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warnings and cautions
5 WARNINGS AND PRECAUTIONS Hypersensitivity : Hypersensitivity reactions, including cases of angioedema, eye swelling, facial swelling, dyspnea, urticaria, and adverse skin reactions, have been reported. In case of known hypersensitivity to any component of the gel, avoid the use of azelaic acid gel. If hypersensitivity develops, discontinue treatment and institute appropriate therapy. ( 5.1 ) Skin Reactions: Skin irritation (i.e. pruritus, burning or stinging) may occur, usually during the first few weeks of treatment. If sensitivity or severe irritation develops and persists, discontinue treatment and institute appropriate therapy. ( 5.2 ) Hypopigmentation: Isolated cases of hypopigmentation occurred after azelaic acid use. Monitor patients with dark complexion for early signs of hypopigmentation ( 5.2 ) Eye and Mucous Membrane Irritation: Azelaic acid gel has been reported to cause irritation of the eyes. Avoid contact with the eyes and mucous membranes. ( 5.3 ) Exacerbation of Asthma: Consult a physician if asthma is exacerbated with azelaic acid gel use. ( 5.4 ) 5.1 Hypersensitivity Hypersensitivity reactions, including cases of angioedema, eye swelling, facial swelling, dyspnea, urticaria, and adverse skin reactions, have been reported during post marketing surveillance. Avoid the use of azelaic acid gel in patients with known hypersensitivity to any component of the gel. If hypersensitivity develops during treatment, discontinue azelaic acid gel and institute appropriate therapy. 5.2 Skin Reactions Skin irritation (i.e. pruritus, burning or stinging) may occur during use of azelaic acid gel, usually during the first few weeks of treatment. If sensitivity or severe irritation develops and persists, discontinue treatment and institute appropriate therapy. There have been isolated reports of hypopigmentation after use of azelaic acid. Since azelaic acid has not been well studied in patients with dark complexion, monitor these patients for early signs of hypopigmentation. 5.3 Eye and Mucous Membranes Irritation Azelaic acid gel has been reported to cause irritation of the eyes. Avoid contact with the eyes, mouth and other mucous membranes. If azelaic acid gel comes in contact with the eyes, wash the eyes with large amounts of water and consult a physician if eye irritation persists [see Adverse Reactions (6.2) ] . 5.4 Exacerbation of Asthma Worsening of asthma has been reported in patients using azelaic acid formulations including azelaic acid gel. Consult a physician if asthma is exacerbated with use of azelaic acid gel.
6 ADVERSE REACTIONS The most common adverse reactions are burning/stinging/tingling (29%), pruritus (11%), scaling/dry skin/xerosis (8%) and erythema/irritation (4%). ( 6 ) To report SUSPECTED ADVERSE REACTIONS, contact Teva at 1-888-838-2872 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. 6.1 Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. In two vehicle-controlled and one active-controlled U.S. clinical trials, treatment safety was monitored in 788 subjects who used twice-daily azelaic acid gel for 12 weeks (N=333) or 15 weeks (N=124), or the gel vehicle (N=331) for 12 weeks. In all three trials, the most common treatment-related adverse events were: burning/stinging/tingling (29%), pruritus (11%), scaling/dry skin/xerosis (8%) and erythema/irritation (4%). In the active-controlled trial, overall adverse reactions (including burning, stinging/tingling, dryness/tightness/scaling, itching, and erythema/irritation/redness) were 19.4% (24/124) for azelaic acid gel compared to 7.1% (9/127) for the active comparator gel at 15 weeks. Table 1: Adverse Events Occurring in ≥1% of Subjects in the Rosacea Trials by Treatment Group and Maximum Intensity* Azelaic Acid Gel, 15% Vehicle N=457 N=331 (100%) (100%) Mild Moderate Severe Mild Moderate Severe N=99 N =61 N =27 N =46 N =30 N =5 (22%) (13%) (6%) (14%) (9%) (2%) Burning/stinging/tingling 71 (16%) 42 (9%) 17 (4%) 8 (2%) 6 (2%) 2 (1%) Pruritus 29 (6%) 18 (4%) 5 (1%) 9 (3%) 6 (2%) 0 (0%) Scaling/dry skin/xerosis 21 (5%) 10 (2%) 5 (1%) 31 (9%) 14 (4%) 1 (<1%) Erythema/irritation 6 (1%) 7 (2%) 2 (<1%) 8 (2%) 4 (1%) 2 (1%) Contact dermatitis 2 (<1%) 3 (1%) 0 (0%) 1 (<1%) 0 (0%) 0 (0%) Edema 3 (1%) 2 (<1%) 0 (0%) 3 (1%) 0 (0%) 0 (0%) Acne 3 (1%) 1 (<1%) 0 (0%) 1 (<1%) 0 (0%) 0 (0%) *Subjects may have ˃ 1 cutaneous adverse event; thus, the sum of the frequencies of preferred terms may exceed the number of subjects with at least 1 cutaneous adverse event. In patients using azelaic acid formulations, the following adverse events have been reported: worsening of asthma, vitiligo, depigmentation, small depigmented spots, hypertrichosis, reddening (signs of keratosis pilaris) and exacerbation of recurrent herpes labialis. Local Tolerability Studies Azelaic acid gel and its vehicle caused irritant reactions at the application site in human dermal safety studies. Azelaic acid gel caused significantly more irritation than its vehicle in a cumulative irritation study. Some improvement in irritation was demonstrated over the course of the clinical trials, but this improvement might be attributed to subject dropouts. No phototoxicity or photoallergenicity were reported in human dermal safety studies. 6.2 Postmarketing Experience The following adverse reactions have been identified post approval of azelaic acid gel. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate the frequency or establish a causal relationship to drug exposure: Eyes: iridocyclitis upon accidental exposure of the eyes to azelaic acid gel. Hypersensitivity: angioedema, eye swelling, facial swelling, urticaria. Respiratory: worsening of asthma, dyspnea, wheezing. Skin reactions: application site rash.
adverse reactions table
<table width="750px" cellspacing="0" cellpadding="0"><caption>Table 1: Adverse Events Occurring in ≥1% of Subjects in the Rosacea Trials by Treatment Group and Maximum Intensity*</caption><col width="1px"/><col width="1px"/><col width="1px"/><col/><col/><col/><col/><tbody><tr><td align="center" styleCode=" Toprule"/><td align="center" colspan="3" styleCode=" Toprule"><paragraph><content styleCode="bold">Azelaic Acid Gel, 15%</content></paragraph></td><td align="center" colspan="3" styleCode=" Toprule"><paragraph><content styleCode="bold">Vehicle</content></paragraph></td></tr><tr><td align="center"/><td align="center" colspan="3"><paragraph><content styleCode="bold">N=457 </content></paragraph></td><td align="center" colspan="3"><paragraph><content styleCode="bold">N=331 </content></paragraph></td></tr><tr><td align="center" styleCode=" Botrule"/><td align="center" colspan="3" styleCode=" Botrule"><paragraph><content styleCode="bold">(100%)</content></paragraph></td><td align="center" colspan="3" styleCode=" Botrule"><paragraph><content styleCode="bold">(100%)</content></paragraph></td></tr><tr><td align="center"/><td align="center"><paragraph><content styleCode="bold">Mild</content></paragraph></td><td align="center"><paragraph><content styleCode="bold">Moderate</content></paragraph></td><td align="center"><paragraph><content styleCode="bold">Severe</content></paragraph></td><td align="center"><paragraph><content styleCode="bold">Mild</content></paragraph></td><td align="center"><paragraph><content styleCode="bold">Moderate</content></paragraph></td><td align="center"><paragraph><content styleCode="bold">Severe</content></paragraph></td></tr><tr><td align="center"/><td align="center"><paragraph><content styleCode="bold">N=99</content></paragraph></td><td align="center"><paragraph><content styleCode="bold">N</content><content styleCode="bold">=61</content></paragraph></td><td align="center"><paragraph><content styleCode="bold">N</content><content styleCode="bold">=27</content></paragraph></td><td align="center"><paragraph><content styleCode="bold">N</content><content