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DRUGS & SUPPLEMENTS
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Addiction, Abuse, and Misuse
Anamorph® exposes patients and other users to the risks of opioid addiction, abuse, and misuse, which can lead to overdose and death. Assess each patient's risk prior to prescribing Anamorph, and monitor all patients regularly for the development of these behaviors and conditions .
Life-threatening Respiratory Depression
Serious, life-threatening, or fatal respiratory depression may occur with use of Anamorph. Monitor for respiratory depression, especially during initiation of Anamorph or following a dose increase. Instruct patients to swallow Anamorph capsules whole, or to sprinkle the contents of the capsule on applesauce and swallow immediately without chewing. Crushing, chewing, or dissolving the pellets in Anamorph can cause rapid release and absorption of a potentially fatal dose of Anamorph .
Accidental Ingestion
Accidental ingestion of even one dose of Anamorph, especially by children, can result in a fatal overdose of Anamorph .
Neonatal Opioid Withdrawal Syndrome
Prolonged use of Anamorph during pregnancy can result in neonatal opioid withdrawal syndrome, which may be life-threatening if not recognized and treated, and requires management according to protocols developed by neonatology experts. If opioid use is required for a prolonged period in a pregnant woman, advise the patient of the risk of neonatal opioid withdrawal syndrome and ensure that appropriate treatment will be available .
Interaction with Alcohol
Instruct patients not to consume alcoholic beverages or use prescription or non-prescription products that contain alcohol while taking Anamorph. The co-ingestion of alcohol with Anamorph may result in increased plasma level and a potentially fatal overdose of Anamorph .
Concomitant use of opioids with benzodiazepines or other central nervous system (CNS) depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death .
WARNING: ADDICTION, ABUSE, AND MISUSE; LIFE-THREATENING RESPIRATORY DEPRESSION; ACCIDENTAL INGESTION; NEONATAL OPIOID WITHDRAWAL SYNDROME; INTERACTION WITH ALCOHOL; and RISKS FROM CONCOMITANT USE WITH BENZODIAZEPINES OR OTHER CNS DEPRESSANTS
See full prescribing information for complete boxed warning.
Boxed Warning | 12/2016 |
Dosage and Administration (2) | 12/2016 |
Contraindications (4) | 12/2016 |
Warnings and Precautions (5) | 12/2016 |
Anamorph is indicated for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate.
Anamorph is a combination opioid agonist/opioid antagonist product indicated for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate. (1)
Limitations of Use
Limitations of Use
Anamorph should be prescribed only by healthcare professionals who are knowledgeable in the use of potent opioids for the management of chronic pain.
Anamorph 100 mg/4 mg capsules, a single dose greater than 60 mg/2.4 mg, or a total daily dose greater than 120 mg/5 mg, are only for use in patients in whom tolerance to an opioid of comparable potency is established. Patients considered opioid-tolerant are those receiving, for one week or longer, at least 60 mg oral Anamorph per day, 25 mcg transdermal fentanyl per hour, 30 mg of oral oxycodone per day, 8 mg of oral hydromorphone per day, 25 mg oral oxymorphone per day, 60 mg oral hydrocodone per day, or an equianalgesic dose of another opioid.
Instruct patients to swallow Anamorph capsules whole . Crushing, chewing, or dissolving Anamorph capsules will result in uncontrolled delivery of Anamorph and can lead to overdose or death .
Instruct patients who are unable to swallow Anamorph to sprinkle the capsule contents on applesauce and immediately swallow without chewing .
Anamorph is administered orally at a frequency of either once daily (every 24 hours) or twice daily (every 12 hours).
Use of Anamorph as the First Opioid Analgesic
Initiate treatment with Anamorph with 20 mg/0.8 mg capsule orally every 24 hours.
Use of Anamorph in Patients who are not Opioid Tolerant (opioid-non-tolerant patients)
The starting dose for patients who are not opioid tolerant is Anamorph 20 mg/0.8 mg orally every 24 hours.
Use of higher starting doses in patients who are not opioid tolerant may cause fatal respiratory depression .
Conversion from Other Opioids to Anamorph
Discontinue all other around-the-clock opioid drugs when Anamorph therapy is initiated.
There are no established conversion ratios from other opioids to Anamorph defined by clinical trials. Initiate dosing using Anamorph 30 mg orally every 24 hours.
It is safer to underestimate a patient's 24-hour oral Anamorph dosage and provide rescue medication (e.g., immediate-release Anamorph) than to overestimate the 24-hour Anamorph dosage and manage an adverse reaction due to an overdose. While there are useful tables of opioid equivalents readily available, there is inter-patient variability in the relative potency of opioid drugs and opioid formulations.
Close observation and frequent titration are warranted until pain management is stable on the new opioid. Monitor patients for signs and symptoms of opioid withdrawal and for signs of over sedation/toxicity after converting patients to Anamorph.
Conversion from Other Oral Anamorph Formulations to Anamorph
Patients receiving other oral Anamorph formulations may be converted to Anamorph by administering one-half of the patient's total daily oral Anamorph dose as Anamorph twice daily, or by administering the total daily oral Anamorph dose as Anamorph once daily. There are no data to support the efficacy or safety of prescribing Anamorph more frequently than every 12 hours.
Conversion from Parenteral Anamorph, or Other Opioids, to Anamorph
When converting from parenteral Anamorph or other non-morphine opioids (parenteral or oral) to Anamorph, consider the following general points:
Conversion from Methadone to Anamorph
Close monitoring is of particular importance when converting from methadone to other opioid agonists. The ratio between methadone and other opioid agonists may vary widely as a function of previous dose exposure. Methadone has a long half-life and can accumulate in the plasma.
The first dose of Anamorph may be taken with the last dose of any immediate-release opioid medication due to the extended-release characteristics of the Anamorph formulation.
Individually titrate Anamorph to a dose that provides adequate analgesia and minimizes adverse reactions. Continually reevaluate patients receiving Anamorph to assess the maintenance of pain control and the relative incidence of adverse reactions, as well as monitoring for the development of addiction, abuse, or misuse . Frequent communication is important among the prescriber, other members of the healthcare team, the patient, and the caregiver/family during periods of changing analgesic requirements, including initial titration. During chronic therapy, periodically reassess the continued need for opioid analgesics.
Patients who experience breakthrough pain may require a dosage adjustment of Anamorph, or may need rescue medication with an appropriate dose of an immediate-release analgesic. If the level of pain increases after dose stabilization, attempt to identify the source of increased pain before increasing the Anamorph dosage. In patients experiencing inadequate analgesia with once-daily dosing of Anamorph, consider a twice-daily regimen. Because steady-state plasma concentrations are approximated within 24 to 36 hours, Anamorph dose may be adjusted every 1 to 2 days.
If unacceptable opioid-related adverse reactions are observed, consider reducing the dosage. Adjust the dosage to obtain an appropriate balance between management of pain and opioid-related adverse reactions.
If the patient is currently taking a central nervous system depressant and the decision is made to begin Anamorph, start with 1/3 to 1/2 the recommended starting dosage of Anamorph, monitor patients for signs of respiratory depression, sedation, and hypotension, and consider using a lower dosage of the concomitant CNS depressant .
When a patient no longer requires therapy with Anamorph, taper the dose gradually, by 25% to 50% every 2 to 4 days, while monitoring carefully for signs and symptoms of withdrawal. If the patient develops these signs or symptoms, raise the dose to the previous level and taper more slowly, either by increasing the interval between decreases, decreasing the amount of change in dose, or both. Do not abruptly discontinue Anamorph .
Instruct patients to swallow Anamorph capsules intact. The capsules contain pellets that consist of Anamorph and sequestered naltrexone. The pellets in the capsules are not to be crushed, dissolved, or chewed due to the risk of rapid release and absorption of a potentially fatal dose of Anamorph . Consuming Anamorph capsules that have been altered by crushing, chewing, or dissolving the pellets can release sufficient naltrexone to precipitate withdrawal in opioid-dependent individuals .
Alternatively, the contents of the Anamorph capsules (pellets) may be sprinkled over applesauce and then swallowed. This method is appropriate only for patients able to reliably swallow the applesauce without chewing. Other foods have not been tested and should not be substituted for applesauce. Instruct the patient to:
Do not administer Anamorph pellets through a nasogastric or gastric tube.
Extended-release capsules (morphine sulfate/naltrexone hydrochloride): 20 mg/0.8 mg, 30 mg/1.2 mg, 50 mg/2 mg, 60 mg/2.4 mg, 80 mg/3.2 mg, 100 mg/4 mg. Anamorph capsules contain creamy white to light tan spheroidal pellets, have an outer opaque capsule with colors as identified below.
Anamorph 20 mg/0.8 mg | Anamorph 30 mg/1.2 mg | Anamorph 50 mg/2 mg | Anamorph 60 mg/2.4 mg | Anamorph 80 mg/3.2 mg | Anamorph 100 mg/4 mg | |
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Anamorph sulfate | 20 mg | 30 mg | 50 mg | 60 mg | 80 mg | 100 mg |
Sequestered naltrexone hydrochloride | 0.8 mg | 1.2 mg | 2 mg | 2.4 mg | 3.2 mg | 4 mg |
Extended-Release Capsule Description For all strengths, the darker-toned cap has "EMBEDA" printed in grey ink and a single grey band around ¾ of the circumference. | Two-toned, yellow opaque hard gelatin capsule. The lighter-toned body has "20" reverse-printed in a grey circle. | Two-toned, blue-violet opaque hard gelatin capsule. The lighter-toned body has "30" reverse-printed in a grey circle. | Two-toned, blue opaque hard gelatin capsule. The lighter-toned body has "50" reverse-printed in a grey circle. | Two-toned, pink opaque hard gelatin capsule. The lighter-toned body has "60" reverse-printed in a grey circle. | Two-toned, light peach opaque elongated hard gelatin capsule. The lighter-toned body has "80" reverse-printed in a grey circle. | Two-toned, green opaque hard gelatin capsule. The lighter-toned body has "100" reverse-printed in a grey circle. |
Extended-release capsules (morphine sulfate/naltrexone hydrochloride): 20 mg/0.8 mg, 30 mg/1.2 mg, 50 mg/2 mg, 60 mg/2.4 mg, 80 mg/3.2 mg, 100 mg/4 mg (3)
Anamorph is contraindicated in patients with:
Anamorph contains Anamorph, a Schedule II controlled substance. As an opioid, Anamorph exposes users to the risks of addiction, abuse, and misuse . Because extended-release products such as Anamorph deliver the opioid over an extended period of time, there is a greater risk for overdose and death due to the larger amount of Anamorph present .
