Neotigason

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Neotigason uses




Rx only

CAUSES BIRTH DEFECTS - DO NOT GET PREGNANT

CONTRAINDICATIONS AND WARNINGS: Pregnancy

Neotigason must not be used by females who are pregnant, or who intend to become pregnant during therapy or at any time for at least 3 years following discontinuation of therapy. Neotigason also must not be used by females who may not use reliable contraception while undergoing treatment and for at least 3 years following discontinuation of treatment. Neotigason is a metabolite of etretinate (TEGISON ®), and major human fetal abnormalities have been reported with the administration of Neotigason and etretinate. Potentially, any fetus exposed can be affected.

Clinical evidence has shown that concurrent ingestion of Neotigason and ethanol has been associated with the formation of etretinate, which has a significantly longer elimination half-life than Neotigason. Because the longer elimination half-life of etretinate would increase the duration of teratogenic potential for female patients, ethanol must not be ingested by female patients of childbearing potential either during treatment with Neotigason or for 2 months after cessation of therapy. This allows for elimination of Neotigason, thus removing the substrate for transesterification to etretinate. The mechanism of the metabolic process for conversion of Neotigason to etretinate has not been fully defined. It is not known whether substances other than ethanol are associated with transesterification.

Neotigason has been shown to be embryotoxic and/or teratogenic in rabbits, mice, and rats at oral doses of 0.6, 3, and 15 mg per kg, respectively. These doses are approximately 0.2, 0.3, and 3 times the maximum recommended therapeutic dose, respectively, based on a mg-per-m2 comparison.

Major human fetal abnormalities associated with Neotigason and/or etretinate administration have been reported including meningomyelocele; meningoencephalocele; multiple synostoses; facial dysmorphia; syndactyly; absence of terminal phalanges; malformations of hip, ankle, and forearm; low-set ears; high palate; decreased cranial volume; cardiovascular malformation; and alterations of the skull and cervical vertebrae.

Neotigason should be prescribed only by those who have special competence in the diagnosis and treatment of severe psoriasis, are experienced in the use of systemic retinoids, and understand the risk of teratogenicity.

Because of the teratogenicity of Neotigason, a program called the Education and Pregnancy Prevention for Neotigason (EPPA) Program, has been developed to educate women of childbearing potential and their healthcare providers about the serious risks associated with Neotigason and to help prevent pregnancies from occurring with the use of this drug and for 3 years after its discontinuation. The EPPA program requirements are described below and program materials are available at www.acitretinEPPA.com or may be requested by calling 1-800-272-5525 .

Important Information for Women of Childbearing Potential:

Neotigason should be considered only for women with severe psoriasis unresponsive to other therapies or whose clinical condition contraindicates the use of other treatments.

Females of reproductive potential must not be given a prescription for Neotigason until pregnancy is excluded. Neotigason is contraindicated in females of reproductive potential unless the patient meets ALL of the following conditions:

- Must have had 2 negative urine or serum pregnancy tests with a sensitivity of at least 25 mIU per mL before receiving the initial prescription for Neotigason. The first test (a screening test) is obtained by the prescriber when the decision is made to pursue therapy with Neotigason. The second pregnancy test (a confirmation test) should be done during the first 5 days of the menstrual period immediately preceding the beginning of therapy with Neotigason. For patients with amenorrhea, the second test should be done at least 11 days after the last act of unprotected sexual intercourse (without using 2 effective forms of contraception [birth control] simultaneously). If the second pregnancy test is negative, initiation of treatment with Neotigason should begin within 7 days of the specimen collection. Neotigason should be limited to a monthly supply.

- Must have a pregnancy test w ith a sensitivity of at least 25 mIU per mL repeated every month during treatment with Neotigason. The patient must have a negative result from a urine or serum pregnancy test before receiving a prescription for Neotigason. To encourage compliance with this recommendation, a m onthly supply of the drug should be prescribed. For at least 3 years after discontinuing therapy with Neotigason, a pregnancy test must be repeated every 3 months.

- Must have selected and have committed to use 2 effective forms of contraception (birth control) simultaneously, at least 1 of which must be a primary form, unless absolute abstinence is the chosen method, or the patient has undergone a hysterectomy or is clearly postmenopausal.

- Patients must use 2 effective forms of contraception (birth control) simultaneously for at least 1 month prior to initiation of therapy with Neotigason, during therapy with Neotigason, and for at least 3 years after discontinuing therapy with Neotigason. A Contraception Counseling Referral Form is available so that patients can receive an initial free contraception counseling session and pregnancy testing. Counseling about contraception and behaviors associated with an increased risk of pregnancy must be repeated on a monthly basis by the prescriber during therapy with Neotigason and every 3 months for at least 3 years following discontinuation of Neotigason.

Effective forms of contraception include both primary and secondary forms of contraception. Primary forms of contraception include: tubal ligation, partner’s vasectomy, intrauterine devices, birth control pills, and injectable/implantable/insertable/topical hormonal birth control products. Secondary forms of contraception include condoms (with or without spermicide), diaphragms and cervical caps (which must be used with a spermicide) , and vaginal sponges (contains spermicide).

Any birth control method can fail. Therefore, it is critically important that women of childbearing potential use 2 effective forms of contraception (birth control) simultaneously. It has not been established if there is a pharmacokinetic interaction between Neotigason and combined oral contraceptives. However, it has been established that Neotigason interferes with the contraceptive effect of microdosed progestin preparations.1 Microdosed “minipill” progestin preparations are not recommended for use with Neotigason. It is not known whether other progestin­-only contraceptives, such as implants and injectables, are adequate methods of contraception during Neotigason therapy.

Prescribers are advised to consult the package insert of any medication administered concomitantly with hormonal contraceptives, since some medications may decrease the effectiveness of these birth control products. Patients should be prospectively cautioned not to self-medicate with the herbal supplement St. John’s wort because a possible interaction has been suggested with hormonal contraceptives based on reports of breakthrough bleeding on oral contraceptives shortly after starting St. John’s wort. Pregnancies have been reported by users of combined hormonal contraceptives who also used some form of St. John’s wort.

- Must have signed a Patient Agreement/Informed Consent for Female Patients that contains warnings about the risk of potential birth defects if the fetus is exposed to Neotigason, about contraceptive failure, about the fact that they must not ingest beverages or products containing ethanol while taking Neotigason and for 2 months after t re at m e n t with Neotigason has been discontinued, and about preventing pregnancy while taking Neotigason and for at least 3 years after discontinuing Neotigason.

If pregnancy does occur during therapy with Neotigason or at any time for at least 3 years following discontinuation of Neotigason, the prescriber and patient should discuss the possible effects on the pregnancy. The available information is as follows:

Neotigason, the active metabolite of etretinate, is teratogenic and is contraindicated during pregnancy. The risk of severe fetal malformations is well established when systemic retinoids are taken during pregnancy. Pregnancy must also be prevented after stopping Neotigason therapy, while the drug is being eliminated to below a threshold blood concentration that would be associated with an increased incidence of birth defects. Because this threshold has not been established for Neotigason in humans and because elimination rates vary among patients, the duration of post therapy contraception to achieve adequate elimination cannot be calculated precisely. It is strongly recommended that contraception be continued for at least 3 years after stopping treatment with Neotigason, based on the following considerations:

- In the absence of transesterification to form etretinate, greater than 98% of the Neotigason would be eliminated within 2 months, assuming a mean elimination half-life of 49 hours.

- In cases where etretinate is formed, as has been demonstrated with concomitant administration of Neotigason and ethanol,

greater than 98% of the etretinate formed would be eliminated in 2 years, assuming a

mean elimination half-life of 120 days.

greater than 98% of the etretinate formed would be eliminated in 3 years, based on

the longest demonstrated elimination half-life of 168 days.

However, etretinate was found in plasma and subcutaneous fat in one patient reported to have had sporadic alcohol intake, 52 months after she stopped Neotigason therapy.2

- Severe birth defects have been reported where conception occurred during the time interval when the patient was being treated with Neotigason and/or etretinate. In addition, severe birth defects have also been reported when conception occurred after the mother completed therapy. These cases have been reported both prospectively (before the outcome was known) and retrospectively (after the outcome was known). The events below are listed without distinction as to whether the reported birth defects are consistent with retinoid-induced embryopathy or not.

- There have been 318 prospectively reported cases involving pregnancies and the use of etretinate, Neotigason, or both. In 238 of these cases, the conception occurred after the last dose of etretinate (103 cases), Neotigason (126), or both (9). Fetal outcome remained unknown in approximately one-half of these cases, of which 62 were terminated and 14 were spontaneous abortions. Fetal outcome is known for the other 118 cases and 15 of the outcomes were abnormal (including cases of absent hand/wrist, clubfoot, GI malformation, hypocalcemia, hypotonia, limb malformation, neonatal apnea/anemia, neonatal ichthyosis, placental disorder/death, undescended testicle, and 5 cases of premature birth). In the 126 prospectively reported cases where conception occurred after the last dose of Neotigason only, 43 cases involved conception at least 1 year but less than 2 years after the last dose. There were 3 reports of abnormal outcomes out of these 43 cases (involving limb malformation, GI tract malformations, and premature birth). There were only 4 cases where conception occurred at least 2 years after the last dose but there were no reports of birth defects in these cases.

- There is also a total of 35 retrospectively reported cases where conception occurred at least 1 year after the last dose of etretinate, Neotigason, or both. From these cases there are 3 reports of birth defects when the conception occurred at least 1 year but less than 2 years after the last dose of Neotigason (including heart malformations, Turner’s Syndrome, and unspecified congenital malformations) and 4 reports of birth defects when conception occurred 2 or more years after the last dose of Neotigason (including foot malformation, cardiac malformations [2 cases], and unspecified neonatal and infancy disorder). There were 3 additional abnormal outcomes in cases where conception occurred 2 or more years after the last dose of etretinate (including chromosome disorder, forearm aplasia, and stillbirth).

- Females who have taken TEGISON (etretinate) must continue to follow the contraceptive recommendations for TEGISON . TEGISON is no longer marketed in the US; for information, call Watson Laboratories, Inc. at 1-800-272-5525.

- Patients should not donate blood during and for at least 3 years following the completion of therapy with Neotigason because women of childbearing potential must not receive blood from patients being treated with Neotigason.

