prescribing information from relevant drugs should be consulted. the addition or withdrawal of these agents in patients on phenytoin therapy may require an adjustment of the phenytoin dose to achieve optimal clinical outcome. table 2: drugs that affect phenytoin concentrations a antacids may affect absorption of phenytoin. b the induction potency of st. john's wort may vary widely based on preparation. interacting agent examples drugs that may increase phenytoin serum levels antiepileptic drugs ethosuximide, felbamate, oxcarbazepine, methsuximide, topiramate azoles fluconazole, ketoconazole, itraconazole, miconazole, voriconazole antineoplastic agents capecitabine, fluorouracil antidepressants fluoxetine, fluvoxamine, sertraline gastric acid reducing agents h 2 antagonists (cimetidine), omeprazole sulfonamides sulfamethizole, sulfaphenazole, sulfadiazine, sulfamethoxazole- trimethoprim other acute alcohol intake, amiodarone, chloramphenicol, chlordiazepoxide, disulfiram, estrogen, fluvastatin, isoniazid, methylphenidate, phenothiazines, salicylates, ticlopidine, tolbutamide, trazodone, warfarin drugs that may decrease phenytoin serum levels antacids a calcium carbonate, aluminum hydroxide, magnesium hydroxide prevention or management: phenytoin and antacids should not be taken at the same time of day antineoplastic agents usually in combination bleomycin, carboplatin, cisplatin, doxorubicin, methotrexate antiviral agents fosamprenavir, nelfinavir, ritonavir antiepileptic drugs carbamazepine, vigabatrin other chronic alcohol abuse, diazepam, diazoxide, folic acid, reserpine, rifampin, st. john's wort b , sucralfate, theophylline drugs that may either increase or decrease phenytoin serum levels antiepileptic drugs phenobarbital, valproate sodium, valproic acid 7.2 drugs affected by phenytoin table 3 includes commonly occurring drug interactions affected by phenytoin. however, this list is not intended to be inclusive or comprehensive. individual drug package inserts should be consulted. the addition or withdrawal of phenytoin during concomitant therapy with these agents may require adjustment of the dose of these agents to achieve optimal clinical outcome. table 3: drugs affected by phenytoin a the effect of phenytoin on phenobarbital, valproic acid and sodium valproate serum levels is unpredictable interacting agent examples drugs whose efficacy is impaired by phenytoin azoles fluconazole, ketoconazole, itraconazole, posaconazole, voriconazole antineoplastic agents irinotecan, paclitaxel, teniposide delavirdine phenytoin can substantially reduce the concentrations of delavirdine. this can lead to loss of virologic response and possible resistance [see contraindications (4)]. neuromuscular blocking agents cisatracurium, pancuronium, rocuronium and vecuronium: resistance to the neuromuscular blocking action of the nondepolarizing neuromuscular blocking agents has occurred in patients chronically administered phenytoin. whether or not phenytoin has the same effect on other non-depolarizing agents is unknown. prevention or management: patients should be monitored closely for more rapid recovery from neuromuscular blockade than expected, and infusion rate requirements may be higher. warfarin increased and decreased pt/inr responses have been reported when phenytoin is coadministered with warfarin other corticosteroids, doxycycline, estrogens, furosemide, oral contraceptives, paroxetine, quinidine, rifampin, sertraline, theophylline, and vitamin d drugs whose level is decreased by phenytoin antiepileptic drugs a carbamazepine, felbamate, lamotrigine, topiramate, oxcarbazepine, antilipidemic agents atorvastatin, fluvastatin, simvastatin antiviral agents efavirenz, lopinavir/ritonavir, indinavir, nelfinavir, ritonavir, saquinavir fosamprenavir: phenytoin when given with fosamprenavir alone may decrease the concentration of amprenavir, the active metabolite. phenytoin when given with the combination of fosamprenavir and ritonavir may increase the concentration of amprenavir calcium channel blockers nifedipine, nimodipine, nisoldipine, verapamil other albendazole (decreases active metabolite), chlorpropamide, clozapine, cyclosporine, digoxin, disopyramide, folic acid, methadone, mexiletine, praziquantel, quetiapine 7.3 drug enteral feeding/nutritional preparations interaction literature reports suggest that patients who have received enteral feeding preparations and/or related nutritional supplements have lower than expected phenytoin serum levels. it is therefore suggested that phenytoin not be administered concomitantly with an enteral feeding preparation. more frequent serum phenytoin level monitoring may be necessary in these patients. 7.4 drug/laboratory test interactions care should be taken when using immunoanalytical methods to measure serum phenytoin concentrations.

