Treatment of Cytomegalovirus (CMV) Retinitis: VALCYTE is indicated for the treatment of CMV retinitis in patients with acquired immunodeficiency syndrome (AIDS) [see Clinical Studies (14.1)].

Prevention of CMV Disease: VALCYTE is indicated for the prevention of CMV disease in kidney, heart, and kidney-pancreas transplant patients at high risk (Donor CMV seropositive/Recipient CMV seronegative [D+/R-]) [see Clinical Studies (14.1)].

Prevention of CMV Disease: VALCYTE is indicated for the prevention of CMV disease in kidney transplant patients (4 months to 16 years of age) and heart transplant patients (1 month to 16 years of age) at high risk [see Clinical Studies (14.2)].

For dosage recommendations in adult patients with renal impairment [see Dosage and Administration (2.5)].

Treatment of CMV Retinitis:

Prevention of CMV Disease:

Prevention of CMV Disease in Pediatric Kidney Transplant Patients: For pediatric kidney transplant patients 4 months to 16 years of age, the recommended once daily mg dose (7 × BSA × CrCl) should start within 10 days of post-transplantation until 200 days post-transplantation.

Prevention of CMV Disease in Pediatric Heart Transplant Patients: For pediatric heart transplant patients 1 month to 16 years of age, the recommended once daily mg dose (7 × BSA × CrCl) should start within 10 days of transplantation until 100 days post-transplantation.

The recommended once daily dosage of VALCYTE is based on body surface area (BSA) and creatinine clearance (CrCl) derived from a modified Schwartz formula, and is calculated using the equation below:

Pediatric Dose (mg) = 7 × BSA × CrCl (calculated using a modified Schwartz formula). If the calculated Schwartz creatinine clearance exceeds 150 mL/min/1.73m2, then a maximum value of 150 mL/min/1.73m2 should be used in the equation. The k values used in the modified Schwartz formula are based on pediatric patient age, as shown in Table 1.

<div class="scrollingtable"><table width="100%"> <colgroup> <col align="right" valign="middle" width="60%"/> <col align="center" valign="middle" width="20%"/> <col align="center" valign="middle" width="20%"/> </colgroup> <tbody class="Headless"> <tr class="First"> <td align="center" colspan="3"><img alt="Equation" src="/dailymed/image.cfm?name=valcyte-01.jpg&amp;setid=4c517a39-2ded-4c5a-8d56-276853414b31"/></td> </tr> <tr> <td align="right" rowspan="2"><span class="Italics">Schwartz Creatinine Clearance</span> (<span class="Italics">mL</span> / min / 1.73<span class="Italics">m</span><span class="Sup">2</span>) = </td><td align="center" class="Botrule"><span class="Italics">k × Height</span> (<span class="Italics">cm</span>)</td><td align="center"></td> </tr> <tr class="Last"> <td align="right"><span class="Italics">Serum Creatinine </span>(<span class="Italics">mg</span> / <span class="Italics">dL</span>)</td><td align="center"></td> </tr> </tbody> </table></div>

<div class="scrollingtable"><table width="60%"> <caption> <span>Table 1 k Values According to Pediatric Patient Age <span class="Sup">*</span></span> </caption> <colgroup> <col align="left" valign="top" width="15%"/> <col align="left" valign="top" width="85%"/> </colgroup> <thead> <tr class="First First Last Last"> <th align="left" class="Lrule Rrule">k value</th><th align="left" class="Rrule">Pediatric Patient Age</th> </tr> </thead> <tbody> <tr class="Botrule First First"> <td align="left" class="Lrule Rrule">0.33</td><td align="left" class="Rrule">Infants less than 1 year of age with low birth weight for gestational age</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">0.45</td><td align="left" class="Rrule">Infants less than 1 year of age with birth weight appropriate for gestational age</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">0.45</td><td align="left" class="Rrule">Children aged 1 to less than 2 years</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">0.55</td><td align="left" class="Rrule">Boys aged 2 to less than 13 years<br/>Girls aged 2 to less than 16 years</td> </tr> <tr class="Last"> <td align="left" class="Lrule Rrule">0.7</td><td align="left" class="Rrule">Boys aged 13 to 16 years</td> </tr> </tbody> </table></div>

Monitor serum creatinine levels regularly and consider changes in height and body weight and adapt the dose as appropriate during prophylaxis period.

All calculated doses should be rounded to the nearest 25 mg increment for the actual deliverable dose. The oral dispenser is graduated in 0.5 mL increments. A 50 mg dose is equivalent to 1 mL. If the calculated dose exceeds 900 mg, a maximum dose of 900 mg should be administered. VALCYTE for oral solution is the preferred formulation since it provides the ability to administer a dose calculated according to the formula above; however, VALCYTE tablets may be used if the calculated doses are within 10% of available tablet strength (450 mg). For example, if the calculated dose is between 405 mg and 495 mg, one 450 mg tablet may be taken. Before prescribing VALCYTE tablets, pediatric patients should be assessed for the ability to swallow tablets.

Wearing disposable gloves is recommended during reconstitution and when wiping the outer surface of the bottle/cap and the table after reconstitution. Prior to dispensing to the patient, VALCYTE for oral solution must be prepared by the pharmacist as follows [see How Supplied/Storage and Handling (16)]:

The patient package insert, which includes the dosing instructions for patients, and 2 oral dispensers should be dispensed to the patient [see Patient Counseling Information (17)].

Serum creatinine levels or estimated creatinine clearance should be monitored regularly during treatment. Dosage recommendations for adult patients with reduced renal function are provided in Table 2. For adult patients on hemodialysis (CrCl less than 10 mL/min), a dose recommendation for VALCYTE cannot be given [see Use in Specific Populations (8.5, 8.6), Clinical Pharmacology (12.3)].

<div class="scrollingtable"><table width="60%"> <caption> <span>Table 2 Dosage Recommendations for Adult Patients with Impaired Renal Function</span> </caption> <col align="center" valign="middle" width="34%"/> <col align="center" valign="middle" width="33%"/> <col align="center" valign="middle" width="33%"/> <thead> <tr class="Botrule First"> <th align="center" class="Lrule Rrule" colspan="3">VALCYTE 450 mg Tablets</th> </tr> <tr class="Last"> <th align="center" class="Lrule Rrule">CrCl* (mL/min)</th><th align="center" class="Rrule">Induction Dose</th><th align="center" class="Rrule">Maintenance/Prevention Dose</th> </tr> </thead> <tbody> <tr class="Botrule First"> <td align="center" class="Lrule Rrule">≥ 60</td><td align="center" class="Rrule">900 mg twice daily</td><td align="center" class="Rrule">900 mg once daily</td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule">40 – 59</td><td align="center" class="Rrule">450 mg twice daily</td><td align="center" class="Rrule">450 mg once daily</td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule">25 – 39</td><td align="center" class="Rrule">450 mg once daily</td><td align="center" class="Rrule">450 mg every 2 days</td> </tr> <tr class="Botrule"> <td align="center" class="Lrule Rrule">10 – 24</td><td align="center" class="Rrule">450 mg every 2 days</td><td align="center" class="Rrule">450 mg twice weekly</td> </tr> <tr class="Last"> <td align="center" class="Lrule Rrule">&lt; 10<br/>(on hemodialysis)</td><td align="center" class="Rrule">not recommended</td><td align="center" class="Rrule">not recommended</td> </tr> </tbody> </table></div>

*An estimated creatinine clearance in adults is calculated from serum creatinine by the following formulas:

<div class="scrollingtable"><table class="Noautorules" width="40%"> <col align="left" valign="middle" width="25%"/> <col align="left" valign="middle" width="75%"/> <tbody class="Headless"> <tr> <td align="left" rowspan="2">For males = </td><td align="left" class="Botrule">(140 – age [years]) × (body weight [kg])</td> </tr> <tr> <td align="left">(72) × (serum creatinine [mg/dL])</td> </tr> </tbody> </table></div>

For females = 0.85 × male value

Dosing in pediatric patients with renal impairment can be done using the recommended equations because CrCl is a component in the calculation [see Dosage and Administration (2.3)].

Caution should be exercised in the handling of VALCYTE tablets and VALCYTE for oral solution. Tablets should not be broken or crushed. Because valganciclovir is considered a potential teratogen and carcinogen in humans, caution should be observed in handling broken tablets, the powder for oral solution, and the constituted oral solution [see Warnings and Precautions (5.4, 5.5)]. Avoid direct contact with broken or crushed tablets, the powder for oral solution, and the constituted oral solution with skin or mucous membranes. If such contact occurs, wash thoroughly with soap and water, and rinse eyes thoroughly with plain water.

Handle and dispose VALCYTE according to guidelines for antineoplastic drugs because ganciclovir shares some of the properties of antitumor agents (i.e., carcinogenicity and mutagenicity).2

{ "type": "ul", "children": [ "VALCYTE tablets: 450 mg, pink, film-coated convex oval tablets with \"VGC\" on one side and \"450\" on the other side.", "VALCYTE for oral solution: 50 mg per mL, supplied as a white to slightly yellow powder for constitution, forming a colorless to brownish yellow tutti-frutti flavored solution. Available in glass bottles containing approximately 100 mL of solution after constitution." ], "text": "" }

VALCYTE is contraindicated in patients who have had a demonstrated clinically significant hypersensitivity reaction (e.g., anaphylaxis) to valganciclovir, ganciclovir, or any component of the formulation [see Adverse Reactions (6.1)].

{ "type": "p", "children": [], "text": "VALCYTE is contraindicated in patients who have had a demonstrated clinically significant hypersensitivity reaction (e.g., anaphylaxis) to valganciclovir, ganciclovir, or any component of the formulation [see Adverse Reactions (6.1)].\n" }

Severe leukopenia, neutropenia, anemia, thrombocytopenia, pancytopenia, and bone marrow failure including aplastic anemia have been reported in patients treated with VALCYTE or ganciclovir. VALCYTE should be avoided if the absolute neutrophil count is less than 500 cells/µL, the platelet count is less than 25,000/µL, or the hemoglobin is less than 8 g/dL. VALCYTE should also be used with caution in patients with pre-existing cytopenias and in patients receiving myelosuppressive drugs or irradiation. Cytopenia may occur at any time during treatment and may worsen with continued dosing. Cell counts usually begin to recover within 3 to 7 days after discontinuing drug. In patients with severe leukopenia, neutropenia, anemia and/or thrombocytopenia, treatment with hematopoietic growth factors may be considered.

Due to the frequency of neutropenia, anemia, and thrombocytopenia in patients receiving VALCYTE [see Adverse Reactions (6.1)], complete blood counts with differential and platelet counts should be performed frequently, especially in infants, in patients with renal impairment, and in patients in whom ganciclovir or other nucleoside analogues have previously resulted in leukopenia, or in whom neutrophil counts are less than 1000 cells/µL at the beginning of treatment. Increased monitoring for cytopenias may be warranted if therapy with oral ganciclovir is changed to VALCYTE because of increased plasma concentrations of ganciclovir after VALCYTE administration [see Clinical Pharmacology (12.3)].

Acute renal failure may occur in:

Based on animal data and limited human data, VALCYTE at the recommended human doses may cause temporary or permanent inhibition of spermatogenesis in males, and may cause suppression of fertility in females. Advise patients that fertility may be impaired with use of VALCYTE [see Use in Specific Populations (8.1, 8.3), Nonclinical Toxicology (13.1)].

Ganciclovir may cause fetal toxicity when administered to pregnant women based on findings in animal studies. When given to pregnant rabbits at dosages resulting in 2 times the human exposure (based on AUC), ganciclovir caused malformations in multiple organs of the fetuses. Maternal and fetal toxicity were also observed in pregnant mice and rabbits. Therefore, VALCYTE has the potential to cause birth defects. Pregnancy should be avoided in female patients taking VALCYTE and in females with male partners taking VALCYTE. Females of reproductive potential should be advised to use effective contraception during treatment and for at least 30 days following treatment with VALCYTE because of the potential risk to the fetus. Similarly, males should be advised to use condoms during and for at least 90 days following treatment with VALCYTE [see Dosage and Administration (2.6), Use in Specific Populations (8.1, 8.3), Nonclinical Toxicology (13.1)].

Animal data indicate that ganciclovir is mutagenic and carcinogenic. VALCYTE should therefore be considered a potential carcinogen in humans [see Dosage and Administration (2.6), Nonclinical Toxicology (13.1)].

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 rates observed in practice.

Valganciclovir, a prodrug of ganciclovir, is rapidly converted to ganciclovir after oral administration. Adverse reactions known to be associated with ganciclovir usage can therefore be expected to occur with VALCYTE.

Adverse Reactions in Adults:

Treatment of CMV Retinitis in AIDS Patients: In a clinical study for the treatment of CMV retinitis in HIV-infected patients, the adverse reactions reported by patients receiving VALCYTE tablets (n=79) or intravenous ganciclovir (n=79) for 28 days of randomized therapy (21 days induction dose and 7 days maintenance dose), respectively, included diarrhea (16%, 10%), nausea (8%, 14%), and headache (9%, 5%). The incidence of adverse reactions was similar between the group who received VALCYTE tablets and the group who received intravenous ganciclovir. The frequencies of neutropenia (ANC less than 500/µL) were 11% for patients receiving VALCYTE tablets compared with 13% for patients receiving intravenous ganciclovir. Anemia (Hgb less than 8 g/dL) occurred in 8% of patients in each group. Other laboratory abnormalities occurred with similar frequencies in the two groups.

Adverse reactions and laboratory abnormalities are available for 370 patients who received maintenance therapy with VALCYTE tablets 900 mg once daily in two open-label clinical trials. Approximately 252 (68%) of these patients received VALCYTE tablets for more than nine months (maximum duration was 36 months). Table 3 and Table 4 show pooled selected adverse reactions and abnormal laboratory values from these patients.

<div class="scrollingtable"><table width="60%"> <caption> <span>Table 3 Pooled Selected Adverse Reactions Reported in greater than or equal to 5% of Patients who Received VALCYTE Tablets Maintenance Therapy for CMV Retinitis</span> </caption> <colgroup> <col align="left" valign="middle" width="50%"/> <col align="center" valign="middle" width="50%"/> </colgroup> <thead> <tr class="Botrule First First"> <th align="left" class="Lrule Rrule"></th><th align="center" class="Rrule">Patients with CMV Retinitis</th> </tr> <tr class="Last"> <th align="center" class="Lrule Rrule">Adverse Reactions according to Body System</th><th align="center" class="Rrule">VALCYTE Tablets<br/>(N=370)<br/>%</th> </tr> </thead> <tbody> <tr class="First"> <td align="left" class="Lrule Rrule"><span class="Bold">Gastrointestinal system</span></td><td align="center" class="Rrule"></td> </tr> <tr> <td align="left" class="Lrule Rrule">  Diarrhea</td><td align="center" class="Rrule">41</td> </tr> <tr> <td align="left" class="Lrule Rrule">  Nausea</td><td align="center" class="Rrule">30</td> </tr> <tr> <td align="left" class="Lrule Rrule">  Vomiting</td><td align="center" class="Rrule">21</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">  Abdominal pain</td><td align="center" class="Rrule">15</td> </tr> <tr> <td align="left" class="Lrule Rrule"><span class="Bold">General disorders and administrative site conditions</span></td><td align="center" class="Rrule"></td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">  Pyrexia</td><td align="center" class="Rrule">31</td> </tr> <tr> <td align="left" class="Lrule Rrule"><span class="Bold">Nervous system disorders</span></td><td align="center" class="Rrule"></td> </tr> <tr> <td align="left" class="Lrule Rrule">  Headache</td><td align="center" class="Rrule">22</td> </tr> <tr> <td align="left" class="Lrule Rrule">  Insomnia</td><td align="center" class="Rrule">16</td> </tr> <tr> <td align="left" class="Lrule Rrule">  Neuropathy peripheral</td><td align="center" class="Rrule">9</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">  Paresthesia</td><td align="center" class="Rrule">8</td> </tr> <tr> <td align="left" class="Lrule Rrule"><span class="Bold">Eye disorders</span></td><td align="center" class="Rrule"></td> </tr> <tr class="Last"> <td align="left" class="Lrule Rrule">  Retinal detachment</td><td align="center" class="Rrule">15</td> </tr> </tbody> </table></div>

<div class="scrollingtable"><table width="60%"> <caption> <span>Table 4 Pooled Selected Laboratory Abnormalities Reported in Patients Who Received VALCYTE Tablets Maintenance Therapy for the Treatment of CMV Retinitis</span> </caption> <colgroup> <col align="left" valign="top" width="50%"/> <col align="center" valign="top" width="50%"/> </colgroup> <thead> <tr class="Botrule First First"> <th align="left" class="Lrule Rrule"></th><th align="center" class="Rrule">Patients with CMV Retinitis</th> </tr> <tr class="Last"> <th align="center" class="Lrule Rrule">Laboratory Abnormalities</th><th align="center" class="Rrule">VALCYTE Tablets<br/>(N=370)<br/>%</th> </tr> </thead> <tbody> <tr class="First"> <td align="left" class="Lrule Rrule">Neutropenia: ANC/µL</td><td align="center" class="Rrule"></td> </tr> <tr> <td align="left" class="Lrule Rrule">  &lt; 500</td><td align="center" class="Rrule">19</td> </tr> <tr> <td align="left" class="Lrule Rrule">  500 – &lt; 750</td><td align="center" class="Rrule">17</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">  750 – &lt; 1000</td><td align="center" class="Rrule">17</td> </tr> <tr> <td align="left" class="Lrule Rrule">Anemia: Hemoglobin g/dL</td><td align="center" class="Rrule"></td> </tr> <tr> <td align="left" class="Lrule Rrule">  &lt; 6.5</td><td align="center" class="Rrule">7</td> </tr> <tr> <td align="left" class="Lrule Rrule">  6.5 – &lt; 8.0</td><td align="center" class="Rrule">13</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">  8.0 – &lt; 9.5</td><td align="center" class="Rrule">16</td> </tr> <tr> <td align="left" class="Lrule Rrule">Thrombocytopenia: Platelets/µL</td><td align="center" class="Rrule"></td> </tr> <tr> <td align="left" class="Lrule Rrule">  &lt; 25000</td><td align="center" class="Rrule">4</td> </tr> <tr> <td align="left" class="Lrule Rrule">  25000 – &lt; 50000</td><td align="center" class="Rrule">6</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">  50000 – &lt; 100000</td><td align="center" class="Rrule">22</td> </tr> <tr> <td align="left" class="Lrule Rrule">Serum Creatinine: mg/dL</td><td align="center" class="Rrule"></td> </tr> <tr> <td align="left" class="Lrule Rrule">  &gt; 2.5</td><td align="center" class="Rrule">3</td> </tr> <tr class="Last"> <td align="left" class="Lrule Rrule">  &gt; 1.5 – 2.5</td><td align="center" class="Rrule">12</td> </tr> </tbody> </table></div>

Prevention of CMV Disease in Solid Organ Transplant Patients:Table 5 shows selected adverse reactions regardless of severity with an incidence of greater than or equal to 5% from a clinical trial (up to 28 days after study treatment) where heart, kidney, kidney-pancreas and liver transplant patients received VALCYTE tablets (N=244) or oral ganciclovir (N=126) until Day 100 post-transplant. The majority of the adverse reactions were of mild or moderate intensity.

<div class="scrollingtable"><table width="60%"> <caption> <span>Table 5 Percentage of Selected Grades 1–4 Adverse Reactions Reported in greater than or equal to 5% of Adult Patients From a Study of Solid Organ Transplant Patients</span> </caption> <colgroup> <col align="left" valign="middle" width="34%"/> <col align="center" valign="middle" width="33%"/> <col align="center" valign="middle" width="33%"/> </colgroup> <thead> <tr class="First First Last Last"> <th align="center" class="Lrule Rrule">Adverse Reactions</th><th align="center" class="Rrule">VALCYTE Tablets<br/>(N=244)<br/>%</th><th align="center" class="Rrule">Oral Ganciclovir<br/>(N=126)<br/>%</th> </tr> </thead> <tbody> <tr class="Botrule First First"> <td align="left" class="Lrule Rrule"><span class="Bold">Gastrointestinal disorders</span></td><td align="center" class="Rrule"></td><td align="center" class="Rrule"></td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">Diarrhea</td><td align="center" class="Rrule">30</td><td align="center" class="Rrule">29</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">Nausea</td><td align="center" class="Rrule">23</td><td align="center" class="Rrule">23</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">Vomiting</td><td align="center" class="Rrule">16</td><td align="center" class="Rrule">14</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule"><span class="Bold">Nervous system disorders</span></td><td align="center" class="Rrule"></td><td align="center" class="Rrule"></td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">Tremors</td><td align="center" class="Rrule">28</td><td align="center" class="Rrule">25</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">Headache</td><td align="center" class="Rrule">22</td><td align="center" class="Rrule">27</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">Insomnia</td><td align="center" class="Rrule">20</td><td align="center" class="Rrule">16</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule"><span class="Bold">General disorders and administration site conditions</span></td><td align="center" class="Rrule"></td><td align="center" class="Rrule"></td> </tr> <tr class="Last"> <td align="left" class="Lrule Rrule">Pyrexia</td><td align="center" class="Rrule">13</td><td align="center" class="Rrule">14</td> </tr> </tbody> </table></div>

Table 6 shows selected adverse reactions regardless of severity with an incidence of greater than or equal to 5% from another clinical trial where kidney transplant patients received either valganciclovir once daily starting within 10 days post-transplant until Day 100 post-transplant followed by 100 days of placebo or valganciclovir once daily until Day 200 post-transplant. The overall safety profile of VALCYTE did not change with the extension of prophylaxis until Day 200 post-transplant in high risk kidney transplant patients.

<div class="scrollingtable"><table width="60%"> <caption> <span>Table 6 Percentage of Selected Grades 1–4 Adverse Reactions Reported in greater than or equal to 5% of Adult Patients from a Study of Kidney Transplant Patients</span> </caption> <colgroup> <col align="left" valign="middle" width="34%"/> <col align="center" valign="middle" width="33%"/> <col align="center" valign="middle" width="33%"/> </colgroup> <thead> <tr class="First First Last Last"> <th align="center" class="Lrule Rrule">Adverse Reactions</th><th align="center" class="Rrule">VALCYTE Tablets<br/>Day 100 Post-transplant<br/>(N=164)<br/>%</th><th align="center" class="Rrule">VALCYTE Tablets<br/>Day 200 Post-transplant<br/>(N=156)<br/>%</th> </tr> </thead> <tbody> <tr class="Botrule First First"> <td align="left" class="Lrule Rrule"><span class="Bold">Gastrointestinal disorders</span></td><td align="center" class="Rrule"></td><td align="center" class="Rrule"></td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">Diarrhea</td><td align="center" class="Rrule">26</td><td align="center" class="Rrule">31</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">Nausea</td><td align="center" class="Rrule">11</td><td align="center" class="Rrule">11</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">Vomiting</td><td align="center" class="Rrule">3</td><td align="center" class="Rrule">6</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule"><span class="Bold">Nervous system disorders</span></td><td align="center" class="Rrule"></td><td align="center" class="Rrule"></td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">Tremors</td><td align="center" class="Rrule">12</td><td align="center" class="Rrule">17</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">Headache</td><td align="center" class="Rrule">10</td><td align="center" class="Rrule">6</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">Insomnia</td><td align="center" class="Rrule">7</td><td align="center" class="Rrule">6</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule"><span class="Bold">General disorders and administration site conditions</span></td><td align="center" class="Rrule"></td><td align="center" class="Rrule"></td> </tr> <tr class="Last"> <td align="left" class="Lrule Rrule">Pyrexia</td><td align="center" class="Rrule">12</td><td align="center" class="Rrule">9</td> </tr> </tbody> </table></div>

Table 7 and Table 8 show selected laboratory abnormalities reported with VALCYTE tablets in two trials in solid organ transplant patients.

<div class="scrollingtable"><table width="60%"> <caption> <span>Table 7 Selected Laboratory Abnormalities Reported in a Study of Adult Solid Organ Transplant Patients <span class="Sup">*</span></span> </caption> <colgroup> <col align="left" valign="top" width="34%"/> <col align="center" valign="top" width="33%"/> <col align="center" valign="top" width="33%"/> </colgroup> <thead> <tr class="First First Last Last"> <th align="center" class="Lrule Rrule" valign="middle">Laboratory Abnormalities</th><th align="center" class="Rrule">VALCYTE Tablets<br/>(N=244)<br/>%</th><th align="center" class="Rrule">Ganciclovir Capsules<br/>(N=126)<br/>%</th> </tr> </thead> <tbody> <tr class="First"> <td align="left" class="Lrule Rrule">Neutropenia: ANC/µL</td><td align="center" class="Rrule"></td><td align="center" class="Rrule"></td> </tr> <tr> <td align="left" class="Lrule Rrule">  &lt; 500</td><td align="center" class="Rrule">5</td><td align="center" class="Rrule">3</td> </tr> <tr> <td align="left" class="Lrule Rrule">  500 – &lt; 750</td><td align="center" class="Rrule">3</td><td align="center" class="Rrule">2</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">  750 – &lt; 1000</td><td align="center" class="Rrule">5</td><td align="center" class="Rrule">2</td> </tr> <tr> <td align="left" class="Lrule Rrule">Anemia: Hemoglobin g/dL</td><td align="center" class="Rrule"></td><td align="center" class="Rrule"></td> </tr> <tr> <td align="left" class="Lrule Rrule">  &lt; 6.5</td><td align="center" class="Rrule">1</td><td align="center" class="Rrule">2</td> </tr> <tr> <td align="left" class="Lrule Rrule">  6.5 – &lt; 8.0</td><td align="center" class="Rrule">5</td><td align="center" class="Rrule">7</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">  8.0 – &lt; 9.5</td><td align="center" class="Rrule">31</td><td align="center" class="Rrule">25</td> </tr> <tr> <td align="left" class="Lrule Rrule">Thrombocytopenia: Platelets/µL</td><td align="center" class="Rrule"></td><td align="center" class="Rrule"></td> </tr> <tr> <td align="left" class="Lrule Rrule">  &lt; 25000</td><td align="center" class="Rrule">0</td><td align="center" class="Rrule">2</td> </tr> <tr> <td align="left" class="Lrule Rrule">  25000 – &lt; 50000</td><td align="center" class="Rrule">1</td><td align="center" class="Rrule">3</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">  50000 – &lt; 100000</td><td align="center" class="Rrule">18</td><td align="center" class="Rrule">21</td> </tr> <tr> <td align="left" class="Lrule Rrule">Serum Creatinine: mg/dL</td><td align="center" class="Rrule"></td><td align="center" class="Rrule"></td> </tr> <tr> <td align="left" class="Lrule Rrule">  &gt; 2.5</td><td align="center" class="Rrule">14</td><td align="center" class="Rrule">21</td> </tr> <tr class="Last"> <td align="left" class="Lrule Rrule">  &gt; 1.5 – 2.5</td><td align="center" class="Rrule">45</td><td align="center" class="Rrule">47</td> </tr> </tbody> </table></div>

<div class="scrollingtable"><table width="60%"> <caption> <span>Table 8 Selected Laboratory Abnormalities Reported in a Study of Adult Kidney Transplant Patients <span class="Sup">*</span></span> </caption> <colgroup> <col align="left" valign="top" width="34%"/> <col align="center" valign="top" width="33%"/> <col align="center" valign="top" width="33%"/> </colgroup> <thead> <tr class="First First Last Last"> <th align="center" class="Lrule Rrule" valign="middle">Laboratory Abnormalities</th><th align="center" class="Rrule">VALCYTE Tablets<br/>Day 100 Post-transplant<br/>(N=164)<br/>%</th><th align="center" class="Rrule">VALCYTE Tablets<br/>Day 200 Post-transplant<br/>(N=156)<br/>%</th> </tr> </thead> <tbody> <tr class="First"> <td align="left" class="Lrule Rrule">Neutropenia: ANC/µL</td><td align="center" class="Rrule"></td><td align="center" class="Rrule"></td> </tr> <tr> <td align="left" class="Lrule Rrule">  &lt; 500</td><td align="center" class="Rrule">9</td><td align="center" class="Rrule">10</td> </tr> <tr> <td align="left" class="Lrule Rrule">  500 – &lt; 750</td><td align="center" class="Rrule">6</td><td align="center" class="Rrule">6</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">  750 – &lt; 1000</td><td align="center" class="Rrule">7</td><td align="center" class="Rrule">5</td> </tr> <tr> <td align="left" class="Lrule Rrule">Anemia: Hemoglobin g/dL</td><td align="center" class="Rrule"></td><td align="center" class="Rrule"></td> </tr> <tr> <td align="left" class="Lrule Rrule">  &lt; 6.5</td><td align="center" class="Rrule">0</td><td align="center" class="Rrule">1</td> </tr> <tr> <td align="left" class="Lrule Rrule">  6.5 – &lt; 8.0</td><td align="center" class="Rrule">5</td><td align="center" class="Rrule">1</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">  8.0 – &lt; 9.5</td><td align="center" class="Rrule">17</td><td align="center" class="Rrule">15</td> </tr> <tr> <td align="left" class="Lrule Rrule">Thrombocytopenia: Platelets/µL</td><td align="center" class="Rrule"></td><td align="center" class="Rrule"></td> </tr> <tr> <td align="left" class="Lrule Rrule">  &lt; 25000</td><td align="center" class="Rrule">0</td><td align="center" class="Rrule">0</td> </tr> <tr> <td align="left" class="Lrule Rrule">  25000 – &lt; 50000</td><td align="center" class="Rrule">1</td><td align="center" class="Rrule">0</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">  50000 – &lt; 100000</td><td align="center" class="Rrule">7</td><td align="center" class="Rrule">3</td> </tr> <tr> <td align="left" class="Lrule Rrule">Serum Creatinine: mg/dL</td><td align="center" class="Rrule"></td><td align="center" class="Rrule"></td> </tr> <tr> <td align="left" class="Lrule Rrule">  &gt; 2.5</td><td align="center" class="Rrule">17</td><td align="center" class="Rrule">14</td> </tr> <tr class="Last"> <td align="left" class="Lrule Rrule">  &gt; 1.5 – 2.5</td><td align="center" class="Rrule">50</td><td align="center" class="Rrule">48</td> </tr> </tbody> </table></div>

Other adverse drug reactions from VALCYTE in clinical trials in CMV retinitis and solid organ transplant patients

Other adverse drug reactions with VALCYTE in clinical trials in either patients with CMV retinitis or solid organ transplant patients that occurred in at least 5% of patients are listed below.

Eye disorders: retinal detachment, eye pain

Gastrointestinal disorders: dyspepsia, constipation, abdominal distention, mouth ulceration

General disorders and administration site conditions: fatigue, pain, malaise, asthenia, chills, peripheral edema

Hepatobiliary disorders: hepatic function abnormal

Infections and infestations: candida infections including oral candidiasis, upper respiratory tract infection, influenza, urinary tract infection, pharyngitis/nasopharyngitis, postoperative wound infection

Injury, poisoning, and procedural complications: postoperative complications, wound secretion

Metabolic and nutrition disorders: decreased appetite, hyperkalemia, hypophosphatemia, weight decreased

Musculoskeletal and connective tissue disorders: back pain, myalgia, arthralgia, muscle spasms

Nervous system disorders: insomnia, neuropathy peripheral, dizziness

Psychiatric disorders: depression, anxiety

Renal and urinary disorders: renal impairment, creatinine clearance renal decreased, blood creatinine increased, hematuria

Respiratory, thoracic and mediastinal disorders: cough, dyspnea

Skin and subcutaneous tissues disorders: dermatitis, night sweats, pruritus

Vascular disorders: hypotension

Other adverse reactions with VALCYTE in clinical trials in either patients with CMV retinitis or solid organ transplant patients that occurred in less than 5% of patients are listed below.

Blood and lymphatic disorders: febrile neutropenia, pancytopenia, bone marrow failure (including aplastic anemia)

Cardiovascular disorders: arrhythmia

Ear and labyrinth disorders: deafness

Eye disorders: macular edema

Gastrointestinal disorders: pancreatitis

Hemorrhage: potentially life-threatening bleeding associated with thrombocytopenia

Immune system disorders: hypersensitivity

Infections and infestations: cellulitis, sepsis

Injury, poisoning, and procedural complications: postoperative pain, wound dehiscence

Investigations: aspartate aminotransferase increased, alanine aminotransferase increased

Musculoskeletal and connective tissue disorders: limb pain

Nervous system disorders: seizure, dysguesia (taste disturbance)

Psychiatric disorders: confusional state, agitation, psychotic disorder, hallucinations

Renal and urinary disorders: renal failure

Adverse Reactions in Pediatric Patients:

VALCYTE for oral solution and tablets have been studied in 179 pediatric solid organ transplant patients who were at risk for developing CMV disease (aged 3 weeks to 16 years) and in 24 neonates with symptomatic congenital CMV disease (aged 8 to 34 days), with duration of ganciclovir exposure ranging from 2 to 200 days [see Use in Specific Populations (8.4), Clinical Studies (14.2)].

Prevention of CMV Disease in Pediatric Solid Organ Transplant Patients: The most frequently reported adverse reactions (greater than 10% of patients), regardless of seriousness, in pediatric solid organ transplant patients taking VALCYTE until Day 100 post-transplant were diarrhea, pyrexia, upper respiratory tract infection, vomiting, anemia, neutropenia, constipation and nausea. The most frequently reported adverse reactions (greater than 10% of patients) in pediatric kidney transplant patients treated with valganciclovir until Day 200 post-transplant were upper respiratory tract infection, urinary tract infection, diarrhea, leukopenia, neutropenia, headache, abdominal pain, tremor, pyrexia, anemia, blood creatinine increased, vomiting, and hematuria.

