ANIMAL PHARMACOLOGY & OR TOXICOLOGY SECTION.

ANIMAL PHARMACOLOGY:. Ciprofloxacin and related drugs have been shown to cause arthropathy in immature animals of most species tested following oral administration. However, one-month topical ocular study using immature Beagle dogs did not demonstrate any articular lesions.

ADVERSE REACTIONS SECTION.

ADVERSE REACTIONS:. The most frequently reported drug related adverse reaction was local burning or discomfort. In corneal ulcer studies with frequent administration of the drug, white crystalline precipitates were seen in approximately 17% of patients (see PRECAUTIONS). Other reactions occurring in less than 10% of patients included lid margin crusting, crystals/scales, foreign body sensation, itching, conjunctival hyperemia and bad taste following instillation. Additional events occurring in less than 1% of patients included corneal staining, keratopathy/keratitis, allergic reactions, lid edema, tearing, photophobia, corneal infiltrates, nausea and decreased vision.

CARCINOGENESIS & MUTAGENESIS & IMPAIRMENT OF FERTILITY SECTION.

Carcinogenesis, Mutagenesis, Impairment of Fertility: Eight in vitro mutagenicity tests have been conducted with ciprofloxacin and the test results are listed below:Salmonella/Microsome Test (Negative)E. coli DNA Repair Assay (Negative)Mouse Lymphoma Cell Forward Mutation Assay (Positive)Chinese Hamster V79 Cell HGPRT Test (Negative)Syrian Hamster Embryo Cell Transformation Assay (Negative)Saccharomyces cerevisiae Point Mutation Assay (Negative)Saccharomyces cerevisiae Mitotic Crossover and Gene Conversion Assay (Negative)Rat Hepatocyte DNA Repair Assay (Positive)Thus, two of the eight tests were positive, but the results of the following three in vivo test systems gave negative results:Rat Hepatocyte DNA Repair AssayMicronucleus Test (Mice)Dominant Lethal Test (Mice)Long term carcinogenicity studies in mice and rats have been completed. After daily oral dosing for up to two years, there is no evidence that ciprofloxacin had any carcinogenic or tumorigenic effects in these species.. Salmonella/Microsome Test (Negative). E. coli DNA Repair Assay (Negative). Mouse Lymphoma Cell Forward Mutation Assay (Positive). Chinese Hamster V79 Cell HGPRT Test (Negative). Syrian Hamster Embryo Cell Transformation Assay (Negative). Saccharomyces cerevisiae Point Mutation Assay (Negative). Saccharomyces cerevisiae Mitotic Crossover and Gene Conversion Assay (Negative). Rat Hepatocyte DNA Repair Assay (Positive). Rat Hepatocyte DNA Repair Assay. Micronucleus Test (Mice). Dominant Lethal Test (Mice).

CLINICAL PHARMACOLOGY SECTION.

