1. Indications and Usage for Azelastine

Azelastine hydrochloride (HCl) nasal spray, 0.1% is indicated for the treatment of the symptoms of seasonal allergic rhinitis in adults and pediatric patients 5 years and older, and for the treatment of the symptoms of vasomotor rhinitis in adults and adolescent patients 12 years and older.

2. Azelastine Dosage and Administration

2.1 Seasonal Allergic Rhinitis

The recommended dosage of azelastine HCl nasal spray, 0.1% in adults and adolescent patients 12 years and older with seasonal allergic rhinitis is one or two sprays per nostril twice daily. The recommended dosage of azelastine HCl nasal spray, 0.1% in pediatric patients 5 years to 11 years of age is one spray per nostril twice daily.

2.2 Vasomotor Rhinitis

The recommended dosage of azelastine HCl nasal spray, 0.1% in adults and adolescent patients 12 years and older with vasomotor rhinitis is two sprays per nostril twice daily.

2.3 Important Administration Instructions

Administer azelastine HCl nasal spray, 0.1% by the intranasal route only.

Priming: Prime azelastine HCl nasal spray, 0.1% before initial use by releasing 4 sprays or until a fine mist appears. When azelastine HCl nasal spray, 0.1% has not been used for 3 or more days, reprime with 2 sprays or until a fine mist appears. Avoid spraying azelastine HCl nasal spray, 0.1% into the eyes.

3. Dosage Forms and Strengths

Azelastine HCl nasal spray, 0.1% is a nasal spray solution. Each spray of azelastine HCl nasal spray, 0.1% delivers a volume of 0.137 mL solution containing 137 mcg of azelastine HCl, USP.

4. Contraindications

None.

5. Warnings and Precautions

5.1 Somnolence in Activities Requiring Mental Alertness

In clinical trials, the occurrence of somnolence has been reported in some patients taking azelastine HCl nasal spray, 0.1% . Patients should be cautioned against engaging in hazardous occupations requiring complete mental alertness and motor coordination such as operating machinery or driving a motor vehicle after administration of azelastine HCl nasal spray, 0.1%. Concurrent use of azelastine HCl nasal spray, 0.1% with alcohol or other central nervous system depressants should be avoided because additional reductions in alertness and additional impairment of central nervous system performance may occur .

6. Adverse Reactions/Side Effects

Use of azelastine HCl nasal spray, 0.1% has been associated with somnolence.

6.1 Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect rates observed in practice.

Seasonal Allergic Rhinitis

Azelastine HCl nasal spray, 0.1% Two Sprays Per Nostril Twice Daily

Adverse experience information for azelastine HCl nasal spray, 0.1% is derived from six placebo- and active-controlled, 2-day to 8-week clinical trials which included 391 patients, 12 years of age and older, with seasonal allergic rhinitis who received azelastine HCl nasal spray, 0.1% at a dose of 2 sprays per nostril twice daily. In placebo-controlled efficacy trials, the incidence of discontinuation due to adverse reactions in patients receiving azelastine HCl nasal spray, 0.1% and vehicle placebo was 2.2% and 2.8%, respectively.

Table 1 contains adverse reactions that were reported with frequencies ≥2% in the azelastine HCl nasal spray, 0.1% 2 sprays per nostril twice daily treatment group and more frequently than placebo.

Table 1: Adverse Reactions Reported in ≥2% Incidence in Placebo-Controlled Trials in Patients with Seasonal Allergic Rhinitis [n (%)]

Azelastine HCl Nasal Spray, 0.1% One Spray Per Nostril Twice Daily

Adverse experience information for azelastine HCl nasal spray, 0.1% at a dose of one spray per nostril twice daily is derived from two placebo-controlled 2-week clinical studies which included 276 patients 12 years of age and older with seasonal allergic rhinitis. The incidence of discontinuation due to adverse reactions in patients receiving azelastine HCl nasal spray, 0.1% and vehicle placebo was 0.0% and 0.8%, respectively. Bitter taste was reported in 8.3% of patients compared to none in the placebo group. Somnolence was reported in 0.4% of patients compared to none in the placebo group.

A total of 176 patients 5 to 11 years of age were exposed to azelastine HCl nasal spray, 0.1% at a dose of 1 spray each nostril twice daily in 3 placebo-controlled studies. In these studies, adverse reactions that occurred more frequently in patients treated with azelastine HCl nasal spray, 0.1% than with placebo, and that were not represented in the adult adverse reactions table above include rhinitis/cold symptoms (17.0% vs. 9.5%), cough (11.4% vs. 8.3%), conjunctivitis (5.1% vs. 1.8%), and asthma (4.5% vs. 4.1%).

Adverse Reactions <2% in azelastine HCl nasal spray, 0.1% One or Two Sprays Per Nostril Twice Daily

The following reactions were observed infrequently (<2% and exceeding placebo incidence) in patients who received azelastine HCl nasal spray, 0.1% dosed at 1 or 2 sprays per nostril twice daily in U.S. clinical trials.

Cardiovascular: flushing, hypertension, tachycardia.

Dermatological: contact dermatitis, eczema, hair and follicle infection, furunculosis, skin laceration.

Digestive: constipation, gastroenteritis, glossitis, ulcerative stomatitis, vomiting, increased SGPT, aphthous stomatitis, diarrhea, toothache.

