WARNINGS
Included as part of the PRECAUTIONS section.
PRECAUTIONS
Flammability
The propellant in AMZEEQ is flammable. Instruct the
patient to avoid fire, flame, and smoking during and immediately following
application. Do not puncture and/or incinerate the containers. Do not expose
containers to heat and/or store at temperatures above 120°F (49°C).
Teratogenic Effects
Minocycline, like other tetracycline-class drugs, may
inhibit bone growth when administered orally during pregnancy. Based on animal
data, when administered orally, tetracyclines cross the placenta, are found in
fetal tissues, and can cause skeletal malformation and retardation of skeletal
development on the developing fetus [see Use In Specific Populations and
Nonclinical Toxicology].
Tooth Discoloration
The use of tetracycline class drugs orally during tooth
development (second and third trimesters of pregnancy, infancy, and childhood
up 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 oral
use of the tetracycline but has been observed following repeated short-term
courses. Enamel hypoplasia has also been reported with oral tetracycline drugs.
Use of tetracycline drugs is not recommended during tooth development.
The safety and effectiveness of AMZEEQ have not been
established in pediatric patients less than 9 years of age.
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 human 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.
The safety and effectiveness of AMZEEQ have not been established in patients
less than 9 years of age [see Use In Specific Populations].
Results of animal studies indicate that oral
tetracyclines cross the placenta, are found in fetal tissues, and can cause
retardation of skeletal development on the developing fetus. Evidence of
embryotoxicity has been noted in animals treated orally early in pregnancy [see
Use In Specific Populations].
Clostridium Difficile Associated Diarrhea
Clostridium difficile associated diarrhea (CDAD)
has been reported with nearly all antibacterial agents, including oral
minocycline, 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 antimicrobial therapy and may require colectomy. CDAD must be
considered in all patients who present with diarrhea following antibiotic 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, antibiotic use not
directed against C. difficile may need to be discontinued. Appropriate
fluid and electrolyte management, protein supplementation, antibiotic treatment
of C. difficile, and surgical evaluation should be instituted as
clinically indicated.
Hepatotoxicity
Post-marketing cases of serious liver injury, including
irreversible drug-induced hepatitis and fulminant hepatic failure (sometimes
fatal) have been reported with oral minocycline use in the treatment of acne.
Metabolic Effects
The anti-anabolic action of the tetracyclines may cause
an increase in blood urea nitrogen (BUN). In patients with significantly
impaired function, higher serum levels of tetracycline-class drugs may lead to
azotemia, hyperphosphatemia, and acidosis. If renal impairment exists,
recommended oral or parenteral doses may lead to excessive systemic
accumulations of the drug and possible liver toxicity. Under such conditions,
adjust the dose downward, and if therapy is prolonged, serum level
determinations of the drug may be advisable.
Central Nervous System Effects
Central nervous system side effects including
light-headedness, dizziness or vertigo have been reported with oral minocycline
therapy. Patients who experience these symptoms should be cautioned about
driving vehicles or using hazardous machinery while on minocycline therapy.
These symptoms may disappear during therapy and may disappear when the drug is
discontinued.
Intracranial Hypertension
Intracranial hypertension has been associated with the
use of tetracycline-class drugs. Clinical manifestations of intracranial
hypertension 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 a greater risk for developing
intracranial hypertension. Patients should be questioned for visual
disturbances prior to initiation of treatment with tetracyclines. Concomitant
use of isotretinoin and tetracycline should be avoided because isotretinoin, a
systemic retinoid, is also known to cause intracranial hypertension.
Although intracranial hypertension typically resolves
after discontinuation of treatment, the possibility for permanent visual loss
exists. If visual disturbance occurs during treatment, prompt ophthalmologic
evaluation is warranted. Because intracranial pressure can remain elevated for
weeks after drug cessation, patients should be monitored until they stabilize.
