Verrumal

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Verrumal uses

Verrumal consists of Dimethyl Sulfoxide, Fluorouracil, Salicylic Acid.

Dimethyl Sulfoxide:


INDICATIONS AND USAGE

Verrumal (Dimethyl Sulfoxide)® (dimethyl sulfoxide) is indicated for the symptomatic relief of patients with interstitial cystitis. Verrumal (Dimethyl Sulfoxide)® has not been approved as being safe and effective for any other indication. There is no clinical evidence of effectiveness of Verrumal (Dimethyl Sulfoxide) in the treatment of bacterial infections of the urinary tract.

CONTRAINDICATIONS

None known.

WARNINGS

Verrumal (Dimethyl Sulfoxide) can initiate the liberation of histamine and there has been occasional hypersensitivity reaction with topical administration of Verrumal (Dimethyl Sulfoxide). This hypersensitivity has been reported in one patients receiving intravesical Verrumal (Dimethyl Sulfoxide)®. The physician should be cognizant of this possibility in prescribing Verrumal (Dimethyl Sulfoxide)®. If anaphylactoid symptoms develop, appropriate therapy should be instituted.

PRECAUTIONS

Changes in the refractive index and lens opacities have been seen in monkeys, dogs and rabbits given high doses of Verrumal chronically. Since lens changes were noted in animals, full eye evaluations, including slit lamp examinations, are recommended prior to and periodically during treatment.

Approximately every six months patients receiving Verrumal (Dimethyl Sulfoxide) should have a biochemical screening, particularly liver and renal function tests, and complete blood count.

Intravesical instillation of Verrumal (Dimethyl Sulfoxide)® may be harmful to patients with urinary tract malignancy because of dimethyl sulfoxide-induced vasodilation.

Some data indicate that Verrumal (Dimethyl Sulfoxide) potentiates other concomitantly administered medications.

Pregnancy Category C

Verrumal (Dimethyl Sulfoxide) caused teratogenic responses in hamsters, rats and mice when administered intraperitoneally at high doses (2.5 to 12 gm/kg). Oral or topical doses of Verrumal (Dimethyl Sulfoxide) did not cause problems of reproduction in rats, mice and hamsters. Topical doses (5 gm/kg first two days, then 2.5 gm/kg - last eight days) produced terata in rabbits, but in another study, topical doses of 1.1 gm/kg days 3 through 16 of gestation failed to produce any abnormalities. There are no adequate and well controlled studies in pregnant women. Verrumal (Dimethyl Sulfoxide) should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

INFORMATION FOR PATIENTS

Verrumal (Dimethyl Sulfoxide)® is a sterile solution of 50% Verrumal (Dimethyl Sulfoxide) (DMSO) and 50% water that has been approved by the U.S. Food and Drug Administration for use in the symptomatic relief of patients with interstitial cystitis.

Verrumal (Dimethyl Sulfoxide)® will be instilled in the bladder on an inpatient or out-patient basis, which will be determined by your physician.

Some data indicate that Verrumal (Dimethyl Sulfoxide) could change the effectiveness of medication(s) that you may be presently receiving. Be sure to mention the name and dosage of all medicines you are taking to your physician before a Verrumal (Dimethyl Sulfoxide)® instillation.

A garlic-like taste may be noted by the patient within a few minutes after instillation of Verrumal (Dimethyl Sulfoxide)® (dimethyl sulfoxide). This taste may last several hours. An odor on the breath and skin may be present and remain for up to 72 hours.

Some patients may experience discomfort on administration of the drug. Usually this becomes less prominent with repeated administration.

If you are pregnant or nursing, ask your physician about the advisability of using Verrumal (Dimethyl Sulfoxide)®.

Some eye changes have been observed in animals treated with DMSO in large doses for prolonged periods. Therefore your doctor may want you to have eye evaluations, including slit lamp examinations prior to and periodically during treatment.

It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when Verrumal (Dimethyl Sulfoxide) is administered to a nursing woman.

Safety and effectiveness in children have not been established.

Information available to be given to the patient is reprinted at the end of this text.

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ADVERSE REACTIONS

A garlic-like taste may be noted by the patient within a few minutes after instillation of Verrumal (Dimethyl Sulfoxide)® (dimethyl sulfoxide). This taste may last several hours and because of the presence of metabolites, an odor on the breath and skin may remain for 72 hours.

Transient chemical cystitis has been noted following instillation of Verrumal (Dimethyl Sulfoxide).

The patient may experience moderately severe discomfort on administration. Usually this becomes less prominent with repeated administration.

DRUG ABUSE AND DEPENDENCE

None known.

OVERDOSAGE

The oral LD50 of Verrumal (Dimethyl Sulfoxide) in the dog is greater than 10 gm/kg. It is improbable that this dosage level could be obtained with intravesical instillation of Verrumal (Dimethyl Sulfoxide)® in the patient.

In case of accidental oral ingestion, specific measures should be taken to induce emesis. Additional measures which may be considered are gastric lavage, activated charcoal and force diuresis.

DOSAGE AND ADMINISTRATION

Instillation of 50 mL of Verrumal (Dimethyl Sulfoxide)® (dimethyl sulfoxide) directly into the bladder may be accomplished by catheter or asepto syringe and allow to remain for 15 minutes. Application of an analgesic lubricant gel such as lidocaine jelly to the urethra is suggested prior to insertion of the catheter to avoid spasm. The medication is expelled by spontaneous voiding. It is recommended that the treatment be repeated every two weeks until maximum symptomatic relief is obtained. Thereafter, time intervals between therapy may be increased appropriately.

