Prescription Drugs

CLINICAL PHARMACOLOGY Mechanism Of Action Azelastine hydrochloride, a phthalazinone derivative, exhibits histamine H1-receptor antagonist activity in isolated tissues, animal models, and humans. Astelin Nasal Spray is administered as a racemic mixture with no difference in pharmacologic activity noted between the enantiomers in in vitro studies. The major metabolite, desmethylazelastine, also possesses H1-receptor antagonist activity. Pharmacodynamics Cardiac Electrophysiology In a placebo-controlled study (95 subjects with allergic rhinitis), there was no evidence of an effect of Astelin Nasal Spray (2 sprays per nostril twice daily for 56 days) on cardiac repolarization as represented by the corrected QT interval (QTc) of the electrocardiogram. Following multiple dose oral administration of azelastine 4 mg or 8 mg twice daily, the mean change in QTc was 7.2 msec and 3.6 msec, respectively. Interaction studies investigating the cardiac repolarization effects of concomitantly administered oral azelastine hydrochloride and erythromycin or ketoconazole were conducted. These drugs had no effect on QTc based on analysis of serial electrocardiograms. At a dose approximately 8 times the maximum recommended dose, azelastine hydrochloride does not prolong the QTc interval to any clinically relevant extent. Pharmacokinetics Absorption After intranasal administration, the systemic bioavailability of azelastine hydrochloride is approximately 40%. Maximum plasma concentrations (Cmax) are achieved in 23 hours. Azelastine hydrochloride administered intranasally at doses above two sprays per nostril twice daily for 29 days resulted in greater than proportional increases in Cmax and area under the curve (AUC) for azelastine. Distribution Based on intravenous and oral administration, the steady-state volume of distribution is 14.5 L/kg. In vitro studies with human plasma indicate that the plasma protein binding of azelastine and its metabolite, desmethylazelastine, are approximately 88% and 97%, respectively. Metabolism Azelastine is oxidatively metabolized to the principal active metabolite, desmethylazelastine, by the cytochrome P450 enzyme system. The specific P450 isoforms responsible for the biotransformation of azelastine have not been identified. After intranasal dosing of azelastine hydrochloride to steady-state, plasma concentrations of desmethylazelastine range from 20-50% of azelastine concentrations. Limited data indicate that the metabolite profile is similar when azelastine hydrochloride is administered via the intranasal or oral route. Elimination Based on intravenous and oral administration, the elimination half-life and plasma clearance are 22 hours and 0.5 L/h/kg, respectively. Approximately 75% of an oral dose of radiolabeled azelastine hydrochloride was excreted in the feces with less than 10% as unchanged azelastine. Special Populations Hepatic Impairment: Following oral administration, pharmacokinetic parameters were not influenced by hepatic impairment. Renal Impairment: Based on oral, single-dose studies, renal insufficiency (creatinine clearance < 50 mL/min) resulted in a 70-75% higher Cmax and AUC compared to normal subjects. Time to maximum concentration was unchanged. Age: Following oral administration, pharmacokinetic parameters were not influenced by age. Gender: Following oral administration, pharmacokinetic parameters were not influenced by gender. Race: The effect of race has not been evaluated. Drug-Drug Interactions Erythromycin: No significant pharmacokinetic interaction was observed with the coadministration of orally administered azelastine (4 mg twice daily) with erythromycin (500 mg three times daily for 7 days). In this study, co-administration of orally administered azelastine with erythromycin resulted in Cmax of 5.36 ± 2.6 ng/mL and AUC of 49.7 ± 24 ng•h/mL for azelastine, whereas, administration of azelastine alone resulted in Cmax of 5.57 ± 2.7 ng/mL and AUC of 48.4 ± 24 ng•h/mL for azelastine. Cimetidine and Ranitidine: In a multiple-dose, steady-state drug interaction trial in healthy subjects, cimetidine (400 mg twice daily) increased orally administered mean azelastine (4 mg twice daily) concentrations by approximately 65%. No pharmacokinetic interaction was observed with co-administration of orally administered azelastine (4 mg twice daily) with ranitidine hydrochloride (150 mg twice daily). Oral co-administration of azelastine with ranitidine resulted in Cmax of 8.89 ±3.28 ng/mL and AUC of 88.22 ± 40.43 ng•h/mL for azelastine, whereas, azelastine when administered alone resulted in Cmax of 7.83 ± 4.06 ng/mL and