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  Minoxidil For Men | Roxane Laboratories, Inc

  

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  2.1 Important General Information • The peak respiratory depressant effect of methadone occurs later and persists longer than its peak therapeutic effect. • A high degree of opioid tolerance does not eliminate the possibility of methadone overdose, iatrogenic or otherwise. Deaths have been reported during conversion to methadone from chronic, high-dose treatment with other opioid agonists and during initiation of methadone treatment of addiction in subjects previously abusing high doses of other agonists. • With repeated dosing, methadone is retained in the liver and then slowly released, prolonging the duration of potential toxicity. • Methadone has a narrow therapeutic index, especially when combined with other drug. 2.2 Initial Dosing for Management of Pain

  Methadone should be prescribed only by healthcare professionals who are knowledgeable in the use of potent opioids for the management of chronic pain.

  Consider the following important factors that differentiate methadone from other opioid analgesics:

  • There is high interpatient variability in absorption, metabolism, and relative analgesic potency. Population-based equianalgesic conversion ratios between methadone and other opioids are not accurate when applied to individuals. • The duration of analgesic action of methadone is 4 to 8 hours (based on single-dose studies) but the plasma elimination half-life is 8 to 59 hours. • Steady-state plasma concentrations, and full analgesic effects, are not attained until at least 3 to 5 days on a dose, and may take longer in some patients.

  Initiate the dosing regimen for each patient individually, taking into account the patient’s prior analgesic treatment experience and risk factors for addiction, abuse, and misuse [see Warnings and Precautions (5.1)]. Monitor patients closely for respiratory depression, especially within the first 24-72 hours of initiating therapy with methadone [see Warnings and Precautions (5.2)].

  Use of Methadone as the First Opioid Analgesic: Initiate treatment with Methadone with 2.5 mg orally every 8 to 12 hours.

  Conversion from Other Oral Opioids to Methadone: Discontinue all other around-the-clock opioid drugs when methadone therapy is initiated. Deaths have occurred in opioid-tolerant patients during conversion to methadone.

  While there are useful tables of opioid equivalents readily available, there is substantial inter-patient variability in the relative potency of different opioid drugs and products. As such, it is safer to underestimate a patient’s 24-hour oral methadone requirements and provide rescue medication (e.g., immediate-release opioid) than to overestimate the 24-hour oral methadone requirements which could result in adverse reactions. With repeated dosing, the potency of methadone increases due to systemic accumulation.

  Consider the following when using the information in Table 1:

  • This is not a table of equianalgesic doses. • The conversion factors in this table are only for the conversion from another oral opioid analgesic to methadone. • The table cannot be used to convert from methadone to another opioid. Doing so will result in an overestimation of the dose of the new opioid and may result in fatal overdose.

  Table 1: Conversion Factors to Methadone

    Total Daily Baseline Oral   Morphine Equivalent Dose

  Estimated Daily Oral Methadone Requirement

  as Percent of Total Daily Morphine Equivalent Dose

  < 100 mg

  20% to 30%

  100 to 300 mg

  10% to 20%

  300 to 600 mg

  8% to 12%

  600 mg to 1000 mg

  5% to 10%

  > 1000 mg

  < 5 %

  To calculate the estimated methadone dose using Table 1:

  • For patients on a single opioid, sum the current total daily dose of the opioid, convert it to a Morphine Equivalent Dose according to specific conversion factor for that specific opioid, then multiply the Morphine Equivalent Dose by the corresponding percentage in the above table to calculate the approximate oral methadone daily dose. Divide the total daily methadone dose derived from the table above to reflect the intended dosing schedule (i.e., for administration every 8 hours, divide total daily methadone dose by 3). • For patients on a regimen of more than one opioid, calculate the approximate oral methadone dose for each opioid and sum the totals to obtain the approximate total methadone daily dose. Divide the total daily methadone dose derived from the table above to reflect the intended dosing schedule (i.e., for administration every 8 hours, divide total daily methadone dose by 3). • For patients on a regimen of fixed-ratio opioid/non-opioid analgesic products, use only the opioid component of these products in the conversion.

  Always round the dose down, if necessary, to the appropriate methadone strength(s) available.

  Example conversion from a single opioid to methadone:

  Step 1 : Sum the total daily dose of the opioid (in this case, Morphine Extended Release Tablets 50 mg twice daily)

  50 mg Morphine Extended Release Tablets 2 times daily = 100 mg total daily dose of Morphine

  Step 2 : Calculate the approximate equivalent dose of methadone based on the total daily dose of Morphine using Table 1.

  100 mg total daily dose of Morphine x 15% (10% to 20% per Table 1) = 15 mg methadone daily

  Step 3 : Calculate the approximate starting dose of methadone to be given every 12 hours. Round down, if necessary, to the appropriate methadone tablets strengths available.

  15 mg daily / 2 = 7.5 mg methadone every 12 hours

  Then 7.5 mg is rounded down to 5 mg methadone every 12 hours

  Close observation and frequent titration are warranted until pain management is stable on the new opioid. Monitor patients for signs and symptoms of opioid withdrawal or for signs of over-sedation/toxicity after converting patients to methadone.

