These Highlights Do Not Include All The Information Needed To Use Tascenso Odt®

Cardiac Evaluation

Obtain a cardiac evaluation in patients with certain preexisting conditions [see Dosage and Administration (2.4) and Warnings and Precautions (5.1)].

Prior to starting treatment, determine whether patients are taking drugs that could slow heart rate or atrioventricular (AV) conduction [see Dosage and Administration (2.4), Drug Interactions (7.5)].

The efficacy of fingolimod was demonstrated in 2 studies that evaluated once-daily doses of fingolimod capsules 0.5 mg and 1.25 mg in patients with relapsing-remitting MS (RRMS). Both studies included patients who had experienced at least 2 clinical relapses during the 2 years prior to randomization or at least 1 clinical relapse during the 1 year prior to randomization and had an Expanded Disability Status Scale (EDSS) score from 0 to 5.5. Study 1 was a 2-year randomized, double-blind, placebo-controlled study in patients with RRMS who had not received any interferon-beta or glatiramer acetate for at least the previous 3 months and had not received any natalizumab for at least the previous 6 months. Neurological evaluations were performed at screening, every 3 months and at time of suspected relapse. MRI evaluations were performed at screening, Month 6, Month 12, and Month 24. The primary endpoint was the annualized relapse rate.

Median age was 37 years, median disease duration was 6.7 years and median EDSS score at baseline was 2.0. Patients were randomized to receive fingolimod 0.5 mg (N = 425), 1.25 mg (N = 429), or placebo (N = 418) for up to 24 months. Median time on study drug was 717 days on 0.5 mg, 715 days on 1.25 mg, and 719 days on placebo.

The annualized relapse rate was significantly lower in patients treated with fingolimod than in patients who received placebo. The secondary endpoint was the time to 3-month confirmed disability progression as measured by at least a 1-point increase from baseline in EDSS (0.5-point increase for patients with baseline EDSS of 5.5) sustained for 3 months. Time to onset of 3-month confirmed disability progression was significantly delayed with fingolimod treatment compared to placebo. The 1.25 mg dose resulted in no additional benefit over the fingolimod 0.5 mg dose. The results for this study are shown in Table 2 and Figure 1.

Abbreviation: CI, confidence interval.

All analyses of clinical endpoints were intent-to-treat. MRI analysis used evaluable dataset.

^§Hazard ratio is an estimate of the relative risk of having the event of disability progression on fingolimod as compared to placebo.

Figure 1: Time to 3-Month Confirmed Disability Progression - Study 1 (ITT population)

Study 2 was a 1-year randomized, double-blind, double-dummy, active-controlled study in patients with RRMS who had not received any natalizumab in the previous 6 months. Prior therapy with interferon-beta or glatiramer acetate up to the time of randomization was permitted.

Neurological evaluations were performed at screening, every 3 months, and at the time of suspected relapses. MRI evaluations were performed at screening and at Month 12. The primary endpoint was the annualized relapse rate.

Median age was 36 years, median disease duration was 5.9 years, and median EDSS score at baseline was 2.0. Patients were randomized to receive fingolimod capsules 0.5 mg (N = 431), 1.25 mg (N = 426), or interferon beta-1a, 30 mcg via the intramuscular route (IM) once-weekly (N = 435) for up to 12 months. Median time on study drug was 365 days on fingolimod 0.5 mg, 354 days on 1.25 mg, and 361 days on interferon beta-1a IM.

The annualized relapse rate was significantly lower in patients treated with fingolimod 0.5 mg than in patients who received interferon beta-1a IM. The key secondary endpoints were number of new and newly enlarging T2 lesions and time to onset of 3-month confirmed disability progression as measured by at least a 1-point increase from baseline in EDSS (0.5-point increase for those with baseline EDSS of 5.5) sustained for 3 months. The number of new and newly enlarging T2 lesions was significantly lower in patients treated with fingolimod than in patients who received interferon beta-1a IM. There was no significant difference in the time to 3-month confirmed disability progression between fingolimod and interferon beta-1a-treated patients at 1 year. The 1.25 mg dose resulted in no additional benefit over the fingolimod 0.5 mg dose. The results for this study are shown in Table 3.

Abbreviation: CI, confidence interval.

All analyses of clinical endpoints were intent-to-treat. MRI analysis used evaluable dataset.

^§Hazard ratio is an estimate of the relative risk of having the event of disability progression on fingolimod as compared to control.

Pooled results of Study 1 and Study 2 showed a consistent and statistically significant reduction of annualized relapse rate compared to comparator in subgroups defined by gender, age, prior MS therapy, and disease activity.

TASCENSO ODT reduces the immune response to vaccination. Vaccination may be less effective during and for up to 2 months after discontinuation of treatment with TASCENSO ODT [see Clinical Pharmacology (12.2)]. Avoid the use of live attenuated vaccines during and for 2 months after treatment with TASCENSO ODT because of the risk of infection.

It is recommended that pediatric patients, if possible, be brought up to date with all immunizations in agreement with current immunization guidelines prior to initiating TASCENSO ODT therapy.

Fingolimod, the active moiety in TASCENSO ODT, can induce bradycardia as well as AV conduction blocks (including complete AV block). The decline in heart rate usually starts within 1 hour of the first dose and is maximal within 6 hours in most patients [see Warnings and Precautions (5.1)]. In case of TASCENSO ODT overdosage, observe patients overnight with continuous ECG monitoring in a medical facility, and obtain regular measurements of blood pressure. [see Dosage and Administration (2.4)].

Neither dialysis nor plasma exchange results in removal of fingolimod from the body.

Fingolimod is a sphingosine 1-phosphate receptor modulator.

Chemically, fingolimod lauryl sulfate is 2-amino-2-[2-(4-octylphenyl)ethyl]propan-1,3-diol lauryl sulfate. Its structure is shown below:

Fingolimod lauryl sulfate is a white to practically white powder that is practically insoluble in water. It has a molecular weight of 573.87 g/mol.

TASCENSO ODT is provided as 0.25 mg and 0.5 mg orally disintegrating tablets for oral use.

Each orally disintegrating tablet contains 0.25 mg or 0.5 mg of fingolimod (equivalent to 0.47 mg or 0.93 mg of fingolimod lauryl sulfate) and the following inactive ingredients: gelatin, mannitol, medium-chain triglycerides, sodium chloride, and sodium lauryl sulfate.

TASCENSO ODT may cause fetal harm when administered to a pregnant woman.

In animal reproduction studies conducted in rats and rabbits, developmental toxicity was observed with administration of fingolimod at doses less than the recommended human dose.

Available observational pregnancy registry data suggest that use of fingolimod is associated with an increased prevalence of major birth defects in comparison to the general population.

Advise pregnant women and females of reproductive potential of the potential risk to a fetus. Because it takes approximately 2 months to eliminate fingolimod from the body, advise females of reproductive potential to use effective contraception to avoid pregnancy during and for 2 months after stopping TASCENSO ODT treatment [see Use in Specific Populations (8.1, 8.3)].

Clinically significant liver injury has occurred in patients treated with fingolimod in the postmarketing setting. Signs of liver injury, including markedly elevated serum hepatic enzymes and elevated total bilirubin, have occurred as early as ten days after the first dose and have also been reported after prolonged use. Cases of acute liver failure requiring liver transplant have been reported.

In 2-year placebo-controlled clinical trials in adult patients, elevation of liver enzymes (ALT, AST and GGT) to 3-fold the upper limit of normal (ULN) or greater occurred in 14% of patients treated with fingolimod 0.5 mg capsules and 3% of patients on placebo. Elevations 5-fold the ULN or greater occurred in 4.5% of patients on fingolimod capsules and 1% of patients on placebo. The majority of elevations occurred within 6 to 9 months. In clinical trials, fingolimod capsules were discontinued if the elevation exceeded 5 times the ULN. Serum transaminase levels returned to normal within approximately 2 months after discontinuation of fingolimod capsules. Recurrence of liver transaminase elevations occurred with rechallenge in some patients.

Prior to starting treatment with TASCENSO ODT (within 6 months), obtain serum transaminases (ALT and AST) and total bilirubin levels. Obtain transaminase levels and total bilirubin levels periodically until two months after TASCENSO ODT discontinuation. Patients should be monitored for signs and symptoms of any hepatic injury. Measure liver transaminase and bilirubin levels promptly in patients who report symptoms that may indicate liver injury, including new or worsening fatigue, anorexia, right upper abdominal discomfort, dark urine, or jaundice. In this clinical context, if the patient is found to have an alanine aminotransferase (ALT) greater than three times the reference range with serum total bilirubin greater than two times the reference range, treatment with TASCENSO ODT should be interrupted. Treatment should not be resumed if a plausible alternative etiology for the signs and symptoms cannot be established, because these patients are at risk of severe drug-induced liver injury.

Because fingolimod exposure is doubled in patients with severe hepatic impairment, these patients should be closely monitored during treatment with TASCENSO ODT, as the risk of adverse reactions is greater [see Use in Specific Populations (8.6), Clinical Pharmacology (12.3)].

The blood levels of fingolimod and fingolimod-phosphate are increased by 1.7-fold when used concomitantly with ketoconazole. Patients who use TASCENSO ODT and systemic ketoconazole concomitantly should be closely monitored, as the risk of adverse reactions is greater.