Although the risk of addiction in any individual is unknown, it can occur in patients appropriately prescribed Anamorph. Addiction can occur at recommended doses and if the drug is misused or abused.
Assess each patient's risk for opioid addiction, abuse, or misuse prior to prescribing Anamorph, and monitor all patients receiving Anamorph for the development of these behaviors and conditions. Risks are increased in patients with a personal or family history of substance abuse (including drug or alcohol abuse or addiction) or mental illness (e.g., major depression). The potential for these risks should not, however, prevent the proper management of pain in any given patient. Patients at increased risk may be prescribed opioids such as Anamorph, but use in such patients necessitates intensive counseling about the risks and proper use of Anamorph along with intensive monitoring for signs of addiction, abuse, and misuse.
Abuse or misuse of Anamorph by crushing, chewing, snorting, or injecting the dissolved product will result in the uncontrolled delivery of the Anamorph and can result in overdose and death . Misuse or abuse of Anamorph by these methods may also release sufficient naltrexone to precipitate withdrawal in opioid-dependent individuals .
Opioids are sought by drug abusers and people with addiction disorders and are subject to criminal diversion. Consider these risks when prescribing or dispensing Anamorph. Strategies to reduce these risks include prescribing the drug in the smallest appropriate quantity and advising the patient on the proper disposal of unused drug . Contact local state professional licensing board or state controlled substances authority for information on how to prevent and detect abuse or diversion of this product.
Serious, life-threatening, or fatal respiratory depression has been reported with the use of opioids, even when used as recommended. Respiratory depression, if not immediately recognized and treated, may lead to respiratory arrest and death. Management of respiratory depression may include close observation, supportive measures, and use of opioid antagonists, depending on the patient's clinical status . Carbon dioxide (CO2) retention from opioid-induced respiratory depression can exacerbate the sedating effects of opioids.
While serious, life-threatening, or fatal respiratory depression can occur at any time during the use of Anamorph, the risk is greatest during the initiation of therapy or following a dosage increase. Monitor patients closely for respiratory depression especially during the first 24–72 hours of initiating therapy with and following dosage increases of Anamorph.
To reduce the risk of respiratory depression, proper dosing and titration of Anamorph are essential . Overestimating the Anamorph dosage when converting patients from another opioid product can result in fatal overdose with the first dose.
Accidental ingestion of even one dose of Anamorph, especially by children, can result in respiratory depression and death due to an overdose of Anamorph.
Prolonged use of Anamorph during pregnancy can result in withdrawal in the neonate. Neonatal opioid withdrawal syndrome, unlike opioid withdrawal syndrome in adults, may be life-threatening if not recognized and treated, and requires management according to protocols developed by neonatology experts. Observe newborns for signs of neonatal opioid withdrawal syndrome and manage accordingly. Advise pregnant women using opioids for a prolonged period of the risk of neonatal opioid withdrawal syndrome and ensure that appropriate treatment will be available .
Profound sedation, respiratory depression, coma, and death may result from the concomitant use of Anamorph with benzodiazepines or other CNS depressants. Because of these risks, reserve concomitant prescribing of these drugs for use in patients for whom alternative treatment options are inadequate.
Observational studies have demonstrated that concomitant use of opioid analgesics and benzodiazepines increases the risk of drug-related mortality compared to use of opioid analgesics alone. Because of similar pharmacological properties, it is reasonable to expect similar risk with the concomitant use of other CNS depressant drugs with opioid analgesics [see Drug Interactions (7) ].
If the decision is made to prescribe a benzodiazepine or other CNS depressant concomitantly with an opioid analgesic, prescribe the lowest effective dosages and minimum durations of concomitant use. In patients already receiving an opioid analgesic, prescribe a lower initial dose of the benzodiazepine or other CNS depressant than indicated in the absence of an opioid, and titrate based on clinical response. If an opioid analgesic is initiated in a patient already taking a benzodiazepine or other CNS depressant, prescribe a lower initial dose of the opioid analgesic, and titrate based on clinical response. Follow patients closely for signs and symptoms of respiratory depression and sedation.
Advise both patients and caregivers about the risks of respiratory depression and sedation when Anamorph is used with benzodiazepines or other CNS depressants (including alcohol and illicit drugs). Advise patients not to drive or operate heavy machinery until the effects of concomitant use of the benzodiazepine or other CNS depressant have been determined. Screen patients for risk of substance use disorders, including opioid abuse and misuse, and warn them of the risk for overdose and death associated with the use of additional CNS depressants including alcohol and illicit drugs .
Patients must not consume alcoholic beverages or prescription or non-prescription products containing alcohol while on Anamorph therapy. The co-ingestion of alcohol with Anamorph may result in increased plasma levels and a potentially fatal overdose of Anamorph .
The use of Anamorph in patients with acute or severe bronchial asthma in an unmonitored setting or in the absence of resuscitative equipment is contraindicated.
Patients with chronic pulmonary disease: EMBEDA-treated patients with significant chronic obstructive pulmonary disease or cor pulmonale, and those with a substantially decreased respiratory reserve, hypoxia, hypercapnia, or pre-existing respiratory depression are at increased risk of decreased respiratory drive including apnea, even at recommended dosages of Anamorph .
Elderly, cachectic, or debilitated patients: Life-threatening respiratory depression is more likely to occur in elderly, cachectic, or debilitated patients because they may have altered pharmacokinetics or altered clearance compared to younger, healthier patients .
Monitor such patients closely, particularly when initiating and titrating Anamorph and when Anamorph is given concomitantly with other drugs that depress respiration . Alternatively, consider the use of non-opioid analgesics in these patients.
Monoamine oxidase inhibitors may potentiate the effects of Anamorph, including respiratory depression, coma, and confusion. Anamorph should not be used in patients taking MAOIs or within 14 days of stopping such treatment.
Cases of adrenal insufficiency have been reported with opioid use, more often following greater than one month of use. Presentation of adrenal insufficiency may include non-specific symptoms and signs including nausea, vomiting, anorexia, fatigue, weakness, dizziness, and low blood pressure. If adrenal insufficiency is suspected, confirm the diagnosis with diagnostic testing as soon as possible. If adrenal insufficiency is diagnosed, treat with physiologic replacement doses of corticosteroids. Wean the patient off of the opioid to allow adrenal function to recover and continue corticosteroid treatment until adrenal function recovers. Other opioids may be tried as some cases reported use of a different opioid without recurrence of adrenal insufficiency. The information available does not identify any particular opioids as being more likely to be associated with adrenal insufficiency.
Anamorph may cause severe hypotension including orthostatic hypotension and syncope in ambulatory patients. There is increased risk in patients whose ability to maintain blood pressure has already been compromised by a reduced blood volume or concurrent administration of certain CNS depressant drugs . Monitor these patients for signs of hypotension after initiating or titrating the dosage of Anamorph. In patients with circulatory shock, Anamorph may cause vasodilation that can further reduce cardiac output and blood pressure. Avoid the use of Anamorph in patients with circulatory shock.
In patients susceptible to the intracranial effects of CO2 retention (e.g., those with evidence of increased intracranial pressure or brain tumors), Anamorph may reduce respiratory drive, and the resultant CO2 retention can further increase intracranial pressure. Monitor such patients for signs of sedation and respiratory depression, particularly when initiating therapy with Anamorph.
Opioids may also obscure the clinical course in a patient with a head injury. Avoid the use of Anamorph in patients with impaired consciousness or coma.
Anamorph is contraindicated in patients with known or suspected gastrointestinal obstruction, including paralytic ileus. The Anamorph in Anamorph may cause spasm of the sphincter of Oddi. Opioids may cause increases in serum amylase. Monitor patients with biliary tract disease, including acute pancreatitis, for worsening symptoms.
The Anamorph in Anamorph may increase the frequency of seizures in patients with seizure disorders, and may increase the risk of seizures in other clinical settings associated with seizures. Monitor patients with a history of seizure disorders for worsened seizure control during Anamorph therapy.
Avoid the use of mixed agonist/antagonist or partial agonist (e.g., buprenorphine) analgesics in patients who have received or are receiving a full opioid agonist analgesic, including Anamorph. In these patients, mixed agonists/antagonist and partial agonist analgesics may reduce the analgesic effect and/or may precipitate withdrawal symptoms.
Consuming Anamorph capsules that have been altered by crushing, chewing, or dissolving the pellets can release sufficient naltrexone to precipitate withdrawal in opioid-dependent individuals. Symptoms of withdrawal usually appear within five minutes of ingestion of naltrexone, can last for up to 48 hours, and can include mental status changes, restlessness, lacrimation, rhinorrhea, yawning, perspiration, chills, myalgia, and mydriasis. Significant fluid losses from vomiting and diarrhea can require intravenous (IV) fluid administration.
When discontinuing Anamorph, gradually taper the dosage . Do not abruptly discontinue Anamorph .
Anamorph may impair the mental or physical abilities needed to perform potentially hazardous activities such as driving a car or operating machinery. Warn patients not to drive or operate dangerous machinery unless they are tolerant to the effects of Anamorph and know how they will react to the medication .
Naltrexone does not interfere with thin-layer, gas-liquid, and high performance liquid chromatographic methods which may be used for the separation and detection of Anamorph, methadone, or quinine in the urine. Naltrexone may or may not interfere with enzymatic methods for the detection of opioids depending on the specificity of the test. Consult the test manufacturer for specific details.
The following serious adverse reactions described, or described in greater detail, in other sections:
Most common adverse reactions (>10%): constipation, nausea, and somnolence. (6.1)
To report SUSPECTED ADVERSE REACTIONS, contact Pfizer, Inc. at 1-800-438-1985 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared with rates in the clinical trials of another drug and may not reflect the rates observed in practice.