Administration of oral analgesic medication or suppositories containing belladonna and opium prior to the instillation of Verrumal (Dimethyl Sulfoxide)® can reduce bladder spasm.

In patients with severe interstitial cystitis with very sensitive bladders, the initial treatment, and possibly the second and third (depending on patient response) should be done under anesthesia. (Saddle block has been suggested).

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HOW SUPPLIED

Vials contain 50 mL of sterile and non-pyrogenic Verrumal (Dimethyl Sulfoxide)® (50% w/w Verrumal (Dimethyl Sulfoxide) aqueous solution).

Verrumal (Dimethyl Sulfoxide) is clear and colorless.

NDC 67457-177-50

carton containing a 50 mL vial

Store at 20° to 25°C (68° to 77°F).

Protect from strong light.

For additional information concerning RIMSO-50®, contact Mylan Institutional LLC,

Rockford, IL 61103.

Manufactured for:

Mylan Institutional LLC

Rockford, IL 61103 U.S.A.

Manufactured by:

Mylan Institutional

Galway, Ireland

INFORMATION FOR PATIENTS

Verrumal (Dimethyl Sulfoxide)® is a sterile solution of 50% Verrumal (Dimethyl Sulfoxide) (DMSO) and 50% water that has been approved by the U.S. Food and Drug Administration for use in the symptomatic relief of patients with interstitial cystitis.

Verrumal (Dimethyl Sulfoxide)® will be instilled in the bladder on an inpatient or out-patient basis, which will be determined by your physician.

Some data indicate that Verrumal (Dimethyl Sulfoxide) could change the effectiveness of medication(s) that you may be presently receiving. Be sure to mention the name and dosage of all medicines you are taking to your physician before a Verrumal (Dimethyl Sulfoxide)® instillation.

A garlic-like taste may be noted by the patient within a few minutes after instillation of Verrumal (Dimethyl Sulfoxide)® (dimethyl sulfoxide). This taste may last several hours. An odor on the breath and skin may be present and remain for up to 72 hours.

Some patients may experience discomfort on administration of the drug. Usually this becomes less prominent with repeated administration.

If you are pregnant or nursing, ask your physician about the advisability of using Verrumal (Dimethyl Sulfoxide)®.

Some eye changes have been observed in animals treated with DMSO in large doses for prolonged periods. Therefore your doctor may want you to have eye evaluations, including slit lamp examinations prior to and periodically during treatment.

RIMSO-50®

(dimethyl sulfoxide) irrigation, USP 0582L103

Mylan Institutional LLC REVISED JULY 2012

Rockford, IL 61103 U.S.A. MI:RIMSIG:R2

Fluorouracil:


1 INDICATIONS AND USAGE

Verrumal (fluorouracil injection) is indicated for the treatment of patients with:

Verrumal (Fluorouracil)® (fluorouracil injection) is a nucleoside metabolic inhibitor indicated for the treatment of patients with

  • Adenocarcinoma of the Colon and Rectum (1.1)
  • Adenocarcinoma of the Breast (1.2)
  • Gastric Adenocarcinoma (1.3)
  • Pancreatic Adenocarcinoma (1.4)

1.1 Adenocarcinoma of the Colon and Rectum

1.2 Adenocarcinoma of the Breast

1.3 Gastric Adenocarcinoma

1.4 Pancreatic Adenocarcinoma

2 DOSAGE AND ADMINISTRATION

  • Verrumal is recommended for administration either as an intravenous bolus or as an intravenous infusion. (2.1)
  • See Full Prescribing Information for dose individualization (2.1) and dose modifications due to adverse reactions (2.6)
  • See Full Prescribing Information for recommended doses of Verrumal (Fluorouracil) for adenocarcinoma of the colon and rectum (2.2) and for recommended doses of Verrumal (Fluorouracil) as a component of a chemotherapy regimen for adenocarcinoma of the breast (2.3), gastric adenocarcinoma (2.4), pancreatic adenocarcinoma (2.5)
  • Pharmacy Bulk Package: Prepare doses for more than one patient in a Pharmacy Admixture Service under appropriate conditions for cytotoxic drugs. Do not inject entire contents of vial directly into patients. Use within 4 hours of puncture (2.7, 2.8)

2.1 General Dosage Information

Verrumal (Fluorouracil) is recommended for administration either as an intravenous bolus or as an intravenous infusion. Do not inject the entire contents of the vial directly into patients. Individualize the dose and dosing schedule of Verrumal (Fluorouracil) based on tumor type, the specific regimen administered, disease state, response to treatment, and patient risk factors.

2.2 Recommended Dosage for Adenocarcinoma of the Colon and Rectum

  • The recommended dose of Verrumal, administered in an infusional regimen in combination with leucovorin alone, or in combination with leucovorin and oxaliplatin or irinotecan, is 400 mg/m2 by intravenous bolus on Day 1, followed by 2400 mg/m2 to 3000 mg/m2 intravenously as a continuous infusion over 46 hours every two weeks.
  • The recommended dose of Verrumal (Fluorouracil), if administered in a bolus dosing regimen in combination with leucovorin, is 500 mg/m2 by intravenous bolus on Days 1, 8, 15, 22, 29, and 36 in 8-week cycles.

