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COMBIGAN: USE IN SPECIFIC POPULATIONS
Teratogenicity studies have been performed in animals. Brimonidine Tartrate was not teratogenic when given orally during gestation days 6 through 15 in rats and days 6 through 18 in rabbits. The highest doses of brimonidine tartrate in rats (2.5 mg / kg per day) and rabbits (5 mg / kg per day) achieved AUC exposure values 580 and 37-fold higher, respectively, than similar values estimated in humans treated with Combigan (Brimonidine, Timolol), 1 drop in both eyes twice daily.
Teratogenicity studies with timolol in mice, rats, and rabbits at oral doses up to 50 mg / kg per day (4,200 times the maximum recommended human ocular dose of 0.012 mg / kg per day on a mg / kg basis (MRHOD)) demonstrated no evidence of fetal malformations. Although delayed fetal ossification was observed at this dose in rats, there were no adverse effects on postnatal development of offspring. Doses of 1,000 mg / kg per day (83,000 times the MRHOD) were maternotoxic in mice and resulted in an increased number of fetal resorptions. Increased fetal resorptions were also seen in rabbits at doses 8,300 times the MRHOD without apparent maternotoxicity.
There are no adequate and well-controlled studies in pregnant women; however, in animal studies, brimonidine crossed the placenta and entered into the fetal circulation to a limited extent. Because animal reproduction studies are not always predictive of human response, Brimonidine with Timolol (Combigan) should be used during pregnancy only if the potential benefit to the mother justifies the potential risk to the fetus.
Timolol has been detected in human milk following oral and ophthalmic drug administration. It is not known whether brimonidine tartrate is excreted in human milk, although in animal studies, brimonidine tartrate has been shown to be excreted in breast milk. Because of the potential for serious adverse reactions from Combigan in nursing infants, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.
Combigan (Brimonidine Tartrate, Timolol Maleate ophthalmic solution) is contraindicated in children under the age of 2 years. During post-marketing surveillance, apnea, bradycardia, coma, hypotension, hypothermia, hypotonia, lethargy, pallor, respiratory depression, and somnolence have been reported in infants receiving brimonidine. The safety and effectiveness of brimonidine tartrate and timolol maleate have not been studied in children below the age of 2 years.
The safety and effectiveness of Combigan (Brimonidine Tartrate, Timolol Maleate) have been established in the age groups 2 – 16 years of age. Use of this medicine in these age groups is supported by evidence from adequate and well-controlled studies of Combigan (Brimonidine, Timolol) in adults with additional data from a study of the concomitant use of brimonidine tartrate ophthalmic solution 0.2% and timolol maleate ophthalmic solution in pediatric glaucoma patients (ages 2 to 7 years). In this study, brimonidine tartrate ophthalmic solution 0.2% was dosed three times a day as adjunctive therapy to beta-blockers. The most commonly observed adverse reactions were somnolence (50%-83% in patients 2 to 6 years) and decreased alertness. In pediatric patients 7 years of age or older (>20 kg), somnolence appears to occur less frequently (25%). Approximately 16% of patients on brimonidine tartrate ophthalmic solution discontinued from the study due to somnolence.
No overall differences in safety or effectiveness have been observed between elderly and other adult patients.
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