Autoimmune Syndromes
Tetracyclines have been associated with the development
of autoimmune syndromes. The longterm use of oral minocycline in the treatment
of acne has been associated with drug-induced lupus-like syndrome, autoimmune
hepatitis and vasculitis. Sporadic cases of serum sickness have presented
shortly after oral minocycline use. Symptoms may be manifested by fever, rash,
arthralgia, and malaise. In symptomatic patients, immediately discontinue the
use of all tetracycline-class drugs, including AMZEEQ.
Photosensitivity
Photosensitivity manifested by an exaggerated sunburn
reaction has been observed in some individuals taking oral tetracyclines; this
reaction has been reported less frequently with minocycline. Although AMZEEQ
did not induce phototoxicity or photoallergic responses in human dermal safety
studies, patients should minimize or avoid exposure to natural or artificial
sunlight (tanning beds or UVA/B treatment) while using minocycline. If patients
need to be outdoors while using AMZEEQ, they should wear loose-fitting clothes
that protect skin from sun exposure and discuss other sun protection measures
with their physician. Advise patients to discontinue treatment with AMZEEQ at
the first evidence of sunburn.
Serious Skin/Hypersensitivity Reaction
Cases of anaphylaxis, serious skin reactions (e.g.
Stevens Johnson syndrome), erythema multiforme, and drug reaction with
eosinophilia and systemic symptoms (DRESS) syndrome have been reported
postmarketing with oral minocycline use in patients with acne. DRESS syndrome
consists of cutaneous reaction (such as rash or exfoliative dermatitis),
eosinophilia, and one or more of the following visceral complications such as:
hepatitis, pneumonitis, nephritis, myocarditis, and pericarditis. Fever and
lymphadenopathy may be present. In some cases, death has been reported with
oral minocycline use. If this syndrome is recognized, discontinue AMZEEQ
immediately.
Tissue Hyperpigmentation
Oral tetracyclines are known to cause hyperpigmentation.
Tetracycline therapy may induce hyperpigmentation in many organs, including
nails, bone, skin, eyes, thyroid, visceral tissue, oral cavity (teeth, mucosa,
alveolar bone), sclerae and heart valves. Skin and oral pigmentation has been
reported to occur independently of time or amount of drug administration,
whereas other tissue pigmentation has been reported to occur upon prolonged
administration. Skin pigmentation includes diffuse pigmentation as well as
pigmentation over sites of scars or injury.
Development Of Drug-Resistant Bacteria
AMZEEQ has not been evaluated in the treatment of
infections. Bacterial resistance to the tetracyclines may develop in patients
using AMZEEQ, therefore, the susceptibility of bacteria associated with
infection should be considered in selecting antimicrobial therapy. Because of
the potential for drug-resistant bacteria to develop during the use of AMZEEQ,
it should be used only as indicated.
Superinfection/Potential For Microbial Overgrowth
Use of AMZEEQ may result in overgrowth of non-susceptible
organisms, including fungi. If superinfection occurs, discontinue AMZEEQ and
institute appropriate therapy.
Patient Counseling Information
Advise the patient to read the FDA-approved patient
labeling (PATIENT INFORMATION and Instructions for Use).
Inform patients using AMZEEQ (minocycline) topical foam,
4% of the following information and instructions:
Flammability
The propellant in AMZEEQ is flammable. Instruct the
patient to avoid fire, flame, and smoking during and immediately following
application.
Tooth Discoloration
Advise caregivers of pediatric patients that AMZEEQ may
cause permanent discoloration of deciduous and permanent teeth during tooth
development (generally up to the age of 8 years) based on observations with
oral tetracycline.
Lactation
Advise women that breastfeeding is not recommended during
AMZEEQ therapy.
Tissue Hyperpigmentation
Inform patients that AMZEEQ may cause discoloration of
skin, scars, teeth or gums based on observations with oral minocycline.
