FULL PRESCRIBING INFORMATION: CONTENTS * WARNING

FULL PRESCRIBING INFORMATION: CONTENTS *

WARNING: SEVERE ACUTE EXACERBATIONS OF HEPATITIS B, PATIENTS

CO-INFECTED WITH HIV AND HBV, AND LACTIC ACIDOSIS AND

HEPATOMEGALY

1 INDICATIONS AND USAGE

2 DOSAGE AND ADMINISTRATION

2.1 Timing of Administration

2.2 Recommended Dosage in Adults

2.3 Recommended Dosage in Pediatric Patients

2.4 Renal Impairment

2.5 Hepatic Impairment

2.6 Duration of Therapy

3 DOSAGE FORMS AND STRENGTHS

4 CONTRAINDICATIONS

5 WARNINGS AND PRECAUTIONS

5.1 Severe Acute Exacerbations of Hepatitis B

5.2 Patients Co-infected with HIV and HBV

5.3 Lactic Acidosis and Severe Hepatomegaly with Steatosis

6 ADVERSE REACTIONS

6.1 Clinical Trial Experience

6.2 Postmarketing Experience

7 DRUG INTERACTIONS

8 USE IN SPECIFIC POPULATIONS

8.1 Pregnancy

8.2 Lactation

8.4 Pediatric Use

8.5 Geriatric Use

8.6 Racial/Ethnic Groups

8.7 Renal Impairment

8.8 Liver Transplant Recipients

10 OVERDOSAGE

11 DESCRIPTION

12 CLINICAL PHARMACOLOGY

12.1 Mechanism of Action

12.3 Pharmacokinetics

12.4 Microbiology

13 NONCLINICAL TOXICOLOGY

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

14 CLINICAL STUDIES

14.1 Outcomes in Adults

14.2 Outcomes in Pediatric Subjects

16 HOW SUPPLIED/STORAGE AND HANDLING

17 PATIENT COUNSELING INFORMATION

* Sections or subsections omitted from the full prescribing information are not listed.

HIGHLIGHTS OF PRESCRIBING INFORMATION

These highlights do not include all the information needed to use BARACLUDE

safely and effectively. See full prescribing information for BARACLUDE.

BARACLUDE

(entecavir) tablets, for oral use

BARACLUDE

(entecavir) oral solution

Initial U.S. Approval: 2005

WARNING: SEVERE ACUTE EXACERBATIONS OF

HEPATITIS B, PATIENTS CO-INFECTED WITH HIV AND HBV,

and LACTIC ACIDOSIS AND HEPATOMEGALY

See full prescribing information for complete boxed warning.

• Severe acute exacerbations of hepatitis B have been reported in patients

who have discontinued anti-hepatitis B therapy, including entecavir.

Hepatic function should be monitored closely for at least several

months after discontinuation. Initiation of anti-hepatitis B therapy may

be warranted. (5.1)

• BARACLUDE is not recommended for patients co-infected with human

immunodeficiency virus (HIV) and hepatitis B virus (HBV) who are not

also receiving highly active antiretroviral therapy (HAART), because of

the potential for the development of resistance to HIV nucleoside reverse

transcriptase inhibitors. (5.2)

• Lactic acidosis and severe hepatomegaly with steatosis, including

fatal cases, have been reported with the use of nucleoside analogue

inhibitors. (5.3)

------------------------------ INDICATIONS AND USAGE ------------------------------

BARACLUDE is a hepatitis B virus nucleoside analogue reverse transcriptase inhibitor

indicated for the treatment of chronic hepatitis B virus infection in adults and children

at least 2 years of age with evidence of active viral replication and either evidence of

persistent elevations in serum aminotransferases (ALT or AST) or histologically active

disease. (1)

---------------------------DOSAGE AND ADMINISTRATION ---------------------------

• Nucleoside-inhibitor-treatment-naïve with compensated liver disease (greater

than or equal to 16 years old): 0.5 mg once daily. (2.2)

• Nucleoside-inhibitor-treatment-naïve and lamivudine-experienced pediatric

patients at least 2 years of age and weighing at least 10 kg: dosing is based on

weight. (2.3)

• Lamivudine-refractory or known lamivudine or telbivudine resistance substitutions

(greater than or equal to 16 years old): 1 mg once daily. (2.2)

• Decompensated liver disease (adults): 1 mg once daily. (2.2)

• Renal impairment: Dosage adjustment is recommended if creatinine clearance

is less than 50 mL/min. (2.4)

• BARACLUDE (entecavir) should be administered on an empty stomach. (2.1)

------------------------- DOSAGE FORMS AND STRENGTHS -------------------------

• Tablets: 0.5 mg and 1 mg (3, 16)

• Oral solution: 0.05 mg/mL (3, 16)

-------------------------------- CONTRAINDICATIONS --------------------------------

• None. (4)

--------------------------- WARNINGS AND PRECAUTIONS ---------------------------

• Severe acute exacerbations of hepatitis B virus infection after discontinuation:

Monitor hepatic function closely for at least several months. (5.1, 6.1)

• Co-infection with HIV: BARACLUDE is not recommended unless the patient is also

receiving HAART. (5.2)

• Lactic acidosis and severe hepatomegaly with steatosis: If suspected, treatment

should be suspended. (5.3)

-------------------------------- ADVERSE REACTIONS --------------------------------

• In adults, the most common adverse reactions (≥3%, all severity grades) are

headache, fatigue, dizziness, and nausea. The adverse reactions observed in

pediatric patients were consistent with those observed in adults. (6.1)

To report SUSPECTED ADVERSE REACTIONS, contact Bristol-Myers Squibb at

1-800-721-5072 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch

---------------------------USE IN SPECIFIC POPULATIONS ---------------------------

• Liver transplant recipients: Limited data on safety and efficacy are available. (8.8)

See 17 for PATIENT COUNSELING INFORMATION and FDA-approved patient labeling.

Revised: 11/2019

BARACLUDE

(entecavir)

FULL PRESCRIBING INFORMATION

WARNING: SEVERE ACUTE EXACERBATIONS OF HEPATITIS B, PATIENTS

CO-INFECTED WITH HIV AND HBV, and LACTIC ACIDOSIS AND HEPATOMEGALY

Severe acute exacerbations of hepatitis B have been reported in patients

who have discontinued anti-hepatitis B therapy, including entecavir. Hepatic

function should be monitored closely with both clinical and laboratory

follow-up for at least several months in patients who discontinue

anti-hepatitis B therapy. If appropriate, initiation of anti-hepatitis B therapy

may be warranted [see Warnings and Precautions (5.1)].

Limited clinical experience suggests there is a potential for the development

of resistance to HIV (human immunodeficiency virus) nucleoside reverse

transcriptase inhibitors if BARACLUDE is used to treat chronic hepatitis B

virus (HBV) infection in patients with HIV infection that is not being treated.

Therapy with BARACLUDE is not recommended for HIV/HBV co-infected

patients who are not also receiving highly active antiretroviral therapy

(HAART) [see Warnings and Precautions (5.2)].

Lactic acidosis and severe hepatomegaly with steatosis, including

fatal cases, have been reported with the use of nucleoside analogue

inhibitors alone or in combination with antiretrovirals [see Warnings and

Precautions (5.3)].

INDICATIONS AND USAGE

BARACLUDE

(entecavir) is indicated for the treatment of chronic hepatitis B virus

infection in adults and pediatric patients 2 years of age and older with evidence of active

viral replication and either evidence of persistent elevations in serum aminotransferases

(ALT or AST) or histologically active disease.

2 DOSAGE AND ADMINISTRATION

2.1 Timing of Administration

BARACLUDE should be administered on an empty stomach (at least 2 hours after a meal

and 2 hours before the next meal).

2.2 Recommended Dosage in Adults

Compensated Liver Disease

The recommended dose of BARACLUDE for chronic hepatitis B virus infection in

nucleoside-inhibitor-treatment-naïve adults and adolescents 16 years of age and older

is 0.5 mg once daily.

The recommended dose of BARACLUDE in adults and adolescents (at least 16 years

of age) with a history of hepatitis B viremia while receiving lamivudine or known

lamivudine or telbivudine resistance substitutions rtM204I/V with or without rtL180M,

rtL80I/V, or rtV173L is 1 mg once daily.

Decompensated Liver Disease

The recommended dose of BARACLUDE for chronic hepatitis B virus infection in adults

with decompensated liver disease is 1 mg once daily.

2.3 Recommended Dosage in Pediatric Patients

Table 1 describes the recommended dose of BARACLUDE for pediatric patients 2 years

of age or older and weighing at least 10 kg. The oral solution should be used for patients

with body weight up to 30 kg.

Table 1: Dosing Schedule for Pediatric Patients

Recommended Once-Daily Dose of Oral Solution (mL)

Body Weight (kg)

Treatment-Naïve

Patients

Lamivudine-Experienced

Patients

10 to 11 3 6

greater than 11 to 14 4 8

greater than 14 to 17 5 10

greater than 17 to 20 6 12

greater than 20 to 23 7 14

greater than 23 to 26 8 16

greater than 26 to 30 9 18

greater than 30 10 20

Children with body weight greater than 30 kg should receive 10 mL (0.5 mg) of oral

solution or one 0.5 mg tablet once daily.

Children with body weight greater than 30 kg should receive 20 mL (1 mg) of oral

solution or one 1 mg tablet once daily.

2.4 Renal Impairment

In adult subjects with renal impairment, the apparent oral clearance of entecavir

decreased as creatinine clearance decreased [see Clinical Pharmacology (12.3)]. Dosage

adjustment is recommended for patients with creatinine clearance less than 50 mL/min,

including patients on hemodialysis or continuous ambulatory peritoneal dialysis (CAPD),

as shown in Table 2. The once-daily dosing regimens are preferred.

Table 2: Recommended Dosage of BARACLUDE in Adult Patients with Renal

Impairment

Creatinine Clearance

(mL/min)

Usual Dose

(0.5 mg)

Lamivudine-Refractory

or Decompensated

Liver Disease (1 mg)

50 or greater 0.5 mg once daily 1 mg once daily

30 to less than 50

0.25 mg once daily

0.5 mg every 48 hours

0.5 mg once daily

1 mg every 48 hours

10 to less than 30

0.15 mg once daily

0.5 mg every 72 hours

0.3 mg once daily

1 mg every 72 hours

Less than 10

Hemodialysis

or CAPD

0.05 mg once daily

0.5 mg every 7 days

0.1 mg once daily

1 mg every 7 days

For doses less than 0.5 mg, BARACLUDE Oral Solution is recommended.

If administered on a hemodialysis day, administer BARACLUDE after the hemodialysis

session.

Although there are insufficient data to recommend a specific dose adjustment of

BARACLUDE in pediatric patients with renal impairment, a reduction in the dose or an

increase in the dosing interval similar to adjustments for adults should be considered.

2.5 Hepatic Impairment

No dosage adjustment is necessary for patients with hepatic impairment.

2.6 Duration of Therapy

The optimal duration of treatment with BARACLUDE for patients with chronic hepatitis B

virus infection and the relationship between treatment and long-term outcomes such as

cirrhosis and hepatocellular carcinoma are unknown.

3 DOSAGE FORMS AND STRENGTHS

• BARACLUDE 0.5 mg film-coated tablets are white to off-white, triangular-shaped,

and debossed with “BMS” on one side and “1611” on the other side.

