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1 Indications And Usage
Oxcarbazepine tablets are indicated for use as monotherapy or adjunctive therapy in the treatment of partial seizures in adults and as monotherapy in the treatment of partial seizures in children aged 4 years and above with epilepsy, and as adjunctive therapy in children aged 2 years and above with partial seizures.
2 Dosage And Administration
All dosing should be given in a twice-a-day regimen. Oxcarbazepine oral suspension and oxcarbazepine film-coated tablets may be interchanged at equal doses.Oxcarbazepine tablets should be kept out of the reach and sight of children.Oxcarbazepine tablets can be taken with or without food [see ].
Clinical Pharmacology (12.3)
2.1 Adjunctive Therapy For Adults
Treatment with oxcarbazepine tablets should be initiated with a dose of 600 mg/day, given in a twice-a-day regimen. If clinically indicated, the dose may be increased by a maximum of 600 mg/day at approximately weekly intervals; the recommended daily dose is 1200 mg/day. Daily doses above 1200 mg/day show somewhat greater effectiveness in controlled trials, but most patients were not able to tolerate the 2400 mg/day dose, primarily because of CNS effects. It is recommended that the patient be observed closely and plasma levels of the concomitant AEDs be monitored during the period of oxcarbazepine tablets titration, as these plasma levels may be altered, especially at oxcarbazepine tablets doses greater than 1200 mg/day [see ].
Drug Interactions (7.1)
2.2 Conversion To Monotherapy For Adults
Patients receiving concomitant AEDs may be converted to monotherapy by initiating treatment with oxcarbazepine tablets at 600 mg/day (given in a twice-a-day regimen) while simultaneously initiating the reduction of the dose of the concomitant AEDs. The concomitant AEDs should be completely withdrawn over 3-6 weeks, while the maximum dose of oxcarbazepine tablets should be reached in about 2-4 weeks. Oxcarbazepine tablets may be increased as clinically indicated by a maximum increment of 600 mg/day at approximately weekly intervals to achieve the recommended daily dose of 2400 mg/day. A daily dose of 1200 mg/day has been shown in one study to be effective in patients in whom monotherapy has been initiated with oxcarbazepine tablets. Patients should be observed closely during this transition phase.
2.3 Initiation Of Monotherapy For Adults
Patients not currently being treated with AEDs may have monotherapy initiated with oxcarbazepine tablets. In these patients, oxcarbazepine tablets should be initiated at a dose of 600 mg/day (given in a twice-a-day regimen); the dose should be increased by 300 mg/day every third day to a dose of 1200 mg/day. Controlled trials in these patients examined the effectiveness of a 1200 mg/day dose; a dose of 2400 mg/day has been shown to be effective in patients converted from other AEDs to oxcarbazepine tablets monotherapy (see above).
2.4 Adjunctive Therapy For Pediatric Patients (Aged 2-16 Years)
In pediatric patients aged 4-16 years, treatment should be initiated at a daily dose of 8-10 mg/kg generally not to exceed 600 mg/day, given in a twice-a-day regimen. The target maintenance dose of oxcarbazepine tablets should be achieved over two weeks, and is dependent upon patient weight, according to the following chart:20-29 kg - 900 mg/day29.1-39 kg - 1200 mg/day>39 kg - 1800 mg/dayIn the clinical trial, in which the intention was to reach these target doses, the median daily dose was 31 mg/kg with a range of 6-51 mg/kg.In pediatric patients aged 2 to <4 years, treatment should also be initiated at a daily dose of 8-10 mg/kg generally not to exceed 600 mg/day, given in a twice-a-day regimen. For patients under 20 kg, a starting dose of 16-20 mg/kg may be considered [see ]. The maximum maintenance dose of oxcarbazepine tablets should be achieved over 2-4 weeks and should not exceed 60 mg/kg/day in a twice-a-day regimen.
Clinical Pharmacology (12.3)In the clinical trial in pediatric patients (2 to 4 years of age) in which the intention was to reach the target dose of 60 mg/kg/day, 50% of patients reached a final dose of at least 55 mg/kg/day.Under adjunctive therapy (with and without enzyme-inducing AEDs), when normalized by body weight, apparent clearance (L/hr/kg) decreased when age increased such that children 2 to <4 years of age may require up to twice the oxcarbazepine dose per body weight compared to adults; and children 4 to ≤12 years of age may require a 50% higher oxcarbazepine dose per body weight compared to adults.
2.5 Conversion To Monotherapy For Pediatric Patients (Aged 4-16 Years)
Patients receiving concomitant antiepileptic drugs may be converted to monotherapy by initiating treatment with oxcarbazepine tablets at approximately 8-10 mg/kg/day given in a twice-a-day regimen, while simultaneously initiating the reduction of the dose of the concomitant antiepileptic drugs. The concomitant antiepileptic drugs can be completely withdrawn over 3-6 weeks while oxcarbazepine tablets may be increased as clinically indicated by a maximum increment of 10 mg/kg/day at approximately weekly intervals to achieve the recommended daily dose. Patients should be observed closely during this transition phase.The recommended total daily dose of oxcarbazepine tablets is shown in the table below.
2.6 Initiation Of Monotherapy For Pediatric Patients (Aged 4-16 Years)
Patients not currently being treated with antiepileptic drugs may have monotherapy initiated with oxcarbazepine tablets. In these patients, oxcarbazepine tablets should be initiated at a dose of 8-10 mg/kg/day given in a twice-a-day regimen. The dose should be increased by 5 mg/kg/day every third day to the recommended daily dose shown in the table below.Table 1 Range of Maintenance Doses of Oxcarbazepine Tablets for Children by Weight During MonotherapyFromToWeight in kgDose (mg/day)Dose (mg/day)20600900259001200309001200359001500409001500451200150050120018005512001800601200210065120021007015002100
2.7 Patients With Hepatic Impairment
In general, dose adjustments are not required in patients with mild-to-moderate hepatic impairment [see .]
Clinical Pharmacology (12.3)
2.8 Patients With Renal Impairment
In patients with impaired renal function (creatinine clearance <30 mL/min) oxcarbazepine tablets therapy should be initiated at one-half the usual starting dose (300 mg/day) and increased slowly to achieve the desired clinical response [see ]
Clinical Pharmacology (12.3)
3 Dosage Forms And Strengths
Film-coated Tablets: 150 mg, 300 mg and 600 mg.
Oxcarbazepine tablets should not be used in patients with a known hypersensitivity to oxcarbazepine or to any of its components.
Clinically significant hyponatremia (sodium <125 mmol/L) can develop during oxcarbazepine tablets use. In the 14 controlled epilepsy studies 2.5% of oxcarbazepine tablets-treated patients (38/1,524) had a sodium of less than 125 mmol/L at some point during treatment, compared to no such patients assigned placebo or active control (carbamazepine and phenobarbital for adjunctive and monotherapy substitution studies, and phenytoin and valproate for the monotherapy initiation studies). Clinically significant hyponatremia generally occurred during the first three months of treatment with oxcarbazepine tablets, although there were patients who first developed a serum sodium <125 mmol/L more than one year after initiation of therapy. Most patients who developed hyponatremia were asymptomatic but patients in the clinical trials were frequently monitored and some had their oxcarbazepine tablets dose reduced, discontinued, or had their fluid intake restricted for hyponatremia. Whether or not these maneuvers prevented the occurrence of more severe events is unknown. Cases of symptomatic hyponatremia have been reported during post-marketing use. In clinical trials, patients whose treatment with oxcarbazepine tablets was discontinued due to hyponatremia generally experienced normalization of serum sodium within a few days without additional treatment.Measurement of serum sodium levels should be considered for patients during maintenance treatment with oxcarbazepine tablets, particularly if the patient is receiving other medications known to decrease serum sodium levels (for example, drugs associated with inappropriate ADH secretion) or if symptoms possibly indicating hyponatremia develop (e.g., nausea, malaise, headache, lethargy, confusion, obtundation, or increase in seizure frequency or severity).
5.2 Anaphylactic Reactions And Angioedema
Rare cases of anaphylaxis and angioedema involving the larynx, glottis, lips and eyelids have been reported in patients after taking the first or subsequent doses of oxcarbazepine tablets. Angioedema associated with laryngeal edema can be fatal. If a patient develops any of these reactions after treatment with oxcarbazepine tablets, the drug should be discontinued and an alternative treatment started. These patients should not be rechallenged with the drug [see ].
Warnings and Precautions (5.3)
5.3 Patients With A Past History Of Hypersensitivity Reaction To Carbamazepine
Patients who have had hypersensitivity reactions to carbamazepine should be informed that approximately 25%-30% of them will experience hypersensitivity reactions with oxcarbazepine tablets. For this reason patients should be specifically questioned about any prior experience with carbamazepine, and patients with a history of hypersensitivity reactions to carbamazepine should ordinarily be treated with oxcarbazepine tablets only if the potential benefit justifies the potential risk. If signs or symptoms of hypersensitivity develop, oxcarbazepine tablets should be discontinued immediately [see , ].