oms of angioedema such as facial, perioral, or upper airway swelling occur. ( 5.7 ) hepatic injury: cases of acute hepatotoxicity have been reported with extended phenytoin sodium capsules. if this occurs, immediately discontinue. ( 4 , 5.8 ) hematopoietic complications: if occurs, follow-up observation is indicated and an alternative antiepileptic treatment should be used.( 5.9 ) 5.1 withdrawal precipitated seizure, status epilepticus abrupt withdrawal of phenytoin in epileptic patients may precipitate status epilepticus. when, in the judgment of the clinician, the need for dosage reduction, discontinuation, or substitution of alternative anticonvulsant medication arises, this should be done gradually. however, in the event of an allergic or hypersensitivity reaction, more rapid substitution of alternative therapy may be necessary. in this case, alternative therapy should be an anticonvulsant drug not belonging to the hydantoin chemical class. 5.2 suicidal behavior and ideation antiepileptic drugs (aeds), including extended phenytoin sodium capsules, increase the risk of suicidal thoughts or behavior in patients taking these drugs for any indication. patients treated with any aed for any indication should be monitored for the emergence or worsening of depression, suicidal thoughts or behavior, and/or any unusual changes in mood or behavior. pooled analyses of 199 placebo-controlled clinical trials (mono- and adjunctive therapy) of 11 different aeds showed that patients randomized to one of the aeds had approximately twice the risk (adjusted relative risk 1.8, 95% ci:1.2, 2.7) of suicidal thinking or behavior compared to patients randomized to placebo. in these trials, which had a median treatment duration of 12 weeks, the estimated incidence rate of suicidal behavior or ideation among 27,863 aed-treated patients was 0.43%, compared to 0.24% among 16,029 placebo-treated patients, representing an increase of approximately one case of suicidal thinking or behavior for every 530 patients treated. there were four suicides in drug-treated patients in the trials and none in placebo-treated patients, but the number is too small to allow any conclusion about drug effect on suicide. the increased risk of suicidal thoughts or behavior with aeds was observed as early as one week after starting drug treatment with aeds and persisted for the duration of treatment assessed. because most trials included in the analysis did not extend beyond 24 weeks, the risk of suicidal thoughts or behavior beyond 24 weeks could not be assessed. the risk of suicidal thoughts or behavior was generally consistent among drugs in the data analyzed. the finding of increased risk with aeds of varying mechanisms of action and across a range of indications suggests that the risk applies to all aeds used for any indication. the risk did not vary substantially by age (5 to 100 years) in the clinical trials analyzed. table 1 shows absolute and relative risk by indication for all evaluated aeds. table 1 risk by indication for antiepileptic drugs in the pooled analysis indication placebo patients with events per 1000 patients drug patients with events per1000 patients relative risk: incidence of events in drug patients/incidence in placebo patients risk difference: additional drug patients with events per 1000 patients epilepsy 1.0 3.4 3.5 2.4 psychiatric 5.7 8.5 1.5 2.9 other 1.0 1.8 1.9 0.9 total 2.4 4.3 1.8 1.9 the relative risk for suicidal thoughts or behavior was higher in clinical trials for epilepsy than in clinical trials for psychiatric or other conditions, but the absolute risk differences were similar for the epilepsy and psychiatric indications. anyone considering prescribing extended phenytoin sodium capsules or any other aed must balance the risk of suicidal thoughts or behavior with the risk of untreated illness. epilepsy and many other illnesses for which aeds are prescribed are themselves associated with morbidity and mortality and an increased risk of suicidal thoughts and behavior. should suicidal thoughts and behavior emerge during treatment, the prescriber needs to consider whether the emergence of these symptoms in any given patient may be related to the illness being treated. patients, their caregivers, and families should be informed that aeds increase the risk of suicidal thoughts and behavior and should be advised of the need to be alert for the emergence or worsening of the signs and symptoms of depression, any unusual changes in mood or behavior, or the emergence of suicidal thoughts, behavior, or thoughts about self-harm. behaviors of concern should be reported immediately to healthcare providers. 5.3 serious dermatologic reactions extended phenytoin sodium capsules can cause severe cutaneous adverse reactions (scars), which may be fatal. reported reactions in phenytoin-treated patients have included toxic epidermal necrolysis (ten) ,stevens-johnson syndrome (sjs),acute generalized exanthematous pustulosis (agep), and drug reaction with eosinophilia and systemic symptoms (dress) [see warnings and precautions ( 5.4 )]. the onset of symptoms is usually within 28 days, but can occur later. extended phenytoin sodium capsules should be discontinued at the first sign of a rash, unless the rash is clearly not drug-related. if signs or symptoms suggest a severe cutaneous adverse reaction, use of this drug should not be resumed and alternative therapy should be considered. if a rash occurs, the patient should be evaluated for signs and symptoms of scars. studies in patients of chinese ancestry have found a strong association between the risk of developing sjs/ten and the presence of hla-b*1502, an inherited allelic variant of the hla b gene, in patients using carbamazepine. limited evidence suggests that hla-b*1502 may be a risk factor for the development of sjs/ten in patients of asian ancestry taking other antiepileptic drugs associated with sjs/ten, including phenytoin. in addition, retrospective, case-control, genome-wide association studies in patients of southeast asian ancestry have also identified an increased risk of scars in carriers of the decreased function cyp2c9*3 variant, which has also been associated with decreased clearance of phenytoin. consider avoiding dilantin as an alternative to carbamazepine in patients who are positive for hla-b*1502 or in cyp2c9*3 carriers [see use in specific populations ( 8.7 ) and clinical pharmacology ( 12.5 )] . the use of hla-b*1502 or cyp2c9 genotyping has important limitations and must never substitute for appropriate clinical vigilance and patient management. the role of other possible factors in the development of, and morbidity from, sjs/ten, such as antiepileptic drug (aed) dose, compliance, concomitant medications, comorbidities, and the level of dermatologic monitoring have not been studied. 