Methamphetamine Hydrochloride

1. INDICATIONS AND USAGE Methamphetamine hydrochloride tablets, USP is indicated for the treatment of Attention Deficit Hyperactivity Disorder (ADHD) in pediatric patients 6 years of age and older. Methamphetamine hydrochloride tablets, USP is a central nervous system (CNS) stimulant indicated for the treatment of Attention Deficit Hyperactivity Disorder (ADHD) in pediatric patients 6 years of age and older.

2. DOSAGE & ADMINISTRATION Administer methamphetamine hydrochloride tablets, USP orally once daily or in two divided doses daily. Avoid administration late in the evening due to the risk of insomnia. ( 2.2 ) Recommended starting dosage is 5 mg once or twice a daily. ( 2.3 ) Daily dosage may be increased in 5 mg increments at weekly intervals depending on clinical response. ( 2.3 ) The recommended dosage range is 20 mg to 25 mg daily. ( 2.3 ) 2.1 Pretreatment Screening Prior to treating patients with methamphetamine hydrochloride tablets, USP, assess: for the presence of cardiac disease (i.e., perform a careful history, family history of sudden death or ventricular arrhythmia, and physical examination) [see Warnings and Precautions ( 5.2 )]. the family history and clinically evaluate patients for motor or verbal tics or Tourette’s syndrome before initiating methamphetamine hydrochloride tablets, USP [see WARNINGS AND PRECAUTIONS ( 5.9 )]. 2.2 Important Dosing Information Administer methamphetamine hydrochloride tablets, USP orally once daily or in two divided doses daily. Avoid taking methamphetamine hydrochloride tablets, USP late in the evening due to the risk of insomnia. 2.3 Recommended Dosage For pediatric patients 6 years of age and older, the recommended starting dosage is 5 mg methamphetamine hydrochloride tablets, USP once or twice daily. The daily dosage may be increased in increments of 5 mg at weekly intervals based on clinical response of the patient. The recommended dosage range is 20 mg to 25 mg daily. 2.4 Dosage Modifications Due to Drug Interactions Agents that alter urinary pH can impact excretion and alter blood levels of amphetamine. Acidifying agents (e.g., ascorbic acid) decrease blood levels, while alkalinizing agents (e.g., sodium bicarbonate) increase blood levels. Adjust methamphetamine dosage based on clinical response [see Drug Interactions ( 7.1 )].

5. WARNINGS AND PRECAUTIONS Risks to Patients with Serious Cardiac Disease: Avoid use in patients with known structural cardiac abnormalities, cardiomyopathy, serious cardiac arrhythmias, coronary artery disease, or other serious cardiac disease. ( 5.2 ). Increased Blood Pressure and Heart Rate: Monitor blood pressure and pulse. ( 5.3 ) Psychiatric Adverse Reactions: Prior to initiating methamphetamine hydrochloride tablets, USP, screen patients for risk factors for developing a manic episode. If new psychotic or manic symptoms occur, consider discontinuing methamphetamine hydrochloride tablets, USP (5 .4 ) Long-Term Suppression of Growth in Pediatric Patients: Closely monitor growth (height and weight) in pediatric patients. Pediatric patients not growing or gaining height or weight as expected may need to have their treatment interrupted. ( 5.5 ) Peripheral Vasculopathy, including Raynaud’s Phenomenon: Careful observation for digital changes is necessary during methamphetamine treatment. Further clinical evaluation (e.g., rheumatology referral) may be appropriate for patients who develop signs or symptoms of peripheral vasculopathy. ( 5.6 ) Seizures: May lower the convulsive threshold. If a seizure occurs, discontinue methamphetamine hydrochloride tablets, USP. ( 5.7 ) Serotonin Syndrome: Increased risk when coadministered with serotonergic agents (e.g., SSRIs, SNRIs, triptans), but also during overdosage situations. If it occurs, discontinue methamphetamine hydrochloride tablets, USP and initiate supportive treatment. ( 5.8 ) Motor and Verbal Tics, and Worsening of Tourette’s Syndrome: Before initiating methamphetamine hydrochloride tablets, USP, assess the family history and clinically evaluate patients for tics or Tourette’s syndrome. Regularly monitor patients for the emergence or worsening of tics or Tourette’s syndrome. Discontinue treatment if clinically appropriate. ( 5.9 ) 5.1 Abuse, Misuse, and Addiction Methamphetamine has a high potential for abuse and misuse. The use of methamphetamine exposes individuals to the risks of abuse and misuse, which can lead to the development of a substance use disorder, including addiction. Methamphetamine can be diverted for non-medical use into illicit channels or distribution [see Drug Abuse and Dependence (9 .2, 9.3 )]. Misuse and abuse of CNS stimulants, including methamphetamine, can result in overdose and death [see Overdosage ( 10 )], and this risk is increased with higher doses or unapproved methods of administration, such as snorting or injection. Before prescribing methamphetamine, assess each patient’s risk for abuse, misuse, and addiction. Educate patients and their families about these risks and proper disposal of any unused drug. Advise patients to store methamphetamine in a safe place, preferably locked, and instruct patients to not give methamphetamine to anyone else. Throughout methamphetamine treatment, reassess each patient’s risk of abuse, misuse, and addiction and frequently monitor for signs and symptoms of abuse, misuse, and addiction. 5.2 Risks to Patients with Serious Cardiac Disease Sudden death has been reported in patients with structural cardiac abnormalities and other serious cardiac disease who were treated with CNS stimulants at recommended ADHD dosage. Avoid methamphetamine use in patients with known structural cardiac abnormalities, cardiomyopathy, serious heart arrhythmia, coronary artery disease, and other serious heart problems. 5.3 Increased Blood Pressure and Heart Rate CNS stimulants cause an increase in blood pressure (mean increase about 2 to 4 mm Hg) and heart rate (mean increase about 3 to 6 bpm). Some patients may have larger increases. Monitor all methamphetamine-treated patients for potential tachycardia and hypertension [see Adverse Reactions ( 6 )]. 5.4 Psychiatric Adverse Reactions Exacerbation of Pre-Existing Psychosis CNS stimulants may exacerbate symptoms of behavior disturbance and thought disorder in patients with a pre-existi…

