Calcitonin Salmon

5 WARNINGS AND PRECAUTIONS Serious hypersensitivity reactions including anaphylactic shock have been reported. Consider skin testing prior to treatment in patients with suspected hypersensitivity to calcitonin salmon ( 5.1 ) Hypocalcemia has been reported. Ensure adequate intake of calcium and vitamin D ( 5.2 ) Nasal adverse reactions, including severe ulceration can occur. Periodic nasal examinations are recommended ( 5.3 ) Malignancy: A meta-analysis of 21 clinical trials suggests an increased risk of overall malignancies in calcitonin salmon-treated patients ( 5.4 , 6.1 ) Circulating antibodies to calcitonin salmon may develop, and may cause loss of response to treatment ( 5.5 ) 5.1 Hypersensitivity Reactions Serious hypersensitivity reactions have been reported in patients receiving calcitonin salmon nasal spray, e.g., bronchospasm, swelling of the tongue or throat, anaphylaxis and anaphylactic shock. Reports of serious hypersensitivity reactions with injectable calcitonin salmon have also been reported, including reports of death attributed to anaphylaxis. The usual provisions should be made for emergency treatment if such a reaction occurs. Hypersensitivity reactions should be differentiated from generalized flushing and hypotension [see Contraindications (4)] . For patients with suspected hypersensitivity to calcitonin salmon, skin testing should be considered prior to treatment utilizing a dilute, sterile solution of a calcitonin salmon injectable product. Healthcare providers may wish to refer patients who require skin testing to an allergist. A detailed skin testing protocol is available from the Customer Service department of Apotex Corp. (1-800-706-5575). 5.2 Hypocalcemia Hypocalcemia associated with tetany (i.e., muscle cramps, twitching) and seizure activity has been reported with calcitonin therapy. Hypocalcemia must be corrected before initiating therapy with calcitonin salmon nasal spray. Other disorders affecting mineral metabolism (such as vitamin D deficiency) should also be effectively treated. In patients with these conditions, serum calcium and symptoms of hypocalcemia should be monitored during therapy with calcitonin salmon nasal spray. Use of calcitonin salmon nasal spray is recommended in conjunction with an adequate intake of calcium and vitamin D [see Dosage and Administration (2.3)] . 5.3 Nasal Adverse Reactions Adverse reactions related to the nose including rhinitis and epistaxis have been reported. Development of mucosal alterations may occur. Therefore, periodic nasal examinations with visualization of the nasal mucosa, turbinates, septum and mucosal blood vessels are recommended prior to start of treatment with calcitonin salmon nasal spray, periodically during the course of therapy, and at any time nasal symptoms occur. Calcitonin salmon nasal spray should be discontinued if severe ulceration of the nasal mucosa occurs, as indicated by ulcers greater than 1.5 mm in diameter or penetrating below the mucosa, or those associated with heavy bleeding. Although smaller ulcers often heal without withdrawal of calcitonin salmon nasal spray, medication should be discontinued temporarily until healing occurs [see Adverse Reactions (6.1)] . 5.4 Malignancy In a meta-analysis of 21 randomized, controlled clinical trials with calcitonin salmon (nasal spray or investigational oral formulations), the overall incidence of malignancies reported was higher among calcitonin salmon-treated patients (4.1%) compared with placebo-treated patients (2.9%). This suggests an increased risk of malignancies in calcitonin salmon-treated patients compared to placebo-treated patients. The benefits for the individual patient should be carefully considered against possible risks [see Adverse Reactions (6.1)] . 5.5 Antibody Formation Circulating antibodies to calcitonin salmon have been reported with calcitonin salmon nasal spray. The possibility of antibody formation should be considered in any patient with an initial response to calcitonin salmon nasal spray who later stops responding to treatment [see Adverse Reactions (6.3)] . 5.6 Urine Sediment Abnormalities Coarse granular casts and casts containing renal tubular epithelial cells were reported in young adult volunteers at bed rest who were given injectable calcitonin salmon to study the effect of immobilization on osteoporosis. There was no other evidence of renal abnormality and the urine sediment normalized after calcitonin salmon was stopped. Periodic examinations of urine sediment should be considered. Urine sediment abnormalities have not been reported in ambulatory volunteers treated with calcitonin salmon nasal spray.