5.4 drug reaction with eosinophilia and systemic symptoms (dress)/multiorgan hypersensitivity drug reaction with eosinophilia and systemic symptoms (dress), also known as multiorgan hypersensitivity, has been reported in patients taking antiepileptic drugs, including extended phenytoin sodium capsules. some of these events have been fatal or life-threatening. dress typically, although not exclusively, presents with fever, rash, lymphadenopathy, and/or facial swelling, in association with other organ system involvement, such as hepatitis, nephritis, hematological abnormalities, myocarditis, or myositis sometimes resembling an acute viral infection. eosinophilia is often present. because this disorder is variable in its expression, other organ systems not noted here may be involved. it is important to note that early manifestations of hypersensitivity, such as fever or lymphadenopathy, may be present even though rash is not evident. if such signs or symptoms are present, the patient should be evaluated immediately. extended phenytoin sodium capsules should be discontinued if an alternative etiology for the signs or symptoms cannot be established. 5.5 hypersensitivity extended phenytoin sodium capsules and other hydantoins are contraindicated in patients who have experienced phenytoin hypersensitivity [see contraindications ( 4 ) and warnings and precautions ( 5.7 )] . additionally, consider alternatives to structurally similar drugs such as carboxamides (e.g., carbamazepine), barbiturates, succinimides, and oxazolidinediones (e.g., trimethadione) in these same patients. similarly, if there is a history of hypersensitivity reactions to these structurally similar drugs in the patient or immediate family members, consider alternatives to extended phenytoin sodium capsules. 5.6 cardiac effects cases of bradycardia and cardiac arrest have been reported in extended phenytoin sodium capsules-treated patients, both at recommended phenytoin doses and levels, and in association with phenytoin toxicity [see overdosage ( 10 )] . most of the reports of cardiac arrest occurred in patients with underlying cardiac disease. 5.7 angioedema angioedema has been reported in patients treated with extended phenytoin sodium capsules in the postmarketing setting. extended phenytoin sodium capsules should be discontinued immediately if symptoms of angioedema, such as facial, perioral, or upper airway swelling occur. extended phenytoin sodium capsules should be discontinued permanently if a clear alternative etiology for the reaction cannot be established. 5.8 hepatic injury cases of acute hepatotoxicity, including infrequent cases of acute hepatic failure, have been reported with extended phenytoin sodium capsules. these events may be part of the spectrum of dress or may occur in isolation [see warnings and precautions ( 5.4 )] . other common manifestations include jaundice, hepatomegaly, elevated serum transaminase levels, leukocytosis, and eosinophilia. the clinical course of acute phenytoin hepatotoxicity ranges from prompt recovery to fatal outcomes. in these patients with acute hepatotoxicity, extended phenytoin sodium capsules should be immediately discontinued and not readministered. 5.9 hematopoietic complications hematopoietic complications, some fatal, have occasionally been reported in association with administration of extended phenytoin sodium capsules. these have included thrombocytopenia, leukopenia, granulocytopenia, agranulocytosis, and pancytopenia with or without bone marrow suppression. there have been a number of reports suggesting a relationship between phenytoin and the development of lymphadenopathy (local or generalized) including benign lymph node hyperplasia, pseudolymphoma, lymphoma, and hodgkin's disease. although a cause and effect relationship has not been established, the occurrence of lymphadenopathy indicates the need to differentiate such a condition from other types of lymph node pathology. lymph node involvement may occur with or without symptoms and signs of dress [see warnings and precautions ( 5.4 )] . in all cases of lymphadenopathy, follow-up observation for an extended period is indicated and every effort should be made to achieve seizure control using alternative antiepileptic drugs. 5.10 effects on vitamin d and bone the chronic use of phenytoin in patients with epilepsy has been associated with decreased bone mineral density (osteopenia, osteoporosis, and osteomalacia) and bone fractures. phenytoin induces hepatic metabolizing enzymes. this may enhance the metabolism of vitamin d and decrease vitamin d levels, which may lead to vitamin d deficiency, hypocalcemia, and hypophosphatemia. consideration should be given to screening with bone-related laboratory and radiological tests as appropriate and initiating treatment plans according to established guidelines. 5.11 renal or hepatic impairment or hypoalbuminemia because the fraction of unbound phenytoin is increased in patients with renal or hepatic disease, or in those with hypoalbuminemia, the monitoring of phenytoin serum levels should be based on the unbound fraction in those patients. 5.12 exacerbation of porphyria in view of isolated reports associating phenytoin with exacerbation of porphyria, caution should be exercised in using this medication in patients suffering from this disease. 5.13 teratogenicity and other harm to the newborn extended phenytoin sodium capsules may cause fetal harm when administered to a pregnant woman. prenatal exposure to phenytoin may increase the risks for congenital malformations and other adverse developmental outcomes [see use in specific populations ( 8.1 )] increased frequencies of major malformations (such as orofacial clefts and cardiac defects), and abnormalities characteristic of fetal hydantoin syndrome, including dysmorphic skull and facial features, nail and digit hypoplasia, growth abnormalities (including microcephaly), and cognitive deficits, have been reported among children born to epileptic women who took phenytoin alone or in combination with other antiepileptic drugs during pregnancy. there have been several reported cases of malignancies, including neuroblastoma. a potentially life-threatening bleeding disorder related to decreased levels of vitamin k- dependent clotting factors may occur in newborns exposed to phenytoin in utero. this drug-induced condition can be prevented with vitamin k administration to the mother before delivery and to the neonate after birth. 5.14 hyperglycemia hyperglycemia, resulting from the drug's inhibitory effects on insulin release, has been reported. phenytoin may also raise the serum glucose level in diabetic patients. 5.15 serum phenytoin levels above therapeutic range serum levels of phenytoin sustained above the therapeutic range may produce confusional states referred to as "delirium," "psychosis," or "encephalopathy," or rarely irreversible cerebellar dysfunction and/or cerebellar atrophy. accordingly, at the first sign of acute toxicity, serum levels should be immediately checked. dose reduction of phenytoin therapy is indicated if serum levels are excessive; if symptoms persist, termination is recommended.

