{"adverse_reactions":["6 ADVERSE REACTIONS The following serious adverse reactions are discussed in more detail in other sections of the labeling: • Ophthalmic Adverse Reaction [ see Warnings and Precautions (5.1) ] • Hypersensitivity Reactions [ see Warnings and Precautions (5.2) ] • Non-Melanoma Skin Cancer [ see Warnings and Precautions (5.3) ] The most common adverse reactions (≥2 %) are local skin reactions, application site pain, application site pruritus, application site irritation, application site infection, periorbital edema, nasopharyngitis and headache. (6.1) To report SUSPECTED ADVERSE REACTIONS, contact Perrigo at 1-866-634-9120 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 clinical practice. The data described below reflect exposure to ingenol mebutate gel in 499 subjects with actinic keratosis, including 274 subjects exposed to ingenol mebutate gel field treatment (skin area of 25 cm 2 in the face or scalp regions) at a concentration of 0.015% once daily for 3 consecutive days, and 225 subjects exposed to ingenol mebutate gel field treatment (skin area of 25 cm 2 in the trunk or extremities regions) at a concentration of 0.05% once daily for 2 consecutive days. Local skin reactions, including erythema, flaking/scaling, crusting, swelling, vesiculation/pustulation, and erosion/ulceration were assessed within the selected treatment area and graded by the investigator on a scale of 0 to 4. A grade of 0 represented no reaction present in the treated area, and a grade of 4 indicated a marked and severe skin reaction that extended beyond the treated area. Table 1. Investigator Assessment of Maximal Local Skin Reactions in the Treatment Area during the 57 Days Post Treatment Period (face/scalp trials) Face and Scalp (N=545) Ingenol Mebutate Gel, 0.015% once daily for 3 days Skin reactions Any Grade a > Baseline Grade 4 Ingenol Mebutate Gel (N=274) Vehicle (N=271) Ingenol Mebutate Gel (N=274) Vehicle (N=271) Erythema 258 (94%) 69 (25%) 66 (24%) 0 (0%) Flaking/Scaling 233 (85%) 67 (25%) 25 (9%) 0 (0%) Crusting 220 (80%) 46 (17%) 16 (6%) 0 (0%) Swelling 217 (79%) 11 (4%) 14 (5%) 0 (0%) Vesiculation/Pustulation 154 (56%) 1 (0%) 15 (5%) 0 (0%) Erosion/Ulceration 87 (32%) 3 (1%) 1 (0%) 0 (0%) a Mild (grade 1), Moderate (grade 2-3) or Severe (grade 4). Table 2. Investigator Assessment of Maximal Local Skin Reactions in the Treatment Area during the 57 Days Post Treatment Period (trunk/extremities trials) Trunk and Extremities (N=457) Ingenol Mebutate Gel, 0.05% once daily for 2 days Skin reactions Any Grade a > Baseline Grade 4 Ingenol Mebutate Gel (N=225) Vehicle (N=232) Ingenol Mebutate Gel (N=225) Vehicle (N=232) Erythema 207 (92%) 43 (19%) 34 (15%) 0 (0%) Flaking/Scaling 203 (90%) 44 (19%) 18 (8%) 0 (0%) Crusting 167 (74%) 23 (10%) 8 (4%) 0 (0%) Swelling 143 (64%) 13 (6%) 7 (3%) 0 (0%) Vesiculation/Pustulation 98 (44%) 2 (1%) 3 (1%) 0 (0%) Erosion/Ulceration 58 (26%) 6 (3%) 2 (1%) 0 (0%) a Mild (grade 1), Moderate (grade 2-3) or Severe (grade 4). Local skin reactions typically occurred within 1 day of treatment initiation, peaked in intensity up to 1 week following completion of treatment, and resolved within 2 weeks for areas treated on the face and scalp, and within 4 weeks for areas treated on the trunk and extremities. Adverse reactions that occurred in ≥2% of subjects treated with ingenol mebutate gel and at a higher frequency than the vehicle are presented in Table 3 and Table 4. Table 3. Adverse reactions occurring in ≥ 2% of subjects treated with ingenol mebutate gel and at higher frequency than vehicle (face/scalp trials) Face/Scalp Adverse Reactions Ingenol Mebutate Gel, 0.015% (N=274) Vehicle (N=271) Application Site Pain 42 (15%) 1 (0%) Application Site Pruritus 22 (8%) 3 (1%) Application Site Infection 7 (3%) 0 (0%) Periorbital Edema 7 (3%) 0 (0%) Headache 6 (2%) 3 (1%) Table 4. Adverse reactions occurring in ≥ 2% of subjects treated with ingenol mebutate gel and at higher frequency than vehicle (trunk/extremities trials) Trunk/Extremities Adverse Reactions Ingenol Mebutate Gel, 0.05% (N=225) Vehicle (N=232) Application Site Pruritus 18 (8%) 0 (0%) Application Site Irritation 8 (4%) 1 (0%) Nasopharyngitis 4 (2%) 2 (1%) Application Site Pain 5 (2%) 0 (0%) Less common adverse reactions in subjects treated with ingenol mebutate gel included: eyelid edema, eye pain, conjunctivitis. A total of 108 subjects treated with ingenol mebutate gel on the face/scalp and 38 subjects treated on the trunk/extremities were followed for 12 months. Results from these studies did not change the safety profile of ingenol mebutate gel. 6.2 Postmarketing Experience The following adverse reactions have been identified during post-approval use of ingenol mebutate gel, 0.015% and 0.05%. 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. Eye disorders: chemical conjunctivitis, corneal burn Immune system disorders: hypersensitivity, Stevens-Johnson syndrome Infections: herpes zoster Skin and Subcutaneous disorders: non-melanoma skin cancer, allergic contact dermatitis, application site pigmentation changes, application site scarring"],"adverse_reactions_table":["
Table 1. Investigator Assessment of Maximal Local Skin Reactions in the Treatment Area during the 57 Days Post Treatment Period (face/scalp trials)
Face and Scalp (N=545)Ingenol Mebutate Gel, 0.015% once daily for 3 days
Skin reactionsAny Gradea > BaselineGrade 4
Ingenol Mebutate Gel(N=274)Vehicle(N=271)Ingenol Mebutate Gel(N=274)Vehicle(N=271)
Erythema258 (94%)69 (25%)66 (24%)0 (0%)
Flaking/Scaling233 (85%)67 (25%)25 (9%)0 (0%)
Crusting220 (80%)46 (17%)16 (6%)0 (0%)
Swelling217 (79%)11 (4%)14 (5%)0 (0%)
Vesiculation/Pustulation154 (56%)1 (0%)15 (5%)0 (0%)
Erosion/Ulceration87 (32%)3 (1%)1 (0%)0 (0%)
","
Table 2. Investigator Assessment of Maximal Local Skin Reactions in the Treatment Area during the 57 Days Post Treatment Period (trunk/extremities trials)
Trunk and Extremities (N=457)Ingenol Mebutate Gel, 0.05% once daily for 2 days
Skin reactionsAny Gradea > BaselineGrade 4
Ingenol Mebutate Gel(N=225)Vehicle(N=232)Ingenol Mebutate Gel(N=225)Vehicle(N=232)
Erythema207 (92%)43 (19%)34 (15%)0 (0%)
Flaking/Scaling203 (90%)44 (19%)18 (8%)0 (0%)
Crusting167 (74%)23 (10%)8 (4%)0 (0%)
Swelling143 (64%)13 (6%)7 (3%)0 (0%)
Vesiculation/Pustulation98 (44%)2 (1%)3 (1%)0 (0%)
Erosion/Ulceration58 (26%)6 (3%)2 (1%)0 (0%)
","
