WARNINGS
Included as part of the PRECAUTIONS section.
PRECAUTIONS
Teratogenic Effects
Avoid MINOLIRA use during pregnancy.
MINOLIRA, like other tetracycline-class drugs, can cause
fetal harm when administered to a pregnant woman. MINOLIRA, like other tetracycline-class
drugs, may cause permanent discoloration of the teeth and inhibit bone growth
when administered during pregnancy. Based on animal data, tetracyclines cross
the placenta, are found in fetal tissues, and can cause skeletal malformation
and retardation of skeletal development on the developing fetus. Evidence of
embryotoxicity has been noted in animals treated early in pregnancy. If
MINOLIRA is used during pregnancy, advise the patient of the potential risk to
the fetus and discontinue treatment [see Use in Specific Populations].
Tooth Discoloration
The use of tetracycline class drugs 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 use
of the tetracycline but has been observed following repeated short-term
courses. Enamel hypoplasia has also been reported. Use of tetracycline drugs is
not recommended during tooth development.
The safety and effectiveness of MINOLIRA have not been
established in pediatric patients less than 12 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 MINOLIRA have not been established in patients
less than 12 years of age [see Use in Specific Populations].
Results of animal studies indicate that 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 early in pregnancy [see Use in Specific
Populations].
Pseudomembranous Colitis
Clostridium difficile associated diarrhea (CDAD)
has been reported with nearly all antibacterial agents, including 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 minocycline use in the treatment of acne.
Metabolic Effects
The anti-anabolic action of the tetracyclines may cause
an increase in BUN. While this is not a problem in those with normal renal
function, in patients with significantly impaired function, higher serum levels
of tetracycline-class drugs may lead to azotemia, hyperphosphatemia, and acidosis.
If renal impairment exists, even usual oral or parenteral doses may lead to
excessive systemic accumulations of the drug and possible liver toxicity. Under
such conditions, lower than usual total doses are indicated, 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 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 usually rapidly disappear when
the drug is discontinued.
Intracranial Hypertension
Intracranial hypertension has been associated with the
use of tetracycline-class drugs including MINOLIRA. 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. 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 long-term use of 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 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 MINOLIRA.
Photosensitivity
Photosensitivity manifested by an exaggerated sunburn
reaction has been observed in some individuals taking tetracyclines; this
reaction has been reported less frequently with minocycline. 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 MINOLIRA, they should wear loose-fitting clothes that protect skin from
sun exposure and discuss other sun protection measures with their physician.
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 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. If this
syndrome is recognized, discontinue MINOLIRA immediately.
Tissue Hyperpigmentation
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
MINOLIRA has not been evaluated in the treatment of infections.
Bacterial resistance to the tetracyclines may develop in
patients using MINOLIRA. Because of the potential for drug-resistant bacteria
to develop during the use of MINOLIRA, it should be used only as indicated.
Superinfection
Use of MINOLIRA may result in overgrowth of
nonsusceptible organisms, including fungi. If super infection occurs,
discontinue MINOLIRA and institute appropriate therapy.
Laboratory Monitoring
Periodic laboratory evaluations of organ systems,
including hematopoietic, renal and hepatic studies should be performed.
Appropriate tests for autoimmune syndromes should be performed as indicated.
Patient Counseling Information
Advise the patient to read the FDA-approved patient
labeling (Patient Information and Instruction for Use).
Advise patients of the following:
Teratogenic Effects
- Advise patients to avoid use of MINOLIRA during
pregnancy.
- Advise patients that MINOLIRA use during pregnancy may
cause inhibition of fetal bone growth.
- Advise patients that MINOLIRA use during pregnancy may
cause discoloration of deciduous teeth.
- Advise patients to discontinue MINOLIRA during pregnancy.
Tooth Discoloration
- Advise caregivers of pediatric patients that MINOLIRA use
may cause permanent discoloration of deciduous and permanent teeth.
Lactation
- Advise a woman that breast feeding is not recommended
during MINOLIRA therapy.
Contraception
- Advise patients of reproductive potential that MINOLIRA
may reduce the effectiveness of low-dose oral contraceptives. Advise patients
of reproductive potential not rely on low-dose oral contraceptives as an
effective contraceptive method and to use an additional method of contraception
during treatment with MINOLIRA.
Infertility
- Advise males of reproductive potential that MINOLIRA may
impair fertility.
Tissue Hyperpigmentation
- Inform patients that MINOLIRA may cause discoloration of
skin, scars, teeth or gums.
Pseudomembranous Colitis
- Advise patients that pseudomembranous colitis can occur
with minocycline therapy, including MINOLIRA. Advise patients to seek medical
attention if they develop watery or bloody stools.
Hepatotoxicity
- Inform patients about the possibility of hepatotoxicity.
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 minocycline
therapy. Caution patients about driving vehicles or using hazardous machinery
if they experience such symptoms while on MINOLIRA.
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.