AUC of 80.09 ± 43.55 ng•h/mL for azelastine. Theophylline: No significant pharmacokinetic interaction was observed with the coadministration of an oral 4 mg dose of azelastine hydrochloride twice daily and theophylline 300 mg or 400 mg twice daily. Clinical Studies Seasonal Allergic Rhinitis Two Sprays Per Nostril Twice Daily The efficacy and safety of Astelin Nasal Spray were evaluated in three placebo-controlled clinical trials of Astelin Nasal Spray including 322 patients with seasonal allergic rhinitis who received two sprays per nostril twice a day for up to 4 weeks. These trials included 55 pediatric patients ages 12 to 16 years. Assessment of efficacy was based on the 12-hour reflective Total Symptom Complex (TSC) and Major Symptom Complex (MSC). The MSC was calculated as the average of individual symptoms of nose blows, sneezes, runny nose/sniffles, itchy nose, and watery eyes as assessed by patients on a 0-5 categorical scale. Astelin Nasal Spray two sprays per nostril twice daily demonstrated a greater decrease in the MSC than placebo (Table 3). Table 3: Mean Change from Baseline in Reflective MSC* in Adults and Adolescents ≥ 12 Years with Seasonal Allergic Rhinitis Treated with Astelin Nasal Spray Two Sprays Per Nostril Twice Daily Versus Placebo Treatment N Baseline LS Mean (SD) Change from Baseline (SD) Treatment Difference P-value Trial 1: 12 Hour AM and PM Reflective MSC Astelin Nasal Spray 63 11.48 (4.13) -3.05 (3.51) 1.98 < 0.01 Placebo Nasal Spray 60 10.84 (4.53) -1.07 (3.52) Trial 2: 12 Hour AM and PM Reflective MSC Astelin Nasal Spray 63 12.50 (4.5) -4.10 (3.46) 2.03 < 0.01 Placebo Nasal Spray 63 12.18 (4.64) -2.07 (4.01) Trial 3: 12 Hour AM and PM Reflective MSC Astelin Nasal Spray 66 12.04 (4.03) -3.31 (3.74) 1.35 0.04 66 11.66 (3.96) -1.96 (3.57) * Major Symptom Comlex (MSC): Average of individual symptoms of nose blows, sneezes, runny nose/sniffles, itchy nose, and watery eyes as assessed by patients on a 0-5 categorical scale. In dose-ranging trials, administration of Astelin Nasal Spray two sprays per nostril twice daily resulted in a statistically significant decrease in symptoms compared to saline placebo within 3 hours after initial dosing and persisted over the 12-hour dosing interval. One Spray Per Nostril Twice Daily The efficacy and safety of Astelin Nasal Spray were evaluated in two placebo-controlled clinical trials of Astelin Nasal Spray including 275 patients with seasonal allergic rhinitis who received one spray per nostril twice a day for up to 2 weeks. Assessment of efficacy was based on the 12hour reflective Total Nasal Symptom Score [rTNSS]. rTNSS is calculated as the sum of the patients scoring of four individual nasal symptoms (runny nose, sneezing, itchy nose, and nasal congestion) as assessed by patients on a 0-3 categorical scale. The primary efficacy endpoint was the change from Baseline to Day 14 in rTNSS. The mean change from baseline in rTNSS was greater in patients receiving Astelin Nasal Spray one spray per nostril twice daily than those receiving placebo (Table 4). Table 4: Mean Change from Baseline in Reflective TNSS* in Adults and Adolescents ≥ 12 years with Seasonal Allergic Rhinitis Treated with Astelin Nasal Spray One Spray Per Nostril Twice Daily Versus Placebo Treatment N Baseline LS Mean (SD) Change from Baseline (SD) Treatment Difference P-value Trial 4: 12 Hour AM and PM Reflective TNSS Astelin Nasal Spray 138 16.34 (4.22) -2.69 (4.79) 1.38 0.01 Placebo Nasal Spray 141 17.21 (4.32) -1.31 (4.29) Trial 5: 12 Hour AM and PM Reflective TNSS Astelin Nasal Spray 137 16.62 (4.20) -3.68 (4.16) 1.18 0.02 Placebo Nasal Spray 136 16.84 (4.77) -2.50 (4.01) * Total Nasal Symptom Score (TNSS): Average of individual symptoms of runny nose, sneezing, itchy nose, and nasal congestion as assessed by patients on a 0-3 categorical scale. Two-week studies comparing the efficacy (and safety) of Astelin Nasal Spray two sprays per nostril twice daily versus one spray per nostril twice daily were not conducted. Vasomotor Rhinitis The efficacy and safety of Astelin Nasal Spray were evaluated in two placebo-controlled clinical trials of Astelin Nasal Spray including 216 patients with vasomotor rhinitis who received two sprays per nostril twice a day for up to 4 weeks. These patients had vasomotor rhinitis for at least one year, negative skin tests to indoor and outdoor aeroallergens, negative nasal smears for eosinophils, and negative sinus X-rays. Astelin Nasal Spray demonstrated a significantly greater decrease in a symptom complex comprised of rhinorrhea, post nasal drip, nasal congestion, and sneezing compared to placebo.

