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| Product NDC Code | 59385-055 | ||||||
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| Drug Name | Elyxyb - celecoxib |
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| Type | Brand | ||||||
| Pharm Class | Anti-Inflammatory Agents, Non-Steroidal [CS], Cyclooxygenase Inhibitors [MoA], Nonsteroidal Anti-inflammatory Drug [EPC] |
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| Route | ORAL | ||||||
| Dosage Form | LIQUID | ||||||
| RxCUI drug identifier | 2373454, 2373460 |
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| Application Number | NDA212157 | ||||||
| Labeler Name | BioDelivery Sciences International Inc | ||||||
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Overdosage of ELYXYB - celecoxib
Information about signs, symptoms, and laboratory findings of acute ovedosage and the general principles of overdose treatment.10 OVERDOSAGE Symptoms following acute NSAID overdosages have been typically limited to lethargy, drowsiness, nausea, vomiting, and epigastric pain, which have been generally reversible with supportive care. Gastrointestinal bleeding has occurred. Hypertension, acute renal failure, respiratory depression, and coma have occurred, but were rare [see Warnings and Precautions (5.1 , 5.2 , 5.4 , 5.6) ]. No overdoses of celecoxib were reported during clinical trials. No information is available regarding the removal of celecoxib by hemodialysis, but based on its high degree of plasma protein binding (>97%), dialysis is unlikely to be useful in overdose. Manage patients with symptomatic and supportive care following an NSAID overdosage. There are no specific antidotes. Consider emesis and/or activated charcoal (60 to 100 grams in adults, 1 to 2 grams per kg of body weight in pediatric patients) and/or osmotic cathartic in symptomatic patients seen within four hours of ingestion or in patients with a large overdosage (5 to 10 times the recommended dosage). Forced diuresis, alkalinization of urine, hemodialysis, or hemoperfusion may not be useful due to high protein binding. For additional information about overdosage treatment contact a poison control center.
Adverse reactions
Information about undesirable effects, reasonably associated with use of the drug, that may occur as part of the pharmacological action of the drug or may be unpredictable in its occurrence. Adverse reactions include those that occur with the drug, and if applicable, with drugs in the same pharmacologically active and chemically related class. There is considerable variation in the listing of adverse reactions. They may be categorized by organ system, by severity of reaction, by frequency, by toxicological mechanism, or by a combination of these.6 ADVERSE REACTIONS The following adverse reactions are discussed in greater detail in other sections of the labeling: Cardiovascular Thrombotic Events [see Warnings and Precautions (5.1) ] GI Bleeding, Ulceration, and Perforation [see Warnings and Precautions (5.2) ] Hepatotoxicity [see Warnings and Precautions (5.3) ] Hypertension [see Warnings and Precautions (5.4) ] Heart Failure and Edema [see Warnings and Precautions (5.5) ] Renal Toxicity and Hyperkalemia [see Warnings and Precautions (5.6) ] Anaphylactic Reactions [see Warnings and Precautions (5.7) ] Exacerbation of Asthma Related to Aspirin Sensitivity [see Warnings and Precautions (5.8) ] Serious Skin Reactions [see Warnings and Precautions (5.9) ] Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) [see Warnings and Precautions (5.10) ] Medication Overuse Headache [see Warnings and Precautions (5.11) ] Fetal Toxicity [see Warnings and Precautions (5.12) ] Hematologic Toxicity [see Warnings and Precautions (5.13) ] Most common adverse reaction (at least 3% and greater than placebo) is dysgeusia ( 6.1 ) To report SUSPECTED ADVERSE REACTIONS, contact BioDelivery Sciences International, Inc. at 1-800-469-0261or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch 6.1 Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to the rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety of ELYXYB was evaluated in 815 patients who received at least one dose of ELYXYB in two, randomized, double-blind, placebo-controlled trials (Study 1 and 2) in adult patients with migraine [see Clinical Studies (14) ]. The most common (at least 2% of patients who received ELYXYB and greater than placebo) adverse reaction in Study 1 and Study 2 was dysgeusia, which occurred in 3% of patients who received ELYXB compared to 1% of patients who received placebo. 6.2 Postmarketing Experience The following adverse reactions have been identified during post-approval use of celecoxib. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Cardiovascular: Vasculitis, deep venous thrombosis General: Anaphylactic reaction, angioedema Liver and biliary: Liver necrosis, hepatitis, jaundice, hepatic failure Hemic and lymphatic: Agranulocytosis, aplastic anemia, pancytopenia, leucopenia Metabolic: Hypoglycemia, hyponatremia Nervous: Aseptic meningitis, ageusia, anosmia, fatal intracranial hemorrhage Renal: Interstitial nephritis
ELYXYB - celecoxib Drug Interactions
Information about and practical guidance on preventing clinically significant drug/drug and drug/food interactions that may occur in people taking the drug.7 DRUG INTERACTIONS See Table 1 for clinically significant drug interactions with celecoxib. Table 1: Clinically Significant Drug Interactions with Celecoxib Drugs That Interfere with Hemostasis Clinical Impact Celecoxib and anticoagulants such as warfarin have a synergistic effect on bleeding. The concomitant use of celecoxib and anticoagulants have an increased risk of serious bleeding compared to the use of either drug alone. Serotonin release by platelets plays an important role in hemostasis. Case-control and cohort epidemiological studies showed that concomitant use of drugs that interfere with serotonin reuptake and an NSAID may potentiate the risk of bleeding more than an NSAID alone. Intervention Monitor patients with concomitant use of ELYXYB with anticoagulants (e.g., warfarin), antiplatelet drugs (e.g., aspirin), SSRIs, and SNRIs for signs of bleeding [see Warnings and Precautions (5.13) ]. Aspirin Clinical Impact In a clinical study, the concomitant use of an NSAID and aspirin was associated with a significantly increased incidence of GI adverse reactions as compared to use of the NSAID alone [see Warnings and Precautions (5.2) ]. In two studies in healthy volunteers and in patients with established heart disease respectively, celecoxib (200 mg to 400 mg daily) has demonstrated a lack of interference with the cardioprotective antiplatelet effect of aspirin (100 mg to 325 mg). Intervention Concomitant use of ELYXYB and analgesic doses of aspirin is not generally recommended because of the increased risk of bleeding [see Warnings and Precautions (5.13) ]. ELYXYB is not a substitute for low dose aspirin for cardiovascular protection. ACE Inhibitors, Angiotensin Receptor Blockers, and Beta-Blockers Clinical Impact NSAIDs may diminish the antihypertensive effect of ACE inhibiters, ARBs, or beta-blockers (including propranolol). In patients who are elderly, volume-depleted (including those on diuretic therapy), or have renal impairment, co-administration of an NSAID with ACE inhibitors or ARBs may result in deterioration of renal function, including possible acute renal failure. These effects are usually reversible. Intervention During concomitant use of ELYXYB and ACE inhibitors, ARBs, or beta-blockers, monitor blood pressure to ensure that the desired blood pressure is obtained. During concomitant use of ELYXYB and ACE inhibitors or ARBs in patients who are elderly, volume-depleted, or have impaired renal function, monitor for signs of worsening renal function [see Warnings and Precautions (5.6) ]. When these drugs are administered concomitantly, patients should be adequately hydrated. Assess renal function at the beginning of the concomitant treatment and periodically thereafter. Diuretics Clinical Impact Clinical studies, as well as postmarketing observations, showed that NSAIDs reduced the natriuretic effect of loop diuretics (e.g., furosemide) and thiazide diuretics in some patients. This effect has been attributed to the NSAID inhibition of renal prostaglandin synthesis. Intervention During concomitant use of ELYXYB with diuretics, observe patients for signs of worsening renal function, in addition to assuring diuretic efficacy including antihypertensive effects [see Warnings and Precautions (5.6) ]. Digoxin Clinical Impact The concomitant use of celecoxib with digoxin has been reported to increase the serum concentration and prolong the half-life of digoxin. Intervention During concomitant use of ELYXYB and digoxin, monitor serum digoxin levels. Lithium Clinical Impact NSAIDs have produced elevations in plasma lithium levels and reductions in renal lithium clearance . The mean minimum lithium concentration increased 15%, and the renal clearance decreased by approximately 20%. This effect has been attributed to NSAID inhibition of renal prostaglandin synthesis. Intervention During concomitant use of ELYXYB and lithium, monitor patients for signs of lithium toxicity. Methotrexate Clinical Impact Concomitant use of NSAIDs and methotrexate may increase the risk for methotrexate toxicity (e.g., neutropenia, thrombocytopenia, renal dysfunction). Celecoxib has no effect on methotrexate pharmacokinetics. Intervention During concomitant use of ELYXYB and methotrexate, monitor patients for methotrexate toxicity. Cyclosporine Clinical Impact Concomitant use of celecoxib and cyclosporine may increase cyclosporine's nephrotoxicity. Intervention During concomitant use of ELYXYB and cyclosporine, monitor patients for signs of worsening renal function. NSAIDs and Salicylates Clinical Impact Concomitant use of celecoxib with other NSAIDs or salicylates (e.g., diflunisal, salsalate) increases the risk of GI toxicity [see Warnings and Precautions (5.2) ]. Intervention The concomitant use of ELYXYB with other NSAIDs or salicylates is not recommended. Pemetrexed Clinical Impact Concomitant use of celecoxib and pemetrexed may increase the risk of pemetrexed-associated myelosuppression, renal, and GI toxicity (see