Data from FDA (Food and Drug Administration, USA) - Curated by Marshall Pearce - Last updated 06 November 2017

Indication(s)

1. INDICATIONS AND USAGE PROBUPHINE is indicated for the maintenance treatment of opioid dependence in patients who have achieved and sustained prolonged clinical stability on low-to-moderate doses of a transmucosal buprenorphine-containing product (i.e., doses of no more than 8 mg per day of Subutex or Suboxone sublingual tablet or generic equivalent). PROBUPHINE should be used as part of a complete treatment program to include counseling and psychosocial support. PROBUPHINE is not appropriate for new entrants to treatment and patients who have not achieved and sustained prolonged clinical stability, while being maintained on buprenorphine 8 mg per day or less of a Subutex or Suboxone sublingual tablet equivalent or generic equivalent. PROBUPHINE contains buprenorphine, a partial opioid agonist. PROBUPHINE is indicated for the maintenance treatment of opioid dependence in patients who have achieved and sustained prolonged clinical stability on low-to-moderate doses of a transmucosal buprenorphine- containing product (i.e., doses of no more than 8 mg per day of Subutex or Suboxone sublingual tablet or generic equivalent). PROBUPHINE should be used as part of a complete treatment program to include counseling and psychosocial support. PROBUPHINE is not appropriate for new entrants to treatment and patients who have not achieved and sustained prolonged clinical stability, while being maintained on buprenorphine 8 mg per day or less of a Subutex or Suboxone sublingual tablet or generic equivalent.

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Advisory information

contraindications
4. CONTRAINDICATIONS PROBUPHINE is contraindicated in patients with a history of hypersensitivity to buprenorphine or any other ingredients in PROBUPHINE (e.g., EVA). [see Warnings and Precautions (5.10)]. Hypersensitivity to buprenorphine or any other ingredients in PROBUPHINE (e.g., EVA). (4)
Adverse reactions
6. ADVERSE REACTIONS The following adverse reactions are discussed in more detail in other sections of the labeling: Serious Complications from Insertion and Removal of PROBUPHINE [see Warnings and Precautions (5.1)] Addiction, Abuse, and Misuse [see Warnings and Precautions (5.3)] Respiratory and CNS Depression [see Warnings and Precautions (5.4)] Neonatal Opioid Withdrawal Syndrome [see Warnings and Precautions (5.5)] Adrenal Insufficiency [see Warnings and Precautions (5.6)] Opioid Withdrawal [see Warnings and Precautions (5.8. 5.11)] Hepatitis, Hepatic Events [see Warnings and Precautions (5.9)] Hypersensitivity Reactions [see Warnings and Precautions (5.10)] Orthostatic Hypotension [see Warnings and Precautions (5.15)] Elevation of Cerebrospinal Fluid Pressure [see Warnings and Precautions (5.16)] Elevation of Intracholedochal Pressure [see Warnings and Precautions (5.17)] Infection [see Warnings and Precautions (5.19)] Adverse events commonly associated with PROBUPHINE administration (>10% of subjects) were implant-site pain, pruritus, and erythema, as well as non-implant-site related events (2:5%) of headache, depression, constipation, nausea, vomiting, back pain, toothache, and oropharyngeal pain (6) To report SUSPECTED ADVERSE REACTIONS, contact Braeburn at 1-844- 859-6341 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch 6.1. Clinical Trials Experience Because clinical trials 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. The safety of PROBUPHINE is supported by clinical trials using PROBUPHINE, and other trials using buprenorphine tablets and buprenorphine sublingual solutions. The safety of PROBUPHINE was evaluated in 349 opioid-dependent subjects across three double-blind trials (n = 309) and two open-label extension studies (n = 40). In these studies, there were a total of 258 subjects exposed to PROBUPHINE for at least 24 weeks and 82 subjects exposed for 48 weeks. The safety of the PROBUPHINE insertion and removal procedures has been evaluated in 568 unique subjects across the entire development program who received PROBUPHINE implants or placebo implants, with 507 subjects across the three double-blind trials, 40 subjects from two open- label extension trials, and 21 subjects from two phase 2 pharmacokinetic studies. In total, safety data from clinical studies are available from over 3000 opioid-dependent subjects exposed to buprenorphine at doses in the range used in the treatment of opioid dependence. Table 1 shows the non-implant-site related adverse events for PROBUPHINE and comparator groups in the three 6-month, double-blind, PROBUPHINE Phase 3 studies. Patients in the PROBUPHINE arm were treated with 4–5 implants and may have received supplemental sublingual buprenorphine. Patients in the Placebo/SL BPN comparator group had either regularly-dosed or as- needed sublingual buprenorphine; some had placebo implants. Adverse events were categorized using the Medical Dictionary for Regulatory Activities (MedDRA, Version 17). In Table 1, MedDRA High Level Group Terms (HLGT) reported in at least 5% of patients in the PROBUPHINE group and more commonly than in the comparator group, are listed at the Higher Level Group Term (HLGT) level along with subordinate Preferred Terms (PT) reported in 2: 1% of PROBUPHINE patients (and at least 0.5% more frequent than comparator). Events involving the implant site, or insertion or removal procedures or complications are not included in the table below, but are shown in Table 2. Table 1: Adverse events (≥ 5% in the PROBUPHINE arm and more than in Placebo/SL BPN) by HLGT and treatment group for phase 3 controlled trials System Organ Class High Level Group Term MedDRA Preferred Term PROBUPHINE (N=309) n (%) A subject reporting more than one adverse event for a particular MedDRA Higher Level Group Term or Preferred Term is counted only once for that MedDRA Higher Level Group Term or Preferred Term. Percentages