ADVERSE REACTIONS SECTION.

6 ADVERSE REACTIONS. The following adverse reactions are discussed in greater detail in other sections of the labeling:Serotonin Syndrome with Concomitant Use of Serotonergic Drugs [see Warnings and Precautions 5.1)] Anaphylaxis [see Warnings and Precautions 5.2)] Lack of Effectiveness [see Warnings and Precautions 5.3)] Hemolytic Anemia [see Warnings and Precautions 5.4)] Interference with In-Vivo Monitoring Devices [see Warnings and Precautions 5.5)] Effects on Ability to Drive and Operate Machinery [see Warnings and Precautions 5.6)] Interference with Laboratory Tests [see Warnings and Precautions 5.7)] Serotonin Syndrome with Concomitant Use of Serotonergic Drugs [see Warnings and Precautions 5.1)] Anaphylaxis [see Warnings and Precautions 5.2)] Lack of Effectiveness [see Warnings and Precautions 5.3)] Hemolytic Anemia [see Warnings and Precautions 5.4)] Interference with In-Vivo Monitoring Devices [see Warnings and Precautions 5.5)] Effects on Ability to Drive and Operate Machinery [see Warnings and Precautions 5.6)] Interference with Laboratory Tests [see Warnings and Precautions 5.7)] The most commonly reported adverse reactions (>=10%) are pain in extremity, chromaturia, dysgeusia, feeling hot, dizziness, hyperhidrosis, nausea, skin, discoloration and headache. 6.1) To report SUSPECTED ADVERSE REACTIONS, contact American Regent at 1-800-734-9236 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. 6.1 Clinical Trials Experience. Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.The safety of PROVAYBLUE (R) was determined in 82 healthy adults of median age of 36 years (range, 19-55 years); 54% were male, and 68% were white. Each individual in the safety population received single dose of PROVAYBLUE (R) mg/kg intravenously. There was one serious adverse reaction reported (syncope due to sinus pauses of 3-14 seconds). The most common (>=2%) moderate or severe adverse reactions were pain in the extremity (56%), headache (7%), feeling hot (6%), syncope (4%), back pain (2%), hyperhidrosis (2%) and nausea (2%). Table lists the adverse reactions of any severity that occurred in at least 2% of individuals who received PROVAYBLUE (R). Table 1. Adverse Reactions Following Infusion of PROVAYBLUE (R) mg/kg Adverse ReactionAny Grade TEAE(n=82)Moderate-Severe TEAE(n=82)Pain in extremity6984%4656%Chromaturia6174%0Dysgeusia1620%11%Feeling hot1417%56%Dizziness1316%45%Hyperhidrosis1113%22%Nausea1113%22%Skin discoloration1113%0Headache810%67%Musculoskeletal pain79%0Paresthesia oral79%0Paresthesia79%0Infusion site pain56%11%Feeling cold56%0Pallor45%0Dermatitis contact45%0Syncope34%34%Influenza like illness34%11%Pruritus34%11%Anxiety34%0Decreased appetite34%0Chest discomfort34%0Back pain22%22%Cold sweat22%11%Dizziness postural22%11%Muscle spasms22%11%Presyncope22%11%Vomiting22%11%Arthralgia22%11%Chills22%0Diarrhea22%0Discomfort22%0Dyspnea22%0Erythema22%0Hypoesthesia oral22%0Infusion site discomfort22%0Limb discomfort22%0Oral discomfort22%0Catheter site pain22%0Ecchymosis22%0Other adverse reactions reported to occur following administration of methylene blue class products include the following:Blood and lymphatic system disorders: hemolytic anemia, hemolysis, hyperbilirubinemia, methemoglobinemia Cardiac disorders: palpitations, tachycardia Eye disorders: eye pruritus, ocular hyperemia, vision blurred Gastrointestinal disorders: abdominal pain lower, dry mouth, flatulence, glossodynia, tongue eruption General disorders and administration site conditions: death, infusion site extravasation, infusion site induration, infusion site pruritus, infusion site swelling, infusion site urticaria, peripheral swelling, thirst Investigations: elevated liver enzymes Musculoskeletal and connective tissue disorders: myalgia Renal and urinary disorders: dysuria Respiratory, thoracic and mediastinal disorders: nasal congestion, oropharyngeal pain, rhinorrhea, sneezing Skin and subcutaneous tissue disorders: necrotic ulcer, papule, phototoxicity Vascular disorders: hypertension.

BOXED WARNING SECTION.

WARNING: SEROTONIN SYNDROME WITH CONCOMITANT USE OF SEROTONERGIC DRUGS. PROVAYBLUE (R) may cause serious or fatal serotonergic syndrome when used in combination with serotonergic drugs. Avoid concomitant use of PROVAYBLUE (R) with selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), and monoamine oxidase inhibitors 5.1, 7.1). [see Warnings and Precautions 5.1) and Drug Interactions 7.1)] WARNING: SEROTONIN SYNDROME WITH CONCOMITANT USE OF SEROTONERGIC DRUGSSee full prescribing information for complete boxed warningPROVAYBLUE (R) may cause serious or fatal serotonergic syndrome when used in combination with serotonergic drugs. Avoid concomitant use 5.1, 7.1).

CARCINOGENESIS & MUTAGENESIS & IMPAIRMENT OF FERTILITY SECTION.

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility. In two-year carcinogenicity study, rats were administered oral doses of methylene blue at 5, 25, or 50 mg/kg. Methylene blue caused pancreatic islet adenomas or carcinomas (combined) in male rats. In two-year carcinogenicity study, mice were administered oral doses of methylene blue at 2.5, 12.5, or 25 mg/kg. There were no drug-related neoplastic findings in mice.Methylene blue was genotoxic in gene mutation assays in bacteria (Ames test), and in an in vitro sister chromatid exchange test and an in vitro chromosomal aberration test in Chinese hamster ovary (CHO) cells. Methylene blue was negative for micronucleus induction in bone marrow or peripheral blood collected from mice treated with methylene blue.Fertility studies with methylene blue have not been conducted. In vitro, methylene blue reduced motility of human sperm in concentration dependent manner.