the pemetrexed prescribing information). Intervention During concomitant use of ELYXYB and pemetrexed, in patients with renal impairment whose creatinine clearance ranges from 45 to 79 mL/min, monitor for myelosuppression, renal, and GI toxicity. NSAIDs with short elimination half-lives (e.g., diclofenac, indomethacin) should be avoided for a period of two days before, the day of, and two days following administration of pemetrexed. In the absence of data regarding potential interaction between pemetrexed and NSAIDs with longer half-lives (e.g., meloxicam, nabumetone), patients taking these NSAIDs should interrupt dosing for at least five days before, the day of, and two days following pemetrexed administration. CYP2C9 Inhibitors or inducers Clinical Impact Celecoxib metabolism is predominantly mediated via cytochrome P450 (CYP) 2C9 in the liver. Co-administration of ELYXYB with drugs that are known to inhibit CYP2C9 (e.g., fluconazole) may enhance the exposure and toxicity of celecoxib whereas co-administration with CYP2C9 inducers (e.g., rifampin) may lead to compromised efficacy of ELYXYB. Intervention Evaluate each patient's medical history when consideration is given to prescribing ELYXYB. A dosage adjustment may be warranted when ELYXYB is administered with CYP2C9 inhibitors or inducers. CYP2D6 substrates Clinical Impact In vitro studies indicate that celecoxib, although not a substrate, is an inhibitor of CYP2D6. Therefore, there is a potential for an in vivo drug interaction with drugs that are metabolized by CYP2D6 (e.g., atomoxetine), and celecoxib may enhance the exposure and toxicity of these drugs. Intervention Evaluate each patient's medical history when consideration is given to prescribing ELYXYB. A dosage adjustment may be warranted when ELYXYB is administered with CYP2D6 substrates. Corticosteroids Clinical Impact Concomitant use of corticosteroids with celecoxib may increase the risk of GI ulceration or bleeding. Intervention Monitor patients with concomitant use of ELYXYB with corticosteroids for signs of bleeding [see Warnings and Precautions (5.2) ]. Drugs that Interfere with Hemostasis (e.g., warfarin, aspirin, SSRIs/SNRIs) : Monitor patients for bleeding who are concomitantly taking ELYXYB with drugs that interfere with hemostasis. Concomitant use of ELYXYB and analgesic doses of aspirin is not generally recommended ( 7 ) ACE Inhibitors, Angiotensin Receptor Blockers (ARB), or Beta- Blockers : Concomitant use with ELYXYB may diminish the antihypertensive effect of these drugs. Monitor blood pressure ( 7 ) ACE Inhibitors and ARBs : Concomitant use with ELYXYB in elderly, volume depleted, or those with renal impairment may result in deterioration of renal function. In such high-risk patients, monitor for signs of worsening renal function ( 7 ) Diuretics : NSAIDs can reduce natriuretic effect of furosemide and thiazide diuretics. Monitor patients to assure diuretic efficacy including antihypertensive effects ( 7 ) Digoxin : Concomitant use with ELYXYB can increase serum concentration and prolong half-life of digoxin. Monitor serum digoxin levels ( 7 )
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| Monitor patients with concomitant use of ELYXYB with anticoagulants (e.g., warfarin), antiplatelet drugs (e.g., aspirin), SSRIs, and SNRIs for signs of bleeding | |
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| Concomitant use of ELYXYB and analgesic doses of aspirin is not generally recommended because of the increased risk of bleeding | |
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| Clinical studies, as well as postmarketing observations, showed that NSAIDs reduced the natriuretic effect of loop diuretics (e.g., furosemide) and thiazide diuretics in some patients. This effect has been attributed to the NSAID inhibition of renal prostaglandin synthesis. | |
| During concomitant use of ELYXYB with diuretics, observe patients for signs of worsening renal function, in addition to assuring diuretic efficacy including antihypertensive effects | |
| The concomitant use of celecoxib with digoxin has been reported to increase the serum concentration and prolong the half-life of digoxin. | |
| During concomitant use of ELYXYB and digoxin, monitor serum digoxin levels. | |
| NSAIDs have produced elevations in plasma lithium levels and reductions in renal lithium clearance | |
| During concomitant use of ELYXYB and lithium, monitor patients for signs of lithium toxicity. | |
| Concomitant use of NSAIDs and methotrexate may increase the risk for methotrexate toxicity (e.g., neutropenia, thrombocytopenia, renal dysfunction). Celecoxib has no effect on methotrexate pharmacokinetics. | |
| During concomitant use of ELYXYB and methotrexate, monitor patients for methotrexate toxicity. | |
| Concomitant use of celecoxib and cyclosporine may increase cyclosporine's nephrotoxicity. | |
| During concomitant use of ELYXYB and cyclosporine, monitor patients for signs of worsening renal function. | |
| Concomitant use of celecoxib with other NSAIDs or salicylates (e.g., diflunisal, salsalate) increases the risk of GI toxicity | |
| The concomitant use of ELYXYB with other NSAIDs or salicylates is not recommended. | |
| Concomitant use of celecoxib and pemetrexed may increase the risk of pemetrexed-associated myelosuppression, renal, and GI toxicity (see the pemetrexed prescribing information). | |
| |
| Celecoxib metabolism is predominantly mediated via cytochrome P450 (CYP) 2C9 in the liver. Co-administration of ELYXYB with drugs that are known to inhibit CYP2C9 (e.g., fluconazole) may enhance the exposure and toxicity of celecoxib whereas co-administration with CYP2C9 inducers (e.g., rifampin) may lead to compromised efficacy of ELYXYB. | |
| Evaluate each patient's medical history when consideration is given to prescribing ELYXYB. A dosage adjustment may be warranted when ELYXYB is administered with CYP2C9 inhibitors or inducers. | |
| Evaluate each patient's medical history when consideration is given to prescribing ELYXYB. A dosage adjustment may be warranted when ELYXYB is administered with CYP2D6 substrates. | |
| Concomitant use of corticosteroids with celecoxib may increase the risk of GI ulceration or bleeding. | |
| Monitor patients with concomitant use of ELYXYB with corticosteroids for signs of bleeding | |
Clinical pharmacology
Information about the clinical pharmacology and actions of the drug in humans.12 CLINICAL PHARMACOLOGY 12.1 Mechanism of Action Celecoxib is a nonsteroidal anti-inflammatory drug with analgesic, anti-inflammatory, and antipyretic properties. The mechanism of action by which celecoxib exerts therapeutic effects in migraine patients is not fully understood but may involve inhibition of prostaglandin synthesis, primarily via inhibition of COX-2. 12.2 Pharmacodynamics Platelets In clinical trials using normal volunteers, celecoxib at single doses up to 800 mg and multiple doses of 600 mg twice daily for up to 7 days duration (higher than recommended therapeutic doses) had no effect on reduction of platelet aggregation or increase in bleeding time. Because of its lack of platelet effects, celecoxib is not a substitute for aspirin for cardiovascular prophylaxis. It is not known if there are any effects of celecoxib on platelets that may contribute to the increased risk of serious cardiovascular thrombotic adverse events associated with the use of celecoxib. Fluid Retention Inhibition of PGE2 synthesis may lead to sodium and water retention through increased reabsorption in the renal medullary thick ascending loop of Henle and perhaps other segments of the distal nephron. In the collecting ducts, PGE2 appears to inhibit water reabsorption by counteracting the action of antidiuretic hormone. 12.3 Pharmacokinetics Celecoxib exhibits a dose-proportional increase in exposure after once daily oral administration of 120 to 240 mg doses (2 times the recommended dosage) of ELYXYB. Absorption Following administration of 120 mg of ELYXYB under fasting condition in 24 healthy subjects, the median time to peak plasma levels (i.e., T max ) of celecoxib was 1 hour (range 0.67 to 3.00). Food Effect When ELYXYB was taken with a high-fat meal, the median time to peak plasma levels (i.e., T max ) was delayed by 2 hours with an approximately 50% decrease in C max and no change in total absorption (i.e., AUC) compared to fasting conditions. However, in Study 1 and Study 2, ELYXYB was administered without regard to food [see Dosage and Administration (2.1) , Clinical Studies (14) ]. Distribution In healthy subjects, celecoxib is highly protein bound (~97%) within the clinical dose range. In vitro studies indicate that celecoxib binds primarily to albumin and, to a lesser extent, α1-acid glycoprotein. The apparent volume of distribution following single dose administration of ELYXYB at fasting state is (Vz/F) is approximately 288 L, suggesting extensive distribution into the tissues. Celecoxib is not preferentially bound to red blood cells. Elimination Metabolism Celecoxib metabolism is primarily mediated via CYP2C9. Three metabolites, a primary alcohol, the corresponding carboxylic acid, and its glucuronide conjugate, have been identified in human plasma. These metabolites are inactive as COX-1 or COX-2 inhibitors. Excretion Celecoxib is eliminated predominantly by hepatic metabolism with little (<3%) unchanged drug recovered in the urine and feces. Following a single oral dose of radiolabeled drug, approximately 57% of the dose was excreted in the feces and 27% was excreted into the urine. The primary metabolite in both urine and feces was the carboxylic acid metabolite (73% of dose) with low amounts of the glucuronide also appearing in the urine. The mean apparent elimination t½ of celecoxib from ELYXYB was approximately 6 hours independent of dosing condition and similar to that observed for Celebrex under fed conditions. Specific Populations Geriatric At steady state, elderly subjects (over 65 years old) had a 40% higher C max and a 50% higher AUC compared to the younger subjects for celecoxib oral capsules. In elderly females, celecoxib C max and AUC are higher than those for elderly males, but these increases are predominantly due to lower body weight in elderly females. Dose adjustment in the elderly is not generally