6 ADVERSE REACTIONS The following serious adverse reactions are discussed in greater detail in other sections of the label: Hypersensitivity Reactions, including anaphylaxis [see Warnings and Precautions (5.1)] Hypocalcemia [see Warnings and Precautions (5.2)] Nasal Adverse Reactions [see Warnings and Precautions (5.3)] Malignancy [see Warnings and Precautions (5.4)] Most common adverse reactions (3% or greater) are rhinitis, epistaxis and other nasal symptoms, back pain, arthralgia, and headache ( 6 ) To report SUSPECTED ADVERSE REACTIONS, contact Apotex Corp. at 1-800-706-5575 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch . 6.1 Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety of calcitonin salmon nasal spray in the treatment of postmenopausal osteoporosis was assessed in 5 randomized, double-blind, placebo controlled trials that enrolled postmenopausal women, aged 45 to 75 years. The duration of the trials ranged from 1 to 2 years. The incidence of adverse reactions reported in studies involving postmenopausal osteoporotic patients chronically exposed to calcitonin salmon nasal spray (N=341) and to placebo nasal spray (N=131), and reported in greater than 3% of calcitonin salmon nasal spray treated patients are presented in the following table. Other than flushing, nausea, possible allergic reactions, and possible local irritative effects in the respiratory tract, a relationship to calcitonin salmon nasal spray has not been established. Table 1: Adverse Reactions Occurring in at Least 3% of Postmenopausal Patients Treated with Calcitonin Salmon Nasal Spray †Symptom of nose includes: nasal crusts, dryness, redness or erythema, nasal sores, irritation, itching, thick feeling, soreness, pallor, infection, stenosis, runny/blocked, small wound, bleeding wound, tenderness, uncomfortable feeling and sore across bridge of nose. Calcitonin Salmon Nasal Spray Placebo Nasal Spray Adverse Reaction N=341 % of Patients N=131 % of Patients Rhinitis 12 7 Symptom of Nose† 11 16 Back Pain 5 2 Arthralgia 4 5 Epistaxis 4 5 Headache 3 5 Nasal Adverse Reactions In all postmenopausal patients treated with calcitonin salmon nasal spray, the most commonly reported nasal adverse reactions included rhinitis (12%), epistaxis (4%), and sinusitis (2%). Smoking did not have a contributory effect on the occurrence of nasal adverse reactions. Adverse reactions reported in 1% to 3% of patients treated with calcitonin salmon nasal spray include: influenza-like symptoms, erythematous rash, arthrosis, myalgia, sinusitis, upper respiratory tract infection, bronchospasm, abdominal pain, nausea, dizziness, paresthesia, abnormal lacrimation, conjunctivitis, lymphadenopathy, infection, and depression. Malignancy A meta-analysis of 21 randomized, controlled clinical trials with calcitonin salmon (nasal spray or investigational oral formulations) was conducted to assess the risk of malignancies in calcitonin salmon-treated patients compared to placebo-treated patients. The trials in the meta-analysis ranged in duration from 6 months to 5 years and included a total of 10883 patients (6151 treated with calcitonin salmon and 4732 treated with placebo). The overall incidence of malignancies reported in these 21 trials was higher among calcitonin salmon-treated patients (254/6151 or 4.1%) compared with placebo-treated patients (137/4732 or 2.9%). Findings were similar when analyses were restricted to the 18 nasal spray only trials [calcitonin salmon 122/2712 (4.5%); placebo 30/1309 (2.3%)]. The meta-analysis results suggest an increased risk of overall malignancies in calcitonin salmon-treated patients compared to placebo-treated patients