Carisoprodol 350 MG Oral Tablet
Generic Name: CARISOPRODOL
Brand Name: Carisoprodol
- Substance Name(s):
7 CNS depressants (e.g., alcohol, benzodiazepines, opioids, tricyclic antidepressants) – additive sedative effects (5.1 and 7.1) See 17 for PATIENT COUSELING INFORMATION Revised: 01/2012 7.1 CNS Depressants The sedative effects of Carisoprodol Tablets and other CNS depressants (e.g., alcohol, benzodiazepines, opioids, tricyclic antidepressants) may be additive. Therefore, caution should be exercised with patients who take more than one of these CNS depressants simultaneously. Concomitant use of Carisoprodol Tablets and meprobamate, a metabolite of Carisoprodol Tablets, is not recommended [see WARNINGS AND PRECAUTIONS (5.1) ]. 7.2 CYP2C19 Inhibitors and Inducers Carisoprodol is metabolized in the liver by CYP2C19 to form meprobamate [see CLINICAL PHARMACOLOGY (12.3)]. Co-administration of CYP2C19 inhibitors, such as omeprazole or fluvoxamine, with Carisoprodol Tablets could result in increased exposure of carisoprodol and decreased exposure of meprobamate. Co-administration of CYP2C19 inducers, such as rifampin or St. John’s Wort, with Carisoprodol Tablets could result in decreased exposure of carisoprodol and increased exposure of meprobamate. Low dose aspirin also showed induction effect on CYP2C19. The full pharmacological impact of these potential alterations of exposures in terms of either efficacy or safety of Carisoprodol Tablets is unknown.
10 Overdosage of Carisoprodol Tablets commonly produces CNS depression. Death, coma, respiratory depression, hypotension, seizures, delirium, hallucinations, dystonic reactions, nystagmus, blurred vision, mydriasis, euphoria, muscular incoordination, rigidity, and/or headache have been reported with Carisoprodol Tablets overdosage. Many of the Carisoprodol Tablets overdoses have occurred in the setting of multiple drug overdoses (including drugs of abuse, illegal drugs, and alcohol). The effects of an overdose of Carisoprodol Tablets and other CNS depressants (e.g., alcohol, benzodiazepines, opioids, tricyclic antidepressants) can be additive even when one of the drugs has been taken in the recommended dosage. Fatal accidental and non-accidental overdoses of Carisoprodol Tablets have been reported alone or in combination with CNS depressants Treatment of Overdosage: Basic life support measures should be instituted as dictated by the clinical presentation of the Carisoprodol Tablets overdose. Induced emesis is not recommended due to the risk of CNS and respiratory depression, which may increase the risk of aspiration pneumonia. Gastric lavage should be considered soon after ingestion (within one hour). Circulatory support should be administered with volume infusion and vasopressor agents if needed. Seizures should be treated with intravenous benzodiazepines and the reoccurrence of seizures may be treated with phenobarbital. In cases of severe CNS depression, airway protective reflexes may be compromised and tracheal intubation should be considered for airway protection and respiratory support. The following types of treatment have been used successfully with an overdose of meprobamate, a metabolite of Carisoprodol Tablets: activated charcoal (oral or via nasogastric tube), forced diuresis, peritoneal dialysis, and hemodialysis (carisoprodol is also dialyzable). Careful monitoring of urinary output is necessary and overhydration should be avoided. Observe for possible relapse due to incomplete gastric emptying and delayed absorption. For more information on the management of an overdose of Carisoprodol Tablets, contact a Poison Control Center.
11 Carisoprodol Tablets are available as 350 mg round, white tablets. Carisoprodol is a white, crystalline powder, having a mild, characteristic odor and a bitter taste. It is slightly soluble in water; freely soluble in alcohol, in chloroform, and in acetone; and its solubility is practically independent of pH. Carisoprodol is present as a racemic mixture. Chemically, carisoprodol is N-isopropyl-2-methyl-2-propyl-1,3-propanediol dicarbamate and the molecular formula is C12H24N2O4, with a molecular weight of 260.33. The structural formula is: Other Ingredients: colloidal silicon dioxide, lactose monohydrate, magnesium stearate, microcrystalline cellulose, methylcellulose, povidone, sodium lauryl sulfate, sodium starch glycolate, and stearic acid. STRUCTURAL FORMULA
14 The safety and efficacy of Carisoprodol Tablets for the relief of acute, idiopathic mechanical low back pain was evaluated in two, 7-day, double blind, randomized, multicenter, placebo controlled, U.S. trials (Studies 1 and 2). Patients had to be 18 to 65 years old and had to have acute back pain (≤ 3 days of duration) to be included in the trials. Patients with chronic back pain; at increased risk for vertebral fracture (e.g., history of osteoporosis); with a history of spinal pathology (e.g., herniated nucleus pulposis, spondylolisthesis or spinal stenosis); with inflammatory back pain, or with evidence of a neurologic deficit were excluded from participation. Concomitant use of analgesics (e.g., acetaminophen, NSAIDs, tramadol, opioid agonists), other muscle relaxants, botulinum toxin, sedatives (e.g., barbiturates, benzodiazepines, promethazine hydrochloride), and