Uzedy Drug Information

Schizophrenia UZEDY is indicated for the treatment of schizophrenia in adults.

General Administration Information

For patients who have never taken risperidone, establish tolerability with oral risperidone prior to initiating UZEDY. UZEDY must be administered by a healthcare professional as an abdominal or upper arm subcutaneous injection. Do not administer UZEDY by any other route.

For detailed preparation and administration instructions, see Dosage and Administration.

Dosage Recommendations for the Treatment of Schizophrenia

To start UZEDY for the treatment of schizophrenia, switch from oral daily risperidone. Initiate UZEDY, as either a once monthly injection or a once every 2 month injection, the day after the last dose of oral therapy. Neither a loading dose nor supplemental oral risperidone doses are recommended when switching.

Table 1: Dosage Recommendations for Switching from Daily Oral Risperidone to UZEDY Given Once Monthly or Once Every 2 Months Patients can switch between doses of UZEDY once monthly and once every 2 months by administering the first dose of the new dosing regimen on the next scheduled date of administration in the original dosing regimen. Revise the dose administration schedule to reflect the change.

Dosage Recommendations for Maintenance Treatment of Bipolar I Disorder Following establishment of tolerability with oral risperidone, start UZEDY as a once monthly injection for monotherapy or adjunctive therapy to lithium or valproate for the maintenance treatment of bipolar I disorder, according to the dosage recommendations in Table 2. UZEDY once every 2 months injection is not recommended for the maintenance treatment of bipolar I disorder. Table 2: Dosage Recommendations for Switching from Daily Oral Risperidone to UZEDY Given Once Monthly For patients currently receiving risperidone long acting intramuscular injectable given once every 2 weeks, switch to UZEDY as a once monthly subcutaneous injection, starting at least 5 weeks after the last dose of risperidone long acting intramuscular injectable given once every 2 weeks.

Table 3: Dosage Recommendations for Switching From

Missed Doses When a dose of UZEDY is missed, administer the next UZEDY injection as soon as possible. Do not administer more frequently than recommended.

Dosage Modifications in Patients with Renal Impairment or Hepatic Impairment Prior to initiating UZEDY in patients with renal or hepatic impairment, titrate with oral risperidone to at least 2 mg once daily. Following oral titration, and based on clinical response and tolerability, the recommended dosage of UZEDY is 50 mg once monthly.

Dosage Modifications for Concomitant Use with Strong CYP2D6 Inhibitors and Strong CYP3A4 Inducers Concomitant Use with Strong CYP2D6 Inhibitors When initiation of fluoxetine or paroxetine is considered, place patients on a lower dose of UZEDY prior to the planned start of fluoxetine or paroxetine therapy to adjust for the expected increase in plasma concentrations of risperidone. When fluoxetine or paroxetine is initiated in patients receiving the recommended dose of 50 mg once monthly or 100 mg once every 2 months of UZEDY, continue treatment with these doses unless clinical judgment necessitates interruption of UZEDY. Concomitant Use with Strong CYP3A4 Inducers At the initiation of therapy with strong CYP3A4 inducers (such as carbamazepine), patients should be closely monitored during the first 4 to 8 weeks since the dose of UZEDY may need to be adjusted.

A dose increase, or additional oral risperidone, may be considered. On discontinuation of a strong CYP3A4 inducer, re-evaluated the dosage of UZEDY or any additional oral risperidone therapy and, if necessary, decrease to adjust for the expected increase in plasma concentration of risperidone. On discontinuation of a strong CYP3A4 inducer in a patient treated with UZEDY 50 mg once monthly or 100 mg once every 2 months, continue treatment with these doses unless clinical judgment necessitates interruption of UZEDY.

Preparation and Administration Instructions Read the instructions for preparation and administration below before administering UZEDY. For subcutaneous injection only. Do not inject by any other route.

To be administered by a healthcare professional only. Allow UZEDY to come to room temperature for at least 30 minutes prior to administration. As a universal precaution, always wear gloves.

STEP 1 Check to make sure UZEDY kit contains: One sterile single-dose, prefilled glass syringe One sterile 21G x 5/8” needle Do not substitute any components of the kit for administration. STEP 2 Remove the kit from refrigerated storage and allow the package to sit at room temperature (20°C to 25°C ) for at least 30 minutes. Note: UZEDY is a solid at refrigerated temperatures and must reach room temperature prior to administration.