when all 21 trials are included and when the analysis is restricted to the 18 nasal spray only trials (see Table 2). It is not possible to exclude an increased risk when calcitonin salmon is administered by the subcutaneous, intramuscular, or intravenous route because these routes of administration were not investigated in the meta-analysis. The increased malignancy risk seen with the meta-analysis was heavily influenced by a single large 5-year trial, which had an observed risk difference of 3.4% [95% CI (0.4%, 6.5%)]. Imbalances in risks were still observed when analyses excluded basal cell carcinoma (see Table 2); the data were not sufficient for further analyses by type of malignancy. A mechanism for these observations has not been identified. Although a definitive causal relationship between calcitonin salmon use and malignancies cannot be established from this meta-analysis, the benefits for the individual patient should be carefully evaluated against all possible risks [see Warnings and Precautions (5.4)] . Table 2: Risk Difference for Malignancies in Calcitonin Salmon-Treated Patients Compared with Placebo-Treated Patients 1 The overall adjusted risk difference is the difference between the percentage of patients who had any malignancy (or malignancy excluding basal cell carcinoma) in calcitonin salmon and placebo treatment groups, using the Mantel-Haenszel (MH) fixed-effect method. A risk difference of 0 is suggestive of no difference in malignancy risks between the treatment groups. 2 The corresponding 95% confidence interval for the overall adjusted risk difference also based on MH fixed-effect method. Patients Malignancies Risk Difference 1 (%) 95% Confidence Interval 2 (%) All (nasal spray + oral) All 1.0 (0.3, 1.6) All (nasal spray + oral) Excluding basal cell carcinoma 0.5 (-0.1, 1.2) All (nasal spray only) All 1.4 (0.3, 2.6) All (nasal spray only) Excluding basal cell carcinoma 0.8 (-0.2, 1.8) 6.2 Postmarketing Experience Because postmarketing adverse reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. The following adverse reactions have been reported during post-approval use of calcitonin salmon nasal spray. Allergic / Hypersensitivity Reactions Serious allergic reactions have been reported in patients receiving calcitonin salmon nasal spray, including anaphylaxis and anaphylactic shock. Hypocalcemia Hypocalcemia with paresthesia has been reported. Body as a whole facial or peripheral edema Cardiovascular hypertension, vasodilatation, syncope, chest pain Nervous system dizziness, seizure, visual or hearing impairment, tinnitus Respiratory/Special Senses cough, bronchospasm, dyspnea, loss of taste/smell Skin rash/dermatitis, pruritus, alopecia, increased sweating Gastrointestinal diarrhea Nervous system disorders tremor 6.3 Immunogenicity Consistent with the potentially immunogenic properties of medicinal products containing peptides, administration of calcitonin salmon nasal spray may trigger the development of anti-calcitonin antibodies. In a two-year calcitonin salmon nasal spray clinical study that evaluated immunogenicity, a measurable antibody titer was found in 69% of patients treated with calcitonin salmon nasal spray and 3% of placebo-treated patients. Antibody formation may be associated with a loss of response to treatment [see Warnings and Precautions (5.5)] . The incidence of antibody formation is highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of a positive antibody test result 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 antibodies to calcitonin salmon nasal spray with the incidence of antibodies to other calcitonin-containing products may be misleading.

