cholic acid (Rx)

Brand and Other Names:Cholbam
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

capsule

  • 50mg
  • 250mg

Bile Acid Synthesis Disorders

Indicated for bile acid synthesis disorders due to single-enzyme defects (SEDs)

10-15 mg/kg/day PO qDay or divided BID

Peroxisomal Disorders

Indicated for adjunctive treatment of peroxisomal disorders (PDs), including Zellweger spectrum disorders in patients who exhibit manifestations of liver disease, steatorrhea, or complications from decreased fat-soluble vitamin absorption

10-15 mg/kg/day PO qDay or divided BID

Dosage Modifications

Familial hypertriglyceridemia

  • Patients with newly diagnosed or a family history of familial hypertriglyceridemia may have poor absorption of cholic acid from the intestine and require a 10% increase in the recommended dosage to account for losses due to malabsorption
  • Recommended dosage range: 11-17 mg/kg/day PO qDay or divided BID
  • Determine adequacy of the dosage regimen by monitoring clinical response, including steatorrhea, and laboratory values, including transaminases, bilirubin, and PT/INR

Dosing Considerations

Safety and effectiveness on extrahepatic manifestations of bile acid synthesis disorders due to SEDs or PDs have not been established

Monitoring

  • Monitor AST, ALT, GGT, alkaline phosphatase, bilirubin, and INR every month for the first 3 months; every 3 months for the next 9 months; every 6 months during the subsequent 3 yr; and annually thereafter
  • Monitor more frequently during periods of rapid growth, concomitant disease, or pregnancy
  • Administer the lowest dose that effectively maintains liver function
  • Discontinue treatment if liver function does not improve within 3 months of the start of treatment or complete biliary obstruction develops
  • Discontinue treatment at any time if there are persistent clinical or laboratory indicators of worsening liver function or cholestasis
  • Concurrent elevations of GGT and ALT may indicate overdose; continue to monitor laboratory parameters of liver function and consider restarting at a lower dose when the parameters return to baseline
  • Serum or urinary bile acid level using mass spectrometry is used in the diagnosis of bile acid synthesis disorders due to SEDs and PDs, including Zellweger spectrum disorders
  • The utility of bile acid measurements in monitoring the clinical course of patients and in decisions regarding dose adjustment has not been demonstrated

Dosage Forms & Strengths

capsule

  • 50mg
  • 250mg

Bile Acid Synthesis Disorders

Indicated for bile acid synthesis disorders due to single-enzyme defects (SEDs)

<3 weeks: Safety and efficacy not established

≥3 weeks: 10-15 mg/kg/day PO qDay or divided BID

Peroxisomal Disorders

Indicated for adjunctive treatment of peroxisomal disorders (PDs), including Zellweger spectrum disorders in patients who exhibit manifestations of liver disease, steatorrhea, or complications from decreased fat-soluble vitamin absorption

<3 weeks: Safety and efficacy not established

≥3 weeks: 10-15 mg/kg/day PO qDay or divided BID

Dosage Modifications

Familial hypertriglyceridemia

  • Patients with newly diagnosed or a family history of familial hypertriglyceridemia may have poor absorption of cholic acid from the intestine and require a 10% increase in the recommended dosage to account for losses due to malabsorption
  • Recommended dosage range: 11-17 mg/kg/day PO qDay or divided BID
  • Determine adequacy of the dosage regimen by monitoring clinical response, including steatorrhea, and laboratory values, including transaminases, bilirubin, and PT/INR

Dosing Considerations

Safety and effectiveness on extrahepatic manifestations of bile acid synthesis disorders due to SEDs or PDs have not been established