Do not warm any other way and keep protected from light. STEP 3 Check that the drug in the syringe is white to off-white, opaque in color, and free from non-white particulate matter. Check that the pouch label states the needle size is 21G x 5/8”.

Do not use if any component of the kit is damaged or if the expiration date has passed. STEP 4 Expose the safety needle hub by peeling back the paper tab of the needle pouch. Set aside for use in Step 7.

STEP 5 IMPORTANT: This step must be performed to ensure complete dosing. Firmly hold the syringe by the white collar. Flick Syringe Forcefully Three Times to Move the Bubble to the Cap Flick with a forceful downward whipping motion of your full arm to move the bubble to the cap of the syringe.

Repeat this action 3 times to ensure that the bubble is at the cap of the syringe. Note: Standing while you do this may help achieve required force. Check that the Bubble is at the Cap of the Syringe The bubble will appear partially opaque.

Holding the syringe up to light or against a dark backdrop may improve visibility. If the bubble is not at the cap, repeat Step 5 until it is. STEP 6 Hold the syringe vertically by the white collar.

Bend and snap off the cap. Do not touch the syringe tip to avoid contamination. STEP 7 Attach the Needle to the Syringe Hold the syringe vertically with the white collar at the top.

Push the green hub of safety needle inside the white collar of syringe and rotate the safety needle while holding the white collar until secure and tight. Inspect the needle connection to check that the hub is not damaged. STEP 8 Select Injection Site from the Following Areas: Stomach area (abdomen) around the belly button Back and outer area of the upper arms Do not inject UZEDY anywhere except in the areas specified above.

Do not inject UZEDY into an area that is tender, red, bruised, callused, tattooed, hard, or has scars or stretch marks. STEP 9 Clean the Injection Site with an alcohol wipe. STEP 10 Remove the needle sheath by pulling the needle sheath away from the green hub to expose the needle.

Do not expel any visible air bubble. STEP 11 Pinch at least 1 inch of the area of cleaned skin with your free hand. STEP 12 Insert the needle into subcutaneous tissue (actual angle of injection will depend on the amount of subcutaneous tissue).

Do not apply pressure to the plunger. STEP 13 Release the pinched skin once the needle is in the subcutaneous tissue. STEP 14 Inject the Medication Push on the plunger using a slow, firm, and steady push until the entire dose is delivered.

Inject the entire dose at one time, without interruption. Check that the plunger stopper is at the White Collar. IMPORTANT: UZEDY is viscous.

Resistance will be experienced during dose delivery. Do not use excessive force in an attempt to deliver UZEDY faster. STEP 15 Wait 2-3 seconds after the entire dose is delivered before removing the needle.

Slowly pull the needle out from the injection site at the same angle as insertion. STEP 16 Activate (lock) the safety needle shield using one of the following methods: Surface Activation: Place the needle shield on a flat surface and pull the syringe backward until the needle shield covers the needle tip. Finger/Thumb Activation: Press either your thumb or finger on the needle shield and push it forward until the needle shield covers the needle tip.

There will be an audible click when the needle safety shield is locked. Dispose of all syringe components in a suitable sharps container. image image image image image image image image image image image image image image image image image image image image

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 clinical practice. Treatment of Schizophrenia in Adults UZEDY is to be administered subcutaneously. The safety of UZEDY for the treatment of schizophrenia in adults is based on adequate and well-controlled studies of oral risperidone in studies of patients with schizophrenia and other indications.

The results of those adequate and well-controlled studies are presented below. The data described in this section are derived from a clinical trial database consisting of 9,803 patients exposed to one or more doses of oral risperidone for the treatment of schizophrenia and other psychiatric disorders. Of these 9,803 patients, 2,687 were patients who received oral risperidone while participating in double-blind, placebo-controlled trials.

The conditions and duration of treatment with oral risperidone varied greatly and included (in overlapping categories) double-blind, fixed- and flexible-dose, placebo- or active-controlled studies and open-label phases of studies, inpatients and outpatients, and short-term (up to 12 weeks) and longer-term (up to 3 years) exposures. Safety was assessed by collecting adverse reactions and performing physical examinations, vital signs, body weights, laboratory analyses, and ECGs. Injection site reactions for UZEDY presented in this section (see “Injection Site Reactions with UZEDY” below) are based on a randomized withdrawal study in patients with schizophrenia consisting of a 12-week open-label oral risperidone (2 mg to 5 mg) stabilization phase, followed by a placebo-controlled phase in which patients were randomized to UZEDY (once monthly or once every 2 months) or placebo for a variable time until impending relapse or study completion.