• BARACLUDE 1 mg film-coated tablets are pink, triangular-shaped, and debossed

with “BMS” on one side and “1612” on the other side.

• BARACLUDE oral solution, 0.05 mg/mL, is a ready-to-use, orange-flavored, clear,

colorless to pale yellow, aqueous solution. Ten milliliters of the oral solution provides

a 0.5 mg dose and 20 mL provides a 1 mg dose of entecavir.

4 CONTRAINDICATIONS

None.

5 WARNINGS AND PRECAUTIONS

5.1 Severe Acute Exacerbations of Hepatitis B

Severe acute exacerbations of hepatitis B have been reported in patients who have

discontinued anti-hepatitis B therapy, including entecavir [see Adverse Reactions

(6.1)]. Hepatic function should be monitored closely with both clinical and laboratory

follow-up for at least several months in patients who discontinue anti-hepatitis B therapy.

If appropriate, initiation of anti-hepatitis B therapy may be warranted.

5.2 Patients Co-infected with HIV and HBV

BARACLUDE has not been evaluated in HIV/HBV co-infected patients who were not

simultaneously receiving effective HIV treatment. Limited clinical experience suggests

there is a potential for the development of resistance to HIV nucleoside reverse

transcriptase inhibitors if BARACLUDE is used to treat chronic hepatitis B virus infection

in patients with HIV infection that is not being treated [see Microbiology (12.4)]. Therefore,

therapy with BARACLUDE is not recommended for HIV/HBV co-infected patients who are

not also receiving HAART. Before initiating BARACLUDE therapy, HIV antibody testing

should be offered to all patients. BARACLUDE has not been studied as a treatment for

HIV infection and is not recommended for this use.

5.3 Lactic Acidosis and Severe Hepatomegaly with Steatosis

Lactic acidosis and severe hepatomegaly with steatosis, including fatal cases, have been

reported with the use of nucleoside analogue inhibitors, including BARACLUDE, alone

or in combination with antiretrovirals. A majority of these cases have been in women.

Obesity and prolonged nucleoside inhibitor exposure may be risk factors. Particular

caution should be exercised when administering nucleoside analogue inhibitors to any

patient with known risk factors for liver disease; however, cases have also been reported

in patients with no known risk factors.

Lactic acidosis with BARACLUDE use has been reported, often in association with

hepatic decompensation, other serious medical conditions, or drug exposures.

Patients with decompensated liver disease may be at higher risk for lactic acidosis.

BARACLUDE

(entecavir) BARACLUDE

(entecavir)

Laboratory Abnormalities

Frequencies of selected treatment-emergent laboratory abnormalities reported during

therapy in four clinical trials of BARACLUDE compared with lamivudine are listed in

Table 4.

Table 4: Selected Treatment-Emergent

Laboratory Abnormalities Reported in

Four Entecavir Clinical Trials Through 2 Years

Nucleoside-Inhibitor-Naïve

Lamivudine-Refractory

Test

BARACLUDE

0.5 mg

n=679

Lamivudine

100 mg

n=668

BARACLUDE

1 mg

n=183

Lamivudine

100 mg

n=190

Any Grade 3–4

laboratory abnormality

35% 36% 37% 45%

ALT >10 × ULN and

>2 × baseline

2% 4% 2% 11%

ALT >5 × ULN 11% 16% 12% 24%

Albumin <2.5 g/dL <1% <1% 0 2%

Total bilirubin >2.5 × ULN 2% 2% 3% 2%

Lipase ≥2.1 × ULN

7% 6% 7% 7%

Creatinine >3 × ULN 0 0 0 0

Conﬁrmed creatinine

increase ≥0.5 mg/dL

1% 1% 2% 1%

Hyperglycemia, fasting

>250 mg/dL

2% 1% 3% 1%

Glycosuria

4% 3% 4% 6%

Hematuria

9% 10% 9% 6%

Platelets <50,000/mm

<1% <1% <1% <1%

On-treatment value worsened from baseline to Grade 3 or Grade 4 for all parameters

except albumin (any on-treatment value <2.5 g/dL), conﬁrmed creatinine increase

≥0.5 mg/dL, and ALT >10 × ULN and >2 × baseline.

Studies AI463022 and AI463027.

Includes Study AI463026 and the BARACLUDE 1 mg and lamivudine treatment arms

of Study AI463014, a Phase 2 multinational, randomized, double-blind study of three

doses of BARACLUDE (0.1, 0.5, and 1 mg) once daily versus continued lamivudine

100 mg once daily for up to 52 weeks in subjects who experienced recurrent viremia

on lamivudine therapy.

Includes hematology, routine chemistries, renal and liver function tests, pancreatic

enzymes, and urinalysis.

Grade 3 = 3+, large, ≥500 mg/dL; Grade 4 = 4+, marked, severe.

Grade 3 = 3+, large; Grade 4 = ≥4+, marked, severe, many.

ULN=upper limit of normal.

Among BARACLUDE-treated subjects in these studies, on-treatment ALT elevations

greater than 10 times the upper limit of normal (ULN) and greater than 2 times baseline

generally resolved with continued treatment. A majority of these exacerbations were

associated with a ≥2 log

/mL reduction in viral load that preceded or coincided with the

ALT elevation. Periodic monitoring of hepatic function is recommended during treatment.

Exacerbations of Hepatitis After Discontinuation of Treatment

An exacerbation of hepatitis or ALT flare was defined as ALT greater than 10 times

ULN and greater than 2 times the subject’s reference level (minimum of the baseline

or last measurement at end of dosing). For all subjects who discontinued treatment

(regardless of reason), Table 5 presents the proportion of subjects in each study who

experienced post-treatment ALT flares. In these studies, a subset of subjects was allowed

to discontinue treatment at or after 52 weeks if they achieved a protocol-defined response

to therapy. If BARACLUDE is discontinued without regard to treatment response, the rate

of post-treatment flares could be higher. [See Warnings and Precautions (5.1).]

Table 5: Exacerbations of Hepatitis During Off-Treatment Follow-up, Subjects in

Studies AI463022, AI463027, and AI463026

Subjects with ALT Elevations >10 × ULN and >2 × Reference

BARACLUDE Lamivudine

Nucleoside-inhibitor-naïve

HBeAg-positive 4/174 (2%) 13/147 (9%)

HBeAg-negative 24/302 (8%) 30/270 (11%)

Lamivudine-refractory 6/52 (12%) 0/16

Reference is the minimum of the baseline or last measurement at end of dosing.

Median time to off-treatment exacerbation was 23 weeks for BARACLUDE-treated

subjects and 10 weeks for lamivudine-treated subjects.

Treatment with BARACLUDE should be suspended in any patient who develops clinical

or laboratory findings suggestive of lactic acidosis or pronounced hepatotoxicity (which

may include hepatomegaly and steatosis even in the absence of marked transaminase

elevations).

6 ADVERSE REACTIONS

The following adverse reactions are discussed in other sections of the labeling:

• Exacerbations of hepatitis after discontinuation of treatment [see Boxed Warning,

Warnings and Precautions (5.1)].

• Lactic acidosis and severe hepatomegaly with steatosis [see Boxed Warning,

Warnings and Precautions (5.3)].

6.1 Clinical Trial Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction

rates observed in the clinical trials of a drug cannot be directly compared to rates in the

clinical trials of another drug and may not reflect the rates observed in practice.

Clinical Trial Experience in Adults

Compensated Liver Disease

Assessment of adverse reactions is based on four studies (AI463014, AI463022,

AI463026, and AI463027) in which 1720 subjects with chronic hepatitis B virus infection

and compensated liver disease received double-blind treatment with BARACLUDE

0.5 mg/day (n=679), BARACLUDE 1 mg/day (n=183), or lamivudine (n=858) for up to

2 years. Median duration of therapy was 69 weeks for BARACLUDE-treated subjects

and 63 weeks for lamivudine-treated subjects in Studies AI463022 and AI463027 and

73 weeks for BARACLUDE-treated subjects and 51 weeks for lamivudine-treated subjects

in Studies AI463026 and AI463014. The safety profiles of BARACLUDE and lamivudine

were comparable in these studies.

The most common adverse reactions of any severity (≥3%) with at least a possible

relation to study drug for BARACLUDE-treated subjects were headache, fatigue, dizziness,

and nausea. The most common adverse reactions among lamivudine-treated subjects

were headache, fatigue, and dizziness. One percent of BARACLUDE-treated subjects in

these four studies compared with 4% of lamivudine-treated subjects discontinued for

adverse events or abnormal laboratory test results.

Clinical adverse reactions of moderate-severe intensity and considered at least possibly

related to treatment occurring during therapy in four clinical studies in which BARACLUDE

was compared with lamivudine are presented in Table 3.

Table 3: Clinical Adverse Reactions

of Moderate-Severe Intensity (Grades 2–4)

Reported in Four Entecavir Clinical Trials Through 2 Years

Nucleoside-Inhibitor-Naïve

Lamivudine-Refractory

Body System/

Adverse Reaction

BARACLUDE

0.5 mg

n=679

Lamivudine

100 mg

n=668

BARACLUDE

1 mg

n=183

Lamivudine

100 mg

n=190

Any Grade 2–4

adverse reaction

15% 18% 22% 23%

Gastrointestinal

Diarrhea <1% 0 1% 0

Dyspepsia <1% <1% 1% 0

Nausea <1% <1% <1% 2%

Vomiting <1% <1% <1% 0

General

Fatigue 1% 1% 3% 3%

Nervous System

Headache 2% 2% 4% 1%

Dizziness <1% <1% 0 1%

Somnolence <1% <1% 0 0

Psychiatric

Insomnia <1% <1% 0 <1%

Includes events of possible, probable, certain, or unknown relationship to treatment

regimen.

Studies AI463022 and AI463027.

Includes Study AI463026 and the BARACLUDE 1 mg and lamivudine treatment arms

of Study AI463014, a Phase 2 multinational, randomized, double-blind study of three

doses of BARACLUDE (0.1, 0.5, and 1 mg) once daily versus continued lamivudine

100 mg once daily for up to 52 weeks in subjects who experienced recurrent viremia

on lamivudine therapy.

BARACLUDE

(entecavir) BARACLUDE

(entecavir)

Table 6: Principal Analyses of Time to Adjudicated Events - Randomized

Treated Subjects

Number of Subjects with Events

Endpoint

BARACLUDE

N=6,216

Non-ETV

N=6,162

Hazard Ratio

[BARACLUDE:Non-ETV]

(CI

)

Primary Endpoints

Overall malignant

neoplasm

331 337 0.93 (0.800, 1.084)

Liver-related HBV

disease progression

350 375 0.89 (0.769, 1.030)

Death 238 264 0.85 (0.713, 1.012)

Secondary Endpoints

Non-HCC malignant

neoplasm

95 81 1.10 (0.817, 1.478)

HCC 240

263 0.87 (0.727, 1.032)

Analyses were stratiﬁed by geographic region and prior HBV nucleos(t)ide experience.

95.03% CI for overall malignant neoplasm, death, and liver-related HBV disease

progression; 95% CI for non-HCC malignant neoplasm and HCC.

One subject had a pre-treatment HCC event and was excluded from the analysis.

Overall malignant neoplasm is a composite event of HCC or non-HCC malignant

neoplasm. Liver-related HBV disease progression is a composite event of liver-related

death, HCC, or non-HCC HBV disease progression.