Important Information for Males Taking Neotigason:

Patients should not donate blood during and for at least 3 years following therapy with Neotigason because women of childbearing potential must not receive blood from patients being treated with Neotigason.

- Samples of seminal fluid from 3 male patients treated with Neotigason and 6 male patients treated with etretinate have been assayed for the presence of Neotigason. The maximum concentration of Neotigason observed in the seminal fluid of these men was 12.5 ng per mL. Assuming an ejaculate volume of 10 mL, the amount of drug transferred in semen would be 125 ng, which is 1/200,000 of a single 25 mg capsule. Thus, although it appears that residual Neotigason in seminal fluid poses little, if any, risk to a fetus while a male patient is taking the drug or after it is discontinued, the no-effect limit for teratogenicity is unknown and there is no registry for birth defects associated with Neotigason. The available data are as follows:

There have been 25 cases of reported conception when the male partner was taking Neotigason. The pregnancy outcome is known in 13 of these 25 cases. Of these, 9 reports were retrospective and 4 were prospective (meaning the pregnancy was reported prior to knowledge of the outcome)3.


Timing of Paternal Neotigason Treatment Relative to Conception


Delivery of Healthy Neonate


Spontaneous Abortion


Induced Abortion


Total


At time of conception


5a


5


1


11


Discontinued ~4 weeks prior


0


0


1b


1


Discontinued ~6 to 8 months prior


0


1


0


1


aFour of 5 cases were prospective.

bWith malformation pattern not typical of retinoid embryopathy (bilateral cystic hygromas of neck, hypoplasia of lungs bilateral, pulmonary atresia, VSD with overriding truncus arteriosus).

For All Patients: AN Neotigason MEDICATION GUIDE MUST BE GIVEN TO THE PATIENT EACH TIME Neotigason IS DISPENSED, AS REQUIRED BY LAW.

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DESCRIPTION

Neotigason, a retinoid, is available in 10 mg, 17.5 mg, 22.5 mg, and 25 mg gelatin capsules for oral administration. Chemically, Neotigason is all-trans-9-(4-methoxy-2,3,6-trimethylphenyl)-3,7-dimethyl-2,4,6,8-nonatetraenoic acid. It is a metabolite of etretinate and is related to both retinoic acid and retinol (vitamin A). It is a yellow to greenish-yellow powder with a molecular weight of 326.44. The structural formula is:

Each capsule contains Neotigason, microcrystalline cellulose, maltodextrin, sodium ascorbate, gelatin, black imprinting ink (the solid components are shellac glaze, propylene glycol and iron oxide black).

Gelatin capsule shells contain gelatin, red ferric oxide (10 mg, 22.5 mg and 25 mg only), yellow ferric oxide (17.5 mg and 25 mg only), sodium lauryl sulfate, and titanium dioxide (10 mg, 17.5 mg and 25 mg only).

Chemical Sructure of Neotigason

CLINICAL PHARMACOLOGY

The mechanism of action of Neotigason is unknown.

Pharmacokinetics:

Absorption:


Oral absorption of Neotigason is optimal when given with food. For this reason, Neotigason was given with food in all of the following trials. After administration of a single 50 mg oral dose of Neotigason to 18 healthy subjects, maximum plasma concentrations ranged from 196 to 728 ng per mL and were achieved in 2 to 5 hours (mean: 2.7 hours). The oral absorption of Neotigason is linear and proportional with increasing doses from 25 to 100 mg. Approximately 72% (range: 47% to 109%) of the administered dose was absorbed after a single 50 mg dose of Neotigason was given to 12 healthy subjects.

Distribution:

Neotigason is more than 99.9% bound to plasma proteins, primarily albumin.

Metabolism: (See Pharmacokinetic Drug Interactions : Ethanol.)

Following oral absorption, Neotigason undergoes extensive metabolism and interconversion by simple isomerization to its 13-cis form (cis-acitretin). The formation of cis-acitretin relative to parent compound is not altered by dose or fed/fast conditions of oral administration of Neotigason. Both parent compound and isomer are further metabolized into chain-shortened breakdown products and conjugates, which are excreted. Following multiple-dose administration of Neotigason, steady-state concentrations of Neotigason and cis-acitretin in plasma are achieved within approximately 3 weeks.

Elimination:

The chain-shortened metabolites and conjugates of Neotigason and cis-acitretin are ultimately excreted in the feces (34% to 54%) and urine (16% to 53%). The terminal elimination half-life of Neotigason following multiple-dose administration is 49 hours (range: 33 to 96 hours), and that of cis-acitretin under the same conditions is 63 hours (range: 28 to 157 hours). The accumulation ratio of the parent compound is 1.2; that of cis-acitretin is 6.6.

Special Populations:

Psoriasis:

In an 8-week trial of Neotigason pharmacokinetics in subjects with psoriasis, mean steady-state trough concentrations of Neotigason increased in a dose-proportional manner with dosages ranging from 10 to 50 mg daily. Neotigason plasma concentrations were nonmeasurable (<4 ng per mL) in all subjects 3 weeks after cessation of therapy.

Elderly:

In a multiple-dose trial in healthy young (n=6) and elderly (n=8) subjects, a 2-fold increase in Neotigason plasma concentrations were seen in elderly subjects, although the elimination half-life did not change.

Renal Failure:

Plasma concentrations of Neotigason were significantly (59.3%) lower in subjects with end-stage renal failure (n=6) when compared with age-matched controls, following single 50 mg oral doses. Neotigason was not removed by hemodialysis in these subjects.

Pharmacokinetic Drug Interactions

(see also boxed CONTRAINDICATIONS AND WARNINGS and PRECAUTIONS: Drug Interactions ):

In studies of in vivo pharmacokinetic drug interactions, no interaction was seen between Neotigason and cimetidine, digoxin, phenprocoumon, or glyburide.

Ethanol:

Clinical evidence has shown that etretinate (a retinoid with a much longer half-life, see below) can be formed with concurrent ingestion of Neotigason and ethanol. In a 2-way crossover trial, all 10 subjects formed etretinate with concurrent ingestion of a single 100 mg oral dose of Neotigason during a 3-hour period of ethanol ingestion (total ethanol, approximately 1.4 g per kg body weight). A mean peak etretinate concentration of 59 ng per mL (range: 22 to 105 ng per mL) was observed, and extrapolation of AUC values indicated that the formation of etretinate in this trial was comparable to a single 5 mg oral dose of etretinate. There was no detectable formation of etretinate when a single 100 mg oral dose of Neotigason was administered without concurrent ethanol ingestion, although the formation of etretinate without concurrent ethanol ingestion cannot be excluded (see boxed CONTRAINDICATIONS AND WARNINGS ). Of 93 evaluable psoriatic subjects on Neotigason therapy in several foreign trials (10 to 80 mg per day), 16% had measurable etretinate levels (>5 ng per mL).

Etretinate has a much longer elimination half-life compared with that of Neotigason. In one trial the apparent mean terminal half-life after 6 months of therapy was approximately 120 days (range: 84 to 168 days). In another trial of 47 subjects treated chronically with etretinate, 5 had detectable serum drug levels (in the range of 0.5 to 12 ng per mL) 2.1 to 2.9 years after therapy was discontinued. The long half-life appears to be due to storage of etretinate in adipose tissue.

Progestin-only Contraceptives:


It has not been established if there is a pharmacokinetic interaction between Neotigason and combined oral contraceptives. However, it has been established that Neotigason interferes with the contraceptive effect of microdosed progestin preparations.1 Microdosed “minipill” progestin preparations are not recommended for use with Neotigason. It is not known whether other progestin-only contraceptives, such as implants and injectables, are adequate methods of contraception during Neotigason therapy.

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CLINICAL STUDIES

In 2 double-blind, placebo-controlled trials, Neotigason was administered once daily to subjects with severe psoriasis (e.g., covering at least 10% to 20% of the body surface area). At 8 weeks subjects treated in Trial A with 50 mg of acitretin per day showed significant improvements (P ≤ 0.05) relative to baseline and to placebo in the physician’s global evaluation and in the mean ratings of severity of psoriasis (scaling, thickness, and erythema). In Trial B, differences from baseline and from placebo were statistically significant (P ≤ 0.05) for all variables at both the 25 mg and 50 mg doses; it should be noted for Trial B that no statistical adjustment for multiplicity was carried out.

Table 1. Summary of the Efficacy Results of the 8-Week Double-Blind Phase of Trials A and B of Neotigason


Efficacy Variables


Trial A


Trial B


Total Daily Dose


Total Daily Dose


Placebo

(N = 29)


5 0 mg

(N = 29)


Placebo

(N = 72)


2 5 mg

(N = 74)


5 0 mg

(N = 71)


Physician’s

Global Evaluation

Baseline

Mean Change

After 8 Weeks


4.62

−0.29


4.55

−2.00a


4.43

−0.06


4.37

−1.06a


4.49

−1.57a


Scaling

Baseline

Mean Change

After 8 Weeks


4.10

−0.22


3.76

−1.62a


3.97

−0.21


4.11

−1.50a


4.10

−1.78a


Thickness

Baseline

Mean Change

After 8 Weeks


4.10

−0.39


4.10

−2.10a


4.03

−0.18


4.11

−1.43a


4.20

−2.11a


Erythema

Baseline

Mean Change

After 8 Weeks


4.21

−0.33


4.59

−2.10a


4.42

−0.37


4.24

−1.12a


4.45

−1.65a


aValues were statistically significantly different from placebo and from baseline (P ≤ 0.05). No adjustment for multiplicity was done for Trial B. The efficacy variables consisted of: the mean severity rating of scale, lesion thickness, erythema, and the physician’s global evaluation of the current status of the disease. Ratings of scaling, erythema, and lesion thickness, and the ratings of the global assessments were made using a 7-point scale (0=none, 1=trace, 2=mild, 3=mild-moderate, 4=moderate, 5=moderate-severe, 6=severe).

A subset of 141 subjects from both pivotal Trials A and B continued to receive Neotigason in an open fashion for up to 24 weeks. At the end of the treatment period, all efficacy variables, as indicated in Table 2, were significantly improved (P ≤ 0.01) from baseline, including extent of psoriasis, mean ratings of psoriasis severity, and physician’s global evaluation.

