Coxanto Oxaprozin Capsule Instructions

Coxanto Oxaprozin Capsule

COXANTO Product Information

WARNING: RISK OF SERIOUS CARDIOVASCULAR AND GASTROINTESTINAL EVENTS
See full prescribing information for complete boxed warning.

• Nonsteroidal anti-inflammatory drugs (NSAIDs) cause an increased risk of serious cardiovascular thrombotic events, including myocardial infarction and stroke, which can be fatal. This risk may occur early in treatment and may increase with duration of use (5.1)
• COXANTO is contraindicated in the setting of coronary artery bypass graft (CABG) surgery (4, 5.1)
• NSAIDs cause an increased risk of serious gastrointestinal (GI) adverse events including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal. These events can occur at any time during use and without warning symptoms. Elderly patients and patients with a prior history of peptic ulcer disease and/or GI bleeding are at greater risk for serious GI events (5.2)

INDICATIONS AND USAGE
COXANTO is a non-steroidal anti-inflammatory drug indicated for

• Relief of signs and symptoms of Osteoarthritis (OA) (1)
• Relief of signs and symptoms of Rheumatoid Arthritis (RA) (1)
• Relief of signs and symptoms of Juvenile Rheumatoid Arthritis (JRA)(1)

DOSAGE AND ADMINISTRATION

• Use the lowest effective dosage for shortest duration consistent with individual patent treatment goals (2.1)
• OA: 1,200 mg (four 300 mg capsules) given orally once a day (2.2, 2.5, 14.1)
• RA: 1,200 mg (four 300 mg capsules) given orally once a day (2.3, 2.5, 14.2)
• JRA: 600 mg (two 300 mg capsules) once daily in patients 22 to 31 kg. 900 mg (three 300 mg capsules) once daily in patients 32 to 54 kg. 1,200 mg (four 300 mg capsules) once daily in patients 55 kg or greater (2.4, 2.5)

DOSAGE FORMS AND STRENGTHS

• Capsules: 300 mg (3)

CONTRAINDICATIONS

• Known hypersensitivity to oxaprozin or any components of the drug product (4)
• History of asthma, urticaria, or other allergic-type reactions after taking aspirin or other NSAIDs (4)
• In the setting of CABG surgery (4)

WARNINGS AND PRECAUTIONS

• Hepatotoxicity: Inform patients of warning signs and symptoms of hepatotoxicity. Discontinue if abnormal liver tests persist or worsen or if clinical signs and symptoms of liver disease develop (5.3)

• Hypertension: Patients taking some antihypertensive medications may have impaired response to these therapies when taking NSAIDs. Monitor blood pressure (5.4, 7)

• Heart Failure and Edema: Avoid use of COXANTO in patients with severe heart failure unless benefits are expected to outweigh risk of worsening heart failure (5.5)

• Renal Toxicity: Monitor renal function in patients with renal or hepatic impairment, heart failure, dehydration, or hypovolemia. Avoid use of COXANTO in patients with advanced renal disease unless benefits are expected to outweigh risk of worsening renal function (5.6)
  Anaphylactic Reactions: Seek emergency help if an anaphylactic reaction occurs (5.7)

• Exacerbation of Asthma Related to Aspirin Sensitivity : COXANTO is contraindicated in patients with aspirin-sensitive asthma. Monitor patients with preexisting asthma (without aspirin sensitivity) (5.8)

• Serious Skin Reactions: Discontinue COXANTO at first appearance of skin rash or other signs of hypersensitivity (5.9)

• Drug Reaction with Eosinophilia and Systemic Symptoms

• (DRESS): Discontinue and evaluate clinically (5.10)

• Fetal Toxicity: Limit use of NSAIDs, including COXANTO, between about 20 to 30 weeks in pregnancy due to the risk of oligohydramnios/fetal renal dysfunction. Avoid use of NSAIDs in women at about 30 weeks gestation and later in pregnancy due to the risks of oligohydramnios/fetal renal dysfunction and premature closure of the fetal ductus arteriosus (5.11, 8.1)

• Hematologic Toxicity: Monitor hemoglobin or hematocrit in patients with any signs or symptoms of anemia (5.12, 7)

ADVERSE REACTIONS
Most common adverse reactions (incidence > 3%) are: constipation, diarrhea, dyspepsia, nausea, rash (6.1)
To report SUSPECTED ADVERSE REACTIONS, contact Solubiomix, LLC. at 1-844-551-9911 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

DRUG INTERACTIONS

• Drugs that Interfere with Hemostasis (e.g., warfarin, aspirin, selective serotonin reuptake inhibitors [SSRIs]/serotonin norepinephrine reuptake inhibitors [SNRIs]): Monitor patients for bleeding who are concomitantly taking COXANTO with drugs that interfere with hemostasis. Concomitant use of COXANTO and analgesic doses of aspirin is not generally recommended (7)
• Angiotensin Converting Enzyme (ACE) Inhibitors, Angiotensin Receptor Blockers (ARB), or Beta-Blockers: Concomitant use with COXANTO may diminish the antihypertensive effect of these drugs. Monitor blood pressure (7)
• ACE Inhibitors and ARBs: Concomitant use with COXANTO in elderly, volume depleted, or those with renal impairment may result in deterioration of renal function. In such high risk patients, monitor for signs of worsening renal function (7)
• Diuretics: NSAIDs can reduce natriuretic effect of furosemide and thiazide diuretics. Monitor patients to assure diuretic efficacy including antihypertensive effects (7)
• Digoxin: Concomitant use with COXANTO can increase serum concentration and prolong half-life of digoxin. Monitor serum digoxin levels (7)

Specifications

• Dosage Forms: Capsules
• Strength: 300 mg

Product Usage Instructions

DOSAGE AND ADMINISTRATION
General Dosing Instructions
Carefully consider the potential benefits and risks of COXANTO and other treatment options before deciding to use COXANTO. Use the lowest effective dosage for the shortest duration consistent with individual patient treatment goals. Different dose strengths and formulations (e.g., capsules, tablets) of oral oxaprozin are not interchangeable. This difference should be taken into consideration when changing strengths or formulations. The highest daily dose for COXANTO is 1,200 mg a day.

Osteoarthritis
For osteoarthritis (OA), the recommended dosage is 1,200 mg (four 300 mg capsules) given orally once a day.

Rheumatoid Arthritis
For rheumatoid arthritis (RA), the recommended dosage is 1,200 mg (four 300 mg capsules) given orally once a day.

Juvenile Rheumatoid Arthritis
For juvenile rheumatoid arthritis (JRA) in patients 6 to 16 years of age, the recommended dosage should be based on the body weight of the patient as given in Table 1.

Recommended Daily Dose of COXANTO by Body Weight in Pediatric Patients

Individualization of Dosage
After observing the response to initial therapy with COXANTO, the dose and frequency should be adjusted to suit an individual patient’s needs. In osteoarthritis and rheumatoid arthritis and juvenile rheumatoid arthritis, the dosage should be individualized to the lowest effective dose of COXANTO to minimize adverse effects. The maximum recommended total daily dose of COXANTO in adults and pediatric patients is 1,200 mg. Patients with low body weight should initiate therapy with 600 mg once daily. Patients with  severe renal impairment or on dialysis should also initiate therapy with 600 mg once daily. If there is insufficient relief of symptoms in such patients, the dose may be cautiously increased to 1,200 mg, but only with close monitoring [see Clinical Pharmacology (12.3)]. Physicians should ensure that patients are tolerating lower doses without gastroentero logic, renal, hepatic, or dermatologic adverse effects before advancing to larger doses. Most patients will tolerate once-a-day dosing with COXANTO, although divided doses may be tried in patients unable to tolerate single doses.

DOSAGE FORMS AND STRENGTHS
COXANTO (oxaprozin) capsules: 300 mg capsules, white opaque capsule imprinted “403” on the cap in black ink.