0.25 mg TASCENSO ODT orally disintegrating tablets are supplied as follows:



White to off-white, round, orally disintegrating tablet debossed with 

Carton of 30 orally disintegrating tablets containing 3 blister cards of 10 orally disintegrating tablets per blister card

NDC 70709-062-30 

0.5 mg TASCENSO ODT orally disintegrating tablets are supplied as follows:

White to off-white, round, orally disintegrating tablet debossed with 

Carton of 30 orally disintegrating tablets containing 3 blister cards of 10 orally disintegrating tablets per blister card

NDC 70709-065-30

S1P receptor modulators, including TASCENSO ODT, have been associated with an increased risk of macular edema. Obtain a baseline evaluation of the fundus, including the macula, near the start of treatment with TASCENSO ODT. Perform an examination of the fundus, including the macula, 3 to 4 months after starting treatment, periodically while on therapy, and any time there is a change in vision.

A dose-dependent increase in the risk of macular edema occurred in the fingolimod capsules clinical development program.

In 2-year double-blind, placebo-controlled studies in adult patients with multiple sclerosis, macular edema with or without visual symptoms occurred in 1.5% of patients (11/799) treated with fingolimod 1.25 mg capsules, 0.5% of patients (4/783) treated with fingolimod 0.5 mg capsules, and 0.4% of patients (3/773) treated with placebo. Macular edema occurred predominantly during the first 3 to 4 months of therapy. These clinical trials excluded patients with diabetes mellitus, a known risk factor for macular edema (see below Macular Edema in Patients with History of Uveitis or Diabetes Mellitus). Symptoms of macular edema included blurred vision and decreased visual acuity. Routine ophthalmological examination detected macular edema in some patients with no visual symptoms. Macular edema generally partially or completely resolved with or without treatment after drug discontinuation. Some patients had residual visual acuity loss even after resolution of macular edema. Macular edema has also been reported in patients taking fingolimod in the postmarketing setting, usually within the first 6 months of treatment.

Continuation of TASCENSO ODT in patients who develop macular edema has not been evaluated. Macular edema over an extended period of time (i.e., 6 months) can lead to permanent visual loss. Consider discontinuing TASCENSO ODT if macular edema develops; this decision should include an assessment of the potential benefits and risks for the individual patient. The risk of recurrence after rechallenge has not been evaluated.

Safety and effectiveness of fingolimod for the treatment of relapsing forms of multiple sclerosis in pediatric patients 10 to less than 18 years of age were established in one randomized, double-blind clinical study in 215 patients (fingolimod n = 107; intramuscular interferon (IFN) beta-1a n = 108) [see Clinical Studies (14.2)].

In the controlled pediatric study, the safety profile in pediatric patients (10 to less than 18 years of age) receiving fingolimod 0.25 mg or 0.5 mg capsules daily was similar to that seen in adult patients. In the pediatric study, cases of seizures were reported in 5.6% of fingolimod-treated patients and 0.9% of interferon beta-1a-treated patients.

It is recommended that pediatric patients, if possible, complete all immunizations in accordance with current immunization guidelines prior to initiating TASCENSO ODT therapy.

Safety and effectiveness of TASCENSO ODT in pediatric patients below the age of 10 years have not been established.

Clinical MS studies of fingolimod capsules did not include sufficient numbers of patients aged 65 years and over to determine whether they respond differently than younger patients. TASCENSO ODT should be used with caution in patients aged 65 years and over, reflecting the greater frequency of decreased hepatic, or renal, function and of concomitant disease or other drug therapy.

The efficacy of TASCENSO ODT is based on the relative bioavailability of TASCENSO ODT orally disintegrating tablets compared to fingolimod capsules in healthy adults [see Clinical Pharmacology (12.3)].

The clinical studies described below were conducted using fingolimod capsules.

TASCENSO ODT is contraindicated in patients who have:

• In the last 6 months experienced myocardial infarction, unstable angina, stroke, TIA, decompensated heart failure requiring hospitalization or Class III/IV heart failure.
• A history or presence of Mobitz Type II second-degree or third-degree AV block or sick sinus syndrome, unless patient has a functioning pacemaker [see Warnings and Precautions (5.1)]
• A baseline QTc interval ≥ 500 msec
• Cardiac arrhythmias requiring anti-arrhythmic treatment with Class Ia or Class III anti-arrhythmic drugs
• Had a hypersensitivity reaction to fingolimod or any of the excipients in TASCENSO ODT. Observed reactions include rash, urticaria, and angioedema [see Warnings and Precautions (5.14)].
• Concomitant use with other products containing fingolimod

The following serious adverse reactions are described elsewhere in labeling:

• Bradyarrhythmia and Atrioventricular Blocks [see Warnings and Precautions (5.1)]
• Infections [see Warnings and Precautions (5.2)]
• Progressive Multifocal Leukoencephalopathy [see Warnings and Precautions (5.3)]
• Macular Edema [see Warnings and Precautions (5.4)]
• Liver Injury [see Warnings and Precautions (5.5)]
• Posterior Reversible Encephalopathy Syndrome [see Warnings and Precautions (5.6)]
• Respiratory Effects [see Warnings and Precautions (5.7)]
• Fetal Risk [see Warnings and Precautions (5.8)]
• Severe Increase in Disability After Stopping TASCENSO ODT [see Warnings and Precautions (5.9)]
• Tumefactive Multiple Sclerosis [see Warnings and Precautions (5.10)]
• Increased Blood Pressure [see Warnings and Precautions (5.11)]
• Malignancies [see Warnings and Precautions (5.12)]
• Immune System Effects Following TASCENSO ODT Discontinuation [see Warnings and Precautions (5.13)]
• Hypersensitivity Reactions [see Warnings and Precautions (5.14)]

• Systemic Ketoconazole: Monitor during concomitant use. (7.2, 12.3)
• Vaccines: Avoid live attenuated vaccines during, and for 2 months after stopping TASCENSO ODT treatment. (5.3, 7.3)

The blood level of some fingolimod metabolites is increased (up to 13-fold) in patients with severe renal impairment [see Clinical Pharmacology (12.3)]. The toxicity of these metabolites has not been fully explored. The blood level of these metabolites has not been assessed in patients with mild or moderate renal impairment.

In adults and pediatric patients 10 years of age and older weighing more than 40 kg, the recommended dosage of TASCENSO ODT is 0.5 mg orally once-daily.

In pediatric patients 10 years of age and older weighing less than or equal to 40 kg, the recommended dosage of TASCENSO ODT is 0.25 mg orally once daily.

Fingolimod doses higher than 0.5 mg are associated with a greater incidence of adverse reactions without additional benefit.

Because fingolimod, but not fingolimod-phosphate, exposure is doubled in patients with severe hepatic impairment, patients with severe hepatic impairment should be closely monitored, as the risk of adverse reactions may be greater [see Warnings and Precautions (5.6) , Clinical Pharmacology (12.3)].

No dose adjustment is needed in patients with mild or moderate hepatic impairment.

TASCENSO ODT is indicated for the treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in patients 10 years of age and older.

Dose-dependent reductions in forced expiratory volume over 1 second (FEV1) and diffusion lung capacity for carbon monoxide (DLCO) were observed in patients treated with fingolimod, the active moiety in TASCENSO ODT, as early as 1 month after treatment initiation. In 2-year placebo-controlled trials in adult patients, the reduction from baseline in the percent of predicted values for FEV1 at the time of last assessment on drug was 2.8% for fingolimod 0.5 mg capsules and 1.0% for placebo. For DLCO, the reduction from baseline in percent of predicted values at the time of last assessment on drug was 3.3% for fingolimod 0.5 mg capsules and 0.5% for placebo. The changes in FEV1 appear to be reversible after treatment discontinuation. There is insufficient information to determine the reversibility of the decrease of DLCO after drug discontinuation. In MS placebo-controlled trials in adult patients, dyspnea was reported in 9% of patients receiving fingolimod 0.5 mg capsules and 7% of patients receiving placebo. Several patients discontinued fingolimod capsules because of unexplained dyspnea during the extension (uncontrolled) studies. Fingolimod, the active moiety in TASCENSO ODT, has not been tested in MS patients with compromised respiratory function.

Spirometric evaluation of respiratory function and evaluation of DLCO should be performed during therapy with TASCENSO ODT if clinically indicated.

TASCENSO ODT has not been studied in patients treated with drugs that prolong the QT interval. Drugs that prolong the QT interval have been associated with cases of torsades de pointes in patients with bradycardia. Since initiation of TASCENSO ODT treatment results in decreased heart rate and may prolong the QT interval, patients on QT prolonging drugs with a known risk of torsades de pointes (e.g., citalopram, chlorpromazine, haloperidol, methadone, erythromycin) should be monitored overnight with continuous ECG in a medical facility [see Dosage and Administration (2.4) , Warnings and Precautions (5.1)].

Fingolimod is metabolized by sphingosine kinase to the active metabolite, fingolimod-phosphate. Fingolimod phosphate is a sphingosine 1-phosphate receptor modulator and binds with high affinity to sphingosine 1-phosphate receptors 1, 3, 4, and 5. Fingolimod-phosphate blocks the capacity of lymphocytes to egress from lymph nodes, reducing the number of lymphocytes in peripheral blood. The mechanism by which fingolimod exerts therapeutic effects in multiple sclerosis is unknown but may involve reduction of lymphocyte migration into the central nervous system.

TASCENSO ODT should be stored at 20°C to 25°C (68°F to 77°F); excursions permitted to 15°C to 30°C (59°F to 86°F). Protect from moisture. Store in sealed blister pack. Do not open blister until ready to administer.

Initiation of TASCENSO ODT treatment results in a decrease in heart rate, for which monitoring is recommended [see Warnings and Precautions (5.1), Clinical Pharmacology (12.2)]. Prior to dosing and at the end of the observation period, obtain an electrocardiogram (ECG) in all patients.