CLINICAL PHARMACOLOGY SECTION.

12 CLINICAL PHARMACOLOGY. 12.1 Mechanism of Action. Methylene blue is water soluble thiazine dye that promotes non-enzymatic redox conversion of metHb to hemoglobin. In situ, methylene blue is first converted to leucomethylene blue (LMB) via NADPH reductase. It is the LMB molecule which then reduces the ferric iron of metHb to the ferrous state of normal hemoglobin.. 12.2 Pharmacodynamics. Low concentrations of methylene blue speeds up the in vivo conversion of methemoglobin to hemoglobin. Methylene blue has been observed to stain tissues selectively. The exposure-response or -safety relationship for methylene is unknown.. Cardiac ElectrophysiologyThe results of thorough QT study demonstrated PROVAYBLUE (R) at an intravenous dose of mg/kg as 5-minute intravenous infusion had no effect on the QT, PR or QRS intervals. 12.3 Pharmacokinetics. The mean (CV%) Cmax and AUC of methylene blue 2,917 ng/mL (39%) and 13977 ng.hr/mL (21%) following 2 mg/kg dose administered as 5-minute intravenous infusion.. DistributionThe mean+- standard deviation steady state volume of distribution of 2 mg/kg dose of PROVAYBLUE (R) was 255 +- 58. The mean plasma protein binding of methylene blue is approximately 94% in vitro. Methylene blue exhibits concentration-dependent partitioning into blood cells in vitro. The blood-to-plasma ratio was 5.1+-2.8 at minutes from the start of 2 mg/kg dose administered as 5-minute intravenous infusion and reached plateau of 0.6 at hours in clinical study. Methylene Blue is substrate for the P-glycoprotein (P-gp, ABCB1) transporter, but not for BCRP or OCT2 in vitro. EliminationMethylene blue has half-life of approximately 24 hours in humans.. MetabolismMethylene blue is metabolized by CYPs 1A2, 2C19 and 2D6 in vitro; however, the predominant in vitro pathway appears to be UGT-mediated conjugation by multiple UGT enzymes, including UGT1A4 and UGT1A9.Azure B, which is minor impurity in methylene blue, is also formed in humans as metabolite of methylene blue, with an overall drug/metabolite AUC ratio of greater than 6:1. Azure has 8-fold lower potency than methylene blue.. ExcretionApproximately 40% of methylene blue is excreted in to the urine unchanged.. Specific PopulationsRenal Impairment After single mg/kg dose of PROVAYBLUE, AUC0-96h increased by 52%, 116%, and 192% in subjects with mild (estimated glomerular filtration rate (eGFR) 60 89 mL/min/1.73 m2), moderate (eGFR 30-59 mL/min/1.73m2), and severe (eGFR 15-29 mL/min/1.732m2) renal impairment, respectively. Cmax increased by 42%, 34%, and 15% in subjects with mild, moderate, and severe renal impairment respectively [see Dosage and Administration 2.2) and Use in Specific Populations 8.6)]. The half-life was unchanged in patients with mild to moderate renal impairment. The AUC0-96h of Azure after single mg/kg dose increased by 29%, 94%, and 339% in subjects with mild (estimated glomerular filtration rate (eGFR) 60 89 mL/min/1.73 m2), moderate (eGFR 30-59 mL/min/1.73m2), and severe (eGFR 15-29 mL/min/1.732m2) renal impairment, respectively. Cmax increased by 23%, 13%, and 65% in subjects with mild, moderate, and severe renal impairment, respectively [see Dosage and Administration 2.2) and Use in Specific Populations 8.6)]. Drug Interactions StudiesClinical Studies:The coadministration of mg/kg dose of PROVAYBLUE(R) with midazolam (a CYP3A4 substrate), caffeine (a CYP1A2 substrate), warfarin (a CYP2C9 substrate), and dextromethorphan (a CYP2D6 substrate) in cocktail study did not affect the exposure of these substrates compared to their exposure without PROVAYBLUE(R) administration. In Vitro Studies:Cytochrome P450 (CYP450) Enzymes: Methylene blue inhibits CYP isozymes 1A2, 2B6, 2C8, 2C9, 2C19, 2D6 and 3A4/5. Possible time-dependent inhibition of CYP2C9, CYP2D6 and CYP3A4/5 (testosterone as substrate) was also observed. Methylene blue induces CYP1A2 but does not induce CYP2B6 or CYP3A4. UDP-Glucuronosyltransferase (UGT):Methylene blue inhibits UGT1A9 and UGT1A4, but did not significantly inhibit UGTs 1A1, 1A3, 1A6, 2B7 or 2B15. Transporter:Methylene blue is both substrate for and an inhibitor of P-gp but is not substrate for BCRP or OCT2 in vitro. Methylene blue is not significant inhibitor of BCRP, OAT1, OAT3, OAT1B1 or OAT1B3. Methylene blue inhibits OCT2, MATE1 and MATE2-K.

CLINICAL STUDIES SECTION.