Warnings and Precautions (5.25.8)
5.4 Serious Dermatological Reactions
Serious dermatological reactions, including Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), have been reported in both children and adults in association with oxcarbazepine tablets use. The median time of onset for reported cases was 19 days. Such serious skin reactions may be life threatening, and some patients have required hospitalization with very rare reports of fatal outcome. Recurrence of the serious skin reactions following rechallenge with oxcarbazepine tablets has also been reported.The reporting rate of TEN and SJS associated with oxcarbazepine tablets use, which is generally accepted to be an underestimate due to underreporting, exceeds the background incidence rate estimates by a factor of 3- to 10-fold. Estimates of the background incidence rate for these serious skin reactions in the general population range between 0.5 to 6 cases per million-person years. Therefore, if a patient develops a skin reaction while taking oxcarbazepine tablets, consideration should be given to discontinuing oxcarbazepine tablets use and prescribing another antiepileptic medication.
5.5 Suicidal Behavior And Ideation
Antiepileptic drugs (AEDs), including oxcarbazepine tablets, increase the risk of suicidal thoughts or behavior in patients taking these drugs for any indication. Patients treated with any AED for any indication should be monitored for the emergence or worsening of depression, suicidal thoughts or behavior, and/or any unusual changes in mood or behavior.Pooled analyses of 199 placebo-controlled clinical trials (mono- and adjunctive therapy) of 11 different AEDs showed that patients randomized to one of the AEDs had approximately twice the risk (adjusted Relative Risk 1.8, 95% CI:1.2, 2.7) of suicidal thinking or behavior compared to patients randomized to placebo. In these trials, which had a median treatment duration of 12 weeks, the estimated incidence rate of suicidal behavior or ideation among 27,863 AED-treated patients was 0.43%, compared to 0.24% among 16,029 placebo-treated patients, representing an increase of approximately one case of suicidal thinking or behavior for every 530 patients treated. There were four suicides in drug-treated patients in the trials and none in placebo-treated patients, but the number is too small to allow any conclusion about drug effect on suicide.The increased risk of suicidal thoughts or behavior with AEDs was observed as early as one week after starting drug treatment with AEDs and persisted for the duration of treatment assessed. Because most trials included in the analysis did not extend beyond 24 weeks, the risk of suicidal thoughts or behavior beyond 24 weeks could not be assessed.The risk of suicidal thoughts or behavior was generally consistent among drugs in the data analyzed. The finding of increased risk with AEDs of varying mechanisms of action and across a range of indications suggests that the risk applies to all AEDs used for any indication. The risk did not vary substantially by age (5-100 years) in the clinical trials analyzed. Table 2 shows absolute and relative risk by indication for all evaluated AEDs.Table 2 Risk by Indication for Antiepileptic Drugs in the Pooled AnalysisIndicationPlacebo Patients with Events Per 1,000 PatientsDrug Patients with Events Per 1,000 PatientsRelative Risk: Incidence of Events in Drug Patients/Incidence in Placebo PatientsRisk Difference: Additional Drug Patients with Events Per 1,000 PatientsEpilepsy1.03.43.52.4Psychiatric220.127.116.11.9Other1.01.81.90.9Total18.104.22.168.9The relative risk for suicidal thoughts or behavior was higher in clinical trials for epilepsy than in clinical trials for psychiatric or other conditions, but the absolute risk differences were similar for the epilepsy and psychiatric indications.Anyone considering prescribing oxcarbazepine tablets or any other AED must balance the risk of suicidal thoughts or behavior with the risk of untreated illness. Epilepsy and many other illnesses for which AEDs are prescribed are themselves associated with morbidity and mortality and an increased risk of suicidal thoughts and behavior. Should suicidal thoughts and behavior emerge during treatment, the prescriber needs to consider whether the emergence of these symptoms in any given patient may be related to the illness being treated.Patients, their caregivers, and families should be informed that AEDs increase the risk of suicidal thoughts and behavior and should be advised of the need to be alert for the emergence or worsening of the signs and symptoms of depression, any unusual changes in mood or behavior, or the emergence of suicidal thoughts, behavior, or thoughts about self-harm. Behaviors of concern should be reported immediately to healthcare providers.
5.6 Withdrawal Of Aeds
As with all antiepileptic drugs, oxcarbazepine tablets should be withdrawn gradually to minimize the potential of increased seizure frequency.
5.7 Cognitive/Neuropsychiatric Adverse Events
Use of oxcarbazepine tablets has been associated with central nervous system-related adverse events. The most significant of these can be classified into three general categories: 1) cognitive symptoms including psychomotor slowing, difficulty with concentration, and speech or language problems, 2) somnolence or fatigue, and 3) coordination abnormalities, including ataxia and gait disturbances.
Adult PatientsIn one large, fixed-dose study, oxcarbazepine tablets was added to existing AED therapy (up to three concomitant AEDs). By protocol, the dosage of the concomitant AEDs could not be reduced as oxcarbazepine tablets was added, reduction in oxcarbazepine tablets dosage was not allowed if intolerance developed, and patients were discontinued if unable to tolerate their highest target maintenance doses. In this trial, 65% of patients were discontinued because they could not tolerate the 2400 mg/day dose of oxcarbazepine tablets on top of existing AEDs. The adverse events seen in this study were primarily CNS related and the risk for discontinuation was dose related.In this trial, 7.1% of oxcarbazepine-treated patients and 4% of placebo-treated patients experienced a cognitive adverse event. The risk of discontinuation for these events was about 6.5 times greater on oxcarbazepine than on placebo. In addition, 26% of oxcarbazepine-treated patients and 12% of placebo-treated patients experienced somnolence. The risk of discontinuation for somnolence was about 10 times greater on oxcarbazepine than on placebo. Finally, 28.7% of oxcarbazepine-treated patients and 6.4% of placebo-treated patients experienced ataxia or gait disturbances. The risk for discontinuation for these events was about seven times greater on oxcarbazepine than on placebo.In a single placebo-controlled monotherapy trial evaluating 2400 mg/day of oxcarbazepine tablets, no patients in either treatment group discontinued double-blind treatment because of cognitive adverse events, somnolence, ataxia, or gait disturbance.In the two dose-controlled conversion to monotherapy trials comparing 2400 mg/day and 300 mg/day oxcarbazepine tablets, 1.1% of patients in the 2400 mg/day group discontinued double-blind treatment because of somnolence or cognitive adverse events compared to 0% in the 300 mg/day group. In these trials, no patients discontinued because of ataxia or gait disturbances in either treatment group.
Pediatric PatientsA study was conducted in pediatric patients (3 to 17 years old) with inadequately controlled partial seizures in which oxcarbazepine tablets was added to existing AED therapy (up to two concomitant AEDs). By protocol, the dosage of concomitant AEDs could not be reduced as oxcarbazepine tablets was added. Oxcarbazepine tablets was titrated to reach a target dose ranging from 30 mg/kg to 46 mg/kg (based on a patient's body weight with fixed doses for predefined weight ranges).Cognitive adverse events occurred in 5.8% of oxcarbazepine-treated patients (the single most common event being concentration impairment, 4 of 138 patients) and in 3.1% of patients treated with placebo. In addition, 34.8% of oxcarbazepine-treated patients and 14.0% of placebo-treated patients experienced somnolence. (No patient discontinued due to a cognitive adverse event or somnolence.). Finally, 23.2% of oxcarbazepine-treated patients and 7.0% of placebo-treated patients experienced ataxia or gait disturbances. Two (1.4%) oxcarbazepine-treated patients and 1 (0.8%) placebo-treated patient discontinued due to ataxia or gait disturbances.
Most Common Adverse Reactions in All Clinical Studies
: The most commonly observed (≥5%) adverse reactions seen in association with oxcarbazepine tablets and substantially more frequent than in placebo-treated patients were: dizziness, somnolence, diplopia, fatigue, nausea, vomiting, ataxia, abnormal vision, abdominal pain, tremor, dyspepsia, abnormal gait.
Adjunctive Therapy/Monotherapy in Adults Previously Treated with other AEDsApproximately 23% of these 1,537 adult patients discontinued treatment because of an adverse experience. The adverse reactions most commonly associated with discontinuation were: dizziness (6.4%), diplopia (5.9%), ataxia (5.2%), vomiting (5.1%), nausea (4.9%), somnolence (3.8%), headache (2.9%), fatigue (2.1%), abnormal vision (2.1%), tremor (1.8%), abnormal gait (1.7%), rash (1.4%), hyponatremia (1.0%).
The most commonly observed (≥5%) adverse reactions seen in association with oxcarbazepine tablets in these patients were similar to those in previously treated patients.
Monotherapy in Adults Not Previously Treated with other AEDs:Approximately 9% of these 295 adult patients discontinued treatment because of an adverse experience. The adverse reactions most commonly associated with discontinuation were: dizziness (1.7%), nausea (1.7%), rash (1.7%), headache (1.4%).
The most commonly observed (≥5%) adverse reactions seen in association with oxcarbazepine tablets in these patients were similar to those seen in adults.
Adjunctive Therapy/Monotherapy in Pediatric Patients 4 Years Old and Above Previously Treated with other AEDs:Approximately 11% of these 456 pediatric patients discontinued treatment because of an adverse experience. The adverse reactions most commonly associated with discontinuation were: somnolence (2.4%), vomiting (2.0%), ataxia (1.8%), diplopia (1.3%), dizziness (1.3%), fatigue (1.1%), nystagmus (1.1%).
The most commonly observed (≥5%) adverse reactions seen in association with oxcarbazepine tablets in these patients were similar to those in adults.
Monotherapy in Pediatric Patients 4 Years Old and Above Not Previously Treated with other AEDs:Approximately 9.2% of 152 pediatric patients discontinued treatment because of an adverse experience. The adverse reactions most commonly associated (≥1%) with discontinuation were rash (5.3%) and maculopapular rash (1.3%).
