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Mefloquine

Pronunciation

Pronunciation

(ME floe kwin)

Index Terms

  • Lariam
  • Mefloquine Hydrochloride

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Tablet, Oral, as hydrochloride:

Generic: 250 mg

Pharmacologic Category

  • Antimalarial Agent

Pharmacology

Mefloquine is a quinoline-methanol compound structurally similar to quinine; mefloquine's effectiveness in the treatment and prophylaxis of malaria is due to the destruction of the asexual blood forms of the malarial pathogens that affect humans, Plasmodium falciparum, P. vivax

Absorption

Well absorbed

Distribution

Distributes into tissues, erythrocytes, blood, urine, CSF

Vd: Children 4 to 10 years: Mean: ~18 to 19 L/kg (Price 1999); Adults: ~20 L/kg

Metabolism

Extensively hepatic primarily by CYP3A4 to 2,8-bis-trifluoromethyl-4-quinoline carboxylic acid (inactive) and other metabolites

Excretion

Primarily bile and feces; urine (9% of total dose as unchanged drug, 4% of total dose as primary metabolite)

Time to Peak

Plasma: ~17 hours (range: 6 to 24 hours)

Half-Life Elimination

Children 4 to 10 years: Mean range: 11.6 to 13.6 days (range: 6.5 to 33 days) (Price 1999); Adults: ~3 weeks (range: 2 to 4 weeks); may be decreased during infection (2 weeks) (WHO 2010)

Protein Binding

~98%

Use: Labeled Indications

Treatment of mild-to-moderate acute malarial infections and prevention of malaria caused by Plasmodium falciparum (including chloroquine-resistant strains) or P. vivax

Note: Due to geographical resistance and cross-resistance, consult current CDC guidelines.

Use: Unlabeled

Treatment of uncomplicated, chloroquine-resistant P. vivax malaria

Contraindications

Hypersensitivity to mefloquine, related compounds (eg, quinine and quinidine), or any component of the formulation; prophylactic use in patients with a history of seizures or psychiatric disorder (including active or recent history of depression, generalized anxiety disorder, psychosis, schizophrenia, or other major psychiatric disorders)

Dosing: Adult

Malaria: Oral (dose expressed as mg of mefloquine hydrochloride):

Mild-to-moderate, treatment: 1250 mg (5 tablets) as a single dose. Note: If clinical improvement is not seen within 48-72 hours, an alternative therapy should be used for re-treatment.

Uncomplicated, treatment (off-label dose): 750 mg (3 tablets) as initial dose, followed 6-12 hours later by 500 mg (2 tablets) (CDC, 2013b)

Uncomplicated, chloroquine-resistant P. vivax malaria treatment (off-label use): 750 mg (3 tablets) as initial dose, followed 6-12 hours later by 500 mg (2 tablets) with concomitant primaquine (CDC, 2013b)

Chemoprophylaxis: 250 mg weekly starting 1 week (CDC, 2014: ≥2 weeks) before arrival in endemic area, continuing weekly during travel and for 4 weeks after leaving endemic area. Note: Prophylaxis may begin 2-3 weeks prior to travel to ensure tolerance.

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

Malaria: Children ≥6 months: Oral (dose expressed as mg of mefloquine hydrochloride):

Mild-to-moderate, treatment: 20-25 mg/kg/day in 2 divided doses, taken 6-8 hours apart (maximum total dose: 1250 mg). Note: If clinical improvement is not seen within 48-72 hours, an alternative therapy should be used for re-treatment.

Uncomplicated, treatment (off-label dose): 15 mg/kg, followed 6-12 hours later by 10 mg/kg/dose (maximum total dose: 1250 mg) (CDC, 2013b)

Uncomplicated, chloroquine-resistant P. vivax malaria treatment (off-label use): 15 mg/kg, followed 6-12 hours later by 10 mg/kg/dose (maximum total dose: 1250 mg) with concomitant primaquine (CDC, 2013b)

Chemoprophylaxis: 5 mg/kg/dose once weekly (maximum dose: 250 mg) starting 1 week (CDC, 2014: ≥2 weeks) before arrival in endemic area, continuing weekly during travel and for 4 weeks after leaving endemic area. Note: Prophylaxis may begin 2-3 weeks prior to travel to ensure tolerance.