14 CLINICAL STUDIES. 14.1 Treatment of Acquired Methemoglobinemia. The efficacy of PROVAYBLUE (R) was assessed on the basis of methemoglobin decrease of at least 50% within hour after intravenous administration of - mg/kg PROVAYBLUE (R) (or bioequivalent formulation) in patients identified by retrospective chart review or literature search. The patients included males and females of median age 54 years (range, days to 69 years). The median methemoglobin level at baseline was 37% (range, 11% to 47%). All (100%) patients had decrease in methemoglobin by at least 50% within hour after treatment. An additional 41 cases of treatment of methemoglobinemia with methylene blue class product were identified in the published literature. These cases included 24 males and 17 females of median age 33 years (range, days to 80 years). The median methemoglobin level at baseline was 40% (range, 10% to 98%). Of these 41 patients, 37 (90%) had methemoglobin decrease of at least 50% within hour after intravenous administration of the methylene blue class product.In combined analysis of all 47 patients treated intravenously with PROVAYBLUE (R) (or bioequivalent formulation) or with another methylene blue class product, there was no difference in response rate by dose. The methemoglobin decreased by at least 50% within hour of infusion for 15/17 (88%) of patients treated with mg/kg, 12/13 (92%) treated with mg/kg and 16/17 (94%) treated with different dose or for those whose dose was not reported.

CONTRAINDICATIONS SECTION.

4 CONTRAINDICATIONS. PROVAYBLUE (R) is contraindicated in the following conditions: Severe hypersensitivity reactions to methylene blue or any other thiazine dye [see Warnings and Precautions 5.2)] Patients with glucose-6-phosphate dehydrogenase deficiency (G6PD) due to the risk of hemolytic anemia [see Warnings and Precautions 5.3, 5.4)] Severe hypersensitivity reactions to methylene blue or any other thiazine dye [see Warnings and Precautions 5.2)] . Patients with glucose-6-phosphate dehydrogenase deficiency (G6PD) due to the risk of hemolytic anemia [see Warnings and Precautions 5.3, 5.4)] PROVAYBLUE (R) is contraindicated in the following conditions 4): Severe hypersensitivity to methylene bluePatients with glucose-6-phosphate dehydrogenase deficiency (G6PD) due to the risk of hemolytic anemia. Severe hypersensitivity to methylene blue. Patients with glucose-6-phosphate dehydrogenase deficiency (G6PD) due to the risk of hemolytic anemia.

DESCRIPTION SECTION.

11 DESCRIPTION. PROVAYBLUE (R) is an oxidation-reduction agent. PROVAYBLUE (R) (methylene blue) is sterile solution intended for intravenous administration. Each PROVAYBLUE (R) 10 mL ampule and vial contains 50 mg Proveblue (R) methylene blue and water for injection q.s. Each PROVAYBLUE (R) mL ampule and vial contains 10 mg Proveblue (R) methylene blue and water for injection q.s. Each mL of solution contains mg methylene blue and water for injection q.s.Methylene blue is 3,7-bis(dimethylamino)phenothiazin-5-ium, chloride. The molecular formula of methylene blue is 16H 18ClN 3S and its molecular weight is 319.86 g/mol. Its structural formula is:PROVAYBLUE(TM) is clear dark blue solution with pH value between 3.0 and 4.5. The osmolality is between 10 and 15 mOsm/kg.. Figure.

DOSAGE & ADMINISTRATION SECTION.

2 DOSAGE AND ADMINISTRATION. Administer mg/kg intravenously over 5-30 minutes. 2.1) If methemoglobin level remains above 30% or if clinical symptoms persist, give repeat dose of up to mg/kg one hour after the first dose. 2.1) Administer single dose of mg/kg in patients with moderate or severe renal impairment. 2.2) Administer mg/kg intravenously over 5-30 minutes. 2.1) If methemoglobin level remains above 30% or if clinical symptoms persist, give repeat dose of up to mg/kg one hour after the first dose. 2.1) Administer single dose of mg/kg in patients with moderate or severe renal impairment. 2.2) 2.1 Dosage and Administration. Ensure patent venous access prior to administration of PROVAYBLUE(R). Do not administer PROVAYBLUE(R) subcutaneously.Monitor vital signs, electrocardiogram and methemoglobin levels during treatment with PROVAYBLUE(R) and through resolution of methemoglobinemia.Administer PROVAYBLUE(R) mg/kg intravenously over 5-30 minutes.If the methemoglobin level remains greater than 30% or if clinical signs and symptoms persist, repeat dose of PROVAYBLUE(R) mg/kg may be given one hour after the first dose.If methemoglobinemia does not resolve after doses of PROVAYBLUE(R), consider initiating alternative interventions for treatment of methemoglobinemia.. Ensure patent venous access prior to administration of PROVAYBLUE(R). Do not administer PROVAYBLUE(R) subcutaneously.. Monitor vital signs, electrocardiogram and methemoglobin levels during treatment with PROVAYBLUE(R) and through resolution of methemoglobinemia.. Administer PROVAYBLUE(R) mg/kg intravenously over 5-30 minutes.. If the methemoglobin level remains greater than 30% or if clinical signs and symptoms persist, repeat dose of PROVAYBLUE(R) mg/kg may be given one hour after the first dose.. If methemoglobinemia does not resolve after doses of PROVAYBLUE(R), consider initiating alternative interventions for treatment of methemoglobinemia.. 2.2 Recommended Dosage for Renal Impairment. The recommended dosage of PROVAYBLUE in patients with moderate or severe renal impairment (eGFR 15-59 mL/min/1.73 m2) is single dose of mg/kg.If the methemoglobin level remains greater than 30% or if the clinical symptoms persist hour after dosing, consider initiating alternative interventions for the treatment of methemoglobinemia.. The recommended dosage of PROVAYBLUE in patients with moderate or severe renal impairment (eGFR 15-59 mL/min/1.73 m2) is single dose of mg/kg.. If the methemoglobin level remains greater than 30% or if the clinical symptoms persist hour after dosing, consider initiating alternative interventions for the treatment of methemoglobinemia.. 2.3 Preparation and Storage. Each mL of PROVAYBLUE (R) contains mg methylene blueEach 10 mL ampule and vial of PROVAYBLUE (R) contains 50 mg methylene blue. Each mL ampule and vial of PROVAYBLUE(R) contains 10 mg methylene blue.PROVAYBLUE (R) is hypotonic and may be diluted before use in solution of 50 mL 5% Dextrose in Water (D5W) in order to avoid local pain, particularly in the pediatric population. Use the diluted solution immediately after preparation.Avoid diluting with sodium chloride solutions, because it has been demonstrated that chloride reduces the solubility of methylene blue.Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.Keep the ampule and the vial in the original package to protect from light.Discard unused portion.

