Sorafenib

6 ADVERSE REACTIONS The following clinically significant adverse reactions are discussed elsewhere in the labeling: • Cardiovascular events [see Warnings and Precautions ( 5.1 )] • Hemorrhage [see Warnings and Precautions ( 5.2 )] • Hypertension [see Warnings and Precautions ( 5.3 )] • Dermatologic toxicities [see Warnings and Precautions ( 5.4 )] • Gastrointestinal perforation [see Warnings and Precautions ( 5.5 )] • QT interval prolongation [see Warnings and Precautions ( 5.9 ) and Clinical Pharmacology ( 12.2 )] • Drug-induced liver injury [see Warnings and Precautions ( 5.10 )] • Impairment of TSH suppression in DTC [see Warnings and Precautions ( 5.12 )] The most common adverse reactions (≥20%) are diarrhea, fatigue, infection, alopecia, hand-foot skin reaction, rash, weight loss, decreased appetite, nausea, gastrointestinal and abdominal pains, hypertension, and hemorrhage. ( 6 ) To report SUSPECTED ADVERSE REACTIONS, contact Dr. Reddy’s Laboratories Inc., at 1-888-375-3784 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch . 6.1 Clinical Trials 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. The data described reflect exposure to sorafenib in 955 patients who participated in placebo-controlled studies in hepatocellular carcinoma (N=297), advanced renal cell carcinoma (N=451), or differentiated thyroid carcinoma (N=207). The most common adverse reactions (≥20%), which were considered to be related to sorafenib, in patients with HCC, RCC or DTC are diarrhea, fatigue, infection, alopecia, hand-foot skin reaction, rash, weight loss, decreased appetite, nausea, gastrointestinal and abdominal pains, hypertension, and hemorrhage. Hepatocellular Carcinoma Table 4 shows the percentage of patients in the SHARP (HCC) study experiencing adverse reactions that were reported in at least 10% of patients and at a higher rate in the sorafenib-treated group than in those receiving placebo. Table 4: Adverse Reactions Reported in at Least 10% of Patients and at a Higher Rate in Sorafenib Arm than the Placebo Arm – SHARP (HCC) Sorafenib N=297 Placebo N=302 Adverse Reaction 1 All Grades % Grade 3 % Grade 4 % All Grades % Grade 3 % Grade 4 % Any Adverse Reaction 98 39 6 96 24 8 Gastrointestinal Diarrhea 55 10 <1 25 2 0 Anorexia 29 3 0 18 3 <1 Nausea 24 1 0 20 3 0 Vomiting 15 2 0 11 2 0 Constipation 14 0 0 10 0 0 Constitutional symptoms Fatigue 46 9 1 45 12 2 Weight loss 30 2 0 10 1 0 Pain Pain, abdomen 31 9 0 26 5 1 Dermatology/skin Hand-foot skin reaction 21 8 0 3 <1 0 Rash/desquamation 19 1 0 14 0 0 Alopecia 14 0 0 2 0 0 Pruritus 14 <1 0 11 <1 0 Dry skin 10 0 0 6 0 0 Hepatobiliary/pancreas Liver dysfunction 11 2 1 8 2 1 1 Adverse reactions graded according to National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0 (NCI CTCAE v3.0). Hypertension was reported in 9% of patients treated with sorafenib and 4% of those receiving placebo. Grade 3 hypertension was reported in 4% of sorafenib-treated patients and 1% of those receiving placebo. Hemorrhage/bleeding was reported in 18% of those receiving sorafenib and 20% of patients receiving placebo. The rates of Grade 3 and 4 bleeding were also higher in patients receiving placebo (Grade 3 – 3% sorafenib and 5% placebo and Grade 4 – 2% sorafenib and 4% placebo). Bleeding from esophageal varices was reported in 2.4% in sorafenib-treated patients and 4% of patients receiving placebo. Renal failure was reported in <1% of patients treated with sorafenib and 3% of patients receiving placebo. Clinical pancreatitis was reported in 1 of 297 sorafenib-treated patients (Grade 2). The rate of adverse reactions (including those associated with progressive disease) resulting in permanent discontinuation was similar in both the sorafenib-treated patients and those receiving placebo (32% of sorafenib-treated patients and 35% of patients receiving placebo). Laboratory test abnormalities reported in SHARP are presented in Table 5. Table 5: Laboratory Test Abnormalities Reported in SHARP (HCC) Laboratory Parameter 1 Sorafenib N=297 Placebo N=302 All Grades (%) Grade 3 or 4 (%) All Grades (%) Grade 3 or 4 (%) Hypoalbuminemia 59 0 47 0 Elevated Lipase 40 9 37 9 Lymphopenia 47 NR 42 NR Thrombocytopenia 46 4 41 <1 Elevated INR 42 4 34 2 Hypophosphatemia 35 11 11 2 Elevated Amylase 34 2 29 2 Hypocalcemia 27 2.4 15 1 Hypokalemia 10 <1 6 <1 1- Laboratory parameters graded according to National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0 (NCI CTCAE v3.0). NR = not reported Renal Cell Carcinoma Table 6 shows the percentage of patients in the TARGET (RCC) study experiencing adverse reactions that were reported in at least 10% of patients and at a higher rate in sorafenib-treated patients arm than in those receiving placebo. The rate of adverse reactions (including those associated with progressive disease) resulting in permanent discontinuation was similar in both the sorafenib-treated patients and patients receiving placebo (10% and 8%, respectively). Clinical pancreatitis was reported in 3 of 451 sorafenib-treated patients (one Grade 2 and two Grade 4). Table 6: Adverse Reactions Reported in at Least 10% of Patients and at a Higher Rate in Sorafenib Arm than the Placebo Arm – TARGET (RCC) Adverse Reaction 1 Sorafenib N=451 Placebo N=451 All Grades % Grade 3 % Grade 4 % All Grades % Grade 3 % Grade 4 % Any Adverse Reactions 95 31 7 86 22 6 Gastrointestinal symptoms Diarrhea 43 2 0 13 <1 0 Nausea 23 <1 0 19 <1 0 Anorexia 16 <1 0 13 1 0 Vomiting 16 <1 0 12 1 0 Constipation 15 <1 0 11 <1 0 Dermatology/skin Rash/desquamation 40 <1 0 16 <1 0 Hand-foot skin reaction 30 6 0 7 0 0 Alopecia 27 <1 0 3 0 0 Pruritus 19 <1 0 6 0 0 Dry skin 11 0 0 4 0 0 Constitutional symptoms Fatigue 37 5 <1 28 3 <1 Weight loss 10 <1 0 6 0 0 Cardiovascular, General Hypertension 17 3 <1 2 <1 0 Hemorrhage/bleeding Hemorrhage – all sites 15 2 0 8 1 <1 Pulmonary Dyspnea 14 3 <1 12 2 <1 Neurology Neuropathy-sensory 13 <1 0 6 <1 0 Pain Pain, abdomen 11 2 0 9 2 0 Pain, headache 10 <1 0 6 <1 0 Pain, joint 10 2 0 6 <1 0 1 Adverse reactions graded according to National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0 (NCI CTCAE v3.0). Laboratory test abnormalities reported in TARGET are presented in Table 7. Table 7: Laboratory Test Abnormalities Reported in TARGET (RCC) Laboratory Parameter 1 Sorafenib N=451 Placebo N=451 All Grades (%) Grade 3 or 4 (%) All Grades (%) Grade 3 or 4 (%) Hypophosphatemia 45 13 11 3 Anemia 44 2 49 4 Elevated Lipase 41 12 30 7 Elevated Amylase 30 1 23 3 Lymphopenia 23 13 13 7 Neutropenia 18 5 10 2 Thrombocytopenia 12 1 5 0 Hypocalcemia 12 2 8 <1 Hypokalemia 5 1 <1 <1 1 Laboratory parameters graded according to National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0 (NCI CTCAE v3.0). Differentiated Thyroid Carcinoma The safety of sorafenib was evaluated in DECISION in 416 patients with locally recurrent or metastatic, progressive differentiated thyroid carcinoma (DTC) refractory to radioactive iodine (RAI) treatment randomized to receive 400 mg twice daily sorafenib (n=207) or matching placebo (n=209) until disease progression or intolerable toxicity in a double-blind trial [see Clinical Studies (14.3)]. The data described below reflect a median exposure to sorafenib for 46 weeks (range 0.3 to 135). The population exposed to sorafenib was 50% male, and had a median age of 63 years. Dose interruptions for adverse reactions were required in 66% of patients receiving sorafenib and dose reductions were required in 64% of patients. Adverse reactions that resulted in treatment discontinuation were reported in 14% of sorafenib-treated patients compared to 1.4% of patients receiving placebo. Table 8 shows the percentage of DTC patients experiencing adverse reactions at a higher rate in sorafenib-treated patients than in patients receiving placebo in the double-blind phase of the DECISION study. Grade 3 adverse reactions occurred in 53% of sorafenib-treated patients compared to 23% of patients receiving placebo. Grade 4 adverse reactions occurred in 12% of sorafenib-treated patients compared to 7% of patients receiving placebo. Table 8: Selected Adverse Reactions Occurring at a Higher Incidence in Sorafenib-Treated Patients [Between Arm Difference of ≥ 5% (All Grades) 1 or ≥ 2% (Grades 3 and 4)] Adverse Reaction Sorafenib N = 207 Placebo N = 209 All Grades (%) Grades 3 and 4 (%) All Grades (%) Grades 3 and 4 (%) Skin and subcutaneous tissue disorders PPES 5 69 19 8 0 Alopecia 67 0 8 0 Rash 35 5 7 0 Pruritus 20 0.5 11 0 Dry skin 13 0.5 5 0 Erythema 10 0 0.5 0 Hyperkeratosis 7 0 0 0 Gastrointestinal disorders Diarrhea 68 6 15 1 Stomatitis 3 24 2 3 0 Nausea 21 0 12 0 Abdominal pain 2 20 1 7 1 Constipation 16 0 8 0.5 Oral pain 4 14 0.5 6 0 Vomiting 11 0 3 0 Investigations Weight loss 49 6 14 1 General disorders and administration site conditions Fatigue 41 5 20 1 Asthenia 12 0 7 0 Pyrexia 11 1 5 0 Vascular disorders Hypertension 6 41 10 12 2 Metabolism and nutrition disorders Decreased appetite 30 2 5 0 Nervous system disorders Headache 17 0 6 0 Dysgeusia 6 0 0 0 Musculoskeletal and connective tissue disorders Pain in extremity 15 1 7 0 Muscle spasms 10 0 3 0 Respiratory, thoracic and mediastinal disorders Dysphonia 13 0.5 3 0 Epistaxis 7 0 1 0 Neoplasms benign, malignant and unspecified Squamous cell carcinoma of skin 3 3 0 0 1 National Cancer Institute Common Terminology Criteria for Adverse Events Version 3.0 2 Includes the following terms: abdominal pain, abdominal discomfort, hepatic pain, esophageal pain, esophageal discomfort, abdominal pain lower, abdominal pain upper, abdominal tenderness, abdominal rigidity 3 Includes the following terms: stomatitis, aphthous stomatitis, mouth ulceration, mucosal inflammation 4 Includes the following terms: oral pain, oropharyngeal discomfort, glossitis, burning mouth syndrome, glossodynia 5 Palmar-plantar erythrodysesthesia syndrome (Hand-foot skin reaction) 6 Includes the following terms: hypertension, blood pressure increased, blood pressure systolic increased The relative increase for the following laboratory abnormalities observed in sorafenib-treated patients as compared to patients receiving placebo in the DECISION study is similar to that observed in the RCC and HCC studies: lipase, amylase, hypokalemia, hypophosphatemia, neutropenia, lymphopenia, anemia, and thrombocytopenia. Hypocalcemia was more frequent and more severe in patients with DTC, especially those with a history of hypoparathyroidism, compared to patients with RCC or HCC. Other laboratory test abnormalities reported in DECISION are presented in Table 9. Table 9: Laboratory Test Abnormalities Reported in DECISION (DTC) Laboratory Parameter 1 Sorafenib N=207 Placebo N=209 All Grades (%) Grade 3 or 4 (%) All Grades (%) Grade 3 or 4 (%) Elevated ALT 59 4 24 0 Elevated AST 54 2 15 0 Hypocalcemia 36 10 11 3 1 Laboratory parameters graded according to National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0 (NCI CTCAE v3.0). Additional Data from Multiple Clinical Trials The following additional drug-related adverse reactions and laboratory abnormalities were reported from clinical trials of sorafenib ( very common 10% or greater, common 1 to less than 10%, uncommon 0.1% to less than 1%, rare less than 0.1 %): Cardiovascular: Common : congestive heart failure *† , myocardial ischemia and/or infarction Uncommon : hypertensive crisis * Rare : QT prolongation * Dermatologic: Very common : erythema Common : exfoliative dermatitis, acne, flushing, folliculitis, hyperkeratosis Uncommon : eczema, erythema multiforme Digestive: Very common : increased lipase, increased amylase Common : mucositis, stomatitis (including dry mouth and glossodynia), dyspepsia, dysphagia, gastrointestinal reflux Uncommon : pancreatitis, gastritis, gastrointestinal perforations * , cholecystitis, cholangitis Note that elevations in lipase are very common (41%, see below); a diagnosis of pancreatitis should not be made solely on the basis of abnormal laboratory values General Disorders: Very common : infection, hemorrhage (including gastrointestinal * and respiratory tract * and uncommon cases of cerebral hemorrhage * ), asthenia, pain (including mouth, bone, and tumor pain), pyrexia, decreased appetite Common : influenza-like illness Hematologic: Very common : leukopenia, lymphopenia Common : anemia, neutropenia, thrombocytopenia Uncommon : INR abnormal Hepatobiliary disorders: Rare : drug-induced liver injury (including hepatic failure and death) Hypersensitivity: Uncommon : hypersensitivity reactions (including skin reactions and urticaria), anaphylactic reaction Metabolic and Nutritional: Very common : hypophosphatemia Common : transient increases in transaminases, hypocalcemia, hypokalemia, hyponatremia, hypothyroidism Uncommon : dehydration, transient increases in alkaline phosphatase, increased bilirubin (including jaundice), hyperthyroidism Musculoskeletal: Very common : arthralgia Common : myalgia, muscle spasms Nervous System and Psychiatric: Common : depression, dysgeusia Uncommon : tinnitus, reversible posterior leukoencephalopathy * Renal and Genitourinary: Common : renal failure, proteinuria Rare : nephrotic syndrome Reproductive: Common : erectile dysfunction Uncommon : gynecomastia Respiratory: Common : rhinorrhea Uncommon : interstitial lung disease-like events (includes reports of pneumonitis, radiation pneumonitis, acute respiratory distress, interstitial pneumonia, pulmonitis and lung inflammation) In addition, the following medically significant adverse reactions were uncommon during clinical trials of sorafenib: transient ischemic attack, arrhythmia, and thromboembolism. For these adverse reactions, the causal relationship to sorafenib has not been established. * adverse reactions may have a life-threatening or fatal outcome. † reported in 1.9% of patients treated with sorafenib (N= 2276). 6.2 Postmarketing Experience The following adverse reactions have been identified during postapproval use of sorafenib. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Blood and lymphatic disorders : Thrombotic microangiopathy (TMA) Dermatologic : Stevens-Johnson syndrome and toxic epidermal necrolysis (TEN) Hypersensitivity : Angioedema Musculoskeletal : Rhabdomyolysis, osteonecrosis of the jaw Respiratory: Interstitial lung disease-like events (which may have a life-threatening or fatal outcome) Vascular : Arterial (including aortic) aneurysms, dissections, and rupture

