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Drug Safety-related Labeling Changes (SrLC)

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TEGRETOL (NDA-016608)

(CARBAMAZEPINE)

Safety-related Labeling Changes Approved by FDA Center for Drug Evaluation and Research (CDER)

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09/30/2025 (SUPPL-122)

Approved Drug Label (PDF)

5 Warnings and Precautions

WARNINGS

Additions and/or revisions underlined:

Propylene Glycol Toxicity

Tegretol suspension contains propylene glycol (see DESCRIPTION). Patients less than 5 years of age are at highest risk for propylene glycol toxicity, and a safe level for propylene glycol exposure with repeated administration has not been established for this age group. Particularly, neonates i.e., less than 4 weeks of age (including full-term babies and pre-term babies less than 44 post-menstrual weeks of age) are known to have immature metabolic and renal clearance of propylene glycol. Therefore, Tegretol suspension should only be used in neonates after careful risk-benefit assessment if no therapeutic alternatives are available. When Tegretol suspension is administered at the maximum dose (35 mg/kg/day) for treatment of epilepsy, the exposure to propylene glycol will be 44 mg/kg/day. The total daily intake of propylene glycol from all sources, including concomitant drugs, should be considered in managing the risk of propylene glycol toxicity.

Monitor patients for signs of potential propylene glycol toxicity, including hemolysis, hyperosmolarity with anion gap metabolic acidosis, acute kidney injury, and central nervous system (CNS) toxicity. Discontinue Tegretol suspension if propylene glycol toxicity is suspected (see DESCRIPTION).

Clinical Considerations

Disease-associated Maternal and/or Embryofetal Risk

Epilepsy, with or without exposure to antiepileptic drugs, has been associated with several adverse outcomes during pregnancy, including preeclampsia, preterm labor, antepartum and postpartum hemorrhage, placental abruption, poor fetal growth, prematurity, fetal death, and maternal mortality. The risk of maternal or fetal injury may be greatest for patients with untreated or poorly controlled convulsive seizures.

Women with epilepsy who become pregnant should not abruptly discontinue antiepileptic drugs, including TEGRETOL, due to the risk of status epilepticus or severe seizures, which may be life-threatening.

8 Use in Specific Populations

Pediatric Use

Additions and/or revisions underlined:

Tegretol suspension contains propylene glycol as an inactive ingredient. Patients less than 5 years of age are at the highest risk for propylene glycol toxicity due to incomplete alcohol dehydrogenase maturity. Particularly, neonates (including full-term babies and pre-term babies less than 44 post-menstrual weeks of age). The total daily intake of propylene glycol from all sources, including concomitant drugs, should be considered in managing the risk of propylene glycol toxicity (see WARNINGS Propylene Glycol Toxicity).

17 PCI/PI/MG (Patient Counseling Information/Patient Information/Medication Guide)

MEDICATION GUIDE

Additions and/or revisions underlined:

4. Tegretol suspension contains 25 mg propylene glycol in each mL. Your healthcare provider will monitor you for side effects of propylene glycol, especially if you are younger than 5 years of age (particularly babies less than 4 weeks old), you have liver or kidney problems, or you are taking other drugs that have propylene glycol or that are broken down by the same enzyme.

How should I store TEGRETOL?

  • Store TEGRETOL Tablets at 20°C to 25°C (68°F to 77°F), excursions permitted between 15°C and 30°C (59°F and 86°F).

    • Keep TEGRETOL Tablets dry.

  • Store TEGRETOL-XR Tablets at 20°C to 25°C (68°F to 77°F); excursions permitted between 15°C and 30°C (59°F and 86°F).

    • Keep TEGRETOL-XR Tablets dry.

  • Do not store TEGRETOL Suspension above 30°C (86°F).

    • Shake well before using.

    • Keep TEGRETOL Suspension in a tight, light resistant container.

    • Keep TEGRETOL and all medicines out of the reach of children.

What are the ingredients in TEGRETOL?

Active ingredient: carbamazepine Inactive ingredients:

  • TEGRETOL Tablets: colloidal silicon dioxide, FD&C Red No. 40, gelatin, glycerin, magnesium stearate, starch, and stearic acid.

