TOBIA, GIUDITTA, ESTER (Libri storici) Il Libro di Tobia Il libro di Tobia è una fantasiosa storia familiare che vuole dimostrare la cura che Dio haLa storia si inquadra nel periodo del 'esilio babilonese e ha come protagonisti Tobi,diventato accidentalmente cieco, e suo figlio Tobia. Tobi prega di poter morire, mentre nel o stesso tempo una giovane di nome Sara prega diessere liberata
Tamiflu capsules(oseltamivir phosphate)
AND FOR ORAL SUSPENSION
TAMIFLU (oseltamivir phosphate) is available as capsules containing 30 mg, 45 mg, or 75 mg oseltamivir for oral use, in the form of oseltamivir phosphate, and as a powder for oral suspension, which when constituted with water as directed contains 12 mg/mL oseltamivir base. In addition to the active ingredient, each capsule contains pregelatinized starch, talc, povidone K 30, croscarmellose sodium, and sodium stearyl fumarate. The 30 mg capsule shell contains gelatin, titanium dioxide, yellow iron oxide, and red iron oxide. The 45 mg capsule shell contains gelatin, titanium dioxide, and black iron oxide. The 75 mg capsule shell contains gelatin, titanium dioxide, yellow iron oxide, black iron oxide, and red iron oxide. Each capsule is printed with blue ink, which includes FD&C Blue No. 2 as the colorant. In addition to the active ingredient, the powder for oral suspension contains sorbitol, monosodium citrate, xanthan gum, titanium dioxide, tutti-frutti flavoring, sodium benzoate, and saccharin sodium. Oseltamivir phosphate is a white crystalline solid with the chemical name (3R,4R,5S)-4- acetylamino-5-amino-3(1-ethylpropoxy)-1-cyclohexene-1-carboxylic acid, ethyl ester, phosphate (1:1). The chemical formula is C16H28N2O4 (free base). The molecular weight is 312.4 for oseltamivir free base and 410.4 for oseltamivir phosphate salt. The structural MICROBIOLOGY
Mechanism of Action
Oseltamivir phosphate is an ethyl ester prodrug requiring ester hydrolysis for conversion to the active form, oseltamivir carboxylate. Oseltamivir carboxylate is an inhibitor of influenza virus neuraminidase affecting release of viral particles. Antiviral Activity
The antiviral activity of oseltamivir carboxylate against laboratory strains and clinical isolates of influenza virus was determined in cell culture assays. The concentrations of oseltamivir carboxylate required for inhibition of influenza virus were highly variable depending on the assay method used and the virus tested. The 50% and 90% effective concentrations (EC50 and EC90) were in the range of 0.0008 µM to >35 µM and 0.004 µM to >100 µM, respectively (1 µM=0.284 µg/mL). The relationship between the antiviral activity in cell culture and the inhibition of influenza virus replication in humans has not Resistance
Influenza A virus isolates with reduced susceptibility to oseltamivir carboxylate have been recovered by serial passage of virus in cell culture in the presence of increasing concentrations of oseltamivir carboxylate. Genetic analysis of these isolates showed that reduced susceptibility to oseltamivir carboxylate is associated with mutations that result in amino acid changes in the viral neuraminidase or viral hemagglutinin or both. Resistance substitutions selected in cell culture in neuraminidase are I222T and H274Y in influenza A N1 and I222T and R292K in influenza A N2. Substitutions E119V, R292K and R305Q have been selected in avian influenza A neuraminidase N9. Substitutions A28T and R124M have been selected in the hemagglutinin of influenza A H3N2 and substitution H154Q in the hemagglutinin of a reassortant human/avian virus H1N9. In clinical studies in the treatment of naturally acquired infection with influenza virus, 1.3% (4/301) of posttreatment isolates in adult patients and adolescents, and 8.6% (9/105) in pediatric patients aged 1 to 12 years showed emergence of influenza variants with decreased neuraminidase susceptibility in cell culture to oseltamivir carboxylate. Substitutions in influenza A neuraminidase resulting in decreased susceptibility were H274Y in neuraminidase N1 and E119V and R292K in neuraminidase N2. Insufficient information is available to fully characterize the risk of emergence of TAMIFLU In clinical studies of postexposure and seasonal prophylaxis, determination of resistance by population nucleotide sequence analysis was limited by the low overall incidence rate of influenza infection and prophylactic effect of TAMIFLU. Cross-resistance
Cross-resistance between zanamivir-resistant influenza mutants and oseltamivir-resistant influenza mutants has been observed in cell culture. Due to limitations in the assays available to detect drug-induced shifts in virus susceptibility, an estimate of the incidence of oseltamivir resistance and possible cross-resistance to zanamivir in clinical isolates cannot be made. However, two of the three oseltamivir-induced substitutions (E119V, H274Y and R292K) in the viral neuraminidase from clinical isolates occur at the same amino acid residues as two of the three substitutions (E119G/A/D, R152K and R292K) Immune Response
No influenza vaccine interaction study has been conducted. In studies of naturally acquired and experimental influenza, treatment with TAMIFLU did not impair normal CLINICAL PHARMACOLOGY
Oseltamivir is readily absorbed from the gastrointestinal tract after oral administration of oseltamivir phosphate and is extensively converted predominantly by hepatic esterases to oseltamivir carboxylate. At least 75% of an oral dose reaches the systemic circulation as oseltamivir carboxylate. Exposure to oseltamivir is less than 5% of the total exposure after oral dosing (see Table 1).