In general, the safety profile was similar in pediatric patients compared to that observed in adult patients. However, the rates of certain adverse reactions, and laboratory abnormalities, such as upper respiratory tract infection, pyrexia, nasopharyngitis, anemia, and abdominal pain were reported more frequently in pediatric patients than in adults [see Use in Specific Populations (8.4), Clinical Studies (14.2)]. Neutropenia was reported at a higher incidence in the two pediatric studies as compared to adults, but there was no correlation between neutropenia and infections observed in the pediatric population.

The overall safety profile of VALCYTE was similar with the extension of prophylaxis until Day 200 post-transplant in high risk pediatric kidney transplant patients. However, the incidence of severe neutropenia (ANC < 500/µL) was higher in pediatric kidney transplant patients treated with VALCYTE until Day 200 (17/57, 30%) compared to pediatric kidney transplant patients treated until Day 100 (3/63, 5%). There were no differences in the incidence of severe (Grade 4) anemia or thrombocytopenia in patients treated 100 or 200 days with VALCYTE.

The following adverse reactions have been identified during post-approval use of VALCYTE. 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. As VALCYTE is rapidly and extensively converted to ganciclovir, any adverse reactions associated with ganciclovir might also occur with valganciclovir.

In general, the adverse reactions reported during the postmarketing use of VALCYTE were similar to those identified during the clinical trials.

In vivo drug-drug interaction studies were not conducted with valganciclovir. However, because valganciclovir is rapidly and extensively converted to ganciclovir, drug-drug interactions associated with ganciclovir will be expected for VALCYTE. Drug-drug interaction studies with ganciclovir were conducted in patients with normal renal function. Following concomitant administration of VALCYTE and other renally excreted drugs, patients with impaired renal function may have increased concentrations of ganciclovir and the coadministered drug. Therefore, these patients should be closely monitored for toxicity of ganciclovir and the coadministered drug.

{ "type": "p", "children": [], "text": "In vivo drug-drug interaction studies were not conducted with valganciclovir. However, because valganciclovir is rapidly and extensively converted to ganciclovir, drug-drug interactions associated with ganciclovir will be expected for VALCYTE. Drug-drug interaction studies with ganciclovir were conducted in patients with normal renal function. Following concomitant administration of VALCYTE and other renally excreted drugs, patients with impaired renal function may have increased concentrations of ganciclovir and the coadministered drug. Therefore, these patients should be closely monitored for toxicity of ganciclovir and the coadministered drug." }

Established and other potentially significant drug interactions conducted with ganciclovir are listed in Table 9.

{ "type": "p", "children": [], "text": "Established and other potentially significant drug interactions conducted with ganciclovir are listed in Table 9." }

<div class="scrollingtable"><table width="75%"> <caption> <span>Table 9 Established and Other Potentially Significant Drug Interactions with Ganciclovir</span> </caption> <col align="left" valign="top" width="34%"/> <col align="left" valign="top" width="33%"/> <col align="left" valign="top" width="33%"/> <thead> <tr class="First Last"> <th align="center" class="Lrule Rrule">Name of the Concomitant Drug</th><th align="center" class="Rrule">Change in the Concentration of Ganciclovir or Concomitant Drug</th><th align="center" class="Rrule">Clinical Comment</th> </tr> </thead> <tbody> <tr class="Botrule First"> <td align="left" class="Lrule Rrule">Imipenem-cilastatin</td><td align="left" class="Rrule">Unknown</td><td align="left" class="Rrule">Coadministration with imipenem-cilastatin is not recommended because generalized seizures have been reported in patients who received ganciclovir and imipenem-cilastatin.</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">Cyclosporine or amphotericin B</td><td align="left" class="Rrule">Unknown</td><td align="left" class="Rrule">Monitor renal function when VALCYTE is coadministered with cyclosporine or amphotericin B because of potential increase in serum creatinine <span class="Italics">[see <a href="#S5.2">Warnings and Precautions (5.2)</a>].</span></td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">Mycophenolate mofetil (MMF)</td><td align="left" class="Rrule">↔ Ganciclovir (in patients with normal renal function)<br/>↔ MMF (in patients with normal renal function)</td><td align="left" class="Rrule">Based on increased risk, patients should be monitored for hematological and renal toxicity.</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">Other drugs associated with myelosuppression or nephrotoxicity (e.g., adriamycin, dapsone, doxorubicin, flucytosine, hydroxyurea, pentamidine, tacrolimus, trimethoprim/ sulfamethoxazole, vinblastine, vincristine, and zidovudine)</td><td align="left" class="Rrule">Unknown</td><td align="left" class="Rrule">Because of potential for higher toxicity, coadministration with VALCYTE should be considered only if the potential benefits are judged to outweigh the risks. </td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">Didanosine</td><td align="left" class="Rrule">↔ Ganciclovir<br/>↑ Didanosine</td><td align="left" class="Rrule">Patients should be closely monitored for didanosine toxicity (e.g., pancreatitis) </td> </tr> <tr class="Last"> <td align="left" class="Lrule Rrule">Probenecid</td><td align="left" class="Rrule">↑ Ganciclovir</td><td align="left" class="Rrule">VALCYTE dose may need to be reduced. Monitor for evidence of ganciclovir toxicity.</td> </tr> </tbody> </table></div>

{ "type": "table", "children": [], "text": "<div class=\"scrollingtable\"><table width=\"75%\">\n<caption>\n<span>Table 9\tEstablished and Other Potentially Significant Drug Interactions with Ganciclovir</span>\n</caption>\n<col align=\"left\" valign=\"top\" width=\"34%\"/>\n<col align=\"left\" valign=\"top\" width=\"33%\"/>\n<col align=\"left\" valign=\"top\" width=\"33%\"/>\n<thead>\n<tr class=\"First Last\">\n<th align=\"center\" class=\"Lrule Rrule\">Name of the Concomitant Drug</th><th align=\"center\" class=\"Rrule\">Change in the Concentration of Ganciclovir or Concomitant Drug</th><th align=\"center\" class=\"Rrule\">Clinical Comment</th>\n</tr>\n</thead>\n<tbody>\n<tr class=\"Botrule First\">\n<td align=\"left\" class=\"Lrule Rrule\">Imipenem-cilastatin</td><td align=\"left\" class=\"Rrule\">Unknown</td><td align=\"left\" class=\"Rrule\">Coadministration with imipenem-cilastatin is not recommended because generalized seizures have been reported in patients who received ganciclovir and imipenem-cilastatin.</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"left\" class=\"Lrule Rrule\">Cyclosporine or amphotericin B</td><td align=\"left\" class=\"Rrule\">Unknown</td><td align=\"left\" class=\"Rrule\">Monitor renal function when VALCYTE is coadministered with cyclosporine or amphotericin B because of potential increase in serum creatinine <span class=\"Italics\">[see <a href=\"#S5.2\">Warnings and Precautions (5.2)</a>].</span></td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"left\" class=\"Lrule Rrule\">Mycophenolate mofetil (MMF)</td><td align=\"left\" class=\"Rrule\">↔ Ganciclovir (in patients with normal renal function)<br/>↔ MMF (in patients with normal renal function)</td><td align=\"left\" class=\"Rrule\">Based on increased risk, patients should be monitored for hematological and renal toxicity.</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"left\" class=\"Lrule Rrule\">Other drugs associated with myelosuppression or nephrotoxicity (e.g., adriamycin, dapsone, doxorubicin, flucytosine, hydroxyurea, pentamidine, tacrolimus, trimethoprim/ sulfamethoxazole, vinblastine, vincristine, and zidovudine)</td><td align=\"left\" class=\"Rrule\">Unknown</td><td align=\"left\" class=\"Rrule\">Because of potential for higher toxicity, coadministration with VALCYTE should be considered only if the potential benefits are judged to outweigh the risks. </td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"left\" class=\"Lrule Rrule\">Didanosine</td><td align=\"left\" class=\"Rrule\">↔ Ganciclovir<br/>↑ Didanosine</td><td align=\"left\" class=\"Rrule\">Patients should be closely monitored for didanosine toxicity (e.g., pancreatitis) </td>\n</tr>\n<tr class=\"Last\">\n<td align=\"left\" class=\"Lrule Rrule\">Probenecid</td><td align=\"left\" class=\"Rrule\">↑ Ganciclovir</td><td align=\"left\" class=\"Rrule\">VALCYTE dose may need to be reduced. Monitor for evidence of ganciclovir toxicity.</td>\n</tr>\n</tbody>\n</table></div>" }

Risk Summary

After oral administration, valganciclovir (prodrug) is converted to ganciclovir (active drug) and, therefore, VALCYTE is expected to have reproductive toxicity effects similar to ganciclovir. In animal studies, ganciclovir caused maternal and fetal toxicity and embryo-fetal mortality in pregnant mice and rabbits as well as teratogenicity in rabbits at exposures two-times the human exposure. There are no available human data on use of VALCYTE or ganciclovir in pregnant women to establish the presence or absence of drug-associated risk. The background risk of major birth defects and miscarriage for the indicated populations is unknown. However, the background risk in the U.S. general population of major birth defects is 2–4% and the risk of miscarriage is 15–20% of clinically recognized pregnancies. Advise pregnant women of the potential risk to the fetus [see Warnings and Precautions (5.3), Use in Specific Populations (8.3)].

Clinical Considerations

Disease-associated maternal and/or embryo/fetal risk

Most maternal CMV infections are asymptomatic or they may be associated with a self-limited mononucleosis-like syndrome. However, in immunocompromised patients (i.e., transplant patients or patients with AIDS) CMV infections may be symptomatic and may result in significant maternal morbidity and mortality. The transmission of CMV to the fetus is a result of maternal viremia and transplacental infection. Perinatal infection can also occur from exposure of the neonate to CMV shedding in the genital tract. Approximately 10% of children with congenital CMV infection are symptomatic at birth. Mortality in these infants is about 10% and approximately 50–90% of symptomatic surviving newborns experience significant morbidity, including mental retardation, sensorineural hearing loss, microcephaly, seizures, and other medical problems. The risk of congenital CMV infection resulting from primary maternal CMV infection may be higher and of greater severity than that resulting from maternal reactivation of CMV infection.

Data

Animal Data

Doses resulting in two-times the human exposure of ganciclovir (based on the human AUC following a single intravenous infusion of 5 mg per kg of ganciclovir) resulted in maternal and embryo-fetal toxicity in pregnant mice and rabbits as well as teratogenicity in the rabbits. Fetal resorptions were present in at least 85% of rabbits and mice. Rabbits showed increased embryo-fetal mortality, growth retardation of the fetuses and structural abnormalities of multiple organs of the fetuses including the palate (cleft palate), eyes (anophthalmia/microphthalmia), brain (hydrocephalus), jaw (brachygnathia), kidneys and pancreas (aplastic organs). Increased embryo-fetal mortality was also seen in mice. Daily intravenous doses of approximately 1.7 times the human exposure (based on AUC) administered to female mice prior to mating, during gestation, and during lactation caused hypoplasia of the testes and seminal vesicles in the male offspring, as well as pathologic changes in the nonglandular region of the stomach.

Data from an ex-vivo human placental model showed that ganciclovir crosses the human placenta. The transfer occurred by passive diffusion and was not saturable over a concentration range of 1 to 10 mg/mL.

Risk Summary

No data are available regarding the presence of valganciclovir (prodrug) or ganciclovir (active drug) in human milk, the effects on the breastfed infant, or the effects on milk production. Animal data indicate that ganciclovir is excreted in the milk of lactating rats. The Centers for Disease Control and Prevention recommend that HIV-infected mothers not breastfeed their infants to avoid risking postnatal transmission of HIV. Advise nursing mothers that breastfeeding is not recommended during treatment with VALCYTE because of the potential for serious adverse events in nursing infants and because of the potential for transmission of HIV [see Boxed Warning, Warnings and Precautions (5.1, 5.3, 5.4, 5.5), Nonclinical Toxicology (13.1)].

Pregnancy Testing

Females of reproductive potential should undergo pregnancy testing before initiation of VALCYTE [see Use in Specific Populations (8.1)].

Contraception

Females

Because of the mutagenic and teratogenic potential of VALCYTE, females of reproductive potential should be advised to use effective contraception during treatment and for at least 30 days following treatment with VALCYTE [see Dosage and Administration (2.6), Warnings and Precautions (5.4, 5.5), Nonclinical Toxicology (13.1)].

Males

Because of its mutagenic potential, males should be advised to use condoms during and for at least 90 days following, treatment with VALCYTE [see Dosage and Administration (2.6), Warnings and Precautions (5.3, 5.5), Nonclinical Toxicology (13.1)].

Infertility

VALCYTE at the recommended doses may cause temporary or permanent female and male infertility [see Warnings and Precautions (5.3), Nonclinical Toxicology (13.1)].

Data

Human Data

In a small, open-label, non-randomized clinical study, adult male renal transplant patients receiving VALCYTE for CMV prophylaxis for up to 200 days post-transplantation were compared to an untreated control group. Patients were followed-up for six months after VALCYTE discontinuation. Among 24 evaluable patients in the VALCYTE group, the mean sperm density at the end of treatment visit decreased by 11 million/mL from baseline; whereas, among 14 evaluable patients in the control group the mean sperm density increased by 33 million/mL. However, at the follow-up visit among 20 evaluable patients in the VALCYTE group the mean sperm density was comparable to that observed among 10 evaluable patients in the untreated control group (the mean sperm density at the end of follow-up visit increased by 41 million/mL from baseline in the VALCYTE group and by 43 million/mL in the untreated group).

VALCYTE for oral solution and tablets are indicated for the prevention of CMV disease in pediatric kidney transplant patients 4 months to 16 years of age and in pediatric heart transplant patients 1 month to 16 years of age at risk for developing CMV disease [see Indications and Usage (1.2), Dosage and Administration (2.3)].

The use of VALCYTE for oral solution and tablets for the prevention of CMV disease in pediatric kidney transplant patients 4 months to 16 years of age is based on two single-arm, open-label, non-comparative studies in patients 4 months to 16 years of age. Study 1 was a safety and pharmacokinetic study in pediatric solid organ transplant patients (kidney, liver, heart, and kidney/pancreas). VALCYTE was administered once daily within 10 days of transplantation for a maximum of 100 days post-transplantation. Study 2 was a safety and tolerability study where VALCYTE was administered once daily within 10 days of transplantation for a maximum of 200 days post-transplantation in pediatric kidney transplant patients. The results of these studies were supported by previous demonstration of efficacy in adult patients [see Adverse Reactions (6.1), Clinical Pharmacology (12.3), Clinical Studies (14.2)].

The use of VALCYTE for oral solution and tablets for the prevention of CMV disease in pediatric heart transplant patients 1 month to 16 years of age is based on two studies (Study 1 described above and Study 3) and was supported by previous demonstration of efficacy in adult patients [see Clinical Pharmacology (12.3), Clinical Studies (14.2)]. Study 3 was a pharmacokinetic and safety study of VALCYTE in pediatric heart transplant patients less than 4 months of age who received a single dose of VALCYTE oral solution on each of two consecutive days. A physiologically based pharmacokinetic (PBPK) model was developed based on the available pharmacokinetic data from pediatric and adult patients to support dosing in heart transplant patients less than 1 month of age. However, due to uncertainty in model predictions for neonates, VALCYTE is not indicated for prophylaxis in this age group.

The safety and efficacy of VALCYTE for oral solution and tablets have not been established in children for prevention of CMV disease in pediatric liver transplant patients, in kidney transplant patients less than 4 months of age, in heart transplant patients less than 1 month of age, in pediatric AIDS patients with CMV retinitis, and in infants with congenital CMV infection.

A pharmacokinetic and pharmacodynamic evaluation of VALCYTE for oral solution was performed in 24 neonates with congenital CMV infection involving the central nervous system. All patients were treated for 6 weeks with a combination of intravenous ganciclovir 6 mg per kg twice daily or VALCYTE for oral solution at doses ranging from 14 mg per kg to 20 mg per kg twice daily. The pharmacokinetic results showed that in infants greater than 7 days to 3 months of age, a dose of 16 mg per kg twice daily of VALCYTE for oral solution provided ganciclovir systemic exposures (median AUC0-12h=23.6 [range 16.8–35.5] mcg∙h/mL; n=6) comparable to those obtained in infants up to 3 months of age from a 6 mg per kg dose of intravenous ganciclovir twice daily (AUC0-12h=25.3 [range 2.4–89.7] mcg∙h/mL; n=18) or to the ganciclovir systemic exposures obtained in adults from a 900 mg dose of VALCYTE tablets twice daily. However, the efficacy and safety of intravenous ganciclovir and of VALCYTE have not been established for the treatment of congenital CMV infection in infants and no similar disease occurs in adults; therefore, efficacy cannot be extrapolated from intravenous ganciclovir use in adults.

Studies of VALCYTE for oral solution or tablets have not been conducted in adults older than 65 years of age. Clinical studies of VALCYTE did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy. VALCYTE is known to be substantially excreted by the kidneys, and the risk of toxic reactions to this drug may be greater in patients with impaired renal function. Because renal clearance decreases with age, VALCYTE should be administered with consideration of their renal status. Renal function should be monitored and dosage adjustments should be made accordingly [see Dosage and Administration (2.5), Warnings and Precautions (5.2), Use in Specific Populations (8.6), Clinical Pharmacology (12.3)].

Dose reduction is recommended when administering VALCYTE to patients with renal impairment [see Dosage and Administration (2.5), Warnings and Precautions (5.2), Clinical Pharmacology (12.3)].

For adult patients on hemodialysis (CrCl less than 10 mL/min), VALCYTE tablets should not be used. Adult hemodialysis patients should use ganciclovir in accordance with the dose-reduction algorithm cited in the CYTOVENE®-IV complete product information section on DOSAGE AND ADMINISTRATION: Renal Impairment [see Dosage and Administration (2.5) and Clinical Pharmacology (12.3)].

The safety and efficacy of VALCYTE have not been studied in patients with hepatic impairment.

Experience with VALCYTE Tablets: An overdose of VALCYTE could possibly result in increased renal toxicity [see Dosage and Administration (2.5), Use in Specific Populations (8.6)]. Because ganciclovir is dialyzable, dialysis may be useful in reducing serum concentrations in patients who have received an overdose of VALCYTE [see Clinical Pharmacology (12.3)]. Adequate hydration should be maintained. The use of hematopoietic growth factors should be considered [see Warnings and Precautions (5.1) and Clinical Pharmacology (12.3)].

Reports of adverse reactions after overdoses with valganciclovir, some with fatal outcomes, have been received from clinical trials and during postmarketing experience. The majority of patients experienced one or more of the following adverse events:

Hematological toxicity: myelosuppression including pancytopenia, bone marrow failure, leukopenia, neutropenia, granulocytopenia

Hepatotoxicity: hepatitis, liver function disorder

Renal toxicity: worsening of hematuria in a patient with pre-existing renal impairment, acute kidney injury, elevated creatinine

Gastrointestinal toxicity: abdominal pain, diarrhea, vomiting

Neurotoxicity: generalized tremor, seizure

VALCYTE contains valganciclovir hydrochloride (valganciclovir HCl), a hydrochloride salt of the L-valyl ester of ganciclovir that exists as a mixture of two diastereomers. Ganciclovir is a synthetic guanine derivative active against CMV.

{ "type": "p", "children": [], "text": "VALCYTE contains valganciclovir hydrochloride (valganciclovir HCl), a hydrochloride salt of the L-valyl ester of ganciclovir that exists as a mixture of two diastereomers. Ganciclovir is a synthetic guanine derivative active against CMV." }

VALCYTE is available as a 450 mg tablet for oral administration. Each tablet contains 496.3 mg of valganciclovir HCl (corresponding to 450 mg of valganciclovir), and the inactive ingredients microcrystalline cellulose, povidone K-30, crospovidone and stearic acid. The film-coat applied to the tablets contains Opadry Pink®.

{ "type": "p", "children": [], "text": "VALCYTE is available as a 450 mg tablet for oral administration. Each tablet contains 496.3 mg of valganciclovir HCl (corresponding to 450 mg of valganciclovir), and the inactive ingredients microcrystalline cellulose, povidone K-30, crospovidone and stearic acid. The film-coat applied to the tablets contains Opadry Pink®." }

VALCYTE is also available as a powder for oral solution, which when constituted with water as directed contains 50 mg/mL valganciclovir free base. The inactive ingredients of VALCYTE for oral solution are sodium benzoate, fumaric acid, povidone K-30, sodium saccharin, mannitol and tutti-frutti flavoring.

{ "type": "p", "children": [], "text": "VALCYTE is also available as a powder for oral solution, which when constituted with water as directed contains 50 mg/mL valganciclovir free base. The inactive ingredients of VALCYTE for oral solution are sodium benzoate, fumaric acid, povidone K-30, sodium saccharin, mannitol and tutti-frutti flavoring." }

Valganciclovir HCl is a white to off-white crystalline powder with a molecular formula of C14H22N6O5∙HCl and a molecular weight of 390.83. The chemical name for valganciclovir HCl is L-Valine, 2-[(2-amino-1,6-dihydro-6-oxo-9H-purin-9-yl) methoxy]-3-hydroxypropyl ester, monohydrochloride. Valganciclovir HCl is a polar hydrophilic compound with a solubility of 70 mg/mL in water at 25°C at a pH of 7.0 and an n-octanol/water partition coefficient of 0.0095 at pH 7.0. The pKa for valganciclovir HCl is 7.6.

{ "type": "p", "children": [], "text": "Valganciclovir HCl is a white to off-white crystalline powder with a molecular formula of C14H22N6O5∙HCl and a molecular weight of 390.83. The chemical name for valganciclovir HCl is L-Valine, 2-[(2-amino-1,6-dihydro-6-oxo-9H-purin-9-yl) methoxy]-3-hydroxypropyl ester, monohydrochloride. Valganciclovir HCl is a polar hydrophilic compound with a solubility of 70 mg/mL in water at 25°C at a pH of 7.0 and an n-octanol/water partition coefficient of 0.0095 at pH 7.0. The pKa for valganciclovir HCl is 7.6." }

The chemical structure of valganciclovir HCl is:

{ "type": "p", "children": [], "text": "The chemical structure of valganciclovir HCl is:" }

All doses in this insert are specified in terms of valganciclovir.

{ "type": "p", "children": [], "text": "All doses in this insert are specified in terms of valganciclovir." }

Valganciclovir is an antiviral drug with activity against CMV [see Microbiology (12.4)].

Valganciclovir is a prodrug of ganciclovir. Valganciclovir Cmax and AUC are approximately 1% and 3% of those of ganciclovir, respectively.

Pharmacokinetics in Adults: The pharmacokinetics of ganciclovir after administration of valganciclovir tablets have been evaluated in HIV- and CMV-seropositive patients, patients with AIDS and CMV retinitis, and in solid organ transplant patients (Table 10).

<div class="scrollingtable"><table width="60%"> <caption> <span>Table 10 Ganciclovir Pharmacokinetics<a class="Sup" href="#footnote-1" name="footnote-reference-1">*</a> in Healthy Volunteers and HIV-positive/CMV-positive Adults Administered VALCYTE Tablets 900 mg Once Daily with Food</span> </caption> <col align="left" valign="top" width="45%"/> <col align="center" valign="top" width="10%"/> <col align="center" valign="top" width="45%"/> <thead> <tr class="First Last"> <th align="center" class="Lrule Rrule">PK parameter</th><th align="center" class="Rrule">N</th><th align="center" class="Rrule">Value (Mean ± SD)</th> </tr> </thead> <tfoot> <tr> <td align="left" colspan="3"> <dl class="Footnote"> <dt> <a href="#footnote-reference-1" name="footnote-1">*</a> </dt> <dd>Data were obtained from single and multiple dose studies in healthy volunteers, HIV-positive patients, and HIV-positive/CMV-positive patients with and without retinitis. Patients with CMV retinitis tended to have higher ganciclovir plasma concentrations than patients without CMV retinitis.</dd> </dl> </td> </tr> </tfoot> <tbody> <tr class="Botrule First"> <td align="left" class="Lrule Rrule">AUC<span class="Sub">0-24h</span> (mcg<span class="Bold">∙</span>h/mL)</td><td align="center" class="Rrule">57</td><td align="center" class="Rrule">29.1 ± 9.7</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">C<span class="Sub">max</span> (mcg/mL)</td><td align="center" class="Rrule">58</td><td align="center" class="Rrule">5.61 ± 1.52</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">Absolute oral bioavailability (%)</td><td align="center" class="Rrule">32</td><td align="center" class="Rrule">59.4 ± 6.1</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">Elimination half-life (hr)</td><td align="center" class="Rrule">73</td><td align="center" class="Rrule">4.08 ± 0.76</td> </tr> <tr class="Last"> <td align="left" class="Lrule Rrule">Renal clearance (mL/min/kg)</td><td align="center" class="Rrule">20</td><td align="center" class="Rrule">3.21 ± 0.75<br/>(1 study, n=20)</td> </tr> </tbody> </table></div>

The systemic ganciclovir exposures attained following administration of 900 mg VALCYTE tablets once daily were comparable across kidney, heart and liver transplant recipients (Table 11).

<div class="scrollingtable"><table width="75%"> <caption> <span>Table 11 Ganciclovir Pharmacokinetics in Solid Organ Transplant Recipients Administered VALCYTE Tablets 900 mg Once Daily with Food</span> </caption> <col align="left" valign="top" width="25%"/> <col align="center" valign="top" width="25%"/> <col align="center" valign="top" width="25%"/> <col align="center" valign="top" width="25%"/> <thead> <tr class="First"> <th align="center" class="Lrule Rrule" rowspan="2" valign="middle">Parameter</th><th align="center" class="Botrule Rrule" colspan="3">Value (Mean ± SD)</th> </tr> <tr class="Last"> <th align="center" class="Lrule Rrule">Heart Transplant Recipients<br/>(N=17)</th><th align="center" class="Rrule">Liver Transplant Recipients<br/>(N=75)</th><th align="center" class="Rrule">Kidney Transplant Recipients<a class="Sup" href="#footnote-2" name="footnote-reference-2">*</a> <br/>(N=68)</th> </tr> </thead> <tfoot> <tr> <td align="left" colspan="4"> <dl class="Footnote"> <dt> <a href="#footnote-reference-2" name="footnote-2">*</a> </dt> <dd>Includes kidney-pancreas</dd> </dl> </td> </tr> </tfoot> <tbody> <tr class="Botrule First"> <td align="left" class="Lrule Rrule">AUC<span class="Sub">0-24h</span> (mcg<span class="Bold">∙</span>h/mL)</td><td align="center" class="Rrule">40.2 ± 11.8</td><td align="center" class="Rrule">46.0 ± 16.1</td><td align="center" class="Rrule">48.2 ± 14.6</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">C<span class="Sub">max</span> (mcg/mL)</td><td align="center" class="Rrule">4.9 ± 1.1</td><td align="center" class="Rrule">5.4 ± 1.5</td><td align="center" class="Rrule">5.3 ± 1.5</td> </tr> <tr class="Last"> <td align="left" class="Lrule Rrule">Elimination half-life (hr)</td><td align="center" class="Rrule">6.58 ± 1.50</td><td align="center" class="Rrule">6.18 ± 1.42</td><td align="center" class="Rrule">6.77 ± 1.25</td> </tr> </tbody> </table></div>

The pharmacokinetic parameters of ganciclovir following 200 days of VALCYTE administration in high-risk kidney transplant patients were similar to those in solid organ transplant patients who received VALCYTE for 100 days.

Absorption, Distribution, Metabolism, and Excretion

The pharmacokinetic (PK) properties of VALCYTE are provided in Table 12.

<div class="scrollingtable"><table width="75%"> <caption> <span>Table 12 Pharmacokinetic Properties of Ganciclovir and Valganciclovir Associated with VALCYTE</span> </caption> <col align="left" valign="top" width="60%"/> <col align="center" valign="top" width="20%"/> <col align="center" valign="top" width="20%"/> <thead> <tr class="First Last"> <th align="left" class="Lrule Rrule"></th><th align="left" class="Rrule">Valganciclovir</th><th align="left" class="Rrule">Ganciclovir</th> </tr> </thead> <tfoot> <tr> <td align="left" colspan="3"> <dl class="Footnote"> <dt> <a href="#footnote-reference-3" name="footnote-3">*</a> </dt> <dd>Steady state ganciclovir PK was assessed after administration of VALCYTE tablets (875 mg once daily) with a high fat meal containing approximately 600 total calories (31.1 g fat, 51.6 g carbohydrates and 22.2 g protein) to 16 HIV-positive subjects. </dd> </dl> </td> </tr> </tfoot> <tbody> <tr class="Botrule First"> <td align="left" class="Lrule Rrule" colspan="3"><span class="Bold">Absorption</span></td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">T<span class="Sub">max</span> (h)<br/>median (min-max) (fed conditions)</td><td align="center" class="Rrule"></td><td align="center" class="Rrule">2.18<br/>1.7h to 3.0h</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">Food effect (high fat meal/fasting): PK parameter ratio and 90% confidence interval<a class="Sup" href="#footnote-3" name="footnote-reference-3">*</a></td><td align="center" class="Rrule"></td><td align="center" class="Rrule">C<span class="Sub">max</span>: <br/>1.14 (0.95, 1.36)<br/>AUC: <br/>1.30 (1.07, 1.51)<a class="Sup" href="#footnote-3">*</a> <br/>T<span class="Sub">max</span>: ↔</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule" colspan="3"><span class="Bold">Distribution</span></td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">% Bound to human plasma proteins (ex vivo)</td><td align="center" class="Rrule" valign="middle">Unknown</td><td align="center" class="Rrule">1–2% over 0.5– 51 mcg/mL</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">Cerebrospinal fluid penetration</td><td align="center" class="Rrule">Unknown</td><td align="center" class="Rrule">Yes</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule" colspan="3"><span class="Bold">Metabolism</span></td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule"></td><td align="center" class="Rrule">Hydrolyzed by intestinal and liver esterases</td><td align="center" class="Rrule">No significant metabolism</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule" colspan="3"><span class="Bold">Elimination</span></td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">Dose proportionality</td><td align="center" class="Rrule"></td><td align="center" class="Rrule">AUC was dose proportional under fed conditions across a valganciclovir dose range of 450 to 2625 mg</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">Major route of elimination </td><td align="center" class="Rrule" valign="middle">Metabolism to ganciclovir</td><td align="center" class="Rrule">Glomerular filtration and active tubular secretion</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">t<span class="Sub">1/2</span> (h)</td><td align="center" class="Rrule"></td><td align="center" class="Rrule">See <a href="#Table10">Tables 10</a> and <a href="#Table11">11</a></td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">% Of dose excreted in urine</td><td align="center" class="Rrule" colspan="2">Unknown</td> </tr> <tr class="Last"> <td align="left" class="Lrule Rrule">% Of dose excreted in feces</td><td align="center" class="Rrule" colspan="2">Unknown</td> </tr> </tbody> </table></div>

Specific Populations:

Renal Impairment: The pharmacokinetics of ganciclovir from a single oral dose of 900 mg VALCYTE tablets were evaluated in 24 otherwise healthy individuals with renal impairment. Decreased renal function results in decreased clearance of ganciclovir and increased terminal half-life (Table 13).

<div class="scrollingtable"><table width="75%"> <caption> <span>Table 13 Pharmacokinetics of Ganciclovir from a Single Oral Dose of 900 mg VALCYTE Tablets</span> </caption> <col align="center" valign="top" width="23%"/> <col align="center" valign="top" width="5%"/> <col align="center" valign="top" width="24%"/> <col align="center" valign="top" width="24%"/> <col align="center" valign="top" width="24%"/> <thead> <tr class="First Last"> <th align="center" class="Lrule Rrule">Estimated Creatinine Clearance<a class="Sup" href="#footnote-4" name="footnote-reference-4">*</a> <br/>(mL/min)</th><th align="center" class="Rrule" valign="bottom">N</th><th align="center" class="Rrule">Apparent Clearance<br/>(mL/min)<br/>Mean ± SD</th><th align="center" class="Rrule">AUC<span class="Sub">last</span> <br/>(mcg∙h/mL)<br/>Mean ± SD</th><th align="center" class="Rrule">Half-life<br/>(hours)<br/>Mean ± SD</th> </tr> </thead> <tfoot> <tr> <td align="left" colspan="5"> <dl class="Footnote"> <dt> <a href="#footnote-reference-4" name="footnote-4">*</a> </dt> <dd>Creatinine clearance calculated from 24-hour urine collection.</dd> </dl> </td> </tr> </tfoot> <tbody> <tr class="First"> <td align="center" class="Lrule Rrule">51-70</td><td align="center" class="Rrule">6</td><td align="center" class="Rrule">249 ± 99</td><td align="center" class="Rrule">49.5 ± 22.4</td><td align="center" class="Rrule">4.85 ± 1.4</td> </tr> <tr> <td align="center" class="Lrule Rrule">21-50</td><td align="center" class="Rrule">6</td><td align="center" class="Rrule">136 ± 64</td><td align="center" class="Rrule">91.9 ± 43.9</td><td align="center" class="Rrule">10.2 ± 4.4</td> </tr> <tr> <td align="center" class="Lrule Rrule">11-20</td><td align="center" class="Rrule">6</td><td align="center" class="Rrule">45 ± 11</td><td align="center" class="Rrule">223 ± 46</td><td align="center" class="Rrule">21.8 ± 5.2</td> </tr> <tr class="Last"> <td align="center" class="Lrule Rrule">≤ 10</td><td align="center" class="Rrule">6</td><td align="center" class="Rrule">12.8 ± 8</td><td align="center" class="Rrule">366 ± 66</td><td align="center" class="Rrule">67.5 ± 34</td> </tr> </tbody> </table></div>

Hemodialysis reduces plasma concentrations of ganciclovir by about 50% following VALCYTE administration. Adult patients receiving hemodialysis (CrCl less than 10 mL/min) cannot use VALCYTE tablets because the daily dose of VALCYTE tablets required for these patients is less than 450 mg [see Dosage and Administration (2.5) and Use in Specific Populations (8.6)].

