Warnings for Acticlate
Included as part of the PRECAUTIONS section.
Precautions for Acticlate
Tooth Development
The use of ACTICLATE or ACTICLATE CAP during tooth development (last half of pregnancy, infancy and childhood to the age of 8 years) may cause permanent discoloration of the teeth (yellow-gray-brown). This adverse reaction is more common during long-term use of the drugs of the tetracycline class, but it has been observed following repeated short-term courses. Enamel hypoplasia has also been reported with drugs of the tetracycline class. Advise the patient of the potential risk to the fetus if ACTICLATE or ACTICLATE CAP is used during pregnancy [see Use In Specific Populations].
Use ACTICLATE or ACTICLATE CAP in pediatric patients 8 years of age or less only when the potential benefits are expected to outweigh the risks in severe or life-threatening conditions (e.g., anthrax, Rocky Mountain spotted fever), particularly when there are no alternative therapies.
Inhibition Of Bone Growth
The use of ACTICLATE or ACTICLATE CAP during the second and third trimester of pregnancy, infancy and childhood up to the age of 8 years may cause reversible inhibition of bone growth. All tetracyclines form a stable calcium complex in any bone-forming tissue. A decrease in fibula growth rate has been observed in premature infants given oral tetracycline in doses of 25 mg/kg every 6 hours. This reaction was shown to be reversible when the drug was discontinued. Advise the patient of the potential risk to the fetus if ACTICLATE or ACTICLATE CAP is used during pregnancy [see Use In Specific Populations].
Clostridioides Difficile Associated Diarrhea
Clostridioides difficile associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, including ACTICLATE or ACTICLATE CAP, and may range in severity from mild diarrhea to fatal colitis. Treatment with antibacterial agents alters the normal flora of the colon leading to overgrowth of C. difficile.
C. difficile produces toxins A and B which contribute to the development of CDAD. Hypertoxin producing strains of C. difficile cause increased morbidity and mortality, as these infections can be refractory to antibacterial therapy and may require colectomy. CDAD must be considered in all patients who present with diarrhea following antibacterial use. Careful medical history is necessary since CDAD has been reported to occur over two months after the administration of antibacterial agents.
If CDAD is suspected or confirmed, ongoing antibacterial use not directed against C. difficile may need to be discontinued. Appropriate fluid and electrolyte management, protein supplementation, antibacterial treatment of C. difficile, and surgical evaluation should be instituted as clinically indicated.
Photosensitivity
Photosensitivity manifested by an exaggerated sunburn reaction has been observed in some individuals taking tetracyclines. Patients apt to be exposed to direct sunlight or ultraviolet light should be advised that this reaction can occur with tetracycline drugs, and treatment should be discontinued at the first evidence of skin erythema.
Severe Skin Reactions
Severe skin reactions, such as exfoliative dermatitis, erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, and drug reaction with eosinophilia and systemic symptoms (DRESS) have been reported in patients receiving doxycycline. Fixed drug eruptions have occurred with doxycycline and have been associated with worsening severity upon subsequent administrations, including generalized bullous fixed drug eruption [see ADVERSE REACTIONS]. If severe skin reactions occur, discontinue ACTICLATE or ACTICLATE CAP immediately and institute appropriate therapy.
Intracranial Hypertension
Intracranial hypertension (IH, pseudotumor cerebri) has been associated with the use of tetracyclines including ACTICLATE or ACTICLATE CAP. Clinical manifestations of IH include headache, blurred vision, diplopia, and vision loss; papilledema can be found on fundoscopy. Women of childbearing age who are overweight or have a history of IH are at greater risk for developing tetracycline associated IH. Concomitant use of isotretinoin and ACTICLATE or ACTICLATE CAP should be avoided because isotretinoin is also known to cause pseudotumor cerebri.
Although IH typically resolves after discontinuation of treatment, the possibility for permanent visual loss exists. If visual disturbance occurs during treatment, prompt ophthalmologic evaluation is warranted. Since intracranial pressure can remain elevated for weeks after drug cessation patients should be monitored until they stabilize.
Antianabolic Action
The antianabolic action of the tetracyclines may cause an increase in BUN. Studies to date indicate that this does not occur with the use of doxycycline in patients with impaired renal function.
Incomplete Suppression Of Malaria
Doxycycline offers substantial but not complete suppression of the asexual blood stages of Plasmodium strains.
Doxycycline does not suppress P. falciparum's sexual blood stage gametocytes. Subjects completing this prophylactic regimen may still transmit the infection to mosquitoes outside endemic areas.