necessary. Race Meta-analysis of pharmacokinetic studies conducted using celecoxib oral capsules has suggested an approximately 40% higher AUC of celecoxib in Blacks compared to Caucasians. The cause and clinical significance of this finding is unknown. Hepatic Impairment The effect of hepatic impairment on the pharmacokinetics of ELYXYB has not been evaluated. A pharmacokinetic study in subjects with mild (Child-Pugh Class A) and moderate (Child-Pugh Class B) hepatic impairment conducted using celecoxib oral capsule has shown that steady-state celecoxib AUC is increased about 40% and 180%, respectively, above that seen in healthy control subjects [see Dosage and Administration (2.2) and Use in Specific Populations (8.6) ]. Patients with severe hepatic impairment (Child-Pugh Class C) have not been studied. Renal Impairment In a cross-study comparison done for celecoxib oral capsules, celecoxib AUC was approximately 40% lower in patients with chronic renal impairment (GFR 35-60 mL/min) than that seen in subjects with normal renal function. No significant relationship was found between GFR and celecoxib clearance. Patients with severe renal impairment have not been studied [see Warnings and Precautions (5.6) and Use in Specific Populations (8.6) ]. Drug Interaction Studies In vitro studies indicate that celecoxib is not an inhibitor of cytochrome P450 2C9, 2C19, or 3A4. In vivo studies have shown the following: Aspirin When NSAIDs were administered with aspirin, the protein binding of NSAIDs was reduced, although the clearance of free NSAID was not altered. The clinical significance of this interaction is not known [see Drug Interactions (7) ]. Lithium In a study conducted in healthy subjects, mean steady-state lithium plasma levels increased approximately 17% in subjects receiving lithium 450 mg twice daily with celecoxib 200 mg oral capsule twice daily as compared to subjects receiving lithium alone [see Drug Interactions (7) ]. Fluconazole Concomitant administration of fluconazole at 200 mg once daily resulted in a two-fold increase in celecoxib plasma concentration. This increase is due to the inhibition of celecoxib metabolism via P450 2C9 by fluconazole [see Drug Interactions (7) ]. Other Drugs The effects of celecoxib on the pharmacokinetics and/or pharmacodynamics of glyburide, ketoconazole, phenytoin, and tolbutamide have been studied in vivo using celecoxib oral capsules and clinically important interactions have not been found. 12.5 Pharmacogenomics CYP2C9 activity is reduced in individuals with genetic polymorphisms that lead to reduced enzyme activity, such as those homozygous for the CYP2C9*2 and CYP2C9*3 polymorphisms. Limited data from 4 published reports that included a total of 8 subjects with the homozygous CYP2C9*3/*3 genotype showed celecoxib systemic levels that were 3- to 7-fold higher in these subjects compared to subjects with CYP2C9*1/*1 or *I/*3 genotypes. The pharmacokinetics of celecoxib have not been evaluated in subjects with other CYP2C9 polymorphisms, such as *2, *5, *6, *9, and *11. It is estimated that the frequency of the homozygous *3/*3 genotype is 0.3% to 1.0% in various ethnic groups [see Dosage and Administration (2.3) and Use in Specific Populations (8.8) ].
Mechanism of action
Information about the established mechanism(s) of the drugÕs action in humans at various levels (for example receptor, membrane, tissue, organ, whole body). If the mechanism of action is not known, this field contains a statement about the lack of information.12.1 Mechanism of Action Celecoxib is a nonsteroidal anti-inflammatory drug with analgesic, anti-inflammatory, and antipyretic properties. The mechanism of action by which celecoxib exerts therapeutic effects in migraine patients is not fully understood but may involve inhibition of prostaglandin synthesis, primarily via inhibition of COX-2.
Pharmacodynamics
Information about any biochemical or physiologic pharmacologic effects of the drug or active metabolites related to the drugÕs clinical effect in preventing, diagnosing, mitigating, curing, or treating disease, or those related to adverse effects or toxicity.12.2 Pharmacodynamics Platelets In clinical trials using normal volunteers, celecoxib at single doses up to 800 mg and multiple doses of 600 mg twice daily for up to 7 days duration (higher than recommended therapeutic doses) had no effect on reduction of platelet aggregation or increase in bleeding time. Because of its lack of platelet effects, celecoxib is not a substitute for aspirin for cardiovascular prophylaxis. It is not known if there are any effects of celecoxib on platelets that may contribute to the increased risk of serious cardiovascular thrombotic adverse events associated with the use of celecoxib. Fluid Retention Inhibition of PGE2 synthesis may lead to sodium and water retention through increased reabsorption in the renal medullary thick ascending loop of Henle and perhaps other segments of the distal nephron. In the collecting ducts, PGE2 appears to inhibit water reabsorption by counteracting the action of antidiuretic hormone.
Pharmacokinetics
Information about the clinically significant pharmacokinetics of a drug or active metabolites, for instance pertinent absorption, distribution, metabolism, and excretion parameters.12.3 Pharmacokinetics Celecoxib exhibits a dose-proportional increase in exposure after once daily oral administration of 120 to 240 mg doses (2 times the recommended dosage) of ELYXYB. Absorption Following administration of 120 mg of ELYXYB under fasting condition in 24 healthy subjects, the median time to peak plasma levels (i.e., T max ) of celecoxib was 1 hour (range 0.67 to 3.00). Food Effect When ELYXYB was taken with a high-fat meal, the median time to peak plasma levels (i.e., T max ) was delayed by 2 hours with an approximately 50% decrease in C max and no change in total absorption (i.e., AUC) compared to fasting conditions. However, in Study 1 and Study 2, ELYXYB was administered without regard to food [see Dosage and Administration (2.1) , Clinical Studies (14) ]. Distribution In healthy subjects, celecoxib is highly protein bound (~97%) within the clinical dose range. In vitro studies indicate that celecoxib binds primarily to albumin and, to a lesser extent, α1-acid glycoprotein. The apparent volume of distribution following single dose administration of ELYXYB at fasting state is (Vz/F) is approximately 288 L, suggesting extensive distribution into the tissues. Celecoxib is not preferentially bound to red blood cells. Elimination Metabolism Celecoxib metabolism is primarily mediated via CYP2C9. Three metabolites, a primary alcohol, the corresponding carboxylic acid, and its glucuronide conjugate, have been identified in human plasma. These metabolites are inactive as COX-1 or COX-2 inhibitors. Excretion Celecoxib is eliminated predominantly by hepatic metabolism with little (<3%) unchanged drug recovered in the urine and feces. Following a single oral dose of radiolabeled drug, approximately 57% of the dose was excreted in the feces and 27% was excreted into the urine. The primary metabolite in both urine and feces was the carboxylic acid metabolite (73% of dose) with low amounts of the glucuronide also appearing in the urine. The mean apparent elimination t½ of celecoxib from ELYXYB was approximately 6 hours independent of dosing condition and similar to that observed for Celebrex under fed conditions. Specific Populations Geriatric At steady state, elderly subjects (over 65 years old) had a 40% higher C max and a 50% higher AUC compared to the younger subjects for celecoxib oral capsules. In elderly females, celecoxib C max and AUC are higher than those for elderly males, but these increases are predominantly due to lower body weight in elderly females. Dose adjustment in the elderly is not generally necessary. Race Meta-analysis of pharmacokinetic studies conducted using celecoxib oral capsules has suggested an approximately 40% higher AUC of celecoxib in Blacks compared to Caucasians. The cause and clinical significance of this finding is unknown. Hepatic Impairment The effect of hepatic impairment on the pharmacokinetics of ELYXYB has not been evaluated. A pharmacokinetic study in subjects with mild (Child-Pugh Class A) and moderate (Child-Pugh Class B) hepatic impairment conducted using celecoxib oral capsule has shown that steady-state celecoxib AUC is increased about 40% and 180%, respectively, above that seen in healthy control subjects [see Dosage and Administration (2.2) and Use in Specific Populations (8.6) ]. Patients with severe hepatic impairment (Child-Pugh Class C) have not been studied. Renal Impairment In a cross-study comparison done for celecoxib oral capsules, celecoxib AUC was approximately 40% lower in patients with chronic renal impairment (GFR 35-60 mL/min) than that seen in subjects with normal renal function. No significant relationship was found between GFR and celecoxib clearance. Patients with severe renal impairment have not been studied [see Warnings and Precautions (5.6) and Use in Specific Populations (8.6) ]. Drug Interaction Studies In vitro studies indicate that celecoxib is not an inhibitor of cytochrome P450 2C9, 2C19, or 3A4. In vivo studies have shown the following: Aspirin When NSAIDs were administered with aspirin, the protein binding of NSAIDs was reduced, although the clearance of free NSAID was not altered. The clinical significance of this interaction is not known [see Drug Interactions (7) ]. Lithium In a study conducted in healthy subjects, mean steady-state lithium plasma levels increased approximately 17% in subjects receiving lithium 450 mg twice daily with celecoxib 200 mg oral capsule twice daily as compared to subjects receiving lithium alone [see Drug Interactions (7) ]. Fluconazole Concomitant administration of fluconazole at 200 mg once daily resulted in a two-fold increase in celecoxib plasma concentration. This increase is due to the inhibition of celecoxib metabolism via P450 2C9 by fluconazole [see Drug Interactions (7) ]. Other Drugs The effects of celecoxib on the pharmacokinetics and/or pharmacodynamics of glyburide, ketoconazole, phenytoin, and tolbutamide have been studied in vivo using celecoxib oral capsules and clinically important interactions have not been found.