In the randomized study, the most common adverse reactions with Anamorph therapy were constipation, nausea, and somnolence. The most common adverse reactions leading to study discontinuation were nausea, constipation (sometimes severe), vomiting, fatigue, dizziness, pruritus, and somnolence.
Short-Term Randomized Study
This study utilized an enriched enrollment with a randomized withdrawal design in which subjects were titrated to effect on open-label Anamorph for up to 45 days. Once their pain was controlled, 344 of 547 subjects were randomized to either an active treatment with Anamorph or were tapered off Anamorph using a double-dummy design and placed on placebo. The maintenance Period was 12 weeks. Adverse reactions, reported in ≥2% of subjects in either the titration or maintenance phase of the 12-week study are presented in Table 1.
Titration | Maintenance | ||
---|---|---|---|
Adverse Reaction | Anamorph (N=547) n (%) | Anamorph (N=171) n (%) | Placebo (N=173) n (%) |
Constipation | 165 (30%) | 12 (7%) | 7 (4%) |
Nausea | 106 (19%) | 19 (11%) | 11 (6%) |
Somnolence | 76 (14%) | 2 (1%) | 5 (3%) |
Vomiting | 46 (8%) | 7 (4%) | 2 (1%) |
Dizziness | 42 (8%) | 2 (1%) | 2 (1%) |
Pruritus | 34 (6%) | 0 | 1 (1%) |
Dry mouth | 31 (6%) | 3 (2%) | 2 (1%) |
Headache | 22 (4%) | 4 (2%) | 2 (1%) |
Fatigue | 16 (3%) | 1 (1%) | 2 (1%) |
Insomnia | 7 (1%) | 5 (3%) | 4 (2%) |
Diarrhea | 6 (1%) | 12 (7%) | 12 (7%) |
Abdominal pain upper | 6 (1%) | 4 (2%) | 3 (2%) |
Flushing | 0 | 4 (2%) | 1 (1%) |
Long-Term Open-Label Safety Study
In the long-term open-label safety study, 465 patients with chronic non-malignant pain were enrolled and 124 patients were treated for up to 1 year. The distributions of adverse events were similar to that of the randomized, controlled studies, and were consistent with the most common opioid-related adverse reactions. Adverse reactions reported in ≥2.0% of subjects are presented in Table 2.
Adverse Reaction | Anamorph (N=465) n (%) |
---|---|
Constipation | 145 (31%) |
Nausea | 103 (22%) |
Vomiting | 37 (8%) |
Somnolence | 34 (7%) |
Headache | 32 (7%) |
Pruritus | 26 (6%) |
Fatigue | 19 (4%) |
Dizziness | 19 (4%) |
Dry mouth | 17 (4%) |
Hyperhidrosis | 16 (3%) |
Insomnia | 13 (3%) |
Diarrhea | 10 (2%) |
Anxiety | 10 (2%) |
Adverse Reactions Observed in the Phase 2/3 Studies
Most common (≥10%): constipation, nausea, somnolence
Common (≥1% to <10%): vomiting, headache, dizziness, pruritus, dry mouth, diarrhea, fatigue, insomnia, hyperhidrosis, anxiety, chills, abdominal pain, lethargy, edema peripheral, dyspepsia, anorexia, muscle spasms, depression, flatulence, restlessness, decreased appetite, irritability, stomach discomfort, tremor, arthralgia, hot flush, sedation
Less common (<1%):
Eye disorders: vision blurred, orthostatic hypotension
Gastrointestinal disorders: abdominal distension, pancreatitis, abdominal discomfort, fecaloma, abdominal pain lower, abdominal tenderness
General disorders and administration site conditions: malaise, asthenia, feeling jittery, drug withdrawal syndrome
Hepatobiliary disorders: cholecystitis
Investigations: alanine aminotransferase increased, aspartate aminotransferase increased
Musculoskeletal and connective tissue disorders: myalgia, muscular weakness
Nervous system disorders: depressed level of consciousness, mental impairment, memory impairment, disturbance in attention, stupor, paresthesia, coordination abnormal
Psychiatric disorders: disorientation, thinking abnormal, mental status changes, confusional state, euphoric mood, hallucination, abnormal dreams, mood swings, nervousness
Renal and urinary disorders: urinary retention, dysuria
Reproductive system and breast disorders: erectile dysfunction
Respiratory, thoracic and mediastinal disorders: dyspnea, rhinorrhea
Skin and subcutaneous tissue disorders: rash, piloerection, cold sweat, night sweats
Vascular disorders: hypotension, flushing
The following adverse reactions have been identified during post-approval use of Anamorph. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.
Serotonin syndrome: Cases of serotonin syndrome, a potentially life-threatening condition, have been reported during concomitant use of opioids with serotonergic drugs.
Adrenal insufficiency: Cases of adrenal insufficiency have been reported with opioid use, more often following greater than one month of use.
Anaphylaxis: Anaphylaxis has been reported with ingredients contained in Anamorph.
Androgen deficiency: Cases of androgen deficiency have occurred with chronic use of opioids .
Table 3 includes clinically significant drug interactions with Anamorph.
Alcohol | |
Clinical Impact: | Concomitant use of alcohol with Anamorph can result in an increase of Anamorph plasma levels and potentially fatal overdose of Anamorph. |
Intervention: | Instruct patients not to consume alcoholic beverages or use prescription or non-prescription products containing alcohol while on Anamorph therapy . |
Benzodiazepines and Other Central Nervous System (CNS) Depressants | |
Clinical Impact: | Due to additive pharmacologic effect, the concomitant use of benzodiazepines or other CNS depressants, including alcohol, can increase the risk of hypotension, respiratory depression, profound sedation, coma, and death. |
Intervention: | Reserve concomitant prescribing of these drugs for use in patients for whom alternative treatment options are inadequate. Limit dosages and durations to the minimum required. Follow patients closely for signs of respiratory depression and sedation . |
Examples: | Benzodiazepines, and other sedatives/hypnotics, anxiolytics, tranquilizers, muscle relaxants, general anesthetics, antipsychotics, other opioids, alcohol. |
Serotonergic Drugs | |
Clinical Impact: | The concomitant use of opioids with other drugs that affect the serotonergic neurotransmitter system has resulted in serotonin syndrome. |
Intervention: | If concomitant use is warranted, carefully observe the patient, particularly during treatment initiation and dose adjustment. Discontinue Anamorph if serotonin syndrome is suspected. |
Examples: | Selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), triptans, 5-HT3 receptor antagonists, drugs that affect the serotonin neurotransmitter system (e.g., mirtazapine, trazodone, tramadol), monoamine oxidase (MAO) inhibitors (those intended to treat psychiatric disorders and also others, such as linezolid and intravenous methylene blue). |
Monoamine Oxidase Inhibitors (MAOIs) | |
Clinical Impact: | MAOI interactions with opioids may manifest as serotonin syndrome or opioid toxicity (e.g., respiratory depression, coma) . |
Intervention: | Do not use Anamorph in patients taking MAOIs or within 14 days of stopping such treatment. |
Examples: | Phenelzine, tranylcypromine, linezolid |
Mixed Agonist/Antagonist and Partial Agonist Opioid Analgesics | |
Clinical Impact: | May reduce the analgesic effect of Anamorph and/or precipitate withdrawal symptoms. |
Intervention: | Avoid concomitant use. |
Examples: | Butorphanol, nalbuphine, pentazocine, buprenorphine |
Muscle Relaxants | |
Clinical Impact: | Opioids may enhance the neuromuscular blocking action of skeletal muscle relaxants and produce an increased degree of respiratory depression. |
Intervention: | Monitor patients for signs of respiratory depression that may be greater than otherwise expected and decrease the dosage of Anamorph and/or muscle relaxant as necessary. |
Cimetidine | |
Clinical Impact: | The concomitant use of cimetidine can potentiate Anamorph effects and increase risk of hypotension, respiratory depression, profound sedation, coma, and death. |
Intervention: | Monitor patients for respiratory depression that may be greater than otherwise expected and decrease the dosage of Anamorph and/or cimetidine as necessary. |
Diuretics | |
Clinical Impact: | Opioids can reduce the efficacy of diuretics by inducing the release of antidiuretic hormone. |
Intervention: | Monitor patients for signs of diminished diuresis and/or effects on blood pressure and increase the dosage of the diuretic as needed. |
Anticholinergic Drugs | |
Clinical Impact: | The concomitant use of anticholinergic drugs may increase risk of urinary retention and/or severe constipation, which may lead to paralytic ileus. |
Intervention: | Monitor patients for signs of urinary retention or reduced gastric motility when Anamorph is used concomitantly with anticholinergic drugs. |
P-Glycoprotein (PGP) Inhibitors | |
Clinical Impact: | The concomitant use of PGP-inhibitors can increase the exposure of Anamorph by about two-fold and can increase risk of hypotension, respiratory depression, profound sedation, coma, and death. |
Intervention: | Monitor patients for signs of respiratory depression that may be greater than otherwise expected and decrease the dosage of Anamorph and/or PGP-inhibitor as necessary. |
Risk Summary
Prolonged use of opioid analgesics during pregnancy can cause neonatal opioid withdrawal syndrome. There are no available data with Anamorph in pregnant women to inform a drug-associated risk for major birth defects and miscarriage. Published studies with Anamorph use during pregnancy have not reported a clear association with Anamorph and major birth defects . In published animal reproduction studies, Anamorph administered subcutaneously during the early gestational period produced neural tube defects (i.e., exencephaly and cranioschisis) at 5 and 16 times the human daily dose of 60 mg based on body surface area (HDD) in hamsters and mice, respectively, lower fetal body weight and increased incidence of abortion at 0.4 times the HDD in the rabbit, growth retardation at 6 times the HDD in the rat, and axial skeletal fusion and cryptorchidism at 16 times the HDD in the mouse. Administration of Anamorph sulfate to pregnant rats during organogenesis and through lactation resulted in cyanosis, hypothermia, decreased brain weights, pup mortality, decreased pup body weights, and adverse effects on reproductive tissues at 3–4 times the HDD; and long-term neurochemical changes in the brain of offspring which correlate with altered behavioral responses that persist through adulthood at exposures comparable to and less than the HDD . Based on animal data, advise pregnant women of the potential risk to a fetus.
