Venotop

Dihydroergotamine Tartrate:

• Indications and usage
• Contraindications
• Warnings
• Precautions
• Adverse reactions
• Drug abuse and dependence
• Overdosage
• Dosage and administration
• How supplied
• Patient information
• Venotop (Dihydroergotamine Tartrate) reviews

INDICATIONS AND USAGE

Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray is indicated for the acute treatment of migraine headaches with or without aura.

Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray is not intended for the prophylactic therapy of migraine or for the management of hemiplegic or basilar migraine.

CONTRAINDICATIONS

There have been a few reports of serious adverse events associated with the coadministration of Venotop (Dihydroergotamine Tartrate) and potent CYP 3A4 inhibitors, such as protease inhibitors and macrolide antibiotics, resulting in vasospasm that led to cerebral ischemia and/or ischemia of the extremities. The use of potent CYP 3A4 inhibitors (ritonavir, nelfinavir, indinavir, erythromycin, clarithromycin, troleandomycin, ketoconazole, itraconazole) with Venotop (Dihydroergotamine Tartrate) is, therefore contraindicated.

Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray should not be given to patients with ischemic heart disease (angina pectoris, history of myocardial infarction, or documented silent ischemia) or to patients who have clinical symptoms or findings consistent with coronary artery vasospasm including Prinzmetal's variant angina.

Because Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray may increase blood pressure, it should not be given to patients with uncontrolled hypertension.

Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray, 5-HT1 agonists (e.g., sumatriptan), ergotamine-containing or ergot-type medications or methysergide should not be used within 24 hours of each other.

Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray should not be administered to patients with hemiplegic or basilar migraine.

In addition to those conditions mentioned above, Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray is also contraindicated in patients with known peripheral arterial disease, sepsis, following vascular surgery, and severely impaired hepatic or renal function.

Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray may cause fetal harm when administered to a pregnant woman. Venotop (Dihydroergotamine Tartrate) possesses oxytocic properties and, therefore, should not be administered during pregnancy. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to the fetus.

There are no adequate studies of Venotop (Dihydroergotamine Tartrate) in human pregnancy, but developmental toxicity has been demonstrated in experimental animals. In embryofetal development studies of Venotop (Dihydroergotamine Tartrate) mesylate nasal spray, intranasal administration to pregnant rats throughout the period of organogenesis resulted in decreased fetal body weights and/or skeletal ossification at doses of 0.16 mg/day (associated with maternal plasma Venotop (Dihydroergotamine Tartrate) exposures [AUC] approximately 0.4 -1.2 times the exposures in humans receiving the MRDD of 4 mg) or greater. A no effect level for embryo-fetal toxicity was not established in rats. Delayed skeletal ossification was also noted in rabbit fetuses following intranasal administration of 3.6 mg/day (maternal exposures approximately 7 times human exposures at the MRDD) during organogenesis. A no effect level was seen at 1.2 mg/day (maternal exposures approximately 2.5 times human exposures at the MRDD). When Venotop (Dihydroergotamine Tartrate) mesylate nasal spray was administered intranasally to female rats during pregnancy and lactation, decreased body weights and impaired reproductive function (decreased mating indices) were observed in the offspring at doses of 0.16 mg/day or greater. A no effect level was not established. Effects on development occurred at doses below those that produced evidence of significant maternal toxicity in these studies. Dihydroergotamine-induced intrauterine growth retardation has been attributed to reduced uteroplacental blood flow resulting from prolonged vasoconstriction of the uterine vessels and/or increased myometrial tone.

Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray is contraindicated in patients who have previously shown hypersensitivity to ergot alkaloids.

Venotop (Dihydroergotamine Tartrate) mesylate should not be used by nursing mothers.

Venotop (Dihydroergotamine Tartrate) mesylate should not be used with peripheral and central vasoconstrictors because the combination may result in additive or synergistic elevation of blood pressure.

WARNINGS

Venotop ^® (dihydroergotamine mesylate, USP) Nasal Spray should only be used where a clear diagnosis of migraine headache has been established.