Metabolic and Nutritional: increased appetite.

Musculoskeletal: myalgia, temporomandibular dislocation, rheumatoid arthritis.

Neurological: hyperkinesia, hypoesthesia, vertigo.

Psychological: anxiety, depersonalization, depression, nervousness, sleep disorder, thinking abnormal.

Respiratory: bronchospasm, coughing, throat burning, laryngitis, bronchitis, dry throat, nocturnal dyspnea, nasopharyngitis, nasal congestion, pharyngolaryngeal pain, sinusitis, nasal dryness, paranasal sinus hypersecretion, post nasal drip.

Special Senses: conjunctivitis, eye abnormality, eye pain, watery eyes, taste loss.

Urogenital: albuminuria, amenorrhea, breast pain, hematuria, increased urinary frequency.

Whole Body: allergic reaction, back pain, herpes simplex, viral infection, malaise, pain in extremities, abdominal pain, pyrexia.

Vasomotor Rhinitis

Adverse experience information for azelastine HCl nasal spray, 0.1% is derived from two placebo-controlled clinical studies which included 216 patients 12 years and older with vasomotor rhinitis who received azelastine HCl nasal spray, 0.1% at a dose of 2 sprays per nostril twice daily for up to 28 days. The incidence of discontinuation due to adverse reactions in patients receiving azelastine HCl nasal spray, 0.1% and vehicle placebo was 2.8% and 2.9%, respectively.

The following adverse reactions were reported with frequencies ≥ 2% in the azelastine HCl nasal spray, 0.1% treatment group and more frequently than placebo.

Table 2: Adverse Reactions Reported in ≥2% Incidence in Placebo-Controlled Trials in Patients with Vasomotor Rhinitis [n (%)]

Reactions observed infrequently (<2% and exceeding placebo incidence) in patients who received azelastine HCl nasal spray, 0.1% (2 sprays/nostril twice daily) in U.S. clinical trials in vasomotor rhinitis were similar to those observed in U.S. clinical trials in seasonal allergic rhinitis.

In controlled trials involving nasal and oral azelastine HCl formulations, there were infrequent occurrences of hepatic transaminase elevations.

6.2 Postmarketing Experience

During the post approval use of azelastine HCl nasal spray, 0.1%, the following adverse reactions have been identified. 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. Adverse reactions reported include: anaphylaxis, application site irritation, atrial fibrillation, chest pain, confusion, dyspnea, facial edema, involuntary muscle contractions, nasal sores, palpitations, paresthesia, parosmia, pruritus, rash, disturbance or loss of sense of smell and/or taste, tolerance, urinary retention, vision abnormal and xerophthalmia.

7. Drug Interactions

7.1 Central Nervous System Depressants

Concurrent use of azelastine HCl nasal spray, 0.1% with alcohol or other central nervous system depressants should be avoided because reductions in alertness and impairment of central nervous system performance may occur .

8 USE IN SPECIFIC POPULATIONS

8.1 Pregnancy

Risk Summary

Limited data from post-marketing experience over decades of use with azelastine HCl nasal spray, 0.1% in pregnant women have not identified any drug associated risks of miscarriage, birth defects, or other adverse maternal or fetal outcomes. In animal reproduction studies, there was no evidence of fetal harm at oral doses approximately 5 times the clinical daily dose. Oral administration of azelastine HCl to pregnant mice, rats, and rabbits, during the period of organogenesis, produced developmental toxicity that included structural abnormalities, decreased embryo-fetal survival, and decreased fetal body weights at doses 270 times and higher than the maximum recommended human daily intranasal dose (MRHDID) of 1.096 mg. However, the relevance of these findings in animals to pregnant women was considered questionable based upon the high animal to human dose multiple.

The estimated background risk of major birth defects and miscarriage for the indicated populations 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.

Data

Animal Data

In an embryo-fetal development study in mice dosed during the period of organogenesis, azelastine HCl caused embryo-fetal death, structural abnormalities (cleft palate; short or absent tail; fused, absent or branched ribs), delayed ossification, and decreased fetal weight at approximately 300 times the maximum recommended human daily intranasal dose (MRHDID) in adults (on a mg/m 2 basis at a maternal oral dose of 68.6 mg/kg/day), which also caused maternal toxicity as evidenced by decreased maternal body weight. Neither fetal nor maternal effects occurred in mice at approximately 15 times the MRHDID in adults (on a mg/m 2 basis at a maternal oral dose of 3 mg/kg/day).

In an embryo-fetal development study in pregnant rats dosed during the period of organogenesis from gestation days 7 to 17, azelastine HCl caused structural abnormalities (oligo-and brachydactylia), delayed ossification, and skeletal variations, in the absence of maternal toxicity, at approximately 270 times the MRHDID in adults (on a mg/m 2 basis at a maternal oral dose of 30 mg/kg/day). Azelastine HCl caused embryo-fetal death and decreased fetal weight and severe maternal toxicity at approximately 610 times the MRHDID (on a mg/m 2 basis at a maternal oral dose of 68.6 mg/kg/day). Neither fetal nor maternal effects occurred at approximately 20 times the MRHDID (on a mg/m 2 basis at a maternal oral dose of 2 mg/kg/day).