4 CONTRAINDICATIONS • Sorafenib tablets are contraindicated in patients with known severe hypersensitivity to sorafenib or any other component of sorafenib tablets. • Sorafenib tablets in combination with carboplatin and paclitaxel is contraindicated in patients with squamous cell lung cancer [see Warnings and Precautions ( 5.8 )]. • Sorafenib tablets are contraindicated in patients with known severe hypersensitivity to sorafenib or any other component of sorafenib tablets. ( 4 ) • Sorafenib in combination with carboplatin and paclitaxel is contraindicated in patients with squamous cell lung cancer. ( 4 )

11 DESCRIPTION Sorafenib, a kinase inhibitor, is the tosylate salt of sorafenib. Sorafenib tosylate, USP has the chemical name 4-(4-{3-[4-Chloro-3-(trifluoromethyl)phenyl]ureido}phenoxy)-N2-methylpyridine-2-carboxamide 4-methylbenzenesulfonate. The molecular formula of sorafenib tosylate, USP is C 21 H 16 ClF 3 N 4 O 3 .C 7 H 8 O 3 S and the molecular weight of sorafenib tosylate, USP is 637.03 grams/mole. Its structural formula is: Sorafenib tosylate, USP is a white or slightly yellowish or brownish powder. Sorafenib tosylate, USP is soluble in polyethylene glycol 400, slightly soluble in ethanol, and practically insoluble in aqueous media (i.e. water) and in heptane. Sorafenib tablets, USP for oral use are supplied as film-coated tablets containing 200 mg of sorafenib equivalent to 274 mg sorafenib tosylate, USP and the following inactive ingredients: croscarmellose sodium, hypromellose, iron oxide yellow, magnesium stearate, microcrystalline cellulose, polyethylene glycol, sodium lauryl sulphate, talc and titanium dioxide. FDA approved dissolution test specifications differ from USP.

