Trexall (methotrexate sodium 15 mg) Dailymed

• Instruct patients and caregivers to take the recommended dosage as directed, because medication errors have led to deaths. (2.1, 5.9)
• Verify pregnancy status in females of reproductive potential before starting TREXALL (4, 5.1).
• ALL: The recommended dosage is 20 mg/m² orally once weekly as a part of a combination chemotherapy maintenance regimen. (2.2)
• Mycosis fungoides: The recommended dosage is 25 mg to 75 mg orally once weekly as monotherapy; 10 mg/m² orally twice weekly as part of combination chemotherapy. (2.2)
• Relapsed or refractory non-Hodgkin lymphoma: The recommended dosage is 2.5 mg orally two to four times per week as part of metronomic combination chemotherapy. (2.2)
• Rheumatoid Arthritis: The recommended starting dosage is 7.5 mg orally once weekly; adjust dose to achieve an optimal response (2.3)
• pJIA: The recommended starting dosage is 10 mg/m² orally once weekly; adjust dose to achieve an optimal response (2.4)
• Psoriasis: The recommended dosage is 10 to 25 mg orally once weekly until adequate response is achieved. (2.5)

2.1 Important Dosage and SafetyInformation

Verify pregnancy status in females of reproductive potential before starting TREXALL [see Contraindications (4), Warnings and Precautions (5.1)].

Instruct patients and caregivers to take the recommended dosage as directed, because medication errors have led to deaths [see Warnings and Precautions (5.9)].

When switching the dosing regimen from oral administration to intravenous, intramuscular, or subcutaneous administration, an alternative dosing regimen may be necessary.

Do not administer to patients who are unable to swallow a tablet.

TREXALL is a cytotoxic drug. Follow applicable special handling and disposal procedures. ¹

2.2 Recommended Dosage for NeoplasticDiseases

Acute Lymphoblastic Leukemia

  The recommended starting dosage of TREXALL is 20 mg/m² orally once weekly, as part of a combination chemotherapy maintenance regimen. After initiating TREXALL, periodically monitor absolute neutrophil count (ANC) and platelet count and adjust the dose to maintain ANC at a desirable level and for excessive myelosuppression.

 Mycosis Fungoides

  The recommended dosage of TREXALL is 25 mg to 75 mg orally once weekly when administered as a single agent or 10 mg/m² orally twice weekly as part of a combination chemotherapy regimen.

  Relapsed or Refractory Non-Hodgkin Lymphomas

  The recommended dosage of methotrexate is 2.5 mg orally 2 to 4 times per week (maximum 10 mg per week) as part of a metronomic combination chemotherapy regimen.

2.3 Recommended Dosage for Rheumatoid Arthritis

The recommended starting dosage of TREXALL is 7.5 mg orally once weekly with escalation to achieve optimal response. Dosages of more than 20 mg once weekly result in an increased risk of serious adverse reactions, including myelosuppression. When responses are observed, the majority occurred between 3 and 6 weeks from initiation of treatment; however, responses have occurred up to 12 weeks after treatment initiation.

Administer folic acid or folinic acid to reduce the risk of TREXALL adverse reactions [see Warnings and Precautions (5.10)].

2.4Recommended Dosage for Polyarticular Juvenile Idiopathic Arthritis

The recommended starting dosage of TREXALL is 10 mg/m² orally once weekly with escalation to achieve optimal response. Dosages of more than 30 mg/m² once weekly result in an increased risk of serious adverse reactions, including myelosuppression. When responses are observed, the majority occurred between 3 and 6 weeks from initiation of treatment; however, responses have occurred up to 12 weeks after treatment initiation.

Administer folic acid or folinic acid to reduce the risk of TREXALL adverse reactions [see Warnings and Precautions (5.10)].

2.5Recommended Dosage for Psoriasis

The recommended dosage of TREXALL is 10 mg to 25 mg orally once weekly until an adequate response is achieved. Adjust the dose gradually to achieve optimal clinical response; do not exceed a dose of 30 mg per week. Once optimal clinical response has been achieved, reduce the dosage to the lowest possible dosing regimen.