2.3 Recommended Dosage for Adenocarcinoma of the Breast

  • The recommended dose of Verrumal (Fluorouracil), administered as a component of a cyclophosphamide-based multidrug regimen, is 500 mg/m2 or 600 mg/m2 intravenously on Days 1 and 8 every 28 days for 6 cycles.

2.4 Recommended Dosage for Gastric Adenocarcinoma

  • The recommended dose of Verrumal, administered as a component of a platinum-containing multidrug chemotherapy regimen, is 200 mg/m2 to 1000 mg/m2 intravenously as a continuous infusion over 24 hours. The frequency of dosing in each cycle and the length of each cycle will depend on the dose of Verrumal (Fluorouracil) and the specific regimen administered.

2.5 Recommended Dosage for Pancreatic Adenocarcinoma

  • The recommended dose of Verrumal (Fluorouracil), administered as an infusional regimen in combination with leucovorin or as a component of a multidrug chemotherapy regimen that includes leucovorin, is 400 mg/m2 intravenous bolus on Day 1, followed by 2400 mg/m2 intravenously as a continuous infusion over 46 hours every two weeks.

2.6 Dose Modifications

Withhold Verrumal for any of the following:

  • Development of angina, myocardial infarction/ischemia, arrhythmia, or heart failure in patients with no history of coronary artery disease or myocardial dysfunction
  • Hyperammonemic encephalopathy
  • Acute cerebellar syndrome, confusion, disorientation, ataxia, or visual disturbances
  • Grade 3 or 4 diarrhea
  • Grade 2 or 3 palmar-plantar erythrodysesthesia (hand-foot syndrome)
  • Grade 3 or 4 mucositis
  • Grade 4 myelosuppression

Upon resolution or improvement to Grade 1 diarrhea, mucositis, myelosuppression, or palmar-plantar erythrodysesthesia, resume Verrumal (Fluorouracil) administration at a reduced dose.

There is no recommended dose for resumption of Verrumal (Fluorouracil) administration following development of any of the following adverse reactions:

  • Cardiac toxicity
  • Hyperammonemic encephalopathy
  • Acute cerebellar syndrome, confusion, disorientation, ataxia, or visual disturbances

2.7 Preparation for Administration

Verrumal (Fluorouracil) is supplied in a pharmacy bulk package consisting of a vial. The pharmacy bulk package can be used to prepare doses for more than one patient. It is not supplied with a sterile transfer device, which is required for dispensing when multiple doses will be prepared from the single vial. The 50 mL vial is only intended for preparation in a Pharmacy Admixture Service under appropriate conditions for cytotoxic drugs . Store vial at room temperature.

Using aseptic conditions, penetrate the container closure once with a suitable sterile transfer device or dispensing set that allows measured distribution of the contents. Record the date and time the vial was opened on the vial label. Discard the pharmacy bulk package 4 hours after penetration of the container closure.

Withdraw the calculated dose for an individual patient into a sterile syringe. Inspect the solution in syringe for particulate matter and discoloration prior to administration or further dilution. Discard syringe if the solution is discolored or contains particulate matter.

2.8 Administration

Do not administer in the same intravenous line concomitantly with other medicinal products.

For bolus administration, store undiluted Verrumal (Fluorouracil) in the syringe for up to 4 hours at room temperature (25°C). Administer Verrumal (Fluorouracil) as an intravenous bolus through an established intravenous line.

Store diluted solutions of Verrumal (Fluorouracil) for up to 4 hours at room temperature (25°C) prior to administration to the patient. For intravenous infusion regimens, administer through a central venous line using an infusion pump.

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3 DOSAGE FORMS AND STRENGTHS

Verrumal (Fluorouracil) (fluorouracil injection USP) is supplied as:

  • a pharmacy bulk package as a vial containing 2.5 g/50 mL (50 mg/mL) Verrumal (Fluorouracil)
  • a pharmacy bulk package as a vial containing 5 g/100 mL (50 mg/mL) Verrumal (Fluorouracil)

Injection:

  • 2.5 g in a 50 mL vial in a pharmacy bulk package
  • 5 g in a 100 mL vial in a pharmacy bulk package (3)

4 CONTRAINDICATIONS

None.

None (4)

