018332s032lbl PDF
018332s032lbl PDF
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(INDOMETHACIN)
ORAL SUSPENSION
Cardiovascular Risk
• NSAIDs may cause an increased risk of serious cardiovascular thrombotic
events, myocardial infarction, and stroke, which can be fatal. This risk may
increase with duration of use. Patients with cardiovascular disease or risk
factors for cardiovascular disease may be at a greater risk. (See
WARNINGS.)
• INDOCIN is contraindicated for the treatment of peri-operative pain in the
Gastrointestinal Risk
• NSAIDs cause an increased risk of serious gastrointestinal adverse events
DESCRIPTION
1
Indomethacin is practically insoluble in water and sparingly soluble in alcohol. It
has a pKa of 4.5 and is stable in neutral or slightly acidic media and decomposes
in strong alkali. The suspension has a pH of 4.0-5.0. The structural formula is:
1 Registered trademark of MERCK & CO., Inc., Whitehouse Station, NJ U.S.A. and
licensed to Iroko Pharmaceuticals, LLC, Philadelphia, PA, U.S.A.
CLINICAL PHARMACOLOGY
2
INDOCIN has been shown to be an effective anti-inflammatory agent,
appropriate for long-term use in rheumatoid arthritis, ankylosing spondylitis, and
osteoarthritis.
INDOCIN affords relief of symptoms; it does not alter the progressive course of
the underlying disease.
Indomethacin has been reported to diminish basal and CO2 stimulated cerebral
blood flow in healthy volunteers following acute oral and intravenous
administration. In one study after one week of treatment with orally administered
indomethacin, this effect on basal cerebral blood flow had disappeared. The
clinical significance of this effect has not been established.
Capsules INDOCIN have been found effective in relieving the pain, reducing the
fever, swelling, redness, and tenderness of acute gouty arthritis (see
INDICATIONS AND USAGE).
3
bioequivalent to a 50 mg INDOCIN capsule when each was administered with
food.
Indomethacin exists in the plasma as the parent drug and its desmethyl,
desbenzoyl, and desmethyldesbenzoyl metabolites, all in the unconjugated form.
About 60 percent of an oral dosage is recovered in urine as drug and metabolites
(26 percent as indomethacin and its glucuronide), and 33 percent is recovered in
feces (1.5 percent as indomethacin).
Carefully consider the potential benefits and risks of INDOCIN and other
treatment options before deciding to use INDOCIN. Use the lowest effective dose
for the shortest duration consistent with individual patient treatment goals (see
WARNINGS).
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CONTRAINDICATIONS
WARNINGS
Cardiovascular Effects
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concurrent use of aspirin and an NSAID does increase the risk of serious GI
events (see WARNINGS, Gastrointestinal Effects).
Two large, controlled, clinical trials of a COX-2 selective NSAID for the treatment
of pain in the first 10-14 days following CABG surgery found an increased
incidence of myocardial infarction and stroke (see CONTRAINDICATIONS).
Hypertension
Fluid retention and edema have been observed in some patients taking NSAIDs.
INDOCIN should be used with caution in patients with fluid retention or heart
failure.
In a study of patients with severe heart failure and hyponatremia, INDOCIN was
associated with significant deterioration of circulatory hemodynamics,
presumably due to inhibition of prostaglandin dependent compensatory
mechanisms.
Gastrointestinal Effects
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serious adverse events can occur at any time, with or without warning symptoms,
in patients treated with NSAIDs. Only one in five patients, who develop a serious
upper GI adverse event on NSAID therapy is symptomatic. Upper GI ulcers,
gross bleeding, or perforation caused by NSAIDs occur in approximately 1% of
patients treated for 3-6 months, and in about 2-4% of patients treated for
one year. These trends continue with longer duration of use, increasing the
likelihood of developing a serious GI event at some time during the course of
therapy. However, even short-term therapy is not without risk.
NSAIDs should be prescribed with extreme caution in those with prior history of
ulcer disease or gastrointestinal bleeding. Patients with a prior history of peptic
ulcer disease and/or gastrointestinal bleeding who use NSAIDs have a greater
than 10-fold increased risk for developing a GI bleed compared to patients with
neither of these risk factors. Other factors that increase the risk for GI bleeding in
patients treated with NSAIDs include concomitant use of oral corticosteroids or
anticoagulants, longer duration of NSAID therapy, smoking, use of alcohol, older
age, and poor general health status. Most spontaneous reports of fatal GI events
are in elderly or debilitated patients and therefore, special care should be taken
in treating this population.