ASTELIN (azelastine hydrochloride) Nasal Spray DESCRIPTION Astelin (azelastine hydrochloride) Nasal Spray, 137 micrograms (mcg), is an antihistamine formulated as a metered-spray solution for intranasal administration. Azelastine hydrochloride occurs as a white, almost odorless, crystalline powder with a bitter taste. It has a molecular weight of 418.37. It is sparingly soluble in water, methanol, and propylene glycol and slightly soluble in ethanol, octanol, and glycerine. It has a melting point of about 225°C and the pH of a saturated solution is between 5.0 and 5.4. Its chemical name is (±)-1-(2H)-phthalazinone,4-[(4chlorophenyl) methyl]-2-(hexahydro-1-methyl-1H-azepin-4-yl)-, monohydrochloride. Its molecular formula is C22H24ClN3O•HCl with the following chemical structure: Astelin Nasal Spray contains 0.1% azelastine hydrochloride in an aqueous solution at pH 6.8 ± 0.3. It also contains benzalkonium chloride (125 mcg/mL), edetate disodium, hypromellose, citric acid, dibasic sodium phosphate, sodium chloride, and purified water. After priming [see DOSAGE AND ADMINISTRATION], each metered spray delivers a 0.137 mL mean volume containing 137 mcg of azelastine hydrochloride (equivalent to 125 mcg of azelastine base). The bottle can deliver 200 metered sprays.

INDICATIONS Astelin Nasal Spray is indicated for the treatment of the symptoms of seasonal allergic rhinitis in adults and pediatric patients 5 years and older, and for the treatment of the symptoms of vasomotor rhinitis in adults and adolescent patients 12 years and older. DOSAGE AND ADMINISTRATION Seasonal Allergic Rhinitis The recommended dosage of Astelin Nasal Spray in adults and adolescent patients 12 years and older with seasonal allergic rhinitis is one or two sprays per nostril twice daily. The recommended dosage of Astelin Nasal Spray in pediatric patients 5 years to 11 years of age is one spray per nostril twice daily. Vasomotor Rhinitis The recommended dosage of Astelin Nasal Spray in adults and adolescent patients 12 years and older with vasomotor rhinitis is two sprays per nostril twice daily. Important Administration Instructions Administer Astelin Nasal Spray by the intranasal route only. Priming: Prime Astelin Nasal Spray before initial use by releasing 4 sprays or until a fine mist appears. When Astelin Nasal Spray has not been used for 3 or more days, reprime with 2 sprays or until a fine mist appears. Avoid spraying Astelin Nasal Spray into the eyes. HOW SUPPLIED Dosage Forms And Strengths Astelin Nasal Spray is a nasal spray solution. Each spray of Astelin Nasal Spray delivers a volume of 0.137 mL solution containing 137 mcg of azelastine hydrochloride. Storage And Handling Astelin (azelastine hydrochloride) Nasal Spray, 137 mcg is supplied as a 30-mL package (NDC 0037-0241-30) delivering 200 metered sprays in a high-density polyethylene (HDPE) bottle fitted with a metered-dose spray pump unit. The spray pump unit consists of a nasal spray pump fitted with a blue safety clip and a blue plastic dust cover. The net content of the bottle is 30 mL (net weight 30 gm of solution). Each bottle contains 30 mg (1 mg/mL) of azelastine hydrochloride. After priming [see DOSAGE AND ADMINISTRATION], each spray delivers a fine mist containing a mean volume of 0.137 mL solution containing 137 mcg of azelastine hydrochloride. The correct amount of medication in each spray cannot be assured before the initial priming and after 200 sprays have been used, even though the bottle is not completely empty. The bottle should be discarded after 200 sprays have been used. Astelin Nasal Spray should not be used after the expiration date “EXP” printed on the medicine label and carton. Storage Store at controlled room temperature 20° to 25°C (68° to 77°F). Protect from freezing. Manufactured by: MEDA Pharmaceuticals Somerset, NJ 08873-4120. Revised: 10/2014

