AFQLIR 40 mg/ml injectable solution in pre-filled syringe

2. What you need to know before you are given Afqlir

You must not be given Afqlir

• if you are allergicto aflibercept or any of the other ingredients of this medicine (listed in section 6)
• if you have an active infection or suspect that you may have an infection in or around the eye
• if you have severe inflammation of the eye (indicated by pain or redness)

Warnings and precautions

Tell your doctor before you are given Afqlir:

• If you have glaucoma.
• If you have a history of flashes of light or floaters or if you suddenly experience an increase in the size and number of floaters.
• If you have had surgery or are scheduled to have surgery in your eye within the previous 4 weeks or the next 4 weeks.
• If you have a severe form of CRVO or BRVO (ischemic CRVO or BRVO), treatment with Afqlir is not recommended.

In addition, it is important that you know that:

• The safety and efficacy of aflibercept when administered in both eyes at the same time have not been studied, and if used in this way, it may increase the risk of side effects.
• Afqlir injections may cause an increase in pressure inside the eye (intraocular pressure) in some patients within 60 minutes after the injection. Your doctor will monitor you after each injection.
• If you develop an infection or inflammation inside the eye (endophthalmitis) or other complications, you may notice pain or increased discomfort in the eye, worsening of redness, blurred or decreased vision, and increased sensitivity to light. It is essential that any symptoms that appear are diagnosed and treated as soon as possible.
• Your doctor will check if you have other risk factors that may increase the likelihood of a tear or detachment of the posterior layers of the eye (retinal tear or detachment, or retinal pigment epithelial tear or detachment), in which case Afqlir will be administered with caution.
• Afqlir must not be used during pregnancy, unless the potential benefit outweighs the potential risk to the fetus.
• Women of childbearing potential must use effective contraceptive methods during treatment and for at least 3 months after the last injection of Afqlir.

The systemic use of VEGF inhibitors, substances similar to those contained in Afqlir, is potentially associated with an increased risk of blood clots in the blood vessels (arterial thromboembolic events) that can lead to a heart attack or stroke. After injection of Afqlir into the eye, there is a theoretical risk that these events may occur. Data on the safety of treatment in patients with CRVO, BRVO, DME, and mCNV who have had a stroke, transient ischemic attack, or myocardial infarction in the last 6 months are limited. If any of these cases apply to you, Afqlir will be administered with caution.

Experience is limited in the treatment of:

• Patient with DME due to type 1 diabetes.
• Diabetic patients with very high average blood sugar levels (HbA1c above 12%).
• Diabetic patients with a diabetic eye disease known as proliferative diabetic retinopathy.

There is no experience in the treatment of:

• Patient with acute infections.
• Patient with other eye diseases such as retinal detachment or macular hole.
• Diabetic patients with uncontrolled hypertension.
• Non-Asian patients with mCNV.
• Patient who have been previously treated for mCNV.
• Patient with damage outside the central part of the macula (extrafoveal lesions) due to mCNV.

If any of the above applies to you, your doctor will take into account this lack of information when treating you with Afqlir.

Children and adolescents

Afqlir has not been studied in children or adolescents under 18 years of age, as wet AMD, CRVO, BRVO, DME, and mCNV mainly occur in adults. Therefore, its use in this age group is not recommended.

Other medicines and Afqlir

Tell your doctor if you are using, have recently used, or might use any other medicines.

Pregnancy and breastfeeding

• Women of childbearing potential must use effective contraceptive methods during treatment and for at least 3 months after the last injection of Afqlir.
• There is no experience with the use of aflibercept in pregnant women. Afqlir must not be used during pregnancy, unless the potential benefit outweighs the potential risk to the fetus. If you are pregnant or planning to become pregnant, tell your doctor before treatment with Afqlir.
• Small amounts of Afqlir may pass into breast milk. The effects on newborns/infants are unknown. Afqlir is contraindicated during breastfeeding. If you are breastfeeding, tell your doctor before treatment with Afqlir.

Driving and using machines

After injection of Afqlir, you may experience some temporary visual disturbances. Do not drive or use machines while these disturbances last.

Important information about some of the ingredients of Afqlir

This medicine contains less than 23 mg of sodium (1 mmol) per dose; this is essentially "sodium-free".

This medicine contains 0.02 mg of polysorbate 20 in each 0.05 ml (50 microliters) dose of solution. Polysorbates may cause allergic reactions. Tell your doctor if you have any known allergies.