In an embryo-fetal development study in pregnant rabbits dosed during the period of organogenesis from gestation days 6 to 18, azelastine HCl caused abortion, delayed ossification and decreased fetal weight and severe maternal toxicity at approximately 530 times the MRHDID in adults (on a mg/m 2 basis at a maternal oral dose of 30 mg/kg/day). Neither fetal nor maternal effects occurred at approximately 5 times the MRHDID (on a mg/m 2 basis at a maternal oral dose of 0.3 mg/kg/day).

In a prenatal and postnatal development study in pregnant rats dosed from late in the gestation period and through the lactation period from gestation day 17 through lactation day 21, azelastine HCl produced no adverse developmental effects on pups at maternal doses up to approximately 270 times the MRHDID (on mg/m 2 basis at a maternal dose of 30 mg/kg/day).

8.2 Lactation

Risk Summary

There are no data on the presence of azelastine HCl in human milk, the effects on the breastfed infant, or the effects on milk production. Breastfed infants should be monitored for signs of milk rejection during azelastine HCl use by lactating women (see Clinical Considerations).The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for azelastine HCl nasal spray, 0.1% and any potential adverse effects on the breastfed infant from azelastine HCl nasal spray, 0.1% or from the underlying maternal condition.

Clinical Considerations

Monitoring for Adverse Reactions
Breastfed infants of lactating women treated with azelastine HCl nasal spray, 0.1% should be monitored for possible signs of milk rejection related to the bitter taste of azelastine HCl.

8.4 Pediatric Use

The safety and effectiveness of azelastine HCl nasal spray, 0.1% for the treatment of symptoms of seasonal allergic rhinitis have been established for patients 5 years and older [see Adverse Reactions (6.1) and Clinical Studies (14.1)] . The safety and effectiveness of azelastine HCl nasal spray, 0.1% for the treatment of vasomotor rhinitis have been established for patients 12 years and older [see Adverse Reactions (6.1) and Clinical Studies (14.2)] . The safety and effectiveness of azelastine HCl nasal spray, 0.1% in pediatric patients below the age of 5 years with seasonal allergic rhinitis and in pediatric patients below the age of 12 years with vasomotor rhinitis have not been established.

8.5 Geriatric Use

Clinical trials of azelastine HCl nasal spray, 0.1% did not include sufficient numbers of patients aged 65 and over to determine whether they respond differently from younger patients. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.

10. Overdosage

There have been no reported overdosages with azelastine HCl nasal spray, 0.1%. Acute overdosage by adults with this dosage form is unlikely to result in clinically significant adverse reactions, other than increased somnolence, since one bottle of azelastine HCl nasal spray, 0.1% contains 30 mg of azelastine(HCl). Clinical trials in adults with single doses of the oral formulation of azelastine (HCl) (up to 16 mg) have not resulted in increased incidence of serious adverse reactions. General supportive measures should be employed if overdosage occurs. There is no known antidote to azelastine HCl nasal spray, 0.1%. Oral ingestion of antihistamines has the potential to cause serious adverse effects in young children. Accordingly, azelastine HCl nasal spray, 0.1% should be kept out of the reach of children.

11. Azelastine Description

Azelastine HCl nasal spray, 0.1%, 137 micrograms (mcg), is an antihistamine formulated as a metered-spray solution for intranasal administration. Azelastine HCl, USP occurs as a white, almost odorless, crystalline powder with a bitter taste. It has a molecular weight of 418.37. It is sparingly soluble in water, methanol, and propylene glycol and slightly soluble in ethanol, octanol, and glycerine. It has a melting point of about 225°C and the pH of a saturated solution is between 5.0 and 5.4. Its chemical name is (±)-1-(2H)-phthalazinone,4-[(4-chlorophenyl) methyl]-2-(hexahydro-1-methyl-1H-azepin-4-yl)-, monohydrochloride. Its molecular formula is C 22H 24ClN 3O•HCl with the following chemical structure:

Azelastine HCl nasal spray, 0.1% contains 0.1% azelastine HCl, USP in an aqueous solution at pH 6.8 ± 0.3. It also contains benzalkonium chloride (125 mcg/mL), citric acid, dibasic sodium phosphate, edetate disodium, hypromellose, purified water (pH 6.8) and sodium chloride.

12. Azelastine – Clinical Pharmacology

12.1 Azelastine Mechanism of Action

Azelastine HCl, a phthalazinone derivative, exhibits histamine H 1-receptor antagonist activity in isolated tissues, animal models, and humans. Azelastine HCl nasal spray, 0.1% is administered as a racemic mixture with no difference in pharmacologic activity noted between the enantiomers in in vitro studies. The major metabolite, desmethylazelastine, also possesses H 1-receptor antagonist activity.

12.2 Pharmacodynamics

Cardiac Electrophysiology:

In a placebo-controlled study (95 subjects with allergic rhinitis), there was no evidence of an effect of azelastine HCl nasal spray, 0.1% (2 sprays per nostril twice daily for 56 days) on cardiac repolarization as represented by the corrected QT interval (QTc) of the electrocardiogram. Following multiple dose oral administration of azelastine 4 mg or 8 mg twice daily, the mean change in QTc was 7.2 msec and 3.6 msec, respectively.

Interaction studies investigating the cardiac repolarization effects of concomitantly administered oral azelastine HCl and erythromycin or ketoconazole were conducted. These drugs had no effect on QTc based on analysis of serial electrocardiograms. At a dose approximately 8 times the maximum recommended dose, azelastine HCl does not prolong the QTc interval to any clinically relevant extent.

