Gilenya

Fingolimod.

Each capsule contains 0.5 mg fingolimod (as hydrochloride).
Fingolimod hydrochloride is a synthetic analogue of sphingosine. The chemical designation is 2-amino-2[2-(4-octylphenyl)ethyl]propane1,3-diol hydrochloride. Its molecular formula is C₁₉H₃₃NO₂·HCl and it has a molecular weight of 343.93.
Fingolimod hydrochloride is a white to almost white crystalline powder which is freely soluble in water.
Excipients/Inactive Ingredients: Mannitol, magnesium stearate, titanium dioxide and gelatin.

Pharmacology: Pharmacodynamics: Mechanism of Action: Fingolimod is a sphingosine-1-phosphate receptor modulator. Fingolimod is metabolized by sphingosine kinase to the active metabolite fingolimod-phosphate. Fingolimod-phosphate, binds at low nanomolar concentrations to sphingosine-1-phosphate receptors 1, 3 and 4 located on lymphocytes and readily crosses the blood-brain barrier to bind to sphingosine-1-phosphate receptors 1, 3 and 5 located on neural cells in the central nervous system (CNS). By acting as a functional antagonist of S1PR on lymphocytes, fingolimod-phosphate blocks the capacity of lymphocytes to egress from lymph nodes, causing a redistribution, rather than depletion, of lymphocytes. This redistribution reduces the infiltration of pathogenic lymphocyte cells into the central nervous system where they would be involved in nerve inflammation and nervous tissue damage.
Animal studies and in vitro experiments indicate that fingolimod may also exert beneficial effects in multiple sclerosis via interaction with S1P receptors on neural cells. Fingolimod penetrates the CNS, in both humans and animals, and has been shown to reduce astrogliosis, demyelination and neuronal loss. Further, fingolimod treatment increases the levels of brain derived neurotropic factor (BDNF) in the cortex, hippocampus and striatum of the brain to support neuronal survival and improve motor functions.
Immune System: Effects on Immune Cell Numbers in the Blood: Within 4-6 hours after the first dose of fingolimod 0.5 mg, the lymphocyte count decreases to approximately 75% of baseline. With continued daily dosing, the lymphocyte count continues to decrease over a 2-week period, reaching a nadir count of approximately 500 cells/μL or approximately 30% of baseline. Eighteen percent of patients reached a nadir of <200 cells/μL on at least 1 occasion. Low lymphocyte counts are maintained with chronic daily dosing. The majority of T and B lymphocytes regularly traffic through lymphoid organs and these are the cells mainly affected by fingolimod. Approximately 15-20% of T lymphocytes have an effector memory phenotype, cells that are important for peripheral immune surveillance. Since this lymphocyte subset typically does not traffic to lymphoid organs, it is not affected by fingolimod. Peripheral lymphocyte count increases are evident within days of stopping fingolimod treatment and typically, normal counts are reached within one to two months. Chronic fingolimod dosing leads to a mild decrease in the neutrophil count to approximately 80% of baseline. Monocytes are unaffected by fingolimod.
Heart Rate and Rhythm: Fingolimod causes a transient reduction in heart rate and atrioventricular conduction at treatment initiation (see Adverse Reactions). The maximum decline of heart rate is seen in the first 6 hours post-dose, with 70% of the negative chronotropic effect achieved on the first day. Heart rate progressively returns to baseline values within 1 month of chronic treatment.
Autonomic responses of the heart, including diurnal variation of heart rate and response to exercise are not affected by fingolimod treatment.
With initiation of fingolimod treatment, there is an increase in atrial premature contractions, but there is no increased rate of atrial fibrillation/flutter or ventricular arrhythmias or ectopy.
Fingolimod treatment is not associated with a decrease in cardiac output.
The decrease in heart rate induced by fingolimod can be reversed by atropine, isoprenaline or salmeterol.
Potential to Prolong the QT Interval: In a thorough QT interval study of doses of fingolimod 1.25 or 2.5 mg at steady state, when a negative chronotropic effect of fingolimod was still present, fingolimod treatment resulted in a prolongation of QTcI, with the upper boundary of the 90% CI ≤13.0 ms. There is no dose or exposure-response relationship of fingolimod and QTcI prolongation. There is no consistent signal of increased incidence of QTcI outliers, either absolute or change from baseline, associated with fingolimod treatment. In the multiple sclerosis studies, there was no clinically relevant prolongation of QT interval.
Pulmonary Function: Fingolimod treatment with single or multiple doses of 0.5 mg and 1.25 mg for two weeks is not associated with a detectable increase in airway resistance as measured by FEV₁ and forced expiratory flow during expiration of 25-75% of the forced vital capacity (FEF_25-75). However, single fingolimod doses ≥5 mg (10-fold the recommended dose) are associated with a dose-dependent increase in airway resistance. Fingolimod treatment with multiple doses of 0.5, 1.25 or 5 mg is not associated with impaired oxygenation or oxygen desaturation with exercise or an increase in airway responsiveness to methacholine. Subjects on fingolimod treatment have a normal bronchodilator response to inhaled β-agonists.
Clinical Studies: The efficacy of Gilenya has been demonstrated in two studies which evaluated once daily doses of Gilenya 0.5 mg and 1.25 mg in patients with relapsing remitting multiple sclerosis. 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) between 0-5.5. A third study targeting the same patient population was completed after registration of Gilenya.
Study D2301 (FREEDOMS): Study D2301 (FREEDOMS) was a 2-year randomized, double-blind, placebo-controlled Phase III study in patients with relapsing-remitting multiple sclerosis who had not received any interferon-β 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 (ARR).
Median age was 37 years, median disease duration was 6.7 years and median EDSS score at baseline was 2. Patients were randomized to receive Gilenya 0.5 mg (n=425) or Gilenya 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 718.5 days on placebo.
The annualized relapse rate was significantly lower in patients treated with Gilenya than in patients who received placebo. The key 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 Gilenya treatment compared to placebo. There were no significant differences between the 0.5 mg and the 1.25 mg doses on either endpoint.
The results for this study are shown in Table 1 and Figures 1 and 2. (See Table 1 and Figures 1 and 2.)

