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Digifab® [Digoxin Immune Fab (Ovine)] is a sterile, purified, lyophilized preparation of digoxin-immune ovine Fab (monovalent) immunoglobulin fragments. These fragments are obtained from the blood of healthy sheep immunized with a digoxin derivative, digoxin-dicarboxymethoxylamine (DDMA), a digoxin analogue which contains the functionally essential cyclopentaperhydrophenanthrene:lactone ring moiety coupled to keyhole limpet hemocyanin (KLH).
The final product is prepared by isolating the immunoglobulin fraction of the ovine serum, digesting it with papain and isolating the digoxin-specific Fab fragments by affinity chromatography. These antibody fragments have a molecular weight of approximately 46,000 Da.
Each vial of Digifab, which will bind approximately 0.5 mg digoxin, contains 40 mg of digoxin immune Fab, 75 mg (approx) of mannitol USP, and 2 mg (approx) sodium acetate USP as a buffering agent.
The product contains no preservatives and is intended for intravenous administration after reconstitution with 4 mL of Sterile Water for Injection USP.
Digifab has an affinity for digoxin in the range of 109 to 1010 M-1, which is greater than the affinity of digoxin for its sodium pump receptor, the presumed receptor for its therapeutic and toxic effects. When administered to the intoxicated patient, Digifab binds to molecules of digoxin reducing free digoxin levels, which results in a shift in the equilibrium away from binding to the receptors, thereby reducing cardio-toxic effects. Fab-digoxin complexes are then cleared by the kidney and reticuloendothelial system.
No toxic effects were observed when Digifab was administered to healthy male Sprague Dawley rats in equimolar doses sufficient to neutralize a 1 mg/kg dose of digoxin. In these studies, the physiologic changes produced by toxic serum concentrations of digoxin were ameliorated rapidly by the administration of Digifab, or another ovine digoxin-specific immune Fab, Digibind® (manufactured by GlaxoSmithKline). Statistically equivalent responses were observed with both Digifab and Digibind to the following variables: PTQ index, heart rate, mean arterial pressure, ventilation, arterial blood gases, and serum potassium concentrations.
The pharmacokinetics of Digifab were assessed in a randomized and controlled study of Digifab and Digibind (comparator Fab product for treatment of digoxin toxicity). Sixteen healthy subjects were given 1 mg of intravenous digoxin followed by an approximately equimolar neutralizing dose of either Digifab (n=8) or Digibind (n=8). The pharmacokinetic profiles of Fab were similar for both products.1 The similar volumes of distribution (0.3 L/kg and 0.4 L/kg for Digifab and Digibind, respectively) indicate considerable penetration from the circulation into the extracellular space and are consistent with previous reports of ovine Fab distribution, as are the elimination half-life values (15 hours and 23 hours for Digifab and Digibind, respectively).2-6 The elimination half-life of 15-20 hours in patients with normal renal function appears to be increased up to 10 fold in patients with renal impairment, although volume of distribution remains unaffected.6
There have been two controlled clinical trials conducted with Digifab: a pharmacokinetic and pharmacodynamic study of Digifab as compared to Digibind in healthy volunteers, and a prospective multi-center study of the efficacy of Digifab in patients presenting with life-threatening digoxin toxicity.
The objective of the pharmacokinetic and pharmacodynamic study was to compare these parameters for Digifab to those for Digibind.1 This trial was conducted in healthy volunteers who were administered a 1 mg intravenous dose of digoxin, followed 2 hours later by an equimolar neutralizing dose of either Digifab or Digibind. The pharmacokinetics of both digoxin and Fab were determined (see Clinical Pharmacokinetics for Fab pharmacokinetic parameters). The primary outcome measure was the serum level of free (unbound) digoxin. The results demonstrated that both products reduced the level of free digoxin in the serum to below the limit of assay quantitation for several hours after Fab administration. Cumulative urinary excretion of digoxin was comparable for both products and exceeded 40% of the administered dose by 24 hours. These results demonstrate that Digifab and Digibind have equivalent pharmacodynamic effects on the digoxin parameters that are relevant to the treatment of digoxin toxicity. In this study, no patients developed a measurable immune response (human anti-ovine antibodies) to Digifab.
The objective of the efficacy study was to demonstrate safety and also to determine the pharmacokinetics of, and clinical response to, Digifab in patients. Results were compared to historical data on another U.S. marketed ovine digoxin immune Fab product, Digibind. Fifteen patients received doses of Digifab based on its theoretical binding capacity for digoxin, and based on the known amount of digoxin ingested or on blood concentrations of digoxin at the time of admission. This study was conducted in both the U.S. and in Finland.