Table 2. Summary of the First Course of Therapy with Neotigason (24 Weeks)


Variables


Trial A


Trial B


Mean Total Daily Dose of Neotigason (mg)


42.8


43.1


Mean Duration of Therapy (Weeks)


21.1


22.6


Physician’s Global Evaluation

Baseline

Mean Change From Baseline


N=39

4.51

−2.26a


N=98

4.43

−2.60a


Scaling

Baseline

Mean Change From Baseline


N=59

3.97

−2.15a


N=132

4.07

−2.42a


Thickness

Baseline

Mean Change From Baseline


N=59

4.00

−2.44a


N=132

4.12

−2.66a


Erythema

Baseline

Mean Change From Baseline


N=59

4.35

−2.31a


N=132

4.33

−2.29a


a Indicates that the difference from baseline was statistically significant (P ≤ 0.01).

The efficacy variables consisted of: the mean severity rating of scale, lesion thickness, erythema, and the physician’s global evaluation of the current status of the disease. Ratings of scaling, erythema, and lesion thickness, and the ratings of the global assessments were made using a 7-point scale (0=none, 1=trace, 2=mild, 3=mild-moderate, 4=moderate, 5=moderate-severe, 6=severe).

All efficacy variables improved significantly in a subset of 55 subjects from Trial A treated for a second, 6-month maintenance course of therapy (for a total of 12 months of treatment); a small subset of subjects (n=4) from Trial A continued to improve after a third 6-month course of therapy (for a total of 18 months of treatment).

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INDICATIONS AND USAGE

Neotigason capsules USP are indicated for the treatment of severe psoriasis in adults. Because of significant adverse effects associated with its use, Neotigason capsules USP should be prescribed only by those knowledgeable in the systemic use of retinoids. In females of reproductive potential, Neotigason capsules USP should be reserved for non-pregnant patients who are unresponsive to other therapies or whose clinical condition contraindicates the use of other treatments (see boxed CONTRAINDICATIONS AND WARNINGS - Neotigason capsules USP can cause severe birth defects).

Most patients experience relapse of psoriasis after discontinuing therapy. Subsequent courses, when clinically indicated, have produced efficacy results similar to the initial course of therapy.

CONTRAINDICATIONS

Pregnancy Category X:


Neotigason is contraindicated in patients with severely impaired liver or kidney function and in patients with chronic abnormally elevated blood lipid values (see boxed WARNINGS: Hepatotoxicity , WARNINGS: Lipids and Possible Cardiovascular Effects , and PRECAUTIONS ).

An increased risk of hepatitis has been reported to result from combined use of methotrexate and etretinate. Consequently, the combination of methotrexate with Neotigason is also contraindicated (see PRECAUTIONS: Drug Interactions ).

Since both Neotigason and tetracyclines can cause increased intracranial pressure, their combined use is contraindicated (see WARNINGS: Pseudotumor Cerebri ).

Neotigason is contraindicated in cases of hypersensitivity (e.g., angioedema, urticaria) to the preparation (acitretin or excipients) or to other retinoids.

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WARNINGS



Hepatotoxicity: Of the 525 subjects treated in US clinical trials, 2 had clinical jaundice with elevated serum bilirubin and transaminases considered related to treatment with Neotigason. Liver function test results in these subjects returned to normal after Neotigason was discontinued. Two of the 1,289 subjects treated in European clinical trials developed biopsy-confirmed toxic hepatitis. A second biopsy in one of these subjects revealed nodule formation suggestive of cirrhosis. One subject in a Canadian clinical trial of 63 subjects developed a 3-fold increase of transaminases. A liver biopsy of this subject showed mild lobular disarray, multifocal hepatocyte loss, and mild triaditis of the portal tracts compatible with acute reversible hepatic injury. The subject's transaminase levels returned to normal 2 months after Neotigason was discontinued.

The potential of therapy with Neotigason to induce hepatotoxicity was prospectively evaluated using liver biopsies in an open-label trial of 128 subjects . Pretreatment and posttreatment biopsies were available for 87 subjects . A comparison of liver biopsy findings before and after therapy revealed 49 (58%) subjects showed no change, 21 (25%) improved, and 14 (17%) subjects had a worsening of their liver biopsy status. For 6 subjects , the classification changed from class 0 (no pathology) to class I (normal fatty infiltration; nuclear variability and portal inflammation; both mild); for 7 subjects , the change was from class I to class II (fatty infiltration, nuclear variability, portal inflammation, and focal necrosis; all moderate to severe); and for 1 subject , the change was from class II to class IIIb (fibrosis, moderate to severe). No correlation could be found between liver function test result abnormalities and the change in liver biopsy status, and no cumulative dose relationship was found.

Elevations of AST (SGOT), ALT (SGPT), GGT (GGTP), or LDH have occurred in approximately 1 in 3 subjects treated with Neotigason. Of the 525 subjects treated in clinical trials in the US, treatment was discontinued in 20 (3.8%) due to elevated liver function test results. If hepatotoxicity is suspected during treatment with Neotigason, the drug should be discontinued and the etiology further investigated.

Ten of 652 subjects treated in US clinical trials of etretinate, of which Neotigason is the active metabolite, had clinical or histologic hepatitis considered to be possibly or probably related to etretinate treatment. There have been reports of hepatitis-related deaths worldwide; a few of these subjects had received etretinate for a month or less before presenting with hepatic symptoms or signs.


Skeletal Abnormalities:

In adults receiving long-term treatment with Neotigason, appropriate examinations should be periodically performed in view of possible ossification abnormalities. Because the frequency and severity of iatrogenic bony abnormality in adults is low, periodic radiography is only warranted in the presence of symptoms or long-term use of Neotigason. If such disorders arise, the continuation of therapy should be discussed with the patient on the basis of a careful risk/benefit analysis. In clinical trials with Neotigason, subjects were prospectively evaluated for evidence of development or change in bony abnormalities of the vertebral column, knees, and ankles.

Of 380 subjects treated with Neotigason, 15% had preexisting abnormalities of the spine which showed new changes or progression of preexisting findings. Changes included degenerative spurs, anterior bridging of spinal vertebrae, diffuse idiopathic skeletal hyperostosis, ligament calcification, and narrowing and destruction of a cervical disc space. De novo changes (formation of small spurs) were seen in 3 subjects after 1½ to 2½ years.

Six of 128 subjects treated with Neotigason showed abnormalities in the knees and ankles before treatment that progressed during treatment. In 5, these changes involved the formation of additional spurs or enlargement of existing spurs. The sixth subject had degenerative joint disease which worsened. No subjects developed spurs de novo. Clinical complaints did not predict radiographic changes.

Lipids and Possible Cardiovascular Effects:

Blood lipid determinations should be performed before Neotigason is administered and again at intervals of 1 to 2 weeks until the lipid response to the drug is established, usually within 4 to 8 weeks. In subjects receiving Neotigason during clinical trials, 66% and 33% experienced elevation in triglycerides and cholesterol, respectively. Decreased high density lipoproteins (HDL) occurred in 40% of subjects. These effects of Neotigason were generally reversible upon cessation of therapy.

Subjects with an increased tendency to develop hypertriglyceridemia included those with disturbances of lipid metabolism, diabetes mellitus, obesity, increased alcohol intake, or a familial history of these conditions. Because of the risk of hypertriglyceridemia, serum lipids must be more closely monitored in high-risk patients and during long-term treatment.

Hypertriglyceridemia and lowered HDL may increase a patient’s cardiovascular risk status. Although no causal relationship has been established, there have been postmarketing reports of acute myocardial infarction or thromboembolic events in patients on therapy with Neotigason. In addition, elevation of serum triglycerides to greater than 800 mg per dL has been associated with fatal fulminant pancreatitis. Therefore, dietary modifications, reduction in dose of Neotigason, or drug therapy should be employed to control significant elevations of triglycerides. If, despite these measures, hypertriglyceridemia and low HDL levels persist, the discontinuation of Neotigason should be considered.

Ophthalmologic Effects:

The eyes and vision of 329 subjects treated with Neotigason were examined by ophthalmologists. The findings included dry eyes (23%), irritation of eyes (9%), and brow and lash loss (5%). The following were reported in less than 5% of subjects: Bell’s palsy, blepharitis and/or crusting of lids, blurred vision, conjunctivitis, corneal epithelial abnormality, cortical cataract, decreased night vision, diplopia, itchy eyes or eyelids, nuclear cataract, pannus, papilledema, photophobia, posterior subcapsular cataract, recurrent sties, and subepithelial corneal lesions.

Any patient treated with Neotigason who is experiencing visual difficulties should discontinue the drug and undergo ophthalmologic evaluation.

Pancreatitis:

Lipid elevations occur in 25% to 50% of subjects treated with Neotigason. Triglyceride increases sufficient to be associated with pancreatitis are much less common, although fatal fulminant pancreatitis has been reported. There have been rare reports of pancreatitis during therapy with Neotigason in the absence of hypertriglyceridemia.

Pseudotumor Cerebri:

Neotigason and other retinoids administered orally have been associated with cases of pseudotumor cerebri (benign intracranial hypertension). Some of these events involved concomitant use of isotretinoin and tetracyclines. However, the event seen in a single patient receiving Neotigason was not associated with tetracycline use. Early signs and symptoms include papilledema, headache, nausea and vomiting, and visual disturbances. Patients with these signs and symptoms should be examined for papilledema and, if present, should discontinue Neotigason immediately and be referred for neurological evaluation and care. Since both Neotigason and tetracyclines can cause increased intracranial pressure, their combined use is contraindicated (see CONTRAINDICATIONS ).

Capillary Leak Syndrome:

Capillary leak syndrome, a potential manifestation of retinoic acid syndrome, has been reported in patients receiving Neotigason. Features of this syndrome may include localized or generalized edema with secondary weight gain, fever, and hypotension. Rhabdomyolysis and myalgias have been reported in association with capillary leak syndrome, and laboratory tests may reveal neutrophilia, hypoalbuminemia, and an elevated hematocrit. Discontinue Neotigason if capillary leak syndrome develops during therapy.

Exfoliative Dermatitis/Erythroderma:

Exfoliative dermatitis/erythroderma has been reported in patients receiving Neotigason.

Discontinue Neotigason if exfoliative dermatitis/erythroderma occurs during therapy.