Clostridium Difficile Associated Diarrhea
Advise patients that Clostridium difficile associated
diarrhea can occur with oral minocycline therapy. Advise patients to seek
medical attention if they develop watery or bloody stools while using AMZEEQ.
Hepatotoxicity
Inform patients about the possibility of hepatotoxicity
reported with oral minocycline. Advise patients to seek medical advice if they
experience symptoms or signs of hepatotoxicity, including loss of appetite,
tiredness, diarrhea, jaundice, increased bleeding tendencies, confusion, and
sleepiness.
Central Nervous System Effects
Inform patients that central nervous system adverse
reactions including dizziness or vertigo have been reported with oral
minocycline therapy. Caution patients about driving vehicles or using hazardous
machinery if they experience such symptoms while on AMZEEQ.
Intracranial Hypertension
Inform patients that intracranial hypertension can occur
with minocycline therapy. Advise patients to seek medical attention if they
develop unusual headache, visual symptoms, such as blurred vision, diplopia,
and vision loss.
Photosensitivity
Inform patients that photosensitivity manifested by an
exaggerated sunburn reaction has been observed in some individuals taking oral
tetracyclines, including minocycline. Advise patients to minimize or avoid
exposure to natural or artificial UV light (tanning beds or UVA/B treatment)
while using AMZEEQ. Discuss other sun protection measures, if patients need to
be outdoors while using AMZEEQ. Advise patients to discontinue treatment at the
first evidence of sunburn.
Autoimmune Syndromes
Inform patients that autoimmune syndromes, including
drug-induced lupus-like syndrome, autoimmune hepatitis, vasculitis and serum
sickness have been observed with oral tetracycline-class drugs, including
minocycline. Symptoms may be manifested by arthralgia, fever, rash and malaise.
Advise patients who experience such symptoms to stop the drug immediately and
seek medical help.
Other Information
AMZEEQ should be applied exactly as directed. AMZEEQ may
stain fabric.
Nonclinical Toxicology
Carcinogenesis, Mutagenesis, Impairment Of Fertility
In a carcinogenicity study in which minocycline
hydrochloride was orally administered to male and female rats once daily for up
to 104 weeks at dosages up to 200 mg/kg/day, minocycline hydrochloride was
associated in both sexes with follicular cell tumors of the thyroid gland,
including increased incidences of adenomas, carcinomas and the combined
incidence of adenomas and carcinomas in males, and adenomas and the combined
incidence of adenomas and carcinomas in females. In a carcinogenicity study in
which minocycline hydrochloride was orally administered to male and female mice
once daily for up to 104 weeks at dosages up to 150 mg/kg/day, exposure to
minocycline hydrochloride did not result in a significantly increased incidence
of neoplasms in either males or females. Minocycline was not mutagenic in vitro
in a bacterial reverse mutation assay (Ames test) or CHO/HGPRT mammalian cell
assay in the presence or absence of metabolic activation. Minocycline was not
clastogenic in vitro using human peripheral blood lymphocytes or in vivo in a
mouse micronucleus test.
Male and female reproductive performance in rats was
unaffected by oral doses of minocycline of up to 300 mg/kg/day (10,000 times
the systemic exposure at the MRHD based on AUC comparison). However, oral
administration of 100 or 300 mg/kg/day of minocycline to male rats (3,800 or
10,000 times, respectively, the systemic exposure at the MRHD based on AUC
comparison), adversely affected spermatogenesis.
Effects observed at 300 mg/kg/day of oral minocycline
included a reduced number of sperm cells per gram of epididymis, an apparent
reduction in the percentage of sperm that were motile, and (at 100 and 300
mg/kg/day) increased numbers of morphologically abnormal sperm cells.
Morphological abnormalities observed in sperm samples included absent heads,
misshapen heads, and abnormal flagella.