Contraindications
Information about situations in which the drug product is contraindicated or should not be used because the risk of use clearly outweighs any possible benefit, including the type and nature of reactions that have been reported.4 CONTRAINDICATIONS ELYXYB is contraindicated in the following patients: Known hypersensitivity (e.g., anaphylactic reactions and serious skin reactions) to celecoxib, any components of the drug product [see Warnings and Precautions (5.7 , 5.9) ]. History of asthma, urticaria, or other allergic-type reactions after taking aspirin or other NSAIDs. Severe, sometimes fatal, anaphylactic reactions to NSAIDs have been reported in such patients [see Warnings and Precautions (5.7 , 5.8) ]. In the setting of coronary artery bypass graft (CABG) surgery [see Warnings and Precautions (5.1) ]. In patients who have demonstrated allergic-type reactions to sulfonamides [see Warnings and Precautions (5.7) ]. Known hypersensitivity to celecoxib, any components of the drug product, or sulfonamides ( 4 ) History of asthma, urticaria, or other allergic-type reactions after taking aspirin or other NSAIDs ( 4 ) In the setting of CABG surgery ( 4 )
Description
General information about the drug product, including the proprietary and established name of the drug, the type of dosage form and route of administration to which the label applies, qualitative and quantitative ingredient information, the pharmacologic or therapeutic class of the drug, and the chemical name and structural formula of the drug.11 DESCRIPTION ELYXYB is an oral solution of celecoxib, a nonsteroidal anti-inflammatory drug. Each unit dose of ELYXYB contains 120 mg of celecoxib. Celecoxib is a white or almost white, crystalline or amorphous powder with a pKa of 11. Celecoxib is hydrophobic (log P is 3.0) and practically insoluble in water. Celecoxib is chemically designated as p -[5- p -tolyl-3-(trifluoromethyl) pyrazol-1-yl] benzenesulfonamide. The empirical formula for celecoxib is C 17 H 14 F 3 N 3 O 2 S, and the molecular weight is 381.37. It has the following chemical structure: The inactive ingredients in ELYXYB include: acesulfame potassium, banana flavor, bubble gum flavor, ethyl alcohol, glycerin, glyceryl monocaprylate, L-menthol, lauroyl polyoxyl-32 glycerides, medium chain triglycerides, monoammonium glycyrrhizinate, peppermint flavor, polyoxyl 35 castor oil, polyoxyl 40 hydrogenated castor oil, propyl gallate, purified water, and sucralose. Chemical Structure
Dosage and administration
Information about the drug product’s dosage and administration recommendations, including starting dose, dose range, titration regimens, and any other clinically sigificant information that affects dosing recommendations.2 DOSAGE AND ADMINISTRATION The recommended dose of ELYXYB is 120 mg taken orally, with or without food. ( 2.1 ) The maximum dosage in a 24-hour period is 120 mg. ( 2.1 ) Use ELYXYB for the fewest number of days per month, as needed. ( 2.1 ) Hepatic Impairment: The recommended and maximum dose is 60 mg (2.4 mL) in patients with moderate hepatic impairment (Child-Pugh Class B) ( 2.2 , 8.6 , 12.3 ) Poor Metabolizers of CYP2C9 Substrates: The recommended and maximum dose is 60 mg (2.4 mL) in patients who are known or suspected to be CYP2C9 poor metabolizers ( 2.3 , 8.8 , 12.5 ) 2.1 Recommended Dosage The recommended dose of ELYXYB is 120 mg taken orally, with or without food [see Clinical Pharmacology (12.3) ] . The maximum dosage in a 24-hour period is 120 mg. The safety and effectiveness of a second dose in a 24-hour period have not been established. Use ELYXYB for the fewest number of days per month, as needed. 2.2 Dosage Modification in Patients with Hepatic Impairment The recommended and maximum dose in patients with moderate hepatic impairment (Child-Pugh Class B) is 60 mg (2.4 mL) [see Use in Specific Populations (8.6) and Clinical Pharmacology (12.3) ]. A calibrated measuring device is recommended to measure and deliver the prescribed dose accurately. A household teaspoon or tablespoon is not an adequate measuring device. Use of ELYXYB in patients with severe hepatic impairment is not recommended. 2.3 Dosage Modification in CYP2C9 Poor Metabolizers The recommended and maximum dose in patients who are known or suspected to be CYP2C9 poor metabolizers is 60 mg (2.4 mL) [see Use in Specific Populations (8.8) and Clinical Pharmacology (12.5) ]. A calibrated measuring device is recommended to measure and deliver the prescribed dose accurately. A household teaspoon or tablespoon is not an adequate measuring device.
Dosage forms and strengths
Information about all available dosage forms and strengths for the drug product to which the labeling applies. This field may contain descriptions of product appearance.3 DOSAGE FORMS AND STRENGTHS Dosage form: Clear colorless oral solution Strength: 120 mg/4.8 mL (25 mg/mL) Oral solution, 120 mg/4.8 mL (25 mg/mL) ( 3 )
Indications and usage
A statement of each of the drug products indications for use, such as for the treatment, prevention, mitigation, cure, or diagnosis of a disease or condition, or of a manifestation of a recognized disease or condition, or for the relief of symptoms associated with a recognized disease or condition. This field may also describe any relevant limitations of use.1 INDICATIONS AND USAGE ELYXYB is indicated for the acute treatment of migraine with or without aura in adults. ELYXYB is a nonsteroidal anti-inflammatory drug indicated for the acute treatment of migraine with or without aura in adults ( 1 ) Limitations of Use ELYXYB is not indicated for the preventive treatment of migraine. ( 1 ) Limitations of Use ELYXYB is not indicated for the preventive treatment of migraine.
Spl product data elements
Usually a list of ingredients in a drug product.ELYXYB - celecoxib celecoxib celecoxib celecoxib LAUROYL PEG-32 GLYCERIDES GLYCERYL MONOCAPRYLATE MEDIUM-CHAIN TRIGLYCERIDES POLYOXYL 35 CASTOR OIL POLYOXYL 40 HYDROGENATED CASTOR OIL Propyl gallate LEVOMENTHOL AMMONIUM GLYCYRRHIZATE Sucralose Acesulfame potassium GLYCERIN ALCOHOL PEPPERMINT BANANA
Animal pharmacology and or toxicology
Information from studies of the drug in animals, if the data were not relevant to nor included in other parts of the labeling. Most labels do not contain this field.13.2 Animal Toxicology and/or Pharmacology An increase in the incidence of background findings of spermatocele with or without secondary changes such as epididymal hypospermia as well as minimal to slight dilation of the seminiferous tubules were seen in the juvenile rat. These reproductive findings while apparently treatment-related did not increase in incidence or severity with dose and may indicate an exacerbation of a spontaneous condition. Similar reproductive findings were not observed in studies of juvenile or adult dogs or in adult rats treated with celecoxib. The clinical significance of this observation is unknown.
Carcinogenesis and mutagenesis and impairment of fertility
Information about carcinogenic, mutagenic, or fertility impairment potential revealed by studies in animals. Information from human data about such potential is part of the warnings field.13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility Carcinogenesis Celecoxib was not carcinogenic when administered orally for two years to rats at oral doses up to 200 mg/kg for males and 10 mg/kg for females (associated with plasma exposures (AUC) approximately 14 and 7 times, respectively, that in humans at the maximum recommended human dose (MRHD) of 120 mg/day) or in mice at oral doses up to 25 mg/kg for males and 50 mg/kg for females (associated with plasma AUCs approximately 4 times in humans at the MRHD. Mutagenesis Celecoxib was not mutagenic in an Ames test and a mutation assay in Chinese hamster ovary (CHO) cells, nor clastogenic in a chromosome aberration assay in CHO cells and an in vivo micronucleus test in rat bone marrow. Impairment of Fertility Administration of celecoxib to male and female rats prior to and during mating and continuing in females through implantation had no effect on fertility or male reproductive function at oral doses up to 600 mg/kg/day, which were associated with plasma AUCs approximately 40 times that in humans at the MRHD. Increased implantation loss was observed at doses ≥50 mg/kg/day, which was associated with plasma AUC approximately 20 times that in humans at the MRHD.