2 DOSAGE AND ADMINISTRATION The recommended dosage is 400 mg orally twice daily without food. ( 2.1 ) 2.1 Recommended Dosage The recommended dosage of sorafenib tablets is 400 mg orally twice daily without food (at least 1 hour before or 2 hours after a meal) until the patient is no longer clinically benefiting from therapy or until unacceptable toxicity. 2.2 Dosage Modifications for Adverse Reactions Recommended Dosage Modifications The recommended dosage modifications for adverse reactions are provided in Tables 1, 2, and 3. Table 1: Recommended Dose Reductions for Adverse Reactions Dose Reduction Hepatocellular Carcinoma and Renal Cell Carcinoma Differentiated Thyroid Carcinoma First Dose Reduction 400 mg orally once daily 400 mg orally in the morning and 200 mg orally in the evening about 12 hours apart OR 200 mg orally in the morning and 400 mg orally in the evening about 12 hours apart Second Dose Reduction 200 mg orally once daily OR 400 every other day 200 mg orally twice daily Third Dose Reduction None 200 mg orally once daily Table 2: Recommended Dosage Modifications of Sorafenib Tablets for Adverse Reactions Adverse Reaction Severity 1 Sorafenib Tablets Dosage Modification Cardiovascular Events [see Warnings and Precautions ( 5.1 )] Cardiac Ischemia and/or Infarction Grade 2 and above Permanently discontinue. Congestive Heart Failure Grade 3 Interrupt 2 until Grade 1 or less, resume at reduced dose by 1 dose level. 3 Grade 4 Permanently discontinue. Hemorrhage [see Warnings and Precautions ( 5.2 ) ] Grade 2 and above requiring medical intervention Permanently discontinue. Hypertension [see Warnings and Precautions ( 5.3 )] Grade 2 (symptomatic/persistent) OR Grade 2 symptomatic increase by greater than 20 mm Hg (diastolic) or greater than 140/90 mm Hg if previously within normal limits OR Grade 3 Interrupt until symptoms resolve and diastolic blood pressure less than 90 mm Hg, then resume at reduced dose by 1 dose level. 3 If needed, reduce another dose level. 3 Grade 4 Permanently discontinue. Gastrointestinal Perforation [see Warnings and Precautions ( 5.5 )] Any grade Permanently discontinue. QT Interval Prolongation [see Warnings and Precautions ( 5.9 )] Greater than 500 milliseconds OR Increase from baseline of 60 milliseconds or greater Interrupt and correct electrolyte abnormalities (magnesium, potassium, calcium). Use medical judgement before restarting. Drug-Induced Liver Injury [see Warnings and Precautions ( 5.10 )] Grade 3 ALT or higher in the absence of another cause 4 OR AST/ALT greater than 3 × upper limit normal (ULN) with bilirubin greater than 2 × ULN in the absence of another cause 4 Permanently discontinue. Non-hematological toxicities [see Adverse Reactions ( 6.1 )] Grade 2 Continue treatment at reduced dose by 1 dose level. Grade 3 1st occurrence Interrupt until Grade 2 or less, then resume at reduced dose by 1 dose level. No improvement within 7 days OR 2 nd or 3 rd occurrence Interrupt until Grade 2 or less, then resume at reduced dose by 2 dose levels. 4 th occurrence Interrupt until Grade 2 or less, then resume at reduced dose by 2 dose levels for HCC and RCC or 3 dose levels for DTC. Grade 4 Permanently discontinue. 1 Adverse reactions graded according to National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0 (NCI CTCAE v3.0). 2 If no recovery after 30 day interruption, discontinue treatment unless the patient is deriving clinical benefit. 3 If more than 2 dose reductions are required, permanently discontinue treatment. 4 In addition, any grade increased alkaline phosphatase in the absence of known bone pathology and Grade 2 or worse increased bilirubin; any 1 of the following: INR of 1.5 or greater, ascites and/or encephalopathy in the absence of underlying cirrhosis or other organ failure considered to be due to drug-induced liver injury. Table 3: Recommended Dosage Modifications for Dermatologic Toxicities Dermatologic Toxicity Grade Occurrence Sorafenib Tablets Dosage Modification Hepatocellular and Renal Cell Carcinoma Differentiated Thyroid Carcinoma Grade 2: Painful erythema and swelling of the hands or feet and/or discomfort affecting the patient’s normal activities 1 st occurrence Continue sorafenib tablets and consider topical therapy for symptomatic relief. If no improvement within 7 days, see below. Decrease sorafenib tablets to 600 mg daily. If no improvement within 7 days, see below. No improvement within 7 days at reduced dose OR 2 nd and 3 rd occurrence Interrupt sorafenib tablets until resolved or improved to Grade 0 to 1. Interrupt sorafenib tablets until completely resolved or improved to Grade1. When resuming treatment, decrease dose by 1 dose level. When resuming treatment, decrease dose by 1 dose level for 2 nd occurrence and 2 doses levels for 3 rd occurrence. 4 th occurrence Discontinue sorafenib tablets treatment. Grade 3: Moist desquamation, ulceration, blistering, or severe pain of the hands or feet, resulting in inability to work or perform activities of daily living 1 st occurrence Interrupt sorafenib tablets until resolved or improved to Grade 0 to 1 Interrupt sorafenib tablets until completely resolved or improved to Grade 1. When resuming treatment, decrease dose by 1 dose level. When resuming treatment, decrease dose by 1 dose level. 2 nd occurrence Interrupt sorafenib tablets until resolved or improved to Grade 0 to 1 Interrupt sorafenib tablets until completely resolved or improved to Grade 1. When resuming treatment, decrease dose by 1 dose level. When resuming treatment, decrease dose by 2 dose levels. 3 rd occurrence Discontinue sorafenib tablets treatment Following improvement of Grade 2 or 3 dermatologic toxicity to Grade 0 or 1 for at least 28 days on a reduced dose of sorafenib tablets, the dose of sorafenib tablets may be increased 1 dose level from the reduced dose. Approximately 50% of patients requiring a dose reduction for dermatologic toxicity are expected to meet these criteria for resumption of the higher dose and roughly 50% of patients resuming the previous dose are expected to tolerate the higher dose (that is, maintain the higher dose level without recurrent Grade 2 or higher dermatologic toxicity).

1 INDICATIONS AND USAGE Sorafenib is a kinase inhibitor indicated for the treatment of • Unresectable hepatocellular carcinoma ( 1.1 ) • Advanced renal cell carcinoma ( 1.2 ) • Locally recurrent or metastatic, progressive, differentiated thyroid carcinoma (DTC) refractory to radioactive iodine treatment ( 1.3 ) 1.1 Hepatocellular Carcinoma Sorafenib tablets are indicated for the treatment of patients with unresectable hepatocellular carcinoma (HCC). 1.2 Renal Cell Carcinoma Sorafenib tablets are indicated for the treatment of patients with advanced renal cell carcinoma (RCC). 1.3 Differentiated Thyroid Carcinoma Sorafenib tablets are indicated for the treatment of patients with locally recurrent or metastatic, progressive, differentiated thyroid carcinoma (DTC) that is refractory to radioactive iodine treatment.