Table 3. Adverse reactions occurring in ≥ 2% of subjects treated with ingenol mebutate gel and at higher frequency than vehicle (face/scalp trials)
Face/Scalp
Adverse ReactionsIngenol Mebutate Gel, 0.015% (N=274)Vehicle (N=271)
Application Site Pain42 (15%)1 (0%)
Application Site Pruritus22 (8%)3 (1%)
Application Site Infection7 (3%)0 (0%)
Periorbital Edema7 (3%)0 (0%)
Headache6 (2%)3 (1%)
","
Table 4. Adverse reactions occurring in ≥ 2% of subjects treated with ingenol mebutate gel and at higher frequency than vehicle (trunk/extremities trials)
Trunk/Extremities
Adverse ReactionsIngenol Mebutate Gel, 0.05% (N=225)Vehicle (N=232)
Application Site Pruritus18 (8%)0 (0%)
Application Site Irritation8 (4%)1 (0%)
Nasopharyngitis4 (2%)2 (1%)
Application Site Pain5 (2%)0 (0%)
"],"carcinogenesis_and_mutagenesis_and_impairment_of_fertility":["13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility Long-term animal studies have not been performed to evaluate the carcinogenic potential of ingenol mebutate gel or ingenol mebutate. The effects of ingenol mebutate on fertility have not been evaluated. Ingenol mebutate was negative in the Ames test, in vitro mouse lymphoma assay, and in vivo rat micronucleus test, but positive in the Syrian hamster embryo (SHE) cell transformation assay."],"clinical_pharmacology":["12 CLINICAL PHARMACOLOGY 12.1 Mechanism of Action The mechanism of action by which ingenol mebutate gel induces cell death in treating AK lesions is unknown. 12.2 Pharmacodynamics The pharmacodynamics of ingenol mebutate gel is unknown. 12.3 Pharmacokinetics Absorption The systemic exposure to ingenol mebutate gel, 0.05% was assessed in two studies in a total of 16 subjects with AK, following application of approximately 1 g of ingenol mebutate gel, 0.05% to an area of 100 cm 2 of the dorsal forearm once daily for two consecutive days. In these studies, the blood levels of ingenol mebutate and two of its metabolites (acyl isomers of ingenol mebutate) were measured. Blood levels of ingenol mebutate and the two metabolites were below the lower limit of quantification (0.1 ng/mL) in all the blood samples of the subjects evaluated. Drug Interactions In vitro studies demonstrated that [ 3 H]-ingenol mebutate undergoes extensive metabolism in human hepatocytes. In vitro studies to assess the potential of ingenol mebutate to inhibit or induce human cytochrome P450 (CYP) enzymes demonstrated that ingenol mebutate does not inhibit CYP 1A2, 2A6, 2B6, 2C8, 2C9, 2C19, 2D6, 2E1, and 3A4 or induce CYP 1A2, 2C9, and 3A4. The estimated expected systemic exposure (< 0.1 ng/mL) following topical application of ingenol mebutate gel, 0.05% to AK subjects in the pharmacokinetic studies described above is negligible compared to the concentrations of ingenol mebutate evaluated in the in vitro studies."],"clinical_studies":["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 clinical practice. The data described below reflect exposure to ingenol mebutate gel in 499 subjects with actinic keratosis, including 274 subjects exposed to ingenol mebutate gel field treatment (skin area of 25 cm 2 in the face or scalp regions) at a concentration of 0.015% once daily for 3 consecutive days, and 225 subjects exposed to ingenol mebutate gel field treatment (skin area of 25 cm 2 in the trunk or extremities regions) at a concentration of 0.05% once daily for 2 consecutive days. Local skin reactions, including erythema, flaking/scaling, crusting, swelling, vesiculation/pustulation, and erosion/ulceration were assessed within the selected treatment area and graded by the investigator on a scale of 0 to 4. A grade of 0 represented no reaction present in the treated area, and a grade of 4 indicated a marked and severe skin reaction that extended beyond the treated area. Table 1. Investigator Assessment of Maximal Local Skin Reactions in the Treatment Area during the 57 Days Post Treatment Period (face/scalp trials) Face and Scalp (N=545) Ingenol Mebutate Gel, 0.015% once daily for 3 days Skin reactions Any Grade a > Baseline Grade 4 Ingenol Mebutate Gel (N=274) Vehicle (N=271) Ingenol Mebutate Gel (N=274) Vehicle (N=271) Erythema 258 (94%) 69 (25%) 66 (24%) 0 (0%) Flaking/Scaling 233 (85%) 67 (25%) 25 (9%) 0 (0%) Crusting 220 (80%) 46 (17%) 16 (6%) 0 (0%) Swelling 217 (79%) 11 (4%) 14 (5%) 0 (0%) Vesiculation/Pustulation 154 (56%) 1 (0%) 15 (5%) 0 (0%) Erosion/Ulceration 87 (32%) 3 (1%) 1 (0%) 0 (0%) a Mild (grade 1), Moderate (grade 2-3) or Severe (grade 4). Table 2. Investigator Assessment of Maximal Local Skin Reactions in the Treatment Area during the 57 Days Post Treatment Period (trunk/extremities trials) Trunk and Extremities (N=457) Ingenol Mebutate Gel, 0.05% once daily for 2 days Skin reactions Any Grade a > Baseline Grade 4 Ingenol Mebutate Gel (N=225) Vehicle (N=232) Ingenol Mebutate Gel (N=225) Vehicle (N=232) Erythema 207 (92%) 43 (19%) 34 (15%) 0 (0%) Flaking/Scaling 203 (90%) 44 (19%) 18 (8%) 0 (0%) Crusting 167 (74%) 23 (10%) 8 (4%) 0 (0%) Swelling 143 (64%) 13 (6%) 7 (3%) 0 (0%) Vesiculation/Pustulation 98 (44%) 2 (1%) 3 (1%) 0 (0%) Erosion/Ulceration 58 (26%) 6 (3%) 2 (1%) 0 (0%) a Mild (grade 1), Moderate (grade 2-3) or Severe (grade 4). Local skin reactions typically occurred within 1 day of treatment initiation, peaked in intensity up to 1 week following completion of treatment, and resolved within 2 weeks for areas treated on the face and scalp, and within 4 weeks for areas treated on the trunk and extremities. Adverse reactions that occurred in ≥2% of subjects treated with ingenol mebutate gel and at a higher frequency than the vehicle are presented in Table 3 and Table 4. Table 3. Adverse reactions occurring in ≥ 2% of subjects treated with ingenol mebutate gel and at higher frequency than vehicle (face/scalp trials) Face/Scalp Adverse Reactions Ingenol Mebutate Gel, 0.015% (N=274) Vehicle (N=271) Application Site Pain 42 (15%) 1 (0%) Application Site Pruritus 22 (8%) 3 (1%) Application Site Infection 7 (3%) 0 (0%) Periorbital Edema 7 (3%) 0 (0%) Headache 6 (2%) 3 (1%) Table 4. Adverse reactions occurring in ≥ 2% of subjects treated with ingenol mebutate gel and at higher frequency than vehicle (trunk/extremities trials) Trunk/Extremities Adverse Reactions Ingenol Mebutate Gel, 0.05% (N=225) Vehicle (N=232) Application Site Pruritus 18 (8%) 0 (0%) Application Site Irritation 8 (4%) 1 (0%) Nasopharyngitis 4 (2%) 2 (1%) Application Site Pain 5 (2%) 0 (0%) Less common adverse reactions in subjects treated with