CI = conﬁdence interval; N = total number of subjects.

Limitations of the study included population changes over the long-term follow-up

period and more frequent post-randomization treatment changes in the non-ETV group.

In addition, the study was underpowered to demonstrate a difference in the non-HCC

malignancy rate because of the lower than expected background rate.

Adverse Reactions from Postmarketing Spontaneous Reports

The following adverse reactions have been reported during postmarketing use of

BARACLUDE. Because these reactions were reported voluntarily from a population of

unknown size, it is not possible to reliably estimate their frequency or establish a causal

relationship to BARACLUDE exposure.

Immune system disorders: Anaphylactoid reaction.

Metabolism and nutrition disorders: Lactic acidosis.

Hepatobiliary disorders: Increased transaminases.

Skin and subcutaneous tissue disorders: Alopecia, rash.

7 DRUG INTERACTIONS

Since entecavir is primarily eliminated by the kidneys [see Clinical Pharmacology (12.3)],

coadministration of BARACLUDE with drugs that reduce renal function or compete for

active tubular secretion may increase serum concentrations of either entecavir or the

coadministered drug. Coadministration of entecavir with lamivudine, adefovir dipivoxil, or

tenofovir disoproxil fumarate did not result in significant drug interactions. The effects of

coadministration of BARACLUDE with other drugs that are renally eliminated or are known

to affect renal function have not been evaluated, and patients should be monitored closely

for adverse events when BARACLUDE is coadministered with such drugs.

8 USE IN SPECIFIC POPULATIONS

8.1 Pregnancy

Pregnancy Exposure Registry

There is a pregnancy exposure registry that monitors pregnancy outcomes in women

exposed to BARACLUDE during pregnancy. Healthcare providers are encouraged to

Risk Summary

Prospective pregnancy data from the APR are not sufficient to adequately assess the risk

of birth defects, miscarriage or adverse maternal or fetal outcomes. Entecavir use during

pregnancy has been evaluated in a limited number of individuals reported to the APR and

the number of exposures to entecavir is insufficient to make a risk assessment compared

to a reference population. The estimated background rate for major birth defects is 2.7%

in the U.S. reference population of the Metropolitan Atlanta Congenital Defects Program

(MACDP). The rate of miscarriage is not reported in the APR. All pregnancies have a

background risk of birth defect, loss, or other adverse outcomes. In the U.S. general

population, the estimated background risk of miscarriage in clinically recognized

pregnancies is 15–20%.

In animal reproduction studies, no adverse developmental effects were observed with

entecavir at clinically relevant exposures. No developmental toxicities were observed at

systemic exposures (AUC) approximately 25 (rats) and 200 (rabbits) times the exposure at

the maximum recommended human dose (MRHD) of 1 mg/day (see Data).

Decompensated Liver Disease

Study AI463048 was a randomized, open-label study of BARACLUDE 1 mg once daily

versus adefovir dipivoxil 10 mg once daily given for up to 48 weeks in adult subjects

with chronic HBV infection and evidence of hepatic decompensation, defined as a

Child-Turcotte-Pugh (CTP) score of 7 or higher [see Clinical Studies (14.1)]. Among the

102 subjects receiving BARACLUDE, the most common treatment-emergent adverse

events of any severity, regardless of causality, occurring through Week 48 were peripheral

edema (16%), ascites (15%), pyrexia (14%), hepatic encephalopathy (10%), and

upper respiratory infection (10%). Clinical adverse reactions not listed in Table 3 that

were observed through Week 48 include blood bicarbonate decreased (2%) and

renal failure (<1%).

Eighteen of 102 (18%) subjects treated with BARACLUDE and 18/89 (20%) subjects

treated with adefovir dipivoxil died during the first 48 weeks of therapy. The majority

of deaths (11 in the BARACLUDE group and 16 in the adefovir dipivoxil group) were

due to liver-related causes such as hepatic failure, hepatic encephalopathy, hepatorenal

syndrome, and upper gastrointestinal hemorrhage. The rate of hepatocellular carcinoma

(HCC) through Week 48 was 6% (6/102) for subjects treated with BARACLUDE and

8% (7/89) for subjects treated with adefovir dipivoxil. Five percent of subjects in either

treatment arm discontinued therapy due to an adverse event through Week 48.

No subject in either treatment arm experienced an on-treatment hepatic flare

(ALT >2 × baseline and >10 × ULN) through Week 48. Eleven of 102 (11%) subjects

treated with BARACLUDE and 11/89 (13%) subjects treated with adefovir dipivoxil had a

confirmed increase in serum creatinine of 0.5 mg/dL through Week 48.

HIV/HBV Co-infected

The safety profile of BARACLUDE 1 mg (n=51) in HIV/HBV co-infected subjects enrolled

in Study AI463038 was similar to that of placebo (n=17) through 24 weeks of blinded

treatment and similar to that seen in non-HIV infected subjects [see Warnings and

Precautions (5.2)].

Liver Transplant Recipients

Among 65 subjects receiving BARACLUDE in an open-label, post-liver transplant trial

[see Use in Specific Populations (8.8)], the frequency and nature of adverse events were

consistent with those expected in patients who have received a liver transplant and the

known safety profile of BARACLUDE.

Clinical Trial Experience in Pediatric Subjects

The safety of BARACLUDE in pediatric subjects 2 to less than 18 years of age is based

on two clinical trials in subjects with chronic HBV infection (one Phase 2 pharmacokinetic

trial [AI463028] and one Phase 3 trial [AI463189]). These trials provided experience in

168 HBeAg-positive subjects treated with BARACLUDE for a median duration of 72 weeks.

The adverse reactions observed in pediatric subjects who received treatment with

BARACLUDE were consistent with those observed in clinical trials of BARACLUDE in

adults. Adverse drug reactions reported in greater than 1% of pediatric subjects included

abdominal pain, rash events, poor palatability (“product taste abnormal”), nausea,

diarrhea, and vomiting.

6.2 Postmarketing Experience

Data from Long-Term Observational Study

Study AI463080 was a randomized, global, observational, open-label Phase 4 study to

assess long-term risks and benefits of BARACLUDE (0.5 mg/day or 1 mg/day) treatment

as compared to other standard-of-care HBV nucleos(t)ide analogues in subjects with

chronic HBV infection.

A total of 12,378 patients were treated with BARACLUDE (n=6,216) or other HBV

nucleos(t)ide treatment [non-entecavir (ETV)] (n=6,162). Patients were evaluated at

baseline and subsequently every 6 months for up to 10 years. The principal clinical

outcome events assessed during the study were overall malignant neoplasms,

liver-related HBV disease progression, HCC, non-HCC malignant neoplasms, and death.

The study showed that BARACLUDE was not significantly associated with an increased

risk of malignant neoplasms compared to other standard-of-care HBV nucleos(t)ides,

as assessed by either the composite endpoint of overall malignant neoplasms or the

individual endpoint of non-HCC malignant neoplasms. The most commonly reported

malignancy in both the BARACLUDE and non-ETV groups was HCC followed by

gastrointestinal malignancies. The data also showed that long-term BARACLUDE use was

not associated with a lower occurrence of HBV disease progression or a lower rate of

death overall compared to other HBV nucleos(t)ides. The principal clinical outcome event

assessments are shown in Table 6.

BARACLUDE

(entecavir) BARACLUDE

(entecavir)

Data

Animal Data

Entecavir was administered orally to pregnant rats (at 2, 20, and 200 mg per kg per

day) and rabbits (at 1, 4, and 16 mg per kg per day) during organogenesis (on gestation

Days 6 through 15 [rat] and 6 through 18 [rabbit]). In rats, embryofetal toxicity including

post-implantation loss, resorptions, tail and vertebral malformations, skeletal variations

including reduced ossification (vertebrate, sternebrae, and phalanges) and extra lumbar

vertebrae and ribs, and lower fetal body weights were observed at systemic exposures

(AUC) 3,100 times those in humans at the MRHD. Maternal toxicity was also observed at

this dose level. In rabbits, embryofetal toxicity including post-implantation loss, resorptions

and skeletal variations, including reduced ossification (hyoid) and increased incidence of

rib, were observed at systemic exposures (AUC) 883 times those in humans at the

MRHD. There were no signs of embryofetal toxicity when pregnant animals received oral

entecavir at 28 (rat) and 212 (rabbit) times the human exposure (AUC) at the MRHD. In a

pre/postnatal development study, entecavir was administered orally to pregnant rats at

0.3, 3, and 30 mg per kg per day from gestation day 6 to lactation/post-partum day 20.

No adverse effects on the offspring occurred at up to the highest dose evaluated, resulting

in exposures (AUC) greater than 94 times those in humans at the MRHD.

8.2 Lactation

Risk Summary

It is not known whether BARACLUDE is present in human breast milk, affects human

milk production, or has effects on the breastfed infant. When administered to lactating

rats, entecavir was present in milk (see Data). The developmental and health benefits of

breastfeeding should be considered along with the mother’s clinical need for BARACLUDE

and any potential adverse effects on the breastfed infant from BARACLUDE or from the

underlying maternal condition.

Data

Entecavir was excreted into the milk of lactating rats following a single oral dose of 10 mg

per kg on lactation day 7. Entecavir in milk was approximately 25% that in maternal

plasma (based on AUC).

8.4 Pediatric Use

BARACLUDE was evaluated in two clinical trials of pediatric subjects 2 years of age

and older with HBeAg-positive chronic HBV infection and compensated liver disease.

The exposure of BARACLUDE in nucleoside-inhibitor-treatment-naïve and lamivudine-

experienced pediatric subjects 2 years of age and older with HBeAg-positive chronic

HBV infection and compensated liver disease receiving 0.015 mg/kg (up to 0.5 mg

once daily) or 0.03 mg/kg (up to 1 mg once daily), respectively, was evaluated in Study

AI463028. Safety and efficacy of the selected dose in treatment-naïve pediatric subjects

were confirmed in Study AI463189, a randomized, placebo-controlled treatment trial

[see Indications and Usage (1), Dosage and Administration (2.3), Adverse Reactions (6.1),

Clinical Pharmacology (12.3), and Clinical Studies (14.2)].

There are limited data available on the use of BARACLUDE in lamivudine-experienced

pediatric patients; BARACLUDE should be used in these patients only if the potential

benefit justifies the potential risk to the child. Since some pediatric patients may require

long-term or even lifetime management of chronic active hepatitis B, consideration should

be given to the impact of BARACLUDE on future treatment options [see Microbiology (12.4)].

The efficacy and safety of BARACLUDE have not been established in patients less than

2 years of age. Use of BARACLUDE in this age group has not been evaluated because

treatment of HBV in this age group is rarely required.

8.5 Geriatric Use

Clinical studies of BARACLUDE did not include sufficient numbers of subjects aged

65 years and over to determine whether they respond differently from younger subjects.

Entecavir is substantially excreted by the kidney, and the risk of toxic reactions to this

drug may be greater in patients with impaired renal function. Because elderly patients

are more likely to have decreased renal function, care should be taken in dose selection,

and it may be useful to monitor renal function [see Dosage and Administration (2.4)].