Nonclinical toxicology
Information about toxicology in non-human subjects.13 NONCLINICAL TOXICOLOGY 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility Carcinogenesis Celecoxib was not carcinogenic when administered orally for two years to rats at oral doses up to 200 mg/kg for males and 10 mg/kg for females (associated with plasma exposures (AUC) approximately 14 and 7 times, respectively, that in humans at the maximum recommended human dose (MRHD) of 120 mg/day) or in mice at oral doses up to 25 mg/kg for males and 50 mg/kg for females (associated with plasma AUCs approximately 4 times in humans at the MRHD. Mutagenesis Celecoxib was not mutagenic in an Ames test and a mutation assay in Chinese hamster ovary (CHO) cells, nor clastogenic in a chromosome aberration assay in CHO cells and an in vivo micronucleus test in rat bone marrow. Impairment of Fertility Administration of celecoxib to male and female rats prior to and during mating and continuing in females through implantation had no effect on fertility or male reproductive function at oral doses up to 600 mg/kg/day, which were associated with plasma AUCs approximately 40 times that in humans at the MRHD. Increased implantation loss was observed at doses ≥50 mg/kg/day, which was associated with plasma AUC approximately 20 times that in humans at the MRHD. 13.2 Animal Toxicology and/or Pharmacology An increase in the incidence of background findings of spermatocele with or without secondary changes such as epididymal hypospermia as well as minimal to slight dilation of the seminiferous tubules were seen in the juvenile rat. These reproductive findings while apparently treatment-related did not increase in incidence or severity with dose and may indicate an exacerbation of a spontaneous condition. Similar reproductive findings were not observed in studies of juvenile or adult dogs or in adult rats treated with celecoxib. The clinical significance of this observation is unknown.
Package label principal display panel
The content of the principal display panel of the product package, usually including the product’s name, dosage forms, and other key information about the drug product.PRINCIPAL DISPLAY PANEL - 4.8 mL Bottle Carton biodelivery SCIENCES NDC 59385-055-06 Elyxyb™ (celecoxib) Oral Solution 120 mg/4.8 mL (25 mg/mL) For Oral use only Rx Only Discard unused portion immediately after use. Do not store or reuse leftover Elyxyb oral solution. Warning: Keep out of reach of children. Warning: Check the dose your healthcare provider has prescribed. Pharmacist: Dispense in this sealed carton, which contains six (6) unit dose glass bottles. Dispense the enclosed Medication Guide to each patient. PRINCIPAL DISPLAY PANEL - 4.8 mL Bottle Carton
Recent major changes
A list of the section(s) that contain substantive changes that have been approved by FDA in the product labeling. The headings and subheadings, if appropriate, affected by the change are listed together with each section’s identifying number and the month and year on which the change was incorporated in the labeling.Warnings and Precautions ( 5.10 , 5.12 ) 04/2021
| Warnings and Precautions ( | 04/2021 |
Spl unclassified section
Information not classified as belonging to one of the other fields. Approximately 40% of labeling with effective_time between June 2009 and August 2014 have information in this field.ELYXYB is a trademark of BioDelivery Sciences International, Inc. Manufactured for: BioDelivery Sciences International, Inc., Raleigh, NC 27612 USA ©2021 BioDelivery Sciences International, Inc. All rights reserved. ELY-001-PI-Sep2021
ELYXYB - celecoxib: Information for patients
Information necessary for patients to use the drug safely and effectively, such as precautions concerning driving or the concomitant use of other substances that may have harmful additive effects.17 PATIENT COUNSELING INFORMATION Advise the patient to read the FDA-approved patient labeling (Medication Guide and Instructions for Use). Administration Information For patients who are prescribed the recommended dosage of 120 mg, instruct them to drink the entire amount of ELYXYB directly from the bottle. For patients who are prescribed the reduced dosage (i.e., patients with moderate hepatic impairment or CYP2C9 poor metabolizers), instruct them to use an oral dosing syringe to correctly measure the prescribed amount of medication. Inform these patients that oral dosing syringes may be obtained from their pharmacy and that a household teaspoon is not an accurate measuring device. Instruct these patients to discard the unused portion of ELYXYB. Cardiovascular Thrombotic Events Advise patients to be alert for the symptoms of cardiovascular thrombotic events, including chest pain, shortness of breath, weakness, or slurring of speech, and to report any of these symptoms to their health care provider immediately [see Warnings and Precautions (5.1) ]. Gastrointestinal Bleeding, Ulceration, and Perforation Advise patients to report symptoms of ulcerations and bleeding, including epigastric pain, dyspepsia, melena, and hematemesis to their health care provider. In the setting of concomitant use of low-dose aspirin for cardiac prophylaxis, inform patients of the increased risk for and the signs and symptoms of GI bleeding [see Warnings and Precautions (5.2) ]. Hepatotoxicity Inform patients of the warning signs and symptoms of hepatotoxicity (e.g., nausea, fatigue, lethargy, pruritus, diarrhea jaundice, right upper quadrant tenderness, and "flu-like" symptoms). If these occur, instruct patients to stop ELYXYB and seek immediate medical therapy [see Warnings and Precautions (5.3) and Use in Specific Populations (8.6) ]. Heart Failure and Edema Advise patients to be alert for the symptoms of congestive heart failure including shortness of breath, unexplained weight gain, or edema and to contact their healthcare provider if such symptoms occur [see Warnings and Precautions (5.5) ]. Anaphylactic Reactions Inform patients of the signs of an anaphylactic reaction (e.g., difficulty breathing, swelling of the face or throat). Instruct patients to seek immediate emergency help if these occur [see Contraindications (4) and Warnings and Precautions (5.7) ]. Serious Skin Reactions, including DRESS Advise patients to stop taking ELYXYB immediately if they develop any type of rash or fever and to contact their healthcare provider as soon as possible [see Warnings and Precautions (5.9 , 5.10) ]. Medication Overuse Headache Inform patients that use of acute migraine drugs for 10 or more days per month, including ELYXYB, may lead to an exacerbation of headache and encourage patients to record headache frequency and drug use (e.g., by keeping a headache diary). Instruct patients to contact their healthcare provider if the frequency of their migraines increases; withdrawal of ELYXYB may be necessary [see Warnings and Precautions (5.11) ]. Female Fertility Advise females of reproductive potential who desire pregnancy that NSAIDs, including ELYXYB, may be associated with a reversible delay in ovulation [see Use in Specific Populations (8.3) ]. Fetal Toxicity Inform pregnant women to avoid use of ELYXYB and other NSAIDs starting at 30 weeks gestation because of the risk of the premature closing of the fetal ductus arteriosus. If treatment with ELYXYB is needed for a pregnant woman between about 20 to 30 weeks gestation, advise her that she may need to be monitored for oligohydramnios, if treatment continues for longer than 48 hours [see Warnings and Precautions (5.12) and Use in Specific Populations (8.1) ] . Avoid Concomitant Use of NSAIDs Inform patients that the concomitant use of ELYXYB with other NSAIDs or salicylates (e.g., diflunisal, salsalate) is not recommended due to the increased risk of gastrointestinal toxicity, and little or no increase in efficacy [see Warnings and Precautions (5.2) and Drug Interactions (7) ]. Alert patients that NSAIDs may be present in "over the counter" medications for treatment of colds, fever, or insomnia. Use of NSAIDS and Low-Dose Aspirin Inform patients not to use low-dose aspirin concomitantly with ELYXYB until they talk to their healthcare provider [see Drug Interactions (7) ].