Monitoring

  • Monitor AST, ALT, GGT, alkaline phosphatase, bilirubin, and INR every month for the first 3 months; every 3 months for the next 9 months; every 6 months during the subsequent 3 yr; and annually thereafter
  • Monitor more frequently during periods of rapid growth, concomitant disease, or pregnancy
  • Administer the lowest dose that effectively maintains liver function
  • Discontinue treatment if liver function does not improve within 3 months of the start of treatment or complete biliary obstruction develops
  • Discontinue treatment at any time if there are persistent clinical or laboratory indicators of worsening liver function or cholestasis
  • Concurrent elevations of GGT and ALT may indicate overdose; continue to monitor laboratory parameters of liver function and consider restarting at a lower dose when the parameters return to baseline
  • Serum or urinary bile acid level using mass spectrometry is used in the diagnosis of bile acid synthesis disorders due to SEDs and PDs, including Zellweger spectrum disorders
  • The utility of bile acid measurements in monitoring the clinical course of patients and in decisions regarding dose adjustment has not been demonstrated
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Interactions

Interaction Checker

and cholic acid

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    Contraindicated

      Serious - Use Alternative

        Significant - Monitor Closely

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            Contraindicated (0)

              Serious - Use Alternative (2)

              • atazanavir

                atazanavir increases toxicity of cholic acid by decreasing elimination. Avoid or Use Alternate Drug. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              • felodipine

                felodipine increases toxicity of cholic acid by decreasing elimination. Avoid or Use Alternate Drug. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              Monitor Closely (35)

              • aluminum hydroxide

                aluminum hydroxide will decrease the level or effect of cholic acid by drug binding in GI tract. Use Caution/Monitor. Take cholic acid at least 1 hr before or 4-6 hr (or as great an interval as possible) after a aluminum-based antacid.

              • atorvastatin

                atorvastatin increases toxicity of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              • bosentan

                bosentan increases toxicity of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              • cholestyramine

                cholestyramine will decrease the level or effect of cholic acid by drug binding in GI tract. Use Caution/Monitor. Take cholic acid at least 1 hr before or 4-6 hr (or as great an interval as possible) after a bile acid binding resin.

              • clarithromycin

                clarithromycin increases toxicity of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              • colesevelam

                colesevelam will decrease the level or effect of cholic acid by drug binding in GI tract. Use Caution/Monitor. Take cholic acid at least 1 hr before or 4-6 hr (or as great an interval as possible) after a bile acid binding resin.

              • colestipol

                colestipol will decrease the level or effect of cholic acid by drug binding in GI tract. Use Caution/Monitor. Take cholic acid at least 1 hr before or 4-6 hr (or as great an interval as possible) after a bile acid binding resin.

              • cyclosporine

                cyclosporine increases toxicity of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              • dipyridamole

                dipyridamole increases toxicity of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              • disulfiram

                disulfiram increases toxicity of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              • eluxadoline

                eluxadoline increases levels of cholic acid by decreasing metabolism. Use Caution/Monitor. Eluxadoline may increase the systemic exposure of coadministered OATP1B1 substrates.

              • fenofibrate

                fenofibrate increases toxicity of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              • fenofibrate micronized

                fenofibrate micronized increases toxicity of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              • fenofibric acid

                fenofibric acid increases toxicity of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              • glimepiride

                glimepiride increases toxicity of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              • glyburide

                glyburide increases toxicity of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              • isradipine

                isradipine increases toxicity of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              • ketoconazole

                ketoconazole increases toxicity of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              • lopinavir

                lopinavir increases toxicity of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              • loratadine

                loratadine increases toxicity of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              • losartan

                losartan increases toxicity of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              • lovastatin

                lovastatin increases toxicity of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              • midazolam

                midazolam increases toxicity of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              • mifepristone

                mifepristone increases toxicity of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              • pioglitazone

                pioglitazone increases toxicity of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              • pitavastatin

                pitavastatin increases toxicity of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              • ranolazine

                ranolazine increases toxicity of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              • repaglinide

                repaglinide increases toxicity of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              • rifampin

                rifampin increases toxicity of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              • ritonavir

                ritonavir increases toxicity of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              • rosiglitazone

                rosiglitazone increases levels of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              • saquinavir

                saquinavir increases toxicity of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              • simvastatin

                simvastatin increases toxicity of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              • spironolactone

                spironolactone increases toxicity of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              • tipranavir

                tipranavir increases toxicity of cholic acid by decreasing elimination. Modify Therapy/Monitor Closely. Avoid concomitant use of inhibitors of the bile salt efflux pump (BSEP). May exacerbate accumulation of conjugated bile salts in the liver and result in clinical symptoms. If concomitant use is necessary, monitor serum transaminases and bilirubin.