8.6 Racial/Ethnic Groups

There are no significant racial differences in entecavir pharmacokinetics. The safety and

efficacy of BARACLUDE 0.5 mg once daily were assessed in a single-arm, open-label

trial of HBeAg-positive or -negative, nucleoside-inhibitor-naïve, Black/African American

(n=40) and Hispanic (n=6) subjects with chronic HBV infection. In this trial, 76% of

subjects were male, the mean age was 42 years, 57% were HBeAg-positive, the mean

baseline HBV DNA was 7.0 log

IU/mL, and the mean baseline ALT was 162 U/L. At

Week 48 of treatment, 32 of 46 (70%) subjects had HBV DNA <50 IU/mL (approximately

300 copies/mL), 31 of 46 (67%) subjects had ALT normalization (≤1 × ULN), and

12 of 26 (46%) HBeAg-positive subjects had HBe seroconversion. Safety data were similar

to those observed in the larger controlled clinical trials.

Because of low enrollment, safety and efficacy have not been established in the US

Hispanic population.

8.7 Renal Impairment

Dosage adjustment of BARACLUDE is recommended for patients with creatinine clearance

less than 50 mL/min, including patients on hemodialysis or CAPD [see Dosage and

Administration (2.4) and Clinical Pharmacology (12.3)].

8.8 Liver Transplant Recipients

The safety and efficacy of BARACLUDE were assessed in a single-arm, open-label trial

in 65 subjects who received a liver transplant for complications of chronic HBV infection.

Eligible subjects who had HBV DNA less than 172 IU/mL (approximately 1000 copies/mL)

at the time of transplant were treated with BARACLUDE 1 mg once daily in addition to

usual post-transplantation management, including hepatitis B immune globulin. The trial

population was 82% male, 39% Caucasian, and 37% Asian, with a mean age of 49 years;

89% of subjects had HBeAg-negative disease at the time of transplant.

Four of the 65 subjects received 4 weeks or less of BARACLUDE (2 deaths,

1 re-transplantation, and 1 protocol violation) and were not considered evaluable. Of the

61 subjects who received more than 4 weeks of BARACLUDE, 60 received hepatitis B

immune globulin post-transplant. Fifty-three subjects (82% of all 65 subjects treated)

completed the trial and had HBV DNA measurements at or after 72 weeks treatment

post-transplant. All 53 subjects had HBV DNA <50 IU/mL (approximately 300 copies/mL).

Eight evaluable subjects did not have HBV DNA data available at 72 weeks, including

3 subjects who died prior to study completion. No subjects had HBV DNA values

≥50 IU/mL while receiving BARACLUDE (plus hepatitis B immune globulin). All 61

evaluable subjects lost HBsAg post-transplant; 2 of these subjects experienced recurrence

of measurable HBsAg without recurrence of HBV viremia. This trial was not designed to

determine whether addition of BARACLUDE to hepatitis B immune globulin decreased the

proportion of subjects with measurable HBV DNA post-transplant compared to hepatitis B

immune globulin alone.

If BARACLUDE treatment is determined to be necessary for a liver transplant recipient

who has received or is receiving an immunosuppressant that may affect renal function,

such as cyclosporine or tacrolimus, renal function must be carefully monitored both before

and during treatment with BARACLUDE [see Dosage and Administration (2.4) and Clinical

Pharmacology (12.3)].

10 OVERDOSAGE

There is limited experience of entecavir overdosage reported in patients. Healthy subjects

who received single entecavir doses up to 40 mg or multiple doses up to 20 mg/day for

up to 14 days had no increase in or unexpected adverse events. If overdose occurs, the

patient must be monitored for evidence of toxicity, and standard supportive treatment

applied as necessary.

Following a single 1 mg dose of entecavir, a 4-hour hemodialysis session removed

approximately 13% of the entecavir dose.

11 DESCRIPTION

BARACLUDE

is the tradename for entecavir, a guanosine nucleoside analogue

with selective activity against HBV. The chemical name for entecavir is 2-amino-1,

9-dihydro-9-[(1S,3R,4S)-4-hydroxy-3-(hydroxymethyl)-2-methylenecyclopentyl]-

6H-purin-6-one, monohydrate. Its molecular formula is C

•H

O, which

corresponds to a molecular weight of 295.3. Entecavir has the following structural

formula:

Entecavir is a white to off-white powder. It is slightly soluble in water (2.4 mg/mL),

and the pH of the saturated solution in water is 7.9 at 25° C ± 0.5° C.

BARACLUDE film-coated tablets are available for oral administration in strengths of

0.5 mg and 1 mg of entecavir. BARACLUDE 0.5 mg and 1 mg film-coated tablets contain

the following inactive ingredients: lactose monohydrate, microcrystalline cellulose,

crospovidone, povidone, and magnesium stearate. The tablet coating contains titanium

dioxide, hypromellose, polyethylene glycol 400, polysorbate 80 (0.5 mg tablet only),

and iron oxide red (1 mg tablet only). BARACLUDE Oral Solution is available for oral

administration as a ready-to-use solution containing 0.05 mg of entecavir per milliliter.

BARACLUDE Oral Solution contains the following inactive ingredients: maltitol, sodium

citrate, citric acid, methylparaben, propylparaben, and orange flavor.

BARACLUDE

(entecavir) BARACLUDE

(entecavir)

12 CLINICAL PHARMACOLOGY

12.1 Mechanism of Action

Entecavir is an antiviral drug against hepatitis B virus [see Microbiology (12.4)].

12.3 Pharmacokinetics

The single- and multiple-dose pharmacokinetics of entecavir were evaluated in healthy

subjects and subjects with chronic hepatitis B virus infection.

Absorption

Following oral administration in healthy subjects, entecavir peak plasma concentrations

occurred between 0.5 and 1.5 hours. Following multiple daily doses ranging from

0.1 to 1 mg, C

max

and area under the concentration-time curve (AUC) at steady state

increased in proportion to dose. Steady state was achieved after 6 to 10 days of

once-daily administration with approximately 2-fold accumulation. For a 0.5 mg oral

dose, C

max

at steady state was 4.2 ng/mL and trough plasma concentration (C

trough

) was

0.3 ng/mL. For a 1 mg oral dose, C

max

was 8.2 ng/mL and C

trough

was 0.5 ng/mL.

In healthy subjects, the bioavailability of the tablet was 100% relative to the oral solution.

The oral solution and tablet may be used interchangeably.

Effects of food on oral absorption: Oral administration of 0.5 mg of entecavir with a

standard high-fat meal (945 kcal, 54.6 g fat) or a light meal (379 kcal, 8.2 g fat) resulted

in a delay in absorption (1.0–1.5 hours fed vs. 0.75 hours fasted), a decrease in C

max

44%–46%, and a decrease in AUC of 18%–20% [see Dosage and Administration (2)].

Distribution

Based on the pharmacokinetic profile of entecavir after oral dosing, the estimated

apparent volume of distribution is in excess of total body water, suggesting that entecavir

is extensively distributed into tissues.

Binding of entecavir to human serum proteins in vitro was approximately 13%.

Metabolism and Elimination

Following administration of

C-entecavir in humans and rats, no oxidative or acetylated

metabolites were observed. Minor amounts of phase II metabolites (glucuronide and

sulfate conjugates) were observed. Entecavir is not a substrate, inhibitor, or inducer of

the cytochrome P450 (CYP450) enzyme system. See Drug Interactions, below.

After reaching peak concentration, entecavir plasma concentrations decreased

in a bi-exponential manner with a terminal elimination half-life of approximately

128–149 hours. The observed drug accumulation index is approximately 2-fold with once-

daily dosing, suggesting an effective accumulation half-life of approximately 24 hours.

Entecavir is predominantly eliminated by the kidney with urinary recovery of unchanged

drug at steady state ranging from 62% to 73% of the administered dose. Renal clearance

is independent of dose and ranges from 360 to 471 mL/min suggesting that entecavir

undergoes both glomerular filtration and net tubular secretion [see Drug Interactions (7)].

Special Populations

Gender: There are no significant gender differences in entecavir pharmacokinetics.

Race: There are no significant racial differences in entecavir pharmacokinetics.

Elderly: The effect of age on the pharmacokinetics of entecavir was evaluated following

administration of a single 1 mg oral dose in healthy young and elderly volunteers.

Entecavir AUC was 29.3% greater in elderly subjects compared to young subjects. The

disparity in exposure between elderly and young subjects was most likely attributable

to differences in renal function. Dosage adjustment of BARACLUDE should be based on

the renal function of the patient, rather than age [see Dosage and Administration (2.4)].

Pediatrics: The steady-state pharmacokinetics of entecavir were evaluated in nucleoside-

inhibitor-naïve and lamivudine-experienced HBeAg-positive pediatric subjects 2 to less

than 18 years of age with compensated liver disease. Results are shown in Table 7.

Entecavir exposure among nucleoside-inhibitor-naïve subjects was similar to the exposure

achieved in adults receiving once-daily doses of 0.5 mg. Entecavir exposure among

lamivudine-experienced subjects was similar to the exposure achieved in adults receiving

once-daily doses of 1 mg.

Table 7:

Pharmacokinetic Parameters in Pediatric Subjects

Nucleoside-Inhibitor-Naïve

n=24

Lamivudine-Experienced

n=19

max

(ng/mL)

(CV%)

6.31

(30)

14.48

(31)

AUC

(0–24)

(ng•h/mL)

(CV%)

18.33

(27)

38.58

(26)

min

(ng/mL)

(CV%)

0.28

(22)

0.47

(23)

Subjects received once-daily doses of 0.015 mg/kg up to a maximum of 0.5 mg.

Subjects received once-daily doses of 0.030 mg/kg up to a maximum of 1 mg.

Renal impairment: The pharmacokinetics of entecavir following a single 1 mg dose were

studied in subjects (without chronic hepatitis B virus infection) with selected degrees

of renal impairment, including subjects whose renal impairment was managed by

hemodialysis or continuous ambulatory peritoneal dialysis (CAPD). Results are shown in

Table 8 [see Dosage and Administration (2.4)].

Table 8: Pharmacokinetic Parameters in Subjects with Selected Degrees of

Renal Function

Renal Function Group

Baseline Creatinine Clearance (mL/min)

Unimpaired

>80

n=6

Mild

>50–≤80

n=6

Moderate

30–50

n=6

Severe

<30

n=6

Severe

Managed with

Hemodialysis

n=6

Severe

Managed

with CAPD

n=4

max

(ng/mL)

(CV%)

8.1

(30.7)

10.4

(37.2)

10.5

(22.7)

15.3

(33.8)

15.4

(56.4)

16.6

(29.7)

AUC

(0-T)

(ng•h/mL)

(CV)

27.9

(25.6)

51.5

(22.8)

69.5

(22.7)

145.7

(31.5)

233.9

(28.4)

221.8

(11.6)

CLR (mL/min)

(SD)

383.2

(101.8)

197.9

(78.1)

135.6

(31.6)

40.3

(10.1)

CLT/F (mL/min)

(SD)

588.1

(153.7)

309.2

(62.6)

226.3

(60.1)

100.6

(29.1)

50.6

(16.5)

35.7

(19.6)

Dosed immediately following hemodialysis.

CLR = renal clearance; CLT/F = apparent oral clearance.

Following a single 1 mg dose of entecavir administered 2 hours before the hemodialysis

session, hemodialysis removed approximately 13% of the entecavir dose over

4 hours. CAPD removed approximately 0.3% of the dose over 7 days [see Dosage and

Administration (2.4)].