Mean (% CV) Pharmacokinetic Parameters of Oseltamivir
and Oseltamivir Carboxylate After a Multiple 75 mg Capsule
Twice Daily Oral Dose (n=20)
Plasma concentrations of oseltamivir carboxylate are proportional to doses up to 500 mg given twice daily (see DOSAGE AND ADMINISTRATION).
Coadministration with food has no significant effect on the peak plasma concentration (551 ng/mL under fasted conditions and 441 ng/mL under fed conditions) and the area under the plasma concentration time curve (6218 ng·h/mL under fasted conditions and 6069 ng·h/mL under fed conditions) of oseltamivir carboxylate. The volume of distribution (Vss) of oseltamivir carboxylate, following intravenous administration in 24 subjects, ranged between 23 and 26 liters. The binding of oseltamivir carboxylate to human plasma protein is low (3%). The binding of oseltamivir to human plasma protein is 42%, which is insufficient to cause significant displacement-based drug interactions. Oseltamivir is extensively converted to oseltamivir carboxylate by esterases located predominantly in the liver. Neither oseltamivir nor oseltamivir carboxylate is a substrate for, or inhibitor of, cytochrome P450 isoforms. Absorbed oseltamivir is primarily (>90%) eliminated by conversion to oseltamivir carboxylate. Plasma concentrations of oseltamivir declined with a half-life of 1 to 3 hours in most subjects after oral administration. Oseltamivir carboxylate is not further metabolized and is eliminated in the urine. Plasma concentrations of oseltamivir carboxylate declined with a half-life of 6 to 10 hours in most subjects after oral administration. Oseltamivir carboxylate is eliminated entirely (>99%) by renal excretion. Renal clearance (18.8 L/h) exceeds glomerular filtration rate (7.5 L/h) indicating that tubular secretion occurs, in addition to glomerular filtration. Less than 20% of an oral radiolabeled dose is eliminated in feces. Special Populations
Administration of 100 mg of oseltamivir phosphate twice daily for 5 days to patients with various degrees of renal impairment showed that exposure to oseltamivir carboxylate is inversely proportional to declining renal function. Oseltamivir carboxylate exposures in patients with normal and abnormal renal function administered various dose regimens of oseltamivir are described in Table 2.
Oseltamivir Carboxylate Exposures in Patients With Normal
and Reduced Serum Creatinine Clearance
Normal Renal Function
Impaired Renal Function
*Observed values. All other values are predicted. In clinical studies oseltamivir carboxylate exposure was not altered in patients with mild or moderate hepatic impairment (see PRECAUTIONS: Hepatic Impairment and
DOSAGE AND ADMINISTRATION).
The pharmacokinetics of oseltamivir and oseltamivir carboxylate have been evaluated in a single dose pharmacokinetic study in pediatric patients aged 5 to 16 years (n=18) and in a small number of pediatric patients aged 3 to 12 years (n=5) enrolled in a clinical trial. Younger pediatric patients cleared both the prodrug and the active metabolite faster than adult patients resulting in a lower exposure for a given mg/kg dose. For oseltamivir carboxylate, apparent total clearance decreases linearly with increasing age (up to 12 years). The pharmacokinetics of oseltamivir in pediatric patients over 12 years of age are Exposure to oseltamivir carboxylate at steady-state was 25% to 35% higher in geriatric patients (age range 65 to 78 years) compared to young adults given comparable doses of oseltamivir. Half-lives observed in the geriatric patients were similar to those seen in young adults. Based on drug exposure and tolerability, dose adjustments are not required for geriatric patients for either treatment or prophylaxis (see DOSAGE AND
ADMINISTRATION: Special Dosage Instructions).
INDICATIONS AND USAGE
Treatment of Influenza
TAMIFLU is indicated for the treatment of uncomplicated acute illness due to influenza infection in patients 1 year and older who have been symptomatic for no more than 2 Prophylaxis of Influenza
TAMIFLU is indicated for the prophylaxis of influenza in patients 1 year and older. The following points should be considered before initiating treatment or prophylaxis with • TAMIFLU is not a substitute for early vaccination on an annual basis as recommended by the Centers for Disease Control and Prevention Advisory • Influenza viruses change over time. Emergence of resistance mutations could decrease drug effectiveness. Other factors (for example, changes in viral virulence) might also diminish clinical benefit of antiviral drugs. Prescribers should consider available information on influenza drug susceptibility patterns and treatment effects Description of Clinical Studies: Studies in Naturally Occurring Influenza
Two phase III placebo-controlled and double-blind clinical trials were conducted: one in the USA and one outside the USA. Patients were eligible for these trials if they had fever >100ºF, accompanied by at least one respiratory symptom (cough, nasal symptoms or sore throat) and at least one systemic symptom (myalgia, chills/sweats, malaise, fatigue or headache) and influenza virus was known to be circulating in the community. In addition, all patients enrolled in the trials were allowed to take fever-reducing Of 1355 patients enrolled in these two trials, 849 (63%) patients were influenza-infected (age range 18 to 65 years; median age 34 years; 52% male; 90% Caucasian; 31% smokers). Of the 849 influenza-infected patients, 95% were infected with influenza A, 3% with influenza B, and 2% with influenza of unknown type. TAMIFLU was started within 40 hours of onset of symptoms. Subjects participating in the trials were required to self-assess the influenza-associated symptoms as “none”, “mild”, “moderate” or “severe”. Time to improvement was calculated from the time of treatment initiation to the time when all symptoms (nasal congestion, sore throat, cough, aches, fatigue, headaches, and chills/sweats) were assessed as “none” or “mild”. In both studies, at the recommended dose of TAMIFLU 75 mg twice daily for 5 days, there was a 1.3 day reduction in the median time to improvement in influenza-infected subjects receiving TAMIFLU compared to subjects receiving placebo. Subgroup analyses of these