3. How Afqlir is given

Afqlir will be given to you by a doctor who is experienced in giving eye injections, under aseptic conditions.

The recommended dose is 2 mg of aflibercept (0.05 ml).

Afqlir is given as an injection into the eye (intravitreal injection).

Before the injection, your doctor will use an antiseptic eye wash to carefully clean your eye to prevent infection. Your doctor will also give you a local anesthetic to reduce or prevent any pain you may feel with the injection.

Wet AMD

Patient with wet AMD will be treated with one injection per month for the first three doses, followed by another injection after two months.

Your doctor will then decide if the treatment interval between injections can be maintained every two months or gradually extended to 2 or 4 weeks if your disease has stabilized.

If your disease worsens, the interval between injections may be shortened.

You do not need to visit your doctor between injections, unless your doctor thinks it is necessary or you experience any problems.

Macular edema secondary to retinal vein occlusion (branch or central)

Your doctor will determine the most suitable treatment schedule for you. Your treatment will start with a series of Afqlir injections given once a month.

The interval between two injections must not be less than one month.

Your doctor may decide to stop treatment with Afqlir if you do not benefit from continued treatment.

Treatment will continue with one injection per month until your disease has stabilized. You may need three or more monthly injections.

Your doctor will monitor your response to treatment and may continue treatment, gradually increasing the interval between injections to stabilize your disease. If your disease worsens with a longer treatment interval, your doctor will shorten the interval between injections.

Depending on your response to treatment, your doctor will decide on the follow-up and treatment schedule.

Diabetic macular edema (DME)

Patient with DME will be treated with one injection per month for the first five consecutive doses, and then one injection every two months.

The interval between treatments may be maintained every two months or adjusted according to your disease, based on the examination by your doctor. Your doctor will decide on the follow-up visit schedule.

Your doctor may decide to stop treatment with Afqlir if you do not benefit from continued treatment.

Myopic choroidal neovascularization (mCNV)

Patient with mCNV will be treated with a single injection. You will only receive more injections if your doctor's examinations reveal that your disease has not improved.

The interval between two injections must not be less than one month.

If your disease disappears and then recurs, your doctor may restart treatment.

Your doctor will decide on the follow-up schedule.

Detailed instructions for use are presented at the end of this leaflet in "How to prepare and administer Afqlir to adults".

If you miss a dose of Afqlir

Make a new appointment to have the injection.

Stopping treatment with Afqlir

Talk to your doctor before stopping treatment.

If you have any further questions on the use of this medicine, ask your doctor.

4. Possible Adverse Effects

Like all medicines, this medicine can cause adverse effects, although not all people suffer from them.

Potentially, allergic reactions(hypersensitivity) may occur. These can be serious and require immediate contact with your doctor.

With the administration of aflibercept, some adverse effects that affect the eyes due to the injection procedure may occur. Some can be serious, including blindness, severe infection or inflammation inside the eye(endophthalmitis), detachment, tear, or hemorrhage of the light-sensitive layer at the back of the eye(retinal detachment or tear), clouding of the lens(cataract), bleeding in the eye(vitreous hemorrhage), detachment of the gel-like substance inside the eye from the retina(vitreous detachment), and increased pressure inside the eye(see section 2). These serious eye adverse effects occurred in less than 1 in 1,900 injections during clinical trials.

If you notice a sudden decrease in vision or an increase in pain and redness in the eye after injection, consult your doctor immediately.

List of Reported Adverse Effects

The following is a list of adverse effects reported as possibly related to the injection procedure or the medicine. You should not be alarmed, as you may not experience any of them. Always consult your doctor about any suspected adverse effect.

Very Common Adverse Effects(may affect more than 1 in 10 people):

• vision impairment
• bleeding in the back of the eye (retinal hemorrhage)
• blood in the eye due to bleeding from small blood vessels in the outer layers of the eye
• eye pain

Common Adverse Effects(may affect up to 1 in 10 people):

• detachment or tear of one of the layers in the back of the eye that produce flashes of light with floating spots that may progress to vision loss (retinal pigment epithelial tear/detachment, retinal tear/detachment)

• *Adverse effects known to be associated with exudative age-related macular degeneration; observed only in patients with exudative age-related macular degeneration.

