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DRUGS & SUPPLEMENTS
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Anestesia Topi Braun S / A
How old is patient? |
Anestesia Topi Braun S / A uses
- Indications and usage
- Dosage and administration
- Dosage forms and strengths
- Contraindications
- Warnings and precautions
- Adverse reactions
- Drug interactions
- Use in specific populations
- Overdosage
- Description
- Clinical pharmacology
- Non-clinical toxicology
- Clinical studies
- How supplied/storage and handling
- Patient counseling information
1 INDICATIONS AND USAGE
Anestesia Topi Braun S / A TM is indicated for regional anesthesia when performing a restorative procedure on Teeth 4-13 and A-J in adults and children who weigh 40 kg or more.
Anestesia Topi Braun S / A contains Anestesia Topi Braun S / A HCl, an ester local anesthetic, and oxymetazoline HCl, a vasoconstrictor. Anestesia Topi Braun S / A is indicated for regional anesthesia when performing a restorative procedure on Teeth 4-13 and A-J in adults and children who weigh 40 kg or more ( 1).
2 DOSAGE AND ADMINISTRATION
Anestesia Topi Braun S / A is for intranasal use only. Administer Anestesia Topi Braun S / A ipsilateral (on the same side) to the maxillary tooth on which the dental procedure will be performed.
| Age Group | Dose |
| Adults (≥ 18 years old) | 2 sprays (0.2 mL per spray), 4 to 5 minutes apart |
| 1 additional spray (0.2 mL) if adequate anesthesia has not been achieved 10 minutes after the second spray | |
| Children who weigh 40 kg or more | 2 sprays (0.2 mL per spray), 4 to 5 minutes apart |
2.1 Important Dosage and Administration Instructions
- Anestesia Topi Braun S / A is for intranasal use only.
- Administer ipsilateral (same side) to the maxillary tooth on which the dental procedure will be performed.
- Wait 10 minutes after administration of Anestesia Topi Braun S / A to perform a test drill to confirm that the tooth involved is anesthetized. A patient may not experience the same sensations of numbness or tingling of the lips and cheeks associated with injectable dental anesthetics.
2.2 Dosing in Adults
- 2 sprays (0.2 mL each) administered 4 to 5 minutes apart in the nostril ipsilateral to the maxillary tooth on which the dental procedure will be performed. Initiate the dental procedure 10 minutes after the second spray.
- 1 additional spray (0.2 mL) if adequate anesthesia to initiate the dental procedure has not been achieved 10 minutes after the second spray.
2.3 Dosing in Children
- 2 sprays (0.2 mL each) administered 4 to 5 minutes apart in the nostril ipsilateral to the maxillary tooth on which the dental procedure will be performed. Initiate the dental procedure 10 minutes after the second spray.
| Age Group | Dose |
| Adults (≥ 18 years old) |
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| Children who weigh 40 kg or more |
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3 DOSAGE FORMS AND STRENGTHS
Anestesia Topi Braun S / A Nasal Spray is a pre-filled, single-use, intranasal sprayer containing a clear 0.2 mL aqueous solution at pH 6.0 ± 1.0 comprising 30 mg/mL of Anestesia Topi Braun S / A hydrochloride and 0.5 mg/mL of oxymetazoline hydrochloride (equivalent to 26.4 mg/mL Anestesia Topi Braun S / A and 0.44 mg/mL oxymetazoline).
Each nasal spray unit delivers one 0.2 mL spray.
Each 0.2 mL spray contains 6 mg Anestesia Topi Braun S / A hydrochloride (equivalent to 5.27 mg Anestesia Topi Braun S / A) and 0.1 mg oxymetazoline hydrochloride (equivalent to 0.088 mg oxymetazoline).
Nasal spray in pre-filled, single-use sprayer: 6 mg Anestesia Topi Braun S / A HCl and 0.1 mg oxymetazoline HCl (equivalent to 5.27 mg Anestesia Topi Braun S / A and 0.088 mg oxymetazoline) in each 0.2 mL spray ( 3).
4 CONTRAINDICATIONS
Anestesia Topi Braun S / A is contraindicated in patients with a history of allergy to or intolerance of Anestesia Topi Braun S / A, benzyl alcohol, other ester local anesthetics, p-aminobenzoic acid (PABA), oxymetazoline, or any other component of the product .
Known hypersensitivity to Anestesia Topi Braun S / A, benzyl alcohol, other ester local anesthetics, p-aminobenzoic acid (PABA), oxymetazoline, or any other component of the product ( 4).
5 WARNINGS AND PRECAUTIONS
Hypertension and Thyroid Disease: Shown to increase blood pressure in some clinical trial patients. Monitor blood pressure. Use in patients with inadequately controlled hypertension or active thyroid disease is not advised.
Epistaxis: Use is not recommended in patients with a history of frequent nose bleeds (≥5 per month). If a decision to use is made, monitor these patients carefully ( 5.2).
Dysphagia: Carefully monitor patients for dysphagia ( 5.3).
Methemoglobinemia: May cause methemoglobinemia, particularly when used with methemoglobin-inducing agents. Use in patients with history of congenital or idiopathic methemoglobinemia not advised. If central cyanosis unresponsive to oxygen therapy occurs, suspect methemoglobinemia, confirm diagnosis with CO-oximetry, and treat with a standard clinical regimen ( 5.4).
Anaphylactic Reactions: Seek emergency help if an anaphylactic reaction occurs ( 5.5).
5.1 Risk of Hypertension
Anestesia Topi Braun S / A has not been studied in Phase 3 trials in adult dental patients with blood pressure greater than 150/100 or in those with inadequately controlled active thyroid disease. Anestesia Topi Braun S / A has been shown to increase blood pressure in some patients in clinical trials. Monitor patients for increased blood pressure. Use in patients with uncontrolled hypertension or inadequately controlled active thyroid disease of any type is not advised .