are rounded to the nearest whole number, and to the nearest decimal when < 0.5%. Placebo/ SL BPN'SL BPN' =Denotes subjects assigned to Daily Sublingual Buprenorphine Arm in PRO-806 and PRO-814 studies. All subjects in all studies took SL BPN before study treatment period was initiated and had the option of taking SL BPN as supplemental medication during treatment. (N=317) n (%) GASTROINTESTINAL DISORDERS GASTROINTESTINAL SIGNS AND SYMPTOMS 42 (14) 39 (12) Nausea 20 (6) 15 (5) Vomiting 17 (6) 11 (3) Abdominal pain upper 10 (3) 7 (2) Flatulence 2 (1) 1 (0.3) GASTROINTESTINAL MOTILITY AND DEFAECATION CONDITIONS 27 (9) 23 (7) Constipation 20 (6) 9 (3) DENTAL AND GINGIVAL CONDITIONS 16 (5) 12 (4) Toothache 14 (5) 10 (3) GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS GENERAL SYSTEM DISORDERS NEC 38 (12) 26 (8) Pain 12 (4) 9 (3) Fatigue 9 (3) 4 (1) Asthenia 5 (2) 1 (0.3) Chest pain 2 (1) 0 Local swelling 2 (1) 0 BODY TEMPERATURE CONDITIONS 14 (5) 6 (2) Pyrexia 8 (3) 4 (1) Chills 5 (2) 2 (1) Feeling cold 2 (1) 0 INJURY, POISONING AND PROCEDURAL COMPLICATIONS INJURIES NEC 25 (8) 23 (7) Laceration 8 (3) 4 (1) Excoriation 6 (2) 2 (1) Scratch 2 (1) 0 MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS NEC 26 (8) 23 (7) Back pain 18 (6) 15 (5) Pain in extremity 8 (3) 3 (1) NERVOUS SYSTEM DISORDERS HEADACHES 42 (14) 35 (11) Headache 39 (13) 32 (10) Migraine 5 (2) 3 (1) NEUROLOGICAL DISORDERS NEC 25 (8) 16 (5) Dizziness 11 (4) 7 (2) Somnolence 9 (3) 1 (0.3) Sedation 3 (1) 0 Paresthesia 2 (1) 0 PSYCHIATRIC DISORDERS DEPRESSED MOOD DISORDERS AND DISTURBANCES 20 (6) 13 (4) Depression 20 (6) 10 (3) RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS RESPIRATORY DISORDERS NEC 31 (10) 19 (6) Oropharyngeal pain 14 (5) 10 (3) Cough 10 (3) 4 (1) Dyspnoea 3 (1) 1 (0.3) SKIN AND SUBCUTANEOUS TISSUE DISORDERS EPIDERMAL AND DERMAL CONDITIONS 16 (5) 6 (2) Rash 5 (2) 2 (1) Skin lesion 2 (1) 0 The following implant site-related adverse events were reported to occur by at least 2% of patients who received either PROBUPHINE or placebo implants in the pooled double-blind, PROBUPHINE Phase 3 studies: Table 2: Implant site adverse events reported by ≥ 2% of subjects in the Phase 3 Controlled Trials MedDRA Preferred Term PROBUPHINE N=309 n (%) Placebo implant N=198 n (%) Total N=507 n (%) Any Implant Site TEAE 115 (37) 54 (27) 169 (33) Individual Implant Site AE Implant site pain 39 (13) 18 (9) 57 (11) Implant site pruritus 38 (12) 15 (8) 53 (11) Implant site erythema 32 (10) 13 (7) 45 (9) Implant site hematoma 20 (7) 15 (8) 35 (7) Implant site hemorrhage 23 (7) 10 (5) 33 (7) Implant site edema 16 (5) 5 (3) 21 (4) The adverse event profile of buprenorphine in a transmucosal form (i.e., sublingual) was also characterized in the dose-controlled study of buprenorphine solution, over a range of doses in four months of treatment. The table below shows adverse events reported by at least 5% of subjects in any dose group in the dose-controlled study. Table 3: Adverse events reported by at least 5% of subjects in any dose group in the dose- controlled study Body System/Adverse Event (COSTART Terminology) Buprenorphine DoseSublingual solution. Doses in this table cannot necessarily be delivered in tablet form, but for comparison purposes: "Very low" dose (1 mg solution) would be less than a tablet dose of 2 mg "Low" dose (4mg solution) approximates a 6 mg tablet dose "Moderate" dose (8mg solution) approximates a 12 mg tablet dose "High" dose (16 mg solution) approximates a 24 mg tablet dose Very Low (N=184) Low (N=180) Moderate (N=186) High (N=181) Total (N=731) N (%) N (%) N (%) N (%) N (%) Body as a Whole Abscess 9 (5%) 2 (1%) 3 (2%) 2 (1%) 16 (2%) Asthenia 26 (14%) 28 (16%) 26 (14%) 24 (13%) 104 (14%) Chills 11 (6%) 12 (7%) 9 (5%) 10 (6%) 42 (6%) Fever 7 (4%) 2 (1%) 2 (1%) 10 (6%) 21 (3%) Flu Syndrome 4 (2%) 13 (7%) 19 (10%) 8 (4%) 44 (6%) Headache 51 (28%) 62 (34%) 54 (29%) 53 (29%) 220 (30%) Infection 32 (17%) 39 (22%) 38 (20%) 40 (22%) 149 (20%) Injury Accidental 5 (3%) 10 (6%) 5 (3%) 5 (3%) 25 (3%) Pain 47 (26%) 37 (21%) 49 (26%) 44 (24%) 177 (24%) Pain Back 18 (10%) 29 (16%) 28 (15%) 27 (15%) 102 (14%) Withdrawal Syndrome 45 (24%) 40 (22%) 41 (22%) 36 (20%) 162 (22%) Digestive System Constipation 10 (5%) 23 (13%) 23 (12%) 26 (14%) 82 (11%) Diarrhea 19 (10%) 8 (4%) 9 (5%) 4 (2%) 40 (5%) Dyspepsia 6 (3%) 10 (6%) 4 (2%) 4 (2%) 24 (3%) Nausea 12 (7%) 22 (12%) 23 (12%) 18 (10%) 75 (10%) Vomiting 8 (4%) 6 (3%) 10 (5%) 14 (8%) 38 (5%) Nervous System Anxiety 22 (12%) 24 (13%) 20 (11%) 25 (14%) 91 (12%) Depression 24 (13%) 16 (9%) 25 (13%) 18 (10%) 83 (11%) Dizziness 4 (2%) 9 (5%) 7 (4%) 11 (6%) 31 (4%) Insomnia 42 (23%) 50 (28%) 43 (23%) 51 (28%) 186 (25%) Nervousness 12 (7%) 11 (6%) 10 (5%) 13 (7%) 46 (6%) Somnolence 5 (3%) 13 (7%) 9 (5%) 11 (6%) 38 (5%) Respiratory System Cough Increase 5 (3%) 11 (6%) 6 (3%) 4 (2%) 26 (4%) Pharyngitis 6 (3%) 7 (4%) 6 (3%) 9 (5%) 28 (4%) Rhinitis 27 (15%) 16 (9%) 15 (8%) 21 (12%) 79 (11%) Skin And Appendages Sweat 23 (13%) 21 (12%) 20 (11%) 23 (13%) 87 (12%) Special Senses Runny Eyes 13 (7%) 9 (5%) 6 (3%) 6 (3%) 34 (5%) 6.2. Postmarketing Experience No post-marketing data exist at this time for PROBUPHINE. The most frequently reported post- marketing adverse event observed with buprenorphine sublingual tablets was drug misuse or abuse. The most frequently reported post-marketing adverse event with buprenorphine/naloxone sublingual tablets was peripheral edema. Serotonin syndrome: Cases of serotonin syndrome, a potentially life-threatening condition, have been reported during concomitant use of opioids with serotonergic drugs. Adrenal insufficiency: Cases of adrenal insufficiency have been reported with opioid use, more often following greater than one month of use. Anaphylaxis: Anaphylaxis has been reported with ingredients contained in PROBUPHINE. Androgen deficiency: Cases of androgen deficiency have occurred with chronic use of opioids [see Clinical Pharmacology (12.2)].