4 to 8 mg/kg/day. ( 2.2 ) serum blood level determinations may be necessary for optimal dosage adjustments—the clinically effective serum total concentration is 10 to 20 mcg/ml (unbound phenytoin concentration is 1 to 2 mcg/ml). ( 2.3 ) 2.1 adult dosage divided daily dosage the recommended starting dose for adult patients who have received no previous treatment is one 100-mg extended phenytoin sodium capsules by mouth three times daily. adjust the dosage to suit individual requirements up to a maximum of two capsules three times a day. for most adults, the satisfactory maintenance dosage will be one capsule three to four times a day. once-a-day dosage in adults, if seizure control is established with divided doses of three 100-mg extended phenytoin sodium capsules daily, once-a-day dosage with 300 mg of extended phenytoin sodium capsules may be considered. studies comparing divided doses of 300 mg with a single daily dose of this quantity indicated absorption, peak serum levels, biologic half-life, difference between peak and minimum values, and urinary recovery were equivalent. once-a-day dosage offers a convenience to the individual patient or to nursing personnel for institutionalized patients and is intended to be used only for patients requiring this amount of drug daily. a major problem in motivating noncompliant patients may also be lessened when the patient can take this drug once a day. however, patients should be cautioned not to miss a dose, inadvertently. only extended phenytoin sodium capsules are recommended for once-a-day dosing. inherent differences in dissolution characteristics and resultant absorption rates of phenytoin due to different manufacturing procedures and/or dosage forms preclude such recommendation for other phenytoin products. when a change in the dosage form or brand is prescribed, careful monitoring of phenytoin serum levels should be carried out. loading dose some authorities have advocated use of an oral loading dose of phenytoin in adults who require rapid steady-state serum levels and where intravenous administration is not desirable. this dosing regimen should be reserved for patients in a clinic or hospital setting where phenytoin serum levels can be closely monitored. patients with a history of renal or liver disease should not receive the oral loading regimen. initially, one gram of extended phenytoin sodium capsules are divided into three doses (400 mg, 300 mg, 300 mg) and administered at two-hour intervals. normal maintenance dosage is then instituted 24 hours after the loading dose, with frequent serum level determinations. 2.2 pediatric dosage the recommended starting dosage for pediatric patients is 5 mg/kg/day by mouth in two or three equally divided doses, with subsequent dosage individualized to a maximum of 300 mg daily in divided doses. a recommended daily maintenance dosage is usually 4 to 8 mg/kg/day in equally divided doses. children over 6 years and adolescents may require the minimum adult dosage (300 mg/day). 2.3 dosage adjustments dosage should be individualized to provide maximum benefit. in some cases, serum blood level determinations may be necessary for optimal dosage adjustments. trough levels provide information about clinically effective serum level range and confirm patient compliance, and are obtained just prior to the patient's next scheduled dose. peak levels indicate an individual's threshold for emergence of dose-related side effects and are obtained at the time of expected peak concentration. therapeutic effect without clinical signs of toxicity occurs more often with serum total concentrations between 10 and 20 mcg/ml (unbound phenytoin concentrations between 1 and 2 mcg/ml), although some mild cases of tonic-clonic (grand mal) epilepsy may be controlled with lower serum levels of phenytoin. in patients with renal or hepatic disease, or in those with hypoalbuminemia, the monitoring of unbound phenytoin concentrations may be more relevant [see dosage and administration ( 2.5 )]. with recommended dosage, a period of seven to ten days may be required to achieve steady-state blood levels with phenytoin and changes in dosage (increase or decrease) should not be carried out at intervals shorter than seven to ten days. 2.4 switching between phenytoin formulations extended phenytoin sodium capsules are formulated with the sodium salt of phenytoin. because there is approximately an 8% increase in drug content with the free acid form over that of the sodium salt, dosage adjustments and serum level monitoring may be necessary when switching from a product formulated with the free acid to a product formulated with the sodium salt and vice versa. 2.5 dosing in patients with renal or hepatic impairment or hypoalbuminemia because the fraction of unbound phenytoin is increased in patients with renal or hepatic disease, or in those with hypoalbuminemia, the monitoring of phenytoin serum levels should be based on the unbound fraction in those patients [see warnings and precautions ( 5.11 ) and use in specific populations ( 8.6 )] . 2.6 geriatric dosage phenytoin clearance is decreased slightly in elderly patients and lower or less frequent dosing may be required [see clinical pharmacology ( 12.3 )] . 2.7 dosing during pregnancy decreased serum concentrations of phenytoin may occur during pregnancy because of altered phenytoin pharmacokinetics. periodic measurement of serum phenytoin concentrations should be performed during pregnancy, and the extended phenytoin sodium capsules dosage should be adjusted as necessary. postpartum restoration of the original dosage will probably be indicated [see use in specific populations ( 8.1 )]. because of potential changes in protein binding during pregnancy, the monitoring of phenytoin serum levels should be based on the unbound fraction.

