ODACTRA- dermatophagoides pteronyssinus and dermatophagoides farinae tablet

Odactra by

Drug Labeling and Warnings

Odactra by is a Other medication manufactured, distributed, or labeled by ALK-Abelló A/S, Catalent Pharma Solutions Limited. Drug facts, warnings, and ingredients follow.

Drug Details [pdf]

• HIGHLIGHTS OF PRESCRIBING INFORMATION

  These highlights do not include all the information needed to use ODACTRA safely and effectively. See full prescribing information for ODACTRA.
     
  ODACTRA™ House Dust Mite (Dermatophagoides farinae and Dermatophagoides pteronyssinus) Allergen Extract
  Tablet for Sublingual Use
  Initial U.S. Approval: 2017
  

  WARNING: SEVERE ALLERGIC REACTIONS

        See full prescribing information for complete boxed warning.

  • ODACTRA can cause life-threatening allergic reactions such as anaphylaxis and severe laryngopharyngeal restriction. (5.1)
    
  • Do not administer ODACTRA to patients with severe, unstable or uncontrolled asthma. (4)
    
  • Observe patients in the office for at least 30 minutes following the initial dose. (5.1)
    
  • Prescribe auto-injectable epinephrine, instruct and train patients on its appropriate use, and instruct patients to seek immediate medical care upon its use. (5.2)
    
  • ODACTRA may not be suitable for patients with certain underlying medical conditions that may reduce their ability to survive a serious allergic reaction. (5.2)
    
  • ODACTRA may not be suitable for patients who may be unresponsive to epinephrine or inhaled bronchodilators, such as those taking beta-blockers. (5.2)

  INDICATIONS AND USAGE

  ODACTRA is an allergen extract indicated as immunotherapy for house dust mite (HDM)-induced allergic rhinitis, with or without conjunctivitis, confirmed by in vitro testing for IgE antibodies to Dermatophagoides farinae or Dermatophagoides pteronyssinus house dust mites, or skin testing to licensed house dust mite allergen extracts. ODACTRA is approved for use in adults 18 through 65 years of age. (1)

  DOSAGE AND ADMINISTRATION

  For sublingual use only. (2)

  • One tablet daily. (2.1)
    
  • Place the tablet immediately under the tongue where it will dissolve within 10 seconds. Do not swallow for at least 1 minute. (2.2)
    
  • Administer the first dose of ODACTRA under the supervision of a physician with experience in the diagnosis and treatment of allergic diseases. Observe patients in the office for at least 30 minutes following the initial dose. (2.2)

  DOSAGE FORMS AND STRENGTHS

  • Tablet, 12 SQ-HDM. (3)

  CONTRAINDICATIONS

  • Severe, unstable or uncontrolled asthma. (4)
    
  • History of any severe systemic allergic reaction or any severe local reaction to sublingual allergen immunotherapy. (4)
    
  • A history of eosinophilic esophagitis. (4)
    
  • Hypersensitivity to any of the inactive ingredients contained in this product. (4)

  WARNINGS AND PRECAUTIONS

  • Inform patients of the signs and symptoms of serious allergic reactions and instruct them to seek immediate medical care and discontinue therapy should any of these occur. (5.1)
    
  • In case of oral inflammation or wounds, stop treatment with ODACTRA to allow complete healing of the oral cavity. (5.7)

  ADVERSE REACTIONS

  • The most common solicited adverse reactions reported in ≥10% of subjects treated with ODACTRA were: throat irritation/tickle, itching in the mouth, itching in the ear, swelling of the uvula/back of the mouth, swelling of the lips, swelling of the tongue, nausea, tongue pain, throat swelling, tongue ulcer/sore on the tongue, stomach pain, mouth ulcer/sore in the mouth, and taste alteration/food tastes different. (6.1)

  
  
  To report SUSPECTED ADVERSE REACTIONS, contact ALK-Abelló Inc., a subsidiary of ALK-Abelló A/S, at +1 512-252-4241or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

  See 17 for PATIENT COUNSELING INFORMATION and Medication Guide.

  Revised: 8/2019

• Table of Contents

  FULL PRESCRIBING INFORMATION: CONTENTS*

  WARNING: SEVERE ALLERGIC REACTIONS

  1       INDICATIONS AND USAGE

  2       DOSAGE AND ADMINISTRATION

  2.1       Dose

  2.2       Administration

  3       DOSAGE FORMS AND STRENGTHS

  4       CONTRAINDICATIONS

  5       WARNINGS AND PRECAUTIONS

  5.1       Severe Allergic Reactions

  5.2       Epinephrine

  5.3       Upper Airway Compromise

  5.4       Eosinophilic Esophagitis

  5.5       Asthma

  5.6       Concomitant Allergen Immunotherapy

  5.7       Oral Conditions

  6       ADVERSE REACTIONS

  6.1       Clinical Trials Experience

  6.2       Postmarketing Experience

  8       USE IN SPECIFIC POPULATIONS

  8.1       Pregnancy

  8.2       Lactation

  8.4       Pediatric Use

  8.5       Geriatric Use

  10       OVERDOSAGE

  11       DESCRIPTION

  12       CLINICAL PHARMACOLOGY

  12.1       Mechanism of Action

  13       NONCLINICAL TOXICOLOGY

  13.1       Carcinogenesis, Mutagenesis, Impairment of Fertility

  14       CLINICAL STUDIES

  16       HOW SUPPLIED/STORAGE AND HANDLING

  17       PATIENT COUNSELING INFORMATION

  * Sections or subsections omitted from the full prescribing information are not listed.

BOXED WARNING

(What is this?)

WARNING: SEVERE ALLERGIC REACTIONS

• ODACTRA can cause life-threatening allergic reactions such as anaphylaxis and severe laryngopharyngeal restriction. (5.1)
  
• Do not administer ODACTRA to patients with severe, unstable or uncontrolled asthma. (4)
  
• Observe patients in the office for at least 30 minutes following the initial dose. (5.1)
  
• Prescribe auto-injectable epinephrine, instruct and train patients on its appropriate use, and instruct patients to seek immediate medical care upon its use. (5.2)
  
• ODACTRA may not be suitable for patients with certain underlying medical conditions that may reduce their ability to survive a serious allergic reaction. (5.2)
  
• ODACTRA may not be suitable for patients who may be unresponsive to epinephrine or inhaled bronchodilators, such as those taking beta-blockers. (5.2)

1       INDICATIONS AND USAGE

      ODACTRA™ is an allergen extract indicated as immunotherapy for house dust mite (HDM)-induced allergic rhinitis, with or without conjunctivitis, confirmed by in vitro testing for IgE antibodies to Dermatophagoides farinae or Dermatophagoides pteronyssinus house dust mites, or skin testing to licensed house dust mite allergen extracts. ODACTRA is approved for use in adults 18 through 65 years of age. 