Usage information

Dosing and administration
2. DOSAGE AND ADMINISTRATION Prescription use of this product is limited under the Drug Addiction Treatment Act. (2.1) Four PROBUPHINE implants are inserted subdermally in the upper arm for 6 months of treatment and are removed by the end of the sixth month. (2.2) PROBUPHINE implants should not be used for additional treatment cycles after one insertion in each upper arm. (2.2) PROBUPHINE implants must be inserted and removed by trained Healthcare Providers only. (2.3) PROBUPHINE implants should be administered in patients who have achieved and sustained prolonged clinical stability on transmucosal buprenorphine. (2.4) Examine the insertion site one week following insertion of PROBUPHINE implants for signs of infection or other problems. (2.5) 2.1. Drug Addiction Treatment Act Under the Drug Addiction Treatment Act (DATA) codified at 21 United States Code (U.S.C.) 823(g), use of this product in the treatment of opioid dependence is limited to physicians who meet certain qualifying requirements, and who have notified the Secretary of Health and Human Services (HHS) of their intent to prescribe or dispense this product for the treatment of opioid dependence and have been assigned a unique identification number that must be included on every prescription. 2.2. General Instructions PROBUPHINE implants should be used only in patients who are opioid tolerant. Each dose consists of four PROBUPHINE implants inserted subdermally in the inner side of the upper arm. PROBUPHINE subdermal implants are intended to be in place for 6 months of treatment. Remove PROBUPHINE implants by the end of the sixth month. New implants may be inserted subdermally in an area of the inner side of either upper arm that has not been previously used at the time of removal, if continued treatment is desired. If new implants are not inserted on the same day as the removal of implants, maintain patients on their previous dosage of transmucosal buprenorphine (i.e., the dose from which they were transferred to PROBUPHINE treatment) prior to additional PROBUPHINE treatment. After one insertion in each arm, most patients should be transitioned back to a transmucosal buprenorphine-containing product for continued treatment. There is no experience with inserting additional implants into other sites in the arm to recommend an approach to a second insertion into a previously-used arm. Neither re-insertion into previously-used administration sites, nor into sites other than the upper arm, has been studied [see Dosage and Administration (2.4, 2.5, and 2.9), Warnings and Precautions (5.1)]. 2.3. Healthcare Provider Training All Healthcare Providers who intend to prescribe PROBUPHINE must successfully complete a live training program [see PROBUPHINE REMS (5.2)]. All Healthcare Providers performing insertions and/or removals of PROBUPHINE must successfully complete a live training program, and demonstrate procedural competency prior to inserting or removing the implants. Information concerning the insertion and removal procedures can be obtained by calling 1-844-859- 6341. The basis for successful use and subsequent removal of PROBUPHINE is a correct and carefully-performed subdermal insertion of the four implants in accordance with the instructions. As a prerequisite for participating in the live training program leading to certification, the Healthcare Provider must have performed at least one qualifying surgical procedure in the last 3 months. Qualifying procedures are those performed under local anesthesia using aseptic technique, and include, at a minimum, making skin incisions, or placing sutures [see PROBUPHINE REMS (5.2)]. 2.4. Patient Selection PROBUPHINE implants are only for use in patients who meet ALL of the following criteria: Achieved and sustained prolonged clinical stability on transmucosal buprenorphine Are currently on a maintenance dose of 8 mg per day or less of a Subutex or Suboxone sublingual tablet or its transmucosal buprenorphine product equivalent (the dose of transmucosal buprenorphine providing blood levels comparable or lower than the level provided by PROBUPHINE) Patients should not be tapered to a lower dose for the sole purpose of transitioning to PROBUPHINE Stable transmucosal buprenorphine dose (of 8 mg per day or less of a sublingual Subutex or Suboxone sublingual tablet or its transmucosal buprenorphine product equivalent) for three months or longer without any need for supplemental dosing or adjustments Examples of acceptable doses of transmucosal buprenorphine include: Subutex (buprenorphine) sublingual tablet (generic equivalent) 8 mg or less Suboxone (buprenorphine and naloxone) sublingual tablet (generic equivalent) 8 mg/2 mg or less Bunavail (buprenorphine and naloxone) buccal film 4.2 mg/0.7 mg or less Zubsolv (buprenorphine and naloxone) sublingual tablets 5.7 mg/1.4 mg or less Consider the following factors in determining clinical stability and suitability for PROBUPHINE treatment: period free from illicit opioid drug use stability of living environment participation in a structured activity/job consistency in participation in recommended behavioral therapy/peer support program consistency in compliance with clinic visit requirements minimal to no desire or need to use illicit opioids period without episodes of hospitalizations (addiction or mental health issues), emergency room visits, or crisis interventions social support system 2.5. Clinical Supervision Examine the insertion site one week following insertion of PROBUPHINE for signs of infection or any problems with wound healing, including evidence of implant extrusion from the skin. The recommended visit schedule for most patients is a frequency of no less than once-monthly for continued counseling and psychosocial support. Although some patients may require occasional supplemental dosing with buprenorphine, patients should not be provided with prescriptions for transmucosal buprenorphine-containing products for as-needed use. Instead, patients who feel the need for supplemental dosing should be seen and evaluated promptly. Ongoing use of supplemental dosing with transmucosal buprenorphine indicates that the amount of buprenorphine delivered by PROBUPHINE is not adequate for stable maintenance. Consider use of alternate buprenorphine products for maintenance of treatment. 2.6. Insertion of PROBUPHINE Preparation Prior to inserting PROBUPHINE, carefully read the insertion instructions as well as the full prescribing information. Before insertion of PROBUPHINE, confirm that: The patient does not have any contraindications for the use of PROBUPHINE [see Contraindications (4)]. The patient has had a medical history and physical examination. The patient understands the benefits and risks of PROBUPHINE. The patient has received a copy of the Medication Guide included in the packaging. The patient does not have allergies to the antiseptic and anesthetic to be used during insertion. Insert PROBUPHINE Under Aseptic Conditions. The Following Equipment is Needed for Implant Insertion: An examination table for the patient to lie on Instrument stand, sterile tray Adequate lighting (e.g., headlamp) Sterile fenestrated drape Latex and talc-free sterile gloves EtOH prep Surgical marker Antiseptic solution (e.g., chlorhexidine) Local anesthetic (1% lidocaine with epinephrine 1:100,000) 5 mL syringe with 1.5 inch 25g needle Adson single tooth tissue forceps #15 blade scalpel ¼ inch thin adhesive strip (butterfly strip) (e.g., Steri-strip skin closures) 4×4 sterile gauze Adhesive bandages 3-inch pressure bandages Liquid adhesive (e.g., Mastisol) 4 PROBUPHINE implants 1 PROBUPHINE disposable applicator (Figure 1) The applicator and its parts are shown in Figure 1. Correctly performed subdermal insertion of the implants will facilitate their removal. Implants should be placed just under the skin to avoid the large blood vessels that lie in the subcutaneous deep tissue. If the implants are placed improperly, resulting in deep tissue placement, the implants will be more difficult to remove. Figure 1 Figure Figure 1 Insertion Procedure Step 1. Have the patient lie on his/her back, with the intended arm flexed at the elbow and externally rotated, so that the hand is positioned next to the head (Figure 2). Figure 2 Step 2. Identify the insertion site, which is at the inner side of the upper arm about 8-10 cm (3-4 inches) above the medial epicondyle of the humerus in the sulcus between the biceps and triceps muscle. Having the patient flex the biceps muscle may facilitate identification of the site (Figure 3). Figure 3 Step 3. Clean