Manufacturer’s labeling:

20-30 kg: 1/2 of 250 mg tablet (125 mg) once weekly

30-45 kg: 3/4 of 250 mg tablet (187.5 mg) once weekly

>45 kg: One tablet (250 mg) once weekly

Off-label dosing (CDC, 2014):

≤9 kg: 5 mg/kg/dose once weekly

>9-19 kg: 1/4 of 250 mg tablet (62.5 mg) once weekly

>19-30 kg: 1/2 of 250 mg tablet (125 mg) once weekly

>30-45 kg: 3/4 of 250 mg tablet (187.5 mg) once weekly

>45 kg: One tablet (250 mg) once weekly

Dosing: Renal Impairment

No dosage adjustment necessary; only a small amount of mefloquine is renally eliminated.

Dosing: Hepatic Impairment

No dosage adjustment provided in manufacturer's labeling; however, half-life may be prolonged and plasma levels may be higher in patients with hepatic impairment.

Administration

Administer with food and with at least 8 oz of water. When used for malaria prophylaxis, dose should be taken once weekly on the same day each week. If vomiting occurs within 30 minutes after the dose, an additional full dose should be given; if it occurs within 30-60 minutes after dose, an additional half-dose should be given. Tablets may be crushed and suspended in a small amount of water, milk, or another beverage for persons unable to swallow tablets.

Dietary Considerations

Take with food and with at least 8 oz of water.

Storage

Store at 20°C to 25°C (68°F to 77°F).

Drug Interactions

Afatinib: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Afatinib. Management: Per US labeling: reduce afatinib by 10mg if not tolerated. Per Canadian labeling: avoid combination if possible; if used, administer the P-gp inhibitor simultaneously with or after the dose of afatinib. Consider therapy modification

Aminoquinolines (Antimalarial): May enhance the adverse/toxic effect of Mefloquine. Specifically, the risk for QTc-prolongation and the risk for convulsions may be increased. Mefloquine may increase the serum concentration of Aminoquinolines (Antimalarial). Management: Avoid concurrent use, and delay administration of mefloquine until at least 12 hours after the last dose of an aminoquinoline antimalarial when possible. Avoid combination

Amodiaquine: May enhance the adverse/toxic effect of Mefloquine. Specifically, the risk for vision problems may be increased. Monitor therapy

Anticonvulsants: Mefloquine may diminish the therapeutic effect of Anticonvulsants. Mefloquine may decrease the serum concentration of Anticonvulsants. Management: Mefloquine is contraindicated for malaria prophylaxis in persons with a history of convulsions. Monitor anticonvulsant concentrations and treatment response closely with concurrent use. Consider therapy modification

Antipsychotic Agents (Phenothiazines): Antimalarial Agents may increase the serum concentration of Antipsychotic Agents (Phenothiazines). Monitor therapy

Aprepitant: May increase the serum concentration of CYP3A4 Substrates. Monitor therapy

Artemether: May enhance the adverse/toxic effect of Antimalarial Agents. Management: Artemether/Lumefantrine (combination product) should not be used with other antimalarials unless there is no other treatment option. Avoid combination

Bosentan: May decrease the serum concentration of CYP3A4 Substrates. Monitor therapy

Bosutinib: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Bosutinib. Avoid combination

Brentuximab Vedotin: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Brentuximab Vedotin. Specifically, concentrations of the active monomethyl auristatin E (MMAE) component may be increased. Monitor therapy

Colchicine: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Colchicine. Colchicine distribution into certain tissues (e.g., brain) may also be increased. Management: Colchicine is contraindicated in patients with impaired renal or hepatic function who are also receiving a p-glycoprotein inhibitor. In those with normal renal and hepatic function, reduce colchicine dose as directed. Consider therapy modification