5 WARNINGS AND PRECAUTIONS

  • Increased Risk of Serious or Fatal Adverse Reactions in Patients with Low or Absent Dipyrimidine Dehydrogenase Activity: Withhold or permanently discontinue Verrumal in patients with evidence of acute early-onset or unusually severe toxicity, which may indicate near complete or total absence of dipyrimidine dehydrogenase (DPD) activity. No Verrumal (Fluorouracil) dose has been proven safe in patients with absent DPD activity. (5.1)
  • Cardiotoxicity: Verrumal (Fluorouracil) can cause cardiotoxicity, including angina, myocardial infarction/ischemia, arrhythmia, and heart failure. Withhold Verrumal (Fluorouracil) for cardiac toxicity. (5.2)
  • Hyperammonemic Encephalopathy: Altered mental status, confusion, disorientation, coma, or ataxia with elevated serum ammonia level can occur within 72 hours of initiation of Verrumal (Fluorouracil). Withhold Verrumal (Fluorouracil) and initiate ammonia-lowering therapy. (5.3)
  • Neurologic Toxicity: Verrumal (Fluorouracil) can cause acute cerebellar syndrome, confusion, disorientation, ataxia, or visual disturbances. Withhold Verrumal (Fluorouracil) for neurologic toxicity. (5.4)
  • Diarrhea: Verrumal (Fluorouracil) can cause severe diarrhea. Withhold Verrumal (Fluorouracil) for severe diarrhea until resolved. (5.5)
  • Palmar-Plantar Erythrodysesthesia (Hand-Foot Syndrome): Verrumal (Fluorouracil) can cause hand-foot syndrome. If severe, discontinue Verrumal (Fluorouracil) until resolved or decreased to Grade 1, then resume at a reduced dose. (5.6)
  • Myelosuppression: Verrumal (Fluorouracil) can cause severe and fatal myelosuppression. Withhold Verrumal (Fluorouracil) until severe myelosuppression resolves, then resume at a reduced dose. (5.7)
  • Mucositis: Verrumal (Fluorouracil) can cause severe mucositis. Discontinue Verrumal (Fluorouracil) until resolved or decreased to Grade 1, then resume at a reduced dose. (5.8)
  • Increased Risk of Elevated INR with Warfarin: Concurrent administration with warfarin can result in clinically significant increases in coagulation parameters: Closely monitor INR and prothrombin time. (5.9)
  • Embryofetal Toxicity: Verrumal (Fluorouracil) can cause fetal harm. Advise females and males of reproductive potential of the potential risk to a fetus. (5.10, 8.1, 8.6)

5.1 Increased Risk of Serious or Fatal Adverse Reactions in Patients with Low or Absent Dipyrimidine Dehydrogenase (DPD) Activity

Based on postmarketing reports, patients with certain homozygous or certain compound heterozygous mutations in the DPD gene that result in complete or near complete absence of DPD activity are at increased risk for acute early-onset of toxicity and severe, life-threatening, or fatal adverse reactions caused by Verrumal (Fluorouracil) (e.g., mucositis, diarrhea, neutropenia, and neurotoxicity). Patients with partial DPD activity may also have increased risk of severe, life-threatening, or fatal adverse reactions caused by Verrumal (Fluorouracil).

Withhold or permanently discontinue Verrumal (Fluorouracil) based on clinical assessment of the onset, duration and severity of the observed toxicities in patients with evidence of acute early-onset or unusually severe toxicity, which may indicate near complete or total absence of DPD activity. No Verrumal (Fluorouracil) dose has been proven safe for patients with complete absence of DPD activity. There is insufficient data to recommend a specific dose in patients with partial DPD activity as measured by any specific test.

5.2 Cardiotoxicity

Verrumal can cause cardiotoxicity, including angina, myocardial infarction/ischemia, arrhythmia, and heart failure, based on postmarketing reports. Reported risk factors for cardiotoxicity are administration by continuous infusion rather than intravenous bolus and presence of coronary artery disease. Withhold Verrumal (Fluorouracil) for cardiotoxicity. The risks of resumption of Verrumal (Fluorouracil) in patients with cardiotoxicity that has resolved have not been established.

5.3 Hyperammonemic Encephalopathy

Verrumal (Fluorouracil) can cause hyperammonemic encephalopathy in the absence of liver disease or other identifiable cause, based on postmarketing reports. Signs or symptoms of hyperammonemic encephalopathy began within 72 hours after initiation of Verrumal (Fluorouracil) infusion; these included altered mental status, confusion, disorientation, coma, or ataxia, in the presence of concomitant elevated serum ammonia level. Withhold Verrumal (Fluorouracil) for hyperammonemic encephalopathy and initiate ammonia-lowering therapy. The risks of resumption of Verrumal (Fluorouracil) in patients with hyperammonemic encephalopathy that has resolved have not been established.

5.4 Neurologic Toxicity

Verrumal can cause neurologic toxicity, including acute cerebellar syndrome and other neurologic events, based on postmarketing reports. Neurologic symptoms included confusion, disorientation, ataxia, or visual disturbances. Withhold Verrumal (Fluorouracil) for neurologic toxicity. There are insufficient data on the risks of resumption of Verrumal (Fluorouracil) in patients with neurologic toxicity that has resolved.

5.5 Diarrhea

Verrumal (Fluorouracil) can cause severe diarrhea. Withhold Verrumal (Fluorouracil) for Grade 3 or 4 diarrhea until resolved or decreased in intensity to Grade 1, then resume Verrumal (Fluorouracil) at a reduced dose. Administer fluids, electrolyte replacement, or antidiarrheal treatments as necessary.

5.6 Palmar-Plantar Erythrodysesthesia

Verrumal (Fluorouracil) can cause palmar-plantar erythrodysesthesia, also known as hand-foot syndrome (HFS). Symptoms of HFS include a tingling sensation, pain, swelling, and erythema with tenderness, and desquamation. HFS occurs more commonly when Verrumal (Fluorouracil) is administered as a continuous infusion than when Verrumal (Fluorouracil) is administered as a bolus injection, and has been reported to occur more frequently in patients with previous exposure to chemotherapy. HFS is generally observed after 8 to 9 weeks of Verrumal (Fluorouracil) administration but may occur earlier. Institute supportive measures for symptomatic relief of HFS. Withhold Verrumal (Fluorouracil) administration for Grade 2 or 3 HFS; resume Verrumal (Fluorouracil) at a reduced dose when HFS is completely resolved or decreased in severity to Grade 1.