10 OVERDOSAGE The adverse reactions observed at a dose of 800 mg twice daily (2 times the recommended dose) were primarily diarrhea and dermatologic. No information is available on symptoms of acute overdose in animals because of the saturation of absorption in oral acute toxicity studies conducted in animals. In cases of suspected overdose, withhold sorafenib tablets and institute supportive care.

7 DRUG INTERACTIONS • Strong CYP3A Inducers: Avoid strong CYP3A4 inducers. ( 7.1 ) 7.1 Effect of Other Drugs on Sorafenib Strong CYP3A4 Inducers The concomitant use of sorafenib with rifampin, a strong CYP3A4 inducer decreased the mean AUC of sorafenib, which may decrease the antitumor activity [see Clinical Pharmacology ( 12.3) ] . Avoid concomitant use of sorafenib with strong CYP3A4 inducers, when possible, because these drugs can decrease the systemic exposure to sorafenib. Neomycin The concomitant use of sorafenib with neomycin decreased the mean AUC of sorafenib, which may decrease the antitumor activity. Avoid concomitant use of sorafenib with neomycin. The effects of other antibiotics on the pharmacokinetics of sorafenib have not been studied [see Clinical Pharmacology ( 12.3 )] . 7.2 Concomitant Use of Warfarin The concomitant use of sorafenib and warfarin may increase the risk of bleeding or increased the INR. Monitor INR and for clinical bleeding episodes in patients taking warfarin while receiving sorafenib tablets [see Warnings and Precautions ( 5.6 )]. 7.3 Drugs That Prolong the QT Interval Sorafenib is associated with QTc interval prolongation. Avoid coadministration of sorafenib tablets with medicinal products with a known potential to prolong QT/QTc interval [see Warnings and Precautions (5.9), Clinical Pharmacology ( 12.2 )].

12 CLINICAL PHARMACOLOGY 12.1 Mechanism of Action Sorafenib is a kinase inhibitor that decreases tumor cell proliferation in vitro . Sorafenib was shown to inhibit multiple intracellular (c-CRAF, BRAF and mutant BRAF) and cell surface kinases (KIT, FLT-3, RET, RET/PTC, VEGFR-1, VEGFR-2, VEGFR-3, and PDGFR-ß). Several of these kinases are thought to be involved in tumor cell signaling, angiogenesis and apoptosis. Sorafenib inhibited tumor growth of HCC, RCC, and DTC human tumor xenografts in immunocompromised mice. Reductions in tumor angiogenesis were seen in models of HCC and RCC upon sorafenib treatment, and increases in tumor apoptosis were observed in models of HCC , RCC, and DTC. 12.2 Pharmacodynamics Cardiac Electrophysiology The effect of sorafenib 400 mg twice daily on the QTc interval was evaluated in a multi-center, open-label, non-randomized trial in 53 patients with advanced cancer. No large changes in the mean QTc intervals (that is, >20 ms) from baseline were detected in the trial. After one 28-day treatment cycle, the largest mean QTc interval change of 8.5 ms (upper bound of two-sided 90% confidence interval, 13.3 ms) was observed at 6 hours post-dose on day 1 of cycle 2 [see Warnings and Precautions ( 5.9 ), Drug Interactions ( 7.3 )]. 12.3 Pharmacokinetics Multiple doses of sorafenib for 7 days resulted in a 2.5- to 7-fold accumulation compared to a single dose. Steady-state plasma sorafenib concentrations were achieved within 7 days, with a peak-to-trough ratio of mean concentrations of less than 2. The steady-state concentrations of sorafenib following administration of sorafenib 400 mg twice daily were evaluated in DTC, RCC and HCC patients. Patients with DTC have mean steady-state concentrations that are 1.8-fold higher than patients with HCC and 2.3-fold higher than those with RCC. The reason for increased sorafenib concentrations in DTC patients is unknown. Mean C max and AUC increased less than proportionally beyond oral doses of 400 mg administered twice daily. Absorption After administration of sorafenib tablets, the mean relative bioavailability was 38 to 49% when compared to an oral solution. Following oral administration, sorafenib reached peak plasma levels in approximately 3 hours. Effects of Food With a moderate-fat meal (30% fat; 700 calories), bioavailability was similar to that in the fasted state. With a high-fat meal (50% fat; 900 calories), bioavailability was reduced by 29% compared to that in the fasted state. Distribution In vitro binding of sorafenib to human plasma proteins was 99.5%. Elimination The mean elimination half-life of sorafenib was approximately 25 to 48 hours. Metabolism Sorafenib undergoes oxidative metabolism by hepatic CYP3A4, as well as glucuronidation by UGT1A9. Excretion Sorafenib accounted for approximately 70 to 85% of the circulating analytes in plasma at steady-state. Eight metabolites of sorafenib have been identified, of which 5 have been detected in plasma. The main circulating metabolite of sorafenib, the pyridine N-oxide that comprises approximately 9 to 16% of circulating analytes at steady-state, showed in vitro potency similar to that of sorafenib. Following oral administration of a 100 mg dose of a solution formulation of sorafenib, 96% of the dose was recovered within 14 days, with 77% of the dose excreted in feces and 19% of the dose excreted in urine as glucuronidated metabolites. Unchanged sorafenib, accounting for 51% of the dose, was found in feces but not in urine. Specific Populations A study of the pharmacokinetics of sorafenib indicated that the mean AUC of sorafenib in Asians (N=78) was 30% lower than in Whites (N=40). Sex and age do not have a clinically meaningful effect on the pharmacokinetics of sorafenib. Patients with Renal Impairment Mild (CLcr 50 to 80 mL/min), moderate (CLcr 30 to <50 mL/min), and severe (CLcr <30 mL/min) renal impairment do not affect the pharmacokinetics of sorafenib [see Use in Specific Populations ( 8.6 )]. Patients with Hepatic Impairment Mild (Child-Pugh A) and moderate (Child-Pugh B) hepatic impairment do not affect the pharmacokinetics of sorafenib [see Use in Specific Populations ( 8.7 )] . Drug Interactions Studies Effect of Strong CYP3A4 Inhibitors on Sorafenib: Ketoconazole, a strong inhibitor of CYP3A4 and P-glycoprotein, administered at a dose of 400 mg once daily for 7 days did not alter the mean AUC of a single oral dose of sorafenib 50 mg in healthy subjects. Effect of Strong CYP3A4 Inducers on Sorafenib: Concomitant use of sorafenib with rifampin administered at a dose of 600 mg once daily for 5 days with a single oral dose of sorafenib 400 mg in healthy volunteers resulted in a 37% decrease in the mean AUC of sorafenib. Effect of Neomycin on Sorafenib: Neomycin administered as an oral dose of 1 gram three times daily for 5 days decreased the mean AUC of sorafenib by 54% in healthy subjects administered a single oral dose of sorafenib 400 mg. Effect of Sorafenib on Other Drugs : Sorafenib 400 mg twice daily for 28 days did not increase the systemic exposure of concomitantly administered midazolam (CYP3A4 substrate), dextromethorphan (CYP2D6 substrate), and omeprazole (CYP2C19 substrate) [see Clinical Pharmacology ( 12.3 )]. Drugs that Increase Gastric pH : The aqueous solubility of sorafenib is pH dependent, with higher pH resulting in lower solubility. However, omeprazole, a proton pump inhibitor, administered at a dose of 40 mg once daily for 5 days, did not result in a clinically meaningful change in sorafenib single dose exposure. In Vitro Studies Sorafenib competitively inhibited CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6, and CYP3A4 in vitro . However, sorafenib 400 mg twice daily for 28 days with substrates of CYP3A4, CYP2D6 and CYP2C19 did not increase the systemic exposure of these substrates [see Drug Interactions ( 7.3 )] . Sorafenib did not increase CYP1A2 and CYP3A4 activities, suggesting that sorafenib is unlikely to induce CYP1A2 or CYP3A4 in humans. Sorafenib inhibits glucuronidation by UGT1A1 and UGT1A9 in vitro . Sorafenib could increase the systemic exposure of concomitantly administered drugs that are UGT1A1 or UGT1A9 substrates. Sorafenib inhibited P-glycoprotein in vitro . Sorafenib could increase the concentrations of concomitantly administered drugs that are P-glycoprotein substrates.