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Click on icon to see table/diagram/image


Click on icon to see table/diagram/image

Patients who completed Study FREEDOMS (D2301) had the option to enter a dose-blinded extension study D2301E1. 920 patients from the core study entered the extension and were all treated with fingolimod (n=331 continued on 0.5 mg, 289 continued on 1.25 mg, 155 switched from placebo to 0.5 mg and 145 switched from placebo to 1.25 mg). 811 of these patients (88.2%) had at least 18 months follow-up in the extension phase. The maximum cumulative duration of exposure to fingolimod 0.5 mg (core + extension study) was 1,782 days.
At Month 24 of the extension study, patients who received placebo in the core study had reductions in ARR of 55% after switching to fingolimod 0.5 mg (ARR ratio 0.45, 95% CI 0.32 to 0.62, p<0.001). The ARR for patients who were treated with fingolimod 0.5 mg in the core study remained low during the extension study (ARR of 0.10 in the extension study).
Study D2309 (FREEDOMS II): Study D2309 (FREEDOMS II) had a design similar to that of Study D2301 (FREEDOMS): It was a 2-year randomized, double-blind, placebo-controlled Phase III study in patients with relapsing-remitting multiple sclerosis 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 (ARR).
Median age was 40.5 years, median disease duration was 8.9 years and median EDSS score at baseline was 2.5. Patients were randomized to receive Gilenya 0.5 mg (n=358) or Gilenya 1.25 mg (n=370), or placebo (n=355) for up to 24 months.
Median time on study drug was 719 days on 0.5 mg and 719 days on placebo. Patients randomized to the fingolimod 1.25 mg dose arm were switched in a blinded manner to receive fingolimod 0.5 mg when results of Study 2301 became available and confirmed a better benefit/risk profile of the lower dose. The dose was switched in 113 patients (30.5%) in this dose arm, median time on fingolimod 1.25 mg in this arm was 496.1 days and 209.8 days on fingolimod 0.5 mg.
The annualized relapse rate was significantly lower in patients treated with Gilenya than in patients who received placebo. The first key secondary endpoint was change from baseline in brain volume. Loss of brain volume was significantly less with Gilenya treatment compared to placebo. The other key 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. The risk of disability progression for Gilenya and placebo groups was not statistically different.
There were no significant differences between the 0.5 mg and the 1.25 mg doses on any of the endpoints.
The results for this study are shown in Table 2 and Figure 3. (See Table 2 and Figure 3.)

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Click on icon to see table/diagram/image

Study D2302 (TRANSFORMS): Study D2302 (TRANFORMS) was a 1-year randomized, double-blind, double dummy, active (interferon β-1a 30 mcg IM once weekly)-controlled phase III study in patients with relapsing-remitting multiple sclerosis who had not received any natalizumab in the previous 6 months. Prior therapy with interferon-β 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. Patients were randomized to receive Gilenya 0.5 mg (n=431) or 1.25 mg (n=426) or interferon beta-1a 30 mcg via IM route once weekly (n=435) for up to 12 months. Median time on study drug was 365 days on 0.5 mg, 354 days on 1.25 mg and 361 days on interferon beta-1a.
The annualized relapse rate was significantly lower in patients treated with Gilenya than in patients who received interferon β-1a IM. There was no significant difference between the Gilenya 0.5 mg and the 1.25 mg doses. The key secondary endpoints were number of new or 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 or newly enlarging T2 lesions was significantly lower in patients treated with Gilenya than in patients who received interferon β-1a IM. There was no significant difference in the time to 3-month confirmed disability progression between Gilenya and interferon β-1a IM-treated patients at 1 year. There were no significant differences between the 0.5 and the 1.25 mg doses on either endpoint.
The results for this study are shown in Table 3 and Figure 4. (See Table 3 and Figure 4.)

