23%) of patients had maculopapular rash and 33% had pruritus. Grade 3-4 skin reactions occurred in 13% of patients, including maculo-papular rash, rash erythematous, rash or drug eruption, symmetrical drug-related intertriginous and flexural exanthema (SDRIFE), dermatitis bullous, dermatitis exfoliative, and palmar-plantar erythrodysesthesia. In clinical trials, the median time to onset of severe skin reactions was 0.6 months (range: 0.1 to 6.4 months). Among patients experiencing a skin reaction leading to dose interruption who then restarted PADCEV (n=59), 24% of patients restarting at the same dose and 16% of patients restarting at a reduced dose experienced recurrent severe skin reactions. Skin reactions led to discontinuation of PADCEV in 2.6% of patients. Monitor patients closely throughout treatment for skin reactions. Consider topical corticosteroids and antihistamines, as clinically indicated. Withhold PADCEV and refer for specialized care for suspected SJS, TEN or for severe (Grade 3) skin reactions. Permanently discontinue PADCEV in patients with confirmed SJS or TEN; or Grade 4 or recurrent Grade 3 skin reactions. Hyperglycemia Hyperglycemia and diabetic ketoacidosis (DKA), including fatal events, occurred in patients with and without pre-existing diabetes mellitus, treated with PADCEV. Patients with baseline hemoglobin A1C ≥ 8% were excluded from clinical trials. In clinical trials, 14% of the 680 patients treated with PADCEV developed hyperglycemia; 7% of patients developed Grade 3-4 hyperglycemia. The incidence of Grade 3-4 hyperglycemia increased consistently in patients with higher body mass index and in patients with higher baseline A1C. Five percent (5%) of patients required initiation of insulin therapy for treatment of hyperglycemia. The median time to onset of hyperglycemia was 0.6 months (range: 0.1 to 20.3 months). Hyperglycemia led to discontinuation of PADCEV in 0.6% of patients. Closely monitor blood glucose levels in patients with, or at risk for, diabetes mellitus or hyperglycemia. If blood glucose is elevated (> 250 mg/dL), withhold PADCEV. Pneumonitis Severe, life-threatening or fatal pneumonitis occurred in patients treated with PADCEV. In clinical trials, 3.1% of the 680 patients treated with PADCEV had pneumonitis of any grade and 0.7% had Grade 3-4. In clinical trials, the median time to onset of pneumonitis was 2.9 months (range: 0.6 to 6 months). Monitor patients for signs and symptoms indicative of pneumonitis such as hypoxia, cough, dyspnea or interstitial infiltrates on radiologic exams. Evaluate and exclude infectious, neoplastic and other causes for such signs and symptoms through appropriate investigations. Withhold PADCEV for patients who develop persistent or recurrent Grade 2 pneumonitis and consider dose reduction. Permanently discontinue PADCEV in all patients with Grade 3 or 4 pneumonitis. Peripheral Neuropathy Peripheral neuropathy occurred in 52% of the 680 patients treated with PADCEV in clinical trials including 39% with sensory neuropathy, 7% with muscular weakness and 6% with motor neuropathy; 4% experienced Grade 3-4 reactions. Peripheral neuropathy occurred in patients treated with PADCEV with or without preexisting peripheral neuropathy. The median time to onset of Grade ≥ 2 peripheral neuropathy was 4.6 months (range: 0.1 to 15.8 months). Neuropathy led to treatment discontinuation in 5% of patients. Monitor patients for symptoms of new or worsening peripheral neuropathy and consider dose interruption or dose reduction of PADCEV when peripheral neuropathy occurs. Permanently discontinue PADCEV in patients who develop Grade ≥ 3 peripheral neuropathy. Ocular Disorders Ocular disorders were reported in 40% of the 384 patients treated with PADCEV in clinical trials in which ophthalmologic exams were scheduled. The majority of these events involved the cornea and included events associated with dry eye such as keratitis, blurred vision, increased lacrimation, conjunctivitis, limbal stem cell deficiency, and keratopathy. Dry eye symptoms occurred in 34% of patients, and blurred vision occurred in 13% of patients, during treatment with PADCEV. The median time to onset to symptomatic ocular disorder was 1.6 months (range: 0 to 19.1 months). Monitor patients for ocular disorders. Consider artificial tears for prophylaxis of dry eyes and ophthalmologic evaluation if ocular symptoms occur or do not resolve. Consider treatment with ophthalmic topical steroids, if indicated after an ophthalmic exam. Consider dose interruption or dose reduction of PADCEV for symptomatic ocular disorders. Infusion Site Extravasation Skin and soft tissue reactions secondary to extravasation have been observed after administration of PADCEV. Of the 680 patients, 1.6% of patients experienced skin and soft tissue reactions, including 0.3% who experienced Grade 3-4 reactions. Reactions may be delayed. Erythema, swelling, increased temperature, and pain worsened until 2-7 days