Hepatic impairment: The pharmacokinetics of entecavir following a single 1 mg dose

were studied in adult subjects (without chronic hepatitis B virus infection) with moderate

or severe hepatic impairment (Child-Turcotte-Pugh Class B or C). The pharmacokinetics

of entecavir were similar between hepatically impaired and healthy control subjects;

therefore, no dosage adjustment of BARACLUDE is recommended for patients with

hepatic impairment. The pharmacokinetics of entecavir have not been studied in pediatric

subjects with hepatic impairment.

Post-liver transplant: Limited data are available on the safety and efficacy of BARACLUDE

in liver transplant recipients. In a small pilot study of entecavir use in HBV-infected

liver transplant recipients on a stable dose of cyclosporine A (n=5) or tacrolimus (n=4),

entecavir exposure was approximately 2-fold the exposure in healthy subjects with

normal renal function. Altered renal function contributed to the increase in entecavir

exposure in these subjects. The potential for pharmacokinetic interactions between

entecavir and cyclosporine A or tacrolimus was not formally evaluated [see Use in Specific

Populations (8.8)].

Drug Interactions

The metabolism of entecavir was evaluated in in vitro and in vivo studies. Entecavir is

not a substrate, inhibitor, or inducer of the cytochrome P450 (CYP450) enzyme system.

At concentrations up to approximately 10,000-fold higher than those obtained in

humans, entecavir inhibited none of the major human CYP450 enzymes 1A2, 2C9, 2C19,

2D6, 3A4, 2B6, and 2E1. At concentrations up to approximately 340-fold higher than

those observed in humans, entecavir did not induce the human CYP450 enzymes 1A2,

2C9, 2C19, 3A4, 3A5, and 2B6. The pharmacokinetics of entecavir are unlikely to be

affected by coadministration with agents that are either metabolized by, inhibit, or induce

the CYP450 system. Likewise, the pharmacokinetics of known CYP substrates are unlikely

to be affected by coadministration of entecavir.

The steady-state pharmacokinetics of entecavir and coadministered drug were not

altered in interaction studies of entecavir with lamivudine, adefovir dipivoxil, and tenofovir

disoproxil fumarate [see Drug Interactions (7)].

12.4 Microbiology

Mechanism of Action

Entecavir, a deoxyguanosine nucleoside analogue with activity against HBV reverse

transcriptase (rt), is efficiently phosphorylated to the active triphosphate form, which

has an intracellular half-life of 15 hours. By competing with the natural substrate

deoxyguanosine triphosphate, entecavir triphosphate functionally inhibits all three

activities of the HBV reverse transcriptase: (1) base priming, (2) reverse transcription

of the negative strand from the pregenomic messenger RNA, and (3) synthesis of the

positive strand of HBV DNA. Entecavir triphosphate is a weak inhibitor of cellular DNA

polymerases α, β, and δ and mitochondrial DNA polymerase γ with K

values ranging

from 18 to >160 μM.

Antiviral Activity

Entecavir inhibited HBV DNA synthesis (50% reduction, EC

) at a concentration of

0.004 µM in human HepG2 cells transfected with wild-type HBV. The median EC

value

for entecavir against lamivudine-resistant HBV (rtL180M, rtM204V) was 0.026 µM (range

0.010–0.059 μM).

The coadministration of HIV nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs)

with BARACLUDE is unlikely to reduce the antiviral efficacy of BARACLUDE against HBV

or of any of these agents against HIV. In HBV combination assays in cell culture, abacavir,

didanosine, lamivudine, stavudine, tenofovir, or zidovudine were not antagonistic to the

anti-HBV activity of entecavir over a wide range of concentrations. In HIV antiviral assays,

BARACLUDE

(entecavir) BARACLUDE

(entecavir)

entecavir was not antagonistic to the cell culture anti-HIV activity of these six NRTIs or

emtricitabine at concentrations greater than 100 times the C

max

of entecavir using the

1 mg dose.

Antiviral Activity Against HIV

A comprehensive analysis of the inhibitory activity of entecavir against a panel of laboratory

and clinical HIV type 1 (HIV-1) isolates using a variety of cells and assay conditions yielded

values ranging from 0.026 to >10 µM; the lower EC

values were observed when

decreased levels of virus were used in the assay. In cell culture, entecavir selected for an

M184I substitution in HIV reverse transcriptase at micromolar concentrations, confirming

inhibitory pressure at high entecavir concentrations. HIV variants containing the M184V

substitution showed loss of susceptibility to entecavir.

Resistance

In Cell Culture

In cell-based assays, 8- to 30-fold reductions in entecavir phenotypic susceptibility were

observed for lamivudine-resistant strains. Further reductions (>70-fold) in entecavir

phenotypic susceptibility required the presence of amino acid substitutions rtM204I/V

with or without rtL180M along with additional substitutions at residues rtT184, rtS202,

or rtM250, or a combination of these substitutions with or without an rtI169 substitution

in the HBV reverse transcriptase. Lamivudine-resistant strains harboring rtL180M

plus rtM204V in combination with the amino acid substitution rtA181C conferred

16- to 122-fold reductions in entecavir phenotypic susceptibility.

Clinical Studies

Nucleoside-inhibitor-naïve subjects: Genotypic evaluations were performed on evaluable

samples (>300 copies/mL serum HBV DNA) from 562 subjects who were treated

with BARACLUDE for up to 96 weeks in nucleoside-inhibitor-naïve studies (AI463022,

AI463027, and rollover study AI463901). By Week 96, evidence of emerging amino acid

substitution rtS202G with rtL180M and rtM204V substitutions was detected in the HBV of

2 subjects (2/562=<1%), and 1 of them experienced virologic rebound (≥1 log

increase

above nadir). In addition, emerging amino acid substitutions at rtM204I/V and rtL80I,

rtV173L, or rtL180M, which conferred decreased phenotypic susceptibility to entecavir in

the absence of rtT184, rtS202, or rtM250 changes, were detected in the HBV of 3 subjects

(3/562=<1%) who experienced virologic rebound. For subjects who continued treatment

beyond 48 weeks, 75% (202/269) had HBV DNA <300 copies/mL at end of dosing

(up to 96 weeks).

HBeAg-positive (n=243) and -negative (n=39) treatment-naïve subjects who failed to

achieve the study-defined complete response by 96 weeks were offered continued

entecavir treatment in a rollover study. Complete response for HBeAg-positive was

<0.7 MEq/mL (approximately 7 × 10

copies/mL) serum HBV DNA and HBeAg loss

and, for HBeAg-negative was <0.7 MEq/mL HBV DNA and ALT normalization. Subjects

received 1 mg entecavir once daily for up to an additional 144 weeks. Of these

282 subjects, 141 HBeAg-positive and 8 HBeAg-negative subjects entered the long-term

follow-up rollover study and were evaluated for entecavir resistance. Of the 149 subjects

entering the rollover study, 88% (131/149), 92% (137/149), and 92% (137/149) attained

serum HBV DNA <300 copies/mL by Weeks 144, 192, and 240 (including end of dosing),

respectively. No novel entecavir resistance-associated substitutions were identified in a

comparison of the genotypes of evaluable isolates with their respective baseline isolates.

The cumulative probability of developing rtT184, rtS202, or rtM250 entecavir resistance-

associated substitutions (in the presence of rtL180M and rtM204V substitutions) at

Weeks 48, 96, 144, 192, and 240 was 0.2%, 0.5%, 1.2%, 1.2%, and 1.2%, respectively.

Lamivudine-refractory subjects: Genotypic evaluations were performed on evaluable

samples from 190 subjects treated with BARACLUDE for up to 96 weeks in studies of

lamivudine-refractory HBV (AI463026, AI463014, AI463015, and rollover study AI463901).

By Week 96, resistance-associated amino acid substitutions at rtT184, rtS202, or

rtM250, with or without rtI169 changes, in the presence of amino acid substitutions

rtM204I/V with or without rtL80V, rtV173L/M, or rtL180M emerged in the HBV from

22 subjects (22/190=12%), 16 of whom experienced virologic rebound (≥1 log

increase

above nadir) and 4 of whom were never suppressed <300 copies/mL. The HBV from 4

of these subjects had entecavir resistance substitutions at baseline and acquired further

changes on entecavir treatment. In addition to the 22 subjects, 3 subjects experienced

virologic rebound with the emergence of rtM204I/V and rtL80V, rtV173L/M, or rtL180M.

For isolates from subjects who experienced virologic rebound with the emergence

of resistance-associated substitutions (n=19), the median fold-change in entecavir

values from reference was 19-fold at baseline and 106-fold at the time of virologic

rebound. For subjects who continued treatment beyond 48 weeks, 40% (31/77) had

HBV DNA <300 copies/mL at end of dosing (up to 96 weeks).

Lamivudine-refractory subjects (n=157) who failed to achieve the study-defined complete

response by Week 96 were offered continued entecavir treatment. Subjects received 1 mg

entecavir once daily for up to an additional 144 weeks. Of these subjects, 80 subjects

entered the long-term follow-up study and were evaluated for entecavir resistance.

By Weeks 144, 192, and 240 (including end of dosing), 34% (27/80), 35% (28/80), and

36% (29/80), respectively, attained HBV DNA <300 copies/mL. The cumulative probability

of developing rtT184, rtS202, or rtM250 entecavir resistance-associated substitutions (in

the presence of rtM204I/V with or without rtL180M substitutions) at Weeks 48, 96, 144,

192, and 240 was 6.2%, 15%, 36.3%, 46.6%, and 51.5%, respectively. The HBV of 6

subjects developed rtA181C/G/S/T amino acid substitutions while receiving entecavir, and

of these, 4 developed entecavir resistance-associated substitutions at rtT184, rtS202, or

rtM250 and 1 had an rtT184S substitution at baseline. Of 7 subjects whose HBV had an

rtA181 substitution at baseline, 2 also had substitutions at rtT184, rtS202, or rtM250 at

baseline and another 2 developed them while on treatment with entecavir.

In a post-approval integrated analysis of entecavir resistance data from 17 Phase 2

and 3 clinical trials, an emergent entecavir resistance-associated substitution rtA181C

was detected in 5 out of 1461 (0.3%) subjects during treatment with entecavir. This

substitution was detected only in the presence of lamivudine resistance-associated

substitutions rtL180M plus rtM204V.

Cross-resistance

Cross-resistance has been observed among HBV nucleoside analogue inhibitors.

In cell-based assays, entecavir had 8- to 30-fold less inhibition of HBV DNA synthesis

for HBV containing lamivudine and telbivudine resistance-associated substitutions

rtM204I/V with or without rtL180M than for wild-type HBV. Substitutions rtM204I/V with

or without rtL80I/V, rtV173L, or rtL180M, which are associated with lamivudine and

telbivudine resistance, also confer decreased phenotypic susceptibility to entecavir. The

efficacy of entecavir against HBV harboring adefovir resistance-associated substitutions

has not been established in clinical trials. HBV isolates from lamivudine-refractory subjects

failing entecavir therapy were susceptible in cell culture to adefovir but remained resistant

to lamivudine. Recombinant HBV genomes encoding adefovir resistance-associated

substitutions at either rtA181V or rtN236T had 1.1- or 0.3-fold shifts in susceptibility to

entecavir in cell culture, respectively.

