Mifepristone

1 INDICATIONS AND USAGE Mifepristone Tablets, 200 mg is indicated, in a regimen with misoprostol, for the medical termination of intrauterine pregnancy through 70 days gestation. Mifepristone Tablets, 200 mg is a progestin antagonist indicated, in a regimen with misoprostol, for the medical termination of intrauterine pregnancy through 70 days gestation. ( 1 )

2 DOSAGE AND ADMINISTRATION 200 mg mifepristone tablet on Day 1, followed 24 to 48 hours after mifepristone tablet dosing by 800 mcg buccal misoprostol. ( 2.1 ) Instruct the patient what to do if significant adverse reactions occur. ( 2.2 ) Follow-up is needed to confirm complete termination of pregnancy. ( 2.3 ) 2.1 Dosing Regimen For purposes of this treatment, pregnancy is dated from the first day of the last menstrual period. The duration of pregnancy may be determined from menstrual history and clinical examination. Assess the pregnancy by ultrasonographic scan if the duration of pregnancy is uncertain or if ectopic pregnancy is suspected. Remove any intrauterine device (“IUD”) before treatment with Mifepristone Tablets, 200 mg begins [see Contraindications (4)] . The dosing regimen for Mifepristone Tablets, 200 mg and misoprostol is: Mifepristone Tablets, 200 mg orally + misoprostol 800 mcg buccally • Day One : Mifepristone Tablets, 200 mg Administration One 200 mg tablets of Mifepristone is taken in a single oral dose. • Day Two or Three : Misoprostol Administration (minimum 24-hour interval between, Mifepristone Tablet, 200 mg and misoprostol) Four 200 mcg tablets (total dose 800 mcg) of misoprostol are taken by the buccal route. Tell the patient to place two 200 mcg misoprostol tablets in each cheek pouch (the area between the cheek and gums) for 30 minutes and then swallow any remnants with water or another liquid (see Figure 1 ). Patients taking Mifepristone Tablets, 200 mg must take misoprostol within 24 to 48 hours after taking Mifepristone Tablets. The effectiveness of the regimen may be lower if misoprostol is administered less than 24 hours or more than 48 hours after mifepristone administration. Because most women will expel the pregnancy within 2 to 24 hours of taking misoprostol [see Clinical Studies ( 14 )], discuss with the patient an appropriate location for them to be when taking the misoprostol, taking into account that expulsion could begin within 2 hours of administration. figure-1 2.2 Patient Management Following Misoprostol Administration During the period immediately following the administration of misoprostol, the patient may need medication for cramps or gastrointestinal symptoms [see Adverse Reactions ( 6 )] . Give the patient: Instructions on what to do if significant discomfort, excessive vaginal bleeding or other adverse reactions occur A phone number to call if the patient has questions following the administration of the misoprostol The name and phone number of the healthcare provider who will be handling emergencies. 2.3 Post-treatment Assessment: Day 7 to 14 Patients should follow-up with their healthcare provider approximately 7 to 14 days after the administration of Mifepristone Tablets, 200 mg. This assessment is very important to confirm that complete termination of pregnancy has occurred and to evaluate the degree of bleeding. Termination can be confirmed by medical history, clinical examination, human Chorionic Gonadotropin (hCG) testing, or ultrasonographic scan. Lack of bleeding following treatment usually indicates failure; however, prolonged or heavy bleeding is not proof of a complete abortion. The existence of debris in the uterus (e.g., if seen on ultrasonography) following the treatment procedure will not necessarily require surgery for its removal. Patients should expect to experience vaginal bleeding or spotting for an average of 9 to 16 days. Women report experiencing heavy bleeding for a median duration of 2 days. Up to 8% of women may experience some type of bleeding for more than 30 days. Persistence of heavy or moderate vaginal bleeding at the time of follow-up, however, could indicate an incomplete abortion. If complete expulsion has not occurred, but the pregnancy is not ongoing, patients may be treated with another dose of misoprostol 800 mcg buccally. There have been rare reports of uterine rupture in women who took Mifepristone Tablets, 200 mg and misoprostol, including women with prior uterine rupture or uterine scar and women who received multiple doses of misoprostol within 24 hours. Patients who choose to use a repeat dose of misoprostol should have a follow-up visit with their healthcare provider in approximately 7 days to assess for complete termination. Surgical evacuation is recommended to manage ongoing pregnancies after medical abortion [see Use in Specific Populations ( 8.1 )] . Advise the patient whether you will provide such care or will refer them to another provider as part of counseling prior to prescribing Mifepristone Tablets, 200 mg. 2.4 Contact for Consultation For consultation 24 hours a day, 7 days a week with an expert in mifepristone, call Evita Solutions LLC at 1-866-718-0098.