  • TEGRETOL Suspension: citric acid, FD&C Yellow No. 6, flavoring, polymer, potassium sorbate, propylene glycol (25 mg/ mL), purified water, sorbitol, sucrose, and xanthan gum.

  • TEGRETOL-XR Tablets: cellulose compounds, dextrates, iron oxides, magnesium stearate, mannitol, polyethylene glycol, sodium lauryl sulfate, titanium dioxide (200 mg tablets only).

09/13/2023 (SUPPL-121)

Approved Drug Label (PDF)

7 Drug Interactions

Additions and revisions underlined:

Effect of Tegretol on Plasma Levels of Concomitant Agents

Decreased Levels of Concomitant Medications

Tegretol is a potent inducer of hepatic 3A4 and is also known to be an inducer of CYP1A2, 2B6, 2C8/9/19, and may therefore reduce plasma concentrations of co-medications mainly metabolized by CYP 1A2, 2B6, 2C8/9/19, and 3A4, through induction of their metabolism.

. . .

  • Concomitant use of carbamazepine with olanzapine, dantrolene, or ibuprofen may increase plasma carbamazepine levels.

03/20/2018 (SUPPL-116)

Approved Drug Label (PDF)

5 Warnings and Precautions

PRECAUTIONS

(additions underlined)

Information for Patients

Patients should be advised that anaphylactic reactions and angioedema may occur during treatment with Tegretol (see WARNINGS). Advise patients to immediately report signs and symptoms suggesting angioedema (swelling of the face, eyes, lips, or tongue, or difficulty in swallowing or breathing) and to stop taking the drug until they have consulted with their healthcare provider.

WARNINGS

(additions underlined)

Anaphylaxis and Angioedema

Rare cases of anaphylaxis and angioedema involving the larynx, glottis, lips, and eyelids have been reported in patients after taking the first or subsequent doses of Tegretol. Angioedema associated with laryngeal edema can be fatal. If a patient develops any of these reactions after treatment with Tegretol, the drug should be discontinued and an alternative treatment started. These patients should not be rechallenged with the drug.

7 Drug Interactions

Effect of Tegretol on Plasma Levels of Concomitant Agents

(addition underlined)

In addition, Tegretol causes, or would be expected to cause, decreased levels of the following drugs, for which monitoring of concentrations or dosage adjustment may be necessary: acetaminophen, albendazole, alprazolam, aprepitant, buprenorphone, bupropion, citalopram, clonazepam, clozapine, corticosteroids (e.g., prednisolone, dexamethasone), cyclosporine, dicumarol, dihydropyridine calcium channel blockers (e.g., felodipine), doxycycline, eslicarbazepine, ethosuximide, everolimus, haloperidol, imatinib, itraconazole, lamotrigine, levothyroxine, methadone, methsuximide, mianserin, midazolam, olanzapine, oral and other hormonal contraceptives, oxcarbazepine, paliperidone, phensuximide, phenytoin, praziquantel, protease inhibitors, risperidone, sertraline, sirolimus, tadalafil, theophylline, tiagabine, topiramate, tramadol, trazodone, tricyclic antidepressants (e.g., imipramine, amitriptyline, nortriptyline), valproate, warfarin, ziprasidone, zonisamide.

Other Drug Interactions

    • Concomitant use of carbamazepine with rivaroxaban, apixaban, dabigatran, and edoxaban (direct acting oral anticoagulants) is expected to result in decreased plasma concentrations of these anticoagulants that may be insufficient to achieve the intended therapeutic effect. In general, coadministration of carbamazepine with rivaroxaban, apixaban, dabigatran, and edoxaban should be avoided.

17 PCI/PI/MG (Patient Counseling Information/Patient Information/Medication Guide)

MEDICATION GUIDE

(additions underlined)

3. TEGRETOL may cause allergic reactions or serious problems, which may affect organs and other parts of your body like the liver or blood cells. You may or may not have a rash with these types of reactions.

Call your healthcare provider right away if you have any of the following:


  • swelling of your face, eyes, lips, or tongue

  • a skin rash

  • painful sores in the mouth or around your eyes

  • unusual bruising or bleeding

  • frequent infections or infections that do not go away

  • fever, swollen glands, or sore throat that do not go away or come and go

  • trouble swallowing or breathing

  • hives

  • yellowing of your skin or eyes

  • severe fatigue or weakness

  • severe muscle pain