The primary outcome of the study was met in that serum free digoxin concentrations in all patients fell to undetectable levels following Digifab administration. This was an expected outcome that is consistent with data in the literature showing that free digoxin concentrations fall rapidly following administration of Digibind.2 In the Digifab trial, an independent blinded review of each patient's ECG showed that 10 of the 15 patients studied had ECG abnormalities that improved within 4 hours after the Digifab infusion. The remaining 5 patients had ECG abnormalities that were unchanged from baseline throughout the 24-hour assessment period, and in one case through the 30-day follow up period. Although the reason for the lack of ECG resolution could not be clearly determined in all cases, it is possible that the ECG abnormalities observed in these patients were not entirely due to digoxin toxicity, but rather to another underlying cardiac problem. Assessing all manifestations of toxicity, investigators classified 7 out of the 15 patients (47%) studied as having complete resolution of digoxin toxicity within 4 hours of Digifab administration, and 14 patients (93%) were classified as having resolved their digoxin toxicity by 20 hours. The data for the proportion of patients who responded to treatment with Digifab is similar to, and consistent with, historical data available for Digibind.2-3 In this study, where 2/15 patients had serum available for human anti-ovine antibody determination, there was no measurable immune response.
Digifab is indicated for the treatment of patients with life-threatening or potentially life-threatening digoxin toxicity or overdose. Although designed specifically to treat digoxin overdose, a product very similar to Digifab (Digibind) has been used successfully to treat life-threatening digitoxin overdose.7 Since human experience is limited, and the consequences of repeated exposure are unknown, Digifab is not indicated for milder cases of digitalis toxicity.
Clinical conditions requiring administration of Digifab include:
There are no known contraindications to the use of Digifab.
Suicidal ingestion may involve more than one drug. Toxic effects of other drugs or poisons should not be overlooked, especially in cases where signs and symptoms of digitalis toxicity are not relieved by administration of Digifab.
The possible risks and side-effects that attend the administration of heterologous animal proteins in humans include anaphylactic and anaphylactoid reactions, delayed allergic reactions and a possible febrile response to immune complexes formed by animal antibodies.8 Since the Fab fragment of the antibody lacks the antigenic determinants of the Fc fragment, it should pose a reduced immunogenic threat to patients compared with intact immunoglobulin molecules. Being monovalent, the product is also unlikely to form extended immune complexes with the antigen. Although no patient in the clinical studies of Digifab has experienced a severe anaphylactic reaction, the possibility of an anaphylactic reaction should be considered. All patients should be informed of the possibility of an anaphylactic reaction and when receiving Digifab should be carefully monitored for signs and symptoms of an acute allergic reaction (e.g., urticaria, pruritus, erythema, angioedema, bronchospasm with wheezing or cough, stridor, laryngeal edema, hypotension, tachycardia) and treated immediately with appropriate emergency medical care (e.g., oxygen, diphenhydramine, corticosteroids, volume expansion and airway management). If an anaphylactic reaction occurs during the infusion, Digifab administration should be terminated at once and appropriate treatment administered. The need for epinephrine should be balanced against its potential risk in the setting of digitalis toxicity. Patients with known allergies to sheep protein would be particularly at risk for an anaphylactic reaction, as would individuals who have previously received intact ovine antibodies or ovine Fab.
Papain is used to cleave the whole antibody into Fab and Fc fragments, and trace amounts of papain or inactivated papain residues may be present in Digifab. Patients with allergies to papain, chymopapain, other papaya extracts, or the pineapple enzyme bromelain may also be at risk for an allergic reaction to Digifab. In addition, it has been noted in the literature that some dust mite allergens and some latex allergens share antigenic structures with papain and patients with these allergies may be allergic to papain.9-10 Digifab should not be administered to patients with a known history of hypersensitivity to papaya or papain unless the benefits outweigh the risks and appropriate management for anaphylactic reactions is readily available.
Skin testing has not proved useful in predicting allergic response to Digibind.11 Because of this, and because it may delay urgently needed therapy, skin testing was not performed during the clinical studies of Digifab and is not suggested prior to dosing with this product.
Standard management of digitalis intoxication includes withdrawal of the intoxicating agent, correction of electrolyte disturbances (especially hyperkalemia), acid-base imbalances, hypoxia and treatment of cardiac arrhythmias.
Massive digitalis intoxication can cause hyperkalemia; administration of potassium supplements in the setting of digitalis intoxication may be hazardous. After treatment with Digifab, the serum potassium concentration may drop rapidly and must be monitored frequently, especially after the first several hours after Digifab is given (see Laboratory Tests).
Patients with poor cardiac function may deteriorate secondary to the withdrawal of the inotropic action of digoxin by Digifab. If needed, additional support can be provided by using other intravenous inotropes such as dopamine, dobutamine or vasodilators. However, care must be taken not to aggravate the digitalis induced rhythm disturbances. Re-digitalization should be postponed, if possible, until the Fab fragments have been eliminated from the body, which may require several days, and patients with impaired renal function may require a week or longer.