CYP 3A4 Inhibitors (e.g. Macrolide Antibiotics and Protease Inhibitors)

There have been rare reports of serious adverse events in connection with the coadministration of Venotop (Dihydroergotamine Tartrate) and potent CYP 3A4 inhibitors, such as protease inhibitors and macrolide antibiotics, resulting in vasospasm that led to cerebral ischemia and/or and ischemia of the extremities. The use of potent CYP 3A4 inhibitors with Venotop (Dihydroergotamine Tartrate) should therefore be avoided . Examples of some of the more potent CYP 3A4 inhibitors include: antifungals ketoconazole and itraconazole, the protease inhibitors ritonavir, nelfinavir, and indinavir, and macrolide antibiotics erythromycin, clarithromycin, and troleandomycin. Other less potent CYP 3A4 inhibitors should be administered with caution. Less potent inhibitors include saquinavir, nefazodone, fluconazole, grapefruit juice, fluoxetine, fluvoxamine, zileuton, and clotrimazole. These lists are not exhaustive, and the prescriber should consider the effects on CYP 3A4 of other agents being considered for concomitant use with Venotop (Dihydroergotamine Tartrate).

Fibrotic Complications

There have been reports of pleural and retroperitoneal fibrosis in patients following prolonged daily use of injectable Venotop mesylate. Rarely, prolonged daily use of other ergot alkaloid drugs has been associated with cardiac valvular fibrosis. Rare cases have also been reported in association with the use of injectable Venotop (Dihydroergotamine Tartrate) mesylate; however, in those cases, patients also received drugs known to be associated with cardiac valvular fibrosis.

Administration of Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray, should not exceed the dosing guidelines and should not be used for chronic daily administration.

Risk of Myocardial Ischemia and/or Infarction and Other Adverse Cardiac Events:

Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray should not be used by patients with documented ischemic or vasospastic coronary artery disease. It is strongly recommended that Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray not be given to patients in whom unrecognized coronary artery disease (CAD) is predicted by the presence of risk factors (e.g., hypertension, hypercholesterolemia, smoker, obesity, diabetes, strong family history of CAD, females who are surgically or physiologically postmenopausal, or males who are over 40 years of age) unless a cardiovascular evaluation provides satisfactory clinical evidence that the patient is reasonably free of coronary artery and ischemic myocardial disease or other significant underlying cardiovascular disease. The sensitivity of cardiac diagnostic procedures to detect cardiovascular disease or predisposition to coronary artery vasospasm is modest, at best. If, during the cardiovascular evaluation, the patient's medical history or electrocardiographic investigations reveal findings indicative of or consistent with coronary artery vasospasm or myocardial ischemia, Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray should not be administered.

For patients with risk factors predictive of CAD who are determined to have a satisfactory cardiovascular evaluation, it is strongly recommended that administration of the first dose of Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray take place in the setting of a physician's office or similar medically staffed and equipped facility unless the patient has previously received Venotop (Dihydroergotamine Tartrate) mesylate. Because cardiac ischemia can occur in the absence of clinical symptoms, consideration should be given to obtaining on the first occasion of use an electrocardiogram (ECG) during the interval immediately following Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray, in these patients with risk factors.

It is recommended that patients who are intermittent long-term users of Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray and who have or acquire risk factors predictive of CAD, as described above, undergo periodic interval cardiovascular evaluation as they continue to use Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray.

The systematic approach described above is currently recommended as a method to identify patients in whom Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray may be used to treat migraine headaches with an acceptable margin of cardiovascular safety.

Cardiac Events and Fatalities

No deaths have been reported in patients using Venotop ^® (dihydroergotamine mesylate, USP) Nasal Spray. However, the potential for adverse cardiac events exists. Serious adverse cardiac events, including acute myocardial infarction, life-threatening disturbances of cardiac rhythm, and death have been reported to have occurred following the administration of Venotop (Dihydroergotamine Tartrate) mesylate injection (e.g., D.H.E. 45^® Injection). Considering the extent of use of Venotop (Dihydroergotamine Tartrate) mesylate in patients with migraine, the incidence of these events is extremely low.