• retinal degeneration (causing vision disturbances)
• bleeding in the eye (vitreous hemorrhage)
• certain forms of clouding of the lens (cataract)
• damage to the superficial layer of the eyeball (cornea)
• increased pressure inside the eye
• spots in vision (floaters)
• detachment of the gel-like substance inside the eye from the retina (vitreous detachment, resulting in flashes of light with floaters)
• sensation of having something in the eye
• increased tear production
• eyelid swelling
• bleeding at the injection site
• eye redness

Uncommon Adverse Effects(may affect up to 1 in 100 people):

• allergic reactions (hypersensitivity)**
• **Allergic reactions were reported as rash, itching (pruritus), hives (urticaria), and some cases of severe allergic reactions (anaphylactic/anaphylactoid).
• severe inflammation or infection inside the eye (endophthalmitis)
• inflammation of the iris or other parts of the eye (iritis, uveitis, iridocyclitis, cells in the anterior chamber)
• abnormal sensation in the eye
• irritation of the eyelid
• swelling of the superficial layer of the eyeball (cornea)

Rare Adverse Effects(may affect up to 1 in 1,000 people):

• blindness
• clouding of the lens due to injury (traumatic cataract)
• pus in the eye

In clinical trials, an increased incidence of bleeding from small blood vessels in the outer layers of the eye (conjunctival hemorrhage) was observed in patients with exudative age-related macular degeneration who received treatment with anticoagulant medications. This increased incidence was comparable in patients treated with ranibizumab and aflibercept.

The use of VEGF inhibitors via the systemic route, substances similar to those contained in Afqlir, is potentially related to the risk of blood clots that block blood vessels (arterial thromboembolic events) that can cause a heart attack or embolism. There is a theoretical risk that this type of event may occur after injection of Afqlir into the eye.

As with all therapeutic proteins, there is a possibility of an immune reaction (formation of antibodies) with Afqlir.

Reporting of Adverse Effects

If you experience any type of adverse effect, consult your doctor, even if it is a possible adverse effect that does not appear in this leaflet. You can also report them directly through the national reporting system included in Appendix V. By reporting adverse effects, you can contribute to providing more information on the safety of this medicine.

5. Storage of Afqlir

• Keep this medicine out of the sight and reach of children.
• Do not use this medicine after the expiration date that appears on the box and on the label after "EXP". The expiration date is the last day of the month indicated.
• Store in a refrigerator (between 2 °C and 8 °C). Do not freeze.
• The unopened blister pack can be stored outside the refrigerator at a temperature below 30 °C for a maximum of 14 days.
• Store in the original packaging to protect it from light.
• Medicines should not be disposed of via wastewater or household waste. Ask your pharmacist how to dispose of the packaging and any unused medicines. This will help protect the environment.

6. Package Contents and Additional Information

Afqlir Composition

• The active ingredient is: aflibercept. Each pre-filled syringe contains 6.6 mg of aflibercept in 0.165 ml of solution. This provides a usable amount to administer a single dose of 0.05 ml containing 2 mg of aflibercept.
• The other components are: polysorbate 20 (E 432), histidine, L-histidine monohydrochloride monohydrate, trehalose dihydrate, sodium hydroxide (for pH adjustment), hydrochloric acid (for pH adjustment), water for injectable preparation.

Afqlir Appearance and Package Contents

Afqlir is an injectable solution (injectable) in a pre-filled syringe (type I glass) marked with a dosing line, with a plunger stopper (elastomeric rubber) and a Luer Lock adapter with a closure cap at the end (elastomeric rubber). The solution is transparent, colorless to slightly yellowish-brown.

Package with 1 pre-filled syringe.

Marketing Authorization Holder

Sandoz GmbH

Biochemiestr. 10

6250 Kundl

Austria

Manufacturer

Novartis Manufacturing

Rijksweg 14

Puurs-Sint-Amands, 2870

Belgium

You can request more information about this medicine by contacting the local representative of the marketing authorization holder:

Date of Last Revision of this Leaflet:

Detailed information on this medicine is available on the European Medicines Agency website: https://www.ema.europa.eu.

This information is intended only for healthcare professionals:

The pre-filled syringe contains more than the recommended dose of 2 mg of aflibercept (equivalent to 0.05 ml). The excess volume must be eliminated before administration.

Instructions for Use of the Pre-filled Syringe:

Storage and Inspection

Preparation and Administration

Each pre-filled syringe is for use in a single eye only.

Do not open the blister pack with the sterile pre-filled syringe outside the clean room.

For intravitreal injection, a 30 G x ½ inch (1.27 cm) injection needle must be used.

Use an aseptic technique to perform the following steps.

Description of the Pre-filled Syringe