13 NONCLINICAL TOXICOLOGY

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

Carcinogenesis

Long-term oral carcinogenicity studies of entecavir in mice and rats were carried out

at exposures up to approximately 42 times (mice) and 35 times (rats) those observed

in humans at the highest recommended dose of 1 mg/day. In mouse and rat studies,

entecavir was positive for carcinogenic findings. It is not known how predictive the results

of rodent carcinogenicity studies may be for humans [see Adverse Reactions (6.2)].

In mice, lung adenomas were increased in males and females at exposures 3 and

40 times those in humans. Lung carcinomas in both male and female mice were

increased at exposures 40 times those in humans. Combined lung adenomas and

carcinomas were increased in male mice at exposures 3 times and in female mice at

exposures 40 times those in humans. Tumor development was preceded by pneumocyte

proliferation in the lung, which was not observed in rats, dogs, or monkeys administered

entecavir, supporting the conclusion that lung tumors in mice may be a species-specific

event. Hepatocellular carcinomas were increased in males and combined liver adenomas

and carcinomas were also increased at exposures 42 times those in humans. Vascular

tumors in female mice (hemangiomas of ovaries and uterus and hemangiosarcomas of

spleen) were increased at exposures 40 times those in humans. In rats, hepatocellular

adenomas were increased in females at exposures 24 times those in humans; combined

adenomas and carcinomas were also increased in females at exposures 24 times those

in humans. Brain gliomas were induced in both males and females at exposures 35 and

24 times those in humans. Skin fibromas were induced in females at exposures 4 times

those in humans.

Mutagenesis

Entecavir was clastogenic to human lymphocyte cultures. Entecavir was not mutagenic in

the Ames bacterial reverse mutation assay using S. typhimurium and E. coli strains in the

presence or absence of metabolic activation, a mammalian-cell gene mutation assay, and

a transformation assay with Syrian hamster embryo cells. Entecavir was also negative in

an oral micronucleus study and an oral DNA repair study in rats.

Impairment of Fertility

In reproductive toxicology studies, in which animals were administered entecavir at up

to 30 mg/kg for up to 4 weeks, no evidence of impaired fertility was seen in male or

female rats at systemic exposures greater than 90 times those achieved in humans

at the highest recommended dose of 1 mg/day. In rodent and dog toxicology studies,

seminiferous tubular degeneration was observed at exposures 35 times or greater than

those achieved in humans. No testicular changes were evident in monkeys.

14 CLINICAL STUDIES

14.1 Outcomes in Adults

At 48 Weeks

The safety and efficacy of BARACLUDE in adults were evaluated in three Phase 3

active-controlled trials. These studies included 1633 subjects 16 years of age or older

with chronic hepatitis B virus infection (serum HBsAg-positive for at least 6 months)

accompanied by evidence of viral replication (detectable serum HBV DNA, as measured

by the bDNA hybridization or PCR assay). Subjects had persistently elevated ALT levels at

least 1.3 times ULN and chronic inflammation on liver biopsy compatible with a diagnosis

of chronic viral hepatitis. The safety and efficacy of BARACLUDE were also evaluated in a

study of 191 HBV-infected subjects with decompensated liver disease and in a study of

68 subjects co-infected with HBV and HIV.

Nucleoside-inhibitor-naïve Subjects with Compensated Liver Disease

HBeAg-positive: Study AI463022 was a multinational, randomized, double-blind study of

BARACLUDE 0.5 mg once daily versus lamivudine 100 mg once daily for a minimum of

52 weeks in 709 (of 715 randomized) nucleoside-inhibitor-naïve subjects with chronic

hepatitis B virus infection, compensated liver disease, and detectable HBeAg. The mean

age of subjects was 35 years, 75% were male, 57% were Asian, 40% were Caucasian,

and 13% had previously received interferon-α. At baseline, subjects had a mean

BARACLUDE

(entecavir) BARACLUDE

(entecavir)

Knodell Necroinflammatory Score of 7.8, mean serum HBV DNA as measured by

Roche COBAS Amplicor

PCR assay was 9.66 log

copies/mL, and mean serum ALT level

was 143 U/L. Paired, adequate liver biopsy samples were available for 89% of subjects.

HBeAg-negative (anti-HBe-positive/HBV DNA-positive): Study AI463027 was a

multinational, randomized, double-blind study of BARACLUDE 0.5 mg once daily versus

lamivudine 100 mg once daily for a minimum of 52 weeks in 638 (of 648 randomized)

nucleoside-inhibitor-naïve subjects with HBeAg-negative (HBeAb-positive) chronic

hepatitis B virus infection and compensated liver disease. The mean age of subjects was

44 years, 76% were male, 39% were Asian, 58% were Caucasian, and 13% had previously

received interferon-α. At baseline, subjects had a mean Knodell Necroinflammatory

Score of 7.8, mean serum HBV DNA as measured by Roche COBAS Amplicor PCR assay

was 7.58 log

copies/mL, and mean serum ALT level was 142 U/L. Paired, adequate

liver biopsy samples were available for 88% of subjects.

In Studies AI463022 and AI463027, BARACLUDE was superior to lamivudine on the

primary efficacy endpoint of Histologic Improvement, defined as a 2-point or greater

reduction in Knodell Necroinflammatory Score with no worsening in Knodell Fibrosis

Score at Week 48, and on the secondary efficacy measures of reduction in viral load

and ALT normalization. Histologic Improvement and change in Ishak Fibrosis Score are

shown in Table 9. Selected virologic, biochemical, and serologic outcome measures are

shown in Table 10.

Table 9: Histologic Improvement and Change in Ishak Fibrosis Score at Week 48,

Nucleoside-Inhibitor-Naïve Subjects in Studies AI463022 and AI463027

Study AI463022

(HBeAg-Positive)

Study AI463027

(HBeAg-Negative)

BARACLUDE

0.5 mg

n=314

Lamivudine

100 mg

n=314

BARACLUDE

0.5 mg

n=296

Lamivudine

100 mg

n=287

Histologic Improvement (Knodell Scores)

Improvement

72% 62% 70% 61%

No improvement 21% 24% 19% 26%

Ishak Fibrosis Score

Improvement

39% 35% 36% 38%

No change 46% 40% 41% 34%

Worsening

8% 10% 12% 15%

Missing Week 48 biopsy 7% 14% 10% 13%

Subjects with evaluable baseline histology (baseline Knodell Necroinﬂammatory Score ≥2).

≥2-point decrease in Knodell Necroinﬂammatory Score from baseline with no worsening of the

Knodell Fibrosis Score.

For Ishak Fibrosis Score, improvement = ≥1-point decrease from baseline and worsening

= ≥1-point increase from baseline.

Table 10: Selected Virologic, Biochemical, and Serologic Endpoints at Week 48,

Nucleoside-Inhibitor-Naïve Subjects in Studies AI463022 and AI463027

Study AI463022

(HBeAg-Positive)

Study AI463027

(HBeAg-Negative)

BARACLUDE

0.5 mg

n=354

Lamivudine

100 mg

n=355

BARACLUDE

0.5 mg

n=325

Lamivudine

100 mg

n=313

HBV DNA

Proportion undetectable

(<300 copies/mL) 67% 36% 90% 72%

Mean change from baseline

(log

copies/mL)

–6.86 –5.39 –5.04 –4.53

ALT normalization (≤1 × ULN) 68% 60% 78% 71%

HBeAg seroconversion 21% 18% NA NA

Roche COBAS Amplicor PCR assay [lower limit of quantiﬁcation (LLOQ) = 300 copies/mL].

Histologic Improvement was independent of baseline levels of HBV DNA or ALT.

Lamivudine-refractory Subjects with Compensated Liver Disease

Study AI463026 was a multinational, randomized, double-blind study of BARACLUDE

in 286 (of 293 randomized) subjects with lamivudine-refractory chronic hepatitis B

virus infection and compensated liver disease. Subjects receiving lamivudine at study

entry either switched to BARACLUDE 1 mg once daily (with neither a washout nor

an overlap period) or continued on lamivudine 100 mg for a minimum of 52 weeks.

The mean age of subjects was 39 years, 76% were male, 37% were Asian, 62% were

Caucasian, and 52% had previously received interferon-α. The mean duration of prior

lamivudine therapy was 2.7 years, and 85% had lamivudine resistance substitutions

at baseline by an investigational line probe assay. At baseline, subjects had a mean

Knodell Necroinflammatory Score of 6.5, mean serum HBV DNA as measured by

Roche COBAS Amplicor PCR assay was 9.36 log

copies/mL, and mean serum ALT level

was 128 U/L. Paired, adequate liver biopsy samples were available for 87% of subjects.

BARACLUDE was superior to lamivudine on a primary endpoint of Histologic Improvement

(using the Knodell Score at Week 48). These results and change in Ishak Fibrosis Score are

shown in Table 11. Table 12 shows selected virologic, biochemical, and serologic endpoints.

Table 11: Histologic Improvement and Change in Ishak Fibrosis Score at

Week 48, Lamivudine-Refractory Subjects in Study AI463026

BARACLUDE

1 mg

n=124

Lamivudine

100 mg

n=116

Histologic Improvement (Knodell Scores)

Improvement

55% 28%

No improvement 34% 57%

Ishak Fibrosis Score

Improvement

34% 16%

No change 44% 42%

Worsening

11% 26%

Missing Week 48 biopsy 11% 16%

Subjects with evaluable baseline histology (baseline Knodell Necroinflammatory

Score ≥2).

≥2-point decrease in Knodell Necroinﬂammatory Score from baseline with no worsening

of the Knodell Fibrosis Score.

For Ishak Fibrosis Score, improvement = ≥1-point decrease from baseline and

worsening = ≥1-point increase from baseline.

Table 12: Selected Virologic, Biochemical, and Serologic Endpoints at Week 48,

Lamivudine-Refractory Subjects in Study AI463026

BARACLUDE

1 mg

n=141

Lamivudine

100 mg

n=145

HBV DNA

Proportion undetectable

(<300 copies/mL)

19% 1%

Mean change from baseline

(log

copies/mL)

–5.11 –0.48

ALT normalization (≤1 × ULN) 61% 15%

HBeAg seroconversion 8% 3%

Roche COBAS Amplicor PCR assay (LLOQ = 300 copies/mL).

Histologic Improvement was independent of baseline levels of HBV DNA or ALT.

Subjects with Decompensated Liver Disease

Study AI463048 was a randomized, open-label study of BARACLUDE 1 mg once daily

versus adefovir dipivoxil 10 mg once daily in 191 (of 195 randomized) adult subjects

with HBeAg-positive or -negative chronic HBV infection and evidence of hepatic

decompensation, defined as a Child-Turcotte-Pugh (CTP) score of 7 or higher. Subjects

were either HBV-treatment-naïve or previously treated, predominantly with lamivudine

or interferon-α.

In Study AI463048, 100 subjects were randomized to treatment with BARACLUDE and

91 subjects to treatment with adefovir dipivoxil. Two subjects randomized to treatment

with adefovir dipivoxil actually received treatment with BARACLUDE for the duration of

the study. The mean age of subjects was 52 years, 74% were male, 54% were Asian,

33% were Caucasian, and 5% were Black/African American. At baseline, subjects had a

mean serum HBV DNA by PCR of 7.83 log

copies/mL and mean ALT level of 100 U/L;

54% of subjects were HBeAg-positive; 35% had genotypic evidence of lamivudine

resistance. The baseline mean CTP score was 8.6. Results for selected study endpoints

at Week 48 are shown in Table 13.