DOSAGE FORMS & STRENGTHS SECTION.

3 DOSAGE FORMS AND STRENGTHS. Injection: 50 mg/10 mL (5 mg/mL) or 10 mg/2 mL (5 mg/mL) clear dark blue solution in single-dose ampules or single-dose vials.. 50 mg/10 mL (5 mg/mL) single-dose ampule. 3)10 mg/2 mL (5 mg/mL) single-dose ampule. 3)50 mg/10 mL (5 mg/mL) single-dose vial. 3)10 mg/2 mL (5 mg/mL) single-dose vial. 3).

DRUG INTERACTIONS SECTION.

7 DRUG INTERACTIONS. 7.1 Serotonergic Drugs. Avoid concomitant use of PROVAYBLUE(R) with medicinal products that enhance serotonergic transmission including SSRIs (selective serotonin reuptake inhibitors), MAO inhibitors, bupropion, buspirone, clomipramine, mirtazapine and venlafaxine; because of the potential for serious CNS reactions, including potentially fatal serotonin syndrome. Although the mechanism is not clearly understood, literature reports suggest inhibition of MAO by methylene blue may be involved. If the intravenous use of PROVAYBLUE(R) cannot be avoided in patients treated with serotonergic medicinal products, choose the lowest possible dose and observe closely the patient for CNS effects for up to hours after administration [see Warning and Precautions 5.1) and Clinical Pharmacology 12.3)].

GERIATRIC USE SECTION.

8.5 Geriatric Use. The retrospective case series included patients age 65 years and over treated with PROVAYBLUE (R) (or bioequivalent formulation) and treated with another methylene blue class product. The efficacy outcomes were consistent across adult and elderly patients in both case series [see Clinical Studies 14)] This drug is known to be substantially excreted by the kidney, so the risk of adverse reactions to this drug may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, treatment of methemoglobinemia in these patients should use the lowest number of doses needed to achieve response [see Dosage and Administration 2)].

HEPATIC IMPAIRMENT SUBSECTION.

8.7 Hepatic Impairment. Methylene blue is extensively metabolized in the liver. Monitor patients with any hepatic impairment for toxicities and potential drug interactions for an extended period of time following treatment with PROVAYBLUE (R).

HOW SUPPLIED SECTION.

16 HOW SUPPLIED/STORAGE AND HANDLING. PROVAYBLUE (R) is supplied in 10 mL and mL single-dose ampules or single-dose vials. Each 10 mL ampule and vial contains 50 mg of methylene blue as clear dark blue solution. Each mL ampule and vial contains 10 mg of methylene blue as clear dark blue solution. box contains five ampules or vials.Box of ampules of 50 mg/10 mL: NDC 0517-0374-05Box of ampules of 10 mg/2 mL: NDC 0517-0125-05Box of vials of 50 mg/10 mL: NDC 0517-0381-05Box of vials of 10 mg/2 mL: NDC 0517-0371-05Storage: Store at 20C to 25C (68F to 77F); excursions permitted to 15C to 30C (59F to 86F). [See USP Controlled Room Temperature] Any unused product or waste material should be disposed of in accordance with local practice.Do not refrigerate or freeze.Keep the ampule or the vial in the original package to protect from light.

INDICATIONS & USAGE SECTION.

1 INDICATIONS AND USAGE. PROVAYBLUE (R) USP is indicated for the treatment of pediatric and adult patients with acquired methemoglobinemia. This indication is approved under accelerated approval. Continued approval for this indication may be contingent upon verification of clinical benefit in subsequent trials see Clinical Studies 14.1) ]. PROVAYBLUE (R) (methylene blue) is an oxidation-reduction agent indicated for the treatment of pediatric and adult patients with acquired methemoglobinemia. This indication is approved under accelerated approval. Continued approval for this indication may be contingent upon verification of clinical benefit in subsequent trials. 1, 14).

INFORMATION FOR PATIENTS SECTION.

17 PATIENT COUNSELING INFORMATION. Serotonin SyndromeAdvise patients of the possibility of serotonin syndrome, especially with concomitant use of serotonergic agents such as medications to treat depression and migraines. Advise patients to seek immediate medical attention if the following symptoms occur after treatment with PROVAYBLUE (R): changes in mental status, autonomic instability, or neuromuscular symptoms with or without gastrointestinal symptoms [see Warnings and Precautions 5.1)]. PregnancyAdvise pregnant women of the potential risk to the fetus with the use of PROVAYBLUE (R) during pregnancy [see Use in Specific populations 8.1)]. BreastfeedingAdvise patients to discontinue breast-feeding for up to days after treatment with PROVAYBLUE (R) [see Use in Specific populations 8.2)] . Driving and Using MachinesAdvise patients to avoid driving and use of machines during treatment with PROVAYBLUE (R). Driving can be affected as result of confusional state, dizziness and possible eye disturbances [see Warnings and Precautions 5.6)] . PhototoxicityAdvise patients to take protective measures against exposure to light, because phototoxicity may occur after administration of methylene blue [see Adverse Reactions 6.1)] . Skin and Body Fluid Blue DiscolorationAdvise patients that PROVAYBLUE (R) may cause blue discoloration of the skin and body fluids [see Adverse Reactions 6.1)]. Manufactured for: PROVEPHARM SAS 22 rue Marc Donadille 13013 Marseille, FranceAmpules manufactured by:CENEXI 52 rue Marcel et Jacques Gaucher 94120 Fontenay sous Bois, FRANCEVials manufactured by: CENEXI HSC2 rue Louis Pasteur14200 Herouville-Saint-Clair, FranceDistributed by: American Regent, Inc. Shirley, NY 11967 Questions 1-800-734-9236.