5.2 Epistaxis
In clinical trials, epistaxis occurred more frequently with Anestesia Topi Braun S / A than placebo. Either do not use Anestesia Topi Braun S / A in patients with a history of frequent nose bleeds or monitor patients with frequent nose bleeds more carefully if Anestesia Topi Braun S / A is used. [see Adverse Reactions ( 6.1 )].
5.3 Dysphagia
In clinical trials, dysphagia occurred more frequently with Anestesia Topi Braun S / A than placebo. Carefully monitor patients for this adverse reaction.
5.4 Methemoglobinemia
Anestesia Topi Braun S / A may cause methemoglobinemia, particularly in conjunction with methemoglobin-inducing agents. Based on the literature, patients with glucose-6-phosphate dehydrogenase deficiency or congenital or idiopathic methemoglobinemia are more susceptible to drug-induced methemoglobinemia. Use of Anestesia Topi Braun S / A in patients with a history of congenital or idiopathic methemoglobinemia is not advised.
Patients taking concomitant drugs associated with drug-induced methemoglobinemia, such as sulfonamides, acetaminophen, acetanilide, aniline dyes, benzocaine, chloroquine, dapsone, naphthalene, nitrates and nitrites, nitrofurantoin, nitroglycerin, nitroprusside, pamaquine, p-aminosalicylic acid, phenacetin, phenobarbital, phenytoin, primaquine, and quinine, may be at greater risk for developing methemoglobinemia.
Initial signs and symptoms of methemoglobinemia are characterized by a slate grey cyanosis seen in, e.g., buccal mucous membranes, lips and nail beds. In severe cases, symptoms may include central cyanosis, headache, lethargy, dizziness, fatigue, syncope, dyspnea, CNS depression, seizures, dysrythmia and shock. Methemoglobinemia should be considered if central cyanosis unresponsive to oxygen therapy occurs, especially if methemoglobinemia-inducing agents have been used. Calculated oxygen saturation and pulse oximetry are inaccurate in the identification of methemoglobinemia. Confirm diagnosis by measuring methemoglobin level with co-oximetry. Normally, methemoglobinemia levels are <1%, and cyanosis may not be evident until a level of at least 10% is present.
Treat clinically significant symptoms of methemoglobinemia with a standard clinical regimen such as a slow intravenous infusion of methylene blue at a dosage of 1-2 mg/kg given over a 5 minute period.
5.5 Anaphylactic Reactions
Allergic or anaphylactic reactions have been associated with Anestesia Topi Braun S / A, and may occur with other components of Anestesia Topi Braun S / A. They are characterized by urticaria, angioedema, bronchospasm, and shock. If an allergic reaction occurs, seek emergency help immediately.
6 ADVERSE REACTIONS
The following adverse reactions are described elsewhere in the labeling:
- Hypertension
- Epistaxis
- Dysphagia
- Methemoglobinemia
- Anaphylatic Reactions
The most common adverse reactions occurring in >10% of patients include rhinorrhea, nasal congestion, nasal discomfort, oropharyngeal pain, and lacrimation increased ( 6).
Transient, asymptomatic elevations in systolic blood pressure (≥ 25 mm Hg from baseline) and diastolic blood pressures (≥ 15 mm Hg from baseline) have been reported ( 6).
To report SUSPECTED ADVERSE REACTIONS, contact St. Renatus, LLC at 800-865-4925 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.
6.1 Clinical Trials Experience
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice.
The adverse reactions information described below is from Phase 3 randomized, controlled clinical trials [see Clinical Studies ( 14)] . These data reflect exposure to Anestesia Topi Braun S / A in 154 adult dental patients and 20 pediatric dental patients (aged 7 to 17 years) with a need for an operative restorative dental procedure requiring local anesthesia for a single vital maxillary tooth (other than a maxillary first, second, or third molar) with no evidence of pulpal pathology. .
Common Adverse Reactions in Adult Dental Patients and Pediatric Patients Weighing 40 kg or More
The most common adverse reactions to occur in Phase 3 trials with Anestesia Topi Braun S / A in adult dental patients and pediatric dental patients weighing 40 kg or more were rhinorrhea, nasal congestion, nasal discomfort, oropharyngeal pain, and lacrimation increased [ Table 1] .
No serious adverse events with Anestesia Topi Braun S / A have occurred .