The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2–4% and 15–20%, respectively.
Clinical Considerations
Fetal/Neonatal Adverse Reactions
Prolonged use of opioid analgesics during pregnancy for medical or nonmedical purposes can result in physical dependence in the neonate and neonatal opioid withdrawal syndrome shortly after birth. Neonatal opioid withdrawal syndrome presents as irritability, hyperactivity and abnormal sleep pattern, high pitched cry, tremor, vomiting, diarrhea, and failure to gain weight. The onset, duration, and severity of neonatal opioid withdrawal syndrome vary based on the specific opioid used, duration of use, timing and amount of last maternal use, and rate of elimination of the drug by the newborn. Observe newborns for symptoms of neonatal opioid withdrawal syndrome and manage accordingly .
Labor or Delivery
Opioids cross the placenta and may produce respiratory depression and psycho-physiologic effects in neonates. An opioid antagonist, such as naloxone, must be available for reversal of opioid-induced respiratory depression in the neonate. Anamorph is not recommended for use in pregnant women during or immediately prior to labor, when use of shorter-acting analgesics or other analgesic techniques are more appropriate. Opioid analgesics, including Anamorph, can prolong labor through actions which temporarily reduce the strength, duration, and frequency of uterine contractions. However, this effect is not consistent and may be offset by an increased rate of cervical dilation, which tends to shorten labor. Monitor neonates exposed to opioid analgesics during labor for signs of excess sedation and respiratory depression.
Data
Human Data
The results from a population-based prospective cohort, including 70 women exposed to Anamorph during the first trimester of pregnancy and 448 women exposed to Anamorph at any time during pregnancy, indicate no increased risk for congenital malformations. However, these studies cannot definitely establish the absence of any risk because of methodological limitations, including small sample size and non-randomized study design.
Animal Data
Formal reproductive and developmental toxicology studies for Anamorph have not been conducted. Exposure margins for the following published study reports are based on human daily dose of 60 mg Anamorph using a body surface area comparison (HDD). Neural tube defects (exencephaly and cranioschisis) were noted following subcutaneous administration of Anamorph sulfate (35–322 mg/kg) on Gestation Day 8 to pregnant hamsters (4.7 to 43.5 times the HDD). A no adverse effect level was not defined in this study and the findings cannot be clearly attributed to maternal toxicity. Neural tube defects (exencephaly), axial skeletal fusions, and cryptorchidism were reported following a single subcutaneous (SC) injection of Anamorph sulfate to pregnant mice (100–500 mg/kg) on Gestation Day 8 or 9 at 200 mg/kg or greater (16 times the HDD) and fetal resorption at 400 mg/kg or higher (32 times the HDD). No adverse effects were noted following 100 mg/kg Anamorph in this model (8 times the HDD). In one study, following continuous subcutaneous infusion of doses greater than or equal to 2.72 mg/kg to mice (0.2 times the HDD), exencephaly, hydronephrosis, intestinal hemorrhage, split supraoccipital, malformed sternebrae, and malformed xiphoid were noted. The effects were reduced with increasing daily dose; possibly due to rapid induction of tolerance under these infusion conditions. The clinical significance of this report is not clear.
Decreased fetal weights were observed in pregnant rats treated with 20 mg/kg/day Anamorph sulfate (3.2 times the HDD) from Gestation Day 7 to 9. There was no evidence of malformations despite maternal toxicity (10% mortality). In a second rat study, decreased fetal weight and increased incidences of growth retardation were noted at 35 mg/kg/day (5.7 times the HDD) and there was a reduced number of fetuses at 70 mg/kg/day (11.4 times the HDD) when pregnant rats were treated with 10, 35, or 70 mg/kg/day Anamorph sulfate via continuous infusion from Gestation Day 5 to 20. There was no evidence of fetal malformations or maternal toxicity.
An increased incidence of abortion was noted in a study in which pregnant rabbits were treated with 2.5 (0.8 times the HDD) to 10 mg/kg Anamorph sulfate via subcutaneous injection from Gestation Day 6 to 10. In a second study, decreased fetal body weights were reported following treatment of pregnant rabbits with increasing doses of Anamorph (10–50 mg/kg/day) during the pre-mating period and 50 mg/kg/day (16 times the HDD) throughout the gestation period. No overt malformations were reported in either publication; although only limited endpoints were evaluated.
In published studies in rats, exposure to Anamorph during gestation and/or lactation periods is associated with: decreased pup viability at 12.5 mg/kg/day or greater (2 times the HDD); decreased pup body weights at 15 mg/kg/day or greater (2.4 times the HDD); decreased litter size, decreased absolute brain and cerebellar weights, cyanosis, and hypothermia at 20 mg/kg/day (3.2 times the HDD); alteration of behavioral responses (play, social-interaction) at 1 mg/kg/day or greater (0.2 times the HDD); alteration of maternal behaviors (e.g., decreased nursing and pup retrievals) in mice at 1 mg/kg or higher (0.08 times the HDD) and rats at 1.5 mg/kg/day or higher (0.2 times the HDD); and a host of behavioral abnormalities in the offspring of rats, including altered responsiveness to opioids at 4 mg/kg/day (0.7 times the HDD) or greater.
Fetal and/or postnatal exposure to Anamorph in mice and rats has been shown to result in morphological changes in fetal and neonatal brain and neuronal cell loss, alteration of a number of neurotransmitter and neuromodulator systems, including opioid and non-opioid systems, and impairment in various learning and memory tests that appear to persist into adulthood. These studies were conducted with Anamorph treatment usually in the range of 4 to 20 mg/kg/day (0.7 to 3.2 times the HDD).
Additionally, delayed sexual maturation and decreased sexual behaviors in female offspring at 20 mg/kg/day (3.2 times the HDD), and decreased plasma and testicular levels of luteinizing hormone and testosterone, decreased testes weights, seminiferous tubule shrinkage, germinal cell aplasia, and decreased spermatogenesis in male offspring were also observed at 20 mg/kg/day (3.2 times the HDD). Decreased litter size and viability were observed in the offspring of male rats that were intraperitoneally administered Anamorph sulfate for 1 day prior to mating at 25 mg/kg/day (4.1 times the HDD) and mated to untreated females. Decreased viability and body weight and/or movement deficits in both first and second generation offspring were reported when male mice were treated for 5 days with escalating doses of 120 to 240 mg/kg/day Anamorph sulfate (9.7 to 19.5 times the HDD) or when female mice treated with escalating doses of 60 to 240 mg/kg/day (4.9 to 19.5 times the HDD) followed by a 5-day treatment-free recovery period prior to mating. Similar multigenerational findings were also seen in female rats pre-gestationally treated with escalating doses of 10 to 22 mg/kg/day Anamorph (1.6 to 3.6 times the HDD).
Risk Summary
Anamorph is present in breast milk. Published lactation studies report variable concentrations of Anamorph in breast milk with administration of immediate-release Anamorph to nursing mothers in the early postpartum period with a milk-to-plasma Anamorph AUC ratio of 2.5:1 measured in one lactation study. However, there is insufficient information to determine the effects of Anamorph on the breastfed infant and the effects of Anamorph on milk production. Lactation studies have not been conducted with extended-release Anamorph, including Anamorph. Because of the potential for serious adverse reactions, including excess sedation and respiratory depression in a breastfed infant, advise patients that breastfeeding is not recommended during treatment with Anamorph.
Clinical Considerations
Monitor infants exposed to Anamorph through breast milk for excess sedation and respiratory depression. Withdrawal symptoms can occur in breastfed infants when maternal administration of Anamorph is stopped, or when breastfeeding is stopped.
Infertility
Chronic use of opioids may cause reduced fertility in females and males of reproductive potential. It is not known whether these effects on fertility are reversible .
In published animal studies, Anamorph administration adversely effected fertility and reproductive endpoints in male rats and prolonged estrus cycle in female rats .
The safety and efficacy of Anamorph in patients less than 18 years of age have not been established.
Clinical studies of Anamorph did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. The pharmacokinetics of Anamorph have not been investigated in elderly patients although such patients were included in clinical studies. In a long-term open-label safety study, the pre-dose plasma Anamorph concentrations after dose normalization were similar for subjects <65 years and those ≥65 years of age. Limited data are available on the pharmacokinetics of Anamorph in geriatric patients .
Elderly patients (aged 65 years or older) may have increased sensitivity to Anamorph. In general, use caution when selecting a dosage for an elderly patient, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function and of concomitant disease or other drug therapy.
Respiratory depression is the chief risk for elderly patients treated with opioids, and has occurred after large initial doses were administered to patients who were not opioid-tolerant or when opioids were co-administered with other agents that depress respiration. Titrate the dosage of Anamorph slowly in geriatric patients and monitor closely for signs of central nervous system and respiratory depression .
This drug is known to be substantially excreted by the kidney, and the risk of adverse reactions to this drug may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function.
Anamorph pharmacokinetics have been reported to be significantly altered in patients with cirrhosis. Start these patients with a lower than usual dosage of Anamorph and titrate slowly while monitoring for signs of respiratory depression, sedation, and hypotension .
Anamorph pharmacokinetics are altered in patients with renal failure. Start these patients with a lower than usual dosage of Anamorph and titrate slowly while monitoring for signs of respiratory depression, sedation, and hypotension .
Anamorph contains Anamorph, a Schedule II controlled substance.
EMBEDA contains Anamorph, a substance with a high potential for abuse similar to other opioids including fentanyl, hydrocodone, hydromorphone, methadone, oxycodone, oxymorphone, and tapentadol. Anamorph can be abused and is subject to misuse, addiction, and criminal diversion .
The high drug content in extended-release formulations adds to the risk of adverse outcomes from abuse and misuse.
All patients treated with opioids require careful monitoring for signs of abuse and addiction, because use of opioid analgesic products carries the risk of addiction even under appropriate medical use.
Prescription drug abuse is the intentional non-therapeutic use of a prescription drug, even once, for its rewarding psychological or physiological effects.
Drug addiction is a cluster of behavioral, cognitive, and physiological phenomena that develop after repeated substance use and includes: a strong desire to take the drug, difficulties in controlling its use, persisting in its use despite harmful consequences, a higher priority given to drug use than to other activities and obligations, increased tolerance, and sometimes a physical withdrawal.