      ODACTRA is not indicated for the immediate relief of allergic symptoms.

2       DOSAGE AND ADMINISTRATION

      For sublingual use only.

2.1       Dose

      One ODACTRA tablet daily.

2.2       Administration

      Administer the first dose of ODACTRA in a healthcare setting under the supervision of a physician with experience in the diagnosis and treatment of allergic diseases. After receiving the first dose of ODACTRA, observe the patient for at least 30 minutes to monitor for signs or symptoms of a severe systemic or a severe local allergic reaction. If the patient tolerates the first dose, the patient may take subsequent doses at home. The patient should administer ODACTRA as follows:

Take the tablet from the blister unit after carefully removing the foil with dry hands.

Place the tablet immediately under the tongue where it will dissolve within 10 seconds. Do not swallow for at least 1 minute.

Wash hands after handling the tablet.

Do not take the tablet with food or beverage.

Food or beverage should not be taken for 5 minutes after taking the tablet.

      Data regarding the safety of restarting treatment after missing a dose of ODACTRA are limited. In the clinical studies, treatment interruptions for up to seven days were allowed.

      Prescribe auto-injectable epinephrine to patients prescribed ODACTRA and instruct patients in the proper use of emergency self-injection of epinephrine [see Warnings and Precautions (5.2)].

3       DOSAGE FORMS AND STRENGTHS

      ODACTRA is available as 12 SQ-HDM* tablets that are white to off-white, circular with a debossed pentagon detail on one side.

      *SQ-HDM is the dose unit for ODACTRA. SQ is a method of standardization of biological potency, major allergen content and complexity of the allergen extract. HDM is an abbreviation for house dust mite.

4       CONTRAINDICATIONS

      ODACTRA is contraindicated in patients with:

• Severe, unstable or uncontrolled asthma
  
• A history of any severe systemic allergic reaction
  
• A history of any severe local reaction after taking any sublingual allergen immunotherapy
  
• A history of eosinophilic esophagitis
  
• Hypersensitivity to any of the inactive ingredients contained in this product [see Description (11)].

5       WARNINGS AND PRECAUTIONS

5.1       Severe Allergic Reactions

      ODACTRA can cause systemic allergic reactions including anaphylaxis which may be life-threatening. In addition, ODACTRA can cause severe local reactions, including laryngopharyngeal swelling, which can compromise breathing and be life-threatening. Educate patients to recognize the signs and symptoms of these allergic reactions and instruct them to seek immediate medical care and discontinue therapy should any of these occur. Allergic reactions may require treatment with epinephrine. [See Warnings and Precautions (5.2).]

      Administer the initial dose of ODACTRA in a healthcare setting under the supervision of a physician with experience in the diagnosis and treatment of allergic diseases and prepared to manage a life-threatening systemic or local allergic reaction. Observe patients in the office for at least 30 minutes following the initial dose of ODACTRA.

5.2       Epinephrine

      Prescribe auto-injectable epinephrine to patients receiving ODACTRA. Instruct patients to recognize the signs and symptoms of a severe allergic reaction and in the proper use of emergency auto-injectable epinephrine. Instruct patients to seek immediate medical care upon use of auto-injectable epinephrine and to stop treatment with ODACTRA. [See Patient Counseling Information (17).]

      See the auto-injectable epinephrine package insert for complete information.

      ODACTRA may not be suitable for patients with certain medical conditions that may reduce the ability to survive a serious allergic reaction or increase the risk of adverse reactions after epinephrine administration. Examples of these medical conditions include but are not limited to: markedly compromised lung function (either chronic or acute), unstable angina, recent myocardial infarction, significant arrhythmia, and uncontrolled hypertension.

      ODACTRA may not be suitable for patients who are taking medications that can potentiate or inhibit the effect of epinephrine. These medications include:

      Βeta-adrenergic blockers: Patients taking beta-adrenergic blockers may be unresponsive to the usual doses of epinephrine used to treat serious systemic reactions, including anaphylaxis. Specifically, beta-adrenergic blockers antagonize the cardiostimulating and bronchodilating effects of epinephrine.

      Alpha-adrenergic blockers, ergot alkaloids: Patients taking alpha-adrenergic blockers may be unresponsive to the usual doses of epinephrine used to treat serious systemic reactions, including anaphylaxis. Specifically, alpha-adrenergic blockers antagonize the vasoconstricting and hypertensive effects of epinephrine. Similarly, ergot alkaloids may reverse the pressor effects of epinephrine.

      Tricyclic antidepressants, levothyroxine sodium, monoamine oxidase inhibitors, and certain antihistamines: The adverse effects of epinephrine may be potentiated in patients taking tricyclic antidepressants, levothyroxine sodium, monoamine oxidase inhibitors, and the antihistamines chlorpheniramine, and diphenhydramine.

      Cardiac glycosides, diuretics: Patients who receive epinephrine while taking cardiac glycosides or diuretics should be observed carefully for the development of cardiac arrhythmias.

5.3       Upper Airway Compromise

      ODACTRA can cause local reactions in the mouth or throat that could compromise the upper airway [see Adverse Reactions (6.1)]. Consider discontinuation of ODACTRA in patients who experience persistent and escalating adverse reactions in the mouth or throat.

5.4       Eosinophilic Esophagitis

      Eosinophilic esophagitis has been reported in association with sublingual tablet immunotherapy [see Contraindications (4)]. Discontinue ODACTRA and consider a diagnosis of eosinophilic esophagitis in patients who experience severe or persistent gastroesophageal symptoms including dysphagia or chest pain.

5.5       Asthma

      Withhold immunotherapy with ODACTRA if the patient is experiencing an acute asthma exacerbation. Re-evaluate patients who have recurrent asthma exacerbations and consider discontinuation of ODACTRA.

