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ISOtretinoin

Pronunciation

Pronunciation

(eye soe TRET i noyn)

Index Terms

  • 13-cis-Retinoic Acid
  • 13-cis-Vitamin A Acid
  • 13-CRA
  • Cis-Retinoic Acid
  • Accutane
  • Isotretinoinum

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Capsule, Oral:

Absorica: 10 mg, 20 mg [contains soybean oil]

Absorica: 25 mg [contains brilliant blue fcf (fd&c blue #1), fd&c yellow #6 (sunset yellow), soybean oil, tartrazine (fd&c yellow #5)]

Absorica: 30 mg [contains soybean oil]

Absorica: 35 mg [contains fd&c blue #2 (indigotine), soybean oil]

Absorica: 40 mg [contains soybean oil]

Amnesteem: 10 mg [DSC], 20 mg [DSC], 40 mg [DSC] [contains soybean oil]

Claravis: 10 mg [contains fd&c yellow #6 (sunset yellow), soybean oil]

Claravis: 20 mg [contains soybean oil]

Claravis: 30 mg

Claravis: 40 mg [contains fd&c yellow #6 (sunset yellow), soybean oil]

Myorisan: 10 mg, 20 mg [contains soybean oil]

Myorisan: 30 mg

Myorisan: 40 mg [contains fd&c yellow #6 (sunset yellow), soybean oil]

Zenatane: 10 mg [contains brilliant blue fcf (fd&c blue #1), edetate disodium, fd&c yellow #10 (quinoline yellow), methylparaben, propylparaben, soybean oil]

Zenatane: 20 mg [contains edetate disodium, methylparaben, propylparaben, soybean oil]

Zenatane: 30 mg [contains edetate disodium, fd&c blue #2 aluminum lake, fd&c yellow #10 (quinoline yellow), methylparaben, propylparaben, soybean oil]

Zenatane: 40 mg [contains brilliant blue fcf (fd&c blue #1), edetate disodium, fd&c blue #2 (indigotine), fd&c yellow #10 (quinoline yellow), methylparaben, propylparaben, soybean oil]

Brand Names: U.S.

  • Absorica
  • Amnesteem [DSC]
  • Claravis
  • Myorisan
  • Zenatane

Pharmacologic Category

  • Acne Products
  • Antineoplastic Agent, Retinoic Acid Derivative
  • Retinoic Acid Derivative

Pharmacology

Reduces sebaceous gland size and reduces sebum production in acne treatment; in neuroblastoma, decreases cell proliferation and induces differentiation

Absorption

Absorption: Enhanced with a high-fat meal; Absorica absorption is ~83% greater than Accutane when administered under fasting conditions; they are bioequivalent when taken with a high-fat meal.

Metabolism

Hepatic via CYP2B6, 2C8, 2C9, 2D6, 3A4; forms metabolites; major metabolite: 4-oxo-isotretinoin (active)

Excretion

Urine and feces (equal amounts)

Time to Peak

Serum: 3 to 5 hours

Half-Life Elimination

Terminal: Parent drug: 21 hours; Metabolite: 21 to 24 hours

Protein Binding

99% to 100%; primarily albumin

Use: Labeled Indications

Acne, severe recalcitrant nodular: Treatment of severe recalcitrant nodular acne unresponsive to conventional therapy (including systemic antibiotics)

Use: Unlabeled

Management of moderate degrees of treatment-resistant acne, management of acne that produces physical or psychological scarring; treatment of cutaneous T-cell lymphomas (mycosis fungoides and Sézary syndrome); prevention of squamous cell skin cancers (in high-risk patients); treatment of high-risk neuroblastoma in children

Contraindications

Hypersensitivity to isotretinoin or any component of the formulation; sensitivity to parabens (Zenatane only) or vitamin A; pregnant women or those who may become pregnant

Documentation of allergenic cross-reactivity for retinoids is limited. However, because of similarities in chemical structure and/or pharmacologic actions, the possibility of cross-sensitivity cannot be ruled out with certainty.