4. CONTRAINDICATIONS Methamphetamine hydrochloride tablets, USP is contraindicated in patients with: known hypersensitivity to amphetamine, or other components of methamphetamine. Hypersensitivity reactions such as angioedema and anaphylactic reactions have been reported in patients treated with other amphetamine products [see Adverse Reactions ( 6 )]. taking monoamine oxidase inhibitors (MAOIs), or within 14 days following discontinuation of treatment with an MAOIs (including MAOIs such as linezolid or intravenous methylene blue), because of the risk of hypertensive crisis [see Drug Interactions ( 7.1 )]. Known hypersensitivity to amphetamine, or other components of methamphetamine hydrochloride tablets, USP. ( 4 ) Concomitant use of monoamine oxidase inhibitors (MAOIs), or use of an MAOI within the preceding 14 days. ( 4 )

7. DRUG INTERACTIONS Acidifying and Alkalinizing Agents: Agents that alter GI and urinary pH can alter blood levels of amphetamine. Acidifying agents can decrease amphetamine blood levels, while alkalinizing agents can increase amphetamine blood levels. ( 7.1 ) 7.1 Drugs Having Clinically Important Interactions with methamphetamine hydrochloride tablets, USP Table 1 presents clinically important drug interactions with methamphetamine hydrochloride tablets, USP . Table 1: Clinically Important Drug Interactions with methamphetamine hydrochloride tablets, USP Monoamine Oxidase Inhibitors (MAOI) Clinical Impact: MAOI antidepressants slow amphetamine metabolism, increasing amphetamines effect on the release of norepinephrine and other monoamines from adrenergic nerve endings causing headaches and other signs of hypertensive crisis. Toxic neurological effects and malignant hyperpyrexia can occur, sometimes with fatal results. Intervention: Concomitant use of methamphetamine hydrochloride tablets, USP with monoamine oxidase inhibitors (MAOIs) or within 14 days after discontinuing MAOI treatment is contraindicated [see Contraindications (4)]. Serotonergic Drugs Clinical Impact: The concomitant use of amphetamines, including methamphetamine hydrochloride tablets, USP , and serotonergic drugs increases the risk of serotonin syndrome. Intervention: Initiate methamphetamine hydrochloride tablets, USP with lower doses and monitor patients for signs and symptoms of serotonin syndrome, particularly during methamphetamine hydrochloride tablets, USP initiation or dosage increase. If serotonin syndrome occurs, discontinue methamphetamine hydrochloride tablets, USP and the concomitant serotonergic drug(s) [see Warnings and Precautions 5.8]. AlkalinizingAgents Clinical Impact: Alkalinizing agents may increase exposure to amphetamines and potentiate the action of amphetamine. Intervention Avoid co-administration of methamphetamine hydrochloride tablets, USP and gastrointestinal and urinary alkalinizing agents. Acidifying Agents Clinical Impact: Acidifying agents lower blood levels and efficacy of amphetamines. Intervention Increase dose of methamphetamine hydrochloride tablets, USP based on clinical response. Tricyclic Antidepressants Clinical Impact: May enhance the activity of tricyclic or sympathomimetic agents causing sustained increases in the concentration of d-amphetamine in the brain; cardiovascular effects can be potentiated. Intervention Monitor frequently and adjust methamphetamine hydrochloride tablets, USP dose or use alternative therapy based on clinical response. CYP2D6 Inhibitors Clinical Impact: Concomitant use of methamphetamine hydrochloride tablets, USP and CYP2D6 inhibitors may increase the exposure of methamphetamine hydrochloride tablets, USP compared to the use of the drug alone, and increase the risk of serotonin syndrome. Intervention Start with lower doses and monitor patients for signs and symptoms of serotonin syndrome particularly during methamphetamine hydrochloride tablets, USP initiation and after a dosage increase. If serotonin syndrome occurs, discontinue methamphetamine hydrochloride tablets, USP and the CYP2D6 inhibitor [see Warnings and Precautions 5.8]. Gastric pH Modulators Clinical Impact: Time to maximum concentration (Tmax) of amphetamine is decreased compared to when administered alone. Intervention Monitor patients for changes in clinical effect and use alternative therapy based on clinical response. Guanethidine Clinical Impact: Methamphetamine may decrease the hypotensive effect ofguanethidine. Intervention Monitor patients and adjust therapy based on clinicalresponse. Insulin requirements in diabetes mellitus may be altered in association with the use of methamphetamine and the concomitant dietary regimen. 7.2 Drug/Laboratory Test Interactions Amphetamines can cause a significant elevation in plasma corticosteroid levels. This increase is greatest in the evening. Amphetamines may interfere with urina…