Conivaptan: May increase the serum concentration of CYP3A4 Substrates. Avoid combination

CYP3A4 Inducers (Moderate): May decrease the serum concentration of CYP3A4 Substrates. Monitor therapy

CYP3A4 Inducers (Strong): May increase the metabolism of CYP3A4 Substrates. Management: Consider an alternative for one of the interacting drugs. Some combinations may be specifically contraindicated. Consult appropriate manufacturer labeling. Consider therapy modification

CYP3A4 Inhibitors (Moderate): May decrease the metabolism of CYP3A4 Substrates. Monitor therapy

CYP3A4 Inhibitors (Strong): May decrease the metabolism of CYP3A4 Substrates. Consider therapy modification

Dabigatran Etexilate: P-glycoprotein/ABCB1 Inhibitors may increase serum concentrations of the active metabolite(s) of Dabigatran Etexilate. Management: Dabigatran dose reductions may be needed. Specific recommendations vary considerably according to US vs Canadian labeling, specific P-gp inhibitor, renal function, and indication for dabigatran treatment. Refer to full monograph or dabigatran labeling. Consider therapy modification

Dabrafenib: May decrease the serum concentration of CYP3A4 Substrates. Management: Seek alternatives to the CYP3A4 substrate when possible. If concomitant therapy cannot be avoided, monitor clinical effects of the substrate closely (particularly therapeutic effects). Consider therapy modification

Dapsone (Systemic): Antimalarial Agents may enhance the adverse/toxic effect of Dapsone (Systemic). Specifically, concomitant use of antimalarial agents with dapsone may increase the risk of hemolytic reactions. Dapsone (Systemic) may enhance the adverse/toxic effect of Antimalarial Agents. Specifically, concomitant use of dapsone with antimalarial agents may increase the risk for hemolytic reactions. Management: Closely monitor patients for signs/symptoms of hemolytic reactions with concomitant use of dapsone and antimalarial agents, particularly in patients deficient in glucose-6-phosphate dehydrogenase (G6PD), methemoglobin reductase, or with hemoglobin M. Consider therapy modification

Dapsone (Topical): Antimalarial Agents may enhance the adverse/toxic effect of Dapsone (Topical). Specifically, the risk of hemolytic reactions may be increased. Management: Closely monitor for signs/symptoms of hemolytic reactions with concomitant use of topical dapsone and antimalarial agents. Patients with glucose-6-phosphate dehydrogenase deficiency may be at particularly high risk for adverse hematologic effects. Consider therapy modification

Dasatinib: May increase the serum concentration of CYP3A4 Substrates. Monitor therapy

Deferasirox: May decrease the serum concentration of CYP3A4 Substrates. Monitor therapy

DOXOrubicin (Conventional): P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of DOXOrubicin (Conventional). Management: Seek alternatives to P-glycoprotein inhibitors in patients treated with doxorubicin whenever possible. One U.S. manufacturer (Pfizer Inc.) recommends that these combinations be avoided. Consider therapy modification

Edoxaban: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Edoxaban. Management: See full monograph for details. Reduced doses are recommended for patients receiving edoxaban for venous thromboembolism in combination with certain inhibitors. Similar dose adjustment is not recommended for edoxaban use in atrial fibrillation. Consider therapy modification

Enzalutamide: May decrease the serum concentration of CYP3A4 Substrates. Management: Concurrent use of enzalutamide with CYP3A4 substrates that have a narrow therapeutic index should be avoided. Use of enzalutamide and any other CYP3A4 substrate should be performed with caution and close monitoring. Consider therapy modification

Everolimus: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Everolimus. Management: Everolimus dose reductions are required for patients being treated for subependymal giant cell astrocytoma or renal cell carcinoma. See prescribing information for specific dose adjustment and monitoring recommendations. Consider therapy modification