CONTRAINDICATIONS
COXANTO is contraindicated in the following patients:

• Known hypersensitivity (e.g., anaphylactic reactions and serious skin reactions) to oxaprozin or any components of the drug product [see Warnings and Precautions (5.7, 5.9)]
• History of asthma, urticaria, or other allergic-type reactions after taking aspirin or other NSAIDs. Severe, sometimes fatal, anaphylactic reactions to NSAIDs have been reported in such patients [see Warnings and Precautions (5.7, 5.8)]
• In the setting of CABG surgery [see Warnings and Precautions (5.1)]

WARNINGS AND PRECAUTIONS
Cardiovascular Thrombotic Events
Clinical trials of several cyclooxygenase-2 (COX-2) selective and nonselective NSAIDs of up to three years duration have shown an increased risk of serious cardiovascular (CV) thrombotic events, including myocardial infarction (MI) and stroke, which can be fatal. Based on available data, it is unclear that the risk for CV thrombotic events is similar for all NSAIDs. The relative increase in serious CV thrombotic events over baseline conferred by NSAID use appears to be similar in those with and without known CV disease or risk factors for CV disease. However, patients with known CV disease or risk factors had a higher absolute incidence of excess serious CV thrombotic events, due to their increased baseline rate. Some observational studies found that this increased risk of serious CV thrombotic events began as early as the first weeks of treatment. The increase in CV thrombotic risk has been observed most consistently at higher doses. To minimize the potential risk for an adverse CV event in NSAID-treated patients, use the lowest effective dose for the shortest duration possible. Physicians and patients should remain alert for the development of such events, throughout the entire treatment course, even in the absence of previous CV symptoms. Patients should be informed about the symptoms of serious CV events and the steps to take if they occur. There is no consistent evidence that concurrent use of aspirin mitigates the increased risk of serious CV thrombotic events associated with NSAID use. The concurrent use of aspirin and an NSAID, such as oxaprozin, increases the risk of serious gastrointestinal (GI) events [see Warnings and Precautions (5.2)].

Status Post Coronary Artery Bypass Graft (CABG) Surgery
Two large, controlled clinical trials of a COX-2 selective NSAID for the treatment of pain in the first 10 to 14 days following CABG surgery found an increased incidence of myocardial infarction and stroke. NSAIDs are contraindicated in the setting of CABG [see Contraindications (4)].

Post-MI Patients
Observational studies conducted in the Danish National Registry have demonstrated that patients treated with NSAIDs in the post-MI period were at increased risk of reinfarction, CV-related death, and all-cause mortality beginning in the first week of treatment. In this same cohort, the incidence of death in the first year post-MI was 20 per 100 person years in NSAID- treated patients compared to12 per 100 person years in non-NSAID exposed patients. Although the absolute rate of death declined somewhat after the first year post-MI, the increased relative risk of death in NSAID users persisted over at least the next four years of follow-up. Avoid the use of COXANTO in patients with a recent MI unless the benefits are expected to outweigh the risk of recurrent CV thrombotic events. If COXANTO is used in patients with a recent MI, monitor patients for signs of cardiac ischemia.

Gastrointestinal Bleeding, Ulceration, and Perforation

NSAIDs, including COXANTO, cause serious gastrointestinal (GI) adverse events including inflammation, bleeding, ulceration, and perforation of the esophagus, stomach, small intestine, or large intestine, which can be fatal. These serious adverse events can occur at any time, with or without warning symptoms, in patients treated with NSAIDs. Only one in five patients, who develop a serious upper GI adverse event on NSAID therapy, is symptomatic. Upper GI ulcers, gross bleeding, or perforation caused by NSAIDs occurred in approximately 1% of patients treated for 3 to 6 months, and in about 2% to 4% of patients treated for one year. However, even short-term NSAID therapy is not without risk.

Risk Factors for GI Bleeding, Ulceration, and Perforation
Patients with a prior history of peptic ulcer disease and/or GI bleeding who used NSAIDs had a greater than 10-times increased risk for developing a GI bleed compared to patients without these risk factors. Other factors that increase the risk of GI bleeding in patients treated with NSAIDs include longer duration of NSAID therapy; concomitant use of oral corticosteroids, antiplatelet drugs (such as  aspirin), anticoagulants, or selective serotonin reuptake inhibitors (SSRIs); smoking; use of alcohol; older age; and poor general health status. Most postmarketing reports of fatal GI events occurred in elderly or debilitated patients. Additionally, patients with advanced liver disease and/or coagulopathy are at increased risk for GI bleeding.

Strategies to Minimize the GI Risks in NSAID-treated patients

• Use the lowest effective dosage for the shortest possible duration.
• Avoid administration of more than one NSAID at a time.
• Avoid use in patients at higher risk unless benefits are expected to outweigh the increased risk of bleeding. For such patients, as well as those with active GI bleeding, consider alternate therapies other than NSAIDs.
• Remain alert for signs and symptoms of GI ulceration and bleeding during NSAID therapy.
• If a serious GI adverse event is suspected, promptly initiate evaluation and treatment, and discontinue COXANTO until a serious GI adverse event is ruled out.
• In the setting of concomitant use of low-dose aspirin for cardiac prophylaxis, monitor patients more closely for evidence of GI bleeding [see Drug Interactions (7)].

Hepatotoxicity
Elevations of alanine aminotransferase (ALT) or aspartate aminotransferase (AST) (three or more times the upper limit of normal [ULN]) have been reported in approximately 1% of NSAID-treated patients in clinical trials. In addition, rare, sometimes fatal, cases of severe hepatic injury, including fulminant hepatitis, liver necrosis, and hepatic failure have been reported. Elevations of ALT or AST (less than three times ULN) may occur in up to 15% of patients treated with NSAIDs including oxaprozin. Inform patients of the warning signs and symptoms of hepatotoxicity (e.g., nausea, fatigue, lethargy, diarrhea, pruritus, jaundice, right upper quadrant tenderness, and “flu-like” symptoms). If clinical signs and symptoms consistent with liver disease develop, or if systemic manifestations occur (e.g., eosinophilia, rash), discontinue COXANTO immediately, and perform a clinical evaluation of the patient.

Hypertension
NSAIDSs, including COXANTO, can lead to new onset of hypertension or worsening of preexisting hypertension, either of which may contribute to the increased incidence of CV events. Patients taking angiotensin converting enzyme (ACE) inhibitors, thiazide diuretics, or loop diuretics may have impaired response to these therapies when taking NSAIDs [see Drug Interactions (7)]. Monitor blood pressure (BP) during the initiation of NSAID treatment and throughout the course of therapy.

Heart Failure and Edema
The Coxib and traditional NSAID Trialists’ Collaboration meta-analysis of randomized controlled trials demonstrated an approximately two-fold increase in hospitalizations for heart failure in COX-2 selective-treated patients and nonselective NSAID-treated patients compared to placebo-treated patients. In a Danish National Registry study of patients with heart failure, NSAID use increased the risk of MI, hospitalization for heart failure, and death. Additionally, fluid retention and edema have been observed in some patients treated with NSAIDs. Use of oxaprozin may blunt the CV effects of several therapeutic agents used to treat these medical conditions (e.g., diuretics, ACE inhibitors, or angiotensin receptor blockers [ARBs]) [see Drug Interactions (7)]. Avoid the use of COXANTO in patients with severe heart failure unless the benefits are expected to outweigh the risk of worsening heart failure. If COXANTO is used in patients with severe heart failure, monitor patients for signs of worsening heart failure.

Renal Toxicity and Hyperkalemia
Renal Toxicity
Long-term administration of NSAIDs has resulted in renal papillary necrosis and other renal injury. Renal toxicity has also been seen in patients in whom renal prostaglandins have a compensatory role in the maintenance of renal perfusion. In these patients, administration of an NSAID may cause a dose- dependent reduction in prostaglandin formation and, secondarily, in renal blood flow, which may precipitate overt renal decompensation. Patients at greatest risk of this reaction are those with impaired renal function, dehydration, hypovolemia, heart failure, liver dysfunction, those taking diuretics and ACE inhibitors or ARBs, and the elderly. Discontinuation of NSAID therapy is usually followed by recovery to the pretreatment state. No information is available from controlled clinical studies regarding the use of COXANTO in patients with advanced renal disease. The renal effects of COXANTO may hasten the progression of renal dysfunction in patients with preexisting renal disease. Correct volume status in dehydrated or hypovolemic patients prior to initiating COXANTO. Monitor renal function in patients with renal or hepatic impairment, heart failure, dehydration, or hypovolemia during use of COXANTO [see Drug Interactions (7)]. Avoid the use of COXANTO in patients with advanced renal disease unless the benefits are expected to outweigh the risk of worsening renal function. If COXANTO is used in patients with advanced renal disease, monitor patients for signs of worsening renal function.

Hyperkalemia
Increases in serum potassium concentration, including hyperkalemia, have been reported with use of NSAIDs even in some patients without renal impairment. In patients with normal renal function, these effects have been attributed to a hyporeninemic-hypoaldosteronism state.