6. ADVERSE REACTIONS The following adverse reactions are discussed in greater detail in other sections of the labeling: Abuse, Misuse, and Addiction[ see Boxed Warning, Warnings and Precautions ( 5.1 ), Drug Abuse and Dependence (9.2, 9.3)] Hypersensitivity to amphetamine products or other ingredients of methamphetamine [ see Contraindications ( 4 )] Hypertensive Crisis When Used Concomitantly with Monoamine Oxidase Inhibitors [see Contraindications ( 4 ), Drug Interactions (7.1)] Risks to Patient with Serious Cardiac Disease [see Warnings and Precautions ( 5.2 )] Increased Blood Pressure and Heart Rate [see Warnings and Precautions ( 5.3 )] Psychiatric Adverse Reactions [see Warnings and Precautions ( 5.4 )] Long-Term Suppression of Growth in Pediatric Patients [see Warnings and Precautions ( 5.5 )] Peripheral Vasculopathy, including Raynaud’s Phenomenon [see Warnings and Precautions ( 5.6 )] Seizures [ see Warnings and Precautions ( 5.7 )] Serotonin Syndrome [see Warnings and Precautions ( 5.8 )] Motor and Verbal Tics, and Worsening of Tourette’s Syndrome [see Warnings and Precautions ( 5.9 )] The following adverse reactions associated with the use of methamphetamine were identified in clinical trials or postmarketing reports. Because these reactions were 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 : Elevation of blood pressure, tachycardia and palpitation. Fatal cardiorespiratory arrest has been reported, mostly in the context of abuse/misuse Central Nervous System : Psychotic episodes reported at recommended doses. Dizziness, dysphoria, overstimulation, euphoria, insomnia, tremor, restlessness and headache. Exacerbation of motor and verbal tics and Tourette’s syndrome Gastrointestinal: Diarrhea, constipation, dryness of mouth, unpleasant taste, intestinal ischemia, and other gastrointestinal disturbances Hypersensitivity : Urticaria Endocrine : Impotence and changes in libido; frequent or prolonged erections Musculoskeletal: Rhabdomyolysis Metabolism and Nutrition Disorders : Suppression of growth has been reported with the long- term use of stimulants in pediatric patients S kin and Subcutaneous Tissue Disorders: Alopecia The following additional adverse reactions have been identified during post approval use of amphetamines: Allergic: Rash, hypersensitivity reactions, including angioedema and anaphylaxis. Serious skin rashes, including Stevens-Johnson syndrome and toxic epidermal necrolysis have been reported. Cardiovascular: Dyspnea, sudden death, myocardial infarction. There have been isolated reports of cardiomyopathy associated with chronic amphetamine use Central Nervous System : dyskinesia, fatigue, aggression, anger, logorrhea, dermatillomania, and paresthesia (including formication) Eye Disorders: Mydriasis Vascular Disorders: Raynaud’s phenomenon Common adverse reactions include: palpitation, dizziness, insomnia, tremor, headache, diarrhea, dryness of mouth. To report SUSPECTED ADVERSE REACTIONS, contact Dr. Reddy’s Laboratories at 1-888-375-3784 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch .