May 26, 2021 GlaxoSmithKline LLC Attention: Debra H. Lake, M.S. Senior Director, Global Regulatory Affairs Five Moore Drive PO Box 13398 Durham, North Carolina 27709 RE: Emergency Use Authorization 100 Dear Ms. Lake: This letter is in response to GlaxoSmithKline LLC’s (GSK) request that the Food and Drug Administration (FDA) issue an Emergency Use Authorization (EUA) for the emergency use of sotrovimab for the treatment of mild-to-moderate coronavirus disease 2019 (COVID-19), as described in the Scope of Authorization (Section II) of this letter, pursuant to Section 564 of the Federal Food, Drug, and Cosmetic Act (the Act) (21 U.S.C. §360bbb-3). On February 4, 2020, pursuant to Section 564(b)(1)(C) of the Act, the Secretary of the Department of Health and Human Services (HHS) determined that there is a public health emergency that has a significant potential to affect national security or the health and security of United States citizens living abroad, and that involves the virus that causes coronavirus disease 2019 (COVID-19).1 On the basis of such determination, the Secretary of HHS on March 27, 2020, declared that circumstances exist justifying the authorization of emergency use of drugs and biological products during the COVID-19 pandemic, pursuant to Section 564 of the Federal Food, Drug, and Cosmetic Act (the Act) (21 U.S.C. 360bbb-3), subject to terms of any authorization issued under that section.2 Sotrovimab is a recombinant human IgG1κ monoclonal antibody that binds to a conserved epitope on the spike protein receptor binding domain of SARS-CoV-2. Sotrovimab does not compete with human ACE2 receptor binding. Sotrovimab is an investigational drug and is not currently approved for any indication. Based on review of the interim analysis of phase 1/2/3 data from the COMET-ICE clinical trial (NCT #04545060), a randomized, double-blind, placebo-controlled clinical trial evaluating the safety and efficacy of sotrovimab 500 mg IV in outpatient (non-hospitalized) adults with SARS- CoV-2 infection, it is reasonable to believe that sotrovimab may be effective for the treatment of 1 U.S. Department of Health and Human Services, Determination of a Public Health Emergency and Declaration that Circumstances Exist Justifying Authorizations Pursuant to Section 564(b) of the Federal Food, Drug, and Cosmetic Act, 21 U.S.C. § 360bbb-3. February 4, 2020. 2 U.S. Department of Health and Human Services, Declaration that Circumstances Exist Justifying Authorizations Pursuant to Section 564(b) of the Federal Food, Drug, and Cosmetic Act, 21 U.S.C. § 360bbb-3, 85 FR 18250 (April 1, 2020). Page 2 – GlaxoSmithKline mild-to-moderate COVID-19 in adults and pediatric patients (12 years of age and older weighing at least 40 kg) with positive results of direct SARS-CoV-2 viral testing, and who are at high risk for progression to severe COVID-19, including hospitalization or death, and when used under the conditions described in this authorization, the known and potential benefits of sotrovimab outweigh the known and potential risks of such product. Having concluded that the criteria for issuance of this authorization under Section 564(c) of the Act are met, I am authorizing the emergency use of sotrovimab for treatment of COVID-19, as described in the Scope of Authorization section of this letter (Section II) and subject to the terms of this authorization. I. Criteria for Issuance of Authorization I have concluded that the emergency use of sotrovimab for the treatment of COVID-19 when administered as described in the Scope of Authorization (Section II) meets the criteria for issuance of an authorization under Section 564(c) of the Act, because: 1. SARS-CoV-2 can cause a serious or life-threatening disease or condition, including severe respiratory illness, to humans infected by this virus; 2. Based on the totality of scientific evidence available to FDA, it is reasonable to believe that sotrovimab may be effective in treating mild-to-moderate COVID-19 in adults and pediatric patients (12 years of age and older weighing at least 40 kg) with positive results of direct SARS-CoV-2 viral testing, and who are at high risk for progression to severe COVID-19, including hospitalization or death, and that, when used under the conditions described in this authorization, the known and potential benefits of sotrovimab outweigh the known and potential risks of such products; and 3. There is no adequate, approved, and available alternative to the emergency use of sotrovimab for the treatment of mild-to-moderate COVID-19 in adults and pediatric patients (12 years of age and older weighing at least 40 kg) with positive results of direct SARS-CoV-2 viral testing, and who are at high risk for progression to severe COVID-19, including hospitalization or death.3 II. Scope of Authorization I have concluded, pursuant to Section 564(d)(1) of the Act, that the scope of this authorization is limited as follows: • Sotrovimab will be used only by healthcare providers to treat mild-to-moderate COVID-19 in adults and pediatric