The elimination half-life of Digifab in renal failure has not been clearly defined, although patients with renal dysfunction have been successfully treated with Digibind.3,12 There is no evidence to suggest that the time-course of therapeutic effect is any different in these patients than in patients with normal renal function, but excretion of the Fab fragment-digoxin complex from the body is probably delayed. There is one case report of recurrence of atrioventricular block due to digoxin in a functionally anephric patient 10 days after its initial reversal by ovine Fab therapy.12 This clinical event persisted for more than a week. In patients that are functionally anephric, failure to clear the Fab-digoxin complex from the blood by glomerular filtration and renal excretion may be anticipated. It is uncertain whether the failure to eliminate the Fab-digoxin complex in severe renal impairment may lead to re-intoxication with digoxin following the release of previously bound digoxin into the blood. However, patients with severe renal failure who receive Digifab for digitalis toxicity should be monitored for a prolonged period for possible recurrence of toxicity. Monitoring of free (unbound) digoxin concentrations after the administration may be appropriate in order to establish recrudescent toxicity in renal failure patients.13
Prior treatment with digoxin-specific ovine immune Fab carries a theoretical risk of sensitization to ovine serum protein (see WARNINGS) and possible diminution of the efficacy of the drug due to the presence of human antibodies against ovine Fab. Human antibodies to ovine Fab have been reported in some patients receiving Digibind, however, to date, there have been no clinical reports of human anti-ovine immunoglobulin antibodies causing a reduction in binding of ovine digoxin immune Fab or neutralization response to ovine digoxin immune Fab.
Digifab will interfere with digitalis immunoassay measurements in the same way that has been reported for Digibind.14,15 Thus, standard serum digoxin concentration measurements may be clinically misleading until the Fab fragments are eliminated from the body. This may take several days or a week or more in patients with markedly impaired renal function. Therefore, serum samples for digoxin concentration should be obtained before Digifab administration, if at all possible. Such measurements would establish the level of serum digoxin at the time of diagnosis of digitalis intoxication. At least 6 to 8 hours are required for equilibration of digoxin between serum and tissue, so absorption of the last dose may continue from the intestine. Therefore, serum measurements may be difficult to interpret if samples are drawn soon after the last digitalis dose. Patients should be closely monitored, including temperature, blood pressure, electrocardiogram, and potassium concentration, during and after administration of Digifab. The total serum digoxin concentration may rise precipitously following administration of Digifab, but this will be almost entirely bound to the Fab fragment and therefore not able to react with receptors in the body.
Digoxin causes a shift of potassium from inside to outside the cell, such that severe intoxication can cause a life-threatening elevation of serum potassium. This may lead to increased urinary excretion of potassium so that a patient may have hyperkalemia but a whole body deficit of potassium. When the toxic effects of digoxin are reversed by Digifab, potassium shifts back into the cell with a resulting decline in serum potassium concentration. This hypokalemia may develop rapidly. For these reasons, serum potassium concentration should be followed closely, especially during the first several hours after Digifab administration. Cautious potassium supplementation should then be given when necessary.
Patients should be advised to contact their physician immediately if they experience any signs and symptoms of delayed allergic reactions or serum sickness (e.g., rash, pruritus, urticaria) after hospital discharge.
Studies of drug interactions have not been conducted with Digifab.
Animal carcinogenicity and reproduction studies have not been conducted with Digifab.
Pregnancy Category C. Animal reproduction studies have not been conducted with Digifab. It is also not known whether Digifab can cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. Digifab should be given to a pregnant woman only if clearly needed.
It is not known whether Digifab is excreted in human breast milk. Because many drugs are excreted in human milk, caution should be exercised when Digifab is administered to a nursing woman.
Specific studies in elderly patients have not been conducted. Of the 15 patients given Digifab for digoxin toxicity in one clinical trial, the average age of all patients was 64 years and over half of the patients (8 of the 15) were 65 years of age or older. The oldest patient studied was 86 years old. There is no evidence that the efficacy of Digifab would be altered due to advanced age alone, however elderly patients have a higher chance of having impaired renal function and therefore should be monitored more closely for recurrent toxicity (see PRECAUTIONS).
Specific studies in pediatric patients have not been conducted and no pediatric patients were enrolled in the clinical studies of Digifab. A similar digoxin ovine Fab product, Digibind, has been used successfully to treat infants.2 As with all drugs, the use of Digifab in infants and children should be based on careful consideration of the benefits compared with the potential risks.