styleCode="bold">=46</content></paragraph></td><td align="center"><paragraph><content styleCode="bold">N</content><content styleCode="bold">=30</content></paragraph></td><td align="center"><paragraph><content styleCode="bold">N</content><content styleCode="bold">=5</content></paragraph></td></tr><tr><td align="center"/><td align="center"><paragraph><content styleCode="bold">(22%)</content></paragraph></td><td align="center"><paragraph><content styleCode="bold">(13%)</content></paragraph></td><td align="center"><paragraph><content styleCode="bold">(6%)</content></paragraph></td><td align="center"><paragraph><content styleCode="bold">(14%)</content></paragraph></td><td align="center"><paragraph><content styleCode="bold">(9%)</content></paragraph></td><td align="center"><paragraph><content styleCode="bold">(2%)</content></paragraph></td></tr><tr><td styleCode=" Toprule"><paragraph>Burning/stinging/tingling</paragraph></td><td align="center" styleCode=" Toprule"><paragraph>71 (16%)</paragraph></td><td align="center" styleCode=" Toprule"><paragraph>42 (9%)</paragraph></td><td align="center" styleCode=" Toprule"><paragraph>17 (4%)</paragraph></td><td align="center" styleCode=" Toprule"><paragraph>8 (2%)</paragraph></td><td align="center" styleCode=" Toprule"><paragraph>6 (2%)</paragraph></td><td align="center" styleCode=" Toprule"><paragraph>2 (1%)</paragraph></td></tr><tr><td><paragraph>Pruritus</paragraph></td><td align="center"><paragraph>29 (6%)</paragraph></td><td align="center"><paragraph>18 (4%)</paragraph></td><td align="center"><paragraph>5 (1%)</paragraph></td><td align="center"><paragraph>9 (3%)</paragraph></td><td align="center"><paragraph>6 (2%)</paragraph></td><td align="center"><paragraph>0 (0%)</paragraph></td></tr><tr><td><paragraph>Scaling/dry skin/xerosis</paragraph></td><td align="center"><paragraph>21 (5%)</paragraph></td><td align="center"><paragraph>10 (2%)</paragraph></td><td align="center"><paragraph>5 (1%)</paragraph></td><td align="center"><paragraph>31 (9%)</paragraph></td><td align="center"><paragraph>14 (4%)</paragraph></td><td align="center"><paragraph>1 (<1%)</paragraph></td></tr><tr><td><paragraph>Erythema/irritation</paragraph></td><td align="center"><paragraph>6 (1%)</paragraph></td><td align="center"><paragraph>7 (2%)</paragraph></td><td align="center"><paragraph>2 (<1%)</paragraph></td><td align="center"><paragraph>8 (2%)</paragraph></td><td align="center"><paragraph>4 (1%)</paragraph></td><td align="center"><paragraph>2 (1%)</paragraph></td></tr><tr><td><paragraph>Contact dermatitis</paragraph></td><td align="center"><paragraph>2 (<1%)</paragraph></td><td align="center"><paragraph>3 (1%)</paragraph></td><td align="center"><paragraph>0 (0%)</paragraph></td><td align="center"><paragraph>1 (<1%)</paragraph></td><td align="center"><paragraph>0 (0%)</paragraph></td><td align="center"><paragraph>0 (0%)</paragraph></td></tr><tr><td><paragraph>Edema</paragraph></td><td align="center"><paragraph>3 (1%)</paragraph></td><td align="center"><paragraph>2 (<1%)</paragraph></td><td align="center"><paragraph>0 (0%)</paragraph></td><td align="center"><paragraph>3 (1%)</paragraph></td><td align="center"><paragraph>0 (0%)</paragraph></td><td align="center"><paragraph>0 (0%)</paragraph></td></tr><tr><td><paragraph>Acne</paragraph></td><td align="center"><paragraph>3 (1%)</paragraph></td><td align="center"><paragraph>1 (<1%)</paragraph></td><td align="center"><paragraph>0 (0%)</paragraph></td><td align="center"><paragraph>1 (<1%)</paragraph></td><td align="center"><paragraph>0 (0%)</paragraph></td><td align="center"><paragraph>0 (0%)</paragraph></td></tr><tr><td colspan="7" styleCode=" Toprule"><paragraph><content styleCode="italics">*Subjects may have <content styleCode="italics">˃</content>1 cutaneous adverse event; thus, the sum of the frequencies of preferred terms may exceed the number of subjects with at least 1 cutaneous adverse event.</content></paragraph></td></tr></tbody></table>