patients (12 years of age and older weighing at least 40 kg) with positive results of direct SARS-CoV-2 viral testing, and who are at high risk for progression to severe COVID-19, including hospitalization or death; 3 No other criteria of issuance have been prescribed by regulation under Section 564(c)(4) of the Act. Page 3 – GlaxoSmithKline • Sotrovimab is not authorized for use in the following patient populations4: • Adults or pediatric patients who are hospitalized due to COVID-19, or • Adults or pediatric patients who require oxygen therapy due to COVID- 19, or • Adults or pediatric patients who require an increase in baseline oxygen flow rate due to COVID-19 in those patients on chronic oxygen therapy due to underlying non-COVID-19-related comorbidity. • Sotrovimab may only be administered in settings in which health care providers have immediate access to medications to treat a severe infusion reaction, such as anaphylaxis, and the ability to activate the emergency medical system (EMS), as necessary. • The use of sotrovimab covered by this authorization must be in accordance with the authorized Fact Sheets. Product Description Sotrovimab is supplied in individual single dose vials. Individual vials and carton container labeling for sotrovimab are clearly marked “For use under Emergency Use Authorization.” Sotrovimab is a recombinant human IgG1κ monoclonal antibody that binds to a conserved epitope on the spike protein receptor binding domain of SARS-CoV-2. Sotrovimab does not compete with human ACE2 receptor binding. Sotrovimab is available as a 500 mg/8 mL (62.5 mg/mL) sterile, preservative-free, clear, colorless or yellow to brown solution to be diluted prior to infusion. Unopened vials of sotrovimab should be stored under refrigerated temperature at 2°C to 8°C (36°F to 46°F). The vials should be kept in the individual original cartons to protect from light. The diluted infusion solution of sotrovimab should be administered immediately. If immediate administration is not possible, store the diluted infusion solution for up to 24 hours at refrigerated temperature (2°C to 8°C [36°F to 46°F]) or up to 4 hours at room temperature (20°C to 25°C [68°F to 77°F]) including transportation and infusion time. Each carton containing a single treatment course of the authorized sotrovimab will include a single copy each of the following product-specific documents detailing information pertaining to its emergency use (referred to as “authorized labeling”)5: • Fact Sheet for Healthcare Providers: Emergency Use Authorization (EUA) of sotrovimab • Fact Sheet for Patients, Parents and Caregivers: Emergency Use Authorization (EUA) of sotrovimab for the treatment Coronavirus Disease 2019 (COVID-19) 4 Benefit of treatment with sotrovimab has not been observed in patients hospitalized due to COVID-19. SARS- CoV-2 monoclonal antibodies may be associated with worse clinical outcomes when administered to hospitalized patients with COVID 19 requiring high flow oxygen or mechanical ventilation. 5 The authorized labeling for EUA 100 will also be available on GSK’s website at www.sotrovimab.com Page 4 – GlaxoSmithKline I have concluded, pursuant to Section 564(d)(2) of the Act, that it is reasonable to believe that the known and potential benefits of sotrovimab, when used for the treatment of COVID-19 and used in accordance with this Scope of Authorization (Section II), outweigh the known and potential risks. I have concluded, pursuant to Section 564(d)(3) of the Act, based on the totality of scientific evidence available to FDA, that it is reasonable to believe that sotrovimab may be effective for the treatment of COVID-19 when used in accordance with this Scope of Authorization (Section II), pursuant to Section 564(c)(2)(A) of the Act. Having reviewed the scientific information available to FDA, including the information supporting the conclusions described in Section I above, I have concluded that sotrovimab (as described in this Scope of Authorization (Section II)) meets the criteria set forth in Section 564(c) of the Act concerning safety and potential effectiveness. The emergency use of your product under an EUA must be consistent with, and may not exceed, the terms of the Authorization, including the Scope of Authorization (Section II) and the Conditions of Authorization (Section III). Subject to the terms of this EUA and under the circumstances set forth in the Secretary of HHS's determination under Section 564(b)(1)(C) described above and the Secretary of HHS’s corresponding declaration under Section 564(b)(1), sotrovimab is authorized to treat mild- to-moderate COVID-19 illness in adults and pediatric patients (12 years of age and older weighing at least 40 kg) with positive results of direct SARS-CoV-2 viral testing, who are at high risk for progression to severe COVID-19, including hospitalization or death, as described in the Scope of Authorization (Section II) under this EUA, despite the fact that it does not meet certain requirements otherwise required by applicable federal law.