Click on icon to see table/diagram/image


Click on icon to see table/diagram/image

Patients who completed Study TRANSFORMS (D2302) had the option to enter a dose-blinded extension. 1,030 patients from the core study entered the extension (Study D2302E1) and were treated with fingolimod (n=357 continued on 0.5 mg, 330 continued on 1.25 mg, 167 switched from interferon beta-1a to 0.5 mg and 176 switched from interferon beta-1a to 1.25 mg). 882 of these patients (85.9%) had at least 12 months follow-up in the extension phase. The maximum cumulative duration of exposure to fingolimod 0.5 mg (core + extension study) was 1,594 days.
At Month 12 of the extension study, patients who received interferon beta-1a i.m. in the core study had relative reductions in ARR of 30% after switching to fingolimod 0.5 mg (ARR ratio=0.70, p=0.06). The ARR for patients who were treated with fingolimod 0.5 mg in the core study was low during the combined core and extension study (ARR of 0.18 up to Month 24).
The pooled results of studies D2301 (FREEDOMS) and D2302 (TRANSFORMS) showed a consistent reduction in the annualized relapse rate with Gilenya compared to comparator in subgroups defined by gender, age, prior multiple sclerosis therapy, disease activity or disability levels at baseline.
Pharmacokinetics: Absorption: Fingolimod absorption is slow (t_max of 12-16 hours) and extensive (≥85%, based on the amount of radioactivity excreted in urine and the amount of metabolites in feces extrapolated to infinity). The apparent absolute oral bioavailability is high (93%).
Food intake does not alter C_max or exposure (AUC) of fingolimod or fingolimod-phosphate. Therefore Gilenya may be taken without regard to meals (see Dosage & Administration).
Steady-state blood concentrations are reached within 1-2 months following once-daily administration and steady-state levels are approximately 10-fold greater than with the initial dose.
Distribution: Fingolimod highly distributes in red blood cells, with the fraction in blood cells of 86%. Fingolimod-phosphate has a smaller uptake in blood cells of <17%. Fingolimod and fingolimod-phosphate are highly protein bound (>99.7%). Fingolimod and fingolimod-phosphate protein-binding is not altered by renal or hepatic impairment.
Fingolimod is extensively distributed to body tissues with a volume of distribution of about 1200±260 L. A study in four healthy subjects who received a single intravenous dose of radioiodolabeled fingolimod demonstrated that fingolimod penetrates into the brain. In a study in 13 male multiple sclerosis patients who received Gilenya 0.5 mg/day at steady-state, the amount of fingolimod (and fingolimod phosphate) in seminal ejaculate was more than 10,000 times lower than the dose administered (0.5 mg).
Metabolism: The biotransformation of fingolimod in humans occurs by three main pathways; by reversible stereoselective phosphorylation to the pharmacologically active (S)-enantiomer of fingolimod-phosphate, by oxidative biotransformation mainly via the CYPP-4504F2 isoenzyme and subsequent fatty acid-like degradation to inactive metabolites, and by formation of pharmacologically inactive nonpolar ceramide analogs of fingolimod.
Following single oral administration of [¹⁴C] fingolimod, the major fingolimod-related components in blood, as judged from their contribution to the AUC up to 816 hrs post-dose of total radiolabeled components, are fingolimod itself (23.3%), fingolimod-phosphate (10.3%) and inactive metabolites [M3 carboxylic acid metabolite (8.3%), M29 ceramide metabolite (8.9%) and M30 ceramide metabolite (7.3%)].
Elimination: Fingolimod blood clearance is 6.3±2.3 L/hr, and the average apparent terminal half-life (t_½) is 6-9 days. Blood levels of fingolimod-phosphate decline in parallel with fingolimod in the terminal phase yielding similar half-life for both.
After an oral administration, about 81% of the dose is slowly excreted in the urine as inactive metabolites. Fingolimod and fingolimod-phosphate are not excreted intact in urine but are the major components in the feces with amounts representing <2.5% of the dose each. After 34 days, the recovery of the administered dose is 89%.
Linearity: Fingolimod and fingolimod-phosphate concentrations increase in an apparent dose-proportional manner after multiple once daily doses of fingolimod 0.5 mg or 1.25 mg.
Special Populations: Renal Dysfunction: Severe renal impairment increases fingolimod C_max and AUC by 32% and 43%, respectively, and fingolimod-phosphate C_max and AUC by 25% and 14%, respectively. The apparent elimination t_½ is unchanged for both analytes. No Gilenya dose adjustments are needed in patients with renal impairment.
Hepatic Dysfunction: The pharmacokinetics of single-dose fingolimod (1 or 5 mg), when assessed in subjects with mild, moderate and severe hepatic impairments (Child-Pugh class A, B and C), showed no change on fingolimod C_max, but an increase in AUC by 12%, 44% and 103%, respectively. The apparent elimination t_½ is unchanged in mild hepatic impairment but is prolonged by 49-50% in moderate and severe hepatic impairment. In patients with severe hepatic impairment (Child-Pugh class C), fingolimod-phosphate C_max was decreased by 22% and AUC increased by 38%. The pharmacokinetics of fingolimod-phosphate were not evaluated in patients with mild or moderate hepatic impairment. Although hepatic impairment elicited changes in the disposition of fingolimod and fingolimod-phosphate, the magnitude of these changes suggests that the fingolimod dose does not need to be adjusted in mild or moderate hepatic impaired patients (Child-Pugh class A and B). Fingolimod should be used with caution in patients with severe hepatic impairment (Child-Pugh class C).
Pediatrics: Safety and efficacy of Gilenya in pediatric patients below the age of 18 year have not been studied. Gilenya is not indicated for use in pediatric patients.
Geriatrics: The mechanism for elimination and results from population pharmacokinetics suggest that dose adjustment would not be necessary in elderly patients. However, clinical experience in patients aged above 65 years is limited.
Ethnicity: The effects of ethnic origin on fingolimod and fingolimod-phosphate pharmacokinetics are not of clinical relevance.
Gender: Gender has no influence on fingolimod and fingolimod-phosphate pharmacokinetics.
Toxicology: Nonclinical Safety Data: The preclinical safety profile of fingolimod was assessed in mice, rats, dogs and monkeys. The major target organs were the lymphoid system (lymphopenia and lymphoid atrophy), lungs (increased weight, smooth muscle hypertrophy at the bronchioalveolar junction) and heart (negative chronotropic effect, increase in blood pressure, perivascular changes and myocardial degeneration) in several species; blood vessels (vasculopathy) in rats only; and pituitary, forestomach, liver, adrenals, gastrointestinal tract and nervous system at high doses only (often associated with signs of general toxicity) in several species.
No evidence of carcinogenicity was observed in a 2-year bioassay in rats at oral doses of fingolimod up to the maximally tolerated dose of 2.5 mg/kg, representing an approximate 50-fold margin based on the human systemic exposure (AUC) at the 0.5-mg dose. However, in a 2-year mouse study, an increased incidence of malignant lymphoma was seen at doses of 0.25 mg/kg and higher, representing an approximate 6-fold margin based on the human systemic exposure (AUC) at a daily dose of 0.5 mg.
Fingolimod was not mutagenic in an Ames test and in a L5178Y mouse lymphoma cell line in vitro. No clastogenic effects were seen in vitro in V79 Chinese hamster lung cells. Fingolimod-induced numerical (polyploidy) chromosomal aberrations in V79 cells at concentrations of ≥3.7 mcg/mL. Fingolimod was not clastogenic in the in vivo micronucleus tests in mice and rats.
Fingolimod had no effect on sperm count/motility, nor on fertility in male and female rats up to the highest dose tested (10 mg/kg), representing an approximate 150-fold margin based on the human systemic exposure (AUC) at a daily dose of 0.5 mg.
Fingolimod was teratogenic in the rat when given at doses of 0.1 mg/kg or higher. The most common fetal visceral malformations included persistent truncus arteriosus and ventricular septum defect. An increase in post-implantation loss was observed in rats at 1 mg/kg and higher and a decrease in viable fetuses at 3 mg/kg. Fingolimod was not teratogenic in the rabbit, where an increased embryo-fetal mortality was seen at doses of 1.5 mg/kg and higher, and a decrease in viable fetuses as well as fetal growth retardation at 5 mg/kg.
In rats, F1 generation pup survival was decreased in the early postpartum period at doses that did not cause maternal toxicity. However, F1 body weights, development, behavior and fertility were not affected by treatment with fingolimod. In a toxicity study in juvenile rats, no additional target organs of toxicity were observed compared to adult rats. Repeated stimulations with Keyhole Limpet Hemocyanin (KLH) showed a moderately decreased response during the treatment period, but fully functional immune reactions at the end of an 8-week recovery period.
Fingolimod was excreted in milk of treated animals during lactation. Fingolimod and its metabolites crossed the placental barrier in pregnant rabbits.

Gilenya is indicated as a disease modifying therapy for the treatment of patients with relapsing multiple sclerosis to reduce the frequency of relapses and to delay the progression of disability.

General Target Population: Recommended Dose: One 0.5-mg cap taken orally once daily, which can be taken with or without food. If a dose is missed treatment should be continued with the next dose as planned.
On initiation of Gilenya treatment, after the first dose, it is recommended that all patients be observed, with hourly pulse and blood pressure measurement, for a period of 6 hours for signs and symptoms of bradycardia. All patients should have an electrocardiogram performed prior to dosing and at the end of the 6-hour monitoring period (see Precautions).
For recommendations related to switching patients from other disease modifying therapies to Gilenya (see Precautions).
Dosing in Special Populations: Renal Impairment: No Gilenya dose adjustments are needed in patients with renal impairment (see Pharmacology under Actions).
Hepatic Impairment: No Gilenya dose adjustments are needed in patients with mild or moderate hepatic impairment. Gilenya should be used with caution in patients with severe hepatic impairment (Child-Pugh class C) (see Pharmacology under Actions).
Pediatric Patients: Gilenya is not indicated for use in pediatric patients (see Pharmacology iunder Actions).
Ethnicity: No Gilenya dose adjustments based on ethnic origin are needed (see Pharmacology under Actions).
Gender: No Gilenya dose adjustments are needed based on gender (see Pharmacology under Actions).
Diabetic Patients: Gilenya should be used with caution in patients with diabetes mellitus due to a potential increased risk of macular edema (see Precautions).

Single doses up to 80-fold the recommended dose (0.5 mg) were well-tolerated in healthy volunteers. At 40 mg, 5 of 6 subjects reported mild chest tightness or discomfort which was clinically consistent with small airway reactivity.
Fingolimod can induce bradycardia. The decline in heart rate usually starts within 1 hr of the 1st dose, and is maximal within 6 hrs. There have been reports of slow atrioventricular conduction with isolated reports of transient, spontaneously resolving complete atrioventricular (AV) block (see Precautions and Adverse Reactions).
If the overdose constitutes 1st exposure to Gilenya, it is important to observe for signs and symptoms of bradycardia, which could include overnight monitoring. Regular measurements of pulse rate and blood pressure are required and electrocardiograms should be performed (see Dosage & Administration and Precautions).
Neither dialysis nor plasma exchange would result in meaningful removal of fingolimod from the body.

None.