PATIENT INFORMATION Astelin [AS-ta-LIN] (azelastine hydrochloride) Nasal Spray Important: For use in your nose only. What is Astelin Nasal Spray? Astelin Nasal Spray is a prescription medicine used to treat symptoms of seasonal allergic rhinitis in people age 5 and older and vasomotor rhinitis in people age 12 and older. Astelin Nasal Spray may help to reduce your nasal symptoms including stuffy nose, runny nose, itching and sneezing. It is not known if Astelin Nasal Spray is safe and effective in children with seasonal allergic rhinitis under 5 years of age or in children with vasomotor rhinitis under 12 years of age. What should I tell my healthcare provider before using Astelin Nasal Spray? Before using Astelin Nasal Spray, tell your healthcare provider if you are: allergic to any of the ingredients in Astelin Nasal Spray. See the end of this leaflet for a complete list of ingredients in Astelin Nasal Spray. pregnant, or plan to become pregnant. It is not known if Astelin Nasal Spray will harm your unborn baby. breastfeeding, or plan to breastfeed. It is not known if Astelin Nasal Spray passes into your breast milk. You and your healthcare provider should decide if you will use Astelin Nasal Spray if you plan to breastfeed. Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. Astelin Nasal Spray and other medicines may affect each other, causing side effects. How should I use Astelin Nasal Spray? Read the Instructions for Use at the end of this leaflet for information about the right way to use Astelin Nasal Spray. Spray Astelin Nasal Spray in your nose only. Do not spray it into your eyes or mouth. Use Astelin Nasal Spray exactly as your healthcare provider tells you to use it. Do not use more than your healthcare provider tells you. Throw away your Astelin Nasal Spray bottle after using 200 sprays. Even though the bottle may not be completely empty, you may not get the correct dose of medicine. If you use too much or a child accidentally swallows Astelin Nasal Spray, call your healthcare provider or go to the nearest hospital emergency room right away. What should I avoid while using Astelin Nasal Spray? Astelin Nasal Spray can cause sleepiness: Do not drive, operate machinery, or do other dangerous activities until you know how Astelin Nasal Spray affects you. Do not drink alcohol or take other medicines that may cause you to feel sleepy while using Astelin Nasal Spray. It may make your sleepiness worse. What are the possible side effects of Astelin Nasal Spray? The most common side effects of Astelin Nasal Spray include: unusual bitter taste headache sleepiness nose burning, pain or discomfort runny nose scratchy or sore throat nosebleeds inflamation or swelling of the sinuses sneezing nausea dry mouth fatigue dizziness weight increase Tell your healthcare provider if you have any side effect that bothers you or that does not go away. These are not all of the possible side effects of Astelin Nasal Spray. For more information, ask your healthcare provider or pharmacist. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1800-FDA-1088. How should I store Astelin Nasal Spray? Keep Astelin Nasal Spray upright at 68°F to 77°F (20°C to 25°C). Do not freeze Astelin Nasal Spray. Do not use Astelin Nasal Spray after the expiration date “EXP” on the medicine label and box. Keep Astelin Nasal Spray and all medicines out of reach of children. General information about the safe and effective use of Astelin Nasal Spray. Medicines are sometimes prescribed for conditions other than those listed in a Patient Information leaflet. Do not use Astelin Nasal Spray for a condition for which it was not prescribed. Do not give Astelin Nasal Spray to other people, even if they have the same symptoms that you have. It may harm them. This Patient Information leaflet summarizes the most important information about Astelin Nasal Spray. If you would like more information, talk with your healthcare provider. You can ask your pharmacist or healthcare provider for information about Astelin Nasal Spray that is written for health professionals. For more information call 1-866-210-5954. What are the ingredients in Astelin Nasal Spray? Active ingredient: azelastine hydrochloride Inactive ingredients: benzalkonium chloride, edetate disodium, hypromellose, citric acid, dibasic sodium phosphate, sodium chloride, and purified water. Instructions for Use Astelin [AS-ta-LIN] (azelastine hydrochloride) Nasal Spray Important: For use in your nose only. For the correct dose of medicine: Keep your head tilted