ingenol mebutate gel included: eyelid edema, eye pain, conjunctivitis. A total of 108 subjects treated with ingenol mebutate gel on the face/scalp and 38 subjects treated on the trunk/extremities were followed for 12 months. Results from these studies did not change the safety profile of ingenol mebutate gel.","14 CLINICAL STUDIES 14.1 Actinic Keratosis of the Face and Scalp In two double-blind, vehicle-controlled, clinical trials, 547 adult subjects with AK on the face or scalp were randomized to treatment with either ingenol mebutate gel, 0.015% or vehicle gel for 3 consecutive days, followed by an 8 week follow-up period. The trials enrolled subjects with 4 to 8 clinically typical, visible, discrete AK lesions within a 25 cm 2 contiguous treatment area. Hypertrophic and hyperkeratotic lesions were excluded from treatment. On each scheduled dosing day, the study gel was applied to the entire treatment area. A total of 536 subjects (98%) completed these trials. Study subjects ranged from 34 to 89 years of age (mean 64 years) and 94% had Fitzpatrick skin type I, II, or III. Approximately 85% of subjects were male, and all ingenol mebutate gel-treated subjects were Caucasian. Efficacy was assessed at Day 57. Complete clearance rate was defined as the proportion of subjects with no (zero) clinically visible AK lesions in the treatment area. Partial clearance rate was defined as the proportion of subjects with 75% or greater reduction in the number of AK lesions at baseline in the selected treatment area. Table 5 presents the efficacy results for each trial. Table 5. Number and Percent of Subjects Achieving Complete and Partial Clearance at Day 57 in Each Trial Study 1 Study 2 Ingenol Mebutate Gel, 0.015% (N=135) Vehicle N=134) Ingenol Mebutate Gel, 0.015% (N=142) Vehicle (N=136) Complete Clearance Rate 50 (37%) 3 (2%) 67 (47%) 7 (5%) Partial Clearance Rate (≥75%) 81 (60%) 9 (7%) 96 (68%) 11 (8%) Table 6 presents the response rates by anatomical location for each trial. Table 6. Number and Percent of Subjects Achieving Complete Clearance at Day 57 by Anatomical Location and by Trial Study 1 Study 2 Ingenol Mebutate Gel, 0.015% (N=135) Vehicle (N=134) Ingenol Mebutate Gel, 0.015% (N=142) Vehicle (N=136) Scalp 4/26 (15%) 0/25 (0%) 9/31 (29%) 1/25 (4%) Face 46/109 (42%) 3/109 (2%) 58/111 (52%) 6/111 (5%) Subjects who achieved complete clearance at Day 57 in Study 1 and Study 2 entered a 12-month follow-up period. Based on 108 ingenol mebutate gel-treated subjects who achieved complete clearance in Study 1 and Study 2, the recurrence rate at 12 months was 54% where recurrence was defined as the percentage of subjects with any identified AK lesion in the previously treated area who achieved complete clearance at Day 57. 14.2 Actinic Keratosis of the Trunk and Extremities In two double-blind, vehicle-controlled clinical trials, 458 adult subjects with AK on the trunk or extremities were randomized to treatment with either ingenol mebutate gel, 0.05% or vehicle gel for 2 consecutive days, followed by an 8 week follow-up period. The trials enrolled subjects with 4 to 8 clinically typical, visible, discrete AK lesions within a 25 cm 2 contiguous treatment area. Hypertrophic and hyperkeratotic lesions were excluded from treatment. On each scheduled dosing day, the study gel was applied to the entire treatment area. A total of 447 subjects (98%) completed these trials. Study subjects ranged from 34 to 89 years of age (mean 66 years) and 94% had Fitzpatrick skin type I, II, or III. Approximately 62% of subjects were male, and all ingenol mebutate gel-treated subjects were Caucasian. Efficacy was assessed at Day 57. Complete clearance rate was defined as the proportion of subjects with no (zero) clinically visible AK lesions in the treatment area. The partial clearance rate was defined as the proportion of subjects with 75% or greater reduction in the number of AK lesions at baseline in the selected treatment area. Table 7 presents the efficacy results for each trial. Table 7. Number and Percent of Subjects Achieving Complete and Partial Clearance at Day 57 in Each Trial Study 3 Study 4 Ingenol Mebutate Gel, 0.05% (N=126) Vehicle (N=129) Ingenol Mebutate Gel, 0.05% (N=100) Vehicle (N=103) Complete Clearance Rate 35 (28%) 6 (5%) 42 (42%) 5 (5%) Partial Clearance Rate (≥75%) 56 (44%) 9 (7%) 55 (55%) 7 (7%) Table 8 presents the response rates by anatomical location for each trial. Table 8. Number and Percent of Subjects Achieving Complete Clearance at Day 57 by Anatomical Location and by Trial Study 3 Study 4 Ingenol Mebutate Gel, 0.05% (N=126) Vehicle (N=129) Ingenol Mebutate Gel, 0.05% (N=100) Vehicle (N=103) Arm 22/84 (26%) 4/82 (5%) 27/59 (46%) 3/67 (5%) Back of Hand 4/25 (16%) 0/29 (0%) 6/28 (21%) 0/27 (0%) Chest 8/9 (89%) 1/8 (13%) 3/5 (60%) 1/3 (33%) Other a 1/8 (13%) 1/10 (10%) 6/8 (75%) 1/6 (17%) a Other includes shoulder, back, leg. Subjects who achieved complete clearance at Day 57 in Study 4 entered a 12-month follow-up period. Based on 38 ingenol mebutate gel-treated subjects who achieved complete clearance in Study 4, the recurrence rate at 12 months was 50% where recurrence was defined as the percentage of subjects with any identified AK lesion in the previously treated area who achieved complete clearance at Day 57. In a separate trial, in an open-label treatment period, subjects were treated for AK lesions on their face or scalp. Those subjects who did not achieve clearance at Day 57 or experienced recurrence after achieving clearance at Day 57 were randomized to receive a second treatment course of ingenol mebutate gel or its vehicle gel. Some subjects had a treatment benefit with the second treatment course of ingenol mebutate gel when evaluated 8 weeks after the retreatment."],"clinical_studies_table":["
Table 1. Investigator Assessment of Maximal Local Skin Reactions in the Treatment Area during the 57 Days Post Treatment Period (face/scalp trials)
Face and Scalp (N=545)Ingenol Mebutate Gel, 0.015% once daily for 3 days
Skin reactionsAny Gradea > BaselineGrade 4
Ingenol Mebutate Gel(N=274)Vehicle(N=271)Ingenol Mebutate Gel(N=274)Vehicle(N=271)
Erythema258 (94%)69 (25%)66 (24%)0 (0%)
Flaking/Scaling233 (85%)67 (25%)25 (9%)0 (0%)
Crusting220 (80%)46 (17%)16 (6%)0 (0%)
Swelling217 (79%)11 (4%)14 (5%)0 (0%)
Vesiculation/Pustulation154 (56%)1 (0%)15 (5%)0 (0%)
Erosion/Ulceration87 (32%)3 (1%)1 (0%)0 (0%)
","