Dosing: Adult

Acne, severe recalcitrant nodular: Oral: 0.5 to 1 mg/kg/day in 2 divided doses for 15 to 20 weeks; may discontinue earlier if the total cyst count decreases by >70%. Adults with very severe disease/scarring or primarily involves the trunk may require dosage adjustment up to 2 mg/kg/day, as tolerated. Adjust dose according to the appearance of clinical side effects and/or response of the disease. A second course of therapy may be initiated after a period of ≥2 months off therapy. A dose of ≤0.5 mg/kg/day may be used to minimize initial flaring (Strauss 2007).

Acne, moderate (off-label use): Oral: 20 mg/day (~0.3-0.4 mg/kg/day) for 6 months (Amichai 2006)

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

Acne, severe recalcitrant nodular: Children ≥12 years to Adolescents ≤17 years: Oral: 0.5 to 1 mg/kg/day in 2 divided doses for 1 to 20 weeks; may discontinue earlier if the total cyst count decreases by >70%. Adjust dose according to the appearance of clinical side effects and/or response of the disease. A second course of therapy may be initiated after a period of ≥2 months off therapy. A dose of ≤0.5 mg/kg/day may be used to minimize initial flaring (Strauss 2007).

Acne, moderate (off-label use): Children ≥12 years to Adolescents ≤17 years: Oral: 20 mg/day (~0.3 to 0.4 mg/kg/day) for 6 months (Amichai 2006)

Neuroblastoma, high-risk (off-label use): Children ≥1 year to Adolescents ≤17 years: Oral: 160 mg/m2/day (in 2 divided doses) days 1 through 14 every 28 days for 6 cycles, beginning after continuation chemotherapy or transplantation (Matthay 1999)

Dosing: Renal Impairment

There are no dosage adjustments provided in the manufacturer’s labeling.

Dosing: Hepatic Impairment

Hepatic impairment prior to treatment: There are no dosage adjustments provided in the manufacturer’s labeling.

Hepatotoxicity during treatment: Liver enzymes may normalize with dosage reduction or with continued treatment; discontinue if normalization does not readily occur or if hepatitis is suspected.

Extemporaneously Prepared

Hazardous agent: Use appropriate precautions for handling and disposal of teratogenic capsule contents (meets NIOSH 2014 criteria).

For patients unable to swallow the capsules whole, an oral liquid may be prepared with softgel capsules (not recommended by the manufacturers) by one of the following methods:

Place capsules (softgel formulations only) in small container and add warm (~37°C [97°F]) water or milk to cover capsule(s); wait 2-3 minutes until capsule is softened and then drink the milk or water with the softened capsule, or swallow softened capsule.

Puncture capsule (softgel formulations only) with needle or cut with scissors; squeeze capsule contents into 5-10 mL of milk or tube feed formula; draw mixture up into oral syringe and administer via feeding tube; flush feeding tube with ≥30 mL additional milk or tube feeding formula.

Puncture capsule (softgel formulations only) with needle or cut with scissors and draw contents into oral syringe; add 1-5 mL of medium chain triglyceride, soybean, or safflower oil to the oral syringe; mix gently and administer via feeding tube; flush feeding tube with ≥30 mL milk or tube feeding formula.

Lam MS, "Extemporaneous Compounding of Oral Liquid Dosage Formulations and Alternative Drug Delivery Methods for Anticancer Drugs," Pharmacotherapy, 2011, 31(2):164-92.21275495

Administration

Oral: Administer with a meal (except Absorica, which may be taken without regard to meals). According to the manufacturer's labeling, capsules should be swallowed whole with a full glass of liquid; do not chew or suck on the capsule. For patients unable to swallow capsule whole, an oral liquid may be prepared; may irritate esophagus if contents are removed from the capsule. Safety of once-daily dosing of isotretinoin has not been established and is not recommended.