studies by gender showed no differences in the treatment effect of TAMIFLU in men and In the treatment of influenza, no increased efficacy was demonstrated in subjects receiving treatment of 150 mg TAMIFLU twice daily for 5 days. Three double-blind placebo-controlled treatment trials were conducted in patients ≥65 years of age in three consecutive seasons. The enrollment criteria were similar to that of adult trials with the exception of fever being defined as >97.5°F. Of 741 patients enrolled, 476 (65%) patients were influenza-infected. Of the 476 influenza-infected patients, 95% were infected with influenza type A and 5% with influenza type B. In the pooled analysis, at the recommended dose of TAMIFLU 75 mg twice daily for 5 days, there was a 1 day reduction in the median time to improvement in influenza- infected subjects receiving TAMIFLU compared to those receiving placebo (p=NS). However, the magnitude of treatment effect varied between studies. One double-blind placebo-controlled treatment trial was conducted in pediatric patients aged 1 to 12 years (median age 5 years), who had fever (>100ºF) plus one respiratory symptom (cough or coryza) when influenza virus was known to be circulating in the community. Of 698 patients enrolled in this trial, 452 (65%) were influenza-infected (50% male; 68% Caucasian). Of the 452 influenza-infected patients, 67% were infected with influenza A and 33% with influenza B. The primary endpoint in this study was the time to freedom from illness, a composite endpoint which required 4 individual conditions to be met. These were: alleviation of cough, alleviation of coryza, resolution of fever, and parental opinion of a return to normal health and activity. TAMIFLU treatment of 2 mg/kg twice daily, started within 48 hours of onset of symptoms, significantly reduced the total composite time to freedom from illness by 1.5 days compared to placebo. Subgroup analyses of this study by gender showed no differences in the treatment effect of TAMIFLU in males and females. The efficacy of TAMIFLU in preventing naturally occurring influenza illness has been demonstrated in three seasonal prophylaxis studies and a postexposure prophylaxis study in households. The primary efficacy parameter for all these studies was the incidence of laboratory-confirmed clinical influenza. Laboratory-confirmed clinical influenza was defined as oral temperature ≥99.0ºF/37.2ºC plus at least one respiratory symptom (cough, sore throat, nasal congestion) and at least one constitutional symptom (aches and pain, fatigue, headache, chills/sweats), all recorded within 24 hours, plus either a positive virus isolation or a fourfold increase in virus antibody titers from baseline. In a pooled analysis of two seasonal prophylaxis studies in healthy unvaccinated adults (aged 13 to 65 years), TAMIFLU 75 mg once daily taken for 42 days during a community outbreak reduced the incidence of laboratory-confirmed clinical influenza from 4.8% (25/519) for the placebo group to 1.2% (6/520) for the TAMIFLU group. In a seasonal prophylaxis study in elderly residents of skilled nursing homes, TAMIFLU 75 mg once daily taken for 42 days reduced the incidence of laboratory-confirmed clinical influenza from 4.4% (12/272) for the placebo group to 0.4% (1/276) for the TAMIFLU group. About 80% of this elderly population were vaccinated, 14% of subjects had chronic airway obstructive disorders, and 43% had cardiac disorders. In a study of postexposure prophylaxis in household contacts (aged ≥13 years) of an index case, TAMIFLU 75 mg once daily administered within 2 days of onset of symptoms in the index case and continued for 7 days reduced the incidence of laboratory- confirmed clinical influenza from 12% (24/200) in the placebo group to 1% (2/205) for the TAMIFLU group. Index cases did not receive TAMIFLU in the study. The efficacy of TAMIFLU in preventing naturally occurring influenza illness has been demonstrated in a randomized, open-label, postexposure prophylaxis study in households that included children aged 1 to 12 years, both as index cases and as family contacts. All index cases in this study received treatment. The primary efficacy parameter for this study was the incidence of laboratory-confirmed clinical influenza in the household. Laboratory-confirmed clinical influenza was defined as oral temperature ≥100°F/37.8°C plus cough and/or coryza recorded within 48 hours, plus either a positive virus isolation or a fourfold or greater increase in virus antibody titers from baseline or at illness visits. Among household contacts 1 to 12 years of age not already shedding virus at baseline, TAMIFLU for Oral Suspension 30 mg to 60 mg taken once daily for 10 days reduced the incidence of laboratory-confirmed clinical influenza from 17% (18/106) in the group not receiving prophylaxis to 3% (3/95) in the group receiving prophylaxis. CONTRAINDICATIONS
TAMIFLU is contraindicated in patients with known hypersensitivity to any of the PRECAUTIONS
There is no evidence for efficacy of TAMIFLU in any illness caused by agents other than Use of TAMIFLU should not affect the evaluation of individuals for annual influenza vaccination in accordance with guidelines of the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices. Efficacy of TAMIFLU in patients who begin treatment after 40 hours of symptoms has Efficacy of TAMIFLU in the treatment of subjects with chronic cardiac disease and/or respiratory disease has not been established. No difference in the incidence of complications was observed between the treatment and placebo groups in this population. No information is available regarding treatment of influenza in patients with any medical condition sufficiently severe or unstable to be considered at imminent risk of requiring Safety and efficacy of repeated treatment or prophylaxis courses have not been studied. Efficacy of TAMIFLU for treatment or prophylaxis has not been established in Serious bacterial infections may begin with influenza-like symptoms or may coexist with or occur as complications during the course of influenza. TAMIFLU has not been shown Hepatic Impairment
The safety and pharmacokinetics in patients with severe hepatic impairment have not been evaluated (see DOSAGE AND ADMINISTRATION).