• Bradyarrhythmia and Atrioventricular Blocks: Because of a risk for bradyarrhythmia and AV blocks, monitor during initiation of treatment (2.4, 5.1)
• Infections: TASCENSO ODT may increase the risk. Obtain a complete blood count (CBC) before initiating TASCENSO ODT (i.e., within 6 months). Monitor for infection during treatment and for 2 months after discontinuation. Do not start in patients with active infections. (5.2)
• Progressive Multifocal Leukoencephalopathy (PML): Withhold TASCENSO ODT at the first sign or symptom suggestive of PML. (5.3)
• Macular Edema: Increases the risk of macular edema. Obtain a baseline evaluation of the fundus, including the macula, near the start of treatment with TASCENSO ODT. Conduct an evaluation of the fundus, including the macula, 3 to 4 months after treatment start, periodically while on therapy, and any time there is a change in vision. Consider discontinuing TASCENSO ODT if macular edema develops. Diabetes mellitus and uveitis increase the risk. (5.4)
• Liver Injury: Obtain liver enzyme results before initiation and periodically during treatment. Closely monitor patients with severe hepatic impairment. Discontinue if there is evidence of liver injury without other cause. (5.5, 8.6, 12.3)
• Posterior Reversible Encephalopathy Syndrome (PRES): If suspected, discontinue TASCENSO ODT. (5.6)
• Respiratory Effects: Evaluate when clinically indicated. (5.7)
• Fetal Risk: May cause fetal harm. Advise females of reproductive potential of the potential risk to a fetus and to use an effective method of contraception during treatment and for 2 months after stopping TASCENSO ODT. (5.8, 8.1, 8.3)
• Severe Increase in Disability After Stopping TASCENSO ODT: Monitor for development of severe increase in disability following discontinuation and begin appropriate treatment as needed. (5.9)
• Tumefactive MS: Consider when severe MS relapse occurs during treatment or after discontinuation. Obtain imaging and begin treatment as needed. (5.10)
• Increased Blood Pressure (BP): Monitor BP during treatment. (5.11)
• Malignancies: Skin examination prior to or shortly after the start of treatment and periodically thereafter is recommended. Suspicious skin lesions should be evaluated. (5.12)

• Assessments are required prior to initiating TASCENSO ODT (2.1)
• Recommended dosage for adults and pediatric patients (10 years of age and older) weighing more than 40 kg: 0.5 mg orally once daily, with or without food. (2.2, 2.3)
• Recommended dosage for pediatric patients (10 years of age and older) weighing less than or equal to 40 kg: 0.25 mg orally once daily, with or without food (2.2, 2.3).
• Administer TASCENSO ODT with or without water. Place tablet directly on the tongue and allow it to dissolve before swallowing. (2.2)
• First-Dose Monitoring (including reinitiation after discontinuation greater than 14 days and dose increases):
  • Observe all patients for bradycardia for at least 6 hours; monitor pulse and blood pressure hourly. Electrocardiograms (ECGs) prior to dosing and at end of observation period required. (2.4)
  • Monitor until resolution if heart rate < 45 beats per minute (bpm) in adults, < 55 bpm in patients aged 12 years and above, or < 60 bpm in pediatric patients aged 10 to below 12 years, atrioventricular (AV) block, or if lowest postdose heart rate is at the end of the observation period. (2.4)
  • Monitor symptomatic bradycardia with ECG until resolved. Continue overnight if intervention is required; repeat first-dose monitoring for second dose. (2.4)
  • Observe patients overnight if at higher risk of symptomatic bradycardia, heart block, prolonged QTc interval, or if taking drugs with known risk of torsades de pointes. (2.4, 7.1)

TASCENSO ODT is available as:

• 0.25 mg orally disintegrating tablets are white to off white, round tablets debossed with

  .

• 0.5 mg orally disintegrating tablets are white to off white, round tablets debossed with 

  .

The following adverse reactions have been identified during postapproval use of fingolimod. 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.

Blood and Lymphatic System Disorders: Hemolytic anemia and thrombocytopenia

Hepatobiliary Disorders: Liver injury [see Warnings and Precautions (5.5)]

Infections: Infections including cryptococcal infections [see Warnings and Precautions (5.2)], human papilloma virus (HPV) infection, including papilloma, dysplasia, warts and HPV-related cancer [see Warnings and Precautions (5.2)], progressive multifocal leukoencephalopathy [see Warnings and Precautions (5.3)]

Musculoskeletal and connective tissue disorders: Arthralgia, myalgia

Nervous System Disorders: Posterior reversible encephalopathy syndrome [see Warnings and Precautions (5.6)], seizures, including status epilepticus [see Adverse Reactions (6.1)]

Neoplasms, Benign, Malignant, and Unspecified (including cysts and polyps): melanoma, Merkel cell carcinoma, cutaneous T- cell lymphoma (including mycosis fungoides), Kaposi’s sarcoma and, squamous cell carcinoma [see Warnings and Precautions (5.12)]

Skin and Subcutaneous Tissue Disorders: Hypersensitivity [see Warnings and Precautions (5.14)]

Increases in blood pressure have been observed in patients treated with Fingolimod.

In adult MS controlled clinical trials, patients treated with fingolimod 0.5 mg capsules had an average increase over placebo of approximately 3 mmHg in systolic pressure, and approximately 2 mmHg in diastolic pressure, first detected after approximately 1 month of fingolimod treatment initiation and persisting with continued treatment. Hypertension was reported as an adverse reaction in 8% of patients on fingolimod 0.5 mg capsules and in 4% of patients on placebo. Blood pressure should be monitored during treatment with TASCENSO ODT.

Monitor blood pressure (BP) in adult and pediatric patients during treatment with TASCENSO ODT.

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

Hypersensitivity reactions, including rash, urticaria, and angioedema have been reported with fingolimod in the postmarketing setting. TASCENSO ODT is contraindicated in patients with history of hypersensitivity to fingolimod or any of its excipients [see Contraindications (4)].

Because fingolimod reduces blood lymphocyte counts via redistribution in secondary lymphoid organs, peripheral blood lymphocyte counts cannot be utilized to evaluate the lymphocyte subset status of a patient treated with fingolimod. A recent CBC should be available before initiating treatment with TASCENSO ODT.

Advise the patient to read the FDA-approved patient labeling (Medication Guide).

Administration

Tell patients not to discontinue TASCENSO ODT without first discussing this with the prescribing healthcare provider. Advise patients to contact their healthcare provider if they accidently take more TASCENSO ODT than prescribed. Advise patients to use dry hands when opening the blister pack. Instruct patients to not push the ODT through the lidding foil, but to peel back the lidding foil and then push the underside [see Dosage and Administration (2.2)].

MS relapses with tumefactive demyelinating lesions on imaging have been observed during fingolimod therapy and after fingolimod discontinuation in the postmarketing setting. Most reported cases of tumefactive MS in patients receiving fingolimod have occurred within the first 9 months after fingolimod initiation, but tumefactive MS may occur at any point during treatment. Cases of tumefactive MS have also been reported within the first 4 months after fingolimod discontinuation.

Tumefactive MS should be considered when a severe MS relapse occurs during TASCENSO ODT treatment, especially during initiation, or after discontinuation of TASCENSO ODT, prompting imaging evaluation and initiation of appropriate treatment.

Patients who initiate TASCENSO ODT, and those who reinitiate treatment after discontinuation for longer than 14 days, require first- dose monitoring. This monitoring is also recommended when the dose is increased in pediatric patients. Patients who are currently treated with another fingolimod product and underwent first-dose monitoring at initiation may be switched to TASCENSO ODT at the same daily dose without a need to repeat first-dose monitoring (unless the previous treatment was discontinued more than 14 days prior) [see Dosage and Administration (2.4, 2.5)].

TASCENSO ODT can be taken with or without food.

Inform the patient about the following administration instructions for TASCENSO ODT:

• Store the orally disintegrating tablet (ODT) in the sealed blister until ready to administer.
• Do not push the ODT through the lidding foil.
• Use dry hands when opening the blister pack.
• Peel back the lidding foil from one blister, then push the underside of the foil packet to release the ODT and gently remove the ODT.
• Take the ODT immediately after opening the blister pack.
• Place the ODT on the tongue and allow it to dissolve before swallowing.
• The ODT may be taken with or without water.

Lung toxicity was observed in 2 different strains of rats and in dogs and monkeys. The primary findings included increase in lung weight, associated with smooth muscle hypertrophy, hyperdistention of the alveoli, and/or increased collagen. Insufficient or lack of pulmonary collapse at necropsy, generally correlated with microscopic changes, was observed in all species. In rats and monkeys, lung toxicity was observed at all oral doses tested in chronic studies. The lowest doses tested in rats (0.05 mg/kg/day in the 2-year carcinogenicity study) and monkeys (0.5 mg/kg/day in the 39-week toxicity study) are similar to and approximately 20 times the RHD on a mg/m² basis, respectively.

In the 52-week oral study in monkeys, respiratory distress associated with ketamine administration was observed at doses of 3 and 10 mg/kg/day; the most affected animal became hypoxic and required oxygenation. As ketamine is not generally associated with respiratory depression, this effect was attributed to fingolimod. In a subsequent study in rats, ketamine was shown to potentiate the bronchoconstrictive effects of fingolimod. The relevance of these findings to humans is unknown.