Pharmacokinetics in Pediatric Patients: The pharmacokinetics of ganciclovir were evaluated following the administration of valganciclovir in 63 pediatric solid organ transplant patients aged 4 months to 16 years, and in 16 pediatric heart transplant patients less than 4 months of age. In these studies, patients received oral doses of valganciclovir (either VALCYTE for oral solution or tablets) to produce exposure equivalent to an adult 900 mg dose [see Dosage and Administration (2.3), Adverse Reactions (6.1), Use in Specific Populations (8.4), Clinical Studies (14.2)].

In studies using the pediatric valganciclovir dosing algorithm, the pharmacokinetics of ganciclovir were similar across organ types and age ranges (Table 14). Relative to adult transplant patients (Table 11), AUC values in pediatric patients were somewhat increased, but were within the range considered safe and effective in adults.

<div class="scrollingtable"><table class="Noautorules" width="75%"> <caption> <span>Table 14 Ganciclovir Pharmacokinetics by Age in Pediatric Solid Organ Transplant Patients Administered VALCYTE</span> </caption> <col align="left" valign="top" width="15%"/> <col align="left" valign="top" width="17%"/> <col align="center" valign="top" width="17%"/> <col align="center" valign="top" width="17%"/> <col align="center" valign="top" width="17%"/> <col align="center" valign="top" width="17%"/> <thead> <tr> <th align="left" class="Botrule Lrule Toprule" rowspan="2" valign="middle">Organ</th><th align="center" class="Botrule Toprule" rowspan="2" valign="middle">PK Parameter mean (SD)</th><th align="center" class="Rrule Toprule" colspan="4" valign="middle">Age Group </th> </tr> <tr class="Botrule"> <th align="center">&lt; 4 months</th><th align="center">4 months to ≤ 2 years</th><th align="center">&gt; 2 to &lt; 12 years</th><th align="center" class="Rrule">≥ 12 years</th> </tr> </thead> <tfoot> <tr> <td align="left" colspan="6">N=number of patients, NA=not applicable</td> </tr> <tr> <td align="left" colspan="6"> <dl class="Footnote"> <dt> <a href="#footnote-reference-5" name="footnote-5">*</a> </dt> <dd>Ages ranged from 26 to 124 days.</dd> </dl> </td> </tr> </tfoot> <tbody> <tr> <td align="left" class="Botrule Lrule" rowspan="4" valign="middle"><span class="Bold">Heart<br/>(N=26)</span></td><td align="left">N</td><td align="center">14<a class="Sup" href="#footnote-5" name="footnote-reference-5">*</a></td><td align="center">6</td><td align="center">2</td><td align="center" class="Rrule">4</td> </tr> <tr> <td align="left" valign="top">AUC<span class="Sub">0-24h</span> (mcg<span class="Bold">∙</span>h/mL)</td><td align="center">66.3 (20.5)</td><td align="center">55.4 (22.8)</td><td align="center">59.6 (21.0)</td><td align="center" class="Rrule">60.6 (25.0)</td> </tr> <tr> <td align="left">C<span class="Sub">max</span> (mcg/mL)</td><td align="center">10.8 (3.30)</td><td align="center">8.2 (2.5)</td><td align="center">12.5 (1.2)</td><td align="center" class="Rrule">9.5 (3.3)</td> </tr> <tr class="Botrule"> <td align="left">t<span class="Sub">1/2</span> (h)</td><td align="center">3.5 (0.87)</td><td align="center">3.8 (1.7)</td><td align="center">2.8 (0.9)</td><td align="center" class="Rrule">4.9 (0.8)</td> </tr> <tr> <td align="left" class="Botrule Lrule" rowspan="4" valign="middle"><span class="Bold">Kidney<br/>(N=31)</span></td><td align="left">N</td><td align="center" class="Botrule" rowspan="4" valign="middle">NA</td><td align="center">2</td><td align="center">10</td><td align="center" class="Rrule">19</td> </tr> <tr> <td align="left" valign="top">AUC<span class="Sub">0-24h</span> <br/>(mcg<span class="Bold">∙</span>h/mL)</td><td align="center">67.6 (13.0)</td><td align="center">55.9 (12.1)</td><td align="center" class="Rrule">47.8 (12.4)</td> </tr> <tr> <td align="left">C<span class="Sub">max</span> (mcg/mL)</td><td align="center">10.4 (0.4)</td><td align="center">8.7 (2.1)</td><td align="center" class="Rrule">7.7 (2.1)</td> </tr> <tr class="Botrule"> <td align="left">t<span class="Sub">1/2</span> (h)</td><td align="center">4.5 (1.5)</td><td align="center">4.8 (1.0)</td><td align="center" class="Rrule">6.0 (1.3)</td> </tr> <tr> <td align="left" class="Botrule Lrule" rowspan="4" valign="middle"><span class="Bold">Liver<br/>(N=17)</span></td><td align="left">N</td><td align="center" class="Botrule" rowspan="4" valign="middle">NA</td><td align="center">9</td><td align="center">6</td><td align="center" class="Rrule">2</td> </tr> <tr> <td align="left" valign="top">AUC<span class="Sub">0-24h</span> (mcg<span class="Bold">∙</span>h/mL)</td><td align="center">69.9 (37.0)</td><td align="center">59.4 (8.1)</td><td align="center" class="Rrule">35.4 (2.8)</td> </tr> <tr> <td align="left">C<span class="Sub">max</span> (mcg/mL)</td><td align="center">11.9 (3.7)</td><td align="center">9.5 (2.3)</td><td align="center" class="Rrule">5.5 (1.1)</td> </tr> <tr class="Botrule"> <td align="left">t<span class="Sub">1/2</span> (h)</td><td align="center">2.8 (1.5)</td><td align="center">3.8 (0.7)</td><td align="center" class="Rrule">4.4 (0.2)</td> </tr> </tbody> </table></div>

Pharmacokinetics in Geriatric Patients: The pharmacokinetic characteristics of VALCYTE in elderly patients have not been established.

Drug Interactions: In vivo drug-drug interaction studies were not conducted with valganciclovir. However, because valganciclovir is rapidly and extensively converted to ganciclovir, interactions associated with ganciclovir will be expected for VALCYTE [see Drug Interactions (7)].

Table 15 and Table 16 provide a listing of established drug interaction studies with ganciclovir. Table 15 provides the effects of coadministered drug on ganciclovir plasma pharmacokinetic parameters, whereas Table 16 provides the effects of ganciclovir on plasma pharmacokinetic parameters of coadministered drug.

<div class="scrollingtable"><table width="70%"> <caption> <span>Table 15 Results of Drug Interaction Studies with Ganciclovir: Effects of Coadministered Drug on Ganciclovir Pharmacokinetic Parameters</span> </caption> <col align="left" valign="top" width="30%"/> <col align="left" valign="top" width="30%"/> <col align="center" valign="top" width="5%"/> <col align="left" valign="top" width="35%"/> <thead> <tr class="First Last"> <th align="center" class="Lrule Rrule" valign="middle">Coadministered Drug</th><th align="center" class="Rrule" valign="middle">Ganciclovir Dosage</th><th align="center" class="Rrule" valign="middle">N</th><th align="center" class="Rrule" valign="middle">Ganciclovir Pharmacokinetic (PK) Parameter</th> </tr> </thead> <tbody> <tr class="Botrule First"> <td align="left" class="Lrule Rrule">Mycophenolate mofetil (MMF) 1.5 g single dose</td><td align="left" class="Rrule">5 mg/kg IV single dose</td><td align="center" class="Rrule">12</td><td align="left" class="Rrule">No effect on ganciclovir PK parameters observed (patients with normal renal function)</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">Trimethoprim 200 mg once daily</td><td align="left" class="Rrule">1000 mg every 8 hours</td><td align="center" class="Rrule">12</td><td align="left" class="Rrule">No effect on ganciclovir PK parameters observed</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule" rowspan="2">Didanosine 200 mg every 12 hours simultaneously administered with ganciclovir</td><td align="left" class="Rrule">5 mg/kg IV twice daily </td><td align="center" class="Rrule">11</td><td align="left" class="Rrule">No effect on ganciclovir PK parameters observed</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">5 mg/kg IV once daily </td><td align="center" class="Rrule">11</td><td align="left" class="Rrule">No effect on ganciclovir PK parameters observed</td> </tr> <tr class="Last"> <td align="left" class="Lrule Rrule">Probenecid 500 mg every 6 hours</td><td align="left" class="Rrule">1000 mg every 8 hours</td><td align="center" class="Rrule">10</td><td align="left" class="Rrule">AUC ↑ 53 ± 91% <br/>(range: -14% to 299%)<br/>Ganciclovir renal clearance ↓ 22 ± 20% <br/>(range: -54% to -4%)</td> </tr> </tbody> </table></div>

<div class="scrollingtable"><table width="70%"> <caption> <span>Table 16 Results of Drug Interaction Studies with Ganciclovir: Effects of Ganciclovir on Pharmacokinetic Parameters of Coadministered Drug</span> </caption> <col align="left" valign="top" width="30%"/> <col align="left" valign="top" width="30%"/> <col align="center" valign="top" width="5%"/> <col align="left" valign="top" width="35%"/> <thead> <tr class="First Last"> <th align="center" class="Lrule Rrule" valign="middle">Coadministered Drug</th><th align="center" class="Rrule" valign="middle">Ganciclovir Dosage</th><th align="center" class="Rrule" valign="middle">N</th><th align="center" class="Rrule" valign="middle">Coadministered Drug Pharmacokinetic (PK) Parameter</th> </tr> </thead> <tbody> <tr class="Botrule First"> <td align="left" class="Lrule Rrule">Oral cyclosporine at therapeutic doses</td><td align="left" class="Rrule">5 mg/kg infused over 1 hour every 12 hours</td><td align="center" class="Rrule">93</td><td align="left" class="Rrule">In a retrospective analysis of liver allograft recipients, there was no evidence of an effect on cyclosporine whole blood concentrations.</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">Mycophenolate mofetil (MMF) 1.5 g single dose</td><td align="left" class="Rrule">5 mg/kg IV single dose</td><td align="center" class="Rrule">12</td><td align="left" class="Rrule">No PK interaction observed (patients with normal renal function)</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">Trimethoprim 200 mg once daily</td><td align="left" class="Rrule">1000 mg every 8 hours</td><td align="center" class="Rrule">12</td><td align="left" class="Rrule">No effect on trimethoprim PK parameters observed</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">Didanosine 200 mg every 12 hours</td><td align="left" class="Rrule">5 mg/kg IV twice daily</td><td align="center" class="Rrule">11</td><td align="left" class="Rrule">AUC<span class="Sub">0-12</span> ↑70 ± 40% <br/>(range: 3% to 121%)<br/>C<span class="Sub">max</span>↑49 ± 48% <br/>(range: -28% to 125%)</td> </tr> <tr class="Last"> <td align="left" class="Lrule Rrule">Didanosine 200 mg every 12 hours</td><td align="left" class="Rrule">5 mg/kg IV once daily</td><td align="center" class="Rrule">11</td><td align="left" class="Rrule">AUC<span class="Sub">0-12</span> ↑50 ± 26%<br/>(range: 22% to 110%)<br/>C<span class="Sub">max</span> ↑36 ± 36%<br/>(range: -27% to 94%)</td> </tr> </tbody> </table></div>

Mechanism of Action: Valganciclovir is an L-valyl ester (prodrug) of ganciclovir that exists as a mixture of two diastereomers. After oral administration, both diastereomers are rapidly converted to ganciclovir by intestinal and hepatic esterases. Ganciclovir is a synthetic analogue of 2'-deoxyguanosine, which inhibits replication of human CMV in cell culture and in vivo.

In CMV-infected cells, ganciclovir is initially phosphorylated to ganciclovir monophosphate by the viral protein kinase, pUL97. Further phosphorylation occurs by cellular kinases to produce ganciclovir triphosphate, which is then slowly metabolized intracellularly (half-life 18 hours). As the phosphorylation is largely dependent on the viral kinase, phosphorylation of ganciclovir occurs preferentially in virus-infected cells. The virustatic activity of ganciclovir is due to inhibition of the viral DNA polymerase, pUL54 by ganciclovir triphosphate.

Antiviral Activity: The quantitative relationship between the cell culture susceptibility of human herpes viruses to antivirals and clinical response to antiviral therapy has not been established, and virus sensitivity testing has not been standardized. Sensitivity test results, expressed as the concentration of drug required to inhibit the growth of virus in cell culture by 50% (EC50), vary greatly depending upon a number of factors including the assay used. Thus, the reported EC50 values of ganciclovir that inhibit human CMV replication in cell culture (laboratory and clinical isolates) have ranged from 0.08 to 22.94 µM (0.02 to 5.75 mcg/mL). The distribution and range in susceptibility observed in one assay evaluating 130 clinical isolates was 0 to 1 µM (35%), 1.1 to 2 µM (20%), 2.1 to 3 µM (27%), 3.1 to 4 µM (13%), 4.1 to 5 µM (5%), less than 5 µM (less than 1%). Ganciclovir inhibits mammalian cell proliferation (CC50) in cell culture at higher concentrations ranging from 40 to greater than 1,000 µM (10.21 to greater than 250 mcg/mL). Bone marrow-derived colony-forming cells are more sensitive [CC50 value = 2.7 to 12 µM (0.69 to 3.06 mcg/mL)].

Viral Resistance:

Cell culture: CMV isolates with reduced susceptibility to ganciclovir have been selected in cell culture. Growth of CMV strains in the presence of ganciclovir resulted in the selection of amino acid substitutions in the viral protein kinase pUL97 (M460I/V, L595S, G598D, and K599T) and the viral DNA polymerase pUL54 (D301N, N410K, F412V, P488R, L516R, C539R, L545S, F595I, V812L, P829S, L862F, D879G, and V946L).

In vivo: Viruses resistant to ganciclovir can arise after prolonged treatment or prophylaxis with valganciclovir by selection of substitutions in pUL97 and/or pUL54. Limited clinical data are available on the development of clinical resistance to ganciclovir and many pathways to resistance likely exist. In clinical isolates, seven canonical pUL97 substitutions, (M460V/I, H520Q, C592G, A594V, L595S, and C603W) are the most frequently reported ganciclovir resistance-associated substitutions. These and other substitutions less frequently reported in the literature, or observed in clinical trials, are listed in Table 17.

<div class="scrollingtable"><table width="95%"> <caption> <span>Table 17 Summary of Resistance-associated Amino Acid Substitutions Observed in the CMV of Patients Failing Ganciclovir Treatment or Prophylaxis</span> </caption> <col align="left" valign="middle" width="20%"/> <col align="left" valign="top" width="80%"/> <tfoot> <tr class="First Last"> <td align="left" colspan="2">Note: Many additional pathways to ganciclovir resistance likely exist</td> </tr> </tfoot> <tbody class="Headless"> <tr class="Botrule First"> <td align="left" class="Lrule Rrule">pUL97</td><td align="left" class="Rrule">F342Y, K359E/Q, L405P, A440V, M460I/V/T/L, V466G/M, C480F, C518Y, H520Q, P521L, del 590-593, A591D/V, C592F/G, A594E/G/T/V/P, L595F/S/T/W, del 595, del 595-603, E596D/G/Y, K599E/M, del 600-601, del 597-600, del 601-603, C603W/R/S/Y, C607F/S/Y, I610T, A613V</td> </tr> <tr class="Last"> <td align="left" class="Lrule Rrule">pUL54</td><td align="left" class="Rrule">E315D, N408D/K/S, F412C/L/S, D413A/E/N, L501F/I, T503I, K513E/N/R, D515E, L516W, I521T, P522A/L/S, V526L, C539G, L545S/W, Q578H/L, D588E/N, G629S, S695T, I726T/V, E756K, L773V, V781I, V787E/L, L802M, A809V, T813S, T821I, A834P, G841A/S, D879G, A972V, del 981-982, A987G</td> </tr> </tbody> </table></div>

The presence of known ganciclovir resistance-associated amino acid substitutions was evaluated in a study that extended valganciclovir CMV prophylaxis from 100 days to 200 days post-transplant in adult kidney transplant patients at high risk for CMV disease (D+/R-) [see Clinical Studies (14.1)]. Five subjects from the 100 day group and four subjects from the 200 day group meeting the resistance analysis criteria had known ganciclovir resistance-associated amino acid substitutions detected. In six subjects, the following resistance-associated amino acid substitutions were detected within pUL97: 100 day group: A440V, M460V, C592G; 200 day group: M460V, C603W. In three subjects, the following resistance-associated amino acid substitutions were detected within pUL54: 100 day group: E315D; 200 day group: E315D, P522S. Overall, the detection of known ganciclovir resistance-associated amino acid substitutions was observed more frequently in patients during prophylaxis therapy than after the completion of prophylaxis therapy (during therapy: 5/12 [42%] versus after therapy: 4/58 [7%]). The possibility of viral resistance should be considered in patients who show poor clinical response or experience persistent viral excretion during therapy.

Cross-Resistance: Cross-resistance has been reported for amino acid substitutions selected in cell culture by ganciclovir, cidofovir or foscarnet. In general, amino acid substitutions in pUL54 conferring cross-resistance to ganciclovir and cidofovir are located within the exonuclease domains and region V of the viral DNA polymerase. Whereas, amino acid substitutions conferring cross-resistance to foscarnet are diverse, but concentrate at and between regions II (codon 696–742) and III (codon 805–845). The amino acid substitutions that resulted in reduced susceptibility to ganciclovir and either cidofovir and/or foscarnet are summarized in Table 18.

Substitutions at amino acid positions pUL97 340–400 have been found to confer resistance to ganciclovir. Resistance data based on assays that do not include this region should be interpreted cautiously.

<div class="scrollingtable"><table width="95%"> <caption> <span>Table 18 Summary of pUL54 Amino Acid Substitutions with Cross-Resistance between Ganciclovir, Cidofovir, and/or Foscarnet</span> </caption> <col align="left" valign="middle" width="20%"/> <col align="left" valign="top" width="80%"/> <tbody class="Headless"> <tr class="Botrule First"> <td align="left" class="Lrule Rrule"><span class="Bold">Cross-resistant to cidofovir</span></td><td align="left" class="Rrule">D301N, N408D/K, N410K, F412C/L/S/V, D413E/N, P488R, L501I, T503I, K513E/N, L516R/W, I521T, P522S/A, V526L, C539G/R, L545S/W, Q578H, D588N, I726T/V, E756K, L733V, V787E, V812L, T813S, A834P, G841A, del 981-982, A987G</td> </tr> <tr class="Last"> <td align="left" class="Lrule Rrule"><span class="Bold">Cross-resistant to foscarnet</span></td><td align="left" class="Rrule">F412C, Q578H/L, D588N, V715A/M, E756K, L733V, V776M, V781I, V787E/L, L802M, A809V, V812L, T813S, T821I, A834P, G841A/S, del 981-982</td> </tr> </tbody> </table></div>

Long-term carcinogenicity studies have not been conducted with VALCYTE. However, upon oral administration, valganciclovir is rapidly and extensively converted to ganciclovir. Therefore, like ganciclovir, valganciclovir is a potential carcinogen.

Ganciclovir was carcinogenic in the mouse at oral doses that produced exposures approximately 0.1× and 1.4×, respectively, the mean drug exposure in humans following the recommended intravenous dose of 5 mg/kg, based on area under the plasma concentration curve (AUC) comparisons. At the higher dose, there was a significant increase in the incidence of tumors of the preputial gland in males, forestomach (nonglandular mucosa) in males and females, and reproductive tissues (ovaries, uterus, mammary gland, clitoral gland and vagina) and liver in females. At the lower dose, a slightly increased incidence of tumors was noted in the preputial and harderian glands in males, forestomach in males and females, and liver in females. Ganciclovir should be considered a potential carcinogen in humans.

Valganciclovir increases mutations in mouse lymphoma cells. In the mouse micronucleus assay, valganciclovir was clastogenic. Valganciclovir was not mutagenic in the Ames Salmonella assay. Ganciclovir increased mutations in mouse lymphoma cells and DNA damage in human lymphocytes in vitro. In the mouse micronucleus assay, ganciclovir was clastogenic. Ganciclovir was not mutagenic in the Ames Salmonella assay.

Valganciclovir is converted to ganciclovir and therefore is expected to have similar reproductive toxicity effects as ganciclovir [see Warnings and Precautions (5.3)]. Ganciclovir caused decreased mating behavior, decreased fertility, and an increased incidence of embryolethality in female mice following intravenous doses that produced an exposure approximately 1.7× the mean drug exposure in humans following the dose of 5 mg per kg, based on AUC comparisons. Ganciclovir caused decreased fertility in male mice and hypospermatogenesis in mice and dogs following daily oral or intravenous administration. Systemic drug exposure (AUC) at the lowest dose showing toxicity in each species ranged from 0.03 to 0.1× the AUC of the recommended human intravenous dose. Valganciclovir caused similar effects on spermatogenesis in mice, rats, and dogs. These effects were reversible at lower doses but irreversible at higher doses. It is considered likely that ganciclovir (and valganciclovir) could cause temporary or permanent inhibition of human spermatogenesis.

Induction Therapy of CMV Retinitis: In one randomized open-label controlled study, 160 patients with AIDS and newly diagnosed CMV retinitis were randomized to receive treatment with either VALCYTE tablets (900 mg twice daily for 21 days, then 900 mg once daily for 7 days) or with intravenous ganciclovir solution (5 mg per kg twice daily for 21 days, then 5 mg per kg once daily for 7 days). Study participants were: male (91%), White (53%), Hispanic (31%), and Black (11%). The median age was 39 years, the median baseline HIV-1 RNA was 4.9 log10, and the median CD4 cell count was 23 cells/mm3. A determination of CMV retinitis progression by the masked review of retinal photographs taken at baseline and Week 4 was the primary outcome measurement of the 3-week induction therapy. Table 19 provides the outcomes at 4 weeks.

<div class="scrollingtable"><table width="60%"> <caption> <span>Table 19 Week 4 Masked Review of Retinal Photographs in CMV Retinitis Study </span> </caption> <col align="left" valign="top" width="50%"/> <col align="center" valign="top" width="25%"/> <col align="center" valign="top" width="25%"/> <thead> <tr class="First Last"> <th align="left" class="Lrule Rrule"></th><th align="center" class="Rrule">Intravenous Ganciclovir</th><th align="center" class="Rrule">VALCYTE Tablets</th> </tr> </thead> <tbody> <tr class="Botrule First"> <td align="left" class="Lrule Rrule">Determination of CMV retinitis progression at Week 4</td><td align="center" class="Rrule">N=80</td><td align="center" class="Rrule">N=80</td> </tr> <tr> <td align="left" class="Lrule Rrule">Progressor</td><td align="center" class="Rrule">7</td><td align="center" class="Rrule">7</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">Non-progressor</td><td align="center" class="Rrule">63</td><td align="center" class="Rrule">64</td> </tr> <tr> <td align="left" class="Lrule Rrule">Death</td><td align="center" class="Rrule">2</td><td align="center" class="Rrule">1</td> </tr> <tr> <td align="left" class="Lrule Rrule">Discontinuations due to Adverse Events</td><td align="center" class="Rrule">1</td><td align="center" class="Rrule">2</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">Failed to return</td><td align="center" class="Rrule">1</td><td align="center" class="Rrule">1</td> </tr> <tr class="Last"> <td align="left" class="Lrule Rrule">CMV not confirmed at baseline or no interpretable baseline photos</td><td align="center" class="Rrule">6</td><td align="center" class="Rrule">5</td> </tr> </tbody> </table></div>

Maintenance Therapy of CMV Retinitis: No comparative clinical data are available on the efficacy of VALCYTE tablets for the maintenance therapy of CMV retinitis because all patients in the CMV retinitis study received open-label VALCYTE tablets after Week 4. However, the AUC for ganciclovir is similar following administration of 900 mg VALCYTE tablets once daily and 5 mg per kg intravenous ganciclovir once daily. Although the ganciclovir Cmax is lower following VALCYTE tablets administration compared to intravenous ganciclovir, it is higher than the Cmax obtained following oral ganciclovir administration. Therefore, use of VALCYTE tablets as maintenance therapy is supported by a plasma concentration-time profile similar to that of two approved products for maintenance therapy of CMV retinitis.

Prevention of CMV Disease in Heart, Kidney, Kidney-Pancreas, or Liver Transplantation: A double blind, double-dummy active comparator study was conducted in 372 heart, liver, kidney, or kidney-pancreas transplant patients at high risk for CMV disease (D+/R-). Patients were randomized (2 VALCYTE: 1 oral ganciclovir) to receive either VALCYTE tablets (900 mg once daily) or oral ganciclovir (1000 mg three times a day) starting within 10 days of transplantation until Day 100 post-transplant. The proportion of patients who developed CMV disease, including CMV syndrome and/or tissue-invasive disease during the first 6 months post-transplant was similar between the VALCYTE tablets arm (12.1%, N=239) and the oral ganciclovir arm (15.2%, N=125). However, in liver transplant patients, the incidence of tissue-invasive CMV disease was significantly higher in the VALCYTE group compared with the ganciclovir group. These results are summarized in Table 20.

Mortality at six months was 3.7% (9/244) in the VALCYTE group and 1.6% (2/126) in the oral ganciclovir group.

<div class="scrollingtable"><table width="75%"> <caption> <span>Table 20 Percentage of Patients with CMV Disease, Tissue-Invasive CMV Disease or CMV Syndrome by Organ Type: Endpoint Committee, 6 Month ITT Population</span> </caption> <col align="left" valign="top" width="20%"/> <col align="center" valign="top" width="13%"/> <col align="center" valign="top" width="14%"/> <col align="center" valign="top" width="13%"/> <col align="center" valign="top" width="14%"/> <col align="center" valign="top" width="13%"/> <col align="center" valign="top" width="13%"/> <thead> <tr class="Botrule First"> <th align="left" class="Lrule Rrule"></th><th align="center" class="Rrule" colspan="2">CMV Disease<a class="Sup" href="#footnote-6" name="footnote-reference-6">*</a></th><th align="center" class="Rrule" colspan="2">Tissue-Invasive CMV Disease</th><th align="center" class="Rrule" colspan="2">CMV Syndrome<a class="Sup" href="#footnote-7" name="footnote-reference-7">†</a></th> </tr> <tr class="Last"> <th align="left" class="Lrule Rrule">Organ</th><th align="center" class="Rrule">VGCV<br/>(N=239)</th><th align="center" class="Rrule">GCV<br/>(N=125)</th><th align="center" class="Rrule">VGCV<br/>(N=239)</th><th align="center" class="Rrule">GCV<br/>(N=125)</th><th align="center" class="Rrule">VGCV<br/>(N=239)</th><th align="center" class="Rrule">GCV<br/>(N=125)</th> </tr> </thead> <tfoot> <tr class="First Last"> <td align="left" colspan="7">GCV = oral ganciclovir; VGCV = valganciclovir</td> </tr> <tr> <td align="left" colspan="7"> <dl class="Footnote"> <dt> <a href="#footnote-reference-6" name="footnote-6">*</a> </dt> <dd>Number of patients with CMV disease = Number of patients with tissue-invasive CMV disease or CMV syndrome</dd> <dt> <a href="#footnote-reference-7" name="footnote-7">†</a> </dt> <dd>CMV syndrome was defined as evidence of CMV viremia accompanied with fever greater than or equal to 38°C on two or more occasions separated by at least 24 hours within a 7-day period and one or more of the following: malaise, leukopenia, atypical lymphocytosis, thrombocytopenia, and elevation of hepatic transaminases</dd> </dl> </td> </tr> </tfoot> <tbody> <tr class="Botrule First"> <td align="left" class="Lrule Rrule">Liver <br/>(n=177)</td><td align="center" class="Rrule">19%<br/>(22/118)</td><td align="center" class="Rrule">12%<br/>(7/59)</td><td align="center" class="Rrule">14%<br/>(16/118)</td><td align="center" class="Rrule">3%<br/>(2/59)</td><td align="center" class="Rrule">5%<br/>(6/118)</td><td align="center" class="Rrule">8%<br/>(5/59)</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">Kidney <br/>(n=120)</td><td align="center" class="Rrule">6%<br/>(5/81)</td><td align="center" class="Rrule">23%<br/>(9/39)</td><td align="center" class="Rrule">1%<br/>(1/81)</td><td align="center" class="Rrule">5%<br/>(2/39)</td><td align="center" class="Rrule">5%<br/>(4/81)</td><td align="center" class="Rrule">18%<br/>(7/39)</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule">Heart<br/>(n=56)</td><td align="center" class="Rrule">6%<br/>(2/35)</td><td align="center" class="Rrule">10%<br/>(2/21)</td><td align="center" class="Rrule">0%<br/>(0/35)</td><td align="center" class="Rrule">5%<br/>(1/21)</td><td align="center" class="Rrule">6%<br/>(2/35)</td><td align="center" class="Rrule">5%<br/>(1/21)</td> </tr> <tr class="Last"> <td align="left" class="Lrule Rrule">Kidney/Pancreas<br/>(n=11)</td><td align="center" class="Rrule">0%<br/>(0/5)</td><td align="center" class="Rrule">17%<br/>(1/6)</td><td align="center" class="Rrule">0%<br/>(0/5)</td><td align="center" class="Rrule">17%<br/>(1/6)</td><td align="center" class="Rrule">0%<br/>(0/5)</td><td align="center" class="Rrule">0%<br/>(0/6)</td> </tr> </tbody> </table></div>

Prevention of CMV Disease in Kidney Transplantation: A double-blind, placebo-controlled study was conducted in 326 kidney transplant patients at high risk for CMV disease (D+/R-) to assess the efficacy and safety of extending VALCYTE CMV prophylaxis from 100 to 200 days post-transplant. Patients were randomized (1:1) to receive VALCYTE tablets (900 mg once daily) within 10 days of transplantation either until Day 200 post-transplant or until Day 100 post-transplant followed by 100 days of placebo. Extending CMV prophylaxis with VALCYTE until Day 200 post-transplant demonstrated superiority in preventing CMV disease within the first 12 months post-transplant in high risk kidney transplant patients compared to the 100 day dosing regimen (primary endpoint). These results are summarized in Table 21.

<div class="scrollingtable"><table width="75%"> <caption> <span>Table 21 Percentage of Kidney Transplant Patients with CMV Disease, Tissue-Invasive CMV Disease or CMV Syndrome, 12 Month ITT Population</span> </caption> <col align="left" valign="top" width="20%"/> <col align="center" valign="top" width="13%"/> <col align="center" valign="top" width="14%"/> <col align="center" valign="top" width="13%"/> <col align="center" valign="top" width="14%"/> <col align="center" valign="top" width="13%"/> <col align="center" valign="top" width="13%"/> <thead> <tr class="Botrule First"> <th align="left" class="Lrule Rrule"></th><th align="center" class="Rrule" colspan="2">CMV Disease<a class="Sup" href="#footnote-8" name="footnote-reference-8">*</a></th><th align="center" class="Rrule" colspan="2">Tissue-Invasive CMV Disease</th><th align="center" class="Rrule" colspan="2">CMV Syndrome<a class="Sup" href="#footnote-9" name="footnote-reference-9">†</a></th> </tr> <tr class="Last"> <th align="left" class="Lrule Rrule"></th><th align="center" class="Rrule">100 Days<br/>VGCV<br/>(N=163) </th><th align="center" class="Rrule">200 Days<br/>VGCV<br/>(N=155) </th><th align="center" class="Rrule">100 Days<br/>VGCV<br/>(N=163)</th><th align="center" class="Rrule">200 Days<br/>VGCV<br/>(N=155)</th><th align="center" class="Rrule">100 Days<br/>VGCV<br/>(N=163)</th><th align="center" class="Rrule">200 Days<br/>VGCV<br/>(N=155)</th> </tr> </thead> <tfoot> <tr class="First Last"> <td align="left" colspan="7">VGCV = valganciclovir.</td> </tr> <tr> <td align="left" colspan="7"> <dl class="Footnote"> <dt> <a href="#footnote-reference-8" name="footnote-8">*</a> </dt> <dd>Number of patients with CMV disease = Number of patients with tissue-invasive CMV disease or CMV syndrome</dd> <dt> <a href="#footnote-reference-9" name="footnote-9">†</a> </dt> <dd>CMV syndrome was defined as evidence of CMV viremia accompanied with at least one of the following: fever (greater than or equal to 38°C), severe malaise, leukopenia, atypical lymphocytosis, thrombocytopenia, and elevation of hepatic transaminases </dd> <dt> <a href="#footnote-reference-10" name="footnote-10">‡</a> </dt> <dd>Two patients in the 100 day group had both tissue-invasive CMV disease and CMV syndrome; however, these patients are counted as having only tissue-invasive CMV disease.</dd> </dl> </td> </tr> </tfoot> <tbody> <tr class="First Last"> <td align="left" class="Lrule Rrule">Cases</td><td align="center" class="Rrule">36.8%<br/>(60/163)</td><td align="center" class="Rrule">16.8%<br/>(26/155)</td><td align="center" class="Rrule">1.8%<br/>(3/163)<a class="Sup" href="#footnote-10" name="footnote-reference-10">‡</a></td><td align="center" class="Rrule">0.6%<br/>(1/155)</td><td align="center" class="Rrule">35. 0%<br/>(57/163)</td><td align="center" class="Rrule">16.1%<br/>(25/155)</td> </tr> </tbody> </table></div>

The percentage of kidney transplant patients with CMV disease at 24 months post-transplant was 38.7% (63/163) for the 100 day dosing regimen and 21.3% (33/155) for the 200 day dosing regimen.