12.3 Pharmacokinetics

Absorption: After intranasal administration, the systemic bioavailability of azelastine HCl is approximately 40%. Maximum plasma concentrations (C max) are achieved in 2 to 3 hours.

Azelastine HCl administered intranasally at doses above two sprays per nostril twice daily for 29 days resulted in greater than proportional increases in C max and area under the curve (AUC) for azelastine.

Distribution: Based on intravenous and oral administration, the steady-state volume of distribution is 14.5 L/kg. In vitro studies with human plasma indicate that the plasma protein binding of azelastine and its metabolite, desmethylazelastine, are approximately 88% and 97%, respectively.

Metabolism: Azelastine is oxidatively metabolized to the principal active metabolite, desmethylazelastine, by the cytochrome P450 enzyme system. The specific P450 isoforms responsible for the biotransformation of azelastine have not been identified. After intranasal dosing of azelastine HCl to steady-state, plasma concentrations of desmethylazelastine range from 20% to 50% of azelastine concentrations. Limited data indicate that the metabolite profile is similar when azelastine HCl is administered via the intranasal or oral route.

Elimination: Based on intravenous and oral administration, the elimination half-life and plasma clearance are 22 hours and 0.5 L/h/kg, respectively. Approximately 75% of an oral dose of radiolabeled azelastine HCl was excreted in the feces with less than 10% as unchanged azelastine.

Special Populations:

Hepatic Impairment: Following oral administration, pharmacokinetic parameters were not influenced by hepatic impairment.

Renal Impairment: Based on oral, single-dose studies, renal insufficiency (creatinine clearance <50 mL/min) resulted in a 70% to 75% higher C max and AUC compared to normal subjects. Time to maximum concentration was unchanged.

Age: Following oral administration, pharmacokinetic parameters were not influenced by age.

Gender: Following oral administration, pharmacokinetic parameters were not influenced by gender.

Race: The effect of race has not been evaluated.

Drug-Drug Interactions:

Erythromycin: No significant pharmacokinetic interaction was observed with the co-administration of orally administered azelastine (4 mg twice daily) with erythromycin (500 mg three times daily for 7 days). In this study, co-administration of orally administered azelastine with erythromycin resulted in C max of 5.36 ± 2.6 ng/mL and AUC of 49.7 ± 24 ng•h/mL for azelastine, whereas, administration of azelastine alone resulted in C max of 5.57 ± 2.7 ng/mL and AUC of 48.4 ± 24 ng•h/mL for azelastine.

Cimetidine and Ranitidine: In a multiple-dose, steady-state drug interaction trial in healthy subjects, cimetidine (400 mg twice daily) increased orally administered mean azelastine (4 mg twice daily) concentrations by approximately 65%. No pharmacokinetic interaction was observed with co-administration of orally administered azelastine (4 mg twice daily) with ranitidine hydrochloride (150 mg twice daily). Oral co-administration of azelastine with ranitidine resulted in C max of 8.89 ±3.28 ng/mL and AUC of 88.22 ± 40.43 ng•h/mL for azelastine, whereas, azelastine when administered alone resulted in C max of 7.83 ± 4.06 ng/mL and AUC of 80.09 ± 43.55 ng•h/mL for azelastine.

Theophylline: No significant pharmacokinetic interaction was observed with the co-administration of an oral 4 mg dose of azelastine HCl twice daily and theophylline 300 mg or 400 mg twice daily.

13. Nonclinical Toxicology

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

Two-year carcinogenicity studies in Crl:CD(SD)BR rats and NMRI mice were conducted to assess the carcinogenic potential of azelastine HCl. No evidence of tumorigenicity was observed in rats at doses up to 30 mg/kg (approximately 270 and 240 times the MRHDID for adults and children, respectively, on a mg/m 2 basis). No evidence for tumorigenicity was observed in mice at doses up to 25 mg/kg (approximately 110 and 100 times the MRHDID for adults and children, respectively, on a mg/m 2 basis).

Azelastine HCl showed no genotoxic effects in the Ames test, DNA repair test, mouse lymphoma forward mutation assay, mouse micronucleus test, or chromosomal aberration test in rat bone marrow.

There were no effects on male or female fertility and reproductive performance in male and female rats at oral doses up to 30 mg/kg (approximately 270 times the MRHDID in adults on a mg/m 2 basis). At 68.6 mg/kg (approximately 610 times the MRHDID on a mg/m 2 basis), the duration of estrous cycles was prolonged and copulatory activity and the number of pregnancies were decreased. The numbers of corpora lutea and implantations were decreased; however, pre-implantation loss was not increased.

14. Clinical Studies

14.1 Seasonal Allergic Rhinitis

Two Sprays Per Nostril Twice Daily

The efficacy and safety of azelastine HCl nasal spray, 0.1% were evaluated in three placebo-controlled clinical trials of azelastine HCl nasal spray, 0.1% including 322 patients with seasonal allergic rhinitis who received two sprays per nostril twice a day for up to 4 weeks. These trials included 55 pediatric patients ages 12 to 16 years. Assessment of efficacy was based on the 12-hour reflective Total Symptom Complex (TSC) and Major Symptom Complex (MSC). The MSC was calculated as the average of individual symptoms of nose blows, sneezes, runny nose/sniffles, itchy nose, and watery eyes as assessed by patients on a 0 to 5 categorical scale. Azelastine HCl nasal spray, 0.1% two sprays per nostril twice daily demonstrated a greater decrease in the MSC than placebo (Table 3).

