Approved Drug Label (PDF)
Boxed Warning
(extensive
additions, please refer to label)
4
Contraindications
(additions
underlined)
VITUZ is contraindicated for:
VITUZ is also contraindicated in patients with:
Significant respiratory depression.
Acute or severe bronchial asthma in an
unmonitored setting or in the absence of resuscitative equipment.
Known or suspected gastrointestinal
obstruction, including paralytic ileus.
Hypersensitivity to hydrocodone, chlorpheniramine,
or any of the inactive ingredients in VITUZ.
5
Warnings and Precautions
5.8 Risks from Concomitant Use with Benzodiazepines or other CNS Depressants
(additions
underlined)
…
Patients must not consume alcoholic
beverages, or prescription or non-prescription products containing alcohol,
while on VITUZ therapy. The co-ingestion
of alcohol with VITUZ may result in increased plasma levels and a potentially
fatal overdose of hydrocodone.
5.9 Risks of Use in Patients with Gastrointestinal Conditions
(additions
underlined)
VITUZ is contraindicated in patients with
known or suspected gastrointestinal obstruction, including paralytic ileus. The
use of hydrocodone in VITUZ may obscure the diagnosis or clinical course of
patients with acute abdominal conditions.
The concurrent use of anticholinergics with VITUZ may
produce paralytic ileus.
The hydrocodone in VITUZ may result in
constipation or obstructive bowel disease, especially in patients with
underlying intestinal motility disorders.
Use with caution in patients with underlying intestinal motility
disorders.
The hydrocodone in VITUZ may cause spasm of
the sphincter of Oddi, resulting in an increase in biliary tract pressure. Opioids may cause increases in serum amylase.
Monitor patients with biliary tract disease, including acute pancreatitis for
worsening symptoms.
(The
following new subsections have been added, please refer to label for more
information)
5.1 Addiction, Abuse, and Misuse
5.2 Life-Threatening Respiratory Depression
5.3 Risks with Use in Pediatric Populations
5.4
Risks with Use in Other At-Risk Populations
5.5 Risk of Accidental Overdose and Death due to
Medication Errors
5.7 Risks from Concomitant Use or Discontinuation
of Cytochrome P450 3A4 Inhibitors and Inducers
5.10 Risks of Use in Patients with Head Injury,
Impaired Consciousness, Increased Intracranial Pressure, or Brain Tumors
5.11 Increased Risk of Seizures in Patients with
Seizure Disorders
5.12 Severe Hypotension
5.13 Neonatal Opioid Withdrawal Syndrome
5.14 Adrenal Insufficiency
5.15 Drug/Laboratory Test Interactions
6
Adverse Reactions
(extensive
additions, please refer to label)
7
Drug Interactions
7.1 Alcohol
(new
subsection added)
Concomitant use of alcohol with VITUZ can result in an
increase of hydrocodone plasma levels and potentially fatal overdose of
hydrocodone. Instruct patients not to
consume alcoholic beverages or use prescription or nonprescription products
containing alcohol while on VITUZ therapy.
7.10 Anticholinergic Drugs
(additions
underlined)
The concomitant use of
anticholinergic drugs with VITUZ may increase risk of urinary retention
and/or severe constipation, which may lead to paralytic ileus. Monitor patients for signs of
urinary retention or reduced gastric motility when VITUZ is used concomitantly
with anticholinergic drugs.
Additive adverse effects resulting from cholinergic
blockade (e.g., xerostomia, blurred vision, or constipation) may occur when
anticholinergic drugs are administered with chlorpheniramine.
7.2 Inhibitors of CYP3A4 and CYP2D6
(new
subsection added)
The concomitant use of VITUZ and CYP3A4 inhibitors, such
as macrolide antibiotics (e.g., erythromycin), azole-antifungal agents (e.g.
ketoconazole), or protease inhibitors (e.g., ritonavir), can increase the
plasma concentration of hydrocodone, resulting in increased or prolonged opioid
effects. These effects could be more
pronounced with concomitant use of VITUZ and CYP2D6 and CYP3A4 inhibitors,
particularly when an inhibitor is added after a stable dose of VITUZ is
achieved [see Warnings and Precautions
(5.7)]. After stopping a CYP3A4
inhibitor, as the effects of the inhibitor decline, the hydrocodone plasma
concentration will decrease.resulting in decreased opioid efficacy or a
withdrawal syndrome in patients who had developed physical dependence to
hydrocodone.
Avoid the use of VITUZ while taking a CYP3A4 or CYP2D6
inhibitor. If concomitant use is
necessary, monitor patients for respiratory depression and sedation at frequent
intervals.
7.3 CYP3A4 Inducers
(new
subsection added)
The concomitant use of VITUZ and CYP3A4 inducers such as
rifampin, carbamazepine, or phenytoin, can decrease the plasma concentration of
hydrocodone, resulting in
decreased efficacy or onset of a withdrawal syndrome in patients who have
developed physical dependence to hydrocodone. After stopping a CYP3A4 inducer, as the effects of the inducer
decline, the hydrocodone plasma concentration will increase, which could increase or prolong both the
therapeutic effects and adverse reactions, and may cause serious respiratory
depression.