The safety of UZEDY was evaluated in a total of 740 adult patients with schizophrenia who received at least 1 dose of UZEDY during the clinical development program. In addition, 32 patients were exposed to UZEDY for at least 24 months. The data presented below are from studies with another risperidone long-acting injection given once every 2 weeks that was administered intramuscularly.

The safety of UZEDY as monotherapy or as adjunctive therapy to lithium or valproate for the maintenance treatment of Bipolar I Disorder in adults is based on adequate and well-controlled studies of another risperidone long-acting injection given once every 2 weeks. Safety data are presented from a trial assessing the efficacy and safety of another risperidone long-acting injection, given once every 2 weeks, when administered as monotherapy for maintenance treatment in patients with bipolar I disorder. Adverse Reactions in Studies with Oral Risperidone The most common adverse reactions in clinical trials of oral risperidone (>5% and twice placebo) were parkinsonism, akathisia, dystonia, tremor, sedation, dizziness, anxiety, blurred vision, nausea, vomiting, upper abdominal pain, stomach discomfort, dyspepsia, diarrhea, salivary hypersecretion, constipation, dry mouth, increased appetite, increased weight, fatigue, rash, nasal congestion, upper respiratory tract infection, nasopharyngitis, and pharyngolaryngeal pain.

Commonly-Observed Adverse Reactions in Double-Blind, Placebo-Controlled Clinical Trials – Adult Patients with Schizophrenia Treated with Oral Risperidone Table 7 lists the adverse reactions reported in 2% or more of oral risperidone-treated adult patients with schizophrenia in three 4- to 8-week, double-blind, placebo-controlled trials. Table 7: Adverse Reactions in ≥2% of Oral Risperidone-Treated Adult Patients (and greater than placebo) with Schizophrenia in Double-Blind, includes extrapyramidal disorder, musculoskeletal stiffness, parkinsonism, cogwheel rigidity, akinesia, bradykinesia, hypokinesia, masked facies, muscle rigidity, and Parkinson’s disease. Akathisia includes akathisia and restlessness.

Dystonia includes dystonia, muscle spasms, muscle contractions involuntary, muscle contracture, oculogyration, tongue paralysis. Tremor includes tremor and parkinsonian rest tremor. Adverse Reactions in Studies with Another Long-Acting Injection Risperidone, Given Once Every 2 Weeks The most common adverse reactions in the double-blind, placebo-controlled periods of the bipolar disorder trials of another risperidone long-acting injection were weight increased (5% in the monotherapy trial) and tremor and parkinsonism (≥ 10% in the adjunctive treatment trial).

Commonly-Observed Adverse Reactions in Double-Blind, Placebo-Controlled Clinical Trials – Adult Patients with Bipolar Disorder Treated with Another Risperidone Long-Acting Injection Given Once Every 2 Weeks Table 8 lists the treatment-emergent adverse reactions reported in 2% or more of patients treated with another risperidone long-acting injection, given once every 2 weeks, in the 24-month double-blind, placebo-controlled treatment period of the trial assessing the efficacy and safety of another risperidone long-acting injection when administered as monotherapy for maintenance treatment in patients with bipolar I disorder. UZEDY is to be administered subcutaneously. Table 9 lists the treatment-emergent adverse reactions reported in 4% or more of patients in the 52-week double-blind, placebo-controlled treatment phase of a trial assessing the efficacy and safety of another Risperidone Long-Acting Injection, given once every 2 weeks, when administered as adjunctive maintenance treatment in patients with bipolar disorder.