Cases of progressive multifocal leukoencephalopathy (PML) have occurred in patients with MS who received fingolimod, the active moiety in TASCENSO ODT, in the postmarketing setting. PML is an opportunistic viral infection of the brain caused by the JC virus (JCV) that typically only occurs in patients who are immunocompromised, and that usually leads to death or severe disability. PML has occurred in patients who had not been treated previously with natalizumab, which has a known association with PML, were not taking any other immunosuppressive or immunomodulatory medications concomitantly and did not have any ongoing systemic medical conditions resulting in compromised immune system function. Longer treatment duration increases the risk of PML in fingolimod-treated patients; the majority of cases have occurred in patients treated with fingolimod for at least 18 months.

At the first sign or symptom suggestive of PML, withhold TASCENSO ODT and perform an appropriate diagnostic evaluation. Typical symptoms associated with PML are diverse, progress over days to weeks, and include progressive weakness on one side of the body or clumsiness of limbs, disturbance of vision, and changes in thinking, memory, and orientation leading to confusion and personality changes.

Magnetic resonance imaging (MRI) findings may be apparent before clinical signs or symptoms. Cases of PML, diagnosed based on MRI findings and the detection of JCV DNA in the cerebrospinal fluid in the absence of clinical signs or symptoms specific to PML, have been reported in patients treated with MS medications associated with PML, including fingolimod. Many of these patients subsequently became symptomatic with PML. Therefore, monitoring with MRI for signs that may be consistent with PML may be useful, and any suspicious findings should lead to further investigation to allow for an early diagnosis of PML, if present. Lower PML-related mortality and morbidity have been reported following discontinuation of another MS medication associated with PML in patients with PML who were initially asymptomatic compared to patients with PML who had characteristic clinical signs and symptoms at diagnosis. It is not known whether these differences are due to early detection and discontinuation of MS treatment or due to differences in disease in these patients.

If PML is confirmed, treatment with TASCENSO ODT should be discontinued.

Immune reconstitution inflammatory syndrome (IRIS) has been reported in patients treated with S1P receptor modulators, including fingolimod, who developed PML and subsequently discontinued treatment. IRIS presents as a clinical decline in the patient’s condition that may be rapid, can lead to serious neurological complications or death, and is often associated with characteristic changes on MRI. The time to onset of IRIS in patients with PML was generally within a few months after S1P receptor modulator discontinuation. Monitoring for development of IRIS and appropriate treatment of the associated inflammation should be undertaken.

Because of a risk for bradyarrhythmia and AV blocks, patients should be monitored during TASCENSO ODT treatment initiation [see Dosage and Administration (2.4)].

There have been rare cases of posterior reversible encephalopathy syndrome (PRES) reported in adult patients receiving fingolimod. Symptoms reported included sudden onset of severe headache, altered mental status, visual disturbances, and seizure. Symptoms of PRES are usually reversible but may evolve into ischemic stroke or cerebral hemorrhage. Delay in diagnosis and treatment may lead to permanent neurological sequelae. If PRES is suspected, TASCENSO ODT should be discontinued.

Oral carcinogenicity studies of fingolimod were conducted in mice and rats. In mice, fingolimod was administered at oral doses of 0, 0.025, 0.25, and 2.5 mg/kg/day for up to 2 years. The incidence of malignant lymphoma was increased in males and females at the mid and high dose. The lowest dose tested (0.025 mg/kg/day) is less than the RHD of 0.5 mg/day on a body surface area (mg/m²) basis. In rats, fingolimod was administered at oral doses of 0, 0.05, 0.15, 0.5, and 2.5 mg/kg/day. No increase in tumors was observed. The highest dose tested (2.5 mg/kg/day) is approximately 50 times the RHD on a mg/m² basis.

Fingolimod was negative in a battery of in vitro (Ames, mouse lymphoma thymidine kinase, chromosomal aberration in mammalian cells) and in vivo (micronucleus in mouse and rat) assays.

When fingolimod was administered orally (0, 1, 3, and 10 mg/kg/day) to male and female rats prior to and during mating, and continuing to Day 7 of gestation in females, no effect on fertility was observed up to the highest dose tested (10 mg/kg), which is approximately 200 times the RHD on a mg/m² basis.

Study 4 (NCT01892722) evaluated the efficacy of once-daily oral doses of fingolimod capsules 0.25 mg or fingolimod capsules 0.5 mg in pediatric patients 10 to less than 18 years of age with relapsing-remitting multiple sclerosis. Study 4 was a 215 patient, double-blind, randomized, clinical trial that compared fingolimod to intramuscular interferon beta-1a. Prior therapy with interferon-beta, dimethyl fumarate, or glatiramer acetate up to the time of randomization was permitted. The study included patients who had experienced at least 1 clinical relapse during the year prior or 2 relapses during the 2 years prior to screening, or evidence of 1 or more Gd-enhancing lesions on MRI within 6 months prior to randomization and had an EDSS score from 0 to 5.5. Neurological evaluations were scheduled at screening, every 3 months, and at the time of suspected relapses. MRI evaluations were performed at screening and every 6 months throughout the study. The primary endpoint was the annualized relapse rate.

At baseline, the median age was 16 years, median disease duration since first symptom was 1.5 years, and median EDSS score was 1.5. One patient received no study drug and is excluded from the analysis of efficacy. Median duration of exposure to study drug was 634 days in the fingolimod group (n = 107) and 547 days in the interferon beta-1a group (n = 107). In the fingolimod group, 6.5% of patients did not complete the study, compared to 18.5% in the interferon beta-1a group.

The primary endpoint, the annualized relapse rate (ARR), was significantly lower in patients treated with fingolimod (0.122) than in patients who received interferon beta-1a (0.675). Relative reduction in ARR was 81.9%. The annualized rate of the number of new or newly enlarged T2 lesions up to month 24 (key secondary endpoint) was significantly lower in patients treated with fingolimod, as was the number of Gd-enhancing T1 lesions per scan up to month 24.

Table 4 summarizes the results of Study 4.

Abbreviations: IM, intramuscular; MRI, magnetic resonance imaging; PO, by mouth.

All analyses of clinical endpoints were on full analysis set. MRI analyses used the evaluable dataset.

^§Indicates statistical significance vs. Interferon beta-1a IM at two-sided 0.05 level.

Severe increase in disability accompanied by multiple new lesions on MRI has been reported after discontinuation of fingolimod in the postmarketing setting. Patients in most of these reported cases did not return to the functional status they had before stopping fingolimod. The increase in disability generally occurred within 12 weeks after stopping fingolimod but was reported up to 24 weeks after fingolimod discontinuation.

Monitor patients for development of severe increase in disability following discontinuation of TASCENSO ODT and begin appropriate treatment as needed.

After stopping TASCENSO ODT in the setting of PML, monitor for development of immune reconstitution inflammatory syndrome (PML-IRIS) [see Warnings and Precautions (5.3)].

Fingolimod remains in the blood and has pharmacodynamic effects, including decreased lymphocyte counts, for up to 2 months following the last dose of TASCENSO ODT. Lymphocyte counts generally return to the normal range within 1 to 2 months of stopping therapy [see Clinical Pharmacology (12.2)]. Because of the continuing pharmacodynamic effects of fingolimod, initiating other drugs during this period warrants the same considerations needed for concomitant administration (e.g., risk of additive immunosuppressant effects) [see Drug Interactions (7.4)].

Rx Only

FOR ORAL USE ONLY

NDC 70709-065-30

CYCLE PHARMA

TASCENSO ODT^® (fingolimod)

orally disintegrating tablets 0.5 mg

Contains 30 tablets

(3 blister cards of 10 tablets)

PHARMACIST: Provide the accompanying

Medication Guide to each patient.

Rx Only

FOR ORAL USE ONLY

NDC 70709-062-30

CYCLE PHARMA

TASCENSO ODT^® (fingolimod)

orally disintegrating tablets 0.25 mg

Contains 30 tablets

(3 blister cards of 10 tablets)

PHARMACIST: Provide the accompanying

Medication Guide to each patient.

Antineoplastic, immune-modulating, or immunosuppressive therapies, (including corticosteroids) are expected to increase the risk of immunosuppression, and the risk of additive immune system effects must be considered if these therapies are coadministered with TASCENSO ODT. When switching from drugs with prolonged immune effects, such as natalizumab, teriflunomide or mitoxantrone, the duration and mode of action of these drugs must be considered to avoid unintended additive immunosuppressive effects when initiating TASCENSO ODT [see Warnings and Precautions (5.2)].

When restarting TASCENSO ODT treatment after discontinuation for more than 14 days after the first month of treatment, perform first-dose monitoring, because effects on heart rate and AV conduction may recur on reintroduction of TASCENSO ODT treatment [see Dosage and Administration (2.4)]. The same precautions (first-dose monitoring) as for initial dosing are applicable. Within the first 2 weeks of treatment, first-dose procedures are recommended after interruption of 1 day or more; during Weeks 3 and 4 of treatment, first-dose procedures are recommended after treatment interruption of more than 7 days.

Experience with fingolimod in patients receiving concurrent therapy with drugs that slow the heart rate or AV conduction (e.g., beta blockers, digoxin, or heart rate-slowing calcium channel blockers such as diltiazem or verapamil) is limited. Because initiation of TASCENSO ODT treatment may result in an additional decrease in heart rate, concomitant use of these drugs during TASCENSO ODT initiation may be associated with severe bradycardia or heart block. Seek advice from the physician prescribing these drugs regarding the possibility to switch to drugs that do not slow the heart rate or atrioventricular conduction before initiating TASCENSO ODT. Patients who cannot switch should have overnight continuous ECG monitoring after the first dose [see Dosage and Administration (2.4) , Warnings and Precautions (5.1)].