<table><caption>Table 1: Adverse Reactions Occurring in at Least 3% of Postmenopausal Patients Treated with Calcitonin Salmon Nasal Spray</caption><col width="250"/><col width="200"/><col width="200"/><tfoot><tr><td colspan="4" styleCode="Toprule">&#x2020;Symptom of nose includes: nasal crusts, dryness, redness or erythema, nasal sores, irritation, itching, thick feeling, soreness, pallor, infection, stenosis, runny/blocked, small wound, bleeding wound, tenderness, uncomfortable feeling and sore across bridge of nose.</td></tr></tfoot><tbody><tr><td styleCode="Toprule Lrule Rrule"/><td align="center" styleCode="Toprule Lrule Rrule"><content styleCode="bold">Calcitonin Salmon Nasal Spray</content></td><td align="center" styleCode="Toprule Lrule Rrule"><content styleCode="bold">Placebo Nasal Spray</content></td></tr><tr><td styleCode="Toprule Lrule Rrule"><content styleCode="bold">Adverse Reaction</content></td><td align="center" styleCode="Toprule Lrule Rrule"><content styleCode="bold">N=341 % of Patients</content></td><td align="center" styleCode="Toprule Lrule Rrule"><content styleCode="bold">N=131 % of Patients</content></td></tr><tr><td styleCode="Toprule Lrule Rrule">Rhinitis</td><td align="center" styleCode="Toprule Lrule Rrule">12</td><td align="center" styleCode="Toprule Lrule Rrule">7</td></tr><tr><td styleCode="Toprule Lrule Rrule">Symptom of Nose&#x2020;</td><td align="center" styleCode="Toprule Lrule Rrule">11</td><td align="center" styleCode="Toprule Lrule Rrule">16</td></tr><tr><td styleCode="Toprule Lrule Rrule">Back Pain</td><td align="center" styleCode="Toprule Lrule Rrule">5</td><td align="center" styleCode="Toprule Lrule Rrule">2</td></tr><tr><td styleCode="Toprule Lrule Rrule">Arthralgia</td><td align="center" styleCode="Toprule Lrule Rrule">4</td><td align="center" styleCode="Toprule Lrule Rrule">5</td></tr><tr><td styleCode="Toprule Lrule Rrule">Epistaxis</td><td align="center" styleCode="Toprule Lrule Rrule">4</td><td align="center" styleCode="Toprule Lrule Rrule">5</td></tr><tr><td styleCode="Toprule Lrule Rrule">Headache</td><td align="center" styleCode="Toprule Lrule Rrule">3</td><td align="center" styleCode="Toprule Lrule Rrule">5</td></tr></tbody></table>

<table><caption>Table 2: Risk Difference for Malignancies in Calcitonin Salmon-Treated Patients Compared with Placebo-Treated Patients</caption><col width="200"/><col width="200"/><col width="200"/><col width="250"/><tfoot><tr><td colspan="4" styleCode="Toprule">¹ The overall adjusted risk difference is the difference between the percentage of patients who had any malignancy (or malignancy excluding basal cell carcinoma) in calcitonin salmon and placebo treatment groups, using the Mantel-Haenszel (MH) fixed-effect method. A risk difference of 0 is suggestive of no difference in malignancy risks between the treatment groups. ² The corresponding 95% confidence interval for the overall adjusted risk difference also based on MH fixed-effect method.</td></tr></tfoot><tbody><tr><td styleCode="Toprule Lrule Rrule"><content styleCode="bold">Patients</content></td><td styleCode="Toprule Lrule Rrule"><content styleCode="bold">Malignancies</content></td><td align="center" styleCode="Toprule Lrule Rrule"><content styleCode="bold">Risk Difference¹ (%)</content></td><td align="center" styleCode="Toprule Lrule Rrule"><content styleCode="bold">95% Confidence Interval² (%)</content></td></tr><tr><td styleCode="Toprule Lrule Rrule">All (nasal spray + oral)</td><td styleCode="Toprule Lrule Rrule">All</td><td align="center" styleCode="Toprule Lrule Rrule">1.0</td><td align="center" styleCode="Toprule Lrule Rrule">(0.3, 1.6)</td></tr><tr><td styleCode="Toprule Lrule Rrule">All (nasal spray + oral)</td><td styleCode="Toprule Lrule Rrule">Excluding basal cell carcinoma</td><td align="center" styleCode="Toprule Lrule Rrule">0.5</td><td align="center" styleCode="Toprule Lrule Rrule">(-0.1, 1.2)</td></tr><tr><td styleCode="Toprule Lrule Rrule">All (nasal spray only)</td><td styleCode="Toprule Lrule Rrule">All</td><td align="center" styleCode="Toprule Lrule Rrule">1.4</td><td align="center" styleCode="Toprule Lrule Rrule">(0.3, 2.6)</td></tr><tr><td styleCode="Toprule Lrule Rrule">All (nasal spray only)</td><td styleCode="Toprule Lrule Rrule">Excluding basal cell carcinoma</td><td align="center" styleCode="Toprule Lrule Rrule">0.8</td><td align="center" styleCode="Toprule Lrule Rrule">(-0.2, 1.8)</td></tr></tbody></table>