12.1 Mechanism of Action Sorafenib is a kinase inhibitor that decreases tumor cell proliferation in vitro . Sorafenib was shown to inhibit multiple intracellular (c-CRAF, BRAF and mutant BRAF) and cell surface kinases (KIT, FLT-3, RET, RET/PTC, VEGFR-1, VEGFR-2, VEGFR-3, and PDGFR-ß). Several of these kinases are thought to be involved in tumor cell signaling, angiogenesis and apoptosis. Sorafenib inhibited tumor growth of HCC, RCC, and DTC human tumor xenografts in immunocompromised mice. Reductions in tumor angiogenesis were seen in models of HCC and RCC upon sorafenib treatment, and increases in tumor apoptosis were observed in models of HCC , RCC, and DTC.

12.2 Pharmacodynamics Cardiac Electrophysiology The effect of sorafenib 400 mg twice daily on the QTc interval was evaluated in a multi-center, open-label, non-randomized trial in 53 patients with advanced cancer. No large changes in the mean QTc intervals (that is, >20 ms) from baseline were detected in the trial. After one 28-day treatment cycle, the largest mean QTc interval change of 8.5 ms (upper bound of two-sided 90% confidence interval, 13.3 ms) was observed at 6 hours post-dose on day 1 of cycle 2 [see Warnings and Precautions ( 5.9 ), Drug Interactions ( 7.3 )].

12.3 Pharmacokinetics Multiple doses of sorafenib for 7 days resulted in a 2.5- to 7-fold accumulation compared to a single dose. Steady-state plasma sorafenib concentrations were achieved within 7 days, with a peak-to-trough ratio of mean concentrations of less than 2. The steady-state concentrations of sorafenib following administration of sorafenib 400 mg twice daily were evaluated in DTC, RCC and HCC patients. Patients with DTC have mean steady-state concentrations that are 1.8-fold higher than patients with HCC and 2.3-fold higher than those with RCC. The reason for increased sorafenib concentrations in DTC patients is unknown. Mean C max and AUC increased less than proportionally beyond oral doses of 400 mg administered twice daily. Absorption After administration of sorafenib tablets, the mean relative bioavailability was 38 to 49% when compared to an oral solution. Following oral administration, sorafenib reached peak plasma levels in approximately 3 hours. Effects of Food With a moderate-fat meal (30% fat; 700 calories), bioavailability was similar to that in the fasted state. With a high-fat meal (50% fat; 900 calories), bioavailability was reduced by 29% compared to that in the fasted state. Distribution In vitro binding of sorafenib to human plasma proteins was 99.5%. Elimination The mean elimination half-life of sorafenib was approximately 25 to 48 hours. Metabolism Sorafenib undergoes oxidative metabolism by hepatic CYP3A4, as well as glucuronidation by UGT1A9. Excretion Sorafenib accounted for approximately 70 to 85% of the circulating analytes in plasma at steady-state. Eight metabolites of sorafenib have been identified, of which 5 have been detected in plasma. The main circulating metabolite of sorafenib, the pyridine N-oxide that comprises approximately 9 to 16% of circulating analytes at steady-state, showed in vitro potency similar to that of sorafenib. Following oral administration of a 100 mg dose of a solution formulation of sorafenib, 96% of the dose was recovered within 14 days, with 77% of the dose excreted in feces and 19% of the dose excreted in urine as glucuronidated metabolites. Unchanged sorafenib, accounting for 51% of the dose, was found in feces but not in urine. Specific Populations A study of the pharmacokinetics of sorafenib indicated that the mean AUC of sorafenib in Asians (N=78) was 30% lower than in Whites (N=40). Sex and age do not have a clinically meaningful effect on the pharmacokinetics of sorafenib. Patients with Renal Impairment Mild (CLcr 50 to 80 mL/min), moderate (CLcr 30 to <50 mL/min), and severe (CLcr <30 mL/min) renal impairment do not affect the pharmacokinetics of sorafenib [see Use in Specific Populations ( 8.6 )]. Patients with Hepatic Impairment Mild (Child-Pugh A) and moderate (Child-Pugh B) hepatic impairment do not affect the pharmacokinetics of sorafenib [see Use in Specific Populations ( 8.7 )] . Drug Interactions Studies Effect of Strong CYP3A4 Inhibitors on Sorafenib: Ketoconazole, a strong inhibitor of CYP3A4 and P-glycoprotein, administered at a dose of 400 mg once daily for 7 days did not alter the mean AUC of a single oral dose of sorafenib 50 mg in healthy subjects. Effect of Strong CYP3A4 Inducers on Sorafenib: Concomitant use of sorafenib with rifampin administered at a dose of 600 mg once daily for 5 days with a single oral dose of sorafenib 400 mg in healthy volunteers resulted in a 37% decrease in the mean AUC of sorafenib. Effect of Neomycin on Sorafenib: Neomycin administered as an oral dose of 1 gram three times daily for 5 days decreased the mean AUC of sorafenib by 54% in healthy subjects administered a single oral dose of sorafenib 400 mg. Effect of Sorafenib on Other Drugs : Sorafenib 400 mg twice daily for 28 days did not increase the systemic exposure of concomitantly administered midazolam (CYP3A4 substrate), dextromethorphan (CYP2D6 substrate), and omeprazole (CYP2C19 substrate) [see Clinical Pharmacology ( 12.3 )]. Drugs that Increase Gastric pH : The aqueous solubility of sorafenib is pH dependent, with higher pH resulting in lower solubility. However, omeprazole, a proton pump inhibitor, administered at a dose of 40 mg once daily for 5 days, did not result in a clinically meaningful change in sorafenib single dose exposure. In Vitro Studies Sorafenib competitively inhibited CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6, and CYP3A4 in vitro . However, sorafenib 400 mg twice daily for 28 days with substrates of CYP3A4, CYP2D6 and CYP2C19 did not increase the systemic exposure of these substrates [see Drug Interactions ( 7.3 )] . Sorafenib did not increase CYP1A2 and CYP3A4 activities, suggesting that sorafenib is unlikely to induce CYP1A2 or CYP3A4 in humans. Sorafenib inhibits glucuronidation by UGT1A1 and UGT1A9 in vitro . Sorafenib could increase the systemic exposure of concomitantly administered drugs that are UGT1A1 or UGT1A9 substrates. Sorafenib inhibited P-glycoprotein in vitro . Sorafenib could increase the concentrations of concomitantly administered drugs that are P-glycoprotein substrates.

20221118

6

3 DOSAGE FORMS AND STRENGTHS Sorafenib tablets USP, 200 mg are light yellow to yellow colour, round, biconvex, film-coated tablets debossed with ‘I’ on one side and plain on the other side and free from physical defects. Tablets: 200 mg ( 3 )

sorafenib sorafenib Sorafenib Tosylate Sorafenib Croscarmellose Sodium Hypromellose 2910 (5 Mpa.S) Hypromellose 2910 (6 Mpa.S) Ferric Oxide Yellow Magnesium Stearate Cellulose, Microcrystalline Polyethylene Glycol 6000 Sodium Lauryl Sulfate Talc Titanium Dioxide light yellow to yellow colour I round, biconvex figure1 figure3 structure container figure2

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility Carcinogenicity studies have not been performed with sorafenib. Sorafenib was clastogenic when tested in an in vitro mammalian cell assay (Chinese hamster ovary) in the presence of metabolic activation. Sorafenib was not mutagenic in the in vitro Ames bacterial cell assay or clastogenic in an in vivo mouse micronucleus assay. One intermediate in the manufacturing process, which is also present in the final drug substance (<0.15%), was positive for mutagenesis in an in vitro bacterial cell assay (Ames test) when tested independently. No specific studies with sorafenib have been conducted in animals to evaluate the effect on fertility. However, results from the repeat-dose toxicity studies suggest there is a potential for sorafenib to impair reproductive function and fertility. Multiple adverse effects were observed in male and female reproductive organs, with the rat being more susceptible than mice or dogs. Typical changes in rats consisted of testicular atrophy or degeneration, degeneration of epididymis, prostate, and seminal vesicles, central necrosis of the corpora lutea and arrested follicular development. Sorafenib-related effects on the reproductive organs of rats were manifested at daily oral doses ≥5 mg/kg (30 mg/m 2 ). This dose results in an exposure (AUC) that is approximately 0.5 times the AUC in patients at the recommended human dose. Dogs showed tubular degeneration in the testes at 30 mg/kg/day (600 mg/m 2 /day). This dose results in an exposure that is approximately 0.3 times the AUC at the recommended human dose. Oligospermia was observed in dogs at 60 mg/kg/day (1,200 mg/m 2 /day) of sorafenib.