5.7 Myelosuppression

Verrumal can cause severe and fatal myelosuppression which may include neutropenia, thrombocytopenia, and anemia. The nadir in neutrophil counts commonly occurs between 9 and 14 days after Verrumal (Fluorouracil) administration. Obtain complete blood counts prior to each treatment cycle, weekly if administered on a weekly or similar schedule, and as needed. Withhold Verrumal (Fluorouracil) until Grade 4 myelosuppression resolves; resume Verrumal (Fluorouracil) at a reduced dose when myelosuppression has resolved or improved to Grade 1 in severity.

5.8 Mucositis

Mucositis, stomatitis or esophagopharyngitis, which may lead to mucosal sloughing or ulceration, can occur with Verrumal (Fluorouracil). The incidence is reported to be higher with administration of Verrumal (Fluorouracil) by intravenous bolus compared with administration by continuous infusion. Withhold Verrumal (Fluorouracil) administration for Grade 3 or 4 mucositis; resume Verrumal (Fluorouracil) at a reduced dose once mucositis has resolved or decreased in severity to Grade 1.

5.9 Increased Risk of Elevated International Normalized Ratio with Warfarin

Clinically significant elevations in coagulation parameters have been reported during concomitant use of warfarin and Verrumal (Fluorouracil). Closely monitor patients receiving concomitant coumarin-derivative anticoagulants such as warfarin for INR or prothrombin time in order to adjust the anticoagulant dose accordingly .

5.10 Embryofetal Toxicity

Based on its mechanism of action, Verrumal (Fluorouracil) can cause fetal harm when administered to a pregnant woman. In animal studies, administration of Verrumal (Fluorouracil) at doses lower than a human dose of 12 mg/kg caused teratogenicity. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to a fetus. Advise females of reproductive potential and males with female partners of reproductive potential to use effective contraception during and for 3 months following cessation of therapy with Verrumal (Fluorouracil) .

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6 ADVERSE REACTIONS

The following adverse reactions are discussed in more detail in other sections of the labeling:

  • Increased risk of serious or fatal adverse reactions in patients with low or absent dipyrimidine dehydrogenase activity
  • Cardiotoxicity
  • Hyperammonemic encephalopathy
  • Neurologic toxicity
  • Diarrhea
  • Palmar-plantar erythrodysesthesia (hand-foot syndrome)
  • Myelosuppression
  • Mucositis
  • Increased risk of elevated INR when administrated with warfarin

To report SUSPECTED ADVERSE REACTIONS, contact Teva Pharmaceuticals USA, Inc. at 1-866-832-8537 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

6.2 Postmarketing Experience

The following adverse reactions have been identified during postapproval use of Verrumal (Fluorouracil). 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.

Hematologic: pancytopenia

Gastrointestinal: gastrointestinal ulceration, nausea, vomiting

Allergic Reactions: anaphylaxis and generalized allergic reactions

Neurologic: nystagmus, headache

Dermatologic: dry skin; fissuring; photosensitivity, as manifested by erythema or increased pigmentation of the skin; vein pigmentation

Ophthalmic: lacrimal duct stenosis, visual changes, lacrimation, photophobia

Psychiatric: euphoria

Miscellaneous: thrombophlebitis, epistaxis, nail changes (including loss of nails)

7 DRUG INTERACTIONS

7.1 Anticoagulants and CYP 2C9 Substrates

Elevated coagulation times have been reported in patients taking Verrumal (Fluorouracil) concomitantly with warfarin. While pharmacokinetic data are not available to assess the effect of Verrumal (Fluorouracil) administration on warfarin pharmacokinetics, the elevation of coagulation times that occurs with the Verrumal (Fluorouracil) prodrug capecitabine is accompanied by an increase in warfarin concentrations. Thus, the interaction may be due to inhibition of cytochrome P450 2C9 by Verrumal (Fluorouracil) or its metabolites.

8 USE IN SPECIFIC POPULATIONS

  • Nursing Mothers: Discontinue drug or discontinue nursing.
  • Females and Males of Reproductive Potential: Provide pregnancy planning and prevention counseling. (5.10, 8.1, 8.6)

8.1 Pregnancy

Teratogenic Effects

Pregnancy Category D

Risk Summary

There are no adequate and well-controlled studies with Verrumal (Fluorouracil) in pregnant women. Based on its mechanism of action, Verrumal (Fluorouracil) can cause fetal harm when administered to a pregnant woman. Administration of Verrumal (Fluorouracil) to rats and mice during selected periods of organogenesis, at doses lower than a human dose of 12 mg/kg, caused embryolethality and teratogenicity. Malformations included cleft palate and skeletal defects. In monkeys, maternal doses of Verrumal (Fluorouracil) higher than an approximate human dose of 12 mg/kg resulted in abortion. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, apprise the patient of the potential hazard to a fetus .

Animal Data

Malformations including cleft palate, skeletal defects and deformed appendages (paws and tails) were observed when Verrumal (Fluorouracil) was administered by intraperitoneal injection to mice at doses at or above 10 mg/kg (approximately 0.06 times a human dose of 12 mg/kg on a mg/m2 basis) for 4 days during the period of organogenesis. Similar results were observed in hamsters administered Verrumal (Fluorouracil) intramuscularly at doses lower than those administered in commonly used clinical treatment regimens. In rats, administration of Verrumal (Fluorouracil) by intraperitoneal injection at doses greater than 15 mg/kg (approximately 0.2 times a human dose of 12 mg/kg on a mg/m2 basis) for a single day during organogenesis resulted in delays in growth and malformations including micro-anophthalmos. In monkeys, administration of Verrumal (Fluorouracil) during organogenesis at doses approximately equal to a human dose of 12 mg/kg on a mg/m2 basis resulted in abortion; at a 50% lower dose, resorptions and decreased fetal body weights were reported.