Use In Specific Populations
Pregnancy
Risk Summary
Available data with AMZEEQ use in pregnant women are
insufficient to evaluate for a drug-associated risk of major birth defects,
miscarriage or other adverse maternal or fetal outcomes. Systemic absorption of
AMZEEQ in humans is low following once daily topical administration of AMZEEQ
for 21 days [see CLINICAL PHARMACOLOGY]. Because of low systemic
exposure, it is not expected that maternal use of AMZEEQ will result in
significant fetal exposure to the drug.
Tetracycline-class drugs may cause permanent
discoloration of teeth and reversible inhibition of bone growth when
administered orally during pregnancy [see WARNINGS AND PRECAUTIONS and Use
In Specific Populations].
Animal reproduction studies were not conducted with
AMZEEQ. In animal reproduction studies, oral administration of minocycline
administered to pregnant rats and rabbits during the period of organogenesis
induced skeletal malformations in fetuses at systemic exposures of 750 and 500
times, respectively, the maximum recommended human dose (MRHD; based on AUC
comparison) of AMZEEQ (see Data).
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 2-4% and 15-20%,
respectively.
Data
Animal Data
Results of animal studies indicate that tetracyclines
cross the placenta, are found in fetal tissues, and can cause retardation of
skeletal development of the developing fetus [see WARNINGS AND PRECAUTIONS].
Minocycline induced skeletal malformations (bent limb
bones) in fetuses when orally administered to pregnant rats and rabbits during
the period of organogenesis at doses of 30 mg/kg/day and 100 mg/kg/day,
respectively, (750 and 500 times, respectively, the systemic exposure at the
MRHD based on AUC comparison). Reduced mean fetal body weight was observed when
minocycline was orally administered to pregnant rats during the period of
organogenesis at a dose of 10 mg/kg/day (250 times the systemic exposure at the
MRHD based on AUC comparison).
Minocycline was assessed for effects on peri-and
post-natal development of rats in a study that involved oral administration to
pregnant rats during the period of organogenesis through lactation, at doses of
5, 10, or 50 mg/kg/day. In this study, body weight gain was significantly
reduced in pregnant females that received 50 mg/kg/day (650 times the systemic
exposure at the MRHD based on AUC comparison). No effects of treatment on the
duration of the gestation period or the number of live pups born per litter
were observed. Gross external anomalies observed in F1 pups (offspring of
animals that received oral minocycline) included reduced body size, improperly
rotated forelimbs, and reduced size of extremities. No effects were observed on
the physical development, behavior, learning ability, or reproduction of F1
pups, and there was no effect on gross appearance of F2 pups (offspring of F1
animals).
Lactation
Risk Summary
Tetracycline-class drugs, including minocycline, are
present in breast milk following oral administration. It is not known whether
minocycline is present in human milk after topical administration to the
nursing mother. There are no data on the effects of minocycline on milk
production. Because of the potential for serious adverse reactions, advise
patients that breastfeeding is not recommended during treatment with AMZEEQ [see
WARNINGS AND PRECAUTIONS].
Pediatric Use
The safety and effectiveness of AMZEEQ have been
established in pediatric patients 9 years of age and older for the treatment of
inflammatory lesions of non-nodular moderate to severe acne vulgaris. Use of
AMZEEQ for this indication is supported by three adequate and well controlled
12-week trials in patients 9 years of age and older; two of the trials included
a 40-week open-label extension. Additional data was obtained from a 7-day
open-label safety and pharmacokinetics study conducted in 20 patients 10 years
to less than 17 years of age with acne vulgaris [see CLINICAL PHARMACOLOGY
and Clinical Studies]. A total of 686 subjects 9 years of age and older
received AMZEEQ in these clinical trials.
Safety and effectiveness for this indication have not
been established in pediatric patients less than 9 years of age. The use of
oral tetracycline drugs during tooth development below the age of 8 years may
cause permanent discoloration of the teeth (yellow-gray-brown) and inhibition
of bone growth [see WARNINGS AND PRECAUTIONS].
Geriatric Use
Clinical studies of AMZEEQ did not include sufficient
numbers of subjects aged 65 years 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.