anti-epileptic drugs was prohibited. In Study 1, patients were randomized to one of two treatment groups (i.e., Carisoprodol Tablets 350 mg, or placebo). In the study, patients received study medication three times a day and at bedtime for seven days. The primary endpoints were the relief from starting backache and the global impression of change, as reported by patients, on Study Day 3. Both endpoints were scored on a 5-point rating scale from 0 (worst outcome) to 4 (best outcome) in the study. The proportion of patients who used concomitant acetaminophen, NSAIDs, tramadol, opioid agonists, other muscle relaxants, and benzodiazepines was similar in the treatment groups. The results for the primary efficacy evaluations in the acute, low back pain studies are presented in Table 3. Table 3. Results of the Primary Efficacy Endpointsa in Study 1 Parameter Placebo Number of Patients n=269 Relief for Starting Backache, Mean (SE)b 1.4(0.1) Difference between Carisoprodol Tablets and Placebo, Mean (SE)b (95% CI) Global Impression of Change, Mean (SE)b 1.9 (0.1) Difference between Carisoprodol and Placebo, Mean (SE)b (95% CI) a The primary efficacy endpoints (Relief from Starting Backache and Global Impression of Change) were assessed by the patients on Study Day #3. These endpoints were scored on a 5-point rating scale from 0 (worst outcome) to 4 (best outcome). b Mean is the least squared mean and SE is the standard error of the mean. Patients treated with Carisoprodol Tablets experienced improvement in function as measured by the Roland-Morris Disability Questionnaire (RMDQ) score on Days 3 and 7.
16 Carisoprodol Tablets USP, 350 mg, are White, Round, Unscored Tablets imprinted “WW 176”, are available in: Bottles of 100 tablets Bottles of 500 tablets Bottles of 1000 tablets Storage: Store at 20-25oC (68-77oF) [See USP Controlled Room Temperature]. Dispense in a tight, light-resistant container as defined in the USP using a child-resistant closure.
RECENT MAJOR CHANGES
Warnings and Precautions, Sedation (5.1) 10/2009 Warnings and precautions, Drug Dependence, Withdrawal, and Abuse (5.2) 10/2009
8.5 Geriatric Use The efficacy, safety, and pharmacokinetics of Carisoprodol Tablets in patients over 65 years old have not been established.
DOSAGE FORMS AND STRENGTHS
3 Carisoprodol Tablets, USP 350 mg are White, Round, Unscored Tablets Imprinted “WW 176”. Tablets: 350 mg (3)
MECHANISM OF ACTION
12.1 Mechanism of Action The mechanism of action of carisoprodol in relieving discomfort associated with acute painful musculoskeletal conditions has not been clearly identified. In animal studies, muscle relaxation induced by carisoprodol is associated with altered interneuronal activity in the spinal cord and in the descending reticular formation of the brain.
INDICATIONS AND USAGE
1 Carisoprodol Tablets, USP are indicated for the relief of discomfort associated with acute, painful musculoskeletal conditions in adults. Carisoprodol Tablets should only be used for short periods (up to two or three weeks) because adequate evidence of effectiveness for more prolonged use has not been established and because acute, painful musculoskeletal conditions are generally of short duration. [see DOSAGE AND ADMINISTRATION (2)]. Carisoprodol Tablets, USP are indicated for the relief of discomfort associated with acute, painful musculoskeletal conditions. (1) Important Limitations: Should only be used for acute treatment periods up to two or three weeks (1) Not recommended in pediatric patients less than 16 years of age (8.4)
8.4 Pediatric Use The efficacy, safety, and pharmacokinetics of Carisoprodol Tablets in pediatric patients less than 16 years of age have not been established.
8.1 Pregnancy: Pregnancy Category C. There are no data on the use of Carisoprodol Tablets during human pregnancy. Animal studies indicate that carisoprodol crosses the placenta and results in adverse effects on fetal growth and postnatal survival. The primary metabolite of carisoprodol, meprobamate, is an approved anxiolytic. Retrospective, post-marketing studies do not show a consistent association between maternal use of meprobamate and an increased risk for particular congenital malformations. Teratogenic effects: Animal studies have not adequately evaluated the teratogenic effects of carisoprodol. There was no increase in the incidence of congenital malformations noted in reproductive studies in rats, rabbits, and mice treated with meprobamate. Retrospective, post-marketing studies of meprobamate during human pregnancy were equivocal for demonstrating an increased risk of congenital malformations following first trimester exposure. Across studies that indicated an increased risk, the types of malformations were inconsistent. Nonteratogenic effects: In animal studies, carisoprodol reduced fetal weights, postnatal weight gain, and postnatal survival at maternal doses equivalent to 1-1.5 times the human dose (based on a body surface area comparison). Rats exposed to meprobamate in-utero showed behavioral alterations that persisted into adulthood. For children exposed to meprobamate in-utero, one study found no adverse effects on mental or motor development or IQ scores. Carisoprodol Tablets should be used during pregnancy only if the potential benefit justifies the risk to the fetus.