Clinical Trial 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 pooled safety population described in the WARNINGS AND PRECAUTIONS reflect exposure to PADCEV as a single agent at 1.25 mg/kg in 680 patients in EV-301, EV-201, EV-101 (NCT02091999), and EV-102 (NCT03070990). Ocular disorders reflect 384 patients in EV-201, EV-101, and EV-102. Among 680 patients receiving PADCEV, 36% were exposed for ≥ 6 months, and 9% were exposed for ≥ 12 months. In this pooled population, the most common (≥ 20%) adverse reactions, including laboratory abnormalities, were rash, aspartate aminotransferase increased, glucose increased, creatinine increased, fatigue, peripheral neuropathy, lymphocytes decreased, alopecia, decreased appetite, hemoglobin decreased, diarrhea, sodium decreased, nausea, pruritus, phosphate decreased, dysgeusia, alanine aminotransferase increased, anemia, albumin decreased, neutrophils decreased, urate increased, lipase increased, platelets decreased, weight decreased and dry skin. The data described in the following sections reflect exposure to PADCEV from an openlabel, randomized, study (EV-301); and Cohort 1 and Cohort 2 of an open-label, single arm, two cohort study (EV-201). Patients received PADCEV 1.25 mg/kg on Days 1, 8 and 15 of a 28-day cycle until disease progression or unacceptable toxicity. Previously Treated Locally Advanced or Metastatic Urothelial Cancer EV-301 The safety of PADCEV was evaluated in EV-301 in patients with locally advanced or metastatic urothelial cancer (n=296) who received at least one dose of PADCEV 1.25 mg/kg and who were previously treated with a PD-1 or PD-L1 inhibitor and a platinum-based chemotherapy. Routine ophthalmologic exams were not conducted in EV-301. The median duration of exposure to PADCEV was 5 months (range: 0.5 to 19.4 months). Serious adverse reactions occurred in 47% of patients treated with PADCEV. The most common serious adverse reactions (≥ 2%) were urinary tract infection, acute kidney injury (7% each) and pneumonia (5%). Fatal adverse reactions occurred in 3% of patients, including multiorgan dysfunction (1.0%), hepatic dysfunction, septic shock, hyperglycemia, pneumonitis and pelvic abscess (0.3% each). Adverse reactions leading to discontinuation occurred in 17% of patients; the most common adverse reactions (≥ 2%) leading to discontinuation were peripheral neuropathy (5%) and rash (4%). Adverse reactions leading to dose interruption occurred in 61% of patients; the most common adverse reactions (≥ 4%) leading to dose interruption were peripheral neuropathy (23%), rash (11%) and fatigue (9%). Adverse reactions leading to dose reduction occurred in 34% of patients; the most common adverse reactions (≥ 2%) leading to dose reduction were peripheral neuropathy (10%), rash (8%), decreased appetite (3%) and fatigue (3%). Table 3 summarizes the most common (≥ 15%) adverse reactions in EV-301. Table 3. Adverse Reactions (≥ 15%) in Patients Treated with PADCEV in EV-301 PADCEV n=296 Adverse Reaction

All Grades %

Chemotherapy n=291 Grade 3-4 %

All Grades %

Grade 3-4 %

Skin and subcutaneous tissue disorders Rash1

0.3

Alopecia

Pruritus

Dry skin

General disorders and administration site conditions Fatigue2

Pyrexia3

Nervous system disorders Peripheral neuropathy4

Dysgeusia5

Metabolism and nutrition disorders Decreased appetite

All Grades %

Chemotherapy n=291 Grade 3-4 %

All Grades %

Grade 3-4 %

Gastrointestinal disorders Diarrhea6

Nausea

Constipation

Abdominal Pain7

Musculoskeletal and connective tissue disorders Musculoskeletal Pain8

ADVERSE REACTIONS

B:11.125"