"Drug-seeking" behavior is very common in persons with substance use disorders. Drug-seeking tactics include emergency calls or visits near the end of office hours, refusal to undergo appropriate examination, testing, or referral, repeated "loss" of prescriptions, tampering with prescriptions, and reluctance to provide prior medical records or contact information for other treating healthcare provider(s). "Doctor shopping" (visiting multiple prescribers to obtain additional prescriptions) is common among drug abusers and people suffering from untreated addiction. Preoccupation with achieving adequate pain relief can be appropriate behavior in a patient with poor pain control.
Abuse and addiction are separate and distinct from physical dependence and tolerance. Healthcare providers should be aware that addiction may not be accompanied by concurrent tolerance and symptoms of physical dependence in all addicts. In addition, abuse of opioids can occur in the absence of true addiction.
Anamorph, like other opioids, can be diverted for non-medical use into illicit channels of distribution. Careful record-keeping of prescribing information, including quantity, frequency, and renewal requests, as required by state and federal law, is strongly advised.
Proper assessment of the patient, proper prescribing practices, periodic re-evaluation of therapy, and proper dispensing and storage are appropriate measures that help to limit abuse of opioid drugs.
Risks Specific to Abuse of Anamorph
Anamorph is for oral use only. Abuse of Anamorph poses a risk of overdose and death. This risk is increased with concurrent abuse of Anamorph with alcohol and other central nervous system depressants. Taking cut, broken, chewed, crushed, or dissolved Anamorph enhances drug release and increases the risk of overdose and death. The sequestered naltrexone hydrochloride in Anamorph is intended to have no clinical effect when Anamorph is taken as directed; however, if the capsules are crushed or chewed, up to 100% of the sequestered naltrexone HCl dose could be released, bioequivalent to an immediate-release (IR) naltrexone HCl oral solution of the same dose. In opioid-tolerant individuals, the absorption of naltrexone HCl may increase the risk of precipitating withdrawal.
Due to the presence of talc as one of the excipients in Anamorph, parenteral abuse can be expected to result in local tissue necrosis, infection, pulmonary granulomas, embolism and death, and increased risk of endocarditis and valvular heart injury. Parenteral drug abuse is commonly associated with transmission of infectious diseases such as hepatitis and HIV.
Abuse Deterrence Studies
Anamorph is formulated with a sequestered opioid antagonist, naltrexone HCl, which is released with manipulation by crushing.
In Vitro Testing
In vitro laboratory tests were performed to evaluate the effect of different physical and chemical conditions intended to defeat the extended-release formulation. When Anamorph is crushed and mixed in a variety of solvents, both Anamorph sulfate and naltrexone hydrochloride are simultaneously extracted.
Clinical Studies
The abuse potential of Anamorph when crushed was examined in three studies following administration by the oral (Studies 1 and 2) and intranasal (Study 3) routes. A fourth study was conducted with IV administration of simulated crushed Anamorph (Study 4). These were randomized, double-blind, single dose, placebo and active-controlled, crossover studies in non-dependent recreational opioid users. Drug Liking in Studies 1– 3 was measured on a bipolar 100-point Visual Analog Scale (VAS) where 0 represents maximum disliking, 50 represents a neutral response (neither like nor dislike), and 100 represents maximum liking. Drug Liking in Study 4 and Drug High in all studies was measured on a unipolar 100-point VAS where 0 represents no response and 100 represents maximum response. Response to whether the subject would take the study drug again was also measured in two studies (Study 2, Study 3) on a bipolar 100-point VAS where 0 represents the strongest negative response (e.g., 'definitely would not'), 50 represents a neutral response, and 100 represents the strongest positive response (e.g., 'definitely would'). The pharmacokinetics of Anamorph sulfate and naltrexone hydrochloride were also determined in these abuse potential studies. When Anamorph was crushed and administered by the oral and intranasal routes, Anamorph and naltrexone were absorbed with similar median time-to-peak concentration (Tmax) values of 1 hour following oral administration and approximately 36 minutes following intranasal administration.
Oral Studies:
Study 1 compared Anamorph to IR Anamorph sulfate. In this study 32 subjects received four treatments: 120 mg/4.8 mg as intact Anamorph capsules, 120 mg/4.8 mg as crushed Anamorph in solution, 120 mg IR Anamorph in solution, and placebo. When Anamorph was crushed and taken orally, the geometric mean (±SD) values for naltrexone Cmax and AUCinf were 1073 ± 721 pg/mL and 3649 ± 1868 pg∙hr/mL, respectively. The oral administration of crushed Anamorph was associated with statistically significantly lower mean and median Drug Liking and Drug High scores compared with crushed IR Anamorph (as summarized in Table 4).
Figure 1 (Study 1) demonstrates a comparison of Drug Liking for crushed Anamorph compared to crushed IR Anamorph sulfate when given by the oral route in subjects who received both treatments. The Y-axis represents the percent of subjects attaining a percent reduction in Drug Liking with crushed Anamorph vs. Anamorph greater than or equal to the value on the X-axis. Of the 32 subjects who completed the study, approximately 81% of subjects had some reduction in Drug Liking and Drug High with crushed Anamorph compared to administration of IR Anamorph sulfate, while approximately 19% had no reduction in Drug Liking or in Drug High. At least a 30% and 50% reduction in Drug Liking with crushed Anamorph compared to IR Anamorph was observed in 72% and 56% of subjects, respectively (summarized in Figure 1). At least a 30% and 50% reduction in Drug High with crushed Anamorph was observed in 56% and 31% of subjects, respectively.
Study 2 compared Anamorph to ER Anamorph sulfate. In this study 36 subjects were randomized to receive three treatments in solution: 120 mg/4.8 mg as crushed Anamorph capsules, 120 mg crushed ER Anamorph, and placebo. When Anamorph was crushed and taken orally, the geometric mean (±SD) values for naltrexone Cmax, AUC0–2h, and AUCinf were 824 ± 469 pg/mL, 1121 ± 561 pg∙hr/mL, and 2984 ± 1388 pg∙hr/mL, respectively. The oral administration of crushed Anamorph was associated with statistically significantly lower mean and median Drug Liking, Drug High, and Take Drug Again scores compared with crushed ER Anamorph (summarized in Table 4).
Figure 1 (Study 2) demonstrates a comparison of maximum Drug Liking for crushed Anamorph compared to crushed ER Anamorph in subjects who received both treatments. Of the 33 subjects who completed the study, approximately 85% of subjects had some reduction in Drug Liking with crushed Anamorph compared to administration of crushed ER Anamorph sulfate, while approximately 15% had no reduction in Drug Liking. Similarly, 100% of subjects showed some reduction in Drug High with crushed Anamorph compared to crushed ER Anamorph. At least a 30% and 50% reduction in Drug Liking with crushed Anamorph compared to crushed ER Anamorph was observed in 76% and 52% of subjects, respectively (summarized in Figure 1). At least a 30% and 50% reduction in Drug High with crushed Anamorph was observed in 79% and 64% of subjects, respectively.
VAS Scale (100 point) | Emax | ||
---|---|---|---|
Crushed Anamorph (120 mg/4.8 mg) | Crushed Anamorph (120 mg ) | ||
Emax = maximal response; ER = extended release; IR = immediate release; SE = standard error. | |||
Study 1 | Immediate Release | ||
Drug Liking | Mean (SE) | 68.1 (3.1) | 89.5 (2.2) |
Median (range) | 62 (50–100) | 93 (57–100) | |
Drug High | Mean (SE) | 54.7 (6.1) | 90.2 (2.1) |
Median (range) | 64 (0–100) | 97 (61–100) | |
Study 2 | Extended Release | ||
Drug Liking | Mean (SE) | 65.2 (2.0) | 80.6 (2.3) |
Median (range) | 65 (51–100) | 81 (50–100) | |
Drug High | Mean (SE) | 29.2 (3.6) | 64.1 (3.3) |
Median (range) | 27 (0–78) | 63 (28–100) | |
Take Drug Again | Mean (SE) | 58.0 (3.8) | 70.6 (4.3) |
Median (range) | 58 (9–100) | 75 (12–100) |
Figure 1: Percent Reduction Profiles for Emax of Drug Liking VAS for Anamorph vs. Anamorph Following Oral Administration in Studies 1 and 2.
Figure 1
Intranasal Study:
Study 3 compared intranasal administration of crushed Anamorph to crushed ER Anamorph sulfate. In this study, 33 subjects were randomized to receive three treatments: 30 mg/1.2 mg as crushed Anamorph, 30 mg crushed ER Anamorph, and crushed placebo. When Anamorph was crushed and taken intranasally, the geometric mean (±SD) values for naltrexone Cmax, AUC0–2h, and AUCinf were 1441 ± 411 pg/mL, 1722 ± 441 pg∙hr/mL and 3228 ± 846 pg∙hr/mL, respectively. Intranasal administration of crushed Anamorph was associated with statistically significantly lower mean and median Drug Liking, Drug High, and Take Drug Again scores compared with crushed ER Anamorph (summarized in Table 5).
Figure 2 demonstrates a comparison of maximum Drug Liking for intranasal administration of crushed Anamorph compared to crushed ER Anamorph in subjects who received both treatments. Of the 27 subjects who completed the study, approximately 78% of subjects had some reduction in Drug Liking with crushed Anamorph compared to administration of crushed ER Anamorph sulfate, while approximately 22% had no reduction in Drug Liking. Similarly, approximately 70% of subjects showed some reduction in Drug High with crushed Anamorph compared to crushed ER Anamorph and approximately 30% of subjects had no reduction in Drug High. At least a 30% and 50% reduction in Drug Liking with crushed Anamorph compared to crushed ER Anamorph was observed in 63% and 59% of subjects, respectively (summarized in Figure 2). At least a 30% and 50% reduction in Drug High with crushed Anamorph was observed in 59% and 37% of subjects, respectively.