Prevention of CMV in Pediatric Heart, Kidney, or Liver Transplantation: Sixty-three children, 4 months to 16 years of age, who had a solid organ transplant (kidney 33, liver 17, heart 12, and kidney/liver 1) and were at risk for developing CMV disease, were enrolled in an open-label, safety, and pharmacokinetic study of oral VALCYTE (VALCYTE for oral solution or tablets). Patients received VALCYTE once daily within 10 days after transplant until a maximum of 100 days post-transplant. The daily doses of VALCYTE were calculated at each study visit based on body surface area and a modified creatinine clearance [see Dosage and Administration (2.3)].

The pharmacokinetics of ganciclovir were similar across organ transplant types and age ranges. The mean daily ganciclovir exposures in pediatric patients were somewhat increased relative to those observed in adult solid organ transplant patients receiving VALCYTE 900 mg once daily, but were within the range considered safe and effective in adults [see Clinical Pharmacology (12.3)]. No case of CMV syndrome or tissue-invasive CMV disease was reported within the first six months post-transplantation.

Prevention of CMV in Pediatric Kidney Transplantation: Fifty-seven children, 1 to 16 years of age, who had a renal transplant and were at risk for developing CMV disease, were enrolled in an open-label tolerability study of oral VALCYTE (VALCYTE for oral solution or tablets). Patients received VALCYTE once daily within 10 days after transplant until a maximum of 200 days post-transplant. The daily doses of VALCYTE were calculated at each study visit based on body surface area and a modified creatinine clearance [see Dosage and Administration (2.3)]. No case of CMV syndrome or tissue-invasive CMV disease was reported within the first 12 months post-transplantation.

1. Brion LP, Fleischman AR, McCarton C, Schwartz GJ. A simple estimate of glomerular filtration rate in low birth weight infants during the first year of life: noninvasive assessment of body composition and growth. J of Ped 1986: 109(4): 698-707.

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2. NIOSH [2014]. NIOSH list of antineoplastic and other hazardous drugs in healthcare settings. By Connor TH, MacKenzie BA, DeBord DG, Trout DB, O'Callaghan JP, Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2014-138 (Supersedes 2012-150).

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VALCYTE tablets: Supplied as 450 mg, pink, convex oval tablets with "VGC" on one side and "450" on the other side. Each tablet contains 450 mg valganciclovir. VALCYTE is supplied in bottles of 60 tablets (NDC 61269-480-60).

Store VALCYTE tablets at 20°C to 25°C (68°F to 77°F); excursions are permitted to 15°C to 30°C (59°F to 86°F) [see USP controlled room temperature].

VALCYTE for oral solution: Supplied as a white to slightly yellow powder blend for constitution, forming a colorless to brownish-yellow tutti-frutti flavored solution. Available in glass bottles containing approximately 100 mL of solution after constitution. Each bottle can deliver up to a total of 88 mL of solution. Each bottle is supplied with a bottle adapter and 2 oral dispensers (NDC 61269-485-10).

Prior to dispensing to the patient, VALCYTE for oral solution must be prepared by the pharmacist [see Dosage and Administration (2.4)].

Store dry powder at 20°C to 25°C (68°F to 77°F); excursions are permitted to 15°C to 30°C (59°F to 86°F) [see USP controlled room temperature].

Store constituted solution under refrigeration at 2°C to 8°C (36°F to 46°F) for no longer than 49 days. Do not freeze.

Serious Adverse Reactions

Inform patients that VALCYTE may cause granulocytopenia (neutropenia), anemia, thrombocytopenia and elevated creatinine levels and that dose modification or discontinuation of dosing may be required. Complete blood counts, platelet counts, and creatinine levels should be monitored frequently during treatment [see Warnings and Precautions (5.1)].

Pregnancy and Contraception

Inform females of reproductive potential that VALCYTE causes birth defects in animals. Advise them to use effective contraception during and for at least 30 days following treatment with VALCYTE. Similarly, advise males to use condoms during and for at least 90 days following treatment with VALCYTE [see Use in Specific Populations (8.1, 8.3)].

Carcinogenicity

Advise patients that VALCYTE is considered a potential carcinogen [see Nonclinical Toxicity (13.1)].

Lactation

Advise mothers not to breast-feed if they are receiving VALCYTE because of the potential for hematologic toxicity and cancer in nursing infants, and because HIV can be passed to the baby in breast milk [see Use in Specific Populations (8.2)].

Infertility

Advise patients that VALCYTE may cause temporary or permanent female and male infertility [see Warnings and Precautions (5.3), Use in Specific Populations (8.3)].

Impairment of Cognitive Ability

Inform patients that tasks requiring alertness may be affected including the patient's ability to drive and operate machinery as seizures, dizziness, and/or confusion have been reported with the use of VALCYTE [see Adverse Reactions (6.1)].

Use in Patients with CMV Retinitis

Inform patients that VALCYTE is not a cure for CMV retinitis, and they may continue to experience progression of retinitis during or following treatment. Advise patients to have ophthalmologic follow-up examinations at a minimum of every 4 to 6 weeks while being treated with VALCYTE. Some patients will require more frequent follow-up.

Administration

Inform adult patients that they should use VALCYTE tablets, not VALCYTE for oral solution [see Dosage and Administration (2.1)].

Inform patients to take VALCYTE with food to maximize bioavailability.

VALCYTE is a registered trademark of CHEPLAPHARM Arzneimittel GmbH.

{ "type": "p", "children": [], "text": " VALCYTE is a registered trademark of CHEPLAPHARM Arzneimittel GmbH. " }

Distributed by: H2-Pharma, LLC Montgomery, AL 36117, USA

{ "type": "p", "children": [], "text": "Distributed by:\nH2-Pharma, LLC\nMontgomery, AL 36117, USA" }

Licensed by: CHEPLAPHARM Arzneimittel GmbH Ziegelhof 24, 17489 Greifswald, Germany

{ "type": "p", "children": [], "text": "Licensed by:\nCHEPLAPHARM Arzneimittel GmbH\nZiegelhof 24, 17489 Greifswald, Germany" }

© 2023 CHEPLAPHARM Arzneimittel GmbH. All rights reserved.

{ "type": "p", "children": [], "text": "© 2023 CHEPLAPHARM Arzneimittel GmbH. All rights reserved." }

For more information call 1-866-946-3684. © 2023 CHEPLAPHARM Arzneimittel GmbH. All rights reserved.

{ "type": "p", "children": [], "text": "For more information call 1-866-946-3684. © 2023 CHEPLAPHARM Arzneimittel GmbH. All rights reserved. " }

<div class="scrollingtable"><table width="100%"> <colgroup> <col align="left" valign="top" width="50%"/> <col align="left" valign="top" width="50%"/> </colgroup> <thead> <tr class="First"> <th align="center" class="Lrule Rrule" colspan="2">PATIENT INFORMATION</th> </tr> <tr class="Last"> <th align="center" class="Lrule">VALCYTE (Val-site) <br/>(valganciclovir)<br/>tablets</th><th align="center" class="Rrule">VALCYTE (Val-site)<br/>(valganciclovir)<br/>for oral solution</th> </tr> </thead> <tbody> <tr class="Botrule First First"> <td align="left" class="Lrule Rrule" colspan="2"> <p class="First"> <a name="Important"></a><span class="Bold">What is the most important information I should know about VALCYTE?<br/>VALCYTE can cause serious side effects, including: </span> </p> <ul> <li> <span class="Bold">Blood and bone marrow problems.</span> VALCYTE can affect the bone marrow lowering the amount of your white blood cells, red blood cells, and platelets and may cause serious and life-threatening problems.</li> <li> <span class="Bold">Kidney failure.</span> Kidney failure may happen in people who are elderly, people who take VALCYTE with certain other medicines, or people who are not adequately hydrated.</li> <li> <span class="Bold">Fertility problems.</span> VALCYTE may lower sperm count in males and cause fertility problems. VALCYTE may also cause fertility problems in women. Talk to your healthcare provider if this is a concern for you.</li> </ul> <ul class="Circle"> <li> <span class="Bold">Birth defects.</span> VALCYTE causes birth defects in animals. It is not known if VALCYTE causes birth defects in people. If you are a female who can become pregnant, you should use effective birth control during treatment with VALCYTE and for at least 30 days after treatment. <span class="Bold">If you are pregnant, talk to your healthcare provider before starting treatment with VALCYTE. If you are a female who can become pregnant, you should have a pregnancy test done before starting VALCYTE.</span> <ul> <li>Tell your healthcare provider right away if you become pregnant during treatment with VALCYTE.</li> <li>Males should use condoms during treatment with VALCYTE, and for at least 90 days after treatment, if their female sexual partner can become pregnant. Talk to your healthcare provider if you have questions about birth control.</li> </ul> </li> </ul> <ul> <li> <span class="Bold">Cancer.</span> VALCYTE causes cancer in animals and may potentially cause cancer in people.</li> </ul> <span class="Bold">Your healthcare provider will do regular blood tests during treatment with VALCYTE to check you for side effects. Your healthcare provider may change your dose or stop treatment with VALCYTE if you have serious side effects. </span></td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule" colspan="2"><span class="Bold">What is VALCYTE?</span> <br/>VALCYTE is a prescription antiviral medicine.<br/> <span class="Bold">In adults, VALCYTE tablets are used:</span> <ul> <li>to treat cytomegalovirus (CMV) retinitis in people who have acquired immunodeficiency syndrome (AIDS). When CMV virus infects the eyes, it is called CMV retinitis. If CMV retinitis is not treated, it can cause blindness.</li> <li>to prevent CMV disease in people who have received a <span class="Bold">kidney, heart, or kidney-pancreas</span> transplant and who have a high risk for getting CMV disease.</li> </ul> <span class="Bold">VALCYTE does not cure CMV retinitis.</span> You may still get retinitis or worsening of retinitis during or after treatment with VALCYTE. It is important to stay under a healthcare provider's care and have your eyes checked at least every 4 to 6 weeks during treatment with VALCYTE.<br/> <span class="Bold">In children, VALCYTE tablets or oral solution are used:</span> <ul> <li>to prevent CMV disease in children 4 months to 16 years of age who have received a <span class="Bold">kidney</span> transplant and have a high risk for getting CMV disease.</li> <li>to prevent CMV disease in children 1 month to 16 years of age who have received a <span class="Bold">heart</span> transplant and have a high risk for getting CMV disease.</li> </ul>It is not known if VALCTYE is safe and effective in children for prevention of CMV disease in liver transplant, in kidney transplant in infants less than 4 months of age, in heart transplant in infants less than 1 month of age, in children with AIDS who have CMV retinitis, and in infants with congenital CMV infection.</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule" colspan="2"><span class="Bold">Do not take VALCYTE if you have had a serious allergic reaction to valganciclovir, ganciclovir or any of the ingredients of VALCYTE.</span> See the end of this leaflet for a list of the ingredients in VALCYTE.</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule" colspan="2"><span class="Bold">Before you take VALCYTE, tell your healthcare provider about all of your medical conditions, including if you:</span> <ul> <li>have low blood cell counts</li> <li>have kidney problems</li> <li>are receiving hemodialysis</li> <li>are receiving radiation treatment</li> <li>are pregnant or plan to become pregnant. <span class="Bold">See "<a href="#Important">What is the most important information I should know about VALCYTE?</a>"</span> </li> <li>are breastfeeding or plan to breastfeed. It is not known if VALCYTE passes into your breast milk. You should not breastfeed if you take VALCYTE.<ul> <li>You should not breastfeed if you have Human Immunodeficiency Virus (HIV-1) because of the risk of passing HIV-1 to your baby.</li> <li>Talk to your healthcare provider about the best way to feed your baby.</li> </ul> </li> </ul> <span class="Bold">Tell your healthcare provider about all the medicines you take,</span>including prescription and over-the-counter medicines, vitamins and herbal supplements. VALCYTE and other medicines may affect each other and cause serious side effects. Keep a list of your medicines to show your healthcare provider and pharmacist.<ul> <li>You can ask your healthcare provider or pharmacist for a list of medicines that interact with VALCYTE.</li> <li> <span class="Bold">Do not start taking a new medicine without telling your healthcare provider.</span> Your healthcare provider can tell you if it is safe to take VALCYTE with other medicines.</li> </ul> </td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule" colspan="2"><span class="Bold">How should I take VALCYTE?</span> <ul> <li>Take VALCYTE exactly as your healthcare provider tells you. Your dose of VALCYTE will depend on your medical condition.</li> <li>Adults should only take VALCYTE tablets. Children may take either VALCYTE tablets or oral solution.</li> <li>Take VALCYTE with food.</li> <li>Do not break or crush VALCYTE tablets. Avoid contact with your skin or eyes. If you come in contact with the contents of the tablet or oral solution, wash your skin well with soap and water or rinse your eyes well with plain water.</li> <li>If your child is prescribed VALCYTE for oral solution, your pharmacist will give you oral dosing dispensers to measure your child's dose of VALCYTE for oral solution. To be sure you receive the prescribed dose, it is important to use the dispenser provided to you. See the detailed <a href="#Instructions">Instructions for Use</a> below for information about how to take VALCYTE for oral solution. Ask your pharmacist if you have any questions. If you lose or damage your oral dispensers and cannot use them, contact your pharmacist.</li> <li>If you take too much VALCYTE, call your healthcare provider or go to the nearest hospital emergency room right away.</li> </ul> </td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule" colspan="2"><span class="Bold">What should I avoid during treatment with VALCYTE?</span> <br/>VALCYTE can cause seizures, dizziness, and confusion. You should not drive a car or operate machinery until you know how VALCYTE affects you.</td> </tr> <tr> <td align="left" class="Lrule Rrule" colspan="2"><span class="Bold">What are the possible side effects of VALCYTE?</span> <br/>VALCYTE may cause serious side effects, including:<br/>See "<span class="Bold"><a href="#Important">What is the most important information I should know about VALCYTE?</a></span>"<br/> <span class="Bold">The most common side effects of VALCYTE in adults include: </span></td> </tr> <tr> <td align="left" class="Lrule"> <ul> <li>diarrhea</li> <li>fever</li> <li>fatigue</li> <li>nausea</li> <li>shaky movements (tremors)</li> </ul> </td><td align="left" class="Rrule"> <ul> <li>low white cell, red cell and platelet cell counts in blood tests</li> <li>headache</li> <li>sleeplessness</li> <li>urinary tract infection</li> <li>vomiting</li> </ul> </td> </tr> <tr> <td align="left" class="Lrule Rrule" colspan="2"><span class="Bold">The most common side effects of VALCYTE in children include:</span></td> </tr> <tr> <td align="left" class="Lrule"> <ul> <li>diarrhea</li> <li>fever</li> <li>upper respiratory tract infection</li> <li>urinary tract infection</li> </ul> </td><td align="left" class="Rrule"> <ul> <li>vomiting</li> <li>low white blood cell counts in blood tests</li> <li>headache</li> </ul> </td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule" colspan="2">These are not all the possible side effects of VALCYTE. <br/>Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.</td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule" colspan="2"><span class="Bold">How should I store VALCYTE?</span> <ul> <li>Store VALCYTE tablets at room temperature between 68°F to 77°F (20°C to 25°C).</li> <li>Store VALCYTE for oral solution in the refrigerator between 36°F to 46°F (2°C to 8°C), for no longer than 49 days.</li> <li>Do not freeze.</li> <li>Do not keep VALCYTE that is out of date or that you no longer need.</li> </ul> <span class="Bold">Keep VALCYTE and all medicines out of the reach of children.</span></td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule" colspan="2"><span class="Bold">General information about the safe and effective use of VALCYTE.</span> <br/>Medicines are sometimes prescribed for purposes other than those listed in a Patient Information leaflet. Do not use VALCYTE for a condition for which it was not prescribed. Do not give VALCYTE to other people, even if they have the same symptoms you have. It may harm them. You can ask your pharmacist or healthcare provider for information about VALCYTE that is written for health professionals.</td> </tr> <tr class="Last"> <td align="left" class="Lrule Rrule" colspan="2"><span class="Bold">What are the ingredients in VALCYTE? <br/>Active ingredient:</span> valganciclovir hydrochloride<br/> <span class="Bold">Inactive ingredients for tablets:</span> microcrystalline cellulose, povidone K-30, crospovidone, and stearic acid. The film-coating applied to the tablets contains Opadry Pink<span class="Sup">®</span>.<br/> <span class="Bold">Inactive ingredients for oral solution:</span> sodium benzoate, fumaric acid, povidone K-30, sodium saccharin, mannitol and tutti-frutti flavoring.</td> </tr> </tbody> </table></div>

{ "type": "table", "children": [], "text": "<div class=\"scrollingtable\"><table width=\"100%\">\n<colgroup>\n<col align=\"left\" valign=\"top\" width=\"50%\"/>\n<col align=\"left\" valign=\"top\" width=\"50%\"/>\n</colgroup>\n<thead>\n<tr class=\"First\">\n<th align=\"center\" class=\"Lrule Rrule\" colspan=\"2\">PATIENT INFORMATION</th>\n</tr>\n<tr class=\"Last\">\n<th align=\"center\" class=\"Lrule\">VALCYTE (Val-site) <br/>(valganciclovir)<br/>tablets</th><th align=\"center\" class=\"Rrule\">VALCYTE (Val-site)<br/>(valganciclovir)<br/>for oral solution</th>\n</tr>\n</thead>\n<tbody>\n<tr class=\"Botrule First First\">\n<td align=\"left\" class=\"Lrule Rrule\" colspan=\"2\">\n<p class=\"First\">\n<a name=\"Important\"></a><span class=\"Bold\">What is the most important information I should know about VALCYTE?<br/>VALCYTE can cause serious side effects, including: </span>\n</p>\n<ul>\n<li>\n<span class=\"Bold\">Blood and bone marrow problems.</span> VALCYTE can affect the bone marrow lowering the amount of your white blood cells, red blood cells, and platelets and may cause serious and life-threatening problems.</li>\n<li>\n<span class=\"Bold\">Kidney failure.</span> Kidney failure may happen in people who are elderly, people who take VALCYTE with certain other medicines, or people who are not adequately hydrated.</li>\n<li>\n<span class=\"Bold\">Fertility problems.</span> VALCYTE may lower sperm count in males and cause fertility problems. VALCYTE may also cause fertility problems in women. Talk to your healthcare provider if this is a concern for you.</li>\n</ul>\n<ul class=\"Circle\">\n<li>\n<span class=\"Bold\">Birth defects.</span> VALCYTE causes birth defects in animals. It is not known if VALCYTE causes birth defects in people. If you are a female who can become pregnant, you should use effective birth control during treatment with VALCYTE and for at least 30 days after treatment. <span class=\"Bold\">If you are pregnant, talk to your healthcare provider before starting treatment with VALCYTE. If you are a female who can become pregnant, you should have a pregnancy test done before starting VALCYTE.</span>\n<ul>\n<li>Tell your healthcare provider right away if you become pregnant during treatment with VALCYTE.</li>\n<li>Males should use condoms during treatment with VALCYTE, and for at least 90 days after treatment, if their female sexual partner can become pregnant. Talk to your healthcare provider if you have questions about birth control.</li>\n</ul>\n</li>\n</ul>\n<ul>\n<li>\n<span class=\"Bold\">Cancer.</span> VALCYTE causes cancer in animals and may potentially cause cancer in people.</li>\n</ul>\n<span class=\"Bold\">Your healthcare provider will do regular blood tests during treatment with VALCYTE to check you for side effects. Your healthcare provider may change your dose or stop treatment with VALCYTE if you have serious side effects. </span></td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"left\" class=\"Lrule Rrule\" colspan=\"2\"><span class=\"Bold\">What is VALCYTE?</span>\n<br/>VALCYTE is a prescription antiviral medicine.<br/>\n<span class=\"Bold\">In adults, VALCYTE tablets are used:</span>\n<ul>\n<li>to treat cytomegalovirus (CMV) retinitis in people who have acquired immunodeficiency syndrome (AIDS). When CMV virus infects the eyes, it is called CMV retinitis. If CMV retinitis is not treated, it can cause blindness.</li>\n<li>to prevent CMV disease in people who have received a <span class=\"Bold\">kidney, heart, or kidney-pancreas</span> transplant and who have a high risk for getting CMV disease.</li>\n</ul>\n<span class=\"Bold\">VALCYTE does not cure CMV retinitis.</span> You may still get retinitis or worsening of retinitis during or after treatment with VALCYTE. It is important to stay under a healthcare provider's care and have your eyes checked at least every 4 to 6 weeks during treatment with VALCYTE.<br/>\n<span class=\"Bold\">In children, VALCYTE tablets or oral solution are used:</span>\n<ul>\n<li>to prevent CMV disease in children 4 months to 16 years of age who have received a <span class=\"Bold\">kidney</span> transplant and have a high risk for getting CMV disease.</li>\n<li>to prevent CMV disease in children 1 month to 16 years of age who have received a <span class=\"Bold\">heart</span> transplant and have a high risk for getting CMV disease.</li>\n</ul>It is not known if VALCTYE is safe and effective in children for prevention of CMV disease in liver transplant, in kidney transplant in infants less than 4 months of age, in heart transplant in infants less than 1 month of age, in children with AIDS who have CMV retinitis, and in infants with congenital CMV infection.</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"left\" class=\"Lrule Rrule\" colspan=\"2\"><span class=\"Bold\">Do not take VALCYTE if you have had a serious allergic reaction to valganciclovir, ganciclovir or any of the ingredients of VALCYTE.</span> See the end of this leaflet for a list of the ingredients in VALCYTE.</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"left\" class=\"Lrule Rrule\" colspan=\"2\"><span class=\"Bold\">Before you take VALCYTE, tell your healthcare provider about all of your medical conditions, including if you:</span>\n<ul>\n<li>have low blood cell counts</li>\n<li>have kidney problems</li>\n<li>are receiving hemodialysis</li>\n<li>are receiving radiation treatment</li>\n<li>are pregnant or plan to become pregnant. <span class=\"Bold\">See \"<a href=\"#Important\">What is the most important information I should know about VALCYTE?</a>\"</span>\n</li>\n<li>are breastfeeding or plan to breastfeed. It is not known if VALCYTE passes into your breast milk. You should not breastfeed if you take VALCYTE.<ul>\n<li>You should not breastfeed if you have Human Immunodeficiency Virus (HIV-1) because of the risk of passing HIV-1 to your baby.</li>\n<li>Talk to your healthcare provider about the best way to feed your baby.</li>\n</ul>\n</li>\n</ul>\n<span class=\"Bold\">Tell your healthcare provider about all the medicines you take,</span>including prescription and over-the-counter medicines, vitamins and herbal supplements. VALCYTE and other medicines may affect each other and cause serious side effects. Keep a list of your medicines to show your healthcare provider and pharmacist.<ul>\n<li>You can ask your healthcare provider or pharmacist for a list of medicines that interact with VALCYTE.</li>\n<li>\n<span class=\"Bold\">Do not start taking a new medicine without telling your healthcare provider.</span> Your healthcare provider can tell you if it is safe to take VALCYTE with other medicines.</li>\n</ul>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"left\" class=\"Lrule Rrule\" colspan=\"2\"><span class=\"Bold\">How should I take VALCYTE?</span>\n<ul>\n<li>Take VALCYTE exactly as your healthcare provider tells you. Your dose of VALCYTE will depend on your medical condition.</li>\n<li>Adults should only take VALCYTE tablets. Children may take either VALCYTE tablets or oral solution.</li>\n<li>Take VALCYTE with food.</li>\n<li>Do not break or crush VALCYTE tablets. Avoid contact with your skin or eyes. If you come in contact with the contents of the tablet or oral solution, wash your skin well with soap and water or rinse your eyes well with plain water.</li>\n<li>If your child is prescribed VALCYTE for oral solution, your pharmacist will give you oral dosing dispensers to measure your child's dose of VALCYTE for oral solution. To be sure you receive the prescribed dose, it is important to use the dispenser provided to you. See the detailed <a href=\"#Instructions\">Instructions for Use</a> below for information about how to take VALCYTE for oral solution. Ask your pharmacist if you have any questions. If you lose or damage your oral dispensers and cannot use them, contact your pharmacist.</li>\n<li>If you take too much VALCYTE, call your healthcare provider or go to the nearest hospital emergency room right away.</li>\n</ul>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"left\" class=\"Lrule Rrule\" colspan=\"2\"><span class=\"Bold\">What should I avoid during treatment with VALCYTE?</span>\n<br/>VALCYTE can cause seizures, dizziness, and confusion. You should not drive a car or operate machinery until you know how VALCYTE affects you.</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Lrule Rrule\" colspan=\"2\"><span class=\"Bold\">What are the possible side effects of VALCYTE?</span>\n<br/>VALCYTE may cause serious side effects, including:<br/>See \"<span class=\"Bold\"><a href=\"#Important\">What is the most important information I should know about VALCYTE?</a></span>\"<br/>\n<span class=\"Bold\">The most common side effects of VALCYTE in adults include: </span></td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Lrule\">\n<ul>\n<li>diarrhea</li>\n<li>fever</li>\n<li>fatigue</li>\n<li>nausea</li>\n<li>shaky movements (tremors)</li>\n</ul>\n</td><td align=\"left\" class=\"Rrule\">\n<ul>\n<li>low white cell, red cell and platelet cell counts in blood tests</li>\n<li>headache</li>\n<li>sleeplessness</li>\n<li>urinary tract infection</li>\n<li>vomiting</li>\n</ul>\n</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Lrule Rrule\" colspan=\"2\"><span class=\"Bold\">The most common side effects of VALCYTE in children include:</span></td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Lrule\">\n<ul>\n<li>diarrhea</li>\n<li>fever</li>\n<li>upper respiratory tract infection</li>\n<li>urinary tract infection</li>\n</ul>\n</td><td align=\"left\" class=\"Rrule\">\n<ul>\n<li>vomiting</li>\n<li>low white blood cell counts in blood tests</li>\n<li>headache</li>\n</ul>\n</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"left\" class=\"Lrule Rrule\" colspan=\"2\">These are not all the possible side effects of VALCYTE. <br/>Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.</td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"left\" class=\"Lrule Rrule\" colspan=\"2\"><span class=\"Bold\">How should I store VALCYTE?</span>\n<ul>\n<li>Store VALCYTE tablets at room temperature between 68°F to 77°F (20°C to 25°C).</li>\n<li>Store VALCYTE for oral solution in the refrigerator between 36°F to 46°F (2°C to 8°C), for no longer than 49 days.</li>\n<li>Do not freeze.</li>\n<li>Do not keep VALCYTE that is out of date or that you no longer need.</li>\n</ul>\n<span class=\"Bold\">Keep VALCYTE and all medicines out of the reach of children.</span></td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"left\" class=\"Lrule Rrule\" colspan=\"2\"><span class=\"Bold\">General information about the safe and effective use of VALCYTE.</span>\n<br/>Medicines are sometimes prescribed for purposes other than those listed in a Patient Information leaflet. Do not use VALCYTE for a condition for which it was not prescribed. Do not give VALCYTE to other people, even if they have the same symptoms you have. It may harm them. You can ask your pharmacist or healthcare provider for information about VALCYTE that is written for health professionals.</td>\n</tr>\n<tr class=\"Last\">\n<td align=\"left\" class=\"Lrule Rrule\" colspan=\"2\"><span class=\"Bold\">What are the ingredients in VALCYTE? <br/>Active ingredient:</span> valganciclovir hydrochloride<br/>\n<span class=\"Bold\">Inactive ingredients for tablets:</span> microcrystalline cellulose, povidone K-30, crospovidone, and stearic acid. The film-coating applied to the tablets contains Opadry Pink<span class=\"Sup\">®</span>.<br/>\n<span class=\"Bold\">Inactive ingredients for oral solution:</span> sodium benzoate, fumaric acid, povidone K-30, sodium saccharin, mannitol and tutti-frutti flavoring.</td>\n</tr>\n</tbody>\n</table></div>" }

VALCYTE is a registered trademark of CHEPLAPHARM Arzneimittel GmbH.

{ "type": "p", "children": [], "text": "VALCYTE is a registered trademark of CHEPLAPHARM Arzneimittel GmbH." }

Distributed by: H2-Pharma, LLC Montgomery, AL 36117, USA

{ "type": "p", "children": [], "text": "Distributed by:\nH2-Pharma, LLC\nMontgomery, AL 36117, USA" }

Licensed by: CHEPLAPHARM Arzneimittel GmbH Ziegelhof 24, 17489 Greifswald, Germany

{ "type": "p", "children": [], "text": "Licensed by:\nCHEPLAPHARM Arzneimittel GmbH\nZiegelhof 24, 17489 Greifswald, Germany" }

Revised: 04/2023

{ "type": "p", "children": [], "text": "Revised: 04/2023" }

For more information call 1-866-946-3684.

{ "type": "p", "children": [], "text": "For more information call 1-866-946-3684." }

© 2023 CHEPLAPHARM Arzneimittel GmbH. All rights reserved.

{ "type": "p", "children": [], "text": "© 2023 CHEPLAPHARM Arzneimittel GmbH. All rights reserved." }

Be sure that you read, and that you understand and follow these instructions carefully to ensure proper dosing of the oral solution.

{ "type": "p", "children": [], "text": "Be sure that you read, and that you understand and follow these instructions carefully to ensure proper dosing of the oral solution." }

Important:

{ "type": "p", "children": [], "text": "\nImportant: \n" }

{ "type": "ul", "children": [ "Avoid contact with your skin or eyes. If you come in contact with the contents of the oral solution, wash your skin well with soap and water or rinse your eyes well with plain water.", "Do not use VALCYTE for oral solution after the discard date on the bottle.", "Always use the oral dispenser provided to give or take a dose of VALCYTE for oral solution.", "Call your pharmacist if your oral dispenser is lost or damaged, and they will tell you how to continue to give or take a dose of VALCYTE for oral solution.", "Ask your healthcare provider or pharmacist to show you how to measure your prescribed dose." ], "text": "" }

To take a dose of VALCYTE for oral solution, you will need the bottle of medicine and an oral dispenser provided with the medicine (see Figure 1). Your pharmacist inserts the bottle adapter in the VALCYTE for oral solution bottle.