Pneumonitis

Dose Modification*

First dose reduction

Adverse Reaction

Embryo-Fetal Toxicity Based on the mechanism of action and findings in animals, PADCEV can cause fetal harm when administered to a pregnant woman. In animal reproduction studies, administration of enfortumab vedotin-ejfv to pregnant rats during the period of organogenesis caused maternal toxicity, embryo-fetal lethality, structural malformations and skeletal anomalies at maternal exposures approximately similar to the clinical exposures at the recommended human dose of 1.25 mg/kg. Advise patients of the potential risk to the fetus. Advise female patients of reproductive potential to use effective contraception during treatment with PADCEV and for 2 months after the last dose. Advise male patients with female partners of reproductive potential to use effective contraception during treatment with PADCEV and for 4 months after the last dose.

T:10.875"

Hyperglycemia

Severity*

1.25 mg/kg up to 125 mg

S:10.375" T:10.5"

Skin Reactions

Table 1. Dose Modifications

Starting dose

PADCEV n=296

0.7

0.3

Eye Disorders Dry eye9

Blood and lymphatic system disorders Anemia

Infections and infestations Urinary Tract Infection10 Vascular disorders Hemorrhage11 Investigations Weight decreased

Includes: blister, blood blister, conjunctivitis, dermatitis, dermatitis bullous, drug eruption, eczema, erythema, erythema multiforme, exfoliative rash, intertrigo, palmar-plantar erythrodysesthesia syndrome, rash, rash erythematous, rash macular, rash maculopapular, rash papular, rash pruritic, rash vesicular, skin irritation, skin exfoliation, stomatitis. 2 Includes: fatigue, asthenia 3 Includes: pyrexia, hyperthermia, hyperpyrexia, body temperature increased 4 Includes: burning sensation, demyelinating polyneuropathy, dysesthesia, hypoesthesia, muscular weakness, neuralgia, neuropathy peripheral, neurotoxicity, paresthesia, peripheral motor neuropathy, peripheral sensorimotor neuropathy, peroneal nerve palsy, peripheral sensory neuropathy, gait disturbance, polyneuropathy, sensory loss 5 Includes: dysgeusia, ageusia, hypogeusia 6 Includes: diarrhea, colitis, enterocolitis 7 Includes: abdominal pain, abdominal pain upper, abdominal pain lower, abdominal discomfort, hepatic pain, abdominal tenderness, gastrointestinal pain 8 Includes: myalgia, arthralgia, back pain, bone pain, pain in extremity, musculoskeletal pain, arthritis, neck pain, non-cardiac chest pain, musculoskeletal chest pain, spinal pain, musculoskeletal stiffness, musculoskeletal discomfort 9 Includes: blepharitis, conjunctivitis, dry eye, eye irritation, keratitis, keratopathy, lacrimation increased, Meibomian gland dysfunction, ocular discomfort, punctate keratitis 10 Includes: urinary tract infection, urinary tract infection bacterial, urinary tract infection enterococcal, streptococcal urinary tract infection, escherichia urinary tract infection, pyelonephritis acute, escherichia pyelonephritis, urinary tract infection fungal, cystitis, urinary tract infection staphylococcal, urinary tract infection pseudomonal 11 Includes: hematuria, rectal hemorrhage, gastrointestinal hemorrhage, epistaxis, upper gastrointestinal hemorrhage, tumor hemorrhage, hemoptysis, vaginal hemorrhage, anal hemorrhage, hemorrhagic stroke, urethral hemorrhage, infusion site hemorrhage, conjunctival hemorrhage, hemorrhagic ascites, hemorrhoidal hemorrhage Clinically relevant adverse reactions (< 15%) include vomiting (14%), aspartate aminotransferase increased (12%), hyperglycemia (10%), alanine aminotransferase increased (9%), dry eye (6%) and infusion site extravasation (0.7%). 1