CLINICAL PHARMACOLOGY:. Systemic Absorption: systemic absorption study was performed in which CILOXAN(R) (ciprofloxacin ophthalmic solution) 0.3% was administered in each eye every two hours while awake for two days followed by every four hours while awake for an additional days. The maximum reported plasma concentration of ciprofloxacin was less than ng/mL. The mean concentration was usually less than 2.5 ng/mL.Microbiology: Ciprofloxacin has in vitro activity against wide range of gram-negative and gram-positive organisms. The bactericidal action of ciprofloxacin results from interference with the enzyme DNA gyrase which is needed for the synthesis of bacterial DNA.Ciprofloxacin has been shown to be active against most strains of the following organisms both in vitro and in clinical infections (see INDICATIONS AND USAGE).Aerobic gram-positive microorganisms:Staphylococcus aureus (methicillin-susceptible strains)Staphylococcus epidermidis (methicillin-susceptible strains)Streptococcus pneumoniaeStreptococcus (Viridans Group)Aerobic gram-negative microorganisms:Haemophilus influenzaePseudomonas aeruginosaSerratia marcescensCiprofloxacin has been shown to be active in vitro against most strains of the following organisms, however, the clinical significance of these data is unknown:Gram-Positive:Enterococcus faecalis (Many strains are only moderately susceptible)Staphylococcus haemolyticusStaphylococcus hominisStaphylococcus saprophyticusStreptococcus pyogenesGram-Negative:Acinetobacter calcoaceticus subsp. anitratusAeromonas caviaeAeromonas hydrophilaBrucella melitensisCampylobacter coliCampylobacter jejuniCitrobacter diversusCitrobacter freundiiEdwardsiella tardaEnterobacter aerogenesEnterobacter cloacaeEscherichia coliHaemophilus ducreyiHaemophilus parainfluenzaeKiebsiella pneumoniaeKlebsiella oxytocaLegionella pneumophilaMoraxella (Branhamella) catarrhalisMorganella morganiiNeisseria gonorrhoeaeNeisseria meningitidisPasteurella multocidaProteus mirabilisProteus vulgarisProvidencia rettgeriProvidencia stuartiiSalmonella enteritidisSalmonella typhiShigella sonneiiShigella flexneriVibrio choleraeVibrio parahaemolyticusVibrio vulnificusYersinia enterocoliticaOther Organisms: Chlamydia trachomatis (only moderately susceptible) and Mycobacterium tuberculosis (only moderately susceptible).Most strains of Pseudomonas cepacia and some strains of Pseudomonas maltophilia are resistant to ciprofloxacin as are most anaerobic bacteria, including Bacteroides fragilis and Clostridium difficile.The minimal bactericidal concentration (MBC) generally does not exceed the minimal inhibitory concentration (MIC) by more than factor of 2. Resistance to ciprofloxacin in vitro usually develops slowly (multiple-step mutation).Ciprofloxacin does not cross-react with other antimicrobial agents such as beta-lactams or aminoglycosides; therefore, organisms resistant to these drugs may be susceptible to ciprofloxacin.

CLINICAL STUDIES SECTION.

CLINICAL STUDIES:. Following therapy with CILOXAN(R) (ciprofloxacin ophthalmic solution) 0.3%, 76% of the patients with corneal ulcers and positive bacterial cultures were clinically cured and complete re-epithelialization occurred in about 92% of the ulcers.In and day multicenter clinical trials, 52% of the patients with conjunctivitis and positive conjunctival cultures were clinically cured and 70%-80% had all causative pathogens eradicated by the end of treatment.In randomized, double-masked, multicenter, parallel-group clinical trial of pediatric patients with bacterial conjunctivitis, between birth and 31 days of age, patients were dosed with CILOXAN or another anti-infective agent. Clinical outcomes for the trial demonstrated clinical cure rate of 80% at Day and microbiological eradication success rate of 85% at Day 9.Please note that microbiologic eradication does not always correlate with clinical outcome in anti-infective trials.(C)2003, 2004, 2006, 2016, 2018 NovartisDistributed by:ALCON LABORATORIES, INC.Fort Worth, Texas 76134 USAAlcon(R) Novartis companyT2018-37 Revised: April 2018.

CONTRAINDICATIONS SECTION.

CONTRAINDICATIONS:. history of hypersensitivity to ciprofloxacin or any other component of the medication is contraindication to its use. history of hypersensitivity to other quinolones may also contraindicate the use of ciprofloxacin.

DESCRIPTION SECTION.

DESCRIPTION:. CILOXAN(R) (ciprofloxacin ophthalmic solution) is synthetic, sterile, multiple dose, antimicrobial for topical ophthalmic use. Ciprofloxacin is fluoroquinolone antibacterial active against broad spectrum of gram-positive and gram-negative ocular pathogens. It is available as the monohydrochloride monohydrate salt of 1-cyclopropyl-6-fluoro-1,4-dihydro-4-oxo-7-(1-piperazinyl)-3-quinoline-carboxylic acid. It is faint to light yellow crystalline powder with molecular weight of 385.8. Its empirical formula is C17H18FN3O3oHCloH2O and its chemical structure is as follows:Ciprofloxacin differs from other quinolones in that it has fluorine atom at the 6-position, piperazine moiety at the 7-position, and cyclopropyl ring at the 1-position.Each mL of CILOXAN(R) (ciprofloxacin ophthalmic solution) 0.3% contains: Active: ciprofloxacin HCl 3.5 mg equivalent to mg base. Preservative: benzalkonium chloride 0.006%. Inactives: sodium acetate, acetic acid, mannitol 4.6%, edetate disodium 0.05%, hydrochloric acid and/or sodium hydroxide (to adjust pH) and purified water. The pH is approximately 4.5 and the osmolality is approximately 300 mOsm.. chemical.