Anaphylactic Reactions
Oxaprozin has been associated with anaphylactic reactions in patients with and without known hypersensitivity to oxaprozin and in patients with aspirin- sensitive asthma [see Contraindications (4) and Warnings and Precautions (5.8)]. Seek emergency help if an anaphylactic reaction occurs.

Exacerbation of Asthma Related to Aspirin Sensitivity
A subpopulation of patients with asthma may have aspirin-sensitive asthma which may include chronic rhinosinusitis complicated by nasal polyps; severe, potentially fatal bronchospasm; and/or intolerance to aspirin and other NSAIDs. Because cross-reactivity between aspirin and other NSAIDs has been reported in such aspirin-sensitive patients, COXANTO is contraindicated in patients with this form of aspirin sensitivity [see Contraindications (4)]. When COXANTO is used in patients with preexisting asthma (without known aspirin sensitivity), monitor patients for changes in the signs and symptoms of asthma.

Serious Skin Reactions
NSAIDs, including oxaprozin, can cause serious skin adverse reactions such as exfoliative dermatitis, Stevens-Johnson Syndrome (SJS), and toxic epidermal necrolysis (TEN), which can be fatal. These serious events may occur without warning. Inform patients about the signs and symptoms of serious skin reactions, and to discontinue the use of COXANTO at the first appearance of skin rash or any other sign of hypersensitivity. COXANTO is contraindicated in patients with previous serious skin reactions to NSAIDs [see Contraindications (4)].

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)
Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) has been reported in patients taking NSAIDs such as COXANTO. Some of these events have been fatal or life-threatening. DRESS typically, although not exclusively, presents with fever, rash, lymphadenopathy, and/or facial swelling. Other clinical manifestations may include hepatitis, nephritis, hematological abnormalities, myocarditis, or myositis. Sometimes symptoms of DRESS may resemble an acute viral infection. Eosinophilia is often present. Because this disorder is variable in its presentation, other organ systems not noted here may be involved. It is important to note that early manifestations of hypersensitivity, such as fever or lymphadenopathy, may be present even though rash is not evident. If such signs or symptoms are present, discontinue COXANTO and evaluate the patient immediately.

Fetal Toxicity
Premature Closure of Fetal Ductus Arteriosus
Avoid use of NSAIDs, including COXANTO, in pregnant women at about 30 weeks gestation and later. NSAIDs, including COXANTO, increase the risk of premature closure of the fetal ductus arteriosus at approximately this gestational age [see Use in Specific Populations (8.1)].

Oligohydramnios/Neonatal Renal Impairment
Use of NSAIDs, including COXANTO, at about 20 weeks gestation or later in pregnancy may cause fetal renal dysfunction leading to oligohydramnios and, in some cases, neonatal renal impairment. These adverse outcomes are seen, on average, after days to weeks of treatment, although oligohydramnios has been infrequently reported as soon as 48 hours after NSAID initiation. Oligohydramnios is often, but not always, reversible with treatment discontinuation. Complications of prolonged oligohydramnios may, for example, include limb contractures and delayed lung maturation. In some postmarketing cases of impaired neonatal renal function, invasive procedures such as exchange transfusion or dialysis were required.
If NSAID treatment is necessary between about 20 weeks and 30 weeks gestation, limit COXANTO use to the lowest effective dose and shortest duration possible. Consider ultrasound monitoring of amniotic fluid if COXANTO treatment extends beyond 48 hours. Discontinue COXANTO if oligohydramnios occurs and follow up according to clinical practice [see Use in Specific Populations (8.1)].

Hematologic Toxicity
Anemia has occurred in NSAID-treated patients. This may be due to occult or gross blood loss, fluid retention, or an incompletely described effect on erythropoiesis. If a patient treated with COXANTO has any signs or symptoms of anemia, monitor hemoglobin or hematocrit. NSAIDs, including COXANTO, may increase the risk of bleeding events. Co-morbid conditions such as coagulation disorders or concomitant use of warfarin, other anticoagulants, antiplatelet drugs (e.g., aspirin), SSRIs, and serotonin norepinephrine reuptake inhibitors (SNRIs) may increase this risk. Monitor these patients for signs of bleeding [see Drug Interactions (7)].

Masking of Inflammation and Fever
The pharmacological activity of COXANTO in reducing inflammation, and possibly fever, may diminish the utility of diagnostic signs in detecting infections.

Laboratory Monitoring
Because serious GI bleeding, hepatotoxicity, and renal injury can occur without warning symptoms or signs, consider monitoring patients on long-term NSAID treatment with a complete blood count (CBC) and a chemistry profile periodically [see Warnings and Precautions (5.2, 5.3, 5.6)].

Photosensitivity
Oxaprozin has been associated with rash and/or mild photosensitivity in dermatologic testing. An increased incidence of rash on sun-exposed skin was seen in some patients in the clinical trials.

ADVERSE REACTIONS **

**

The most common adverse reactions (incidence > 3%) associated with COXANTO are constipation, diarrhea, dyspepsia, nausea, and rash. If you experience any suspected adverse reactions, please contact Solubiomix, LLC. at 1-844-551-9911 or FDA at 1-800-FDA-1088 or visit www.fda.gov/medwatch.

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

• Cardiovascular Thrombotic Events [see Warnings and Precautions (5.1)]
• GI Bleeding, Ulceration and Perforation [see Warnings and Precautions (5.2)]
• Hepatoxicity [see Warnings and Precautions (5.3)]
• Hypertension [see Warnings and Precautions (5.4)]
• Heart Failure and Edema [see Warnings and Precautions (5.5)]
• Renal Toxicity and Hyperkalemia [see Warnings and Precautions (5.6)]
• Anaphylactic Reactions [see Warnings and Precautions (5.7)]
• Serious Skin Reactions [see Warnings and Precautions (5.9)]
• Hematologic Toxicity [see Warnings and Precautions (5.12)]

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. Adverse reaction data were derived from patients who received oxaprozin, the active component of COXANTO, in multidose, controlled, and open-label clinical trials. Rates for events from clinical trial experience are based on 2253 patients who took 1,200 mg to 1,800 mg of the active component of COXANTO per day in clinical trials. Of these, 1721 patients were treated for at least 1 month, 971 patients for at least 3 months, and 366 patients for more than 1 year.

• Incidence Greater than 1%: In clinical trials of oxaprozin, the active component of COXANTO, or in patients taking other NSAIDs, the following adverse reactions occurred at an incidence greater than 1%.

• Cardiovascular system: edema.

• Digestive system: abdominal pain/distress, anorexia, constipation, diarrhea, dyspepsia, flatulence, gastrointestinal ulcers (gastric/duodenal), gross bleeding/perforation, heartburn, liver enzyme elevations, nausea, vomiting.

• Hematologic system: anemia, increased bleeding time.

• Nervous system: CNS inhibition (depression, sedation, somnolence, or confusion), disturbance of sleep, dizziness, headache.

• Skin and appendages: pruritus, rash.

• Special senses: tinnitus.

• Urogenital system: abnormal renal function, dysuria or frequency.

• Incidence Greater than 1%: The following adverse reactions were reported in clinical trials or in patients taking other NSAIDs.

• Body as a whole: appetite changes, death, drug hypersensitivity reactions including anaphylaxis, fever, infection, sepsis.

• Cardiovascular system: arrhythmia, blood pressure changes, congestive heart failure, hypertension, hypotension, myocardial infarction, palpitations, tachycardia, syncope, vasculitis.

• Digestive system: alteration in taste, dry mouth, eructation, esophagitis, gastritis, glossitis, hematemesis, jaundice, liver function abnormalities including liver failure, stomatitis, hemorrhoidal or rectal bleeding.

• Hematologic system: aplastic anemia, ecchymoses, eosinophilia, hemolytic anemia, lymphadenopathy, melena, purpura, thrombocytopenia, leukopenia.

• Metabolic system: hyperglycemia, weight changes.

• Nervous system: anxiety, asthenia, coma, convulsions, dream abnormalities, drowsiness, hallucinations, insomnia, malaise, meningitis, nervousness, paresthesia, tremors, vertigo, weakness.

• Respiratory system: asthma, dyspnea, pulmonary infections, pneumonia, sinusitis, symptoms of upper respiratory tract infection, respiratory depression.
  Skin: alopecia, angioedema, urticaria, photosensitivity, sweat.

• Special senses: blurred vision, conjunctivitis, hearing decrease.

• Urogenital: cystitis, hematuria, increase in menstrual flow, oliguria/ polyuria, proteinuria, renal insufficiency, decreased menstrual flow.