LABORATORY TESTS SECTION.

5.7 Interference with Laboratory Tests. PROVAYBLUE (R) is blue dye which passes freely into the urine and may interfere with the interpretation of any urine test which relies on blue indicator, such as the dipstick test for leucocyte esterase.

LACTATION SECTION.

8.2 Lactation. Risk SummaryThere is no information regarding the presence of methylene blue in human milk, the effects on the breastfed infant, or the effects on milk production. Because of the potential for serious adverse reactions, including genotoxicity discontinue breast-feeding during and for up to days after treatment with PROVAYBLUE (R) [see Clinical Pharmacology 12.3)].

MECHANISM OF ACTION SECTION.

12.1 Mechanism of Action. Methylene blue is water soluble thiazine dye that promotes non-enzymatic redox conversion of metHb to hemoglobin. In situ, methylene blue is first converted to leucomethylene blue (LMB) via NADPH reductase. It is the LMB molecule which then reduces the ferric iron of metHb to the ferrous state of normal hemoglobin.

NONCLINICAL TOXICOLOGY SECTION.

13 NONCLINICAL TOXICOLOGY. 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility. In two-year carcinogenicity study, rats were administered oral doses of methylene blue at 5, 25, or 50 mg/kg. Methylene blue caused pancreatic islet adenomas or carcinomas (combined) in male rats. In two-year carcinogenicity study, mice were administered oral doses of methylene blue at 2.5, 12.5, or 25 mg/kg. There were no drug-related neoplastic findings in mice.Methylene blue was genotoxic in gene mutation assays in bacteria (Ames test), and in an in vitro sister chromatid exchange test and an in vitro chromosomal aberration test in Chinese hamster ovary (CHO) cells. Methylene blue was negative for micronucleus induction in bone marrow or peripheral blood collected from mice treated with methylene blue.Fertility studies with methylene blue have not been conducted. In vitro, methylene blue reduced motility of human sperm in concentration dependent manner.

OVERDOSAGE SECTION.

10 OVERDOSAGE. Hypotension, wheezing and reduced oxygenation have been reported in patients who received methylene blue class products in single doses of mg/kg or more.Administration of large intravenous doses (cumulative dose >= mg/kg of methylene blue class product caused nausea, vomiting, precordial pain, dyspnea, tachypnea, chest tightness, tachycardia, apprehension, tremor, mydriasis, blue staining of the urine, the skin and mucous membranes, abdominal pain, dizziness, paresthesia, headache, confusion, mild methemoglobinemia (up to 7%) and electrocardiogram changes (T-wave flattening or inversion) These effects lasted 2-12 hours following administration.A severe overdosage (single dose of 20 mg/kg or more) of methylene blue class product caused severe intravascular hemolysis, hyperbilirubinemia and death.In case of overdose of PROVAYBLUE (R), maintain the patient under observation until signs and symptoms have resolved, monitor for cardiopulmonary, hematologic and neurologic toxicities, and institute supportive measures as necessary.

PACKAGE LABEL.PRINCIPAL DISPLAY PANEL.

Principal Display Panel 50 mg/10 mL (5 mg/mL) Ampule Label. NDC 0517-0374-01ProvayBlue(R) (methylene blue) Injection USP50 mg/10 mL (5 mg/mL)Intravenous use onlyUse 5% Dextrose in Water When DilutingSingle dose ampule RX onlyDiscard unused portionManufactured by CENEXI for:PROVEPHARM SASDistributed by:AMERICAN REGENT, INCShirley, NY 11967. Ampule Label 10 mL.

PEDIATRIC USE SECTION.

8.4 Pediatric Use. The safety and effectiveness of PROVAYBLUE (R) have been established in pediatric patients. Use of PROVAYBLUE (R) is supported by two retrospective case series that included pediatric patients treated with PROVAYBLUE (R) and 12 treated with another methylene blue class product. The case series included pediatric patients in the following age groups: neonates (less than month), infants (1 month up to less than years), children (2 years up to less than 12 years), and adolescents (12 years to less than 17 years). The efficacy outcomes were consistent across pediatric and adult patients in both case series [see Clinical Studies 14)].

PHARMACODYNAMICS SECTION.

12.2 Pharmacodynamics. Low concentrations of methylene blue speeds up the in vivo conversion of methemoglobin to hemoglobin. Methylene blue has been observed to stain tissues selectively. The exposure-response or -safety relationship for methylene is unknown.. Cardiac ElectrophysiologyThe results of thorough QT study demonstrated PROVAYBLUE (R) at an intravenous dose of mg/kg as 5-minute intravenous infusion had no effect on the QT, PR or QRS intervals.

PHARMACOKINETICS SECTION.