PRECAUTIONS

A description of the Education and Pregnancy Prevention for Neotigason Program materials is provided below. The main goals of the materials are to explain the program requirements, to reinforce the educational messages, and to assess program effectiveness.

The EPPA Program includes:


The Education and Pregnancy Prevention for Neotigason (EPPA) Program also includes a voluntary patient survey for women of childbearing potential to assess the effectiveness of the EPPA Program.

Education and Pregnancy Prevention for Neotigason (EPPA) Program materials are available at www.acitretinEPPA.com or may be requested by calling 1-800-272-5525.

Information for Patients:


Patients should be instructed to read the Medication Guide supplied as required by law when Neotigason capsules are dispensed.

Females of Reproductive Potential:

Neotigason can cause severe birth defects. Female patients must not be pregnant when therapy with Neotigason is initiated, they must not become pregnant while taking Neotigason and for at least 3 years after stopping Neotigason, so that the drug can be eliminated to below a blood concentration that would be associated with an increased incidence of birth defects. Because this threshold has not been established for Neotigason in humans and because elimination rates vary among patients, the duration of post therapy contraception to achieve adequate elimination cannot be calculated precisely.

Females of reproductive potential should also be advised that they must not ingest beverages or products containing ethanol while taking Neotigason and for 2 months after Neotigason has been discontinued. This allows for elimination of the Neotigason which can be converted to etretinate in the presence of alcohol.

Female patients should be advised that any method of birth control can fail, including tubal ligation, and that microdosed progestin “minipill” preparations are not recommended for use with Neotigason (see CLINICAL

Pharmacology: Pharmacokinetic Drug Interactions ). Data from one patient who received a very low-dosed progestin contraceptive (levonorgestrel 0.03 mg) had a significant increase of the progesterone level after 3 menstrual cycles during Neotigason treatment.2

Female patients should sign a consent form prior to beginning therapy with Neotigason (see boxed CONTRAINDICATIONS AND WARNINGS ).

Nursing Mothers:

Studies on lactating rats have shown that etretinate is excreted in the milk. There is one prospective case report where Neotigason is reported to be excreted in human milk. Therefore, nursing mothers should not receive Neotigason prior to or during nursing because of the potential for serious adverse reactions in nursing infants.

All Patients:

Depression and/or other psychiatric symptoms such as aggressive feelings or thoughts of self-harm have been reported. These events, including self-injurious behavior, have been reported in patients taking other systemically administered retinoids, as well as in patients taking Neotigason. Since other factors may have contributed to these events, it is not known if they are related to Neotigason. Patients should be counseled to stop taking Neotigason and notify their prescriber immediately if they experience psychiatric symptoms.

Patients should be advised that a transient worsening of psoriasis is sometimes seen during the initial treatment period. Patients should be advised that they may have to wait 2 to 3 months before they get the full benefit of Neotigason, although some patients may achieve significant improvements within the first 8 weeks of treatment as demonstrated in clinical trials.

Decreased night vision has been reported during therapy with Neotigason. Patients should be advised of this potential problem and warned to be cautious when driving or operating any vehicle at night. Visual problems should be carefully monitored. Patients should be advised that they may experience decreased tolerance to contact lenses during the treatment period and sometimes after treatment has stopped.

Patients should not donate blood during and for at least 3 years following therapy because Neotigason can cause birth defects and women of childbearing potential must not receive blood from patients being treated with Neotigason.

Because of the relationship of Neotigason to vitamin A, patients should be advised against taking vitamin A supplements in excess of minimum recommended daily allowances to avoid possible additive toxic effects.

Patients should avoid the use of sun lamps and excessive exposure to sunlight (non-medical UV exposure) because the effects of UV light are enhanced by retinoids.

Patients should be advised that they must not give their Neotigason capsules to any other person.

For Prescribers:

Neotigason has not been studied in and is not indicated for treatment of acne.

Phototherapy:

Significantly lower doses of phototherapy are required when Neotigason is used because effects on the stratum corneum induced by Neotigason can increase the risk of erythema (see DOSAGE AND ADMINISTRATION ).

Drug Interactions:

Ethanol:

Clinical evidence has shown that etretinate can be formed with concurrent ingestion of Neotigason and ethanol (see boxed CONTRAINDICATIONS AND WARNINGS and CLINICAL

Pharmacology: Pharmacokinetics ).

Glyburide:

In a trial of 7 healthy male volunteers, Neotigason treatment potentiated the blood glucose-lowering effect of glyburide (a sulfonylurea similar to chlorpropamide) in 3 of the 7 subjects. Repeating the trial with 6 healthy male volunteers in the absence of glyburide did not detect an effect of Neotigason on glucose tolerance. Careful supervision of diabetic patients under treatment with Neotigason is recommended (see CLINICAL

Pharmacology: Pharmacokinetics and DOSAGE AND ADMINISTRATION ).

Hormonal Contraceptives:

It has not been established if there is a pharmacokinetic interaction between Neotigason and combined oral contraceptives. However, it has been established that Neotigason interferes with the contraceptive effect of microdosed progestin “minipill” preparations. Microdosed “minipill” progestin preparations are not recommended for use with Neotigason (see CLINICAL PHARMACOLOGY : Pharmacokinetic Drug Interactions ). It is not known whether other progestin-only contraceptives, such as implants and injectables, are adequate methods of contraception during Neotigason therapy.

Methotrexate:

An increased risk of hepatitis has been reported to result from combined use of methotrexate and etretinate. Consequently, the combination of methotrexate with Neotigason is also contraindicated (see CONTRAINDICATIONS ).

Phenytoin:

If Neotigason is given concurrently with phenytoin, the protein binding of phenytoin may be reduced.

Tetracyclines:

Since both Neotigason and tetracyclines can cause increased intracranial pressure, their combined use is contraindicated (see CONTRAINDICATIONS and WARNINGS: Pseudotumor Cerebri ).

Vitamin A and Oral Retinoids:

Concomitant administration of vitamin A and/or other oral retinoids with Neotigason must be avoided because of the risk of hypervitaminosis A.

Other:

There appears to be no pharmacokinetic interaction between Neotigason and cimetidine, digoxin, or glyburide. Investigations into the effect of Neotigason on the protein binding of anticoagulants of the coumarin type (warfarin) revealed no interaction.

Laboratory Tests:

If significant abnormal laboratory results are obtained, either dosage reduction with careful monitoring or treatment discontinuation is recommended, depending on clinical judgment.

Blood Sugar:

Some patients receiving retinoids have experienced problems with blood sugar control. In addition, new cases of diabetes have been diagnosed during retinoid therapy, including diabetic ketoacidosis. In diabetics, blood-sugar levels should be monitored very carefully.

Lipids:

In clinical trials, the incidence of hypertriglyceridemia was 66%, hypercholesterolemia was 33%, and that of decreased HDL was 40%. Pretreatment and follow-up measurements should be obtained under fasting conditions. It is recommended that these tests be performed weekly or every other week until the lipid response to Neotigason has stabilized.

Liver Function Tests:

Elevations of AST (SGOT), ALT (SGPT), or LDH were experienced by approximately 1 in 3 patients treated with Neotigason. It is recommended that these tests be performed prior to initiation of therapy with Neotigason, at 1- to 2-week intervals until stable, and thereafter at intervals as clinically indicated (see CONTRAINDICATIONS and boxed WARNINGS ).

Carcinogenesis, Mutagenesis, Impairment of Fertility:

Carcinogenesis:

A carcinogenesis study of Neotigason in Wistar rats, at doses up to 2 mg per kg per day administered 7 days per week for 104 weeks, has been completed. There were no neoplastic lesions observed that were considered to have been related to treatment with Neotigason. An 80-week carcinogenesis study in mice has been completed with etretinate, the ethyl ester of Neotigason. Blood level data obtained during this study demonstrated that etretinate was metabolized to Neotigason and that blood levels of Neotigason exceeded those of etretinate at all times studied. In the etretinate study, an increased incidence of blood vessel tumors (hemangiomas and hemangiosarcomas at several different sites) was noted in male, but not female, mice at doses approximately one-half the maximum recommended human therapeutic dose based on a

mg-per-m2 comparison.

Mutagenesis:

Neotigason was evaluated for mutagenic potential in the Ames test, in the Chinese hamster (V79/HGPRT) assay, in unscheduled DNA synthesis assays using rat hepatocytes and human fibroblasts, and in an in vivo mouse micronucleus assay. No evidence of mutagenicity of Neotigason was demonstrated in any of these assays.

Impairment of Fertility:

In a fertility study in rats, the fertility of treated animals was not impaired at the highest dosage of Neotigason tested, 3 mg per kg per day (approximately one-half the maximum recommended therapeutic dose based on a mg-per-m2 comparison). Chronic toxicity studies in dogs revealed testicular changes (reversible mild to moderate spermatogenic arrest and appearance of multinucleated giant cells) in the highest dosage group (50 then 30 mg per kg per day).

No decreases in sperm count or concentration and no changes in sperm motility or morphology were noted in 31 men (17 psoriatic subjects, 8 subjects with disorders of keratinization, and 6 healthy volunteers) given 30 to 50 mg per day of Neotigason for at least 12 weeks. In these trials, no deleterious effects were seen on either testosterone production, LH, or FSH in any of the 31 men.4-6 No deleterious effects were seen on the hypothalamic-pituitary axis in any of the 18 men where it was measured.4,5

Pregnancy:

Teratogenic Effects:

Pregnancy Category X.

In a study in which Neotigason was administered to male rats only at a dosage of 5 mg per kg per day for 10 weeks (approximate duration of one spermatogenic cycle) prior to and during mating with untreated female rats, no teratogenic effects were observed in the progeny (see boxed CONTRAINDICATIONS AND WARNINGS for information about male use of Neotigason).

Nonteratogenic Effects:

In rats dosed at 3 mg per kg per day (approximately one-half the maximum recommended therapeutic dose based on a mg-per-m2 comparison), slightly decreased pup survival and delayed incisor eruption were noted. At the next lowest dose tested, 1 mg per kg per day, no treatment-related adverse effects were observed.