Table 13: Selected Endpoints at Week 48, Subjects with Decompensated Liver

Disease, Study AI463048

BARACLUDE

1 mg

n=100

Adefovir Dipivoxil

10 mg

n=91

HBV DNA

Proportion undetectable (<300 copies/mL) 57% 20%

Stable or improved CTP score

61% 67%

HBsAg loss 5% 0

Normalization of ALT (≤1 × ULN)

49/78 (63%) 33/71 (46%)

Endpoints were analyzed using intention-to-treat (ITT) method, treated subjects

as randomized.

Roche COBAS Amplicor PCR assay (LLOQ = 300 copies/mL).

Deﬁned as decrease or no change from baseline in CTP score.

Denominator is subjects with abnormal values at baseline.

ULN=upper limit of normal.

BARACLUDE

(entecavir) BARACLUDE

(entecavir)

Lamivudine-refractory Subjects

Among lamivudine-refractory subjects (Study AI463026), 77 (55%) BARACLUDE-

treated subjects and 3 (2%) lamivudine subjects continued blinded treatment for

up to 96 weeks. In this cohort of BARACLUDE subjects, 31 (40%) subjects achieved

HBV DNA <300 copies/mL, 62 (81%) subjects had ALT ≤1 × ULN, and 8 (10%) subjects

demonstrated HBeAg seroconversion at the end of dosing.

14.2 Outcomes in Pediatric Subjects

The pharmacokinetics, safety and antiviral activity of BARACLUDE in pediatric subjects

were initially assessed in Study AI463028. Twenty-four treatment-naïve and 19

lamivudine-experienced HBeAg-positive pediatric subjects 2 to less than 18 years of

age with compensated chronic hepatitis B virus infection and elevated ALT were treated

with BARACLUDE 0.015 mg/kg (up to 0.5 mg) or 0.03 mg/kg (up to 1 mg) once daily.

Fifty-eight percent (14/24) of treatment-naïve subjects and 47% (9/19) of lamivudine-

experienced subjects achieved HBV DNA <50 IU/mL at Week 48 and ALT normalized in

83% (20/24) of treatment-naïve and 95% (18/19) of lamivudine-experienced subjects.

Safety and antiviral efficacy were confirmed in Study AI463189, a study of BARACLUDE

among 180 nucleoside-inhibitor-treatment-naïve pediatric subjects 2 to less than 18 years

of age with HBeAg-positive chronic hepatitis B infection, compensated liver disease, and

elevated ALT. Subjects were randomized 2:1 to receive blinded treatment with BARACLUDE

0.015 mg/kg up to 0.5 mg/day (N=120) or placebo (N=60). The randomization was

stratified by age group (2 to 6 years; >6 to 12 years; and >12 to <18 years). Baseline

demographics and HBV disease characteristics were comparable between the 2 treatment

arms and across age cohorts. At study entry, the mean HBV DNA was 8.1 log

IU/mL

and mean ALT was 103 U/L. The primary efficacy endpoint was a composite of HBeAg

seroconversion and serum HBV DNA <50 IU/mL at Week 48 assessed in the first 123

subjects reaching 48 weeks of blinded treatment. Twenty-four percent (20/82) of subjects

in the BARACLUDE-treated group and 2% (1/41) of subjects in the placebo-treated group

met the primary endpoint. Forty-six percent (38/82) of BARACLUDE-treated subjects and

2% (1/41) of placebo-treated subjects achieved HBV DNA <50 IU/mL at Week 48. ALT

normalization occurred in 67% (55/82) of BARACLUDE-treated subjects and 22% (9/41)

of placebo-treated subjects; 24% (20/82) of BARACLUDE-treated subjects and 12% (5/41)

of placebo-treated subjects had HBeAg seroconversion.

16 HOW SUPPLIED/STORAGE AND HANDLING

BARACLUDE

(entecavir) Tablets and Oral Solution are available in the following strengths

and configurations of plastic bottles with child-resistant closures:

Product

Strength and

Dosage

Form

Description Quantity NDC Number

0.5 mg film-

coated tablet

White to off-white, triangular-shaped

tablet, debossed with “BMS” on

one side and “1611” on the other side.

30 tablets 0003-1611-12

1 mg film-

coated tablet

Pink, triangular-shaped tablet,

debossed with “BMS” on one side

and “1612” on the other side.

30 tablets 0003-1612-12

0.05 mg/mL

oral solution

Ready-to-use, orange-flavored,

clear, colorless to pale yellow,

aqueous solution in a 260 mL bottle.

210 mL 0003-1614-12

BARACLUDE Oral Solution is a ready-to-use product; dilution or mixing with water or

any other solvent or liquid product is not recommended. Each bottle of the oral solution

is accompanied by a dosing spoon that is calibrated in 0.5 mL increments up to 10 mL.

Storage

BARACLUDE Tablets should be stored in a tightly closed container at 25°C (77°F);

excursions permitted between 15°C and 30°C (59°F and 86°F) [see USP Controlled Room

Temperature]. Store in the outer carton to protect from light.

BARACLUDE Oral Solution should be stored in the outer carton at 25°C (77°F); excursions

permitted between 15°C and 30°C (59°F and 86°F) [see USP Controlled Room

Temperature]. Protect from light. After opening, the oral solution can be used up to the

expiration date on the bottle. The bottle and its contents should be discarded after the

expiration date.

17 PATIENT COUNSELING INFORMATION

See FDA-approved patient labeling (Patient Information).

Severe Acute Exacerbation of Hepatitis after Discontinuation of Treatment

Inform patients that discontinuation of anti-hepatitis B therapy, including BARACLUDE,

may result in severe acute exacerbations of hepatitis B. Advise the patient to not

discontinue BARACLUDE without first informing their healthcare provider [see Warnings

and Precautions (5.1)].

Risk of Development of HIV-1 Resistance in Patients with HIV-1 Coinfection

Inform patients that if they have or develop HIV infection and are not receiving effective

HIV treatment, BARACLUDE may increase the risk of development of resistance to

HIV medication [see Warnings and Precautions (5.2)].

Subjects Co-infected with HIV and HBV

Study AI463038 was a randomized, double-blind, placebo-controlled study of BARACLUDE

versus placebo in 68 subjects co-infected with HIV and HBV who experienced recurrence

of HBV viremia while receiving a lamivudine-containing highly active antiretroviral (HAART)

regimen. Subjects continued their lamivudine-containing HAART regimen (lamivudine dose

300 mg/day) and were assigned to add either BARACLUDE 1 mg once daily (51 subjects)

or placebo (17 subjects) for 24 weeks followed by an open-label phase for an additional

24 weeks where all subjects received BARACLUDE. At baseline, subjects had a mean

serum HBV DNA level by PCR of 9.13 log

copies/mL. Ninety-nine percent of subjects

were HBeAg-positive at baseline, with a mean baseline ALT level of 71.5 U/L. Median

HIV RNA level remained stable at approximately 2 log

copies/mL through 24 weeks of

blinded therapy. Virologic and biochemical endpoints at Week 24 are shown in Table 14.

There are no data in patients with HIV/HBV co-infection who have not received prior

lamivudine therapy. BARACLUDE has not been evaluated in HIV/HBV co-infected patients

who were not simultaneously receiving effective HIV treatment [see Warnings and

Precautions (5.2)].

Table 14:

Virologic and Biochemical Endpoints at Week 24, Study AI463038

BARACLUDE 1 mg

n=51

Placebo

n=17

HBV DNA

Proportion undetectable (<300 copies/mL) 6% 0

Mean change from baseline (log

copies/mL) –3.65 +0.11

ALT normalization (≤1 × ULN) 34%

All subjects also received a lamivudine-containing HAART regimen.

Roche COBAS Amplicor PCR assay (LLOQ = 300 copies/mL).

Percentage of subjects with abnormal ALT (>1 × ULN) at baseline who achieved ALT

normalization (n=35 for BARACLUDE and n=12 for placebo).

For subjects originally assigned to BARACLUDE, at the end of the open-label phase

(Week 48), 8% of subjects had HBV DNA <300 copies/mL by PCR, the mean change

from baseline HBV DNA by PCR was −4.20 log

copies/mL, and 37% of subjects with

abnormal ALT at baseline had ALT normalization (≤1 × ULN).

Beyond 48 Weeks

The optimal duration of therapy with BARACLUDE is unknown. According to protocol-

mandated criteria in the Phase 3 clinical trials, subjects discontinued BARACLUDE

or lamivudine treatment after 52 weeks according to a definition of response based

on HBV virologic suppression (<0.7 MEq/mL by bDNA assay) and loss of HBeAg (in

HBeAg-positive subjects) or ALT <1.25 × ULN (in HBeAg-negative subjects) at Week 48.

Subjects who achieved virologic suppression but did not have serologic response

(HBeAg-positive) or did not achieve ALT <1.25 × ULN (HBeAg-negative) continued

blinded dosing through 96 weeks or until the response criteria were met. These

protocol-specified subject management guidelines are not intended as guidance for

clinical practice.

Nucleoside-inhibitor-naïve Subjects

Among nucleoside-inhibitor-naïve, HBeAg-positive subjects (Study AI463022),

243 (69%) BARACLUDE-treated subjects and 164 (46%) lamivudine-treated subjects

continued blinded treatment for up to 96 weeks. Of those continuing blinded treatment

in Year 2, 180 (74%) BARACLUDE subjects and 60 (37%) lamivudine subjects achieved

HBV DNA <300 copies/mL by PCR at the end of dosing (up to 96 weeks). 193 (79%)

BARACLUDE subjects achieved ALT ≤1 × ULN compared to 112 (68%) lamivudine

subjects, and HBeAg seroconversion occurred in 26 (11%) BARACLUDE subjects and

20 (12%) lamivudine subjects.

Among nucleoside-inhibitor-naïve, HBeAg-positive subjects, 74 (21%) BARACLUDE

subjects and 67 (19%) lamivudine subjects met the definition of response at Week

48, discontinued study drugs, and were followed off treatment for 24 weeks. Among

BARACLUDE responders, 26 (35%) subjects had HBV DNA <300 copies/mL, 55 (74%)

subjects had ALT ≤1 × ULN, and 56 (76%) subjects sustained HBeAg seroconversion

at the end of follow-up. Among lamivudine responders, 20 (30%) subjects had HBV

DNA <300 copies/mL, 41 (61%) subjects had ALT ≤1 × ULN, and 47 (70%) subjects

sustained HBeAg seroconversion at the end of follow-up.

Among nucleoside-inhibitor-naïve, HBeAg-negative subjects (Study AI463027), 26 (8%)

BARACLUDE-treated subjects and 28 (9%) lamivudine-treated subjects continued

blinded treatment for up to 96 weeks. In this small cohort continuing treatment in

Year 2, 22 BARACLUDE and 16 lamivudine subjects had HBV DNA <300 copies/mL by

PCR, and 7 and 6 subjects, respectively, had ALT ≤1 × ULN at the end of dosing (up

to 96 weeks).

Among nucleoside-inhibitor-naïve, HBeAg-negative subjects, 275 (85%) BARACLUDE

subjects and 245 (78%) lamivudine subjects met the definition of response at Week

48, discontinued study drugs, and were followed off treatment for 24 weeks. In this

cohort, very few subjects in each treatment arm had HBV DNA <300 copies/mL by PCR

at the end of follow-up. At the end of follow-up, 126 (46%) BARACLUDE subjects and

84 (34%) lamivudine subjects had ALT ≤1 × ULN.

