Prescription Drugs

CLINICAL PHARMACOLOGY Mechanism of Action Corticosteroids inhibit the inflammatory response to a variety of inciting agents and probably delay or slow healing. They inhibit the edema, fibrin deposition, capillary dilation, leukocyte migration, capillary proliferation, fibroblast proliferation, deposition of collagen, and scar formation associated with inflammation. While glucocorticoids are known to bind to and activate the glucocorticod receptor, the molecular mechanisms involved in glucocorticoid/glucocorticoid receptor-dependent modulation of inflammation are not clearly established. However, corticosteroids are thought to inhibit prostaglandin production through several independent mechanisms. Pharmacokinetics The systemic exposure to loteprednol etabonate following ocular administration of LOTEMAX ointment has not been studied in humans. However, results from a bioavailability study with LOTEMAX suspension in normal volunteers established that plasma concentrations of loteprednol etabonate and Δ1 cortienic acid etabonate (PJ 91), its primary, inactive metabolite, were below the limit of quantitation (1 ng/mL) at all sampling times. The results were obtained following the ocular administration of one drop in each eye of 0.5% loteprednol etabonate suspension, 8 times daily for 2 days or 4 times daily for 42 days. The maximum systemic exposure to loteprednol following administration of the ointment product dosed four times daily is not expected to exceed exposures attained with LOTEMAX suspension dosed up to two drops four times daily. Clinical Studies In two independent, randomized, multicenter, double-masked, parallel-group, vehicle-controlled studies in 805 subjects meeting a protocol-specified threshold amount of anterior chamber inflammation, LOTEMAX ointment was more effective compared to its vehicle for complete resolution of post-operative anterior chamber cell, flare, and pain following cataract surgery. Primary endpoint was complete resolution of anterior chamber cells and flare (cell count of 0 and no flare) and no pain at post-operative day 8. The individual clinical trial results are provided below. In the 2 studies, Lotemax had statistically significant higher incidence of completely clearing of anterior chamber cells and flare at post-operative day 8 (24-32% vs. 1114%) and also had a statistically significant higher incidence of subjects that were pain free at post-operative day 8 (73-78% vs. 4145%).

LOTEMAX (loteprednol etabonate) Ophthalmic Ointment DESCRIPTION LOTEMAX (loteprednol etabonate ophthalmic ointment) 0.5% is a sterile, topical corticosteroid for ophthalmic use. Loteprednol etabonate is a white to off-white powder. Loteprednol etabonate is represented by the following structural formula: Chemical Name: chloromethyl 17α-[(ethoxycarbonyl)oxy]11β-hydroxy-3-oxoandrosta-1,4-diene-17βcarboxylate Each gram contains ACTIVE: Loteprednol Etabonate 5 mg (0.5%); INACTIVES: Mineral Oil and White Petrolatum.

INDICATIONS LOTEMAX® ointment is a corticosteroid indicated for the treatment of post-operative inflammation and pain following ocular surgery. DOSAGE AND ADMINISTRATION Apply a small amount (approximately ½ inch ribbon) into the conjunctival sac(s) four times daily beginning 24 hours after surgery and continuing throughout the first 2 weeks of the post-operative period. HOW SUPPLIED Dosage Forms And Strengths LOTEMAX is supplied sterile in a 3.5 gram tube filled with loteprednol etabonate ophthalmic ointment, 0.5%. Storage And Handling LOTEMAX (loteprednol etabonate ophthalmic ointment), 0.5% is a sterile ointment supplied in a tin tube with a pink polypropylene cap in the following size: 3.5 gram (NDC 24208-443-35) Do not use if tamper evident skirt is visible on bottom of cap. Storage Store between 15°–25°C (59°– 77°F). Manufactured by: Bausch & Lomb Incorporated Tampa, Florida 33637. Revised: 04/2011

PATIENT INFORMATION Risk of Contamination Patients should be advised not to touch the eyelid or surrounding areas with the tip of the tube. The cap should remain on the tube when not in use. Patients should be advised to wash hands prior to using LOTEMAX ointment. Do not use if tamper evident skirt is visible on bottom of cap. Contact Lens Wear Patients should also be advised not to wear contact lenses during their course of therapy. Risk of Secondary Infection If pain, redness, itching or inflammation becomes aggravated, the patient should be advised to consult a physician.

OVERDOSE No information provided. CONTRAINDICATIONS LOTEMAX ointment, as with other ophthalmic corticosteroids, is contraindicated in most viral diseases of the cornea and conjunctiva including epithelial herpes simplex keratitis (dendritic keratitis), vaccinia, and varicella, and also in mycobacterial infection of the eye and fungal diseases of ocular structures.

SIDE EFFECTS Adverse reactions associated with ophthalmic steroids include elevated intraocular pressure, which may be associated with optic nerve damage, visual acuity and field defects, posterior subcapsular cataract formation, secondary ocular infection from pathogens including herpes simplex, and perforation of the globe where there is thinning of the cornea or sclera. The most common ocular adverse event reported at approximately 25% in subjects in clinical studies with Lotemax ointment was anterior chamber inflammation. Other common adverse events, with an incidence of 4-5%, were conjunctival hyperemia, corneal edema, and eye pain. Many of these events may have been the consequence of the surgical procedure. The only non-ocular adverse event occurring at ≥ 1% was headache (1.5%). DRUG INTERACTIONS No information provided.