Fosaprepitant: May increase the serum concentration of CYP3A4 Substrates. Monitor therapy

Fusidic Acid (Systemic): May increase the serum concentration of CYP3A4 Substrates. Avoid combination

Halofantrine: Mefloquine may enhance the QTc-prolonging effect of Halofantrine. Avoid combination

Highest Risk QTc-Prolonging Agents: QTc-Prolonging Agents (Indeterminate Risk and Risk Modifying) may enhance the QTc-prolonging effect of Highest Risk QTc-Prolonging Agents. Management: Avoid such combinations when possible. Use should be accompanied by close monitoring for evidence of QT prolongation or other alterations of cardiac rhythm. Consider therapy modification

Idelalisib: May increase the serum concentration of CYP3A4 Substrates. Avoid combination

Ivacaftor: May increase the serum concentration of CYP3A4 Substrates. Monitor therapy

Luliconazole: May increase the serum concentration of CYP3A4 Substrates. Monitor therapy

Lumefantrine: Antimalarial Agents may enhance the adverse/toxic effect of Lumefantrine. Management: Artemether/Lumefantrine (combination product) should not be used with other antimalarials unless there is no other treatment option. Avoid combination

MiFEPRIStone: May increase the serum concentration of CYP3A4 Substrates. Management: Minimize doses of CYP3A4 substrates, and monitor for increased concentrations/toxicity, during and 2 weeks following treatment with mifepristone. Avoid cyclosporine, dihydroergotamine, ergotamine, fentanyl, pimozide, quinidine, sirolimus, and tacrolimus. Consider therapy modification

MiFEPRIStone: May enhance the QTc-prolonging effect of QTc-Prolonging Agents (Indeterminate Risk and Risk Modifying). Management: Though the drugs listed here have uncertain QT-prolonging effects, they all have some possible association with QT prolongation and should generally be avoided when possible. Consider therapy modification

Mitotane: May decrease the serum concentration of CYP3A4 Substrates. Management: Doses of CYP3A4 substrates may need to be adjusted substantially when used in patients being treated with mitotane. Consider therapy modification

Moderate Risk QTc-Prolonging Agents: QTc-Prolonging Agents (Indeterminate Risk and Risk Modifying) may enhance the QTc-prolonging effect of Moderate Risk QTc-Prolonging Agents. Monitor therapy

Naloxegol: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Naloxegol. Monitor therapy

Netupitant: May increase the serum concentration of CYP3A4 Substrates. Monitor therapy

Palbociclib: May increase the serum concentration of CYP3A4 Substrates. Monitor therapy

PAZOPanib: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of PAZOPanib. Avoid combination

P-glycoprotein/ABCB1 Substrates: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of P-glycoprotein/ABCB1 Substrates. P-glycoprotein inhibitors may also enhance the distribution of p-glycoprotein substrates to specific cells/tissues/organs where p-glycoprotein is present in large amounts (e.g., brain, T-lymphocytes, testes, etc.). Monitor therapy

Prucalopride: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Prucalopride. Monitor therapy

QuiNIDine: May enhance the adverse/toxic effect of Mefloquine. Specifically, the risk for QTc-prolongation and the risk for convulsions may be increased. Management: Avoid concurrent use, and delay administration of mefloquine until at least 12 hours after the last dose of quinidine when possible. Avoid combination

QuiNINE: May enhance the adverse/toxic effect of Mefloquine. Specifically, the risk for QTc-prolongation and the risk for convulsions may be increased. Mefloquine may increase the serum concentration of QuiNINE. Management: Avoid concurrent use, and delay administration of mefloquine until at least 12 hours after the last dose of quinine when possible. Avoid combination

Ranolazine: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Ranolazine. Monitor therapy

RifAXIMin: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of RifAXIMin. Monitor therapy

Silodosin: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Silodosin. Avoid combination

Siltuximab: May decrease the serum concentration of CYP3A4 Substrates. Monitor therapy