 
Administer folic acid or folinic acid supplementation to reduce the risk of TREXALL adverse reactions [see Warnings and Precautions (5.10)].

2.6Dosage Modifications for Adverse Reactions

Discontinue TREXALL for:

• Anaphylaxis or other severe hypersensitivity reactions [see Warnings and Precautions (5.2)]
• Lymphoproliferative disease [see Warnings and Precautions (5.13)]

Withhold, dose reduce or discontinue TREXALL as appropriate for:

• Myelosuppression [see Warnings and Precautions (5.3)]

Withhold or discontinue TREXALL as appropriate for:

• Severe gastrointestinal toxicity [see Warnings and Precautions (5.4)]
• Hepatotoxicity [see Warnings and Precautions (5.5)]
• Pulmonary toxicity [see Warnings and Precautions (5.6)]
• Severe dermatologic reactions [see Warnings and Precautions (5.7)]
• Severe renal toxicity [see Warnings and Precautions (5.8)]
• Serious infections [see Warnings and Precautions (5.11)]
•  Neurotoxicity [see Warnings and Precautions (5.12)]

3 Dosage Forms And Strengths

Tablets: 5 mg:  Green, oval-shaped, film-coated, scored, biconvex tablet. Debossed with stylized b on one side and 927/5 on the other side.

7.5 mg:  Blue, oval-shaped, film-coated, scored, biconvex tablet. Debossed with stylized b on one side and 928/7½ on the other side.

10 mg:  Pink, oval-shaped, film-coated, scored, biconvex tablet. Debossed with stylized b on one side and 929/10 on the other side.

15 mg:  Purple, oval-shaped, film-coated, scored, biconvex tablet. Debossed with stylized b on one side and 945/15 on the other side. 


Tablets: 5 mg, 7.5 mg, 10 mg and 15 mg (3)

4 Contraindications

TREXALL is contraindicated in:

• Pregnant women receiving TREXALL for treatment of non-neoplastic diseases [see Warnings and Precautions (5.1), and Use in Specific Populations (8.1, 8.3)].
• Patients with a history of a severe hypersensitivity reactions, including anaphylaxis, to TREXALL [see Warnings and Precautions (5.2)].

• In pregnancy for non-neoplastic diseases (4)
• History of severe hypersensitivity to TREXALL (4)

5 Warnings And Precautions

• Serious Infections: Monitor patients for infection during and after treatment with TREXALL. Withhold or discontinue TREXALL for serious infections as appropriate. (5.11)
• Neurotoxicity: Monitor patients for neurotoxicity and withhold or discontinue TREXALL as appropriate. (5.12)
• Secondary Malignancies: Can occur with methotrexate. (5.13)
• Tumor Lysis Syndrome: Institute appropriate prophylactic measures in patients at risk for tumor lysis syndrome prior to initiation of TREXALL. (5.14)
• Immunizations and Risk Live Vaccines: Immunizations with live vaccines is not recommended. Follow current vaccination practice guidelines. (5.15)
• Infertility: Can cause impairment of fertility, oligospermia, and menstrual dysfunction. (5.16, 8.3)

5.1 Embryo-Fetal Toxicity

Based on published reports and its mechanism of action, methotrexate can cause fetal harm, including fetal death, when administered to a pregnant woman. Methotrexate is contraindicated for use in pregnant women receiving TREXALL for the treatment of non-malignant diseases. Advise pregnant women with neoplastic diseases of the potential risk to a fetus. Advise females of reproductive potential to use effective contraception during treatment with TREXALL and for 6 months after the final dose. Advise males with female partners of reproductive potential to use effective contraception during TREXALL treatment and for 3 months after the final dose [see Contraindications (4), Use in Specific Populations (8.1, 8.3)].

5.2 Hypersensitivity Reactions

Hypersensitivity reactions, including anaphylaxis, can occur with TREXALL [see Contraindications (4), Adverse Reactions (6.1)].