Adverse Reactions in Pediatric Patients with Juvenile Rheumatoid Arthritis
In a 3-month open label study in 59 pediatric patients with juvenile rheumatoid arthritis treated with oxaprozin, the active component of COXANTO, adverse events were reported by 58% of patients. Gastrointestinal symptoms were the most frequently reported adverse effects and occurred at a higher incidence than those historically seen in controlled studies in adults. Of 30 patients who continued treatment for more than 3 months (19 to 48 weeks range total treatment duration), nine
(30%) experienced rash on sun-exposed areas of the skin and five of those discontinued treatment.

Postmarketing Experience
The following adverse reactions have been identified during post approval use of oxaprozin, the active component of COXANTO. 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. Body as a whole: serum sickness. Digestive system: hepatitis, pancreatitis.
Hematologic system: agranulocytosis, pancytopenia.
Skin: pseudoporphyria, exfoliative dermatitis, erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis (Lyell’s syndrome).
Urogenital: acute interstitial nephritis, nephrotic syndrome, acute renal failure.

DRUG INTERACTIONS

See Table 2 for clinically significant drug interactions with oxaprozin [see Clinical Pharmacology (12.3)].

Clinically Significant Drug Interactions with Oxaprozin

Drugs That Interfere with Hemostasis

****Clinical Impact:|

• Oxaprozin and anticoagulants such as warfarin have a synergistic effect on bleeding. The concomitant use of oxaprozin and anticoagulants have an increased risk of serious bleeding compared to the use of either drug alone.
•  Serotonin release by platelets plays an important role in hemostasis. Case- control and cohort epidemiological studies showed that concomitant use of drugs that interfere with serotonin reuptake and an NSAID may potentiate the risk of bleeding more than an NSAID alone.

**Intervention:| Monitor patients with concomitant use of COXANTO with anticoagulants (e.g., warfarin), antiplatelet drugs (e.g., aspirin), SSRIs, and SNRIs for signs of bleeding [ see Warnings and Precautions (5.12) ].
Aspirin
**Clinical Impact:| Controlled clinical studies showed that the concomitant use of NSAIDs and analgesic doses of aspirin does not produce any greater therapeutic effect than the use of NSAIDs alone. In a clinical study, the concomitant use of an NSAID and aspirin was associated with a significantly increased incidence of GI adverse reactions as compared to use of the NSAID alone [ see Warnings and Precautions (5.2) ].
****Intervention:| Concomitant use of COXANTO and analgesic doses of aspirin is not generally recommended because of the increased risk of bleeding [ see Warnings and Precautions (5.12) ]. COXANTO is not a substitute for low dose aspirin for cardiovascular protection.
ACE Inhibitors, Angiotensin Receptor Blockers, and Beta-Blockers
****Clinical Impact:| NSAIDs may diminish the antihypertensive effect of ACE inhibitors, ARBs, or beta-blockers (including propranolol).

• In patients who are elderly, volume-depleted (including those on diuretic therapy), or have renal impairment, co-administration of an NSAID with ACE inhibitors or ARBs may result in deterioration of renal function, including possible acute renal failure. These effects are usually reversible.

**** Intervention|

• During concomitant use of COXANTO and ACE inhibitors, ARBs, or beta- blockers, monitor blood pressure to ensure that the desired blood pressure is obtained.
• During concomitant use of COXANTO and ACE inhibitors or ARBs in patients who are elderly, volume-depleted, or have impaired renal function, monitor for signs of worsening renal function [ see Warnings and Precautions (5.6) ] .
  When these drugs are administered concomitantly, patients should be adequately hydrated. Assess renal function at the beginning of the concomitant treatment and periodically thereafter.

---|---
Diuretics
Clinical Impact:| Clinical studies, as well as post-marketing observations, showed that NSAIDs reduced the natriuretic effect of loop diuretics (e.g., furosemide) and thiazide diuretics in some patients. This effect has been attributed to the NSAID inhibition of renal prostaglandin synthesis.
Intervention:| During concomitant use of COXANTO with diuretics, observe patients for signs of worsening renal function, in addition to assuring diuretic efficacy including antihypertensive effects [ see Warnings and Precautions (5.6) ].
Digoxin
Clinical Impact:| The concomitant use of oxaprozin with digoxin has been reported to increase the serum concentration and prolong the half-life of digoxin.
Intervention:| During concomitant use of COXANTO and digoxin, monitor serum digoxin levels.
Lithium
**Clinical Impact:| NSAIDs have produced elevations in plasma lithium levels and reductions in renal lithium clearance . The mean minimum lithium concentration increased 15%, and the renal clearance decreased by approximately 20%. This effect has been attributed to NSAID inhibition of renal prostaglandin synthesis.
Intervention:| During concomitant use of COXANTO and lithium, monitor patients for signs of lithium toxicity.
Methotrexate
**Clinical Impact| Concomitant use of NSAIDs and methotrexate may increase the risk for methotrexate toxicity (e.g., neutropenia, thrombocytopenia, renal dysfunction) because NSAID administration may result in increased plasma levels of methotrexate, especially in patients receiving high doses of methotrexate.
Intervention| During concomitant use of COXANTO and methotrexate, monitor patients for methotrexate toxicity.
Cyclosporine
Clinical Impact| Concomitant use of COXANTO and cyclosporine may increase cyclosporine’s nephrotoxicity.
Intervention:| During concomitant use of COXANTO and cyclosporine, monitor patients for signs of worsening renal function.
NSAIDs and Salicylates
**Clinical Impact:| Concomitant use of oxaprozin with other NSAIDs or salicylates (e.g., diflunisal, salsalate) increases the risk of GI toxicity, with little or no increase in efficacy [ see Warnings and Precautions (5.2) ] .
Intervention:| The concomitant use of oxaprozin with other NSAIDs or salicylates is not recommended.
Pemetrexed
**Clinical Impact:| Concomitant use of COXANTO and pemetrexed may increase the risk of pemetrexed-associated myelosuppression, renal, and GI toxicity (see the pemetrexed prescribing information).
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**Intervention:| During concomitant use of COXANTO and pemetrexed, in patients with renal impairment whose creatinine clearance ranges from 45 to 79 mL/min, monitor for myelosuppression, renal and GI toxicity. NSAIDs with short elimination half-lives (e.g., diclofenac, indomethacin) should be avoided for a period of two days before, the day of, and two days following administration of pemetrexed.In the absence of data regarding potential interaction between pemetrexed and NSAIDs with longer half-lives (e.g., meloxicam, nabumetone), patients taking these NSAIDs should interrupt dosing for at least five days before, the day of, and two days following pemetrexed administration.
Corticosteroids
Clinical Impact:| Concomitant use of corticosteroids with COXANTO may increase the risk of GI ulceration or bleeding.
Intervention:| Monitor patients with concomitant use of COXANTO with corticosteroids for signs of bleeding [ see Warnings and Precautions (5.2) ].
Glyburide
**Clinical Impact:| While oxaprozin does alter the pharmacokinetics of glyburide, coadministration of oxaprozin to type II non-insulin dependent diabetic patients did not affect the area under the glucose concentration curve nor the magnitude or duration of control.
Intervention:| During concomitant use of COXANTO and glyburide, monitor patient’s blood glucose in the beginning phase of cotherapy.

Laboratory Test Interactions
False-positive urine immunoassay screening tests for benzodiazepines have been reported in patients taking COXANTO. This is due to lack of specificity of the screening tests. False-positive test results may be expected for several days following discontinuation of COXANTO therapy. Confirmatory tests, such as gas chromatography/mass spectrometry, will distinguish COXANTO from benzodiazepines.