5.6       Concomitant Allergen Immunotherapy

      ODACTRA has not been studied in subjects who are receiving concomitant allergen immunotherapy. Concomitant dosing with other allergen immunotherapy may increase the likelihood of local or systemic adverse reactions to either subcutaneous or sublingual allergen immunotherapy.

5.7       Oral Conditions

      Stop treatment with ODACTRA to allow complete healing of the oral cavity in patients with oral inflammation (e.g., oral lichen planus, mouth ulcers, or thrush) or oral wounds, such as those following oral surgery or dental extraction.

6       ADVERSE REACTIONS

     

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 clinical practice.

      In four double-blind, placebo-controlled, randomized clinical studies, a total of 1279 subjects with house dust mite-induced allergic rhinitis, with or without conjunctivitis, 18 through 65 years of age was treated with at least one dose of ODACTRA 12 SQ-HDM. Of subjects treated with ODACTRA in the four studies, 50% had mild to moderate asthma and 71% were polysensitized to other allergens in addition to HDM, including trees, grasses, weeds, molds, and animal danders. The study population was 88% White, 6% African American, 4% Asian and 55% female. 

      Study 1 (NCT01700192) was a randomized, double-blind, placebo-controlled study conducted in the US and Canada evaluating ODACTRA in 1482 subjects 12 years of age and older with house dust mite-induced allergic rhinitis with or without conjunctivitis. Of the 1482 subjects, 640 subjects 18 through 65 years of age received at least one dose of ODACTRA, with a median treatment duration of 267 days (range 1 to 368 days). 631 subjects received placebo. Placebo tablets contained the same inactive ingredients as ODACTRA without allergen extract and were packaged identically so that treatment blind/masking was maintained. Participants were monitored for unsolicited adverse events and serious adverse events (SAEs) for the duration of therapy (up to 52 weeks). Participants were monitored for solicited adverse reactions for the first 28 days following treatment initiation.

      Study participants were provided side effect report cards in which they recorded the occurrence of specific solicited adverse reactions daily for the first 28 days following treatment initiation with ODACTRA or placebo. In Study 1, the most common solicited adverse reactions reported in ≥10% of subjects treated with ODACTRA were: throat irritation/tickle (67.0% vs. 20.8% placebo), itching in the mouth (61.3% vs. 14.1%), itching in the ear (51.7% vs. 11.7%), swelling of the uvula/back of the mouth (19.8% vs. 2.4%), swelling of the lips (18.0% vs. 2.7%), swelling of the tongue (15.8% vs. 2.1%), nausea (14.2% vs. 7.1%), tongue pain (14.2% vs. 3.0%), throat swelling (13.6% vs. 2.4%), tongue ulcer/sore on the tongue (11.6% vs. 2.1%), stomach pain (11.3% vs. 5.2%), mouth ulcer/sore in the mouth (10.3% vs. 2.9%), and taste alteration/food tastes different (10.0% vs. 3.6%). Table 1 summarizes all solicited adverse reactions reported within the first 28 days of treatment initiation in subjects 18 through 65 years of age using the patient-friendly term.

Table 1: Percentages of Solicited* Adverse Reactions Within 28 Days After Initiation of Treatment with ODACTRA (Study 1, Safety Analysis Set) in Patients 18 through 65 Years of Age (NCT01700192)

Adverse Reaction; (Patient-Friendly Term)	Study Population: Study 1; Adverse Reactions of Any Intensity		Study Population: Study 1; Adverse Reactions That Were Severe†
	ODACTRA; (N=640)	Placebo; (N=631)	ODACTRA; (N=640)	Placebo; (N=631)
Ear and labyrinth disorders
Itching in the ear	51.7%	11.7%	0.3%	-
Gastrointestinal disorders
Itching in the mouth	61.3%	14.1%	0.2%	-
Swelling of the uvula/back of the mouth‡	19.8%	2.4%	-	-
Swelling of the lips	18.0%	2.7%	-	-
Swelling of the tongue	15.8%	2.1%	-	-
Nausea	14.2%	7.1%	-	-
Tongue pain	14.2%	3.0%	-	-
Tongue ulcer/sore on the tongue	11.6%	2.1%	-	-
Stomach pain	11.3%	5.2%	0.2%	-
Mouth ulcer/sore in the mouth	10.3%	2.9%	-	-
Diarrhea	6.9%	3.6%	-	-
Vomiting	2.5%	1.4%	-	-
Nervous system disorders
Taste alteration/food tastes different	10.0%	3.6%	-	-
Respiratory, thoracic and mediastinal disorders
Throat irritation/tickle	67.0%	20.8%	0.3%	-
Throat swelling	13.6%	2.4%	0.2%	-

In Table 1, the dashes represent no subjects.

*Solicited adverse reactions (modified from World Allergy Organization [WAO] list of local side effects of sublingual immunotherapy [SLIT]) were those reported by subjects within the first 28 days after treatment initiation.

†Severe adverse reactions were those assessed by the investigator as severe in intensity, which is defined as incapacitating with inability to work or do usual activity.

‡The percentage of subjects reported for the patient-friendly term of "swelling of the uvula/back of the mouth" includes subjects with an enlarged uvula, palatal swelling/edema, and/or mouth swelling/edema (which can be anywhere in the mouth, not specifically back of the mouth).

      In Study 1, the timing of the adverse reaction relative to exposure to ODACTRA was evaluated for 7 solicited adverse reactions (itching in the ear, itching in the mouth, swelling of the uvula/back of the mouth, swelling of the lips, swelling of the tongue, throat irritation/tickle, and throat swelling). The median time to onset of these adverse reactions following initiation of treatment with ODACTRA varied from 1 to 7 days. The median duration of these adverse reactions that occurred on the first day of treatment initiation varied from 30 to 60 minutes. These adverse reactions recurred for a median of 2 to 12 days.