autions ( 5.14 )] the following adverse reactions associated with the use of extended phenytoin sodium capsules were identified in clinical studies or postmarketing reports. because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. body as a whole allergic reactions in the form of rash and rarely more serious forms and dress have been observed, as has angioedema [see warnings and precautions ( 5.3 , 5.4 , 5.7 )] . anaphylaxis has also been reported. there have also been reports of coarsening of facial features, systemic lupus erythematosus, periarteritis nodosa, and immunoglobulin abnormalities. digestive system acute hepatic failure, toxic hepatitis, liver damage, nausea, vomiting, constipation, enlargement of the lips, and gingival hyperplasia. hematologic and lymphatic system hematopoietic complications, some fatal, have occasionally been reported in association with administration of phenytoin. these have included thrombocytopenia, leukopenia, granulocytopenia, agranulocytosis, and pancytopenia with or without bone marrow suppression. while macrocytosis and megaloblastic anemia have occurred, these conditions usually respond to folic acid therapy. lymphadenopathy including benign lymph node hyperplasia, pseudolymphoma, lymphoma, and hodgkin's disease have been reported [see warnings and precautions ( 5.9 )] . laboratory test abnormality phenytoin may decrease serum concentrations of thyroid hormone (t4 and t3), sometimes with an accompanying increase in thyroid-stimulating hormone (tsh), but usually in the absence of clinical hypothyroidism. phenytoin may also produce lower than normal values for dexamethasone or metyrapone tests. phenytoin may cause increased serum levels of glucose [see warnings and precautions ( 5.14 )] , alkaline phosphatase, and gamma glutamyl transpeptidase (ggt). nervous system the most common adverse reactions encountered with phenytoin therapy are nervous system reactions and are usually dose-related. reactions include nystagmus, ataxia, slurred speech, decreased coordination, somnolence, and mental confusion. dizziness, vertigo, insomnia, transient nervousness, motor twitchings, paresthesias, and headaches have also been observed. there have also been rare reports of phenytoin-induced dyskinesias, including chorea, dystonia, tremor and asterixis, similar to those induced by phenothiazine and other neuroleptic drugs. cerebellar atrophy has been reported, and appears more likely in settings of elevated phenytoin levels and/or long-term phenytoin use [see warnings and precautions ( 5.15 )] . a predominantly sensory peripheral polyneuropathy has been observed in patients receiving long-term phenytoin therapy. skin and appendages dermatological manifestations sometimes accompanied by fever have included scarlatiniform or morbilliform rashes. a morbilliform rash (measles-like) is the most common; other types of dermatitis are seen more rarely. other more serious forms which may be fatal have included bullous, exfoliative or purpuric dermatitis, acute generalized exanthematous pustulosis, stevens-johnson syndrome, and toxic epidermal necrolysis [see warnings and precautions ( 5.3 )] . there have also been reports of hypertrichosis and urticaria. special senses altered taste sensation including metallic taste. urogenital peyronie's disease the most common adverse reactions are nervous system reactions, including nystagmus, ataxia, slurred speech, decreased coordination, somnolence, and mental confusion. ( 6 ) to report suspected adverse reactions, contact lupin pharmaceuticals, inc. at 1-800-399-2561, or fda at 1-800-fda-1088 or www.fda.gov/medwatch.

prescribing information from relevant drugs should be consulted. the addition or withdrawal of these agents in patients on phenytoin therapy may require an adjustment of the phenytoin dose to achieve optimal clinical outcome. table 2: drugs that affect phenytoin concentrations a antacids may affect absorption of phenytoin. b the induction potency of st. john's wort may vary widely based on preparation. interacting agent examples drugs that may increase phenytoin serum levels antiepileptic drugs ethosuximide, felbamate, oxcarbazepine, methsuximide, topiramate azoles fluconazole, ketoconazole, itraconazole, miconazole, voriconazole antineoplastic agents capecitabine, fluorouracil antidepressants fluoxetine, fluvoxamine, sertraline gastric acid reducing agents h 2 antagonists (cimetidine), omeprazole sulfonamides sulfamethizole, sulfaphenazole, sulfadiazine, sulfamethoxazole- trimethoprim other acute alcohol intake, amiodarone, chloramphenicol, chlordiazepoxide, disulfiram, estrogen, fluvastatin, isoniazid, methylphenidate, phenothiazines, salicylates, ticlopidine, tolbutamide, trazodone, warfarin drugs that may decrease phenytoin serum levels antacids a calcium carbonate, aluminum hydroxide, magnesium hydroxide prevention or management: phenytoin and antacids should not be taken at the same time of day antineoplastic agents usually in combination bleomycin, carboplatin, cisplatin, doxorubicin, methotrexate antiviral agents fosamprenavir, nelfinavir, ritonavir antiepileptic drugs carbamazepine, vigabatrin other chronic alcohol abuse, diazepam, diazoxide, folic acid, reserpine, rifampin, st. john's wort b , sucralfate, theophylline drugs that may either increase or decrease phenytoin serum levels antiepileptic drugs phenobarbital, valproate sodium, valproic acid 7.2 drugs affected by phenytoin table 3 includes commonly occurring drug interactions affected by phenytoin. however, this list is not intended to be inclusive or comprehensive. individual drug package inserts should be consulted. the addition or withdrawal of phenytoin during concomitant therapy with these agents may require adjustment of the dose of these agents to achieve optimal clinical outcome. table 3: drugs affected by phenytoin a the effect of phenytoin on phenobarbital, valproic acid and sodium valproate serum levels is unpredictable interacting agent examples drugs whose efficacy is impaired by phenytoin azoles fluconazole, ketoconazole, itraconazole, posaconazole, voriconazole antineoplastic agents irinotecan, paclitaxel, teniposide delavirdine phenytoin can substantially reduce the concentrations of delavirdine. this can lead to loss of virologic response and possible resistance [see contraindications (4)]. neuromuscular blocking agents cisatracurium, pancuronium, rocuronium and vecuronium: resistance to the neuromuscular blocking action of the nondepolarizing neuromuscular blocking agents has occurred in patients chronically administered phenytoin. whether or not phenytoin has the same effect on other non-depolarizing agents is unknown. prevention or management: patients should be monitored closely for more rapid recovery from neuromuscular blockade than expected, and infusion rate requirements may be higher. warfarin increased and decreased pt/inr responses have been reported when phenytoin is coadministered with warfarin other corticosteroids, doxycycline, estrogens, furosemide, oral contraceptives, paroxetine, quinidine, rifampin, sertraline, theophylline, and vitamin d drugs whose level is decreased by phenytoin antiepileptic drugs a carbamazepine, felbamate, lamotrigine, topiramate, oxcarbazepine, antilipidemic agents atorvastatin, fluvastatin, simvastatin antiviral agents efavirenz, lopinavir/ritonavir, indinavir, nelfinavir, ritonavir, saquinavir fosamprenavir: phenytoin when given with fosamprenavir alone may decrease the concentration of amprenavir, the active metabolite. phenytoin when given with the combination of fosamprenavir and ritonavir may increase the concentration of amprenavir calcium channel blockers nifedipine, nimodipine, nisoldipine, verapamil other albendazole (decreases active metabolite), chlorpropamide, clozapine, cyclosporine, digoxin, disopyramide, folic acid, methadone, mexiletine, praziquantel, quetiapine 7.3 drug enteral feeding/nutritional preparations interaction literature reports suggest that patients who have received enteral feeding preparations and/or related nutritional supplements have lower than expected phenytoin serum levels. it is therefore suggested that phenytoin not be administered concomitantly with an enteral feeding preparation. more frequent serum phenytoin level monitoring may be necessary in these patients. 7.4 drug/laboratory test interactions care should be taken when using immunoanalytical methods to measure serum phenytoin concentrations.