EV-201, Cohort 2 The safety of PADCEV was evaluated in EV-201, Cohort 2 in patients with locally advanced or metastatic urothelial cancer (n=89) who received at least one dose of PADCEV 1.25 mg/kg and had prior treatment with a PD-1 or PD-L1 inhibitor and were not eligible for cisplatin-based chemotherapy. The median duration of exposure was 5.98 months (range: 0.3 to 24.6 months). Serious adverse reactions occurred in 39% of patients treated with PADCEV. The most common serious adverse reactions (≥ 3%) were pneumonia, sepsis and diarrhea (5% each). Fatal adverse reactions occurred in 8% of patients, including acute kidney injury (2.2%), metabolic acidosis, sepsis, multiorgan dysfunction, pneumonia and pneumonitis (1.1% each). Adverse reactions leading to discontinuation occurred in 20% of patients; the most common adverse reaction (≥ 2%) leading to discontinuation was peripheral neuropathy (7%). Adverse reactions leading to dose interruption occurred in 60% of patients; the most common adverse reactions (≥ 3%) leading to dose interruption were peripheral neuropathy (19%), rash (9%), fatigue (8%), diarrhea (5%), aspartate aminotransferase increased (3%) and hyperglycemia (3%). Adverse reactions leading to dose reduction occurred in 49% of patients; the most common adverse reactions (≥ 3%) leading to dose reduction were peripheral neuropathy (19%), rash (11%) and fatigue (7%). Table 4 summarizes the All Grades and Grade 3-4 adverse reactions reported in patients in EV-201, Cohort 2.

Table 4. Adverse Reactions ≥ 15% (All Grades) or ≥ 5% (Grades 3-4) in Patients Treated with PADCEV in EV-201, Cohort 2 PADCEV n=89 Grades 3-4 (%)

Rash1

Alopecia

Pruritus

Dry skin

Peripheral neuropathy2

Dysgeusia3

Skin and subcutaneous tissue disorders

Nervous system disorders

General disorders and administration site conditions

Hyperglycemia

Diarrhea5

Nausea

Blood and lymphatic disorders Anemia Gastrointestinal disorders

Investigations Weight decreased Eye disorders Dry eye6

Includes: blister, conjunctivitis, dermatitis bullous, dermatitis exfoliative generalized, eczema, erythema, erythema multiforme, intertrigo, palmar-plantar erythrodysesthesia syndrome, rash, rash erythematous, rash macular, rash maculo-papular, rash papular, rash vesicular, skin exfoliation, stomatitis 2 Includes: demyelinating polyneuropathy, gait disturbance, hypoesthesia, motor dysfunction, muscle atrophy, muscular weakness, paresthesia, peripheral motor neuropathy, peripheral sensorimotor neuropathy, peroneal nerve palsy, peripheral sensory neuropathy 3 Includes: dysgeusia, ageusia, hypogeusia 4 Includes: fatigue, asthenia 5 Includes: diarrhea, colitis, enterocolitis 6 Includes: blepharitis, conjunctivitis, dry eye, eye irritation, keratitis, keratopathy, lacrimation increased, limbal stem cell deficiency, Meibomian gland dysfunction, ocular discomfort, punctate keratitis, tear break up time decreased Clinically relevant adverse reactions (<15%) include vomiting (13%), aspartate aminotransferase increased (12%), alanine aminotransferase increased (10%) and infusion site extravasation (1%). 1

Immunogenicity As with all therapeutic proteins, there is a potential for immunogenicity. The detection of antibody formation is highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, comparison of the incidence of antibodies in the trials described below with the incidence of antibodies in other trials or other enfortumab vedotin-ejfv products may be misleading. Following administration of PADCEV 1.25 mg/kg; 16/590 (2.7%) patients tested positive for anti-therapeutic antibody (ATA) against enfortumab vedotin-ejfv at one or more postbaseline time points. Due to the limited number of patients with ATA against enfortumab vedotin-ejfv, no conclusions can be drawn concerning a potential effect of immunogenicity on efficacy, safety or pharmacokinetics. DRUG INTERACTIONS