      In Study 1, the following unsolicited adverse events were reported in numerically more subjects treated with ODACTRA than with placebo and occurred in ≥1% of subjects 18 through 65 years of age within 28 days after initiation of treatment with ODACTRA: paresthesia oral (9.2% vs. 3.2%), tongue pruritus (4.7% vs. 1.1%), oral pain (2.7% vs. 0.6%), stomatitis (2.5% vs. 1.1%), dyspepsia (2.2% vs. 0.0%), pharyngeal erythema (2.0% vs. 0.3%), eye pruritus (1.7% vs. 1.4%), oral mucosal erythema (1.7% vs. 0.2%), upper respiratory tract infection (1.6% vs. 1.1%), sneezing (1.6% vs. 0.3%), lip pruritus (1.4% vs. 0.3%), dysphagia (1.4% vs. 0.0%), fatigue (1.3% vs. 1.0%), hypoesthesia oral (1.3% vs. 1.0%), oropharyngeal pain (1.3% vs. 0.6%), chest discomfort (1.3% vs. 0.3%), dry throat (1.3% vs. 0.3%), pruritus (1.1% vs. 1.0%), and urticaria (1.1% vs. 0.3%).

      Studies 2 (NCT01454544) and 3 (NCT01644617) were randomized, double-blind, placebo-controlled studies of subjects 18 years of age and older with house dust mite-induced allergic rhinitis with or without conjunctivitis, and with or without asthma. Study 4 (NCT01433523) was a randomized, double-blind placebo-controlled study that included subjects 18 years of age and older with house dust mite-induced asthma and allergic rhinitis, with or without conjunctivitis.

      Across the four clinical studies, 1279 subjects received at least one dose of ODACTRA, of whom 1104 (86%) completed at least 4 months of therapy.

      The percentages of subjects in these studies who discontinued treatment because of an adverse reaction while exposed to ODACTRA or placebo were 8.1% and 3.0%, respectively. The most common adverse reactions (≥1.0%) that led to study discontinuation in subjects who received ODACTRA were throat irritation (1.5%), oral pruritus (1.3%), ear pruritus (1.1%), and mouth swelling (1.0%). 

      Serious adverse events were reported, 16/1279 (1.3%) among ODACTRA recipients and 23/1277 (1.8%) among placebo recipients. No deaths were reported.

      Epinephrine use was reported in 5/1279 (0.4%) subjects who received ODACTRA compared to 3/1277 (0.2%) of subjects who received placebo. Of these subjects, 1 ODACTRA recipient reported a systemic allergic reaction and used epinephrine on the day of treatment initiation compared to 2 placebo recipients who reported anaphylaxis and used epinephrine 6 and 25 days after treatment initiation, respectively.

      Of 1279 subjects who received ODACTRA, 34 (2.7%) reported dyspepsia compared to 0/1277 (0%) of subjects who received placebo. Twenty subjects who received ODACTRA (1.6%) reported symptoms of gastroesophageal reflux disease (GERD) compared to 3/1277 (0.2%) of subjects who received placebo.

      Across 8 clinical studies conducted with different doses of ODACTRA, eosinophilic esophagitis was reported in 2/2737 (0.07%) subjects who received ODACTRA compared to 0/1636 (0%) subjects who received placebo. 

     

6.2       Postmarketing Experience

      The following adverse reaction has been identified during post-approval use of ODACTRA. Because this reaction is reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate the frequency or establish a causal relationship to drug exposure.

      Skin and Subcutaneous Tissue Disorders: erythema.

8       USE IN SPECIFIC POPULATIONS

8.1       Pregnancy

Risk Summary

      All pregnancies have a 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. Available data on ODACTRA administered to pregnant women are insufficient to inform associated risks in pregnancy.

      In a fetal/embryo developmental toxicity study performed in mice, administration of ODACTRA during gestation did not reveal adverse developmental outcomes in fetuses (see 8.1 Data).

Data

Animal Data

      In a developmental toxicity study, the effect of ODACTRA on embryo/fetal development was evaluated in mice. Animals were administered ODACTRA subcutaneously daily from day 6 to day 17 of the gestation period at up to 5 times the human sublingual dose. There were no ODACTRA-related post-implantation loss, fetal malformations or variations.

8.2       Lactation

Risk Summary

      Data are not available to assess the effects of ODACTRA on the breastfed child or on milk production and excretion in the nursing woman. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for ODACTRA and any potential adverse effects on the breastfed child from ODACTRA or from the underlying maternal condition.

8.4       Pediatric Use

      Safety and effectiveness have not been established in persons younger than 18 years of age.

8.5       Geriatric Use

      Safety and effectiveness have not been established in persons older than 65 years of age.

10       OVERDOSAGE

      Symptoms of overdose may include hypersensitivity reactions such as systemic allergic reactions or severe local allergic reactions [see Warnings and Precautions (5.1)]. In case of severe adverse reactions such as angioedema, difficulty in swallowing, difficulty in breathing, changes in voice, or feeling of fullness in the throat, immediate medical evaluation is needed. These reactions should be treated as medically indicated, including the use of epinephrine as appropriate [see Warnings and Precautions (5.2)].

11       DESCRIPTION

      ODACTRA tablets contain house dust mite allergen extract from Dermatophagoides farinae and Dermatophagoides pteronyssinus. ODACTRA is a sublingual tablet that dissolves within 10 seconds.

      ODACTRA is available as a tablet of 12 SQ-HDM [6 SQ-HDM D. farinae and 6 SQ-HDM D. pteronyssinus]. Each tablet contains a 1:1:1:1 potency ratio of D. farinae group 1 allergen, D. farinae group 2 allergen, D. pteronyssinus group 1 allergen, and D. pteronyssinus group 2 allergen.

      Inactive ingredients: gelatin NF (fish source), mannitol USP, and sodium hydroxide NF.

12       CLINICAL PHARMACOLOGY

12.1       Mechanism of Action

      The precise mechanisms of action of allergen immunotherapy have not been fully established.

13       NONCLINICAL TOXICOLOGY

13.1       Carcinogenesis, Mutagenesis, Impairment of Fertility

      ODACTRA has not been evaluated for carcinogenic potential or impairment of fertility in animals. Two in vitro chromosome aberration assays, an in vitro bacterial mutagenesis assay and a combined in vivo Comet and micronucleus assay for mutagenicity in rats were performed using HDM (D. farinae and D. pteronyssinus) allergen extracts. One in vitro chromosome aberration assay was positive. Based on the aggregated results, the weight of evidence indicates that this finding is unlikely to be of clinical relevance.

14       CLINICAL STUDIES

      The efficacy of ODACTRA for the treatment of HDM-induced allergic rhinitis was investigated in two double-blind, placebo-controlled, randomized clinical field efficacy studies (Studies 1 and 2) and one environmental exposure chamber (EEC) study.