Table 2. Investigator Assessment of Maximal Local Skin Reactions in the Treatment Area during the 57 Days Post Treatment Period (trunk/extremities trials)
Trunk and Extremities (N=457)Ingenol Mebutate Gel, 0.05% once daily for 2 days
Skin reactionsAny Gradea > BaselineGrade 4
Ingenol Mebutate Gel(N=225)Vehicle(N=232)Ingenol Mebutate Gel(N=225)Vehicle(N=232)
Erythema207 (92%)43 (19%)34 (15%)0 (0%)
Flaking/Scaling203 (90%)44 (19%)18 (8%)0 (0%)
Crusting167 (74%)23 (10%)8 (4%)0 (0%)
Swelling143 (64%)13 (6%)7 (3%)0 (0%)
Vesiculation/Pustulation98 (44%)2 (1%)3 (1%)0 (0%)
Erosion/Ulceration58 (26%)6 (3%)2 (1%)0 (0%)
","
Table 3. Adverse reactions occurring in ≥ 2% of subjects treated with ingenol mebutate gel and at higher frequency than vehicle (face/scalp trials)
Face/Scalp
Adverse ReactionsIngenol Mebutate Gel, 0.015% (N=274)Vehicle (N=271)
Application Site Pain42 (15%)1 (0%)
Application Site Pruritus22 (8%)3 (1%)
Application Site Infection7 (3%)0 (0%)
Periorbital Edema7 (3%)0 (0%)
Headache6 (2%)3 (1%)
","
Table 4. Adverse reactions occurring in ≥ 2% of subjects treated with ingenol mebutate gel and at higher frequency than vehicle (trunk/extremities trials)
Trunk/Extremities
Adverse ReactionsIngenol Mebutate Gel, 0.05% (N=225)Vehicle (N=232)
Application Site Pruritus18 (8%)0 (0%)
Application Site Irritation8 (4%)1 (0%)
Nasopharyngitis4 (2%)2 (1%)
Application Site Pain5 (2%)0 (0%)
","
Table 5. Number and Percent of Subjects Achieving Complete and Partial Clearance at Day 57 in Each Trial
Study 1Study 2
Ingenol Mebutate Gel, 0.015%(N=135)VehicleN=134)Ingenol Mebutate Gel, 0.015%(N=142)Vehicle(N=136)
Complete Clearance Rate50 (37%)3 (2%)67 (47%)7 (5%)
Partial Clearance Rate (≥75%)81 (60%)9 (7%)96 (68%)11 (8%)
","
Table 6. Number and Percent of Subjects Achieving Complete Clearance at Day 57 by Anatomical Location and by Trial
Study 1Study 2
Ingenol Mebutate Gel, 0.015%(N=135)Vehicle(N=134)Ingenol Mebutate Gel, 0.015%(N=142)Vehicle(N=136)
Scalp4/26 (15%)0/25 (0%)9/31 (29%)1/25 (4%)
Face46/109 (42%)3/109 (2%)58/111 (52%)6/111 (5%)
","
Table 7. Number and Percent of Subjects Achieving Complete and Partial Clearance at Day 57 in Each Trial
Study 3Study 4
Ingenol Mebutate Gel, 0.05%(N=126)Vehicle(N=129)Ingenol Mebutate Gel, 0.05%(N=100)Vehicle(N=103)
Complete Clearance Rate35 (28%)6 (5%)42 (42%)5 (5%)
Partial Clearance Rate (≥75%)56 (44%)9 (7%)55 (55%)7 (7%)
","
Table 8. Number and Percent of Subjects Achieving Complete Clearance at Day 57 by Anatomical Location and by Trial
Study 3Study 4
Ingenol Mebutate Gel, 0.05%(N=126)Vehicle(N=129)Ingenol Mebutate Gel, 0.05%(N=100)Vehicle(N=103)
Arm22/84 (26%)4/82 (5%)27/59 (46%)3/67 (5%)
Back of Hand4/25 (16%)0/29 (0%)6/28 (21%)0/27 (0%)
Chest8/9 (89%)1/8 (13%)3/5 (60%)1/3 (33%)
Othera1/8 (13%)1/10 (10%)6/8 (75%)1/6 (17%)
"],"contraindications":["4 CONTRAINDICATIONS Ingenol Mebutate Gel is contraindicated in patients with known hypersensitivity to ingenol mebutate or any component of the formulation. Anaphylaxis, as well as allergic reactions leading to hospitalization have been reported in postmarketing use with ingenol mebutate gel [ see Warnings and Precautions (5.2) ]. Known hypersensitivity to ingenol mebutate or any component of the formulation."],"description":["11 DESCRIPTION Ingenol Mebutate Gel, 0.015% or 0.05% is a clear colorless gel for topical administration, which contains the active substance ingenol mebutate, an inducer of cell death. The chemical name of ingenol mebutate is: 2-Butenoic acid, 2-methyl-, (1a R ,2 S ,5 R ,5a S ,6 S ,8a S ,9 R ,10a R )-1a,2,5,5a,6,9,10,10a-octahydro- 5,5a-dihydroxy-4-(hydroxymethyl)-1,1,7,9-tetramethyl-11-oxo-1 H -2,8a-methanocyclopenta [ a ]cyclopropa[ e ]cyclodecen-6-yl ester, (2Z) – or (1a R ,2 S ,5 R ,5a S ,6 S ,8a S ,9 R ,10a R )-5,5a-dihydroxy-4-(hydroxymethyl)-1,1,7,9-tetramethyl-11- oxo-1a,2,5,5a,6,9,10,10a-octahydro-1 H 2,8a-methanocyclopenta[ a ]cyclopropa[ e ]cyclodecen-6-yl (2Z) 2 methylbut-2-enoate. The molecular formula is C 25 H 34 O 6 and molecular weight is 430.5. Ingenol mebutate is represented by the following structural formula: Ingenol mebutate is a white to off-white powder. Ingenol Mebutate Gel, 0.015% or 0.05% contains 150 mcg and 500 mcg of ingenol mebutate, respectively, in each gram of gel consisting of benzyl alcohol, citric acid monohydrate, hydroxyethyl cellulose, isopropyl alcohol, propylene glycol, purified water and sodium citrate. Ingenol Mebutate Gel is clear colorless gel and supplied in unit dose laminate tubes, for single use, containing a nominal fill weight of 0.47 g, with a deliverable weight of 0.25 g. The tubes should be discarded after single use. Ingenol Mebutate Gel Structual Formula"],"dosage_and_administration":["2 DOSAGE AND ADMINISTRATION For the treatment of actinic keratosis on the face or scalp Ingenol Mebutate Gel, 0.015% should be applied to the affected area once daily for 3 consecutive days . For the treatment of actinic keratosis on the trunk or extremities Ingenol Mebutate Gel, 0.05% should be applied to the affected area once daily for 2 consecutive days . Ingenol Mebutate Gel may be applied to the affected area, up to one contiguous skin area of approximately 25 cm 2 (e.g., 5 cm x 5 cm) using one unit dose tube. After spreading evenly over the treatment area, the gel should be allowed to dry for 15 minutes. Patients should wash their hands immediately after applying Ingenol Mebutate Gel and take care not to transfer the applied drug to other areas, including the eye. Patients should avoid washing and touching the treated area for a period of 6 hours after application of Ingenol Mebutate Gel. Following this time, patients may wash the area with a mild soap. Avoid transfer of Ingenol Mebutate Gel to periocular area [ see Warnings and Precautions (5.1) ]. Avoid application near and around the mouth and lips. For topical use only; not for oral, ophthalmic, or intravaginal use. • For application of up to one contiguous skin area of approximately 25 cm 2 (5 cm x 5 cm) using one unit dose tube. (2) • Actinic keratosis on the face or scalp : Apply Ingenol Mebutate Gel, 0.015% to the affected area once daily for 3 consecutive days. (2) • Actinic keratosis on the trunk or extremities : Apply Ingenol Mebutate Gel, 0.05% to the affected area once daily for 2 consecutive days. (2) • Avoid transfer of Ingenol Mebutate Gel to periocular area. (2) • Avoid application near and around the mouth and lips. (2) • For topical use only; not for