The most commonly observed (≥5%) adverse reactions seen in association with oxcarbazepine tablets in these patients were similar to those seen in older children and adults except for infections and infestations which were more frequently seen in these younger children.
Adjunctive Therapy/Monotherapy in Pediatric Patients 1 Month to <4 Years Old Previously Treated or Not Previously Treated with other AEDs:Approximately 11% of these 241 pediatric patients discontinued treatment because of an adverse experience. The adverse reaction most commonly associated with discontinuation were: convulsions (3.7%), status epilepticus (1.2%), and ataxia (1.2%).
The prescriber should be aware that the figures in Tables 3, 4, 5 and 6 cannot be used to predict the frequency of adverse reactions in the course of usual medical practice where patient characteristics and other factors may differ from those prevailing during clinical studies. Similarly, the cited frequencies cannot be directly compared with figures obtained from other clinical investigations involving different treatments, uses, or investigators. An inspection of these frequencies, however, does provide the prescriber with one basis to estimate the relative contribution of drug and nondrug factors to the adverse event incidences in the population studied.
Incidence in Controlled Clinical Studies:
Table 3 lists treatment-emergent signs and symptoms that occurred in at least 2% of adult patients with epilepsy treated with oxcarbazepine tablets or placebo as adjunctive treatment and were numerically more common in the patients treated with any dose of oxcarbazepine tablets. Table 4 lists treatment-emergent signs and symptoms in patients converted from other AEDs to either high dose oxcarbazepine tablets or low dose (300 mg) oxcarbazepine tablets. Note that in some of these monotherapy studies patients who dropped out during a preliminary tolerability phase are not included in the tables.
Controlled Clinical Studies of Adjunctive Therapy/Monotherapy in Adults Previously Treated with other AEDs:Table 3 Treatment-Emergent Adverse Event Incidence in a Controlled Clinical Study of Adjunctive Therapy in Adults (Events in at Least 2% of Patients Treated with 2400 mg/day of Oxcarbazepine Tablets and Numerically More Frequent than in the Placebo Group)Oxcarbazepine Dosage (mg/day)Body System/ Adverse Event
OXC 600 N=163 %
OXC 1200 N=171 %
OXC 2400 N=126 %
Placebo N=166 %
Body as a Whole Fatigue1512157 Asthenia6365 Edema Legs2121 Weight Increase1221 Feeling Abnormal0120Cardiovascular System Hypotension0120Digestive System Nausea15252910 Vomiting1325365 Pain Abdominal1013115 Diarrhea5676 Dyspepsia5562 Constipation2264 Gastritis2121Metabolic and Nutritional Disorders Hyponatremia3121Musculoskeletal System Muscle Weakness1220 Sprains and Strains0221Nervous System Headache32282623 Dizziness26324913 Somnolence20283612 Ataxia917315 Nystagmus720265 Gait Abnormal510171 Insomnia4231 Tremor38165 Nervousness2421 Agitation1121 Coordination Abnormal1321 EEG Abnormal0020 Speech Disorder1130 Confusion1121 Cranial Injury NOS1021 Dysmetria1230 Thinking Abnormal0240Respiratory System Rhinitis2454Skin and Appendages Acne1220Special Senses Diplopia1430405 Vertigo612152 Vision Abnormal614134 Accommodation Abnormal0020Table 4 Treatment-Emergent Adverse Event Incidence in Controlled Clinical Studies of Monotherapy in Adults Previously Treated with Other AEDs (Events in at Least 2% of Patients Treated with 2400 mg/day of Oxcarbazepine Tablets and Numerically More Frequent than in the Low Dose Control Group)Oxcarbazepine Dosage (mg/day)Body System/ Adverse Event
2400 N=86 %
300 N=86 %
Body as a Whole Fatigue215 Fever30 Allergy20 Edema Generalized21 Pain Chest20Digestive System Nausea227 Vomiting155 Diarrhea75 Dyspepsia61 Anorexia53 Pain Abdominal53 Mouth Dry30 Hemorrhage Rectum20 Toothache21Hemic and Lymphatic System Lymphadenopathy20Infections and Infestations Infection Viral75 Infection20Metabolic and Nutritional Disorders Hyponatremia50 Thirst20Nervous System Headache3115 Dizziness288 Somnolence195 Anxiety75 Ataxia71 Confusion70 Nervousness70 Insomnia63 Tremor63 Amnesia51 Convulsions Aggravated52 Emotional Lability32 Hypoesthesia31 Coordination Abnormal21 Nystagmus20 Speech Disorder20Respiratory System Upper Respiratory Tract Infection105 Coughing50 Bronchitis30 Pharyngitis30Skin and Appendages Hot Flushes21 Purpura20Special Senses Vision Abnormal142 Diplopia121 Taste Perversion50 Vertigo30 Earache21 Ear Infection NOS20Urogenital and Reproductive System Urinary Tract Infection51 Micturition Frequency21 Vaginitis20
Controlled Clinical Study of Monotherapy in Adults Not Previously Treated with other AEDs: Table 5 lists treatment-emergent signs and symptoms in a controlled clinical study of monotherapy in adults not previously treated with other AEDs that occurred in at least 2% of adult patients with epilepsy treated with oxcarbazepine tablets or placebo and were numerically more common in the patients treated with oxcarbazepine tablets.Table 5 Treatment-Emergent Adverse Event Incidence in a Controlled Clinical Study of Monotherapy in Adults Not Previously Treated with Other AEDs (Events in at Least 2% of Patients Treated with Oxcarbazepine Tablets and Numerically More Frequent than in the Placebo Group)Body System/ Adverse Event
Oxcarbazepine N=55 %
Placebo N=49 %
Body as a Whole Falling Down NOS40Digestive System Nausea1612 Diarrhea72 Vomiting76 Constipation50 Dyspepsia54Musculoskeletal System Pain Back42Nervous System Dizziness226 Headache1310 Ataxia50 Nervousness52 Amnesia42 Coordination Abnormal42 Tremor40Respiratory System Upper Respiratory Tract Infection70 Epistaxis40 Infection Chest40 Sinusitis42Skin and Appendages Rash42Special Senses Vision Abnormal40
Controlled Clinical Studies of Adjunctive Therapy/Monotherapy in Pediatric Patients Previously Treated with other AEDs: Table 6 lists treatment-emergent signs and symptoms that occurred in at least 2% of pediatric patients with epilepsy treated with oxcarbazepine tablets or placebo as adjunctive treatment and were numerically more common in the patients treated with oxcarbazepine tablets.Table 6 Treatment-Emergent Adverse Event Incidence in Controlled Clinical Studies of Adjunctive Therapy/Monotherapy in Pediatric Patients Previously Treated with Other AEDs (Events in at Least 2% of Patients Treated with Oxcarbazepine Tablets and Numerically More Frequent than in the Placebo Group)Body System/ Adverse Event
Oxcarbazepine N=171 %
Placebo N=139 %
Body as a Whole Fatigue139 Allergy20 Asthenia21Digestive System Vomiting3314 Nausea195 Constipation41 Dyspepsia20Nervous System Headache3119 Somnolence3113 Dizziness288 Ataxia134 Nystagmus91 Emotional Lability84 Gait Abnormal83 Tremor64 Speech Disorder31 Concentration Impaired21 Convulsions21 Muscle Contractions Involuntary21Respiratory System Rhinitis109 Pneumonia21Skin and Appendages Bruising42 Sweating Increased30Special Senses Diplopia171 Vision Abnormal131 Vertigo20
Other Events Observed in Association with the Administration of Oxcarbazepine TabletsIn the paragraphs that follow, the adverse events, other than those in the preceding tables or text, that occurred in a total of 565 children and 1,574 adults exposed to oxcarbazepine tablets and that are reasonably likely to be related to drug use are presented. Events common in the population, events reflecting chronic illness and events likely to reflect concomitant illness are omitted particularly if minor. They are listed in order of decreasing frequency. Because the reports cite events observed in open label and uncontrolled trials, the role of oxcarbazepine tablets in their causation cannot be reliably determined.fever, malaise, pain chest precordial, rigors, weight decrease.
Body as a Whole:bradycardia, cardiac failure, cerebral hemorrhage, hypertension, hypotension postural, palpitation, syncope, tachycardia.
Cardiovascular System:appetite increased, blood in stool, cholelithiasis, colitis, duodenal ulcer, dysphagia, enteritis, eructation, esophagitis, flatulence, gastric ulcer, gingival bleeding, gum hyperplasia, hematemesis, hemorrhage rectum, hemorrhoids, hiccup, mouth dry, pain biliary, pain right hypochondrium, retching, sialoadenitis, stomatitis, stomatitis ulcerative.
Hematologic and Lymphatic System:Laboratory Abnormality: gamma-GT increased, hyperglycemia, hypocalcemia, hypoglycemia, hypokalemia, liver enzymes elevated, serum transaminase increased.hypertonia muscle.
Musculoskeletal System:aggressive reaction, amnesia, anguish, anxiety, apathy, aphasia, aura, convulsions aggravated, delirium, delusion, depressed level of consciousness, dysphonia, dystonia, emotional lability, euphoria, extrapyramidal disorder, feeling drunk, hemiplegia, hyperkinesia, hyperreflexia, hypoesthesia, hypokinesia, hyporeflexia, hypotonia, hysteria, libido decreased, libido increased, manic reaction, migraine, muscle contractions involuntary, nervousness, neuralgia, oculogyric crisis, panic disorder, paralysis, paroniria, personality disorder, psychosis, ptosis, stupor, tetany.