If anaphylaxis or other serious hypersensitivity reaction occurs, immediately and permanently discontinue TREXALL [see Dosage and Administration (2.6)].

5.3Myelosuppression

TREXALL suppresses hematopoiesis and can cause severe and life-threatening pancytopenia, anemia, leukopenia, neutropenia, and thrombocytopenia [see Adverse Reactions (6.1)].

Obtain blood counts at baseline, periodically during treatment, and as clinically indicated. Monitor patients for clinical complications of myelosuppression. Withhold, dose reduce, or discontinue methotrexate taking into account the importance of TREXALL treatment in the context of the severity of the disease being treated, the severity of the adverse drug reaction, and availability of alternative therapy [see Dosage and Administration (2.6)].

5.4Gastrointestinal Toxicity

Diarrhea, vomiting, nausea, and stomatitis occurred in up to 10% of patients receiving TREXALL for treatment of non-neoplastic diseases. Hemorrhagic enteritis and fatal intestinal perforation have been reported [see Adverse Reactions (6.1, 6.2)]. Patients with peptic ulcer disease or ulcerative colitis are at a greater risk of developing severe gastrointestinal adverse reactions [see Drug Interactions (7.1)].

Withhold or discontinue TREXALL for severe gastrointestinal toxicity taking into account the importance of TREXALL treatment in the context of the severity of the disease being treated, the severity of the adverse drug reaction, and availability of alternative therapy [see Dosage and Administration (2.6)].

5.5Hepatotoxicity

TREXALL can cause severe and potentially irreversible hepatotoxicity, including fibrosis, cirrhosis, and fatal liver failure [see Adverse Reactions (6.1)]. The safety of TREXALL in patients with hepatic disease is unknown.

The risk of hepatotoxicity is increased with heavy alcohol consumption. In patients with psoriasis, fibrosis or cirrhosis may occur in the absence of symptoms or abnormal liver tests; the risk of hepatotoxicity appears to increase with total cumulative dose and generally occurs after receipt of a total cumulative dose of 1.5 g or more.

Monitor liver tests at baseline, periodically during treatment and as clinically indicated. Withhold or discontinue TREXALL taking into account the importance of TREXALL treatment in the context of the severity of the disease being treated, the severity of the adverse drug reaction, and availability of alternative therapy [see Dosage and Administration (2.6)].

5.6 Pulmonary Toxicity

Pulmonary toxicity, including acute or chronic interstitial pneumonitis and irreversible or fatal cases, can occur with TREXALL [see Adverse Reactions (6.1, 6.2)].

Monitor patients for pulmonary toxicity and withhold or discontinue methotrexate taking into account the importance of TREXALL treatment in the context of the severity of the disease being treated, the severity of the adverse drug reaction, and availability of alternative therapy [see Dosage and Administration (2.6)].

5.7Dermatologic Reactions

Severe, including fatal dermatologic reactions, such as toxic epidermal necrolysis, Stevens- Johnson syndrome, exfoliative dermatitis, skin necrosis, and erythema multiforme, can occur with TREXALL [see Adverse Reactions (6.1, 6.2)].

Exposure to ultraviolet radiation while taking methotrexate may aggravate psoriasis.

TREXALL can cause radiation recall dermatitis and photodermatitis (sunburn) reactivation.

Monitor patients for dermatologic toxicity and withhold or permanently discontinue TREXALL for severe dermatologic reactions taking into account the importance of TREXALL treatment in the context of the severity of the disease being treated, the severity of the adverse drug reaction, and availability of alternative therapy [see Dosage and Administration (2.6)]. Advise patients to avoid excessive sun exposure and use sun protection measures.

5.8Renal Toxicity

TREXALL can cause renal toxicity, including irreversible acute renal failure [see Adverse Reactions (6.2)].

Monitor renal function at baseline, periodically during treatment and as clinically indicated. Withhold or discontinue TREXALL for severe renal toxicity taking into account the importance of TREXALL treatment in the context of the severity of the disease being treated, the severity of the adverse drug reaction, and availability of alternative therapy [see Dosage and Administration (2.6)].