4 CONTRAINDICATIONS Administration of Mifepristone Tablets, 200 mg and misoprostol for the termination of pregnancy (the “treatment procedure”) is contraindicated in patients with any of the following conditions: Confirmed or suspected ectopic pregnancy or undiagnosed adnexal mass (the treatment procedure will not be effective to terminate an ectopic pregnancy) [ see Warnings and Precautions ( 5.4 )] Chronic adrenal failure (risk of acute adrenal insufficiency) Concurrent long-term corticosteroid therapy (risk of acute adrenal insufficiency) History of allergy to mifepristone, misoprostol, or other prostaglandins (allergic reactions including anaphylaxis, angioedema, rash, hives, and itching have been reported [ see Adverse Reactions ( 6.2 )]) Hemorrhagic disorders or concurrent anticoagulant therapy (risk of heavy bleeding) Inherited porphyrias (risk of worsening or of precipitation of attacks) Use of Mifepristone Tablets, 200 mg and misoprostol for termination of intrauterine pregnancy is contraindicated in patients with an intrauterine device (“IUD”) in place (the IUD might interfere with pregnancy termination). If the IUD is removed, Mifepristone Tablets, 200 mg may be used. Confirmed/suspected ectopic pregnancy or undiagnosed adnexal mass ( 4 ) Chronic adrenal failure ( 4 ) Concurrent long-term corticosteroid therapy ( 4 ) History of allergy to mifepristone, misoprostol, or other prostaglandins ( 4 ) Hemorrhagic disorders or concurrent anticoagulant therapy ( 4 ) Inherited porphyria ( 4 ) Intrauterine device (IUD) in place ( 4 )

5 WARNINGS AND PRECAUTIONS Ectopic pregnancy: Exclude before treatment. ( 5.4 ) Rhesus immunization: Prevention needed as for surgical abortion. ( 5.5 ) 5.1 Infection and Sepsis As with other types of abortion, cases of serious bacterial infection, including very rare cases of fatal septic shock, have been reported following the use of Mifepristone Tablets, 200 mg [see Boxed Warning ] . Healthcare providers evaluating a patient who is undergoing a medical abortion should be alert to the possibility of this rare event. A sustained (> 4 hours) fever of 100.4°F or higher, severe abdominal pain, or pelvic tenderness in the days after a medical abortion may be an indication of infection. A high index of suspicion is needed to rule out sepsis (e.g., from Clostridium sordellii ) if a patient reports abdominal pain or discomfort or general malaise (including weakness, nausea, vomiting or diarrhea) more than 24 hours after taking misoprostol. Very rarely, deaths have been reported in patients who presented without fever, with or without abdominal pain, but with leukocytosis with a marked left shift, tachycardia, hemoconcentration, and general malaise. No causal relationship between Mifepristone Tablets, 200 mg and misoprostol use and an increased risk of infection or death has been established. Clostridium sordellii infections have also been reported very rarely following childbirth (vaginal delivery and caesarian section), and in other gynecologic and non-gynecologic conditions. 5.2 Uterine Bleeding Uterine bleeding occurs in almost all patients during a medical abortion. Prolonged heavy bleeding (soaking through two thick full-size sanitary pads per hour for two consecutive hours) may be a sign of incomplete abortion or other complications and prompt medical or surgical intervention may be needed to prevent the development of hypovolemic shock. Counsel patients to seek immediate medical attention if they experience prolonged heavy vaginal bleeding following a medical abortion [see Boxed Warning ] . Women should expect to experience vaginal bleeding or spotting for an average of 9 to 16 days. Women report experiencing heavy bleeding for a median duration of 2 days. Up to 8% of all subjects may experience some type of bleeding for 30 days or more. In general, the duration of bleeding and spotting increased as the duration of the pregnancy increased. Decreases in hemoglobin concentration, hematocrit, and red blood cell count may occur in patient who bleed heavily. Excessive uterine bleeding usually requires treatment by uterotonics, vasoconstrictor drugs, surgical uterine evacuation, administration of saline infusions, and/or blood transfusions. Based on data from several large clinical trials, vasoconstrictor drugs were used in 4.3% of all subjects, there was a decrease in hemoglobin of more than 2 g/dL in 5.5% of subjects, and blood transfusions were administered to ≤0.1% of subjects. Because heavy bleeding requiring surgical uterine evacuation occurs in about 1% of patients, special care should be given to patients with hemostatic disorders, hypocoagulability, or severe anemia. 