Nervous System:asthma, dyspnea, epistaxis, laryngismus, pleurisy.
Respiratory System:acne, alopecia, angioedema, bruising, dermatitis contact, eczema, facial rash, flushing, folliculitis, heat rash, hot flushes, photosensitivity reaction, pruritus genital, psoriasis, purpura, rash erythematous, rash maculopapular, vitiligo, urticaria.
Skin and Appendages:accommodation abnormal, cataract, conjunctival hemorrhage, edema eye, hemianopia, mydriasis, otitis externa, photophobia, scotoma, taste perversion, tinnitus, xerophthalmia.
Special Senses:procedure dental oral, procedure female reproductive, procedure musculoskeletal, procedure skin.
Surgical and Medical Procedures:dysuria, hematuria, intermenstrual bleeding, leukorrhea, menorrhagia, micturition frequency, pain renal, pain urinary tract, polyuria, priapism, renal calculus.
Urogenital and Reproductive System:Other: Systemic lupus erythematosus.
Human Overdose ExperienceIsolated cases of overdose with oxcarbazepine tablets have been reported. The maximum dose taken was approximately 24,000 mg. All patients recovered with symptomatic treatment.
Treatment and ManagementThere is no specific antidote. Symptomatic and supportive treatment should be administered as appropriate. Removal of the drug by gastric lavage and/or inactivation by administering activated charcoal should be considered.
AbsorptionBased on MHD concentrations, oxcarbazepine tablets and suspension were shown to have similar bioavailability. After single-dose administration of oxcarbazepine tablets to healthy male volunteers under fasted conditions, the median tmax was 4.5 (range 3 to 13) hours.Steady-state plasma concentrations of MHD are reached within 2-3 days in patients when oxcarbazepine tablets are given twice a day. At steady state the pharmacokinetics of MHD are linear and show dose proportionality over the dose range of 300 to 2400 mg/day.Food has no effect on the rate and extent of absorption of oxcarbazepine from oxcarbazepine tablets. Oxcarbazepine tablets can be taken with or without food.
Effect of Food:
DistributionThe apparent volume of distribution of MHD is 49L.Approximately 40% of MHD is bound to serum proteins, predominantly to albumin. Binding is independent of the serum concentration within the therapeutically relevant range. Oxcarbazepine and MHD do not bind to alpha-1-acid glycoprotein.
Metabolism and ExcretionOxcarbazepine is rapidly reduced by cytosolic enzymes in the liver to its 10-monohydroxy metabolite, MHD, which is primarily responsible for the pharmacological effect of oxcarbazepine tablets. MHD is metabolized further by conjugation with glucuronic acid. Minor amounts (4% of the dose) are oxidized to the pharmacologically inactive 10,11-dihydroxy metabolite (DHD).Oxcarbazepine is cleared from the body mostly in the form of metabolites which are predominantly excreted by the kidneys. More than 95% of the dose appears in the urine, with less than 1% as unchanged oxcarbazepine. Fecal excretion accounts for less than 4% of the administered dose. Approximately 80% of the dose is excreted in the urine either as glucuronides of MHD (49%) or as unchanged MHD (27%); the inactive DHD accounts for approximately 3% and conjugates of MHD and oxcarbazepine account for 13% of the dose.The half-life of the parent is about two hours, while the half-life of MHD is about nine hours.
Hepatic ImpairmentThe pharmacokinetics and metabolism of oxcarbazepine and MHD were evaluated in healthy volunteers and hepatically-impaired subjects after a single 900-mg oral dose. Mild-to-moderate hepatic impairment did not affect the pharmacokinetics of oxcarbazepine and MHD. No dose adjustment for oxcarbazepine tablets is recommended in patients with mild-to-moderate hepatic impairment. The pharmacokinetics of oxcarbazepine and MHD have not been evaluated in severe hepatic impairment and, therefore, caution should be exercised when dosing severely impaired patients [see ].
Dosage and Administration (2.7)
Renal ImpairmentThere is a linear correlation between creatinine clearance and the renal clearance of MHD. When oxcarbazepine tablets are administered as a single 300-mg dose in renally-impaired patients (creatinine clearance <30 mL/min), the elimination half-life of MHD is prolonged to 19 hours, with a two-fold increase in AUC. Dose adjustment for oxcarbazepine tablets is recommended in these patients [see and see ].
Use in Specific Populations (8.6)Dosage and Administration (2.8)
PediatricsWeight-adjusted MHD clearance decreases as age and weight increases, approaching that of adults. The mean weight-adjusted clearance in children 2 years-<4 years of age is approximately 80% higher on average than that of adults. Therefore, MHD exposure in these children is expected to be about one-half that of adults when treated with a similar weight-adjusted dose. The mean weight-adjusted clearance in children 4-12 years of age is approximately 40% higher on average than that of adults. Therefore, MHD exposure in these children is expected to be about three-quarters that of adults when treated with a similar weight-adjusted dose. As weight increases, for patients 13 years of age and above, the weight-adjusted MHD clearance is expected to reach that of adults.
PregnancyDue to physiological changes during pregnancy, MHD plasma levels may gradually decrease throughout pregnancy [see ]
Use in Specific Populations (8.1)
GeriatricsFollowing administration of single (300 mg) and multiple (600 mg/day) doses of oxcarbazepine tablets to elderly volunteers (60-82 years of age), the maximum plasma concentrations and AUC values of MHD were 30%-60% higher than in younger volunteers (18-32 years of age). Comparisons of creatinine clearance in young and elderly volunteers indicate that the difference was due to age-related reductions in creatinine clearance.
GenderNo gender-related pharmacokinetic differences have been observed in children, adults, or the elderly.
RaceNo specific studies have been conducted to assess what effect, if any, race may have on the disposition of oxcarbazepine.
In VitroOxcarbazepine can inhibit CYP2C19 and induce CYP3A4/5 with potentially important effects on plasma concentrations of other drugs. In addition, several AEDs that are cytochrome P450 inducers can decrease plasma concentrations of oxcarbazepine and MHD.Oxcarbazepine was evaluated in human liver microsomes to determine its capacity to inhibit the major cytochrome P450 enzymes responsible for the metabolism of other drugs. Results demonstrate that oxcarbazepine and its pharmacologically active 10-monohydroxy metabolite (MHD) have little or no capacity to function as inhibitors for most of the human cytochrome P450 enzymes evaluated (CYP1A2, CYP2A6, CYP2C9, CYP2D6, CYP2E1, CYP4A9 and CYP4A11) with the exception of CYP2C19 and CYP3A4/5. Although inhibition of CYP3A4/5 by oxcarbazepine and MHD did occur at high concentrations, it is not likely to be of clinical significance. The inhibition of CYP2C19 by oxcarbazepine and MHD, is clinically relevant.the UDP-glucuronyl transferase level was increased, indicating induction of this enzyme. Increases of 22% with MHD and 47% with oxcarbazepine were observed. As MHD, the predominant plasma substrate, is only a weak inducer of UDP-glucuronyl transferase, it is unlikely to have an effect on drugs that are mainly eliminated by conjugation through UDP-glucuronyl transferase (e.g., valproic acid, lamotrigine).
In vitro,In addition, oxcarbazepine and MHD induce a subgroup of the cytochrome P450 3A family (CYP3A4 and CYP3A5) responsible for the metabolism of dihydropyridine calcium antagonists, oral contraceptives and cyclosporine resulting in a lower plasma concentration of these drugs.As binding of MHD to plasma proteins is low (40%), clinically significant interactions with other drugs through competition for protein binding sites are unlikely.
In VivoFor drug interactions [see ].
in vivoDrug Interactions (7)
CarcinogenesisIn two-year carcinogenicity studies, oxcarbazepine was administered in the diet at doses of up to 100 mg/kg/day to mice and by gavage at doses of up to 250 mg/kg/day to rats, and the pharmacologically active 10-hydroxy metabolite (MHD) was administered orally at doses of up to 600 mg/kg/day to rats. In mice, a dose-related increase in the incidence of hepatocellular adenomas was observed at oxcarbazepine doses ≥70 mg/kg/day or approximately 0.1 times the maximum recommended human dose (MRHD) on a mg/m basis. In rats, the incidence of hepatocellular carcinomas was increased in females treated with oxcarbazepine at doses ≥25 mg/kg/day (0.1 times the MRHD on a mg/m basis), and incidences of hepatocellular adenomas and/or carcinomas were increased in males and females treated with MHD at doses of 600 mg/kg/day (2.4 times the MRHD on a mg/m basis) and ≥250 mg/kg/day (equivalent to the MRHD on a mg/m basis), respectively. There was an increase in the incidence of benign testicular interstitial cell tumors in rats at 250 mg oxcarbazepine/kg/day and at ≥250 mg MHD/kg/day, and an increase in the incidence of granular cell tumors in the cervix and vagina in rats at 600 mg MHD/kg/day.
MutagenesisOxcarbazepine increased mutation frequencies in the Ames test in the absence of metabolic activation in one of five bacterial strains. Both oxcarbazepine and MHD produced increases in chromosomal aberrations and polyploidy in the Chinese hamster ovary assay in the absence of metabolic activation. MHD was negative in the Ames test, and no mutagenic or clastogenic activity was found with either oxcarbazepine or MHD in V79 Chinese hamster cells . Oxcarbazepine and MHD were both negative for clastogenic or aneugenic effects (micronucleus formation) in an rat bone marrow assay.
in vitroin vitroin vitroin vivo
Impairment of FertilityIn a fertility study in which rats were administered MHD (50, 150, or 450 mg/kg) orally prior to and during mating and early gestation, estrous cyclicity was disrupted and numbers of corpora lutea, implantations, and live embryos were reduced in females receiving the highest dose (approximately two times the MRHD on a mg/m basis).