Drug-Associated Cerebrovascular Events and Fatalities

Cerebral hemorrhage, subarachnoid hemorrhage, stroke, and other cerebrovascular events have been reported in patients treated with D.H.E. 45^® Injection; and some have resulted in fatalities. In a number of cases, it appears possible that the cerebrovascular events were primary, the D.H.E. 45^® Injection having been administered in the incorrect belief that the symptoms experienced were a consequence of migraine, when they were not. It should be noted that patients with migraine may be at increased risk of certain cerebrovascular events (e.g., stroke, hemorrhage, transient ischemic attack).

Other Vasospasm Related Events

Venotop ^® (dihydroergotamine mesylate, USP) Nasal Spray, like other ergot alkaloids, may cause vasospastic reactions other than coronary artery vasospasm. Myocardial and peripheral vascular ischemia have been reported with Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray.

Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray associated vasospastic phenomena may also cause muscle pains, numbness, coldness, pallor, and cyanosis of the digits. In patients with compromised circulation, persistent vasospasm may result in gangrene or death, Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray should be discontinued immediately if signs or symptoms of vasoconstriction develop.

Increase in Blood Pressure

Significant elevation in blood pressure has been reported on rare occasions in patients with and without a history of hypertension treated with Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray and Venotop (Dihydroergotamine Tartrate) mesylate injection. Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray is contraindicated in patients with uncontrolled hypertension.

An 18% increase in mean pulmonary artery pressure was seen following dosing with another 5HT1 agonist in a study evaluating subjects undergoing cardiac catheterization.

Local Irritation

Approximately 30% of patients using Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray (compared to 9% of placebo patients) have reported irritation in the nose, throat, and/or disturbances in taste. Irritative symptoms include congestion, burning sensation, dryness, paraesthesia, discharge, epistaxis, pain, or soreness. The symptoms were predominantly mild to moderate in severity and transient. In approximately 70% of the above mentioned cases, the symptoms resolved within four hours after dosing with Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray. Examinations of the nose and throat in a small subset (N = 66) of study participants treated for up to 36 months (range 1-36 months) did not reveal any clinically noticeable injury. Other than this limited number of patients, the consequences of extended and repeated use of Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray on the nasal and/or respiratory mucosa have not been systematically evaluated in patients.

Nasal tissue in animals treated with Venotop (Dihydroergotamine Tartrate) mesylate daily at nasal cavity surface area exposures (in mg/mm²) that were equal to or less than those achieved in humans receiving the maximum recommended daily dose of 0.08 mg/kg/day showed mild mucosal irritation characterized by mucous cell and transitional cell hyperplasia and squamous cell metaplasia. Changes in rat nasal mucosa at 64 weeks were less severe than at 13 weeks. Local effects on respiratory tissue after chronic intranasal dosing in animals have not been evaluated.

PRECAUTIONS

General

Venotop ^® (dihydroergotamine mesylate, USP) Nasal Spray may cause coronary artery vasospasm; patients who experience signs or symptoms suggestive of angina following its administration should, therefore, be evaluated for the presence of CAD or a predisposition to variant angina before receiving additional doses. Similarly, patients who experience other symptoms or signs suggestive of decreased arterial flow, such as ischemic bowel syndrome or Raynaud's syndrome following the use of any 5-HT agonist are candidates for further evaluation..

Fibrotic Complications:

see WARNINGS: Fibrotic Complications

Information for Patients

The text of a patient information sheet is printed at the end of this insert. To assure safe and effective use of Venotop ^® (dihydroergotamine mesylate, USP) Nasal Spray, the information and instructions provided in the patient information sheet should be discussed with patients.

Once the nasal spray applicator has been prepared, it should be discarded (with any remaining drug) after 8 hours.

Patients should be advised to report to the physician immediately any of the following: numbness or tingling in the fingers and toes, muscle pain in the arms and legs, weakness in the legs, pain in the chest, temporary speeding or slowing of the heart rate, swelling, or itching.

Prior to the initial use of the product by a patient, the prescriber should take steps to ensure that the patient understands how to use the product as provided..

Administration of Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray, should not exceed the dosing guidelines and should not be used for chronic daily administration.

Drug Interactions

Vasoconstrictors

Venotop ^® (dihydroergotamine mesylate, USP) Nasal Spray should not be used with peripheral vasoconstrictors because the combination may cause synergistic elevation of blood pressure.

