The following directions are provided for use only during emergency situations and when FDA-approved, commercially manufactured oseltamivir phosphate for oral suspension is not available from wholesalers or the manufacturer.
The following emergency preparation instructions will provide one patient with enough oseltamivir phosphate for a 5-day course of treatment of influenza or a 10-day course of prophylaxis of influenza:
Step #1: Determine the dosage of oseltamivir phosphate for the patient [see Dosage and Administration (2.2,2.3, and 2.4)] then determine the total volume of oral suspension needed to be prepared (see Table 3).
Table 3 Emergency Preparation: Volume of Prepared Oral Suspension (6 mg per mL) Based Upon Oseltamivir Phosphate Capsules Dose
|Oseltamivir Phosphate Capsules Dose*||Total Volume to Prepare per Patient|
|15 mg or less||37.5 mL|
|30 mg||75 mL|
|45 mg||100 mL|
|60 mg||125 mL|
|75 mg||150 mL|
* If the oseltamivir phosphate capsules dose is between the doses listed, use the greater listed dose to determine the total volume of prepared oral suspension.
Step #2: Preparation must be performed with only one of the following vehicles (other vehicles have not been studied): Cherry Syrup (Humco ®), Ora-Sweet ® SF (sugar-free) (Paddock Laboratories), or simple syrup. Determine the number of capsules and the amount of water and vehicle needed to prepare the total volume (see Table 3) of prepared oral suspension (6 mg per mL) for a complete treatment or prophylaxis course (see Table 4).
Table 4 Emergency Preparation: Number of Oseltamivir Phosphate 75 mg Capsules and Amount of Water and Vehicle Needed to Prepare the Total Volume of a Prepared Oral Suspension (6 mg per mL)
|Total Volume of Prepared Oral Suspension||37.5 mL||75 mL||100 mL||125 mL||150 mL|
|Number of Oseltamivir Phosphate 75 mg Capsules (Total Strength)*||3 (225 mg)||6 (450 mg)||8 (600 mg)||10 (750 mg)||12 (900 mg)|
|Amount of Water||2.5 mL||5 mL||7 mL||8 mL||10 mL|
Volume of Vehicle
Cherry Syrup (Humco ®) OR Ora-Sweet ® SF (Paddock Laboratories) OR simple syrup
|34.5 mL||69 mL||91 mL||115 mL||137 mL|
*Includes overage to ensure all doses can be delivered
Step #3: Follow the instructions below for preparing the 75 mg oseltamivir phosphate capsules to produce the oral suspension (6 mg per mL):
a. Place the specified amount of water into a polyethyleneterephthalate (PET) or glass bottle (see Table 4). Constitution in other bottle types is not recommended because there is no stability data with other bottle types.
b. Carefully separate the capsule body and cap and pour the contents of the required number of oseltamivir phosphate 75 mg capsules into the PET or glass bottle.
c. Gently swirl the suspension to ensure adequate wetting of the oseltamivir phosphate capsules powder for at least 2 minutes.
d. Slowly add the specified amount of vehicle to the bottle.
e. Close the bottle using a child-resistant cap and shake well for 30 seconds to completely dissolve the active drug and to ensure homogeneous distribution of the dissolved drug in the resulting suspension. The active drug, oseltamivir phosphate, readily dissolves in the specified vehicles. The suspension is caused by inert ingredients of oseltamivir phosphate capsules which are insoluble in these vehicles.
f. Put an ancillary label on the bottle indicating “Shake Well Before Use.”
g. Instruct the parent or caregiver that any unused suspension remaining in the bottle following completion of therapy must be discarded by either affixing an ancillary label to the bottle or adding a statement to the pharmacy label instructions.
h. Place a pharmacy label on the bottle that includes the patient’s name, dosing instructions, drug name and any other required information to be in compliance with all State and Federal Pharmacy Regulations. Place an appropriate expiration date on the label according to storage conditions below.
j. Store the prepared oral suspension in glass or PET bottles either:
- In a refrigerator [2° to 8°C (36° to 46°F)]: Stable for 5 weeks when stored in a refrigerator.
- At room temperature [25°C (77°F)]: Stable for 5 days when stored at room temperature.
Oseltamivir Phosphate Capsules, USP:
- 30-mg (30 mg free base equivalent of the phosphate salt): Hard gelatin capsules with yellow ivory opaque cap and yellow ivory opaque body printed “AMNEAL” on cap and “264” on body with blue ink.
- 45-mg (45 mg free base equivalent of the phosphate salt): Hard gelatin capsules with light gray opaque cap and light gray opaque body printed “AMNEAL” on cap and “265” on body with blue ink.
- 75-mg (75 mg free base equivalent of the phosphate salt): Hard gelatin capsules with yellow ivory opaque cap and light gray opaque body printed “AMNEAL” on cap and “266” on body with blue ink.
Oseltamivir phosphate capsules are contraindicated in patients with known serious hypersensitivity to oseltamivir or any component of the product. Severe allergic reactions have included anaphylaxis and serious skin reactions including toxic epidermal necrolysis, Stevens-Johnson Syndrome, and erythema multiforme [see Warnings and Precautions (5.1)].
Cases of anaphylaxis and serious skin reactions including toxic epidermal necrolysis, Stevens-Johnson Syndrome, and erythema multiforme have been reported in postmarketing experience with oseltamivir phosphate. Stop oseltamivir phosphate and institute appropriate treatment if an allergic-like reaction occurs or is suspected. The use of oseltamivir phosphate is contraindicated in patients with known serious hypersensitivity to oseltamivir phosphate [see Contraindications (4) and Adverse Reactions (6.2)].