lformations and other adverse developmental outcomes. prenatal phenytoin exposure is associated with an increased incidence of major malformations, including orofacial clefts and cardiac defects. in addition, the fetal hydantoin syndrome, a pattern of abnormalities including dysmorphic skull and facial features, nail and digit hypoplasia, growth abnormalities (including microcephaly), and cognitive deficits has been reported among children born to epileptic women who took phenytoin alone or in combination with other antiepileptic drugs during pregnancy [see data] . there have been several reported cases of malignancies, including neuroblastoma, in children whose mothers received phenytoin during pregnancy. administration of phenytoin to pregnant animals resulted in an increased incidence of fetal malformations and other manifestations of developmental toxicity (including embryofetal death, growth impairment, and behavioral abnormalities) in multiple species at clinically relevant doses [see data]. in the u.s. general population, the estimated background risk of major birth defects and of miscarriage in clinically recognized pregnancies is 2 to 4% and 15 to 20%, respectively. the background risk of major birth defects and miscarriage for the indicated population is unknown. clinical considerations disease-associated maternal risk: an increase in seizure frequency may occur during pregnancy because of altered phenytoin pharmacokinetics. periodic measurement of serum phenytoin concentrations may be valuable in the management of pregnant women as a guide to appropriate adjustment of dosage [see dosage and administration (2.3, 2.7)] . however, postpartum restoration of the original dosage will probably be indicated [see clinical pharmacology ( 12.3 )]. fetal/neonatal adverse reactions: a potentially life-threatening bleeding disorder related to decreased levels of vitamin k- dependent clotting factors may occur in newborns exposed to phenytoin in utero . this drug-induced condition can be prevented with vitamin k administration to the mother before delivery and to the neonate after birth. data human data: meta-analyses using data from published observational studies and registries have estimated an approximately 2.4-fold increased risk for any major malformation in children with prenatal phenytoin exposure compared to controls. an increased risk of heart defects, facial clefts, and digital hypoplasia has been reported. the fetal hydantoin syndrome is a pattern of congenital anomalies including craniofacial anomalies, nail and digital hypoplasia, prenatal-onset growth deficiency, and neurodevelopmental deficiencies. animal data: administration of phenytoin to pregnant rats, rabbits, and mice during organogenesis resulted in embryofetal death, fetal malformations, and decreased fetal growth. malformations (including craniofacial, cardiovascular, neural, limb, and digit abnormalities) were observed in rats, rabbits, and mice at doses as low as 100, 75, and 12.5 mg/kg, respectively. 8.2 lactation risk summary phenytoin is secreted in human milk. the developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for extended phenytoin sodium capsules and any potential adverse effects on the breastfed infant from extended phenytoin sodium capsules or from the underlying maternal condition. 8.4 pediatric use initially, 5 mg/kg/day in two or three equally divided doses, with subsequent dosage individualized to a maximum of 300 mg daily. a recommended daily maintenance dosage is usually 4 to 8 mg/kg. children over 6 years and adolescents may require the minimum adult dosage (300 mg/day) [see dosage and administration ( 2.2 )] . 8.5 geriatric use phenytoin clearance tends to decrease with increasing age [see clinical pharmacology ( 12.3 )] . lower or less frequent dosing may be required [see dosage and administration ( 2.6 )] . 8.6 renal and/or hepatic impairment or hypoalbuminemia the liver is the chief site of biotransformation of phenytoin; patients with impaired liver function, elderly patients, or those who are gravely ill may show early signs of toxicity. because the fraction of unbound phenytoin is increased in patients with renal or hepatic disease, or in those with hypoalbuminemia, the monitoring of phenytoin serum levels should be based on the unbound fraction in those patients. 8.7 use in patients with decreased cyp2c9 function patients who are intermediate or poor metabolizers of cyp2c9 substrates (e.g., *1/*3, *2/*2, *3/*3) may exhibit increased phenytoin serum concentrations compared to patients who are normal metabolizers (e.g., *1/*1). thus, patients who are known to be intermediate or poor metabolizers may ultimately require lower doses of phenytoin to maintain similar steady-state concentrations compared to normal metabolizers. if early signs of dose-related central nervous system (cns) toxicity develop, serum concentrations should be checked immediately [see clinical pharmacology ( 12.5 )].