Infections: A core pharmacodynamic effect of Gilenya is a dose dependent reduction of peripheral lymphocyte count to 20-30% of baseline values. This is due to the reversible sequestration of lymphocytes in lymphoid tissues (see Pharmacology under Actions).
The immune system effects (see Pharmacology under Actions) of Gilenya may increase the risk of infections (see Adverse Drug Reactions). Before initiating treatment with Gilenya, a recent complete blood count (CBC) (i.e. within 6 months or after discontinuation of prior therapy) should be available.
Initiation of treatment with Gilenya should be delayed in patients with severe active infection until resolution. Effective diagnostic and therapeutic strategies should be employed in patients with symptoms of infection while on therapy. Because elimination of fingolimod after discontinuation of Gilenya may take up to two months, vigilance for infection should be continued throughout this period (see text as follows: Stopping Gilenya therapy).
Anti-neoplastic, immune-modulating or immunosuppressive therapies (including corticosteroids) should be co-administered with caution due to the risk of additive immune system effects. Specific decisions as to the dosage and duration of treatment with corticosteroids should be based on clinical judgment. Co-administration of a short course of corticosteroids (up to 5 days as per study protocols) did not increase the overall rate of infection in patients treated with fingolimod in the Phase III clinical trials, compared to placebo. Based on these data, short courses of corticosteroids (up to 5 days) can be used in combination with Gilenya (see Adverse Drug Reactions and Interactions).
Patients receiving Gilenya should be instructed to report symptoms of infections to their physician. Suspension of treatment with Gilenya should be considered if a patient develops a serious infection and consideration of benefit-risk should be undertaken prior to re-initiation of therapy.
Patients need to be assessed for their immunity to varicella (chickenpox) prior to Gilenya treatment. It is recommended that patients without a health care professional confirmed history of chickenpox or documentation of a full course of vaccination with varicella vaccine undergo antibody testing to varicella zoster virus (VZV) before initiating Gilenya therapy. A full course of vaccination for antibody-negative patients with varicella vaccine is recommended prior to commencing treatment with Gilenya (see Adverse Drug Reactions). Initiation of treatment with Gilenya should be postponed for 1 month to allow full effect of vaccination to occur.
Vaccination: Vaccination may be less effective during and for up to two months after stopping treatment with Gilenya (see text as follows: Stopping Gilenya Therapy). The use of live attenuated vaccines should be avoided (see Interactions).
Macular Edema: Macular edema (see Adverse Drug Reactions) with or without visual symptoms has been reported in 0.5% of patients treated with Gilenya 0.5 mg, occurring predominantly in the first 3-4 months of therapy. An ophthalmic evaluation is therefore recommended 3-4 months after treatment initiation. If patients report visual disturbances at any time while on Gilenya therapy, an evaluation of the fundus, including the macula, should be carried out.
Patients with a history of uveitis and patients with diabetes mellitus are at increased risk of macular edema (see Adverse Drug Reactions). Gilenya has not been studied in multiple sclerosis patients with concomitant diabetes mellitus. It is recommended that multiple sclerosis patients with diabetes mellitus or a history of uveitis undergo an ophthalmic evaluation prior to initiating Gilenya therapy and have follow-up evaluations while receiving Gilenya therapy.
Continuation of Gilenya in patients with macular edema has not been evaluated. A decision on whether or not Gilenya therapy should be discontinued needs to take into account the potential benefits and risks for the individual patient.
Bradyarrhythmia: Initiation of Gilenya treatment results in a transient decrease in heart rate. After the first dose, the heart rate decrease starts within an hour and the Day 1 decline is maximal within 6 hours.
With continued dosing, heart rate returns to baseline within one month of chronic treatment (see Pharmacology under Actions). In patients receiving Gilenya 0.5 mg, this decrease in heart rate, as measured by pulse, averages approximately 8 beats per minute (bpm). Heart rates below 40 bpm were rarely observed (see Adverse Drug Reactions). Patients who experienced bradycardia were generally asymptomatic but some patients experienced mild to moderate symptoms, including hypotension, dizziness, fatigue and/or palpitations, which resolved within the first 24 hours of treatment.
Initiation of Gilenya treatment has been associated with atrioventricular conduction delays, usually first-degree atrioventricular blocks (prolonged PR interval on electrocardiogram). Second-degree atrioventricular blocks, usually Mobitz type I (Wenckebach) have been observed in less than 0.2% of patients receiving Gilenya 0.5 mg in clinical trials. The conduction abnormalities typically were transient, asymptomatic, usually did not require treatment and resolved within the first 24 hours on treatment. Isolated cases of transient, spontaneously resolving complete AV block have been reported during post-marketing use of Gilenya (see Adverse Drug Reactions).
Therefore, on initiation of Gilenya treatment, it is recommended that all patients be observed, with hourly pulse and blood pressure measurements, for a period of 6 hours for signs and symptoms of bradycardia. All patients should have an electrocardiogram performed prior to dosing and at the end of the 6-hour monitoring period. Should post-dose bradyarrhythmia-related symptoms occur, appropriate management should be initiated as necessary and the patient should be observed until the symptoms have resolved. Should a patient require pharmacological intervention during the first-dose observation period, overnight monitoring in a medical facility should be instituted and the first-dose monitoring strategy should be repeated after the second dose of Gilenya.
Additional observation until the finding has resolved is also required: If the heart rate at 6 hours post-dose is <45 bpm or is the lowest value post-dose (suggesting that the maximum pharmacodynamic effect on the heart is not yet manifest), or if the ECG at 6 hours after the first dose shows new onset second degree or higher AV block.
If the ECG at 6 hours after the first dose shows a QTc interval ≥500 msec patients should be monitored overnight.
Due to the risk of serious cardiac rhythm disturbances, Gilenya should not be used in patients with second degree Mobitz type II or higher AV block, sick-sinus syndrome, or sino-atrial heart block. Since significant bradycardia may be poorly tolerated in patients with known ischemic heart disease, history of myocardial infarction, congestive heart failure, history of cardiac arrest, cerebrovascular disease, uncontrolled hypertension or severe untreated sleep apnea, Gilenya should not be used in these patients. If treatment is considered, advice from a cardiologist should be sought prior to initiation of treatment in order to determine the most appropriate monitoring strategy, which should last overnight.
Since initiation of Gilenya treatment results in decreased heart rate and therefore a prolongation of the QT interval, Gilenya should not be used in patients with significant QT prolongation [QTc >470 msec (females) or >450 msec (males)]. Gilenya is best avoided in patients with relevant risk factors for QT prolongation, for example, hypokalemia, hypomagnesemia or congenital QT prolongation. If treatment is considered, advice from a cardiologist should be sought prior to initiation of treatment in order to determine the most appropriate monitoring strategy, which should last overnight.
Use of Gilenya in patients with a history of recurrent syncope or symptomatic bradycardia should be based on an overall benefit-risk assessment. If treatment is considered, advice from a cardiologist should be sought prior to initiation of treatment in order to determine the most appropriate monitoring which should last overnight.
Gilenya has not been studied in patients with arrhythmias requiring treatment with Class Ia (e.g. quinidine, procainamide) or Class III anti-arrhythmic drugs (e.g., amiodarone, sotalol). Class Ia and Class III anti-arrhythmic drugs have been associated with cases of Torsades de Pointes in patients with bradycardia. Since initiation of Gilenya treatment results in decreased heart rate, Gilenya should not be used concomitantly with these drugs.
Experience with Gilenya is limited in patients receiving concurrent therapy with beta blockers, heart rate lowering calcium channel blockers (such as verapamil, diltiazem or ivabradine), or other substances that may decrease heart rate (e.g. digoxin). Since the initiation of Gilenya treatment is also associated with slowing of the heart rate (see Bradyarrhythmia in previous text), concomitant use of these substances during Gilenya initiation may be associated with severe bradycardia and heart block. Because of the potential additive effect on heart rate, treatment with Gilenya should generally not be initiated in patients who are concurrently treated with these substances. If treatment with Gilenya is considered, advice from a cardiologist should be sought regarding the switch to non-heart-rate lowering drugs or appropriate monitoring for treatment initiation (should last overnight) (see Interactions).
If Gilenya therapy is discontinued for more than 2 weeks after the first month of treatment. the effects on heart rate and atrioventricular conduction may recur on reintroduction of Gilenya treatment and the same precautions as for the first dose should apply. Within the first 2 weeks of treatment, first-dose procedures are recommended after an interruption of one day or more. During weeks 3 and 4 of treatment, first-dose procedures are recommended after a treatment interruption of more than 7 days.
Liver Function: Increased hepatic enzymes, mostly alanine aminotransaminase (ALT) elevation, have been reported in multiple sclerosis patients treated with Gilenya. In clinical trials, a 3-fold or greater elevation in ALT occurred in 8.0% of patients treated with Gilenya 0.5 mg and the drug was discontinued if the elevation exceeded a 5-fold increase. Recurrence of ALT elevations occurred upon re-challenge in some patients, supporting a relationship to the drug. Recent (i.e. within last 6 months) transaminase and bilirubin levels should be available before initiation of treatment with Gilenya. Patients who develop symptoms suggestive of hepatic dysfunction, such as unexplained nausea, vomiting, abdominal pain, fatigue, anorexia, or jaundice, and/or dark urine during treatment, should have liver enzymes checked and Gilenya should be discontinued if significant liver injury is confirmed (see Adverse Drug Reactions: Liver Function). Although there are no data to establish that patients with preexisting liver disease are at increased risk to develop elevated liver function test (LFT) values when taking Gilenya, caution should be exercised when using of Gilenya in patients with a history of significant liver disease.
Posterior Reversible Encephalopathy Syndrome: Rare cases of posterior reversible encephalopathy syndrome (PRES) have been reported at 0.5 mg dose in clinical trials and in the post-marketing setting (see Adverse Reactions). Symptoms reported included sudden onset of severe headache, nausea, vomiting, 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, Gilenya should be discontinued.
Prior Treatment with Immunosuppressive or Immune-Modulating Therapies: When switching from other disease modifying therapies, the half-life and mode of action of the other therapy must be considered in order to avoid an additive immune effect whilst at the same time minimizing risk of disease reactivation. Before initiating treatment with Gilenya, a recent CBC (i.e. after discontinuation of prior therapy) should be available to ensure any immune effects (i.e. cytopenia) of such therapies have resolved.
Beta Interferon, Glatiramer Acetate or Dimethyl Fumarate: Gilenya can generally be started immediately after discontinuation of beta interferon, glatiramer acetate or dimethyl fumarate.
Natalizumab or Teriflunomide: Due to the long half-life of natalizumab or teriflunomide, caution regarding potential additive immune effects is required when switching patients from these therapies to Gilenya. A careful case-by-case assessment regarding the timing of the initiation of Gilenya treatment is recommended.
Elimination of natalizumab usually takes up to 2-3 months following discontinuation.
Teriflunomide is also eliminated slowly from the plasma. Without an accelerated elimination procedure, clearance of teriflunomide from plasma can take several months to up to 2-years. An accelerated elimination procedure is described in the teriflunomide product information.
Alemtuzumab: Due to the characteristics and duration of alemtuzumab immune suppressive effects described in its product information, initiating treatment with Gilenya after alemtuzumab is not recommended unless the benefits of Gilenya treatment clearly outweigh the risks for the individual patient.
Stopping Therapy: If a decision is made to stop treatment with Gilenya, the physician needs to be aware that fingolimod remains in the blood and has pharmacodynamic effects, such as decreased lymphocyte counts, for up to two months following the last dose. Lymphocyte counts typically return to the normal range within 1-2 months of stopping therapy (see Pharmacology under Actions). Starting other therapies during this interval will result in concomitant exposure to fingolimod. Use of immunosuppressants soon after the discontinuation of Gilenya may lead to an additive effect on the immune system and therefore caution should be applied.
Women of Child-Bearing Potential: Before initiation of Gilenya treatment, women of childbearing potential should be counselled on the potential for a serious risk to the fetus and the need for effective contraception during treatment with Gilenya. Since it takes approximately 2 months to eliminate the compound from the body after stopping treatment (see Precautions) the potential risk to the fetus may persist and contraception should be pursued during this period.
Labour and Delivery: There are no data on the effects of fingolimod on labor and delivery.
Fertility:Data from preclinical studies does not suggest that fingolimod would be associated with an increased risk of reduced fertility.
Male Reproductive Toxicity: Available data do not suggest that Gilenya would be associated with an increased risk of male-mediated fetal toxicity.