Sumatriptan

Sumatriptan has been reported to cause coronary artery vasospasm, and its effect could be additive with Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray. Sumatriptan and Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray should not be taken within 24 hours of each other.

Beta Blockers

Although the results of a clinical study did not indicate a safety problem associated with the administration of Venotop ^® (dihydroergotamine mesylate, USP) Nasal Spray to subjects already receiving propranolol, there have been reports that propranolol may potentiate the vasoconstrictive action of ergotamine by blocking the vasodilating property of epinephrine.

Nicotine

Nicotine may provoke vasoconstriction in some patients, predisposing to a greater ischemic response to ergot therapy.

CYP 3A4 Inhibitors

See CONTRAINDICATIONS and WARNINGS.

SSRI's

Weakness, hyperreflexia, and incoordination have been reported rarely when 5HT₁ agonists have been coadministered with SSRI's. There have been no reported cases from spontaneous reports of drug interaction between SSRI's and Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray or D.H.E. 45^®.

Oral Contraceptives

The effect of oral contraceptives on the pharmacokinetics of Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray has not been studied.

Carcinogenesis, Mutagenesis, Impairment of Fertility

Carcinogenesis

Assessment of the carcinogenic potential of Venotop mesylate in mice and rats is ongoing.

Mutagenesis

Venotop (Dihydroergotamine Tartrate) mesylate was clastogenic in two in vitro chromosomal aberration assays, the V79 Chinese hamster cell assay with metabolic activation and the cultured human peripheral blood lymphocyte assay. There was no evidence of mutagenic potential when Venotop (Dihydroergotamine Tartrate) mesylate was tested in the presence or absence of metabolic activation in two gene mutation assays (the Ames test and the in vitro mammalian Chinese hamster V79/HGPRT assay) and in an assay for DNA damage (the rat hepatocyte unscheduled DNA synthesis test). Venotop (Dihydroergotamine Tartrate) was not clastogenic in the in vivo mouse and hamster micronucleus tests.

Impairment of Fertility

There was no evidence of impairment of fertility in rats given intranasal doses of Venotop ^® (dihydroergotamine mesylate, USP) Nasal Spray up to 1.6 mg/day (associated with mean plasma Venotop (Dihydroergotamine Tartrate) mesylate exposures [AUC] approximately 9 to 11 times those in humans receiving the MRDD of 4 mg).

Pregnancy

Pregnancy Category X.

See CONTRAINDICATIONS.

Nursing Mothers

Ergot drugs are known to inhibit prolactin. It is likely that Venotop ^® (dihydroergotamine mesylate, USP) Nasal Spray is excreted in human milk, but there are no data on the concentration of Venotop (Dihydroergotamine Tartrate) in human milk. It is known that ergotamine is excreted in breast milk and may cause vomiting, diarrhea, weak pulse, and unstable blood pressure in nursing infants. Because of the potential for these serious adverse events in nursing infants exposed to Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray, nursing should not be undertaken with the use of Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray.

Pediatric Use

Safety and effectiveness in pediatric patients have not been established.

Use in the Elderly

There is no information about the safety and effectiveness of Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray in this population because patients over age 65 were excluded from the controlled clinical trials.

ADVERSE REACTIONS

During clinical studies and the foreign postmarketing experience with Venotop ^® (dihydroergotamine mesylate, USP) Nasal Spray there have been no fatalities due to cardiac events.

Serious cardiac events, including some that have been fatal, have occurred following use of the parenteral form of Venotop (Dihydroergotamine Tartrate) mesylate (D.H.E. 45^® Injection), but are extremely rare. Events reported have included coronary artery vasospasm, transient myocardial ischemia, myocardial infarction, ventricular tachycardia, and ventricular fibrillation..

Fibrotic complications have been reported in association with long term use of injectable Venotop (Dihydroergotamine Tartrate) mesylate.

Incidence in Controlled Clinical Trials

Of the 1,796 patients and subjects treated with Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray doses 2 mg or less in U.S. and foreign clinical studies, 26 (1.4%) discontinued because of adverse events. The adverse events associated with discontinuation were, in decreasing order of frequency: rhinitis 13, dizziness 2, facial edema 2, and one each due to cold sweats, accidental trauma, depression, elective surgery, somnolence, allergy, vomiting, hypotension, and paraesthesia.