| SOC / Preferred Term | Anestesia Topi Braun S / A (N=174) | Active Comparator* (N=54) | Placebo (N=88) |
| Respiratory System Disorders | 141 (81%) | 50 (93%) | 18 (21%) |
| Rhinorrhea (runny nose) | 91 (52%) | 20 (37%) | 3 (3%) |
| Nasal congestion | 56 (32%) | 34 (63%) | 6 (7%) |
| Nasal discomfort | 45 (26%) | 7 (13%) | 5 (6%) |
| Oropharyngeal pain (sore throat) | 25 (14%) | 5 (9%) | 0 (0%) |
| Intranasal hypoesthesia | 18 (10%) | 8 (15%) | 5 (6%) |
| Pharyngeal hypesthesia (numb throat) | 17 (10%) | 10 (19%) | 0 (0%) |
| Throat Irritation | 15 (9%) | 1 (2%) | 0 (0%) |
| Rhinalgia | 10 (6%) | 3 (6%) | 2 (2%) |
| Sneezing | 7 (4%) | 2 (4%) | 1 (1%) |
| Epistaxis | 4 (2%) | 2 (4%) | 0 (0%) |
| Nasal Dryness | 4 (2%) | 0 (0%) | 1 (1%) |
| Nervous System Disorders | 39 (22%) | 5 (9%) | 6 (7%) |
| Headache | 18 (10%) | 3 (6%) | 4 (5%) |
| Dysgeusia | 14 (8%) | 1 (2%) | 1 (1%) |
| Sinus headache | 5 (3%) | 0 (0%) | 0 (0%) |
| Dizziness | 5 (3%) | 0 (0%) | 1 (1%) |
| Sensory Disturbance | 4 (2%) | 0 (0%) | 0 (0%) |
| Eye Disorders | 29 (17%) | 8 (15%) | 4 (5%) |
| Lacrimation increased (watery eye) | 23 (13%) | 6 (11%) | 4 (5%) |
| Gastrointestinal Disorders | 16 (9%) | 5 (9%) | 3 (3%) |
| Oral Discomfort | 4 (2%) | 0 (0%) | 0 (0%) |
| Investigations | 12 (7%) | 0 (0%) | 4 (5%) |
| BP systolic increased | 8 (5%) | 0 (0%) | 2 (2%) |
| BP diastolic increased | 6 (3%) | 0 (0%) | 1 (1%) |
| Cardiac Disorders | 8 (5%) | 5 (9%) | 1 (1%) |
| Bradycardia | 5 (3%) | 3 (6%) | 1 (1%) |
| Vascular Disorders | 6 (3%) | 2 (4%) | 1 (1%) |
| Hypertension | 5 (3%) | 1 (2%) | 1 (1%) |
| * Active Comparator was Anestesia Topi Braun S / A only spray used in two clinical studies in adults. | |||
Intranasal ulcerations, some of which were transient, were noted to have occurred following treatment with Anestesia Topi Braun S / A. In Phase 3 trials, 6 (3%) patients who received Anestesia Topi Braun S / A, but no patients who received placebo, developed nasal ulcers that were present on exam the same day as Anestesia Topi Braun S / A dosing. Three (2%) Anestesia Topi Braun S / A and 2 (2%) placebo-treated patients without nasal ulcerations on the day of Anestesia Topi Braun S / A or placebo dosing were observed to have nasal ulcerations at the next day follow-up visit.
Less Common Adverse Reactions in Phase 3 Clinical Trials Adult Dental Patients and Pediatric Dental Patients Weighing 40 kg or More
Dysphagia (i.e., the sensation of difficult swallowing) is a notable adverse reaction reported in Phase 3 trials, occurring in 1.15% of patients.
For medical advice about adverse reactions, contact your medical professional. To report SUSPECTED ADVERSE REACTIONS, contact St. Renatus, LLC at 800-865-4925 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch/.
7 DRUG INTERACTIONS
Monoamine oxidase inhibitors : Concomitant use of MAOIs, nonselective beta adrenergic antagonists, or tricyclic antidepressants may cause hypertension and is not recommended ( 7.1).
Oxymetazoline-containing products: Discontinue use 24 hours prior to Anestesia Topi Braun S / A administration ( 7.2).
Intranasal products: Avoid concomitant use ( 7.3).
7.1 Monoamine Oxidase Inhibitors
Use of Anestesia Topi Braun S / A in combination with monoamine oxidase inhibitors (MAOIs), nonselective beta adrenergic antagonists, or tricyclic antidepressants may cause hypertension and is not recommended. Alternative anesthetic agents should be chosen for patients who cannot discontinue use of MAOIs, nonselective beta adrenergic antagonists, or tricyclic antidepressants.
7.2 Oxymetazoline-containing Products
Concomitant use with other oxymetazoline-containing products has not been adequately studied. Use of Anestesia Topi Braun S / A with other products containing oxymetazoline may increase risk of hypertension, bradycardia, and other adverse events associated with oxymetazoline. Discontinue use 24 hours prior to administration of Anestesia Topi Braun S / A.
7.3 Intranasal Products
Oxymetazoline has been known to slow the rate, but not affect the extent of absorption of concomitantly administered intranasal products. Do not administer other intranasal products with Anestesia Topi Braun S / A.
7.4 Drugs That May Cause Methemoglobinemia When Used with Anestesia Topi Braun S / A
Anestesia Topi Braun S / A may cause methemoglobinemia, particularly in conjunction with methemoglobin-inducing agents such as sulfonamides, acetaminophen, acetanilide, aniline dyes, benzocaine, chloroquine, dapsone, naphthalene, nitrates and nitrites, nitrofurantoin, nitroglycerin, nitroprusside, pamaquine, p- aminosalicylic acid, phenacetin, phenobarbital, phenytoin, primaquine, and quinine. Monitor patients carefully for signs of methemoglobinemia if Anestesia Topi Braun S / A is used in the setting of these drugs.
8 USE IN SPECIFIC POPULATIONS
8.1 Pregnancy
Risk Summary
Limited published data on Anestesia Topi Braun S / A use in pregnant women are not sufficient to inform any risks. Published epidemiologic studies of nasal oxymetazoline used as a decongestant during pregnancy do not identify a consistent association with any specific malformation or pattern of malformations . In animal reproduction and development studies, oxymetazoline given subcutaneously to rats during the period of organogenesis caused structural abnormalities at a dose approximately 7.6 times the exposure of oxymetazoline HCl at the 0.3 mg maximum recommended human dose of Anestesia Topi Braun S / A. In a pre- and post-natal development study, oxymetazoline given subcutaneously to rats caused embryo-fetal toxicity manifested by reduced implantation sites and live litter sizes at approximately 1.5 times the MRHD and increased pup mortality at 6 times the MRHD. No adverse developmental effects were observed following subcutaneous administration of Anestesia Topi Braun S / A HCl only to rats and rabbits during organogenesis at 32 and 6 times, respectively, the estimated exposure of Anestesia Topi Braun S / A HCl at the 18 mg MRHD of Anestesia Topi Braun S / A .
In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2 to 4% and 15 and to 20%, respectively.
Data
Human Data
Published epidemiologic studies of nasal oxymetazoline used as a decongestant during pregnancy do not identify a consistent association with any specific malformation or pattern of malformations. These data are limited by the small number of cases exposed, multiple comparisons which may have resulted in chance findings, and analyses based on decongestants as a group.