Use in Pregnancy: The use of Gilenya in women who are or may become pregnant should only be considered if the potential benefit justifies the potential risk to the fetus (see above Women of childbearing potential under Precautions).
Animal studies have shown reproductive toxicity including fetal loss and organ defects, notably persistent truncus arteriosus and ventricular septal defect (see Pharmacology: Toxicology: Non-clinical safety data under Actions). Furthermore, the receptor affected by fingolimod (sphingosine-1-phosphate receptor) is known to be involved in vascular formation during embryogenesis. At the present time it is not known whether cardiovascular malformations will be found in humans. There are very limited data from the use of fingolimod in pregnant women. In clinical trials, 20 pregnancies were reported in patients exposed to fingolimod at the time of diagnosis of pregnancy, but data are too limited to draw conclusions on the safety of Gilenya in pregnancy.
Use in Lactation: Fingolimod is excreted in the milk of treated animals during lactation. Because of the potential for serious adverse drug reactions to fingolimod in nursing infants, women receiving Gilenya should not breast feed.

Summary of The Safety Profile: The safety population of Gilenya is derived from two Phase III placebo-controlled clinical trials and one Phase III active-controlled clinical trial in patients with relapsing remitting multiple sclerosis. It includes a total of 2,431 patients on Gilenya (0.5 or 1.25 mg dose). Study D2301 (FREEDOMS) was a 2-year placebo-controlled clinical study in 854 multiple sclerosis patients treated with fingolimod (placebo: 418). Study D2309 (FREEDOMS II) was a 2 year placebo-controlled clinical study in 728 multiple sclerosis patients treated with fingolimod (placebo: 355). In the pooled data from these two studies the most serious adverse drug reactions (ADRs) for the 0.5 mg recommended therapeutic dose were infections, macular edema and transient atrioventricular blocks on treatment initiation. The most frequent ADRs (incidence ≥10%) at the 0.5 mg dose were headache, hepatic enzyme increased, diarrhoea, cough, influenza, sinusitis and back pain. The most frequent adverse event reported for Gilenya 0.5 mg at an incidence greater than 1% leading to treatment interruption was ALT elevations (2.2%).
The ADRs for fingolimod in Study D2302 (TRANSFORMS), a 1-year controlled study using interferon beta-1a as comparator in 849 patients with multiple sclerosis treated with fingolimod, were generally similar to placebo-controlled studies, taking into account the differences in study duration.
Tabulated Summary of Adverse Drug Reactions:Table 4 (see Table 4) presents the frequency of ADRs reported in the pooled analysis of the placebo-controlled studies FREEDOMS and FREEDOMS II.
ADRs are listed according to MedDRA system organ class. Frequencies were defined as follows: Very Common (≥1/10); Common (≥1/100 to <1/10); Uncommon (≥1/1,000 to <1/100).