Study 1 (North American Field Efficacy Study)

      Study 1 was a double-blind, placebo-controlled, randomized field efficacy study conducted in the United States and Canada for a duration of up to 12 months, that compared the efficacy of ODACTRA (N=741) compared to placebo (N=741) in the treatment of HDM-induced allergic rhinitis. Subjects 12 through 85 years of age were enrolled if they had a history of symptomatic allergic rhinitis and were sensitized to D. farinae and/or D. pteronyssinus as determined by house dust mite specific IgE. Subjects were required to be symptomatic and were not taking symptom-relieving allergy medications at enrollment.

      Subjects with mild to moderate asthma, defined as asthma of a severity that required, at most, a daily medium dose of an inhaled corticosteroid, were enrolled in the study.

      In this study, 31% of subjects had asthma, 48% had conjunctivitis, and 76% were polysensitized to other allergens in addition to HDM, including trees, grasses, weed, animal danders and molds. The subject population was 76% White, 11% African American, 7% Asian, and 59% female. The mean age of subjects was 35 years.

      The efficacy of ODACTRA in the treatment of HDM-induced allergic rhinitis was assessed through self-reporting of symptoms and medication use. Based on these self-assessments, the Total Combined Rhinitis Score (TCRS), daily symptom scores (DSS) and daily medication scores (DMS) for rhinoconjunctivitis were calculated. Daily symptoms included four nasal symptoms (runny nose, stuffy nose, sneezing, and itchy nose) and two ocular symptoms (gritty/itchy eyes and watery eyes). Each of these rhinoconjunctivitis symptoms was individually graded by subjects daily on a scale of 0 (none) to 3 (severe) and then summed. Subjects in active and placebo arms of this study were allowed to take symptom-relieving allergy medications (including oral and ocular antihistamines and nasal corticosteroids) during the study as needed. The DMS measured the use of these standard symptom-relieving allergy medications. Predefined daily maximum scores were assigned to each class of rhinitis and conjunctivitis medication as 0=none, 6=oral antihistamine, 6=ocular antihistamine, and 8=nasal corticosteroid.

      The primary endpoint was the difference between the treatment and placebo groups in the average TCRS during approximately the last 8 weeks of treatment. The TCRS represents the sum of the daily rhinitis DSS and the rhinitis DMS. Other secondary endpoints in this study included the average rhinitis DSS, the average rhinitis DMS, and the Total Combined Score (TCS). The TCS represents the sum of the rhinoconjunctivitis DSS and the rhinoconjunctivitis DMS, which was then averaged during approximately the last 8 weeks of treatment.

      Subjects in this study were required to stop taking symptom-relieving allergy medication during the baseline period. The mean rhinitis DSS at baseline was 7.94 out of 12 total points in both the treatment arm and in the placebo arm. The results of this study are shown in Table 2. 

Table 2: Total Combined Rhinitis Score (TCRS), Rhinitis Daily Symptom Score (DSS), Rhinitis Daily Medication Score (DMS), and Total Combined Score (TCS) During the Last 8 Weeks of Treatment with ODACTRA in Subjects 12 Years of Age and Older (Study 1, Field Efficacy Study) (NCT: NCT01700192)

Endpoint*	ODACTRA (n=566)†; Score‡	Placebo (n=620)†; Score‡	Treatment Difference (ODACTRA- Placebo)	Difference Relative to Placebo§
				Estimate	(95% CI)
Primary Endpoint
TCRS¶	4.10	4.95	-0.80	-17.2%	(-25.0%, -9.7%)
Secondary Endpoints
Rhinitis DSS	3.55	4.20	-0.60	-15.5%	(-24.4%, -7.3%)
Rhinitis DMS	0.65	0.79	-0.15	-18.4%	(-41.0%, 4.3%)
TCS	5.50	6.60	-1.10	-16.7%	(-24.6%, -4.0%)

TCRS=Total Combined Rhinitis Score (Rhinitis DSS + Rhinitis DMS); TCS=Total Combined Score (Rhinoconjunctivitis DSS + Rhinoconjunctivitis DMS); CI=Confidence Interval

Analyses were based on the full analysis set (FAS), which included all randomized and treated subjects. Subjects were analyzed according to the treatment group to which they were randomized.

*Non-parametric analysis for TCRS, Rhinitis DSS, and TCS endpoints; Parametric analysis using zero-inflated log-normal model for Rhinitis DMS endpoint.

†Number of subjects in analyses.

‡For TCRS, Rhinitis DSS, and TCS endpoints, the estimated group medians are reported. Treatment difference and that relative to placebo is based on estimated group medians. For Rhinitis DMS, the estimated group means are reported. Treatment difference and that relative to placebo is based on estimated group means.

§Difference relative to placebo computed as: (ODACTRA – placebo)/placebo x 100.

¶The pre-specified criteria for demonstration of efficacy was defined as a TCRS difference relative to placebo less than or equal to -15 percent, and the upper bound of the 95 percent confidence interval (CI) of TCRS difference relative to placebo less than or equal to -10 percent.

Study 2 (European Field Efficacy Study)

      This double-blind, placebo-controlled, randomized field efficacy study evaluated adult subjects 18 through 66 years of age comparing ODACTRA (N=318) and placebo (N=338) administered as a sublingual tablet daily for a duration of approximately 12 months. Subjects in this study had a history of symptomatic allergic rhinitis when exposed to house dust and were sensitized to D. farinae and/or D. pteronyssinus as determined by house dust mite specific IgE testing. At study entry, subjects were required to be symptomatic despite taking symptom-relieving allergy medications during the baseline period.

      In this study, 46% of subjects had asthma, 97% had conjunctivitis and 67% were polysensitized to other allergens in addition to HDM, including trees, grass, weeds, animal danders and molds. The study population was 98% White, <1% African American, and <1% Asian; 50% of subjects were female. The mean age of subjects in this study was 32 years. The primary efficacy endpoint was the difference relative to placebo in the average TCRS during the last 8 weeks of treatment. The mean Rhinitis DSS at baseline was 7.95 out of 12 for the treatment arm and 8.00 out of 12 total points for the placebo arm. The results of this study are shown in Table 3.