To minimize the potential risk for an adverse GI event in patients treated with an
NSAID, the lowest effective dose should be used for the shortest possible
duration. Patients and physicians should remain alert for signs and symptoms of
GI ulceration and bleeding during NSAID therapy and promptly initiate additional
evaluation and treatment if a serious GI adverse event is suspected. This should
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include discontinuation of the NSAID until a serious GI adverse event is ruled
out. For high risk patients, alternate therapies that do not involve NSAIDs should
be considered.
Renal Effects
Anaphylactic/Anaphylactoid Reactions
8
As with other NSAIDs, anaphylactic/anaphylactoid reactions may occur in
patients without known prior exposure to INDOCIN. INDOCIN should not be
given to patients with the aspirin triad. This symptom complex typically occurs in
asthmatic patients who experience rhinitis with or without nasal polyps, or who
exhibit severe, potentially fatal bronchospasm after taking aspirin or other
NSAIDs (see CONTRAINDICATIONS, and PRECAUTIONS - Preexisting
Asthma). Emergency help should be sought in cases where an
anaphylactic/anaphylactoid reaction occurs.
Skin Reactions
NSAIDs, including INDOCIN, can cause serious skin adverse events such as
exfoliative dermatitis, Stevens-Johnson Syndrome (SJS), and toxic epidermal
necrolysis (TEN), which can be fatal. These serious events may occur without
warning. Patients should be informed about the signs and symptoms of serious
skin manifestations and use of the drug should be discontinued at the first
appearance of skin rash or any other sign of hypersensitivity.
Pregnancy
Ocular Effects
Corneal deposits and retinal disturbances, including those of the macula, have
been observed in some patients who had received prolonged therapy with
INDOCIN. The prescribing physician should be alert to the possible association
between the changes noted and INDOCIN. It is advisable to discontinue therapy
if such changes are observed. Blurred vision may be a significant symptom and
warrants a thorough ophthalmological examination. Since these changes may be
asymptomatic, ophthalmologic examination at periodic intervals is desirable in
patients where therapy is prolonged.
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Central Nervous System Effects
PRECAUTIONS
General
Hepatic Effects
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jaundice and fatal fulminant hepatitis, liver necrosis and hepatic failure, some of
them with fatal outcomes have been reported.
Hematological Effects
NSAIDs inhibit platelet aggregation and have been shown to prolong bleeding
time in some patients. Unlike aspirin, their effect on platelet function is
quantitatively less, of shorter duration, and reversible. Patients receiving
INDOCIN who may be adversely affected by alterations in platelet function, such
as those with coagulation disorders or patients receiving anticoagulants, should
be carefully monitored.
Preexisting Asthma
Patients with asthma may have aspirin-sensitive asthma. The use of aspirin in
patients with aspirin-sensitive asthma has been associated with severe
bronchospasm which can be fatal. Since cross reactivity, including
bronchospasm, between aspirin and other nonsteroidal anti-inflammatory drugs
has been reported in such aspirin-sensitive patients, INDOCIN should not be
administered to patients with this form of aspirin sensitivity and should be used
with caution in patients with preexisting asthma.
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Information for Patients
12
4. Patients should promptly report signs or symptoms of unexplained weight
gain or edema to their physicians.
5. Patients should be informed of the warning signs and symptoms of
hepatotoxicity (e.g., nausea, fatigue, lethargy, pruritus, jaundice, right upper
quadrant tenderness, and “flu-like” symptoms). If these occur, patients should
be instructed to stop therapy and seek immediate medical therapy.
6. Patients should be informed of the signs of an anaphylactic/anaphylactoid
reaction (e.g. difficulty breathing, swelling of the face or throat). If these occur,
patients should be instructed to seek immediate emergency help (see
WARNINGS).
7. In late pregnancy, as with other NSAIDs, INDOCIN should be avoided
because it may cause premature closure of the ductus arteriosus.
Laboratory Tests
Because serious GI tract ulcerations and bleeding can occur without warning
symptoms, physicians should monitor for signs or symptoms of GI bleeding.
Patients on long-term treatment with NSAIDs should have their CBC and a
chemistry profile checked periodically. If clinical signs and symptoms consistent
with liver or renal disease develop, systemic manifestations occur (e.g.,
eosinophilia, rash, etc.) or if abnormal liver tests persist or worsen, INDOCIN
should be discontinued.