Administer glucarpidase in patients with toxic plasma methotrexate concentrations (> 1 micromole per liter) and delayed TREXALL clearance due to impaired renal function. Refer to the glucarpidase prescribing information for additional information.

5.9Risk of Serious Adverse Reactions with Medication Error

Deaths occurred in patients as a result of medication errors. Most commonly, these errors occurred in patients who were taking TREXALL daily when a weekly dosing regimen was prescribed.

For patients prescribed a once weekly dosing regimen, instruct patients and caregivers to take the recommended dosage as directed, because medication errors have led to death.

5.10Folic Acid Supplementation

Neoplastic Diseases

Products containing folic acid or its derivatives may decrease the clinical effectiveness of methotrexate. Therefore, instruct patients not to take products containing folic acid or folinic acid unless directed to do so by their healthcare provider.

Non-neoplastic Diseases
Folate deficiency may increase TREXALL adverse reactions. Administer folic acid or folinic acid for patients with rheumatoid arthritis, pJIA, and psoriasis [see Dosage and Administration (2.3, 2.4, 2.5)].

5.11Serious Infections

Patients treated with TREXALL are at increased risk for developing life-threatening or fatal bacterial, fungal, or viral infections, including opportunistic infections such as Pneumocystis  jiroveci pneumonia, invasive fungal infections, hepatitis B reactivation, tuberculosis primary infection or reactivation, and disseminated Herpes zoster and cytomegalovirus infections [see Adverse Reactions (6.2)].

Monitor patients for infection during and after treatment with methotrexate. Withhold or discontinue methotrexate for serious infections taking into account the importance of methotrexate  treatment in the context of the severity of the disease being treated, the severity of the adverse drug reaction, and availability of alternative therapy [see Dosage and Administration (2.6)].

5.12 Neurotoxicity

TREXALL can cause severe acute and chronic neurotoxicity, which can be progressive, irreversible, and fatal [see Adverse Reactions (6.2)]. The risk of leukoencephalopathy is increased in patients who received prior cranial radiation.

Monitor patients for neurotoxicity and withhold or discontinue TREXALL taking into account the importance of methotrexate treatment in the context of the severity of the disease being treated, the severity of the adverse drug reaction, and availability of alternative therapy [see Dosage and Administration (2.6)].

5.13Secondary Malignancies

Secondary malignancies can occur with TREXALL [see Adverse Reactions (6.2)]. The risk of cutaneous malignancies is further increased when cyclosporine is administered to patients with psoriasis who received prior methotrexate.

In some cases, lymphoproliferative disease occurring during therapy with low-dose TREXALL regressed completely following withdrawal of methotrexate. If lymphoproliferative disease occurs, discontinue methotrexate [see Dosage and Administration (2.6)].

5.14 Tumor Lysis Syndrome

TREXALL can induce tumor lysis syndrome in patients with rapidly growing tumors. Institute appropriate prophylactic measures in patients at risk for tumor lysis syndrome prior to initiation of TREXALL.

5.15 Immunization and Risks Associated with Live Vaccines

Disseminated infections following administration of live vaccines have been reported. Immunization with live vaccines is not recommended during treatment. Follow current vaccination practice guidelines for administration of immunizations in patients receiving TREXALL.

Update immunizations according to immunization guidelines prior to initiating methotrexate. The interval between live vaccinations and initiation of methotrexate should be in accordance with current vaccination guidelines regarding immunosuppressive agents.

5.16 Infertility

Based on published reports, methotrexate can cause impairment of fertility, oligospermia, and menstrual dysfunction. It is not known if the infertility may be reversible. Discuss the risk of infertility with females and males of reproductive potential [see Use in Specific Populations (8.3)].