Hazardous agent; use appropriate precautions for handling and disposal (meets NIOSH 2014 criteria).

Dietary Considerations

Should be taken with food, except Absorbica which may be taken without regard to meals. Limit intake of vitamin A; avoid use of other vitamin A products. Some formulations may contain soybean oil.

Storage

Store at 20°C to 25°C (68°F to 77° F); excursions permitted between 15°C to 30°C (59°F to 86°F). Protect from light.

Drug Interactions

Alcohol (Ethyl): May enhance the adverse/toxic effect of ISOtretinoin. Specifically, the risk for elevated triglyceride concentrations may be increased. Monitor therapy

Aminolevulinic Acid: Photosensitizing Agents may enhance the photosensitizing effect of Aminolevulinic Acid. Monitor therapy

Contraceptives (Estrogens): Retinoic Acid Derivatives may diminish the therapeutic effect of Contraceptives (Estrogens). Two forms of contraception are recommended in females of child-bearing potential during retinoic acid derivative therapy. Monitor therapy

Contraceptives (Progestins): Retinoic Acid Derivatives may diminish the therapeutic effect of Contraceptives (Progestins). Retinoic Acid Derivatives may decrease the serum concentration of Contraceptives (Progestins). Management: Two forms of effective contraception should be used in patients receiving retinoic acid derivatives. Particularly, microdosed progesterone-only preparations may be inadequately effective. Consider therapy modification

Mipomersen: ISOtretinoin may enhance the hepatotoxic effect of Mipomersen. Monitor therapy

Multivitamins/Fluoride (with ADE): May enhance the adverse/toxic effect of Retinoic Acid Derivatives. Avoid combination

Multivitamins/Minerals (with ADEK, Folate, Iron): May enhance the adverse/toxic effect of Retinoic Acid Derivatives. Avoid combination

Multivitamins/Minerals (with AE, No Iron): May enhance the adverse/toxic effect of Retinoic Acid Derivatives. Avoid combination

Porfimer: Photosensitizing Agents may enhance the photosensitizing effect of Porfimer. Monitor therapy

Tetracycline Derivatives: May enhance the adverse/toxic effect of Retinoic Acid Derivatives. The development of pseudotumor cerebri is of particular concern. Avoid combination

Verteporfin: Photosensitizing Agents may enhance the photosensitizing effect of Verteporfin. Monitor therapy

Vitamin A: May enhance the adverse/toxic effect of Retinoic Acid Derivatives. Avoid combination

Adverse Reactions

>10%:

Endocrine & metabolic: Increased serum triglycerides (25%)

Neuromuscular & skeletal: Back pain (children: 29%)

1% to 10%:

Ophthalmic: Conjunctivitis (4%), blepharitis (1%), chalazion (1%), hordeolum (1%)

Frequency not defined:

Cardiovascular: Cerebrovascular accident, chest pain, edema, flushing, palpitations, syncope, tachycardia, thrombosis

Central nervous system: Aggressive behavior, attempted suicide, depression, dizziness, drowsiness, emotional lability, fatigue, headache, insomnia, lethargy, malaise, nervousness, paresthesia, pseudotumor cerebri, psychosis, seizure, suicidal ideation, violent behavior

Dermatologic: Acne fulminans, allergic skin reaction, alopecia, cheilitis, diaphoresis, eczema, eruptive xanthoma, facial erythema, hair disease, hirsutism, hyperpigmentation, hypopigmentation, nail disease, paronychia, pruritus, pyogenic granuloma, scaling of skin of feet, skin atrophy, skin photosensitivity, skin rash, sunburn (increased susceptibility), superficial peeling of palms, xeroderma

Endocrine & metabolic: Decreased HDL cholesterol, increased gamma-glutamyl transferase, increased lactate dehydrogenase, increased serum cholesterol, increased serum glucose, hyperuricemia, menstrual disease, weight loss