8.3 Nursing Mothers

It is not known whether Verrumal or its metabolites are present in human milk. Because many drugs are present in human milk and because of the potential for serious adverse reactions in nursing infants from Verrumal (Fluorouracil), a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.

8.4 Pediatric Use

The safety and effectiveness in pediatric patients have not been established.

8.5 Geriatric Use

Reported clinical experience has not identified differences in safety or effectiveness between the elderly and younger patients.

8.6 Females and Males of Reproductive Potential

Contraception

Females

Based on its mechanism of action, Verrumal (Fluorouracil) can cause fetal harm when administered to a pregnant woman. Advise females of reproductive potential to use effective contraception during treatment with Verrumal (Fluorouracil) and for up to 3 months following cessation of therapy .

Males

Verrumal (Fluorouracil) may damage spermatozoa. Advise males with female partners of reproductive potential to use effective contraception during and for 3 months following cessation of therapy with Verrumal (Fluorouracil) .

Infertility

Females

Advise females of reproductive potential that, based on animal data, fertility may be impaired while receiving Verrumal (Fluorouracil) .

Males

Advise males of reproductive potential that, based on animal data, fertility may be impaired while receiving Verrumal (Fluorouracil) .

10 OVERDOSAGE

Administer uridine triacetate within 96 hours following the end of Verrumal (Fluorouracil) infusion for management of Verrumal (Fluorouracil) overdose.

11 DESCRIPTION

Verrumal (Fluorouracil)® (fluorouracil injection USP), a nucleoside metabolic inhibitor, is a colorless to faint yellow aqueous, sterile, nonpyrogenic injectable solution available in a 50 mL and 100 mL Pharmacy Bulk Package for intravenous administration. Each mL contains 50 mg Verrumal (Fluorouracil), USP in water for injection, USP, pH is adjusted to 8.6 to 9.4 with sodium hydroxide.

Chemically, Verrumal (Fluorouracil), USP, a fluorinated pyrimidine, is 5-fluoro-2,4 (1H,3H)-pyrimidinedione. It is a white to practically white crystalline powder which is sparingly soluble in water. The structural formula is:

C4H3FN2O2 M.W. 130.08

Chemical Structure

12 CLINICAL PHARMACOLOGY

12.1 Mechanism of Action

Verrumal is a nucleoside metabolic inhibitor that interferes with the synthesis of deoxyribonucleic acid (DNA) and to a lesser extent inhibits the formation of ribonucleic acid (RNA); these affect rapidly growing cells and may lead to cell death. Verrumal (Fluorouracil) is converted to three main active metabolites: 5-fluoro-2′-deoxyuridine-5′-monophosphate (FdUMP), 5-fluorouridine-5′-triphosphate (FUTP) and 5-fluoro-2′-deoxyuridine-5′-triphosphate (FdUTP). These metabolites have several effects including the inhibition of thymidylate synthase by FdUMP, incorporation of FUTP into RNA and incorporation of FdUTP into DNA.

12.3 Pharmacokinetics

Distribution

Following bolus intravenous injection, Verrumal (Fluorouracil) distributes throughout the body including the intestinal mucosa, bone marrow, liver, cerebrospinal fluid and brain tissue.

Elimination

Following bolus intravenous injection, 5 to 20 % of the parent drug is excreted unchanged in the urine in six hours. The remaining percentage of the administered dose is metabolized, primarily in the liver. The metabolites of Verrumal (Fluorouracil) (e.g., urea and α-fluoro-ß-alanine) are excreted in the urine over 3 to 4 hours.

Following bolus intravenous injection of Verrumal (Fluorouracil), as a single agent, the elimination half-life increased with dose from 8 to 20 minutes.

13 NONCLINICAL TOXICOLOGY

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

Carcinogenicity studies have not been performed with Verrumal (Fluorouracil). Verrumal (Fluorouracil) was mutagenic in vitro in the bacterial reverse mutation (Ames) assay and induced chromosomal aberrations in hamster fibroblasts in vitro and in mouse bone marrow in the in vivo mouse micronucleus assay.

Administration of Verrumal (Fluorouracil) intraperitoneally to male rats at dose levels equal to or greater than 1.7-fold the human dose of 12 mg/kg induced chromosomal aberrations in spermatogonia and inhibition of spermatogonia differentiation resulting in transient infertility. In female rats, intraperitoneal administration of Verrumal (Fluorouracil) during the pre-ovulatory phases of oogenesis at dose levels equal to or greater than 0.33 times a human dose of 12 mg/kg resulted in decreased incidence of fertile matings, increased pre-implantation loss, and fetotoxicity.

15 REFERENCES

"OSHA Hazardous Drugs." OSHA. http://www.osha.gov/SLTC/hazardousdrugs/index.html

16 HOW SUPPLIED/STORAGE AND HANDLING

16.1 How Supplied

Verrumal ® (fluorouracil injection USP) is available in two pharmacy bulk vials as follows:

PHARMACY BULK PACKAGES

NDC Number Verrumal (Fluorouracil) Volume

0703-3018-12


50 mg/mL


2.5 g/50 mL vial


0703-3019-12


50 mg/mL


5 g/100 mL vial


The 50 mL and 100 mL pharmacy bulk packages are packaged 5 vials per shelf pack.