Click on icon to see table/diagram/image

Infections:In multiple sclerosis clinical trials, the overall rate of infections (65.1%) at the 0.5 mg dose was similar to placebo. However, bronchitis, herpes zoster and pneumonia, were more common in Gilenya treated patients. Serious infections occurred at a rate of 1.6% in the fingolimod 0.5 mg group versus 1.4% in the placebo group.
There have been very rare fatal cases of VZV infections in the context of prolonged concomitant corticosteroid use (more than 5 days) for treatment of multiple sclerosis relapses, however, a causal relationship between the concomitant treatment and fatal outcome has not been established. Co-administration of a short course of corticosteroids (up to 5 days as per study protocols) did not increase the overall rate of infection in patients treated with fingolimod in the Phase III clinical trials, compared to placebo (see Precautions and Interactions).
There have been very rare cases of other herpes viral infections with fatal outcome. However, a causal relationship with Gilenya has not been established.
Macular Edema:In clinical trials, macular edema occurred in 0.5% of patients treated with the recommended Gilenya dose of 0.5 mg and in 1.1% of patients treated with the higher 1.25 mg dose.
The majority of cases in multiple sclerosis clinical trials occurred within the first 3-4 months of therapy. Some patients presented with blurred vision or decreased visual acuity, but others were asymptomatic and diagnosed on routine ophthalmic examination. The macular edema generally improved or resolved spontaneously after drug discontinuation. The risk of recurrence after re-challenge has not been evaluated.
Macular edema incidence is increased in multiple sclerosis patients with a history of uveitis (approximately 20% with a history of uveitis vs 0.6% without a history of uveitis).
Gilenya has not been tested in multiple sclerosis patients with diabetes mellitus. In renal transplant clinical studies where patients with diabetes mellitus were included, therapy with Gilenya 2.5 mg and 5 mg resulted in a 2-fold increase in the incidence of macular edema. Multiple sclerosis patients with diabetes mellitus are therefore expected to be at a higher risk for macular edema (see Precautions).
Bradyarrhythmia:Initiation of Gilenya treatment results in a transient decrease in heart rate and may also be associated with atrioventricular conduction delays (see Precautions).
In multiple sclerosis clinical trials the mean maximum decrease in heart rate after the first dose intake was seen 4-5 hours post-dose, with a decline in the mean heart rate, as measured by pulse, of 8 beats per minute for Gilenya 0.5 mg. The second dose may result in a slight further decrease. Heart rates below 40 beats per minute were rarely observed in patients on Gilenya 0.5 mg. Heart rate returned to baseline within 1 month of chronic dosing.
In the multiple sclerosis clinical program first-degree atrioventricular block (prolonged PR interval on electrocardiogram) was detected following drug initiation in 4.7% of patients on Gilenya 0.5 mg, in 2.8% of patients on intramuscular interferon beta-1a IM and in 1.6% of patients on placebo. Second-degree atrioventricular block was detected in less than 0.2% patients on Gilenya 0.5 mg.
In the post-marketing setting, isolated reports of transient, spontaneously resolving complete AV block have been observed during the six hour observation period following the first dose of Gilenya. The patients recovered spontaneously.
The conduction abnormalities observed both in clinical trials and post-marketing were typically transient, asymptomatic and resolved within 24 hours on treatment. Although most patients did not require medical intervention, in clinical trials one patient on the 0.5 mg dose received isoprenaline for an asymptomatic second degree Mobitz I atrioventricular block.
In the post-marketing setting, isolated delayed onset events, including transient asystole and unexplained death, have occurred within 24 hours of the first dose. These cases have been confounded by concomitant medications and/or pre-existing disease. The relationship of such events to Gilenya is uncertain.
Blood Pressure: In multiple sclerosis clinical trials Gilenya 0.5 mg was associated with a mild increase of approximately 1 mmHg on average in mean arterial pressure manifesting after approximately 1 month of treatment initiation. This increase persisted with continued treatment. Hypertension was reported in 6.5% of patients on Gilenya 0.5 mg and in 3.3% of patients on placebo.
Liver Function: Increased hepatic enzymes (mostly ALT elevation) have been reported in multiple sclerosis patients treated with Gilenya. In clinical trials, 8.0% and 1.8% of patients treated with Gilenya 0.5 mg experienced an asymptomatic elevation in serum levels of ALT of ≥3x ULN and ≥5x ULN, respectively, compared with corresponding figures in the placebo group of 1.9% and 0.9% respectively. The majority of elevations occurred within 6-9 months. ALT levels returned to normal within approximately 2 months after discontinuation of Gilenya. In the few patients who experienced ALT elevations of ≥5x ULN and who continued on Gilenya therapy, the ALT levels returned to normal within approximately 5 months (see Precautions).
Respiratory System: Minor dose-dependent reductions in forced expiratory volume in 1 second (FEV₁) and in the diffusing capacity of the lung for carbon monoxide (DLCO) values were observed with fingolimod treatment starting at month 1 and remaining stable thereafter. At Month 24, the reduction from baseline values in percent of predicted FEV₁ was 2.7% for fingolimod 0.5 mg and 1.2% for placebo, a difference that resolved after treatment discontinuation. For DLCO the reductions at Month 24 were 3.3% for fingolimod 0.5 mg and 2.7% for placebo.
Vascular Events: In Phase III clinical trials rare cases of peripheral arterial occlusive disease occurred in patients treated with Gilenya at higher doses (1.25 or 5.0 mg). Rare cases of ischemic and hemorrhagic strokes have also been reported at the 0.5 mg dose in clinical trials and in the post-marketing setting although a causal relationship has not been established.
Lymphomas: There have been cases of lymphoma in clinical studies and the post-marketing setting. The cases reported were heterogeneous in nature, including B-cell and T-cell lymphomas. The relationship to Gilenya remains uncertain.