              Minor (0)

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                Adverse Effects

                1-10%

                Diarrhea (2%)

                Reflux esophagitis (1%)

                Malaise (1%)

                Jaundice (1%)

                Skin lesion (1%)

                Nausea (1%)

                Abdominal pain (1%)

                Intestinal polyp (1%)

                Urinary tract infection (1%)

                Peripheral neuropathy (1%)

                Postmarketing Reports

                Gastrointestinal disorders: discomfort and distention, emesis, constipation

                General disorders and administrative site conditions: pyrexia/fever

                Skin and subcutaneous tissue disorders: rash

                Hepatic function: Exacerbation of liver impairment

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                Warnings

                Contraindications

                None

                Cautions

                Monitor liver function and discontinue at any time there are clinical or laboratory indicators of worsening liver function or cholestasis

                Concurrent elevations of GGT and ALT may indicate overdose; discontinue (see Dosage Modifications)

                Evidence of liver impairment was present before treatment with cholic acid in ~86% of patients with bile acid synthesis disorders due to SEDs and in ~50% of patients with PDs, including Zellweger spectrum disorders

                In patients with cirrhosis, cases of severe hepatotoxicity observed following postmarket use of therapy; exacerbation of liver impairment in these patients cannot be ruled out

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                Pregnancy & Lactation

                Pregnancy

                No studies in pregnant women or animal reproduction studies have been conducted

                Limited published case reports discuss pregnancies in women taking cholic acid for 3beta-HSD deficiency, resulting in healthy infants

                COCOA Registry (ChOlbam: Child and mOther's heAlth)

                • Women who become pregnant during treatment are encouraged to enroll
                • Patients or their healthcare provider should call 1-844-20C-OCOA or 1-844-202-6262

                Lactation

                Endogenous cholic acid is present in human milk

                Clinical lactation studies have not been conducted to assess the presence of Cholbam in human milk, the effects on the breastfed infant, or the effects on milk production

                There are no animal lactation data and no data from case reports available in the published literature

                The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for the drug and any potential adverse effects on the breastfed infant from the drug or from the underlying maternal condition

                Pregnancy Categories

                A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

                B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

                C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

                D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

                X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

                NA: Information not available.

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                Pharmacology

                Mechanism of Action

                Cholic acid is a primary bile acid synthesized from cholesterol in the liver

                In bile acid synthesis disorders due to SEDs in the biosynthetic pathway and in PDs, including Zellweger spectrum disorders, deficiency of primary bile acids leads to unregulated accumulation of intermediate bile acids and cholestasis

                Bile acids facilitate fat digestion and absorption by forming mixed micelles, and they facilitate absorption of fat-soluble vitamins in the intestine

                Endogenous bile acids, including cholic acid, enhance bile flow and provide the physiologic feedback inhibition of bile acid synthesis

                The mechanism of action of cholic acid has not been fully established; however, it is known that cholic acid and its conjugates are endogenous ligands of the nuclear receptor, farnesoid X receptor (FXR)

                FXR regulates enzymes and transporters that are involved in bile acid synthesis and in the enterohepatic circulation to maintain bile acid homeostasis under normal physiologic conditions

                Absorption

                Cholic acid is absorbed by passive diffusion along the length of the GI tract

                Once absorbed, cholic acid enters into the body’s bile acid pool and undergoes enterohepatic circulation mainly in conjugated forms