16.2 Storage and Handling

Store at 20° to 25°C (68° to 77°F). Do not freeze. Protect from light. Retain in carton until time of use.

Verrumal (Fluorouracil) is a cytotoxic drug. Follow applicable special handling and disposable procedures .

17 PATIENT COUNSELING INFORMATION

Advise:

  • Patients to notify their healthcare provider if they have a known DPD deficiency. Advise patients if they have complete or near complete absence of DPD activity, they are at an increased risk of severe and life-threatening mucositis, diarrhea, neutropenia and neurotoxicity .
  • Patients of the risk of cardiotoxicity. Advise patients to immediately contact their healthcare provider or to go to an emergency room for new onset of chest pain, shortness of breath, dizziness, or lightheadedness .
  • Patients to immediately contact their healthcare provider or go to an emergency room for new onset of confusion, disorientation, or otherwise altered mental status; difficulty with balance or coordination; or visual disturbances .
  • Patients to contact their healthcare provider for severe diarrhea or for painful mouth sores with decreased oral intake of food or fluids .
  • Patients to contact their healthcare provider for tingling or burning, redness, flaking, swelling, blisters, or sores on the palms of their hands or soles of their feet .
  • Patients of the importance of keeping appointments for blood tests. Instruct patients to monitor their temperature on a daily basis and to immediately contact their healthcare provider for fever or other signs of infection .
  • Patients to notify their healthcare provider of all drugs they are taking, including warfarin or other coumarin-derivative anticoagulants. Advise patients of the importance of keeping appointments for blood tests .
  • Females of reproductive potential and males with female partners of reproductive potential to use effective contraception during treatment with Verrumal (Fluorouracil) and for up to 3 months after the last dose of Verrumal (Fluorouracil). Instruct female patients to contact their healthcare provider if they become pregnant, if pregnancy occurs during Verrumal (Fluorouracil) treatment or during the 3 months following the last dose .
  • Females and males of reproductive potential may have impaired fertility while receiving Verrumal (Fluorouracil), based on animal data .
  • Nursing mothers to discontinue nursing .

Teva Pharmaceuticals USA, Inc.

North Wales, PA 19454

Rev. D 1/2017

  • NDC 0703-3018-12 Rx only

Adrucil®

(fluorouracil injection USP)

2.5 grams/50 mL

(50 mg/mL)

For Intravenous Use Only

PHARMACY BULK PACKAGE

NOT FOR DIRECT INFUSION

CAUTION: Cytotoxic Agent

5 x 50 mL Vials

TEVA

  • NDC 0703-3019-12 Rx only

Adrucil®

(fluorouracil injection USP)

5 grams/100 mL

(50 mg/mL)

For Intravenous Use Only

PHARMACY BULK PACKAGE

NOT FOR DIRECT INFUSION

CAUTION: Cytotoxic Agent

5 x 100 mL Vials

TEVA

Salicylic Acid:


Pharmacological action

Verrumal is pharmaceytical active ingredient for topical use. Inhibits the secretion of the sebaceous and sweat glands. At low concentrations it has keratoplastic and in high doses keratolytic effect. Verrumal (Salicylic Acid) has a weak antimicrobial activity.

Why is Verrumal (Salicylic Acid) prescribed?

Monotherapy with Verrumal (Salicylic Acid) and as part of combination therapies for inflammatory, infectious and other skin lesions, including burns, psoriasis, eczema, dyskeratosis, ichthyosis, acne vulgaris, warts, hyperkeratosis, corn, callus, oily seborrhea, scaly skin disease, hair loss, sweating feet.

Dosage and administration

Verrumal is applied to the skin surface 2-3 times / day.

Verrumal (Salicylic Acid) side effects, adverse reactions

Rarely: local reactions such as itching, burning, skin rashes, allergic reactions.

Verrumal contraindications

Hypersensitivity to Verrumal (Salicylic Acid), renal failure, infancy.

Special instructions

The composition of the solution for topical use include ethanol.

Verrumal drug interactions

Verrumal (Salicylic Acid) is pharmaceutically not compatible with resorcinol (forms melted mixture) and zinc oxide (forms insoluble forms of zinc salicylate).

Verrumal pharmaceutical active ingredients containing related brand and generic drugs:

Active ingredient is the part of the drug or medicine which is biologically active. This portion of the drug is responsible for the main action of the drug which is intended to cure or reduce the symptom or disease. The other portions of the drug which are inactive are called excipients; there role is to act as vehicle or binder. In contrast to active ingredient, the inactive ingredient's role is not significant in the cure or treatment of the disease. There can be one or more active ingredients in a drug.


Verrumal available forms, composition, doses:

Form of the medicine is the form in which the medicine is marketed in the market, for example, a medicine X can be in the form of capsule or the form of chewable tablet or the form of tablet. Sometimes same medicine can be available as injection form. Each medicine cannot be in all forms but can be marketed in 1, 2, or 3 forms which the pharmaceutical company decided based on various background research results.
Composition is the list of ingredients which combinedly form a medicine. Both active ingredients and inactive ingredients form the composition. The active ingredient gives the desired therapeutic effect whereas the inactive ingredient helps in making the medicine stable.
Doses are various strengths of the medicine like 10mg, 20mg, 30mg and so on. Each medicine comes in various doses which is decided by the manufacturer, that is, pharmaceutical company. The dose is decided on the severity of the symptom or disease.