Pediatric Use Safety and effectiveness of PADCEV in pediatric patients have not been established. Geriatric Use Of the 680 patients treated with PADCEV in clinical trials, 440 (65%) were 65 years or older and 168 (25%) were 75 years or older. No overall differences in safety or effectiveness were observed between these patients and younger patients. Hepatic Impairment Avoid the use of PADCEV in patients with moderate or severe hepatic impairment (total bilirubin > 1.5 x ULN and AST any). PADCEV has only been studied in a limited number of patients with moderate hepatic impairment (n=3) and has not been evaluated in patients with severe hepatic impairment. In another ADC that contains MMAE, the frequency of ≥ Grade 3 adverse reactions and deaths was greater in patients with moderate (Child-Pugh B) or severe (Child-Pugh C) hepatic impairment compared to patients with normal hepatic function. No adjustment in the starting dose is required when administering PADCEV to patients with mild hepatic impairment (total bilirubin 1 to 1.5 × ULN and AST any, or total bilirubin ≤ ULN and AST >ULN). Renal Impairment No dose adjustment is required in patients with mild (CrCL > 60-90 mL/min), moderate (CrCL 30-60 mL/min) or severe (CrCL < 30 mL/min) renal impairment. Manufactured and Marketed by: Astellas Pharma US, Inc., Northbrook, IL 60062 Distributed and Marketed by: Seagen Inc., Bothell, WA 98021; 1-855-4SEAGEN U.S. License 2124 Revised: 07/2021 Rx Only © 2019 Agensys, Inc. and Seagen Inc. PADCEV® and the PADCEV device are trademarks jointly owned by Agensys, Inc. and Seagen Inc.

IDENTIFYING MIS-C WITH RISK PREDICTION MODEL BY PHYSICIANS OFFICE RESOURCE

Astellas and the flying star logo are registered trademarks of Astellas Pharma Inc.

While children often recover quickly from COVID-19, with the emergence of the highly contagious omicron variant, cases and hospitalizations are on the rise. With the rise in COVID-19 cases, brings on another concern, MIS-C.

Seagen and the Seagen logo are registered trademarks of Seagen Inc.

What is MIS-C?

Effects of Other Drugs on PADCEV Dual P-gp and Strong CYP3A4 Inhibitors Concomitant use with dual P-gp and strong CYP3A4 inhibitors may increase unconjugated MMAE exposure which may increase the incidence or severity of PADCEV toxicities. Closely monitor patients for signs of toxicity when PADCEV is given concomitantly with dual P-gp and strong CYP3A4 inhibitors.

T:10.875"

Decreased appetite

Metabolism and nutrition disorders

Females and Males of Reproductive Potential Pregnancy testing Verify pregnancy status in females of reproductive potential prior to initiating PADCEV treatment. Contraception Females PADCEV can cause fetal harm when administered to a pregnant woman. Advise females of reproductive potential to use effective contraception during PADCEV treatment and for 2 months after the last dose. Males Advise male patients with female partners of reproductive potential to use effective contraception during treatment with PADCEV and for 4 months after the last dose. Infertility Males Based on findings from animal studies, PADCEV may impair male fertility.

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Lactation Risk Summary There are no data on the presence of enfortumab vedotin-ejfv in human milk, the effects on the breastfed child, or the effects on milk production. Because of the potential for serious adverse reactions in a breastfed child, advise lactating women not to breastfeed during treatment with PADCEV and for at least 3 weeks after the last dose.

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Fatigue4

Pregnancy Risk Summary Based on the mechanism of action and findings in animals, PADCEV can cause fetal harm when administered to a pregnant woman. There are no available human data on PADCEV use in pregnant women to inform a drug-associated risk. In an animal reproduction study, administration of enfortumab vedotin-ejfv to pregnant rats during organogenesis caused maternal toxicity, embryo-fetal lethality, structural malformations and skeletal anomalies at maternal exposures approximately similar to the exposures at the recommended human dose of 1.25 mg/kg. Advise patients of the potential risk to the fetus. The background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2%-4% and 15%-20%, respectively.