UZEDY is to be administered subcutaneously. b Patients received double-blind treatment with another risperidone long-acting injection, given once every 2 weeks, or placebo in addition to continuing their treatment as usual, which included mood stabilizers, antidepressants, and/or anxiolytics. c Parkinsonism includes muscle rigidity, hypokinesia, cogwheel rigidity, and bradykinesia. d Dyskinesia includes muscle twitching and dyskinesia. e Sedation includes sedation and somnolence. Other Adverse Reactions Observed During the Clinical Trial Evaluations of Oral Risperidone The following is a list of additional adverse drug reactions that have been reported during the clinical trial evaluation of oral risperidone: Blood and Lymphatic System Disorders: anemia, granulocytopenia, neutropenia Cardiac Disorders: sinus bradycardia, sinus tachycardia, atrioventricular block first degree, bundle branch block left, bundle branch block right, atrioventricular block Ear and Labyrinth Disorders: ear pain, tinnitus Endocrine Disorders: hyperprolactinemia Eye Disorders: ocular hyperemia, eye discharge, conjunctivitis, eye rolling, eyelid edema, eye swelling, eyelid margin crusting, dry eye, lacrimation increased, photophobia, glaucoma, visual acuity reduced Gastrointestinal Disorders: dysphagia, fecaloma, fecal incontinence, gastritis, lip swelling, cheilitis, aptyalism General Disorders: edema peripheral, thirst, gait disturbance, chest discomfort, chest pain, influenza-like illness, pitting edema, edema, chills, sluggishness, malaise, face edema, discomfort, generalized edema, drug withdrawal syndrome, peripheral coldness, feeling abnormal Immune System Disorders: drug hypersensitivity Infections and Infestations: pneumonia, influenza, ear infection, viral infection, pharyngitis, tonsillitis, bronchitis, eye infection, localized infection, cystitis, cellulitis, otitis media, onychomycosis, acarodermatitis, bronchopneumonia, respiratory tract infection, tracheobronchitis, otitis media chronic Investigations: body temperature increased, blood prolactin increased, alanine aminotransferase increased, electrocardiogram abnormal, eosinophil count increased, white blood cell count decreased, blood glucose increased, hemoglobin decreased, hematocrit decreased, body temperature decreased, blood pressure decreased, transaminases increased Metabolism and Nutrition Disorders: decreased appetite, polydipsia, anorexia Musculoskeletal, Connective Tissue, and Bone Disorders: joint swelling, joint stiffness, musculoskeletal chest pain, posture abnormal, myalgia, neck pain, muscular weakness, muscle rigidity, rhabdomyolysis, torticollis Nervous System Disorders: balance disorder, disturbance in attention, dysarthria, unresponsive to stimuli, depressed level of consciousness, movement disorder, transient ischemic attack, coordination abnormal, cerebrovascular accident, speech disorder, syncope, loss of consciousness, hypoesthesia, tardive dyskinesia, cerebral ischemia, cerebrovascular disorder, neuroleptic malignant syndrome, diabetic coma, head titubation Psychiatric Disorders: agitation, blunted affect, confusional state, middle insomnia, nervousness, sleep disorder, listlessness, libido decreased, anorgasmia Renal and Urinary Disorders: enuresis, dysuria, pollakiuria, urinary incontinence Reproductive System and Breast Disorders: menstruation irregular, amenorrhea, gynecomastia, galactorrhea, vaginal discharge, menstrual disorder, erectile dysfunction, retrograde ejaculation, ejaculation disorder, sexual dysfunction, breast enlargement Respiratory, Thoracic, and Mediastinal Disorders: wheezing, pneumonia aspiration, sinus congestion, dysphonia, productive cough, pulmonary congestion, respiratory tract congestion, rales, respiratory disorder, hyperventilation, nasal edema Skin and Subcutaneous Tissue Disorders: erythema, skin discoloration, skin lesion, pruritus, skin disorder, rash erythematous, rash papular, acne, hyperkeratosis, seborrheic dermatitis, rash generalized, rash maculopapular Vascular Disorders: hypotension, flushing Additional Adverse Reactions Reported With Another Risperidone Long-Acting Injection, Given Once Every 2 Weeks The following is a list of additional adverse reactions that have been reported during the premarketing evaluation of another risperidone long-acting injection, given once every 2 weeks, regardless of frequency of occurrence: Cardiac Disorders: bradycardia, tachycardia, palpitations Ear and Labyrinth Disorders: vertigo Eye Disorders: blepharospasm Gastrointestinal Disorders: toothache, tongue spasm, diarrhea, vomiting, abdominal pain upper, abdominal pain, stomach discomfort General Disorders and Administration Site Conditions: pain, injection site pain, induration, injection site induration, injection site swelling, injection site reaction Infections and Infestations: lower respiratory tract infection, infection, gastroenteritis, subcutaneous abscess, nasopharyngitis, urinary tract infection, rhinitis, sinusitis Injury and Poisoning: fall, procedural pain Investigations: weight decreased, gamma-glutamyltransferase increased, hepatic enzyme increased, aspartate aminotransferase increased, electrocardiogram QT prolonged, glucose urine present Musculoskeletal, Connective Tissue, and Bone Disorders: buttock pain, back pain Nervous System Disorders: convulsion, paresthesia, dystonia, drooling, dizziness postural, akinesia, hypokinesia Psychiatric Disorders: depression, insomnia, anxiety, initial insomnia Reproductive System and Breast Disorders: oligomenorrhea, breast discomfort, menstruation delayed, ejaculation delayed Respiratory, Thoracic, and Mediastinal Disorders: nasal congestion, pharyngolaryngeal pain, dyspnea, rhinorrhea Skin and Subcutaneous Tissue Disorders: eczema, rash, pruritis generalized Vascular Disorders: hypertension, orthostatic hypotension Discontinuations Due to Adverse Drug Reactions with Oral Risperidone Schizophrenia Approximately 7% (39/564) of oral risperidone-treated patients in double-blind, placebo-controlled trials discontinued treatment due to an adverse reaction, compared with 4% (10/225) who were receiving placebo. The adverse reactions associated with discontinuation in 2 or more oral risperidone-treated patients were: Table 10: Adverse Reactions Associated with Discontinuation in ≥2% of Oral Risperidone-Treated Adult Patients in Schizophrenia Trials Discontinuation for extrapyramidal symptoms (including Parkinsonism, akathisia, dystonia, and tardive dyskinesia) was 1% in placebo-treated patients, and 3.4% in active control-treated patients in a double-blind, placebo- and active-controlled trial.

Discontinuations Due to Adverse Drug Reactions with Another Long-Acting Injection Risperidone, Given Once Every 2 Weeks Bipolar Disorder In a 24-month double-blind, placebo-controlled treatment period of the trial assessing the efficacy and safety of another risperidone long-acting injection, given once every 2 weeks, monotherapy for maintenance treatment in patients with bipolar I disorder, 1 (0.6%) of 154 patients treated with another risperidone long-acting injection, given once every 2 weeks, discontinued due to an adverse reaction (hyperglycemia). In the 52-week double-blind phase of the placebo-controlled trial in which patients treated with another risperidone long-acting injection, given once every 2 weeks, was administered as adjunctive therapy to patients with bipolar disorder in addition to continuing with their usual treatment, approximately 4% (3/72) of patients treated with another risperidone long-acting injection, given once every 2 weeks, discontinued treatment due to an adverse event, compared with 1.5% (1/67) of placebo-treated patients. Adverse reactions associated with discontinuation in patients treated with another risperidone long-acting injection, given once every 2 weeks, were hypokinesia (one patient) and tardive dyskinesia (one patient).

Dose Dependency of Adverse Reactions in Clinical Trials of Oral Risperidone Extrapyramidal Symptoms Data from two fixed-dose trials in adults with schizophrenia provided evidence of dose-relatedness for extrapyramidal symptoms associated with oral risperidone treatment. Two methods were used to measure extrapyramidal symptoms (EPS) in an 8-week trial comparing 4 fixed doses of oral risperidone mg/day, including a Parkinsonism score (mean change from baseline) from the Extrapyramidal Symptom Rating Scale, and incidence of spontaneous complaints of EPS: Table 11: Extrapyramidal Symptoms Associated with Oral Risperidone-Treated Adult Patients in an 8-Week Fixed Dose Schizophrenia Trial Similar methods were used to measure extrapyramidal symptoms (EPS) in an 8-week trial comparing 5 fixed doses of oral risperidone mg/day: Table 12: Extrapyramidal Symptoms Associated with Oral Risperidone-Treated Adult Patients in an 8-Week Fixed Dose Schizophrenia Trial Changes in Body Weight Weight gain was observed in short-term, controlled trials and longer-term uncontrolled studies in adults. Dystonia Symptoms of dystonia, prolonged abnormal contractions of muscle groups, may occur in susceptible individuals during the first few days of treatment.

Dystonic symptoms include: spasm of the neck muscles, sometimes progressing to tightness of the throat, swallowing difficulty, difficulty breathing, and/or protrusion of the tongue. While these symptoms can occur at low doses, they occur more frequently and with greater severity with high potency and at higher doses of first generation antipsychotic drugs. An elevated risk of acute dystonia is observed in males and younger age groups.