Avoid the use of VITUZ in patients who are taking CYP3A4
inducers. If concomitant use of a CYP3A4
inducer is necessary, follow the patient for reduced efficacy.
7.4 Phenytoin
(new
subsection added)
Adverse event reports in the literature suggest a
possible drug interaction involving increased serum phenytoin levels and
phenytoin toxicity when chlorpheniramine and phenytoin are
co-administered. The exact mechanism for
this interaction is not known, however it is believed that chlorpheniramine may
inhibit the hepatic metabolism of phenytoin.
Avoid the use of VITUZ in patients who are taking phenytoin.
7.5 Benzodiazepines, and Other CNS Depressants
(additions
underlined)
Due to additive pharmacologic effect, the
concomitant use of benzodiazepines or other CNS
depressants, including alcohol, other sedatives/hypnotics, anxiolytics,
tranquilizers, muscle relaxants, general anesthetics, antipsychotics, and other
opioids, can increase the risk of hypotension, respiratory depression, profound
sedation, coma, and death. Avoid
the use of VITUZ in patients who are taking benzodiazepines or other CNS
depressants, and instruct
patients to avoid consumption of alcohol while on VITUZ.
7.6 Serotonergic Drugs
(new
subsection added)
The concomitant use of opioids with other drugs that
affect the serotonergic neurotransmitter system has resulted in serotonin
syndrome. If concomitant use is
warranted, carefully observe the patient, particularly during treatment
initiation. Discontinue VITUZ if
serotonin syndrome is suspected.
7.7 Monoamine Oxidase Inhibitors (MAOIs)
(additions
underlined)
Avoid the use of VITUZ in patients who are
taking monoamine oxidase inhibitors (MAOIs) or have taken MAOIs within 14 days. The use of MAOIs or tricyclic antidepressants
with hydrocodone, one of the active ingredients in VITUZ, may increase
the effect of either the antidepressant or hydrocodone. MAOI interactions with opioids may
manifest as serotonin syndrome or opioid toxicity (e.g., respiratory
depression, coma).
7.8 Muscle Relaxants
(new
subsection added)
Hydrocodone may enhance the neuromuscular blocking action
of skeletal muscle relaxants and produce an increased degree of respiratory
depression. Avoid the use of VITUZ in
patients taking muscle relaxants. If
concomitant use is necessary, monitor patients for signs of respiratory
depression that may be greater than otherwise expected.
7.9 Diuretics
(new
subsection added)
Opioids can reduce the efficacy of diuretics by inducing
the release of antidiuretic hormone.
Monitor patients for signs of diminished diuresis and/or effects on
blood pressure and increase the dosage of the diuretic as needed.
8
Use in Specific Populations
8.1 Pregnancy
(PLLR
conversion, please refer to label)
8.2 Lactation
(PLLR
conversion)
Risk Summary
Because of the potential for serious adverse reactions,
including excess sedation, respiratory depression, and death in a breastfed
infant, advise patients that breastfeeding is not recommended during treatment
with VITUZ.
There are no data on the presence of VITUZ in human milk,
the effects of VITUZ on the breastfed infant, or the effects of VITUZ on milk
production; however, data are available with hydrocodone and chlorpheniramine.
Hydrocodone
Hydrocodone is present in breast milk. Published cases report variable
concentrations of hydrocodone and hydromorphone (an active metabolite) in
breast milk with administration of immediate-release hydrocodone to nursing
mothers in the early post-partum period with relative infant doses of
hydrocodone ranging between 1.4 and 3.7%.
There are case reports of excessive sedation and respiratory depression
in breastfed infants exposed to hydrocodone.
No information is available on the effects of hydrocodone on milk
production.
Chlorpheniramine
Chlorpheniramine is present in human milk. Chlorpheniramine has not been reported to
cause effects on the breastfed infant.
The published literature suggests that chlorpheniramine may decrease
milk production based on its anticholinergic effects. (see Clinical Considerations)
Clinical Considerations
Infants exposed to VITUZ through breast milk should be
monitored for excess sedation and respiratory depression. Withdrawal symptoms can occur in breastfed
infants when maternal administration of an opioid is stopped, or when
breastfeeding is stopped.
8.3 Females and Males of Reproductive Potential
(PLLR
conversion)
Infertility
Chronic use of opioids, such as
hydrocodone, a component of VITUZ, may cause reduced fertility in females and
males of reproductive potential. It is
not known whether these effects on fertility are reversible.
8.4 Pediatric Use
(additions
underlined)
VITUZ is not indicated for use in patients
younger than 18 years of age because the benefits of symptomatic treatment of
cough associated with allergies or the common cold do not outweigh the risks
for use of hydrocodone in these patients.
Life-threatening
respiratory depression and death have occurred in children who received
hydrocodone.Because of the risk
of life-threatening respiratory depression and death, VITUZ is
contraindicated in children less than 6 years of age.