Pediatric Use:

Safety and effectiveness in pediatric patients have not been established. No clinical trials have been conducted in pediatric subjects. Ossification of interosseous ligaments and tendons of the extremities, skeletal hyperostoses, decreases in bone mineral density, and premature epiphyseal closure have been reported in children taking other systemic retinoids, including etretinate, a metabolite of Neotigason. A causal relationship between these effects and Neotigason has not been established. While it is not known that these occurrences are more severe or more frequent in children, there is special concern in pediatric patients because of the implications for growth potential (see WARNINGS: Hyperostosis ).

Geriatric Use:

Clinical trials of Neotigason did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently than younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger subjects. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy. A 2-fold increase in Neotigason plasma concentrations was seen in healthy elderly subjects compared with young subjects, although the elimination half-life did not change (see CLINICAL

Pharmacology: Special Populations ).

ADVERSE REACTIONS

Hypervitaminosis A produces a wide spectrum of signs and symptoms primarily of the mucocutaneous, musculoskeletal, hepatic, neuropsychiatric, and central nervous systems. Many of the clinical adverse reactions reported to date with administration of Neotigason resemble those of the hypervitaminosis A syndrome.

Adverse Events/Postmarketing Reports:

In addition to the events listed in the tables for the clinical trials, the following adverse events have been identified during postapproval use of Neotigason. Because these events are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

Cardiovascular:

Acute myocardial infarction, thromboembolism (see WARNINGS ), stroke.

Immune System Disorders:

Hypersensitivity, including angioedema and urticaria (see CONTRAINDICATIONS ).

Nervous System:

Myopathy with peripheral neuropathy has been reported during therapy with Neotigason. Both conditions improved with discontinuation of the drug.

Psychiatric:

Aggressive feelings and/or suicidal thoughts have been reported. These events, including self-injurious behavior, have been reported in patients taking other systemically administered retinoids, as well as in patients taking Neotigason. Since other factors may have contributed to these events, it is not known if they are related to Neotigason (see PRECAUTIONS ).

Reproductive:

Vulvo-vaginitis due to Candida albicans.

Skin and Appendages:

Thinning of the skin, skin fragility, and scaling may occur all over the body, particularly on the palms and soles; nail fragility is frequently observed. Madarosis and exfoliative dermatitis/erythroderma have been reported (see WARNINGS ).

Vascular Disorders: Capillary leak syndrome (see WARNINGS ).

Clinical Trials:

During clinical trials with Neotigason, 513 of 525 (98%) subjects reported a total of 3,545 adverse events. One-hundred sixteen subjects (22%) left trials prematurely, primarily because of adverse experiences involving the mucous membranes and skin. Three subjects died. Two of the deaths were not drug-related (pancreatic adenocarcinoma and lung cancer); the other subject died of an acute myocardial infarction, considered remotely related to drug therapy. In clinical trials, Neotigason was associated with elevations in liver function test results or triglyceride levels and hepatitis.

The tables below list by body system and frequency the adverse events reported during clinical trials of 525 subjects with psoriasis.

Table 3. Adverse Events Frequently Reported during Clinical Trials

Percent of Subjects Reporting (N = 525)

Body System >75% 50% to 75% 25% to 50% 10% to 25%
CNS Rigors
Eye Disorders Xerophthalmia
Mucous

Membranes

Cheilitis Rhinitis

Dry mouth

Epistaxis

Musculoskeletal Arthralgia

Spinal hyperostosis

(progression

of existing

lesions)

Skin and Appendages Alopecia

Skin peeling


Dry skin

Nail disorder

Pruritus

Erythematous

rash

Hyperesthesia

Paresthesia

Paronychia

Skin atrophy

Skicky skin


Table 4. Adverse Events Less Frequently Reported during Clinical Trials (Some of Which

May Bear No Relationship to Therapy)

Percent of Subjects Reporting (N = 525)


Body System


1% to 10%


<1%


Body as a Whole


Anorexia

Edema

Fatigue

Hot flashes

Increased appetite


Alcohol

intolerance

Dizziness

Fever

Influenza-like

symptoms

Malaise

Moniliasis

Muscle weakness

Weight increase


Cardiovascular


Flushing


Chest pain

Cyanosis

Increased

bleeding time

Intermittent

claudication

Peripheral

ischemia


CNS (also see

Psychiatric)


Headache

Pain


Abnormal gait

Migraine

Neuritis


Pseudotumor

cerebri

(intracranial

hypertension)


Eye Disorders


Abnormal/ Decreased night

blurred vision vision/night

Blepharitis blindness

Conjunctivitis/ Eye abnormality

irritation Eye pain

Corneal epithelial Photophobia

abnormality


Abnormal

lacrimation

Chalazion

Conjunctival

hemorrhage

Corneal ulceration

Diplopia

Ectropion

Itchy eyes and lids

Papilledema

Recurrent sties

Subepithelial

corneal lesions


Gastrointestinal


Abdominal pain

Diarrhea

Nausea

Tongue disorder


Constipation

Dyspepsia

Esophagitis

Gastritis

Gastroenteritis

Glossitis

Hemorrhoids

Melena

Tenesmus

Tongue ulceration

Liver and Biliary Hepatic function

abnormal

Hepatitis

Jaundice


Mucous Membranes


Gingival bleeding Stomatitis

Gingivitis Thirst

Increased saliva Ulcerative

stomatitis


Altered saliva

Anal disorder

Gum hyperplasia

Hemorrhage

Pharyngitis


Musculoskeletal


Arthritis Osteodynia

Arthrosis Peripheral joint

Back pain hyperostosis

Hypertonia (progression of

Myalgia existing lesions)


Bone disorder

Olecranon bursitis

Spinal

hyperostosis

(new lesions)

Tendonitis


Psychiatric


Depression

Insomnia

Somnolence


Anxiety

Dysphonia

Libido decreased

Nervousness

Reproductive Atrophic vaginitis

Leukorrhea


Respiratory


Sinusitis


Coughing

Increased sputum

Laryngitis


Skin and

Appendages


Abnormal skin Psoriasiform rash

odor Purpura

Abnormal hair Pyogenic

texture granuloma

Bullous eruption Rash

Cold/clammy skin Seborrhea

Dermatitis Skin fissures

Increased Skin ulceration

sweating Sunburn

Infection


Acne

Breast pain

Cyst

Eczema

Fungal infection

Furunculosis

Hair discoloration

Herpes simplex

Hyperkeratosis

Hypertrichosis

Hypoesthesia

Impaired healing

Otitis media


Otitis externa

Photosensitivity

reaction

Psoriasis

aggravated

Scleroderma

Skin nodule

Skin hypertrophy

Skin disorder

Skin irritation

Sweat gland

disorder

Urticaria

Verrucae


Special Senses/

Other


Earache

Taste perversion

Tinnitus


Ceruminosis

Deafness

Taste loss

Urinary

Abnormal urine

Dysuria

Penis disorder


Laboratory:

Therapy with Neotigason induces changes in liver function tests in a significant number of patients. Elevations of AST (SGOT), ALT (SGPT) or LDH were experienced by approximately 1 in 3 subjects treated with Neotigason. In most subjects, elevations were slight to moderate and returned to normal either during continuation of therapy or after cessation of treatment. In subjects receiving Neotigason during clinical trials, 66% and 33% experienced elevation in triglycerides and cholesterol, respectively. Decreased high density lipoproteins (HDL) occurred in 40% (see WARNINGS ). Transient, usually reversible elevations of alkaline phosphatase have been observed.

Table 5 lists the laboratory abnormalities reported during clinical trials.

Table 5. Abnormal Laboratory Test Results Reported during Clinical Trials

Percent of Subjects Reporting


B ody System


50% to 75%


25% to 50%


10% to 25%


1% to 10%


Electrolytes

Increased:

–Phosphorus

–Potassium

–Sodium

Increased and decreased:

–Magnesium

Decreased:

–Phosphorus

–Potassium

–Sodium

Increased and decreased:

–Calcium

–Chloride


Hematologic

Increased:

–Reticulocytes

Decreased:

–Hematocrit

–Hemoglobin

–WBC Increased:

–Haptoglobin

–Neutrophils

–WBC


Increased:

–Bands

–Basophils

–Eosinophils

–Hematocrit

–Hemoglobin

–Lymphocytes

–Monocytes

Decreased:

–Haptoglobin

–Lymphocytes

–Neutrophils

–Reticulocytes Increased or decreased:

–Platelets

–RBC

Hepatic Increased:

–Cholesterol

–LDH

–SGOT

–SGPT Decreased:

–HDL cholesterol

Increased:

–Alkaline phosphatase

–Direct bilirubin

–GGTP

Increased:

–Globulin

–Total bilirubin

–Total protein

Increased and

decreased:

–Serum albumin


Miscellaneous


Increased:

–Triglycerides


Increased:

–CPK

–Fasting blood sugar


Decreased:

–Fasting blood sugar

–High occult blood


Increased and

decreased:

–Iron

Renal

Increased:

–Uric acid


Increased:

–BUN

–Creatinine

Urinary WBC in urine

Acetonuria

Hematuria

RBC in urine


Glycosuria

Proteinuria


To report SUSPECTED ADVERSE EVENTS, contact Watson at 1-800-272-5525 or FDA at 1-800-FDA-1088 or http://www.fda.gov/ for voluntary reporting of adverse reactions.

OVERDOSAGE

In the event of acute overdosage, Neotigason must be withdrawn at once. Symptoms of overdose are identical to acute hypervitaminosis A (e.g., headache and vertigo). The acute oral toxicity (LD50) of Neotigason in both mice and rats was greater than 4,000 mg per kg.

In one reported case of overdose, a 32-year-old male with Darier’s disease took 21 x 25 mg capsules (525 mg single dose). He vomited several hours later but experienced no other ill effects.

All female patients of childbearing potential who have taken an overdose of Neotigason must:

1) Have a pregnancy test at the time of overdose; 2) Be counseled as per the boxed CONTRAINDICATIONS AND WARNINGS and PRECAUTIONS sections regarding birth defects and contraceptive use for at least 3 years’ duration after the overdose.

DOSAGE AND ADMINISTRATION

There is intersubject variation in the pharmacokinetics, clinical efficacy, and incidence of side effects with Neotigason. A number of the more common side effects are dose-related. Individualization of dosage is required to achieve sufficient therapeutic response while minimizing side effects. Therapy with Neotigason should be initiated at 25 to 50 mg per day, given as a single dose with the main meal. Maintenance doses of 25 to 50 mg per day may be given dependent upon an individual patient’s response to initial treatment. Relapses may be treated as outlined for initial therapy.