Cardiac Evaluation

Obtain a cardiac evaluation in patients with certain preexisting conditions [see Dosage and Administration (2.4) and Warnings and Precautions (5.1)].

Prior to starting treatment, determine whether patients are taking drugs that could slow heart rate or atrioventricular (AV) conduction [see Dosage and Administration (2.4), Drug Interactions (7.5)].

The efficacy of fingolimod was demonstrated in 2 studies that evaluated once-daily doses of fingolimod capsules 0.5 mg and 1.25 mg in patients with relapsing-remitting MS (RRMS). Both studies included patients who had experienced at least 2 clinical relapses during the 2 years prior to randomization or at least 1 clinical relapse during the 1 year prior to randomization and had an Expanded Disability Status Scale (EDSS) score from 0 to 5.5. Study 1 was a 2-year randomized, double-blind, placebo-controlled study in patients with RRMS who had not received any interferon-beta or glatiramer acetate for at least the previous 3 months and had not received any natalizumab for at least the previous 6 months. Neurological evaluations were performed at screening, every 3 months and at time of suspected relapse. MRI evaluations were performed at screening, Month 6, Month 12, and Month 24. The primary endpoint was the annualized relapse rate.

Median age was 37 years, median disease duration was 6.7 years and median EDSS score at baseline was 2.0. Patients were randomized to receive fingolimod 0.5 mg (N = 425), 1.25 mg (N = 429), or placebo (N = 418) for up to 24 months. Median time on study drug was 717 days on 0.5 mg, 715 days on 1.25 mg, and 719 days on placebo.

The annualized relapse rate was significantly lower in patients treated with fingolimod than in patients who received placebo. The secondary endpoint was the time to 3-month confirmed disability progression as measured by at least a 1-point increase from baseline in EDSS (0.5-point increase for patients with baseline EDSS of 5.5) sustained for 3 months. Time to onset of 3-month confirmed disability progression was significantly delayed with fingolimod treatment compared to placebo. The 1.25 mg dose resulted in no additional benefit over the fingolimod 0.5 mg dose. The results for this study are shown in Table 2 and Figure 1.

Abbreviation: CI, confidence interval.

All analyses of clinical endpoints were intent-to-treat. MRI analysis used evaluable dataset.

^§Hazard ratio is an estimate of the relative risk of having the event of disability progression on fingolimod as compared to placebo.

Figure 1: Time to 3-Month Confirmed Disability Progression - Study 1 (ITT population)

Study 2 was a 1-year randomized, double-blind, double-dummy, active-controlled study in patients with RRMS who had not received any natalizumab in the previous 6 months. Prior therapy with interferon-beta or glatiramer acetate up to the time of randomization was permitted.

Neurological evaluations were performed at screening, every 3 months, and at the time of suspected relapses. MRI evaluations were performed at screening and at Month 12. The primary endpoint was the annualized relapse rate.

Median age was 36 years, median disease duration was 5.9 years, and median EDSS score at baseline was 2.0. Patients were randomized to receive fingolimod capsules 0.5 mg (N = 431), 1.25 mg (N = 426), or interferon beta-1a, 30 mcg via the intramuscular route (IM) once-weekly (N = 435) for up to 12 months. Median time on study drug was 365 days on fingolimod 0.5 mg, 354 days on 1.25 mg, and 361 days on interferon beta-1a IM.

The annualized relapse rate was significantly lower in patients treated with fingolimod 0.5 mg than in patients who received interferon beta-1a IM. The key secondary endpoints were number of new and newly enlarging T2 lesions and time to onset of 3-month confirmed disability progression as measured by at least a 1-point increase from baseline in EDSS (0.5-point increase for those with baseline EDSS of 5.5) sustained for 3 months. The number of new and newly enlarging T2 lesions was significantly lower in patients treated with fingolimod than in patients who received interferon beta-1a IM. There was no significant difference in the time to 3-month confirmed disability progression between fingolimod and interferon beta-1a-treated patients at 1 year. The 1.25 mg dose resulted in no additional benefit over the fingolimod 0.5 mg dose. The results for this study are shown in Table 3.

Abbreviation: CI, confidence interval.

All analyses of clinical endpoints were intent-to-treat. MRI analysis used evaluable dataset.

^§Hazard ratio is an estimate of the relative risk of having the event of disability progression on fingolimod as compared to control.

Pooled results of Study 1 and Study 2 showed a consistent and statistically significant reduction of annualized relapse rate compared to comparator in subgroups defined by gender, age, prior MS therapy, and disease activity.

TASCENSO ODT reduces the immune response to vaccination. Vaccination may be less effective during and for up to 2 months after discontinuation of treatment with TASCENSO ODT [see Clinical Pharmacology (12.2)]. Avoid the use of live attenuated vaccines during and for 2 months after treatment with TASCENSO ODT because of the risk of infection.

It is recommended that pediatric patients, if possible, be brought up to date with all immunizations in agreement with current immunization guidelines prior to initiating TASCENSO ODT therapy.

Fingolimod, the active moiety in TASCENSO ODT, can induce bradycardia as well as AV conduction blocks (including complete AV block). The decline in heart rate usually starts within 1 hour of the first dose and is maximal within 6 hours in most patients [see Warnings and Precautions (5.1)]. In case of TASCENSO ODT overdosage, observe patients overnight with continuous ECG monitoring in a medical facility, and obtain regular measurements of blood pressure. [see Dosage and Administration (2.4)].

Neither dialysis nor plasma exchange results in removal of fingolimod from the body.

Fingolimod is a sphingosine 1-phosphate receptor modulator.

Chemically, fingolimod lauryl sulfate is 2-amino-2-[2-(4-octylphenyl)ethyl]propan-1,3-diol lauryl sulfate. Its structure is shown below:

Fingolimod lauryl sulfate is a white to practically white powder that is practically insoluble in water. It has a molecular weight of 573.87 g/mol.

TASCENSO ODT is provided as 0.25 mg and 0.5 mg orally disintegrating tablets for oral use.

Each orally disintegrating tablet contains 0.25 mg or 0.5 mg of fingolimod (equivalent to 0.47 mg or 0.93 mg of fingolimod lauryl sulfate) and the following inactive ingredients: gelatin, mannitol, medium-chain triglycerides, sodium chloride, and sodium lauryl sulfate.

TASCENSO ODT may cause fetal harm when administered to a pregnant woman.

In animal reproduction studies conducted in rats and rabbits, developmental toxicity was observed with administration of fingolimod at doses less than the recommended human dose.

Available observational pregnancy registry data suggest that use of fingolimod is associated with an increased prevalence of major birth defects in comparison to the general population.

Advise pregnant women and females of reproductive potential of the potential risk to a fetus. Because it takes approximately 2 months to eliminate fingolimod from the body, advise females of reproductive potential to use effective contraception to avoid pregnancy during and for 2 months after stopping TASCENSO ODT treatment [see Use in Specific Populations (8.1, 8.3)].

Clinically significant liver injury has occurred in patients treated with fingolimod in the postmarketing setting. Signs of liver injury, including markedly elevated serum hepatic enzymes and elevated total bilirubin, have occurred as early as ten days after the first dose and have also been reported after prolonged use. Cases of acute liver failure requiring liver transplant have been reported.

In 2-year placebo-controlled clinical trials in adult patients, elevation of liver enzymes (ALT, AST and GGT) to 3-fold the upper limit of normal (ULN) or greater occurred in 14% of patients treated with fingolimod 0.5 mg capsules and 3% of patients on placebo. Elevations 5-fold the ULN or greater occurred in 4.5% of patients on fingolimod capsules and 1% of patients on placebo. The majority of elevations occurred within 6 to 9 months. In clinical trials, fingolimod capsules were discontinued if the elevation exceeded 5 times the ULN. Serum transaminase levels returned to normal within approximately 2 months after discontinuation of fingolimod capsules. Recurrence of liver transaminase elevations occurred with rechallenge in some patients.

Prior to starting treatment with TASCENSO ODT (within 6 months), obtain serum transaminases (ALT and AST) and total bilirubin levels. Obtain transaminase levels and total bilirubin levels periodically until two months after TASCENSO ODT discontinuation. Patients should be monitored for signs and symptoms of any hepatic injury. Measure liver transaminase and bilirubin levels promptly in patients who report symptoms that may indicate liver injury, including new or worsening fatigue, anorexia, right upper abdominal discomfort, dark urine, or jaundice. In this clinical context, if the patient is found to have an alanine aminotransferase (ALT) greater than three times the reference range with serum total bilirubin greater than two times the reference range, treatment with TASCENSO ODT should be interrupted. Treatment should not be resumed if a plausible alternative etiology for the signs and symptoms cannot be established, because these patients are at risk of severe drug-induced liver injury.

Because fingolimod exposure is doubled in patients with severe hepatic impairment, these patients should be closely monitored during treatment with TASCENSO ODT, as the risk of adverse reactions is greater [see Use in Specific Populations (8.6), Clinical Pharmacology (12.3)].

The blood levels of fingolimod and fingolimod-phosphate are increased by 1.7-fold when used concomitantly with ketoconazole. Patients who use TASCENSO ODT and systemic ketoconazole concomitantly should be closely monitored, as the risk of adverse reactions is greater.