al features, nail and digit hypoplasia, growth abnormalities (including microcephaly), and cognitive deficits has been reported among children born to epileptic women who took phenytoin alone or in combination with other antiepileptic drugs during pregnancy [see data] . there have been several reported cases of malignancies, including neuroblastoma, in children whose mothers received phenytoin during pregnancy. administration of phenytoin to pregnant animals resulted in an increased incidence of fetal malformations and other manifestations of developmental toxicity (including embryofetal death, growth impairment, and behavioral abnormalities) in multiple species at clinically relevant doses [see data]. in the u.s. general population, the estimated background risk of major birth defects and of miscarriage in clinically recognized pregnancies is 2 to 4% and 15 to 20%, respectively. the background risk of major birth defects and miscarriage for the indicated population is unknown. clinical considerations disease-associated maternal risk: an increase in seizure frequency may occur during pregnancy because of altered phenytoin pharmacokinetics. periodic measurement of serum phenytoin concentrations may be valuable in the management of pregnant women as a guide to appropriate adjustment of dosage [see dosage and administration (2.3, 2.7)] . however, postpartum restoration of the original dosage will probably be indicated [see clinical pharmacology ( 12.3 )]. fetal/neonatal adverse reactions: a potentially life-threatening bleeding disorder related to decreased levels of vitamin k- dependent clotting factors may occur in newborns exposed to phenytoin in utero . this drug-induced condition can be prevented with vitamin k administration to the mother before delivery and to the neonate after birth. data human data: meta-analyses using data from published observational studies and registries have estimated an approximately 2.4-fold increased risk for any major malformation in children with prenatal phenytoin exposure compared to controls. an increased risk of heart defects, facial clefts, and digital hypoplasia has been reported. the fetal hydantoin syndrome is a pattern of congenital anomalies including craniofacial anomalies, nail and digital hypoplasia, prenatal-onset growth deficiency, and neurodevelopmental deficiencies. animal data: administration of phenytoin to pregnant rats, rabbits, and mice during organogenesis resulted in embryofetal death, fetal malformations, and decreased fetal growth. malformations (including craniofacial, cardiovascular, neural, limb, and digit abnormalities) were observed in rats, rabbits, and mice at doses as low as 100, 75, and 12.5 mg/kg, respectively.

averages 22 hours, with a range of 7 to 42 hours. metabolism: phenytoin is primarily metabolized by the hepatic cytochrome p450 enzyme cyp2c9 and to a lesser extent by cyp2c19. because phenytoin is hydroxylated in the liver by an enzyme system which is saturable at high serum levels, small incremental doses may increase the half-life and produce very substantial increases in serum levels, when these are in the upper range. the steady-state level may be disproportionately increased, with resultant intoxication, from an increase in dosage of 10% or more. in most patients maintained at a steady dosage, stable phenytoin serum levels are achieved. there may be wide interpatient variability in phenytoin serum levels with equivalent dosages. patients with unusually low levels may be noncompliant or hypermetabolizers of phenytoin. unusually high levels result from liver disease, variant cyp2c9 and cyp2c19 alleles, or drug interactions which result in metabolic interference. the patient with large variations in phenytoin serum levels, despite standard doses, presents a difficult clinical problem. serum level determinations in such patients may be particularly helpful. as phenytoin is highly protein bound, free phenytoin levels may be altered in patients whose protein binding characteristics differ from normal. excretion: most of the drug is excreted in the bile as inactive metabolites which are then reabsorbed from the intestinal tract and excreted in the urine. urinary excretion of phenytoin and its metabolites occurs partly with glomerular filtration but, more importantly, by tubular secretion. specific populations age: geriatric population: phenytoin clearance tends to decrease with increasing age (20% less in patients over 70 years of age relative to that in patients 20 to 30 years of age). since phenytoin clearance is decreased slightly in elderly patients, lower or less frequent dosing may be required [see dosage and administration ( 2.6 )]. sex/race: gender and race have no significant impact on phenytoin pharmacokinetics. renal or hepatic impairment: increased fraction of unbound phenytoin in patients with renal or hepatic disease, or in those with hypoalbuminemia has been reported. pregnancy: it has been reported in the literature that the plasma clearance of phenytoin generally increased during pregnancy, reached a peak in the third trimester and returned to the level of pre-pregnancy after few weeks or months of delivery. drug interaction studies phenytoin is primarily metabolized by the hepatic cytochrome p450 enzyme cyp2c9 and to a lesser extent by cyp2c19.phenytoin is a potent inducer of hepatic drug-metabolizing enzymes [see drug interactions ( 7.1 , 7.2 )] . 12.5 pharmacogenomics cyp2c9 activity is decreased in individuals with genetic variants such as the cyp2c9*2 and cyp2c9*3 alleles. carriers of variant alleles, resulting in intermediate (e.g., *1/*3, *2/*2) or poor metabolism (e.g., *2/*3, *3/*3) have decreased clearance of phenytoin. other decreased or nonfunctional cyp2c9 alleles may also result in decreased clearance of phenytoin (e.g., *5, *6, *8, *11). the prevalence of the cyp2c9 poor metabolizer phenotype is approximately 2-3% in the white population, 0.5-4% in the asian population, and <1% in the african american population. the cyp2c9 intermediate phenotype prevalence is approximately 35% in the white population, 24% in the african american population, and 15-36% in the asian population [see warnings and precautions (5.3) and use in specific populations (8.7)].