5.3 Mifepristone REMS Program Mifepristone Tablets, 200 mg is available only through a restricted program under a REMS called the Mifepristone REMS Program, because of the risks of serious complications [see Warnings and Precautions ( 5.1 , 5.2 )]. Notable requirements of the Mifepristone REMS Program include the following: Prescribers must be certified with the program by completing the Prescriber Agreement Form. Patients must sign a Patient Agreement Form. Mifepristone Tablets, 200 mg must only be dispensed to patients by or under the supervision of a certified prescriber, or by certified pharmacies on prescriptions issued by certified prescribers. Further information is available at 1-866-718-0098. 5.4 Ectopic Pregnancy Mifepristone Tablets, 200 mg is contraindicated in patients with a confirmed or suspected ectopic pregnancy because mifepristone tablets is not effective for terminating ectopic pregnancies [see Contraindications ( 4 )] . Healthcare providers should remain alert to the possibility that a patient who is undergoing a medical abortion could have an undiagnosed ectopic pregnancy because some of the expected symptoms experienced with a medical abortion (abdominal pain, uterine bleeding) may be similar to those of a ruptured ectopic pregnancy. The presence of an ectopic pregnancy may have been missed even if the patient underwent ultrasonography prior to being prescribed mifepristone tablets, 200 mg. Patients who became pregnant with an IUD in place should be assessed for ectopic pregnancy. 5.5 Rhesus Immunization The use of Mifepristone Tablets, 200 mg is assumed to require the same preventive measures as those taken prior to and during surgical abortion to prevent rhesus immunization.

7 DRUG INTERACTIONS CYP3A4 inducers can lower mifepristone concentrations. ( 7.1 ) CYP3A4 inhibitors can increase mifepristone concentrations. Use with caution. ( 7.2 ) CYP3A4 substrate concentrations can be increased. Caution with coadministration of substrates with narrow therapeutic margin. ( 7.3 ) 7.1 Drugs that May Reduce Mifepristone Tablets, 200 mg Exposure (Effect of CYP 3A4 Inducers on Mifepristone Tablets, 200 mg) CYP450 3A4 is primarily responsible for the metabolism of mifepristone. CYP3A4 inducers such as rifampin, dexamethasone, St. John's Wort, and certain anticonvulsants (such as phenytoin, phenobarbital, carbamazepine) may induce mifepristone metabolism (lowering serum concentrations of mifepristone). Whether this action has an impact on the efficacy of the dose regimen is unknown. Refer to the follow-up assessment [see Dosage and Administration ( 2.3 )] to verify that treatment has been successful. 7.2 Drugs that May Increase Mifepristone Tablets, 200 mg Exposure (Effect of CYP 3A4 Inhibitors on Mifepristone Tablets, 200 mg) Although specific drug or food interactions with mifepristone have not been studied, on the basis of this drug's metabolism by CYP 3A4, it is possible that ketoconazole, itraconazole erythromycin, and grapefruit juice may inhibit its metabolism (increasing serum concentrations of mifepristone). Mifepristone Tablets, 200 mg should be used with caution in patients currently or recently treated with CYP 3A4 inhibitors. 7.3 Effects of Mifepristone Tablets, 200 mg on Other Drugs (Effect of Mifepristone Tablets, 200 mg on CYP 3A4 Substrates) Based on in vitro inhibition information, coadministration of mifepristone may lead to an increase in serum concentrations of drugs that are CYP 3A4 substrates. Due to the slow elimination of mifepristone from the body, such interaction may be observed for a prolonged period after its administration. Therefore, caution should be exercised when mifepristone is administered with drugs that are CYP 3A4 substrates and have a narrow therapeutic range.