WARNINGS Included as part of the PRECAUTIONS section. PRECAUTIONS Intraocular pressure (IOP) increase Prolonged use of corticosteroids may result in glaucoma with damage to the optic nerve, defects in visual acuity and fields of vision. If this product is used for 10 days or longer, IOP should be monitored even though it may be difficult in children and uncooperative patients. Cataracts Use of corticosteroids may result in posterior subcapsular cataract formation. Delayed healing The use of steroids after cataract surgery may delay healing and increase the incidence of bleb formation. In those diseases causing thinning of the cornea or sclera, perforations have been known to occur with the use of topical steroids. The initial prescription and renewal of the medication order beyond 14 days should be made by a physician only after examination of the patient with the aid of magnification such as slit lamp biomicroscopy and, where appropriate, fluorescein staining. Bacterial infections Prolonged use of corticosteroids may suppress the host response and thus increase the hazard of secondary ocular infections. In acute purulent conditions, steroids may mask infection or enhance existing infection. If signs and symptoms fail to improve after 2 days, the patient should be re-evaluated. Viral infections Employment of a corticosteroid medication in the treatment of patients with a history of herpes simplex requires great caution. Use of ocular steroids may prolong the course and may exacerbate the severity of many viral infections of the eye (including herpes simplex). Fungal infections Fungal infections of the cornea are particularly prone to develop coincidentally with long-term local steroid application. Fungus invasion must be considered in any persistent corneal ulceration where a steroid has been used or is in use. Fungal culture should be taken when appropriate. Contact Lens Wear Patients should not wear contact lenses during their course of therapy with LOTEMAX ointment. Amblyopia LOTEMAX (loteprednol etabonate ophthalmic ointment), 0.5% should not be used in children following ocular surgery. Its use may interfere with amblyopia treatment by hindering the child's ability to see out of the operated eye (see Pediatric Use). Topical ophthalmic use only Lotemax is not indicated for intraocular administration. Nonclinical Toxicology Carcinogenesis, Mutagenesis, Impairment Of Fertility Long-term animal studies have not been conducted to evaluate the carcinogenic potential of loteprednol etabonate. Loteprednol etabonate was not genotoxic in vitro in the Ames test, the mouse lymphoma tk assay, or in a chromosome aberration test in human lymphocytes, or in vivo in the single dose mouse micronucleus assay. Treatment of male and female rats with up to 50 mg/kg/day and 25 mg/kg/day of loteprednol etabonate, respectively, (2500 and 1250 times the maximum daily clinical dose, respectively) prior to and during mating did not impair fertility in either gender. Use In Specific Populations Pregnancy Teratogenic effects - Pregnancy Category C Loteprednol etabonate has been shown to be embryotoxic (delayed ossification) and teratogenic (increased incidence of meningocele, abnormal left common carotid artery, and limb flexures) when administered orally to rabbits during organogenesis at a dose of 3 mg/kg/day (150 times the maximum daily clinical dose), a dose which caused no maternal toxicity. The noobserved-effect-level (NOEL) for these effects was 0.5 mg/kg/day (25 times the maximum daily clinical dose). Oral treatment of rats during organogenesis resulted in teratogenicity (absent innominate artery at ≥ 5 mg/kg/day doses, and cleft palate and umbilical hernia at ≥ 50 mg/kg/day) and embryotoxicity (increased post-implantation losses at 100 mg/kg/day and decreased fetal body weight and skeletal ossification with ≥ 50 mg/kg/day). Treatment of rats with 0.5 mg/kg/day (25 times the maximum daily clinical dose) during organogenesis did not result in any reproductive toxicity. Loteprednol etabonate was maternally toxic (significantly reduced body weight gain during treatment) when administered to pregnant rats during organogenesis at doses of ≥ 5 mg/kg/day. Oral exposure of female rats to 50 mg/kg/day of loteprednol etabonate from the start of the fetal period through the end of lactation, a maternally toxic treatment regimen (significantly decreased body weight gain), gave rise to decreased growth and survival, and retarded development in the offspring during lactation; the NOEL for these effects was 5 mg/kg/day. Loteprednol etabonate had no effect on the duration of gestation or parturition when administered orally to pregnant rats at doses up to 50 mg/kg/day during the fetal period. LOTEMAX should be used during pregnancy only if the potential benefit justifies the potential risk to the embryo or fetus. Nursing Mothers It is not known whether topical ophthalmic administration of corticosteroids could result in sufficient systemic absorption to produce detectable quantities in human milk. Systemically administered steroids appear in human milk and could suppress growth, interfere with endogenous corticosteroid production, or cause other untoward effects. Caution should be exercised when LOTEMAX ointment is administered to a nursing woman. Pediatric Use Safety and effectiveness in pediatric patients have not been established. LOTEMAX (loteprednol etabonate ophthalmic ointment) 0.5% should not be used in children following ocular surgery. Its use may interfere with amblyopia treatment by hindering the child's ability to see out of the operated eye. Geriatric Use No overall differences in safety and effectiveness have been observed between elderly and younger patients.