5.17Increased Risk of Adverse Reactions Due to Third-Space Accumulation

Methotrexate accumulates in third-spaces (e.g., pleural effusions or ascites), which results in prolonged elimination and increases the risk of adverse reactions. Evacuate significant third- space accumulations prior to methotrexate administration taking into account the importance of methotrexate  treatment in the context of the severity of the disease being treated, the severity of the adverse drug reaction, and availability of alternative therapy.

6 Adverse Reactions

The following clinically significant adverse reactions are described elsewhere in the labeling:

• Hypersensitivity Reactions [see Warnings and Precautions (5.2)]
• Myelosuppression [see Warnings and Precautions (5.3)]
• Gastrointestinal Toxicity [see Warnings and Precautions (5.4)]
• Hepatotoxicity [see Warnings and Precautions (5.5)]
• Pulmonary Toxicity [see Warnings and Precautions (5.6)]
• Dermatologic Reactions [see Warnings and Precautions (5.7)]
• Renal Toxicity [see Warnings and Precautions (5.8)]
• Serious Infections [see Warnings and Precautions (5.11)]
• Neurotoxicity [see Warnings and Precautions (5.12)]
• Secondary Malignancies [see Warnings and Precautions (5.13)]
• Tumor Lysis Syndrome [see Warnings and Precautions (5.14)]
•  Increased Risk of Adverse Reactions Due to Third-Space Accumulation [see Warnings and Precautions (5.17)]

Common adverse reactions include ulcerative stomatitis, leukopenia, nausea, abdominal distress. (6.1)

To report SUSPECTED ADVERSE REACTIONS, contact Teva Pharmaceuticals USA, Inc. at 1-888-838-2872 or FDA at 1-800-FDA-1088 www.fda.gov/medwatch.

6.1Clinical Trials Experience

Because clinical trials and other studies 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.

Common adverse reactions were: ulcerative stomatitis, leukopenia, nausea, and abdominal distress. Other clinically relevant adverse reactions were infection, malaise, fatigue, chills, fever, and dizziness.

Rheumatoid Arthritis

The most common adverse reactions of methotrexate that exceeded the rate of placebo in 12- to 18-week double-blind studies in patients (n=128) with rheumatoid arthritis are uled below.

Patients received methotrexate 7.5 mg to 15 mg orally once weekly. Most patients received concomitant nonsteroidal anti-inflammatory drugs (NSAIDs) and some also received corticosteroids. Hepatic histology was not examined in these short-term studies.

Incidence ≥10%:	Elevated liver tests 15%, nausea/vomiting 10%
Incidence 3% to <10%:	Stomatitis, thrombocytopenia (platelet count < 100,000/mm3)
Incidence 1% to <3%:	Rash/pruritus/dermatitis, diarrhea, alopecia, leukopenia (white blood cell count < 3000/mm3), pancytopenia, dizziness

Two other controlled trials of patients (n=680) with rheumatoid arthritis who received methotrexate 7.5 mg to 15 mg orally once weekly showed the following serious adverse reaction:

Incidence 1%:

Interstitial pneumonitis

Other less common adverse reactions were: anemia, headache, upper respiratory infection, anorexia, arthralgias, chest pain, coughing, dysuria, eye discomfort, epistaxis, fever, infection, sweating, tinnitus, vaginal discharge.

Polyarticular Juvenile Idiopathic Arthritis (pJIA)

The most common adverse reactions reported in patients 2 to 18 years of age with pJIA treated with methotrexate 5 mg/m² to 20 mg/m² orally once weekly or 0.1 to 0.65 mg/kg orally once weekly were as follows: elevated liver tests 14%; gastrointestinal reactions (e.g., nausea, vomiting, diarrhea) 11%; stomatitis 2%; leukopenia 2%; headache 1.2%; alopecia 0.5%; dizziness 0.2%; rash 0.2%. Most patients received concomitant NSAIDs and some also received corticosteroids.

Psoriasis

In two published series of adults with psoriasis (n=204, 248) who received methotrexate up to 25 mg per week for up to 4 years, adverse reaction rates were similar to those in patients with rheumatoid arthritis, except for alopecia, photosensitivity, and “burning of skin lesions” (3% to 10% each). Painful plaque erosions have been reported.