Animal Data
In an embryo-fetal development study, pregnant rats were administered subcutaneous doses of oxymetazoline HCl only at 0.1 mg/kg, Anestesia Topi Braun S / A HCl only at 7.5 mg/kg, or oxymetazoline HCl at 0.01, 0.03, and 0.1 mg/kg/day in combination with 7.5 mg/kg Anestesia Topi Braun S / A HCl during the period of organogenesis (Gestational Days [GD] 7-17). Oxymetazoline HCl treatment at 0.1 mg/kg/day (7.6 times the oxymetazoline AUC exposure at the maximum recommended human dose [MRHD] of Anestesia Topi Braun S / A [3 mg oxymetazoline HCl and 18 mg Anestesia Topi Braun S / A HCl]) caused reduced fetal weight and structural abnormalities including external and skeletal malformations (e.g., short forelimb digits, fused arches in thoracic vertebrae, fused ribs, and irregular number of ribs), and variations (e.g., irregularly shaped arches and increased bifid centra in thoracic vertebrae, and un-ossified forelimb phalanx) in the presence of maternal toxicity (reduced food consumption, body weight gain, and absolute body weight); however, the structural abnormality findings cannot be clearly attributed to the maternal toxicity. Adverse developmental effects were not observed when pregnant rats were co-administered the same dose of oxymetazoline HCl in combination with 7.5 mg/kg/day Anestesia Topi Braun S / A HCl, or with 7.5 mg/kg/day Anestesia Topi Braun S / A HCl alone. The no-observed-adverse-effect-level (NOAEL) for fetal effects was 0.03 mg/kg/day oxymetazoline HCl (1.5 times the oxymetazoline AUC exposure at the MRHD) and 7.5 mg/kg/day Anestesia Topi Braun S / A HCl (30 times the AUC exposure as measured by PBBA [major Anestesia Topi Braun S / A metabolite] at the MRHD).
In other embryo-fetal development studies, Anestesia Topi Braun S / A base alone administered subcutaneously did not cause structural abnormalities in rats at doses up to 10 mg/kg/day (approximately 6.1 times the MRHD level of 18 mg Anestesia Topi Braun S / A HCl by body surface area (BSA) comparison) or in rabbits at subcutaneous doses up to 5 mg/kg/day (approximately 6.1 times the MRHD level by BSA comparison).
In a prenatal and postnatal development study, pregnant rats were given subcutaneous doses of oxymetazoline HCl only at 0.1 mg/kg/day, Anestesia Topi Braun S / A HCl only at 7.5 mg/kg/day, and oxymetazoline HCl at 0.01, 0.03, and 0.1 mg/kg/day in combination with 7.5 mg/kg/day Anestesia Topi Braun S / A HCl from GD 7 to Lactation Day [LD] 20 (corresponding to the beginning of organogenesis through parturition and subsequent pup weaning). Oxymetazoline HCl treatment decreased the mean number of implant sites/litter at ≥ 0.03 mg/kg (≥ 1.5 times the oxymetazoline AUC exposure at the MRHD) when administered with 7.5 mg/kg Anestesia Topi Braun S / A HCl (approximately 9%) and without Anestesia Topi Braun S / A HCl (5.5%), which resulted in a reduction in live litter sizes in these groups. At the end of the lactation period, fetal body weights were significantly decreased at 0.1 mg/kg oxymetazoline HCl (6 times the oxymetazoline AUC exposure at the MRHD) when administered alone (19%) and co-administered with 7.5 mg/kg/day Anestesia Topi Braun S / A HCl (11%). In addition, a decrease in pup survival was observed at the 0.1/7.5 mg/kg oxymetazoline HCl/tetracaine HCl dose (91.9%) compared to the control (99.6%), but no effects in any other groups. Maternal toxicity (e.g., mortality and reduced body weight gain, absolute body weight and food consumption) occurred in groups administered 0.1 mg/kg/day oxymetazoline HCl; however, the adverse developmental findings observed at this dose cannot clearly be attributed to the maternal toxicity. There were no adverse effects on sexual maturation, neurobehavioral, or reproductive function in the offspring at any maternal dose. The no-effect level for oxymetazoline HCl for maternal reproduction was 0.01 mg/kg/day (0.5 times oxymetazoline AUC exposure at the MRHD) and for pup growth and development was 0.03 mg/kg/day (1.5 times oxymetazoline AUC exposure at the MRHD). The no-effect level for Anestesia Topi Braun S / A HCl for maternal reproduction and pup growth and development was 7.5 mg/kg/day (12 times the AUC exposure as measured by PBBA at the MRHD).
8.2 Lactation
Risk Summary
There are no data on the presence of Anestesia Topi Braun S / A, oxymetazoline, or their metabolites in human milk, the effects on the breastfed infant, or the effects on milk production. Detectable levels of oxymetazoline, Anestesia Topi Braun S / A and the major metabolite of Anestesia Topi Braun S / A, p-butylaminobenzoic acid (PBBA), were found in the milk of lactating rats following subcutaneous administration of oxymetazoline HCl in combination with Anestesia Topi Braun S / A HCl during the period of organogenesis through parturition and subsequent pup weaning . Due to species-specific differences in lactation physiology, animal data may not reliably predict drug levels in human milk.
The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for Anestesia Topi Braun S / A and any potential adverse effects on the breastfed infant from Anestesia Topi Braun S / A or from the underlying maternal condition.
Data
In a pre- and post-natal development study, rats were given oxymetazoline HCl subcutaneously at doses of 0.01, 0.03, and 0.1 mg/kg/day (0.6, 1.5, and 7.6 times, respectively, the oxymetazoline AUC exposure at the MRHD) in combination with 7.5 mg/kg Anestesia Topi Braun S / A HCl (12 times the AUC exposure as measured by PBBA at the MRHD) from Gestational Day [GD] 7 to Lactation Day [LD] 20. Concentrations of oxymetazoline, Anestesia Topi Braun S / A, and PBBA were measured in the milk of lactating rats at approximately 2 hours postdose on LD 15. The concentrations of oxymetazoline were generally dose dependent (2.5, 7.0, and 33.8 ng/mL at 0.01, 0.03, and 0.1 mg/kg/day, respectively). The concentrations of Anestesia Topi Braun S / A and PBBA were generally similar across all 7.5 mg/kg/day Anestesia Topi Braun S / A HCl dosing groups regardless of the presence of oxymetazoline (54.2 – 72.9 ng/mL for Anestesia Topi Braun S / A, and 100.5 – 131.2 ng/mL for PBBA).
8.3 Females and Males of Reproductive Potential
Infertility
No information is available on fertility effects in humans.
Females
Based on animal data, Anestesia Topi Braun S / A may reduce fertility in females of reproductive potential. In female rats, decreased fertility noted as a decrease in litter size occurred at 0.7 times the oxymetazoline AUC exposure at the MRHD of Anestesia Topi Braun S / A. It is not known if the effects on fertility are reversible [ see Nonclinical Toxicology ] .
Males
Based on animal data, Anestesia Topi Braun S / A may reduce male fertility. In male rats, decreased sperm motility and sperm concentration occurred at approximately 2 times the oxymetazoline AUC exposure at the MRHD of Anestesia Topi Braun S / A .
8.4 Pediatric Use
Anestesia Topi Braun S / A has not been studied in pediatric patients under 3 years of age and is not advised for use in pediatric patients weighing less than 40 kg because efficacy has not been demonstrated in these patients .
8.5 Geriatric Use
Clinical studies of Anestesia Topi Braun S / A did not include sufficient numbers of patients aged 65 and over to determine whether they respond differently from younger patients. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. Monitor geriatric patients for signs of local anesthetic toxicity, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.
Of note, comparisons of Anestesia Topi Braun S / A safety and efficacy results were generally similar among dental patients who were > 50 years old and ≤ 50 years old (n=148). However, a trend toward a higher incidence of notable increases in systolic blood pressure was observed in dental patients > 50 years of age compared with patients ≤ 50 years of age (16.6% vs 1.4, respectively) [see Adverse Reactions ( 6.1 )]. These increases in blood pressure measurements were generally asymptomatic and transient in nature, and all spontaneously resolved without the need for medical intervention [see Clinical Studies ( 14.1 )] .
8.6 Hepatic Disease
Because of an inability to metabolize local anesthetics, those patients with severe hepatic disease may be at a greater risk of developing toxic plasma concentrations of Anestesia Topi Braun S / A. Monitor patients with hepatic disease for signs of local anesthetic toxicity.
8.7 Pseudocholinesterase Deficiency
Because of an inability to metabolize local anesthetics, those patients with pseudocholinesterase deficiency may be at a greater risk of developing toxic plasma concentrations of Anestesia Topi Braun S / A. Monitor patients with pseudocholinesterase deficiency for signs of local anesthetic toxicity.
10 OVERDOSAGE
No addictive properties have been reported in the literature for either Anestesia Topi Braun S / A or oxymetazoline, but there have been numerous case reports of unintended overdose for both compounds. Side effects in adults and children associated with oxymetazoline overdose include dizziness, chest pain, headaches, myocardial infarction, stroke, visual disturbances, arrhythmia, hypertension, or hypotension. Side effects of Anestesia Topi Braun S / A overdose include rapid circulatory collapse, cardiac arrest, and cerebral events.
Possible rebound nasal congestion, irritation of nasal mucosa, and adverse systemic effects (particularly in children), including serious cardiac events, have been associated with overdosage and/or prolonged or too frequent intranasal use of oxymetazoline containing agents.
Accidental ingestion of imidazoline derivatives (i.e., oxymetazoline, naphazoline, tetrahydrozoline) in children has resulted in serious adverse events requiring hospitalization (e.g., coma, bradycardia, decreased respiration, sedation, and somnolence).
Patients should be instructed to avoid using oxymetazoline-containing products (such as Afrin ®) and other α-adrenergic agonists within 24 hours prior to their scheduled dental procedure .
Management of an overdose includes close monitoring, supportive care, and symptomatic treatment.
11 DESCRIPTION
Anestesia Topi Braun S / A (tetracaine HCl and oxymetazoline HCl) Nasal Spray is a clear aqueous solution in a pre-filled, single-use intranasal sprayer. The solution pH is 6.0 ± 1.0. The product contains two active ingredients: 30 mg/mL Anestesia Topi Braun S / A HCl (equivalent to 26.4 mg/mL Anestesia Topi Braun S / A) and 0.5 mg/mL oxymetazoline hydrochloride (equivalent to 0.44 mg/mL oxymetazoline). Each spray delivers 0.2 mL of solution containing 6 mg Anestesia Topi Braun S / A hydrochloride (equivalent to 5.27 mg Anestesia Topi Braun S / A) and 0.1 mg of oxymetazoline hydrochloride (equivalent to 0.088 mg oxymetazoline). The product also contains citric acid, sodium citrate, hydroxyethylcellulose, benzyl alcohol, and water. Sodium hydroxide and/or hydrochloric acid are added for pH adjustment as needed.