6 ADVERSE REACTIONS The following adverse reactions are described in greater detail in other sections: Infection and sepsis [ see Warnings and Precautions ( 5.1 )] Uterine bleeding [ see Warnings and Precautions ( 5.2 )] Most common adverse reactions (>15%) are nausea, weakness, fever/chills, vomiting, headache, diarrhea, and dizziness. ( 6 ) To report SUSPECTED ADVERSE REACTIONS, contact Evita Solutions LLC at 1-866-718-0098 or medical@evitasolutionsllc.com or www.medicalabortionpill.com or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch 6.1 Clinical Trials Experience Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice. Information presented on common adverse reactions relies solely on data from U.S. studies, because rates reported in non-U.S. studies were markedly lower and are not likely generalizable to the U.S. population. In three U.S. clinical studies totaling 1,248 women through 70 days gestation who used mifepristone 200 mg orally followed 24 to 48 hours later by misoprostol 800 mcg buccally, women reported adverse reactions in diaries and in interviews at the follow-up visit. These studies enrolled generally healthy women of reproductive age without contraindications to mifepristone or misoprostol use according to the Mifepristone Tablets, 200 mg product label.Gestational age was assessed prior to study enrollment using the date of the woman's last menstrual period, clinical evaluation, and/or ultrasound examination. About 85% of patients report at least one adverse reaction following administration of Mifepristone Tablets, 200 mg and misoprostol, and many can be expected to report more than one such reaction. The most commonly reported adverse reactions (>15%) were nausea, weakness, fever/chills, vomiting, headache, diarrhea, and dizziness (see Table 1). The frequency of adverse reactions varies between studies and may be dependent on many factors including the patient population and gestational age. Abdominal pain/cramping is expected in all medical abortion patients and its incidence is not reported in clinical studies. Treatment with Mifepristone Tablets, 200 mg and misoprostol is designed to induce uterine bleeding and cramping to cause termination of an intrauterine pregnancy. Uterine bleeding and cramping are expected consequences of the action of Mifepristone Tablets, 200 mg and misoprostol as used in the treatment procedure. Most patients can expect bleeding more heavily than they do during a heavy menstrual period [see Warnings and Precautions ( 5.2 )] . Table 1 lists the adverse reactions reported in U.S. clinical studies with incidence >15% of women. Table 1 Adverse Reactions Reported in Women Following Administration of Mifepristone (oral) and Misoprostol (buccal) in U.S. Clinical Studies Adverse Reaction # U.S. studies Number of Evaluable Women Range of frequency (%) Upper Gestational Age of Studies Reporting Outcome Nausea 3 1,248 51-75% 70 days Weakness 2 630 55-58% 63 days Fever/chills 1 414 48% 63 days Vomiting 3 1,248 37-48% 70 days Headache 2 630 41-44% 63 days Diarrhea 3 1,248 18-43% 70 days Dizziness 2 630 39-41% 63 days One study provided gestational-age stratified adverse reaction rates for women who were 57 to 63 and 64 to 70 days; there was little difference in frequency of the reported common adverse reactions by gestational age. Information on serious adverse reactions was reported in six U.S. and four non-U.S. clinical studies, totaling 30,966 women through 70 days gestation who used mifepristone 200 mg orally followed 24 to 48 hours later by misoprostol 800 mcg buccally. Serious adverse reaction rates were similar between U.S. and non-U.S. studies, so rates from both U.S. and non-U.S. studies are presented. In the U.S. studies, one studied women through 56 days gestation, four through 63 days gestation, and one through 70 days gestation, while in the non-U.S. studies, two studied women through 63 days gestation, and two through 70 days gestation. Serious adverse reactions were reported in <0.5% of women. Information from the U.S. and non-U.S. studies is presented in Table 2. Table 2 Serious Adverse Reactions Reported in Women Following Administration of Mifepristone (oral) and Misoprostol (buccal) in U.S. and Non-U.S. Clinical Studies NR= Not reported * This outcome represents a single patient who experienced death related to sepsis. Adverse