6.2Postmarketing Experience

The following adverse reactions have been identified during postapproval use of methotrexate. 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

Cardiovascular: Thromboembolic events (including arterial thrombosis, cerebral thrombosis, deep vein thrombosis, retinal vein thrombosis, thrombophlebitis, and pulmonary embolus), pericarditis, pericardial effusion, hypotension, sudden death

Endocrine: Diabetes

Eye: Optic neuropathy, blurred vision, ocular pain, conjunctivitis, xerophthalmia

Gastrointestinal: Hemorrhagic enteritis, intestinal perforation, gingivitis, pancreatitis, pharyngitis, hematemesis, melena, gastrointestinal ulceration

Hematology: Aplastic anemia, lymphadenopathy, hypogammaglobulinemia

Hepatobiliary: Acute hepatitis, decreased serum albumin, fibrosis, cirrhosis

Immune system: Anaphylaxis, anaphylactoid reactions, vasculitis

Metabolism: Hyperglycemia

Musculoskeletal: Stress fracture, soft tissue and bone necrosis, arthralgia, myalgia, osteoporosis

Nervous system: Headaches, drowsiness, blurred vision, speech impairment (including dysarthria and aphasia), transient cognitive dysfunction, mood alteration, unusual cranial sensations, paresis, encephalopathy, and convulsions.

Renal: Azotemia, hematuria, proteinuria, cystitis

Reproductive: Defective oogenesis or spermatogenesis, loss of libido, impotence, gynecomastia, menstrual dysfunction

Respiratory: Pulmonary fibrosis, respiratory failure, chronic interstitial obstructive pulmonary disease, pleuritic pain and thickening, alveolitis

Skin: Toxic epidermal necrolysis, Stevens-Johnson syndrome, exfoliative dermatitis, skin necrosis, and erythema multiforme, erythematous rashes, pruritus, alopecia, skin ulceration, accelerated nodulosis, urticaria, pigmentary changes, ecchymosis, telangiectasia, photosensitivity, acne, furunculosis

7 Drug Interactions

Refer to the full prescribing information for drug interactions with methotrexate. (7)

7.1 Effectsof Other Drugs on Methotrexate

Drugs that Increase Methotrexate Exposure

 Coadministration of methotrexate with the following products may increase methotrexate plasma concentrations, which may increase the risk of methotrexate severe adverse reactions. In some cases, the coadministration of methotrexate with these products may also subsequently reduce active metabolite formation, which may decrease the clinical effectiveness of methotrexate. Increased organ specific adverse reactions may also occur when methotrexate is coadministered with hepatotoxic or nephrotoxic products.

If coadministration cannot be avoided, monitor closely for methotrexate adverse reactions when coadministered with:

Oral antibiotics (including neomycin)	Antifolate drugs (e.g., dapsone, pemetrexed, pyrimethamine and sulfonamides)
Oral or intravenous penicillin or sulfonamide antibiotics	Aspirin and other nonsteroidal anti-inflammatory drugs
	Hepatotoxic products
Highly protein-bound drugs (e.g., oral	Proton pump inhibitors
anticoagulants, phenytoin, salicylates,	Weak acids (e.g., salicylates)
sulfonamides, sulfonylureas, and tetracyclines)	Nephrotoxic products
Probenecid

  Nitrous Oxide Coadministration of methotrexate with nitrous oxide anesthesia potentiates the effect of methotrexate on folate-dependent metabolic pathways, which may increase the risk of severe methotrexate adverse reactions. Avoid nitrous oxide anesthesia in patients receiving methotrexate. Consider alternative therapies in patients who have received prior nitrous oxide anesthesia.

Folic Acid Coadministration of methotrexate with folic acid or its derivatives decreases the clinical effectiveness of methotrexate in patients with neoplastic diseases. Methotrexate competes with reduced folates for active transport across cell membranes. Instruct patients to take folic or folinic acid only as directed by their healthcare provider [see Warnings and Precautions (5.10)].