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5.8 Multi-Organ Hypersensitivity
Multi-organ hypersensitivity reactions have occurred in close temporal association (median time to detection 13 days: range 4-60) to the initiation of oxcarbazepine tablets therapy in adult and pediatric patients. Although there have been a limited number of reports, many of these cases resulted in hospitalization and some were considered life threatening. Signs and symptoms of this disorder were diverse; however, patients typically, although not exclusively, presented with fever and rash associated with other organ system involvement. These may include hematologic and lymphatic (e.g., eosinophilia, thrombocytopenia, lymphadenopathy, leukopenia, neutropenia, splenomegaly), hepatobiliary (e.g., hepatitis, liver function test abnormalities), renal (e.g., proteinuria, nephritis, oliguria, renal failure), muscles and joints (e.g., joint swelling, myalgia, arthralgia, asthenia), nervous system (e.g., hepatic encephalopathy), respiratory (e.g., dyspnea, pulmonary edema, asthma, bronchospasm, interstitial lung disease), hepatorenal syndrome, pruritus, and angioedema. Because the disorder is variable in its expression, other organ system symptoms and signs, not noted here, may occur. If this reaction is suspected, oxcarbazepine tablets should be discontinued and an alternative treatment started. Although there are no case reports to indicate cross sensitivity with other drugs that produce this syndrome, the experience amongst drugs associated with multi-organ hypersensitivity would indicate this to be a possibility [see ].
Warnings and Precautions (5.3)
5.9 Hematologic Events
Rare reports of pancytopenia, agranulocytosis, and leukopenia have been seen in patients treated with oxcarbazepine tablets during post-marketing experience. Discontinuation of the drug should be considered if any evidence of these hematologic events develop.
5.10 Seizure Control During Pregnancy
Due to physiological changes during pregnancy, plasma levels of the active metabolite of oxcarbazepine, the 10-monohydroxy derivative (MHD), may gradually decrease throughout pregnancy. It is recommended that patients be monitored carefully during pregnancy. Close monitoring should continue through the postpartum period because MHD levels may return after delivery.
5.11 Laboratory Tests
Serum sodium levels below 125 mmol/L have been observed in patients treated with oxcarbazepine tablets [see ]. Experience from clinical trials indicates that serum sodium levels return toward normal when the oxcarbazepine tablets dosage is reduced or discontinued, or when the patient was treated conservatively (e.g., fluid restriction).
Warnings and Precautions (5.1)Laboratory data from clinical trials suggest that oxcarbazepine tablets use was associated with decreases in T , without changes in T or TSH.
5.12 Fd&C Yellow No. 5 (Tartrazine)
This product contains FD&C Yellow No. 5 (tartrazine) which may cause allergic type reactions (including bronchial asthma) in certain susceptible persons. Although the overall incidence of FD&C Yellow No. 5 (tartrazine) sensitivity in the general population is low, it is frequently seen in patients who also have aspirin sensitivity.
6 Adverse Reactions
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
6.2 Post-Marketing And Other Experience
The following adverse events not seen in controlled clinical trials have been observed in named patient programs or post- marketing experience:multi-organ hypersensitivity disorders characterized by features such as rash, fever, lymphadenopathy, abnormal liver function tests, eosinophilia and arthralgia [see ]
Body as a Whole:Warnings and Precautions (5.8)[see ]
Anaphylaxis:Warnings and Precautions (5.2)pancreatitis and/or lipase and/or amylase increase
Digestive System:Systems: aplastic anemia [see ]
Hematologic and LymphaticWarnings and Precautions (5.9)hypothyroidism
Metabolism:erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis [see ]
Skin and Appendages:Warnings and Precautions (5.4)
7 Drug Interactions
Oxcarbazepine can inhibit CYP2C19 and induce CYP3A4/5 with potentially important effects on plasma concentrations of other drugs. The inhibition of CYP2C19 by oxcarbazepine and MHD can cause increased plasma concentrations of drugs that are substrates of CYP2C19. Oxcarbazepine and MHD induce a subgroup of the cytochrome P450 3A family (CYP3A4 and CYP3A5) responsible for the metabolism of dihydropyridine calcium antagonists, oral contraceptives and cyclosporine resulting in a lower plasma concentration of these drugs. [see ]
Clinical Pharmacology (12.3)In addition, several AEDs that are cytochrome P450 inducers can decrease plasma concentrations of oxcarbazepine and MHD. No autoinduction has been observed with oxcarbazepine tablets.
7.1 Antiepileptic Drugs
Potential interactions between oxcarbazepine tablets and other AEDs were assessed in clinical studies. The effect of these interactions on mean AUCs and C are summarized in Table 7.
minTable 7 Summary of AED Interactions with Oxcarbazepine TabletsAED CoadministeredDose of AED (mg/day)
Oxcarbazepine Tablets Dose (mg/day)
Influence of Oxcarbazepine Tablets on AED Concentration (Mean Change, 90% Confidence Interval)Influence of AED on MHD Concentration (Mean Change, 90% Confidence Interval)Carbamazepine400-2000900nc
nc denotes a mean change of less than 10%40% decrease [CI:17% decrease, 57% decrease]Phenobarbital100-150600-180014% increase [CI: 2% increase, 24% increase]25% decrease [CI:12% decrease, 51% decrease]Phenytoin250-500600-1800nc
,Pediatrics30% decrease>1200-2400up to 40% increase [CI: 12% increase, 60% increase]
Mean increase in adults at high oxcarbazepine tablets doses[CI: 3% decrease, 48% decrease]Valproic acid400-2800600-1800nc
18% decrease [CI:13% decrease, 40% decrease], the plasma levels of phenytoin increased by up to 40% when oxcarbazepine tablets was given at doses above 1200 mg/day. Therefore, when using doses of oxcarbazepine tablets greater than 1200 mg/day during adjunctive therapy, a decrease in the dose of phenytoin may be required. The increase of phenobarbital level, however, is small (15%) when given with oxcarbazepine tablets.
In vivoStrong inducers of cytochrome P450 enzymes (i.e., carbamazepine, phenytoin and phenobarbital) have been shown to decrease the plasma levels of MHD (29%-40%).No autoinduction has been observed with oxcarbazepine tablets.
7.2 Hormonal Contraceptives
Coadministration of oxcarbazepine tablets with an oral contraceptive has been shown to influence the plasma concentrations of the two hormonal components, ethinylestradiol (EE) and levonorgestrel (LNG). The mean AUC values of EE were decreased by 48% [90% CI: 22-65] in one study and 52% [90% CI: 38-52] in another study. The mean AUC values of LNG were decreased by 32% [90% CI: 20-45] in one study and 52% [90% CI: 42-52] in another study. Therefore, concurrent use of oxcarbazepine tablets with hormonal contraceptives may render these contraceptives less effective. Studies with other oral or implant contraceptives have not been conducted.
7.3 Calcium Antagonists
After repeated coadministration of oxcarbazepine tablets, the AUC of felodipine was lowered by 28% [90% CI: 20-33]. Verapamil produced a decrease of 20% [90% CI: 18-27] of the plasma levels of MHD.
7.4 Other Drug Interactions
Cimetidine, erythromycin and dextropropoxyphene had no effect on the pharmacokinetics of MHD. Results with warfarin show no evidence of interaction with either single or repeated doses of oxcarbazepine tablets.
7.5 Drug/Laboratory Test Interactions
There are no known interactions of oxcarbazepine tablets with commonly used laboratory tests.
Oxcarbazepine tablets levels may decrease during pregnancy [see ].
Warnings and Precautions (5.10)
Pregnancy Category CThere are no adequate and well-controlled clinical studies of oxcarbazepine tablets in pregnant women; however, oxcarbazepine tablets is closely related structurally to carbamazepine, which is considered to be teratogenic in humans. Given this fact, and the results of the animal studies described, it is likely that oxcarbazepine tablets is a human teratogen. Oxcarbazepine tablets should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.Increased incidences of fetal structural abnormalities and other manifestations of developmental toxicity (embryolethality, growth retardation) were observed in the offspring of animals treated with either oxcarbazepine or its active 10-hydroxy metabolite (MHD) during pregnancy at doses similar to the maximum recommended human dose.When pregnant rats were given oxcarbazepine (30, 300, or 1000 mg/kg) orally throughout the period of organogenesis, increased incidences of fetal malformations (craniofacial, cardiovascular, and skeletal) and variations were observed at the intermediate and high doses (approximately 1.2 and 4 times, respectively, the maximum recommended human dose [MRHD] on a mg/m basis). Increased embryofetal death and decreased fetal body weights were seen at the high dose. Doses ≥300 mg/kg were also maternally toxic (decreased body weight gain, clinical signs), but there is no evidence to suggest that teratogenicity was secondary to the maternal effects.
2In a study in which pregnant rabbits were orally administered MHD (20, 100, or 200 mg/kg) during organogenesis, embryofetal mortality was increased at the highest dose (1.5 times the MRHD on a mg/m basis). This dose produced only minimal maternal toxicity.