Anestesia Topi Braun S / A hydrochloride is an ester local anesthetic. Chemically it is 2-(dimethylamino)ethyl 4-(butylamino)benzoate hydrochloride. Its molecular weight is 300.8 for the hydrochloride salt and 264.4 for the free base. It is freely soluble in water and soluble in ethanol. Its structural formula is:
Oxymetazoline hydrochloride is a vasoconstrictor. Chemically it is 3-[(4,5-dihydro-1 H-imidazol-2-yl)methyl]-6-(1,1,-dimethylethyl)-2,4-dimethylphenol mono-hydrochloride. Its molecular weight is 296.8 for the hydrochloride salt and 260.4 for the free base. It is freely soluble in water and ethanol and has a partition coefficient of 0.1 in octanol/water. Its structural formula is:
Anestesia Topi Braun S / A Hydrochloride Structural Formula Oxymetazoline Hydrochloride Structural Formula
12 CLINICAL PHARMACOLOGY
12.1 Mechanism of Action
Anestesia Topi Braun S / A is a local anesthetic of the ester type and exerts its activity by blocking sodium ion channels required for the initiation and conduction of neuronal impulses. Oxymetazoline is an imidazoline derivative with sympathomimetic activity. It is believed to be a mixed α 1/α 2-adrenoceptor agonist and, by stimulating adrenergic receptors, it elicits vasoconstriction of dilated arterioles and reduces nasal blood flow.
12.3 Pharmacokinetics
Absorption
Following nasal administration of 0.6 mL Anestesia Topi Braun S / A in adult subjects (n=24), oxymetazoline attained maximum concentrations within approximately 10 minutes following the end of dosing. The observed mean oxymetazoline C max and AUC 0-inf value were 1.78 ng/mL and 4.24 ng.h/mL, respectively. The observed median T max was 5 minutes.
Plasma concentrations of Anestesia Topi Braun S / A in all subjects were at or below the limit of assay quantification (0.05 ng/mL). Of all plasma samples analyzed, only one quantifiable Anestesia Topi Braun S / A concentration was observed in a single sample from one subject, which was at the limit of assay quantification. The primary metabolite of Anestesia Topi Braun S / A, p-butylaminobenzoic acid (PBBA) achieved peak concentrations within approximately 25 minutes following the end of Anestesia Topi Braun S / A dosing. The observed mean PBBA C max and AUC 0-inf value were 465 ng/mL and 973 ng.h/mL, respectively. The observed median T max was 20 minutes.
Distribution
Protein binding and distribution of oxymetazoline and PBBA have not been determined. Plasma protein binding of Anestesia Topi Braun S / A has been reported to be 75% to 85%.
Elimination
The terminal half-life of oxymetazoline in plasma following nasal administration of Anestesia Topi Braun S / A to adult subjects is approximately 5.2 hours.
The elimination half-life and apparent clearance of Anestesia Topi Braun S / A could not be determined after Anestesia Topi Braun S / A administration because it is rapidly and thoroughly hydrolyzed in plasma. The plasma half-life of PBBA is approximately 2.6 hours in adult subjects.
Metabolism
Oxymetazoline is converted to a glucuronide conjugate in vitro by UGT1A9.
Anestesia Topi Braun S / A is rapidly and thoroughly cleaved by esterases in plasma and other tissues to PBBA and dimethylaminoethanol. These metabolites have an unspecified activity.
Excretion
The apparent clearance of oxymetazoline after nasal administration of Anestesia Topi Braun S / A has not been determined. It is thought that the primary route of oxymetazoline elimination at clinically relevant concentrations is by renal excretion.
PBBA clearance cannot be determined after administration of Anestesia Topi Braun S / A.
Special Populations
Pediatrics:
In subjects 4-15 years of age (n=18) that received Anestesia Topi Braun S / A doses of 0.1 mL (10 to < 20 kg body weight), 0.2 mL (20 to < 40 kg), or 0.4 mL (≥ 40 kg), oxymetazoline attained maximum concentrations within approximately 10 minutes to 30 minutes (median time) following the end of dosing. The observed oxymetazoline mean C max values were 0.37 ± 0.43, 0.85 ± 0.45, and 1.2 ± 0.39 ng/mL in the 0.1 mL, 0.2 mL, and 0.4 mL dose groups, respectively. The observed oxymetazoline mean AUC 0-inf values were 0.99 (AUC can be calculated only in one subject), 2.53 ± 1.08, and 2.64 ± 0.41 ng.h/mL in the 0.1 mL, 0.2 mL, and 0.4 mL dose groups, respectively. Mean elimination half-life values for oxymetazoline were approximately 1.6 to 4.3 hours across pediatric dose groups.
Plasma concentrations of Anestesia Topi Braun S / A were below the limit of assay quantification (0.05 ng/mL) in all subjects.
PBBA attained maximum concentrations within approximately 20 minutes to 30 minutes (median time) following the end of dosing. The observed PBBA mean C max values were 166 ± 71, 345 ± 172, and 365 ± 30 ng/mL in the 0.1 mL, 0.2 mL, and 0.4 mL dose groups, respectively. The observed PBBA mean AUC 0-inf values were 529 ± 222, 826 ± 606, and 665 ± 86 ng.h/mL in the 0.1 mL, 0.2 mL, and 0.4 mL dose groups, respectively. Mean elimination half-life values for PBBA were approximately 1.6 to 2.8 hours across pediatric dose groups.
Elderly: The pharmacokinetics of Anestesia Topi Braun S / A were not evaluated in subjects greater than 50 years of age.
Renal or Hepatic Impairment: The pharmacokinetics of oxymetazoline, Anestesia Topi Braun S / A, and PBBA were not evaluated after nasal administration of Anestesia Topi Braun S / A in subjects with renal or hepatic impairment.
Race: There were insufficient data to evaluate the effect of race on oxymetazoline, Anestesia Topi Braun S / A, and PBBA pharmacokinetics after nasal administration of Anestesia Topi Braun S / A.
13 NON-CLINICAL TOXICOLOGY
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
Carcinogenesis
Long-term studies in animals have not been performed to evaluate the carcinogenic potential of Anestesia Topi Braun S / A or oxymetazoline.