13 NONCLINICAL TOXICOLOGY 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility Carcinogenicity studies have not been performed with sorafenib. Sorafenib was clastogenic when tested in an in vitro mammalian cell assay (Chinese hamster ovary) in the presence of metabolic activation. Sorafenib was not mutagenic in the in vitro Ames bacterial cell assay or clastogenic in an in vivo mouse micronucleus assay. One intermediate in the manufacturing process, which is also present in the final drug substance (<0.15%), was positive for mutagenesis in an in vitro bacterial cell assay (Ames test) when tested independently. No specific studies with sorafenib have been conducted in animals to evaluate the effect on fertility. However, results from the repeat-dose toxicity studies suggest there is a potential for sorafenib to impair reproductive function and fertility. Multiple adverse effects were observed in male and female reproductive organs, with the rat being more susceptible than mice or dogs. Typical changes in rats consisted of testicular atrophy or degeneration, degeneration of epididymis, prostate, and seminal vesicles, central necrosis of the corpora lutea and arrested follicular development. Sorafenib-related effects on the reproductive organs of rats were manifested at daily oral doses ≥5 mg/kg (30 mg/m 2 ). This dose results in an exposure (AUC) that is approximately 0.5 times the AUC in patients at the recommended human dose. Dogs showed tubular degeneration in the testes at 30 mg/kg/day (600 mg/m 2 /day). This dose results in an exposure that is approximately 0.3 times the AUC at the recommended human dose. Oligospermia was observed in dogs at 60 mg/kg/day (1,200 mg/m 2 /day) of sorafenib.

ANDA216073

Sorafenib

sorafenib

43598-458

HUMAN PRESCRIPTION DRUG

ORAL

PACKAGE LABEL PRINCIPAL DISPLAY PANEL SECTION Sorafenib Tablets, 200 mg - 120's Count Container Label Unvarnished Area Consists of: 2D Barcode, Lot Number, Expiry Date and Serial Number

17 PATIENT COUNSELING INFORMATION Advise the patient to read FDA-approved patient labeling (Patient Information). Cardiovascular Events Discuss with patients that cardiac ischemia and/or infarction and congestive heart failure, have been reported during sorafenib treatment, and that they should immediately report any episodes of chest pain or other symptoms of cardiac ischemia or congestive heart failure [ see Warnings and Precautions ( 5.1 )] . Bleeding Inform patients that sorafenib tablets can increase the risk of bleeding and that they should promptly report any episodes of bleeding [see Warnings and Precautions ( 5.2 )]. Inform patients that bleeding or elevations in the International Normalized Ratio (INR) have been reported in some patients taking warfarin while on sorafenib tablets and that their INR should be monitored regularly [see Warnings and Precautions ( 5.6 )]. Hypertension Inform patients that hypertension can develop during sorafenib tablets treatment, especially during the first six weeks of therapy, and that blood pressure should be monitored regularly during treatment [see Warnings and Precautions ( 5.3 )]. Skin Reactions Advise patients of the possible occurrence of hand-foot skin reaction and rash during sorafenib tablets treatment and appropriate counter measures [see Warnings and Precautions ( 5.4 )]. Gastrointestinal Perforation Advise patients that cases of gastrointestinal perforation have been reported in patients taking sorafenib tablets [see Warnings and Precautions ( 5.5 )]. Risk of Impaired Wound Healing Advise patients that sorafenib tablets may impair wound healing. Advise patients to inform their healthcare provider of any planned surgical procedure [see Warnings and Precautions ( 5.7 )]. QT Interval Prolongation Inform patients with a history of prolonged QT interval that sorafenib tablets can worsen the condition [ see Warnings and Precautions ( 5.9 ) and Clinical Pharmacology ( 12.2 )]. Drug-Induced Liver Injury Inform patients that sorafenib tablets can cause hepatitis which may result in hepatic failure and death. Advise patients that liver function tests should be monitored regularly during treatment and to report signs and symptoms of hepatitis [see Warnings and Precautions ( 5.10 )]. Embryo-Fetal Toxicity Advise females to inform their healthcare provider if they are pregnant or become pregnant. Inform female patients of the risk to a fetus and potential loss of pregnancy [see Use in Specific Populations ( 8.1 )]. Advise females of reproductive potential to use effective contraception during treatment with sorafenib tablets and for 6 months after the last dose. Advise male patients with female partners of reproductive potential or who are pregnant to use effective contraception during treatment with sorafenib tablets and for 3 months after receiving the last dose of sorafenib tablets [see Warnings and Precautions ( 5.11 ), Use in Specific Populations ( 8.1, 8.3 )]. Lactation Advise patients not to breastfeed while taking sorafenib tablets and for 2 weeks after receiving the last dose of sorafenib tablets [see Use in Specific Populations ( 8.2 ) ]. Missed Doses Instruct patients that if a dose of sorafenib tablets is missed, the next dose should be taken at the regularly scheduled time, and not double the dose. Instruct patients to contact their healthcare provider immediately if they take too much sorafenib tablets. Rx only Distributor: Dr. Reddy’s Laboratories Inc., Princeton, NJ 08540 Made in India Revised: 11/2022