Development Of Drug-Resistant Bacteria
Prescribing ACTICLATE and ACTICLATE CAP in the absence of a proven or strongly suspected bacterial infection or a prophylactic indication is unlikely to provide benefit to the patient and increases the risk of the development of drug-resistant bacteria.
Potential For Microbial Overgrowth
ACTICLATE and ACTICLATE CAP may result in overgrowth of non-susceptible organisms, including fungi. If such infections occur, discontinue use and institute appropriate therapy.
Laboratory Monitoring For Long-Term Therapy
In long-term therapy, periodic laboratory evaluation of organ systems, including hematopoietic, renal and hepatic studies should be performed.
Patient Counseling Information
Advise the patient to read the FDA-approved patient labeling (Instructions for Use).
Important Administration And Safety Information For Patients And Caregivers
Advise patients taking ACTICLATE and ACTICLATE CAP for malaria prophylaxis:
- that no present-day antimalarial agent, including doxycycline, guarantees protection against malaria.
- to avoid being bitten by mosquitoes by using personal protective measures that help avoid contact with mosquitoes, especially from dusk to dawn (for example, staying in well-screened areas, using mosquito nets, covering the body with clothing, and using an effective insect repellent).
- that doxycycline prophylaxis:
- should begin 1 day to 2 days before travel to the malarious area,
- should be continued daily while in the malarious area and after leaving the malarious area,
- should be continued for 4 further weeks to avoid development of malaria after returning from an endemic area,
- should not exceed 4 months.
Advise all patients taking ACTICLATE and ACTICLATE CAP:
- that ACTICLATE Tablets (150 mg) can be broken into two-thirds or one-third at the scored lines to provide 100 mg or 50 mg strength doses, respectively.
- that they must swallow ACTICLATE CAP whole. They must not break, open, crush, dissolve or chew the capsule [see DOSAGE AND ADMINISTRATION].
- to avoid excessive sunlight or artificial ultraviolet light while receiving doxycycline and to discontinue therapy if phototoxicity (for example, skin eruptions, etc.) occurs. Sunscreen or sunblock should be considered [see WARNINGS AND PRECAUTIONS].
- to drink fluids liberally along with ACTICLATE and ACTICLATE CAP to reduce the risk of esophageal irritation and ulceration [see ADVERSE REACTIONS].
- that the absorption of tetracyclines is reduced when taken with foods, especially those that contain calcium [see DRUG INTERACTIONS]. However, the absorption of doxycycline is not markedly influenced by simultaneous ingestion of food or milk [see CLINICAL PHARMACOLOGY].
- that if gastric irritation occurs, ACTICLATE and ACTICLATE CAP may be given with food or milk [see CLINICAL PHARMACOLOGY].
- that the absorption of tetracyclines is reduced when taken with antacids containing aluminum, calcium or magnesium, bismuth subsalicylate, and iron-containing preparations [see DRUG INTERACTIONS].
- that the use of doxycycline might increase the incidence of vaginal candidiasis.
Tooth Discoloration And Inhibition Of Bone Growth
Advise patients that ACTICLATE and ACTICLATE CAP, like other tetracycline-class drugs, may cause permanent tooth discoloration of deciduous teeth and reversible inhibition of bone growth when administered during pregnancy. Tell your healthcare provider right away if you become pregnant during treatment [see WARNINGS AND PRECAUTIONS and Use In Specific Populations].
Lactation
Advise women not to breastfeed during treatment with ACTICLATE or ACTICLATE CAP and for 5 days after the last dose [see Use In Specific Populations].
Diarrhea
Advise patients that diarrhea is a common problem caused by antibacterial drugs which usually ends when the antibacterial is discontinued. Sometimes after starting treatment with antibacterial drugs, patients can develop watery and bloody stools (with or without stomach cramps and fever) even as late as two or more months after having taken the last dose of antibacterial. If this occurs, patients should contact their physician as soon as possible.
Development Of Resistance
Counsel patients that antibacterial drugs including ACTICLATE and ACTICLATE CAP should only be used to treat bacterial infections. They do not treat viral infections (for example, the common cold). When ACTICLATE and ACTICLATE CAP are prescribed to treat a bacterial infection, patients should be told that although it is common to feel better early in the course of therapy, the medication should be taken exactly as directed. Skipping doses or not completing the full course of therapy may (1) decrease the effectiveness of the immediate treatment and (2) increase the likelihood that bacteria will develop resistance and will not be treatable by ACTICLATE and ACTICLATE CAP or other antibacterial drugs in the future.
Nonclinical Toxicology
Carcinogenesis, Mutagenesis, Impairment Of Fertility
Long-term studies in animals to evaluate carcinogenic potential of ACTICLATE (doxycycline hyclate) and ACTICLATE CAP (doxycycline hyclate) have not been conducted.