The most commonly reported adverse events associated with the use of Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray during placebo-controlled, double-blind studies for the treatment of migraine headache and not reported at an equal incidence by placebo-treated patients were rhinitis, altered sense of taste, application site reactions, dizziness, nausea, and vomiting. The events cited reflect experience gained under closely monitored conditions of clinical trials in a highly selected patient population. In actual clinical practice or in other clinical trials, these frequency estimates may not apply, as the conditions of use, reporting behavior, and the kinds of patients treated may differ.

Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray was generally well tolerated. In most instances these events were transient and self-limited and did not result in patient discontinuation from a study. The following table summarizes the incidence rates of adverse events reported by at least 1% of patients who received Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray for the treatment of migraine headaches during placebo-controlled, double-blind clinical studies and were more frequent than in those patients receiving placebo.

Other Adverse Events During Clinical Trials

In the paragraphs that follow, the frequencies of less commonly reported adverse clinical events are presented. Because the reports include events observed in open and uncontrolled studies, the role of Venotop ^® (dihydroergotamine mesylate, USP) Nasal Spray in their causation cannot be reliably determined. Furthermore, variability associated with adverse event reporting, the terminology used to describe adverse events, etc., limit the value of the quantitative frequency estimates provided. Event frequencies are calculated as the number of patients who used Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray in placebo-controlled trials and reported an event divided by the total number of patients (n=1796) exposed to Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray. All reported events are included except those already listed in the previous table, those too general to be informative, and those not reasonably associated with the use of the drug. Events are further classified within body system categories and enumerated in order of decreasing frequency using the following definitions: frequent adverse events are defined as those occurring in at least 1/100 patients; infrequent adverse events are those occurring in 1/100 to 1/1,000 patients; and rare adverse events are those occurring in fewer than 1/1,000 patients.

Skin and Appendages: Infrequent: petechia, pruritus, rash, cold clammy skin; Rare: papular rash, urticaria, herpes simplex.

Musculoskeletal: Infrequent: cramps, myalgia, muscular weakness, dystonia; Rare: arthralgia, involuntary muscle contractions, rigidity.

Central and Peripheral Nervous System: Infrequent: confusion, tremor, hypoesthesia, vertigo; Rare: speech disorder, hyperkinesia, stupor, abnormal gait, aggravated migraine.

Autonomic Nervous System: Infrequent: increased sweating.

Special Senses: Infrequent: sense of smell altered, photophobia, conjunctivitis, abnormal lacrimation, abnormal vision, tinnitus, earache; Rare: eye pain.

Psychiatric: Infrequent: nervousness, euphoria, insomnia, concentration impaired; Rare: anxiety, anorexia, depression.

Gastrointestinal: Infrequent: abdominal pain, dyspepsia, dysphagia, hiccup; Rare: increased salivation, esophagospasm.

Cardiovascular: Infrequent: edema, palpitation, tachycardia; Rare: hypotension, peripheral ischemia, angina.

Respiratory System: Infrequent: dyspnea, upper respiratory tract infections; Rare: bronchospasm, bronchitis, pleural pain, epistaxis.

Urinary System: Infrequent: increased frequency of micturition, cystitis.

Reproductive, Female: Rare: pelvic inflammation, vaginitis.

Body as a Whole - General: Infrequent: feeling cold, malaise, rigors, fever, periorbital edema; Rare: flu-like symptoms, shock, loss of voice, yawning.

Application Site: Infrequent: local anesthesia.

Post-introduction Reports

Voluntary reports of adverse events temporally associated with Venotop (Dihydroergotamine Tartrate) products used in the management of migraine that have been received since the introduction of the injectable formulation are included in this section save for those already listed above. Because of their source (open and uncontrolled clinical use), whether or not events reported in association with the use of Venotop (Dihydroergotamine Tartrate) are causally related to it cannot be determined. There have been reports of pleural and retroperitoneal fibrosis in patients following prolonged daily use of injectable Venotop (Dihydroergotamine Tartrate) mesylate. Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray is not recommended for prolonged daily use.