Table 3: Total Combined Rhinitis Score (TCRS), Rhinitis Daily Symptom Score (DSS), Rhinitis Daily Medication Score (DMS), and Total Combined Score (TCS) During the Last 8 Weeks of Treatment with ODACTRA in Subjects 18 Years of Age and Older (Study 2, European Field Efficacy Study) (NCT01454544)

Endpoint*	ODACTRA		Placebo		Treatment Difference (ODACTRA - Placebo)	Difference Relative to Placebo§
	n†	Score‡	n†	Score‡		Estimate	(95% CI)
Primary Endpoint
TCRS¶	318	5.71	338	6.81	-1.09	-16.1%		(-25.8%, -5.7%)
Secondary Endpoints
Rhinitis DSS¶	318	2.84	338	3.31	-0.47	-14.1%		(-23.8%, -3.9%)
Rhinitis DMS¶	318	2.32	338	2.86	-0.54	-18.9%		(-34.7%, -1.3%)
TCS#	241	7.91	257	9.12	-1.21	-13.2%		(-23.7%, -1.5%)

TCRS=Total Combined Rhinitis Score (Rhinitis DSS + Rhinitis DMS); TCS=Total Combined Score (Rhinoconjunctivitis DSS + Rhinoconjunctivitis DMS); CI=Confidence Interval

*Parametric analysis using analysis of covariance model for all endpoints.

†Number of subjects in analyses.

‡The estimated group least squares means are reported. Treatment difference and that relative to placebo is based on estimated group least squares means.

§Difference relative to placebo computed as: (ODACTRA – placebo)/placebo x 100.

¶Analysis based on FAS-MI: full analysis set with multiple imputations. The analysis treats subjects who discontinued the study before the efficacy assessment period as placebo subjects. For the primary analysis (FAS-MI) only the absolute difference was pre-specified. Additional analyses describing the corresponding pre-specified relative differences to placebo for the full analysis set (FAS): TCRS: -18.1% (-27.6%, -7.7%); rhinitis DSS: -16.2% (-25.7%, -5.8%); and rhinitis DMS: -21.4% (-36.6%, -3.2%).

#Subjects from Serbia and Croatia were excluded from the analysis of TCS because the preferred formulations of antihistamine eyedrops were not available in these countries at the time the study was conducted. The TCS analysis is based on the full analysis set (FAS). All available data used to its full extent, i.e. subjects who provided data during the efficacy assessment period.

Study 3 (Environmental Exposure Chamber Study)

      This double-blind, placebo-controlled, randomized EEC study evaluated adult subjects 18 through 58 years of age comparing ODACTRA (N=42) and placebo (N=41) administered as a sublingual tablet daily for approximately 24 weeks. Subjects had a history of symptomatic allergic rhinitis and were sensitized to D. farinae and/or D. pteronyssinus as determined by HDM specific IgE. In this study, 23% of subjects had asthma, 87% had conjunctivitis, and 84% were polysensitized to other allergens in addition to HDM, including tree, grass, weed, animal danders and molds. The subject population was 90% White, <1% African American, 8% Asian, and 43% female. The mean age of subjects was 27 years. 

      The primary endpoint was the difference relative to placebo in the average TNSS at Week 24. The Total Nasal Symptom Score (TNSS) represents the sum of 4 nasal symptoms (runny nose, stuffy nose, sneezing, and itchy nose). Secondary endpoints were the differences relative to placebo in the average TNSS at Weeks 8 and 16 and average Total Symptom Score (TSS) at Week 24, which represents the sum of TNSS plus 2 ocular symptoms (gritty/itchy eyes and watery eyes). Baseline TNSS following house dust mite EEC challenge prior to treatment was 7.74 out of 12 total points for ODACTRA and 7.32 out of 12 total points for placebo. The results of this study are shown in Table 4.

Table 4: Total Nasal Symptom Score (TNSS) and Total Symptom Score (TSS) During HDM-Allergen Challenge (Study 3, Environmental Exposure Chamber Study) (NCT01644617)

Endpoint*	ODACTRA; (n)†; Score‡	Placebo; (n)†; Score‡	Treatment Difference (ODACTRA - Placebo)	Difference Relative to Placebo§
				Estimate	(95% CI)
Primary Endpoint
TNSS –; Week 24	(36); 3.83	(34); 7.45	-3.62	-48.6%	(-60.2%, -35.3%)
Secondary Endpoints
TNSS –; Week 8	(40); 5.34	(39); 6.71	-1.37	-20.4%	(-33.3%, -6.8%)
TNSS –; Week 16	(39); 4.82	(38); 6.90	-2.08	-30.1%	(-42.3%, -16.8%)
TSS –; Week 24	(36); 4.43	(34); 9.27	-4.84	-52.2%	(-65.0%, -37.0%)

TNSS=Total Nasal Symptom Score; TSS=Total Symptom Score (TNSS + total ocular symptom score); CI=Confidence Interval

*Parametric analysis using analysis of covariance for all endpoints.

†Number of subjects in analyses.

‡The estimated group least squares means are reported. Treatment difference and that relative to placebo is based on estimated group least squares means.

§Difference relative to placebo computed as: (ODACTRA – placebo)/placebo x 100.

16       HOW SUPPLIED/STORAGE AND HANDLING

      ODACTRA 12 SQ-HDM tablets are white to off-white, circular freeze-dried sublingual tablets with a debossed pentagon detail on one side.

ODACTRA is supplied as follows:

3 blister packages of 10 tablets (30 tablets total). NDC: 52709-1701-3

      Store at controlled room temperature, 20ºC-25ºC (68ºF-77ºF). Store in the original package until use to protect from moisture.

17       PATIENT COUNSELING INFORMATION

      Advise patients to read the FDA-approved patient labeling (Medication Guide) and to keep ODACTRA and all medicines out of the reach of children.

      Severe Allergic Reactions

• Advise patients that ODACTRA may cause life-threatening systemic or local allergic reactions, including anaphylaxis. Educate patients about the signs and symptoms of these allergic reactions [see Warnings and Precautions (5.1)]. The signs and symptoms of a severe allergic reaction may include: syncope, dizziness, hypotension, tachycardia, dyspnea, wheezing, bronchospasm, chest discomfort, cough, abdominal pain, vomiting, diarrhea, rash, pruritus, flushing, and urticaria.
  