Table 3: Mean Change from Baseline in Reflective MSC* in Adults and Adolescents ≥12 Years with Seasonal Allergic Rhinitis Treated with Azelastine HCl Nasal Spray, 0.1% Two Sprays Per Nostril Twice Daily Versus Placebo

In dose-ranging trials, administration of azelastine HCl nasal spray, 0.1% two sprays per nostril twice daily resulted in a statistically significant decrease in symptoms compared to saline placebo within 3 hours after initial dosing and persisted over the 12-hour dosing interval.

One Spray Per Nostril Twice Daily

The efficacy and safety of azelastine HCl nasal spray, 0.1% were evaluated in two placebo-controlled clinical trials of azelastine HCl nasal spray, 0.1% including 275 patients with seasonal allergic rhinitis who received one spray per nostril twice a day for up to 2 weeks. Assessment of efficacy was based on the 12-hour reflective Total Nasal Symptom Score [rTNSS]. rTNSS is calculated as the sum of the patients scoring of four individual nasal symptoms (runny nose, sneezing, itchy nose, and nasal congestion) as assessed by patients on a 0 to 3 categorical scale. The primary efficacy endpoint was the change from Baseline to Day 14 in rTNSS. The mean change from baseline in rTNSS was greater in patients receiving azelastine HCl nasal spray, 0.1% one spray per nostril twice daily than those receiving placebo (Table 4).

Table 4: Mean Change from Baseline in Reflective TNSS* in Adults and Adolescents ≥12 years with Seasonal Allergic Rhinitis Treated with Azelastine HCl Nasal Spray, 0.1% One Spray Per Nostril Twice Daily Versus Placebo

Two-week studies comparing the efficacy (and safety) of azelastine HCl nasal spray, 0.1% two sprays per nostril twice daily versus one spray per nostril twice daily were not conducted.

14.2 Vasomotor Rhinitis

The efficacy and safety of azelastine HCl nasal spray, 0.1% were evaluated in two placebo-controlled clinical trials of azelastine HCl nasal spray, 0.1% including 216 patients with vasomotor rhinitis who received two sprays per nostril twice a day for up to 4 weeks. These patients had vasomotor rhinitis for at least one year, negative skin tests to indoor and outdoor aeroallergens, negative nasal smears for eosinophils, and negative sinus X-rays. Azelastine HCl nasal spray, 0.1% demonstrated a significantly greater decrease in a symptom complex comprised of rhinorrhea, post nasal drip, nasal congestion, and sneezing compared to placebo.

16. How is Azelastine supplied

Azelastine HCl nasal spray 0.1%, 137 mcg, is supplied as a 30-mL package (NDC 42291-094-30) delivering 200 metered sprays in a high-density polyethylene (HDPE) bottle fitted with a metered-dose spray pump unit.

The spray pump unit consists of a nasal spray pump fitted with a white safety clip and a white or clear plastic dust cover. The net content of the bottle is 30 mL (net weight 30 g of solution). Each bottle contains 30 mg (1 mg/mL) of azelastine HCl, USP. After priming [see Dosage and Administration (2.3)] , each spray delivers a fine mist containing a mean volume of 0.137 mL solution containing 137 mcg of azelastine HCl, USP. The correct amount of medication in each spray cannot be assured before the initial priming and after 200 sprays have been used, even though the bottle is not completely empty.

The bottle should be discarded after 200 sprays have been used. Azelastine HCl nasal spray, 0.1% should not be used after the expiration date “EXP” printed on the medicine label and carton.

Storage:

Store upright at 20° to 25°C (68° to 77°F) [see USP Controlled Room Temperature]. Protect from freezing.

17. Patient Counseling Information

See FDA-approved patient labeling ( Patient Information and Instructions for Use).

Activities Requiring Mental Alertness

Somnolence has been reported in some patients taking azelastine HCl nasal spray, 0.1%. Caution patients against engaging in hazardous occupations requiring complete mental alertness and motor coordination such as driving or operating machinery after administration of azelastine HCl nasal spray, 0.1%.

Concurrent Use of Alcohol and other Central Nervous System Depressants

Instruct patients to avoid concurrent use of azelastine HCl nasal spray, 0.1% with alcohol or other central nervous system depressants because additional reductions in alertness and additional impairment of central nervous system performance may occur .

Common Adverse Reactions

Inform patients that the treatment with azelastine HCl nasal spray, 0.1% may lead to adverse reactions, which include bitter taste, headache, somnolence, dysesthesia, rhinitis, nasal burning, pharyngitis, epistaxis, sinusitis, paroxysmal sneezing, nausea, dry mouth, fatigue, dizziness, and weight increase  .

Priming

Instruct patients to prime the pump before initial use and when azelastine HCl nasal spray, 0.1% has not been used for 3 or more days .

Keep Spray Out of Eyes

Instruct patients to avoid spraying azelastine HCl nasal spray, 0.1% into their eyes.

Keep Out of Children’s Reach

Instruct patients to keep azelastine HCl nasal spray, 0.1% out of the reach of children. If a child accidentally ingests azelastine HCl nasal spray, 0.1%, seek medical help or call a poison control center immediately.