Gastrointestinal: Colitis, esophagitis, esophageal ulcer, gastrointestinal symptoms (nonspecific), gingival hemorrhage, gingivitis, inflammatory bowel disease, nausea, pancreatitis, xerostomia

Genitourinary: Genitourinary disease (nonspecific findings), hematuria, proteinuria, pyuria, renal vasculitis

Hematologic & oncologic: Anemia, bruise, lymphadenopathy, neutropenia, purpura, thrombocytopenia

Hepatic: Increased serum alkaline phosphatase, increased serum ALT, increased serum AST, hepatitis

Hypersensitivity: Anaphylaxis, hypersensitivity reaction

Infection: Herpes simplex infection (disseminated), infection

Neuromuscular & skeletal: Arthralgia, arthritis, bone disease, calcification of ligament, calcification of tendon, decreased bone mineral density, increased creatine phosphokinase, myalgia, premature epiphyseal closure, skeletal hyperostosis, tendonitis, weakness

Ophthalmic: Cataract, corneal opacity, keratitis, nocturnal amblyopia, optic neuritis, photophobia, vision color changes, visual disturbance

Otic: Auditory impairment, tinnitus

Renal: Glomerulonephritis

Respiratory: Bronchospasm, dry nose, epistaxis, respiratory tract infection, voice disorder, Wegener's granulomatosis

Miscellaneous: Wound healing impairment

<1% (Limited to important or life-threatening): Agranulocytosis, erythema multiforme, eye pain, increased osmolarity (tears), meibomian gland disease (atrophy and abnormal gland secretion), myopia, rhabdomyolysis, Stevens-Johnson syndrome, toxic epidermal necrolysis

ALERT: U.S. Boxed Warning

Pregnancy:

Isotretinoin must not be used by women and adolescents who are pregnant or who may become pregnant. There is an extremely high risk that severe birth defects can result if pregnancy occurs while taking isotretinoin in any amount, even for short periods of time. Potentially, any fetus exposed during pregnancy can be affected. There are no accurate means of determining whether an exposed fetus has been affected.

Birth defects that have been documented following isotretinoin exposure include abnormalities of the face, eyes, ears, skull, CNS, cardiovascular system, and thymus and parathyroid glands. Cases of intelligence quotient (IQ) scores less than 85 with or without other abnormalities have been reported. There is an increased risk of spontaneous abortion, and premature births have been reported.

Documented external abnormalities include skull abnormality; ear abnormalities (including anotia, micropinna, small or absent external auditory canals); eye abnormalities (including microphthalmia); facial dysmorphia; cleft palate. Documented internal abnormalities include CNS abnormalities (including cerebral abnormalities, cerebellar malformation, hydrocephalus, microcephaly, cranial nerve deficit); cardiovascular abnormalities; thymus gland abnormality; parathyroid hormone deficiency. In some cases, death has occurred with some of the abnormalities previously noted.

If pregnancy does occur during treatment of a female patient who is taking isotretinoin, isotretinoin must be discontinued immediately and she should be referred to an obstetrician-gynecologist experienced in reproductive toxicity for further evaluation and counseling.

Special prescribing requirements:

Because of isotretinoin's teratogenicity and to minimize fetal exposure, isotretinoin is approved for marketing only under a special restricted distribution program approved by the Food and Drug Administration. This program is called iPLEDGE. Isotretinoin must only be prescribed by prescribers who are registered and activated with the iPLEDGE program. Isotretinoin must only be dispensed by a pharmacy registered and activated with iPLEDGE, and must only be dispensed to patients who are registered and meet all the requirements of iPLEDGE.

Warnings/Precautions

Concerns related to adverse effects:

• Auditory impairment: Hearing impairment, which can continue after therapy is discontinued, may occur. Discontinue therapy if hearing impairment or tinnitus develops.