DOSAGE & ADMINISTRATION SECTION.

DOSAGE AND ADMINISTRATION:. Corneal Ulcers: The recommended dosage regimen for the treatment of corneal ulcers is two drops into the affected eye every 15 minutes for the first six hours and then two drops into the affected eye every 30 minutes for the remainder of the first day. On the second day, instill two drops in the affected eye hourly. On the third through the fourteenth day, place two drops in the affected eye every four hours. Treatment may be continued after 14 days if corneal re-epithelialization has not occurred.Bacterial Conjunctivitis: The recommended dosage regimen for the treatment of bacterial conjunctivitis is one or two drops instilled into the conjunctival sac(s) every two hours while awake for two days and one or two drops every four hours while awake for the next five days.

DRUG INTERACTIONS SECTION.

Drug Interactions: Specific drug interaction studies have not been conducted with ophthalmic ciprofloxacin. However, the systemic administration of some quinolones has been shown to elevate plasma concentrations of theophylline, interfere with the metabolism of caffeine, enhance the effects of the oral anticoagulant, warfarin, and its derivatives, and has been associated with transient elevations in serum creatinine in patients receiving cyclosporine concomitantly.

GENERAL PRECAUTIONS SECTION.

General: As with other antibacterial preparations, prolonged use of ciprofloxacin may result in overgrowth of nonsusceptible organisms, including fungi. If superinfection occurs, appropriate therapy should be initiated. Whenever clinical judgment dictates, the patient should be examined with the aid of magnification, such as slit lamp biomicroscopy and, where appropriate, fluorescein staining.Ciprofloxacin should be discontinued at the first appearance of skin rash or any other sign of hypersensitivity reaction.In clinical studies of patients with bacterial corneal ulcer, white crystalline precipitate located in the superficial portion of the corneal defect was observed in 35 (16.6%) of 210 patients. The onset of the precipitate was within 24 hours to days after starting therapy. In one patient, the precipitate was immediately irrigated out upon its appearance. In 17 patients, resolution of the precipitate was seen in to days (seven within the first 24 to 72 hours), in five patients, resolution was noted in 10 to 13 days. In nine patients, exact resolution days were unavailable; however, at follow-up examinations, 18 to 44 days after onset of the event, complete resolution of the precipitate was noted. In three patients, outcome information was unavailable. The precipitate did not preclude continued use of ciprofloxacin, nor did it adversely affect the clinical course of the ulcer or visual outcome (see ADVERSE REACTIONS).

GERIATRIC USE SECTION.

Geriatric Use: No overall differences in safety or effectiveness have been observed between elderly and younger patients.

HOW SUPPLIED SECTION.

How Supplied: As sterile ophthalmic solution in Alcons DROP-TAINER(R) dispensing system consisting of natural low density polyethylene bottle and dispensing plug and tan polypropylene closure. Tamper evidence is provided with shrink band around the closure and neck area of the package.5 mL in mL bottle NDC 0065-0656-05Storage: Store at 2C to 25C (36F-77F). Protect from light.

INDICATIONS & USAGE SECTION.

INDICATIONS AND USAGE:. CILOXAN Ophthalmic Solution is indicated for the treatment of infections caused by susceptible strains of the designated microorganisms in the conditions listed below:Corneal Ulcers: Pseudomonas aeruginosaSerratia marcescens Staphylococcus aureusStaphylococcus epidermidisStreptococcus pneumoniaeStreptococcus (Viridans Group)Conjunctivitis: Haemophilus influenzaeStaphylococcus aureusStaphylococcus epidermidisStreptococcus pneumoniaeEfficacy for this organism was studied in fewer than 10 infections.