12.3 Pharmacokinetics. The mean (CV%) Cmax and AUC of methylene blue 2,917 ng/mL (39%) and 13977 ng.hr/mL (21%) following 2 mg/kg dose administered as 5-minute intravenous infusion.. DistributionThe mean+- standard deviation steady state volume of distribution of 2 mg/kg dose of PROVAYBLUE (R) was 255 +- 58. The mean plasma protein binding of methylene blue is approximately 94% in vitro. Methylene blue exhibits concentration-dependent partitioning into blood cells in vitro. The blood-to-plasma ratio was 5.1+-2.8 at minutes from the start of 2 mg/kg dose administered as 5-minute intravenous infusion and reached plateau of 0.6 at hours in clinical study. Methylene Blue is substrate for the P-glycoprotein (P-gp, ABCB1) transporter, but not for BCRP or OCT2 in vitro. EliminationMethylene blue has half-life of approximately 24 hours in humans.. MetabolismMethylene blue is metabolized by CYPs 1A2, 2C19 and 2D6 in vitro; however, the predominant in vitro pathway appears to be UGT-mediated conjugation by multiple UGT enzymes, including UGT1A4 and UGT1A9.Azure B, which is minor impurity in methylene blue, is also formed in humans as metabolite of methylene blue, with an overall drug/metabolite AUC ratio of greater than 6:1. Azure has 8-fold lower potency than methylene blue.. ExcretionApproximately 40% of methylene blue is excreted in to the urine unchanged.. Specific PopulationsRenal Impairment After single mg/kg dose of PROVAYBLUE, AUC0-96h increased by 52%, 116%, and 192% in subjects with mild (estimated glomerular filtration rate (eGFR) 60 89 mL/min/1.73 m2), moderate (eGFR 30-59 mL/min/1.73m2), and severe (eGFR 15-29 mL/min/1.732m2) renal impairment, respectively. Cmax increased by 42%, 34%, and 15% in subjects with mild, moderate, and severe renal impairment respectively [see Dosage and Administration 2.2) and Use in Specific Populations 8.6)]. The half-life was unchanged in patients with mild to moderate renal impairment. The AUC0-96h of Azure after single mg/kg dose increased by 29%, 94%, and 339% in subjects with mild (estimated glomerular filtration rate (eGFR) 60 89 mL/min/1.73 m2), moderate (eGFR 30-59 mL/min/1.73m2), and severe (eGFR 15-29 mL/min/1.732m2) renal impairment, respectively. Cmax increased by 23%, 13%, and 65% in subjects with mild, moderate, and severe renal impairment, respectively [see Dosage and Administration 2.2) and Use in Specific Populations 8.6)]. Drug Interactions StudiesClinical Studies:The coadministration of mg/kg dose of PROVAYBLUE(R) with midazolam (a CYP3A4 substrate), caffeine (a CYP1A2 substrate), warfarin (a CYP2C9 substrate), and dextromethorphan (a CYP2D6 substrate) in cocktail study did not affect the exposure of these substrates compared to their exposure without PROVAYBLUE(R) administration. In Vitro Studies:Cytochrome P450 (CYP450) Enzymes: Methylene blue inhibits CYP isozymes 1A2, 2B6, 2C8, 2C9, 2C19, 2D6 and 3A4/5. Possible time-dependent inhibition of CYP2C9, CYP2D6 and CYP3A4/5 (testosterone as substrate) was also observed. Methylene blue induces CYP1A2 but does not induce CYP2B6 or CYP3A4. UDP-Glucuronosyltransferase (UGT):Methylene blue inhibits UGT1A9 and UGT1A4, but did not significantly inhibit UGTs 1A1, 1A3, 1A6, 2B7 or 2B15. Transporter:Methylene blue is both substrate for and an inhibitor of P-gp but is not substrate for BCRP or OCT2 in vitro. Methylene blue is not significant inhibitor of BCRP, OAT1, OAT3, OAT1B1 or OAT1B3. Methylene blue inhibits OCT2, MATE1 and MATE2-K.

PREGNANCY SECTION.

8.1 Pregnancy. Risk SummaryPROVAYBLUE (R) may cause fetal harm when administered to pregnant woman. Intra-amniotic injection of pregnant women with methylene blue class product during the second trimester was associated with neonatal intestinal atresia and fetal death. Methylene blue produced adverse developmental outcomes in rats and rabbits when administered orally during organogenesis at doses at least 32 and 16 times, respectively, the clinical dose of mg/kg [see Data] Advise pregnant women of the potential risk to fetus. In the U.S. general population, the estimated background risks of major birth defects and miscarriage in clinically recognized pregnancies are 2-4% and 15-20%, respectively.. Clinical Considerations. Fetal/neonatal adverse reactionsIntra-amniotic injection of methylene blue class product hours to days prior to birth can result hyperbilirubinemia, hemolytic anemia, skin staining, methemoglobinemia, respiratory distress and photosensitivity in the newborn. Following administration of PROVAYBLUE (R) to pregnant woman at term, observe the newborn for these adverse reactions and institute supportive care. Data. Animal DataMethylene blue was administered orally to pregnant rats at doses of 50 to 350 mg/kg/day, during the period of organogenesis. Maternal and embryofetal toxicities were observed at all doses of methylene blue and were most evident at the 200 and 350 mg/kg/day doses. Maternal toxicity consisted of increased spleen weight. Embryo-fetal toxicities included reduced fetal weight, post-implantation loss, edema, and malformations including enlarged lateral ventricles. The dose of 200 mg/kg (1200 mg/m 2) in rats is approximately 32 times clinical dose of mg/kg based on body surface area. Methylene blue was administered orally to pregnant rabbits at doses of 50, 100, or 150 mg/kg/day, during the period of organogenesis. Maternal death was observed at the methylene blue dose of 100 mg/kg. Embryofetal toxicities included spontaneous abortion at all dose levels and malformation (umbilical hernia) at the 100 and 150 mg/kg/day doses. The dose of 50 mg/kg (600 mg/m 2) in rabbits is approximately 16 times clinical dose of mg/kg based on body surface area.

RENAL IMPAIRMENT SUBSECTION.

8.6 Renal Impairment. Methylene blue concentrations increased in subjects with renal impairment (eGFR 15 to 89 mL/min/1.73m2) significantly [see Clinical Pharmacology 12.3)]. Adjust PROVAYBLUE(R) dosage in patients with moderate or severe renal impairment (eGFR 15 to 59 mL/min/1.73 m2) [see Dosage and Administration 2.2)]. No dose adjustment is recommended in patients with mild renal impairment (eGFR 60 89 mL/min/1.73 m2).

SPL UNCLASSIFIED SECTION.