insertion site with alcohol prep pad prior to marking the skin. Step 4. Mark the insertion site with the surgical marker. The implants will be inserted through a small 2.5 mm-3mm subdermal incision. Step 5. Using the surgical marker, mark the channel tracks where each implant will be inserted by drawing 4 lines with each line 4 cm in length. The implants will be positioned in a close fan-shaped distribution 4-6 mm apart with the fan opening towards the shoulder (Figure 4). The closer the implants lie to each other at time of insertion, the more easily they can be removed. There should be at least 5 mm between the incision and the implant when the implant is properly positioned. Figure 4 Step 6. Put on sterile gloves. Step 7. Using aseptic technique, place the sterile equipment, PROBUPHINE implants and the applicator on the sterile field of the instrument stand. One applicator is used to insert all four implants. Step 8. Check applicator function by removing the obturator from the cannula and relocking it. Step 9. Clean the insertion site with an antiseptic solution (e.g., chlorhexidine) using gentle repeated back-and-forth strokes for 30 seconds. When using triple swab stick applicators, use each swab stick sequentially within the 30 seconds. Allow the area to air dry for approximately 30 seconds and do not blot or wipe away. Step 10. Apply the sterile drape to the arm of the patient. Step 11. Anesthetize the insertion area at the incision site and just under the skin along the planned insertion channels using local anesthetic (for example, by injecting 5 mL lidocaine 1% with epinephrine 1:100,000). Step 12. After determining that anesthesia is adequate and effective, make a shallow incision that is 2.5-3 mm in length. Step 13. Lift the edge of the incision opening with a toothed forceps. While applying counter- traction to the skin, insert only the tip of the applicator at a slight angle (no greater than 20 degrees), into the subdermal space (depth of 3-4 mm below the skin), with the bevel-up stop marking on the cannula facing upwards and visible with the obturator locked fully into the cannula (Figure 5). Figure 5 Figure 6 Figure 7 Step 14. Lower the applicator to a horizontal position, lift the skin up with the tip of the applicator but keep the cannula in the subdermal connective tissue (Figure 6). While tenting (lifting), gently advance the applicator subdermally along the channel marking on the skin until the proximal marking on the cannula just disappears into the incision (Figure 7). Step 15. While holding the cannula in place, unlock the obturator and remove the obturator. Step 16. Insert one implant into the cannula (Figure 8), re-insert the obturator, and gently push the obturator forward (mild resistance should be felt) until the obturator stop line is level with the bevel-up stop marking, which indicates the implant is positioned at the tip of the cannula (Figure 9). Do not force the implant beyond the end of the cannula with the obturator. There should be at least 5 mm between the incision and the implant when the implant is properly positioned. Figure 8 Figure 9 Step 17. While holding the obturator fixed in place on the arm, retract the cannula along the obturator, leaving the implant in place (Figure 10). Note: do not push the obturator. By holding the obturator fixed in place on the arm and by retracting the cannula, the implant will be left in its correct subdermal position. Figure 10 Step 18. Withdraw the cannula until the hub is flush with the obturator, and then twist the obturator clockwise to lock onto the cannula (Figure 11). Retract the applicator, bevel up, until the distal marking of the cannula is visualized at the incision opening (the sharp tip remaining in the subcutaneous space). Figure 11 Step 19. Redirect the applicator to the next channel marking while stabilizing the previously inserted implant, with your index finger, away from the sharp tip (Figure 12). Follow steps 13 through 16 for the insertion of the three remaining implants through the same incision, placing implants in a close fan-shaped distribution 4-6 mm apart at the top of the implant. The applicator can now be removed. Figure 12 Step 20. Always verify the presence of each implant by palpation of the patient's arm immediately after the insertion. By palpating both ends of the implant, you should be able to confirm the presence of the 26 mm implant (Figure 13). If you cannot feel each of the four implants, or are in doubt of their presence, use other methods to confirm the presence of the implant. Suitable methods to locate are: Ultrasound with a high frequency linear array transducer (10 MHz or greater) or Magnetic Resonance Imaging (MRI). Please note that the PROBUPHINE implants are not radiopaque and cannot be seen by X-ray or CT scan. If ultrasound and MRI fail, call 1-844-859-6341. Figure 13 Step 21. Apply pressure to the incision site for approximately five minutes if necessary. Step 22. Clean the incision site. Apply liquid adhesive to the skin margins and allow to dry before closing the incision with the ¼ inch thin adhesive strip (butterfly strip) (for example Steri-strip skin closures). Step 23. Place a small adhesive bandage over the insertion site. Step 24. Apply a pressure bandage with sterile gauze to minimize bruising. The pressure bandage can be removed in 24 hours and the adhesive bandage can be removed in three to five days. Step 25. Complete the PATIENT IDENTIFICATION CARD and give it to the patient to keep. Also, complete the PATIENT CHART STICKER and affix it to the patient medical record or scan or input into electronic medical record. Provide the patient with the Medication Guide and explain proper care of the insertion site. Step 26. The applicator is for single use only. Dispose of the applicator in accordance with the Centers for Disease Control and Prevention guidelines for hazardous waste. Step 27. Instruct the patient to apply an ice pack on his/her arm for 40 minutes every two hours for first 24 hours and as needed. Step 28. Complete the PROBUPHINE REMS Insertion/Removal Log Form. Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 2.7. PROBUPHINE Removal Procedure Before initiating the removal procedure, read the instructions for removal. Identify the location of the implants by consulting the PATIENT IDENTIFICATION CARD and/or THE PATIENT CHART STICKER. The exact location of all implants in the arm (patients will have four implants) should be verified by palpation. If all of the implants are not palpable, use other methods to confirm the presence of the implant(s). Non-palpable implants should always be located prior to attempted removal. Suitable methods to locate implants are: Ultrasound with a high frequency linear array transducer (10 MHz or greater) or Magnetic Resonance Imaging (MRI). Note that PROBUPHINE implants are not radiopaque and cannot be seen by X-ray or CT scan. Report any event of failure to locate non-palpable implants using MRI or ultrasound, by calling 1- 844-859-6341 for company surveillance purposes. After localization of a non-palpable implant, removal should be performed under ultrasound guidance. Exploratory surgery without knowledge of the exact location of all implants is strongly discouraged. There is a greater risk of injury to neural and vascular structures during removal of implants located deeper than the subdermal space. As the anatomical location of these structures must be taken into consideration during the removal of deeply inserted implants, the procedure should only be attempted by healthcare providers familiar with this anatomy. A surgical specialist consulted to assist with a difficult removal does not need to be certified in the REMS program. Preparation Before removal of PROBUPHINE, confirm that: The patient does not have allergies to the antiseptic or the anesthetic to be used. Implants Should be Removed Under Aseptic Conditions. The Following Equipment is Needed for Implant Removal: An examination table for the patient to lie on Instrument stand Sterile tray Adequate lighting (e.g., headlamp) Sterile fenestrated drapes Latex and talc-free sterile gloves EtOH prep Antiseptic solution (e.g., chlorhexidine) Surgical marker Local anesthetic (e.g., 1% lidocaine with epinephrine 1:100,000) 5 mL syringe with 1.5 inch 25g needle Adson single tooth tissue forceps Mosquito forceps Two X-plant clamps (vasectomy fixation clamps with 2.5 mm ring diameter) Iris scissors Needle driver #15 blade scalpel Sterile ruler 4×4 sterile gauze Adhesive bandage 3-inch pressure bandage Sutures (e.g., 4-0 Prolene™ with an FS-2 cutting needle) (may be