Drug Interactions
Reports suggest that NSAIDs may diminish the antihypertensive effect of ACE-
inhibitors and angiotensin II antagonists. INDOCIN can reduce the
antihypertensive effects of captopril and losartan. These interactions should be
given consideration in patients taking NSAIDs concomitantly with ACE-inhibitors
or angiotensin II antagonists. In some patients with compromised renal function,
the co-administration of an NSAID and an ACE-inhibitor or an angiotensin II
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antagonist may result in further deterioration of renal function, including possible
acute renal failure, which is usually reversible.
Aspirin
Cyclosporine
14
Diflunisal
Digoxin
INDOCIN given concomitantly with digoxin has been reported to increase the
serum concentration and prolong the half-life of digoxin. Therefore, when
INDOCIN and digoxin are used concomitantly, serum digoxin levels should be
closely monitored.
Diuretics
INDOCIN reduces basal plasma renin activity (PRA), as well as those elevations
of PRA induced by furosemide administration, or salt or volume depletion. These
facts should be considered when evaluating plasma renin activity in hypertensive
patients.
15
Most of the above effects concerning diuretics have been attributed, at least in
part, to mechanisms involving inhibition of prostaglandin synthesis by INDOCIN.
During concomitant therapy with NSAIDs, the patient should be observed closely
for signs of renal failure (see WARNINGS, Renal Effects), as well as to assure
diuretic efficacy.
Lithium
Methotrexate
NSAIDs
The concomitant use of INDOCIN with other NSAIDs is not recommended due to
the increased possibility of gastrointestinal toxicity, with little or no increase in
efficacy.
Oral anticoagulants
16
Clinical studies have shown that INDOCIN does not influence the
hypoprothrombinemia produced by anticoagulants. However, when any
additional drug, including INDOCIN, is added to the treatment of patients on
anticoagulant therapy, the patients should be observed for alterations of the
prothrombin time. In post-marketing experience, bleeding has been reported in
patients on concomitant treatment with anticoagulants and INDOCIN. Caution
should be exercised when INDOCIN and anticoagulants are administered
concomitantly. The effects of warfarin and NSAIDs on GI bleeding are
synergistic, such that users of both drugs together have a risk of serious GI
bleeding higher than users of either drug alone.
Probenecid
17
Indomethacin did not have any mutagenic effect in in vitro bacterial tests (Ames
test and E. coli with or without metabolic activation) and a series of in vivo tests
including the host-mediated assay, sex-linked recessive lethals in Drosophila,
and the micronucleus test in mice.
Pregnancy
Teratogenic Effects
Pregnancy Category C
Teratogenic studies were conducted in mice and rats at dosages of 0.5, 1.0, 2.0,
and 4.0 mg/kg/day. Except for retarded fetal ossification at 4 mg/kg/day
considered secondary to the decreased average fetal weights, no increase in
fetal malformations was observed as compared with control groups. Other
studies in mice reported in the literature using higher doses (5 to 15 mg/kg/day)
have described maternal toxicity and death, increased fetal resorptions, and fetal
malformations. Comparable studies in rodents using high doses of aspirin have
shown similar maternal and fetal effects. However, animal reproduction studies
are not always predictive of human response. There are no adequate and well-
controlled studies in pregnant women.
INDOCIN should be used during pregnancy only if the potential benefit justifies
the potential risk to the fetus.
Nonteratogenic Effects
18
The known effects of indomethacin and other drugs of this class on the human
fetus during the third trimester of pregnancy include: constriction of the ductus
arteriosus prenatally, tricuspid incompetence, and pulmonary hypertension; non-
closure of the ductus arteriosus postnatally which may be resistant to medical
management; myocardial degenerative changes, platelet dysfunction with
resultant bleeding, intracranial bleeding, renal dysfunction or failure, renal
injury/dysgenesis which may result in prolonged or permanent renal failure,
oligohydramnios, gastrointestinal bleeding or perforation, and increased risk of
necrotizing enterocolitis.
In rats and mice, 4.0 mg/kg/day given during the last three days of gestation
caused a decrease in maternal weight gain and some maternal and fetal deaths.
An increased incidence of neuronal necrosis in the diencephalon in the live-born
fetuses was observed. At 2.0 mg/kg/day, no increase in neuronal necrosis was
observed as compared to the control groups. Administration of 0.5 or 4.0
mg/kg/day during the first three days of life did not cause an increase in neuronal
necrosis at either dose level.
In rat studies with NSAIDs, as with other drugs known to inhibit prostaglandin
synthesis, an increased incidence of dystocia, delayed parturition, and decreased
pup survival occurred. The effects of INDOCIN on labor and delivery in pregnant
women are unknown.