• Ensure that patients have auto-injectable epinephrine and instruct patients in its proper use. Instruct patients who experience a severe allergic reaction to seek immediate medical care, discontinue ODACTRA, and resume treatment only when advised by a physician to do so. [See Warnings and Precautions (5.2).]
  
• Advise patients to read the patient information for epinephrine.
  
• Inform patients that the first dose of ODACTRA must be administered in a healthcare setting under the supervision of a physician and that they will be monitored for at least 30 minutes to watch for signs and symptoms of life-threatening systemic or local allergic reaction [see Warnings and Precautions (5.1)].
  
• Because of the risk of upper airway compromise, instruct patients with persistent and escalating adverse reactions in the mouth or throat to discontinue ODACTRA and to contact their healthcare professional. [See Warnings and Precautions (5.3).]
  
• Because of the risk of eosinophilic esophagitis, instruct patients with severe or persistent symptoms of esophagitis to discontinue ODACTRA and to contact their healthcare professional. [See Warnings and Precautions (5.4).]

      Asthma

• Instruct patients with asthma that if they have difficulty breathing or if their asthma becomes difficult to control, they should stop taking ODACTRA and contact their healthcare professional immediately [see Warnings and Precautions (5.5)].

      Administration Instructions

• Instruct patients to carefully remove the foil from the blister unit with dry hands and then take the sublingual tablet immediately by placing it under the tongue where it will dissolve within 10 seconds. Instruct patients to avoid swallowing for at least 1 minute. Also instruct patients to wash their hands after handling the tablet, and to avoid food or beverages for 5 minutes after taking the tablet. [See Dosage and Administration (2.2).]

Manufactured for: ALK-Abelló A/S

ALK-Abelló A/S, Bøge Allé 6-8, DK-2970 Hørsholm, Denmark

U.S. License No. 1292

Manufactured by:

Catalent Pharma Solutions Limited, Blagrove,

Swindon, Wiltshire, SN5 8RU UK

© 2019 ALK-Abelló A/S. 

All rights reserved.

MEDICATION GUIDE

MEDICATION GUIDE
ODACTRA™ (OH-dack-trah)
House Dust Mite (Dermatophagoides farinae and Dermatophagoides pteronyssinus) Allergen Extract
Sublingual Tablets

Carefully read this Medication Guide before you start taking ODACTRA and each time you get a refill. This Medication Guide does not take the place of talking with your doctor about your medical condition or treatment. Talk with your doctor or pharmacist if there is something you do not understand or if you want to learn more about ODACTRA.

What is the Most Important Information I Should Know about ODACTRA?
ODACTRA can cause severe allergic reactions that may be life-threatening. Stop taking ODACTRA and get medical treatment right away if you have any of the following symptoms after taking ODACTRA:

• Trouble breathing
  
• Throat tightness or swelling
  
• Trouble swallowing or speaking
  
• Dizziness or fainting
  
• Rapid or weak heartbeat
  
• Severe stomach cramps or pain, vomiting, or diarrhea
  
• Severe flushing or itching of the skin

For home administration of ODACTRA, your doctor will prescribe auto-injectable epinephrine, a medicine you can inject if you have a severe allergic reaction after taking ODACTRA. Your doctor will train and instruct you on the proper use of auto-injectable epinephrine.
Talk to your doctor or read the epinephrine patient information if you have any questions about the use of auto-injectable epinephrine.

What is ODACTRA?
ODACTRA is a prescription medicine used for sublingual (under the tongue) immunotherapy to treat house dust mite allergies that can cause sneezing, runny or itchy nose, stuffy or congested nose, or itchy and watery eyes. ODACTRA may be prescribed for persons 18 through 65 years of age who are allergic to house dust mites.
ODACTRA is NOT a medication that gives immediate relief for symptoms of house dust mite allergy.

Who Should Not Take ODACTRA?
You should not take ODACTRA if:

• You have severe, unstable or uncontrolled asthma

You had a severe allergic reaction in the past that included any of these symptoms:
         ○ Trouble breathing
         ○ Dizziness or fainting
         ○ Rapid or weak heartbeat

• You have ever had difficulty with breathing due to swelling of the throat or upper airway after using any sublingual immunotherapy before.
  
• You have ever been diagnosed with eosinophilic esophagitis.
  
• You are allergic to any of the inactive ingredients contained in ODACTRA. The inactive ingredients contained in ODACTRA are: gelatin, mannitol, and sodium hydroxide.

What Should I Tell My Doctor Before Taking ODACTRA?
Your doctor may decide that ODACTRA is not the best treatment if:

• You have asthma, depending on how severe it is.
  
• You suffer from lung disease such as chronic obstructive pulmonary disease (COPD)
  
• You suffer from heart disease such as coronary artery disease, an irregular heart rhythm, or you have hypertension that is not well controlled.
  
• You are pregnant, plan to become pregnant during the time you will be taking ODACTRA, or are breast-feeding.
  
• You are unable or unwilling to administer auto-injectable epinephrine to treat a severe allergic reaction to ODACTRA.
  
• You are taking certain medicines that enhance the likelihood of a severe reaction, or interfere with the treatment of a severe reaction. These medicines include:
  • beta blockers and alpha-blockers (prescribed for high blood pressure)
    
  • cardiac glycosides (prescribed for heart failure or problems with heart rhythm)
    
  • diuretics (prescribed for heart conditions and high blood pressure)
    
  • ergot alkaloids (prescribed for migraine headache)
    
  • monoamine oxidase inhibitors or tricyclic antidepressants (prescribed for depression)
    
  • thyroid hormone (prescribed for low thyroid activity).
  
  
• You are receiving allergy shots or other immunotherapy under the tongue. Use of more than one of these types of medicines together may increase the likelihood of a severe allergic reaction.

You should tell your doctor if you are taking or have recently taken any other medicines, including medicines obtained without a prescription and herbal supplements. Keep a list of them and show it to your doctor and pharmacist each time you get a new supply of ODACTRA. Ask your doctor or pharmacist for advice before taking ODACTRA.
ODACTRA is not indicated for use in children under 18 years of age or adults over 65 years of age.

