DB08869 TESAMORELIN C221H366N72O67S • xC2H4O2 where x averages 7.4 acetate counter ions per peptide molecule 5135.9 Daltons (base free)

DESCRIPTION Tesamorelin is a stabilized synthetic peptide analogue of the hypothalamic peptide, Growth Hormone Releasing Hormone (GHRH) indicated for the reduction of excess abdominal fat in HIV-infected patients with lipodystrophy. Lipodystrophy is a metabolic condition characterized by insulin resistance, fat redistribution, and hyperlipidemia associated with antiretroviral therapy for HIV infection. INDICATION Tesamorelin acetate is a synthetic analogue of human hypothalamic Growth Hormone Releasing Factor (hGRF) indicated to induce and maintain a reduction of excess abdominal fat in HIV-infected patients with lipodystrophy. PHARMACODYNAMICS Tesamorelin stimulates growth hormone secretion, and subsequently increases IGF-1 and IGFBP-3 levels.

MECHANISM OF ACTION By acting on the pituitary cells in the brain, tesamorelin stimulates production and release of the endogenous hormone (hGRF). Tesamorelin therapy predisposes the patient to glucose intolerance and can also increase the risk of type 2 diabetes, so the drug is contraindicated in pregnancy. TOXICITY Diarrhea, congestive heart failure, peripheral neuropathy, and loss of mobility were the four serious adverse events reported during the clinical studies METABOLISM No formal metabolism studies have been performed in humans. ABSORPTION The absolute bioavailability was determined to be less than 4% in healthy adult subjects following a 2 mg subcutaneous dose.

HALF-LIFE 26 and 38 minutes in healthy subjects and HIV-infected patients, respectively. VOLUME OF DISTRIBUTION = 9.4 ±3.1 L/kg in healthy subjects.10.5 ±6.1 L/kg in HIV-infected patients. SEQUENCE YADAIFTNSYRKVLGQLSARKLLQDIMSRQQGESNQERGARAR TARGETS Growth hormone-releasing hormone receptor

EGRIFTA SEQUENCE: YADAIFTNSYRKVLGQLSARKLLQDIMSRQQGESNQERGARARL EGRIFTA™ contains tesamorelin (as the acetate salt), an analog of human growth hormone-releasing factor (GRF). The peptide precursor of tesamorelin acetate is produced synthetically and is comprised of the 44 amino acid sequence of human GRF. Tesamorelin acetate is made by attaching a hexenoyl moiety, a C6 chain with a double bond at position 3, to the tyrosine residue at the N-terminal part of the molecule. The molecular formula of tesamorelin acetate is C221H366N72O67S • x C2H4O2 (x ≈7) and its molecular weight (free base) is 5135.9 Daltons.

FORMULATION Tesamorelin as a lyophilized powder. The diluent (Sterile Water for Injection, 10 mL) is provided in a separate vial. EGRIFTA™ is a sterile, white to off-white, preservative-free lyophilized powder for subcutaneous injection. After reconstitution with the supplied diluent (Sterile Water for Injection, USP), a solution of EGRIFTA™ is clear and colorless. Each single-use vial of EGRIFTA™ contains 2 mg of tesamorelin as the free base (2.2 mg tesamorelin acetate, anhydrous) and the following inactive ingredient: 100 mg mannitol, USP DOSAGE: 2 mg injected subcutaneously once a day HALF-LIFE: 26 and 38 minutes in healthy subjects and HTV-infected patients, respectively, after subcutaneous administration for 14 consecutive days.

ADVERSE REACTION: Hypersensitivity (e.g., rash, urticaria) reactions due to the effect of GH (e.g., arthralgia, extremity pain, peripheral edema, hyperglycemia, carpal tunnel syndrome), injection site reactions (injection site erythema, pruritis, pain, urticaria, irritation, swelling, hemorrhage) DRUG INTERACTION: Published data, however, indicate that GH may modulate cytochrome P450 (CYP450) mediated antipyrine clearance in man. These data suggest that GH may alter the clearance of compounds known to be metabolized by CYP450 liver enzymes (e.g., corticosteroids, sex steroids, anticonvulsants, cyclosporine). Because tesamorelin stimulates GH production, careful monitoring is advisable when EGRIFTA™ is administered in combination with other drugs known to be metabolized by CYP450 liver enzymes PATENT Country Patent Number Approved Expires (estimated) United States 5861379 2011-11-29 2015-05-26

REFERENCE Spooner LM, Olin JL: Tesamorelin: a growth hormone-releasing factor analogue for HIV-associated lipodystrophy. Ann Pharmacother. 2012 Feb;46(2):240-7. doi: 10.1345/aph.1Q629. Epub 2012 Jan 31. Pubmed McLarnon A: Neuroendocrinology: Tesamorelin can improve cognitive function. Nat Rev Endocrinol. 2012 Oct;8(10):568. doi: 10.1038/nrendo.2012.151. Epub 2012 Aug 28. Pubmed Bedimo R: Growth hormone and tesamorelin in the management of HIV-associated lipodystrophy. HIV AIDS (Auckl). 2011;3:69-79. doi: 10.2147/HIV.S14561. Epub 2011 Jul 10. Pubmed Dhillon S: Spotlight on tesamorelin in HIV-associated lipodystrophy. BioDrugs. 2011 Dec 1;25(6):405-8. doi: 10.2165/11208290-000000000-00000. Pubmed Garg A: Acquired and inherited lipodystrophies. N Engl J Med. 2004 Mar 18;350(12):1220-34. Pubmed Patel A, Gandhi H, Upaganlawar A: Tesamorelin: A hope for ART-induced lipodystrophy. J Pharm Bioallied Sci. 2011 Apr;3(2):319-20. doi: 10.4103/0975-7406.80763. Pubmed Campbell RM, Lee Y, Rivier J, Heimer EP, Felix AM, Mowles TF: GRF analogs and fragments: correlation between receptor binding, activity and structure. Peptides. 1991 May-Jun;12(3):569-74. Pubmed http://www.ncbi.nlm.nih.gov/pubmed/25358450 http://www.ncbi.nlm.nih.gov/pubmed/25038357 http://www.ncbi.nlm.nih.gov/pubmed/24178787 http://www.ncbi.nlm.nih.gov/pubmed/22926095 http://www.ncbi.nlm.nih.gov/pubmed/22495074