Pediatric Use
Safety and effectiveness in pediatric patients 14 years of age and younger has
not been established.
19
INDOCIN should not be prescribed for pediatric patients 14 years of age and
younger unless toxicity or lack of efficacy associated with other drugs warrants
the risk.
In experience with more than 900 pediatric patients reported in the literature or to
the manufacturer who were treated with Capsules INDOCIN, side effects in
pediatric patients were comparable to those reported in adults. Experience in
pediatric patients has been confined to the use of Capsules INDOCIN.
If a decision is made to use indomethacin for pediatric patients two years of age
or older, such patients should be monitored closely and periodic assessment of
liver function is recommended. There have been cases of hepatotoxicity reported
in pediatric patients with juvenile rheumatoid arthritis, including fatalities. If
indomethacin treatment is instituted, a suggested starting dose is 1-2 mg/kg/day
given in divided doses. Maximum daily dosage should not exceed 3 mg/kg/day or
150-200 mg/day, whichever is less. Limited data are available to support the use
of a maximum daily dosage of 4 mg/kg/day or 150-200 mg/day, whichever is
less. As symptoms subside, the total daily dosage should be reduced to the
lowest level required to control symptoms, or the drug should be discontinued.
Geriatric Use
As with any NSAID, caution should be exercised in treating the elderly (65 years
and older) since advancing age appears to increase the possibility of adverse
reactions (see WARNINGS, Gastrointestinal Effects - Risk of Ulceration,
Bleeding, and Perforation and DOSAGE AND ADMINISTRATION). Elderly
patients seem to tolerate ulceration or bleeding less well than other individuals
and many spontaneous reports of fatal GI events are in this population (see
WARNINGS, Gastrointestinal Effects - Risk of Ulceration, Bleeding, and
Perforation).
20
Indomethacin may cause confusion or, rarely, psychosis (see ADVERSE
REACTIONS); physicians should remain alert to the possibility of such adverse
effects in the elderly.
This drug is known to be substantially excreted by the kidney and the risk of toxic
reactions to this drug may be greater in patients with impaired renal function.
Because elderly patients are more likely to have decreased renal function, care
should be taken in dose selection and it may be useful to monitor renal function
(see WARNINGS, Renal Effects).
ADVERSE REACTIONS
The adverse reactions for Capsules INDOCIN listed in the following table have
been arranged into two groups: (1) incidence greater than 1%; and (2) incidence
less than 1%. The incidence for group (1) was obtained from 33 double-blind
controlled clinical trials reported in the literature (1,092 patients). The incidence
for group (2) was based on reports in clinical trials, in the literature, and on
voluntary reports since marketing. The probability of a causal relationship exists
between INDOCIN and these adverse reactions, some of which have been
reported only rarely.
The adverse reactions reported with Capsules INDOCIN may also occur with use
of the suspension.
GASTROINTESTINAL
21
Incidence greater than 1% Incidence less than 1%
SPECIAL SENSES
CARDIOVASCULAR
METABOLIC
INTEGUMENTARY
22
Incidence greater than 1% Incidence less than 1%
HEMATOLOGIC
HYPERSENSITIVITY
GENITOURINARY
MISCELLANEOUS
none epistaxis
breast changes, including enlargement
and tenderness, or gynecomastia
* Reactions occurring in 3% to 9% of patients treated with INDOCIN. (Those reactions occurring in less
23
Causal relationship unknown: Other reactions have been reported but occurred
under circumstances where a causal relationship could not be established.
However, in these rarely reported events, the possibility cannot be excluded.
Therefore, these observations are being listed to serve as alerting information to
physicians:
Cardiovascular: Thrombophlebitis
OVERDOSAGE
24
The oral LD50 of indomethacin in mice and rats (based on 14 day mortality
response) was 50 and 12 mg/kg, respectively.
Carefully consider the potential benefits and risks of INDOCIN and other
treatment options before deciding to use INDOCIN. Use the lowest effective dose
for the shortest duration consistent with individual patient treatment goals (see
WARNINGS).
After observing the response to initial therapy with INDOCIN, the dose and
frequency should be adjusted to suit an individual patient’s needs.
Adverse reactions appear to correlate with the size of the dose of INDOCIN in
most patients but not all. Therefore, every effort should be made to determine the
smallest effective dosage for the individual patient.