USE IN SPECIFIC POPULATIONS

Pregnancy
Risk Summary
Use of NSAIDs, including COXANTO, can cause premature closure of the fetal ductus arteriosus and fetal renal dysfunction leading to oligohydramnios and, in some cases, neonatal renal impairment. Because of these risks, limit dose and duration of COXANTO use between about 20 and 30 weeks of gestation and avoid COXANTO use at about 30 weeks of gestation and later in pregnancy (see Clinical Considerations, Data).
Premature Closure of Fetal Ductus Arteriosus
Use of NSAIDs, including COXANTO, at about 30 weeks gestation or later in pregnancy increases the risk of premature closure of the fetal ductus arteriosus. Oligohydramnios/Neonatal Renal Impairment Use of NSAIDs at about 20 weeks gestation or later in pregnancy has been associated with cases of fetal renal dysfunction leading to oligohydramnios, and in some cases, neonatal renal impairment. Data from observational studies regarding other potential embryofetal risks of NSAID use in women in the first or second trimesters of pregnancy are inconclusive. In animal reproduction studies, oral administration of oxaprozin to pregnant rabbits at doses 0.1 times the maximum daily human dose (based on body surface area) resulted in evidence of teratogenicity; however, oral administration of oxaprozin to pregnant mice and rats during organogenesis at doses 0.2 times and 1.6 times the maximum recommended human dose, respectively, revealed no evidence of teratogenicity or embryotoxicity. In rat reproduction studies in which oxaprozin was administered through late gestation failure to deliver and a reduction in live birth index was observed at a dose 1.6 times the maximum recommended human dose (based on body surface area). Based on animal data, prostaglandins have been shown to have an important role in endometrial vascular permeability, blastocyst implantation, and decidualization. In animal studies, administration of prostaglandin synthesis inhibitors such as oxaprozin, resulted in increased pre- and post-implantation loss. Prostaglandins also have been shown to have an important role in fetal kidney development. In published animal studies, prostaglandin synthesis inhibitors have been reported to impair kidney development when administered at clinically relevant doses.
The background risk of major birth defects and miscarriage for the indicated population(s) is 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% to 4% and 15% to 20%, respectively.

Clinical Considerations
Fetal/Neonatal Adverse Reactions

Premature Closure of Fetal Ductus Arteriosus:
Avoid use of NSAIDs in women at about 30 weeks gestation and later in pregnancy, because NSAIDs, including COXANTO, can cause premature closure of the fetal ductus arteriosus (see Data).

Oligohydramnios/Neonatal Renal Impairment:
If an NSAID is necessary at about 20 weeks gestation or later in pregnancy, limit the use to the lowest effective dose and shortest duration possible. If COXANTO treatment extends beyond 48 hours, consider monitoring with ultrasound for oligohydramnios. If oligohydramnios occurs, discontinue COXANTO and follow up according to clinical practice (see Data).
Labor or Delivery
There are no studies on the effects of COXANTO during labor or delivery. In animal studies, NSAIDS, including oxaprozin, inhibit prostaglandin synthesis, cause delayed parturition, and increase the incidence of stillbirth.

Data
Human Data

Premature Closure of Fetal Ductus Arteriosus:
Published literature reports that the use of NSAIDs at about 30 weeks of gestation and later in pregnancy may cause premature closure of the fetal ductus arteriosus.

Oligohydramnios/Neonatal Renal Impairment:
Published studies and postmarketing reports describe maternal NSAID use at about 20 weeks gestation or later in pregnancy associated with fetal renal dysfunction leading to oligohydramnios, and in some cases, neonatal renal impairment. These adverse outcomes are seen, on average, after days to weeks of treatment, although oligohydramnios has been infrequently reported as soon as 48 hours after NSAID initiation. In many cases, but not all, the decrease in amniotic fluid was transient and reversible with cessation of the drug. There have been a limited number of case reports of maternal NSAID use and neonatal renal dysfunction without oligohydramnios, some of which were irreversible. Some cases of neonatal renal dysfunction required treatment with invasive procedures, such as exchange transfusion or dialysis. Methodological limitations of these postmarketing studies and reports include lack of a control group; limited information regarding dose, duration, and timing of drug exposure; and concomitant use of other medications. These limitations preclude establishing a reliable estimate of the risk of adverse fetal and neonatal outcomes with maternal NSAID use. Because the published safety data on neonatal outcomes involved mostly preterm infants, the generalizability of certain reported risks to the full-term infant exposed to NSAIDs through maternal use is uncertain.
Animal data
Teratology studies with oxaprozin were performed in mice, rats, and rabbits in pregnant animals administered oral doses up to 200 mg/kg/day, 200 mg/kg/day, and 30 mg/kg/day, respectively, during the period of organogenesis. In rabbits, malformations were observed at doses greater than or equal to 7.5 mg/kg/day of oxaprozin (0.1 times the maximum recommended human daily dose [MRHD] of 1,200 mg based on body surface area). However, in mice and rats, no drug-related developmental abnormalities or embryo-fetal toxicity were observed at doses up to 50 and 200 mg/kg/day of oxaprozin, respectively (0.2 times and 1.6 times the maximum recommended human daily dose of 1,200 mg based on a body surface area comparison, respectively). In fertility/reproductive studies in rats, 200 mg/kg/day oxaprozin was orally administered to female rats for 14 days prior to mating through lactation day (LD) 2, or from gestation day (GD) 15 through LD 2 and the females were mated with males treated with 200 mg/kg/day oxaprozin for 60 days prior to mating. Oxaprozin administration resulted in failure to deliver and a reduction in live birth index at 200 mg/kg/day (1.6 times the maximum recommended human daily dose of 1,200 mg based on a body surface area comparison).

Lactation
Risk Summary
There are no data on the presence of oxaprozin in human milk, the effects on the breastfed infant, or the effect on milk production. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for COXANTO and any potential adverse effects on the breastfed infant from the COXANTO or from the underlying maternal condition.

Females and Males of Reproductive Potential
Infertility
Females
Based on the mechanism of action, the use of prostaglandin-mediated NSAIDs, including COXANTO, may delay or prevent rupture of ovarian follicles, which has been associated with reversible infertility in some women. Published animal studies have shown that administration of prostaglandin synthesis inhibitors has the potential to disrupt prostaglandin-mediated follicular rupture required for ovulation. Small studies in women treated with NSAIDs have also shown a reversible delay in ovulation.  Consider withdrawal of NSAIDs, including COXANTO, in women who have difficulties conceiving or who are undergoing investigation of infertility.
Males
Testicular degeneration was observed in beagle dogs treated with 37.5 mg/kg/day (1.0 times the maximum recommended human daily dose based on body surface area) of oxaprozin for 42 days or 6 months [see Nonclinical Toxicology (13.1)]

Pediatric Use
Safety and effectiveness of oxaprozin, the active component of the COXANTO, have been established for the treatment of the signs and symptoms of juvenile rheumatoid arthritis (JRA) in pediatric patients aged 6 to 16 years. Use of oxaprozin for this indication is supported by evidence from one open label study in 59 pediatric JRA patients and evidence from adequate and well controlled studies in adult rheumatoid arthritis patients [see Clinical Studies (14.1, 14.2, 14.3)]. Gastrointestinal symptoms occurred in pediatric patients at a higher incidence than those historically seen in controlled studies in adults. Of 30 patients in the pediatric JRA trial who continued treatment more than 3 months (19 to 48 weeks range total treatment duration), nine experienced rash on sun-exposed areas of the skin and five of those discontinued treatment [see Adverse Reactions (6.1)]. Safety and effectiveness of COXANTO in pediatric patients below the age of 6 years of age have not been established.

Geriatric Use
Elderly patients, compared to younger patients, are at greater risk for NSAID- associated serious cardiovascular, gastrointestinal, and/or renal adverse reactions. If the anticipated benefit for the elderly patient outweighs these potential risks, start dosing at the low end of the dosing range, and monitor patients for adverse effects [see Warnings and Precautions (5.1, 5.2, 5.3, 5.6, 5.14)]. No adjustment of the dose of COXANTO is necessary in the elderly, although many elderly may need to receive a reduced dose because of low body weight or disorders associated with aging [see Clinical Pharmacology (12.3)]. Of the total number of subjects evaluated in four placebo controlled clinical studies of oxaprozin, 39% were 65 and over, and 11% were 75 and over. No overall differences in safety or effectiveness were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out. Although selected elderly patients in controlled clinical trials tolerated oxaprozin as well as younger patients, caution should be exercised in treating the elderly. COXANTO is substantially excreted by the kidney, and the risk of toxic reactions to COXANTO may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function [see Warnings and Precautions (5.6)].

OVERDOSAGE
Symptoms following acute NSAID overdosages have been typically limited to lethargy, drowsiness, nausea, vomiting, and epigastric pain, which have been generally reversible with supportive care. Gastrointestinal bleeding has occurred. Hypertension, acute renal failure, respiratory depression, and coma have occurred, but were rare [see Warnings and Precautions (5.1, 5.2, 5.4, 5.6)]. Manage patients with symptomatic and supportive care following an NSAID overdosage. There are no specific antidotes. Consider emesis and/or activated charcoal (60 grams to 100 grams in adults, 1 gram to 2 grams per kg of body weight in pediatric patients) and/or osmotic cathartic in symptomatic patients seen within four hours of ingestion or in patients with a large overdosage (5 to 10 times the recommended dosage). Forced diuresis, alkalinization of urine, hemodialysis, or hemoperfusion may not be useful due to high protein binding. For additional information about overdosage treatment contact a poison control center (1-800-222-1222).