Reaction U.S. Non-U.S. # of studies Number of Evaluable Women Range of frequency (%) # of studies Number of Evaluable Women Range of frequency (%) Transfusion 4 17,774 0.03-0.5% 3 12,134 0-0.1% Sepsis 1 629 0.2% 1 11,155 <0.01% * ER visit 2 1,043 2.9-4.6% 1 95 0 Hospitalization Related to Medical Abortion 3 14,339 0.04-0.6% 3 1,286 0-0.7% Infection without sepsis 1 216 0 1 11,155 0.2% Hemorrhage NR NR NR 1 11,155 0.1% 6.2 Postmarketing Experience The following adverse reactions have been identified during post approval use of Mifepristone Tablets, 200 mg and misoprostol. Because these 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. Infections and infestations: post-abortal infection (including endometritis, endomyometritis, parametritis, pelvic infection, pelvic inflammatory disease, salpingitis) Blood and the lymphatic system disorders: anemia Immune system disorders: allergic reaction (including anaphylaxis, angioedema, hives, rash, itching) Psychiatric disorders: anxiety Cardiac disorders: tachycardia (including racing pulse, heart palpitations, heart pounding) Vascular disorders: syncope, fainting, loss of consciousness, hypotension (including orthostatic), light-headedness Respiratory, thoracic and mediastinal disorders: shortness of breath Gastrointestinal disorders: dyspepsia Musculoskeletal, connective tissue and bone disorders: back pain, leg pain Reproductive system and breast disorders: uterine rupture, ruptured ectopic pregnancy, hematometra, leukorrhea General disorders and administration site conditions: pain

8 USE IN SPECIFIC POPULATIONS Pregnancy: Risk of fetal malformations in ongoing pregnancy if not terminated is unknown. ( 8.1 ) 8.1 Pregnancy Risk Summary Mifepristone Tablets, 200 mg is indicated, in a regimen with misoprostol, for the medical termination of intrauterine pregnancy through 70 days gestation. Risks to pregnant women are discussed throughout the labeling. Refer to misoprostol labeling for risks to pregnant patients with the use of misoprostol. The risk of adverse developmental outcomes with a continued pregnancy after a failed pregnancy termination with Mifepristone Tablets, 200 mg in a regimen with misoprostol is unknown; however, the process of a failed pregnancy termination could disrupt normal embryo-fetal development and result in adverse developmental effects. Birth defects have been reported with a continued pregnancy after a failed pregnancy termination with Mifepristone Tablets, 200 mg in a regimen with misoprostol. In animal reproduction studies, increased fetal losses were observed in mice, rats, and rabbits and skull deformities were observed in rabbits with administration of mifepristone at doses lower than the human exposure level based on body surface area. Data Animal Data In teratology studies in mice, rats and rabbits at doses of 0.25 to 4.0mg/kg (less than 1/100 to approximately 1/3 the human exposure based on body surface area), because of the antiprogestational activity of mifepristone, fetal losses were much higher than in control animals. Skull deformities were detected in rabbit studies at approximately 1/6 the human exposure, although no teratogenic effects of mifepristone have been observed to date in rats or mice. These deformities were most likely due to the mechanical effects of uterine contractions resulting from inhibition of progesterone action. 8.2 Lactation Mifepristone Tablets, 200 mg is present in human milk. Limited data demonstrate undetectable to low levels of the drug in human milk with the relative (weight-adjusted) infant dose 0.5% or less as compared to maternal dosing. There is no information on the effects of Mifepristone Tablets, 200 mg in a regimen with misoprostol in a breastfed infant or on milk production. Refer to misoprostol labeling for lactation information with the use of misoprostol. The developmental and health benefits of breast-feeding should be considered along with any potential adverse effects on the breast-fed child from Mifepristone Tablets, 200 mg in a regimen with misoprostol. 8.4 Pediatric Use Safety and efficacy of Mifepristone Tablets, 200 mg have been established in pregnant females. Data from a clinical study of Mifepristone Tablets, 200 mg that included a subset of 322 females under age 17 demonstrated a safety and efficacy profile similar to that observed in adults.