When Neotigason is used with phototherapy, the prescriber should decrease the phototherapy dose, dependent on the patient’s individual response (see PRECAUTIONS: General ).

Females who have taken TEGISON (etretinate) must continue to follow the contraceptive recommendations for TEGISON . TEGISON is no longer marketed in the US; for information, call Watson Laboratories, Inc. at 1-800-272-5525.

Information for Pharmacists:

Neotigason must only be dispensed in no more than a monthly supply. An Neotigason Medication Guide must be given to the patient each time Neotigason is dispensed, as required by law.

HOW SUPPLIED

White to off-white body and a brown cap, 10 mg, imprinted in black “WPI” on the capsule cap and “2263” on the capsule body; bottles of 30 (NDC 0591-2263-30).

Yellow to light yellow body and cap, 17.5 mg, imprinted in black “WPI” on the capsule cap and “2264” on the capsule body; bottles of 30 (NDC 0591-2264-30).

Brown body and cap, 22.5 mg, imprinted in black with “WPI” on the capsule cap and “2265” on the capsule body; bottles of 30 (NDC 0591-2265-30).

Yellow to light yellow body and a brown cap, 25 mg, imprinted in black “WPI” on the capsule cap and “2266” on the capsule body; bottles of 30 (NDC 0591-2266-30).

Store at 20° to 25°C (68° to 77°F). Protect from light. Avoid exposure to high temperatures and humidity after the bottle is opened.

REFERENCES

1. Berbis Ph, et al.: Arch Dermatol Res (1988) 280:388-389. 2. Maier H, Honigsmann H: Concentration of etretinate in plasma and subcutaneous fat after long-term Neotigason. Lancet 348:1107, 1996. 3. Geiger JM, Walker M: Is there a reproductive safety risk in male patients treated with Neotigason (Neotigason®/ Soriatane®)? Dermatology 205:105-107, 2002. 4. Sigg C, et al.: Andrological investigations in patients treated with etretin. Dermatologica 175:48-49, 1987. 5. Parsch EM, et al.: Andrological investigation in men treated with Neotigason (Ro 10-1670). Andrologia 22:479-482, 1990. 6. Kadar L, et al.: Spermatological investigations in psoriatic patients treated with Neotigason. In: Pharmacology of Retinoids in the Skin; Reichert U. et al., ed, KARGER, Basel, vol. 3, pp 253-254, 1988.

Manufactured by:

Micro-Sphere SA

Via Cantonale

CH-6996 Ponte Cremenaga

Lugano

Switzerland

Distributed by:

Watson Pharma, Inc.

Parsippany, NJ 07054 USA

Revised: June 2015

PATIENT AGREEMENT/INFORMED CONSENT FOR FEMALE PATIENTS

To be completed by the patient* and signed by her prescriber


*Must also be initialed by the parent or guardian of a minor patient (under age 18).

Read each item below and initial in the space provided to show that you understand each item.

Do not sign this consent and do not take Neotigason if there is anything that you do not understand.

­­

(Patient’s name)

1. I understand that there is a very high risk that my unborn baby could have severe birth defects if I am pregnant or become pregnant while taking Neotigason in any amount even for short periods of time. Birth defects have also happened in babies of women who became pregnant after stopping treatment with Neotigason.

INITIAL: ___________

2. I understand that I must not become pregnant while taking Neotigason and for at least 3 years after the end of my treatment with Neotigason.

INITIAL: ___________

3. I know that I must avoid all alcohol, including drinks, food, medicines, and over-the-counter products that contain alcohol. I understand that the risk of birth defects may last longer than 3 years if I swallow any form of alcohol during therapy with Neotigason, and for 2 months after I stop taking Neotigason.

INITIAL: ___________

4. I understand that I must not have sexual intercourse, or I must use 2 separate, effective forms of birth control at the same time. The only exceptions are if I have had surgery to remove the womb (a hysterectomy) or my prescriber has told me I have gone completely through menopause.

INITIAL: ___________

5. I understand that I have to use 2 effective forms of birth control (contraception) at the same time for at least 1 month before starting Neotigason, for the entire time of therapy with Neotigason, and for at least 3 years after stopping Neotigason.

INITIAL: ___________

6. I understand that any form of birth control can fail. Therefore, I must use 2 different methods at the same time, every time I have sexual intercourse.

INITIAL: ___________

7. I understand that the following are considered effective forms of birth control: Primary: Tubal ligation (having my tubes tied), partner’s vasectomy, birth control pills (not progestin-only “minipills”), injectable/implantable/insertable/topical (patch) hormonal birth control products, and IUDs (intrauterine devices). Secondary: Condoms (with or without spermicide, which is a special cream or jelly that kills sperm), diaphragms and cervical caps (which must be used with a spermicide), and vaginal sponges (contains spermicide). I understand that at least 1 of my 2 methods of birth control must be a primary method.

INITIAL: ___________

8. I will talk with my prescriber about any medicines or dietary supplements I plan to take while taking Neotigason because certain birth control methods may not work if I am taking certain medicines or herbal products (for example, St. John’s wort).

INITIAL: ___________

9. Unless I have had a hysterectomy or my prescriber says I have gone completely through menopause, I understand that I must have 2 negative pregnancy test results before I can get a prescription to start Neotigason. I understand that if the second pregnancy test is negative, I must start taking my Neotigason within 7 days of the specimen collection. I will then have pregnancy tests on a monthly basis during therapy with Neotigason as instructed by my prescriber. In addition, for at least 3 years after I stop taking Neotigason, I will have a pregnancy test every 3 months.

INITIAL: ___________

10. I understand that I should not start taking Neotigason until I am sure that I am not pregnant and have negative results from 2 pregnancy tests.

INITIAL: ___________

11. I have received information on emergency contraception (birth control).

INITIAL: ___________

12. I understand that my prescriber can give me a referral for a free contraception (birth control) counseling session and pregnancy testing.

INITIAL: ___________

13. I understand that on a monthly basis during therapy with Neotigason and every 3 months for at least 3 years after stopping Neotigason that I should receive counseling from my prescriber about contraception (birth control) and behaviors associated with an increased risk of pregnancy.

INITIAL: ___________

14. I understand that I must stop taking Neotigason right away and call my prescriber if I get pregnant, miss my menstrual period, stop using birth control, or have sexual intercourse without using my 2 birth control methods during and at least 3 years after stopping Neotigason.

INITIAL: ___________

15. If I do become pregnant while on Neotigason or at any time within 3 years of stopping Neotigason, I understand that I should report my pregnancy to Watson Laboratories, Inc. and its affiliates at 1-800-272-5525 or to the Food and Drug Administration (FDA) MedWatch program at 1-800-FDA-1088. The information I share will be kept confidential (private) unless disclosure is legally required. This will help the company and the FDA evaluate the pregnancy prevention program to prevent birth defects.

INITIAL: ___________

I have received a copy of the Education and Pregnancy Prevention for Neotigason (EPPA) Program Booklet. My prescriber has answered all my questions about Neotigason. I understand that it is my responsibility to follow my doctor’s instructions, and not to get pregnant during treatment with acitretin or for at least 3 years after I stop taking Neotigason.

I now authorize my prescriber, ______________________________________________, to begin my treatment with Neotigason.

Patient signature: ________________________________________

Date: ___________________

Parent/guardian signature (if under age 18): ____________________

Date: ___________________

Please print: Patient name and address: ______________________________________________________________________________

_______________________________________________________________

Telephone: _____________________________________________________________

I have fully explained to the patient, _______________________________________, the nature and purpose of the treatment described above and the risks to females of childbearing potential. I have asked the patient if she has any questions regarding her treatment with Neotigason and have answered those questions to the best of my ability.

Prescriber signature: _______________________________________

Date: __________________

Revised: June 2015

do not get pregnant image

MEDICATION GUIDE

Neotigason CAPSULES USP

Read this Medication Guide carefully before you start taking Neotigason and read it each time you get more Neotigason. There may be new information.

The first information in this Guide is about birth defects and how to avoid pregnancy. After this section there is important safety information about possible effects for any patient taking Neotigason. ALL patients should read this entire Medication Guide carefully.

This information does not take the place of talking with your prescriber about your medical condition or treatment.

What is the most important information I should know about Neotigason?

Neotigason can cause serious side effects, including:

1 . Severe birth defects. If you are a female who can get pregnant, you should use Neotigason only if you are not pregnant now, can avoid becoming pregnant for at least 3 years, and other medicines do not work for your severe psoriasis or you cannot use other psoriasis medicines. Information about effects on unborn babies and about how to avoid pregnancy is found in the next section: “What are the important warnings and instructions for females taking Neotigason?”


2 . Liver problems, including abnormal liver function tests and inflammation of your liver (hepatitis). Your prescriber should do blood tests to check how your liver is working before you start taking and during treatment with Neotigason. Stop taking Neotigason and call your prescriber right away if you have any of the following signs or symptoms of a serious liver problem:


What are the important warnings and instructions for females taking Neotigason?

- Before you receive your first prescription for Neotigason, you should have discussed and signed a Patient Agreement/Informed Consent for Female Patients form with your prescriber. This is to help make sure you understand the risk of birth defects and how to avoid getting pregnant. If you did not talk to your prescriber about this and sign the form, contact your prescriber.

NOTE: If you are a female who can become pregnant:

- You must not take Neotigason if you are pregnant or might become pregnant during treatment or at any time for at least 3 years after you stop treatment because Neotigason can cause severe birth defects.

- During treatment with Neotigason and for 2 months after you stop treatment with Neotigason, you must avoid drinks, foods, and all medicines that contain alcohol. This includes over-the-counter products that contain alcohol. Avoiding alcohol is very important, because alcohol changes Neotigason into a drug that may take longer than 3 years to leave your body. The chance of birth defects may last longer than 3 years if you swallow any form of alcohol during treatment with Neotigason and for 2 months after you stop taking Neotigason.