oral, ophthalmic, or intravaginal use. (2)"],"dosage_forms_and_strengths":["3 DOSAGE FORMS AND STRENGTHS Ingenol Mebutate Gel contains 0.015% or 0.05% of ingenol mebutate in a clear colorless gel base. Gel, 0.015% or 0.05%"],"effective_time":"20210921","geriatric_use":["8.5 Geriatric Use Of the 1165 subjects treated with ingenol mebutate gel in the clinical trials, 56% were 65 years and older and, 21% were 75 years and older. No overall differences in safety or effectiveness were observed between these subjects and younger subjects."],"how_supplied":["16 HOW SUPPLIED/STORAGE AND HANDLING Ingenol Mebutate Gel is a clear colorless gel and is supplied in unit dose laminate tubes containing a nominal fill weight of 0.47 g, with a deliverable weight of 0.25 g. The tubes should be discarded after single use. Ingenol Mebutate Gel is available in 2 dosage strengths: 0.015% and 0.05%. Dosage Strength Number of unit dose tubes per carton NDC# 0.015% 3 45802-074-14 0.05% 2 45802-108-54 Store Ingenol Mebutate Gel in a refrigerator at 36°F – 46°F (2°C – 8°C); excursions permitted between 32°F – 59°F (0°C – 15°C) (see USP for controlled cold temperature). Protect from freezing."],"how_supplied_table":["
Dosage StrengthNumber of unit dose tubes per cartonNDC#
0.015%345802-074-14
0.05%245802-108-54
"],"id":"60746d8b-c4a6-43e5-bcfc-e7847ef3c738","indications_and_usage":["1 INDICATIONS AND USAGE Ingenol Mebutate Gel is indicated for the topical treatment of actinic keratosis. Ingenol Mebutate Gel is an inducer of cell death indicated for the topical treatment of actinic keratosis."],"information_for_patients":["17 PATIENT COUNSELING INFORMATION Advise the patient to read the FDA-approved patient labeling (Patient Information and Instructions for Use) Ophthalmic Adverse Reactions Inform patients that severe eye injury can occur with Ingenol Mebutate Gel. Advise patients that Ingenol Mebutate Gel is not for ophthalmic use. Advise patients to avoid application around the eyes. If severe eye pain or other symptoms of accidental exposure occur, advise patients to flush eyes with water and seek medical care [ see Warnings and Precautions (5.1) ]. Hypersensitivity Reactions Inform patients that hypersensitivity reactions can occur with Ingenol Mebutate Gel. Advise patients of the symptoms of allergic reactions and anaphylaxis, and instruct patients to seek immediate medical attention if these symptoms occur [ see Warnings and Precautions (5.2) ]. Non-Melanoma Skin Cancer Inform patients that non-melanoma skin cancers have been reported in patients treated with Ingenol Mebutate Gel. Instruct patients to notify their physician if any new or changing skin lesions occur in the treatment area after treatment completion [ see Warnings and Precautions (5.3) ]. Local Skin Reactions Inform patients that treatment with Ingenol Mebutate Gel may lead to local skin reactions [ see Warnings and Precautions (5.4) ]. Important Administration Instructions Advise patients that Ingenol Mebutate Gel is for external use only. Advise patients to avoid application near and around the eyes, mouth and lips. Patients should avoid inadvertent transfer of Ingenol Mebutate Gel to other areas, or to another person. Instruct patients to: • allow the treated area to dry for 15 minutes after application. • avoid washing and touching the treated area, or participating in activities that cause excessive sweating, for 6 hours after treatment. Following this time, patients may wash the area with a mild soap and water. • keep out of the reach of children. Lactation Advise breastfeeding women to avoid accidental transfer of Ingenol Mebutate Gel to the nipple and areola area to prevent direct infant exposure [ see Use in Specific Populations (8.2) ]."],"instructions_for_use":["INSTRUCTIONS FOR USE Ingenol Mebutate (IN-je-nol-MEB-u-tate) Gel, 0.015% This Instructions for Use contains information on how to apply Ingenol Mebutate Gel. Be sure that you read, understand, and follow these Instructions for Use before you use Ingenol Mebutate Gel for the first time. Also read the Patient Information leaflet that comes with Ingenol Mebutate Gel. Important Information You Need to Know Before Applying Ingenol Mebutate Gel: • For topical use only (apply on top of skin) • Always use Ingenol Mebutate Gel exactly as your healthcare provider tells you. Check with your healthcare provider or pharmacist if you are not sure. • Only use Ingenol Mebutate Gel, 0.015% to treat actinic keratosis on your face or scalp . • Apply Ingenol Mebutate Gel, 0.015% to the skin area to be treated 1 time each day for 3 days in a row. Use a new tube for each day of treatment. • Avoid touching the treatment area or doing activities that cause a lot of sweating for 6 hours after applying Ingenol Mebutate Gel. After 6 hours you may wash the treatment area with a mild soap and water. Do not: • apply right after taking a shower or less than 2 hours before bedtime. • get Ingenol Mebutate Gel in, around, or near your eyes. Do not touch your eyes while you are applying Ingenol Mebutate Gel. • Wash your hands well with soap and water after applying it. After applying Ingenol Mebutate Gel, be careful to keep Ingenol Mebutate Gel on the treated area from coming into contact with your eyes. Irritation may happen if you get Ingenol Mebutate Gel in your eyes. • If you accidentally get Ingenol Mebutate Gel in your eyes , flush them with large amounts of water and get medical care as soon as possible. Also see the section of Patient Information leaflet section called “What are the possible side effects of Ingenol Mebutate Gel?” • get Ingenol Mebutate Gel in, around, or near your lips and mouth. Applying Ingenol Mebutate Gel. Step 1. Open a new tube each time you use Ingenol Mebutate Gel. Step 2. Remove cap from tube just before use. (See Figure A. ) Step 3. Squeeze the gel from the tube onto a fingertip. (See Figure B. ) Only use enough gel needed to cover the affected area, as directed by your healthcare provider. One tube contains enough gel to cover a skin area of about 2 inches by 2 inches. Step 4. Spread the gel evenly over only the skin area to be treated. Do not get in, around or near the eyes, lips, and mouth. Allow the treated area to dry for 15 minutes. (See Figure C. ) Step 5. Wash your hands right away after applying Ingenol Mebutate Gel. (See Figure D. ) Step 6. Safely throw away (dispose of) the tube after use. Repeat the above steps for each day