downward when spraying into your nostril. Change nostrils each time you use the spray. Breathe gently and do not tip your head back after using the spray. This will keep the medicine from running down into your throat. You may get a bitter taste in your mouth. Figure A identifies the parts of your Astelin Nasal Spray pump Figure A Before you use Astelin Nasal Spray for the first time, you will need to prime the bottle. Priming your Astelin Nasal Spray Remove the blue dust cover over the tip of the pump and the blue safety clip just under the “shoulders” of the pump (See Figure B). Figure B Hold the bottle upright with 2 fingers on the shoulders of the spray pump unit and put your thumb on the bottom of the bottle. Press upward with your thumb and release for the pumping action. Repeat this until you see a fine mist (See Figure C). To get a fine mist you must pump the spray fast and use firm pressure against the bottom of the bottle. If you see a stream of liquid, the pump is not working correctly and you may have nasal discomfort. This should happen in 4 sprays or less. Now your pump is primed and ready to use. Figure C Do not use Astelin Nasal Spray unless you see a fine mist after you do the priming sprays. If you do not see a fine mist, clean the tip of the spray nozzle. See the “Cleaning the Spray Tip of your Astelin Nasal Spray” section below. If you do not use Astelin Nasal Spray for 3 or more days, you will need to prime the pump with 2 sprays or until you see a fine mist. Using your Astelin Nasal Spray Step 1. Blow your nose to clear your nostrils. Step 2. Keep your head tilted downward toward your toes. Step 3. Place the spray tip about ¼ inch to ½ inch into 1 nostril. Hold bottle upright and aim the spray tip toward the back of your nose (See Figure D). Figure D Step 4. Close your other nostril with a finger. Press the pump 1 time and sniff gently at the same time, keeping your head tilted forward and down (See Figure E). Figure E Step 5. Repeat Step 3 and Step 4 in your other nostril. Step 6. If your healthcare provider tells you to use 2 sprays in each nostril, repeat Steps 2 through 4 above for the second spray in each nostril. Step 7. Breathe in gently, and do not tilt your head back after using Astelin Nasal Spray. This will help to keep the medicine from going into your throat. Step 8. When you finish using your Astelin Nasal Spray, wipe the spray tip with a clean tissue or cloth. Put the safety clip and dust cover back on the bottle. Cleaning the Spray Tip of your Astelin Nasal Spray If the spray tip opening is clogged, do not use a pin or pointed object to unclog the tip. Unscrew the spray pump unit from the bottle by turning it to the left (counter-clockwise) (See Figure F). Soak only the spray pump unit in warm water. Squirt the spray unit several times while holding it under water. Use the pumping action to clear the opening in the tip (See Figure G). Figure F Figure G Let the spray pump unit air dry. Make sure it is dry before you put it back onto the bottle. Put the spray pump unit back into the open bottle and tighten it by turning clockwise (to the right). To keep the medicine from leaking out, use firm pressure when you put the pump back onto the bottle. After cleaning, follow the instructions for priming. This Patient Information and Instructions for Use has been approved by the U.S. Food and Drug Administration.

OVERDOSE There have been no reported overdosages with Astelin Nasal Spray. Acute overdosage by adults with this dosage form is unlikely to result in clinically significant adverse reactions, other than increased somnolence, since one bottle of Astelin Nasal Spray contains 30 mg of azelastine hydrochloride. Clinical trials in adults with single doses of the oral formulation of azelastine hydrochloride (up to 16 mg) have not resulted in increased incidence of serious adverse reactions. General supportive measures should be employed if overdosage occurs. There is no known antidote to Astelin Nasal Spray. Oral ingestion of antihistamines has the potential to cause serious adverse effects in young children. Accordingly, Astelin Nasal Spray should be kept out of the reach of children. CONTRAINDICATIONS None.