Pharmacodynamic Interactions: Anti-neoplastic, immune-modulating or immunosuppressive therapies (including corticosteroids) should be co-administered with caution due to the risk of additive immune system effects. Specific decisions as to the dosage and duration of concomitant treatment with corticosteroids should be based on clinical judgment. Co-administration of a short course of corticosteroids (up to 5 days as per study protocols) did not increase the overall rate of infection in patients treated with fingolimod in the Phase III clinical trials, compared to placebo (see Precautions and Adverse Reactions).
Caution should also be applied when switching patients from long-acting therapies with immune effects such as natalizumab, teriflunomide or mitoxantrone (see Prior Treatment with Immunosuppressive or Immune-modulating Therapies under Precautions).
When fingolimod is used with atenolol, there is an additional 15% reduction in heart rate upon fingolimod initiation, an effect not seen with diltiazem. Treatment with Gilenya should not be initiated in patients receiving beta blockers, heart rate lowering calcium channel blockers (such as verapamil, diltiazem or ivabradine), or other substances which may decrease heart rate (e.g. digoxin) because of the potential additive effects on heart rate. If treatment with Gilenya is considered, advice from a cardiologist should be sought regarding the switch to non-heart-rate lowering medicinal products or appropriate monitoring for treatment initiation (should last overnight) (see Precautions).
During and for up to two months after treatment with Gilenya vaccination may be less effective. The use of live attenuated vaccines may carry the risk of infection and should therefore be avoided (see Precautions and Adverse Reactions).
Pharmacokinetic Interactions: Fingolimod is primarily cleared via cytochrome P450 4F2 (CYP4F2) and possibly other CYP4F isoenzymes. In vitro studies in hepatocytes indicated that CYP3A4 may contribute to fingolimod metabolism in the case of strong induction of CYP3A4.
Potential of Fingolimod and Fingolimod-Phosphate to Inhibit the Metabolism of Co-Medications:  In vitro inhibition studies using pooled human liver microsomes and specific metabolic probe substrates demonstrated that fingolimod and fingolimod-phosphate have little or no capacity to inhibit the activity of CYP enzymes [CYP1A2, CYP2A6, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6, CYP2E1, CYP3A4/5, or CYP4A9/11 (fingolimod only)]. Therefore, fingolimod and fingolimod-phosphate are unlikely to reduce the clearance of drugs that are mainly cleared through metabolism by the major CYP isoenzymes.
Potential of Fingolimod and Fingolimod-Phosphate to Induce its Own and/or the Metabolism of Co-Medications: Fingolimod was examined for its potential to induce human CYP3A4, CYP1A2, CYP4F2, and ABCB1 (P-gp) mRNA and CYP3A, CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19, and CYP4F2 activity in primary human hepatocytes. Fingolimod did not induce mRNA or activity of the different CYP enzymes and ABCB1 with respect to the vehicle control. Therefore, no clinically relevant induction of the tested CYP enzymes or ABCB1 (P-gp) by fingolimod is expected at therapeutic concentrations. In vitro experiments did not provide an indication of CYP induction by fingolimod-phosphate.
Potential of Fingolimod and Fingolimod-Phosphate to Inhibit the Active Transport of Co-Medications: Based on in vitro data, fingolimod as well as fingolimod-phosphate are not expected to inhibit the uptake of co-medications and/or biologics transported by the organic anion transporting polypeptides 1B1 and 1B3 (OATP1B1, OATP1B3) or the sodium taurocholate co-transporting polypeptide (NTCP). Similarly, they are not expected to inhibit the efflux of co-medications and/or biologics transported by the breast cancer resistance protein (BCRP), the bile salt export pump (BSEP), the multidrug resistance-associated protein 2 (MRP2) or P-glycoprotein (P-gp) at therapeutic concentrations.
Oral Contraceptives: The co-administration of fingolimod 0.5 mg daily with oral contraceptives (ethinylestradiol and levonorgestrel) did not elicit any change in oral contraceptive exposure. Fingolimod and fingolimod-phosphate exposure were consistent with those from previous studies. No interaction studies have been performed with oral contraceptives containing other progestagens, however an effect of fingolimod on their exposure is not expected.
Cyclosporine: The pharmacokinetics of single-dose fingolimod were not altered during co-administration with cyclosporine at steady-state, nor were cyclosporine steady-state pharmacokinetics altered by single-dose, or multi-dose (28 days) fingolimod administration. These data indicate that fingolimod is unlikely to reduce, or increase the clearance of drugs mainly cleared by CYP3A4 and that inhibition of CYP3A4 is unlikely to reduce the clearance of fingolimod. Potent inhibition of transporters P-gp, MRP2 and OATP1B1 does not influence fingolimod disposition.
Ketoconazole: The co-administration of ketoconazole 200 mg twice daily at steady-state and a single dose of fingolimod 5 mg led to a modest increase in the AUC of fingolimod and fingolimod-phosphate (1.7-fold increase) by inhibition of CYP4F2.
Isoproterenol, Atropine, Atenolol and Diltiazem: Single-dose fingolimod and fingolimod-phosphate exposure was not altered by co-administered isoproterenol, or atropine. Likewise, the single-dose pharmacokinetics of fingolimod and fingolimod-phosphate and the steady-state pharmacokinetics of both atenolol and diltiazem were unchanged during the co-administration of the latter two drugs with fingolimod.
Carbamazepine: The co-administration of carbamazepine 600 mg twice daily at steady-state and a single dose of fingolimod 2 mg had a weak effect on the AUC of fingolimod and fingolimod-phosphate, decreasing both by approximately 40%. The clinical relevance of this decrease is unknown.
Population Pharmacokinetics Analysis of Potential Drug-Drug Interactions: A population pharmacokinetics evaluation, performed in multiple sclerosis patients did not provide evidence for a significant effect of fluoxetine and paroxetine (strong CYP2D6 inhibitors) on fingolimod or fingolimod-phosphate concentrations. In addition, the following, commonly prescribed substances had no clinically relevant effect (≤20%) on fingolimod or fingolimod-phosphate concentrations: Baclofen, gabapentin, oxybutynin, amantadine, modafinil, amitriptyline, pregabalin, corticosteroids and oral contraceptives.
Laboratory Tests: Since fingolimod reduces blood lymphocyte counts via re-distribution in secondary lymphoid organs, peripheral blood lymphocyte counts cannot be utilized to evaluate the lymphocyte subset status of a patient treated with Gilenya.
Laboratory tests requiring the use of circulating mononuclear cells require larger blood volumes due to reduction in the number of circulating lymphocytes.

Instructions for Use and Handling: No special requirements.
Incompatibilities: Not applicable.

Immunosuppressants

L04AA27 - fingolimod ; Belongs to the class of selective immunosuppressive agents. Used to induce immunosuppression.

S

Cap (hard) 0.5 mg x 28's.