of treatment. To help prevent transfer of Ingenol Mebutate Gel to other areas of your body or to another person, allow the treated area to dry for 15 minutes after you apply Ingenol Mebutate Gel. Storing Ingenol Mebutate Gel • Store Ingenol Mebutate Gel in a refrigerator at 36°F to 46°F (2°C to 8°C). Do not freeze. • Ingenol Mebutate Gel has an expiration date (exp) marked on the end of the tube. Do not use the gel after this date. Disposing of Ingenol Mebutate Gel • Safely throw away used Ingenol Mebutate Gel tubes in household trash. This Instructions for Use has been approved by the U.S. Food and Drug Administration. Made in Israel Manufactured By Perrigo Yeruham, Israel Distributed By Perrigo® Allegan, MI 49010 • www.perrigorx.com Rev 02-20 0J900 RC IC2 For more information call Perrigo at 1-866-634-9120 Figure A Figure B Figure C Figure D"],"mechanism_of_action":["12.1 Mechanism of Action The mechanism of action by which ingenol mebutate gel induces cell death in treating AK lesions is unknown."],"nonclinical_toxicology":["13 NONCLINICAL TOXICOLOGY 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility Long-term animal studies have not been performed to evaluate the carcinogenic potential of ingenol mebutate gel or ingenol mebutate. The effects of ingenol mebutate on fertility have not been evaluated. Ingenol mebutate was negative in the Ames test, in vitro mouse lymphoma assay, and in vivo rat micronucleus test, but positive in the Syrian hamster embryo (SHE) cell transformation assay."],"openfda":{},"overdosage":["10 OVERDOSAGE Topical overdosing of Ingenol Mebutate Gel could result in an increased incidence of local skin reactions."],"package_label_principal_display_panel":["PACKAGE/LABEL PRINCIPAL DISPLAY PANEL Rx Only NDC 45802 - 074-14 Ingenol Mebutate Gel, 0.015% For Topical Use on Face or Scalp Only Not for Oral, Ophthalmic, or Intravaginal Use Must be refrigerated 3 Unit Dose Tubes Net Wt. 0.47 g in each tube carton-0j9"],"pediatric_use":["8.4 Pediatric Use Actinic keratosis is not a condition generally seen within the pediatric population. The safety and effectiveness of ingenol mebutate gel for actinic keratosis in patients less than 18 years of age have not been established."],"pharmacodynamics":["12.2 Pharmacodynamics The pharmacodynamics of ingenol mebutate gel is unknown."],"pharmacokinetics":["12.3 Pharmacokinetics Absorption The systemic exposure to ingenol mebutate gel, 0.05% was assessed in two studies in a total of 16 subjects with AK, following application of approximately 1 g of ingenol mebutate gel, 0.05% to an area of 100 cm 2 of the dorsal forearm once daily for two consecutive days. In these studies, the blood levels of ingenol mebutate and two of its metabolites (acyl isomers of ingenol mebutate) were measured. Blood levels of ingenol mebutate and the two metabolites were below the lower limit of quantification (0.1 ng/mL) in all the blood samples of the subjects evaluated. Drug Interactions In vitro studies demonstrated that [ 3 H]-ingenol mebutate undergoes extensive metabolism in human hepatocytes. In vitro studies to assess the potential of ingenol mebutate to inhibit or induce human cytochrome P450 (CYP) enzymes demonstrated that ingenol mebutate does not inhibit CYP 1A2, 2A6, 2B6, 2C8, 2C9, 2C19, 2D6, 2E1, and 3A4 or induce CYP 1A2, 2C9, and 3A4. The estimated expected systemic exposure (< 0.1 ng/mL) following topical application of ingenol mebutate gel, 0.05% to AK subjects in the pharmacokinetic studies described above is negligible compared to the concentrations of ingenol mebutate evaluated in the in vitro studies."],"pregnancy":["8.1 Pregnancy Risk Summary There are no available data on ingenol mebutate gel use in pregnant women to evaluate a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. Systemic concentrations following topical administration of ingenol mebutate gel were below the limit of quantification of 0.1 ng/mL, and maternal use is not expected to result in fetal exposure to the drug [ see Clinical Pharmacology (12.3) ]. In animal reproduction studies, ingenol mebutate did not cause malformations in pregnant rats and rabbits when given by the intravenous route of administration during the period of organogenesis (see Data) . The available data do not allow the calculation of relevant comparisons between the systemic exposure of ingenol mebutate observed in the animal studies to the systemic exposure that would be expected in humans after topical use of ingenol mebutate gel. The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have a background risk of major birth defects, loss, and other adverse outcomes. The background risk in the U.S. general population of major birth defects is 2 to 4% and of miscarriage is 15 to 20% of clinically recognized pregnancies. Data Animal Data Intravenous doses of 1.5, 3, and 5 μg/kg/day (9, 18, and 30 μg/m 2 /day, respectively) ingenol mebutate were administered during the period of organogenesis (gestational days 6 – 16) to pregnant female rats. No treatment-related effects on embryofetal development or malformations were noted at doses up to 5 μg/kg/day (30 μg/m 2 /day). Intravenous doses of 1, 2, and 4 μg/kg/day (12, 24, and 48 μg/m 2 /day, respectively) ingenol mebutate were administered during the period of organogenesis (gestational days 6 – 18) to pregnant female rabbits. Maternal toxicity (increased breathing rate) was observed at doses ≥ 1 μg/kg/day (12 μg/m 2 /day). An increase in embryo-fetal mortality was noted at 4 μg/kg/day (48 μg/m 2 /day). An increased incidence of fetal visceral and skeletal variations was noted in all three ingenol mebutate dose groups."],"recent_major_changes":["Warnings and Precautions, Non-Melanoma Skin Cancer ( 5.3 ) 01/2021"],"set_id":"e5d0d52f-ed36-4971-9a26-7cd05e14dcd4","spl_patient_package_insert":["PATIENT INFORMATION Ingenol Mebutate (IN-je-nol-MEB-u-tate) Gel Important: For use on the skin only (topical). Do not use Ingenol Mebutate Gel in, around, or near your eyes, lips, mouth, or vagina. What is Ingenol Mebutate Gel? • Ingenol Mebutate Gel, 0.015% is a prescription medicine used on the skin to treat actinic keratosis on the face or scalp . • Ingenol Mebutate Gel, 0.05% is a prescription medicine used on the skin to treat actinic keratosis on the body or arms and legs . It is not known if Ingenol Mebutate Gel is safe and effective for the treatment of actinic keratosis in children less than 