ses may increase the half-life and produce very substantial increases in serum levels, when these are in the upper range. the steady-state level may be disproportionately increased, with resultant intoxication, from an increase in dosage of 10% or more. in most patients maintained at a steady dosage, stable phenytoin serum levels are achieved. there may be wide interpatient variability in phenytoin serum levels with equivalent dosages. patients with unusually low levels may be noncompliant or hypermetabolizers of phenytoin. unusually high levels result from liver disease, variant cyp2c9 and cyp2c19 alleles, or drug interactions which result in metabolic interference. the patient with large variations in phenytoin serum levels, despite standard doses, presents a difficult clinical problem. serum level determinations in such patients may be particularly helpful. as phenytoin is highly protein bound, free phenytoin levels may be altered in patients whose protein binding characteristics differ from normal. excretion: most of the drug is excreted in the bile as inactive metabolites which are then reabsorbed from the intestinal tract and excreted in the urine. urinary excretion of phenytoin and its metabolites occurs partly with glomerular filtration but, more importantly, by tubular secretion. specific populations age: geriatric population: phenytoin clearance tends to decrease with increasing age (20% less in patients over 70 years of age relative to that in patients 20 to 30 years of age). since phenytoin clearance is decreased slightly in elderly patients, lower or less frequent dosing may be required [see dosage and administration ( 2.6 )]. sex/race: gender and race have no significant impact on phenytoin pharmacokinetics. renal or hepatic impairment: increased fraction of unbound phenytoin in patients with renal or hepatic disease, or in those with hypoalbuminemia has been reported. pregnancy: it has been reported in the literature that the plasma clearance of phenytoin generally increased during pregnancy, reached a peak in the third trimester and returned to the level of pre-pregnancy after few weeks or months of delivery. drug interaction studies phenytoin is primarily metabolized by the hepatic cytochrome p450 enzyme cyp2c9 and to a lesser extent by cyp2c19.phenytoin is a potent inducer of hepatic drug-metabolizing enzymes [see drug interactions ( 7.1 , 7.2 )] .

ames test and in the in vitro clastogenicity assay in chinese hamster ovary (cho) cells. in studies reported in the literature, phenytoin was negative in the in vitro mouse lymphoma assay and the in vivo micronucleus assay in mouse. phenytoin was clastogenic in the in vitro sister chromatid exchange assay in cho cells. fertility phenytoin has not been adequately assessed for effects on male or female fertility.

advise them of the need to be alert for the emergence or worsening of symptoms of depression, any unusual changes in mood or behavior, or the emergence of suicidal thoughts, behavior, or thoughts about self-harm. behaviors of concern should be reported immediately to healthcare providers [see warnings and precautions ( 5.2 )] . serious dermatologic reactions advise patients of the early signs and symptoms of severe cutaneous adverse reactions and to report any occurrence immediately to a physician [see warnings and precautions ( 5.3 )] . potential signs of drug reaction with eosinophilia and systemic symptoms (dress) and other systemic reactions advise patients of the early toxic signs and symptoms of potential hematologic, dermatologic, hypersensitivity, or hepatic reactions. these symptoms may include, but are not limited to, fever, sore throat, rash, ulcers in the mouth, easy bruising, lymphadenopathy, facial swelling, and petechial or purpuric hemorrhage, and in the case of liver reactions, anorexia, nausea/vomiting, or jaundice. advise the patient that, because these signs and symptoms maysignal a serious reaction, that they must report any occurrence immediately to a physician. in addition, advise the patient that these signs and symptoms should be reported even if mild or when occurring after extended use [see warnings and precautions ( 5.3 , 5.4 , 5.5 , 5.8 , 5.9 )] . cardiac effects counsel patients that cases of bradycardia and cardiac arrest have been reported, both at recommended phenytoin doses and levels, and in association with phenytoin toxicity. patients should report cardiac signs or symptoms to their healthcare provider [see warnings and precautions ( 5.6 ) and overdosage ( 10 )] . angioedema advise patients to discontinue extended phenytoin sodium capsules and seek immediate medical care if they develop signs or symptoms of angioedema, such as facial, perioral, or upper airway swelling [see warnings and precautions ( 5.7 )] . effects of alcohol use and other drugs and over-the-counter drug interactions caution patients against the use of other drugs or alcoholic beverages without first seeking their physician's advice [drug interactions ( 7.1 , 7.2 )] . inform patients that certain over-the-counter medications (e.g., antacids, cimetidine, and omeprazole), vitamins (e.g., folic acid), and herbal supplements (e.g., st. john's wort) can alter their phenytoin levels. hyperglycemia advise patients that extended phenytoin sodium capsules may cause an increase in blood glucose levels [see warnings and precautions ( 5.15 )] . gingival hyperplasia advise patients of the importance of good dental hygiene in order to minimize the development of gingival hyperplasia and its complications. neurologic effects counsel patients that extended phenytoin sodium capsules may cause dizziness, gait disturbance, decreased coordination and somnolence. advise patients taking extended phenytoin sodium capsules not to drive, operate complex machinery, or engage in other hazardous activities until they have become accustomed to any such effects associated with extended phenytoin sodium capsules. use in pregnancy inform pregnant women and women of childbearing potential that use of extended phenytoin sodium capsules during pregnancy can cause fetal harm, including an increased risk for cleft lip and/or cleft palate (oral clefts), cardiac defects, dysmorphic skull and facial features, nail anddigit hypoplasia, growth abnormalities (including microcephaly), and cognitive deficits. when appropriate, counsel pregnant women and women of childbearing potential about alternative therapeutic options. advise women of childbearing potential who are not planning a pregnancy to use effective contraception while using extended phenytoin sodium capsules, keeping in mind that there is a potential for decreased hormonal contraceptive efficacy [see drug interactions ( 7.2 )]. instruct patients to notify their physician if they become pregnant or intend to become pregnant during therapy, and to notify their physician if they are breastfeeding or intend to breastfeed during therapy [see use in specific populations ( 8.1 , 8.2 )] . encourage patients to enroll in the north american antiepileptic drug (naaed) pregnancy registry if they become pregnant. this registry is collecting information about the safety of antiepileptic drugs during pregnancy [see use in specific populations ( 8.1 )] . manufactured for: lupin pharmaceuticals, inc. baltimore, maryland 21202 united states manufactured by: lupin limited nagpur 441 108 india revised: march 2022 id#: 269280