SIDE EFFECTS Use of Astelin Nasal Spray has been associated with somnolence [see WARNINGS AND PRECAUTIONS]. Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect rates observed in practice. Seasonal Allergic Rhinitis Astelin Nasal Spray Two Sprays Per Nostril Twice Daily Adverse experience information for Astelin Nasal Spray is derived from six placebo-and active-controlled, 2-day to 8-week clinical trials which included 391 patients, 12 years of age and older, with seasonal allergic rhinitis who received Astelin Nasal Spray at a dose of 2 sprays per nostril twice daily. In placebo-controlled efficacy trials, the incidence of discontinuation due to adverse reactions in patients receiving Astelin Nasal Spray and vehicle placebo was 2.2% and 2.8%, respectively. Table 1 contains adverse reactions that were reported with frequencies ≥ 2% in the Astelin Nasal Spray 2 sprays per nostril twice daily treatment group and more frequently than placebo. Table 1: Adverse Reactions Reported in ≥ 2% Incidence in Placebo-Controlled Trials in Patients with Seasonal Allergic Rhinitis [n (%)] Astelin Nasal Spray N = 391 Vehicle Placebo N = 353 Bitter Taste 77 (19.7%) 2 (0.6%) Headache 58 (14.8%) 45 (12.7%) Somnolence 45 (11.5%) 19 (5.4%) Nasal Burning 16 (4.1%) 6 (1.7%) Pharyngitis 15 (3.8%) 10 (2.8%) Paroxysmal Sneezing 12 (3.1%) 4 (1.1%) Dry Mouth 11 (2.8%) 6 (1.7%) Nausea 11 (2.8%) 4 (1.1%) Rhinitis 9 (2.3%) 5 (1.4%) Fatigue 9 (2.3%) 5 (1.4%) Dizziness 8 (2.0%) 5 (1.4%) Epistaxis 8 (2.0%) 5 (1.4%) Weight Increase 8 (2.0%) 0 (0.0%) Astelin Nasal Spray One Spray Per Nostril Twice Daily Adverse experience information for Astelin Nasal Spray at a dose of one spray per nostril twice daily is derived from two placebo-controlled 2-week clinical studies which included 276 patients 12 years of age and older with seasonal allergic rhinitis. The incidence of discontinuation due to adverse reactions in patients receiving Astelin Nasal Spray and vehicle placebo was 0.0% and 0.8%, respectively. Bitter taste was reported in 8.3% of patients compared to none in the placebo group. Somnolence was reported in 0.4% of patients compared to none in the placebo group. A total of 176 patients 5 to 11 years of age were exposed to Astelin Nasal Spray at a dose of 1 spray each nostril twice daily in 3 placebo-controlled studies. In these studies, adverse reactions that occurred more frequently in patients treated with Astelin Nasal Spray than with placebo, and that were not represented in the adult adverse reactions table above include rhinitis/cold symptoms (17.0% vs. 9.5%), cough (11.4% vs. 8.3%), conjunctivitis (5.1% vs. 1.8%), and asthma (4.5% vs. 4.1%). Adverse Reactions < 2% in Astelin Nasal Spray One or Two Sprays Per Nostril Twice Daily The following reactions were observed infrequently ( < 2% and exceeding placebo incidence) in patients who received Astelin Nasal Spray dosed at 1 or 2 sprays per nostril twice daily in U.S. clinical trials. Cardiovascular: flushing, hypertension, tachycardia. Dermatological: contact dermatitis, eczema, hair and follicle infection, furunculosis, skin laceration. Digestive: constipation, gastroenteritis, glossitis, ulcerative stomatitis, vomiting, increased SGPT, aphthous stomatitis, diarrhea, toothache. Metabolic and Nutritional: increased appetite. Musculoskeletal: myalgia, temporomandibular dislocation, rheumatoid arthritis. Neurological: hyperkinesia, hypoesthesia, vertigo. Psychological: anxiety, depersonalization, depression, nervousness, sleep disorder, thinking abnormal. Respiratory: bronchospasm, coughing, throat burning, laryngitis, bronchitis, dry throat, nocturnal dyspnea, nasopharyngitis, nasal congestion, pharyngolaryngeal pain, sinusitis, nasal dryness, paranasal sinus hypersecretion, post nasal drip. Special Senses: conjunctivitis, eye abnormality, eye pain, watery eyes, taste loss. Urogenital: albuminuria, amenorrhea, breast pain, hematuria, increased urinary frequency. Whole Body: allergic reaction, back pain, herpes simplex, viral infection, malaise, pain in extremities, abdominal pain, pyrexia. Vasomotor Rhinitis Adverse experience information for Astelin Nasal Spray is derived from two placebo-controlled clinical studies which included 216 patients 12 years