DESCRIPTION

COXANTO (oxaprozin) is a nonsteroidal anti-inflammatory drug, available as capsules of 300 mg for oral administration. The chemical name is 4,5-diphenyl-2-oxazole-propionic acid. The molecular weight is 293.32 g/mol. Its molecular formula is C18H15NO3, and it has the following chemical structure.

Oxaprozin is a white to off-white powder with a slight odor and a melting point of 162°C to 163°C. It is slightly soluble in alcohol and insoluble in water, with an octanol/water partition coefficient of 4.8 at physiologic pH (7.4). The pKa in water is 4.3. The inactive ingredients in COXANTO include: microcrystalline cellulose, pregelatinized corn starch, hypromellose 2910, sodium starch glycolate, stearic acid, and silicon dioxide, in gelatin capsules. COXANTO 300 mg capsules are white opaque capsules imprinted “403” on the cap in black ink.

CLINICAL PHARMACOLOGY

Mechanism of Action
Oxaprozin has analgesic, anti-inflammatory, and antipyretic properties. The mechanism of action of COXANTO, like that of other NSAIDs, is not completely understood but involves inhibition of cyclooxygenase (COX-1 and COX-2). Oxaprozin is a potent inhibitor of prostaglandin synthesis in vitro. Oxaprozin concentrations reached during therapy have produced in vivo effects. Prostaglandins sensitize afferent nerves and potentiate the action of bradykinin in inducing pain in animal models. Prostaglandins are mediators of inflammation. Because oxaprozin is an inhibitor of prostaglandin synthesis, its mode of action may be due to a decrease of prostaglandins in peripheral tissues.

Pharmacokinetics
General Pharmacokinetic Characteristics
In dose proportionality studies utilizing 600 mg, 1,200 mg, and 1,800 mg doses, the pharmacokinetics of oxaprozin in healthy subjects demonstrated nonlinear kinetics of both the total and unbound drug in opposite directions, i.e., dose exposure related increase in the clearance of total drug and decrease in the clearance of the unbound drug. Decreased clearance of the unbound drug was related predominantly to a decrease in the volume of distribution of the unbound drug and not an increase in the elimination half- life. This phenomenon is considered to have minimal impact on drug accumulation upon multiple dosing. The pharmacokinetic parameters of oxaprozin in healthy subjects receiving a single dose of 600 mg (two 300 mg capsules) are presented in Table 3.
Oxaprozin Pharmacokinetic Parameters [Mean (%CV)] (600 mg)

Cmax: Maximum observed concentration occurring at the time Tmax
Tmax: Time of maximum observed concentration
AUC0-72: Area under the concentration curve (AUC) from the time zero to 72 hours

Absorption
COXANTO is 95% absorbed after oral administration. Food may reduce the rate of absorption of oxaprozin, but the extent of absorption is unchanged.

Distribution
The apparent volume of distribution (Vd/F) of total oxaprozin is approximately 11 to 17 L/70 kg. Oxaprozin is 99% bound to plasma proteins, primarily to albumin. At therapeutic drug concentrations, the plasma protein binding of oxaprozin is saturable, resulting in a higher proportion of the free drug as the total drug concentration is increased. With increases in single doses or following multiple once-daily dosing, the apparent volume of distribution and clearance of total drug increased, while that of unbound drug decreased due to the effects of nonlinear protein binding. Oxaprozin penetrates into synovial tissues of rheumatoid arthritis patients with oxaprozin concentrations 2-fold and 3-fold greater than in plasma and synovial fluid, respectively. Oxaprozin is expected to be excreted in human milk based on its physical-chemical properties; however, the amount of oxaprozin excreted in breast milk has not been evaluated.

Elimination
Metabolism
Several oxaprozin metabolites have been identified in human urine or feces.
Oxaprozin is primarily metabolized in the liver, by both microsomal oxidation (65%) and glucuronic acid conjugation (35%). Ester and ether glucuronide are the major conjugated metabolites of oxaprozin. On chronic dosing, metabolites do not accumulate in the plasma of patients with normal renal function. Concentrations of the metabolites in plasma are very low. Oxaprozin’s metabolites do not have significant pharmacologic activity. The major ester and ether glucuronide conjugated metabolites have been evaluated along with oxaprozin in receptor binding studies and in vivo animal models and have demonstrated no activity. A small amount (<5%) of active phenolic metabolites are produced, but the contribution to overall activity is limited.
Excretion
Approximately 5% of the oxaprozin dose is excreted unchanged in the urine. Sixty-five percent (65%) of the dose is excreted in the urine and 35% in the feces as metabolites. Biliary excretion of unchanged oxaprozin is a minor pathway, and enterohepatic recycling of oxaprozin is insignificant. Upon chronic dosing, the accumulation half-life is approximately 22 hours. The elimination half-life is approximately twice the accumulation half-life due to increased binding and decreased clearance at lower concentrations.

Specific Populations
Geriatric: A multiple dose study comparing the pharmacokinetics of oxaprozin (1,200 mg once daily) in 20 young (21 to 44 years) adults and 20 elderly (64 to 83 years) adults did not show any statistically significant differences between age groups.
Pediatric: A population pharmacokinetic study indicated no clinically important age dependent changes in the apparent clearance of unbound oxaprozin between adult rheumatoid arthritis patients (N=40) and juvenile rheumatoid arthritis (JRA) patients (≥6 years, N=44) when adjustments were made for differences in body weight between these patient groups. The extent of protein binding of oxaprozin at various therapeutic total plasma concentrations was also similar between the adult and pediatric patient groups. Pharmacokinetic model-based estimates of daily exposure (AUC0-24) to unbound oxaprozin in JRA patients relative to adult rheumatoid arthritis patients suggest dose to body weight range relationships, as shown in Table 4.
Dose to Body Weight Range to Achieve Similar Steady-State Exposure (AUC0-24hr) to Unbound Oxaprozin in JRA Patients Relative to 70 kg Adult

Rheumatoid Arthritis Patients Administered Oxaprozin 1,200 mg Once Daily1

1Model-based nomogram derived from unbound oxaprozin steady-state plasma concentrations in JRA patients weighing 22.1 – 42.7 kg or ≥45.0 kg administered oxaprozin 600 mg or 1,200 mg once daily for 14 days, respectively.
Race: Pharmacokinetic Differences due to race have not been identified.
Hepatic Impairment: Approximately 95% of oxaprozin is metabolized by the liver. However, patients with well-compensated cirrhosis do not require reduced doses of oxaprozin as compared to patients with normal hepatic function. Nevertheless, monitor patients with severe hepatic dysfunction for adverse reactions.
Renal Impairment: Oxaprozin’s renal clearance decreased proportionally with creatinine clearance (CrCL), but since only approximately 5% of oxaprozin dose is excreted unchanged in the urine, the decrease in total body clearance becomes clinically important only in those subjects with highly decreased CrCL. Oxaprozin is not significantly removed from the blood in patients undergoing hemodialysis or continuous ambulatory peritoneal dialysis (CAPD) due to its high protein binding. Oxaprozin plasma protein binding may decrease in patients with severe renal deficiency. Dosage adjustment may be necessary in patients with renal insufficiency [see Warnings and Precautions (5.6)].
Cardiac Failure: Well-compensated cardiac failure does not affect the plasma protein binding or the pharmacokinetics of oxaprozin.