Based on experience with Digibind, the following adverse reactions could occur with the use of Digifab:
In the clinical trials of Digifab, 6 of 15 patients in the digoxin overdose study had a total of 17 adverse experiences, most were mild to moderate in nature and all were deemed "remotely associated" with Digifab. Three events were deemed "severe", all occurred in one patient and consisted of the following: pulmonary edema, bilateral pleural effusion and renal failure. After reviewing the case, it was determined that these events were likely due to the loss of digoxin inotropic support in combination with the patient's underlying medical condition. Of 8 healthy volunteers who received Digifab, only 2 experienced an adverse reaction that was considered to be associated with Digifab. The reactions were 1 episode of phlebitis of the infusion vein and 1 episode of moderate postural hypotension, which became mild prior to resolving.
The maximum amount of Digifab that can safely be administered in single or multiple doses has not been determined.
The dosage of Digifab will vary according to the amount of digoxin or digitoxin to be neutralized.
If a patient presents with life-threatening digitalis toxicity caused by an acute ingestion and neither a serum digitalis concentration nor an estimated ingestion amount is available, 20 vials of Digifab may be administered. This amount should be adequate to treat most life-threatening overdoses in adults and children. However, in small children it is important to monitor for volume overload. In general, a larger dose of Digifab has a faster onset of effect but may enhance the possibility of a febrile reaction. In such cases, 10 vials may be administered first with careful monitoring of the patient's response followed at the physician's discretion by 10 additional vials and continued monitoring. Failure of the patient to respond to Digifab should alert the physician to the possibility that the clinical problem may not be caused by digitalis toxicity.
For adult patients who are in acute distress or for whom a serum digoxin concentration is not available, 6 vials (240 mg) should be adequate to reverse most cases of toxicity. For infants and small children (≤ 20 kg) on chronic therapy with digoxin and showing signs of toxicity, a single vial should be sufficient.
Methods for calculating a neutralizing dose of Digifab, based on a known or estimated amount of digoxin or digitoxin in the body, are provided below. When using the dose calculation methods provided, the following guidelines should be considered:
Each vial of Digifab contains 40 mg of purified digoxin-specific Fab, which will bind approximately 0.5 mg of digoxin. The total number of vials required can be calculated by dividing the total body load of digoxin in milligrams (mg) by 0.5 mg per vial (see Formula 1). Following an acute ingestion, total body load will be approximately equal to the amount ingested in milligrams for either digoxin capsules or digitoxin. If digoxin tablets were ingested, the total body load will be approximately equal to the amount ingested (in mg) multiplied by the bioavailability of the tablet preparation, which is 0.8.
Table 1 gives dosage estimates in number of vials for adults and children who have ingested a single large dose of digoxin and for whom the approximate number of tablets or capsules is known. The dose of Digifab (in number of vials) represented in Table 1 can be approximated using the following formula:
Dose = total digitalis body load in mg
(in # of vials) 0.5 mg of digitalis bound/vial
* 0.25 mg tablets with 80% bioavailability or 0.2 mg capsules with 100% bioavailability | |
| Number of Digoxin Tablets | Dose of Digifab |
| or Capsules Ingested* | # of Vials |
| 25 | 10 |
| 50 | 20 |
| 75 | 30 |
| 100 | 40 |
| 150 | 60 |
| 200 | 80 |
If, after several hours, toxicity is not adequately reversed, or appears to recur, additional administration of Digifab at a dose guided by clinical judgment may be required.
Table 2 gives dosage estimates in number of vials for adult patients for whom a steady-state serum digoxin concentration is known. The dose of Digifab (in number of vials) represented in Table 2 can be approximated using the following formula:
Dose = (Serum digoxin concentration in ng/mL (weight in kg)
(in # of vials) 100
Table 3 gives dosage estimates in milligrams for infants and small children based on the steady-state serum digoxin concentration. The dose of Digifab represented in Table 3 can be estimated by multiplying the dose (in number of vials) calculated from Formula 2 by the amount of Digifab contained in a vial (40 mg/vial) (see Formula 3). Since infants and small children can have much smaller dosage requirements, it is recommended that the 40 mg vial be reconstituted as directed and administered with a tuberculin syringe. For very small doses, a reconstituted vial can be diluted with 36 mL of sterile isotonic saline to achieve a concentration of 1 mg/mL.
Dose (in mg) = (Dose in # of vials) (40 mg/vial)
The dose of Digifab for digitoxin toxicity can be approximated by using the following formula (which differs from Formula 2 in the denominator due to a 10-fold decrease in the volume of distribution of digitoxin as compared to digoxin).