absorbable) Figure Removal Procedure Step 1. Have the patient lie on his/her back, with the implant arm flexed at the elbow and externally rotated, so that the hand is positioned next to the head. Step 2. Reconfirm the location of the implants by palpation. Step 3. Clean removal site with alcohol prep pad prior to marking the skin. Step 4. Mark the location of the implants with a surgical marker. In addition, mark the location of the incision, parallel to the axis of the arm, between the second and third implants (Figure 14). Figure 14 Step 5. Put on sterile gloves. Step 6. Using aseptic technique, place the sterile equipment on the sterile field of the instrument stand. Step 7. Clean the removal site with an antiseptic solution (e.g. chlorhexidine) using gentle repeated back and forth strokes for 30 seconds. When using triple swab stick applicators, use each swab stick sequentially within the 30 seconds. Allow the area to air dry for approximately 30 seconds and do not blot or wipe away. Step 8. Apply the sterile drape to the arm of the patient. Step 9. Anesthetize the incision site and the subcutaneous space containing the implants (for example, by injecting 5-7 mL lidocaine 1% with epinephrine 1:100,000). Separate needles may be used for the incision site and the subcutaneous injections. NOTE: Be sure to inject the local anesthetic just beneath the implants; this will effectively lift the implants toward the skin, facilitating removal of the implants. Step 10. After determining that anesthesia is adequate and effective, make a 7-10 mm incision with a scalpel, parallel to the axis of the arm, between the second and third implants. Step 11. Pick up the skin edge with Adson single-toothed tissue forceps and separate the tissues above and below the first visualized implant using an iris scissors or a curved mosquito forceps (Figure 15). Grasp the center of the implant with the X-plant clamp and apply gentle traction. Use the technique of spreading and closing with either the iris scissors or mosquito forceps to separate the fibrous tissue (Figure 16). If the implant is encapsulated use the scalpel to shave the tissue sheath and carefully dissect the tissue around the implant. The implant can then be removed. Figure 15 Figure 16 Step 12. Retract the next visible implant toward the incisional opening. You may see tenting of the skin at this point if the surrounding tissue is still adhering to the implant. Maintain gentle traction on the implant while you continue to dissect proximally and distally until the implant is free of all adhering tissue. At this point, you may require the use of your second X-plant clamp to remove the implant. If the implant is encapsulated use the scalpel to shave the tissue sheath and carefully dissect the tissue around the implant. The implant can then be removed. Step 13. After removal of each implant confirm that the entire implant, which is 26 mm long, has been removed by measuring its length. If a partial implant (less than 26 mm) is removed, the remaining piece should be removed by following the same removal instructions. Follow steps 11 through 13 for the removal of the remaining implants through the same incision. Visual identification of whether an entire implant has been removed is unreliable. Therefore, it is important to measure the implant to ensure the entire implant has been removed. Step 14. After removal of all four implants, clean the incision site. Step 15. Close the incision with sutures. Step 16. Place an adhesive bandage over the incision. Step 17. Use the sterile gauze and apply gentle pressure for five minutes to the incision site to ensure hemostasis. Step 18. Apply a pressure bandage with sterile gauze to minimize bruising. The pressure bandage can be removed in 24 hours and the adhesive bandage in three to five days. Step 19. Counsel the patient on proper aseptic wound care. Instruct the patient to apply an ice pack to his/her arm for 40 minutes every two hours for first 24 hours and as needed. Step 20. Schedule an appointment for the sutures to be removed. Step 21. The removed implant contains a significant amount of residual buprenorphine. It must be handled with adequate security, accountability, and proper disposal, per facility procedure for a Schedule III drug product, and per applicable federal, state, and local regulations. Disposal of PROBUPHINE implants should also be in keeping with local, State and Federal regulations governing the disposal of pharmaceutical biohazardous waste. Step 22. Complete the PROBUPHINE REMS Insertion/Removal Log Form. If implant(s) or implant fragment(s) are not removed during a removal attempt, the patient should undergo imaging for localization as soon as is feasible. The subsequent removal attempt should be performed on the same day of localization. If localization and a second removal attempt are not performed on the same day as the initial removal attempt that necessitated imaging for localization, the wound should be closed with sutures in the interim. Figure 14 Figure 15 Figure 16 2.8. Spontaneous Expulsion If spontaneous expulsion of the implant occurs after insertion, the following steps should be taken. Schedule two appointments for the patient to return to the office of the inserting healthcare provider as soon as possible and to the office of the prescribing healthcare provider. Instruct the patient to place the implant in a plastic bag, store it safely out of reach of children, and to bring it to the healthcare provider office to determine whether the full implant has been expelled. If the patient returns the expelled implant, measure it to ensure that the entire implant was expelled (26 mm). Dispose of the removed implant in keeping with local, state, and federal regulations governing the disposal of pharmaceutical biohazardous waste, after measuring. Examine incision site for infection. If infected, treat appropriately and determine if remaining implants need to be removed. If the expelled implant is not intact, palpate the insertion location to identify the location of any remaining partial implant. Remove the remaining partial implant using the techniques described above. Call 1-844-859-6341 to obtain a new kit that will include four implants and return instructions for any unused implants. The Prescribing HCP must carefully monitor patient until the implant is replaced to evaluate for withdrawal or other clinical indicators that supplemental transmucosal buprenorphine may be needed. Schedule an appointment to insert replacement implant(s). Insert the replacement implant(s) in same arm either medially or laterally to in situ implants. Alternatively, replacement implant(s) may be inserted in the contralateral arm. Record the new serial number on the PROBUPHINE REMS Insertion/Removal Log Form 2.9. Continuation of Therapy: Subsequent Insertion of PROBUPHINE in the Contralateral Arm There is no clinical experience with insertion of PROBUPHINE beyond a single insertion in each arm. If continued treatment is desired at the end of the first six-month treatment cycle, PROBUPHINE implants may be replaced by new implants at the time of removal in the contralateral arm, following the insertion steps above to locate the appropriate insertion site. If new implants are not inserted on the same day as the removal, patients should be maintained on their previous dose of transmucosal buprenorphine (i.e., the dose from which they were transferred to PROBUPHINE treatment) prior to additional PROBUPHINE treatment [see Dosage and Administration (2.6), Warnings and Precautions (5.1)]. There is no experience with inserting additional implants into other sites in the arm to recommend an approach to a second insertion into a previously-used arm. Neither re-insertion into previously-used administration sites, nor into sites other than the upper arm, have been studied. It is important to avoid previously-implanted sites because the effect of scarring and fibrosis in previously-used insertion sites on either the effectiveness of PROBUPHINE or the safety of insertion have not been evaluated. After one insertion in each arm, additional cycles of treatment should only be considered if the potential benefits of continuing PROBUPHINE outweigh the potential risks of additional insertion and removal procedures, taking into account the experience of the healthcare provider with PROBUPHINE procedures and related procedures, and the clinical need of the patient for ongoing treatment with subdermal medication. In most cases, patients should be transitioned back to a transmucosal buprenorphine-containing product for continued treatment.
Use in special populations
8. USE IN SPECIFIC POPULATIONS There are no well-controlled studies of PROBUPHINE in the populations discussed in this section. The data noted in this section were reported from studies and post-marketing reports for other buprenorphine products marketed globally. Lactation: Buprenorphine passes into the mother's milk. (8.2) Elderly: Monitor elderly patients for sedation or respiratory depression. (8.5) Hepatic Impairment: Monitor patients with liver dysfunction for sedation and respiratory depression. (8.6) 8.1. Pregnancy Risk Summary The data on use of buprenorphine, the active ingredient in PROBUPHINE implant, in pregnancy, are limited; however, these data do not indicate an increased risk of major malformations specifically due to buprenorphine exposure. There are limited data from randomized clinical trials in women maintained on buprenorphine that were not designed appropriately to assess the risk of major malformations [see Data ]. Observational studies have reported on congenital malformations among buprenorphine-exposed pregnancies, but were also not designed appropriately to assess the risk of congenital malformations specifically due to buprenorphine exposure [see Data]. Adequate and well-controlled studies have not been conducted with PROBUPHINE or buprenorphine in pregnant women. Neonatal opioid withdrawal syndrome has been reported in the infants of women treated with buprenorphine sublingual tablets during pregnancy [see Clinical Considerations below]. Reproductive and developmental studies in rats and rabbits identified adverse events at clinically relevant and higher doses. Embryofetal death was observed in both rats and rabbits administered buprenorphine during the period of organogenesis at doses approximately 12 and 0.5 times, respectively, the human sublingual dose of 8 mg/day of buprenorphine, which represents the target exposure with the maximum recommended human dose (MRHD) of PROBUPHINE. Pre- and post-natal development studies in rats demonstrated increased neonatal deaths at a dose approximately equivalent to and dystocia at approximately 6-times the human sublingual dose of 8 mg/day of buprenorphine. No clear teratogenic effects were seen when buprenorphine was administered during organogenesis with a range of doses equivalent to or greater than the human sublingual dose of 8 mg/day of buprenorphine. However, increases in skeletal abnormalities were noted in rats and rabbits administered buprenorphine daily during organogenesis at a dose approximately 5 times- and approximately 2 times the human sublingual dose of 8 mg/day of buprenorphine, respectively. In a few studies, some events such as acephalus and omphalocele were also observed but these findings were not clearly treatment-related [see Data ]. The estimated background risk of major birth defects and miscarriage for the indicated population are unknown. All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively. Clinical Considerations Disease-associated maternal and embryo-fetal risk Untreated opioid addiction in pregnancy is associated with adverse obstetrical outcomes such as low birth weight, preterm birth, and fetal death. In addition, untreated opioid addiction often results in continued or relapsing illicit opioid use. Dose Adjustment during Pregnancy and the Postpartum Period Dosage adjustments of buprenorphine may be required during pregnancy, even if the patient was maintained on a stable dose prior to pregnancy. The PROBUPHINE dose cannot be adjusted. Therefore, women who become pregnant while being treated with PROBUPHINE should be closely monitored by their physicians to ensure that they are adequately treated. Likewise, because the dose of PROBUPHINE cannot be adjusted, PROBUPHINE may not be an appropriate treatment option to initiate in patients who are pregnant. Fetal/neonatal adverse reactions Neonatal opioid withdrawal syndrome may occur in newborn infants of mothers who are receiving treatment with PROBUPHINE implant. Neonatal opioid withdrawal syndrome presents as irritability, hyperactivity and abnormal sleep pattern, high pitched cry, tremor, vomiting, diarrhea, and/or failure to gain weight. Signs of neonatal withdrawal usually occur in the first days after birth. The duration and severity of neonatal opioid withdrawal syndrome may vary. Observe newborns for signs of neonatal opioid withdrawal syndrome and manage accordingly [see Warnings and Precautions (5.5)] Labor or Delivery Opioid-dependent women on buprenorphine maintenance therapy may require additional analgesia during labor. Data Human Data Studies have been conducted to evaluate neonatal outcomes in women exposed to buprenorphine during pregnancy. Limited data from trials, observational studies, case series, and case reports on buprenorphine use in pregnancy do not indicate an increased risk of major malformations specifically due to buprenorphine. Several factors may complicate the interpretation of investigations of the children of women who take buprenorphine during pregnancy, including maternal use of illicit drugs, late presentation for prenatal care, infection, poor compliance, poor nutrition, and psychosocial circumstances. Interpretation of data is complicated further by the lack of information on untreated opioid-dependent pregnant women, who would be the most appropriate group for comparison. Rather, women on another form of opioid medication-assisted treatment, or women in the general population are generally used as the comparison group. However, women in these comparison groups may be different from women prescribed buprenorphine-containing products with respect to maternal factors that may lead to poor pregnancy outcomes. In a multicenter, double-blind, randomized, controlled trial [Maternal Opioid Treatment: Human Experimental Research (MOTHER)] designed primarily to assess neonatal opioid withdrawal effects, opioid-dependent pregnant women were randomized to buprenorphine (n=86) or methadone (n=89) treatment, with enrollment at an average gestational age of 18.7 weeks in both groups. A total of 28 of the 86 women in the buprenorphine group (33%) and 16 of the 89 women in the methadone group (18%) discontinued treatment before the end of pregnancy. Among women who remained in treatment until delivery, there was no difference between buprenorphine-treated and methadone-treated groups in the number of neonates requiring NOWS treatment or in the peak severity of NOWS. Buprenorphine-exposed neonates required less morphine (mean total dose, 1.1 mg vs 10.4 mg), had shorter hospital stays (10.0 days vs 17.5 days), and shorter duration of treatment for NOWS (4.1 days vs 9.9 days) compared to the methadone-exposed group. There were no differences between groups in other primary outcomes (neonatal head circumference,) or secondary outcomes (weight and length at birth, preterm birth, gestational age at delivery, and 1-minute and 5-minute Apgar scores), or in the rates of maternal or neonatal adverse events. The outcomes among mothers who discontinued treatment before delivery and may have relapsed to illicit opioid use are not known. Because of the imbalance in discontinuation rates between the buprenorphine and methadone groups, the study findings are difficult to interpret. Animal Data The exposure margins listed below are based on body surface area comparisons (mg/m2) to the human sublingual dose of 8 mg buprenorphine via SUBUTEX sublingual tablet unless otherwise indicated. No definitive drug-related teratogenic effects were observed in rats and rabbits at IM doses up to 30 mg/kg/day (estimated exposure approximately 40 times and 70 times, respectively, the human sublingual dose of 8 mg). Maternal toxicity resulting in mortality was noted in these studies in both rats and rabbits. Acephalus was observed in one rabbit fetus from the low-dose group and omphalocele was observed in two rabbit fetuses from the same litter in the mid-dose group; no findings were observed in fetuses from the high-dose group. Maternal toxicity was seen in the high-dose group but not at the lower doses where the findings were observed. Following oral administration of buprenorphine to rats, dose-related post-implantation losses, evidenced by increases in the numbers of early resorptions with consequent reductions in the numbers of fetuses, were observed at doses of 10 mg/kg/day or greater (estimated exposure approximately 12 times the human sublingual dose of 8 mg). In the rabbit, increased post-implantation losses occurred at an oral dose of 40 mg/kg/day. Following IM administration in the rat and the rabbit, post-implantation losses, as evidenced by decreases in live fetuses and increases in resorptions, occurred at 30 mg/kg/day. Buprenorphine was not teratogenic in rats and rabbits after subcutaneous (SC) doses of up to 5 mg/kg/day (estimated exposure was approximately 18 and 21 times, respectively, the highest daily exposure from the maximum recommended human dose (MRHD) of PROBUPHINE on an area under the blood level curve/AUC basis), after IM doses of up to 5 mg/kg/day (estimated exposure was approximately 6 and 12 times, respectively, the human sublingual dose of 8 mg), after IV doses up to 0.8 mg/kg/day (estimated exposure was approximately 1 and 2 times, respectively, the human sublingual dose of 8 mg), or after oral doses up to 160 mg/kg/day in rats (estimated exposure was approximately 190 times the human daily sublingual dose of 8 mg) and 25 mg/kg/day in rabbits (estimated exposure was approximately 60 times the human daily sublingual dose of 8 mg). Significant increases in skeletal abnormalities (e.g., extra thoracic vertebra or thoraco-lumbar ribs) were noted in rats after SC administration of 1 mg/kg/day and up (estimated exposure was approximately 5 times the highest daily exposure from the MRHD of PROBUPHINE on an AUC basis), but were not observed at oral doses up to 160 mg/kg/day. Increases in skeletal abnormalities in rabbits after IM administration of 5 mg/kg/day (estimated exposure was approximately 12 times the human daily sublingual dose of 8 mg) in the absence of maternal toxicity or oral administration of 1 mg/kg/day or greater (estimated exposure was approximately 2 times the human sublingual dose of 8 mg) were not statistically significant. In rabbits, buprenorphine produced statistically significant pre-implantation losses at oral doses of 1 mg/kg/day or greater and post-implantation losses that were statistically significant at IV doses of 0.2 mg/kg/day or greater (estimated exposure approximately 0.5 times the human daily sublingual dose of 8 mg. No maternal toxicity was noted at doses causing post-implantation loss in this study. Dystocia was noted in pregnant rats treated intramuscularly with buprenorphine from Gestation Day 14 through Lactation Day 21 at 5 mg/kg/day (approximately 6 times the human sublingual does of 8 mg). Fertility, pre-, and post-natal development studies with buprenorphine in rats indicated increases in neonatal mortality after oral doses of 0.8 mg/kg/day and up (approximately equivalent to the human daily sublingual dose of 8 mg), after IM doses of 0.5 mg/kg/day and up (approximately 0.6 times the human sublingual dose of 8 mg), and after SC doses of 0.1 mg/kg/day and up (approximately equivalent to the highest daily exposure from the MRHD of PROBUPHINE on an AUC basis). An apparent lack of milk production during these studies likely contributed to the decreased pup viability and lactation indices. Delays in the occurrence of righting reflex and startle response were noted in rat pups at an oral dose of 80 mg/kg/day (approximately 97 times the human sublingual dose of 8 mg). 8.2. Lactation Risk Summary Based on two studies in 13 lactating women maintained on sublingual buprenorphine treatment, buprenorphine and its metabolite norbuprenorphine were present in low levels in human milk and available data have not shown adverse reactions in breastfed infants. The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for buprenorphine treatment and any potential adverse effects on the breastfed child from the drug or from the underlying maternal condition. Clinical Considerations Advise breastfeeding women taking buprenorphine products to monitor the infant for increased drowsiness and breathing difficulties. Data Data were consistent from two studies (N=13) of breastfeeding infants whose mothers were maintained on sublingual doses of buprenorphine ranging from 2.4 to 24 mg/day, showing that the infants were exposed to less than 1% of the maternal daily dose. In a study of six lactating women who were taking a median sublingual buprenorphine dose of 0.29 mg/kg/day 5 to 8 days after delivery, breast milk provided a median infant dose of 0.42 mcg/kg/day of buprenorphine and 0.33 mcg/kg/day of norbuprenorphine, equal to 0.2% and 0.12% respectively, of the maternal weight-adjusted dose (relative dose/kg (%) of norbuprenorphine was calculated from the assumption that buprenorphine and norbuprenorphine are equipotent). Data from a study of seven lactating women who were taking a median sublingual buprenorphine dose of 7 mg/day an average of 1.12 months after delivery indicated that the mean milk concentrations (Cavg) of buprenorphine and norbuprenorphine were 3.65 mcg/L and 1.94 mcg/L respectively. Based on the study data, and assuming milk consumption of 150 mL/kg/day, an exclusively breastfed infant would receive an estimated mean absolute infant dose (AID) of 0.55 mcg/kg/day of buprenorphine and 0.29 mcg/kg/day of norbuprenorphine, or a mean relative infant dose (RID) of 0.38% and 0.18%, respectively, of the maternal weight-adjusted dose. 8.3. Females and Males of Reproductive Potential Infertility Dietary administration of buprenorphine in the rat at dose levels of 500 ppm or greater (equivalent to approximately 47 mg/kg/day or greater; estimated exposure approximately 22 times the highest daily exposure from PROBUPHINE on an AUC basis) produced a reduction in fertility demonstrated by reduced female conception rates [see Nonclinical Toxicology (13.1)] Chronic use of opioids may cause reduced fertility in females and males of reproductive potential. It is not known whether these effects on fertility are reversible [see Adverse Reactions (6.2), Clinical Pharmacology (12.2)]. 8.4. Pediatric Use The safety and effectiveness of PROBUPHINE have not been established in children or adolescents < 16 years of age. 8.5. Geriatric Use Clinical studies of PROBUPHINE did not include subjects over the age of 65. Other reported clinical experience with buprenorphine has not identified differences in responses between the geriatric and younger patients. Due to possible decreased hepatic, renal, or cardiac function and of concomitant disease or other drug therapy in geriatric patients, the decision to prescribe PROBUPHINE should be made cautiously in individuals 65 years of age or older and these patients should be monitored for signs and symptoms of toxicity or overdose. 8.6. Hepatic Impairment The effect of hepatic impairment on the pharmacokinetics of sublingual buprenorphine has been evaluated in a pharmacokinetic study. While no clinically significant changes have been observed in subjects with mild hepatic impairment, the plasma levels have been shown to be higher and half-life values have been shown to be longer for buprenorphine in subjects with moderate and severe hepatic impairment. The effect of hepatic impairment on the pharmacokinetics of implanted buprenorphine, such as PROBUPHINE, has not been studied. Since the drug is extensively metabolized, the plasma levels can be expected to be higher in patients with moderate and severe hepatic impairment. Because PROBUPHINE cannot be titrated, patients with pre-existing moderate to severe hepatic impairment are not candidates for treatment with PROBUPHINE. Monitor patients who develop moderate or severe hepatic impairment while being treated with PROBUPHINE for signs and symptoms of toxicity or overdose caused by increased levels of buprenorphine. If signs and symptoms of toxicity or overdose are observed, removal of PROBUPHINE implants may be required [see Dosage and Administration (2.5), Clinical Pharmacology (12.3)]. 8.7. Renal Impairment Clinical studies of PROBUPHINE did not include subjects with renal impairment. No differences in buprenorphine pharmacokinetics were observed between 9 dialysis-dependent and 6 normal patients following IV administration of 0.3 mg buprenorphine.