VAS Scale (100 point) | Emax | ||
---|---|---|---|
Crushed Anamorph (30 mg/1.2 mg) | Crushed ER Anamorph (30 mg) | ||
Emax = maximal response; ER = extended release; SE = standard error. | |||
Drug Liking | Mean (SE) | 69.0 (3.5) | 88.4 (3.2) |
Median (range) | 66 (50–100) | 100 (51–100) | |
Drug High | Mean (SE) | 48.6 (7.8) | 84.4 (3.8) |
Median (range) | 51 (-39–100) | 100 (42–100) | |
Take Drug Again | Mean (SE) | 59.1 (5.4) | 87.0 (4.0) |
Median (range) | 56 (0–100) | 100 (12–100) |
Figure 2: Percent Reduction Profiles for Emax of Drug Liking VAS for Anamorph vs. Anamorph Following Intranasal Administration in Study 3.
Figure 2
Simulated IV Study:
Study 4, a randomized double-blind, placebo-controlled, three-way cross-over trial in 28 non-dependent recreational opioid users, was performed using 30 mg of intravenous (IV) Anamorph sulfate alone and 30 mg of IV Anamorph sulfate in combination with 1.2 mg of IV naltrexone to simulate parenteral use of crushed Anamorph. These doses were based on the assumption of the complete release of both Anamorph sulfate and naltrexone hydrochloride upon crushing Anamorph. Intravenous administration of the combination of Anamorph sulfate and naltrexone hydrochloride was associated with statistically significantly lower mean and median Drug Liking and Drug High scores (median scores 34 and 23, respectively) compared with Anamorph alone (median scores 86 and 89, respectively). Three of the 26 subjects who completed the study had no reduction in Drug Liking and all the subjects showed some reduction in Drug High. Intravenous injection of crushed Anamorph may result in serious injury and death due to a Anamorph overdose and may precipitate a severe withdrawal syndrome in opioid-dependent patients.
Summary
The in vitro and pharmacokinetic data demonstrate that crushing Anamorph pellets results in the simultaneous release and rapid absorption of Anamorph sulfate and naltrexone hydrochloride. These data along with results from the oral and intranasal human abuse potential studies indicate that Anamorph has properties that are expected to reduce abuse via the oral and intranasal route. However, abuse of Anamorph by these routes is still possible.
Additional data, including epidemiological data, when available, may provide further information on the impact of the current formulation of Anamorph on the abuse liability of the drug. Accordingly, this section may be updated in the future as appropriate.
A human abuse potential study of intravenous Anamorph and naltrexone to simulate crushed Anamorph demonstrated lower Drug Liking and Drug High compared with Anamorph alone. However, it is unknown whether these results with simulated crushed Anamorph predict a reduction in abuse by the IV route until additional postmarketing data are available.
Anamorph contains Anamorph sulfate, an opioid agonist and Schedule II controlled substance with an abuse liability similar to other opioid agonists, legal and illicit, including fentanyl, hydromorphone, methadone, oxycodone, and oxymorphone. Anamorph can be abused and is subject to misuse, addiction, and criminal diversion .
Both tolerance and physical dependence can develop during chronic opioid therapy. Tolerance is the need for increasing doses of opioids to maintain a defined effect such as analgesia (in the absence of disease progression or other external factors). Tolerance may occur to both the desired and undesired effects of drugs, and may develop at different rates for different effects.
Physical dependence results in withdrawal symptoms after abrupt discontinuation or a significant dosage reduction of a drug. Withdrawal also may be precipitated through the administration of drugs with opioid antagonist activity (e.g., naloxone, nalmefene), mixed agonist/antagonist analgesics (e.g., pentazocine, butorphanol, nalbuphine), or partial agonists (e.g., buprenorphine). Physical dependence may not occur to a clinically significant degree until after several days to weeks of continued opioid usage.
Anamorph should not be abruptly discontinued . If Anamorph is abruptly discontinued in a physically dependent patient, a withdrawal syndrome may occur. Some or all of the following can characterize this syndrome: restlessness, lacrimation, rhinorrhea, yawning, perspiration, chills, myalgia, and mydriasis. Other signs and symptoms also may develop, including irritability, anxiety, backache, joint pain, weakness, abdominal cramps, insomnia, nausea, anorexia, vomiting, diarrhea, or increased blood pressure, respiratory rate, or heart rate.
Infants born to mothers physically dependent on opioids will also be physically dependent and may exhibit respiratory difficulties and withdrawal symptoms .
Clinical Presentation
Acute overdose with Anamorph can be manifested by respiratory depression, somnolence progressing to stupor or coma, skeletal muscle flaccidity, cold and clammy skin, constricted pupils, and, in some cases, pulmonary edema, bradycardia, hypotension, partial or complete airway obstruction, atypical snoring, and death. Marked mydriasis rather than miosis may be seen due to severe hypoxia in overdose situations .
Treatment of Overdose
In case of overdose, priorities are the reestablishment of a patent and protected airway and institution of assisted or controlled ventilation, if needed. Employ other supportive measures (including oxygen and vasopressors) in the management of circulatory shock and pulmonary edema as indicated. Cardiac arrest or arrhythmias will require advanced life support techniques.
The opioid antagonists, naloxone or nalmefene, are specific antidotes to respiratory depression resulting from opioid overdose. For clinically significant respiratory or circulatory depression secondary to Anamorph overdose, administer an opioid antagonist. Opioid antagonists should not be administered in the absence of clinically significant respiratory or circulatory depression secondary to Anamorph overdose.
Because the duration of opioid reversal is be expected to be less than the duration of action of Anamorph in Anamorph, carefully monitor the patient until spontaneous respiration is reliably reestablished. Anamorph will continue to release Anamorph and add to the Anamorph load for 24 to 48 hours or longer following ingestion, necessitating prolonged monitoring. If the response to opioid antagonists is suboptimal or only brief in nature, administer additional antagonist as directed in the product's prescribing information.
In an individual physically dependent on opioids, administration of the recommended usual dosage of the antagonist may precipitate an acute withdrawal syndrome. The severity of the withdrawal symptoms experienced will depend on the degree of physical dependence and the dose of the antagonist administered. If a decision is made to treat serious respiratory depression in the physically dependent patient, administration of the antagonist should be initiated with care and by titration with smaller than usual doses of the antagonist.
The sequestered naltrexone in Anamorph has no role in the treatment of opioid overdose.
Anamorph extended-release capsules are for oral use and contain pellets of Anamorph sulfate and naltrexone hydrochloride at a ratio of 100:4. Anamorph sulfate is an opioid agonist and naltrexone hydrochloride is an opioid antagonist.
Each Anamorph extended-release capsule contains the following inactive ingredients common to all strengths: talc, ammonio methacrylate copolymer, sugar spheres, ethylcellulose, sodium chloride, polyethylene glycol, hydroxypropyl cellulose, dibutyl sebacate, methacrylic acid copolymer, diethyl phthalate, magnesium stearate, sodium lauryl sulfate, and ascorbic acid.
The capsule shells contain gelatin, titanium dioxide, and grey ink, FD&C yellow #10 (EMBEDA 20 mg/0.8 mg), FD&C red #3, FD&C blue #1 (EMBEDA 30 mg/1.2 mg), D&C red #28, FD&C red #40, FD&C blue #1 (EMBEDA 50 mg/2 mg), D&C red #28, FD&C red #40, FD&C blue #1 (EMBEDA 60 mg/2.4 mg), FD&C blue #1, FD&C red #40, FD&C yellow #6 (EMBEDA 80 mg/3.2 mg), D&C yellow #10, FD&C blue #1 (EMBEDA 100 mg/4 mg).
Anamorph Sulfate
The chemical name of Anamorph sulfate is 7,8-didehydro-4,5 α-epoxy-17-methyl-morphinan-3,6 α-diol sulfate (2:1) (salt) pentahydrate. The empirical formula is (C17H19NO3)2∙H2SO4∙5H2O and its molecular weight is 758.85.
Anamorph sulfate is an odorless, white, crystalline powder with a bitter taste. It has a solubility of 1 in 21 parts of water and 1 in 1000 parts of alcohol, but is practically insoluble in chloroform or ether. The octanol:water partition coefficient of Anamorph is 1.42 at physiologic pH and the pKb is 7.9 for the tertiary nitrogen (mostly ionized at pH 7.4). Its structural formula is:
Chemical Structure
Naltrexone Hydrochloride
The chemical name of naltrexone hydrochloride is (5α)-17-(Cyclopropylmethyl)-4,5-epoxy-3,14-dihydroxymorphinan-6-one hydrochloride. The empirical formula is C20H23NO4∙HCl and its molecular weight is 377.46.
Naltrexone hydrochloride is a white to slightly off-white powder that is soluble in water. Its structural formula is:
Anamorph Sulfate
Anamorph is a full opioid agonist and is relatively selective for the mu-opioid receptor, although it can bind to other opioid receptors at higher doses. The principal therapeutic action of Anamorph is analgesia. Like all full opioid agonists, there is no ceiling effect for analgesia with Anamorph. Clinically, dosage is titrated to provide adequate analgesia and may be limited by adverse reactions, including respiratory and CNS depression.
The precise mechanism of the analgesic action is unknown. However, specific CNS opioid receptors for endogenous compounds with opioid-like activity have been identified throughout the brain and spinal cord and are thought to play a role in the analgesic effects of this drug.
Naltrexone Hydrochloride
Naltrexone is an opioid antagonist that reverses the subjective and analgesic effects of mu-opioid receptor agonists by competitively binding at mu-opioid receptors.
CNS Depressant/Alcohol Interaction
Additive pharmacodynamic effects may be expected when Anamorph is used in conjunction with alcohol, other opioids, or illicit drugs that cause CNS depression.
Effects on the Central Nervous System
Anamorph produces respiratory depression by direct action on brainstem respiratory centers. The mechanism of respiratory depression involves a reduction in the responsiveness of the brainstem respiratory centers to both increases in carbon dioxide tension and electrical stimulation.
Anamorph causes miosis, even in total darkness. Pinpoint pupils are a sign of opioid overdose but are not pathognomonic. Marked mydriasis rather than miosis may be seen with hypoxia in overdose situations.
Effects on the Gastrointestinal Tract and Other Smooth Muscle
Anamorph causes a reduction in motility associated with an increase in tone in the antrum of the stomach and duodenum. Digestion of food in the small intestine is delayed and propulsive contractions are decreased. Propulsive peristaltic waves in the colon are decreased, while tone is increased to the point of spasm, resulting in constipation. Other opioid-induced effects may include a reduction in biliary and pancreatic secretions, spasm of sphincter of Oddi, and transient elevations in serum amylase.