Dose = (Serum digitoxin concentration in ng/mL) (weight in kg)
(in # of vials) 1000
If in any case, the dose estimated based on ingested amount (Formula 1) differs substantially from that calculated based on the serum digoxin or digitoxin concentration (Formulas 2 and 4), it may be preferable to use the higher dose estimate.
v = vials | |||||||
| Patient Weight (kg) | Serum Digoxin Concentration (ng/mL) | ||||||
| 1 | 2 | 4 | 8 | 12 | 16 | 20 | |
| 40 | 0.5v | 1v | 2v | 3v | 5v | 7v | 8v |
| 60 | 0.5v | 1v | 3v | 5v | 7v | 10v | 12v |
| 70 | 1v | 2v | 3v | 6v | 9v | 11v | 14v |
| 80 | 1v | 2v | 3v | 7v | 10v | 13v | 16v |
| 100 | 1v | 2v | 4v | 8v | 12v | 16v | 20v |
* dilution of reconstituted vial to 1 mg/mL may be desirable | |||||||
| Patient Weight (kg) | Serum Digoxin Concentration (ng/mL) | ||||||
| 1 | 2 | 4 | 8 | 12 | 16 | 20 | |
| 1 | 0.4 mg* | 1 mg* | 1.5 mg* | 3 mg* | 5 mg | 6.5 mg | 8 mg |
| 3 | 1 mg* | 2.5 mg* | 5 mg | 10 mg | 14 mg | 19 mg | 24 mg |
| 5 | 2 mg* | 4 mg | 8 mg | 16 mg | 24 mg | 32 mg | 40 mg |
| 10 | 4 mg | 8 mg | 16 mg | 32 mg | 48 mg | 64 mg | 80 mg |
| 20 | 8 mg | 16 mg | 32 mg | 64 mg | 96 mg | 128 mg | 160 mg |
Each vial of Digifab should be reconstituted with 4 mL of Sterile Water for Injection USP and gently mixed to provide a solution containing approximately 10 mg/mL of digoxin immune Fab protein. The reconsituted product should be used promptly. If not used immediately, it may be stored under refrigeration at 2° to 8°C (36° to 46°F} for up to 4 hours. The reconstituted product may be added to an appropriate volume of 0.9% sodium chloride for injection.
Digifab should be administered slowly as an intravenous infusion over at least 30 minutes. If infusion rate-related reactions occur, the infusion should be stopped and re-started at a slower rate. If cardiac arrest is imminent, Digifab can be given by bolus injection. With bolus injection, an increased incidence of infusion-related reactions may be expected.
For infants and small children who may require very small doses, it is recommended that the 40 mg vial be reconstituted as directed and administered undiluted using a tuberculin syringe. For very small doses, a reconstituted vial can be diluted with an additional 36 mL of isotonic saline to achieve a concentration of 1 mg/mL.
Digifab is supplied as a sterile, purified, lyophilized preparation. Each vial contains 40 mg of digoxin immune Fab protein, contains no preservatives and is intended for one time use.
Each box contains 1 vial of Digifab.
NDC 0281-0365-10
The product should be stored at 2° to 8°C (36° to 46°F). Do not freeze. The product must be used within 4 hours after reconstitution.
Rx only
Manufactured by: Protherics Inc.
Brentwood, TN 37027
Distributed by: E. FOUGERA & CO. and Savage Laboratories®
both divisions of Nycomed US Inc., Melville, NY 11747
U.S. License No. 1575
Revised: July 2008
IF7036510B
NDC 0281-0365-10
Digoxin Immune Fab (Ovine)
Digifab®
40 mg
Rx Only
| Digifab ovine digoxin immune fab injection, powder, lyophilized, for solution | ||||||||||||||||||||
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| Marketing Information | |||
| Marketing Category | Application Number or Monograph Citation | Marketing Start Date | Marketing End Date |
| BLA | BLA103910 | 08/31/2001 | |
| Labeler - SAVAGE LABORATORIES, A division of Nycomed US Inc. (043838424) |
| Establishment | |||
| Name | Address | ID/FEI | Operations |
| Protherics Inc. | 867586898 | MANUFACTURE, ANALYSIS | |
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Diphenhydramine/Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID). It may cause an increased risk of serious and sometimes fatal heart and blood vessel problems (eg, heart attack, stroke). The risk may be greater if you already have heart problems or if you take Diphenhydramine/Ibuprofen for a long time. Do not use Diphenhydramine/Ibuprofen right before or after bypass heart surgery.
Diphenhydramine/Ibuprofen may cause an increased risk of serious and sometimes fatal stomach ulcers and bleeding. Elderly patients may be at greater risk. This may occur without warning signs.
Treating minor aches and pains that may cause sleeplessness. It may also be used as a nighttime sleep aid. It may also be used for other conditions as determined by your doctor.
Diphenhydramine/Ibuprofen contains diphenhydramine (antihistamine/anticholinergic) and ibuprofen (NSAID). Exactly how the NSAID works is not known. It may block certain substances in the body that are linked to inflammation. NSAIDs treat the symptoms of pain and inflammation. They do not treat the disease that causes those symptoms. The antihistamine/anticholinergic works in the brain to cause sedation.