Pediatric Use
Adult Use
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THIS AMOUNT GENERALLY DO NOT INCREASE THE EFFECTIVENESS
OF THE DRUG.
In patients who have persistent night pain and/or morning stiffness, the giving
of a large portion, up to a maximum of 100 mg (20 mL), of the total daily dose
at bedtime, may be helpful in affording relief. The total daily dose should not
exceed 200 mg (40 mL). In acute flares of chronic rheumatoid arthritis, it may
be necessary to increase the dosage by 25 mg (5 mL) or, if required, by
50 mg (10 mL) daily.
If minor adverse effects develop as the dosage is increased, reduce the
dosage rapidly to a tolerated dose and OBSERVE THE PATIENT CLOSELY.
If severe adverse reactions occur, STOP THE DRUG. After the acute phase
of the disease is under control, an attempt to reduce the daily dose should be
made repeatedly until the patient is receiving the smallest effective dose or
the drug is discontinued.
Careful instructions to, and observations of, the individual patient are
essential to the prevention of serious, irreversible, including fatal, adverse
reactions.
As advancing years appear to increase the possibility of adverse reactions,
INDOCIN should be used with greater care in the elderly (see
PRECAUTIONS, Geriatric Use).
2. Acute painful shoulder (bursitis and/or tendinitis).
Initial Dose:
75-150 mg (15-30 mL) daily in 3 or 4 divided doses.
The drug should be discontinued after the signs and symptoms of
inflammation have been controlled for several days. The usual course of
therapy is 7-14 days.
3. Acute gouty arthritis.
Suggested Dose:
INDOCIN 50 mg (10 mL) t.i.d. until pain is tolerable. The dose should then be
rapidly reduced to complete cessation of the drug. Definite relief of pain has
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been reported within 2 to 4 hours. Tenderness and heat usually subside in 24
to 36 hours, and swelling gradually disappears in 3 to 5 days.
HOW SUPPLIED
Storage
Store Oral Suspension INDOCIN below 30°C (86°F). Avoid temperatures above
Distributed by:
Philadelphia, PA 19112
Rev 10/08
4221C002
TE00
(See the end of this Medication Guide for a list of prescription NSAID medicines.)
What is the most important information I should know about medicines called
27
NSAID medicines may increase the chance of a heart attack or stroke that can
lead to death. This chance increases:
• with longer use of NSAID medicines
NSAID medicines should never be used right before or after a heart surgery
called a “coronary artery bypass graft (CABG).”
NSAID medicines can cause ulcers and bleeding in the stomach and intestines
at any time during treatment.
• longer use
• smoking
• drinking alcohol
• older age
28
NSAID medicines are used to treat pain and redness, swelling, and heat
(inflammation) from medical conditions such as:
• different types of arthritis
• about all of the medicines you take. NSAIDs and some other medicines can
interact with each other and cause serious side effects. Keep a list of your
medicines to show to your healthcare provider and pharmacist.
• if you are pregnant. NSAID medicines should not be used by pregnant
29
Serious side effects include: Other side effects include:
Get emergency help right away if you have any of the following symptoms:
Stop your NSAID medicine and call your healthcare provider right away if you
have any of the following symptoms:
These are not all the side effects with NSAID medicines. Talk to your healthcare
provider or pharmacist for more information about NSAID medicines.
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• Some of these NSAID medicines 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.
Celecoxib Celebrex
Diflunisal Dolobid
Flurbiprofen Ansaid
Ketoprofen Oruvail
Ketorolac Toradol
Mefenamic Ponstel
Acid
Meloxicam Mobic
Nabumetone Relafen
Oxaprozin Daypro
Piroxicam Feldene
Sulindac Clinoril
NSAIDs, and is usually used for less than 10 days to treat pain. The OTC
NSAID label warns that long term continuous use may increase the risk of heart
attack or stroke.
31
This Medication Guide has been approved by the U.S. Food and Drug
Administration.
4221C002
TE00
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INDOCIN (indomethacin)
PRODUCT INFO
Route Of DEA
ORAL
Administration Schedule
INGREDIENTS
Name (Active Moiety) Type Strength
water Inactive
tragacanth Inactive
alcohol Inactive
IMPRINT INFORMATION
Characteristic Appearance Characteristic Appearance
Color Score
Shape Symbol
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Size
PACKAGING
# NDC Package Description Multilevel Packaging
42211-
1 1 BOTTLE In 1 CARTON contains a BOTTLE
101-11
This package is contained within
1 237 MILLILITER In 1 BOTTLE
the CARTON (42211-101-11)
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