8.5 Geriatric Use
(additions
underlined)
Clinical studies have not been conducted with VITUZ in
geriatric populations.
Use caution when considering the use of VITUZ
in patients 65 years of age or older.
Elderly patients may have increased sensitivity to hydrocodone;
greater frequency of decreased hepatic, renal, or cardiac function; or
concomitant disease or other drug therapy.
Respiratory depression is the chief risk for
elderly patients treated with opioids, including VITUZ. Respiratory depression has occurred after
large initial doses of opioids were administered to patients who were not
opioid-tolerant or when opioids were co-administered with other agents that
depress respiration.
Hydrocodone is known to be substantially
excreted by the kidney, and the risk of adverse reactions to this drug may be
greater in patients with impaired renal function. Because elderly patients are more likely to
have decreased renal function, monitor these patients closely for respiratory
depression, sedation, and hypotension.
8.6 Renal Impairment
(additions
underlined)
The pharmacokinetics of VITUZ has not been
characterized in patients with renal impairment. Patients with renal impairment may have
higher plasma concentrations than those with normal function. Chlorpheniramine
maleate is cleared substantially by the kidney.
As such, impaired renal function could potentially lead to the risk of
decreased clearance and thereby increased retention or systemic levels of
chlorpheniramine. Therefore, VITUZ
should be used with caution in patients with severe impairment of renal
function, and patients should be monitored closely for signs of hydrocodone
toxicity (respiratory depression, sedation, and hypotension) and
chlorpheniramine toxicity.
8.7 Hepatic Impairment
(additions
underlined)
The pharmacokinetics of VITUZ has not been
characterized in patients with hepatic impairment. Patients with severe hepatic impairment may
have higher plasma concentrations than those with normal hepatic function.
Chlorpheniramine maleate is extensively metabolized by liver before elimination
from the body. As such, impaired hepatic
function could potentially lead to the risk of decreased metabolism and thereby
increased systemic levels of chlorpheniramine.
Therefore, VITUZ should be used with caution in patients with severe
impairment of hepatic function, and patients should be monitored closely for
signs of hydrocodone toxicity (respiratory depression, sedation, and
hypotension) and chlorpheniramine toxicity.
17 PCI/PI/MG (Patient Counseling Information/Patient Information/Medication Guide)
MEDICATION GUIDE
(additions
and revisions, please refer to label)
PATIENT COUNSELING INFORMATION
(extensive
additions, please refer to label)
Approved Drug Label (PDF)
Boxed Warning
(New
section added)
WARNING: RISKS FROM CONCOMITANT USE WITH
BENZODIAZEPINES OR OTHER CNS DEPRESSANTS
Concomitant use of opioids with
benzodiazepines or other central nervous system (CNS) depressants, including
alcohol, may result in profound sedation, respiratory depression, coma, and
death. Avoid use of opioid cough
medications in patients taking benzodiazepines, other CNS depressants, or
alcohol.
5
Warnings and Precautions
5.1 Risks from Concomitant Use with Benzodiazepines or other CNS Depressants
(subsection
added)
Concomitant use of opioids, including REZIRA, with benzodiazepines, or
other CNS depressants, including alcohol, may result in profound sedation,
respiratory depression, coma, and death. Because of these risks, avoid use of
opioid cough medications in patients taking benzodiazepines, other CNS
depressants, or alcohol.
Observational studies have
demonstrated that concomitant use of opioid analgesics and benzodiazepines
increases the risk of drug-related mortality compared to use of opioids alone.
Because of similar pharmacologic properties, it is reasonable to expect similar
risk with concomitant use of opioid cough medications and benzodiazepines,
other CNS depressants, or alcohol.
Advise both patients and
caregivers about the risks of respiratory depression and sedation if REZIRA is
used with benzodiazepines, alcohol, or other CNS depressants.
7
Drug Interactions
7.1 Benzodiazepines, Opioids, Antihistamines, Antipsychotics, Anti-anxiety Agents, or Other CNS Depressants (Including Alcohol)
(subsection
revised, additions underlined)
The use of benzodiazepines,
opioids, antihistamines, antipsychotics, anti-anxiety agents, or other CNS
depressants (including alcohol) concomitantly with REZIRA Oral Solution
may cause an additive CNS depressant effect, profound sedation, respiratory
depression, coma, and death and should be avoided.
17 PCI/PI/MG (Patient Counseling Information/Patient Information/Medication Guide)
17 PATIENT COUNSELING INFORMATION
17.3 Interactions
with Benzodiazepines and Other Central Nervous System Depressants
(subsection
revised, additions underlined)
Inform patients and
caregivers that potentially fatal additive effects may occur if REZIRA Oral Solution is used with
benzodiazepines or other CNS depressants, including alcohol. Because of
this risk, patients should avoid concomitant use of REZIRA Oral Solution with
benzodiazepines or other CNS depressants, including alcohol.
MEDICATION GUIDE
(New
section added, please refer to label)