Simeprevir: May increase the serum concentration of CYP3A4 Substrates. Monitor therapy

St John's Wort: May decrease the serum concentration of CYP3A4 Substrates. Management: Consider an alternative for one of the interacting drugs. Some combinations may be specifically contraindicated. Consult appropriate manufacturer labeling. Consider therapy modification

Stiripentol: May increase the serum concentration of CYP3A4 Substrates. Management: Use of stiripentol with CYP3A4 substrates that are considered to have a narrow therapeutic index should be avoided due to the increased risk for adverse effects and toxicity. Any CYP3A4 substrate used with stiripentol requires closer monitoring. Consider therapy modification

Tocilizumab: May decrease the serum concentration of CYP3A4 Substrates. Monitor therapy

Topotecan: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Topotecan. Avoid combination

Venetoclax: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Venetoclax. Management: Reduce the venetoclax dose by at least 50% in patients requiring these combinations. Consider therapy modification

VinCRIStine (Liposomal): P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of VinCRIStine (Liposomal). Avoid combination

Adverse Reactions

1% to 10%:

Central nervous system: Chills, dizziness, fatigue, headache

Dermatologic: Skin rash

Gastrointestinal: Vomiting (3%), abdominal pain, decreased appetite, diarrhea, nausea

Neuromuscular & skeletal: Myalgia

Otic: Tinnitus

Miscellaneous: Fever

<1% (Limited to important or life-threatening): Abnormal dreams, abnormal T waves on ECG, aggressive behavior, agitation, alopecia, anxiety, arthralgia, ataxia, atrioventricular block, auditory impairment, bradycardia, brain disease, cardiac arrhythmia, cardiac conduction disturbance (transient), chest pain, confusion, decreased hematocrit, depression, diaphoresis, drowsiness, dyspepsia, dyspnea, edema, emotional lability, erythema, erythema multiforme, extrasystoles, flushing, forgetfulness, hallucination, hypersensitivity pneumonitis, hypertension, hypotension, increased liver enzymes, insomnia, irregular pulse, leukocytosis, leukopenia, loss of balance, malaise, mood changes, muscle cramps, myasthenia, palpitations, panic attack, paranoia, paresthesia, prolonged Q-T interval on ECG, pruritus, psychosis, restlessness, seizure, Stevens-Johnson syndrome, suicidal ideation (causal relationship not established), suicidal tendencies (causal relationship not established), syncope, tachycardia, thrombocytopenia, tremor, urticaria, vertigo, visual disturbance, weakness

ALERT: U.S. Boxed Warning

Neuropsychiatric disorders:

Mefloquine should not be prescribed for prophylaxis in patients with major psychiatric disorders. During prophylactic use, if psychiatric or neurologic symptoms occur, the drug should be discontinued and an alternative medication should be substituted.

Neuropsychiatric effects:

Mefloquine may cause neuropsychiatric adverse reactions that can persist after mefloquine has been discontinued.

Warnings/Precautions

Concerns related to adverse effects:

• Agranulocytosis/aplastic anemia: Agranulocytosis and aplastic anemia have been reported with use.

• Altered cardiac conduction: Mefloquine may cause alterations in the ECG including sinus bradycardia, sinus arrhythmia, first-degree AV block, QT-interval prolongation, and abnormal T waves. Use caution or avoid concomitant use of agents known to cause QT-interval prolongation (eg, halofantrine, quinine, quinidine).

• Hypersensitivity reactions: Hypersensitivity reactions ranging from mild skin reactions to anaphylaxis have occurred.