and older with vasomotor rhinitis who received Astelin Nasal Spray at a dose of 2 sprays per nostril twice daily for up to 28 days. The incidence of discontinuation due to adverse reactions in patients receiving Astelin Nasal Spray and vehicle placebo was 2.8% and 2.9%, respectively. The following adverse reactions were reported with frequencies ≥ 2% in the Astelin Nasal Spray treatment group and more frequently than placebo. Table 2: Adverse Reactions Reported in ≥ 2% Incidence in Placebo-Controlled Trials in Patients with Vasomotor Rhinitis [n (%)] Astelin Nasal Spray N = 216 Vehicle Placebo N = 210 Bitter Taste 42 (19.4%) 5 (2.4%) Headache 17 (7.9%) 16 (7.6%) Dysesthesia 17 (7.9%) 7 (3.3%) Rhinitis 12 (5.6%) 5 (2.4%) Epistaxis 7 (3.2%) 5 (2.4%) Sinusitis 7 (3.2%) 4 (1.9%) Somnolence 7 (3.2%) 2 (1.0%) Reactions observed infrequently ( < 2% and exceeding placebo incidence) in patients who received Astelin Nasal Spray (2 sprays/nostril twice daily) in U.S. clinical trials in vasomotor rhinitis were similar to those observed in U.S. clinical trials in seasonal allergic rhinitis. In controlled trials involving nasal and oral azelastine hydrochloride formulations, there were infrequent occurrences of hepatic transaminase elevations. Postmarketing Experience During the post approval use of Astelin Nasal Spray, the following adverse reactions have been identified. 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. Adverse reactions reported include: anaphylaxis, application site irritation, atrial fibrillation, chest pain, confusion, dyspnea, facial edema, involuntary muscle contractions, nasal sores, palpitations, paresthesia, parosmia, pruritus, rash, disturbance or loss of sense of smell and/or taste, tolerance, urinary retention, vision abnormal and xerophthalmia. DRUG INTERACTIONS Central Nervous System Depressants Concurrent use of Astelin Nasal Spray with alcohol or other central nervous system depressants should be avoided because reductions in alertness and impairment of central nervous system performance may occur [see WARNINGS AND PRECAUTIONS].

WARNINGS Included as part of the PRECAUTIONS section. PRECAUTIONS Somnolence In Activities Requiring Mental Alertness In clinical trials, the occurrence of somnolence has been reported in some patients taking Astelin Nasal Spray [see ADVERSE REACTIONS]. Patients should be cautioned against engaging in hazardous occupations requiring complete mental alertness and motor coordination such as operating machinery or driving a motor vehicle after administration of Astelin Nasal Spray. Concurrent use of Astelin Nasal Spray with alcohol or other central nervous system depressants should be avoided because additional reductions in alertness and additional impairment of central nervous system performance may occur [see DRUG INTERACTIONS]. Patient Counseling Information See FDA-approved patient labeling (PATIENT INFORMATION and Instructions for Use). Activities Requiring Mental Alertness Somnolence has been reported in some patients taking Astelin Nasal Spray. Caution patients against engaging in hazardous occupations requiring complete mental alertness and motor coordination such as driving or operating machinery after administration of Astelin Nasal Spray [see WARNINGS AND PRECAUTIONS]. Concurrent Use of Alcohol and other Central Nervous System Depressants Instruct patients to avoid concurrent use of Astelin Nasal Spray with alcohol or other central nervous system depressants because additional reductions in alertness and additional impairment of central nervous system performance may occur [see WARNINGS AND PRECAUTIONS]. Common Adverse Reactions Inform patients that the treatment with Astelin Nasal Spray may lead to adverse reactions, which include bitter taste, headache, somnolence, dysesthesia, rhinitis, nasal burning, pharyngitis, epistaxis, sinusitis, paroxysmal sneezing, nausea, dry mouth, fatigue, dizziness, and weight increase [see ADVERSE REACTIONS]. Priming Instruct patients to prime the pump before initial use and when Astelin Nasal Spray has not been used for 3 or more days [see DOSAGE AND ADMINISTRATION]. Keep Spray Out of Eyes Instruct patients to avoid spraying Astelin Nasal Spray into their eyes. Keep Out of Children's