There have been postmarketing reports of delirium and abnormal behavior leading to injury, and in some cases resulting in fatal outcomes, in patients with influenza who were receiving oseltamivir phosphate [see Adverse Reactions (6.2)]. Because these events were reported voluntarily during clinical practice, estimates of frequency cannot be made but they appear to be uncommon based on oseltamivir phosphate usage data. These events were reported primarily among pediatric patients and often had an abrupt onset and rapid resolution. The contribution of oseltamivir phosphate to these events has not been established. Influenza can be associated with a variety of neurologic and behavioral symptoms that can include events such as hallucinations, delirium, and abnormal behavior, in some cases resulting in fatal outcomes. These events may occur in the setting of encephalitis or encephalopathy but can occur without obvious severe disease. Closely monitor oseltamivir phosphate-treated patients with influenza for signs of abnormal behavior. If neuropsychiatric symptoms occur, evaluate the risks and benefits of continuing oseltamivir phosphate for each patient.
There is no evidence for efficacy of oseltamivir phosphate in any illness caused by pathogens other than influenza viruses. Serious bacterial infections may begin with influenza-like symptoms or may coexist with or occur as complications during the course of influenza. Oseltamivir phosphate has not been shown to prevent such complications. Prescribers should be alert to the potential for secondary bacterial infections and treat them as appropriate.
The following serious adverse reactions are discussed below and elsewhere in the labeling:
- Serious skin and hypersensitivity reactions [see Warnings and Precautions (5.1)]
- Neuropsychiatric events [see Warnings and Precautions (5.2)]
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 Reactions from Treatment and Prophylaxis Trials in Adult and Adolescent Subjects (13 years of age and older)
The overall safety profile of oseltamivir phosphate is based on data from 2,646 adult and adolescent subjects that received the recommended dosage of 75 mg orally twice daily for 5 days for treatment of influenza and 1,943 adult and adolescent subjects that received the recommended dosage of 75 mg orally once daily for up to 6 weeks for prophylaxis of influenza in clinical trials.
The most common adverse reactions in the pooled treatment and pooled prophylaxis trials in adults and adolescents are displayed in Table 5. The majority of these adverse reactions were reported on a single occasion, occurred on either the first or second treatment day and resolved spontaneously within 1 to 2 days. This summary includes otherwise healthy adults/adolescents and subjects “at risk” (subjects at higher risk of developing complications associated with influenza, e.g., elderly patients and patients with chronic cardiac or respiratory disease). In general, the safety profile in the subjects “at risk” was qualitatively similar to that in otherwise healthy adults/adolescents.
Table 5 Adverse Reactions Occurring in ≥ 1% of Adults and Adolescents (13 years of age and older) in Treatment and Prophylaxis Trials*
System Organ Class
|Treatment Trials||Prophylaxis Trials|
75 mg twice daily
(n = 2,646)
(n = 1,977)
75 mg once daily
(n = 1,943)
(n = 1,586)
Nervous System Disorders
* Adverse reactions that occurred in ≥1% of oseltamivir phosphate-treated adults and adolescents and ≥1% greater in oseltamivir phosphate-treated subjects compared to placebo-treated subjects in either the treatment or prophylaxis trials.
Adverse Reactions from Treatment and Prophylaxis Trials in Pediatric Subjects (1 year to 12 years of age)
A total of 1,481 pediatric subjects (including otherwise healthy pediatric subjects aged 1 year to 12 years and asthmatic pediatric subjects aged 6 to 12 years) participated in clinical trials of oseltamivir phosphate for the treatment of influenza. A total of 859 pediatric subjects received treatment with oseltamivir phosphate for oral suspension either at a 2 mg per kg twice daily for 5 days or weight-band dosing. Vomiting was the only adverse reaction reported at a frequency of ≥1 % in subjects receiving oseltamivir phosphate (16%) compared to placebo (8%).
Amongst the 148 pediatric subjects aged 1 year to 12 years who received oseltamivir phosphate at doses of 30 to 60 mg once daily for 10 days in a post-exposure prophylaxis study in household contacts (n = 99), and in a separate 6-week seasonal influenza prophylaxis safety study (n = 49), vomiting was the most frequent adverse reaction (8% on oseltamivir phosphate versus 2% in the no prophylaxis group).
Adverse Reactions from Treatment Trials in Pediatric Subjects (2 weeks to less than 1 year of age)
Assessment of adverse reactions in pediatric subjects 2 weeks to less than 1 year of age was based on two open-label studies that included safety data on 135 influenza-infected subjects 2 weeks to less than 1 year of age (including premature infants at least 36 weeks post conceptional age) exposed to oseltamivir phosphate at doses ranging from 2 to 3.5 mg per kg of the formulation for oral suspension twice daily orally for 5 days. The safety profile of oseltamivir phosphate was similar across the age range studied, with vomiting (9%), diarrhea (7%) and diaper rash (7%) being the most frequently reported adverse reactions, and was generally comparable to that observed in older pediatric and adult subjects.
Adverse Reactions from the Prophylaxis Trial in Immunocompromised Subjects
In a 12-week seasonal prophylaxis study in 475 immunocompromised subjects, including 18 pediatric subjects 1 year to 12 years of age, the safety profile in the 238 subjects receiving oseltamivir phosphate 75 mg once daily was consistent with that previously observed in other oseltamivir phosphate prophylaxis clinical trials [see Clinical Studies (14.2)].
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