Dose adjustment is recommended for patients with a serum creatinine clearance <30 mL/min (see DOSAGE AND ADMINISTRATION).
Serious Skin/Hypersensitivity Reactions
Rare cases of anaphylaxis and serious skin reactions including toxic epidermal necrolysis, Stevens-Johnson Syndrome, and erythema multiforme have been reported in post- marketing experience with TAMIFLU. TAMIFLU should be stopped and appropriate treatment instituted if an allergic-like reaction occurs or is suspected. Neuropsychiatric Events
Influenza can be associated with a variety of neurologic and behavioral symptoms which can include events such as hallucinations, delirium, and abnormal behavior, in some cases resulting in fatal outcomes. These events may occur in the setting of encephalitis or encephalopathy but can occur without obvious severe disease. There have been postmarketing reports (mostly from Japan) of delirium and abnormal behavior leading to injury, and in some cases resulting in fatal outcomes, in patients with influenza who were receiving TAMIFLU. Because these events were reported voluntarily during clinical practice, estimates of frequency cannot be made but they appear to be uncommon based on TAMIFLU usage data. These events were reported primarily among pediatric patients and often had an abrupt onset and rapid resolution. The contribution of TAMIFLU to these events has not been established. Patients with influenza should be closely monitored for signs of abnormal behavior. If neuropsychiatric symptoms occur, the risks and benefits of continuing treatment should be evaluated for each patient. Information for Patients
Patients should be instructed to begin treatment with TAMIFLU as soon as possible from the first appearance of flu symptoms. Similarly, prevention should begin as soon as possible after exposure, at the recommendation of a physician. Patients should be instructed to take any missed doses as soon as they remember, except if it is near the next scheduled dose (within 2 hours), and then continue to take TAMIFLU is not a substitute for a flu vaccination. Patients should continue receiving an annual flu vaccination according to guidelines on immunization practices. A bottle of 13 g TAMIFLU for Oral Suspension contains approximately 11 g sorbitol. One dose of 75 mg TAMIFLU for Oral Suspension delivers 2 g sorbitol. For patients with hereditary fructose intolerance, this is above the daily maximum limit of sorbitol and Drug Interactions
The concurrent use of TAMIFLU with live attenuated influenza vaccine (LAIV) intranasal has not been evaluated. However, because of the potential for interference between these products, LAIV should not be administered within 2 weeks before or 48 hours after administration of TAMIFLU, unless medically indicated. The concern about possible interference arises from the potential for antiviral drugs to inhibit replication of live vaccine virus. Trivalent inactivated influenza vaccine can be administered at any Information derived from pharmacology and pharmacokinetic studies of oseltamivir suggests that clinically significant drug interactions are unlikely. Oseltamivir is extensively converted to oseltamivir carboxylate by esterases, located predominantly in the liver. Drug interactions involving competition for esterases have not been extensively reported in literature. Low protein binding of oseltamivir and oseltamivir carboxylate suggests that the probability of drug displacement interactions is In vitro studies demonstrate that neither oseltamivir nor oseltamivir carboxylate is a good substrate for P450 mixed-function oxidases or for glucuronyl transferases. Clinically important drug interactions involving competition for renal tubular secretion are unlikely due to the known safety margin for most of these drugs, the elimination characteristics of oseltamivir carboxylate (glomerular filtration and anionic tubular secretion) and the excretion capacity of these pathways. Coadministration of probenecid results in an approximate twofold increase in exposure to oseltamivir carboxylate due to a decrease in active anionic tubular secretion in the kidney. However, due to the safety margin of oseltamivir carboxylate, no dose adjustments are required when No pharmacokinetic interactions have been observed when coadministering oseltamivir with amoxicillin, acetaminophen, cimetidine or with antacids (magnesium and aluminum Carcinogenesis, Mutagenesis, and Impairment of Fertility
In 2-year carcinogenicity studies in mice and rats given daily oral doses of the pro-drug oseltamivir phosphate up to 400 mg/kg and 500 mg/kg, respectively, the pro-drug oseltamivir phosphate and the active form oseltamivir carboxylate induced no statistically significant increases in tumors over controls. The mean maximum daily exposures to the prodrug in mice and rats were approximately 130- and 320-fold, respectively, greater than those in humans at the proposed clinical dose based on AUC comparisons. The respective safety margins of the exposures to the active oseltamivir carboxylate were 15- Oseltamivir was found to be non-mutagenic in the Ames test and the human lymphocyte chromosome assay with and without enzymatic activation and negative in the mouse micronucleus test. It was found to be positive in a Syrian Hamster Embryo (SHE) cell transformation test. Oseltamivir carboxylate was non-mutagenic in the Ames test and the L5178Y mouse lymphoma assay with and without enzymatic activation and negative in In a fertility and early embryonic development study in rats, doses of oseltamivir at 50, 250, and 1500 mg/kg/day were administered to females for 2 weeks before mating, during mating and until day 6 of pregnancy. Males were dosed for 4 weeks before mating, during and for 2 weeks after mating. There were no effects on fertility, mating performance or early embryonic development at any dose level. The highest dose was approximately 100 times the human systemic exposure (AUC0-24h) of oseltamivir Pregnancy