Contact your doctor or health care provider right away if any of these apply to you.
Some medical conditions may interact with Diphenhydramine/Ibuprofen. Tell your doctor or pharmacist if you have any medical conditions, especially if any of the following apply to you:
Some MEDICINES MAY INTERACT with Diphenhydramine/Ibuprofen. Tell your health care provider if you are taking any other medicines, especially any of the following:
This may not be a complete list of all interactions that may occur. Ask your health care provider if Diphenhydramine/Ibuprofen may interact with other medicines that you take. Check with your health care provider before you start, stop, or change the dose of any medicine.
Use Diphenhydramine/Ibuprofen as directed by your doctor. Check the label on the medicine for exact dosing instructions.
Ask your health care provider any questions you may have about the proper use of Diphenhydramine/Ibuprofen.
All medicines can cause side effects, but many people have no, or minor, side effects. Check with your doctor if any of these most COMMON side effects persist or become bothersome:
Constipation; diarrhea; dizziness; drowsiness; dry mouth, throat, and nose; excitability; gas; headache; heartburn; nausea; stomach pain or upset; thickening of mucus in nose or throat.
Severe allergic reactions (rash; hives; itching; trouble breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); bloody or black, tarry stools; change in the amount of urine produced; chest pain; confusion; dark urine; depression; fainting; fast or irregular heartbeat; fever, chills, or persistent sore throat; hallucinations; mental or mood changes; numbness of an arm or leg; one-sided weakness; red, swollen, blistered, or peeling skin; ringing in the ears; seizures; severe headache or dizziness; severe or persistent stomach pain or nausea; severe vomiting; shortness of breath; stiff neck; sudden or unexplained weight gain; swelling of hands, legs, or feet; tremor; unusual bruising or bleeding; unusual joint or muscle pain; unusual tiredness or weakness; vision or speech changes; vomit that looks like coffee grounds; wheezing; yellowing of the skin or eyes.
This is not a complete list of all side effects that may occur. If you have questions about side effects, contact your health care provider. Call your doctor for medical advice about side effects. To report side effects to the appropriate agency, please read the Guide to Reporting Problems to FDA.
See also: Diphenhydramine/Ibuprofen side effects (in more detail)
Contact 1-800-222-1222 (the American Association of Poison Control Centers), your local poison control center, or emergency room immediately. Symptoms may include decreased urination; excitement; hallucinations; loss of consciousness; muscle twitching; seizures; severe dizziness or drowsiness; severe nausea or stomach pain; slow or troubled breathing; tremor; unusual bleeding or bruising; vomit that looks like coffee grounds; weakness.
Store Diphenhydramine/Ibuprofen at room temperature, between 68 and 77 degrees F (20 and 25 degrees C). Avoid temperatures above 104 degrees F (40 degrees C). Store away from heat, moisture, and light. Do not store in the bathroom. Keep Diphenhydramine/Ibuprofen out of the reach of children and away from pets.
This information is a summary only. It does not contain all information about Diphenhydramine/Ibuprofen. If you have questions about the medicine you are taking or would like more information, check with your doctor, pharmacist, or other health care provider.
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Class: Antineoplastic Agents
VA Class: AN900
Chemical Name: N-l-Methionyl-387-l-histidine-388-l-alanine-1-388 toxin (Corynebacterium diphtheriae strain C7) (377→2′) protein with 2-133-interleukin 2 (human clone pTIL2-21a).
Molecular Formula: C2560H4038N678O799S17
CAS Number: 173146-27-5
Brands: Ontak
Administer only under supervision of qualified clinicians experienced in use of cytotoxic therapy.1
Closely monitor patients in a setting equipped and staffed by health-care personnel appropriately trained in CPR.1
Antineoplastic agent; recombinant DNA-derived cytotoxic protein.1
Treatment of persistent or recurrent cutaneous T-cell lymphoma (CTCL) in patients whose malignant cells express the CD25 component of the IL-2 receptor1 3 8 (designated an orphan drug by FDA for this use).5
Safety and efficacy in patients with CTCL whose malignant cells do not express the CD25 component of the IL-2 receptor not established but currently being studied.1 6
Consult specialized references for procedures for proper handling and disposal of antineoplastics.
Prior to initiation of denileukin therapy, test patient's malignant cells for CD25 expression.1
Limited data suggest that administering oral corticosteroids (e.g., oral prednisone 20 mg) prior to each IV denileukin infusion or administering IV corticosteroids (e.g., IV dexamethasone 8 mg) on day 1 and prior to each subsequent IV denileukin infusion may minimize risk of potentially fatal acute hypersensitivity reactions.6 7
Not known if prophylactic administration of antipyretics, antiemetics, or antidiarrhea agents will ameliorate or decrease the incidence of flu-like syndrome.1
For solution and drug compatibility information, see Compatibility under Stability.