14 CLINICAL STUDIES 14.1 Hepatocellular Carcinoma The SHARP (HCC) study (NCT00105443) was an international, multicenter, randomized, double blind, placebo-controlled trial in patients with unresectable hepatocellular carcinoma. Overall survival was the primary endpoint. A total of 602 patients were randomized; 299 to sorafenib 400 mg twice daily and 303 to matching placebo. All 602 randomized subjects were included in the ITT population for the efficacy analyses. Demographics and baseline disease characteristics were similar between the sorafenib and placebo arms with regard to age, gender, race, performance status, etiology (including hepatitis B, hepatitis C and alcoholic liver disease), TNM stage (stage I: <1% vs. <1%; stage II: 10.4% vs. 8.3%; stage III: 37.8% vs. 43.6%; stage IV: 50.8% vs. 46.9%), absence of both macroscopic vascular invasion and extrahepatic tumor spread (30.1% vs. 30%), and Barcelona Clinic Liver Cancer stage (stage B: 18.1% vs. 16.8%; stage C: 81.6% vs. 83.2%; stage D: <1% vs. 0%). Liver impairment by Child-Pugh score was comparable between the sorafenib and placebo arms (Class A: 95% vs. 98%; B: 5% vs. 2%). Only one patient with Child-Pugh class C was entered. Prior treatments included surgical resection procedures (19.1% vs. 20.5%), locoregional therapies (including radiofrequency ablation, percutaneous ethanol injection and transarterial chemoembolization; 38.8% vs. 40.6%), radiotherapy (4.3% vs. 5%) and systemic therapy (3% vs. 5%). The trial was stopped for efficacy following a pre-specified second interim analysis for survival showing a statistically significant advantage for sorafenib over placebo for overall survival (HR: 0.69, p=0.00058) (see Table 10 and Figure 1). This advantage was consistent across all subsets analyzed. Final analysis of time to tumor progression (TTP) based on data from an earlier time point (by independent radiologic review) also was significantly longer in the sorafenib arm (HR: 0.58, p=0.000007) (see Table 10). Table 10: Efficacy Results from SHARP (HCC) Efficacy Parameter Sorafenib (N=299) Placebo (N=303) Overall Survival Number of Events 143 178 Median, months 10.7 7.9 (95% CI) (9.4, 13.3) (6.8, 9.1) Hazard Ratio 1 (95% CI) 0.69 (0.55, 0.87) P-value (log-rank test 2 ) 0.00058 Time to Progression 3 Number of Events 107 156 Median, months 5.5 2.8 (95% CI) (4.1, 6.9) (2.7, 3.9) Hazard Ratio 1 (95% CI) 0.58 (0.45, 0.74) P-value (log-rank test 2 ) 0.000007 CI=Confidence interval 1 Hazard ratio, sorafenib/placebo, stratified Cox model 2 Stratified log rank (for the interim analysis of survival, the stopping boundary one-sided alpha = 0.0077) 3 The time-to-progression (TTP) analysis, based on independent radiologic review, was based on data from an earlier time point than the survival analysis Figure 1: Kaplan-Meier Curve of Overall Survival in SHARP (HCC) (Intent-to-Treat Population) 14.2 Renal Cell Carcinoma The safety and efficacy of sorafenib in the treatment of advanced renal cell carcinoma (RCC) were studied in the following two randomized controlled clinical trials. TARGET TARGET (NCT00073307) was an international, multicenter, randomized, double blind, placebo-controlled trial in patients with advanced renal cell carcinoma who had received one prior systemic therapy. Primary study endpoints included overall survival and progression-free survival (PFS). Tumor response rate was a secondary endpoint. The PFS analysis included 769 patients, per protocol, stratified by MSKCC (Memorial Sloan Kettering Cancer Center) prognostic risk category (low or intermediate) and country and randomized to sorafenib 400 mg twice daily (N=384) or to placebo (N=385). Table 11 summarizes the demographic and disease characteristics of the study population analyzed. Baseline demographics and disease characteristics were well balanced for both treatment groups. The median time from initial diagnosis of RCC to randomization was 1.6 and 1.9 years for the sorafenib and placebo arms, respectively. Table 11: Demographic and Disease Characteristics – TARGET (RCC) Characteristics Sorafenib N=384 Placebo N=385 N (%) N (%) Gender Male 267 (70) 287 (75) Female 116 (30) 98 (25) Race White 276 (72) 278 (73) Black/Asian/ Hispanic/Other 11 (3) 10 (2) Not reported 1 97 (25) 97 (25) Age group < 65 years 255 (67) 280 (73) ≥ 65 years 127 (33) 103 (27) ECOG performance status at baseline 0 184 (48) 180 (47) 1 191 (50) 201 (52) 2 6 (2) 1 (<1) Not reported 3 (<1) 3 (<1) MSKCC prognostic risk category Low 200 (52) 194 (50) Intermediate 184 (48) 191 (50) Prior IL-2 and/or interferon Yes 319 (83) 313 (81) No 65 (17) 72 (19) 1 Race was not collected from the 186 patients enrolled in France due to local regulations. In 8 other patients, race was not available at the time of analysis. Progression-free survival, defined as the time from randomization to progression or death from any cause, whichever occurred earlier, was evaluated by blinded independent radiological review using RECIST criteria. Figure 2 depicts Kaplan-Meier curves for PFS. The PFS analysis was based on a two-sided Log-Rank test stratified by MSKCC prognostic risk category and country. Figure 2: Kaplan-Meier Curves for Progression-free Survival – TARGET (RCC) NOTE: HR is from Cox regression model with the following covariates: MSKCC prognostic risk category and country. P-value is from two-sided Log-Rank test stratified by MSKCC prognostic risk category and country. The median PFS for patients randomized to sorafenib was 167 days compared to 84 days for patients randomized to placebo. The estimated hazard ratio (immediate risk of progression or death with sorafenib compared to placebo) was 0.44 (95% CI: 0.35, 0.55). A series of patient subsets were examined in exploratory univariate analyses of PFS. The subsets included age above or below 65 years, ECOG PS 0 or 1, MSKCC prognostic risk category, whether the prior therapy was for progressive metastatic disease or for an earlier disease setting and time from diagnosis of less than or greater than 1.5 years. The effect of sorafenib on PFS was consistent across these subsets, including patients with no prior IL-2 or interferon therapy (N=137; 65 patients receiving sorafenib and 72 placebo), for whom the median PFS was 172 days in the sorafenib arm compared to 85 days in the placebo arm. Tumor response was determined by independent radiologic review according to RECIST criteria. Overall, of 672 patients who were evaluable for response, 7 (2%) patients in the sorafenib and no (0%) patients in the placebo arms had a confirmed partial response. Thus the gain in PFS primarily reflects the stable disease population. At the time of a planned interim survival analysis, based on 220 deaths, overall survival was longer for those randomized to sorafenib compared with placebo with a hazard ratio of 0.72. This analysis did not meet the prespecified criteria for statistical significance. Additional analyses are planned as the survival data mature. BAY43-9006 BAY43-9006 (NCT00101413) was a randomized discontinuation trial in patients with metastatic malignancies, including RCC. The primary endpoint was the percentage of randomized patients remaining progression-free at 24 weeks. All patients received sorafenib for the first 12 weeks. Radiologic assessment was repeated at week 12. Patients with <25% change in bi-dimensional tumor measurements from baseline were randomized to sorafenib or placebo for a further 12 weeks. Patients who were randomized to placebo were permitted to cross over to open-label sorafenib upon progression. Patients with tumor shrinkage ≥25% continued sorafenib, whereas patients with tumor growth ≥25% discontinued treatment. A total of 202 patients with advanced RCC were enrolled into BAY43-9006, including patients who had received no prior therapy and patients with tumor histology other than clear cell carcinoma. After the initial 12 weeks of sorafenib, 79 patients with RCC continued on open-label sorafenib, and 65 patients were randomized to sorafenib or placebo. After an additional 12 weeks, at week 24, for the 65 randomized patients, the progression-free rate was significantly higher in patients randomized to sorafenib (16/32, 50%) than in patients randomized to placebo (6/33, 18%) (p=0.0077). Progression-free survival was significantly longer in the sorafenib arm (163 days) than in the those randomized to placebo (41 days) (p=0.0001, HR=0.29). 14.3 Differentiated Thyroid Carcinoma The safety and effectiveness of sorafenib was evaluated in a multicenter, randomized (1:1), double-blind, placebo-controlled trial (DECISION; NCT00984282) conducted in 417 patients with locally recurrent or metastatic, progressive differentiated thyroid carcinoma (DTC) refractory to radioactive iodine (RAI) treatment. Randomization was stratified by age (< 60 years versus ≥ 60 years) and geographical region (North America, Europe, and Asia). All 417 subjects were included in the ITT population for the efficacy analyses. All patients were required to have actively progressing disease defined as progression within 14 months of enrollment. RAI-refractory disease was defined based on four criteria that were not mutually exclusive. All RAI treatments and diagnostic scans were to be performed under conditions of a low iodine diet and adequate TSH stimulation. Following are the RAI-refractory criteria and the proportion of patients in the study that met each one: a target lesion with no iodine uptake on RAI scan (68%); tumors with iodine uptake and progression after RAI treatment within 16 months of enrollment (12%); tumors with iodine uptake and multiple RAI treatments with the last treatment greater than 16 months prior to enrollment, and disease progression after each of two RAI treatments administered within 16 months of each other (7%); cumulative RAI dose ≥ 600 mCi administered (34%). The major efficacy outcome measure was progression-free survival (PFS) as determined by a blinded, independent radiological review using a modified Response Evaluation Criteria in Solid Tumors v. 1.0 (RECIST). RECIST was modified by inclusion of clinical progression of bone lesions based on the need for external beam radiation (4.4% of progression events). Additional efficacy outcomes measures included overall survival (OS), tumor response rate, and duration of response. Patients were randomized to receive sorafenib 400 mg twice daily (n=207) or placebo (n=210). Of the 417 patients randomized, 48% were male, the median age was 63 years, 61% were 60 years or older, 60% were white, 62% had an ECOG performance status of 0, and 99% had undergone thyroidectomy. The histological diagnoses were papillary carcinoma in 57%, follicular carcinoma (including Hürthle cell) in 25%, and poorly differentiated carcinoma in 10%, and other in 8% of the study population. Metastases were present in 96% of the patients: lungs in 86%, lymph nodes in 51%, and bone in 27%. The median cumulative RAI activity administered prior to study entry was 400 mCi. A statistically significant prolongation of PFS was demonstrated for sorafenib-treated patients compared to those receiving placebo (Figure 3); no statistically significant difference was seen in the final overall survival (OS) analysis (Table 12). Crossover to open label sorafenib occurred in 161 (77%) patients randomized to placebo after investigator-determined disease progression. Table 12: Efficacy Results from DECISION in Differentiated Thyroid Carcinoma Sorafenib N=207 Placebo N=210 Progression-free Survival 1 Number of Deaths or Progression 113 (55%) 136 (65%) Median PFS in Months (95% CI) 10.8 (9.1, 12.9) 5.8 ( 5.3, 7.8) Hazard Ratio (95% CI) 0.59 (0.46, 0.76) P-value 2 <0.001 Overall Survival 3 Number of Deaths 103 (49.8%) 109 (51.9%) Median OS in Months (95% CI) 42.8 (34.6, 52.6) 39.4 (32.7, 51.4) Hazard Ratio (95% CI) 0.92 (0.71, 1.21) P-value 2 0.570 Objective Response Number of Objective Responders 4 24 (12%) 1 (0.5%) (95% CI) (7.6%, 16.8%) (0.01%, 2.7%) Median Duration of Response in Months (95% CI) 10.2 (7.4, 16.6) NE 1 Independent radiological review 2 Two-sided log-rank test stratified by age (< 60 years, ≥ 60 years) and geographic region (North America, Europe, Asia) 3 Conducted after 212 events, which occurred 36 months after the primary PFS analysis. 4 All objective responses Se partial responses NR = Not Reached, CI = Confidence interval, NE = Not Estimable Figure 3: Kaplan-Meier Curve of Progression-Free Survival in DECISION (DTC)