Effects on the Cardiovascular System
Anamorph produces peripheral vasodilation which may result in orthostatic hypotension or syncope. Manifestations of histamine release or peripheral vasodilation may include pruritus, flushing, red eyes, sweating, and/or orthostatic hypotension.
Effects on the Endocrine System
Opioids inhibit the secretion of adrenocorticotropic hormone (ACTH), cortisol, and luteinizing hormone (LH) in humans . They also stimulate prolactin, growth hormone (GH) secretion, and pancreatic secretion of insulin and glucagon.
Chronic use of opioids may influence the hypothalamic-pituitary-gonadal axis, leading to androgen deficiency that may manifest as low libido, impotence, erectile dysfunction, amenorrhea, or infertility. The causal role of opioids in the clinical syndrome of hypogonadism is unknown because the various medical, physical, lifestyle, and psychological stressors that may influence gonadal hormone levels have not been adequately controlled for in studies conducted to date .
Effects on the Immune System
Opioids have been shown to have a variety of effects on components of the immune system in in vitro and animal models. The clinical significance of these findings is unknown. Overall, the effects of opioids appear to be modestly immunosuppressive.
Concentration-Efficacy Relationships
The minimum effective analgesic concentration will vary widely among patients, especially among patients who have been previously treated with potent agonist opioids. The minimum effective analgesic concentration of Anamorph for any individual patient may increase over time due to an increase in pain, the development of a new pain syndrome, and/or the development of analgesic tolerance .
Concentration-Adverse Reaction Relationships
There is a relationship between increasing Anamorph plasma concentration and increasing frequency of dose-related opioid adverse reactions such as nausea, vomiting, CNS effects, and respiratory depression. In opioid-tolerant patients, the situation may be altered by the development of tolerance to opioid-related adverse reactions .
Absorption
Anamorph Sulfate
Anamorph Capsules contain extended-release pellets of Anamorph sulfate that release Anamorph slowly compared to an oral Anamorph solution. Following the administration of oral Anamorph solution, approximately 50% of the Anamorph absorbed reaches the systemic circulation within 30 minutes, compared to 8 hours with an equal amount of Anamorph. Because of pre-systemic elimination, only about 20 to 40% of the administered dose reaches the systemic circulation.
Anamorph is bioequivalent to a similarly formulated Anamorph sulfate extended-release capsules product with regard to rate and extent of plasma Anamorph absorption. The median time to peak plasma Anamorph levels (Tmax) was shorter for Anamorph (7.5 hrs) compared to the comparator (10 hrs). Dose-related increase in steady-state pre-dose plasma concentrations of Anamorph were noted following multiple-dose administration of Anamorph in patients.
Naltrexone
Following single dose administration of intact Anamorph 60/2.4 – 120/4.8 mg, a limited number (~2%) of blood samples had low plasma naltrexone levels (median = 7.74 pg/mL, range 4–132 pg/mL); naltrexone was not detected in the remaining samples. In patients titrated up to 60/2.4–80/3.2 mg Anamorph twice daily, naltrexone levels (4–26 pg/mL) were detected in 13 out of 67 patients at steady-state. In a long-term safety study where an average dose of Anamorph was up to 860 mg of Anamorph administered twice daily for 12 months, 11% of blood samples at pre-dose timepoints at steady-state had detectable plasma naltrexone concentrations ranging from 4 to 145 pg/mL.
Compared to 2.4 mg naltrexone oral solution, which produced mean (SD) naltrexone plasma levels of 689 (± 429 pg/mL) and mean (SD) 6β-naltrexol plasma levels of 3920 (± 1350 pg/mL), administration of intact 60 mg Anamorph produced no naltrexone plasma levels and mean (SD) 6β-naltrexol plasma levels of 16.7 (± 13.5 pg/mL). Trough levels of plasma naltrexone and 6-β-naltrexol did not accumulate upon repeated administration of Anamorph.
When Anamorph is crushed or chewed, up to 100% of the sequestered naltrexone dose could be released, bioequivalent to an immediate-release oral solution of the same dose.
Food Effect
While concurrent administration of high-fat food decreased the rate and extent of Anamorph absorption from Anamorph, the total bioavailability was not affected. Co-administration of a high-fat meal with Anamorph did not compromise the sequestration of naltrexone.
Distribution
Anamorph
Once absorbed, Anamorph is distributed to skeletal muscle, kidneys, liver, intestinal tract, lungs, spleen, and brain. The volume of distribution of Anamorph is approximately 3 to 4 L/kg. Anamorph is 30 to 35% reversibly bound to plasma proteins. Although the primary site of action of Anamorph is in the CNS, only small quantities pass the blood-brain barrier. Anamorph also crosses the placental membranes and has been found in breast milk .
Elimination
Metabolism
Anamorph:
Major pathways of Anamorph metabolism include glucuronidation in the liver to produce metabolites including morphine-3-glucuronide, M3G (about 50%) and morphine-6-glucuronide, M6G (about 5 to 15%) and sulfation in the liver to produce morphine-3-etheral sulfate. A small fraction (less than 5%) of Anamorph is demethylated. M3G has no significant contribution to the analgesic activity. Although M6G does not readily cross the blood-brain barrier, it has been shown to have opioid agonist and analgesic activity in humans.
Naltrexone:
Naltrexone is extensively metabolized into 6-β-naltrexol.
Excretion
Anamorph:
Approximately 10% of a Anamorph dose is excreted unchanged in the urine. Elimination of Anamorph is primarily via hepatic metabolism to glucuronide metabolites M3G and M6G which are then renally excreted. A small amount of the glucuronide metabolites is excreted in the bile and there is some minor enterohepatic cycling.
The mean adult plasma clearance of Anamorph is about 20 to 30 mL/minute/kg. The effective half-life of Anamorph after IV administration is reported to be approximately 2 hours. The terminal elimination half-life of Anamorph following single dose Anamorph administration is approximately 29 hours.
Specific Populations
Age: Geriatric Population
The pharmacokinetics of Anamorph have not been investigated in elderly patients (>65 years) although such patients were included in clinical studies. In a long-term open label safety study, the pre-dose plasma Anamorph concentrations after dose normalization were similar for subjects <65 years and those ≥65 years of age.
Sex
No meaningful differences were noted between male and female patients in the analysis of pharmacokinetic data of Anamorph from clinical studies.
Race/Ethnicity
Chinese subjects given IV Anamorph in one study had a higher clearance when compared to Caucasian subjects (1852 ± 116 mL/min vs. 1495 ± 80 mL/min).
Hepatic Impairment
Anamorph pharmacokinetics are altered in patient with alcoholic cirrhosis. Clearance was found to decrease with a corresponding increase in half-life. M3G and M6G to Anamorph plasma AUC ratios also decreased in these patients, indicating a decrease in metabolic activity. Adequate studies of the pharmacokinetics of Anamorph in patients with severe hepatic impairment have not been conducted.
Renal Impairment
Anamorph pharmacokinetics are altered in patients with renal failure. The AUC is increased and clearance is decreased and the metabolites, M3G and M6G, may accumulate several-fold in patients with renal failure compared to healthy subjects. Adequate studies of the pharmacokinetics of Anamorph in patients with severe renal impairment have not been conducted.
Drug Interaction Studies
Alcohol
A pharmacokinetic drug interaction is noted with concomitant administration of 40% alcohol and Anamorph, where an average 2-fold (range 1.4- to 5-fold increase) higher Cmax of Anamorph was noted compared to Anamorph consumed with water.
Carcinogenesis
Long-term studies in animals to evaluate the carcinogenic potential of Anamorph have not been conducted.
Mutagenesis
No formal studies to assess the mutagenic potential of Anamorph have been conducted. In the published literature, Anamorph was found to be mutagenic in vitro increasing DNA fragmentation in human T-cells. Anamorph was reported to be mutagenic in the in vivo mouse micronucleus assay and positive for the induction of chromosomal aberrations in mouse spermatids and murine lymphocytes. Mechanistic studies suggest that the in vivo clastogenic effects reported with Anamorph in mice may be related to increases in glucocorticoid levels produced by Anamorph in this species. In contrast to the above positive findings, in vitro studies in the literature have also shown that Anamorph did not induce chromosomal aberrations in human leukocytes or translocations or lethal mutations in Drosophila.
Impairment of Fertility
No formal nonclinical studies to assess the potential of Anamorph to impair fertility have been conducted. Several nonclinical studies from the literature have demonstrated adverse effects on male fertility in the rat from exposure to Anamorph.
One study in which male rats were administered Anamorph sulfate subcutaneously prior to mating (up to 30 mg/kg twice daily) and during mating (20 mg/kg twice daily) with untreated females, a number of adverse reproductive effects including reduction in total pregnancies and higher incidence of pseudopregnancies at 20 mg/kg/day (3.2 times the HDD) were reported.
Studies from the literature have also reported changes in hormonal levels in male rats (i.e. testosterone, luteinizing hormone) following treatment with Anamorph at 10 mg/kg/day or greater (1.6 times the HDD).
Female rats that were administered Anamorph sulfate intraperitoneally prior to mating exhibited prolonged estrous cycles at 10 mg/kg/day (1.6 times the HDD).
Exposure of adolescent male rats to Anamorph has been associated with delayed sexual maturation and following mating to untreated females, smaller litters, increased pup mortality, and/or changes in reproductive endocrine status in adult male offspring have been reported (estimated 5 times the plasma levels at the HDD).
The analgesic efficacy of Anamorph has been evaluated in one randomized, double-blind, placebo-controlled clinical trial in osteoarthritis patients with moderate to severe pain (Study ALO-KNT-301). This study, with a randomized withdrawal design, was conducted in subjects with moderate to severe pain from osteoarthritis of the hip or knee over a 12-week treatment period. Subjects started open-label treatment with Anamorph and titrated to effect. Once their pain was controlled (Brief Pain Inventory [BPI] Average 24-hour Pain Intensity ≤4 AND at least a 2-point drop from screening baseline), they were randomized to either active treatment with Anamorph or were tapered off Anamorph using a double-dummy design and placed on placebo. Of these, 75.1% of the randomized subjects were opioid-naïve and distributed evenly between the 2 groups.