However, a 2 year carcinogenicity study with doxycycline administered daily by oral gavage to adult rats (20, 75, 200 mg/kg/day) demonstrated an increase in uterine polyps in female rats at 200 mg/kg/day (10 times the maximum recommended daily adult dose of ACTICLATE and ACTICLATE CAP based on body surface area comparison) with no change in tumor incidence in male rats at the same dose. A 2-year carcinogenicity study with doxycycline administered daily by oral gavage to adult male (maximum dose 150 mg/kg/day) and female (maximum dose 300 mg/kg/day) mice showed no changes in tumor incidence, at approximately 4 and 7 times the maximum recommended daily adult dose of ACTICLATE and ACTICLATE CAP, based on a body surface area comparison, respectively.
Mutagenesis and fertility studies have not been conducted with ACTICLATE and ACTICLATE CAP. Mutagenesis studies with doxycycline demonstrated no potential to cause genetic toxicity in an in vitro point mutation study with mammalian cells or in an in vivo micronucleus assay in CD-1 mice. However, data from an in vitro mammalian chromosomal aberration assay conducted in CHO cells suggest that doxycycline is a weak clastogen. Oral administration of doxycycline to Sprague-Dawley rats showed adverse effects on fertility and reproduction including increased time for mating, reduced sperm motility, velocity and concentration as well as increased pre and post implantation loss. Reduced sperm velocity was seen at the lowest dosage tested, 50 mg/kg/day which is 2.5 times the maximum recommended daily adult dose of ACTICLATE and ACTICLATE CAP. Although doxycycline impairs the fertility of rats when administered at sufficient dosages, the effect of ACTICLATE and ACTICLATE CAP on human fertility is unknown.
Use In Specific Populations
Pregnancy
Risk Summary
ACTICLATE and ACTICLATE CAP, like other tetracycline-class antibacterial drugs, may cause discoloration deciduous teeth, and reversible inhibition of bone growth when administered during the second and third trimester of pregnancy [see WARNINGS AND PRECAUTIONS]. Available data from published studies over decades have not shown a difference in major birth defect risk compared to unexposed pregnancies with doxycycline exposure in the first trimester of pregnancy (see Data). There are no available data on the risk of miscarriage following exposure to doxycycline in pregnancy. Advise the patient of the potential risk to the fetus if ACTICLATE or ACTICLATE CAP is used during pregnancy.
The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.
Data
Human Data
A retrospective cohort study of 1,690 pregnant patients who received doxycycline prescriptions in the first trimester of pregnancy compared to an unexposed pregnant cohort showed no difference in the major malformation rate. There is no information on the dose or duration of treatment, or if the patients actually ingested the doxycycline that was prescribed.
Other published studies on exposure to doxycycline in the first trimester of pregnancy have small sample sizes; however, these studies have not shown an increased risk of major malformations.
The use of tetracyclines during tooth development (second and third trimester of pregnancy) may cause permanent discoloration of the teeth (yellow-gray-brown). This adverse reaction is more common during long-term use of the drug but has been observed following repeated short-term courses. [see WARNINGS AND PRECAUTIONS].
Animal Data
Results of animal studies indicate that tetracyclines cross the placenta, are found in fetal tissues, and can have toxic effects on the developing fetus (often related to retardation of skeletal development). Evidence of embryotoxicity also has been noted in animals treated early in pregnancy.
Lactation
Risk Summary
Based on available published data, doxycycline is present in human milk. There are no data that inform the levels of doxycycline in breastmilk, the effects on the breastfed infant, or the effects on milk production. Because of the potential for serious adverse reactions, including tooth discoloration and inhibition of bone growth, advise patients that breastfeeding is not recommended during treatment with ACTICLATE or ACTICLATE CAP and for 5 days after the last dose.
Females And Males Of Reproductive Potential
Infertility
Based on findings from a fertility study in animals, doxycycline may impair female and male fertility. The reversibility of this finding is unclear. [see Nonclinical Toxicology].
Pediatric Use
Because of the effects of drugs of the tetracycline-class on tooth development and growth, use ACTICLATE or ACTICLATE CAP in pediatric patients 8 years of age or less only when the potential benefits are expected to outweigh the risks in severe or life-threatening conditions (e.g., anthrax, Rocky Mountain spotted fever), particularly when there are no alternative therapies [see WARNINGS AND PRECAUTIONS and DOSAGE AND ADMINISTRATION].
Geriatric Use
Clinical studies of doxycycline hyclate tablets did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. ACTICLATE Tablets each contains less than 1 mg of sodium.