FEATURE

All Grades (%)

Adverse Reaction

USE IN SPECIFIC POPULATIONS

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According to the CDC, “Multisystem inflammatory syndrome in children (MIS-C) is a condition where different

body parts can become inflamed, including the heart, lungs, kidneys, brain, skin, eyes, or gastrointestinal organs.” Scientists aren’t quite sure what causes MIS-C; however they do know that many children with MIS-C have had COVID-19. The CDC continues, “MIS-C can be serious, even deadly, but most children who were diagnosed with this condition have gotten better with medical care.”1 MIS-C often comes as a surprise to parents and clinicians 2022 · ISSUE 1 | 37

FEATURE

MIS-C often comes as a surprise to parents and clinicians as some who develop this serious condition never showed signs or symptoms of COVID-19 and symptoms of MIS-C often do not arise until two to six weeks after COVID-19 infection. 1139

as some who develop this serious condition never showed signs or symptoms of COVID-19 and symptoms of MIS-C often do not arise until two to six weeks after COVID-19 infection. While MIS-C is rare, there have been almost 6,500 cases and 55 deaths over the last year. Experts expect that number to increase this year as we battle against the highly contagious omicron variant, especially within children younger than 5 who are unable to receive the vaccine. Can MIS-C be Prevented? Much is still being learned about MIS-C and its relationship to COVID-19, however according to a new report from the CDC, the “estimated effectiveness of 2 doses of Pfizer-BioNTech vaccine against MIS-C was 91% [in patients aged 12-18]. Among critically ill MIS-C case patients requiring life support, all were unvaccinated.”2 MIS-C Prediction Model Late last year, a team of medical scientists and investigators from Vanderbilt University and John Hopkins presented a risk prediction model at the annual meeting of the American College of Rheumatology. The model utilizes clinical, laboratory, and cardiac feature to help identify MIS-C cases within 24 hours of observed symptoms. Identifying MIS-C is difficult because MIS-C shares features common with infectious and inflammatory syndromes. Therefore, having a prediction model could be verry valuable to clinicians needing to identify these cases quickly and accurately.4 The four predictors in the model included: • Hypotension (defined as requiring fluid resuscitation, vasopressor support or blood pressure less than 10th percentile for 38 | PHYSICIANS OFFICE RESOURCE

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age, height, and sex). • Abdominal Pain • Rash • Serum Sodium To develop this prediction model, investigators used retrospective chart data of children less than 20 years old that were evaluated for MIS-C at Vanderbilt Children’s Hospital during the pandemic. While in the care of the hospital, clinicians collected a set of standardized clinical, lab, and cardiac characteristics. In all the trial population included 127 children admitted to the Vanderbilt hospital that were evaluated for MIS-C. Utilizing the retrospective chart data of the 127 children evaluated for MIS-C, 45 cases of MIS-C were confirmed versus 82 non-cases. Matthew Clark, MD, RhMSUS and lead investigator on the study said, “We used early clinical and laboratory features to inform the design of a clinical diagnostic prediction model with excellent discrimination to assist clinicians in distinguishing patients with MIS-C from those without… We plan to test this model with external and prospective validation.”3

Sources 1. https://www.cdc.gov/mis/mis-c.html 2. https://www.cdc.gov/mmwr/volumes/71/wr/ mm7102e1.htm 3. https://acrabstracts.org/abstract/a-prediction-model-to-distinguish-patients-with-multisysteminflammatory-syndrome-in-children/ 4. https://www.hcplive.com/view/risk-prediction-model-identify-pediatric-mis-c-cases

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lumiradx.com The LumiraDx SARS-CoV-2 Ag Test and the LumiraDx SARS-CoV-2 Ab Test have not been cleared or approved by FDA, but have been authorized for emergency use by FDA under an EUA for use by authorized laboratories. The LumiraDx SARS-CoV-2 Ag Test has been authorized only for the detection of SARS-CoV-2 nucleocapsid protein. The LumiraDx SARS-CoV-2 Ab Test has been authorized only for detecting the presence of total antibodies to SARS-CoV-2. They have not been authorized for use to detect any other viruses or pathogens. The emergency use of these Tests are only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of in vitro diagnostic Tests for detection and/or diagnosis of COVID-19 under Section 564(b)(1) of the Federal Food, Drug and Cosmetic Act, 21 U.S.C. § 360bbb-3(b)(1), unless the authorization is terminated or revoked sooner. S-COM-ART 01806 R1