INFORMATION FOR PATIENTS SECTION.

Information for patients: Do not touch dropper tip to any surface, as this may contaminate the solution.

LACTATION SECTION.

Nursing Mothers: It is not known whether topically applied ciprofloxacin is excreted in human milk; however, it is known that orally administered ciprofloxacin is excreted in the milk of lactating rats and oral ciprofloxacin has been reported in human breast milk after single 500 mg dose. Caution should be exercised when CILOXAN(R) (ciprofloxacin ophthalmic solution) 0.3% is administered to nursing mother.

OVERDOSAGE SECTION.

OVERDOSAGE:. topical overdose of CILOXAN(R) (ciprofloxacin ophthalmic solution) 0.3% may be flushed from the eye(s) with warm tap water.

PACKAGE LABEL.PRINCIPAL DISPLAY PANEL.

PRINCIPAL DISPLAY PANEL. NDC 0065-0656-05 Alcon(R) Ciloxan(R) (ciprofloxacin ophthalmic solution) 0.3% mL Sterile carton.

PEDIATRIC USE SECTION.

Pediatric Use: The safety and effectiveness of CILOXAN(R) (ciprofloxacin ophthalmic solution) 0.3% have been established in all ages. Use of CILOXAN is supported by evidence from adequate and well controlled studies of CILOXAN in adults, children and neonates (see Clinical Studies). Although ciprofloxacin and other quinolones cause arthropathy in immature animals after oral administration, topical ocular administration of ciprofloxacin to immature animals did not cause any arthropathy and there is no evidence that the ophthalmic dosage form has any effect on the weight bearing joints.

PRECAUTIONS SECTION.