• Bone mineral density loss: May decrease bone mineral density; osteoporosis, osteopenia, bone fractures, and delayed healing of bone fractures have been reported. Use caution in patients with a genetic predisposition for bone loss (eg, age-related osteoporosis, history of childhood osteoporosis conditions, osteomalacia or other disorders of bone metabolism); including patients diagnosed with anorexia nervosa and those on concomitant medications that may cause drug-induced osteoporosis/osteomalacia and/or affect vitamin D metabolism (eg, systemic corticosteroids, anticonvulsants). Patients may be at increased risk when participating in activities with repetitive impact (such as sports) where the risk of spondylolisthesis with and without pars fractures and hip growth plate injuries in early and late adolescence are known.

• Dermatologic effects: Postmarketing reports of erythema multiforme severe skin reactions (eg, Stevens-Johnson syndrome, toxic epidermal necrolysis), including fatalities, have been reported; monitor for severe skin reactions; discontinue use if severe skin reaction occurs.

• Growth effects: Skeletal hyperostosis and premature epiphyseal closure have also been reported with the use.

• Hematologic effects: Neutropenia and rare cases of agranulocytosis have been reported; discontinue if clinically significant decreases in white cell counts occur.

• Hepatic effects: Clinical hepatitis and mild to moderate elevated liver enzymes have been reported with use; liver enzymes may normalize with dosage reduction or with continued treatment. Discontinue therapy if hepatic enzymes do not normalize or if hepatitis is suspected.

• Hypersensitivity reactions: Anaphylaxis and other types of allergic reactions, including cutaneous reactions and serious cases of allergic vasculitis, often with purpura of the extremities and extracutaneous involvement (including renal) have been reported. Discontinue therapy if a serious allergic reaction occurs and institute appropriate medical management.

• Inflammatory bowel disease: Inflammatory bowel disease, including regional ileitis, has been reported in patients without a prior history of intestinal disorders; discontinue treatment immediately if abdominal pain, rectal bleeding, or severe diarrhea occurs.

• Musculoskeletal effects: Musculoskeletal symptoms (including arthralgia) have been reported; generally symptoms were mild to moderate, but occasionally required discontinuation of therapy. Transient pain in the chest has occurred; symptoms generally cleared after discontinuation of therapy, but in some cases persisted. Rhabdomyolysis, some associated with strenuous physical activity, has been reported (rarely).

• Ocular effects: Vision impairment, corneal opacities, decreased tolerance to contact lenses (due to dry eyes), and decreased night vision have been reported with use; discontinue therapy in patients experiencing visual difficulties. Warn patients to be cautious when driving or operating machinery at night.

• Pancreatitis: Acute pancreatitis may occur in patients with normal or elevated triglyceride levels; fatal hemorrhagic pancreatitis (rare) has been reported; discontinue therapy if hypertriglyceridemia cannot be controlled at an acceptable level or symptoms of pancreatitis occurs.

• Photosensitivity: Avoid prolonged exposure to UV rays or sunlight.

• Pseudotumor cerebri: Retinoids have been associated with pseudotumor cerebri (benign intracranial hypertension), especially in children. Concurrent use of other drugs associated with this effect (eg, tetracyclines) may increase risk. Early signs and symptoms include papilledema, headache, nausea, vomiting, and visual disturbances; discontinue immediately and refer patient to a neurologist if papilledema occurs.

• Psychiatric effects: May cause depression, psychosis, mood disturbance, and rarely, suicidal ideation, suicide attempts, suicide, and aggressive and/or violent behaviors. All patients should be observed closely for symptoms of depression or suicidal thoughts. Discontinue therapy if depression, mood disturbance, psychosis, or aggression develops. Discontinuation of treatment alone may not be sufficient, further evaluation may be necessary. Use with extreme caution in patients with a history of psychiatric disorder.

Disease-related concerns:

• Diabetes: Use with caution in patients with diabetes mellitus; impaired glucose control has been reported.