0.25 mg TASCENSO ODT orally disintegrating tablets are supplied as follows:



White to off-white, round, orally disintegrating tablet debossed with 

Carton of 30 orally disintegrating tablets containing 3 blister cards of 10 orally disintegrating tablets per blister card

NDC 70709-062-30 

0.5 mg TASCENSO ODT orally disintegrating tablets are supplied as follows:

White to off-white, round, orally disintegrating tablet debossed with 

Carton of 30 orally disintegrating tablets containing 3 blister cards of 10 orally disintegrating tablets per blister card

NDC 70709-065-30

S1P receptor modulators, including TASCENSO ODT, have been associated with an increased risk of macular edema. Obtain a baseline evaluation of the fundus, including the macula, near the start of treatment with TASCENSO ODT. Perform an examination of the fundus, including the macula, 3 to 4 months after starting treatment, periodically while on therapy, and any time there is a change in vision.

A dose-dependent increase in the risk of macular edema occurred in the fingolimod capsules clinical development program.

In 2-year double-blind, placebo-controlled studies in adult patients with multiple sclerosis, macular edema with or without visual symptoms occurred in 1.5% of patients (11/799) treated with fingolimod 1.25 mg capsules, 0.5% of patients (4/783) treated with fingolimod 0.5 mg capsules, and 0.4% of patients (3/773) treated with placebo. Macular edema occurred predominantly during the first 3 to 4 months of therapy. These clinical trials excluded patients with diabetes mellitus, a known risk factor for macular edema (see below Macular Edema in Patients with History of Uveitis or Diabetes Mellitus). Symptoms of macular edema included blurred vision and decreased visual acuity. Routine ophthalmological examination detected macular edema in some patients with no visual symptoms. Macular edema generally partially or completely resolved with or without treatment after drug discontinuation. Some patients had residual visual acuity loss even after resolution of macular edema. Macular edema has also been reported in patients taking fingolimod in the postmarketing setting, usually within the first 6 months of treatment.

Continuation of TASCENSO ODT in patients who develop macular edema has not been evaluated. Macular edema over an extended period of time (i.e., 6 months) can lead to permanent visual loss. Consider discontinuing TASCENSO ODT if macular edema develops; this decision should include an assessment of the potential benefits and risks for the individual patient. The risk of recurrence after rechallenge has not been evaluated.

Safety and effectiveness of fingolimod for the treatment of relapsing forms of multiple sclerosis in pediatric patients 10 to less than 18 years of age were established in one randomized, double-blind clinical study in 215 patients (fingolimod n = 107; intramuscular interferon (IFN) beta-1a n = 108) [see Clinical Studies (14.2)].

In the controlled pediatric study, the safety profile in pediatric patients (10 to less than 18 years of age) receiving fingolimod 0.25 mg or 0.5 mg capsules daily was similar to that seen in adult patients. In the pediatric study, cases of seizures were reported in 5.6% of fingolimod-treated patients and 0.9% of interferon beta-1a-treated patients.

It is recommended that pediatric patients, if possible, complete all immunizations in accordance with current immunization guidelines prior to initiating TASCENSO ODT therapy.

Safety and effectiveness of TASCENSO ODT in pediatric patients below the age of 10 years have not been established.

Clinical MS studies of fingolimod capsules did not include sufficient numbers of patients aged 65 years and over to determine whether they respond differently than younger patients. TASCENSO ODT should be used with caution in patients aged 65 years and over, reflecting the greater frequency of decreased hepatic, or renal, function and of concomitant disease or other drug therapy.

The efficacy of TASCENSO ODT is based on the relative bioavailability of TASCENSO ODT orally disintegrating tablets compared to fingolimod capsules in healthy adults [see Clinical Pharmacology (12.3)].

The clinical studies described below were conducted using fingolimod capsules.

TASCENSO ODT is contraindicated in patients who have:

• In the last 6 months experienced myocardial infarction, unstable angina, stroke, TIA, decompensated heart failure requiring hospitalization or Class III/IV heart failure.
• A history or presence of Mobitz Type II second-degree or third-degree AV block or sick sinus syndrome, unless patient has a functioning pacemaker [see Warnings and Precautions (5.1)]
• A baseline QTc interval ≥ 500 msec
• Cardiac arrhythmias requiring anti-arrhythmic treatment with Class Ia or Class III anti-arrhythmic drugs
• Had a hypersensitivity reaction to fingolimod or any of the excipients in TASCENSO ODT. Observed reactions include rash, urticaria, and angioedema [see Warnings and Precautions (5.14)].
• Concomitant use with other products containing fingolimod

The following serious adverse reactions are described elsewhere in labeling:

• Bradyarrhythmia and Atrioventricular Blocks [see Warnings and Precautions (5.1)]
• Infections [see Warnings and Precautions (5.2)]
• Progressive Multifocal Leukoencephalopathy [see Warnings and Precautions (5.3)]
• Macular Edema [see Warnings and Precautions (5.4)]
• Liver Injury [see Warnings and Precautions (5.5)]
• Posterior Reversible Encephalopathy Syndrome [see Warnings and Precautions (5.6)]
• Respiratory Effects [see Warnings and Precautions (5.7)]
• Fetal Risk [see Warnings and Precautions (5.8)]
• Severe Increase in Disability After Stopping TASCENSO ODT [see Warnings and Precautions (5.9)]
• Tumefactive Multiple Sclerosis [see Warnings and Precautions (5.10)]
• Increased Blood Pressure [see Warnings and Precautions (5.11)]
• Malignancies [see Warnings and Precautions (5.12)]
• Immune System Effects Following TASCENSO ODT Discontinuation [see Warnings and Precautions (5.13)]
• Hypersensitivity Reactions [see Warnings and Precautions (5.14)]

• Systemic Ketoconazole: Monitor during concomitant use. (7.2, 12.3)
• Vaccines: Avoid live attenuated vaccines during, and for 2 months after stopping TASCENSO ODT treatment. (5.3, 7.3)

The blood level of some fingolimod metabolites is increased (up to 13-fold) in patients with severe renal impairment [see Clinical Pharmacology (12.3)]. The toxicity of these metabolites has not been fully explored. The blood level of these metabolites has not been assessed in patients with mild or moderate renal impairment.

In adults and pediatric patients 10 years of age and older weighing more than 40 kg, the recommended dosage of TASCENSO ODT is 0.5 mg orally once-daily.

In pediatric patients 10 years of age and older weighing less than or equal to 40 kg, the recommended dosage of TASCENSO ODT is 0.25 mg orally once daily.

Fingolimod doses higher than 0.5 mg are associated with a greater incidence of adverse reactions without additional benefit.

Because fingolimod, but not fingolimod-phosphate, exposure is doubled in patients with severe hepatic impairment, patients with severe hepatic impairment should be closely monitored, as the risk of adverse reactions may be greater [see Warnings and Precautions (5.6) , Clinical Pharmacology (12.3)].

No dose adjustment is needed in patients with mild or moderate hepatic impairment.

TASCENSO ODT is indicated for the treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in patients 10 years of age and older.

Dose-dependent reductions in forced expiratory volume over 1 second (FEV1) and diffusion lung capacity for carbon monoxide (DLCO) were observed in patients treated with fingolimod, the active moiety in TASCENSO ODT, as early as 1 month after treatment initiation. In 2-year placebo-controlled trials in adult patients, the reduction from baseline in the percent of predicted values for FEV1 at the time of last assessment on drug was 2.8% for fingolimod 0.5 mg capsules and 1.0% for placebo. For DLCO, the reduction from baseline in percent of predicted values at the time of last assessment on drug was 3.3% for fingolimod 0.5 mg capsules and 0.5% for placebo. The changes in FEV1 appear to be reversible after treatment discontinuation. There is insufficient information to determine the reversibility of the decrease of DLCO after drug discontinuation. In MS placebo-controlled trials in adult patients, dyspnea was reported in 9% of patients receiving fingolimod 0.5 mg capsules and 7% of patients receiving placebo. Several patients discontinued fingolimod capsules because of unexplained dyspnea during the extension (uncontrolled) studies. Fingolimod, the active moiety in TASCENSO ODT, has not been tested in MS patients with compromised respiratory function.

Spirometric evaluation of respiratory function and evaluation of DLCO should be performed during therapy with TASCENSO ODT if clinically indicated.

TASCENSO ODT has not been studied in patients treated with drugs that prolong the QT interval. Drugs that prolong the QT interval have been associated with cases of torsades de pointes in patients with bradycardia. Since initiation of TASCENSO ODT treatment results in decreased heart rate and may prolong the QT interval, patients on QT prolonging drugs with a known risk of torsades de pointes (e.g., citalopram, chlorpromazine, haloperidol, methadone, erythromycin) should be monitored overnight with continuous ECG in a medical facility [see Dosage and Administration (2.4) , Warnings and Precautions (5.1)].

Fingolimod is metabolized by sphingosine kinase to the active metabolite, fingolimod-phosphate. Fingolimod phosphate is a sphingosine 1-phosphate receptor modulator and binds with high affinity to sphingosine 1-phosphate receptors 1, 3, 4, and 5. Fingolimod-phosphate blocks the capacity of lymphocytes to egress from lymph nodes, reducing the number of lymphocytes in peripheral blood. The mechanism by which fingolimod exerts therapeutic effects in multiple sclerosis is unknown but may involve reduction of lymphocyte migration into the central nervous system.

TASCENSO ODT should be stored at 20°C to 25°C (68°F to 77°F); excursions permitted to 15°C to 30°C (59°F to 86°F). Protect from moisture. Store in sealed blister pack. Do not open blister until ready to administer.

Initiation of TASCENSO ODT treatment results in a decrease in heart rate, for which monitoring is recommended [see Warnings and Precautions (5.1), Clinical Pharmacology (12.2)]. Prior to dosing and at the end of the observation period, obtain an electrocardiogram (ECG) in all patients.