There are insufficient human data upon which to base an evaluation of risk of TAMIFLU to the pregnant woman or developing fetus. Studies for effects on embryo-fetal development were conducted in rats (50, 250, and 1500 mg/kg/day) and rabbits (50, 150, and 500 mg/kg/day) by the oral route. Relative exposures at these doses were, respectively, 2, 13, and 100 times human exposure in the rat and 4, 8, and 50 times human exposure in the rabbit. Pharmacokinetic studies indicated that fetal exposure was seen in both species. In the rat study, minimal maternal toxicity was reported in the 1500 mg/kg/day group. In the rabbit study, slight and marked maternal toxicities were observed, respectively, in the 150 and 500 mg/kg/day groups. There was a dose- dependent increase in the incidence rates of a variety of minor skeletal abnormalities and variants in the exposed offspring in these studies. However, the individual incidence rate of each skeletal abnormality or variant remained within the background rates of Because animal reproductive studies may not be predictive of human response and there are no adequate and well-controlled studies in pregnant women, TAMIFLU should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Nursing Mothers
In lactating rats, oseltamivir and oseltamivir carboxylate are excreted in the milk. It is not known whether oseltamivir or oseltamivir carboxylate is excreted in human milk. TAMIFLU should, therefore, be used only if the potential benefit for the lactating mother justifies the potential risk to the breast-fed infant. Geriatric Use
The safety of TAMIFLU has been established in clinical studies which enrolled 741 subjects (374 received placebo and 362 received TAMIFLU). Some seasonal variability was noted in the clinical efficacy outcomes (see INDICATIONS AND USAGE:
Description of Clinical Studies: Studies in Naturally Occurring Influenza:
Treatment of Influenza: Geriatric Patients).
Safety and efficacy have been demonstrated in elderly residents of nursing homes who took TAMIFLU for up to 42 days for the prevention of influenza. Many of these individuals had cardiac and/or respiratory disease, and most had received vaccine that season (see INDICATIONS AND USAGE: Description of Clinical Studies: Studies
in Naturally Occurring Influenza: Prophylaxis of Influenza: Adult Patients).
The safety and efficacy of TAMIFLU in pediatric patients younger than 1 year of age have not been studied. TAMIFLU is not indicated for either treatment or prophylaxis of influenza in pediatric patients younger than 1 year of age because of uncertainties regarding the rate of development of the human blood-brain barrier and the unknown clinical significance of non-clinical animal toxicology data for human infants (see ANIMAL TOXICOLOGY).
In a 2-week study in unweaned rats, administration of a single dose of 1000 mg/kg oseltamivir phosphate to 7-day-old rats resulted in deaths associated with unusually high exposure to the prodrug. However, at 2000 mg/kg, there were no deaths or other significant effects in 14-day-old unweaned rats. Further follow-up investigations of the unexpected deaths of 7-day-old rats at 1000 mg/kg revealed that the concentrations of the prodrug in the brains were approximately 1500-fold those of the brains of adult rats administered the same oral dose of 1000 mg/kg, and those of the active metabolite were approximately 3-fold higher. Plasma levels of the prodrug were 10-fold higher in 7-day- old rats as compared with adult rats. These observations suggest that the levels of oseltamivir in the brains of rats decrease with increasing age and most likely reflect the maturation stage of the blood-brain barrier. No adverse effects occurred at 500 mg/kg/day administered to 7- to 21-day-old rats. At this dosage, the exposure to prodrug was approximately 800-fold the exposure expected in a 1-year-old child. ADVERSE REACTIONS
Treatment Studies in Adult Patients
A total of 1171 patients who participated in adult phase III controlled clinical trials for the treatment of influenza were treated with TAMIFLU. The most frequently reported adverse events in these studies were nausea and vomiting. These events were generally of mild to moderate degree and usually occurred on the first 2 days of administration. Less than 1% of subjects discontinued prematurely from clinical trials due to nausea and Adverse events that occurred with an incidence of ≥1% in 1440 patients taking placebo or TAMIFLU 75 mg twice daily in adult phase III treatment studies are shown in Table 3.