2In a study in which female rats were dosed orally with oxcarbazepine (25, 50, or 150 mg/kg) during the latter part of gestation and throughout the lactation period, a persistent reduction in body weights and altered behavior (decreased activity) were observed in offspring exposed to the highest dose (0.6 times the MRHD on a mg/m basis). Oral administration of MHD (25, 75, or 250 mg/kg) to rats during gestation and lactation resulted in a persistent reduction in offspring weights at the highest dose (equivalent to the MRHD on a mg/m basis).
22To provide information regarding the effects of exposure to oxcarbazepine tablets, physicians are advised to recommend that pregnant patients taking oxcarbazepine tablets enroll in the NAAED Pregnancy Registry. This can be done by calling the toll free number 1-888-233-2334, and must be done by patients themselves. Information on the registry can also be found at the website http://www.aedpregnancyregistry.org/.
8.2 Labor And Delivery
The effect of oxcarbazepine tablets on labor and delivery in humans has not been evaluated.
8.3 Nursing Mothers
Oxcarbazepine and its active metabolite (MHD) are excreted in human milk. A milk-to-plasma concentration ratio of 0.5 was found for both. Because of the potential for serious adverse reactions to oxcarbazepine tablets in nursing infants, a decision should be made about whether to discontinue nursing or to discontinue the drug in nursing women, taking into account the importance of the drug to the mother.
8.4 Pediatric Use
Oxcarbazepine tablets is indicated for use as adjunctive therapy for partial seizures in patients aged 2-16 years. Oxcarbazepine tablets is also indicated as monotherapy for partial seizures in patients aged 4-16 years. Oxcarbazepine tablets has been given to 898 patients between the ages of 1 month-17 years in controlled clinical trials (332 treated as monotherapy) and about 677 patients between the ages of 1 month-17 years in other trials [see for a description of the adverse events associated with oxcarbazepine tablets use in this population].
Adverse Reactions (6.1)
8.5 Geriatric Use
There were 52 patients over age 65 in controlled clinical trials and 565 patients over the age of 65 in other trials. Following administration of single (300 mg) and multiple (600 mg/day) doses of oxcarbazepine tablets in elderly volunteers (60-82 years of age), the maximum plasma concentrations and AUC values of MHD were 30%-60% higher than in younger volunteers (18-32 years of age). Comparisons of creatinine clearance in young and elderly volunteers indicate that the difference was due to age-related reductions in creatinine clearance.
8.6 Renal Impairment
In renally-impaired patients (creatinine clearance <30 mL/min), the elimination half-life of MHD is prolonged with a corresponding two-fold increase in AUC [see ]. Oxcarbazepine tablets therapy should be initiated at one-half the usual starting dose and increased, if necessary, at a slower than usual rate until the desired clinical response is achieved.
Clinical Pharmacology (12.3)
The abuse potential of oxcarbazepine tablets has not been evaluated in human studies.
Intragastric injections of oxcarbazepine to four cynomolgus monkeys demonstrated no signs of physical dependence as measured by the desire to self-administer oxcarbazepine by lever pressing activity.
Oxcarbazepine tablets is an antiepileptic drug available as 150 mg, 300 mg and 600 mg film-coated tablets for oral administration. Oxcarbazepine is 10,11-Dihydro-10-oxo-5 -dibenz[b,ƒ]azepine-5-carboxamide, and its structural formula is
HOxcarbazepine is a white to faintly orange crystalline powder. It is slightly soluble in chloroform, dichloromethane, acetone, and methanol and practically insoluble in ethanol, ether and water. Its molecular weight is 252.27.Oxcarbazepine film-coated tablets contain the following inactive ingredients: microcrystalline cellulose, crospovidone, hypromellose, colloidal silicon dioxide, magnesium stearate, talc.Coating: polyvinyl alcohol, talc, titanium dioxide, polyethylene glycol, FD&C Yellow No. 6 aluminum lake, lecithin, FD&C Blue No. 2 aluminum lake, FD&C Yellow No. 5 aluminum lake.
Contains FD&C Yellow No. 6 as a color additive.Contains FD&C Yellow No. 5 as a color additive. [See ].
WARNINGS AND PRECAUTIONS (5.12)Allergen Statement: This product contains soy.
12.1 Mechanism Of Action
The pharmacological activity of oxcarbazepine tablets is primarily exerted through the 10-monohydroxy metabolite (MHD) of oxcarbazepine [see ]. The precise mechanism by which oxcarbazepine and MHD exert their antiseizure effect is unknown; however, electrophysiological studies indicate that they produce blockade of voltage-sensitive sodium channels, resulting in stabilization of hyperexcited neural membranes, inhibition of repetitive neuronal firing, and diminution of propagation of synaptic impulses. These actions are thought to be important in the prevention of seizure spread in the intact brain. In addition, increased potassium conductance and modulation of high-voltage activated calcium channels may contribute to the anticonvulsant effects of the drug. No significant interactions of oxcarbazepine or MHD with brain neurotransmitter or modulator receptor sites have been demonstrated.
Clinical Pharmacology (12.3)in vitro
Oxcarbazepine and its active metabolite (MHD) exhibit anticonvulsant properties in animal seizure models. They protected rodents against electrically induced tonic extension seizures and, to a lesser degree, chemically induced clonic seizures, and abolished or reduced the frequency of chronically recurring focal seizures in Rhesus monkeys with aluminum implants. No development of tolerance (i.e., attenuation of anticonvulsive activity) was observed in the maximal electroshock test when mice and rats were treated daily for five days and four weeks, respectively, with oxcarbazepine or MHD.
Following oral administration of oxcarbazepine tablets, oxcarbazepine is completely absorbed and extensively metabolized to its pharmacologically active 10-monohydroxy metabolite (MHD). In a mass balance study in people, only 2% of total radioactivity in plasma was due to unchanged oxcarbazepine, with approximately 70% present as MHD, and the remainder attributable to minor metabolites.The half-life of the parent is about two hours, while the half-life of MHD is about nine hours, so that MHD is responsible for most antiepileptic activity.
14 Clinical Studies
The effectiveness of oxcarbazepine tablets as adjunctive and monotherapy for partial seizures in adults, and as adjunctive therapy in children aged 2-16 years was established in seven multicenter, randomized, controlled trials.The effectiveness of oxcarbazepine tablets as monotherapy for partial seizures in children aged 4-16 years was determined from data obtained in the studies described, as well as by pharmacokinetic/pharmacodynamic considerations.
14.1 Oxcarbazepine Tablets Monotherapy Trials
Four randomized, controlled, double-blind, multicenter trials, conducted in a predominately adult population, demonstrated the efficacy of oxcarbazepine tablets as monotherapy. Two trials compared oxcarbazepine tablets to placebo and two trials used a randomized withdrawal design to compare a high dose (2400 mg) with a low dose (300 mg) of oxcarbazepine tablets, after substituting oxcarbazepine tablets 2400 mg/day for one or more antiepileptic drugs (AEDs). All doses were administered on a twice-a-day schedule. A fifth randomized, controlled, rater-blind, multicenter study, conducted in a pediatric population, failed to demonstrate a statistically significant difference between low and high dose oxcarbazepine tablets treatment groups.One placebo-controlled trial was conducted in 102 patients (11-62 years of age) with refractory partial seizures who had completed an inpatient evaluation for epilepsy surgery. Patients had been withdrawn from all AEDs and were required to have 2-10 partial seizures within 48 hours prior to randomization. Patients were randomized to receive either placebo or oxcarbazepine tablets given as 1500 mg/day on Day 1 and 2400 mg/day thereafter for an additional nine days, or until one of the following three exit criteria occurred: 1) the occurrence of a fourth partial seizure, excluding Day 1, 2) two new-onset secondarily generalized seizures, where such seizures were not seen in the one-year period prior to randomization, or 3) occurrence of serial seizures or status epilepticus. The primary measure of effectiveness was a between-group comparison of the time to meet exit criteria. There was a statistically significant difference in favor of oxcarbazepine tablets (see ), p=0.0001.
Figure 1Figure 1 Kaplan-Meier Estimates of Exit Rate by Treatment GroupThe second placebo-controlled trial was conducted in 67 untreated patients (8-69 years of age) with newly-diagnosed and recent-onset partial seizures. Patients were randomized to placebo or oxcarbazepine tablets, initiated at 300 mg twice a day and titrated to 1200 mg/day (given as 600 mg twice a day) in six days, followed by maintenance treatment for 84 days. The primary measure of effectiveness was a between-group comparison of the time to first seizure. The difference between the two treatments was statistically significant in favor of oxcarbazepine tablets (see ), p=0.046.
Figure 2Figure 2 Kaplan-Meier Estimates of First Seizure Event Rate by Treatment GroupA third trial substituted oxcarbazepine tablets monotherapy at 2400 mg/day for carbamazepine in 143 patients (12-65 years of age) whose partial seizures were inadequately controlled on carbamazepine (CBZ) monotherapy at a stable dose of 800 to 1600 mg/day, and maintained this oxcarbazepine tablets dose for 56 days (baseline phase). Patients who were able to tolerate titration of oxcarbazepine tablets to 2400 mg/day during simultaneous carbamazepine withdrawal were randomly assigned to either 300 mg/day of oxcarbazepine tablets or 2400 mg/day oxcarbazepine tablets. Patients were observed for 126 days or until one of the following four exit criteria occurred: 1) a doubling of the 28-day seizure frequency compared to baseline, 2) a two-fold increase in the highest consecutive two-day seizure frequency during baseline, 3) a single generalized seizure if none had occurred during baseline, or 4) a prolonged generalized seizure. The primary measure of effectiveness was a between-group comparison of the time to meet exit criteria. The difference between the curves was statistically significant in favor of the oxcarbazepine tablets 2400 mg/day group (see ), p=0.0001.