Instructions for use
Information about safe handling and use of the drug product.Instructions For Use ELYXYB (ee-lix'-ib) (celecoxib) oral solution 25 mg/mL Read this Instructions for Use before you start taking ELYXYB and each time you get a refill. There may be new information. This leaflet does not take the place of talking to your healthcare provider about your medical condition or treatment. Take ELYXYB exactly how your healthcare provider tells you to. If your healthcare provider has prescribed 120 mg of ELYXYB, take all of the medicine in the bottle as described below in Instructions-1 . If your healthcare provider has prescribed 60 mg of ELYXYB, take 2.4 mL of the medicine, as described in Instructions-2 . You will need a dosing syringe from the pharmacy to give the right amount of medicine. Do not use a household teaspoon to measure ELYXYB. Instructions-1 (Full dose of 120 mg) Step 1 : When you need to take ELYXYB, push down the cap and turn it to the left (counterclockwise) to open it. Step 2 : When taking 120 mg of ELYXYB, drink it directly from the bottle. Hold the bottle upside down for 10 seconds to make sure the full amount of medicine is taken. Step 3 : Close the bottle by turning the cap to the right (clockwise) right away after drinking the medicine. Step 4 : Throw away (discard) the bottle. Step 5 : After you take ELYXYB, you may drink up to 8 ounces (240 mL) of water. Instructions-2 (50% reduced dose of 60 mg) Step 1 : When you need to take ELYXYB, push down the cap and turn it to the left (counterclockwise to open it. Step 2 : Use an oral dosing syringe (3 mL or 5 mL) from your pharmacy to withdraw 2.4 mL of ELYXYB. Insert the syringe through ELYXYB bottle opening and draw up 2.4 mL of ELYXYB directly from the bottle into the syringe. This 2.4 mL will be your 60 mg dose. Note: Do not use a household teaspoon to measure ELYXYB. Step 3 : Place the 2.4 mL of the ELYXYB that is in the dosing syringe in your mouth and swallow it right away. Step 4 : Close the bottle tightly by turning the cap to the right (clockwise) right away after taking the correct dose of ELYXYB. Note: Do not store the bottle to reuse the remaining medicine. Step 5 : Throw away (discard) the bottle with the unused ELYXYB. Step 6 : After you take ELYXYB, you may drink up to 8 ounces (240 mL) of water. This Instructions for Use has been approved by the U.S. Food and Drug Administration Revised: Sep 2021 For more information call BioDelivery Sciences International, Inc. at 1-800-469-0261. Manufactured for: BioDelivery Sciences International, Inc., Raleigh, NC 27612 ELYXYB is a trademark of BioDelivery Sciences International, Inc. ©2021 BioDelivery Sciences International, Inc. All rights reserved. ELY-001-MGIFU-Sep2021 Figure Figure Figure Figure Figure Figure Figure Figure Figure Figure
Spl medguide
Information about the patient medication guide that accompanies the drug product. Certain drugs must be dispensed with an accompanying medication guide. This field may contain information about when to consult the medication guide and the contents of the medication guide.Medication Guide ELYXYB (ee-lix'-ib)) (celecoxib) oral solution What is the most important information I should know about ELYXYB? ELYXYB contains celecoxib (a non-steroidal anti-inflammatory drug or NSAID). NSAIDs, including ELYXYB, can cause serious side effects, including: Increased risk of a heart attack or stroke that can lead to death. This risk may happen early in treatment and may increase: with increasing doses of NSAIDs with longer use of NSAIDs Do not take ELYXYB right before or after a heart surgery called a "coronary artery bypass graft (CABG)." Avoid taking NSAIDs, including ELYXYB, after a recent heart attack, unless your healthcare provider tells you to. You may have an increased risk of another heart attack if you take NSAIDs after a recent heart attack. Increased risk of bleeding, ulcers, and tears (perforation) of the esophagus (tube leading from the mouth to the stomach), stomach and intestines: anytime during use without warning symptoms that may cause death The risk of getting an ulcer or bleeding increases with: past history of stomach ulcers, or stomach or intestinal bleeding with use of NSAIDs taking medicines called "corticosteroids", "antiplatelet drugs", "anticoagulants", "SSRIs" or "SNRIs" increasing doses of NSAIDs longer use of NSAIDs smoking drinking alcohol older age poor health advanced liver disease bleeding problems ELYXYB should only be used: exactly as prescribed for the shortest time needed What is ELYXYB? ELYXYB is a prescription medicine used for the acute treatment of migraine attacks with or without aura in adults. ELYXYB is not used as a preventive treatment of migraine. It is not known if ELYXYB is safe and effective in children. Who should not take ELYXYB? Do not take ELYXYB: if you are allergic to celecoxib or any of the ingredients in ELYXYB. See the end of this Medication Guide for a complete list of ingredients in ELYXYB. If you are allergic to sulfonamides. if you have had an asthma attack, hives, or other allergic reaction with aspirin or any other NSAIDs. right before or after heart bypass surgery. Before taking ELYXYB, tell your healthcare provider about all of your medical conditions, including if you: have liver or kidney problems. have a history of stomach ulcer or bleeding in your stomach or intestines. have heart disease or risk factors that increase your chance of getting heart disease. have high blood pressure. have asthma. are pregnant or plan to become pregnant. Taking NSAIDs, including ELYXYB, at about 20 weeks of pregnancy or later may harm your unborn baby. If you need to take NSAIDs for more than 2 days when you are between 20 and 30 weeks of pregnancy, your healthcare provider may need to monitor the amount of fluid in your womb around your baby. You should not take NSAIDs after about 30 weeks of pregnancy. are breastfeeding or plan to breast feed. ELYXYB may pass into your breast milk. Talk with your healthcare provider about the best way to feed your baby if you take ELYXYB. Tell your healthcare provider about all of the medicines you take, including prescription or over-the-counter medicines, vitamins or herbal supplements. NSAIDs, including ELYXYB, and some other medicines can interact with each other and cause serious side effects. Do not start taking any new medicine without talking to your healthcare provider first. How should I take ELYXYB? See the detailed " Instructions for Use " on how to take ELYXYB solution. Take ELYXYB exactly as your healthcare provider tells you to take it. Take ELYXYB by mouth with or without food. Do not take more than one dose in a 24-hour period. Use ELYXYB for the fewest number of days a month, as needed. What are the possible side effects of ELYXYB? ELYXYB can cause serious side effects, including: See " What is the most important information I should know about ELYXYB? liver problems including liver failure new or worse high blood pressure heart failure kidney problems including kidney failure life-threatening allergic reactions asthma attacks in people who have asthma life-threatening skin reactions medication overuse headaches. Some people who use too much ELYXYB may have worse headaches (medication overuse headache). If your headaches get worse, your healthcare provider may decide to stop your treatment with ELYXYB. low red blood cells (anemia) Other side effects of NSAIDs include: stomach pain, constipation, diarrhea, gas, heartburn, nausea, vomiting, and dizziness. Get emergency help right away if you get any of the following symptoms: shortness of breath or trouble breathing chest pain weakness in one part or side of your body slurred speech swelling of the face or throat Stop taking ELYXYB and call your healthcare provider right away if you get any of the following symptoms: nausea more tired or weaker than usual diarrhea itching your skin or eyes look yellow indigestion or stomach pain flu-like symptoms vomit blood there is blood in your bowel movement or it is black and sticky like tar unusual weight gain skin rash or blisters with fever swelling of the arms, legs, hands and feet If you take too much ELYXYB, call your healthcare provider or get medical help right away. These are not all the possible side effects of NSAIDs. For more information, ask your healthcare provider or pharmacist about NSAIDs. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. Other information about NSAIDs Aspirin is an NSAID but it does not increase the chance of a heart attack. Aspirin can cause bleeding in the brain, stomach, and intestines. Aspirin can also cause ulcers in the stomach and intestines. Some NSAIDs are sold in lower doses without a prescription (over-the counter). Talk to your healthcare provider before using over the-counter NSAIDs for more than 10 days. General information about the safe and effective use of ELYXYB Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Do not use ELYXYB for a condition for which it was not prescribed. Do not give ELYXYB to other people, even if they have the same symptoms that you have. It may harm them. If you would like more information about ELYXYB, talk with your healthcare provider. You can ask your pharmacist or healthcare provider for information about ELYXYB that is written for health professionals. Manufactured for: BioDelivery Sciences International, Inc.ted This Medication Guide has been approved by the U.S. Food and Drug Administration. Revised: Sep 2021
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Clinical studies
This field may contain references to clinical studies in place of detailed discussion in other sections of the labeling.14 CLINICAL STUDIES 14.1 Migraine The efficacy of ELYXYB for the acute treatment of migraine with or without aura was demonstrated in two randomized, double-blind, placebo-controlled clinical trials [Study 1 (NCT03009019) and Study 2 (NCT03006276)]. In Study 1, patients were randomized to receive ELYXYB 120 mg (n=316) or placebo (n=315); in Study 2, patients were also randomized to receive ELYXYB 120 mg (n=311) or placebo (n=311). In both studies, patients were instructed to treat a migraine with moderate to severe pain intensity. Patients enrolled in the trials were predominantly female (86%) and White (74%), with a mean age of 40.6 years (range 18 to 75 years). The primary efficacy analyses were conducted in patients who treated a migraine with moderate to severe pain. The efficacy of ELYXYB was established by an effect on pain freedom at 2 hours post-dose and most bothersome symptom (MBS) freedom at 2 hours post-dose. Pain freedom was defined as a reduction of moderate or severe headache pain to no pain, and MBS freedom was defined as the absence of the self-identified MBS (photophobia, phonophobia, or nausea). Among patients who selected a MBS, the most commonly selected MBS was photophobia (56%), followed by nausea (25%), and phonophobia (18%). In both studies, the percentage of patients achieving MBS freedom at 2 hours post-dose was significantly greater among patients receiving ELYXYB, compared to those receiving placebo. In Study 2, the percentage of patients achieving headache pain freedom at 2 hours post-dose was significantly greater among patients receiving ELYXYB, compared to those receiving placebo ( see Table 2 ). Table 2: Migraine Efficacy Endpoints for Study 1 and Study 2 Study 1 Study 2 Placebo ELYXYB 120 mg Placebo ELYXYB 120 mg Pain Free at 2 hours N 273 284 271 279 % Responders 25.3 32.4 21.0 35.1 Difference from placebo (%) 7 14 p-value 0.076 Not statistically significant <0.001 Most Bothersome Symptom Free at 2 hours N 234 245 237 236 % Responders 44.4 58.0 43.9 56.8 Difference from placebo (%) 14 13 p-value 0.003 0.006
| Study 1 | Study 2 | |||
|---|---|---|---|---|
| Placebo | ELYXYB 120 mg | Placebo | ELYXYB 120 mg | |
| N | 273 | 284 | 271 | 279 |
| % Responders | 25.3 | 32.4 | 21.0 | 35.1 |
| Difference from placebo (%) | 7 | 14 | ||
| p-value | 0.076 | <0.001 | ||
| N | 234 | 245 | 237 | 236 |
| % Responders | 44.4 | 58.0 | 43.9 | 56.8 |
| Difference from placebo (%) | 14 | 13 | ||
| p-value | 0.003 | 0.006 | ||
Geriatric use
Information about any limitations on any geriatric indications, needs for specific monitoring, hazards associated with use of the drug in the geriatric population.8.5 Geriatric Use Elderly patients, compared to younger patients, are at greater risk for NSAID-associated serious cardiovascular, gastrointestinal, and/or renal adverse reactions. If the anticipated benefit for the elderly patient outweighs these potential risks, treat for the fewest number of days per month, as needed, and monitor patients for adverse effects [see Warnings and Precautions (5.1 , 5.2 , 5.3 , 5.6 , 5.15) ]. In the controlled clinical trials for migraine, approximately 70 patients were ≥ 65 years of age. Of the total number of patients who received celecoxib (for indications other than migraine) in pre-approval clinical trials, more than 3,300 were 65-74 years of age, while approximately 1,300 additional patients were 75 years and over. No substantial differences in effectiveness were observed between these subjects and younger subjects. In clinical studies comparing renal function as measured by the GFR, BUN and creatinine, and platelet function as measured by bleeding time and platelet aggregation, the results were not different between elderly and young volunteers. However, as with other NSAIDs, including those that selectively inhibit COX-2, there have been more spontaneous postmarketing reports of fatal GI events and acute renal failure in the elderly than in younger patients [see Warnings and Precautions (5.4 , 5.6) ].