Are there any Reasons to Stop Taking ODACTRA?
Stop ODACTRA and contact your doctor if you have any of the following after taking ODACTRA:

• Any type of a serious allergic reaction
  
• Throat tightness that worsens or swelling of the tongue or throat that causes trouble speaking, breathing, or swallowing
  
• Asthma or any other breathing condition that gets worse
  
• Dizziness or fainting
  
• Rapid or weak heartbeat
  
• Severe stomach cramps or pain, vomiting, or diarrhea
  
• Severe flushing or itching of the skin
  
• Heartburn, difficulty swallowing, pain with swallowing, or chest pain that does not go away or worsens

Also, stop taking ODACTRA following: mouth surgery procedures (such as tooth removal), or if you develop any mouth infections, ulcers or cuts in the mouth or throat.

How Should I Take ODACTRA?
Take ODACTRA exactly as your doctor tells you.
ODACTRA is a prescription medicine that is placed under the tongue.

• Take the tablet from the blister package after carefully removing the foil with dry hands.
  
• Place the tablet immediately under the tongue where it will dissolve within 10 seconds. Do not swallow for at least 1 minute.
  
• Do not take ODACTRA with food or beverage. Food and beverage should not be taken for the following 5 minutes.
  
• Wash hands after taking the tablet.

Take the first tablet of ODACTRA in your doctor’s office. After taking the first tablet, you will be watched for at least 30 minutes for symptoms of a serious allergic reaction.
If you tolerate the first tablet of ODACTRA, you will continue ODACTRA therapy at home by taking one tablet every day.
Take ODACTRA every day for as long as your doctor prescribes it, even if you have no allergy symptoms.
If you forget to take ODACTRA, do not take two tablets. Take the next tablet at your normal scheduled time the next day. If you miss more than one tablet of ODACTRA, contact your doctor before restarting.
You may begin to have relief of your house dust mite allergy symptoms within 2 to 3 months of starting ODACTRA.

What are the Possible Side Effects of ODACTRA?
The most commonly reported side effects were throat irritation/tickle, itching in the mouth or ears, swelling of the back of the mouth, lips or tongue, nausea, tongue pain, throat swelling, tongue ulcer/sore on the tongue, stomach pain, mouth ulcer/sore in the mouth, and taste alteration/food tastes different. These side effects, by themselves, were not dangerous or life-threatening. Typically, these common side effects begin within the first week of starting ODACTRA and may reoccur for up to two weeks. These common side effects experienced after taking the first tablet typically last up to one hour.
ODACTRA can cause severe allergic reactions that may be life-threatening. Symptoms of allergic reactions to ODACTRA include:

• Trouble breathing
  
• Throat tightness or swelling
  
• Trouble swallowing or speaking
  
• Dizziness or fainting
  
• Rapid or weak heartbeat
  
• Severe stomach cramps or pain, vomiting, or diarrhea
  
• Severe flushing or itching of the skin

For additional information on the possible side effects of ODACTRA talk with your doctor or pharmacist. You may report side effects to the U.S. Food and Drug Administration (FDA) at 1-800-FDA-1088 or www.fda.gov/medwatch.

How Should I Store ODACTRA?
Keep ODACTRA out of the reach of children.
Throw away any unused ODACTRA after the expiration date which is stated on the carton and blister pack after “EXP.”
Store ODACTRA in a dry place at room temperature, 20ºC to 25ºC (68ºF to 77ºF), in the original package. 

General Information about ODACTRA
Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Do not use ODACTRA for a condition for which it was not prescribed. Do not give ODACTRA to other people, even if they have the same symptoms. It may harm them.
This Medication Guide summarizes the most important information about ODACTRA. If you would like more information, talk with your doctor. You can ask your doctor or pharmacist for information about ODACTRA that was written for healthcare professionals.
For more information, go to: www.ODACTRA.com or call 1-855-782-9323 (toll-free).

Manufactured for: ALK-Abelló A/S

ALK-Abelló A/S, Bøge Allé 6-8, DK-2970 Hørsholm, Denmark
U.S. License No. 1292
Manufactured by:
Catalent Pharma Solutions Limited, Blagrove,
Swindon, Wiltshire, SN5 8RU UK
© 2019 ALK-Abelló A/S.
All rights reserved.
1061244

This Medication Guide has been approved by the U.S. Food and Drug Administration.       Revised: 08/2019

PRINCIPAL DISPLAY PANEL

NDC: 52709-1701-3
House Dust Mite (Dermatophagoides farinae and
Dermatophagoides pteronyssinus) Allergen Extract
ODACTRA™
Tablet for sublingual use 12SQ-HDM
Rx Only

INGREDIENTS AND APPEARANCE

ODACTRA 
dermatophagoides pteronyssinus and dermatophagoides farinae tablet

Product Information
Product Type	STANDARDIZED ALLERGENIC	Item Code (Source)	NDC: 52709-1701
Route of Administration	SUBLINGUAL

Active Ingredient/Active Moiety
Ingredient Name	Basis of Strength	Strength
DERMATOPHAGOIDES PTERONYSSINUS (UNII: 57L1Z5378K) (DERMATOPHAGOIDES PTERONYSSINUS - UNII:57L1Z5378K)	DERMATOPHAGOIDES PTERONYSSINUS	6 [arb'U]
DERMATOPHAGOIDES FARINAE (UNII: PR9U2YPF3Q) (DERMATOPHAGOIDES FARINAE - UNII:PR9U2YPF3Q)	DERMATOPHAGOIDES FARINAE	6 [arb'U]

Inactive Ingredients
Ingredient Name	Strength
MARINE NON-GELLING GELATIN, HIGH MW (UNII: AHQ60JKI5D)
MARINE NON-GELLING GELATIN (UNII: JSM64OJO9B)
MANNITOL (UNII: 3OWL53L36A)
SODIUM HYDROXIDE (UNII: 55X04QC32I)

Product Characteristics
Color	WHITE (white to off-white)	Score	no score
Shape	ROUND	Size	12mm
Flavor		Imprint Code
Contains

Packaging
#	Item Code	Package Description	Marketing Start Date	Marketing End Date
1	NDC: 52709-1701-5	1 in 1 CARTON
1		5 in 1 BLISTER PACK; Type 0: Not a Combination Product
2	NDC: 52709-1701-3	3 in 1 CARTON
2	NDC: 52709-1701-1	10 in 1 BLISTER PACK; Type 0: Not a Combination Product

Marketing Information
Marketing Category	Application Number or Monograph Citation	Marketing Start Date	Marketing End Date
BLA	BLA125592	01/01/2018

Labeler - ALK-Abello A S (306020926)