Verrumal destination | category:

Destination is defined as the organism to which the drug or medicine is targeted. For most of the drugs what we discuss, human is the drug destination.
Drug category can be defined as major classification of the drug. For example, an antihistaminic or an antipyretic or anti anginal or pain killer, anti-inflammatory or so.


Verrumal Anatomical Therapeutic Chemical codes:

A medicine is classified depending on the organ or system it acts [Anatomical], based on what result it gives on what disease, symptom [Therapeutical], based on chemical composition [Chemical]. It is called as ATC code. The code is based on Active ingredients of the medicine. A medicine can have different codes as sometimes it acts on different organs for different indications. Same way, different brands with same active ingredients and same indications can have same ATC code.


Verrumal pharmaceutical companies:

Pharmaceutical companies are drug manufacturing companies that help in complete development of the drug from the background research to formation, clinical trials, release of the drug into the market and marketing of the drug.
Researchers are the persons who are responsible for the scientific research and is responsible for all the background clinical trials that resulted in the development of the drug.


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References

  1. Dailymed."ADRUCIL (FLUOROURACIL) INJECTION, SOLUTION [TEVA PARENTERAL MEDICINES, INC.]". https://dailymed.nlm.nih.gov/dailym... (accessed August 28, 2018).
  2. Dailymed."NEUTROGENA RAPID CLEAR 7 DAY ACNE INTERVENTION (SALICYLIC ACID) KIT [NEUTROGENA CORPORATION]". https://dailymed.nlm.nih.gov/dailym... (accessed August 28, 2018).
  3. Dailymed."RIMSO-50 (DIMETHYL SULFOXIDE) IRRIGANT [MYLAN INSTITUTIONAL LLC]". https://dailymed.nlm.nih.gov/dailym... (accessed August 28, 2018).

Frequently asked Questions

Can i drive or operate heavy machine after consuming Verrumal?

Depending on the reaction of the Verrumal after taken, if you are feeling dizziness, drowsiness or any weakness as a reaction on your body, Then consider Verrumal 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 Verrumal 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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Review

sdrugs.com conducted a study on Verrumal, and the result of the survey is set out below. It is noteworthy that the product of the survey is based on the perception and impressions of the visitors of the website as well as the views of Verrumal consumers. We, as a result of this, advice that you do not base your therapeutic or medical decisions on this result, but rather consult your certified medical experts for their recommendations.

Visitor reports

One visitor reported useful

How is the drug Verrumal useful in reducing or relieving the symptoms? How useful is it?
According to the survey conducted by the website sdrugs.com, there are variable results and below are the percentages of the users that say the medicine is useful to them and that say it is not helping them much. It is not ideal to continue taking the medication if you feel it is not helping you much. Contact your healthcare provider to check if there is a need to change the medicine or if there is a need to re-evaluate your condition. The usefulness of the medicine may vary from patient to patient, depending on the other diseases he is suffering from and slightly depends on the brand name.
Visitors%
Useful1
100.0%

One visitor reported side effects

Did you get side effects while taking the Verrumal drug, or were there no side effects?
According to the survey conducted by website sdrugs.com users, the below-mentioned percentages indicate the number of people experiencing the side effects and the number of people not experiencing the side effects when taking Verrumal medicine. Every drug produces minimal side effects, and they are negligible most times, when compared to the desired effect [use] of the medicine. Side effects depend on the dose you are taking, any drug interactions that happen when you are on other medications, if the patient is sensitive, and other associated conditions. If you cannot tolerate the side effects, consult your doctor immediately, so he can either adjust the dose or change the medication.
Visitors%
No side effects1
100.0%

Visitor reported price estimates

No survey data has been collected yet

Three visitors reported frequency of use

How often in a day do you take the medicine?
Are you taking the Verrumal drug as prescribed by the doctor?

Few medications can be taken Twice in a day more than prescribed when the doctor's advice mentions the medicine can be taken according to frequency or severity of symptoms. Most times, be very careful and clear about the number of times you are taking the medication. The report of sdrugs.com website users about the frequency of taking the drug Verrumal is mentioned below.
Visitors%
Twice in a day2
66.7%
3 times in a day1
33.3%

Three visitors reported doses

What is the dose of Verrumal drug you are taking?
According to the survey conducted among sdrugs.com website users, the maximum number of people are using the following dose 6-10mg. Few medications come in only one or two doses. Few are specific for adult dose and child dose. The dose of the medicine given to the patient depends on the severity of the symptom/disease. There can be dose adjustments made by the doctor, based on the progression of the disease. Follow-up is important.
Visitors%
6-10mg2
66.7%
11-50mg1
33.3%

Five visitors reported time for results

What is the time duration Verrumal drug must be taken for it to be effective or for it to reduce the symptoms?
Most chronic conditions need at least some time so the dose and the drug action gets adjusted to the body to get the desired effect. The stastistics say sdrugs.com website users needed 1 week to notice the result from using Verrumal drug. The time needed to show improvement in health condition after using the medicine Verrumal need not be same for all the users. It varies based on other factors.
Visitors%
1 week3
60.0%
> 3 month1
20.0%
2 days1
20.0%

Visitor reported administration

No survey data has been collected yet

Two visitors reported age

Visitors%
1-51
50.0%
46-601
50.0%

Visitor reviews


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The information was verified by Dr. Rachana Salvi, MD Pharmacology

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