- Inform patients that autoimmune syndromes, including
drug-induced lupus-like syndrome, autoimmune hepatitis, vasculitis and serum
sickness have been observed with 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.
Photosensitivity
- Inform patients that photosensitivity manifested by an
exaggerated sunburn reaction has been observed in some individuals taking
tetracyclines, including minocycline.
- Advise patients to minimize or avoid exposure to natural
or artificial UV light (tanning beds or UVA/B treatment) while using MINOLIRA.
- Discuss other sun protection measures, if patients need
to be outdoors while using MINOLIRA.
- Advise patients to discontinue treatment at the first
evidence of sunburn.
Important Administration Instructions
- Inform patients to take MINOLIRA as directed. Missing
doses or not completing the full course of therapy may decrease the
effectiveness of the current treatment course and increase the likelihood that
bacteria will develop resistance and will not be treatable by other
antibacterial drugs in the future.
- Advise patient not to chew or crush the tablet.
- Advise patients to split MINOLIRA tablet across the score
line, if required depending on patient's body weight.
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 genders 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 (which resulted
in up to approximately 40 times the level of systemic exposure to minocycline
observed in patients administered MINOLIRA). However, oral administration of
100 or 300 mg/kg/day of minocycline to male rats (resulting in approximately 15
to 40 times the level of systemic exposure to minocycline observed in patients
administered MINOLIRA) adversely affected spermatogenesis. Effects observed at
300 mg/kg/day 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
MINOLIRA, like tetracycline class drugs, may cause
permanent discoloration of teeth and reversible inhibition of bone growth when
administered during pregnancy [see WARNINGS AND
PRECAUTIONS and Use in Specific Populations]. Post-marketing
cases of minocycline use in pregnant women report congenital anomalies such as
limb reductions. The limited data are not sufficient to inform a
drug-associated risk for birth defects or miscarriage. In animal reproduction
studies, minocycline induced skeletal malformations in fetuses when orally
administered to pregnant rats and rabbits during the period of organogenesis at
systemic exposure of approximately 3 times and 2 times, respectively, the
systemic exposure to minocycline observed in patients administered MINOLIRA (see
Data). If a patient becomes pregnant while taking this drug, advise the
patient of the risk to the fetus and discontinue treatment.
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
Human Data
The use of tetracycline during tooth development (second
and third trimesters of pregnancy) may cause permanent discoloration of
deciduous teeth. This adverse reaction is more common during long-term use of
the drug but has been observed following repeated short-term courses.
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 administered to pregnant rats and rabbits during the
period of organogenesis at doses of 30 mg/kg/day and 100 mg/kg/day,
respectively, (resulting in approximately 3 times and 2 times, respectively,
the systemic exposure to minocycline observed in patients administered
MINOLIRA). Reduced mean fetal body weight was observed when minocycline was
administered to pregnant rats during the period of organogenesis at a dose of
10 mg/kg/day (which resulted in approximately the same level of systemic
exposure to minocycline as that observed in patients administered MINOLIRA).
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 (resulting in
approximately 2.5 times the systemic exposure to minocycline observed in
patients administered MINOLIRA). 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 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. It is not known whether minocycline has an effect on
the breastfed infant or on milk production. Because of the potential for
serious adverse effects on bone and tooth development in breastfed infants from
the tetracycline-class drugs, advise a woman that breastfeeding is not
recommended with MINOLIRA therapy [see WARNINGS
AND PRECAUTIONS].
Females And Males Of Reproductive Potential
Contraception
MINOLIRA may reduce the effectiveness of low-dose oral
contraceptives. Patients of reproductive potential should not rely on low-dose
oral contraceptives as an effective contraceptive method, and should use an
additional method of contraception during treatment with MINOLIRA [see DRUG
INTERACTIONS].
Infertility
Avoid using MINOLIRA in males who are attempting to
conceive a child. Limited human studies suggest that minocycline may have a
deleterious effect on spermatogenesis. In a fertility study in rats,
minocycline adversely affected spermatogenesis when orally administered to male
rats at doses resulting in approximately 15 to 40 times the level of systemic
exposure to minocycline observed in patients administered MINOLIRA [see
Nonclinical Toxicology].
Pediatric Use
The safety and effectiveness of MINOLIRA have been
established in pediatric patients 12 years of age and older for the treatment
of inflammatory lesions of non-nodular moderate to severe acne vulgaris [see
Pharmacokinetics and Clinical Studies]. Tooth discoloration and
inhibition of bone growth have been observed in pediatric patients [see WARNINGS AND PRECAUTIONS]. The safety and
effectiveness of MINOLIRA have not been established in pediatric patients less
than 12 years of age.
Geriatric Use
Clinical studies of MINOLIRA 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.
In general, dose selection for an elderly patient should
be cautious, usually starting at the low end of the dosing range, reflecting
the greater frequency of decreased hepatic, renal, or cardiac function, and
concomitant disease or other drug therapy.