Reach Instruct patients to keep Astelin Nasal Spray out of the reach of children. If a child accidentally ingests Astelin Nasal Spray, seek medical help or call a poison control center immediately. Nonclinical Toxicology Carcinogenesis, Mutagenesis, Impairment Of Fertility In 2-year carcinogenicity studies in rats and mice, azelastine hydrochloride did not show evidence of carcinogenicity at oral doses up to 30 mg/kg and 25 mg/kg, respectively. These doses were approximately 150 and 60 times the maximum recommended human daily intranasal dose [MRHDID] on a mg/m² basis. Azelastine hydrochloride showed no genotoxic effects in the Ames test, DNA repair test, mouse lymphoma forward mutation assay, mouse micronucleus test, or chromosomal aberration test in rat bone marrow. Reproduction and fertility studies in rats showed no effects on male or female fertility at oral doses up to 30 mg/kg (approximately 150 times the MRHDID in adults on a mg/m² basis). At 68.6 mg/kg (approximately 340 times the MRHDID on a mg/m² basis), the duration of estrous cycles was prolonged and copulatory activity and the number of pregnancies were decreased. The numbers of corpora lutea and implantations were decreased; however, pre-implantation loss was not increased. Use In Specific Populations Pregnancy Pregnancy Category C There are no adequate and well-controlled clinical studies in pregnant women. Azelastine hydrochloride has been shown to cause developmental toxicity in mice, rats, and rabbits. Astelin Nasal Spray should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Teratogenic Effects In mice, azelastine hydrochloride caused embryo-fetal death, malformations (cleft palate; short or absent tail; fused, absent or branched ribs), delayed ossification, and decreased fetal weight at approximately 170 times the maximum recommended human daily intranasal dose (MRHDID) in adults (on a mg/m² basis at a maternal oral dose of 68.6 mg/kg/day which also caused maternal toxicity as evidenced by decreased body weight). Neither fetal nor maternal effects occurred in mice at approximately 7 times the MRHDID in adults (on a mg/m² basis at a maternal oral dose of 3 mg/kg/day). In rats, azelastine hydrochloride caused malformations (oligo-and brachydactylia), delayed ossification and skeletal variations, in the absence of maternal toxicity, at approximately 150 times the MRHDID in adults (on a mg/m² basis at a maternal oral dose of 30 mg/kg/day). Azelastine hydrochloride caused embryo-fetal death and decreased fetal weight and severe maternal toxicity at approximately 340 times the MRHDID (on a mg/m² basis at a maternal oral dose of 68.6 mg/kg/day). Neither fetal nor maternal effects occurred at approximately 15 times the MRHDID (on a mg/m² basis at a maternal oral dose of 2 mg/kg/day). In rabbits, azelastine hydrochloride caused abortion, delayed ossification and decreased fetal weight and severe maternal toxicity at approximately 300 times the MRHDID in adults (on a mg/m² basis at a maternal oral dose of 30 mg/kg/day). Neither fetal nor maternal effects occurred at approximately 3 times the MRHDID (on a mg/m² basis at a maternal oral dose of 0.3 mg/kg/day). Nursing Mothers It is not known whether azelastine hydrochloride is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when Astelin Nasal Spray is administered to a nursing woman. Pediatric Use The safety and effectiveness of Astelin Nasal Spray for the treatment of symptoms of seasonal allergic rhinitis have been established for patients 5 years and older [see ADVERSE REACTIONS and Clinical Studies]. The safety and effectiveness of Astelin Nasal Spray for the treatment of vasomotor rhinitis have been established for patients 12 years and older [see ADVERSE REACTIONS and Clinical Studies]. The safety and effectiveness of Astelin Nasal Spray in pediatric patients below the age of 5 years with seasonal allergic rhinitis and in pediatric patients below the age of 12 years with vasomotor rhinitis have not been established. Geriatric Use Clinical trials of Astelin Nasal Spray did not include sufficient numbers of patients aged 65 and over to determine whether they respond differently from younger patients. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.