This summary includes 945 healthy young adults and 495 “at risk” patients (elderly patients and patients with chronic cardiac or respiratory disease). Those events reported numerically more frequently in patients taking TAMIFLU compared with placebo were nausea, vomiting, bronchitis, insomnia, and vertigo. Prophylaxis Studies in Adult Patients
A total of 4187 subjects (adolescents, healthy adults and elderly) participated in phase III prophylaxis studies, of whom 1790 received the recommended dose of 75 mg once daily for up to 6 weeks. Adverse events were qualitatively very similar to those seen in the treatment studies, despite a longer duration of dosing (see Table 3). Events reported more
frequently in subjects receiving TAMIFLU compared to subjects receiving placebo in prophylaxis studies, and more commonly than in treatment studies, were aches and pains, rhinorrhea, dyspepsia and upper respiratory tract infections. However, the difference in incidence between TAMIFLU and placebo for these events was less than 1%. There were no clinically relevant differences in the safety profile of the 942 elderly subjects who received TAMIFLU or placebo, compared with the younger population. Most Frequent Adverse Events in Studies in Naturally
Acquired Influenza in Patients 13 Years of Age and Older
The majority of subjects received placebo; 254 subjects from a randomized, open-label post exposure prophylaxis study in households did not receive placebo or prophylaxis therapy. Adverse events included are: all events reported in the treatment studies with frequency ≥1% in the oseltamivir 75 mg bid group. Additional adverse events occurring in <1% of patients receiving TAMIFLU for treatment included unstable angina, anemia, pseudomembranous colitis, humerus fracture, pneumonia, pyrexia, and peritonsillar abscess. Treatment Studies in Pediatric Patients
A total of 1032 pediatric patients aged 1 to 12 years (including 698 otherwise healthy pediatric patients aged 1 to 12 years and 334 asthmatic pediatric patients aged 6 to 12 years) participated in phase III studies of TAMIFLU given for the treatment of influenza. A total of 515 pediatric patients received treatment with TAMIFLU for Oral Suspension. Adverse events occurring in ≥1% of pediatric patients receiving TAMIFLU treatment are listed in Table 4. The most frequently reported adverse event was vomiting. Other events
reported more frequently by pediatric patients treated with TAMIFLU included abdominal pain, epistaxis, ear disorder, and conjunctivitis. These events generally occurred once and resolved despite continued dosing. They did not cause discontinuation The adverse event profile in adolescents is similar to that described for adult patients and Prophylaxis in Pediatric Patients
Pediatric patients aged 1 to 12 years participated in a postexposure prophylaxis study in households, both as index cases (134) and as contacts (222). Gastrointestinal events were the most frequent, particularly vomiting. The adverse events noted were consistent with those previously observed in pediatric treatment studies (see Table 4).
Most Frequent Adverse Events Occurring in Children Aged
1 to 12 Years in Studies in Naturally Acquired Influenza
Household Prophylaxis Trialb
2 mg/kg bid
Pooled data from Phase III trials of TAMIFLU treatment of naturally acquired influenza. A randomized, open-label study of household transmission in which household contacts received either prophylaxis or no prophylaxis but treatment if they became ill. Only contacts who received prophylaxis or who remained on no prophylaxis are included in this table. Adverse events included in Table 4 are: all events reported in the treatment studies with frequency ≥1% in the oseltamivir 75 mg bid group. Observed During Clinical Practice
The following adverse reactions have been identified during postmarketing use of TAMIFLU. Because these reactions are reported voluntarily from a population of uncertain size, it is not possible to reliably estimate their frequency or establish a causal Body as a Whole: Swelling of the face or tongue, allergy, anaphylactic/anaphylactoid Dermatologic: Dermatitis, rash, eczema, urticaria, erythema multiforme, Stevens-Johnson Syndrome, toxic epidermal necrolysis (see PRECAUTIONS)
Digestive: Hepatitis, liver function tests abnormal Gastrointestinal disorders: Gastrointestinal bleeding, hemorrhagic colitis Psychiatric: Delirium, including symptoms such as altered level of consciousness, confusion, abnormal behavior, delusions, hallucinations, agitation, anxiety, nightmares (see PRECAUTIONS)
At present, there has been no experience with overdose. Single doses of up to 1000 mg of TAMIFLU have been associated with nausea and/or vomiting. DOSAGE AND ADMINISTRATION
TAMIFLU may be taken with or without food (see CLINICAL PHARMACOLOGY:
Pharmacokinetics). However, when taken with food, tolerability may be enhanced in
Standard Dosage – Treatment of Influenza
The recommended oral dose of TAMIFLU for treatment of influenza in adults and adolescents 13 years and older is 75 mg twice daily for 5 days. Treatment should begin within 2 days of onset of symptoms of influenza. TAMIFLU is not indicated for treatment of influenza in pediatric patients younger than The recommended oral dose of TAMIFLU for pediatric patients 1 year and older is shown in Table 5. TAMIFLU for Oral Suspension may also be used by patients who
cannot swallow a capsule. For pediatric patients who cannot swallow capsules, TAMIFLU for Oral Suspension is the preferred formulation. If the for Oral Suspension product is not available, TAMIFLU Capsules may be opened and mixed with sweetened liquids such as regular or sugar-free chocolate syrup. Oral Dose of TAMIFLU for Treatment of Influenza in Pediatric
Patients by Weight
Body Weight Body Weight Recommended Dose Number of Bottles of Number of TAMIFLU
for 5 Days
TAMIFLU for Oral
Capsules Needed to
to Obtain the
for a 5 Day Regimen
for a 5 Day Regimen
An oral dosing dispenser with 30 mg, 45 mg, and 60 mg graduations is provided with the oral suspension; the 75 mg dose can be measured using a combination of 30 mg and 45 mg. It is recommended that patients use this dispenser. In the event that the dispenser provided is lost or damaged, another dosing syringe or other device may be used to deliver the following volumes: 2.5 mL (1/2 tsp) for children ≤15 kg, 3.8 mL (3/4 tsp) for >15 to 23 kg, 5.0 mL (1 tsp) for >23 to 40 kg, and 6.2 mL (1 1/4 tsp) for >40 kg. Standard Dosage – Prophylaxis of Influenza
The recommended oral dose of TAMIFLU for prophylaxis of influenza in adults and adolescents 13 years and older following close contact with an infected individual is 75 mg once daily for at least 10 days. Therapy should begin within 2 days of exposure. The recommended dose for prophylaxis during a community outbreak of influenza is 75 mg once daily. Safety and efficacy have been demonstrated for up to 6 weeks. The duration of protection lasts for as long as dosing is continued. The safety and efficacy of TAMIFLU for prophylaxis of influenza in pediatric patients younger than 1 year of age have not been established. The recommended oral dose of TAMIFLU for pediatric patients 1 year and older following close contact with an infected individual is shown in Table 6. TAMIFLU for
Oral Suspension may also be used by patients who cannot swallow a capsule. For pediatric patients who cannot swallow capsules, TAMIFLU for Oral Suspension is the preferred formulation. If the for Oral Suspension product is not available, TAMIFLU Capsules may be opened and mixed with sweetened liquids such as regular or sugar-free Oral Dose of TAMIFLU for Prophylaxis of Influenza in
Pediatric Patients by Weight
Number of Bottles of
Number of TAMIFLU
TAMIFLU for Oral
Capsules Needed to
Suspension Needed to
for a 10 Day Regimen
for a 10 Day Regimen
An oral dosing dispenser with 30 mg, 45 mg, and 60 mg graduations is provided with the oral suspension; the 75 mg dose can be measured using a combination of 30 mg and 45 mg. It is recommended that patients use this dispenser. In the event that the dispenser provided is lost or damaged, another dosing syringe or other device may be used to deliver the following volumes: 2.5 mL (1/2 tsp) for children ≤15 kg, 3.8 mL (3/4 tsp) for >15 to 23 kg, 5.0 mL (1 tsp) for >23 to 40 kg, and 6.2 mL (1 1/4 tsp) for >40 kg. Prophylaxis in pediatric patients following close contact with an infected individual is recommended for 10 days. Prophylaxis in patients 1 to 12 years of age has not been evaluated for longer than 10 days duration. Therapy should begin within 2 days of Special Dosage Instructions
No dose adjustment is recommended for patients with mild or moderate hepatic impairment (Child-Pugh score ≤9) (see CLINICAL PHARMACOLOGY:
Pharmacokinetics: Special Populations).
For plasma concentrations of oseltamivir carboxylate predicted to occur following various dosing schedules in patients with renal impairment, see CLINICAL
PHARMACOLOGY: Pharmacokinetics: Special Populations.
Dose adjustment is recommended for patients with creatinine clearance between 10 and 30 mL/min receiving TAMIFLU for the treatment of influenza. In these patients it is recommended that the dose be reduced to 75 mg of TAMIFLU once daily for 5 days. No recommended dosing regimens are available for patients undergoing routine hemodialysis and continuous peritoneal dialysis treatment with end-stage renal disease. For the prophylaxis of influenza, dose adjustment is recommended for patients with creatinine clearance between 10 and 30 mL/min receiving TAMIFLU. In these patients it is recommended that the dose be reduced to 75 mg of TAMIFLU every other day or 30 mg TAMIFLU every day. No recommended dosing regimens are available for patients undergoing routine hemodialysis and continuous peritoneal dialysis treatment with end- No dose adjustment is required for geriatric patients (see CLINICAL
PHARMACOLOGY: Pharmacokinetics: Special Populations and PRECAUTIONS).
Preparation of TAMIFLU for Oral Suspension
It is recommended that TAMIFLU for Oral Suspension be constituted by the pharmacist 1. Tap the closed bottle several times to loosen the powder. 2. Measure 23 mL of water in a graduated cylinder.
3. Add the total amount of water for constitution to the bottle and shake the closed bottle 4. Remove the child-resistant cap and push bottle adapter into the neck of the bottle. 5. Close bottle with child-resistant cap tightly. This will assure the proper seating of the bottle adapter in the bottle and child-resistant status of the cap. NOTE: SHAKE THE TAMIFLU FOR ORAL SUSPENSION WELL BEFORE EACH The constituted TAMIFLU for Oral Suspension (12 mg/mL) should be used within 10 days of preparation; the pharmacist should write the date of expiration of the constituted suspension on a pharmacy label. The patient package insert and oral dispenser should be Emergency Compounding of an Oral Suspension from TAMIFLU Capsules
(Final Concentration 15 mg/mL)
The following directions are provided for use only during emergency situations. These directions are not intended to be used if the FDA-approved, commercially manufactured TAMIFLU for Oral Suspension is readily available from wholesalers or the Compounding an oral suspension with this procedure will provide one patient with enough medication for a 5-day course of treatment or a 10-day course of prophylaxis. Commercially manufactured TAMIFLU for Oral Suspension (12 mg/mL) is the preferred product for pediatric and adult patients who have difficulty swallowing capsules or where lower doses are needed. In the event that TAMIFLU for Oral Suspension is not available, the pharmacist may compound a suspension (15 mg/mL) from TAMIFLU (oseltamivir phosphate) Capsules 75 mg using either of two vehicles: Cherry Syrup (Humco®) or Ora-Sweet SF (sugar-free) (Paddock Laboratories). Other vehicles have not been studied. This compounded suspension should not be used for convenience or when
the FDA-approved TAMIFLU for Oral Suspension is commercially available.
First, calculate the Total Volume of an oral suspension needed to be compounded and dispensed for each patient. The Total Volume required is determined by the weight of each patient. Refer to Table 7.