Manufactured for:

AvKARE

Pulaski, TN 38478

Manufactured by:

Amneal Pharmaceuticals LLC

Branchburg, NJ 08876

Mfg. Rev. 10-2018-02 AV 02/21

PATIENT INFORMATION

Azelastine Hydrochloride (ay” ze las’ teen hye” droe klor’ ide) Nasal Spray, 0.1%

What is azelastine HCl nasal spray, 0.1%?

• Azelastine HCl nasal spray, 0.1% is a prescription medicine used to treat symptoms of seasonal allergic rhinitis in people age 5 and older and vasomotor rhinitis in people age 12 and older.
• Azelastine HCl nasal spray, 0.1% may help to reduce your nasal symptoms including stuffy nose, runny nose, itching and sneezing.

It is not known if azelastine HCl nasal spray, 0.1% is safe and effective in children with seasonal allergic rhinitis under 5 years of age or in children with vasomotor rhinitis under 12 years of age.

What should I tell my healthcare provider before using azelastine HCl nasal spray, 0.1%?

Before using azelastine HCl nasal spray, 0.1%, tell your healthcare provider if you are:

• allergic to any of the ingredients in azelastine HCl nasal spray, 0.1%. See the end of this leaflet for a complete list of ingredients in azelastine HCl nasal spray, 0.1%.
• pregnant, or plan to become pregnant.
• breastfeeding, or plan to breastfeed. It is not known if azelastine HCl passes into your breast milk. You and your healthcare provider should decide if you will use azelastine HCl nasal spray, 0.1% if you plan to breastfeed.

Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. Azelastine HCl nasal spray, 0.1% and other medicines may affect each other, causing side effects.

How should I use azelastine HCl nasal spray, 0.1%?

• Read the Instructions for Use at the end of this leaflet for information about the right way to use azelastine HCl nasal spray, 0.1%.
• Spray azelastine HCl nasal spray, 0.1% in your nose only. Do not spray it into your eyes or mouth.
• Use azelastine HCl nasal spray, 0.1% exactly as your healthcare provider tells you to use it.
• Do not use more than your healthcare provider tells you.
• Throw away your azelastine HCl nasal spray, 0.1% bottle after using 200 sprays. Even though the bottle may not be completely empty, you may not get the correct dose of medicine.
• If you use too much or a child accidentally swallows azelastine HCl nasal spray, 0.1%, call your healthcare provider or go to the nearest hospital emergency room right away.

What should I avoid while using azelastine HCl nasal spray, 0.1%?

Azelastine HCl nasal spray, 0.1% can cause sleepiness:

• Do not drive, operate machinery, or do other dangerous activities until you know how azelastine HCl nasal spray, 0.1% affects you.
• Do not drink alcohol or take other medicines that may cause you to feel sleepy while using azelastine HCl nasal spray, 0.1%. It may make your sleepiness worse.

What are the possible side effects of azelastine HCl nasal spray, 0.1%?

The most common side effects of azelastine HCl nasal spray, 0.1% include:

• unusual bitter taste
• headache
• sleepiness
• nose burning, pain or discomfort
• runny nose
• scratchy or sore throat
• nosebleeds
• inflammation or swelling of the sinuses
• sneezing
• nausea
• dry mouth
• fatigue
• dizziness
• weight increase

Tell your healthcare provider if you have any side effect that bothers you or that does not go away.

These are not all of the possible side effects of azelastine HCl nasal spray, 0.1%. For more information, ask your healthcare provider or pharmacist.

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

How should I store azelastine HCl nasal spray, 0.1%?

• Keep azelastine HCl nasal spray, 0.1% upright at 68° to 77°F (20° to 25°C).
• Do not freeze azelastine HCl nasal spray, 0.1%.
• Do not use azelastine HCl nasal spray, 0.1% after the expiration date “EXP” on the medicine label and box.

Keep azelastine HCl nasal spray, 0.1% and all medicines out of reach of children.

General information about the safe and effective use of azelastine HCl nasal spray, 0.1%.

Medicines are sometimes prescribed for conditions other than those listed in a Patient Information leaflet. Do not use azelastine HCl nasal spray, 0.1% for a condition for which it was not prescribed. Do not give azelastine HCl nasal spray, 0.1% to other people, even if they have the same symptoms that you have. It may harm them.

This Patient Information leaflet summarizes the most important information about azelastine HCl nasal spray, 0.1%. If you would like more information, talk with your healthcare provider. You can ask your pharmacist or healthcare provider for information about azelastine HCl nasal spray, 0.1% that is written for health professionals.

For more information call 1-855-361-3993.

What are the ingredients in azelastine HCl nasal spray, 0.1%?

Active ingredient: Azelastine HCl, USP

Inactive ingredients: Benzalkonium chloride, citric acid, dibasic sodium phosphate, edetate disodium, hypromellose, purified water (pH 6.8) and sodium chloride.

* Trademarks are the property of their respective owners.

Manufactured for:

AvKARE

Pulaski, TN 38478

Manufactured by:

Amneal Pharmaceuticals LLC

Branchburg, NJ 08876

Mfg. Rev. 10-2018-02 AV 02/21

Instructions for Use

Azelastine Hydrochloride (ay” ze las’ teen hye” droe klor’ ide) Nasal Spray, 0.1%

For the correct dose of medicine:

• Keep your head tilted downward when spraying into your nostril.
• Change nostrils each time you use the spray.
• Breathe gently and do not tip your head back after using the spray. This will keep the medicine from running down into your throat. You may get a bitter taste in your mouth.