• Hypertriglyceridemia: Marked elevations of serum triglycerides have been reported; use with caution in patients with hypertriglyceridemia or those who may be at high risk (eg, patients with diabetes, obesity, increased alcohol intake, family history of or those with lipid metabolism disorder). The effects on triglycerides, HDL, and cholesterol have been reversible upon discontinuation of therapy. Instruct patients to avoid or limit ethanol; may increase triglyceride levels if taken in excess.

Concurrent drug therapy issues:

• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.

Special populations:

• Pregnancy: [US Boxed Warnings]: Use of isotretinoin is contraindicated in females who are or may become pregnant. Birth defects (facial, eye, ear, skull, central nervous system, cardiovascular, thymus and parathyroid gland abnormalities) have been noted following isotretinoin exposure during pregnancy and the risk for severe birth defects is high, with any dose or even with short treatment duration. Low IQ scores have also been reported. The risk for spontaneous abortion and premature births is increased. Because of the high likelihood of teratogenic effects, all patients (male and female), prescribers, wholesalers, and dispensing pharmacists must register and be active in the iPLEDGE risk evaluation and mitigation strategy (REMS) program; do not prescribe isotretinoin for women who are or who are likely to become pregnant while using the drug. If pregnancy occurs during therapy, isotretinoin should be discontinued immediately and the patient referred to an obstetrician-gynecologist specializing in reproductive toxicity.

Dosage form specific issues:

• Absorica: Absorption is ~83% greater than Accutane when administered under fasting conditions; they are bioequivalent when taken with a high-fat meal. Absorica is not interchangeable with other generic isotretinoin products.

• Product interchange: Isotretinoin and tretinoin (which is also known as all-trans retinoic acid, or ATRA) may be confused, while both products may be used in cancer treatment, they are not interchangeable; verify product prior to dispensing and administration to prevent medication errors.

• Tartrazine: Some products may contain tartrazine (FD&C yellow no. 5), which may cause allergic reactions, including bronchial asthma, in certain individuals. Allergy is frequently seen in patients who also have an aspirin hypersensitivity.

Special handling:

• Hazardous agent: Use appropriate precautions for handling and disposal (meets NIOSH 2014 criteria).

Other warnings/precautions:

• Blood donation: Patients should be instructed not to donate blood during therapy and for 1 month following discontinuation of therapy due to risk of donated blood being given to a pregnant female.

• Experienced health care provider: This medication should only be prescribed by health care providers competent in treating severe recalcitrant nodular acne and experienced with the use of systemic retinoids.

• Long-term use: Safety of long-term use is not established and is not recommended; the effect on bone loss is unknown.

• REMS program: [US Boxed Warning]: Because of the high likelihood of teratogenic effects, all patients (male and female), prescribers, wholesalers, and dispensing pharmacists must register and be active in the iPLEDGE risk evaluation and mitigation strategy (REMS) management program; do not prescribe isotretinoin for women who are or who are likely to become pregnant while using the drug (see Additional Information or Pharmacotherapy Pearls for details). Women of childbearing potential must be capable of complying with effective contraceptive measures. Patients must select and commit to two forms of contraception. Therapy is begun after two negative pregnancy tests; effective contraception must be used for at least 1 month before beginning therapy, during therapy, and for 1 month after discontinuation of therapy. Prescriptions should be written for no more than a 30-day supply, and pregnancy testing and counseling should be repeated monthly.

• Skin resurfacing procedures: Avoid skin resurfacing procedures (eg, dermabrasion, laser) and wax epilation during therapy and for at least 6 months after discontinuation of isotretinoin due to the risk of scarring.