{ "type": "p", "children": [], "text": "To take a dose of VALCYTE for oral solution, you will need the bottle of medicine and an oral dispenser provided with the medicine (see Figure 1). Your pharmacist inserts the bottle adapter in the VALCYTE for oral solution bottle." }

<div class="scrollingtable"><table width="100%"> <colgroup> <col align="center" valign="top" width="100%"/> </colgroup> <tbody class="Headless"> <tr class="First"> <td align="center"><span class="Bold">Figure 1</span></td> </tr> <tr class="Last"> <td align="center"><img alt="Figure 1" src="/dailymed/image.cfm?name=valcyte-03.jpg&amp;setid=4c517a39-2ded-4c5a-8d56-276853414b31"/></td> </tr> </tbody> </table></div>

{ "type": "table", "children": [], "text": "<div class=\"scrollingtable\"><table width=\"100%\">\n<colgroup>\n<col align=\"center\" valign=\"top\" width=\"100%\"/>\n</colgroup>\n<tbody class=\"Headless\">\n<tr class=\"First\">\n<td align=\"center\"><span class=\"Bold\">Figure 1</span></td>\n</tr>\n<tr class=\"Last\">\n<td align=\"center\"><img alt=\"Figure 1\" src=\"/dailymed/image.cfm?name=valcyte-03.jpg&amp;setid=4c517a39-2ded-4c5a-8d56-276853414b31\"/></td>\n</tr>\n</tbody>\n</table></div>" }

<div class="scrollingtable"><table width="100%"> <colgroup> <col align="left" valign="top" width="50%"/> <col align="center" valign="middle" width="50%"/> </colgroup> <tbody class="Headless"> <tr class="Botrule First First"> <td align="left" class="Lrule Rrule"><span class="Bold">Step 1:</span> With the child-resistant cap on the bottle, shake the bottle well for about 5 seconds before each use.</td><td align="center" class="Rrule"><img alt="Figure" src="/dailymed/image.cfm?name=valcyte-04.jpg&amp;setid=4c517a39-2ded-4c5a-8d56-276853414b31"/></td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule"><span class="Bold">Step 2:</span> Open the bottle by pressing downward firmly on the child-resistant cap and turning it counter-clockwise. <span class="Bold">Do not throw away the child-resistant cap.</span></td><td align="center" class="Rrule"><img alt="Figure" src="/dailymed/image.cfm?name=valcyte-05.jpg&amp;setid=4c517a39-2ded-4c5a-8d56-276853414b31"/></td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule"><span class="Bold">Step 3:</span> Check the dose in milliliters (mL) as prescribed by your healthcare provider. Find this number on the oral dispenser.</td><td align="center" class="Rrule"><img alt="Figure" src="/dailymed/image.cfm?name=valcyte-06.jpg&amp;setid=4c517a39-2ded-4c5a-8d56-276853414b31"/></td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule"><span class="Bold">Step 4:</span> Push the plunger down toward the tip of the oral dispenser.</td><td align="center" class="Rrule"><img alt="Figure" src="/dailymed/image.cfm?name=valcyte-07.jpg&amp;setid=4c517a39-2ded-4c5a-8d56-276853414b31"/></td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule"><span class="Bold">Step 5:</span> With the bottle in an upright position, insert the oral dispenser into the bottle adapter opening until firmly in place.</td><td align="center" class="Rrule"><img alt="Figure" src="/dailymed/image.cfm?name=valcyte-08.jpg&amp;setid=4c517a39-2ded-4c5a-8d56-276853414b31"/></td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule"><span class="Bold">Step 6</span>: Carefully turn the bottle upside down with the oral dispenser in place. Pull the plunger to withdraw the prescribed dose. <br/>If you see air bubbles in the oral dispenser, fully push in the plunger so that the oral solution flows back into the bottle. <br/>Then withdraw your prescribed dose of VALCYTE for oral solution.</td><td align="center" class="Rrule"><img alt="Figure" src="/dailymed/image.cfm?name=valcyte-09.jpg&amp;setid=4c517a39-2ded-4c5a-8d56-276853414b31"/></td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule"><span class="Bold">Step 7:</span> Leave the oral dispenser in the bottle adapter and turn the bottle to an upright position. Slowly remove the oral dispenser from the bottle adapter.</td><td align="center" class="Rrule"><img alt="Figure" src="/dailymed/image.cfm?name=valcyte-10.jpg&amp;setid=4c517a39-2ded-4c5a-8d56-276853414b31"/></td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule"><span class="Bold">Step 8:</span>Give or take the dose of VALCYTE for oral solution.<ul> <li>Place the tip of the oral dispenser in the mouth.</li> <li>Slowly push down the oral dispenser plunger until the oral dispenser is empty.</li> </ul> </td><td align="center" class="Rrule"><img alt="Figure" src="/dailymed/image.cfm?name=valcyte-11.jpg&amp;setid=4c517a39-2ded-4c5a-8d56-276853414b31"/></td> </tr> <tr class="Botrule"> <td align="left" class="Lrule Rrule"><span class="Bold">Step 9:</span> Put the child-resistant cap back on the bottle. Return the bottle back to the refrigerator.</td><td align="center" class="Rrule"><img alt="Figure" src="/dailymed/image.cfm?name=valcyte-12.jpg&amp;setid=4c517a39-2ded-4c5a-8d56-276853414b31"/></td> </tr> <tr> <td align="left" class="Lrule Rrule"><span class="Bold">Step 10</span>: Rinse the oral dispenser with tap water after each use.<ul> <li>Remove the plunger from the oral dispenser barrel by pulling the plunger all the way out of the barrel.</li> <li>Rinse the oral dispenser barrel and plunger with water and let them air dry.</li> </ul> </td><td align="center" class="Rrule"><img alt="Figure" src="/dailymed/image.cfm?name=valcyte-13.jpg&amp;setid=4c517a39-2ded-4c5a-8d56-276853414b31"/></td> </tr> <tr class="Last"> <td align="left" class="Lrule Rrule"> <ul> <li>When the oral dispenser barrel and plunger are dry, put the plunger back into the oral dispenser barrel for the next use.</li> </ul> <span class="Bold">Do not throw away the oral dispenser.</span></td><td align="center" class="Rrule"><img alt="Figure" src="/dailymed/image.cfm?name=valcyte-14.jpg&amp;setid=4c517a39-2ded-4c5a-8d56-276853414b31"/></td> </tr> </tbody> </table></div>

{ "type": "table", "children": [], "text": "<div class=\"scrollingtable\"><table width=\"100%\">\n<colgroup>\n<col align=\"left\" valign=\"top\" width=\"50%\"/>\n<col align=\"center\" valign=\"middle\" width=\"50%\"/>\n</colgroup>\n<tbody class=\"Headless\">\n<tr class=\"Botrule First First\">\n<td align=\"left\" class=\"Lrule Rrule\"><span class=\"Bold\">Step 1:</span> With the child-resistant cap on the bottle, shake the bottle well for about 5 seconds before each use.</td><td align=\"center\" class=\"Rrule\"><img alt=\"Figure\" src=\"/dailymed/image.cfm?name=valcyte-04.jpg&amp;setid=4c517a39-2ded-4c5a-8d56-276853414b31\"/></td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"left\" class=\"Lrule Rrule\"><span class=\"Bold\">Step 2:</span> Open the bottle by pressing downward firmly on the child-resistant cap and turning it counter-clockwise. <span class=\"Bold\">Do not throw away the child-resistant cap.</span></td><td align=\"center\" class=\"Rrule\"><img alt=\"Figure\" src=\"/dailymed/image.cfm?name=valcyte-05.jpg&amp;setid=4c517a39-2ded-4c5a-8d56-276853414b31\"/></td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"left\" class=\"Lrule Rrule\"><span class=\"Bold\">Step 3:</span> Check the dose in milliliters (mL) as prescribed by your healthcare provider. Find this number on the oral dispenser.</td><td align=\"center\" class=\"Rrule\"><img alt=\"Figure\" src=\"/dailymed/image.cfm?name=valcyte-06.jpg&amp;setid=4c517a39-2ded-4c5a-8d56-276853414b31\"/></td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"left\" class=\"Lrule Rrule\"><span class=\"Bold\">Step 4:</span> Push the plunger down toward the tip of the oral dispenser.</td><td align=\"center\" class=\"Rrule\"><img alt=\"Figure\" src=\"/dailymed/image.cfm?name=valcyte-07.jpg&amp;setid=4c517a39-2ded-4c5a-8d56-276853414b31\"/></td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"left\" class=\"Lrule Rrule\"><span class=\"Bold\">Step 5:</span> With the bottle in an upright position, insert the oral dispenser into the bottle adapter opening until firmly in place.</td><td align=\"center\" class=\"Rrule\"><img alt=\"Figure\" src=\"/dailymed/image.cfm?name=valcyte-08.jpg&amp;setid=4c517a39-2ded-4c5a-8d56-276853414b31\"/></td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"left\" class=\"Lrule Rrule\"><span class=\"Bold\">Step 6</span>: Carefully turn the bottle upside down with the oral dispenser in place. Pull the plunger to withdraw the prescribed dose. <br/>If you see air bubbles in the oral dispenser, fully push in the plunger so that the oral solution flows back into the bottle. <br/>Then withdraw your prescribed dose of VALCYTE for oral solution.</td><td align=\"center\" class=\"Rrule\"><img alt=\"Figure\" src=\"/dailymed/image.cfm?name=valcyte-09.jpg&amp;setid=4c517a39-2ded-4c5a-8d56-276853414b31\"/></td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"left\" class=\"Lrule Rrule\"><span class=\"Bold\">Step 7:</span> Leave the oral dispenser in the bottle adapter and turn the bottle to an upright position. Slowly remove the oral dispenser from the bottle adapter.</td><td align=\"center\" class=\"Rrule\"><img alt=\"Figure\" src=\"/dailymed/image.cfm?name=valcyte-10.jpg&amp;setid=4c517a39-2ded-4c5a-8d56-276853414b31\"/></td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"left\" class=\"Lrule Rrule\"><span class=\"Bold\">Step 8:</span>Give or take the dose of VALCYTE for oral solution.<ul>\n<li>Place the tip of the oral dispenser in the mouth.</li>\n<li>Slowly push down the oral dispenser plunger until the oral dispenser is empty.</li>\n</ul>\n</td><td align=\"center\" class=\"Rrule\"><img alt=\"Figure\" src=\"/dailymed/image.cfm?name=valcyte-11.jpg&amp;setid=4c517a39-2ded-4c5a-8d56-276853414b31\"/></td>\n</tr>\n<tr class=\"Botrule\">\n<td align=\"left\" class=\"Lrule Rrule\"><span class=\"Bold\">Step 9:</span> Put the child-resistant cap back on the bottle. Return the bottle back to the refrigerator.</td><td align=\"center\" class=\"Rrule\"><img alt=\"Figure\" src=\"/dailymed/image.cfm?name=valcyte-12.jpg&amp;setid=4c517a39-2ded-4c5a-8d56-276853414b31\"/></td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Lrule Rrule\"><span class=\"Bold\">Step 10</span>: Rinse the oral dispenser with tap water after each use.<ul>\n<li>Remove the plunger from the oral dispenser barrel by pulling the plunger all the way out of the barrel.</li>\n<li>Rinse the oral dispenser barrel and plunger with water and let them air dry.</li>\n</ul>\n</td><td align=\"center\" class=\"Rrule\"><img alt=\"Figure\" src=\"/dailymed/image.cfm?name=valcyte-13.jpg&amp;setid=4c517a39-2ded-4c5a-8d56-276853414b31\"/></td>\n</tr>\n<tr class=\"Last\">\n<td align=\"left\" class=\"Lrule Rrule\">\n<ul>\n<li>When the oral dispenser barrel and plunger are dry, put the plunger back into the oral dispenser barrel for the next use.</li>\n</ul>\n<span class=\"Bold\">Do not throw away the oral dispenser.</span></td><td align=\"center\" class=\"Rrule\"><img alt=\"Figure\" src=\"/dailymed/image.cfm?name=valcyte-14.jpg&amp;setid=4c517a39-2ded-4c5a-8d56-276853414b31\"/></td>\n</tr>\n</tbody>\n</table></div>" }

How should I store VALCYTE for oral solution?

{ "type": "p", "children": [], "text": "\nHow should I store VALCYTE for oral solution?\n" }

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This Patient Information and Instructions for Use have been approved by the U.S. Food and Drug Administration.

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VALCYTE is a registered trademark of CHEPLAPHARM Arzneimittel GmbH.

{ "type": "p", "children": [], "text": "VALCYTE is a registered trademark of CHEPLAPHARM Arzneimittel GmbH." }

Distributed by: H2-Pharma, LLC Montgomery, AL 36117, USA

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Licensed by: CHEPLAPHARM Arzneimittel GmbH Ziegelhof 24, 17489 Greifswald, Germany

{ "type": "p", "children": [], "text": "Licensed by:\nCHEPLAPHARM Arzneimittel GmbH\nZiegelhof 24, 17489 Greifswald, Germany" }

Revised: 04/2023

{ "type": "p", "children": [], "text": "Revised: 04/2023" }

For more information call 1-866-946-3684.

{ "type": "p", "children": [], "text": "For more information call 1-866-946-3684." }

© 2023 CHEPLAPHARM Arzneimittel GmbH. All rights reserved.

{ "type": "p", "children": [], "text": "© 2023 CHEPLAPHARM Arzneimittel GmbH. All rights reserved." }

Representative sample of labeling (see the HOW SUPPLIED section for complete listing):

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NDC 61269-480-60

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Valcyte® (valganciclovir) tablets

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450 mg

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DO NOT BREAK OR CRUSH TABLETS

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CAUTION: Strict adherence to dosage recommendations is essential to avoid overdose.

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60 tabletsRx only

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CHEPLAPHARM

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NDC 61269-485-10

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Valcyte® (valganciclovir)for oral solution

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50 mg/mL

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Each mL of constituted oralsolution contains 50 mgvalganciclovir free base.

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100 mL (3.4 fl oz)

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Rx only

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CHEPLAPHARM

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Treatment of Cytomegalovirus (CMV) Retinitis: Valganciclovir Tablets are indicated for the treatment of CMV retinitis in patients with acquired immunodeficiency syndrome (AIDS) [see Clinical Studies (14.1)].

Prevention of CMV Disease: Valganciclovir Tablets are indicated for the prevention of CMV disease in kidney, heart, and kidney-pancreas transplant patients at high risk (Donor CMV seropositive/Recipient CMV seronegative [D+/R-]) [see Clinical Studies (14.1)].

Prevention of CMV Disease: Valganciclovir Tablets are indicated for the prevention of CMV disease in kidney transplant patients (4 months to 16 years of age) and heart transplant patients (1 month to 16 years of age) at high risk [see Clinical Studies (14.2)].

For dosage recommendations in adult patients with renal impairment [see Dosage and Administration (2.5)].

Treatment of CMV Retinitis

Prevention of CMV Disease

Prevention of CMV Disease in Pediatric Kidney Transplant Patients: For pediatric kidney transplant patients 4 months to 16 years of age, the recommended once daily mg dose (7 x BSA x CrCl) should start within 10 days of post-transplantation until 200 days post-transplantation.

Prevention of CMV Disease in Pediatric Heart Transplant Patients: For pediatric heart transplant patients 1 month to 16 years of age, the recommended once daily mg dose (7 x BSA x CrCl) should start within 10 days of transplantation until 100 days post-transplantation.

The recommended once daily dosage of valganciclovir tablets is based on body surface area (BSA) and creatinine clearance (CrCl) derived from a modified Schwartz formula, and is calculated using the equation below:

Pediatric Dose (mg) = 7 x BSA x CrCl (calculated using a modified Schwartz formula). If the calculated Schwartz creatinine clearance exceeds 150 mL/min/1.73m2, then a maximum value of 150 mL/min/1.73m2 should be used in the equation. The k values used in the modified Schwartz formula are based on pediatric patient age, as shown in Table 1.

<div class="scrollingtable"><table class="Noautorules" width="100%"> <caption> <span> Table 1 k Values According to Pediatric Patient Age * </span> </caption> <col width="50%"/> <col width="50%"/> <tfoot> <tr> <td align="left" colspan="2"> <p class="First Footnote">*The k values provided are based on the Jaffe method of measuring serum creatinine, and may require correction when enzymatic methods are used<span class="Sup">1</span>.</p> </td> </tr> </tfoot> <tbody class="Headless"> <tr> <td align="left" class="Botrule Lrule Rrule Toprule" valign="top"><span class="Bold"> k value</span> <br/> </td><td align="left" class="Botrule Rrule Toprule" valign="top"><span class="Bold"> Pediatric Patient Age</span> <br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> 0.33<br/> </td><td align="left" class="Botrule Rrule" valign="top"> Infants less than 1 year of age with low birth weight for gestational age<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> 0.45<br/> </td><td align="left" class="Botrule Rrule" valign="top"> Infants less than 1 year of age with birth weight appropriate for gestational age<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> 0.45<br/> </td><td align="left" class="Botrule Rrule" valign="top"> Children aged 1 to less than 2 years<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> 0.55<br/> </td><td align="left" class="Botrule Rrule" valign="top"> Boys aged 2 to less than 13 years<br/>  Girls aged 2 to less than 16 years<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> 0.7<br/> </td><td align="left" class="Botrule Rrule" valign="top"> Boys aged 13 to 16 years<br/> </td> </tr> </tbody> </table></div>

Monitor serum creatinine levels regularly and consider changes in height and body weight and adapt the dose as appropriate during prophylaxis period.

 All calculated doses should be rounded to the nearest 25 mg increment for the actual deliverable dose. If the calculated dose exceeds 900 mg, a maximum dose of 900 mg should be administered. Valganciclovir for oral solution is the preferred formulation since it provides the ability to administer a dose calculated according to the formula above; however, valganciclovir tablets may be used if the calculated doses are within 10% of available tablet strength (450 mg). For example, if the calculated dose is between 405 mg and 495 mg, one 450 mg tablet may be taken. Before prescribing valganciclovir tablets, pediatric patients should be assessed for the ability to swallow tablets.

Serum creatinine levels or estimated creatinine clearance should be monitored regularly during treatment. Dosage recommendations for adult patients with reduced renal function are provided in Table 2. For adult patients on hemodialysis (CrCl less than 10 mL/min), a dose recommendation for valganciclovir tablets cannot be given [see Use in Specific Populations (8.5, 8.6), Clinical Pharmacology (12.3)].

<div class="scrollingtable"><table class="Noautorules" width="100%"> <caption> <span> Table 2 Dosage Recommendations for Adult Patients with Impaired Renal Function </span> </caption> <col width="33%"/> <col width="33%"/> <col width="33%"/> <tbody class="Headless"> <tr> <td align="center" class="Botrule Lrule Rrule Toprule" colspan="3" valign="top"> Valganciclovir 450 mg Tablets<br/> </td> </tr> <tr> <td align="center" class="Botrule Lrule Rrule" valign="top"> CrCl*(mL/min)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> Induction Dose<br/> </td><td align="center" class="Botrule Rrule" valign="top"> Maintenance/ Prevention Dose<br/> </td> </tr> <tr> <td align="center" class="Botrule Lrule Rrule" valign="top"> ≥ 60<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 900 mg twice daily<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 900 mg once daily<br/> </td> </tr> <tr> <td align="center" class="Botrule Lrule Rrule" valign="top"> 40 – 59<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 450 mg twice daily<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 450 mg once daily<br/> </td> </tr> <tr> <td align="center" class="Botrule Lrule Rrule" valign="top"> 25 – 39<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 450 mg once daily<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 450 mg every 2 days<br/> </td> </tr> <tr> <td align="center" class="Botrule Lrule Rrule" valign="top"> 10 – 24<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 450 mg every 2 days<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 450 mg twice weekly<br/> </td> </tr> <tr> <td align="center" class="Botrule Lrule Rrule" valign="top"> &lt; 10<br/> (on hemodialysis)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> not recommended<br/> </td><td align="center" class="Botrule Rrule" valign="top"> not recommended<br/> </td> </tr> </tbody> </table></div>

*An estimated creatinine clearance in adults is calculated from serum creatinine by the following formulas:

Dosing in pediatric patients with renal impairment can be done using the recommended equations because CrCl is a component in the calculation [see Dosage and Administration (2.3)].

Caution should be exercised in the handling of valganciclovir tablets. Tablets should not be broken or crushed. Because valganciclovir is considered a potential teratogen and carcinogen in humans, caution should be observed in handling broken tablets [see Warnings and Precautions (5.4, 5.5)]. Avoid direct contact with broken or crushed tablets with skin or mucous membranes. If such contact occurs, wash thoroughly with soap and water, and rinse eyes thoroughly with plain water.

Handle and dispose valganciclovir tablets according to guidelines for antineoplastic drugs because ganciclovir shares some of the properties of antitumor agents (i.e., carcinogenicity and mutagenicity).2

Valganciclovir Tablets, USP

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Valganciclovir is contraindicated in patients who have had a demonstrated clinically significant hypersensitivity reaction (e.g., anaphylaxis) to valganciclovir, ganciclovir, or any component of the formulation [see Adverse Reactions (6.1)]. 

{ "type": "p", "children": [], "text": "\nValganciclovir is contraindicated in patients who have had a demonstrated clinically significant hypersensitivity reaction (e.g., anaphylaxis) to valganciclovir, ganciclovir, or any component of the formulation [see Adverse Reactions (6.1)]. " }

Severe leukopenia, neutropenia, anemia, thrombocytopenia, pancytopenia, and bone marrow failure including aplastic anemia have been reported in patients treated with valganciclovir or ganciclovir. Valganciclovir should be avoided if the absolute neutrophil count is less than 500 cells/μL, the platelet count is less than 25,000/μL, or the hemoglobin is less than 8 g/dL. Valganciclovir should also be used with caution in patients with pre-existing cytopenias and in patients receiving myelosuppressive drugs or irradiation. Cytopenia may occur at any time during treatment and may worsen with continued dosing. Cell counts usually begin to recover within 3 to 7 days after discontinuing drug. In patients with severe leukopenia, neutropenia, anemia and/or thrombocytopenia, treatment with hematopoietic growth factors may be considered.

Due to the frequency of neutropenia, anemia, and thrombocytopenia in patients receiving valganciclovir [see Adverse Reactions (6.1)], complete blood counts with differential and platelet counts should be performed frequently, especially in infants, in patients with renal impairment and in patients in whom ganciclovir or other nucleoside analogues have previously resulted in leukopenia, or in whom neutrophil counts are less than 1000 cells/μL at the beginning of treatment. Increased monitoring for cytopenias may be warranted if therapy with oral ganciclovir is changed to valganciclovir, because of increased plasma concentrations of ganciclovir after valganciclovir administration [see Clinical Pharmacology (12.3)].

Acute renal failure may occur in:

Based on animal data and limited human data, valganciclovir at the recommended human doses may cause temporary or permanent inhibition of spermatogenesis in males, and may cause suppression of fertility in females. Advise patients that fertility may be impaired with use of valganciclovir [see Use in Specific Populations (8.1, 8.3), Nonclinical Toxicology (13.1)].

Ganciclovir may cause fetal toxicity when administered to pregnant women based on findings in animal studies. When given to pregnant rabbits at dosages resulting in 2 times the human exposure (based on AUC), ganciclovir caused malformations in multiple organs of the fetuses. Maternal and fetal toxicity were also observed in pregnant mice and rabbits. Therefore, valganciclovir has the potential to cause birth defects. Pregnancy should be avoided in female patients taking valganciclovir and in females with male partners taking valganciclovir. Females of reproductive potential should be advised to use effective contraception during treatment and for at least 30 days following treatment with valganciclovir because of the potential risk to the fetus. Similarly, males should be advised to use condoms during and for at least 90 days following treatment with valganciclovir [see Dosage and Administration (2.6), Use in Specific Populations (8.1, 8.3), Nonclinical Toxicology (13.1)].

Animal data indicate that ganciclovir is mutagenic and carcinogenic. Valganciclovir should therefore be considered a potential carcinogen in humans [see Dosage and Administration (2.6), Nonclinical Toxicology (13.1)].

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 rates observed in practice.

Valganciclovir, a prodrug of ganciclovir, is rapidly converted to ganciclovir after oral administration. Adverse reactions known to be associated with ganciclovir usage can therefore be expected to occur with valganciclovir.

Adverse Reactions in Adults:

Treatment of CMV Retinitis in AIDS Patients: In a clinical study for the treatment of CMV retinitis in HIV-infected patients, the adverse reactions reported by patients receiving valganciclovir tablets (n=79) or intravenous ganciclovir (n=79) for 28 days of randomized therapy (21 days induction dose and 7 days maintenance dose), respectively, included diarrhea (16%, 10%), nausea (8%, 14%), and headache (9%, 5%). The incidence of adverse reactions was similar between the group who received valganciclovir tablets and the group who received intravenous ganciclovir. The frequencies of neutropenia (ANC less than 500/μL) were 11% for patients receiving valganciclovir tablets compared with 13% for patients receiving intravenous ganciclovir. Anemia (Hgb less than 8 g/dL) occurred in 8% of patients in each group. Other laboratory abnormalities occurred with similar frequencies in the two groups.

Adverse reactions and laboratory abnormalities are available for 370 patients who received maintenance therapy with valganciclovir tablets 900 mg once daily in two open-label clinical trials. Approximately 252 (68%) of these patients received valganciclovir tablets for more than nine months (maximum duration was 36 months). Table 3 and Table 4 show pooled selected adverse reactions and abnormal laboratory values from these patients.

<div class="scrollingtable"><table class="Noautorules" width="100%"> <caption> <span> Table 3 Pooled Selected Adverse Reactions Reported in greater than or equal to 5% of Patients who Received Valganciclovir Tablets Maintenance Therapy for CMV Retinitis </span> </caption> <col width="50%"/> <col width="50%"/> <tbody class="Headless"> <tr> <td class="Botrule Lrule Rrule Toprule" valign="top"></td><td align="center" class="Botrule Rrule Toprule" valign="top"><span class="Bold"> Patients with CMV Retinitis</span> <br/> </td> </tr> <tr> <td align="center" class="Botrule Lrule Rrule"><span class="Bold"> Adverse Reactions According to Body System</span> <br/> </td><td align="center" class="Botrule Rrule" valign="top"><span class="Bold"> Valganciclovir Tablets</span> <br/> <span class="Bold"> (N=370)</span> <br/> %<br/> </td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"><span class="Bold"> Gastrointestinal system</span> <br/> </td><td class="Rrule" valign="top"></td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"> Diarrhea<br/> </td><td align="center" class="Botrule Rrule" rowspan="4" valign="top"> 41<br/> 30<br/> 21<br/> 15<br/> </td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"> Nausea<br/> </td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"> Vomiting<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Abdominal pain<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" rowspan="2" valign="top"><span class="Bold"> General disorders and administrative site conditions</span> <br/> Pyrexia<br/> </td><td class="Rrule" valign="top"></td> </tr> <tr> <td align="center" class="Botrule Rrule" valign="top"> 31<br/> </td> </tr> <tr> <td align="left" class="Lrule Rrule"><span class="Bold"> Nervous system disorders</span> <br/> Headache<br/> Insomnia<br/> Neuropathy peripheral<br/> Paresthesia<br/> </td><td align="center" class="Rrule" valign="top"> 22<br/> 16<br/> 9<br/> 8<br/> </td> </tr> <tr> <td align="left" class="Lrule Rrule Toprule" valign="top"><span class="Bold"> Eye disorders</span> <br/> </td><td align="center" class="Botrule Rrule Toprule" rowspan="2" valign="top"> 15<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Retinal detachment<br/> </td> </tr> </tbody> </table></div>

<div class="scrollingtable"><table class="Noautorules" width="100%"> <caption> <span> Table 4 Pooled Selected Laboratory Abnormalities Reported in Patients Who Received Valganciclovir Tablets Maintenance Therapy for the Treatment of CMV Retinitis </span> </caption> <col width="50%"/> <col width="50%"/> <tbody class="Headless"> <tr> <td align="center" class="Botrule Lrule Rrule Toprule" valign="top"> <br/> </td><td align="center" class="Botrule Rrule Toprule" valign="top"><span class="Bold"> Patients with CMV Retinitis</span> <br/> </td> </tr> <tr> <td align="center" class="Botrule Lrule Rrule"><span class="Bold"> Laboratory Abnormalities</span> <br/> </td><td align="center" class="Botrule Rrule" valign="top"><span class="Bold"> Valganciclovir Tablets</span> <br/> <span class="Bold"> (N=370)</span> <br/> %<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" colspan="2" valign="top"> Neutropenia: ANC/µL<br/> </td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"> &lt; 500<br/> </td><td align="center" class="Rrule" valign="top"> 19<br/> </td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"> 500 – &lt; 750<br/> </td><td align="center" class="Rrule"> 17<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> 750 – &lt; 1000<br/> </td><td align="center" class="Botrule Rrule"> 17<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" colspan="2" valign="top"> Anemia: Hemoglobin g/dL<br/> </td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"> &lt; 6.5<br/> </td><td align="center" class="Rrule" valign="top"> 7<br/> </td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"> 6.5 – &lt; 8.0<br/> </td><td align="center" class="Rrule"> 13<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> 8.0 – &lt; 9.5<br/> </td><td align="center" class="Botrule Rrule"> 16<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" colspan="2" valign="top"> Thrombocytopenia: Platelets/µL<br/> </td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"> &lt; 25000<br/> </td><td align="center" class="Rrule" valign="top"> 4<br/> </td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"> 25000 – &lt; 50000<br/> </td><td align="center" class="Rrule" valign="top"> 6<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> 50000 – &lt; 100000<br/> </td><td align="center" class="Botrule Rrule"> 22<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" colspan="2" valign="top"> Serum Creatinine: mg/dL<br/> </td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"> &gt; 2.5<br/> </td><td align="center" class="Rrule" valign="top"> 3<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> &gt; 1.5 – 2.5<br/> </td><td align="center" class="Botrule Rrule"> 12<br/> </td> </tr> </tbody> </table></div>

Prevention of CMV Disease in Solid Organ Transplant Patients: Table 5 shows selected adverse reactions regardless of severity with an incidence of greater than or equal to 5% from a clinical trial (up to 28 days after study treatment) where heart, kidney, kidney-pancreas and liver transplant patients received valganciclovir tablets (N=244) or oral ganciclovir (N=126) until Day 100 post-transplant. The majority of the adverse reactions were of mild or moderate intensity.

<div class="scrollingtable"><table class="Noautorules" width="100%"> <caption> <span> Table 5 Percentage of Selected Grades 1-4 Adverse Reactions Reported in greater than or equal to 5% of Adult Patients From a Study of Solid Organ Transplant Patients </span> </caption> <col width="33%"/> <col width="33%"/> <col width="33%"/> <tbody class="Headless"> <tr> <td align="center" class="Botrule Lrule Rrule Toprule"><span class="Bold"> Adverse Reactions</span> <br/> </td><td align="center" class="Botrule Rrule Toprule" valign="top"><span class="Bold"> Valganciclovir Tablets</span> <br/> <span class="Bold"> (N=244)</span> <br/> %<br/> </td><td align="center" class="Botrule Rrule Toprule" valign="top"><span class="Bold"> Oral Ganciclovir</span> <br/> <span class="Bold"> (N=126)</span> <br/> %<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" colspan="3" valign="top">  <span class="Bold"> Gastrointestinal disorders</span> <br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Diarrhea<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 30<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 29<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Nausea<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 23<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 23<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Vomiting<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 16<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 14<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" colspan="3" valign="top">  <span class="Bold"> Nervous system disorders</span> <br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Tremors<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 28<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 25<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Headache<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 22<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 27<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Insomnia<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 20<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 16<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" colspan="3" valign="top">  <span class="Bold"> General disorders and administration site conditions</span> <br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Pyrexia<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 13<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 14<br/> </td> </tr> </tbody> </table></div>

Table 6 shows selected adverse reactions regardless of severity with an incidence of greater than or equal to 5% from another clinical trial where kidney transplant patients received either valganciclovir once daily starting within 10 days post-transplant until Day 100 post-transplant followed by 100 days of placebo or valganciclovir once daily until Day 200 post-transplant. The overall safety profile of valganciclovir did not change with the extension of prophylaxis until Day 200 post-transplant in high risk kidney transplant patients.

<div class="scrollingtable"><table class="Noautorules" width="100%"> <caption> <span> Table 6 Percentage of Selected Grades 1-4 Adverse Reactions Reported in greater than or equal to 5% of Adult Patients from a Study of Kidney Transplant Patients </span> </caption> <col width="33%"/> <col width="33%"/> <col width="33%"/> <tbody class="Headless"> <tr> <td align="center" class="Botrule Lrule Rrule Toprule"><span class="Bold"> Adverse Reactions</span> <br/> </td><td align="center" class="Botrule Rrule Toprule" valign="top"><span class="Bold"> Valganciclovir Tablets</span> <br/> <span class="Bold"> Day 100 Post-transplant</span> <br/> <span class="Bold"> (N=164)</span> <br/> %<br/> </td><td align="center" class="Botrule Rrule Toprule" valign="top"><span class="Bold"> Valganciclovir Tablets</span> <br/> <span class="Bold"> Day 200 Post-transplant</span> <br/> <span class="Bold"> (N=156)</span> <br/> %<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" colspan="3" valign="top"><span class="Bold">  Gastrointestinal disorders</span> <br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Diarrhea<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 26<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 31<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Nausea<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 11<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 11<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Vomiting<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 3<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 6<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" colspan="3" valign="top">  <span class="Bold"> Nervous system disorders</span> <br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Tremors<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 12<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 17<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Headache<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 10<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 6<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Insomnia<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 7<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 6<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" colspan="3" valign="top"><span class="Bold">  General disorders and administration site conditions</span> <br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Pyrexia<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 12<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 9<br/> </td> </tr> </tbody> </table></div>

Table 7 and Table 8 show selected laboratory abnormalities reported with valganciclovir tablets in two trials in solid organ transplant patients.