PRECAUTIONS:. General: As with other antibacterial preparations, prolonged use of ciprofloxacin may result in overgrowth of nonsusceptible organisms, including fungi. If superinfection occurs, appropriate therapy should be initiated. Whenever clinical judgment dictates, the patient should be examined with the aid of magnification, such as slit lamp biomicroscopy and, where appropriate, fluorescein staining.Ciprofloxacin should be discontinued at the first appearance of skin rash or any other sign of hypersensitivity reaction.In clinical studies of patients with bacterial corneal ulcer, white crystalline precipitate located in the superficial portion of the corneal defect was observed in 35 (16.6%) of 210 patients. The onset of the precipitate was within 24 hours to days after starting therapy. In one patient, the precipitate was immediately irrigated out upon its appearance. In 17 patients, resolution of the precipitate was seen in to days (seven within the first 24 to 72 hours), in five patients, resolution was noted in 10 to 13 days. In nine patients, exact resolution days were unavailable; however, at follow-up examinations, 18 to 44 days after onset of the event, complete resolution of the precipitate was noted. In three patients, outcome information was unavailable. The precipitate did not preclude continued use of ciprofloxacin, nor did it adversely affect the clinical course of the ulcer or visual outcome (see ADVERSE REACTIONS).. Information for patients: Do not touch dropper tip to any surface, as this may contaminate the solution.. Drug Interactions: Specific drug interaction studies have not been conducted with ophthalmic ciprofloxacin. However, the systemic administration of some quinolones has been shown to elevate plasma concentrations of theophylline, interfere with the metabolism of caffeine, enhance the effects of the oral anticoagulant, warfarin, and its derivatives, and has been associated with transient elevations in serum creatinine in patients receiving cyclosporine concomitantly.. Carcinogenesis, Mutagenesis, Impairment of Fertility: Eight in vitro mutagenicity tests have been conducted with ciprofloxacin and the test results are listed below:Salmonella/Microsome Test (Negative)E. coli DNA Repair Assay (Negative)Mouse Lymphoma Cell Forward Mutation Assay (Positive)Chinese Hamster V79 Cell HGPRT Test (Negative)Syrian Hamster Embryo Cell Transformation Assay (Negative)Saccharomyces cerevisiae Point Mutation Assay (Negative)Saccharomyces cerevisiae Mitotic Crossover and Gene Conversion Assay (Negative)Rat Hepatocyte DNA Repair Assay (Positive)Thus, two of the eight tests were positive, but the results of the following three in vivo test systems gave negative results:Rat Hepatocyte DNA Repair AssayMicronucleus Test (Mice)Dominant Lethal Test (Mice)Long term carcinogenicity studies in mice and rats have been completed. After daily oral dosing for up to two years, there is no evidence that ciprofloxacin had any carcinogenic or tumorigenic effects in these species.. Salmonella/Microsome Test (Negative). E. coli DNA Repair Assay (Negative). Mouse Lymphoma Cell Forward Mutation Assay (Positive). Chinese Hamster V79 Cell HGPRT Test (Negative). Syrian Hamster Embryo Cell Transformation Assay (Negative). Saccharomyces cerevisiae Point Mutation Assay (Negative). Saccharomyces cerevisiae Mitotic Crossover and Gene Conversion Assay (Negative). Rat Hepatocyte DNA Repair Assay (Positive). Rat Hepatocyte DNA Repair Assay. Micronucleus Test (Mice). Dominant Lethal Test (Mice). Pregnancy: Reproduction studies have been performed in rats and mice at doses up to six times the usual daily human oral dose and have revealed no evidence of impaired fertility or harm to the fetus due to ciprofloxacin. In rabbits, as with most antimicrobial agents, ciprofloxacin (30 and 100 mg/kg orally) produced gastrointestinal disturbances resulting in maternal weight loss and an increased incidence of abortion. No teratogenicity was observed at either dose. After intravenous administration, at doses up to 20 mg/kg, no maternal toxicity was produced and no embryotoxicity or teratogenicity was observed. There are no adequate and well controlled studies in pregnant women. CILOXAN(R) (ciprofloxacin ophthalmic solution) 0.3% should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.. Nursing Mothers: It is not known whether topically applied ciprofloxacin is excreted in human milk; however, it is known that orally administered ciprofloxacin is excreted in the milk of lactating rats and oral ciprofloxacin has been reported in human breast milk after single 500 mg dose. Caution should be exercised when CILOXAN(R) (ciprofloxacin ophthalmic solution) 0.3% is administered to nursing mother.. Pediatric Use: The safety and effectiveness of CILOXAN(R) (ciprofloxacin ophthalmic solution) 0.3% have been established in all ages. Use of CILOXAN is supported by evidence from adequate and well controlled studies of CILOXAN in adults, children and neonates (see Clinical Studies). Although ciprofloxacin and other quinolones cause arthropathy in immature animals after oral administration, topical ocular administration of ciprofloxacin to immature animals did not cause any arthropathy and there is no evidence that the ophthalmic dosage form has any effect on the weight bearing joints.. Geriatric Use: No overall differences in safety or effectiveness have been observed between elderly and younger patients.

PREGNANCY SECTION.

Pregnancy: Reproduction studies have been performed in rats and mice at doses up to six times the usual daily human oral dose and have revealed no evidence of impaired fertility or harm to the fetus due to ciprofloxacin. In rabbits, as with most antimicrobial agents, ciprofloxacin (30 and 100 mg/kg orally) produced gastrointestinal disturbances resulting in maternal weight loss and an increased incidence of abortion. No teratogenicity was observed at either dose. After intravenous administration, at doses up to 20 mg/kg, no maternal toxicity was produced and no embryotoxicity or teratogenicity was observed. There are no adequate and well controlled studies in pregnant women. CILOXAN(R) (ciprofloxacin ophthalmic solution) 0.3% should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

WARNINGS SECTION.

WARNINGS:. NOT FOR INJECTION INTO THE EYE.Serious and occasionally fatal hypersensitivity (anaphylactic) reactions, some following the first dose, have been reported in patients receiving systemic quinolone therapy. Some reactions were accompanied by cardiovascular collapse, loss of consciousness, tingling, pharyngeal or facial edema, dyspnea, urticaria, and itching. Only few patients had history of hypersensitivity reactions. Serious anaphylactic reactions require immediate emergency treatment with epinephrine and other resuscitation measures, including oxygen, intravenous fluids, intravenous antihistamines, corticosteroids, pressor amines and airway management, as clinically indicated.Remove contact lenses before using.