Drug Interaction Studies
ACE inhibitors (enalapril): Oxaprozin has been shown to alter the pharmacokinetics of enalapril (significant decrease in dose-adjusted AUC0-24 and Cmax) and its active metabolite enalaprilat (significant increase in dose- adjusted AUC0-24) [see Drug Interactions (7)].
Aspirin: When oxaprozin was administered with aspirin, the protein binding of oxaprozin was reduced, although the clearance of free oxaprozin was not altered. The clinical significance of this interaction is not known. An in vitro study showed that oxaprozin significantly interfered with the anti- platelet activity of aspirin [see Drug Interactions (7)].
Beta-blockers (metoprolol): Subjects receiving 1,200 mg oxaprozin once daily with 100 mg metoprolol twice daily exhibited statistically significant but transient increases in sitting and standing blood pressures after 14 days [see Drug Interactions (7)].
Glyburide: Oxaprozin altered the pharmacokinetics of glyburide; however, coadministration of oxaprozin to type II non-insulin dependent diabetic patients did not affect the area under the glucose concentration curve nor the magnitude or duration of control [see Drug Interactions (7)].
H2-receptor antagonists (cimetidine, ranitidine): The total clearance of oxaprozin was reduced by 20% in subjects who concurrently received therapeutic doses of cimetidine or ranitidine; no other pharmacokinetic parameter was affected. A change of clearance of this magnitude lies within the range of normal variation and is unlikely to produce a clinically detectable difference in the outcome of therapy.
Lithium: Oxaprozin has produced an elevation in plasma lithium levels and a reduction in renal lithium clearance. The mean minimum lithium concentration increased 15%, and the renal clearance decreased by approximately 20% [see Drug Interactions (7)].
Methotrexate: Coadministration of oxaprozin with methotrexate resulted in approximately 36% reduction in apparent oral clearance of methotrexate [see Drug Interactions (7)].
Other drugs: The coadministration of oxaprozin and acetaminophen, or conjugated estrogens resulted in no statistically significant changes in pharmacokinetic parameters in single- and/or multiple-dose studies. The interaction of oxaprozin with cardiac glycosides has not been studied.

NONCLINICAL TOXICOLOGY

Carcinogenesis, Mutagenesis, Impairment of Fertility
Carcinogenesis
In carcinogenicity studies in rats and mice, oxaprozin administration for 2 years was associated with the exacerbation of liver neoplasms (hepatic adenomas and carcinomas) in male CD mice, but not in female CD mice or male or female rats treated with up to 216 mg/kg via the diet (1.7 times the maximum daily human dose of 1,200 mg based on body surface area). The significance of this species- specific finding to man is unknown.

Mutagenesis
Oxaprozin was not genotoxic in the Ames test, forward mutation in yeast and Chinese hamster ovary (CHO) cells, DNA repair testing in CHO cells, micronucleus testing in mouse bone marrow, chromosomal aberration testing in human lymphocytes, or cell transformation testing in mouse fibroblast.

Impairment of Fertility
Oxaprozin administration was not associated with impairment of fertility in male and female rats at oral doses up to 200 mg/kg/day (1.6 times the maximum recommended human daily dose [MRHD] of 1,200 mg based on a body surface area comparison). However, testicular degeneration was observed in beagle dogs treated with 37.5 mg/kg/day (1.0 times the MRHD based on body surface area) of oxaprozin for 42 days or 6 months, a finding not confirmed in other species. The clinical relevance of this finding is not known.

CLINICAL STUDIES

Osteoarthritis
Oxaprozin, the active component of COXANTO, was evaluated for the management of the signs and symptoms of osteoarthritis in a total of 616 patients in active controlled clinical trials against aspirin (N=464), piroxicam (N=102), and other NSAIDs. The active component of COXANTO was given both in variable (600 to 1,200 mg/day) and in fixed (1,200 mg/day) dosing schedules in either single or divided doses. In these trials, oxaprozin was found to be comparable to 2,600 to 3,200 mg/day doses of aspirin or 20 mg/day doses of piroxicam. Oxaprozin was effective both in once daily and in divided dosing schedules. In controlled clinical trials several days of oxaprozin therapy were needed for the drug to reach its full effects [see Dosage and Administration (2.5)].

Rheumatoid Arthritis
Oxaprozin, the active component of COXANTO, was evaluated for managing the signs and symptoms of rheumatoid arthritis in placebo and active controlled clinical trials in a total of 646 patients. Oxaprozin was given in single or divided daily doses of 600 to 1,800 mg/day and was found to be comparable to 2,600 to 3,900 mg/day of aspirin. At these doses there was a trend (over all trials) for oxaprozin to be more effective and cause fewer gastrointestinal side effects than aspirin. Oxaprozin was given as a once-a-day dose of 1,200 mg in most of the clinical trials, but larger doses (up to 26 mg/kg or 1,800 mg/day) were used in selected patients. In some patients, COXANTO may be better tolerated in divided doses. Due to its long half-life, several days of oxaprozin were needed for the drug to reach its full effect [see Dosage and Administration (2.5)].

Juvenile Rheumatoid Arthritis
In a 3-month open label study, 10 to 20 mg/kg/day of oxaprozin, the active component of COXANTO, were administered to 59 JRA patients. Fifty-two patients completed 3 months of treatment with a mean daily dose of 20 mg/kg [see Clinical Pharmacology (12.3)].

HOW SUPPLIED/STORAGE AND HANDLING
COXANTO (oxaprozin) capsules 300 mg are white opaque capsule imprinted “403” on the cap in black ink, supplied as:
NDC Number     Size
69499-403-60  bottle of 60

Storage
Keep bottles tightly closed. Store at room temperature 20°C to 25°C (68°F to 77°F); excursions permitted between 15°C to 30°C (59°F to 86°F) [see USP Controlled Room Temperature]. Dispense in a tight, light-resistant container with a child-resistant closure. Protect the unit dose from light.

PATIENT COUNSELING INFORMATION

Advise the patient to read the FDA-approved patient labeling (Medication Guide) that accompanies each prescription dispensed. Inform patients, families, or their caregivers of the following information before initiating therapy with COXANTO and periodically during the course of ongoing therapy

Cardiovascular Thrombotic Events
Advise patients to be alert for the symptoms of cardiovascular thrombotic events, including chest pain, shortness of breath, weakness, or slurring of speech, and to report any of these symptoms to their health care provider immediately [see Warnings and Precautions (5.1)].

Gastrointestinal Bleeding, Ulceration, and Perforation
Advise patients to report symptoms of ulcerations and bleeding, including epigastric pain, dyspepsia, melena, and hematemesis to their health care provider. In the setting of concomitant use of low-dose aspirin for cardiac prophylaxis, inform patients of the increased risk for and the signs and symptoms of GI bleeding [see Warnings and Precautions (5.2)].

Hepatotoxicity
Inform patients of the warning signs and symptoms of hepatotoxicity (e.g., nausea, fatigue, lethargy, pruritus, diarrhea, jaundice, right upper quadrant tenderness, and “flu-like” symptoms). If these occur, instruct patients to stop COXANTO and seek immediate medical therapy [see Warnings and Precautions (5.3)].

Heart Failure and Edema
Advise patients to be alert for the symptoms of congestive heart failure including shortness of breath, unexplained weight gain, or edema and to contact their healthcare provider if such symptoms occur [see Warnings and Precautions (5.5)].

Anaphylactic Reactions
Inform patients of the signs of an anaphylactic reaction (e.g., difficulty breathing, swelling of the face or throat). Instruct patients to seek immediate emergency help if these occur [see Contraindications (4) and Warnings and Precautions (5.7)].

Serious Skin Reactions, including DRESS
Advise patients to stop taking COXANTO immediately if they develop any type of rash or fever and to contact their healthcare provider as soon as possible [see Warnings and Precautions (5.9, 5.10)].

Female Fertility
Advise females of reproductive potential who desire pregnancy that NSAIDs, including COXANTO, may be associated with a reversible delay in ovulation [see Use in Specific Populations (8.3)].

Fetal Toxicity
Inform pregnant women to avoid use of COXANTO and other NSAIDs starting at 30 weeks gestation because of the risk of the premature closing of the fetal ductus arteriosus. If treatment with COXANTO is needed for a pregnant woman between about 20 to 30 weeks gestation, advise her that she may need to be monitored for oligohydramnios, if treatment continues for longer than 48 hours [see Warnings and Precautions (5.11) and Use in Specific Populations (8.1)].

Avoid Concomitant Use of NSAIDs
Inform patients that the concomitant use of COXANTO with other NSAIDs or salicylates (e.g., diflunisal, salsalate) is not recommended due to the increased risk of gastrointestinal toxicity, and little or no increase in efficacy [see Warnings and Precautions (5.2) and Drug Interactions (7)]. Alert patients that NSAIDs may be present in “over the counter” medications for treatment of colds, fever, or insomnia.

Use of NSAIDS and Low-Dose Aspirin
Inform patients not to use low-dose aspirin concomitantly with COXANTO until they talk to their healthcare provider [see Drug Interactions (7)]. This product’s labeling may have been updated. For the most recent prescribing information, please visit www.solubiomix.com.
Manufactured for and Distributed by:
SOLUBIOMIX
INNOVATING HEALTH SOLUTIONS
Madisonville, LA 70447
COXANTO is a prescription medicine that contains oxaprozin (a nonsteroidal anti-inflammatory drug [NSAID]).