2.1 Dosage and Administration. Ensure patent venous access prior to administration of PROVAYBLUE(R). Do not administer PROVAYBLUE(R) subcutaneously.Monitor vital signs, electrocardiogram and methemoglobin levels during treatment with PROVAYBLUE(R) and through resolution of methemoglobinemia.Administer PROVAYBLUE(R) mg/kg intravenously over 5-30 minutes.If the methemoglobin level remains greater than 30% or if clinical signs and symptoms persist, repeat dose of PROVAYBLUE(R) mg/kg may be given one hour after the first dose.If methemoglobinemia does not resolve after doses of PROVAYBLUE(R), consider initiating alternative interventions for treatment of methemoglobinemia.. Ensure patent venous access prior to administration of PROVAYBLUE(R). Do not administer PROVAYBLUE(R) subcutaneously.. Monitor vital signs, electrocardiogram and methemoglobin levels during treatment with PROVAYBLUE(R) and through resolution of methemoglobinemia.. Administer PROVAYBLUE(R) mg/kg intravenously over 5-30 minutes.. If the methemoglobin level remains greater than 30% or if clinical signs and symptoms persist, repeat dose of PROVAYBLUE(R) mg/kg may be given one hour after the first dose.. If methemoglobinemia does not resolve after doses of PROVAYBLUE(R), consider initiating alternative interventions for treatment of methemoglobinemia.

USE IN SPECIFIC POPULATIONS SECTION.

8 USE IN SPECIFIC POPULATIONS. Pregnancy: Only use during pregnancy if the potential benefit justifies the potential risk to the fetus. 8.1) Lactation: Discontinue breast-feeding for up to days after treatment. 8.2). Hepatic Impairment: Monitor patients longer for toxicity and drug interactions due to delayed clearance. 8.7) Pregnancy: Only use during pregnancy if the potential benefit justifies the potential risk to the fetus. 8.1) Lactation: Discontinue breast-feeding for up to days after treatment. 8.2). Hepatic Impairment: Monitor patients longer for toxicity and drug interactions due to delayed clearance. 8.7) 8.1 Pregnancy. Risk SummaryPROVAYBLUE (R) may cause fetal harm when administered to pregnant woman. Intra-amniotic injection of pregnant women with methylene blue class product during the second trimester was associated with neonatal intestinal atresia and fetal death. Methylene blue produced adverse developmental outcomes in rats and rabbits when administered orally during organogenesis at doses at least 32 and 16 times, respectively, the clinical dose of mg/kg [see Data] Advise pregnant women of the potential risk to fetus. In the U.S. general population, the estimated background risks of major birth defects and miscarriage in clinically recognized pregnancies are 2-4% and 15-20%, respectively.. Clinical Considerations. Fetal/neonatal adverse reactionsIntra-amniotic injection of methylene blue class product hours to days prior to birth can result hyperbilirubinemia, hemolytic anemia, skin staining, methemoglobinemia, respiratory distress and photosensitivity in the newborn. Following administration of PROVAYBLUE (R) to pregnant woman at term, observe the newborn for these adverse reactions and institute supportive care. Data. Animal DataMethylene blue was administered orally to pregnant rats at doses of 50 to 350 mg/kg/day, during the period of organogenesis. Maternal and embryofetal toxicities were observed at all doses of methylene blue and were most evident at the 200 and 350 mg/kg/day doses. Maternal toxicity consisted of increased spleen weight. Embryo-fetal toxicities included reduced fetal weight, post-implantation loss, edema, and malformations including enlarged lateral ventricles. The dose of 200 mg/kg (1200 mg/m 2) in rats is approximately 32 times clinical dose of mg/kg based on body surface area. Methylene blue was administered orally to pregnant rabbits at doses of 50, 100, or 150 mg/kg/day, during the period of organogenesis. Maternal death was observed at the methylene blue dose of 100 mg/kg. Embryofetal toxicities included spontaneous abortion at all dose levels and malformation (umbilical hernia) at the 100 and 150 mg/kg/day doses. The dose of 50 mg/kg (600 mg/m 2) in rabbits is approximately 16 times clinical dose of mg/kg based on body surface area. 8.2 Lactation. Risk SummaryThere is no information regarding the presence of methylene blue in human milk, the effects on the breastfed infant, or the effects on milk production. Because of the potential for serious adverse reactions, including genotoxicity discontinue breast-feeding during and for up to days after treatment with PROVAYBLUE (R) [see Clinical Pharmacology 12.3)] . 8.4 Pediatric Use. The safety and effectiveness of PROVAYBLUE (R) have been established in pediatric patients. Use of PROVAYBLUE (R) is supported by two retrospective case series that included pediatric patients treated with PROVAYBLUE (R) and 12 treated with another methylene blue class product. The case series included pediatric patients in the following age groups: neonates (less than month), infants (1 month up to less than years), children (2 years up to less than 12 years), and adolescents (12 years to less than 17 years). The efficacy outcomes were consistent across pediatric and adult patients in both case series [see Clinical Studies 14)]. 8.5 Geriatric Use. The retrospective case series included patients age 65 years and over treated with PROVAYBLUE (R) (or bioequivalent formulation) and treated with another methylene blue class product. The efficacy outcomes were consistent across adult and elderly patients in both case series [see Clinical Studies 14)] This drug is known to be substantially excreted by the kidney, so the risk of adverse reactions to this drug may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, treatment of methemoglobinemia in these patients should use the lowest number of doses needed to achieve response [see Dosage and Administration 2)] . 8.6 Renal Impairment. Methylene blue concentrations increased in subjects with renal impairment (eGFR 15 to 89 mL/min/1.73m2) significantly [see Clinical Pharmacology 12.3)]. Adjust PROVAYBLUE(R) dosage in patients with moderate or severe renal impairment (eGFR 15 to 59 mL/min/1.73 m2) [see Dosage and Administration 2.2)]. No dose adjustment is recommended in patients with mild renal impairment (eGFR 60 89 mL/min/1.73 m2) 8.7 Hepatic Impairment. Methylene blue is extensively metabolized in the liver. Monitor patients with any hepatic impairment for toxicities and potential drug interactions for an extended period of time following treatment with PROVAYBLUE (R).