Pediatric use
Information about any limitations on any pediatric indications, needs for specific monitoring, hazards associated with use of the drug in any subsets of the pediatric population (such as neonates, infants, children, or adolescents), differences between pediatric and adult responses to the drug, and other information related to the safe and effective pediatric use of the drug.8.4 Pediatric Use Safety and effectiveness in pediatric patients have not been established. Disseminated intravascular coagulation has occurred in pediatric patients [see Warnings and Precautions (5.16) ].
Pregnancy
Information about effects the drug may have on pregnant women or on a fetus. This field may be ommitted if the drug is not absorbed systemically and the drug is not known to have a potential for indirect harm to the fetus. It may contain information about the established pregnancy category classification for the drug. (That information is nominally listed in the teratogenic_effects field, but may be listed here instead.)8.1 Pregnancy Risk Summary Use of NSAIDs, including ELYXYB, can cause premature closure of the fetal ductus arteriosus and fetal renal dysfunction leading to oligohydramnios and, in some cases, neonatal renal impairment. Because of these risks, limit dose and duration of Elyxyb use between about 20 and 30 weeks of gestation, and avoid ELYXYB use at about 30 weeks of gestation and later in pregnancy ( see Clinical Considerations , Data ). Premature Closure of Fetal Ductus Arteriosus Use of NSAIDs, including ELYXYB, at about 30 weeks gestation or later in pregnancy increases the risk of premature closure of the fetal ductus arteriosus. Oligohydramnios/Neonatal Renal Impairment Use of NSAIDs at about 20 weeks gestation or later in pregnancy has been associated with cases of fetal renal dysfunction leading to oligohydramnios, and in some cases, neonatal renal impairment. Data from observational studies regarding other potential embryofetal risks of NSAID use in women in the first or second trimesters of pregnancy are inconclusive. In animal reproduction studies, administration of celecoxib during pregnancy resulted in adverse effects on development, including increases in embryonic death and fetal malformations, at doses or maternal plasma drug exposures greater than those used clinically ( see Data ). Based on animal data, prostaglandins have been shown to have an important role in endometrial vascular permeability, blastocyst implantation, and decidualization. In animal studies, administration of prostaglandin synthesis inhibitors such as celecoxib, resulted in increased pre- and post-implantation loss. Prostaglandins also have been shown to have an important role in fetal kidney development. In published animal studies, prostaglandin synthesis inhibitors have been reported to impair kidney development when administered at clinically relevant doses. All pregnancies have a background risk of birth defects, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively. The reported rate of major birth defects among deliveries to women with migraine ranged from 2.2% to 2.9% and the reported rate of miscarriage was 17%, which were similar to rates reported in women without migraine. Clinical Considerations Fetal/Neonatal Adverse Reactions Premature Closure of Fetal Ductus Arteriosus: Avoid use of NSAIDs in women at about 30 weeks gestation and later in pregnancy, because NSAIDs, including ELYXYB, can cause premature closure of the fetal ductus arteriosus (see Data ) . Oligohydramnios/Neonatal Renal Impairment If an NSAID is necessary at about 20 weeks gestation or later in pregnancy, limit the use to the lowest effective dose and shortest duration possible. If ELYXYB treatment extends beyond 48 hours, consider monitoring with ultrasound for oligohydramnios. If oligohydramnios occurs, discontinue ELYXYB and follow up according to clinical practice ( see Data ). Labor or Delivery There are no studies on the effects of celecoxib during labor or delivery. In animal studies, NSAIDs, including celecoxib, inhibit prostaglandin synthesis, cause delayed parturition, and increase the incidence of stillbirth. Data Human Data Premature Closure of Fetal Ductus Arteriosus: Published literature reports that the use of NSAIDs at about 30 weeks of gestation and later in pregnancy may cause premature closure of the fetal ductus arteriosus. Oligohydramnios/Neonatal Renal Impairment: Published studies and postmarketing reports describe maternal NSAID use at about 20 weeks gestation or later in pregnancy associated with fetal renal dysfunction leading to oligohydramnios, and in some cases, neonatal renal impairment. These adverse outcomes are seen, on average, after days to weeks of treatment, although oligohydramnios has been infrequently reported as soon as 48 hours after NSAID initiation. In many cases, but not all, the decrease in amniotic fluid was transient and reversible with cessation of the drug. There have been a limited number of case reports of maternal NSAID use and neonatal renal dysfunction without oligohydramnios, some of which were irreversible. Some cases of neonatal renal dysfunction required treatment with invasive procedures, such as exchange transfusion or dialysis. Methodological limitations of these postmarketing studies and reports include lack of a control group; limited information regarding dose, duration, and timing of drug exposure; and concomitant use of other medications. These limitations preclude establishing a reliable estimate of the risk of adverse fetal and neonatal outcomes with maternal NSAID use. Because the published safety data on neonatal outcomes involved mostly preterm infants, the generalizability of certain reported risks to the full-term infant exposed to NSAIDs through maternal use is uncertain. Animal data Administration of celecoxib to rats during early embryonic development resulted in increased pre- and postimplantation loss at oral doses ≥50 mg/kg/day, which was associated with plasma exposure (AUC) approximately 20 times that in humans at the maximum recommended dose (MRHD) of 120 mg/day. Administration of celecoxib to pregnant rats throughout the period of organogenesis resulted in increased incidences of a specific fetal malformation (diaphragmatic hernia) at oral doses ≥30 mg/kg/day, associated with plasma exposure (AUC) approximately 20 times that in humans at the MRHD. Administration of celecoxib to pregnant rabbits throughout organogenesis produced increased incidences of fetal visceral (ventricular septal defects) and skeletal malformations at oral doses ≥150 mg/kg/day, associated with maternal plasma AUC approximately 7 times that in humans at the MRHD. Celecoxib produced no evidence of delayed labor or parturition in rats at oral doses up to 100 mg/kg/day, which was associated with maternal plasma AUC approximately 25 times that in humans at the MRHD.
Use in specific populations
Information about use of the drug by patients in specific populations, including pregnant women and nursing mothers, pediatric patients, and geriatric patients.8 USE IN SPECIFIC POPULATIONS Infertility : NSAIDs are associated with reversible infertility. Consider withdrawal of ELYXYB in women who have difficulties conceiving ( 8.3 ) 8.1 Pregnancy Risk Summary Use of NSAIDs, including ELYXYB, can cause premature closure of the fetal ductus arteriosus and fetal renal dysfunction leading to oligohydramnios and, in some cases, neonatal renal impairment. Because of these risks, limit dose and duration of Elyxyb use between about 20 and 30 weeks of gestation, and avoid ELYXYB use at about 30 weeks of gestation and later in pregnancy ( see Clinical Considerations , Data ). Premature Closure of Fetal Ductus Arteriosus Use of NSAIDs, including ELYXYB, at about 30 weeks gestation or later in pregnancy increases the risk of premature closure of the fetal ductus arteriosus. Oligohydramnios/Neonatal Renal Impairment Use of NSAIDs at about 20 weeks gestation or later in pregnancy has been associated with cases of fetal renal dysfunction leading to oligohydramnios, and in some cases, neonatal renal impairment. Data from observational studies regarding other potential embryofetal risks of NSAID use in women in the first or second trimesters of pregnancy are inconclusive. In animal reproduction studies, administration of celecoxib during pregnancy resulted in adverse effects on development, including increases in embryonic death and fetal malformations, at doses or maternal plasma drug exposures greater than those used clinically ( see Data ). Based on animal data, prostaglandins have been shown to have an important role in endometrial vascular permeability, blastocyst implantation, and decidualization. In animal studies, administration of prostaglandin synthesis inhibitors such as celecoxib, resulted in increased pre- and post-implantation loss. Prostaglandins also have been shown to have an important role in fetal kidney development. In published animal studies, prostaglandin synthesis inhibitors have been reported to impair kidney development when administered at clinically relevant doses. All pregnancies have a background risk of birth defects, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively. The reported rate of major birth defects among deliveries to women with migraine ranged from 2.2% to 2.9% and the reported rate of miscarriage was 17%, which were similar to rates reported in women without migraine. Clinical Considerations Fetal/Neonatal Adverse Reactions Premature Closure of Fetal Ductus Arteriosus: Avoid use of NSAIDs in women at about 30 weeks gestation and later in pregnancy, because NSAIDs, including ELYXYB, can cause premature closure of the fetal ductus arteriosus (see Data ) . Oligohydramnios/Neonatal Renal Impairment If an NSAID is necessary at about 20 weeks gestation or later in pregnancy, limit the use to the lowest effective dose and shortest duration possible. If ELYXYB treatment extends beyond 48 hours, consider monitoring with ultrasound for oligohydramnios. If oligohydramnios occurs, discontinue ELYXYB and follow up according to clinical practice ( see Data ). Labor or Delivery There are no studies on the effects of celecoxib during labor or delivery. In animal studies, NSAIDs, including celecoxib, inhibit prostaglandin synthesis, cause