Mutagenesis
Anestesia Topi Braun S / A base was negative in the in vitro Ames bacterial reverse mutation assay and the in vivo mouse micronucleus assay. In the in vitro chromosome aberration assay using Chinese hamster ovary cells, Anestesia Topi Braun S / A base was negative in the absence of metabolic activation, and equivocal in the presence of metabolic activation. No studies have been conducted to evaluate the mutagenic potential of oxymetazoline.
Impairment of Fertility
Male and female rats were given subcutaneous doses of oxymetazoline HCl alone at 0.1 mg/kg/day, Anestesia Topi Braun S / A HCl alone at 7.5 mg/kg/day, or the combination of oxymetazoline HCl at 0.01, 0.03, or 0.1 mg/kg/day oxymetazoline with 7.5 mg/kg/day Anestesia Topi Braun S / A HCl prior to and during mating. Oxymetazoline HCl at ≥ 0.03 mg/kg/day reduced the percentage of motile sperm and sperm counts at 2 times the oxymetazoline AUC exposure at the MRHD of Anestesia Topi Braun S / A. There were no effects on male mating behavior at any dose tested. The no-effect level for sperm effects was 0.01 mg/kg/day (0.7 times the oxymetazoline AUC exposure at the MRHD of Anestesia Topi Braun S / A).
In female rats, a reduction in the number of viable embryos was observed at oxymetazoline AUC exposures equivalent to 0.7 times the MRHD and higher, given alone or in combination with Anestesia Topi Braun S / A HCl. Reduced numbers of corpora lutea and implantation sites were observed at 7.5 times the oxymetazoline AUC exposure at the MRHD in animals given oxymetazoline HCl alone or in combination with Anestesia Topi Braun S / A HCl. These effects were attributed to oxymetazoline HCl because similar effects were not observed in rats given Anestesia Topi Braun S / A HCl alone. A no-effect level for fertility in female rats was not established in this study.
No effects on male or female fertility were attributed to Anestesia Topi Braun S / A HCl at 7.5 mg/kg/day (28 and 33 times the AUC exposure for males and females, respectively, as measured by PBBA [major Anestesia Topi Braun S / A metabolite] at the MRHD of Anestesia Topi Braun S / A).
14 CLINICAL STUDIES
The efficacy of Anestesia Topi Braun S / A Nasal Spray for regional anesthesia when performing a restorative procedure on Teeth 4-13 and A-J has been evaluated in three adult dental patient studies, as well as one pediatric dental patient study. The primary endpoint for all four studies was the successful completion of a restorative operative dental procedure without the need for a rescue injection. One adult dental study was terminated early for reasons related to the administration of Anestesia Topi Braun S / A. Unlike the other studies conducted, in this study all three sprays were delivered horizontally.
14.1 Studies in Adults
Study 1
Study 1 was a Phase 3, multicenter, randomized, double-blind, placebo and active-controlled, parallel-groups study designed to compare the efficacy and safety of intranasally administered Anestesia Topi Braun S / A to both Anestesia Topi Braun S / A HCl alone and placebo, for providing dental anesthesia sufficient to allow completion of the standard dental procedure on a single maxillary tooth in adults.
A total of 110 patients were enrolled in two clinical centers and randomized to receive three 0.2 mL intranasal sprays of either Anestesia Topi Braun S / A (n=44), Anestesia Topi Braun S / A alone (n=44), or placebo (n=22). All randomized patients completed the study dental procedure.
Fifty-three percent (53%) of randomized patients were female and 76% were White, with a mean age of 35 years (range 18 to 73 years).
Eighty-four percent (95% CI: 70%, 93%) of Anestesia Topi Braun S / A patients were able to complete the dental procedure without the need for rescue medication compared to 27% (95% CI: 15%, 43%) who received Anestesia Topi Braun S / A alone and 27% (95% CI: 11%, 50%) who received placebo.
Anestesia Topi Braun S / A had a lower success rate for dental procedures on the 2 nd pre-molar (teeth #4 and #13) compared with more anterior teeth (#5 through #12): 63% for the 2 nd pre-molars vs 96% for more anterior teeth.
In this trial, the median duration of a dental procedure successfully completed with Anestesia Topi Braun S / A was 11 minutes, although one successfully completed dental procedure was as long as 43 minutes. Of the people that needed rescue medication in the Anestesia Topi Braun S / A arm, they required it within the first 6 minutes following the start of the dental procedure.
Study 2
Study 2 was a Phase 3, multicenter, randomized, double-blind, parallel-groups study designed to compare the efficacy and safety of intranasally administered Anestesia Topi Braun S / A to placebo, for providing dental anesthesia sufficient to allow completion of the standard dental procedure on a single maxillary tooth (#4-13) in adults.
A total of 150 adult patients were enrolled at three study centers and received either Anestesia Topi Braun S / A (n=100) or placebo (n=50) as a dose of two or three 0.2 mL intranasal sprays. All except two randomized patients (one each in the Anestesia Topi Braun S / A and placebo groups) completed the study dental procedure.
Fifty-five percent (55%) of randomized patients were female and 63% were White, with a mean age of 41 years (range 18 to 78 years).
Eighty-eight percent (95% CI: 80%, 94%) of Anestesia Topi Braun S / A patients were able to complete the dental procedure without the need for rescue medication compared to 28% (95% CI: 16%, 43%) of patients who received placebo.
Anestesia Topi Braun S / A had a lower success rate for dental procedures on the 2 nd pre-molar (teeth #4 and #13) compared with more anterior teeth (#5 through #12): 64% for the 2 nd pre-molars vs 96% for more anterior teeth.
14.2 Study in Children
Study 3
Study 3 was a Phase 3, multicenter, randomized, double-blind, parallel-groups study designed to compare the efficacy and safety of intranasally administered Anestesia Topi Braun S / A to placebo for providing dental anesthesia sufficient to allow completion of the standard dental procedure on a single maxillary tooth (permanent teeth 4-13 or primary teeth A-J) for pediatric patients aged 3 through 17.
