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warnings and cautions
5 WARNINGS AND PRECAUTIONS Severe Optic Atrophy in Patients with Leber's Disease : Patients with early Leber's disease who were treated with vitamin B12 suffered severe and swift optic atrophy. Cyanocobalamin Nasal Spray is not recommended for use in these patients ( 5.1 ) Anaphylactic Reactions : Anaphylactic shock and death have been reported after parenteral vitamin B12 administration. If patients are to start Cyanocobalamin Nasal Spray before having tolerated cyanocobalamin parenterally, consider administering an intradermal test dose of parenteral vitamin B12 to patients suspected of cyanocobalamin hypersensitivity. ( 2.1 , 5.2 ) Masking of Folate Deficiency with Vitamin B12 Use : Doses of vitamin B12 exceeding 10 mcg daily may produce hematologic response in patients with folate deficient megaloblastic anemia and may therefore mask a previously unrecognized folate deficiency. Assess both vitamin B12 and folate levels prior to initiating therapy with Cyanocobalamin Nasal Spray or with folic acid. ( 5.3 ) Hypokalemia and Thrombocytosis Due to Intense Treatment of Megaloblastic Anemia : Hypokalemia and sudden death may occur in severe megaloblastic anemia that is treated intensely with vitamin B12. Monitor serum potassium levels and platelet count during therapy. ( 5.4 ) Unmasking of Polycythemia Vera : Vitamin B12 deficiency may suppress the signs of polycythemia vera. Treatment with Cyanocobalamin Nasal Spray may unmask this condition. Patients exhibiting clinical or hematologic response consistent with polycythemia vera should be referred for further evaluation. ( 5.5 ) 5.1 Severe Optic Atrophy in Patients with Leber’s Disease Patients with early Leber's disease (hereditary optic nerve atrophy) who were treated with vitamin B12 suffered severe and swift optic atrophy. Cyanocobalamin products, including Cyanocobalamin Nasal Spray, is not recommended for use in patients with Leber's optic atrophy. For patients with Leber's disease requiring vitamin B12, consider alternative therapy (e.g., hydroxocobalamin) for B12 supplementation. 5.2 Anaphylactic Reactions Anaphylactic shock and death have been reported after parenteral vitamin B12 administration. If patients are to start Cyanocobalamin Nasal Spray before having tolerated cyanocobalamin parenterally, consider administering an intradermal test dose of parenteral vitamin B12 to patients suspected of cyanocobalamin hypersensitivity [ see Dosage and Administration (2.1) ] . 5.3 Masking of Folate Deficiency with Vitamin B12 Use Doses of vitamin B12 exceeding 10 mcg daily may produce hematologic response in patients with folate deficient megaloblastic anemia and may therefore mask a previously unrecognized folate deficiency. Vitamin B12 is not a substitute for folic acid [ see Dosage and Administration (2.4) ] . Assess both vitamin B12 and folate levels prior to initiating therapy with vitamin B12, including Cyanocobalamin Nasal Spray, or with folic acid [ see Dosage and Administration (2.1) ] . 5.4 Hypokalemia and Thrombocytosis Due to Intense Treatment of Megaloblastic Anemia Hypokalemia and sudden death may occur in severe megaloblastic anemia that is treated intensely with vitamin B12. Hypokalemia and thrombocytosis can occur upon conversion of severe megaloblastic anemia to normal erythropoiesis with vitamin B12 therapy. Therefore, serum potassium levels and platelet count should be monitored carefully during therapy [ see Dosage and Administration (2.3) ] . 5.5 Unmasking of Polycythemia Vera Vitamin B12 deficiency may suppress the signs of polycythemia vera. Treatment with vitamin B12 may unmask this condition. Patients exhibiting clinical or hematologic response consistent with polycythemia vera should be referred for further evaluation.