WARNINGS AND PRECAUTIONS SECTION.

5 WARNINGS AND PRECAUTIONS. Hypersensitivity: If severe or life threatening allergic reaction occurs, discontinue PROVAYBLUE (R), treat the allergic reaction, and monitor until signs and symptoms resolve 5.2) Lack of Effectiveness: Consider alternative treatments if there is no resolution of methemoglobinemia after doses 2.1, 5.3) Hemolytic Anemia: Discontinue PROVAYBLUE (R) and transfuse 5.4) Interference with In-Vivo Monitoring Devices: Use methods other than pulse oximetry to assess oxygen satruation 5.5) Effects on Ability to Drive and Operate Machinery: Advise patients to refrain from these activities until neurologic and visual symptoms have resolved 5.6) Hypersensitivity: If severe or life threatening allergic reaction occurs, discontinue PROVAYBLUE (R), treat the allergic reaction, and monitor until signs and symptoms resolve 5.2) Lack of Effectiveness: Consider alternative treatments if there is no resolution of methemoglobinemia after doses 2.1, 5.3) Hemolytic Anemia: Discontinue PROVAYBLUE (R) and transfuse 5.4) Interference with In-Vivo Monitoring Devices: Use methods other than pulse oximetry to assess oxygen satruation 5.5) Effects on Ability to Drive and Operate Machinery: Advise patients to refrain from these activities until neurologic and visual symptoms have resolved 5.6) 5.1 Serotonin Syndrome with Concomitant Use of Serotonergic Drugs. The development of serotonin syndrome has been reported with use of methylene blue class products. Most reports have been associated with concomitant use of serotonergic drugs (e.g., selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors). Some of the reported cases were fatal. Symptoms associated with serotonin syndrome may include the following combination of signs and symptoms: mental status changes (e.g., agitation, hallucinations, delirium, and coma), autonomic instability (e.g., tachycardia, labile blood pressure, dizziness, diaphoresis, flushing, and hyperthermia), neuromuscular symptoms (e.g., tremor, rigidity, myoclonus, hyperreflexia, and incoordination), seizures, and/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea). Avoid concomitant use of PROVAYBLUE (R) with serotonergic drugs. Patients treated with PROVAYBLUE (R) should be monitored for the emergence of serotonin syndrome. If symptoms of serotonin syndrome occur, discontinue use of PROVAYBLUE (R), and initiate supportive treatment. Inform patients of the increased risk of serotonin syndrome and advise them to not to take serotonergic drugs within 72 hours after the last dose of PROVAYBLUE (R) [see Drug Interactions 7), Patient Counseling Information 17)] . 5.2 Hypersensitivity. Anaphylactic reactions to methylene blue class products have been reported. Patients treated with PROVAYBLUE (R) should be monitored for anaphylaxis. If anaphylaxis or other severe hypersensitivity reactions (e.g., angioedema, urticaria, bronchospasm) should occur, discontinue use of PROVAYBLUE (R) and initiate supportive treatment. PROVAYBLUE (R) is contraindicated in patients who have experienced anaphylaxis or other severe hypersensitivity reactions to methylene blue class product in the past. 5.3 Lack of Effectiveness. Methemoglobinemia may not resolve or may rebound after response to treatment with PROVAYBLUE (R) in patients with methemoglobinemia due to aryl amines such as aniline or sulfa drugs such as dapsone. Monitor response to therapy with PROVAYBLUE (R) through resolution of methemoglobinemia. If methemoglobinemia does not respond to doses of PROVAYBLUE (R) or if methemoglobinemia rebounds after response, consider additional treatment options [see Dosage and Administration 2.2)] Patients with glucose-6-phosphate dehydrogenase deficiency may not reduce PROVAYBLUE (R) to its active form in vivo. PROVAYBLUE (R) may not be effective in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. 5.4 Hemolytic Anemia. Hemolysis can occur during treatment of methemoglobinemia with PROVAYBLUE (R). Laboratory testing may show Heinz bodies, elevated indirect bilirubin and low haptoglobin, but the Coombs test is negative. The onset of anemia may be delayed or more days after treatment with PROVAYBLUE (R). The anemia may require red blood cell transfusions [see Adverse Reactions 6.1)]. Use the lowest effective number of doses of PROVAYBLUE (R) to treat methemoglobinemia. Discontinue PROVAYBLUE (R) and consider alternative treatments of methemoglobinemia if severe hemolysis occurs. Treatment of patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency with PROVAYBLUE (R) may result in severe hemolysis and severe anemia. PROVAYBLUE (R) is contraindicated for use in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency [see Contraindications 4)]. 5.5 Interference with In Vivo Monitoring Devices. Inaccurate Pulse Oximeter ReadingsThe presence of methylene blue in the blood may result in an underestimation of the oxygen saturation reading by pulse oximetry. If measure of oxygen saturation is required during or shortly after infusion of PROVAYBLUE (R), it is advisable to obtain an arterial blood sample for testing by an alternative method. Bispectral index monitorA fall in the Bispectral Index (BIS) has been reported following administration of methylene blue class products. If PROVAYBLUE (R) is administered during surgery, alternative methods for assessing the depth of anesthesia should be employed. Inaccurate Pulse Oximeter Readings. Bispectral index monitor. 5.6 Effects on Ability to Drive and Operate Machinery. Treatment with PROVAYBLUE (R) may cause confusion, dizziness and disturbances in vision [see Adverse Reactions 6)] Advise patients to refrain from driving or engaging in hazardous occupations or activities such as operating heavy or potentially dangerous machinery until such adverse reactions to PROVAYBLUE (R) have resolved. 5.7 Interference with Laboratory Tests. PROVAYBLUE (R) is blue dye which passes freely into the urine and may interfere with the interpretation of any urine test which relies on blue indicator, such as the dipstick test for leucocyte esterase.