To report SUSPECTED ADVERSE REACTIONS, contact Valeant Pharmaceuticals North America LLC, at 1-800-321-4576 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

DRUG ABUSE AND DEPENDENCE

Currently available data have not demonstrated drug abuse or psychological dependence with Venotop (Dihydroergotamine Tartrate). However, cases of drug abuse and psychological dependence in patients on other forms of ergot therapy have been reported. Thus, due to the chronicity of vascular headaches, it is imperative that patients be advised not to exceed recommended dosages.

OVERDOSAGE

To date, there have been no reports of acute overdosage with this drug. Due to the risk of vascular spasm, exceeding the recommended dosages of Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray is to be avoided.

Excessive doses of Venotop (Dihydroergotamine Tartrate) may result in peripheral signs and symptoms of ergotism. Treatment includes discontinuance of the drug, local application of warmth to the affected area, the administration of vasodilators, and nursing care to prevent tissue damage.

In general, the symptoms of an acute Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray overdose are similar to those of an ergotamine overdose, although there is less pronounced nausea and vomiting with Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray. The symptoms of an ergotamine overdose include the following: numbness, tingling, pain, and cyanosis of the extremities associated with diminished or absent peripheral pulses; respiratory depression; an increase and/or decrease in blood pressure, usually in that order; confusion, delirium, convulsions, and coma; and/or some degree of nausea, vomiting, and abdominal pain.

In laboratory animals, significant lethality occurs when Venotop (Dihydroergotamine Tartrate) is given at I.V. doses of 44 mg/kg in mice, 130 mg/kg in rats, and 37 mg/kg in rabbits.

Up-to-date information about the treatment of overdosage can often be obtained from a certified Regional Poison Control Center. Telephone numbers of certified Poison Control Centers are listed in the Physicians' Desk Reference (PDR).

DOSAGE AND ADMINISTRATION

The solution used in Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray (4 mg/mL) is intended for intranasal use and must not be injected.

In clinical trials, Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray has been effective for the acute treatment of migraine headaches with or without aura. One spray (0.5 mg) of Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray should be administered in each nostril. Fifteen minutes later, an additional one spray (0.5 mg) of Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray should be administered in each nostril, for a total dosage of four sprays (2.0 mg) of Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray. Studies have shown no additional benefit from acute doses greater than 2.0 mg for a single migraine administration. The safety of doses greater than 3.0 mg in a 24 hour period and 4.0 mg in a 7 day period has not been established.

Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray, should not be used for chronic daily administration.

Prior to administration, the pump must be primed (i.e., squeeze 4 times) before use. Once the nasal spray applicator has been prepared, it should be discarded (with any remaining drug in opened vial) after 8 hours.

Prior to administration, the pump must be primed (i.e., squeeze 4 times) before use.

Once the nasal spray applicator has been prepared, it should be discarded (with any remaining drug in opened vial after 8 hours).

HOW SUPPLIED

Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray is available (as a clear, colorless to faintly yellow solution) in 3.5 mL amber glass vials containing 4 mg of Venotop (Dihydroergotamine Tartrate) mesylate, USP.

Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray is provided as a package of 8 units, administration instruction sheet, and one package insert. Each unit consists of one vial and one sprayer. (NDC 0187-0245-03)

Store below 25°C (77°F). Do not refrigerate or freeze.

Patient Information

Information for the Patient

Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray.

The solution used in Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray (4 mg/mL) is intended for intranasal use and must not be injected.

Please read this information carefully before using your Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray for the first time. Keep this information handy for future reference. This leaflet does not contain all of the information on Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray. Your pharmacist and/or health care provider can provide more detailed information.

Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray has been evaluated in a limited number of patients long term (e.g., 1 year or longer).