Administer by IV infusion; not for rapid (i.e., bolus) IV injection.1
Do not use in-line filter.1
Prior to administration, thaw denileukin diftitox concentrate at room temperature for 1–2 hours or under refrigeration (2–8°C) for up to 24 hours; do not heat solution.1
Must then be diluted with preservative-free 0.9% sodium chloride injection prior to administration.1
Do not admix with any other drug.1
Use strict aseptic technique and only plastic syringes and plastic IV bags to prepare and/or administer the drug; do not use glass containers.1 (See Compatibility under Stability.)
Add appropriate volume of denileukin diftitox concentrate to an empty IV infusion bag and dilute each mL of the concentrate with no more than 9 mL of the 0.9% sodium chloride injection to provide a solution containing at least 15 mcg/mL, a concentration that must be maintained during all steps of solution preparation.1
Mix by gentle swirling; do not shake vigorously.1
Administer by IV infusion over at least 15 minutes.1
If infusion-related adverse effects occur, discontinue infusion or administer the drug over longer periods (e.g., up to 80 minutes), depending on the severity of symptoms.1 3
9 or 18 mcg/kg daily for 5 consecutive days; repeat every 21 days.1 3
Optimum duration of therapy not established; only 2% of patients who do not experience at least a 25% decrease in tumor burden prior to the fourth course of treatment subsequently respond.1
No special population recommendations at this time.1
Known hypersensitivity to denileukin diftitox, diphtheria toxin, aldesleukin (interleukin-2), or any other ingredient in the formulation.1
Administer only under supervision of qualified clinicians experienced in use of cytotoxic therapy.1
Closely monitor patients in a setting equipped and staffed by health-care personnel appropriately trained in CPR.1
Risk of severe and/or fatal capillary leak syndrome (e.g., hypotension, edema, hypoalbuminemia).1 3 4
Syndrome usually occurs within the first 2 weeks of the infusion and may persist or worsen after completion of the treatment cycle.1 6
Use with caution in patients with preexisting cardiovascular disease and/or low serum albumin concentrations, since they appear to be at increased risk of developing this syndrome.1 3 6
Monitor weight, edema, BP, and serum albumin concentrations.1 Usually self-limiting; initiate treatment only if clinically indicated.1 6
Loss of visual acuity, usually with loss of color vision, reported; occurred with or without retinal pigment mottling.a b Although recovery was reported in some affected patients, most patients reported persistent visual impairment.a b
Potentially fatal, acute hypersensitivity reactions (e.g., hypotension, dyspnea, anaphylaxis) reported in about 69% of patients during or within 24 hours of infusion; about 50% of cases occurred on the first day of dosing, regardless of the treatment cycle.1 3 4 8
If hypersensitivity reaction occurs, discontinue immediately and/or institute appropriate therapy as indicated (e.g., IV antihistamine, epinephrine, corticosteroids).1 Have these drugs and resuscitative equipment immediately available during denileukin diftitox therapy.1
Perform CBCs, blood chemistries, and renal and hepatic function tests prior to initiation of therapy and at weekly intervals during therapy.1 8
Possible development of antibodies to denileukin diftitox; may inhibit functional activity of denileukin diftitox.1
Systemic exposure to denileukin diftitox also may be decreased.1 3 (See Special Populations under Pharmacokinetics.)
Manufacturer states that presence or absence of antibodies does not correlate with the risk of immediate hypersensitivity reactions associated with IV infusion of the drug.1
May impair immune function; monitor carefully for development of possibly severe infections.1 3
Patients with CTCL may be predisposed to cutaneous infection.1
Possible moderate to severe hypoalbuminemia, usually occurring 1 or 2 weeks after administration of denileukin diftitox.1
Monitor serum albumin concentrations prior to initiating each course of therapy.1 Delay administration of the drug until serum albumin concentrations are at least 3 g/dL.1
Flu-like syndrome (e.g., fever and/or chills, asthenia, GI effects, myalgia, arthralgia) frequently reported within several hours to days after denileukin diftitox infusion.1 3 8
Mild to moderate symptoms generally responsive to antipyretics, antiemetics, or antidiarrhea agents.1 3
Category C.1
Not known whether denileukin diftitox is distributed into milk.1 Discontinue nursing because of potential risk to nursing infants.1
Safety and efficacy not established.1
No substantial differences in efficacy relative to younger adults.1
Higher incidence and greater severity of anorexia, hypotension, anemia, confusion, rash, nausea, and/or vomiting observed in patients ≥65 years of age than in younger adults.1
Hypoalbuminemia, chills/fever, asthenia, infection, chest pain, hypotension, vasodilation, edema, dyspnea, nausea/vomiting, anorexia, diarrhea, anemia, increase in serum aminotransferase concentrations, dizziness, pain, headache, cough, rash, pruritus.1 3 4
No formal drug interaction studies to date.1
No effect on CYP enzyme system in one rodent study.1
Distributed into liver and kidneys in rats.1
Metabolized by proteolytic degradation.1
Biphasic; terminal half-life is approximately 70–80 minutes.1
In patients with denileukin diftitox antibodies, clearance may be increased twofold to threefold.1 3
-10°C or less.1 Once thawed, solutions should not be refrozen.1
Use diluted solutions within 6 hours; immediately discard any unused portions.1
For information on systemic interactions resulting from concomitant use, see Interactions.