6 ADVERSE REACTIONS The following serious adverse reactions are described elsewhere in the labeling: Severe Optic Atrophy in Patients with Leber's Disease [ see Warnings and Precautions (5.1) ]. Anaphylactic Reactions [ see Warnings and Precautions (5.2) ]. Hypokalemia and Thrombocytosis Due to Intense Treatment of Megaloblastic Anemia [ see Warnings and Precautions (5.4) ]. The most common adverse reactions (≥ 4%) were infection, headache, glossitis, paresthesia, asthenia, nausea and rhinitis ( 6.1 ) To report SUSPECTED ADVERSE REACTIONS, contact Lupin Pharmaceuticals, Inc., at 1-866-403-7592 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. The adverse reactions described in Table 1 below are based on data from an eight week cross over trial in which vitamin B12 deficient patients in hematologic remission received one vitamin B12 intramuscular injection (N=25) and then received once weekly intranasal administration of another nasal cyanocobalamin formulation (N=24) for 4 weeks. Table 1. Adverse Reactions Following Intranasal or Intramuscular Administration of Cyanocobalamin In Vitamin B12 Deficient Patients in Hematologic Remission Adverse Reaction Number of Patients (%) Another Cyanocobalamin Nasal Formulation, 500 mcg (n=24) Intramuscular Cyanocobalamin*, 100 mcg (n=25) Infectiona 3 (13) 3 (12) Headache 1 (4) 5 (20) Asthenia 1 (4) 4 (16) Nausea 1 (4) 1 (4) Glossitis 1 (4) 0 (0) Paresthesia 1 (4) 1 (4) Rhinitis 1 (4) 2 (8) a Sore throat, common cold * The data are not an adequate basis for comparison of rates between the study drug and the active control
adverse reactions table
<table ID="ID341" width="492"><caption> Table 1. Adverse Reactions Following Intranasal or Intramuscular Administration of Cyanocobalamin In Vitamin B12 Deficient Patients in Hematologic Remission </caption><col width="174"/><col width="144"/><col width="174"/><tbody><tr><td rowspan="2" valign="top" styleCode="Lrule Toprule Botrule Rrule" align="left"> Adverse Reaction </td><td colspan="2" valign="top" styleCode=" Toprule Botrule Rrule" align="left"> Number of Patients (%) </td></tr><tr><td valign="top" styleCode=" Botrule Rrule" align="center"> Another Cyanocobalamin Nasal Formulation, 500 mcg (n=24) </td><td valign="top" styleCode=" Botrule Rrule" align="center"> Intramuscular Cyanocobalamin*, 100 mcg (n=25) </td></tr><tr><td valign="top" styleCode="Lrule Botrule Rrule" align="left"> Infectiona </td><td valign="top" styleCode=" Botrule Rrule" align="center"> 3 (13) </td><td valign="top" styleCode=" Botrule Rrule" align="left"> 3 (12) </td></tr><tr><td valign="top" styleCode=" Lrule Botrule Rrule" align="left"> Headache </td><td valign="top" styleCode=" Botrule Rrule" align="center"> 1 (4) </td><td valign="top" styleCode=" Botrule Rrule" align="left"> 5 (20) </td></tr><tr><td valign="top" styleCode="Lrule Botrule Rrule" align="left"> Asthenia </td><td valign="top" styleCode=" Botrule Rrule" align="center"> 1 (4) </td><td valign="top" styleCode=" Botrule Rrule" align="left"> 4 (16) </td></tr><tr><td valign="top" styleCode="Lrule Botrule Rrule" align="left"> Nausea </td><td valign="top" styleCode=" Botrule Rrule" align="center"> 1 (4) </td><td valign="top" styleCode=" Botrule Rrule" align="left"> 1 (4) </td></tr><tr><td valign="top" styleCode=" Lrule Botrule Rrule" align="left"> Glossitis </td><td valign="top" styleCode=" Botrule Rrule" align="center"> 1 (4) </td><td valign="top" styleCode=" Botrule Rrule" align="left"> 0 (0) </td></tr><tr><td valign="top" styleCode=" Lrule Botrule Rrule" align="left"> Paresthesia </td><td valign="top" styleCode=" Botrule Rrule" align="center"> 1 (4) </td><td valign="top" styleCode=" Botrule Rrule" align="left"> 1 (4) </td></tr><tr><td valign="top" styleCode="Lrule Botrule Rrule" align="left"> Rhinitis </td><td valign="top" styleCode=" Botrule Rrule" align="center"> 1 (4) </td><td valign="top" styleCode=" Botrule Rrule" align="left"> 2 (8) </td></tr><tr><td colspan="3" valign="top" align="left"> a Sore throat, common cold * The data are not an adequate basis for comparison of rates between the study drug and the active control </td></tr></tbody></table>