Figure A identifies the parts of your azelastine HCl nasal spray, 0.1% pump

Before you use azelastine HCl nasal spray, 0.1% for the first time, you will need to prime the bottle.

Priming your azelastine HCl nasal spray, 0.1%

Remove the dust cover over the tip of the pump and the white safety clip just under the “shoulders” of the pump (See Figure B).

Hold the bottle upright with 2 fingers on the shoulders of the spray pump unit and

• put your thumb on the bottom of the bottle. Press upward with your thumb and release for the pumping action. Repeat this until you see a fine mist (See Figure C).
• To get a fine mist you must pump the spray fast and use firm pressure against the bottom of the bottle. If you see a stream of liquid, the pump is not working correctly and you may have nasal discomfort.
• This should happen in 4 sprays or less.

Now your pump is primed and ready to use.

• Do not use azelastine HCl nasal spray, 0.1% unless you see a fine mist after you do the priming sprays. If you do not see a fine mist, clean the tip of the spray nozzle. See the “Cleaning the Spray Tip of your azelastine HCl nasal spray, 0.1%” section below.
• If you do not use azelastine HCl nasal spray, 0.1% for 3 or more days, you will need to prime the pump with 2 sprays or until you see a fine mist.Using your azelastine HCl nasal spray, 0.1%

Step 1. Blow your nose to clear your nostrils.

Step 2. Keep your head tilted downward toward your toes.

Step 3. Place the spray tip about ¼ inch to ½ inch into 1 nostril. Hold bottle upright and aim the

spray tip toward the back of your nose (See Figure D).

Step 4. Close your other nostril with a finger. Press the pump 1 time and sniff gently at the same time, keeping your head tilted forward and down (See Figure E).

Step 5. Repeat Step 3 and Step 4 in your other nostril.

Step 6. If your healthcare provider tells you to use 2 sprays in each nostril, repeat Steps 2 through 4 above for the second spray in each nostril.

Step 7. Breathe in gently, and do not tilt your head back after using azelastine HCl nasal spray, 0.1%. This will help to keep the medicine from going into your throat.

Step 8. When you finish using your azelastine HCl nasal spray, 0.1%, wipe the spray tip with a clean tissue or cloth. Put the safety clip and dust cover back on the bottle.

Cleaning the Spray Tip of your azelastine HCl nasal spray, 0.1%

• The spray tip opening is clogged, do not use a pin or pointed object to unclog the tip. Unscrew the spray pump unit from the bottle by turning it to the left (counter-clockwise) (See Figure F).
• Soak only the spray pump unit in warm water. Squirt the spray unit several times while holding it under water. Use the pumping action to clear the opening in the tip (See Figure G).

• Let the spray pump unit air dry. Make sure it is dry before you put it back onto the bottle.
• Put the spray pump unit back into the open bottle and tighten it by turning clockwise (to the right).
• To keep the medicine from leaking out, use firm pressure when you put the pump back onto the bottle.
• After cleaning, follow the instructions for priming.

This Patient Information and Instructio

What is olopatadine nasal?

Olopatadine nasal (for the nose) is used to treat seasonal allergy symptoms such as congestion, sneezing, and runny nose.

Olopatadine nasal is for use in adults and children at least 6 years old.

Olopatadine nasal may also be used for purposes not listed in this medication guide.

Olopatadine nasal side effects

Get emergency medical help if you have signs of an allergic reaction: hives; difficult breathing; swelling of your face, lips, tongue, or throat.

Olopatadine may cause serious side effects. Stop using olopatadine and call your doctor at once if you have:

• nosebleed;
• painful sores inside your nose;
• fever; or
• pain or burning when you urinate.

Common side effects of olopatadine may include:

• runny or stuffy nose, nosebleeds;
• cough, throat pain or irritation;
• a bitter taste in your mouth;
• drowsiness;
• headache;
• fever;
• rash; or
• painful urination.

This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects.

Warnings

Use only as directed. Tell your doctor if you use other medicines or have other medical conditions or allergies.

Before taking this medicine

You should not use olopatadine if you are allergic to olopatadine.

Tell your doctor if you have other conditions that affect the inside of your nose.

Tell your doctor if you are pregnant or breastfeeding.

Not approved for use by anyone younger than 6 years old.

How should I use olopatadine nasal?

Follow all directions on your prescription label and read all medication guides or instruction sheets. Use the medicine exactly as directed.

Before your first use, shake the nasal spray well and prime it with 5 sprays into the air, until a fine mist appears. Spray away from your face. Prime again with 2 sprays whenever the medicine has not been used in longer than 7 days.

Gently blow your nose before using the nasal spray.

Carefully follow all Instructions for Use provided with this medicine.

Call your doctor if your symptoms do not improve, or if they get worse.

Store at room temperature away from moisture and heat.

Throw away the bottle after 240 sprays have been used, even if there is still medicine left inside. If used daily, one bottle contains enough medicine for 30 days for an adult dose or 60 days for a child’s dose.