Figure 3Figure 3 Kaplan-Meier Estimates of Exit Rate by Treatment GroupAnother monotherapy substitution trial was conducted in 87 patients (11-66 years of age) whose seizures were inadequately controlled on one or two AEDs. Patients were randomized to either oxcarbazepine tablets 2400 mg/day or 300 mg/day and their standard AED regimen(s) were eliminated over the first six weeks of double-blind therapy. Double-blind treatment continued for another 84 days (total double-blind treatment of 126 days) or until one of the four exit criteria described for the previous study occurred. The primary measure of effectiveness was a between-group comparison of the percentage of patients meeting exit criteria. The results were statistically significant in favor of the oxcarbazepine tablets 2400 mg/day group (14/34; 41.2%) compared to the oxcarbazepine tablets 300 mg/day group (42/45; 93.3%) (p<0.0001). The time to meeting one of the exit criteria was also statistically significant in favor of the oxcarbazepine tablets 2400 mg/day group (see ), p=0.0001.
Figure 4Figure 4 Kaplan-Meier Estimates of Exit Rate by Treatment GroupA monotherapy trial was conducted in 92 pediatric patients (1 month to 16 years of age) with inadequately-controlled or new-onset partial seizures. Patients were hospitalized and randomized to either oxcarbazepine tablets 10 mg/kg/day or were titrated up to 40-60 mg/kg/day within three days while withdrawing the previous AED on the second day of oxcarbazepine tablets therapy. Seizures were recorded through continuous video-EEG monitoring from Day 3 to Day 5. Patients either completed the 5-day treatment or met one of the two exit criteria: 1) three study-specific seizures (i.e., electrographic partial seizures with a behavioral correlate), 2) a prolonged study-specific seizure. The primary measure of effectiveness was a between-group comparison of the time to meet exit criteria in which the difference between the curves was not statistically significant (p=0.904). The majority of patients from both dose groups completed the 5-day study without exiting.Although this study failed to demonstrate an effect of oxcarbazepine as monotherapy in pediatric patients, several design elements, including the short treatment and assessment period, the absence of a true placebo, and the likely persistence of plasma levels of previously administered AEDs during the treatment period, make the results uninterpretable. For this reason, the results do not undermine the conclusion, based on pharmacokinetic/pharmacodynamic considerations, that oxcarbazepine is effective as monotherapy in pediatric patients 4 years old and older.
14.2 Oxcarbazepine Tablets Adjunctive Therapy Trials
The effectiveness of oxcarbazepine tablets as an adjunctive therapy for partial seizures was established in two multicenter, randomized, double-blind, placebo-controlled trials, one in 692 patients (15-66 years of age) and one in 264 pediatric patients (3-17 years of age), and in one multicenter, rater-blind, randomized, age-stratified, parallel-group study comparing two doses of oxcarbazepine in 128 pediatric patients (1 month to <4 years of age).Patients in the two placebo-controlled trials were on 1-3 concomitant AEDs. In both of the trials, patients were stabilized on optimum dosages of their concomitant AEDs during an 8-week baseline phase. Patients who experienced at least 8 (minimum of 1-4 per month) partial seizures during the baseline phase were randomly assigned to placebo or to a specific dose of oxcarbazepine tablets in addition to their other AEDs.In these studies, the dose was increased over a two-week period until either the assigned dose was reached, or intolerance prevented increases. Patients then entered a 14- (pediatrics) or 24-week (adults) maintenance period.In the adult trial, patients received fixed doses of 600, 1200 or 2400 mg/day. In the pediatric trial, patients received maintenance doses in the range of 30-46 mg/kg/day, depending on baseline weight. The primary measure of effectiveness in both trials was a between-group comparison of the percentage change in partial seizure frequency in the double-blind treatment phase relative to baseline phase. This comparison was statistically significant in favor of oxcarbazepine tablets at all doses tested in both trials (p=0.0001 for all doses for both trials). The number of patients randomized to each dose, the median baseline seizure rate, and the median percentage seizure rate reduction for each trial are shown in Table 8. It is important to note that in the high-dose group in the study in adults, over 65% of patients discontinued treatment because of adverse events; only 46 (27%) of the patients in this group completed the 28-week study [see ], an outcome not seen in the monotherapy studies.
Adverse Reactions(7)Table 8 Summary of Percentage Change in Partial Seizure Frequency from Baseline for Placebo-Controlled Adjunctive Therapy TrialsTrialTreatment GroupNBaseline Median Seizure Rate
= # per 28 daysMedian % Reduction1 (pediatrics)Oxcarbazepine Tablets13612.534.8
p=0.0001Placebo12813.19.42 (adults)Oxcarbazepine Tablets 2400 mg/day17410.049.9
Oxcarbazepine Tablets 1200 mg/day1779.840.2
Oxcarbazepine Tablets 600 mg/day1689.626.4
Placebo1738.67.6Subset analyses of the antiepileptic efficacy of oxcarbazepine tablets with regard to gender in these trials revealed no important differences in response between men and women. Because there were very few patients over the age of 65 in controlled trials, the effect of the drug in the elderly has not been adequately assessed.The third adjunctive therapy trial enrolled 128 pediatric patients (1 month to <4 years of age) with inadequately-controlled partial seizures on 1-2 concomitant AEDs. Patients who experienced at least 2 study-specific seizures (i.e., electrographic partial seizures with a behavioral correlate) during the 72-hour baseline period were randomly assigned to either oxcarbazepine tablets 10 mg/kg/day or were titrated up to 60 mg/kg/day within 26 days. Patients were maintained on their randomized target dose for 9 days and seizures were recorded through continuous video-EEG monitoring during the last 72 hours of the maintenance period. The primary measure of effectiveness in this trial was a between-group comparison of the change in seizure frequency per 24 hours compared to the seizure frequency at baseline. For the entire group of patients enrolled, this comparison was statistically significant in favor of oxcarbazepine tablets 60 mg/kg/day. In this study, there was no evidence that oxcarbazepine tablets were effective in patients below the age of 2 years (N=75).
16 How Supplied/Storage And Handling
NDC:64725-0292-1 in a BOTTLE of 100 TABLET, FILM COATEDS
Storage And Handling
Store at 20°-25°C (77°F); excursions permitted to 15°-30°C (59°-86°F) [See USP Controlled Room Temperature].Dispense in tight container (USP).
17 Patient Counseling Information
Patients and caregivers should be informed of the availability of a Medication Guide, and they should be instructed to read the Medication Guide prior to taking oxcarbazepine tablets.Patients should be advised that oxcarbazepine tablets may reduce the serum sodium concentrations especially if they are taking other medications that can lower sodium. Patients should be advised to report symptoms of low sodium like nausea, tiredness, lack of energy, confusion, and more frequent or more severe seizures [see ].
Warnings and Precautions (5.1)Anaphylactic reactions and angioedema may occur during treatment with oxcarbazepine tablets. Patients should be advised to report immediately signs and symptoms suggesting angioedema (swelling of the face, eyes, lips, tongue or difficulty in swallowing or breathing) and to stop taking the drug until they have consulted with their physician [see ].
Warnings and Precautions (5.2)Patients who have exhibited hypersensitivity reactions to carbamazepine should be informed that approximately 25%-30% of these patients may experience hypersensitivity reactions with oxcarbazepine tablets. Patients should be advised that if they experience a hypersensitivity reaction while taking oxcarbazepine tablets they should consult with their physician immediately [see ].
Warnings and Precautions (5.3)Patients should be advised that serious skin reactions have been reported in association with oxcarbazepine tablets. In the event a skin reaction should occur while taking oxcarbazepine tablets, patients should consult with their physician immediately [see ].
Warnings and Precautions (5.4)Patients should be instructed that a fever associated with other organ system involvement (rash, lymphadenopathy, etc.) may be drug related and should be reported to the physician immediately [see ].
Warnings and Precautions (5.8)Patients should be advised that there have been rare reports of blood disorders reported in patients treated with oxcarbazepine tablets. Patients should be instructed to immediately consult with their physician if they experience symptoms suggestive of blood disorders [see ].
Warnings and Precautions (5.9)Female patients of childbearing age should be warned that the concurrent use of oxcarbazepine tablets with hormonal contraceptives may render this method of contraception less effective [see ]. Additional non-hormonal forms of contraception are recommended when using oxcarbazepine tablets.
Drug Interactions (7.2)Patients, their caregivers, and families should be counseled that AEDs, including oxcarbazepine tablets, may increase the risk of suicidal thoughts and behavior and should be advised of the need to be alert for the emergence or worsening of symptoms of depression, any unusual changes in mood or behavior, or the emergence of suicidal thoughts, behavior, or thoughts about self-harm. Behaviors of concern should be reported immediately to healthcare providers.Caution should be exercised if alcohol is taken in combination with oxcarbazepine tablets therapy, due to a possible additive sedative effect.Patients should be advised that oxcarbazepine tablets may cause dizziness and somnolence. Accordingly, patients should be advised not to drive or operate machinery until they have gained sufficient experience on oxcarbazepine tablets to gauge whether it adversely affects their ability to drive or operate machinery.Patients should be encouraged to enroll in the North American Antiepileptic Drug (NAAED) Pregnancy Registry if they become pregnant. This registry is collecting information about the safety of antiepileptic drugs during pregnancy. To enroll, patients can call the toll free number 1-888-233-2334 [see ].