• Bradyarrhythmia and Atrioventricular Blocks: Because of a risk for bradyarrhythmia and AV blocks, monitor during initiation of treatment (2.4, 5.1)
• Infections: TASCENSO ODT may increase the risk. Obtain a complete blood count (CBC) before initiating TASCENSO ODT (i.e., within 6 months). Monitor for infection during treatment and for 2 months after discontinuation. Do not start in patients with active infections. (5.2)
• Progressive Multifocal Leukoencephalopathy (PML): Withhold TASCENSO ODT at the first sign or symptom suggestive of PML. (5.3)
• Macular Edema: Increases the risk of macular edema. Obtain a baseline evaluation of the fundus, including the macula, near the start of treatment with TASCENSO ODT. Conduct an evaluation of the fundus, including the macula, 3 to 4 months after treatment start, periodically while on therapy, and any time there is a change in vision. Consider discontinuing TASCENSO ODT if macular edema develops. Diabetes mellitus and uveitis increase the risk. (5.4)
• Liver Injury: Obtain liver enzyme results before initiation and periodically during treatment. Closely monitor patients with severe hepatic impairment. Discontinue if there is evidence of liver injury without other cause. (5.5, 8.6, 12.3)
• Posterior Reversible Encephalopathy Syndrome (PRES): If suspected, discontinue TASCENSO ODT. (5.6)
• Respiratory Effects: Evaluate when clinically indicated. (5.7)
• Fetal Risk: May cause fetal harm. Advise females of reproductive potential of the potential risk to a fetus and to use an effective method of contraception during treatment and for 2 months after stopping TASCENSO ODT. (5.8, 8.1, 8.3)
• Severe Increase in Disability After Stopping TASCENSO ODT: Monitor for development of severe increase in disability following discontinuation and begin appropriate treatment as needed. (5.9)
• Tumefactive MS: Consider when severe MS relapse occurs during treatment or after discontinuation. Obtain imaging and begin treatment as needed. (5.10)
• Increased Blood Pressure (BP): Monitor BP during treatment. (5.11)
• Malignancies: Skin examination prior to or shortly after the start of treatment and periodically thereafter is recommended. Suspicious skin lesions should be evaluated. (5.12)

• Assessments are required prior to initiating TASCENSO ODT (2.1)
• Recommended dosage for adults and pediatric patients (10 years of age and older) weighing more than 40 kg: 0.5 mg orally once daily, with or without food. (2.2, 2.3)
• Recommended dosage for pediatric patients (10 years of age and older) weighing less than or equal to 40 kg: 0.25 mg orally once daily, with or without food (2.2, 2.3).
• Administer TASCENSO ODT with or without water. Place tablet directly on the tongue and allow it to dissolve before swallowing. (2.2)
• First-Dose Monitoring (including reinitiation after discontinuation greater than 14 days and dose increases):
  • Observe all patients for bradycardia for at least 6 hours; monitor pulse and blood pressure hourly. Electrocardiograms (ECGs) prior to dosing and at end of observation period required. (2.4)
  • Monitor until resolution if heart rate < 45 beats per minute (bpm) in adults, < 55 bpm in patients aged 12 years and above, or < 60 bpm in pediatric patients aged 10 to below 12 years, atrioventricular (AV) block, or if lowest postdose heart rate is at the end of the observation period. (2.4)
  • Monitor symptomatic bradycardia with ECG until resolved. Continue overnight if intervention is required; repeat first-dose monitoring for second dose. (2.4)
  • Observe patients overnight if at higher risk of symptomatic bradycardia, heart block, prolonged QTc interval, or if taking drugs with known risk of torsades de pointes. (2.4, 7.1)

TASCENSO ODT is available as:

• 0.25 mg orally disintegrating tablets are white to off white, round tablets debossed with

  .

• 0.5 mg orally disintegrating tablets are white to off white, round tablets debossed with 

  .

The following adverse reactions have been identified during postapproval use of fingolimod. 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.

Blood and Lymphatic System Disorders: Hemolytic anemia and thrombocytopenia

Hepatobiliary Disorders: Liver injury [see Warnings and Precautions (5.5)]

Infections: Infections including cryptococcal infections [see Warnings and Precautions (5.2)], human papilloma virus (HPV) infection, including papilloma, dysplasia, warts and HPV-related cancer [see Warnings and Precautions (5.2)], progressive multifocal leukoencephalopathy [see Warnings and Precautions (5.3)]

Musculoskeletal and connective tissue disorders: Arthralgia, myalgia

Nervous System Disorders: Posterior reversible encephalopathy syndrome [see Warnings and Precautions (5.6)], seizures, including status epilepticus [see Adverse Reactions (6.1)]

Neoplasms, Benign, Malignant, and Unspecified (including cysts and polyps): melanoma, Merkel cell carcinoma, cutaneous T- cell lymphoma (including mycosis fungoides), Kaposi’s sarcoma and, squamous cell carcinoma [see Warnings and Precautions (5.12)]

Skin and Subcutaneous Tissue Disorders: Hypersensitivity [see Warnings and Precautions (5.14)]

Increases in blood pressure have been observed in patients treated with Fingolimod.

In adult MS controlled clinical trials, patients treated with fingolimod 0.5 mg capsules had an average increase over placebo of approximately 3 mmHg in systolic pressure, and approximately 2 mmHg in diastolic pressure, first detected after approximately 1 month of fingolimod treatment initiation and persisting with continued treatment. Hypertension was reported as an adverse reaction in 8% of patients on fingolimod 0.5 mg capsules and in 4% of patients on placebo. Blood pressure should be monitored during treatment with TASCENSO ODT.

Monitor blood pressure (BP) in adult and pediatric patients during treatment with TASCENSO ODT.

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

Hypersensitivity reactions, including rash, urticaria, and angioedema have been reported with fingolimod in the postmarketing setting. TASCENSO ODT is contraindicated in patients with history of hypersensitivity to fingolimod or any of its excipients [see Contraindications (4)].

Because fingolimod reduces blood lymphocyte counts via redistribution in secondary lymphoid organs, peripheral blood lymphocyte counts cannot be utilized to evaluate the lymphocyte subset status of a patient treated with fingolimod. A recent CBC should be available before initiating treatment with TASCENSO ODT.

Advise the patient to read the FDA-approved patient labeling (Medication Guide).

Administration

Tell patients not to discontinue TASCENSO ODT without first discussing this with the prescribing healthcare provider. Advise patients to contact their healthcare provider if they accidently take more TASCENSO ODT than prescribed. Advise patients to use dry hands when opening the blister pack. Instruct patients to not push the ODT through the lidding foil, but to peel back the lidding foil and then push the underside [see Dosage and Administration (2.2)].

MS relapses with tumefactive demyelinating lesions on imaging have been observed during fingolimod therapy and after fingolimod discontinuation in the postmarketing setting. Most reported cases of tumefactive MS in patients receiving fingolimod have occurred within the first 9 months after fingolimod initiation, but tumefactive MS may occur at any point during treatment. Cases of tumefactive MS have also been reported within the first 4 months after fingolimod discontinuation.

Tumefactive MS should be considered when a severe MS relapse occurs during TASCENSO ODT treatment, especially during initiation, or after discontinuation of TASCENSO ODT, prompting imaging evaluation and initiation of appropriate treatment.

Patients who initiate TASCENSO ODT, and those who reinitiate treatment after discontinuation for longer than 14 days, require first- dose monitoring. This monitoring is also recommended when the dose is increased in pediatric patients. Patients who are currently treated with another fingolimod product and underwent first-dose monitoring at initiation may be switched to TASCENSO ODT at the same daily dose without a need to repeat first-dose monitoring (unless the previous treatment was discontinued more than 14 days prior) [see Dosage and Administration (2.4, 2.5)].

TASCENSO ODT can be taken with or without food.

Inform the patient about the following administration instructions for TASCENSO ODT:

• Store the orally disintegrating tablet (ODT) in the sealed blister until ready to administer.
• Do not push the ODT through the lidding foil.
• Use dry hands when opening the blister pack.
• Peel back the lidding foil from one blister, then push the underside of the foil packet to release the ODT and gently remove the ODT.
• Take the ODT immediately after opening the blister pack.
• Place the ODT on the tongue and allow it to dissolve before swallowing.
• The ODT may be taken with or without water.

Lung toxicity was observed in 2 different strains of rats and in dogs and monkeys. The primary findings included increase in lung weight, associated with smooth muscle hypertrophy, hyperdistention of the alveoli, and/or increased collagen. Insufficient or lack of pulmonary collapse at necropsy, generally correlated with microscopic changes, was observed in all species. In rats and monkeys, lung toxicity was observed at all oral doses tested in chronic studies. The lowest doses tested in rats (0.05 mg/kg/day in the 2-year carcinogenicity study) and monkeys (0.5 mg/kg/day in the 39-week toxicity study) are similar to and approximately 20 times the RHD on a mg/m² basis, respectively.

In the 52-week oral study in monkeys, respiratory distress associated with ketamine administration was observed at doses of 3 and 10 mg/kg/day; the most affected animal became hypoxic and required oxygenation. As ketamine is not generally associated with respiratory depression, this effect was attributed to fingolimod. In a subsequent study in rats, ketamine was shown to potentiate the bronchoconstrictive effects of fingolimod. The relevance of these findings to humans is unknown.