8.3 Nursing Mothers Very limited data in humans show that Carisoprodol Tablets is present in breast milk and may reach concentrations two to four times the maternal plasma concentrations. In one case report, a breast-fed infant received about 4-6% of the maternal daily dose through breast milk and experienced no adverse effects. However, milk production was inadequate and the baby was supplemented with formula. In lactation studies in mice, female pup survival and pup weight at weaning were decreased. This information suggests that maternal use of Carisoprodol Tablets may lead to reduced or less effective infant feeding (due to sedation) and/or decreased milk production. Caution should be exercised when Carisoprodol Tablets are administered to a nursing woman.
WARNING AND CAUTIONS
5 WARNINGS AND PRECAUTIONS • Due to sedative properties, may impair ability to perform hazardous tasks such as driving or operating machinery (5.1) • Additive sedative effects when used with other CNS depressants including alcohol (5.1) • Cases of Drug Dependence, Withdrawal, and Abuse (5.2) • Seizures (5.3) 5.1 Sedation Carisoprodol Tablets have sedative properties (in the low back pain trials, 13% to 17% of patients who received Carisoprodol Tablets experienced sedation compared to 6% of patients who received placebo) [see ADVERSE REACTIONS (6.1) ] and may impair the mental and/or physical abilities required for the performance of potentially hazardous tasks such as driving a motor vehicle or operating machinery. There have been post-marketing reports of motor vehicle accidents associated with the use of Carisoprodol Tablets. Since the sedative effects of Carisoprodol Tablets and other CNS depressants (e.g., alcohol, benzodiazepines, opioids, tricyclic antidepressants) may be additive, appropriate caution should be exercised with patients who take more than one of these CNS depressants simultaneously. 5.2 Drug Dependence, Withdrawal, and Abuse In the postmarketing experience with Carisoprodol Tablets, cases of dependence, withdrawal, and abuse have been reported with prolonged use. Most cases of dependence, withdrawal, and abuse occurred in patients who have had a history of addiction or who used Carisoprodol Tablets in combination with other drugs with abuse potential. However, there have been post-marketing adverse event reports of Carisoprodol Tablets-associated abuse when used without other drugs with abuse potential. Withdrawal symptoms have been reported following abrupt cessation after prolonged use. To reduce the chance of Carisoprodol Tablets dependence, withdrawal, or abuse, Carisoprodol Tablets should be used with caution in addiction-prone patients and in patients taking other CNS depressants including alcohol, and Carisoprodol Tablets should not be used more than two to three weeks for the relief of acute musculoskeletal discomfort. Carisoprodol Tablets and one of its metabolites, meprobamate (a controlled substance), may cause dependence [see CLINICAL PHARMACOLOGY 12.3) ]. 5.3 Seizures There have been postmarketing reports of seizures in patients who received Carisoprodol Tablets. Most of these cases have occurred in the setting of multiple drug overdoses (including drugs of abuse, illegal drugs, and alcohol) [see OVERDOSAGE (10) ].
INFORMATION FOR PATIENTS
17 PATIENT COUNSELING INFORMATION Patients should be advised to contact their physician if they experience any adverse reactions to Carisoprodol Tablets. 17.1 Sedation Patients should be advised that Carisoprodol Tablets may cause drowsiness and/or dizziness, and has been associated with motor vehicle accidents. Patients should be advised to avoid taking Carisoprodol Tablets before engaging in potentially hazardous activities such as driving a motor vehicle or operating machinery [see WARNINGS AND PRECAUTIONS (5.1) ]. 17.2 Avoidance of Alcohol and Other CNS Depressants Patients should be advised to avoid alcoholic beverages while taking Carisoprodol Tabletsl and to check with their doctor before taking other CNS depressants such as benzodiazepines, opioids, tricyclic antidepressants, sedating antihistamines, or other sedatives [see WARNINGS AND PRECAUTIONS (5.1) ]. 17.3 Carisoprodol Tablets Should Only be Used for Short-Term Treatment Patients should be advised that treatment with Carisoprodol Tablets should be limited to acute use (up to two or three weeks) for the relief of acute, musculoskeletal discomfort. In the post-marketing experience with Carisoprodol Tablets, cases of dependence, withdrawal and abuse have been reported with prolonged use. If the musculoskeletal symptoms still persist, patients should contact their healthcare provider for further evaluation. To report SUSPECTED ADVERSE REACTIONS, contact West-ward Pharmaceutical Corp. at 1-877-233-2001, or FDA at 1-800-1088 or www.fda.gov/medwatch. Manufactured by: West-ward Pharmaceutical CorpEatontown, NJ 07724 Revised January 2012 Repacked by: H.J. Harkins Company, Inc. Grover Beach, CA 93433
DOSAGE AND ADMINISTRATION
2 The recommended dose of Carisoprodol Tablets is 350 mg three times a day and at bedtime. The recommended maximum duration of Carisoprodol Tablets use is up to two or three weeks. • Recommended dose is 350 mg three times a day and at bedtime (2)