Volume of an Oral Suspension (15 mg/mL) Needed to be
Compounded Based Upon the Patient’s Weight
Body Weight (kg) Body Weight (lbs)
Total Volume to Compound
per patient (mL)
Second, determine the number of capsules and the amount of vehicle (Cherry Syrup or Ora-Sweet SF) that are needed to prepare the Total Volume (calculated from Table 7: 30 mL, 40 mL, 50 mL, or 60 mL) of compounded oral suspension (15 mg/mL). Refer to Number of TAMIFLU 75 mg Capsules and Amount of Vehicle
(Cherry Syrup OR Ora-Sweet SF) Needed to Prepare the
Total Volume of a Compounded Oral Suspension (15 mg/mL)
Total Volume of
Suspension needed to be
Required number of
TAMIFLU 75 mg
Required volume of
Cherry Syrup (Humco) OR
Third, follow the procedure below for compounding the oral suspension (15 mg/mL) 1. Carefully separate the capsule body and cap and transfer the contents of the required number of TAMIFLU 75 mg Capsules into a clean mortar. 2. Triturate the granules to a fine powder. 3. Add one-third (1/3) of the specified amount of vehicle and triturate the powder until a 4. Transfer the suspension to an amber glass or amber polyethyleneterephthalate (PET) bottle. A funnel may be used to eliminate any spillage. 5. Add another one-third (1/3) of the vehicle to the mortar, rinse the pestle and mortar by a triturating motion and transfer the vehicle into the bottle. 6. Repeat the rinsing (Step 5) with the remainder of the vehicle. 7. Close the bottle using a child-resistant cap. 8. Shake well to completely dissolve the active drug and to ensure homogeneous distribution of the dissolved drug in the resulting suspension. (Note: The active drug, oseltamivir phosphate, readily dissolves in the specified vehicles. The suspension is caused by some of the inert ingredients of TAMIFLU Capsules which are insoluble in 9. Put an ancillary label on the bottle indicating “Shake Gently Before Use”. [This compounded suspension should be gently shaken prior to administration to minimize the tendency for air entrapment, particularly with the Ora-Sweet SF preparation.] 10. Instruct the parent or guardian that any remaining material following completion of therapy must be discarded by either affixing an ancillary label to the bottle or adding a statement to the pharmacy label instructions. 11. Place an appropriate expiration date label according to storage condition (see below). STORAGE OF THE PHARMACY-COMPOUNDED SUSPENSION: Refrigeration: Stable for 5 weeks (35 days) when stored in a refrigerator at 2° to 8°C
Room Temperature: Stable for five days (5 days) when stored at room temperature,
Note: The storage conditions are based on stability studies of compounded oral suspensions, using the above mentioned vehicles, which were placed in amber glass and amber polyethyleneterephthalate (PET) bottles. Stability studies have not been conducted Place a pharmacy label on the bottle that includes the patient’s name, dosing instructions, and drug name and any other required information to be in compliance with all State and Federal Pharmacy Regulations. Refer to Table 9 for the proper dosing instructions.
Note: This compounding procedure results in a 15 mg/mL suspension, which is
different from the commercially available TAMIFLU for Oral Suspension, which
has a concentration of 12 mg/mL.
Dosing Chart for Pharmacy-Compounded Suspension from
TAMIFLU Capsules 75 mg
Dose (for 5
Consider dispensing the suspension with a graduated oral syringe for measuring small
amounts of suspension. If possible, mark or highlight the graduation corresponding to
the appropriate dose (2 mL, 3 mL, 4 mL, or 5 mL) on the oral syringe for each patient.
The dosing device dispensed with the commercially available TAMIFLU for Oral
Suspension should NOT be used with the compounded suspension since they have
30-mg capsules (30 mg free base equivalent of the phosphate salt): light yellow hard gelatin capsules. "ROCHE" is printed in blue ink on the light yellow body and "30 mg" is printed in blue ink on the light yellow cap. Available in blister packages of 10 (NDC 45-mg capsules (45 mg free base equivalent of the phosphate salt): grey hard gelatin capsules. "ROCHE" is printed in blue ink on the grey body and "45 mg" is printed in blue ink on the grey cap. Available in blister packages of 10 (NDC 0004-0801-85). 75-mg capsules (75 mg free base equivalent of the phosphate salt): grey/light yellow hard gelatin capsules. "ROCHE" is printed in blue ink on the grey body and "75 mg" is printed in blue ink on the light yellow cap. Available in blister packages of 10 (NDC 0004-0800- Store the capsules at 25ºC (77ºF); excursions permitted to 15º to 30ºC (59º to 86ºF). [See TAMIFLU for Oral Suspension
Supplied as a white powder blend for constitution to a white tutti-frutti–flavored suspension. Available in glass bottles containing approximately 33 mL of suspension after constitution. Each bottle delivers 25 mL of suspension equivalent to 300 mg oseltamivir base. Each bottle is supplied with a bottle adapter and 1 oral dispenser (NDC Store dry powder at 25ºC (77ºF); excursions permitted to 15º to 30ºC (59º to 86ºF). [See Store constituted suspension under refrigeration at 2º to 8ºC (36º to 46ºF). Do not freeze. Humco® is a registered trademark of Humco Holding Group, Inc. Ora-Sweet® SF is a registered trademark of Paddock Laboratories Copyright 1999-2008 by Roche Laboratories Inc. All rights reserved.
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