Cases of progressive multifocal leukoencephalopathy (PML) have occurred in patients with MS who received fingolimod, the active moiety in TASCENSO ODT, in the postmarketing setting. PML is an opportunistic viral infection of the brain caused by the JC virus (JCV) that typically only occurs in patients who are immunocompromised, and that usually leads to death or severe disability. PML has occurred in patients who had not been treated previously with natalizumab, which has a known association with PML, were not taking any other immunosuppressive or immunomodulatory medications concomitantly and did not have any ongoing systemic medical conditions resulting in compromised immune system function. Longer treatment duration increases the risk of PML in fingolimod-treated patients; the majority of cases have occurred in patients treated with fingolimod for at least 18 months.

At the first sign or symptom suggestive of PML, withhold TASCENSO ODT and perform an appropriate diagnostic evaluation. Typical symptoms associated with PML are diverse, progress over days to weeks, and include progressive weakness on one side of the body or clumsiness of limbs, disturbance of vision, and changes in thinking, memory, and orientation leading to confusion and personality changes.

Magnetic resonance imaging (MRI) findings may be apparent before clinical signs or symptoms. Cases of PML, diagnosed based on MRI findings and the detection of JCV DNA in the cerebrospinal fluid in the absence of clinical signs or symptoms specific to PML, have been reported in patients treated with MS medications associated with PML, including fingolimod. Many of these patients subsequently became symptomatic with PML. Therefore, monitoring with MRI for signs that may be consistent with PML may be useful, and any suspicious findings should lead to further investigation to allow for an early diagnosis of PML, if present. Lower PML-related mortality and morbidity have been reported following discontinuation of another MS medication associated with PML in patients with PML who were initially asymptomatic compared to patients with PML who had characteristic clinical signs and symptoms at diagnosis. It is not known whether these differences are due to early detection and discontinuation of MS treatment or due to differences in disease in these patients.

If PML is confirmed, treatment with TASCENSO ODT should be discontinued.

Immune reconstitution inflammatory syndrome (IRIS) has been reported in patients treated with S1P receptor modulators, including fingolimod, who developed PML and subsequently discontinued treatment. IRIS presents as a clinical decline in the patient’s condition that may be rapid, can lead to serious neurological complications or death, and is often associated with characteristic changes on MRI. The time to onset of IRIS in patients with PML was generally within a few months after S1P receptor modulator discontinuation. Monitoring for development of IRIS and appropriate treatment of the associated inflammation should be undertaken.

Because of a risk for bradyarrhythmia and AV blocks, patients should be monitored during TASCENSO ODT treatment initiation [see Dosage and Administration (2.4)].

There have been rare cases of posterior reversible encephalopathy syndrome (PRES) reported in adult patients receiving fingolimod. Symptoms reported included sudden onset of severe headache, altered mental status, visual disturbances, and seizure. Symptoms of PRES are usually reversible but may evolve into ischemic stroke or cerebral hemorrhage. Delay in diagnosis and treatment may lead to permanent neurological sequelae. If PRES is suspected, TASCENSO ODT should be discontinued.

Oral carcinogenicity studies of fingolimod were conducted in mice and rats. In mice, fingolimod was administered at oral doses of 0, 0.025, 0.25, and 2.5 mg/kg/day for up to 2 years. The incidence of malignant lymphoma was increased in males and females at the mid and high dose. The lowest dose tested (0.025 mg/kg/day) is less than the RHD of 0.5 mg/day on a body surface area (mg/m²) basis. In rats, fingolimod was administered at oral doses of 0, 0.05, 0.15, 0.5, and 2.5 mg/kg/day. No increase in tumors was observed. The highest dose tested (2.5 mg/kg/day) is approximately 50 times the RHD on a mg/m² basis.

Fingolimod was negative in a battery of in vitro (Ames, mouse lymphoma thymidine kinase, chromosomal aberration in mammalian cells) and in vivo (micronucleus in mouse and rat) assays.

When fingolimod was administered orally (0, 1, 3, and 10 mg/kg/day) to male and female rats prior to and during mating, and continuing to Day 7 of gestation in females, no effect on fertility was observed up to the highest dose tested (10 mg/kg), which is approximately 200 times the RHD on a mg/m² basis.

Study 4 (NCT01892722) evaluated the efficacy of once-daily oral doses of fingolimod capsules 0.25 mg or fingolimod capsules 0.5 mg in pediatric patients 10 to less than 18 years of age with relapsing-remitting multiple sclerosis. Study 4 was a 215 patient, double-blind, randomized, clinical trial that compared fingolimod to intramuscular interferon beta-1a. Prior therapy with interferon-beta, dimethyl fumarate, or glatiramer acetate up to the time of randomization was permitted. The study included patients who had experienced at least 1 clinical relapse during the year prior or 2 relapses during the 2 years prior to screening, or evidence of 1 or more Gd-enhancing lesions on MRI within 6 months prior to randomization and had an EDSS score from 0 to 5.5. Neurological evaluations were scheduled at screening, every 3 months, and at the time of suspected relapses. MRI evaluations were performed at screening and every 6 months throughout the study. The primary endpoint was the annualized relapse rate.

At baseline, the median age was 16 years, median disease duration since first symptom was 1.5 years, and median EDSS score was 1.5. One patient received no study drug and is excluded from the analysis of efficacy. Median duration of exposure to study drug was 634 days in the fingolimod group (n = 107) and 547 days in the interferon beta-1a group (n = 107). In the fingolimod group, 6.5% of patients did not complete the study, compared to 18.5% in the interferon beta-1a group.

The primary endpoint, the annualized relapse rate (ARR), was significantly lower in patients treated with fingolimod (0.122) than in patients who received interferon beta-1a (0.675). Relative reduction in ARR was 81.9%. The annualized rate of the number of new or newly enlarged T2 lesions up to month 24 (key secondary endpoint) was significantly lower in patients treated with fingolimod, as was the number of Gd-enhancing T1 lesions per scan up to month 24.

Table 4 summarizes the results of Study 4.

Abbreviations: IM, intramuscular; MRI, magnetic resonance imaging; PO, by mouth.

All analyses of clinical endpoints were on full analysis set. MRI analyses used the evaluable dataset.

^§Indicates statistical significance vs. Interferon beta-1a IM at two-sided 0.05 level.

Severe increase in disability accompanied by multiple new lesions on MRI has been reported after discontinuation of fingolimod in the postmarketing setting. Patients in most of these reported cases did not return to the functional status they had before stopping fingolimod. The increase in disability generally occurred within 12 weeks after stopping fingolimod but was reported up to 24 weeks after fingolimod discontinuation.

Monitor patients for development of severe increase in disability following discontinuation of TASCENSO ODT and begin appropriate treatment as needed.

After stopping TASCENSO ODT in the setting of PML, monitor for development of immune reconstitution inflammatory syndrome (PML-IRIS) [see Warnings and Precautions (5.3)].

Fingolimod remains in the blood and has pharmacodynamic effects, including decreased lymphocyte counts, for up to 2 months following the last dose of TASCENSO ODT. Lymphocyte counts generally return to the normal range within 1 to 2 months of stopping therapy [see Clinical Pharmacology (12.2)]. Because of the continuing pharmacodynamic effects of fingolimod, initiating other drugs during this period warrants the same considerations needed for concomitant administration (e.g., risk of additive immunosuppressant effects) [see Drug Interactions (7.4)].

Rx Only

FOR ORAL USE ONLY

NDC 70709-065-30

CYCLE PHARMA

TASCENSO ODT^® (fingolimod)

orally disintegrating tablets 0.5 mg

Contains 30 tablets

(3 blister cards of 10 tablets)

PHARMACIST: Provide the accompanying

Medication Guide to each patient.

Rx Only

FOR ORAL USE ONLY

NDC 70709-062-30

CYCLE PHARMA

TASCENSO ODT^® (fingolimod)

orally disintegrating tablets 0.25 mg

Contains 30 tablets

(3 blister cards of 10 tablets)

PHARMACIST: Provide the accompanying

Medication Guide to each patient.

Antineoplastic, immune-modulating, or immunosuppressive therapies, (including corticosteroids) are expected to increase the risk of immunosuppression, and the risk of additive immune system effects must be considered if these therapies are coadministered with TASCENSO ODT. When switching from drugs with prolonged immune effects, such as natalizumab, teriflunomide or mitoxantrone, the duration and mode of action of these drugs must be considered to avoid unintended additive immunosuppressive effects when initiating TASCENSO ODT [see Warnings and Precautions (5.2)].

When restarting TASCENSO ODT treatment after discontinuation for more than 14 days after the first month of treatment, perform first-dose monitoring, because effects on heart rate and AV conduction may recur on reintroduction of TASCENSO ODT treatment [see Dosage and Administration (2.4)]. The same precautions (first-dose monitoring) as for initial dosing are applicable. Within the first 2 weeks of treatment, first-dose procedures are recommended after interruption of 1 day or more; during Weeks 3 and 4 of treatment, first-dose procedures are recommended after treatment interruption of more than 7 days.

Experience with fingolimod in patients receiving concurrent therapy with drugs that slow the heart rate or AV conduction (e.g., beta blockers, digoxin, or heart rate-slowing calcium channel blockers such as diltiazem or verapamil) is limited. Because initiation of TASCENSO ODT treatment may result in an additional decrease in heart rate, concomitant use of these drugs during TASCENSO ODT initiation may be associated with severe bradycardia or heart block. Seek advice from the physician prescribing these drugs regarding the possibility to switch to drugs that do not slow the heart rate or atrioventricular conduction before initiating TASCENSO ODT. Patients who cannot switch should have overnight continuous ECG monitoring after the first dose [see Dosage and Administration (2.4) , Warnings and Precautions (5.1)].