• Neuropsychiatric effects: [U.S. Boxed Warning]: May cause neuropsychiatric adverse effects that can persist after mefloquine has been discontinued. During prophylactic use, if symptoms occur, discontinue therapy and substitute an alternative medication. Symptoms may develop early in the course of therapy. Due to the difficulty in identifying these symptoms in infants and children, monitor closely especially in pediatric patients. Psychiatric symptoms may include anxiety, paranoia, depression, hallucinations, and psychosis. Suicidal ideation and suicide have also been reported. Neurologic symptoms of dizziness or vertigo, tinnitus, and loss of balance may also occur and have been reported to be permanent in some cases. During prophylactic use, the occurrence of psychiatric symptoms such as acute anxiety, depression, restlessness, or confusion may be a prodrome to more serious neuropsychiatric adverse reactions. Use caution in activities requiring alertness and fine motor coordination (eg, driving, piloting planes, operating machinery) with neurologic symptoms.

Disease-related concerns:

• Cardiovascular disease: Use with caution in patients with significant cardiac disease; ECG changes (eg, sinus bradycardia, sinus arrhythmia, first-degree AV block, QT-interval prolongation, abnormal T waves) have been reported.

• Hepatic impairment: Use with caution in patients with hepatic impairment; elimination may be prolonged.

• Neuropsychiatric disorders: [U.S. Boxed Warning]: Do not prescribe for prophylaxis in patients with major psychiatric disorders including patients with active depression, generalized anxiety disorder, psychosis, or schizophrenia; use is contraindicated in these patients. Use with caution in patients with a previous history of depression.

Plasmodium falciparum infections: Appropriate use: In cases of life-threatening, serious, or overwhelming malaria infections due to Plasmodium falciparum, patients should be treated with intravenous antimalarial drug. Mefloquine may be given orally to complete the course.

Plasmodium vivax infections: Appropriate use: In cases of acute Plasmodium vivax infection treated with mefloquine, patients should subsequently be treated with an 8-aminoquinoline derivative (eg, primaquine) to avoid relapse.

• Seizure disorder: When using for treatment, use with caution in patients with a history of seizures; increase risk of seizures. Prophylactic use is contraindicated in patients with seizure disorder (WHO, 2010).

Concurrent drug therapy issues:

• Chloroquine: Concurrent use with chloroquine may increase risk of seizures (WHO, 2010).

• 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:

• Pediatric: Early vomiting leading to treatment failure in children has been reported in some studies; consider alternate therapy if a second dose is not tolerated.

Other warnings/precautions:

• Appropriate use: Not recommended for the treatment of malaria acquired in Southeast Asia due to drug resistance (CDC, 2013b).

• Prolonged use: If mefloquine is to be used for a prolonged period, liver function tests, evaluations for neuropsychiatric effects, and ophthalmic examinations should be performed periodically. (Retinal abnormalities have not been observed with mefloquine in humans; however, abnormalities have been reported with long-term administration to rats.)

Monitoring Parameters

When use is prolonged, periodic liver function tests, evaluations for neuropsychiatric effects, and ocular examinations

Pregnancy Risk Factor

B

Pregnancy Considerations

Adverse events have been observed in animal reproduction studies. Mefloquine crosses the placenta; however, clinical experience with mefloquine has not shown adverse effects in pregnant women. Use with caution during pregnancy if travel to endemic areas cannot be postponed. Malaria infection in pregnant women may be more severe than in nonpregnant women and may increase the risk of adverse pregnancy outcomes. Nonpregnant women of childbearing potential are advised to use contraception and avoid pregnancy during malaria prophylaxis and for 3 months thereafter. In case of an unplanned pregnancy, treatment with mefloquine is not considered a reason for pregnancy termination. CDC treatment guidelines are available for the use of mefloquine in the treatment of malaria during pregnancy (CDC, 2013b).

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 headache, nausea, vomiting, abdominal pain, diarrhea, lack of appetite, or muscle pain. Have patient report immediately to prescriber signs of liver problems (dark urine, feeling tired, lack of appetite, nausea, abdominal pain, light-colored stools, vomiting, or yellow skin or eyes), dizziness, change in balance, tinnitus, anxiety, paranoia, depression, seizures, illogical thinking, mood changes, behavioral changes, hallucination, angina, tachycardia, flu-like symptoms, vision changes, memory impairment, insomnia, or suicidal ideation (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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