Do not mix with other drugs.1
Manufacturer states adsorption of the drug to glass containers may occur.1
Compatible1 |
|---|
Sodium chloride 0.9% (preservative-free) |
Recombinant DNA-derived cytotoxic protein containing domains of diphtheria toxin fragments A and B (Met1 to Thr387)-His and of interleukin-2 (IL-2; Ala1-Thr133);1 3 4 8 prepared from cultures of genetically modified Escherichia coli and purified using reverse phase chromatography followed by a multistep diafiltration process.1 6
Exact mechanism of action in the treatment of CTCL has not been fully elucidated but is designed to direct the cytocidal activity of diphtheria toxin to cells with high affinity IL-2 receptor on the cell surface, thereby inhibiting cellular protein synthesis, which results in cell death within hours.1
Risk of hypersensitivity reactions and flu-like syndrome.1
Importance of women informing their clinician if they are or plan to become pregnant or plan to breast-feed.1
Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, as well as concomitant illnesses.1
Importance of informing patients of other important precautionary information.1 (See Cautions.)
Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.
Routes | Dosage Forms | Strengths | Brand Names | Manufacturer |
|---|---|---|---|---|
Parenteral | For injection concentrate (frozen), for IV infusion | 150 mcg per mL (300 mcg) | Ontak | Ligand |
This report on medications is for your information only, and is not considered individual patient advice. Because of the changing nature of drug information, please consult your physician or pharmacist about specific clinical use.
The American Society of Health-System Pharmacists, Inc. and Drugs.com represent that the information provided hereunder was formulated with a reasonable standard of care, and in conformity with professional standards in the field. The American Society of Health-System Pharmacists, Inc. and Drugs.com make no representations or warranties, express or implied, including, but not limited to, any implied warranty of merchantability and/or fitness for a particular purpose, with respect to such information and specifically disclaims all such warranties. Users are advised that decisions regarding drug therapy are complex medical decisions requiring the independent, informed decision of an appropriate health care professional, and the information is provided for informational purposes only. The entire monograph for a drug should be reviewed for a thorough understanding of the drug's actions, uses and side effects. The American Society of Health-System Pharmacists, Inc. and Drugs.com do not endorse or recommend the use of any drug. The information is not a substitute for medical care.
AHFS Drug Information. © Copyright, 1959-2011, Selected Revisions July 2006. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.
1. Ligand. Ontak (denileukin diftitox) prescribing information. San Diego, CA; 2002 Feb.
2. Nakase K, Kita K, Nasu K et al. Differential expression of interleukin-2 receptors (alpha and beta chain) in mature lymphoid neoplasms. Am J Hematol. 1994; 46:179-83. [PubMed 7514848]
3. Olsen E, Duvic M, Frankel A et al. Pivotal phase III trial of two dose levels of denileukin diftitox for the treatment of cutaneous T-cell lymphoma. J Clin Oncol. 2001; 19:376-88. [IDIS 460619] [PubMed 11208829]
4. Kreitman RJ. Immunotoxins. Expert Opin Pharmacother. 2000; 1:1117-29. [PubMed 11249483]
5. Food and Drug Administration. Orphan designations pursuant to Section 526 of the Federal Food and Cosmetic Act as amended by the Orphan Drug Act (P.L. 97-414). Rockville, MD; 2001 Aug 21. From FDA web site ().
6. Ligand, San Diego, CA: Personal communication.
7. Foss FM, Bacha P, Osann KE et al. Biological correlates of acute hypersensitivity events with DAB389IL-2 (denileukin diftitox, Ontak) in cutaneous T-cell lymphoma: decreased frequency and severity with steroid premedication. Clin Lymphoma. 2001; 1:298-302. [PubMed 11707845]
8. Anon. FDA approves novel treatment for rare form of cancer. FDA Talk Paper. Rockville, MD: Food and Drug Administration. 1999 Feb 5.
a. Ligand. Ontak (denileukin diftitox) prescribing information. San Diego, CA; 2006 Feb.
b. Ghalie R. Dear healthcare professional letter: important drug warning. San Diego, CA: Ligand; 2006 Mar 3. From FDA website ().