Other Adverse Reactions Adverse reaction data elicited by a checklist for side effects from a large study comparing 5 fixed doses of oral risperidone mg/day were explored for dose-relatedness of adverse events. A Cochran-Armitage Test for trend in these data revealed a positive trend (p<0.05) for the following adverse reactions: somnolence, vision abnormal, dizziness, palpitations, weight increase, erectile dysfunction, ejaculation disorder, sexual function abnormal, fatigue, and skin discoloration. Changes in ECG Between-group comparisons for pooled placebo-controlled trials of oral risperidone in adults revealed no statistically significant differences between oral risperidone and placebo in mean changes from baseline in ECG parameters, including QT, QTc, and PR intervals, and heart rate.

When all oral risperidone doses were pooled from randomized controlled trials in several indications, there was a mean increase in heart rate of 1 beat per minute compared to no change for placebo patients. In short-term schizophrenia trials, higher doses of oral risperidone were associated with a higher mean increase in heart rate compared to placebo (4 to 6 beats per minute). The ECGs of 227 patients with Bipolar I Disorder were evaluated in the 24-month double-blind, placebo-controlled period.

There were no clinically relevant differences in QTc intervals (using Fridericia's and linear correction factors) during treatment with another risperidone long-acting injection, given once every 2 weeks, compared to placebo. The ECGs of 85 patients with bipolar disorder were evaluated in the 52-week double-blind, placebo-controlled trial. Injection Site Reactions with UZEDY Local tolerability assessments were administered to patients who reported injection site adverse reactions in a randomized withdrawal study with UZEDY in adult patients with schizophrenia.

The injection site was assessed by appropriately trained personnel throughout the clinical development program. All injection site reactions (nodule, pruritus, erythema, mass, and swelling) were mild to moderate in severity with the exception of 1 case of severe pruritus which resolved after 6 days. 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.

These adverse reactions include: alopecia, anaphylactic reaction, angioedema, atrial fibrillation, cardiopulmonary arrest, catatonia, diabetic ketoacidosis in patients with impaired glucose metabolism, dysgeusia, hypoglycemia, hypothermia, ileus, inappropriate antidiuretic hormone secretion, intestinal obstruction, jaundice, mania, pancreatitis, pituitary adenoma, precocious puberty, pulmonary embolism, QT prolongation, sleep apnea syndrome, somnambulism, Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN), sudden death, thrombocytopenia, thrombotic thrombocytopenic purpura, urinary retention, and water intoxication. In addition, the following adverse reactions have been observed during postapproval use of UZEDY: injection site pain. In addition, the following adverse reactions have been observed during postapproval use of another risperidone long-acting injection, given intramuscularly once every 2 weeks: cerebrovascular disorders, including cerebrovascular accidents, and diabetes mellitus aggravated.

Retinal artery occlusion after injection of another risperidone long-acting injection, given intramuscularly once every 2 weeks, has been reported during postmarketing surveillance. This has been reported in the presence of abnormal arteriovenous anastomosis. Serious injection site reactions including abscess, cellulitis, cyst, hematoma, necrosis, nodule, and ulcer have been reported with another risperidone long-acting injection, given intramuscularly once every 2 weeks, during postmarketing surveillance.

Isolated cases required surgical intervention. Very rarely, cases of anaphylactic reaction after injection with another risperidone long-acting injection, given intramuscularly once every 2 weeks, have been reported during postmarketing experience in patients who have previously tolerated oral risperidone. Postmarketing cases of extrapyramidal symptoms (dystonia and dyskinesia) have been reported in patients concomitantly taking methylphenidate and risperidone when there was an increase or decrease in dosage, initiation, or discontinuation of either or both medications.

Drugs Having Clinically Important Interactions with UZEDY Table 13 includes clinically significant drug interactions with UZEDY. Table 13: Clinically Important Drug Interactions with UZEDY Strong CYP2D6 Inhibitors Clinical Impact: Concomitant use of UZEDY with strong CYP2D6 inhibitors may increase the plasma exposure of risperidone and lower the plasma exposure of a major active metabolite, 9-hydroxyrisperidone. Intervention: When initiation of strong CYP2D6 inhibitors is considered, patients may be placed on the lowest dose (50 mg once monthly or 100 mg once every 2 months) of UZEDY prior to the planned start of strong CYP2D6 inhibitors to adjust for the expected increase in plasma concentrations of risperidone.