<div class="scrollingtable"><table class="Noautorules" width="100%"> <caption> <span> Table 7 Selected Laboratory Abnormalities Reported in a Study of Adult Solid Organ Transplant Patients*</span> </caption> <col width="33%"/> <col width="33%"/> <col width="33%"/> <tfoot> <tr> <td align="left" colspan="3"> <p class="First Footnote">*Laboratory abnormalities are those reported by investigators.</p> </td> </tr> </tfoot> <tbody class="Headless"> <tr> <td align="center" class="Botrule Lrule Rrule Toprule"><span class="Bold"> Laboratory Abnormalities</span> <br/> </td><td align="center" class="Botrule Rrule Toprule" valign="top"><span class="Bold"> Valganciclovir Tablets </span> <br/> <span class="Bold"> (N=244)</span> <br/> %<br/> </td><td align="center" class="Botrule Rrule Toprule" valign="top"><span class="Bold"> Ganciclovir Capsules</span> <br/> <span class="Bold"> (N=126)</span> <br/> %<br/> </td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"> Neutropenia: ANC/µL<br/> </td><td class="Rrule" valign="top"></td><td class="Rrule" valign="top"></td> </tr> <tr> <td align="left" class="Lrule Rrule"> &lt; 500<br/> </td><td align="center" class="Botrule Rrule" rowspan="3" valign="top"> 5<br/> 3<br/> 5<br/> </td><td align="center" class="Botrule Rrule" rowspan="3" valign="top"> 3<br/> 2<br/> 2<br/> </td> </tr> <tr> <td align="left" class="Lrule Rrule"> 500  - &lt; 750<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule"> 750 - &lt; 1000<br/> </td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"> Anemia: Hemoglobin g/dL<br/> </td><td class="Rrule" valign="top"></td><td class="Rrule" valign="top"></td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"> &lt; 6.5<br/> </td><td align="center" class="Rrule" valign="top"> 1<br/> </td><td align="center" class="Rrule" valign="top"> 2<br/> </td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"> 6.5 – &lt; 8.0<br/> </td><td align="center" class="Botrule Rrule" rowspan="2" valign="top"> 5<br/> 31<br/> </td><td align="center" class="Botrule Rrule" rowspan="2" valign="top"> 7<br/> 25<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> 8.0 – &lt; 9.5<br/> </td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"> Thrombocytopenia: Platelets/µL<br/> </td><td class="Rrule" valign="top"></td><td class="Rrule" valign="top"></td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"> &lt; 25000<br/> </td><td align="center" class="Botrule Rrule" rowspan="3" valign="top"> 0<br/> 1<br/> 18<br/> </td><td align="center" class="Botrule Rrule" rowspan="3" valign="top"> 2<br/> 3<br/> 21<br/> </td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"> 25000 – &lt; 50000<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> 50000 – &lt; 100000<br/> </td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"> Serum Creatinine: mg/dL<br/> </td><td align="center" class="Botrule Rrule" rowspan="3" valign="top"> 14<br/> 45<br/> </td><td class="Rrule" valign="top"></td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"> &gt; 2.5<br/> </td><td align="center" class="Botrule Rrule" rowspan="2" valign="top"> 21<br/> 47<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> &gt; 1.5 – 2.5<br/> </td> </tr> </tbody> </table></div>

<div class="scrollingtable"><table class="Noautorules" width="100%"> <caption> <span> Table 8 Selected Laboratory Abnormalities Reported in a Study of Adult Kidney Transplant Patients*</span> </caption> <col width="33%"/> <col width="33%"/> <col width="33%"/> <tfoot> <tr> <td align="left" colspan="3"> <p class="First Footnote">*Laboratory abnormalities are those reported by investigators.</p> </td> </tr> </tfoot> <tbody class="Headless"> <tr> <td align="center" class="Botrule Lrule Rrule Toprule"><span class="Bold"> Laboratory Abnormalities</span> <br/> </td><td align="center" class="Botrule Rrule Toprule" valign="top"><span class="Bold"> Valganciclovir Tablets</span> <br/> <span class="Bold"> Day 100 Post-transplant</span> <br/> <span class="Bold"> (N=164)</span> <br/> %<br/> </td><td align="center" class="Botrule Rrule Toprule" valign="top"><span class="Bold"> Valganciclovir Tablets</span> <br/> <span class="Bold"> Day 200 Post-transplant</span> <br/> <span class="Bold"> (N=156)</span> <br/> %<br/> </td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"> Neutropenia: ANC/µL<br/> </td><td align="center" class="Botrule Rrule" rowspan="4" valign="top"> 9<br/> 6<br/> 7<br/> </td><td class="Rrule" valign="top"></td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"> &lt; 500<br/> </td><td align="center" class="Botrule Rrule" rowspan="3" valign="top"> 10<br/> 6<br/> 5<br/> </td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"> 500 – &lt; 750<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> 750 – &lt; 1000<br/> </td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"> Anemia: Hemoglobin g/dL<br/> </td><td class="Rrule" valign="top"></td><td class="Rrule" valign="top"></td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"> &lt; 6.5<br/> </td><td align="center" class="Botrule Rrule" rowspan="3" valign="top"> 0<br/> 5<br/> 17<br/> </td><td align="center" class="Botrule Rrule" rowspan="3" valign="top"> 1<br/> 1<br/> 15<br/> </td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"> 6.5 – &lt; 8.0<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> 8.0 – &lt; 9.5<br/> </td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"> Thrombocytopenia: Platelets/µL<br/> </td><td class="Rrule" valign="top"></td><td class="Rrule" valign="top"></td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"> &lt; 25000<br/> </td><td align="center" class="Botrule Rrule" rowspan="3" valign="top"> 0<br/> 1<br/> 7<br/> </td><td align="center" class="Botrule Rrule" rowspan="3" valign="top"> 0<br/> 0<br/> 3<br/> </td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"> 25000 – &lt; 50000<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> 50000 – &lt; 100000<br/> </td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"> Serum Creatinine: mg/dL<br/> </td><td class="Rrule" valign="top"></td><td class="Rrule" valign="top"></td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top"> &gt; 2.5<br/> </td><td align="center" class="Botrule Rrule" rowspan="2" valign="top"> 17<br/> 50<br/> </td><td align="center" class="Botrule Rrule" rowspan="2" valign="top"> 14<br/> 48<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> &gt; 1.5 – 2.5<br/> </td> </tr> </tbody> </table></div>

Other adverse drug reactions from valganciclovir in clinical trials in CMV Retinitis and solid organ transplant patients

Other adverse drug reactions with valganciclovir in clinical trials in either patients with CMV retinitis or solid organ transplant patients that occurred in at least 5% of patients are listed below.

Eye disorders: retinal detachment, eye pain

Gastrointestinal disorders: dyspepsia, constipation, abdominal distention, mouth ulceration

General disorders and administration site conditions: fatigue, pain, malaise, asthenia, chills, peripheral edema

Hepatobiliary disorders: hepatic function abnormal

Infections and infestations: candida infections including oral candidiasis, upper respiratory tract infection, influenza, urinary tract infection, pharyngitis/nasopharyngitis, postoperative wound infection

Injury, poisoning, and procedural complications: postoperative complications, wound secretion

Metabolic and nutrition disorders: decreased appetite, hyperkalemia, hypophosphatemia, weight decreased

Musculoskeletal and connective tissue disorders: back pain, myalgia, arthralgia, muscle spasms

Nervous system disorders: insomnia, neuropathy peripheral, dizziness

Psychiatric disorders: depression, anxiety

Renal and urinary disorders: renal impairment, creatinine clearance renal decreased, blood creatinine increased, hematuria

Respiratory, thoracic and mediastinal disorders: cough, dyspnea

Skin and subcutaneous tissues disorders: dermatitis, night sweats, pruritus

Vascular disorders: hypotension

Other adverse reactions with valganciclovir in clinical trials in either patients with CMV retinitis or solid organ transplant patients that occurred in less than 5% of patients are listed below.

Blood and lymphatic disorders: febrile neutropenia, pancytopenia, bone marrow failure (including aplastic anemia)

Cardiovascular disorders: arrhythmia

Ear and labyrinth disorders: deafness

Eye disorders: macular edema

Gastrointestinal disorders: pancreatitis

Hemorrhage: potentially life-threatening bleeding associated with thrombocytopenia

Immune system disorders: hypersensitivity

Infections and infestations: cellulitis, sepsis

Injury, poisoning, and procedural complications: postoperative pain, wound dehiscence

Investigations: aspartate aminotransferase increased, alanine aminotransferase increased

Musculoskeletal and connective tissue disorders: limb pain

Nervous system disorders: seizure, dysguesia (taste disturbance)

Psychiatric disorders: confusional state, agitation, psychotic disorder, hallucinations

Renal and urinary disorders: renal failure

Adverse Reactions in Pediatric Patients:

Valganciclovir for oral solution and tablets have been studied in 179 pediatric solid organ transplant patients who were at risk for developing CMV disease (aged 3 weeks to 16 years) and in 24 neonates with symptomatic congenital CMV disease (aged 8 to 34 days), with duration of ganciclovir exposure ranging from 2 to 200 days [see Use in Specific Populations (8.4), Clinical Studies (14.2)].

Prevention of CMV Disease in Pediatric Solid Organ Transplant Patients: The most frequently reported adverse reactions (greater than 10% of patients), regardless of seriousness, in pediatric solid organ transplant patients taking valganciclovir until Day 100 post-transplant were diarrhea, pyrexia, upper respiratory tract infection, vomiting, anemia, neutropenia, constipation and nausea. The most frequently reported adverse reactions (greater than 10% of patients) in pediatric kidney transplant patients treated with valganciclovir until Day 200 post-transplant were upper respiratory tract infection, urinary tract infection, diarrhea, leukopenia, neutropenia, headache, abdominal pain, tremor, pyrexia, anemia, blood creatinine increased, vomiting, and hematuria.

In general, the safety profile was similar in pediatric patients compared to that observed in adult patients. However, the rates of certain adverse reactions, and laboratory abnormalities, such as upper respiratory tract infection, pyrexia, nasopharyngitis, anemia, and abdominal pain were reported more frequently in pediatric patients than in adults [see Use in Specific Populations (8.4), Clinical Studies (14.2)]. Neutropenia was reported at a higher incidence in the two pediatric studies as compared to adults, but there was no correlation between neutropenia and infections observed in the pediatric population.

The overall safety profile of valganciclovir was similar with the extension of prophylaxis until Day 200 post-transplant in high risk pediatric kidney transplant patients. However, the incidence of severe neutropenia (ANC < 500/μL) was higher in pediatric kidney transplant patients treated with valganciclovir until Day 200 (17/57, 30%) compared to pediatric kidney transplant patients treated until Day 100 (3/63, 5%). There were no differences in the incidence of severe (Grade 4) anemia or thrombocytopenia in patients treated 100 or 200 days with valganciclovir.

The following adverse reactions have been identified during post-approval use of valganciclovir. 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. As valganciclovir is rapidly and extensively converted to ganciclovir, any adverse reactions associated with ganciclovir might also occur with valganciclovir.

In general, the adverse reactions reported during the postmarketing use of valganciclovir were similar to those identified during the clinical trials.

In vivo drug-drug interaction studies were not conducted with valganciclovir. However, because valganciclovir is rapidly and extensively converted to ganciclovir, drug-drug interactions associated with ganciclovir will be expected for valganciclovir. Drug-drug interaction studies with ganciclovir were conducted in patients with normal renal function. Following concomitant administration of valganciclovir and other renally excreted drugs, patients with impaired renal function may have increased concentrations of ganciclovir and the coadministered drug. Therefore, these patients should be closely monitored for toxicity of ganciclovir and the coadministered drug.

{ "type": "p", "children": [], "text": "\nIn vivo drug-drug interaction studies were not conducted with valganciclovir. However, because valganciclovir is rapidly and extensively converted to ganciclovir, drug-drug interactions associated with ganciclovir will be expected for valganciclovir. Drug-drug interaction studies with ganciclovir were conducted in patients with normal renal function. Following concomitant administration of valganciclovir and other renally excreted drugs, patients with impaired renal function may have increased concentrations of ganciclovir and the coadministered drug. Therefore, these patients should be closely monitored for toxicity of ganciclovir and the coadministered drug." }

Established and other potentially significant drug interactions conducted with ganciclovir are listed in Table 9.

{ "type": "p", "children": [], "text": "Established and other potentially significant drug interactions conducted with ganciclovir are listed in Table 9." }

<div class="scrollingtable"><table class="Noautorules" width="100%"> <caption> <span> Table 9 Established and Other Potentially Significant Drug Interactions with Ganciclovir </span> </caption> <col width="33%"/> <col width="33%"/> <col width="33%"/> <tbody class="Headless"> <tr> <td align="center" class="Botrule Lrule Rrule Toprule"><span class="Bold"> Name of the Concomitant Drug</span> <br/> </td><td align="center" class="Botrule Rrule Toprule"><span class="Bold"> Change in the Concentration of Ganciclovir or Concomitant Drug</span> <br/> </td><td align="center" class="Botrule Rrule Toprule"><span class="Bold"> Clinical Comment</span> <br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Imipenem-cilastatin<br/> </td><td align="left" class="Botrule Rrule" valign="top"> Unknown<br/> </td><td align="left" class="Botrule Rrule" valign="top"> Coadministration with imipenem-cilastatin is not recommended because generalized seizures have been reported in patients who received ganciclovir and imipenem-cilastatin.<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Cyclosporine or amphotericin B<br/> </td><td align="left" class="Botrule Rrule" valign="top"> Unknown<br/> </td><td align="left" class="Botrule Rrule" valign="top"> Monitor renal function when valganciclovir is coadministered with cyclosporine or amphotericin B because of potential increase in serum creatinine [<span class="Italics">see Warnings and Precautions (5.2)</span> ].<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Mycophenolate mofetil (MMF)<br/> </td><td align="left" class="Botrule Rrule" valign="top"> ↔ Ganciclovir (in patients with normal renal function)<br/> ↔ MMF (in patients with normal renal function)<br/> </td><td align="left" class="Botrule Rrule" valign="top"> Based on increased risk, patients should be monitored for hematological and renal toxicity.<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Other drugs associated with myelosuppresion or nephrotoxicity (e.g., adriamycin, dapsone, doxorubicin, flucytosine, hydroxyurea, pentamidine, tacrolimus, trimethoprim/ sulfamethoxazole, vinblastine, vincristine, and zidovudine)<br/> </td><td align="left" class="Botrule Rrule" valign="top"> Unknown<br/> </td><td align="left" class="Botrule Rrule" valign="top"> Because of potential for higher toxicity, coadministration with valganciclovir should be considered only if the potential benefits are judged to outweigh the risks.<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Didanosine<br/> </td><td align="left" class="Botrule Rrule" valign="top"> ↔ Ganciclovir<br/>  ↑ Didanosine<br/> </td><td align="left" class="Botrule Rrule" valign="top"> Patients should be closely monitored for didanosine toxicity (e.g., pancreatitis)<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Probenecid<br/> </td><td align="left" class="Botrule Rrule" valign="top"> ↑ Ganciclovir<br/> </td><td align="left" class="Botrule Rrule" valign="top"> Valganciclovir dose may need to be reduced. Monitor for evidence of ganciclovir toxicity.<br/> </td> </tr> </tbody> </table></div>

{ "type": "table", "children": [], "text": "<div class=\"scrollingtable\"><table class=\"Noautorules\" width=\"100%\">\n<caption>\n<span> Table 9 Established and Other Potentially Significant Drug Interactions with Ganciclovir </span>\n</caption>\n<col width=\"33%\"/>\n<col width=\"33%\"/>\n<col width=\"33%\"/>\n<tbody class=\"Headless\">\n<tr>\n<td align=\"center\" class=\"Botrule Lrule Rrule Toprule\"><span class=\"Bold\"> Name of the Concomitant Drug</span>\n<br/>\n</td><td align=\"center\" class=\"Botrule Rrule Toprule\"><span class=\"Bold\"> Change in the Concentration of Ganciclovir or Concomitant Drug</span>\n<br/>\n</td><td align=\"center\" class=\"Botrule Rrule Toprule\"><span class=\"Bold\"> Clinical Comment</span>\n<br/>\n</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" valign=\"top\"> Imipenem-cilastatin<br/>\n</td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\"> Unknown<br/>\n</td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\"> Coadministration with imipenem-cilastatin is not recommended because generalized seizures have been reported in patients who received ganciclovir and imipenem-cilastatin.<br/>\n</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" valign=\"top\"> Cyclosporine or amphotericin B<br/>\n</td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\"> Unknown<br/>\n</td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\"> Monitor renal function when valganciclovir is coadministered with cyclosporine or amphotericin B because of potential increase in serum creatinine [<span class=\"Italics\">see Warnings and Precautions (5.2)</span> ].<br/>\n</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" valign=\"top\"> Mycophenolate mofetil (MMF)<br/>\n</td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\"> ↔ Ganciclovir (in patients with normal renal function)<br/> ↔ MMF (in patients with normal renal function)<br/>\n</td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\"> Based on increased risk, patients should be monitored for hematological and renal toxicity.<br/>\n</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" valign=\"top\"> Other drugs associated with myelosuppresion or nephrotoxicity (e.g., adriamycin, dapsone, doxorubicin, flucytosine, hydroxyurea, pentamidine, tacrolimus, trimethoprim/ sulfamethoxazole, vinblastine, vincristine, and zidovudine)<br/>\n</td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\"> Unknown<br/>\n</td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\"> Because of potential for higher toxicity, coadministration with valganciclovir should be considered only if the potential benefits are judged to outweigh the risks.<br/>\n</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" valign=\"top\"> Didanosine<br/>\n</td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\"> ↔ Ganciclovir<br/>  ↑ Didanosine<br/>\n</td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\"> Patients should be closely monitored for didanosine toxicity (e.g., pancreatitis)<br/>\n</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" valign=\"top\"> Probenecid<br/>\n</td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\"> ↑ Ganciclovir<br/>\n</td><td align=\"left\" class=\"Botrule Rrule\" valign=\"top\"> Valganciclovir dose may need to be reduced. Monitor for evidence of ganciclovir toxicity.<br/>\n</td>\n</tr>\n</tbody>\n</table></div>" }

Risk Summary

After oral administration, valganciclovir (prodrug) is converted to ganciclovir (active drug) and, therefore, valganciclovir is expected to have reproductive toxicity effects similar to ganciclovir. In animal studies, ganciclovir caused maternal and fetal toxicity and embryo-fetal mortality in pregnant mice and rabbits as well as teratogenicity in rabbits at exposures two-times the human exposure. There are no available human data on use of valganciclovir or ganciclovir in pregnant women to establish the presence or absence of drug-associated risk. The background risk of major birth defects and miscarriage for the indicated populations is unknown. However, the background risk in the U.S. general population of major birth defects is 2-4% and the risk of miscarriage is 15-20% of clinically recognized pregnancies. Advise pregnant women of the potential risk to the fetus [see Warnings and Precautions (5.3), Use in Specific Populations (8.3)].

Clinical Considerations

Disease-associated maternal and/or embryo/fetal risk

Most maternal CMV infections are asymptomatic or they may be associated with a self-limited mononucleosis-like syndrome. However, in immunocompromised patients (i.e., transplant patients or patients with AIDS) CMV infections may be symptomatic and may result in significant maternal morbidity and mortality. The transmission of CMV to the fetus is a result of maternal viremia and transplacental infection. Perinatal infection can also occur from exposure of the neonate to CMV shedding in the genital tract. Approximately 10% of children with congenital CMV infection are symptomatic at birth. Mortality in these infants is about 10% and approximately 50-90% of symptomatic surviving newborns experience significant morbidity, including mental retardation, sensorineural hearing loss, microcephaly, seizures, and other medical problems. The risk of congenital CMV infection resulting from primary maternal CMV infection may be higher and of greater severity than that resulting from maternal reactivation of CMV infection.

Data

Animal Data

Doses resulting in two-times the human exposure of ganciclovir (based on the human AUC following a single intravenous infusion of 5 mg per kg of ganciclovir) resulted in maternal and embryo-fetal toxicity in pregnant mice and rabbits as well as teratogenicity in the rabbits. Fetal resorptions were present in at least 85% of rabbits and mice. Rabbits showed increased embryo fetal mortality, growth retardation of the fetuses and structural abnormalities of multiple organs of the fetuses including the palate (cleft palate), eyes (anophthalmia/microphthalmia), brain (hydrocephalus), jaw (brachygnathia), kidneys and pancreas (aplastic organs). Increased embryo-fetal mortality was also seen in mice. Daily intravenous doses of approximately 1.7 times the human exposure (based on AUC) administered to female mice prior to mating, during gestation, and during lactation caused hypoplasia of the testes and seminal vesicles in the male offspring, as well as pathologic changes in the nonglandular region of the stomach.

Data from an ex-vivo human placental model showed that ganciclovir crosses the human placenta. The transfer occurred by passive diffusion and was not saturable over a concentration range of 1 to 10 mg/mL.

Risk Summary

 No data are available regarding the presence of valganciclovir (prodrug) or ganciclovir (active drug) in human milk, the effects on the breastfed infant, or the effects on milk production. Animal data indicate that ganciclovir is excreted in the milk of lactating rats. The Centers for Disease Control and Prevention recommend that HIV-infected mothers not breastfeed their infants to avoid risking postnatal transmission of HIV. Advise nursing mothers that breastfeeding is not recommended during treatment with valganciclovir because of the potential for serious adverse events in nursing infants and because of the potential for transmission of HIV [see Boxed Warning, Warnings and Precautions (5.1, 5.3, 5.4, 5.5), Nonclinical Toxicology (13.1)].

Pregnancy Testing

Females of reproductive potential should undergo pregnancy testing before initiation of valganciclovir [see Use in Specific Populations (8.1)].

Contraception

Females

Because of the mutagenic and teratogenic potential of valganciclovir, females of reproductive potential should be advised to use effective contraception during treatment and for at least 30 days following treatment with valganciclovir [see Dosage and Administration (2.6), Warnings and Precautions (5.4, 5.5), Nonclinical Toxicology (13.1)].

Males

Because of its mutagenic potential, males should be advised to use condoms during and for at least 90 days following, treatment with valganciclovir [see Dosage and Administration (2.6), Warnings and Precautions (5.3, 5.5), Nonclinical Toxicology (13.1)].

Infertility:

Valganciclovir at the recommended doses may cause temporary or permanent female and male infertility [see Warnings and Precautions (5.3), Nonclinical Toxicology (13.1)].

Data

Human Data

In a small, open-label, non-randomized clinical study, adult male renal transplant patients receiving valganciclovir for CMV prophylaxis for up to 200 days post-transplantation were compared to an untreated control group. Patients were followed-up for six months after valganciclovir discontinuation. Among 24 evaluable patients in the valganciclovir group, the mean sperm density at the end of treatment visit decreased by 11 million/mL from baseline; whereas, among 14 evaluable patients in the control group the mean sperm density increased by 33 million/mL. However, at the follow-up visit among 20 evaluable patients in the valganciclovir group the mean sperm density was comparable to that observed among 10 evaluable patients in the untreated control group (the mean sperm density at the end of follow-up visit increased by 41 million/mL from baseline in the valganciclovir group and by 43 million/mL in the untreated group).

Valganciclovir for oral solution and tablets are indicated for the prevention of CMV disease in pediatric kidney transplant patients 4 months to 16 years of age and in pediatric heart transplant patients 1 month to 16 years of age at risk for developing CMV disease [see Indications and Usage (1.2), Dosage and Administration (2.3)].

The use of valganciclovir for oral solution and tablets for the prevention of CMV disease in pediatric kidney transplant patients 4 months to 16 years of age is based on two single-arm, open-label, non-comparative studies in patients 4 months to 16 years of age. Study 1 was a safety and pharmacokinetic study in pediatric solid organ transplant patients (kidney, liver, heart, and kidney/pancreas). Valganciclovir was administered once daily within 10 days of transplantation for a maximum of 100 days post-transplantation. Study 2 was a safety and tolerability study where valganciclovir was administered once daily within 10 days of transplantation for a maximum of 200 days post-transplantation in pediatric kidney transplant patients. The results of these studies were supported by previous demonstration of efficacy in adult patients [see Adverse Reactions (6.1), Clinical Pharmacology (12.3), Clinical Studies (14.2)].

The use of valganciclovir for oral solution and tablets for the prevention of CMV disease in pediatric heart transplant patients 1 month to 16 years of age is based on two studies (Study 1 described above and Study 3) and was supported by previous demonstration of efficacy in adult patients [see Clinical Pharmacology (12.3), Clinical Studies (14.2)]. Study 3 was a pharmacokinetic and safety study of valganciclovir in pediatric heart transplant patients less than 4 months of age who received a single dose of valganciclovir oral solution on each of two consecutive days. A physiologically based pharmacokinetic (PBPK) model was developed based on the available pharmacokinetic data from pediatric and adult patients to support dosing in heart transplant patients less than 1 month of age. However, due to uncertainty in model predictions for neonates, valganciclovir is not indicated for prophylaxis in this age group.

The safety and efficacy of valganciclovir for oral solution and tablets have not been established in children for prevention of CMV disease in pediatric liver transplant patients, in kidney transplant patients less than 4 months of age, in heart transplant patients less than 1 month of age, in pediatric AIDS patients with CMV retinitis, and in infants with congenital CMV infection.

A pharmacokinetic and pharmacodynamic evaluation of valganciclovir for oral solution was performed in 24 neonates with congenital CMV infection involving the central nervous system. All patients were treated for 6 weeks with a combination of intravenous ganciclovir 6 mg per kg twice daily or valganciclovir for oral solution at doses ranging from 14 mg per kg to 20 mg per kg twice daily. The pharmacokinetic results showed that in infants greater than 7 days to 3 months of age, a dose of 16 mg per kg twice daily of valganciclovir for oral solution provided ganciclovir systemic exposures (median AUC0-12h = 23.6 [range 16.8-35.5] mcg·h/mL; n = 6) comparable to those obtained in infants up to 3 months of age from a 6 mg per kg dose of intravenous ganciclovir twice daily (AUC0-12h = 25.3 [range 2.4-89.7] mcg·h/mL; n = 18) or to the ganciclovir systemic exposures obtained in adults from a 900 mg dose of valganciclovir tablets twice daily. However, the efficacy and safety of intravenous ganciclovir and of valganciclovir have not been established for the treatment of congenital CMV infection in infants and no similar disease occurs in adults; therefore, efficacy cannot be extrapolated from intravenous ganciclovir use in adults.

Studies of valganciclovir tablets have not been conducted in adults older than 65 years of age. Clinical studies of valganciclovir did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy. Valganciclovir is known to be substantially excreted by the kidneys, and the risk of toxic reactions to this drug may be greater in patients with impaired renal function. Because renal clearance decreases with age, valganciclovir should be administered with consideration of their renal status. Renal function should be monitored and dosage adjustments should be made accordingly [see Dosage and Administration (2.5), Warnings and Precautions (5.2), Use in Specific Populations (8.6), Clinical Pharmacology (12.3)].

Dose reduction is recommended when administering valganciclovir to patients with renal impairment [see Dosage and Administration (2.5), Warnings and Precautions (5.2), Clinical Pharmacology (12.3)].

For adult patients on hemodialysis (CrCl less than10 mL/min), valganciclovir tablets should not be used. Adult hemodialysis patients should use ganciclovir in accordance with the dose-reduction algorithm cited in the CYTOVENE®-IV complete product information section on DOSAGE AND ADMINISTRATION: Renal Impairment [see Dosage and Administration (2.5) and Clinical Pharmacology (12.3)].

The safety and efficacy of valganciclovir have not been studied in patients with hepatic impairment.

Experience with Valganciclovir Tablets: An overdose of valganciclovir could possibly result in increased renal toxicity [see Dosage and Administration (2.5), Use in Specific Populations (8.6)]. Because ganciclovir is dialyzable, dialysis may be useful in reducing serum concentrations in patients who have received an overdose of valganciclovir [see Clinical Pharmacology (12.3)]. Adequate hydration should be maintained. The use of hematopoietic growth factors should be considered [see Warnings and Precautions (5.1) and Clinical Pharmacology (12.3)].

{ "type": "p", "children": [], "text": "\nExperience with Valganciclovir Tablets: An overdose of valganciclovir could possibly result in increased renal toxicity [see Dosage and Administration (2.5), Use in Specific Populations (8.6)]. Because ganciclovir is dialyzable, dialysis may be useful in reducing serum concentrations in patients who have received an overdose of valganciclovir [see Clinical Pharmacology (12.3)]. Adequate hydration should be maintained. The use of hematopoietic growth factors should be considered [see Warnings and Precautions (5.1) and Clinical Pharmacology (12.3)]." }

Reports of adverse reactions after overdoses with valganciclovir, some with fatal outcomes, have been received from clinical trials and during postmarketing experience. The majority of patients experienced one or more of the following adverse events:

{ "type": "p", "children": [], "text": "Reports of adverse reactions after overdoses with valganciclovir, some with fatal outcomes, have been received from clinical trials and during postmarketing experience. The majority of patients experienced one or more of the following adverse events:" }

Hematological toxicity: myelosuppression including pancytopenia, bone marrow failure, leukopenia, neutropenia, granulocytopenia

{ "type": "p", "children": [], "text": "\nHematological toxicity: myelosuppression including pancytopenia, bone marrow failure, leukopenia, neutropenia, granulocytopenia" }

Hepatotoxicity: hepatitis, liver function disorder

{ "type": "p", "children": [], "text": "\nHepatotoxicity: hepatitis, liver function disorder" }

Renal toxicity: worsening of hematuria in a patient with pre-existing renal impairment, acute kidney injury, elevated creatinine

{ "type": "p", "children": [], "text": "\nRenal toxicity: worsening of hematuria in a patient with pre-existing renal impairment, acute kidney injury, elevated creatinine" }

Gastrointestinal toxicity: abdominal pain, diarrhea, vomiting

{ "type": "p", "children": [], "text": "\nGastrointestinal toxicity: abdominal pain, diarrhea, vomiting" }

Neurotoxicity: generalized tremor, seizure

{ "type": "p", "children": [], "text": "\nNeurotoxicity: generalized tremor, seizure" }

Valganciclovir Tablets, USP contains valganciclovir hydrochloride (valganciclovir HCl), a hydrochloride salt of the L-valyl ester of ganciclovir that exists as a mixture of two diastereomers. Ganciclovir is a synthetic guanine derivative active against CMV.

{ "type": "p", "children": [], "text": "\nValganciclovir Tablets, USP contains valganciclovir hydrochloride (valganciclovir HCl), a hydrochloride salt of the L-valyl ester of ganciclovir that exists as a mixture of two diastereomers. Ganciclovir is a synthetic guanine derivative active against CMV." }

Valganciclovir Tablets, USP is available as a 450 mg tablet for oral administration. Each tablet contains 496.3 mg of valganciclovir HCl (corresponding to 450 mg of valganciclovir), and the inactive ingredients colloidal silicon dioxide, crospovidone, microcrystalline cellulose, povidone K-30, and stearic acid. The film-coat applied to the tablets contains polyvinyl alcohol, titanium dioxide, polyethylene glycol, talc, and iron oxide red.

{ "type": "p", "children": [], "text": "Valganciclovir Tablets, USP is available as a 450 mg tablet for oral administration. Each tablet contains 496.3 mg of valganciclovir HCl (corresponding to 450 mg of valganciclovir), and the inactive ingredients colloidal silicon dioxide, crospovidone, microcrystalline cellulose, povidone K-30, and stearic acid. The film-coat applied to the tablets contains polyvinyl alcohol, titanium dioxide, polyethylene glycol, talc, and iron oxide red." }

Valganciclovir HCl is a white to off-white amorphous powder with a molecular formula of C14H22N6O5•HCl and a molecular weight of 390.83. The chemical name for valganciclovir HCl is L-Valine, 2-[(2-amino-1,6-dihydro-6-oxo-9H-purin-9-yl)methoxy]-3-hydroxypropyl ester, monohydrochloride. Valganciclovir HCl is a polar hydrophilic compound with a solubility of 70 mg/mL in water at 25°C at a pH of 7.0 and an n-octanol/water partition coefficient of 0.0095 at pH 7.0. The pKa for valganciclovir HCl is 7.6.

{ "type": "p", "children": [], "text": "Valganciclovir HCl is a white to off-white amorphous powder with a molecular formula of C14H22N6O5•HCl and a molecular weight of 390.83. The chemical name for valganciclovir HCl is L-Valine, 2-[(2-amino-1,6-dihydro-6-oxo-9H-purin-9-yl)methoxy]-3-hydroxypropyl ester, monohydrochloride. Valganciclovir HCl is a polar hydrophilic compound with a solubility of 70 mg/mL in water at 25°C at a pH of 7.0 and an n-octanol/water partition coefficient of 0.0095 at pH 7.0. The pKa for valganciclovir HCl is 7.6." }

The chemical structure of valganciclovir HCl is:

{ "type": "p", "children": [], "text": "The chemical structure of valganciclovir HCl is:" }

All doses in this insert are specified in terms of valganciclovir.

{ "type": "p", "children": [], "text": "\nAll doses in this insert are specified in terms of valganciclovir." }

Valganciclovir is an antiviral drug with activity against CMV [see Microbiology (12.4)].

Valganciclovir is a prodrug of ganciclovir. Valganciclovir Cmax and AUC are approximately 1% and 3% of those of ganciclovir, respectively.

Pharmacokinetics in Adults: The pharmacokinetics of ganciclovir after administration of valganciclovir tablets have been evaluated in HIV- and CMV-seropositive patients, patients with AIDS and CMV retinitis, and in solid organ transplant patients (Table 10).

<div class="scrollingtable"><table class="Noautorules" width="100%"> <caption> <span> Table 10 Ganciclovir Pharmacokinetics* in Healthy Volunteers and HIV-positive/CMV-positive Adults Administered Valganciclovir Tablets 900 mg Once Daily with Food </span> </caption> <col width="33%"/> <col width="33%"/> <col width="33%"/> <tfoot> <tr> <td align="left" colspan="3"> <p class="First Footnote">*Data were obtained from single and multiple dose studies in healthy volunteers, HIV-positive patients, and HIV-positive/CMV-positive patients with and without retinitis. Patients with CMV retinitis tended to have higher ganciclovir plasma concentrations than patients without CMV retinitis.</p> </td> </tr> </tfoot> <tbody class="Headless"> <tr> <td align="center" class="Botrule Lrule Rrule Toprule"><span class="Bold"> PK Parameter</span> <br/> </td><td align="center" class="Botrule Rrule Toprule"><span class="Bold"> N</span> <br/> </td><td align="center" class="Botrule Rrule Toprule"><span class="Bold"> Value (Mean ± SD</span> )<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">  AUC<span class="Sub">0-24h</span>(mcg∙h/mL)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 57<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 29.1 ± 9.7<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">  C<span class="Sub">max</span> (mcg/mL)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 58<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 5.61 ± 1.52<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Absolute oral bioavailability (%)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 32<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 59.4 ± 6.1<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Elimination half-life (hr)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 73<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 4.08 ± 0.76<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Renal clearance (mL/min/kg)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 20<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 3.21 ± 0.75<br/> (1study, n=20)<br/> </td> </tr> </tbody> </table></div>

The systemic ganciclovir exposures attained following administration of 900 mg valganciclovir tablets once daily were comparable across kidney, heart, and liver transplant recipients (Table 11).