A total of 90 patients, 3 through 17 years of age inclusive, were enrolled at two study centers. Patients received one or two intranasal sprays of either Anestesia Topi Braun S / A (n=60) or placebo (n=30) based on body weight: one 0.1 mL spray for patients weighing 10 kg to less than 20 kg; two 0.1 mL sprays for 20 kg to less than 40 kg; or two 0.2 mL sprays for patients weighing 40 kg or more. All except one randomized patient in the Anestesia Topi Braun S / A group completed the study dental procedure.
Fifty-one percent (51%) of randomized patients were male and 89% were White, with a mean age of 8 years (range 3 to 17 years).
Even though a greater percentage of patients were able to complete the dental procedure without the need for rescue anesthesia for Anestesia Topi Braun S / A: 77% for Anestesia Topi Braun S / A (95% CI: 64%, 87%) compared to 53% for placebo (95% CI: 34%, 72%) an analysis by weight indicated that efficacy was only established for patients weighing 40 kg or more .
| Successful Anesthetic Response by Weight N (%) | Anestesia Topi Braun S / A (N = 60) | Placebo (N = 30) |
| 40 kg or more | 18/20 (90%) | 4/10 (40%) |
| 20 to less than 40 kg | 14/24 (58%) | 5/12 (42%) |
| 10 to less than 20 kg | 14/16 (88%) | 7/8 (88%) |
16 HOW SUPPLIED/STORAGE AND HANDLING
Anestesia Topi Braun S / A Nasal Spray is supplied as pre-filled, single-use sprayers containing a clear aqueous solution of 30 mg/mL of Anestesia Topi Braun S / A hydrochloride (equivalent to 26.4 mg/mL Anestesia Topi Braun S / A) and 0.5 mg/mL of oxymetazoline hydrochloride (equivalent to 0.44 mg/mL oxymetazoline). Each sprayer delivers 0.2 mL.
The product is available as:
- NDC 69803-100-10: Box of 30 sprayers
Store between 2° and 8°C (36° and 46°F); excursions permitted between 0° and 15°C (32° and 59°F).
Discard any unused solution. DO NOT use if drug is left out at room temperature for more than 5 days.
17 PATIENT COUNSELING INFORMATION
- Inform patients of the likelihood of expected side effects (including runny nose, nasal congestion, mild nose bleeds, dizziness, and/or a sensation of difficulty in swallowing) that should resolve within the same day. Instruct patients to contact their dentist or health care professional if these symptoms persist .
- Advise patients to inform the dental practitioner if they are taking monoamine oxidase inhibitors (MAOIs), nonselective beta adrenergic antagonists, or tricyclic antidepressants .
- Instruct patients to avoid using oxymetazoline-containing products (such as Afrin ® and other α-adrenergic agonists) within 24 hours prior to their scheduled dental procedure. .
- Advise patients of the signs and symptoms of hypersensitivity reactions and to seek immediate medical attention should they occur .
St. Renatus, LLC
Manufactured for:
St. Renatus, LLC
Fort Collins, CO 80526
Anestesia Topi Braun S / A is a trademark of St. Renatus, LLC.
Principal Display Panel - Box Label
NDC 69803-100-10
Anestesia Topi Braun S / A
(tetracaine HCl and oxymetazoline HCl)
NASAL SPRAY
0.2 mL per sprayer
Containing 6 mg Anestesia Topi Braun S / A HCl and 0.1 mg oxymetazoline HCl
(equivalent to 5.27 mg Anestesia Topi Braun S / A and 0.088 mg oxymetazoline)
Contents: 30 sprayers
Rx only
NOT FOR INJECTION
Store refrigerated at 2 to 8°C (36 to 46°F)
Manufactured for
St. Renatus, LLC
Fort Collins, CO 80526
Anestesia Topi Braun S / A pharmaceutical active ingredients containing related brand and generic drugs:
Anestesia Topi Braun S / A available forms, composition, doses:
Anestesia Topi Braun S / A destination | category:
Anestesia Topi Braun S / A Anatomical Therapeutic Chemical codes:
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References
- Dailymed."BLT 3 (TETRACAINE) OINTMENT [CENTURA PHARMACEUTICALS INC]". https://dailymed.nlm.nih.gov/dailym... (accessed August 28, 2018).
- Dailymed."TETRACAINE: DailyMed provides trustworthy information about marketed drugs in the United States. DailyMed is the official provider of FDA label information (package inserts).". https://dailymed.nlm.nih.gov/dailym... (accessed August 28, 2018).
- "tetracaine". https://pubchem.ncbi.nlm.nih.gov/co... (accessed August 28, 2018).
Frequently asked Questions
Can i drive or operate heavy machine after consuming Anestesia Topi Braun S / A?Depending on the reaction of the Anestesia Topi Braun S / A after taken, if you are feeling dizziness, drowsiness or any weakness as a reaction on your body, Then consider Anestesia Topi Braun S / A not safe to drive or operate heavy machine after consumption. Meaning that, do not drive or operate heavy duty machines after taking the capsule if the capsule has a strange reaction on your body like dizziness, drowsiness. As prescribed by a pharmacist, it is dangerous to take alcohol while taking medicines as it exposed patients to drowsiness and health risk. Please take note of such effect most especially when taking Primosa capsule. It's advisable to consult your doctor on time for a proper recommendation and medical consultations.
Is Anestesia Topi Braun S / A addictive or habit forming?Medicines are not designed with the mind of creating an addiction or abuse on the health of the users. Addictive Medicine is categorically called Controlled substances by the government. For instance, Schedule H or X in India and schedule II-V in the US are controlled substances.
Please consult the medicine instruction manual on how to use and ensure it is not a controlled substance.In conclusion, self medication is a killer to your health. Consult your doctor for a proper prescription, recommendation, and guidiance.
Review
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The information was verified by Dr. Rachana Salvi, MD Pharmacology