Use in Specific Populations (8.1)
- MEDICATION GUIDE Oxcarbazepine Tablets
- Oxcarbazepine Tablets contains FD&C yellow no. 5 (tartrazine) which may cause allergic-type reactions (including bronchial asthma) in certain susceptible individuals. Although the overall incidence of FD&C yellow no. 5 (tartrazine) sensitivity in the general population is low, it is frequently seen in patients who also have aspirin hypersensitivity.Read this Medication Guide before you start taking oxcarbazepine tablets and each time you get a refill. There may be new information. This information does not take the place of talking to your healthcare provider about your medical condition or treatment.What is the most important information I should know about oxcarbazepine tablets?Do not stop taking oxcarbazepine tablets without first talking to your healthcare provider.Stopping oxcarbazepine tablets suddenly can cause serious problems.Oxcarbazepine tablets can cause serious side effects, including:Oxcarbazepine tablets may cause the level of sodium in your blood to be low. Symptoms of low blood sodium include:
- Nauseatiredness, lack of energyheadacheconfusionmore frequent or more severe seizures.Similar symptoms that are not related to low sodium may occur from taking oxcarbazepine tablets. You should tell your healthcare provider if you have any of these side effects and if they bother you or they do not go away.Some other medicines can also cause low sodium in your blood. Be sure to tell your healthcare provider about all the other medicines that you are taking.Oxcarbazepine tablets may also cause allergic reactions or serious problems which may affect organs and other parts of your body like the liver or blood cells. You may or may not have a rash with these types of reactions.
- Call your healthcare provider right away if you have any of the following:swelling of your face, eyes, lips, or tonguetrouble swallowing or breathinga skin rashhivesfever, swollen glands, or sore throat that do not go away or come and gopainful sores in the mouth or around your eyesyellowing of your skin or eyesunusual bruising or bleedingsevere fatigue or weaknesssevere muscle painfrequent infections or infections that do not go awayMany people who are allergic to carbamazepine are also allergic to oxcarbazepine tablets. Tell your healthcare provider if you are allergic to carbamazepine.Like other antiepileptic drugs, oxcarbazepine tablets may cause suicidal thoughts or actions in a very small number of people, about 1 in 500.Call a doctor right away if you have any of these symptoms, especially if they are new, worse, or worry you:thoughts about suicide or dyingattempts to commit suicidenew or worse depressionnew or worse anxietyfeeling agitated or restlesspanic attackstrouble sleeping (insomnia)new or worse irritabilityacting aggressive, being angry, or violentacting on dangerous impulsesan extreme increase in activity and talking (mania)other unusual changes in behavior or moodHow can I watch for early symptoms of suicidal thoughts and actions?Pay attention to any changes, especially sudden changes, in mood, behaviors, thoughts, or feelings.Keep all follow-up visits with your healthcare provider as scheduled.Call your healthcare provider between visits as needed, especially if you are worried about symptoms.Do not stop taking oxcarbazepine tablets without first talking to a healthcare provider.Stopping oxcarbazepine tablets suddenly can cause serious problems. Stopping a seizure medicine suddenly in a patient who has epilepsy may cause seizures that will not stop (status epilepticus).Suicidal thoughts or actions may be caused by things other than medicines. If you have suicidal thoughts or actions, your healthcare provider may check for other causes.What are oxcarbazepine tablets?Oxcarbazepine tablets are a prescription medicine used:alone or with other medicines to treat partial seizures in adults.alone to treat partial seizures in children 4 years and older.with other medicines to treat partial seizures in children 2 years and older.Who should not take oxcarbazepine tablets?Do not take oxcarbazepine tablets if you are allergic to oxcarbazepine tablets or any of the other ingredients in oxcarbazepine tablets. See the end of this leaflet for a complete list of ingredients in oxcarbazepine tablets.Many people who are allergic to carbamazepine are also allergic to oxcarbazepine tablets. Tell your healthcare provider if you are allergic to carbamazepine.What should I tell my healthcare provider before taking oxcarbazepine tablets?Before taking oxcarbazepine tablets, tell your healthcare provider about all your medical conditions, including if you:have or have had suicidal thoughts or actions, depression or mood problemshave liver problemshave kidney problemsare allergic to carbamazepine. Many people who are allergic to carbamazepine are also allergic to oxcarbazepine tablets.use birth control medicine. Oxcarbazepine tablets may cause your birth control medicine to be less effective. Talk to your healthcare provider about the best birth control method to use.are pregnant or plan to become pregnant. Oxcarbazepine tablets may harm your unborn baby. Tell your healthcare provider right away if you become pregnant while taking oxcarbazepine tablets. You and your healthcare provider will decide if you should take oxcarbazepine tablets while you are pregnant.
- If you become pregnant while taking oxcarbazepine tablets, talk to your healthcare provider about registering with the North American Antiepileptic Drug (NAAED) Pregnancy Registry. The purpose of this registry is to collect information about the safety of antiepileptic medicine during pregnancy. You can enroll in this registry by calling 1-888-233-2334.are breastfeeding or plan to breastfeed. Oxcarbazepine tablets passes into breast milk. You and your healthcare provider should discuss whether you should take oxcarbazepine tablets or breastfeed; you should not do both.Tell your healthcare provider about all the medicines you take, including prescription and non-prescription medicines, vitamins, and herbal supplements.Taking oxcarbazepine tablets with certain other medicines may cause side effects or affect how well they work. Do not start or stop other medicines without talking to your healthcare provider.Know the medicines you take. Keep a list of them and show it to your healthcare provider and pharmacist when you get a new medicine.How should I take oxcarbazepine tablets?Do not stop taking oxcarbazepine tablets without talking to your healthcare provider. Stopping oxcarbazepine tablets suddenly can cause serious problems, including seizures that will not stop (status epilepticus).Take oxcarbazepine tablets exactly as prescribed. Your healthcare provider may change your dose. Your healthcare provider will tell you how many oxcarbazepine tablets to take.Take oxcarbazepine tablets 2 times a day.Take oxcarbazepine tablets with or without food.If you take too many oxcarbazepine tablets, call your healthcare provider or local Poison Control Center right away.What should I avoid while taking oxcarbazepine tablets?Do not drive, operate heavy machinery, or do other dangerous activities until you know how oxcarbazepine tablets affects you. Oxcarbazepine tablets may slow your thinking and motor skills.Do not drink alcohol or take other drugs that make you sleepy or dizzy while taking oxcarbazepine tablets until you talk to your healthcare provider. Oxcarbazepine tablets taken with alcohol or drugs that cause sleepiness or dizziness may make your sleepiness or dizziness worse.What are the possible side effects of oxcarbazepine tablets?See
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- What is the most important information I should know about oxcarbazepine tablets?Oxcarbazepine tablets may cause other serious side effects including:your seizures can happen more often or become worsetrouble concentratingproblems with your speech and languagefeeling confusedfeeling sleepy and tiredtrouble walking and with coordinationGet medical help right away if you have any of the symptoms listed above or listed in " "
- What is the most important information I should know about oxcarbazepine tablets?The most common side effects of oxcarbazepine tablets include:dizzinesssleepinessdouble visiontirednessnauseavomitingproblems with visionstomach paintremblingupset stomachproblems with walking and coordination (unsteadiness)rashinfections (especially in children)These are not all the possible side effects of oxcarbazepine tablets. For more information, ask your healthcare provider or pharmacist. Tell your healthcare provider if you have any side effect that bothers you or does not go awayCall your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.How should I store oxcarbazepine tablets?Store oxcarbazepine tablets between 15°C to 30°C (59°F to 86°F)Keep oxcarbazepine tablets dry.Keep oxcarbazepine tablets and all medicines out of the reach of children.General Information about the safe and effective use of oxcarbazepine tabletsMedicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Do not use oxcarbazepine tablets for a condition for which it was not prescribed. Do not give oxcarbazepine tablets to other people, even if they have the same symptoms that you have. It may harm them.This Medication Guide summarizes the most important information about oxcarbazepine tablets. If you would like more information, talk with your healthcare provider. You can ask your pharmacist or healthcare provider for the full prescribing information about oxcarbazepine tablets that is written for health professionals.For more information, go to www.bpirx.com or call 1-800-367-3395.What are the ingredients in oxcarbazepine tablets?oxcarbazepine
- Active ingredient:microcrystalline cellulose, crospovidone, hypromellose, colloidal silicon dioxide, magnesium stearate, talc. Coating: polyvinyl alcohol, talc, titanium dioxide, polyethylene glycol, FD&C Yellow No. 6 aluminum lake, lecithin, FD&C Blue No. 2 aluminum lake, FD&C Yellow No. 5 aluminum lake.
- Inactive ingredients:Contains FD&C Yellow No. 6 as a color additive.This product contains FD&C Yellow No. 5 (tartrazine) which may cause allergic-type reactions (including bronchial asthma) in certain susceptible persons. Although the overall incidence of FD&C Yellow No. 5 (tartrazine) sensitivity in the general population is low, it is frequently seen in patients who also have aspirin hypersensitivity.This Medication Guide has been approved by the U.S. Food and Drug Administration.Distributed by: Boca Raton, FL 33487
- BRECKENRIDGE PHARMACEUTICAL, INC.Manufactured by: Irvine, CA 92614
- NEXGEN PHARMA, INC.05/13
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