18 years of age. Who should not use Ingenol Mebutate Gel? Do not use Ingenol Mebutate Gel if you are allergic to ingenol mebutate or any of the ingredients in Ingenol Mebutate Gel. See the end of this leaflet for a list of the ingredients in Ingenol Mebutate Gel. What should I tell my healthcare provider before using Ingenol Mebutate Gel? Before using Ingenol Mebutate Gel, tell your healthcare provider about all of your medical conditions, including if you: • are being treated or have been treated for actinic keratosis with other medicines or surgery. You should not use Ingenol Mebutate Gel until your skin has healed from other treatments. • have other skin problems or sunburn in the treatment area. • are pregnant or plan to become pregnant. It is not known if Ingenol Mebutate Gel can harm your unborn baby. • are breastfeeding or plan to breastfeed. If you use Ingenol Mebutate Gel while breastfeeding, make sure that your treated skin does not come into contact with the infant. Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins and herbal supplements. How should I use Ingenol Mebutate Gel? • Use Ingenol Mebutate Gel exactly as your healthcare provider tells you. Ingenol Mebutate Gel is for skin use only. • Your healthcare provider will tell you where to apply Ingenol Mebutate Gel, and how often, and how long to apply it. Do not apply Ingenol Mebutate Gel to other areas. • Do not use more Ingenol Mebutate Gel than you need to cover the treatment area. Using too much Ingenol Mebutate Gel, or using it too often, or for too long can increase your chances for having a severe skin reaction or other side effects. • Do not get Ingenol Mebutate Gel in, around, or near your eyes. Do not touch your eyes while you are applying Ingenol Mebutate Gel. • Wash your hands well with soap and water after applying Ingenol Mebutate Gel. After applying Ingenol Mebutate Gel, be careful to keep Ingenol Mebutate Gel on the treated area from coming into contact with your eyes. Irritation may happen if you get Ingenol Mebutate Gel in your eyes. • If you accidentally get Ingenol Mebutate Gel in your eyes , flush them with large amounts of water and get medical care as soon as possible. Also see “What are the possible side effects of Ingenol Mebutate Gel?” • Do not get Ingenol Mebutate Gel in, around, or near your mouth or lips. • To help prevent accidental transfer of Ingenol Mebutate Gel to other areas of your body or to another person: • allow the treated area to dry for 15 minutes after you apply Ingenol Mebutate Gel. • avoid washing and touching the treated area, or doing activities that cause a lot of sweating, for 6 hours after treatment. After 6 hours, you may wash the area with a mild soap and water. • Only use a tube of Ingenol Mebutate Gel 1 time. Throw away any open tube of Ingenol Mebutate Gel after use even if there is medicine still left in it. • See the Instructions for Use that comes with your Ingenol Mebutate Gel for information about the right way to apply it. What are the possible side effects of Ingenol Mebutate Gel? Ingenol Mebutate Gel may cause serious or severe side effects including: • Eye problems can happen if Ingenol Mebutate Gel gets in your eyes. Eye problems may include severe eye pain, swelling or drooping of your eyelids, or swelling around your eyes. If you accidentally get Ingenol Mebutate Gel in your eyes, flush them with large amounts of water and get medical care as soon as possible. • Serious allergic reactions. Serious allergic reactions have happened with Ingenol Mebutate Gel, and in some cases have required treatment in a hospital. See “Who should not use Ingenol Mebutate Gel?” Get medical help right away if you get any of the following symptoms of a serious allergic reaction: • swelling of the lips or tongue • chest tightness • trouble breathing or wheezing • dizziness or passing out • Skin cancers. Actinic keratosis occurs on sun-damaged skin which is more prone to developing skin cancer. Some people treated with Ingenol Mebutate Gel were diagnosed with certain types of skin cancer within the treatment area after treatment completion. Tell your doctor if you notice any new skin changes in the treated area after completing treatment with Ingenol Mebutate Gel. • Local skin reactions. Skin reactions in the treatment area are common with Ingenol Mebutate Gel. You may get a skin reaction such as mild redness, flaking or scaling, crusting, or swelling. You may also see changes in your skin color (pigmentation changes) and scarring where Ingenol Mebutate Gel is applied. Call your healthcare provider if you get skin redness, flaking or scaling, crusting, or swelling that is more severe, or if you get blisters, pus, ulcers or breakdown of your skin. The most common side effects with Ingenol Mebutate Gel include: • local skin reactions, see “Local skin reactions” above • swelling around the eyes • pain, itching, or skin irritation at the treatment area • nose and throat irritation • infection at the treatment area • headache Tell your healthcare provider if you have any side effect that bothers you or that does not go away. These are not all the possible side effects of Ingenol Mebutate Gel. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. You may also report side effects to Perrigo at 1-866-634-9120. How should I store Ingenol Mebutate Gel? • Store Ingenol Mebutate Gel in a refrigerator at 36°F to 46°F (2°C to 8°C). Do not freeze. • Ingenol Mebutate Gel has an expiration date (exp) marked on the end of the tube. Do not use the gel after this date. • Safely throw away used Ingenol Mebutate Gel tubes in household trash. Keep Ingenol Mebutate Gel and all medicines out of the reach of children. General information about the safe and effective use of Ingenol Mebutate Gel. Medicines are sometimes prescribed for purposes other than those listed in a Patient Information leaflet. Do not use Ingenol Mebutate Gel for a condition for which it was not prescribed. Do not give Ingenol Mebutate Gel to other people, even if they have the same symptoms you have. It may harm them. You can ask your pharmacist or healthcare provider for information about Ingenol Mebutate Gel that is written for health professionals. What are the ingredients in Ingenol Mebutate Gel? Active ingredient: ingenol mebutate. Inactive ingredients: benzyl alcohol, citric acid monohydrate, hydroxyethyl cellulose, isopropyl alcohol, propylene glycol, purified water and