delayed parturition, and increase the incidence of stillbirth. Data Human Data Premature Closure of Fetal Ductus Arteriosus: Published literature reports that the use of NSAIDs at about 30 weeks of gestation and later in pregnancy may cause premature closure of the fetal ductus arteriosus. Oligohydramnios/Neonatal Renal Impairment: Published studies and postmarketing reports describe maternal NSAID use at about 20 weeks gestation or later in pregnancy associated with fetal renal dysfunction leading to oligohydramnios, and in some cases, neonatal renal impairment. These adverse outcomes are seen, on average, after days to weeks of treatment, although oligohydramnios has been infrequently reported as soon as 48 hours after NSAID initiation. In many cases, but not all, the decrease in amniotic fluid was transient and reversible with cessation of the drug. There have been a limited number of case reports of maternal NSAID use and neonatal renal dysfunction without oligohydramnios, some of which were irreversible. Some cases of neonatal renal dysfunction required treatment with invasive procedures, such as exchange transfusion or dialysis. Methodological limitations of these postmarketing studies and reports include lack of a control group; limited information regarding dose, duration, and timing of drug exposure; and concomitant use of other medications. These limitations preclude establishing a reliable estimate of the risk of adverse fetal and neonatal outcomes with maternal NSAID use. Because the published safety data on neonatal outcomes involved mostly preterm infants, the generalizability of certain reported risks to the full-term infant exposed to NSAIDs through maternal use is uncertain. Animal data Administration of celecoxib to rats during early embryonic development resulted in increased pre- and postimplantation loss at oral doses ≥50 mg/kg/day, which was associated with plasma exposure (AUC) approximately 20 times that in humans at the maximum recommended dose (MRHD) of 120 mg/day. Administration of celecoxib to pregnant rats throughout the period of organogenesis resulted in increased incidences of a specific fetal malformation (diaphragmatic hernia) at oral doses ≥30 mg/kg/day, associated with plasma exposure (AUC) approximately 20 times that in humans at the MRHD. Administration of celecoxib to pregnant rabbits throughout organogenesis produced increased incidences of fetal visceral (ventricular septal defects) and skeletal malformations at oral doses ≥150 mg/kg/day, associated with maternal plasma AUC approximately 7 times that in humans at the MRHD. Celecoxib produced no evidence of delayed labor or parturition in rats at oral doses up to 100 mg/kg/day, which was associated with maternal plasma AUC approximately 25 times that in humans at the MRHD. 8.2 Lactation Risk Summary Limited data from 3 published reports that included a total of 12 breastfeeding women showed low levels of celecoxib in breast milk. The calculated average daily infant dose was 10 to 40 mcg/kg/day, less than 1% of the weight-based therapeutic dose for a two-year old-child. A report of two breastfed infants who were 17 and 22 months of age did not show any adverse events. There is no information available regarding the effects of celecoxib on milk production. The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for ELYXYB and any potential adverse effects on the breastfed infant from the celecoxib or from the underlying maternal condition. 8.3 Females and Males of Reproductive Potential Infertility Females Based on the mechanism of action, the use of prostaglandin-mediated NSAIDs, including ELYXYB, may delay or prevent rupture of ovarian follicles, which has been associated with reversible infertility in some women. Published animal studies have shown that administration of prostaglandin synthesis inhibitors has the potential to disrupt prostaglandin mediated follicular rupture required for ovulation. Small studies in women treated with NSAIDs have also shown a reversible delay in ovulation. Consider withdrawal of NSAIDs, including ELYXYB, in women who have difficulties conceiving or who are undergoing investigation of infertility. 8.4 Pediatric Use Safety and effectiveness in pediatric patients have not been established. Disseminated intravascular coagulation has occurred in pediatric patients [see Warnings and Precautions (5.16) ]. 8.5 Geriatric Use Elderly patients, compared to younger patients, are at greater risk for NSAID-associated serious cardiovascular, gastrointestinal, and/or renal adverse reactions. If the anticipated benefit for the elderly patient outweighs these potential risks, treat for the fewest number of days per month, as needed, and monitor patients for adverse effects [see Warnings and Precautions (5.1 , 5.2 , 5.3 , 5.6 , 5.15) ]. In the controlled clinical trials for migraine, approximately 70 patients were ≥ 65 years of age. Of the total number of patients who received celecoxib (for indications other than migraine) in pre-approval clinical trials, more than 3,300 were 65-74 years of age, while approximately 1,300 additional patients were 75 years and over. No substantial differences in effectiveness were observed between these subjects and younger subjects. In clinical studies comparing renal function as measured by the GFR, BUN and creatinine, and platelet function as measured by bleeding time and platelet aggregation, the results were not different between elderly and young volunteers. However, as with other NSAIDs, including those that selectively inhibit COX-2, there have been more spontaneous postmarketing reports of fatal GI events and acute renal failure in the elderly than in younger patients [see Warnings and Precautions (5.4 , 5.6) ]. 8.6 Hepatic Impairment No dosage adjustment is needed for patients with mild hepatic impairment (Child-Pugh Class A). Reduce the dose of ELYXYB in patients with moderate hepatic impairment (Child-Pugh Class B) [see Dosage and Administration (2.2) and Clinical Pharmacology (12.3) ]. The use of ELYXYB in patients with severe hepatic impairment (Child-Pugh Class C) is not recommended. 8.7 Renal Impairment No dosage adjustment is needed for patients with mild or moderate renal impairment. ELYXYB is not recommended in patients with severe renal impairment [see Warnings and Precautions (5.6) and Clinical Pharmacology (12.3) ]. 8.8 Poor Metabolizers of CYP2C9 Substrates In patients who are known or suspected to be poor CYP2C9 metabolizers (i.e., CYP2C9*3/*3), based on genotype or previous history/experience with other CYP2C9 substrates (e.g., warfarin, phenytoin) reduce the dose of ELYXYB [see Dosage and Administration (2.3) and Clinical Pharmacology (12.5) ].
How supplied
Information about the available dosage forms to which the labeling applies, and for which the manufacturer or distributor is responsible. This field ordinarily includes the strength of the dosage form (in metric units), the units in which the dosage form is available for prescribing, appropriate information to facilitate identification of the dosage forms (such as shape, color, coating, scoring, and National Drug Code), and special handling and storage condition information.16 HOW SUPPLIED/STORAGE AND HANDLING 16.1 How Supplied ELYXYB (celecoxib) oral solution, 120 mg/4.8 mL (25 mg/mL) is a clear colorless oral solution supplied in a disposable glass bottle with a child resistant cap. Each carton (NDC 59385-055-06) contains six (6) glass bottles, a Full Prescribing Information, Medication Guide, and Instructions for Use. 16.2 Storage and Handling Store at room temperature 20°C to 25°C (68°F to 77°F); excursions permitted between 15°C to 30°C (59°F to 86°F) [see USP Controlled Room Temperature]. Do not refrigerate or freeze. Unused portion should be discarded immediately after use.
Storage and handling
Information about safe storage and handling of the drug product.16.2 Storage and Handling Store at room temperature 20°C to 25°C (68°F to 77°F); excursions permitted between 15°C to 30°C (59°F to 86°F) [see USP Controlled Room Temperature]. Do not refrigerate or freeze. Unused portion should be discarded immediately after use.
Boxed warning
Information about contraindications or serious warnings, particularly those that may lead to death or serious injury.WARNING: RISK OF SERIOUS CARDIOVASCULAR AND GASTROINTESTINAL EVENTS WARNING: RISK OF SERIOUS CARDIOVASCULAR and GASTROINTESTINAL EVENTS See full prescribing information for complete boxed warning. Nonsteroidal anti-inflammatory drugs (NSAIDs) cause an increased risk of serious cardiovascular thrombotic events, including myocardial infarction and stroke, which can be fatal. This risk may occur early in the treatment and may increase with duration of use. ( 5.1 ) ELYXYB is contraindicated in the setting of coronary artery bypass graft (CABG) surgery. ( 4 , 5.1 ) NSAIDs cause an increased risk of serious gastrointestinal (GI) adverse events including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal. These events can occur at any time during use and without warning symptoms. Elderly patients and patients with a prior history of peptic ulcer disease and/or GI bleeding are at greater risk for serious GI events. ( 5.2 ) Cardiovascular Thrombotic Events Nonsteroidal anti-inflammatory drugs (NSAIDs) cause an increased risk of serious cardiovascular thrombotic events, including myocardial infarction and stroke, which can be fatal. This risk may occur early in the treatment and may increase with duration of use [see Warnings and Precautions (5.1) ]. ELYXYB is contraindicated in the setting of coronary artery bypass graft (CABG) surgery [see Contraindications (4) and Warnings and Precautions (5.1) ]. Gastrointestinal Bleeding, Ulceration, and Perforation NSAIDs cause an increased risk of serious gastrointestinal (GI) adverse events including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal. These events can occur at any time during use and without warning symptoms. Elderly patients and patients with a prior history of peptic ulcer disease and/or GI bleeding are at greater risk for serious (GI) events [see Warnings and Precautions (5.2) ].
Disclaimer: Do not rely on openFDA or Phanrmacy Near Me to make decisions regarding medical care. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: OpenFDA, Healthporta Drugs API