The effects of discontinuation of strong CYP2D6 inhibitors on the pharmacokinetics of risperidone and 9-hydroxyrisperidone have not been studied. Strong CYP3A4 Inducers Clinical Impact: Concomitant use of UZEDY and a strong CYP3A4 inducer may cause decreases in the combined plasma concentrations of risperidone and 9-hydroxyrisperidone which could lead to decreased efficacy of UZEDY. Intervention: Changes in efficacy and safety should be carefully monitored with any dose adjustment of UZEDY.

For patients treated with UZEDY 50 mg once monthly or UZEDY 100 mg once every 2 months discontinuing from a strong CYP3A4 inducer, it is recommended to continue treatment with the same dose unless clinical judgment necessitates interruption of UZEDY treatment. Concomitant use with methylphenidate, when there is change in dosage of either medication, may increase the risk of extrapyramidal symptoms (EPS). Intervention: Monitor for symptoms of EPS with concomitant use of UZEDY and methylphenidate.

Drugs Having No Clinically Important Interactions with UZEDY Based on pharmacokinetic studies with oral risperidone, no dosage adjustment of UZEDY is required when administered concomitantly with amitriptyline, cimetidine, ranitidine, clozapine, topiramate, and moderate CYP3A4 inhibitors (erythromycin). Additionally, no dosage adjustment is necessary for lithium, valproate, topiramate, digoxin, and CYP2D6 substrates (donepezil and galantamine) when co-administered with UZEDY.

Pregnancy Pregnancy Exposure Registry There is a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to atypical antipsychotics, including UZEDY, during pregnancy. Healthcare providers are encouraged to register patients by contacting the National Pregnancy Registry for Atypical Antipsychotics at 1-866-961-2388 or online at http://womensmentalhealth.org/clinical-and-research-programs/pregnancyregistry/. Risk Summary Neonates exposed to antipsychotic drugs during the third trimester of pregnancy are at risk for extrapyramidal and/or withdrawal symptoms following delivery ( see Clinical Considerations ).

Overall, available data from published epidemiologic studies of pregnant women exposed to risperidone have not established a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes ( see Data ). There are risks to the mother associated with untreated schizophrenia or bipolar I disorder and with exposure to antipsychotics, including UZEDY, during pregnancy ( see Clinical Considerations ). Oral administration of risperidone to pregnant mice caused cleft palate at doses 3- to 4-times the oral maximum recommended human dose (MRHD) of 16 mg/day with maternal toxicity observed at 4-times MRHD based on mg/m 2 body surface area.

Risperidone was not teratogenic in rats or rabbits at doses up to 6-times the oral MRHD based on mg/m 2 body surface area. Increased stillbirths and decreased birth weight occurred after oral risperidone administration to pregnant rats at 1.5-times the oral MRHD based on mg/m 2 body surface area. Learning was impaired in offspring of rats when the dams were dosed at 0.6-times the oral MRHD and offspring mortality increased at doses 0.1- to 3-times the oral MRHD based on mg/m 2 body surface area.

The background risks of major birth defects and miscarriage for the indicated population 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 respectively.

Clinical Considerations Disease-associated maternal and/or embryo/fetal risk There is a risk to the mother from untreated schizophrenia or bipolar I disorder, including increased risk of relapse, hospitalization, and suicide. Schizophrenia or bipolar I disorder are associated with increased adverse perinatal outcomes, including preterm birth. It is not known if this is a direct result of the illness or other comorbid factors.

Fetal/Neonatal Adverse Reactions Extrapyramidal and/or withdrawal symptoms, including agitation, hypertonia, hypotonia, tremor, somnolence, respiratory distress, and feeding disorder have been reported in neonates who were exposed to antipsychotic drugs, including risperidone, during the third trimester of pregnancy. These symptoms have varied in severity. Monitor neonates for extrapyramidal and/or withdrawal symptoms and manage symptoms appropriately.

Some neonates recovered within hours or days without specific treatment; others required prolonged hospitalization. Data Human Data Published data from observational studies, birth registries, and case reports on the use of atypical antipsychotics during pregnancy do not report a clear association with antipsychotics and major birth defects. A prospective observational study including 6 women treated with risperidone demonstrated placental passage of risperidone.

A retrospective cohort study from a Medicaid database of 9258 women exposed to antipsychotics during pregnancy did not indicate an overall increased risk for major birth defects. Animal data No developmental toxicity studies were conducted with subcutaneous risperidone suspension. Oral administration of risperidone to pregnant mice during organogenesis caused cleft palate at 10 mg/kg/day which is 3-times the oral MRHD of 16 mg/day based on mg/m 2 body surface area; maternal toxicity occurred at 4-times the oral MRHD.