  Conversion from Parenteral Methadone to Methadone: Use a conversion ratio of 1:2 mg for parenteral to oral methadone (e.g., 5 mg parenteral methadone to 10 mg oral methadone).

  2.3 Titration and Maintenance of Therapy for Pain

  Individually titrate methadone to a dose that provides adequate analgesia and minimizes adverse reactions. Continually reevaluate patients receiving methadone to assess the maintenance of pain control and the relative incidence of adverse reactions, as well as monitoring for the development of addiction, abuse, or misuse. Frequent communication is important among the prescriber, other members of the healthcare team, the patient, and the caregiver/family during periods of changing analgesic requirements, including initial titration. During chronic therapy, periodically reassess the continued need for the use of opioid analgesics.

  Because of individual variability in the pharmacokinetic profile (i.e., terminal half-life (T1/2) from 8 to 59 hours in different studies [see Clinical Pharmacology (12.3)]), titrate methadone slowly, with dose increases no more frequent than every 3 to 5 days. However, because of this high variability, some patients may require substantially longer periods between dose increases (up to 12 days). Monitor patients closely for the development of potentially life-threatening adverse reactions (e.g., CNS and respiratory depression).

  Patients who experience breakthrough pain may require a dose increase of methadone, or may need rescue medication with an appropriate dose of an immediate-release medication. If the level of pain increases after dose stabilization, attempt to identify the source of increased pain before increasing the methadone dose.

  If unacceptable opioid-related adverse reactions are observed, the subsequent doses may be reduced and/or the dosing interval adjusted (i.e., every 8 hours or every 12 hours). Adjust the dose to obtain an appropriate balance between management of pain and opioid-related adverse reactions.

  2.4 Discontinuation of Methadone for Pain 2.5 Induction/Initial Dosing for Detoxification and Maintenance Treatment of Opioid Addiction

  For detoxification and maintenance of opioid dependence methadone should be administered in accordance with the treatment standards cited in 42 CFR Section 8.12, including limitations on unsupervised administration.

  Administer the initial methadone dose under supervision, when there are no signs of sedation or intoxication, and the patient shows symptoms of withdrawal. An initial single dose of 20 to 30 mg of methadone will often be sufficient to suppress withdrawal symptoms. The initial dose should not exceed 30 mg.

  To make same-day dosing adjustments, have the patient wait 2 to 4 hours for further evaluation, when peak levels have been reached. Provide an additional 5 to 10 mg of methadone if withdrawal symptoms have not been suppressed or if symptoms reappear.

  The total daily dose of methadone on the first day of treatment should not ordinarily exceed 40 mg. Adjust the dose over the first week of treatment based on control of withdrawal symptoms at the time of expected peak activity (e.g., 2 to 4 hours after dosing). When adjusting the dose, keep in mind that methadone levels will accumulate over the first several days of dosing; deaths have occurred in early treatment due to the cumulative effects. Instruct patients that the dose will “hold” for a longer period of time as tissue stores of methadone accumulate.

  Use lower initial doses for patients whose tolerance is expected to be low at treatment entry. Any patient who has not taken opioids for more than 5 days may no longer be tolerant. Do not determine initial doses based on previous treatment episodes or dollars spent per day on illicit drug use.

  Short-Term Detoxification: For a brief course of stabilization followed by a period of medically supervised withdrawal, titrate the patient to a total daily dose of about 40 mg in divided doses to achieve an adequate stabilizing level. After 2 to 3 days of stabilization, gradually decrease the dose of methadone. Decrease the dose of methadone on a daily basis or at 2-day intervals, keeping the amount of methadone sufficient to keep withdrawal symptoms at a tolerable level. Hospitalized patients may tolerate a daily reduction of 20% of the total daily dose. Ambulatory patients may need a slower schedule.

  2.6 Titration and Maintenance Treatment of Opioid Dependence Detoxification

  Titrate patients in maintenance treatment to a dose that prevents opioid withdrawal symptoms for 24 hours, reduces drug hunger or craving, and blocks or attenuates the euphoric effects of self-administered opioids, ensuring that the patient is tolerant to the sedative effects of methadone. Most commonly, clinical stability is achieved at doses between 80 to 120 mg/day.

  2.7 Medically Supervised Withdrawal After a Period of Maintenance Treatment for Opioid Addiction

  There is considerable variability in the appropriate rate of methadone taper in patients choosing medically supervised withdrawal from methadone treatment. Dose reductions should generally be less than 10% of the established tolerance or maintenance dose, and 10 to 14-day intervals should elapse between dose reductions. Apprise patients of the high risk of relapse to illicit drug use associated with discontinuation of methadone maintenance treatment.

  2.8 Risk of Relapse in Patients on Methadone Maintenance Treatment of Opioid Addiction

  Abrupt opioid discontinuation can lead to development of opioid withdrawal symptoms [see Drug Abuse and Dependence (9.3)]. Opioid withdrawal symptoms have been associated with an increased risk of relapse to illicit drug use in susceptible patients.

  2.9 Considerations for Management of Acute Pain During Methadone Maintenance Treatment

  Patients in methadone maintenance treatment for opioid dependence who experience physical trauma, postoperative pain or other acute pain cannot be expected to derive analgesia from their existing dose of methadone. Such patients should be administered analgesics, including opioids, in doses that would otherwise be indicated for non-methadone-treated patients with similar painful conditions. When opioids are required for management of acute pain in methadone maintenance patients, somewhat higher and/or more frequent doses will often be required than would be the case for non-tolerant patients due to the opioid tolerance induced by methadone.

  2.10 Dosage Adjustment During Pregnancy

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  Minoxidil For Men | Mylan Pharmaceuticals Inc.

  

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  Generally, when estrogen is prescribed for a postmenopausal woman with a uterus, a progestin should be considered to reduce the risk of endometrial cancer. A woman without a uterus does not need a progestin. In some cases, however, hysterectomized women with a history of endometriosis may need a progestin [see Warnings and Precautions (5.2, 5.14)].

  Use of estrogen-alone or in combination with a progestin, should be with the lowest effective dose and the shortest duration consistent with treatment goals and risks for the individual woman. Postmenopausal women should be reevaluated periodically as clinically appropriate to determine whether treatment is still necessary.

  The adhesive side of estradiol transdermal system (twice-weekly) should be placed on a clean, dry area of the trunk of the body (including the abdomen or buttocks). Estradiol transdermal system (twice-weekly) should not be applied to the breasts.

  Estradiol transdermal system (twice-weekly) should be replaced twice weekly. The sites of application must be rotated, with an interval of at least 1 week allowed between applications to a particular site. The area selected should not be oily, damaged, or irritated. The waistline should be avoided, since tight clothing may rub the system off. The system should be applied immediately after opening the pouch and removing the oversized protective liner. The system should be pressed firmly in place with the palm of the hand for about 10 seconds, making sure there is good contact, especially around the edges. In the event that a system should fall off, the same system may be reapplied. If the same system cannot be reapplied, a new system should be applied to another location. In either case, the original treatment schedule should be continued. If a woman has forgotten to apply a patch, she should apply a new patch as soon as possible. The new patch should be applied on the original treatment schedule. The interruption of treatment in women taking estradiol transdermal system (twice-weekly) might increase the likelihood of breakthrough bleeding, spotting and recurrence of symptoms.

  2.1 Moderate to Severe Vasomotor Symptoms

  Start therapy with estradiol transdermal system (twice-weekly) 0.0375 mg per day applied to the skin twice weekly. Dosage adjustment should be guided by the clinical response. In women not currently taking oral estrogens or in women switching from another estradiol transdermal therapy, treatment with estradiol transdermal system (twice-weekly) may be initiated at once. In women who are currently taking oral estrogens, treatment with estradiol transdermal system (twice-weekly) should be initiated 1 week after withdrawal of oral hormone therapy, or sooner if menopausal symptoms reappear in less than 1 week. Attempts to taper or discontinue the medication should be made at 3 to 6 month intervals.

  Estradiol transdermal system (twice-weekly) may be given continuously in patients who do not have an intact uterus. In those patients with an intact uterus, estradiol transdermal system (twice-weekly) may be given on a cyclic schedule (for example, 3 weeks on drug followed by 1 week off drug).

  2.2 Moderate to Severe Symptoms of Vulvar and Vaginal Atrophy

  Start therapy with estradiol transdermal system (twice-weekly) 0.0375 mg per day applied to the skin twice weekly. Dosage adjustment should be guided by the clinical response. Attempts to taper or discontinue the medication should be made at 3 to 6 month intervals.

  In women not currently taking oral estrogens or in women switching from another estradiol transdermal therapy, treatment with estradiol transdermal system (twice-weekly) may be initiated at once. In women who are currently taking oral estrogens, treatment with estradiol transdermal system (twice-weekly) should be initiated 1 week after withdrawal of oral hormone therapy, or sooner if menopausal symptoms reappear in less than 1 week.

  Estradiol transdermal system (twice-weekly) may be given continuously in patients who do not have an intact uterus. In those patients with an intact uterus, estradiol transdermal system (twice-weekly) may be given on a cyclic schedule (for example, 3 weeks on drug followed by 1 week off drug).

  2.3 Hypoestrogenism Due to Hypogonadism, Castration, or Primary Ovarian Failure

       

  2.4 Prevention of Postmenopausal Osteoporosis

  Start therapy with estradiol transdermal system (twice-weekly) 0.025 mg per day applied to the skin twice weekly.

  In women not currently taking oral estrogens or in women switching from another estradiol transdermal therapy, treatment with estradiol transdermal system (twice-weekly) may be initiated at once. In women who are currently taking oral estrogens, treatment with estradiol transdermal system (twice-weekly) should be initiated 1 week after withdrawal of oral hormone therapy, or sooner if menopausal symptoms reappear in less than 1 week.

  Estradiol transdermal system (twice-weekly) may be given continuously in patients who do not have an intact uterus. In those patients with an intact uterus, estradiol transdermal system (twice-weekly) may be given on a cyclic schedule (for example, 3 weeks on drug followed by 1 week off drug).

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