What is the most important information I should know about COXANTO, and medicines called nonsteroidal anti-inflammatory drugs (NSAIDs)?
COXANTO may cause serious side effects, including: 

• Increased risk of a heart attack or stroke that can lead to death.
  This risk may happen early in treatment and may increase:

  • with increasing doses of NSAIDs
  • with longer use of NSAIDs
    Do not take COXANTO right before or after a heart surgery called a “coronary artery bypass graft (CABG)”. Avoid taking COXANTO after a recent heart attack, unless your healthcare provider tells you to. You may have an increased risk of another heart attack if you take COXANTO after a recent heart attack.

• Increased risk of bleeding, ulcers, and tears (perforation) of the esophagus (tube leading from the mouth to the stomach), stomach and intestines:

  • anytime during use
  • without warning symptoms
  • that may cause death

• The risk of getting an ulcer or bleeding increases with:

  • history of stomach ulcers, or stomach or intestinal bleeding with use of NSAIDs
  • taking medicines called “corticosteroids”, “antiplatelet drugs”, “anticoagulants”, “selective serotonin reuptake inhibitors (SSRIs)”, “serotonin norepinephrine reuptake inhibitors (SNRIs)”
  • increasing doses of NSAIDs
  • longer use of NSAIDs
  • smoking
  • drinking alcohol
  • older age
  • poor health
  • advanced liver disease
  • bleeding problems

COXANTO should only be used:

• exactly as prescribed
• at the lowest dose possible for your treatment
• for the shortest time needed

What is COXANTO?
COXANTO is a prescription medicine used:

• for relief of the signs and symptoms of osteoarthritis
• for relief of the signs and symptoms of rheumatoid arthritis
• for relief of the signs and symptoms of juvenile rheumatoid arthritis.
  It is not known if COXANTO is safe and effective in children below 6 years of age.

Do not take COXANTO:

• if you are allergic to oxaprozin or to any of the ingredients in COXANTO. See the end of this Medication Guide for a complete list of ingredients in COXANTO.
• if you have had an asthma attack, hives, or other allergic reaction after taking aspirin or any other NSAIDs. Severe allergic reactions that have sometimes led to death have happened in people with a history of allergic reactions to NSAIDs.
• right before or after heart bypass surgery.

Before taking COXANTO, tell your healthcare provider about all of your or your child’s medical conditions, including if you:

• have heart problems
• have bleeding problems
• have or have had ulcers
• have liver or kidney problems
• have high blood pressure
• have asthma
• are pregnant or plan to become pregnant. Taking COXANTO at about 20 weeks of pregnancy or later may harm your unborn baby.
  • If you need to take COXANTO for more than 2 days when you are between 20 and 30 weeks of pregnancy, your healthcare provider may need to monitor the amount of fluid in your womb around your baby. You should not take COXANTO after about 30 weeks of pregnancy.
  • COXANTO may cause fertility problems in females, which may affect your ability to become pregnant. Talk to your healthcare provider if this is a concern for you.
• are breastfeeding or plan to breastfeed. Talk to your healthcare provider about the best way to feed your baby during treatment with COXANTO.

Tell your healthcare provider about all of the medicines you or your child take, including prescription or over-the-counter medicines, vitamins or herbal supplements.
COXANTO and some other medicines can interact with each other and cause serious side effects.

Do not start taking any new medicine without talking to your healthcare provider first.
How should I take COXANTO?

• Take COXANTO exactly as your healthcare provider tells you to take it.
• If you take too much COXANTO, call your healthcare provider or Poison Control Center at 1-800-222-1222, or go to the nearest hospital emergency room right away.

What are the possible side effects of COXANTO?
COXANTO may cause serious side effects, including:
See “What is the most important information I should know about COXANTO, and medicines called nonsteroidal anti-inflammatory drugs (NSAIDs)?”

• liver problems including liver failure
• new or worse high blood pressure
• heart failure
• kidney problems including kidney failure
• increase in blood potassium level (hyperkalemia)
• life-threatening allergic reactions
• asthma attacks in people who have asthma
• serious skin reactions, including life-threatening skin reactions
• low red blood cells (anemia)
• skin sensitivity to sunlight

Other side effects of COXANTO include: constipation, diarrhea, indigestion, nausea, and rash.

Get emergency help right away if you get any of the following symptoms:

• shortness of breath or trouble breathing
• chest pain
• weakness in one part or side of your body
• slurred speech
• swelling of the face or throat

Stop taking COXANTO and call your healthcare provider right away if you get any of the following symptoms:

• nausea
• more tired or weaker than usual
• diarrhea
• itching
• your skin or eyes look yellow
• indigestion or stomach pain
• flu-like symptoms
• vomit blood
• there is blood in your bowel movement or it is black and sticky like tar
• unusual weight gain
• skin rash or blisters with fever
• swelling of the arms, legs, hands and feet

These are not all of the possible side effects of COXANTO.
Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

Other information about NSAIDs

• Aspirin is an NSAID but it does not increase the chance of a heart attack. Aspirin can cause bleeding in the brain, stomach, and intestines. Aspirin can also cause ulcers in the stomach and intestines.
• Some NSAIDs are sold in lower doses without a prescription (over-the-counter). Talk to your healthcare provider before using over-the-counter NSAIDs.

How should I store COXANTO?

• Store COXANTO at room temperature between 68°F to 77°F (20°C to 25°C).
• Keep the COXANTO bottles tightly closed.
• Protect the bottle from light.

Keep COXANTO and all medicines out of the reach of children.

General information about the safe and effective use of COXANTO.
Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Do not use COXANTO for a condition for which it was not prescribed. Do not give COXANTO to other people, even if they have the same symptoms that you have. It may harm them. You can ask your pharmacist or healthcare provider for information about COXANTO that is written for health professionals.

What are the ingredients in COXANTO?
Active ingredient: oxaprozin
Inactive ingredients: microcrystalline cellulose, pregelatinized corn starch, hypromellose 2910, sodium starch glycolate, stearic acid, and silicon dioxide.

Manufactured for and Distributed by:
SOLUBIOMIX INNOVATING HEALTH SOLUTIONS
Madisonville, LA 70447
For more information, call 1-844-551-9911.

Use in Specific Populations
For more information on the use of COXANTO in specific populations, please refer to section 17 for Patient Counseling Information and Medication Guide.

• Infertility: NSAIDs are associated with reversible infertility. Consider withdrawal of COXANTO in women who have difficulties conceiving (8.3)

FULL PRESCRIBING INFORMATION
WARNING: RISK OF SERIOUS CARDIOVASCULAR AND GASTROINTESTINAL EVENTS

Cardiovascular Thrombotic Events

• Nonsteroidal anti-inflammatory drugs (NSAIDs) cause an increased risk of serious cardiovascular thrombotic events, including myocardial infarction and stroke, which can be fatal. This risk may occur early in treatment and may increase with duration of use [see Warnings and Precautions (5.1)].
• COXANTO is contraindicated in the setting of coronary artery bypass graft (CABG) surgery [see Contraindications (4) and Warnings and Precautions (5.1)].

Gastrointestinal Bleeding, Ulceration, and Perforation

• NSAIDs cause an increased risk of serious gastrointestinal (GI) adverse events including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal. These events can occur at any time during use and without warning symptoms. Elderly patients and patients with a prior history of peptic ulcer disease and/or GI bleeding are at greater risk for serious GI events [see Warnings and Precautions (5.2)].

INDICATIONS AND USAGE
COXANTO is indicated:

• For relief of the signs and symptoms of osteoarthritis
• For relief of the signs and symptoms of rheumatoid arthritis
• For relief of the signs and symptoms of juvenile rheumatoid arthritis

Frequently Asked Questions (FAQ)

1. What is the highest daily dose for COXANTO?
   The highest daily dose for COXANTO is 1,200 mg a day.

2. What are the common adverse reactions associated with COXANTO?
   The most common adverse reactions associated with COXANTO are constipation, diarrhea, dyspepsia, nausea, and rash.

3. How can I report suspected adverse reactions?
   If you experience any suspected adverse reactions, please contact Solubiomix, LLC. at 1-844-551-9911 or FDA at 1-800-FDA-1088 or visit www.fda.gov/medwatch.

References

• MedWatch: The FDA Safety Information and Adverse Event Reporting Program | FDA

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