Monitoring Parameters

CBC with differential and platelet count, baseline sedimentation rate, glucose, CPK; signs of depression, mood alteration, psychosis, aggression, severe skin reactions; changes in vision

Pregnancy test (for all female patients of childbearing potential): Two negative tests with a sensitivity of at least 25 milliunits/mL prior to beginning therapy (the second performed at least 19 days after the first test and performed during the first 5 days of the menstrual period immediately preceding the start of therapy); monthly tests to rule out pregnancy prior to refilling prescription.

Lipids: Prior to treatment and at weekly or biweekly intervals until response to treatment is established. Test should not be performed <36 hours after consumption of ethanol.

Liver function tests: Prior to treatment and at weekly or biweekly intervals until response to treatment is established.

Pregnancy Risk Factor

X

Pregnancy Considerations

Isotretinoin and its metabolites can be detected in fetal tissue following maternal use during pregnancy (Benifla 1995; Kraft 1989). [US Boxed Warnings]: Use of isotretinoin is contraindicated in females who are or may become pregnant. Birth defects (facial, eye, ear, skull, central nervous system, cardiovascular, thymus and parathyroid gland abnormalities) have been noted following isotretinoin exposure during pregnancy and the risk for severe birth defects is high, with any dose or even with short treatment duration. Low IQ scores have also been reported. The risk for spontaneous abortion and premature births is increased. Because of the high likelihood of teratogenic effects, all patients (male and female), prescribers, wholesalers, and dispensing pharmacists must register and be active in the iPLEDGE™ risk evaluation and mitigation strategy (REMS) program; do not prescribe isotretinoin for women who are or who are likely to become pregnant while using the drug. If pregnancy occurs during therapy, isotretinoin should be discontinued immediately and the patient referred to an obstetrician-gynecologist specializing in reproductive toxicity. This medication is contraindicated in females of childbearing potential unless they are able to comply with the guidelines of the iPLEDGE™ pregnancy prevention program. Females of childbearing potential must have two negative pregnancy tests with a sensitivity of at least 25 milliunits/mL prior to beginning therapy and testing should continue monthly during therapy. Females of childbearing potential should not become pregnant during therapy or for 1 month following discontinuation of isotretinoin. Upon discontinuation of treatment, females of childbearing potential should have a pregnancy test after their last dose and again one month after their last dose. Two forms of contraception should be continued during this time. Any pregnancies should be reported to the iPLEDGE™ program (www.ipledgeprogram.com or 866-495-0654) and the FDA through MedWatch (800-FDA-1088).

Patient Education

• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)

• Patient may experience dry mouth, dry eyes, dry skin, dry lips, nasal irritation, or contact lens discomfort. Have patient report immediately to prescriber signs of severe cerebrovascular disease (change in strength on one side is greater than the other, trouble speaking or thinking, change in balance, or change in eyesight), seizures, nausea, vomiting, severe headache, dizziness, severe diarrhea, rectal bleeding, rectal pain, severe abdominal pain, signs of depression (suicidal ideation, anxiety, emotional instability, illogical thinking, suicidal ideation), aggressive behavior, signs of infection, signs of liver problems (dark urine, feeling tired, lack of appetite, nausea, abdominal pain, light-colored stools, vomiting, or yellow skin or eyes), signs of esophageal problems (angina, difficulty swallowing, or heartburn), signs of high blood sugar (confusion, feeling sleepy, more thirst, hunger, passing urine more often, flushing, fast breathing, or breath that smells like fruit), signs of a pancreas problem (pancreatitis; severe abdominal pain, severe back pain, severe nausea, or vomiting), eye pain, muscle pain, joint pain, bone pain, bruising, bleeding, loss of strength and energy, urinary retention, change in amount of urine passed, back pain, hearing impairment, tinnitus, or signs of Stevens-Johnson syndrome/toxic epidermal necrolysis (red, swollen, blistered, or peeling skin [with or without fever]; red or irritated eyes; or sores in mouth, throat, nose, or eyes) (HCAHPS).

• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for healthcare professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience and judgment in diagnosing, treating and advising patients.

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