sodium citrate. This Patient Information has been approved by the U.S. Food and Drug Administration. For more information call Perrigo at 1-866-634-9120. Made in Israel Manufactured By Perrigo, Yeruham, Israel Distributed By Perrigo, Allegan, MI 49010 www.perrigorx.com Rev 01-21 0J900 RC J3"],"spl_product_data_elements":["Ingenol Mebutate ingenol mebutate INGENOL MEBUTATE INGENOL MEBUTATE BENZYL ALCOHOL CITRIC ACID MONOHYDRATE HYDROXYETHYL CELLULOSE (2000 MPA.S AT 1%) HYDROXYETHYL CELLULOSE (4000 MPA.S AT 1%) ISOPROPYL ALCOHOL PROPYLENE GLYCOL WATER SODIUM CITRATE, UNSPECIFIED FORM"],"use_in_specific_populations":["8 USE IN SPECIFIC POPULATIONS 8.1 Pregnancy Risk Summary There are no available data on ingenol mebutate gel use in pregnant women to evaluate a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. Systemic concentrations following topical administration of ingenol mebutate gel were below the limit of quantification of 0.1 ng/mL, and maternal use is not expected to result in fetal exposure to the drug [ see Clinical Pharmacology (12.3) ]. In animal reproduction studies, ingenol mebutate did not cause malformations in pregnant rats and rabbits when given by the intravenous route of administration during the period of organogenesis (see Data) . The available data do not allow the calculation of relevant comparisons between the systemic exposure of ingenol mebutate observed in the animal studies to the systemic exposure that would be expected in humans after topical use of ingenol mebutate gel. The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have a background risk of major birth defects, loss, and other adverse outcomes. The background risk in the U.S. general population of major birth defects is 2 to 4% and of miscarriage is 15 to 20% of clinically recognized pregnancies. Data Animal Data Intravenous doses of 1.5, 3, and 5 μg/kg/day (9, 18, and 30 μg/m 2 /day, respectively) ingenol mebutate were administered during the period of organogenesis (gestational days 6 – 16) to pregnant female rats. No treatment-related effects on embryofetal development or malformations were noted at doses up to 5 μg/kg/day (30 μg/m 2 /day). Intravenous doses of 1, 2, and 4 μg/kg/day (12, 24, and 48 μg/m 2 /day, respectively) ingenol mebutate were administered during the period of organogenesis (gestational days 6 – 18) to pregnant female rabbits. Maternal toxicity (increased breathing rate) was observed at doses ≥ 1 μg/kg/day (12 μg/m 2 /day). An increase in embryo-fetal mortality was noted at 4 μg/kg/day (48 μg/m 2 /day). An increased incidence of fetal visceral and skeletal variations was noted in all three ingenol mebutate dose groups. 8.2 Lactation Risk Summary There are no data on the presence of ingenol mebutate in human or animal milk, the effects on the breastfed infant or the effects on milk production. Systemic concentrations following topical administration of ingenol mebutate gel were below the limit of quantification of 0.1 ng/mL, and breastfeeding is not expected to result in exposure of the child to ingenol mebutate gel [ see Clinical Pharmacology (12.3) ]. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for ingenol mebutate gel and any potential adverse effects on the breastfed infant from ingenol mebutate gel or from the underlying maternal condition. Clinical Considerations Advise breastfeeding women to avoid accidental transfer of ingenol mebutate gel to the nipple and areola area to prevent direct infant exposure. 8.4 Pediatric Use Actinic keratosis is not a condition generally seen within the pediatric population. The safety and effectiveness of ingenol mebutate gel for actinic keratosis in patients less than 18 years of age have not been established. 8.5 Geriatric Use Of the 1165 subjects treated with ingenol mebutate gel in the clinical trials, 56% were 65 years and older and, 21% were 75 years and older. No overall differences in safety or effectiveness were observed between these subjects and younger subjects."],"version":"5","warnings_and_cautions":["5 WARNINGS AND PRECAUTIONS Ophthalmic Adverse Reactions. Eye disorders, including severe eye pain, chemical conjunctivitis, corneal burn, eyelid edema, eyelid ptosis, periorbital edema can occur after exposure. Avoid accidental transfer of the drug into the eyes and to the periocular area. If accidental exposure occurs, flush eyes with water and seek medical care. ( 5.1 ) Non-Melanoma Skin Cancer. Cases of non-melanoma skin cancer have been reported after treatment with Ingenol Mebutate Gel. Monitor patients with risk factors for skin cancer. ( 5.3 ) Local Skin Reactions. Local skin reactions can occur including severe reactions (e.g., vesiculation/pustulation, erosion/ulceration). Administration of Ingenol Mebutate Gel is not recommended until skin is healed from any previous drug or surgical treatment. ( 5.4 ) 5.1 Ophthalmic Adverse Reactions Eye disorders, including severe eye pain, chemical conjunctivitis, corneal burn, eyelid edema, eyelid ptosis, periorbital edema can occur after exposure [ see Adverse Reactions (6) ]. To avoid transfer of the drug into the eyes and to the periocular area during and after application, patients should wash hands well after applying Ingenol Mebutate Gel. If accidental exposure occurs, the area should be flushed with water and the patient should seek medical care as soon as possible. 5.2 Hypersensitivity Reactions Hypersensitivity reactions, including anaphylaxis and allergic contact dermatitis, have been reported postmarketing. If anaphylactic or other clinically significant hypersensitivity reactions occur, discontinue Ingenol Mebutate Gel immediately and institute appropriate medical therapy. 5.3 Non-Melanoma Skin Cancer Non-melanoma skin cancers have been reported in patients treated with Ingenol Mebutate Gel. Cases of rapidly growing squamous cell carcinoma have been reported in the treatment area within a few weeks after treatment completion. Counsel patients on the potential risk and monitor closely those patients with risk factors for skin cancer. 5.4 Local Skin Reactions Severe skin reactions in the treated area, including erythema, crusting, swelling, vesiculation/postulation, and erosion/ulceration, can occur after topical application of Ingenol Mebutate Gel [ see Adverse Reactions (6) ]. Administration of Ingenol Mebutate Gel is not recommended until the skin is healed from any previous drug or surgical treatment."]}