BARACLUDE

(entecavir) BARACLUDE

(entecavir)

Lactic Acidosis and Severe Hepatomegaly

Lactic acidosis and severe hepatomegaly with steatosis, including fatal cases, have

been reported with use of drugs similar to BARACLUDE. Advise patients to contact

their healthcare provider immediately and stop BARACLUDE if they develop clinical

symptoms suggestive of lactic acidosis or pronounced hepatotoxicity [see Warnings and

Precautions (5.3)].

Missed Dosage

Inform patients that it is important to take BARACLUDE on a regular dosing schedule on

an empty stomach (at least 2 hours after a meal and 2 hours before the next meal) and

to avoid missing doses as it can result in development of resistance [see Dosage and

Administration (2.1)].

Treatment Duration

Advise patients that in the treatment of chronic hepatitis B, the optimal duration of

treatment is unknown. The relationship between response and long-term prevention of

outcomes such as hepatocellular carcinoma is not known.

Instructions for Use

Inform patients using the oral solution to hold the dosing spoon in a vertical position

and fill it gradually to the mark corresponding to the prescribed dose. Rinsing of the

dosing spoon with water is recommended after each daily dose. Some patients may find

it difficult to accurately measure the prescribed dose using the provided dosing spoon;

therefore, patients/caregivers should refer to the steps in the Patient Information section

that demonstrate the correct technique of using the provided dosing spoon to measure

the prescribed BARACLUDE dose.

Pregnancy Registry

Advise patients that there is a pregnancy exposure registry that monitors pregnancy

outcomes in women exposed to BARACLUDE during pregnancy [see Use in Specific

Populations (8.1)].

BARACLUDE

(entecavir)

Patient Information

BARACLUDE

(BEAR ah klude)

(entecavir)

Tablets

BARACLUDE

(BEAR ah klude)

(entecavir)

Oral Solution

Read this Patient Information before you start taking BARACLUDE and each time you get a rell. There may be

new information. This information does not take the place of talking with your healthcare provider about your

medical condition or treatment.

What is the most important information I should know about BARACLUDE?

1. Your hepatitis B virus (HBV) infection may get worse if you stop taking BARACLUDE. This usually

happens within 6 months after stopping BARACLUDE.

• Take BARACLUDE exactly as prescribed.

• Do not run out of BARACLUDE.

• Do not stop BARACLUDE without talking to your healthcare provider.

• Your healthcare provider should monitor your health and do regular blood tests to check your liver if you

stop taking BARACLUDE.

2. If you have or get HIV that is not being treated with medicines while taking BARACLUDE,

the HIV virus may develop resistance to certain HIV medicines and become harder to treat. You

should get an HIV test before you start taking BARACLUDE and anytime after that when there is a chance

you were exposed to HIV.

BARACLUDE can cause serious side effects including:

3. Lactic acidosis (buildup of acid in the blood). Some people who have taken BARACLUDE or

medicines like BARACLUDE (a nucleoside analogue) have developed a serious condition called

lactic acidosis. Lactic acidosis is a serious medical emergency that can cause death. Lactic acidosis must

be treated in the hospital. Reports of lactic acidosis with BARACLUDE generally involved patients who were

seriously ill due to their liver disease or other medical condition.

Call your healthcare provider right away if you get any of the following signs or symptoms of lactic

acidosis:

• You feel very weak or tired.

• You have unusual (not normal) muscle pain.

• You have trouble breathing.

• You have stomach pain with nausea and vomiting.

• You feel cold, especially in your arms and legs.

• You feel dizzy or light-headed.

• You have a fast or irregular heartbeat.

4. Serious liver problems. Some people who have taken medicines like BARACLUDE have developed

serious liver problems called hepatotoxicity, with liver enlargement (hepatomegaly) and fat

in the liver (steatosis). Hepatomegaly with steatosis is a serious medical emergency that can

cause death.

Call your healthcare provider right away if you get any of the following signs or symptoms of

liver problems:

• Your skin or the white part of your eyes turns yellow (jaundice).

• Your urine turns dark.

• Your bowel movements (stools) turn light in color.

BARACLUDE

(entecavir)

• You don’t feel like eating food for several days or longer.

• You feel sick to your stomach (nausea).

• You have lower stomach pain.

You may be more likely to get lactic acidosis or serious liver problems if you are female, very overweight, or

have been taking nucleoside analogue medicines, like BARACLUDE, for a long time.

What is BARACLUDE?

BARACLUDE is a prescription medicine used to treat chronic hepatitis B virus (HBV) in adults and children 2 years

of age and older who have active liver disease.

• BARACLUDE will not cure HBV.

• BARACLUDE may lower the amount of HBV in the body.

• BARACLUDE may lower the ability of HBV to multiply and infect new liver cells.

• BARACLUDE may improve the condition of your liver.

• It is not known whether BARACLUDE will reduce your chances of getting liver cancer or liver damage

(cirrhosis), which may be caused by chronic HBV infection.

• It is not known if BARACLUDE is safe and effective for use in children less than 2 years of age.

What should I tell my healthcare provider before taking BARACLUDE?

Before you take BARACLUDE, tell your healthcare provider if you:

• have kidney problems. Your BARACLUDE dose or schedule may need to be changed.

• have received medicine for HBV before. Some people, especially those who have already been treated

with certain other medicines for HBV infection, may develop resistance to BARACLUDE. These people may

have less benet from treatment with BARACLUDE and may have worsening of hepatitis after resistant

virus appears. Your healthcare provider will test the level of the hepatitis B virus in your blood regularly.

• have any other medical conditions.

• are pregnant or plan to become pregnant. It is not known if BARACLUDE will harm your unborn baby. Talk

to your healthcare provider if you are pregnant or plan to become pregnant.

Antiretroviral Pregnancy Registry. If you take BARACLUDE while you are pregnant, talk to your

healthcare provider about how you can take part in the BARACLUDE Antiretroviral Pregnancy Registry.

The purpose of the pregnancy registry is to collect information about the health of you and your baby.

• are breastfeeding or plan to breastfeed. It is not known if BARACLUDE can pass into your breast milk.

You and your healthcare provider should decide if you will take BARACLUDE or breastfeed.

Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter

medicines, vitamins, and herbal supplements. Especially tell your healthcare provider if you have taken a medicine

to treat HBV in the past.

Know the medicines you take. Keep a list of your medicines with you to show your healthcare provider and

pharmacist when you get a new medicine.

How should I take BARACLUDE?

• Take BARACLUDE exactly as your healthcare provider tells you to.

• Your healthcare provider will tell you how much BARACLUDE to take.

• Your healthcare provider will tell you when and how often to take BARACLUDE.

• Take BARACLUDE on an empty stomach, at least 2 hours after a meal and at least 2 hours before the

next meal.

Figure 2

BARACLUDE

(entecavir)

• If you are taking BARACLUDE Oral Solution, or giving it to your child, carefully measure the dose with

the dosing spoon provided, as follows:

• Hold the dosing spoon in an upright

(vertical) position and slowly ll it to the

measurement line on the dosing spoon

that is the same as the prescribed dose.

Bring the dosing spoon to eye level to be

sure that the level of the BARACLUDE Oral

Solution is at the correct measurement

line (see Figure 1).

• With the dosing spoon at eye level, holding

it with the measurement lines facing

you, check that it has been lled to the

correct measurement line. The top of the

BARACLUDE Oral Solution in the dosing

spoon will look curved, not at. Measure

the dose of BARACLUDE Oral Solution at

the bottom of the curve. Your dose of

BARACLUDE Oral Solution is measured

correctly when the bottom of the curve is

lined up with the measurement line of the

prescribed dose. As an example, Figure 2

shows the right way to measure a 5 mL

dose of BARACLUDE (see Figure 2).

• BARACLUDE Oral Solution should be swallowed directly from the dosing spoon.

• BARACLUDE Oral Solution should not be mixed with water or any other liquid.

• After each use, rinse the dosing spoon with water and allow it to air dry.

• If you lose the dosing spoon, call your pharmacist or healthcare provider for instructions.

• Do not change your dose or stop taking BARACLUDE without talking to your healthcare provider.

• If you miss a dose of BARACLUDE, take it as soon as you remember and then take your next dose at

its regular time. If it is almost time for your next dose, skip the missed dose. Do not take two doses at

the same time. Call your healthcare provider or pharmacist if you are not sure what to do.

• When your supply of BARACLUDE starts to run low, call your healthcare provider or pharmacy for a rell.

Do not run out of BARACLUDE.

• If you take too much BARACLUDE, call your healthcare provider or go to the nearest emergency room

right away.

What are the possible side effects of BARACLUDE?

BARACLUDE may cause serious side effects. See “What is the most important information I should

know about BARACLUDE?”

The most common side effects of BARACLUDE include:

• headache

• tiredness

• dizziness

• nausea

Tell your healthcare provider if you have any side effect that bothers you or that does not go away.

These are not all the possible side effects of BARACLUDE. For more information, ask your healthcare provider or

pharmacist.

Call your doctor for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088.

Figure 1

BARACLUDE

(entecavir)

How should I store BARACLUDE?

• Store BARACLUDE Tablets or Oral Solution at room temperature, between 68°F and 77°F (20°C and 25°C).

• Keep BARACLUDE Tablets in a tightly closed container.

• Store BARACLUDE Tablets or BARACLUDE Oral Solution in the original carton, and keep the carton out of

the light.

• Safely throw away BARACLUDE that is out of date or no longer needed. Dispose of unused medicines

through community take-back disposal programs when available or place BARACLUDE in an unrecognizable

closed container in the household trash.

Keep BARACLUDE and all medicines out of the reach of children.

General information about the safe and effective use of BARACLUDE

BARACLUDE does not stop you from spreading the hepatitis B virus (HBV) to others by sex, sharing needles,

or being exposed to your blood. Talk with your healthcare provider about safe sexual practices that protect

your partner. Never share needles. Do not share personal items that can have blood or body uids on them,

like toothbrushes or razor blades. A shot (vaccine) is available to protect people at risk from becoming infected

with HBV.

Medicines are sometimes prescribed for purposes other than those listed in a Patient Information leaet. Do not

use BARACLUDE for a condition for which it was not prescribed. Do not give BARACLUDE to other people, even

if they have the same symptoms you have. It may harm them.

This Patient Information leaet summarizes the most important information about BARACLUDE. If you would

like more information, talk with your healthcare provider. You can ask your healthcare provider or pharmacist

for information about BARACLUDE that is written for health professionals.

For more information, go to www.Baraclude.com or call 1-800-321-1335.

What are the ingredients in BARACLUDE?

Active ingredient: entecavir

Inactive ingredients in BARACLUDE Tablets: lactose monohydrate, microcrystalline cellulose, crospovidone,

povidone, magnesium stearate.

Tablet lm-coat: titanium dioxide, hypromellose, polyethylene glycol 400, polysorbate 80 (0.5 mg tablet only),

and iron oxide red (1 mg tablet only).

Inactive ingredients in BARACLUDE Oral Solution: maltitol, sodium citrate, citric acid, methylparaben, propylparaben,

and orange avor.

Distributed by:

Bristol-Myers Squibb Company

Princeton, NJ 08543 USA

This Patient Information has been approved by the U.S. Food and Drug Administration.

Revised: August 2015

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