                Metabolism

                In the liver, cholic acid is conjugated with glycine or taurine by bile acid-CoA synthetase and bile acid-CoA: amino acid N-acetyltransferase

                Conjugated cholic acid is actively secreted into bile mainly by the bile salt efflux pump (BSEP) and then released into the small intestine, along with other components of bile

                Conjugated cholic acid is mostly reabsorbed in the ileum mainly by the apical-sodium-dependent-bile acid transporter, passed back to the liver by transporters including sodium-taurocholate cotransporting polypeptide and organic anion transport protein, and enters another cycle of enterohepatic circulation

                Elimination

                Any conjugated cholic acid not absorbed in the ileum passes into the colon and may be reabsorbed in the colon or excreted in the feces

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                Administration

                Instructions

                Take with food

                Take at least 1 hr before or 4-6 hr (or at as great an interval as possible) after a bile acid binding resin (eg, cholestyramine) or aluminum-based antacid

                Do not crush or chew the capsules

                Unable to Swallow Capsules

                Capsules can be opened and the contents mixed with either infant formula or expressed breast milk (for younger children), or soft food such as mashed potatoes or apple puree (for older children and adults) in order to mask any unpleasant taste

                Mix with soft food or liquid

                • Hold the capsule over the prepared liquid/food, gently twist open, and allow the contents to fall into the liquid/food
                • Mix the entire capsule contents with 1-2 tablespoons (ie, 15-30 mL) of infant formula, expressed breast milk, or soft food (eg, mashed potatoes, applesauce)
                • Stir for 30 seconds
                • The capsule contents will remain as fine granules in the milk or food and will not dissolve
                • Administer mixture immediately

                Storage

                Store at room temperature 20-25°C (69-77°F)

                Excursions permitted from 15-30°C (59-86°F)

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                Images

                No images available for this drug.
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                Patient Handout

                Patient Education
                cholic acid oral

                NO MONOGRAPH AVAILABLE AT THIS TIME

                USES: Consult your pharmacist.

                HOW TO USE: Consult your pharmacist.

                SIDE EFFECTS: Consult your pharmacist.In the US -Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088 or at www.fda.gov/medwatch.In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.

                PRECAUTIONS: Consult your pharmacist.

                DRUG INTERACTIONS: Consult your pharmacist.Keep a list of all your medications with you, and share the list with your doctor and pharmacist.

                OVERDOSE: If someone has overdosed and has serious symptoms such as passing out or trouble breathing, call 911. Otherwise, call a poison control center right away. US residents can call their local poison control center at 1-800-222-1222. Canada residents can call a provincial poison control center.

                NOTES: No monograph available at this time.

                MISSED DOSE: Consult your pharmacist.

                STORAGE: Consult your pharmacist.Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company for more details about how to safely discard your product.

                Information last revised July 2016. Copyright(c) 2021 First Databank, Inc.

                IMPORTANT: HOW TO USE THIS INFORMATION: This is a summary and does NOT have all possible information about this product. This information does not assure that this product is safe, effective, or appropriate for you. This information is not individual medical advice and does not substitute for the advice of your health care professional. Always ask your health care professional for complete information about this product and your specific health needs.

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                Formulary

                FormularyPatient Discounts

                Adding plans allows you to compare formulary status to other drugs in the same class.

                To view formulary information first create a list of plans. Your list will be saved and can be edited at any time.

                Adding plans allows you to:

                • View the formulary and any restrictions for each plan.
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                • Compare formulary status to other drugs in the same class.
                • Access your plan list on any device – mobile or desktop.

                The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

                Tier Description
                1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
                2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
                3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
                4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
                5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
                6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
                NC NOT COVERED – Drugs that are not covered by the plan.
                Code Definition
                PA Prior Authorization
                Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
                QL Quantity Limits
                Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
                ST Step Therapy
                Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
                OR Other Restrictions
                Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.
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                Medscape prescription drug monographs are based on FDA-approved labeling information, unless otherwise noted, combined with additional data derived from primary medical literature.