Learning was impaired in offspring of rats dosed orally throughout pregnancy at 1 mg/kg/day which is 0.6-times the oral MRHD and neuronal cell death increased in fetal brains of offspring of rats dosed during pregnancy at 1 and 2 mg/kg/day which are 0.6- and 1.2-times the oral MRHD based on mg/m 2 body surface area; postnatal development and growth of the offspring were also delayed. It is not known whether these deaths were due to a direct effect on the fetuses or pups or to effects on the dams; a no-effect dose could not be determined. The rate of stillbirths was increased at 2.5 mg/kg or 1.5-times the oral MRHD based on mg/m 2 body surface area.

In a rat cross-fostering study the number of live offspring was decreased, the number of stillbirths increased, and the birth weight was decreased in offspring of drug-treated pregnant rats. In addition, the number of deaths increased by Day 1 among offspring of drug-treated pregnant rats, regardless of whether or not the offspring were cross-fostered. Risperidone also appeared to impair maternal behavior in that offspring body weight gain and survival (from Day 1 to 4 of lactation) were reduced in offspring born to control but reared by drug-treated dams.

All of these effects occurred at 5 mg/kg which is 3-times the oral MRHD based on mg/m 2 and the only dose tested in the study.

Pediatric Use The safety and effectiveness of UZEDY have not been established in pediatric patients. Juvenile Animal Toxicity Data No juvenile animal studies were conducted with subcutaneous risperidone suspension. Bone length and density were decreased with a no-effect dose of 0.31 mg/kg/day; this dose produced plasma AUC of risperidone plus its active metabolite paliperidone (9-hydroxyrisperidone) that were similar to those in children and adolescents receiving the oral MRHD of 6 mg/day.

In addition, sexual maturation was delayed at all doses in both males and females. The above effects showed little or no reversibility in females after a 12 week drug-free recovery period. Juvenile rats, treated with oral risperidone from days 12 to 50 of age (equivalent to the period of infancy through adolescence in humans) showed impaired learning and memory performance (reversible only in females), with a no-effect dose of 0.63 mg/kg/day which is 0.5 times the oral MRHD of 6 mg/day for children, based on mg/m 2 body surface area.

This dose produced plasma AUC of risperidone plus paliperidone about half the exposure observed in humans at the oral MRHD. No other consistent effects on neurobehavioral or reproductive development were seen up to the highest tested dose of 1.25 mg/kg/day which is 1 time the oral MRHD and produced plasma AUC of risperidone plus paliperidone that were about two thirds of those observed in humans at the oral MRHD of 6 mg/day for children.

UZEDY is contraindicated in patients with a known hypersensitivity to risperidone, its metabolite, paliperidone, or to any of its components. Hypersensitivity reactions, including anaphylactic reactions and angioedema, have been reported in patients treated with risperidone or paliperidone.

Human Experience No cases of overdose were reported in premarketing studies with UZEDY. In premarketing experience with oral risperidone, there were eight reports of acute risperidone overdosage with estimated doses ranging from 20 to 300 mg and no fatalities. In general, reported signs and symptoms were those resulting from an exaggeration of the drug's known pharmacological effects, i.e., drowsiness and sedation, tachycardia and hypotension, and extrapyramidal symptoms.

One case, involving an estimated overdose of 240 mg, was associated with hyponatremia, hypokalemia, prolonged QT, and widened QRS. Another case, involving an estimated overdose of 36 mg, was associated with a seizure. Postmarketing experience with oral risperidone included reports of acute overdosage with estimated doses of up to 360 mg.

Other postmarketing adverse reactions related to oral risperidone overdose include prolonged QT interval and convulsions. Torsade de pointes has been reported in association with combined overdose of oral risperidone and paroxetine. Management of Overdosage There is no specific antidote to risperidone.

Provide supportive care including close medical supervision and monitoring. Treatment should consist of general measures employed in the management of overdosage with any drug. Consider the possibility of multiple drug overdosage.

Ensure an adequate airway, oxygenation, and ventilation. Monitor cardiac rhythm and vital signs. Consider contacting the Poison Help Line (1-800-222-1222) or medical toxicologist for additional overdosage management recommendations.