- You and your prescriber must be sure you are not pregnant before you start therapy with Neotigason. You must have negative results from 2 pregnancy tests before you start treatment with Neotigason. A negative result shows you are not pregnant. Because it takes a few days after pregnancy begins for a test to show that you are pregnant, the first negative test may not ensure you are not pregnant. Do not start Neotigason until you have negative results from 2 pregnancy tests.

- The first pregnancy test (urine or blood) will be done at the time you and your prescriber decide if Neotigason might be right for you.

- The second pregnancy test will usually be done during the first 5 days of your menstrual period. You must start taking Neotigason within 7 days of when the urine or blood for the second pregnancy test is collected.

- After you start taking Neotigason, you must have a pregnancy test repeated each month that you are taking Neotigason. This is to be sure that you are not pregnant during treatment because Neotigason can cause birth defects. In addition, your prescription of Neotigason will be limited to a monthly supply.

- For at least 3 years after stopping treatment with Neotigason, you must have a pregnancy test repeated every 3 months to make sure that you are not pregnant.

- Discuss effective birth control (contraception) with your prescriber. You must use 2 effective forms of birth control (contraception) at the same time during all of the following:

- for at least 1 month before beginning treatment with Neotigason

- during treatment with Neotigason

- for at least 3 years after stopping treatment with Neotigason - If you are sexually active, you must use 2 effective forms of birth control (contraception) at the same time even if you think you cannot become pregnant, unless 1 of the following is true for you:


- You can get a free birth control counseling session and pregnancy testing from a prescriber or family planning expert. Your prescriber can give you a Contraception Counseling Referral Form for this free session.

The following are considered effective forms of birth control:

Primary Forms:

- having your tubes tied (tubal ligation)

- partner’s vasectomy

- IUD (Intrauterine device)

- birth control pills that contain both estrogen and progestin (combination oral contraceptives); not progestin-only “minipills”

- hormonal birth control products that are injected, implanted, or inserted in your body

- birth control patch

Secondary Forms (use with a Primary Form):

- diaphragms with spermicide

- condoms (with or without spermicide)

- cervical caps with spermicide

- vaginal sponge (contains spermicide)

At least 1 of your 2 methods of birth control must be a primary form.

- If you have sex at any time without using 2 effective forms of birth control (contraception) at the same time, or if you get pregnant or miss your period, stop using Neotigason and call your prescriber right away.

- Consider “Emergency Contraception” (EC) if you have sex with a male without correctly using 2 effective forms of birth control (contraception) at the same time. EC is also called “emergency birth control” or the “morning after” pill. Contact your prescriber as soon as possible if you have sex without using 2 effective forms of birth control (contraception) at the same time, because EC works best if it is used within 1 or 2 days after sex. EC is not a replacement for your usual 2 effective forms of birth control (contraception) because it is not as effective as regular birth control methods.

You can get EC from private doctors or nurse practitioners, women’s health centers, or hospital emergency rooms. You can get the name and phone number of EC providers nearest you by calling the free Emergency Contraception Hotline at 1-888-668-2528 (1-888-NOT-2-LATE) or www.not-2-late.com.

- Stop taking Neotigason right away and contact your prescriber if you get pregnant while taking Neotigason or at any time for at least 3 years after treatment has stopped. You need to discuss the possible effects on the unborn baby with your prescriber.

- If you do become pregnant while taking Neotigason or at any time for at least 3 years after stopping Neotigason, you should report your pregnancy to Watson Laboratories, Inc. at 1-800-272-5525 or directly to the Food and Drug Administration (FDA) MedWatch program at 1-800-FDA-1088. Your name will be kept in private (confidential). The information you share will help the FDA and the manufacturer evaluate the Pregnancy Prevention Program for Neotigason.

- Do not take Neotigason if you are breastfeeding. Neotigason can pass into your milk and may harm your baby. You will need to choose either to breastfeed or take Neotigason, but not both.

What should males know before taking Neotigason?

Small amounts of Neotigason are found in the semen of males taking Neotigason. Based upon available information, it appears that these small amounts of Neotigason in semen pose little, if any, risk to an unborn child while a male patient is taking the drug or after it is discontinued. Discuss any concerns you have about this with your prescriber.

All patients should read the rest of this Medication Guide.

What is Neotigason?

Neotigason is a medicine used to treat severe forms of psoriasis in adults. Psoriasis is a skin disease that causes cells in the outer layer of the skin to grow faster than normal and pile up on the skin’s surface. In the most common type of psoriasis, the skin becomes inflamed and produces red, thickened areas, often with silvery scales.

Because Neotigason can have serious side effects, you should talk with your prescriber about whether possible benefits of Neotigason outweigh its possible risks.

Neotigason may not work right away. You may have to wait 2 to 3 months before you get the full benefit of Neotigason. Psoriasis gets worse for some patients when they first start treatment with Neotigason.

Neotigason has not been studied in children.

Who should not take Neotigason?

- Do NOT take Neotigason if you can get pregnant. Do not take Neotigason if you are pregnant or might get pregnant during treatment with Neotigason or at any time for at least 3 years after you stop treatment with Neotigason.

- Do NOT take Neotigason if you are breastfeeding. Neotigason can pass into your milk and may harm your baby. You will need to choose either to breastfeed or take Neotigason, but not both.

- Do NOT take Neotigason if you have severe liver or kidney disease.

- Do NOT take Neotigason if you have repeated high blood lipids (fat in the blood).

- Do NOT take Neotigason if you take these medicines:

- methotrexate

- tetracyclines

The use of these medicines with Neotigason may cause serious side effects.

- Do NOT take Neotigason if you are allergic to Neotigason, the active ingredient in Neotigason, to any of the other ingredients in Neotigason, or to any medicines that are like Neotigason. Ask your prescriber or pharmacist if any medicines you are allergic to are like Neotigason.

Tell your prescriber if you have or ever had:

- diabetes or high blood sugar

- liver problems

- kidney problems

- high cholesterol or high triglycerides (fat in the blood)

- heart disease

- depression

- alcoholism

- an allergic reaction to a medication

Your prescriber needs this information to decide if Neotigason is right for you and to know what dose is best for you.

Tell your prescriber about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. Some medicines can cause serious side effects if taken while you also take Neotigason. Some medicines may affect how Neotigason works, or Neotigason may affect how your other medicines work. Be especially sure to tell your prescriber if you are taking the following medicines:

- methotrexate

- tetracyclines

- glyburide

- phenytoin

- vitamin A supplements

- progestin-only oral contraceptives (“minipills”)

-TEGISON® or TIGASON (etretinate). Tell your prescriber if you have ever taken this medicine in the past.

- St. John’s wort herbal supplement

Tell your prescriber if you are getting phototherapy treatment. Your doses of phototherapy may need to be changed to prevent a burn.

How should I take Neotigason?

- Take Neotigason with food.

- Be sure to take your medicine as prescribed by your prescriber. The dose of Neotigason varies from patient to patient. The number of capsules you must take is chosen specially for you by your prescriber. This dose may change during treatment.

- If you miss a dose, do not double the next dose. Skip the missed dose and resume your normal schedule.

- If you take too much Neotigason (overdose), call your local poison control center or emergency room.

You should have blood tests for liver function, cholesterol, and triglycerides before starting treatment and during treatment to check your body’s response to Neotigason. Your prescriber may also do other tests.

Once you stop taking Neotigason, your psoriasis may return. Do not treat this new psoriasis with leftover Neotigason. It is important to see your prescriber again for treatment recommendations because your situation may have changed.

What should I avoid while taking Neotigason?

- Avoid pregnancy. See “What is the most important information I should know about Neotigason?”, and “What are the important warnings and instructions for females taking Neotigason?”

- Avoid breastfeeding. See “What are the important warnings and instructions for females taking Neotigason?”

- Avoid alcohol. Females who are able to become pregnant must avoid drinks, foods, medicines, and over-the-counter products that contain alcohol. The risk of birth defects may continue for longer than 3 years if you swallow any form of alcohol during treatment with Neotigason and for 2 months after stopping Neotigason.

- Avoid giving blood. Do not donate blood while you are taking Neotigason and for at least 3 years after stopping treatment with Neotigason. Neotigason in your blood can harm an unborn baby if your blood is given to a pregnant woman. Neotigason does not affect your ability to receive a blood transfusion.

- Avoid progestin-only birth control pills (“minipills”). This type of birth control pill may not work while you take Neotigason. Ask your prescriber if you are not sure what type of pills you are using.

- Avoid night driving if you develop any sudden vision problems. Stop taking Neotigason and call your prescriber if this occurs.

- Avoid non-medical ultraviolet (UV) light. Neotigason can make your skin more sensitive to UV light. Do not use sunlamps, and avoid sunlight as much as possible. If you are taking light treatment (phototherapy), your prescriber may need to change your light dosages to avoid burns.

- Avoid dietary supplements containing vitamin A. Neotigason is related to vitamin A. Therefore, do not take supplements containing vitamin A, because they may add to the unwanted effects of Neotigason. Check with your prescriber or pharmacist if you have any questions about vitamin supplements.

- DO NOT SHARE Neotigason with anyone else, even if they have the same symptoms. Your medicine may harm them or their unborn child.

What are the possible side effects of Neotigason?

Neotigason can cause serious side effects. See “What is the most important information I should know about Neotigason?” and “What are the important warnings and instructions for females taking Neotigason?”

Stop taking Neotigason and call your prescriber right away if you get the following signs or symptoms of possible serious side effects :

- Bad headaches, nausea, vomiting, blurred vision. These symptoms can be signs of increased brain pressure that can lead to blindness or even death.

- Vision problems. Decreased vision in the dark (night blindness). Since this can start suddenly, you should be very careful when driving at night. This problem usually goes away when treatment with Neotigason stops. Stop taking Neotigason and call your prescriber if you develop any vision problems or eye pain.

- Depression. There have been some reports of patients developing mental problems including a depressed mood, aggressive feelings, or thoughts of ending their own life (suicide). These events, including suicidal behavior, have been reported in patients taking other drugs similar to Neotigason as well as patients taking Neotigason. Since other things may have contributed to these problems, it is not known if they are related to Neotigason.

- Aches or pains in your bones, joints, muscles, or back, trouble moving, or loss of feeling in your hands or feet. These can be signs of abnormal changes to your bones or muscles.

- Frequent urination, great thirst or hunger. Neotigason can affect blood sugar control, even if you do not already have diabetes. These are some of the signs of high blood sugar.