<div class="scrollingtable"><table class="Noautorules" width="100%"> <caption> <span> Table 11 Ganciclovir Pharmacokinetics in Solid Organ Transplant Recipients Administered Valganciclovir Tablets 900 mg Once Daily with Food </span> </caption> <col width="25%"/> <col width="25%"/> <col width="25%"/> <col width="25%"/> <tfoot> <tr> <td align="left" colspan="4"> <p class="First Footnote">*Includes kidney-pancreas</p> </td> </tr> </tfoot> <tbody class="Headless"> <tr> <td align="center" class="Botrule Lrule Rrule Toprule" rowspan="2"><span class="Bold"> Parameter</span> <br/> </td><td align="center" class="Botrule Rrule Toprule" colspan="3"><span class="Bold"> Value (Mean ± SD)</span> <br/> </td> </tr> <tr> <td align="center" class="Botrule Rrule"><span class="Bold"> Heart Transplant Recipients</span> <br/> <span class="Bold"> (N=17)</span> <br/> </td><td align="center" class="Botrule Rrule"><span class="Bold"> Liver Transplant Recipients</span> <br/> <span class="Bold"> (N=75)</span> <br/> </td><td align="center" class="Botrule Rrule"><span class="Bold"> Kidney Transplant Recipients*</span> <br/> <span class="Bold"> (N=68)</span> <br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">  AUC<span class="Sub">0-24h</span>(mcg∙h/mL)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 40.2 ± 11.8<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 46.0 ± 16.1<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 48.2 ± 14.6<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">  C<span class="Sub">max</span> (mcg/mL)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 4.9 ± 1.1<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 5.4 ± 1.5<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 5.3 ± 1.5<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Elimination half-life (hr)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 6.58 ± 1.50<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 6.18 ± 1.42<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 6.77 ± 1.25<br/> </td> </tr> </tbody> </table></div>

The pharmacokinetic parameters of ganciclovir following 200 days of valganciclovir administration in high-risk kidney transplant patients were similar to those in solid organ transplant patients who received valganciclovir for 100 days.

Absorption, Distribution, Metabolism, and Excretion

The pharmacokinetic (PK) properties of valganciclovir are provided in Table 12.

<div class="scrollingtable"><table class="Noautorules" width="100%"> <caption> <span> Table 12 Pharmacokinetic Properties of Ganciclovir and Valganciclovir Associated with Valganciclovir Tablets </span> </caption> <col width="33%"/> <col width="33%"/> <col width="33%"/> <tfoot> <tr> <td align="left" colspan="3"> <p class="First Footnote"> <span class="Sup">a</span>Steady state ganciclovir PK was assessed after administration of valganciclovir tablets (875 mg once daily) with a high fat meal containing approximately 600 total calories (31.1 g fat, 51.6 g carbohydrates and 22.2 g protein) to 16 HIV-positive subjects.</p> </td> </tr> </tfoot> <tbody class="Headless"> <tr> <td class="Botrule Lrule Rrule Toprule" valign="top"></td><td align="left" class="Botrule Rrule Toprule" valign="top"><span class="Bold"> Valganciclovir</span> <br/> </td><td align="left" class="Botrule Rrule Toprule" valign="top"><span class="Bold"> Ganciclovir</span> <br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" colspan="3" valign="top"><span class="Bold">  Absorption</span> <br/> </td> </tr> <tr> <td align="left" class="Lrule Rrule" valign="top">  T<span class="Sub">max</span> (h)<br/> </td><td class="Rrule" valign="top"></td><td align="center" class="Rrule" valign="top"> 2.18<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Median (min-max)(fed conditions)<br/> </td><td class="Botrule Rrule" valign="top"></td><td align="center" class="Botrule Rrule" valign="top"> 1.7h to 3.0h<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Food effect (high fat meal/fasting): PK parameter ratio and 90% confidence interval<span class="Sup">a</span> <br/> </td><td class="Botrule Rrule" valign="top"></td><td align="center" class="Botrule Rrule"> C<span class="Sub">max</span>: 1.14 (0.95, 1.36)<br/> AUC: 1.30 (1.07, 1.51)<span class="Sup">a</span> <br/> T<span class="Sub">max</span><span class="Sup">: ↔</span> <br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" colspan="3" valign="top"><span class="Bold">  Distribution</span> <br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> % Bound to human plasma proteins (ex vivo)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> Unknown<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 1-2% over 0.5-51 mcg/mL<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Cerebrospinal fluid penetration<br/> </td><td align="center" class="Botrule Rrule" valign="top"> Unknown<br/> </td><td align="center" class="Botrule Rrule" valign="top"> Yes<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" colspan="3" valign="top">  <span class="Bold"> Metabolism</span> <br/> </td> </tr> <tr> <td class="Botrule Lrule Rrule" valign="top"></td><td align="center" class="Botrule Rrule" valign="top"> Hydrolyzed by intestinal and liver esterases<br/> </td><td align="center" class="Botrule Rrule" valign="top"> No significant metabolism<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" colspan="3" valign="top"><span class="Bold">  Elimination</span> <br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Dose proportionality<br/> </td><td class="Botrule Rrule" valign="top"></td><td align="center" class="Botrule Rrule" valign="top"> AUC was dose proportional under fed conditions across a valganciclovir dose range of 450 to 2625 mg<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Major route of elimination<br/> </td><td align="center" class="Botrule Rrule" valign="top"> Metabolism to ganciclovir<br/> </td><td align="center" class="Botrule Rrule" valign="top"> Glomerular filtration and active tubular secretion<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top">  t<span class="Sub">½</span> (h)<br/> </td><td class="Botrule Rrule" valign="top"></td><td align="center" class="Botrule Rrule" valign="top"> See Tables 10 and 11<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> % Of dose excreted in urine<br/> </td><td align="center" class="Botrule Rrule" colspan="2" valign="top"> Unknown<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> % Of dose excreted in feces<br/> </td><td align="center" class="Botrule Rrule" colspan="2" valign="top"> Unknown<br/> </td> </tr> </tbody> </table></div>

Specific Populations:

Renal Impairment: The pharmacokinetics of ganciclovir from a single oral dose of 900 mg valganciclovir tablets were evaluated in 24 otherwise healthy individuals with renal impairment. Decreased renal function results in decreased clearance of ganciclovir and increased terminal half-life (Table 13).

<div class="scrollingtable"><table class="Noautorules" width="100%"> <caption> <span> Table 13 Pharmacokinetics of Ganciclovir from a Single Oral Dose of 900 mg Valganciclovir Tablets </span> </caption> <col width="20%"/> <col width="20%"/> <col width="20%"/> <col width="20%"/> <col width="20%"/> <tfoot> <tr> <td align="left" colspan="5"> <p class="First Footnote">*Creatinine clearance calculated from 24-hour urine collection.</p> </td> </tr> </tfoot> <tbody class="Headless"> <tr> <td align="center" class="Botrule Lrule Rrule Toprule"><span class="Bold"> Estimated Creatinine Clearance* (mL/min)</span> <br/> </td><td align="center" class="Botrule Rrule Toprule"><span class="Bold"> N</span> <br/> </td><td align="center" class="Botrule Rrule Toprule"><span class="Bold"> Apparent Clearance</span> <br/> <span class="Bold"> (mL/min)</span> <br/> <span class="Bold"> Mean ± SD</span> <br/> </td><td align="center" class="Botrule Rrule Toprule"><span class="Bold"> AUC<span class="Sub">last</span></span> <br/> <span class="Bold"> (mcg∙h/mL) </span> <br/> <span class="Bold"> Mean ± SD</span> <br/> </td><td align="center" class="Botrule Rrule Toprule"><span class="Bold"> Half-life</span> <br/> <span class="Bold"> (hours) </span> <br/> <span class="Bold"> Mean ± SD</span> <br/> </td> </tr> <tr> <td align="center" class="Botrule Lrule Rrule" valign="top"> 51-70<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 6<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 249 ± 99<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 49.5 ± 22.4<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 4.85± 1.4<br/> </td> </tr> <tr> <td align="center" class="Botrule Lrule Rrule" valign="top"> 21-50<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 6<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 136 ± 64<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 91.9 ± 43.9<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 10.2 ± 4.4<br/> </td> </tr> <tr> <td align="center" class="Botrule Lrule Rrule" valign="top"> 11-20<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 6<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 45 ± 11<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 223 ± 46<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 21.8 ±5.2<br/> </td> </tr> <tr> <td align="center" class="Botrule Lrule Rrule" valign="top"> ≤ 10<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 6<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 12.8 ± 8<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 366 ± 66<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 67.5 ± 34<br/> </td> </tr> </tbody> </table></div>

Hemodialysis reduces plasma concentrations of ganciclovir by about 50% following valganciclovir administration. Adult patients receiving hemodialysis (CrCl less than 10 mL/min) cannot use valganciclovir tablets because the daily dose of valganciclovir tablets required for these patients is less than 450 mg [see Dosage and Administration (2.5) and Use in Specific Populations (8.6)].

Pharmacokinetics in Pediatric Patients: The pharmacokinetics of ganciclovir were evaluated following the administration of valganciclovir in 63 pediatric solid organ transplant patients aged 4 months to 16 years, and in 16 pediatric heart transplant patients less than 4 months of age. In these studies, patients received oral doses of valganciclovir (either valganciclovir for oral solution or tablets) to produce exposure equivalent to an adult 900 mg dose [see Dosage and Administration (2.3), Adverse Reactions (6.1), Use in Specific Populations (8.4), Clinical Studies (14.2)].

In studies using the pediatric valganciclovir dosing algorithm, the pharmacokinetics of ganciclovir were similar across organ types and age ranges (Table 14). Relative to adult transplant patients (Table 11), AUC values in pediatric patients were somewhat increased, but were within the range considered safe and effective in adults.

<div class="scrollingtable"><table class="Noautorules" width="100%"> <caption> <span> Table 14 Ganciclovir Pharmacokinetics by Age in Pediatric Solid Organ Transplant Patients Administered Valganciclovir Tablets </span> </caption> <col width="16%"/> <col width="25%"/> <col width="7%"/> <col width="16%"/> <col width="16%"/> <col width="16%"/> <tfoot> <tr> <td align="left" colspan="6"> <p class="First Footnote"> <span class="Sup">a</span>Ages ranged from 26 to 124 days.</p> </td> </tr> </tfoot> <tbody class="Headless"> <tr> <td align="center" class="Botrule Lrule Rrule Toprule" rowspan="2"><span class="Bold"> Organ</span> <br/> </td><td align="center" class="Botrule Toprule" rowspan="2"><span class="Bold"> PK Parameter</span> <br/> <span class="Bold"> Mean (SD)</span> <br/> </td><td align="center" class="Rrule Toprule" colspan="4"><span class="Bold"> Age Group</span> <br/> </td> </tr> <tr> <td align="center" class="Botrule"><span class="Bold"> &lt; 4 months</span> <br/> </td><td align="center" class="Botrule"><span class="Bold"> 4 months to</span> <br/> <span class="Bold"> ≤ 2 years</span> <br/> </td><td align="center" class="Botrule"><span class="Bold"> &gt; 2 to</span> <br/> <span class="Bold"> &lt; 12 years</span> <br/> </td><td align="center" class="Botrule Rrule"><span class="Bold"> ≥ 12 years</span> <br/> </td> </tr> <tr> <td align="center" class="Botrule Lrule" rowspan="4"><span class="Bold"> Heart</span> <br/> <span class="Bold"> (N=26)</span> <br/> </td><td align="center"> N<br/> </td><td align="center"> 14<span class="Sup">a</span> <br/> </td><td align="center"> 6<br/> </td><td align="center"> 2<br/> </td><td align="center" class="Rrule"> 4<br/> </td> </tr> <tr> <td align="center"> AUC<span class="Sub">0-24h</span>(mcg∙h/mL)<br/> </td><td align="center"> 66.3 (20.5)<br/> </td><td align="center"> 55.4 (22.8)<br/> </td><td align="center"> 59.6 (21.0)<br/> </td><td align="center" class="Rrule"> 60.6 (25.0)<br/> </td> </tr> <tr> <td align="center"> C<span class="Sub">max</span> (mcg/mL)<br/> </td><td align="center"> 10.8 (3.30)<br/> </td><td align="center"> 8.2 (2.5)<br/> </td><td align="center"> 12.5 (1.2)<br/> </td><td align="center" class="Rrule"> 9.5 (3.3)<br/> </td> </tr> <tr> <td align="center" class="Botrule"> t<span class="Sub">½</span> (h)<br/> </td><td align="center" class="Botrule"> 3.5 (0.87)<br/> </td><td align="center" class="Botrule"> 3.8 (1.7)<br/> </td><td align="center" class="Botrule"> 2.8 (0.9)<br/> </td><td align="center" class="Botrule Rrule"> 4.9 (0.8)<br/> </td> </tr> <tr> <td align="center" class="Botrule Lrule" rowspan="4"><span class="Bold"> Kidney</span> <br/> <span class="Bold"> (N=31)</span> <br/> </td><td align="center"> N<br/> </td><td align="center" class="Botrule" rowspan="4" valign="top"> NA<br/> </td><td align="center"> 2<br/> </td><td align="center"> 10<br/> </td><td align="center" class="Rrule"> 19<br/> </td> </tr> <tr> <td align="center"> AUC<span class="Sub">0-24h</span> (mcg∙h/mL)<br/> </td><td align="center"> 67.6 (13.0)<br/> </td><td align="center"> 55.9 (12.1)<br/> </td><td align="center" class="Rrule"> 47.8 (12.4)<br/> </td> </tr> <tr> <td align="center"> C<span class="Sub">max</span> (mcg/mL)<br/> </td><td align="center"> 10.4 (0.4)<br/> </td><td align="center"> 8.7 (2.1)<br/> </td><td align="center" class="Rrule"> 7.7 (2.1)<br/> </td> </tr> <tr> <td align="center" class="Botrule"> t<span class="Sub">½</span> (h)<br/> </td><td align="center" class="Botrule"> 4.5 (1.5)<br/> </td><td align="center" class="Botrule"> 4.8 (1.0)<br/> </td><td align="center" class="Botrule Rrule"> 6.0 (1.3)<br/> </td> </tr> <tr> <td align="center" class="Botrule Lrule" rowspan="4"><span class="Bold"> Liver</span> <br/> <span class="Bold"> (N=17)</span> <br/> </td><td align="center"> N<br/> </td><td align="center" class="Botrule" rowspan="4"> NA<br/> </td><td align="center"> 9<br/> </td><td align="center"> 6<br/> </td><td align="center" class="Rrule"> 2<br/> </td> </tr> <tr> <td align="center"> AUC<span class="Sub">0-24h</span> (mcg∙h/mL)<br/> </td><td align="center"> 69.9 (37.0)<br/> </td><td align="center"> 59.4 (8.1)<br/> </td><td align="center" class="Rrule"> 35.4 (2.8)<br/> </td> </tr> <tr> <td align="center"> C<span class="Sub">max</span> (mcg/mL)<br/> </td><td align="center"> 11.9 (3.7)<br/> </td><td align="center"> 9.5 (2.3)<br/> </td><td align="center" class="Rrule"> 5.5 (1.1)<br/> </td> </tr> <tr> <td align="center" class="Botrule"> t<span class="Sub">½</span> (h)<br/> </td><td align="center" class="Botrule"> 2.8 (1.5)<br/> </td><td align="center" class="Botrule"> 3.8 (0.7)<br/> </td><td align="center" class="Botrule Rrule"> 4.4 (0.2)<br/> </td> </tr> <tr> <td align="left" colspan="6" valign="top"> N=number of patients, NA=not applicable<br/> </td> </tr> </tbody> </table></div>

Pharmacokinetics in Geriatric Patients: The pharmacokinetic characteristics of valganciclovir in elderly patients have not been established.

Drug Interactions: In vivo drug-drug interaction studies were not conducted with valganciclovir. However, because valganciclovir is rapidly and extensively converted to ganciclovir, interactions associated with ganciclovir will be expected for valganciclovir [see Drug Interactions (7)].

Table 15 and Table 16 provide a listing of established drug interaction studies with ganciclovir. Table 15 provides the effects of coadministered drug on ganciclovir plasma pharmacokinetic parameters, whereas Table 16 provides the effects of ganciclovir on plasma pharmacokinetic parameters of coadministered drug.

<div class="scrollingtable"><table class="Noautorules" width="52%"> <caption> <span> Table 15 Results of Drug Interaction Studies with Ganciclovir: Effects of Coadministered Drug on Ganciclovir Pharmacokinetic Parameters </span> </caption> <col width="26%"/> <col width="23%"/> <col width="10%"/> <col width="38%"/> <tbody class="Headless"> <tr> <td align="center" class="Botrule Lrule Rrule Toprule"><span class="Bold"> Coadministered Drug</span> <br/> </td><td align="center" class="Botrule Rrule Toprule"><span class="Bold"> Ganciclovir Dosage</span> <br/> </td><td align="center" class="Botrule Rrule Toprule"><span class="Bold"> N</span> <br/> </td><td align="center" class="Botrule Rrule Toprule"><span class="Bold"> Ganciclovir Pharmacokinetic (PK) Parameter</span> <br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Mycophenolate mofetil (MMF) 1.5 g single dose<br/> </td><td align="left" class="Botrule Rrule" valign="top"> 5 mg/kg IV single dose<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 12<br/> </td><td align="left" class="Botrule Rrule" valign="top"> No effect on ganciclovir PK parameters observed (patients with normal renal function)<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Trimethoprim 200 mg once daily<br/> </td><td align="left" class="Botrule Rrule" valign="top"> 1000 mg every 8 hours<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 12<br/> </td><td align="left" class="Botrule Rrule" valign="top"> No effect on ganciclovir PK parameters observed<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" rowspan="2" valign="top"> Didanosine 200 mg every 12 hours simultaneously administered with ganciclovir<br/> </td><td align="left" class="Botrule Rrule" valign="top"> 5 mg/kg IV twice daily<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 11<br/> </td><td align="left" class="Botrule Rrule" valign="top"> No effect on ganciclovir PK parameters observed<br/> </td> </tr> <tr> <td align="left" class="Botrule Rrule" valign="top"> 5 mg/kg IV once daily<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 11<br/> </td><td align="left" class="Botrule Rrule" valign="top"> No effect on ganciclovir PK parameters observed<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Probenecid 500 mg every 6 hours<br/> </td><td align="left" class="Botrule Rrule" valign="top"> 1000 mg every 8 hours<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 10<br/> </td><td align="left" class="Botrule Rrule" valign="top"> AUC ↑ 53 ± 91%<br/>  (range: -14% to 299%)<br/> Ganciclovir renal clearance ↓ 22  ± 20% (range: -54% to -4%)<br/> </td> </tr> </tbody> </table></div>

<div class="scrollingtable"><table class="Noautorules" width="100%"> <caption> <span> Table 16 Results of Drug Interaction Studies with Ganciclovir: Effects of Ganciclovir on Pharmacokinetic Parameters of Coadministered Drug </span> </caption> <col width="25%"/> <col width="25%"/> <col width="6%"/> <col width="43%"/> <tbody class="Headless"> <tr> <td align="left" class="Botrule Lrule Rrule Toprule" valign="top"><span class="Bold"> Coadministered Drug</span> <br/> </td><td align="left" class="Botrule Rrule Toprule" valign="top"><span class="Bold"> Ganciclovir Dosage</span> <br/> </td><td align="left" class="Botrule Rrule Toprule" valign="top"><span class="Bold"> N</span> <br/> </td><td align="left" class="Botrule Rrule Toprule" valign="top"><span class="Bold"> Coadministered Drug Pharmacokinetic (PK) Parameter</span> <br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Oral cyclosporine at therapeutic doses<br/> </td><td align="left" class="Botrule Rrule" valign="top"> 5 mg/kg infused over 1 hour every 12 hours<br/> </td><td align="left" class="Botrule Rrule" valign="top"> 93<br/> </td><td align="left" class="Botrule Rrule" valign="top"> In a retrospective analysis of liver allograft recipients, there was no evidence of an effect on cyclosporine whole blood concentrations.<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Mycophenolate mofetil (MMF) 1.5 g single dose<br/> </td><td align="left" class="Botrule Rrule" valign="top"> 5 mg/kg IV single dose<br/> </td><td align="left" class="Botrule Rrule" valign="top"> 12<br/> </td><td align="left" class="Botrule Rrule" valign="top"> No PK interaction observed (patients with normal renal function)<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Trimethoprim 200 mg once daily<br/> </td><td align="left" class="Botrule Rrule" valign="top"> 1000 mg every 8 hours<br/> </td><td align="left" class="Botrule Rrule" valign="top"> 12<br/> </td><td align="left" class="Botrule Rrule" valign="top"> No effect on trimethoprim PK parameters observed<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Didanosine 200 mg every <br/>  12 hours<br/> </td><td align="left" class="Botrule Rrule" valign="top"> 5 mg/kg IV twice daily<br/> </td><td align="left" class="Botrule Rrule" valign="top"> 11<br/> </td><td align="left" class="Botrule Rrule" valign="top">   AUC<span class="Sub">0-12</span> ↑70 ± 40% (range: 3% to 121%)<br/> C<span class="Sub">max</span>↑49 ± 48% (range: -28% to 125%)<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Didanosine 200 mg every <br/>  12 hours<br/> </td><td align="left" class="Botrule Rrule" valign="top"> 5 mg/kg IV once daily<br/> </td><td align="left" class="Botrule Rrule" valign="top"> 11<br/> </td><td align="left" class="Botrule Rrule" valign="top"> AUC<span class="Sub">0-12</span> ↑50 ± 26% (range: 22% to 110%)<br/> C<span class="Sub">max</span>↑36 ± 36% (range: -27% to 94%)<br/> </td> </tr> </tbody> </table></div>

Mechanism of Action: Valganciclovir is an L-valyl ester (prodrug) of ganciclovir that exists as a mixture of two diastereomers. After oral administration, both diastereomers are rapidly converted to ganciclovir by intestinal and hepatic esterases. Ganciclovir is a synthetic analogue of 2'-deoxyguanosine, which inhibits replication of human CMV in cell culture and in vivo.

In CMV-infected cells, ganciclovir is initially phosphorylated to ganciclovir monophosphate by the viral protein kinase, pUL97. Further phosphorylation occurs by cellular kinases to produce ganciclovir triphosphate, which is then slowly metabolized intracellularly (half-life 18 hours). As the phosphorylation is largely dependent on the viral kinase, phosphorylation of ganciclovir occurs preferentially in virus-infected cells. The virustatic activity of ganciclovir is due to inhibition of the viral DNA polymerase, pUL54 by ganciclovir triphosphate.

Antiviral Activity: The quantitative relationship between the cell culture susceptibility of human herpes viruses to antivirals and clinical response to antiviral therapy has not been established, and virus sensitivity testing has not been standardized. Sensitivity test results, expressed as the concentration of drug required to inhibit the growth of virus in cell culture by 50% (EC50), vary greatly depending upon a number of factors including the assay used. Thus, the reported EC50 values of ganciclovir that inhibit human CMV replication in cell culture (laboratory and clinical isolates) have ranged from 0.08 to 22.94 μM (0.02 to 5.75 mcg/mL). The distribution and range in susceptibility observed in one assay evaluating 130 clinical isolates was 0 to 1 μM (35%), 1.1 to 2 μM (20%), 2.1 to 3 μM (27%), 3.1 to 4 μM (13%), 4.1 to 5 μM (5%), less than 5 μM (less than 1%). Ganciclovir inhibits mammalian cell proliferation (CC50 ) in cell culture at higher concentrations ranging from 40 to greater than 1,000 μM (10.21 to greater than 250 mcg/mL). Bone marrow-derived colony-forming cells are more sensitive [CC50 value = 2.7 to 12 μM (0.69 to 3.06 mcg/mL)].

Viral Resistance:

 Cell culture: CMV isolates with reduced susceptibility to ganciclovir have been selected in cell culture. Growth of CMV strains in the presence of ganciclovir resulted in the selection of amino acid substitutions in the viral protein kinase pUL97 (M460I/V, L595S, G598D, and K599T) and the viral DNA polymerase pUL54 (D301N, N410K, F412V, P488R, L516R, C539R, L545S, F595I, V812L, P829S, L862F, D879G, and V946L).

In vivo: Viruses resistant to ganciclovir can arise after prolonged treatment or prophylaxis with valganciclovir by selection of substitutions in pUL97 and/or pUL54. Limited clinical data are available on the development of clinical resistance to ganciclovir and many pathways to resistance likely exist. In clinical isolates, seven canonical pUL97 substitutions, (M460V/I, H520Q, C592G, A594V, L595S, and C603W) are the most frequently reported ganciclovir resistance-associated substitutions. These and other substitutions less frequently reported in the literature, or observed in clinical trials, are listed in Table 17.

<div class="scrollingtable"><table class="Noautorules" width="100%"> <caption> <span> Table 17 Summary of Resistance-associated Amino Acid Substitutions Observed in the CMV of Patients Failing Ganciclovir Treatment or Prophylaxis </span> </caption> <col width="50%"/> <col width="50%"/> <tbody class="Headless"> <tr> <td align="left" class="Botrule Lrule Rrule Toprule" valign="top"> pUL97 <br/> </td><td align="left" class="Botrule Rrule Toprule" valign="top"> F342Y, K359E/Q, L405P, A440V, M460I/V/T/L, V466G/M, C480F, C518Y, H520Q, P521L, del 590-593, A591D/V, C592F/G, A594E/G/T/V/P, L595F/S/T/W, del 595, del 595-603, E596D/G/Y, K599E/M, del 600-601, del 597-600, del 601-603, C603W/R/S/Y, C607F/S/Y, I610T, A613V<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> pUL54 <br/> </td><td align="left" class="Botrule Rrule" valign="top"> E315D, N408D/K/S, F412C/L/S, D413A/E/N, L501F/I, T503I, K513E/N/R, D515E, L516W, I521T, P522A/L/S, V526L, C539G, L545S/W, Q578H/L, D588E/N, G629S, S695T, I726T/V, E756K, L773V, V781I, V787E/L, L802M, A809V, T813S, T821I, A834P, G841A/S, D879G, A972V, del 981-982, A987G<br/> </td> </tr> <tr> <td align="left" colspan="2" valign="top"> Note: Many additional pathways to ganciclovir resistance likely exist<br/> </td> </tr> </tbody> </table></div>

The presence of known ganciclovir resistance-associated amino acid substitutions was evaluated in a study that extended valganciclovir CMV prophylaxis from 100 days to 200 days post-transplant in adult kidney transplant patients at high risk for CMV disease (D+/R-) [see Clinical Studies (14.1)]. Five subjects from the 100 day group and four subjects from the 200 day group meeting the resistance analysis criteria had known ganciclovir resistance-associated amino acid substitutions detected. In six subjects, the following resistance-associated amino acid substitutions were detected within pUL97: 100-day group: A440V, M460V, C592G; 200 day group: M460V, C603W. In three subjects, the following resistance-associated amino acid substitutions were detected within pUL54: 100 day group: E315D, 200 day group: E315D, P522S. Overall, the detection of known ganciclovir resistance-associated amino acid substitutions was observed more frequently in patients during prophylaxis therapy than after the completion of prophylaxis therapy (during therapy: 5/12 [42%] versus after therapy: 4/58 [7%]). The possibility of viral resistance should be considered in patients who show poor clinical response or experience persistent viral excretion during therapy.

Cross-Resistance: Cross-resistance has been reported for amino acid substitutions selected in cell culture by ganciclovir, cidofovir or foscarnet. In general, amino acid substitutions in pUL54 conferring cross-resistance to ganciclovir and cidofovir are located within the exonuclease domains and region V of the viral DNA polymerase. Whereas, amino acid substitutions conferring cross-resistance to foscarnet are diverse, but concentrate at and between regions II (codon 696-742) and III (codon 805-845). The amino acid substitutions that resulted in reduced susceptibility to ganciclovir and either cidofovir and/or foscarnet are summarized in Table 18.

Substitutions at amino acid positions pUL97 340-400 have been found to confer resistance to ganciclovir. Resistance data based on assays that do not include this region should be interpreted cautiously.

<div class="scrollingtable"><table class="Noautorules" width="100%"> <caption> <span> Table 18 Summary of pUL54 Amino Acid Substitutions with Cross-Resistance between Ganciclovir, Cidofovir, and/or Foscarnet </span> </caption> <col width="50%"/> <col width="50%"/> <tbody class="Headless"> <tr> <td align="left" class="Botrule Lrule Rrule Toprule" valign="top"><span class="Bold"> Cross-resistant to cidofovir</span> <br/> </td><td align="left" class="Botrule Rrule Toprule" valign="top"> D301N, N408D/K, N410K, F412C/L/S/V, D413E/N, P488R, L501I, T503I, K513E/N, L516R/W, I521T, P522S/A, V526L, C539G/R, L545S/W, Q578H, D588N, I726T/V, E756K, L733V, V787E, V812L, T813S, A834P, G841A, del 981-982, A987G<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"><span class="Bold"> Cross-resistant to foscarnet</span> <br/> </td><td align="left" class="Botrule Rrule" valign="top"> F412C, Q578H/L, D588N, V715A/M, E756K, L776M, V781I, V787E/L, L802M, A809V, V812L, T813S, T821I, A834P, G841A/S, del 981-982<br/> </td> </tr> </tbody> </table></div>

Long-term carcinogenicity studies have not been conducted with valganciclovir. However, upon oral administration, valganciclovir is rapidly and extensively converted to ganciclovir. Therefore, like ganciclovir, valganciclovir is a potential carcinogen.

Ganciclovir was carcinogenic in the mouse at oral doses that produced exposures approximately 0.1x and 1.4x, respectively, the mean drug exposure in humans following the recommended intravenous dose of 5 mg/kg, based on area under the plasma concentration curve (AUC) comparisons. At the higher dose, there was a significant increase in the incidence of tumors of the preputial gland in males, forestomach (nonglandular mucosa) in males and females, and reproductive tissues (ovaries, uterus, mammary gland, clitoral gland and vagina) and liver in females. At the lower dose, a slightly increased incidence of tumors was noted in the preputial and harderian glands in males, forestomach in males and females, and liver in females. Ganciclovir should be considered a potential carcinogen in humans.

Valganciclovir increases mutations in mouse lymphoma cells. In the mouse micronucleus assay, valganciclovir was clastogenic. Valganciclovir was not mutagenic in the Ames Salmonella assay. Ganciclovir increased mutations in mouse lymphoma cells and DNA damage in human lymphocytes in vitro. In the mouse micronucleus assay, ganciclovir was clastogenic. Ganciclovir was not mutagenic in the Ames Salmonella assay.

Valganciclovir is converted to ganciclovir and therefore is expected to have similar reproductive toxicity effects as ganciclovir [see Warnings and Precautions (5.3)]. Ganciclovir caused decreased mating behavior, decreased fertility, and an increased incidence of embryolethality in female mice following intravenous doses that produced an exposure approximately 1.7x the mean drug exposure in humans following the dose of 5 mg per kg, based on AUC comparisons. Ganciclovir caused decreased fertility in male mice and hypospermatogenesis in mice and dogs following daily oral or intravenous administration. Systemic drug exposure (AUC) at the lowest dose showing toxicity in each species ranged from 0.03 to 0.1x the AUC of the recommended human intravenous dose. Valganciclovir caused similar effects on spermatogenesis in mice, rats, and dogs. These effects were reversible at lower doses but irreversible at higher doses. It is considered likely that ganciclovir (and valganciclovir) could cause temporary or permanent inhibition of human spermatogenesis.

Induction Therapy of CMV Retinitis: In one randomized open-label controlled study, 160 patients with AIDS and newly diagnosed CMV retinitis were randomized to receive treatment with either valganciclovir tablets (900 mg twice daily for 21 days, then 900 mg once daily for 7 days) or with intravenous ganciclovir solution (5 mg per kg twice daily for 21 days, then 5 mg per kg once daily for 7 days). Study participants were: male (91%), White (53%), Hispanic (31%), and Black (11%). The median age was 39 years, the median baseline HIV-1 RNA was 4.9 log10, and the median CD4 cell count was 23 cells/mm3. A determination of CMV retinitis progression by the masked review of retinal photographs taken at baseline and Week 4 was the primary outcome measurement of the 3-week induction therapy. Table 19 provides the outcomes at 4 weeks.

<div class="scrollingtable"><table class="Noautorules" width="100%"> <caption> <span> Table 19 Week 4 Masked Review of Retinal Photographs in CMV Retinitis Study </span> </caption> <col width="33%"/> <col width="33%"/> <col width="33%"/> <tbody class="Headless"> <tr> <td class="Botrule Lrule Rrule Toprule" valign="top"></td><td align="center" class="Botrule Rrule Toprule" valign="top"><span class="Bold"> Intravenous Ganciclovir</span> <br/> </td><td align="center" class="Botrule Rrule Toprule" valign="top"><span class="Bold"> Valganciclovir Tablets</span> <br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Determination of CMV retinitis progression at Week 4<br/> </td><td align="center" class="Botrule Rrule" valign="top"> N=80<br/> </td><td align="center" class="Botrule Rrule" valign="top"> N=80<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Progressor<br/> Non-progressor<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 7<br/> 63<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 7<br/> 64<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Death<br/> Discontinuations due to Adverse Events<br/> Failed to return<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 2<br/> 1<br/> 1<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 1<br/> 2<br/> 1<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> CMV not confirmed at baseline or no interpretable baseline photos<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 6<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 5<br/> </td> </tr> </tbody> </table></div>

Maintenance Therapy of CMV Retinitis: No comparative clinical data are available on the efficacy of valganciclovir tablets for the maintenance therapy of CMV retinitis because all patients in the CMV retinitis study received open-label valganciclovir tablets after Week 4. However, the AUC for ganciclovir is similar following administration of 900 mg valganciclovir tablets once daily and 5 mg per kg intravenous ganciclovir once daily. Although the ganciclovir Cmax is lower following valganciclovir tablets administration compared to intravenous ganciclovir, it is higher than the Cmax obtained following oral ganciclovir administration. Therefore, use of valganciclovir tablets as maintenance therapy is supported by a plasma concentration-time profile similar to that of two approved products for maintenance therapy of CMV retinitis.