Olopatadine dosing information

Usual Adult Dose for Allergic Rhinitis:

2 sprays in each nostril twice a day

Use: For the relief of symptoms of seasonal allergic rhinitis

Usual Pediatric Dose for Allergic Rhinitis:

6 to 11 years: 1 spray in each nostril twice a day

12 years or older: 2 sprays in each nostril twice a day

Use: For the relief of symptoms of seasonal allergic rhinitis

What happens if I miss a dose?

Use the medicine as soon as you can, but skip the missed dose if it is almost time for your next dose. Do not use two doses at one time.

What happens if I overdose?

Seek emergency medical attention or call the Poison Help line.

Overdose symptoms may include feeling agitated or restless and then drowsy.

What should I avoid while taking olopatadine nasal?

Avoid driving or hazardous activity until you know how olopatadine will affect you. Your reactions could be impaired.

Drinking alcohol with this medicine can cause side effects.

Avoid getting this medication in your eyes.

What is oxymetazoline nasal?

Oxymetazoline is a decongestant that shrinks blood vessels in the nasal passages. Dilated blood vessels can cause nasal congestion (stuffy nose).

Oxymetazoline nasal (for the nose) is for temporary relief of nasal congestion (stuffy nose) caused by allergies or the common cold.

Oxymetazoline nasal may also be used for purposes not listed in this medication guide.

Oxymetazoline nasal side effects

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficult breathing; swelling of your face, lips, tongue, or throat.

Oxymetazoline nasal may cause serious side effects. Stop using oxymetazoline nasal and call your doctor at once if you have:

• ongoing or worsening symptoms;
• severe burning or stinging in your nose after using the nasal spray;
• chest pain, fast or uneven heart rate; or
• severe headache, buzzing in your ears, anxiety, confusion, or feeling short of breath.

Common side effects of oxymetazoline nasal may include:

• mild burning or stinging of the nose;
• sneezing; or
• runny nose.

This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects.

Warnings

Oxymetazoline nasal (for the nose) is used for temporary relief of nasal congestion caused by allergies or the common cold.

Stop using oxymetazoline nasal and call your doctor at once if you have ongoing or worsening symptoms, or if you have severe burning or stinging in your nose after using the nasal spray

Before taking this medicine

You should not use oxymetazoline nasal if you are allergic to it.

Ask a doctor or pharmacist if it is safe for you to take this medicine if you have other medical conditions, especially:

• heart disease, high blood pressure, coronary artery disease;
• diabetes;
• a thyroid disorder; or
• enlarged prostate or urination problems.

FDA pregnancy category C. It is not known whether oxymetazoline nasal will harm an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant while using this medication.

It is not known whether oxymetazoline nasal passes into breast milk or if it could harm a nursing baby. Tell your doctor if you are breast-feeding a baby.

How should I use oxymetazoline nasal?

Use exactly as directed on the label, or as prescribed by your doctor. Do not use in larger or smaller amounts or for longer than recommended.

Using the medication too long or too often may worsen your symptoms or cause nasal congestion to clear up and come back.

Call your doctor if your symptoms do not improve after 3 days of treatment.

Do not share this medication with another person, even if they have the same symptoms you have. Sharing a nasal spray bottle can spread infection.

To use the nose drops (nasal solution):

• Blow your nose gently. Tilt your head back as far as possible, or lie down and hang your head over the side of a bed. Hold the dropper over your nose and place the correct number of drops into your nose.
• Sit up and bend your head slightly forward, then move it gently left and right. Stay seated with your head bent forward for a few minutes.
• Avoid sneezing or blowing your nose for at least a few minutes after using the nose drops.

To use the nasal spray:

• Blow your nose gently. Keep your head upright and insert the tip of bottle into one nostril. Press your other nostril closed with your finger. Breathe in quickly and gently spray the medicine into your nose. Then use the spray in your other nostril.
• Do not blow your nose for at least a few minutes after using the nasal spray.

Do not use the nasal spray more than 2 times in 24 hours.

Wipe the tip of the spray bottle with a clean tissue but do not wash with water or soap.

Store at room temperature away from moisture and heat. Do not freeze. Keep the bottle tightly closed when not in use.

Oxymetazoline nasal dosing information

Usual Adult Dose for Nasal Congestion:

2 or 3 sprays in each nostril not more often than every 10 to 12 hours

Comments:
-Do not exceed 2 doses in any 24-hour period.

Uses: Temporary relief of nasal congestion due to common cold, hay fever, and
upper respiratory allergies

Usual Pediatric Dose for Nasal Congestion:

6 years or older:
2 or 3 sprays in each nostril not more often than every 10 to 12 hours

Comments:
-Do not exceed 2 doses in any 24-hour period.
-Children ages 6 to under 12 years of age should use this drug with adult supervision.

Uses: Temporary relief of nasal congestion due to common cold, hay fever,
upper respiratory allergies

What happens if I miss a dose?

Use the missed dose as soon as you remember. Skip the missed dose if it is almost time for your next scheduled dose. Do not use extra medicine to make up the missed dose.

What happens if I overdose?

Seek emergency medical attention or call the Poison Help line if anyone has accidentally swallowed the medication.

Keep oxymetazoline nasal out of the reach of children. Certain nasal medications can cause serious medical problems in a young child who accidentally sucks on or swallows medicine from the nasal spray bottle.

What should I avoid while using oxymetazoline nasal?

Follow your doctor’s instructions about any restrictions on food, beverages, or activity.