The mean change in the weekly diary BPI average pain score from randomization baseline (Visit Y) to the end of study (Visit Y + 12 Weeks/Early Termination) was statistically significantly superior for those treated with Anamorph compared to the placebo group.
Anamorph 20 mg/0.8 mg | Anamorph 30 mg/1.2 mg | Anamorph 50 mg/2 mg | Anamorph 60 mg/2.4 mg | Anamorph 80 mg/3.2 mg | Anamorph 100 mg/4 mg | |
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Anamorph sulfate | 20 mg | 30 mg | 50 mg | 60 mg | 80 mg | 100 mg |
Sequestered naltrexone hydrochloride | 0.8 mg | 1.2 mg | 2 mg | 2.4 mg | 3.2 mg | 4 mg |
Extended-Release Capsule Description For all strengths, the darker-toned cap has "EMBEDA" printed in grey ink and a single grey band around ¾ of the circumference. | Two-toned, yellow opaque hard gelatin capsule. The lighter-toned body has "20" reverse-printed in a grey circle. | Two-toned, blue-violet opaque hard gelatin capsule. The lighter-toned body has "30" reverse-printed in a grey circle. | Two-toned, blue opaque hard gelatin capsule. The lighter-toned body has "50" reverse-printed in a grey circle. | Two-toned, pink opaque hard gelatin capsule. The lighter-toned body has "60" reverse-printed in a grey circle. | Two-toned, light peach opaque elongated hard gelatin capsule. The lighter-toned body has "80" reverse-printed in a grey circle. | Two-toned, green opaque hard gelatin capsule. The lighter-toned body has "100" reverse-printed in a grey circle. |
Bottle Size | 75 cc | 75 cc | 75 cc | 75 cc | 75 cc | 75 cc |
Bottle Count | 30 capsules | 30 capsules | 30 capsules | 30 capsules | 30 capsules | 30 capsules |
NDC # | 60793-430-20 | 60793-431-20 | 60793-433-20 | 60793-434-20 | 60793-435-20 | 60793-437-20 |
Store at 25°C (77°F); excursions permitted between 15° and 30°C (59° and 86°F).
Dispense in a sealed, tamper-evident, childproof, light-resistant container.
Advise the patient to read the FDA-approved patient labeling (Medication Guide and Instructions for Use)
Addiction, Abuse, and Misuse
Inform patients that the use of Anamorph, even when taken as recommended, can result in addiction, abuse, and misuse, which can lead to overdose and death . Instruct patients not to share Anamorph with others and to take steps to protect Anamorph from theft or misuse.
Life-Threatening Respiratory Depression
Inform patients of the risk of life-threatening respiratory depression, including information that the risk is greatest when starting Anamorph or when the dosage is increased, and that it can occur even at recommended doses . Advise patients how to recognize respiratory depression and to seek medical attention if breathing difficulties develop.
Accidental Ingestion
Inform patients that accidental ingestion, especially by children, may result in respiratory depression or death . Instruct patients to take steps to store Anamorph securely and to dispose of unused Anamorph by flushing the capsules down the toilet.
Interactions with Alcohol
Instruct patients not to consume alcoholic beverages, or prescription and non-prescription products that contain alcohol, during treatment with Anamorph. The co-ingestion of alcohol with Anamorph may result in increased plasma levels and a potentially fatal overdose of Anamorph.
Interactions with Benzodiazepines and Other CNS Depressants
Inform patients and caregivers that potentially fatal additive effects may occur if Anamorph is used with benzodiazepines or other CNS depressants, including alcohol, and not to use these concomitantly unless supervised by a healthcare provider .
Serotonin Syndrome
Inform patients that opioids could cause a rare but potentially life-threatening condition resulting from concomitant administration of serotonergic drugs. Warn patients of the symptoms of serotonin syndrome and to seek medical attention right away if symptoms develop. Instruct patients to inform their physicians if they are taking, or plan to take serotonergic medications .
MAOI Interaction
Inform patients not to take Anamorph while using any drugs that inhibit monoamine oxidase. Patients should not start MAOIs while taking Anamorph .
Adrenal Insufficiency
Inform patients that opioids could cause adrenal insufficiency, a potentially life-threatening condition. Adrenal insufficiency may present with non-specific symptoms and signs such as nausea, vomiting, anorexia, fatigue, weakness, dizziness, and low blood pressure. Advise patients to seek medical attention if they experience a constellation of these symptoms .
Important Administration Instructions
Instruct patients how to properly take Anamorph, including the following:
Hypotension
Inform patients that Anamorph may cause orthostatic hypotension and syncope. Instruct patients how to recognize symptoms of low blood pressure and how to reduce the risk of serious consequences should hypotension occur (e.g., sit or lie down, carefully rise from a sitting or lying position) .
Anaphylaxis
Inform patients that anaphylaxis has been reported with ingredients contained in Anamorph. Advise patients how to recognize such a reaction and when to seek medical attention .
Pregnancy
Neonatal Opioid Withdrawal Syndrome
Inform female patients of reproductive potential that prolonged use of Anamorph during pregnancy can result in neonatal opioid withdrawal syndrome, which may be life-threatening if not recognized and treated .
Embryo-Fetal Toxicity
Inform female patients of reproductive potential that Anamorph can cause fetal harm and to inform their healthcare provider of a known or suspected pregnancy .
Lactation
Advise patients that breastfeeding is not recommended during treatment with Anamorph .
Infertility
Inform patients that chronic use of opioids may cause reduced fertility. It is not known whether these effects on fertility are reversible .
Driving or Operating Heavy Machinery
Inform patients that Anamorph may impair the ability to perform potentially hazardous activities such as driving a car or operating heavy machinery. Advise patients not to perform such tasks until they know how they will react to the medication .
Constipation
Advise patients of the potential for severe constipation, including management instructions and when to seek medical attention .
Disposal of Unused Anamorph
Advise patients to flush the unused capsules down the toilet when Anamorph is no longer needed.
This product's label may have been updated. For current full prescribing information please visit www.pfizer.com.
LAB-0599-6.0
Logo
This Medication Guide has been approved by the U.S. Food and Drug Administration December 2016; LAB-0643-2.0 | |
Medication Guide Anamorph® (im-bed-a) (morphine sulfate and naltrexone hydrochloride) extended-release capsules, CII | |
Anamorph is:
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Important information about Anamorph:
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Do not take Anamorph if you have:
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Before taking Anamorph, tell your healthcare provider if you have a history of: | |
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Tell your healthcare provider if you are:
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When taking Anamorph:
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While taking Anamorph DO NOT:
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The possible side effects of Anamorph are:
Get emergency medical help if you have:
These are not all the possible side effects of Anamorph. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. For more information go to dailymed.nlm.nih.gov Manufactured for: Pfizer Inc, New York, NY 10017 by: Actavis Elizabeth LLC, 200 Elmora Avenue, Elizabeth, NJ 07207, www.embeda.com or call 1-800-438-1985 |
Anamorph® (im-bed-a)
(morphine sulfate and naltrexone hydrochloride) extended-release Capsules, CII
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Figure 1 | ||
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Figure 2 | ||
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Figure 3 | ||
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Figure 4 |
This Instructions for Use has been approved by the U.S. Food and Drug Administration.
Manufactured for: Pfizer Inc, New York, NY 10017
by: Actavis Elizabeth LLC, 200 Elmora Avenue, Elizabeth, NJ 07207
LAB-0631-2.0
April 2014
Figure 1 Figure 2 Figure 3 Figure 4
ALWAYS DISPENSE WITH MEDICATION GUIDE
NDC 60793-430-20
Pfizer
Anamorph ®
(morphine sulfate and
naltrexone hydrochloride)
Extended Release Capsules
CII
20 mg/0.8 mg
THE PELLETS SHOULD NOT BE CHEWED, CRUSHED, OR DISSOLVED.
30 Capsules
Rx only
ALWAYS DISPENSE WITH MEDICATION GUIDE
NDC 60793-431-20
Pfizer
Anamorph ®
(morphine sulfate and
naltrexone hydrochloride)
Extended Release Capsules
CII
30 mg/1.2 mg
THE PELLETS SHOULD NOT BE CHEWED, CRUSHED, OR DISSOLVED.
30 Capsules
Rx only
ALWAYS DISPENSE WITH MEDICATION GUIDE
NDC 60793-433-20
Pfizer
Anamorph ®
(morphine sulfate and
naltrexone hydrochloride)
Extended Release Capsules
CII
50 mg/2 mg
THE PELLETS SHOULD NOT BE CHEWED, CRUSHED, OR DISSOLVED.
30 Capsules
Rx only
ALWAYS DISPENSE WITH MEDICATION GUIDE
NDC 60793-434-20
Pfizer
Anamorph ®
(morphine sulfate and
naltrexone hydrochloride)
Extended Release Capsules
CII
60 mg/2.4 mg
THE PELLETS SHOULD NOT BE CHEWED, CRUSHED, OR DISSOLVED.
30 Capsules
Rx only
ALWAYS DISPENSE WITH MEDICATION GUIDE
NDC 60793-435-20
Pfizer
Anamorph ®
(morphine sulfate and
naltrexone hydrochloride)
Extended Release Capsules
CII
80 mg/3.2 mg
THE PELLETS SHOULD NOT BE CHEWED, CRUSHED, OR DISSOLVED.
30 Capsules
Rx only
ALWAYS DISPENSE WITH MEDICATION GUIDE
NDC 60793-437-20
Pfizer
Anamorph ®
(morphine sulfate and
naltrexone hydrochloride)
Extended Release Capsules
CII
100 mg/4 mg
THE PELLETS SHOULD NOT BE CHEWED, CRUSHED, OR DISSOLVED.
For use in opioid-tolerant patients only
30 Capsules
Rx only
Depending on the reaction of the Anamorph after taken, if you are feeling dizziness, drowsiness or any weakness as a reaction on your body, Then consider Anamorph 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 Anamorph 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.
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The information was verified by Dr. Rachana Salvi, MD Pharmacology