Interactions

7. DRUG INTERACTIONS CYP3A4 Inhibitors and Inducers: Monitor patients starting or ending CYP3A4 inhibitors or inducers for potential over- or under-dosing. (7.1) Serotonergic Drugs: Concomitant use may result in serotonin syndrome. Discontinue PROBUPHINE if serotonin syndrome is suspected. (7.4) 7.1. Cytochrome P450 3A4 (CYP3A4) Inhibitors and Inducers Buprenorphine is metabolized to norbuprenorphine primarily by CYP3A4; therefore, potential interactions may occur when PROBUPHINE is given concurrently with agents that affect CYP3A4 activity. The effects of co-administered inducers or inhibitors have been established in studies using transmucosal buprenorphine; the effects on buprenorphine exposure in patients treated with PROBUPHINE have not been studied, and the effects may be dependent on the route of administration. Patients who transfer to PROBUPHINE treatment from a regimen of transmucosal buprenorphine used concomitantly with CYP3A4 inhibitors (e.g., azole antifungals such as ketoconazole, macrolide antibiotics such as erythromycin, and HIV protease inhibitors [e.g. ritonavir, indinavir, and saquinavir]) should be monitored to ensure that the plasma buprenorphine level provided by PROBUPHINE is adequate. If patients already on PROBUPHINE require newly-initiated treatment with CYP3A4 inhibitors, the patients should be monitored for signs and symptoms of over- medication. If the concomitant medication cannot be reduced or discontinued, it may be necessary to remove the PROBUPHINE implants and treat the patient with a formulation of buprenorphine that permits dose adjustments. Conversely, if a patient has been stabilized on PROBUPHINE in the setting of concomitant medication that is a CYP3A4 inhibitor, and the concomitant medication is discontinued, the patient should be monitored for withdrawal. If the dose of PROBUPHINE is not adequate in the absence of the concomitant medication, that patient should be transitioned back to a formulation of buprenorphine that permits dose adjustments. CYP3A4 inducers may induce the metabolism of buprenorphine and, therefore, may cause increased clearance of the drug which could lead to a decrease in buprenorphine plasma concentrations, lack of efficacy or, possibly, development of an abstinence syndrome. It is not known whether the effects of CYP3A4 inducers are dependent on the route of administration of buprenorphine. Patients who transfer to PROBUPHINE treatment from a regimen of transmucosal buprenorphine used concomitantly with CYP3A4 inducers should be monitored to ensure that the plasma buprenorphine level provided by PROBUPHINE is not excessive. If patients already on PROBUPHINE require newly-initiated treatment with CYP3A4 inducers, the patients should be monitored for withdrawal. If the dose of PROBUPHINE is not adequate in the absence of the concomitant medication, and the concomitant medication cannot be reduced or discontinued, that patient should be transitioned back to a formulation of buprenorphine that permits dose adjustments. Conversely, if a patient has been stabilized on PROBUPHINE in the setting of concomitant medication that is a CYP3A4 inducer, and the concomitant medication is discontinued, the patient should be monitored for signs and symptoms of over-medication. If the dose provided by PROBUPHINE is excessive in the absence of the concomitant inducer, it may be necessary to remove the PROBUPHINE implants and treat the patient with a formulation of buprenorphine that permits dose adjustments [see Clinical Pharmacology (12)]. 7.2. Antiretrovirals Three classes of antiretroviral agents have been evaluated for CYP3A4 interactions with buprenorphine, though these evaluations have not been specifically performed with PROBUPHINE. Nucleoside reverse transcriptase inhibitors (NRTIs) do not appear to induce or inhibit the P450 enzyme pathway; thus no interactions with buprenorphine are expected. Non-nucleoside reverse transcriptase inhibitors (NNRTIs) are metabolized principally by CYP3A4. Efavirenz, nevirapine, and etravirine are known CYP3A4 inducers, whereas delaviridine is a CYP3A4 inhibitor. Significant pharmacokinetic interactions between NNRTIs (e.g., efavirenz and delavirdine) and buprenorphine have been shown in clinical studies, but these pharmacokinetic interactions did not result in any significant pharmacodynamic effects. It is recommended that patients who are on PROBUPHINE treatment have their dose monitored if NNRTIs are added to their treatment regimen. Studies have shown some antiretroviral protease inhibitors (PIs) with CYP3A4 inhibitory activity (e.g., nelfinavir, lopinavir/ritonavir, ritonavir) have little effect on buprenorphine pharmacokinetics and no significant pharmacodynamic effects. Other PIs with CYP3A4 inhibitory activity (e.g., atazanavir and atazanavir/ritonavir) resulted in elevated levels of buprenorphine and norbuprenorphine and patients in one study reported increased sedation. Symptoms of opioid excess have been found in post-marketing reports of patients receiving buprenorphine and atazanavir with and without ritonavir concomitantly. If treatment with atazanavir with and without ritonavir must be initiated in a patient already treated with PROBUPHINE, the patient should be monitored for signs and symptoms of over-medication. It may be necessary to remove the PROBUPHINE implants and treat the patient with a formulation of buprenorphine that permits dose adjustments. 7.3. Benzodiazepines There have been post-marketing reports of coma and death associated with the concomitant use of buprenorphine and benzodiazepines. In many, but not all, of these cases, buprenorphine was misused by self-injection. Studies have shown that the combination of benzodiazepines and other buprenorphine products altered the usual ceiling effect on buprenorphine-induced respiratory depression, making the respiratory effects of buprenorphine appear similar to those of full opioid agonists. PROBUPHINE should be prescribed with caution to patients taking benzodiazepines or other drugs that act on the CNS, regardless of whether these drugs are taken on the advice of a physician or are being abused. Patients should be warned that it is extremely dangerous to self-administer non-prescribed benzodiazepines while taking PROBUPHINE, and should also be cautioned to use benzodiazepines concurrently with PROBUPHINE only as directed by their physician. 7.4. Serotonergic Drugs The concomitant use of opioids with other drugs that affect the serotonergic neurotransmitter system, such as selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), triptans, 5-HT3 receptor antagonists, drugs that affect the serotonin neurotransmitter system (e.g., mirtazapine, trazodone, tramadol), and monoamine oxidase (MAO) inhibitors (those intended to treat psychiatric disorders and also others, such as linezolid and intravenous methylene blue), has resulted in serotonin syndrome. If concomitant use is warranted, carefully observe the patient, particularly during treatment initiation, and during dose adjustment of the serotonergic drug. Discontinue PROBUPHINE if serotonin syndrome is suspected.

More information

Category Value
Authorisation number NDA204442
Agency product number 56W8MW3EN1
Orphan designation No
Product NDC 58284-100
Date Last Revised 09-08-2017
Type HUMAN PRESCRIPTION DRUG
RXCUI 1797650
Storage and handling Store PROBUPHINE at 20 to 25°C (68 to 77°F); excursions permitted at 15 to 30°C (59-86°F) [see USP Controlled Room Temperature]. Store PROBUPHINE in accordance with Federal and State controlled substance laws and regulations. Contact state controlled substances authority for information on how to store and prevent diversion of this product. The PROBUPHINE implant is a Schedule III drug product. Handle with adequate security and accountability. Expired implants should be properly disposed, per facility procedure for a Schedule III drug product, and per applicable federal, state, and local regulations. NDC code for set of four implants is 58284-100-14.
Marketing authorisation holder Braeburn Pharmaceuticals
Warnings WARNING: IMPLANT MIGRATION, PROTRUSION, EXPULSION, and NERVE DAMAGE ASSOCIATED WITH INSERTION and REMOVAL WARNING: IMPLANT MIGRATION, PROTRUSION, EXPULSION, and NERVE DAMAGE ASSOCIATED WITH INSERTION and REMOVAL See full prescribing information for complete boxed warning. Insertion and removal of PROBUPHINE are associated with the risk of implant migration, protrusion, expulsion, and nerve damage resulting from the procedure. (5.1) PROBUPHINE is available only through a restricted program called the PROBUPHINE REMS Program. (5.2) Risk Associated with Insertion and Removal Insertion and removal of PROBUPHINE are associated with the risk of implant migration, protrusion, and expulsion resulting from the procedure. Rare but serious complications including nerve damage and migration resulting in embolism and death may result from improper insertion of drug implants inserted in the upper arm. Additional complications may include local migration, protrusion and expulsion. Incomplete insertions or infections may lead to protrusion or expulsion. [see Warnings and Precautions (5.1)] . Because of the risks associated with insertion and removal, PROBUPHINE is available only through a restricted program called the PROBUPHINE REMS Program. All Healthcare Providers must successfully complete a live training program on the insertion and removal procedures and become certified, prior to performing insertions or prescribing PROBUPHINE implants. Patients must be monitored to ensure that PROBUPHINE is removed by a healthcare provider certified to perform insertions. [see Warnings and Precautions (5.2)] .