Prevention of CMV Disease in Heart, Kidney, Kidney-Pancreas, or Liver Transplantation: A doubleblind, double-dummy active comparator study was conducted in 372 heart, liver, kidney, or kidney-pancreas transplant patients at high risk for CMV disease (D+/R-). Patients were randomized (2 valganciclovir: 1 oral ganciclovir) to receive either valganciclovir tablets (900 mg once daily) or oral ganciclovir (1000 mg three times a day) starting within 10 days of transplantation until Day 100 post-transplant. The proportion of patients who developed CMV disease, including CMV syndrome and/or tissue-invasive disease during the first 6 months post-transplant was similar between the valganciclovir tablets arm (12.1%, N=239) and the oral ganciclovir arm (15.2%, N=125). However, in liver transplant patients, the incidence of tissue-invasive CMV disease was significantly higher in the valganciclovir group compared with the ganciclovir group. These results are summarized in Table 20.

Mortality at six months was 3.7% (9/244) in the valganciclovir group and 1.6% (2/126) in the oral ganciclovir group.

<div class="scrollingtable"><table class="Noautorules" width="100%"> <caption> <span> Table 20 Percentage of Patients with CMV Disease, Tissue-Invasive CMV Disease or CMV Syndrome by Organ Type: Endpoint Committee, 6 Month ITT Population </span> </caption> <col width="14%"/> <col width="14%"/> <col width="14%"/> <col width="14%"/> <col width="14%"/> <col width="14%"/> <col width="14%"/> <tfoot> <tr> <td align="left" colspan="7"> <p class="First Footnote">GCV = oral ganciclovir; VGCV = valganciclovir</p> </td> </tr> <tr> <td align="left" colspan="7"> <p class="First Footnote"> <span class="Sup">1</span>Number of patients with CMV disease = Number of patients with tissue-invasive CMV disease or CMV syndrome</p> </td> </tr> <tr> <td align="left" colspan="7"> <p class="First Footnote"> <span class="Sup">2</span>CMV syndrome was defined as evidence of CMV viremia accompanied with fever greater than or equal to 38°C on two or more occasions separated by at least 24 hours within a 7-day period and one or more of the following: malaise, leukopenia, atypical lymphocytosis, thrombocytopenia, and elevation of hepatic transaminases</p> </td> </tr> </tfoot> <tbody class="Headless"> <tr> <td align="center" class="Botrule Lrule Rrule Toprule" rowspan="2"><span class="Bold"> Organ</span> <br/> </td><td align="center" class="Botrule Rrule Toprule" colspan="2" valign="top"><span class="Bold"> CMV Disease<span class="Sup">1</span></span> <br/> </td><td align="center" class="Botrule Rrule Toprule" colspan="2" valign="top"><span class="Bold"> Tissue-Invasive CMV Disease</span> <br/> </td><td align="center" class="Botrule Rrule Toprule" colspan="2" valign="top"><span class="Bold"> CMV Syndrome<span class="Sup">2</span></span> <br/> </td> </tr> <tr> <td align="center" class="Botrule Rrule" valign="top"> VGCV<br/> (N=239)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> GCV<br/> (N=125)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> VGCV<br/> (N=239)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> GCV<br/> (N=125)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> VGCV<br/> (N=239)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> GCV<br/> (N=125)<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Liver<br/> (n=177)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 19%<br/> (22/118)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 12%<br/> (7/59)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 14%<br/> (16/118)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 3%<br/> (2/59)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 5%<br/> (6/118)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 8%<br/> (5/59)<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Kidney<br/> (n=120)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 6%<br/> (5/81)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 23%<br/> (9/39)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 1%<br/> (1/81)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 5%<br/> (2/39)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 5%<br/> (4/81)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 18%<br/> (7/39)<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Heart<br/> (n=56)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 6%<br/> (2/35)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 10%<br/> (2/21)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 0%<br/> (0/35)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 5%<br/> (1/21)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 6%<br/> (2/35)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 5%<br/> (1/21)<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Kidney / Pancreas<br/> (n=11)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 0%<br/> (0/5)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 17%<br/> (1/6)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 0%<br/> (0/5)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 17%<br/> (1/6)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 0%<br/> (0/5)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 0%<br/> (0/6)<br/> </td> </tr> </tbody> </table></div>

Prevention of CMV Disease in Kidney Transplantation: A double-blind, placebo-controlled study was conducted in 326 kidney transplant patients at high risk for CMV disease (D+/R-) to assess the efficacy and safety of extending valganciclovir CMV prophylaxis from 100 to 200 days post-transplant. Patients were randomized (1:1) to receive valganciclovir tablets (900 mg once daily) within 10 days of transplantation either until Day 200 post-transplant or until Day 100 post-transplant followed by 100 days of placebo. Extending CMV prophylaxis with valganciclovir until Day 200 post-transplant demonstrated superiority in preventing CMV disease within the first 12 months post-transplant in high risk kidney transplant patients compared to the 100 day dosing regimen (primary endpoint). These results are summarized in Table 21.

<div class="scrollingtable"><table class="Noautorules" width="100%"> <caption> <span> Table 21 Percentage of Kidney Transplant Patients with CMV Disease, Tissue-Invasive CMV Disease or CMV Syndrome, 12 Month ITT Population </span> </caption> <col width="14%"/> <col width="14%"/> <col width="14%"/> <col width="14%"/> <col width="14%"/> <col width="14%"/> <col width="14%"/> <tfoot> <tr> <td align="left" colspan="7"> <dl class="Footnote"> <dt> <a href="#footnote-reference-1" name="footnote-1">*</a> </dt> <dd>Number of patients with CMV disease = Number of patients with tissue-invasive CMV disease or CMV syndrome</dd> <dt> <a href="#footnote-reference-2" name="footnote-2">†</a> </dt> <dd>CMV syndrome was defined as evidence of CMV viremia accompanied with at least one of the following: fever (greater than or equal to 38°C), severe malaise, leukopenia, atypical lymphocytosis, thrombocytopenia, and elevation of hepatic transaminases</dd> <dt> <a href="#footnote-reference-3" name="footnote-3">‡</a> </dt> <dd>Two patients in the 100 day group had both tissue-invasive CMV disease and CMV syndrome; however, these patients are counted as having only tissue-invasive CMV disease.</dd> </dl> </td> </tr> </tfoot> <tbody class="Headless"> <tr> <td class="Botrule Lrule Rrule Toprule" valign="top"></td><td align="center" class="Botrule Rrule Toprule" colspan="2" valign="top">  <span class="Bold"> CMV Disease<a class="Sup" href="#footnote-1" name="footnote-reference-1">*</a></span> <br/> </td><td align="center" class="Botrule Rrule Toprule" colspan="2" valign="top">  <span class="Bold"> Tissue-Invasive CMV Disease</span> <br/> </td><td align="center" class="Botrule Rrule Toprule" colspan="2" valign="top"><span class="Bold"> CMV Syndrome<a class="Sup" href="#footnote-2" name="footnote-reference-2">†</a></span> <br/> </td> </tr> <tr> <td class="Botrule Lrule Rrule" valign="top"></td><td align="left" class="Botrule Rrule" valign="top"> 100 Days<br/> VGCV<br/> (N=163)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 200 Days<br/> VGCV<br/> (N=155)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 100 Days<br/> VGCV<br/> (N=163)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 200 Days<br/> VGCV<br/> (N=155)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 100 Days<br/> VGCV<br/> (N=163)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 200 Days<br/> VGCV<br/> (N=155)<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"> Cases<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 36.8%<br/> (60/163)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 16.8%<br/> (26/155)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 1.8%<br/> (3/163)<a class="Sup" href="#footnote-3" name="footnote-reference-3">‡</a> <br/> </td><td align="center" class="Botrule Rrule" valign="top"> 0.6%<br/> (1/155)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 35.0%<br/> (57/163)<br/> </td><td align="center" class="Botrule Rrule" valign="top"> 16.1%<br/> (25/155)<br/> </td> </tr> <tr> <td align="left" colspan="7" valign="top"> VGCV = valganciclovir<br/> </td> </tr> </tbody> </table></div>

The percentage of kidney transplant patients with CMV disease at 24 months post-transplant was 38.7% (63/163) for the 100 day dosing regimen and 21.3% (33/155) for the 200 day dosing regimen.

Prevention of CMV in Pediatric Heart, Kidney, or Liver Transplantation: Sixty-three children, 4 months to 16 years of age, who had a solid organ transplant (kidney 33, liver 17, heart 12, and kidney/liver 1) and were at risk for developing CMV disease, were enrolled in an open-label, safety, and pharmacokinetic study of oral valganciclovir (valganciclovir for oral solution or tablets). Patients received valganciclovir once daily within 10 days after transplant until a maximum of 100 days post-transplant. The daily doses of valganciclovir were calculated at each study visit based on body surface area and a modified creatinine clearance [see Dosage and Administration (2.3)].

The pharmacokinetics of ganciclovir were similar across organ transplant types and age ranges. The mean daily ganciclovir exposures in pediatric patients were somewhat increased relative to those observed in adult solid organ transplant patients receiving valganciclovir 900 mg once daily, but were within the range considered safe and effective in adults [see Clinical Pharmacology (12.3)]. No case of CMV syndrome or tissue-invasive CMV disease was reported within the first six months post-transplantation.

Prevention of CMV in Pediatric Kidney Transplantation: Fifty-seven children, 1 to 16 years of age, who had a renal transplant and were at risk for developing CMV disease, were enrolled in an open-label tolerability study of oral valganciclovir (valganciclovir for oral solution or tablets). Patients received valganciclovir once daily within 10 days after transplant until a maximum of 200 days post-transplant. The daily doses of valganciclovir were calculated at each study visit based on body surface area and a modified creatinine clearance [see Dosage and Administration (2.3)]. No case of CMV syndrome or tissue-invasive CMV disease was reported within the first 12 months post-transplantation.

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Valganciclovir Tablets, USP: Supplied as 450 mg, pink, convex oval tablets with "E114" on one side and plain on the other side. Each film-coated tablet contains 450 mg of valganciclovir as valganciclovir hydrochloride. Valganciclovir Tablets, USP, is supplied in bottles of 60 tablets (NDC 64380-161-01).

{ "type": "p", "children": [], "text": "\nValganciclovir Tablets, USP: Supplied as 450 mg, pink, convex oval tablets with \"E114\" on one side and plain on the other side. Each film-coated tablet contains 450 mg of valganciclovir as valganciclovir hydrochloride. Valganciclovir Tablets, USP, is supplied in bottles of 60 tablets (NDC 64380-161-01)." }

Store at 25°C (77°F); excursions permitted to 15°C to 30°C (59°F to 86°F) [See USP controlled room temperature].

{ "type": "p", "children": [], "text": "Store at 25°C (77°F); excursions permitted to 15°C to 30°C (59°F to 86°F) [See USP controlled room temperature]." }

Advise the patient to read the FDA-approved patient labeling (Patient Information and Instructions for Use).

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Serious Adverse Reactions

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Inform patients that valganciclovir may cause granulocytopenia (neutropenia), anemia, thrombocytopenia and elevated creatinine levels and that dose modification or discontinuation of dosing may be required. Complete blood counts, platelet counts, and creatinine levels should be monitored frequently during treatment [see Warnings and Precautions (5.1)].

{ "type": "p", "children": [], "text": "Inform patients that valganciclovir may cause granulocytopenia (neutropenia), anemia, thrombocytopenia and elevated creatinine levels and that dose modification or discontinuation of dosing may be required. Complete blood counts, platelet counts, and creatinine levels should be monitored frequently during treatment [see Warnings and Precautions (5.1)]." }

Pregnancy and Contraception

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Inform females of reproductive potential that valganciclovir causes birth defects in animals. Advise them to use effective contraception during and for at least 30 days following treatment with valganciclovir. Similarly, advise males to use condoms during and for at least 90 days following treatment with valganciclovir [see Use in Specific Populations (8.1, 8.3)].

{ "type": "p", "children": [], "text": "Inform females of reproductive potential that valganciclovir causes birth defects in animals. Advise them to use effective contraception during and for at least 30 days following treatment with valganciclovir. Similarly, advise males to use condoms during and for at least 90 days following treatment with valganciclovir [see Use in Specific Populations (8.1, 8.3)]." }

Carcinogenicity

{ "type": "p", "children": [], "text": "\nCarcinogenicity\n" }

Advise patients that valganciclovir is considered a potential carcinogen [see Nonclinical Toxicity (13.1)].

{ "type": "p", "children": [], "text": "Advise patients that valganciclovir is considered a potential carcinogen [see Nonclinical Toxicity (13.1)]." }

Lactation

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Advise mothers not to breast-feed if they are receiving valganciclovir because of the potential for hematologic toxicity and cancer in nursing infants, and because HIV can be passed to the baby in breast milk [see Use in Specific Populations (8.2)].

{ "type": "p", "children": [], "text": "Advise mothers not to breast-feed if they are receiving valganciclovir because of the potential for hematologic toxicity and cancer in nursing infants, and because HIV can be passed to the baby in breast milk [see Use in Specific Populations (8.2)]." }

Infertility

{ "type": "p", "children": [], "text": "\nInfertility\n" }

Advise patients that valganciclovir may cause temporary or permanent female and male infertility [see Warnings and Precautions (5.3), Use in Specific Populations (8.3)].

{ "type": "p", "children": [], "text": "Advise patients that valganciclovir may cause temporary or permanent female and male infertility [see Warnings and Precautions (5.3), Use in Specific Populations (8.3)]." }

Impairment of Cognitive Ability

{ "type": "p", "children": [], "text": "\nImpairment of Cognitive Ability\n" }

Inform patients that tasks requiring alertness may be affected including the patient's ability to drive and operate machinery as seizures, dizziness, and/or confusion have been reported with the use of valganciclovir [see Adverse Reactions (6.1)].

{ "type": "p", "children": [], "text": "Inform patients that tasks requiring alertness may be affected including the patient's ability to drive and operate machinery as seizures, dizziness, and/or confusion have been reported with the use of valganciclovir [see Adverse Reactions (6.1)]." }

Use in Patients with CMV Retinitis

{ "type": "p", "children": [], "text": "\nUse in Patients with CMV Retinitis\n" }

Inform patients that valganciclovir is not a cure for CMV retinitis, and they may continue to experience progression of retinitis during or following treatment. Advise patients to have ophthalmologic follow-up examinations at a minimum of every 4 to 6 weeks while being treated with valganciclovir. Some patients will require more frequent follow-up.

{ "type": "p", "children": [], "text": "Inform patients that valganciclovir is not a cure for CMV retinitis, and they may continue to experience progression of retinitis during or following treatment. Advise patients to have ophthalmologic follow-up examinations at a minimum of every 4 to 6 weeks while being treated with valganciclovir. Some patients will require more frequent follow-up." }

Administration

{ "type": "p", "children": [], "text": "\nAdministration\n" }

Inform adult patients that they should use valganciclovir tablets, not valganciclovir for oral solution [see Dosage and Administration (2.1)].

{ "type": "p", "children": [], "text": "Inform adult patients that they should use valganciclovir tablets, not valganciclovir for oral solution [see Dosage and Administration (2.1)]." }

Inform patients to take valganciclovir with food to maximize bioavailability.

{ "type": "p", "children": [], "text": "Inform patients to take valganciclovir with food to maximize bioavailability." }

For more information, go to www.strides.com or call 1-877-244-9825

{ "type": "p", "children": [], "text": "For more information, go to www.strides.com or call 1-877-244-9825" }

Distributed by:

{ "type": "p", "children": [], "text": "Distributed by:" }

Strides Pharma Inc.

{ "type": "p", "children": [], "text": "\nStrides Pharma Inc. \n" }

East Brunswick, NJ 08816

{ "type": "p", "children": [], "text": "East Brunswick, NJ 08816" }

Issued: 03/2025                                                                                                

{ "type": "p", "children": [], "text": "Issued: 03/2025                                                                                                " }

<div class="scrollingtable"><table class="Noautorules" width="638"> <col width="638"/> <tbody class="Headless"> <tr> <td align="left" class="Botrule Lrule Rrule Toprule" valign="top"><span class="Bold"> PATIENT INFORMATION</span> <br/> <span class="Bold">  Valganciclovir (val'gan-si'klo-vir) Tablets</span> <br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"><span class="Bold"> What is the most important information I should know about valganciclovir? </span> <br/> <span class="Bold"> Valganciclovir can cause serious side effects, including:</span> <br/> • <span class="Bold"> Blood and bone marrow problems. </span> Valganciclovir can affect the bone marrow lowering the amount of your white blood cells, red blood cells, and platelets and may cause serious and life-threatening problems. <br/> • <span class="Bold"> Kidney failure. </span> Kidney failure may happen in people who are elderly, people who take valganciclovir with certain other medicines, or people who are not adequately hydrated.<br/>  • <span class="Bold"> Fertility problems. </span> Valganciclovir may lower sperm count in males and cause fertility problems. Valganciclovir may also cause fertility problems in women. Talk to your healthcare provider if this is a concern for you. <br/> • <span class="Bold"> Birth defects. </span> Valganciclovir causes birth defects in animals. It is not known if valganciclovir causes birth defects in people. If you are a female who can become pregnant, you should use effective birth control during treatment with valganciclovir and for at least 30 days after treatment. <span class="Bold"> If you are pregnant, talk to your healthcare provider before starting treatment with valganciclovir. If you are a female who can become pregnant, you should have a pregnancy test done before starting valganciclovir. </span> <br/> <ul class="Disc"> <li>Tell your healthcare provider right away if you become pregnant during treatment with valganciclovir.</li> <li>Males should use condoms during treatment with valganciclovir, and for at least 90 days after treatment, if their female sexual partner can become pregnant. Talk to your healthcare provider if you have questions about birth control.</li> </ul>  • <span class="Bold"> Cancer. </span> Valganciclovir causes cancer in animals and may potentially cause cancer in people. <br/> <span class="Bold"> Your healthcare provider will do regular blood tests during treatment with valganciclovir to check you for side effects. Your healthcare provider may change your dose or stop treatment with valganciclovir if you have serious side effects.</span> <br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"><span class="Bold"> What is valganciclovir? </span> <br/> Valganciclovir is a prescription antiviral medicine.<br/>  <span class="Bold"> In adults, valganciclovir tablets are used: </span> <br/> • to treat cytomegalovirus (CMV) retinitis in people who have acquired immunodeficiency syndrome (AIDS). When CMV virus infects the eyes, it is called CMV retinitis. If CMV retinitis is not treated, it can cause blindness. <br/> • to prevent CMV disease in people who have received a <span class="Bold"> kidney, heart, or kidney-pancreas </span> transplant and who have a high risk for getting CMV disease. <br/> <span class="Bold"> Valganciclovir does not cure CMV retinitis. </span> You may still get retinitis or worsening of retinitis during or after treatment with valganciclovir. It is important to stay under a healthcare provider's care and have your eyes checked at least every 4 to 6 weeks during treatment with valganciclovir.<br/>  <span class="Bold"> In children, valganciclovir tablets or oral solution are used: </span> <br/> • to prevent CMV disease in children 4 months to 16 years of age who have received a <span class="Bold"> kidney </span> transplant and have a high risk for getting CMV disease.<br/>  • to prevent CMV disease in children 1 month to 16 years of age who have received a <span class="Bold"> heart </span> transplant and have a high risk for getting CMV disease. <br/> It is not known if valganciclovir is safe and effective in children for prevention of CMV disease in liver transplant, in kidney transplant in infants less than 4 months of age, in heart transplant in infants less than 1 month of age, in children with AIDS who have CMV retinitis, and in infants with congenital CMV infection.<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"><span class="Bold"> Do not take valganciclovir if you have had a serious allergic reaction to valganciclovir, ganciclovir or any of the ingredients of valganciclovir. </span> See the end of this leaflet for a list of the ingredients in Valganciclovir.<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"><span class="Bold"> Before you take valganciclovir, tell your healthcare provider about all of your medical conditions, including if you:</span> <br/> <span class="Bold">  </span> • have low blood cell counts<br/>  • have kidney problems <br/> • are receiving hemodialysis <br/> • are receiving radiation treatment <br/> • are pregnant or plan to become pregnant. <span class="Bold"> See "What is the most important information I should know about valganciclovir?" </span> <br/> • are breastfeeding or plan to breastfeed. It is not known if valganciclovir passes into your breast milk. You should not breastfeed if you take valganciclovir. <br/> <ul class="Disc"> <li>You should not breastfeed if you have Human Immunodeficiency Virus (HIV-1) because of the risk of passing HIV-1 to your baby. </li> <li>Talk to your healthcare provider about the best way to feed your baby.</li> </ul> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"><span class="Bold"> Tell your healthcare provider about all the medicines you take, </span> including prescription and over-the-counter medicines, vitamins and herbal supplements. Valganciclovir and other medicines may affect each other and cause serious side effects. Keep a list of your medicines to show your healthcare provider and pharmacist. <br/> •     You can ask your healthcare provider or pharmacist for a list of medicines that interact with  valganciclovir.<br/> •<span class="Bold">      Do not start taking a new medicine without telling your healthcare provider.</span> Your healthcare provider can tell you if it is safe to take valganciclovir with other medicines.<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"><span class="Bold"> How should I take valganciclovir? </span> <br/> •      Take valganciclovir exactly as your healthcare provider tells you. Your dose of valganciclovir will depend on your medical condition.<br/> •      Adults should only take valganciclovir tablets. Children may take either valganciclovir tablets or oral solution. <br/> •      Take valganciclovir with food. <br/> •      Do not break or crush valganciclovir tablets. Avoid contact with your skin or eyes. If you come in contact with the contents of the tablet or oral solution, wash your skin well with soap and water or rinse your eyes well with plain water. <br/> •      If you take too much valganciclovir, call your healthcare provider or go to the nearest hospital emergency room right away.<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"><span class="Bold"> What should I avoid during treatment with valganciclovir? </span> <br/> Valganciclovir can cause seizures, dizziness, and confusion. You should not drive a car or operate machinery until you know how valganciclovir affects you.<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"><span class="Bold"> What are the possible side effects of valganciclovir? </span> <br/> Valganciclovir may cause serious side effects, including: <br/> See <span class="Bold"> "What is the most important information I should know about valganciclovir?" </span> <br/> <span class="Bold"> The most common side effects of valganciclovir in adults include: </span> <br/> • diarrhea                                       • low white cell, red cell and platelet cell counts in blood tests <br/> • fever                                                   • headache <br/> • fatigue                                                • sleeplessness <br/> • nausea                                                • urinary tract infection <br/> • shaky movements (tremors)         • vomiting <br/> <span class="Bold"> The most common side effects of valganciclovir in children include: </span> <br/> • diarrhea                                                  • vomiting <br/> • fever                                                        • low white blood cell counts in blood tests <br/> • upper respiratory tract infection      • headache <br/> • urinary tract infection <br/> These are not all the possible side effects of valganciclovir. <br/> Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"><span class="Bold"> How should I store valganciclovir? </span> <br/> • Store valganciclovir tablets at room temperature between 59°F to 86°F (15°C to 30°C). <br/> • Do not keep valganciclovir tablets that are out of date or that you no longer need. <br/> <span class="Bold"> Keep valganciclovir and all medicines out of the reach of children.</span> <br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"><span class="Bold"> General information about the safe and effective use of valganciclovir. </span> <br/> Medicines are sometimes prescribed for purposes other than those listed in a Patient Information leaflet. Do not use valganciclovir for a condition for which it was not prescribed. Do not give valganciclovir to other people, even if they have the same symptoms you have. It may harm them. You can ask your pharmacist or healthcare provider for information about valganciclovir that is written for health professionals<br/> </td> </tr> <tr> <td align="left" class="Botrule Lrule Rrule" valign="top"><span class="Bold"> What are the ingredients in valganciclovir? </span> <br/> <span class="Bold"> Active ingredient: </span> valganciclovir hydrochloride<br/> <span class="Bold"> Inactive ingredients for tablets: </span> colloidal silicon dioxide, crospovidone, microcrystalline cellulose, povidone K-30, and stearic acid. The film-coating applied to the tablets contains polyvinyl alcohol, titanium dioxide, polyethylene glycol, talc, and iron oxide red.<br/> </td> </tr> </tbody> </table></div>

{ "type": "table", "children": [], "text": "<div class=\"scrollingtable\"><table class=\"Noautorules\" width=\"638\">\n<col width=\"638\"/>\n<tbody class=\"Headless\">\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule Toprule\" valign=\"top\"><span class=\"Bold\"> PATIENT INFORMATION</span>\n<br/>\n<span class=\"Bold\">  Valganciclovir (val'gan-si'klo-vir) Tablets</span>\n<br/>\n</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Bold\"> What is the most important information I should know about valganciclovir? </span>\n<br/>\n<span class=\"Bold\"> Valganciclovir can cause serious side effects, including:</span>\n<br/> • <span class=\"Bold\"> Blood and bone marrow problems. </span> Valganciclovir can affect the bone marrow lowering the amount of your white blood cells, red blood cells, and platelets and may cause serious and life-threatening problems. <br/> • <span class=\"Bold\"> Kidney failure. </span> Kidney failure may happen in people who are elderly, people who take valganciclovir with certain other medicines, or people who are not adequately hydrated.<br/>  • <span class=\"Bold\"> Fertility problems. </span> Valganciclovir may lower sperm count in males and cause fertility problems. Valganciclovir may also cause fertility problems in women. Talk to your healthcare provider if this is a concern for you. <br/> • <span class=\"Bold\"> Birth defects. </span> Valganciclovir causes birth defects in animals. It is not known if valganciclovir causes birth defects in people. If you are a female who can become pregnant, you should use effective birth control during treatment with valganciclovir and for at least 30 days after treatment. <span class=\"Bold\"> If you are pregnant, talk to your healthcare provider before starting treatment with valganciclovir. If you are a female who can become pregnant, you should have a pregnancy test done before starting valganciclovir. </span>\n<br/>\n<ul class=\"Disc\">\n<li>Tell your healthcare provider right away if you become pregnant during treatment with valganciclovir.</li>\n<li>Males should use condoms during treatment with valganciclovir, and for at least 90 days after treatment, if their female sexual partner can become pregnant. Talk to your healthcare provider if you have questions about birth control.</li>\n</ul>\n  • <span class=\"Bold\"> Cancer. </span> Valganciclovir causes cancer in animals and may potentially cause cancer in people. <br/>\n<span class=\"Bold\"> Your healthcare provider will do regular blood tests during treatment with valganciclovir to check you for side effects. Your healthcare provider may change your dose or stop treatment with valganciclovir if you have serious side effects.</span>\n<br/>\n</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Bold\"> What is valganciclovir? </span>\n<br/> Valganciclovir is a prescription antiviral medicine.<br/>  <span class=\"Bold\"> In adults, valganciclovir tablets are used: </span>\n<br/> • to treat cytomegalovirus (CMV) retinitis in people who have acquired immunodeficiency syndrome (AIDS). When CMV virus infects the eyes, it is called CMV retinitis. If CMV retinitis is not treated, it can cause blindness. <br/> • to prevent CMV disease in people who have received a <span class=\"Bold\"> kidney, heart, or kidney-pancreas </span> transplant and who have a high risk for getting CMV disease. <br/>\n<span class=\"Bold\"> Valganciclovir does not cure CMV retinitis. </span> You may still get retinitis or worsening of retinitis during or after treatment with valganciclovir. It is important to stay under a healthcare provider's care and have your eyes checked at least every 4 to 6 weeks during treatment with valganciclovir.<br/>  <span class=\"Bold\"> In children, valganciclovir tablets or oral solution are used: </span>\n<br/> • to prevent CMV disease in children 4 months to 16 years of age who have received a <span class=\"Bold\"> kidney </span> transplant and have a high risk for getting CMV disease.<br/>  • to prevent CMV disease in children 1 month to 16 years of age who have received a <span class=\"Bold\"> heart </span> transplant and have a high risk for getting CMV disease. <br/> It is not known if valganciclovir is safe and effective in children for prevention of CMV disease in liver transplant, in kidney transplant in infants less than 4 months of age, in heart transplant in infants less than 1 month of age, in children with AIDS who have CMV retinitis, and in infants with congenital CMV infection.<br/>\n</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Bold\"> Do not take valganciclovir if you have had a serious allergic reaction to valganciclovir, ganciclovir or any of the ingredients of valganciclovir. </span> See the end of this leaflet for a list of the ingredients in Valganciclovir.<br/>\n</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Bold\"> Before you take valganciclovir, tell your healthcare provider about all of your medical conditions, including if you:</span>\n<br/>\n<span class=\"Bold\">  </span> • have low blood cell counts<br/>  • have kidney problems <br/> • are receiving hemodialysis <br/> • are receiving radiation treatment <br/> • are pregnant or plan to become pregnant. <span class=\"Bold\"> See \"What is the most important information I should know about valganciclovir?\" </span>\n<br/> • are breastfeeding or plan to breastfeed. It is not known if valganciclovir passes into your breast milk. You should not breastfeed if you take valganciclovir. <br/>\n<ul class=\"Disc\">\n<li>You should not breastfeed if you have Human Immunodeficiency Virus (HIV-1) because of the risk of passing HIV-1 to your baby. </li>\n<li>Talk to your healthcare provider about the best way to feed your baby.</li>\n</ul>\n</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Bold\"> Tell your healthcare provider about all the medicines you take, </span> including prescription and over-the-counter medicines, vitamins and herbal supplements. Valganciclovir and other medicines may affect each other and cause serious side effects. Keep a list of your medicines to show your healthcare provider and pharmacist. <br/> •     You can ask your healthcare provider or pharmacist for a list of medicines that interact with  valganciclovir.<br/> •<span class=\"Bold\">      Do not start taking a new medicine without telling your healthcare provider.</span> Your healthcare provider can tell you if it is safe to take valganciclovir with other medicines.<br/>\n</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Bold\"> How should I take valganciclovir? </span>\n<br/> •      Take valganciclovir exactly as your healthcare provider tells you. Your dose of valganciclovir will depend on your medical condition.<br/> •      Adults should only take valganciclovir tablets. Children may take either valganciclovir tablets or oral solution. <br/> •      Take valganciclovir with food. <br/> •      Do not break or crush valganciclovir tablets. Avoid contact with your skin or eyes. If you come in contact with the contents of the tablet or oral solution, wash your skin well with soap and water or rinse your eyes well with plain water. <br/> •      If you take too much valganciclovir, call your healthcare provider or go to the nearest hospital emergency room right away.<br/>\n</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Bold\"> What should I avoid during treatment with valganciclovir? </span>\n<br/> Valganciclovir can cause seizures, dizziness, and confusion. You should not drive a car or operate machinery until you know how valganciclovir affects you.<br/>\n</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Bold\"> What are the possible side effects of valganciclovir? </span>\n<br/> Valganciclovir may cause serious side effects, including: <br/> See <span class=\"Bold\"> \"What is the most important information I should know about valganciclovir?\" </span>\n<br/>\n<span class=\"Bold\"> The most common side effects of valganciclovir in adults include: </span>\n<br/> • diarrhea                                       • low white cell, red cell and platelet cell counts in blood tests <br/> • fever                                                   • headache <br/> • fatigue                                                • sleeplessness <br/> • nausea                                                • urinary tract infection <br/> • shaky movements (tremors)         • vomiting <br/>\n<span class=\"Bold\"> The most common side effects of valganciclovir in children include: </span>\n<br/> • diarrhea                                                  • vomiting <br/> • fever                                                        • low white blood cell counts in blood tests <br/> • upper respiratory tract infection      • headache <br/> • urinary tract infection <br/> These are not all the possible side effects of valganciclovir. <br/> Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.<br/>\n</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Bold\"> How should I store valganciclovir? </span>\n<br/> • Store valganciclovir tablets at room temperature between 59°F to 86°F (15°C to 30°C). <br/> • Do not keep valganciclovir tablets that are out of date or that you no longer need. <br/>\n<span class=\"Bold\"> Keep valganciclovir and all medicines out of the reach of children.</span>\n<br/>\n</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Bold\"> General information about the safe and effective use of valganciclovir. </span>\n<br/> Medicines are sometimes prescribed for purposes other than those listed in a Patient Information leaflet. Do not use valganciclovir for a condition for which it was not prescribed. Do not give valganciclovir to other people, even if they have the same symptoms you have. It may harm them. You can ask your pharmacist or healthcare provider for information about valganciclovir that is written for health professionals<br/>\n</td>\n</tr>\n<tr>\n<td align=\"left\" class=\"Botrule Lrule Rrule\" valign=\"top\"><span class=\"Bold\"> What are the ingredients in valganciclovir? </span>\n<br/>\n<span class=\"Bold\"> Active ingredient: </span> valganciclovir hydrochloride<br/>\n<span class=\"Bold\"> Inactive ingredients for tablets: </span> colloidal silicon dioxide, crospovidone, microcrystalline cellulose, povidone K-30, and stearic acid. The film-coating applied to the tablets contains polyvinyl alcohol, titanium dioxide, polyethylene glycol, talc, and iron oxide red.<br/>\n</td>\n</tr>\n</tbody>\n</table></div>" }

For more information, go to www.strides.com or call 1-877-244-9825.

{ "type": "p", "children": [], "text": "\nFor more information, go to www.strides.com or call 1-877-244-9825." }

Distributed by:

{ "type": "p", "children": [], "text": "Distributed by: " }

Strides Pharma Inc.

{ "type": "p", "children": [], "text": "\nStrides Pharma Inc. \n" }

East Brunswick, NJ 08816

{ "type": "p", "children": [], "text": "East Brunswick, NJ 08816" }

Revised: 03/2025

{ "type": "p", "children": [], "text": "Revised: 03/2025" }