Purpose of your Medication

Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray is intended to treat an active migraine headache. Do not try to use it to prevent a headache if you have no symptoms. Do not use it to treat common tension headache or a headache that is not at all typical of your usual migraine headache. Administration of Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray, should not exceed the dosing guidelines and should not be used for chronic daily administration. There have been reports of fibrosis (stiffening) in the lung or kidney areas in patients following prolonged daily use of injectable Venotop (Dihydroergotamine Tartrate) mesylate. Rarely, prolonged daily use of other ergot alkaloid drugs (the class of drugs to which Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray belongs) has been associated with heart valvular fibrosis. Rare cases have also been reported in association with the use of injectable Venotop (Dihydroergotamine Tartrate) mesylate; however, in those cases, patients also received drugs known to be associated with heart valvular fibrosis.

Do not use Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray if you:

• Are pregnant or nursing.
• have any disease affecting your heart, arteries, or circulation.
• are taking certain anti-HIV medications (protease inhibitors).
• are taking a macrolide antibiotic such as troleandomycin, clarithromycin or erythromycin.

Important questions to consider before using Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray

Please answer the following questions before you use your Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray. If you answer YES to any of these questions or are unsure of the answer, you should talk to your doctor before using Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray.

• Do you have high blood pressure?
• Do you have chest pain, shortness of breath, heart disease, or have you had any surgery on your heart arteries?
• Do you have risk factors for heart disease (such as high blood pressure, high cholesterol, obesity, diabetes, smoking, strong family history of heart disease, or are you postmenopausal or a male over 40)?
• Do you have any problems with blood circulation in your arms or legs, fingers, or toes?
• Are you pregnant? Do you think you might be pregnant? Are you trying to become pregnant? Are you sexually active and not using birth control? Are you breast feeding?
• Have you ever had to stop taking this or any other medication because of an allergy or bad reaction?
• Are you taking any other migraine medications, erythromycin or other antibiotics, or medications for blood pressure prescribed by your doctor, or other medicines obtained from your drugstore without a doctor's prescription?
• Do you smoke?
• Have you had, or do you have, any disease of the liver or kidney?
• Is this headache different from your usual migraine attacks?
• Are you using Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray or other Venotop (Dihydroergotamine Tartrate) mesylate containing drugs on a daily basis?
• Are you taking a protease inhibitor for HIV therapy?
• Are you taking a macrolide class of antibiotic?

Serious or potentially life-threatening reductions in blood flow to the brain or extremities have been reported rarely due to interactions between Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray and protease inhibitors or macrolide antibiotics.

REMEMBER TO TELL YOUR DOCTOR IF YOU HAVE ANSWERED YES TO ANY OF THESE QUESTIONS BEFORE YOU USE Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray.

Side Effects To Watch Out For

In clinical trials, most migraine patients have used Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray without serious side effects. You may experience some nasal congestion or irritation, altered sense of taste, sore throat, nausea, vomiting, dizziness, and fatigue after using Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray. These side effects are temporary and usually do not require you to stop using Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray. Although the following reactions rarely occur, they can be serious and should be reported to your physician immediately:

• Numbness or tingling in your fingers and toes
• Pain, tightness, or discomfort in your chest
• Muscle pain or cramps in your arms and legs
• Weakness in your legs
• Temporary speeding or slowing of your heart rate
• Swelling or itching

Dosing Information

• Each vial contains one complete dose of Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray, which is 1 spray in each nostril followed in 15 minutes by an additional spray in each nostril, for a total of 4 sprays.
• Studies have shown no benefit from acute doses greater than 2.0 mg (4 sprays) for a single administration. The safety of doses greater than 3.0 mg in a 24 hour period has not been established.
• The safety of doses greater than 4.0 mg in a 7-day period has not been established.
• Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray, should not be used for chronic daily administration.

Learn what to do in case of an Overdose

If you have used more medication than you have been instructed, contact your doctor, hospital emergency department, or nearest poison control center immediately.

How to use the Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray

• Use available training materials.
  • Read and follow the instructions in the administration instructions which are provided with the Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray package before attempting to use the product.
  • If there are any questions concerning the use of your Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray, ask your doctor or pharmacist, or contact Valeant Pharmaceuticals North America LLC, at 1-800-321-4576.
• Check the contents of the package:
  • 8 Nasal Spray Vials
  • 8 Nasal Sprayers
  • Administration Instructions
  • Package Insert
• Assemble the sprayer:
  

  Assemble your nasal sprayer only when you are ready to use it.