- Shortness of breath, dizziness, nausea, chest pain, weakness, trouble speaking, or swelling of a leg. These may be signs of a heart attack, blood clots, or stroke. Neotigason can cause serious changes in blood fats (lipids). It is possible for these changes to cause blood vessel blockages that lead to heart attacks, strokes, or blood clots.

- Blood vessel problems. Neotigason can cause fluid to leak out of your blood vessels into your body tissues. Call your prescriber right away if you have any of the following symptoms: sudden swelling in one part of your body or all over your body, weight gain, fever, lightheadedness or feeling faint, or muscle aches. If this happens, your prescriber will tell you to stop taking Neotigason.

- Serious allergic reactions. See “Who should not take Neotigason?” Serious allergic reactions can happen during treatment with Neotigason. Call your prescriber right away if you get any of the following symptoms of an allergic reaction: hives, itching, swelling of your face, mouth, or tongue, or problems breathing. If this happens, stop taking a citretin and do not take it again.

- Serious skin problems. Neotigason can cause skin problems that can begin in a small area and then spread over large areas of your body. Call your prescriber right away if your skin becomes red and swollen (inflamed), you have peeling of your skin, or your skin becomes itchy and painful. You should stop Neotigason if this happens.

Common side effects

If you develop any of these side effects or any unusual reaction, check with your prescriber to find out if you need to change the amount of Neotigason you take. These side effects usually get better if the dose of Neotigason is reduced or Neotigason is stopped.

- Chapped lips, peeling fingertips, palms, and soles, itching, scaly skin all over, weak nails, sticky or fragile (weak) skin, runny or dry nose, or nosebleeds. Your prescriber or pharmacist can recommend a lotion or cream to help treat drying or chapping.

- Dry mouth

- Joint pain

- Tight muscles

- Hair loss. Most patients have some hair loss, but this condition varies among patients. No one can tell if you will lose hair, how much hair you may lose or if and when it may grow back. You may also lose your eyelashes.

- Dry eyes. Neotigason may dry your eyes. Wearing contact lenses may be uncomfortable during and after treatment with Neotigason because of the dry feeling in your eyes. If this happens, remove your contact lenses and call your prescriber. Also read the section about vision under “Serious side effects”.

- Rise in blood fats (lipids). Neotigason can cause your blood fats (lipids) to rise. Most of the time this is not serious. But sometimes the increase can become a serious problem. You should have blood tests as directed by your prescriber.

Psoriasis gets worse for some patients when they first start treatment with Neotigason. Some patients have more redness or itching. If this happens, tell your prescriber. These symptoms usually get better as treatment continues, but your prescriber may need to change the amount of your medicine.

These are not all the possible side effects of Neotigason. For more information, ask your prescriber or pharmacist.

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

How should I store Neotigason?


What are the ingredients in Neotigason?

Active ingredient: Neotigason.

Inactive ingredients: microcrystalline cellulose, maltodextrin, sodium ascorbate, gelatin, black imprinting ink (the solid components are shellac glaze, propylene glycol and iron oxide black). Gelatin capsule shells contain gelatin, red ferric oxide (10 mg, 22.5 mg and 25 mg only), yellow ferric oxide (17.5 mg and 25 mg only), sodium lauryl sulfate, and titanium dioxide (10 mg, 17.5 mg and 25 mg only).

General information about the safe and effective use of Neotigason

Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Do not use Neotigason for a condition for which it was not prescribed. Do not give Neotigason to other people, even if they have the same symptoms that you have.

This Medication Guide summarizes the most important information about Neotigason. If you would like more information, talk with your prescriber. You can ask your pharmacist or prescriber for information about Neotigason that is written for health professionals.

For more information about Neotigason call 1-800-272-5525 or go to www.acitretinEPPA.com.

This Medication Guide has been approved by the U.S. Food and Drug Administration.

TEGISON® is a registered trademark of Hoffmann-La Roche Inc.

Manufactured by:

Micro-Sphere SA

Via Cantonale

CH-6996 Ponte Cremenaga

Lugano

Switzerland

Distributed by:

Watson Pharma, Inc.

Parsippany, NJ 07054 USA

Revised: June 2015

image-do not get pregnant

Neotigason pharmaceutical active ingredients containing related brand and generic drugs:

Active ingredient is the part of the drug or medicine which is biologically active. This portion of the drug is responsible for the main action of the drug which is intended to cure or reduce the symptom or disease. The other portions of the drug which are inactive are called excipients; there role is to act as vehicle or binder. In contrast to active ingredient, the inactive ingredient's role is not significant in the cure or treatment of the disease. There can be one or more active ingredients in a drug.


Neotigason available forms, composition, doses:

Form of the medicine is the form in which the medicine is marketed in the market, for example, a medicine X can be in the form of capsule or the form of chewable tablet or the form of tablet. Sometimes same medicine can be available as injection form. Each medicine cannot be in all forms but can be marketed in 1, 2, or 3 forms which the pharmaceutical company decided based on various background research results.
Composition is the list of ingredients which combinedly form a medicine. Both active ingredients and inactive ingredients form the composition. The active ingredient gives the desired therapeutic effect whereas the inactive ingredient helps in making the medicine stable.
Doses are various strengths of the medicine like 10mg, 20mg, 30mg and so on. Each medicine comes in various doses which is decided by the manufacturer, that is, pharmaceutical company. The dose is decided on the severity of the symptom or disease.


Neotigason destination | category:

Destination is defined as the organism to which the drug or medicine is targeted. For most of the drugs what we discuss, human is the drug destination.
Drug category can be defined as major classification of the drug. For example, an antihistaminic or an antipyretic or anti anginal or pain killer, anti-inflammatory or so.


Neotigason Anatomical Therapeutic Chemical codes:

A medicine is classified depending on the organ or system it acts [Anatomical], based on what result it gives on what disease, symptom [Therapeutical], based on chemical composition [Chemical]. It is called as ATC code. The code is based on Active ingredients of the medicine. A medicine can have different codes as sometimes it acts on different organs for different indications. Same way, different brands with same active ingredients and same indications can have same ATC code.


Neotigason pharmaceutical companies:

Pharmaceutical companies are drug manufacturing companies that help in complete development of the drug from the background research to formation, clinical trials, release of the drug into the market and marketing of the drug.
Researchers are the persons who are responsible for the scientific research and is responsible for all the background clinical trials that resulted in the development of the drug.


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References

  1. Dailymed."ACITRETIN CAPSULE [ACTAVIS PHARMA, INC.]". https://dailymed.nlm.nih.gov/dailym... (accessed August 28, 2018).
  2. Dailymed."ACITRETIN: DailyMed provides trustworthy information about marketed drugs in the United States. DailyMed is the official provider of FDA label information (package inserts).". https://dailymed.nlm.nih.gov/dailym... (accessed August 28, 2018).
  3. "Acitretin". https://pubchem.ncbi.nlm.nih.gov/co... (accessed August 28, 2018).

Frequently asked Questions

Can i drive or operate heavy machine after consuming Neotigason?

Depending on the reaction of the Neotigason after taken, if you are feeling dizziness, drowsiness or any weakness as a reaction on your body, Then consider Neotigason not safe to drive or operate heavy machine after consumption. Meaning that, do not drive or operate heavy duty machines after taking the capsule if the capsule has a strange reaction on your body like dizziness, drowsiness. As prescribed by a pharmacist, it is dangerous to take alcohol while taking medicines as it exposed patients to drowsiness and health risk. Please take note of such effect most especially when taking Primosa capsule. It's advisable to consult your doctor on time for a proper recommendation and medical consultations.

Is Neotigason addictive or habit forming?

Medicines are not designed with the mind of creating an addiction or abuse on the health of the users. Addictive Medicine is categorically called Controlled substances by the government. For instance, Schedule H or X in India and schedule II-V in the US are controlled substances.

Please consult the medicine instruction manual on how to use and ensure it is not a controlled substance.In conclusion, self medication is a killer to your health. Consult your doctor for a proper prescription, recommendation, and guidiance.

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Review

sdrugs.com conducted a study on Neotigason, and the result of the survey is set out below. It is noteworthy that the product of the survey is based on the perception and impressions of the visitors of the website as well as the views of Neotigason consumers. We, as a result of this, advice that you do not base your therapeutic or medical decisions on this result, but rather consult your certified medical experts for their recommendations.

Visitor reports

Visitor reported useful

No survey data has been collected yet

One visitor reported side effects

Did you get side effects while taking the Neotigason drug, or were there no side effects?
According to the survey conducted by website sdrugs.com users, the below-mentioned percentages indicate the number of people experiencing the side effects and the number of people not experiencing the side effects when taking Neotigason medicine. Every drug produces minimal side effects, and they are negligible most times, when compared to the desired effect [use] of the medicine. Side effects depend on the dose you are taking, any drug interactions that happen when you are on other medications, if the patient is sensitive, and other associated conditions. If you cannot tolerate the side effects, consult your doctor immediately, so he can either adjust the dose or change the medication.
Visitors%
No side effects1
100.0%

Visitor reported price estimates

No survey data has been collected yet

Visitor reported frequency of use

No survey data has been collected yet

One visitor reported doses

What is the dose of Neotigason drug you are taking?
According to the survey conducted among sdrugs.com website users, the maximum number of people are using the following dose 11-50mg. Few medications come in only one or two doses. Few are specific for adult dose and child dose. The dose of the medicine given to the patient depends on the severity of the symptom/disease. There can be dose adjustments made by the doctor, based on the progression of the disease. Follow-up is important.
Visitors%
11-50mg1
100.0%

One visitor reported time for results

What is the time duration Neotigason drug must be taken for it to be effective or for it to reduce the symptoms?
Most chronic conditions need at least some time so the dose and the drug action gets adjusted to the body to get the desired effect. The stastistics say sdrugs.com website users needed 1 week to notice the result from using Neotigason drug. The time needed to show improvement in health condition after using the medicine Neotigason need not be same for all the users. It varies based on other factors.
Visitors%
1 week1
100.0%

Visitor reported administration

No survey data has been collected yet

One visitor reported age

Visitors%
30-451
100.0%

Visitor reviews


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The information was verified by Dr. Rachana Salvi, MD Pharmacology

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