8.5 Geriatric Use In total, 59% of HCC patients treated with sorafenib were age 65 years or older and 19% were 75 and older. In total, 32% of RCC patients treated with sorafenib were age 65 years or older and 4% were 75 and older. No differences in safety or efficacy were observed between older and younger patients, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out.

8.4 Pediatric Use The safety and effectiveness of sorafenib have not been established in pediatric patients. Juvenile Animal Toxicity Data Repeat dosing of sorafenib to young and growing dogs resulted in irregular thickening of the femoral growth plate at daily sorafenib doses ≥600 mg/m 2 (approximately 0.3 times the AUC at the recommended human dose), hypocellularity of the bone marrow adjoining the growth plate at 200 mg/m 2 /day (approximately 0.1 times the AUC at the recommended human dose), and alterations of the dentin composition at 600 mg/m 2 /day. Similar effects were not observed in adult dogs when dosed for 4 weeks or less.

8.1 Pregnancy Risk Summary Based on findings from animal studies and its mechanism of action [ see Clinical Pharmacology ( 12.1 )] , sorafenib may cause fetal harm when administered to a pregnant woman. There are no available data in pregnant women to inform a drug-associated risk. In animal reproduction studies, oral administration of sorafenib to pregnant rats and rabbits during the period of organogenesis resulted in embryo-fetal toxicities at maternal exposures that were significantly lower than human exposures at the recommended dose of 400 mg twice daily (see Data) . Advise pregnant women and females of reproductive potential of the potential risk to a fetus. The background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively. Data Animal Data In animal reproduction studies, sorafenib was teratogenic and induced embryo-fetal toxicity (including increased post-implantation loss, resorptions, skeletal retardations, and retarded fetal weight) when administered orally to pregnant rats and rabbits during the period of organogenesis. The effects occurred at doses considerably below the recommended human dose of 400 mg twice daily (approximately 500 mg/m 2 /day on a body surface area basis). Adverse intrauterine development effects were seen at doses >0.2 mg/kg/day (1.2 mg/m 2 /day) in rats and ≥0.3 mg/kg/day (≥3.6 mg/m 2 /day) in rabbits. These doses result in exposures (AUC) that are approximately 0.008 times the AUC in patients at the recommended dose.

8 USE IN SPECIFIC POPULATIONS • Lactation: Advise women not to breastfeed. ( 8.2 ) 8.1 Pregnancy Risk Summary Based on findings from animal studies and its mechanism of action [ see Clinical Pharmacology ( 12.1 )] , sorafenib may cause fetal harm when administered to a pregnant woman. There are no available data in pregnant women to inform a drug-associated risk. In animal reproduction studies, oral administration of sorafenib to pregnant rats and rabbits during the period of organogenesis resulted in embryo-fetal toxicities at maternal exposures that were significantly lower than human exposures at the recommended dose of 400 mg twice daily (see Data) . Advise pregnant women and females of reproductive potential of the potential risk to a fetus. The background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively. Data Animal Data In animal reproduction studies, sorafenib was teratogenic and induced embryo-fetal toxicity (including increased post-implantation loss, resorptions, skeletal retardations, and retarded fetal weight) when administered orally to pregnant rats and rabbits during the period of organogenesis. The effects occurred at doses considerably below the recommended human dose of 400 mg twice daily (approximately 500 mg/m 2 /day on a body surface area basis). Adverse intrauterine development effects were seen at doses >0.2 mg/kg/day (1.2 mg/m 2 /day) in rats and ≥0.3 mg/kg/day (≥3.6 mg/m 2 /day) in rabbits. These doses result in exposures (AUC) that are approximately 0.008 times the AUC in patients at the recommended dose. 8.2 Lactation Risk Summary There are no data on the presence of sorafenib or its metabolites in human milk, or its effects on the breast-fed child or on milk production. Sorafenib was present in milk of lactating rats (see Data) . Because of the potential for serious adverse reactions in a breastfed child from sorafenib, advise women not to breastfeed during treatment with sorafenib tablets and for 2 weeks after the last dose. Data Animal Data Following administration of radiolabeled sorafenib to lactating Wistar rats, approximately 27% of the radioactivity was secreted into milk. The milk to plasma AUC ratio was approximately 5:1. 8.3 Females and Males of Reproductive Potential Sorafenib may cause fetal harm when administered to a pregnant woman [see Use in Specific Populations ( 8.1 )] . Pregnancy Testing Verify the pregnancy status of females of reproductive potential prior to the initiation of sorafenib. Contraception Females Advise females of reproductive potential to use effective contraception during treatment and for 6 months following the last dose of sorafenib tablets. Males Based on genotoxicity and findings in animal reproduction studies, advise males with female partners of reproductive potential and pregnant partners to use effective contraception during treatment with sorafenib tablets and for 3 months following the last dose of sorafenib tablets [see Use in Specific Populations ( 8.1) , Nonclinical Toxicology ( 13.1 )] . Infertility Males Based on findings in animal studies, sorafenib may impair fertility in males of reproductive potential [see Nonclinical Toxicology ( 13.1 )]. 8.4 Pediatric Use The safety and effectiveness of sorafenib have not been established in pediatric patients. Juvenile Animal Toxicity Data Repeat dosing of sorafenib to young and growing dogs resulted in irregular thickening of the femoral growth plate at daily sorafenib doses ≥600 mg/m 2 (approximately 0.3 times the AUC at the recommended human dose), hypocellularity of the bone marrow adjoining the growth plate at 200 mg/m 2 /day (approximately 0.1 times the AUC at the recommended human dose), and alterations of the dentin composition at 600 mg/m 2 /day. Similar effects were not observed in adult dogs when dosed for 4 weeks or less. 8.5 Geriatric Use In total, 59% of HCC patients treated with sorafenib were age 65 years or older and 19% were 75 and older. In total, 32% of RCC patients treated with sorafenib were age 65 years or older and 4% were 75 and older. No differences in safety or efficacy were observed between older and younger patients, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out. 8.6 Renal Impairment No dose adjustment is necessary for patients with mild, moderate or severe renal impairment who are not on dialysis. The pharmacokinetics of sorafenib have not been studied in patients who are on dialysis [see Clinical Pharmacology ( 12.3 )]. 8.7 Hepatic Impairmen t No dose adjustment is necessary for patients with mild or moderate hepatic impairment. The pharmacokinetics of sorafenib have not been studied in patients with severe (Child-Pugh C) hepatic impairment [see Clinical Pharmacology ( 12.3 )] .

16 HOW SUPPLIED/STORAGE AND HANDLING Sorafenib tablets USP, 200 mg are supplied as light yellow to yellow colour, round, biconvex, film-coated tablets debossed with ‘I’ on one side and plain on the other side and free from physical defects. Bottles of 120 tablets NDC 43598-458-04 Bottles of 360 tablets NDC 43598-458-36 Store at 20°C to 25°C (68°F to 77°F); excursions permitted to 15°C to 30°C (59°F to 86°F) [see USP Controlled Room Temperature]. Store in a dry place.