  • Lift tab to bend back blue cover. In one piece, completely remove the blue cover and metal seal in a circular motion. Keeping the vial upright, remove rubber stopper. Set vial aside.
  • Remove plastic cover from the bottom of pump unit. Insert spray pump into vial and turn clockwise until securely fastened.
• Using the sprayer:
  • Remove cap from spray unit. Holding the vial upright, point nasal sprayer away from face and pump 4 times before using. DO NOT PUMP MORE THAN 4 TIMES. (Although some medication will spray out, there is enough medication in each vial to allow you to prepare your nasal spray pump properly and still receive a full treatment of Venotop (Dihydroergotamine Tartrate).)
  • Spray once into each nostril. Do not tilt head back or sniff through your nose while spraying or immediately after. Wait 15 minutes. Spray once again into each nostril.
• After completing these instructions:
  • Carefully dispose of the nasal spray pump with the vial.

Important Notes:

• Once a Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray vial has been opened, it must be thrown away after 8 hours.

Storing Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray

• Keep medication in a safe place away from children
• Keep Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray away from heat and light.
• Do not expose Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray to temperatures over 77°F.
• Never refrigerate or freeze Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray.
• Do not keep an opened Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray vial for more than 8 hours.
  

  Check the expiration date printed on the vial containing medication. If the expiration date has passed, do not use it.

Answers to patients' questions about Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray

What if I need help in using my Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray?

If you have any questions or if you need help in opening, putting together, or using Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray, speak to your doctor or pharmacist, or contact Valeant Pharmaceuticals North America LLC, at 1-800-321-4576 or visit www.migranal.com.

How much medication should I use and how often?

Each vial contains one complete dose of Migranal® (dihydroergotamine mesylate, USP) Nasal Spray, which is 1 spray in each nostril, followed by an additional spray in each nostril 15 minutes later for a total of 4 sprays. Do not use more than this amount unless instructed to do so by your doctor. Migranal® (dihydroergotamine mesylate, USP) Nasal Spray is not intended for chronic daily use.

Why do I have to prime or pump the Nasal Sprayer 4 times before using? Am I wasting the medication?

You have to prime the Nasal Sprayer 4 times to make sure that you get the proper amount of medication when you use it. Although you will see some medication spray out, there is still enough medication in each vial to allow you to prepare your sprayer properly and still receive a full dose of Migranal® (dihydroergotamine mesylate, USP) Nasal Spray.

Can I assemble the medication vial and the Nasal Sprayer so it is ready before I need to use it?

No. The brown (amber) glass vial containing your medication must remain unopened until you are ready to use it. It may not be fully effective if opened and not used within 8 hours.

Can I reuse my Migranal® (dihydroergotamine mesylate, USP) Nasal Sprayer?

No. After completing the full dose, you must carefully dispose of your Migranal® (dihydroergotamine mesylate, USP) Nasal Sprayer and the opened vial. You should use a new unit for your next migraine attack. Each Unit contains a new Nasal Sprayer, and a vial of Migranal® (dihydroergotamine mesylate, USP) Nasal Spray medication.

Can I use Migranal® (dihydroergotamine mesylate, USP) Nasal Spray if I have a stuffy nose, cold, or allergies?

Yes. Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray can be used if you have a stuffy nose, cold, or allergies. However, if you are taking any medications for your cold, or allergies, even those you can buy without a doctor's prescription, speak with your doctor before using Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray.

Do I need to sniff the medication when I spray it in my nostril?

No, you should not sniff because Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray should remain in the nose so that it can be absorbed into the bloodstream through the lining of the nose. If you have any other unanswered questions about Venotop (Dihydroergotamine Tartrate)^® (dihydroergotamine mesylate, USP) Nasal Spray, consult your doctor or pharmacist.

Trademark of Medical Economics Company, Inc.

Manufactured for:

Valeant Pharmaceuticals North America LLC

Bridgewater, NJ 08807 USA

Manufactured by:

Mipharm, S.p. A.

Milan, Italy

®/ are trademarks of Valeant Pharmaceuticals International, Inc. or its affiliates.

©Valeant Pharmaceuticals North America LLC

www.migranal.com

Rev. 08/17

9603500

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