PREGNANCY SECTION.

8.1 Pregnancy. Pregnancy Category XPhentermine is contraindicated during pregnancy because weight loss offers no potential benefit to pregnant woman and may result in fetal harm. minimum weight gain, and no weight loss, is currently recommended for all pregnant women, including those who are already overweight or obese, due to obligatory weight gain that occurs in maternal tissues during pregnancy. Phentermine has pharmacologic activity similar to amphetamine (d- and d/l-amphetamine) [see Clinical Pharmacology (12.1)]. Animal reproduction studies have not been conducted with phentermine. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to fetus.

SPL UNCLASSIFIED SECTION.

2.1 Exogenous Obesity. One capsule daily, before breakfast or 10-14 hours before retiring. For individuals exhibiting greater drug responsiveness, phentermine resin extended-release capsules, 15 mg, will usually suffice. Phentermine resin extended-release capsules, 30 mg, are recommended for less responsive patients. Phentermine resin extended-release capsules are not recommended for use in pediatric patients under 16 years of age.Phentermine resin extended-release capsules should be swallowed whole.Late evening medication should be avoided because of the possibility of resulting insomnia.

ADVERSE REACTIONS SECTION.

6 ADVERSE REACTIONS. The following adverse reactions are described, or described in greater detail, in other sections:- Primary pulmonary hypertension [see Warnings and Precautions (5.2)]- Valvular heart disease [see Warnings and Precautions (5.3)]- Effect on the ability to engage in potentially hazardous tasks [see Warnings and Precautions (5.5)]- Withdrawal effects following prolonged high dosage administration [see Drug Abuse and Dependence (9.3)]The following adverse reactions to phentermine have been identified:CardiovascularPrimary pulmonary hypertension and/or regurgitant cardiac valvular disease, palpitation, tachycardia, elevation of blood pressure, ischemic events.Central Nervous SystemOverstimulation, restlessness, dizziness, insomnia, euphoria, dysphoria, tremor, headache, psychosis.GastrointestinalDryness of the mouth, unpleasant taste, diarrhea, constipation, other gastrointestinal disturbances.AllergicUrticaria.EndocrineImpotence, changes in libido.. Adverse events have been reported in the cardiovascular, central nervous, gastrointestinal, allergic, and endocrine systems. (6)To report SUSPECTED ADVERSE REACTIONS, contact Lannett Company, Inc. at 1-844-834-0530 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

CARCINOGENESIS & MUTAGENESIS & IMPAIRMENT OF FERTILITY SECTION.

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility. Studies have not been performed with phentermine to determine the potential for carcinogenesis, mutagenesis or impairment of fertility.

CLINICAL PHARMACOLOGY SECTION.

12 CLINICAL PHARMACOLOGY. 12.1 Mechanism of Action. Phentermine is sympathomimetic amine with pharmacologic activity similar to the prototype drugs of this class used in obesity, amphetamine (d- and d/l-amphetamine). Drugs of this class used in obesity are commonly known as anorectics or anorexigenics. It has not been established that the primary action of such drugs in treating obesity is one of appetite suppression since other central nervous system actions, or metabolic effects, may also be involved.. 12.2 Pharmacodynamics. Typical of amphetamines include central nervous system stimulation and elevation of blood pressure. Tachyphylaxis and tolerance have been demonstrated with all drugs of this class in which these phenomena have been looked for.. 12.3 Pharmacokinetics. Following the administration of phentermine, phentermine reaches peak concentrations (Cmax) after to 4.4 hours. Drug InteractionsIn single-dose study comparing the exposures after oral administration of combination capsule of 15 mg phentermine and 92 mg topiramate to the exposures after oral administration of 15 mg phentermine capsule or 92 mg topiramate capsule, there is no significant topiramate exposure change in the presence of phentermine. However in the presence of topiramate, phentermine Cmax and AUC increase 13% and 42%, respectively.Specific PopulationsRenal ImpairmentCumulative urinary excretion of phentermine under uncontrolled urinary pH conditions was 62% 85%. Systemic exposure of phentermine may increase up to 91%, 45%, and 22% in patients with severe, moderate, and mild renal impairment, respectively [see Dosage and Administration (2.2) and Use in Specific Populations (8.6)].

CLINICAL STUDIES SECTION.

14 CLINICAL STUDIES. In relatively short-term clinical trials, adult obese subjects instructed in dietary management and treated with anorectic drugs lost more weight on the average than those treated with placebo and diet.The magnitude of increased weight loss of drug-treated patients over placebo-treated patients is only fraction of pound week. The rate of weight loss is greatest in the first weeks of therapy for both drug and placebo subjects and tends to decrease in succeeding weeks. The possible origins of the increased weight loss due to the various drug effects are not established. The amount of weight loss associated with the use of an anorectic drug varies from trial to trial, and the increased weight loss appears to be related in part to variables other than the drugs prescribed, such as the physician-investigator, the population treated and the diet prescribed. Studies do not permit conclusions as to the relative importance of the drug and non-drug factors on weight loss.The natural history of obesity is measured over several years, whereas the studies cited are restricted to few weeks duration; thus, the total impact of drug-induced weight loss over that of diet alone must be considered clinically limited.The bioavailability of phentermine resin extended-release capsules has been studied in humans in which blood levels of phentermine were measured by gas chromatography method. Blood levels obtained with the 15 mg and 30 mg resin complex formulations indicated slower absorption with reduced but prolonged peak concentration and without significant difference in prolongation of blood levels when compared with the same doses of phentermine hydrochloride. The clinical significance of these differences is not known. In clinical trials establishing the efficacy of phentermine resin extended-release capsules, single daily dose produced an effect comparable to that produced by other regimens of anorectic drug therapy.

CONTRAINDICATIONS SECTION.

4 CONTRAINDICATIONS. History of cardiovascular disease (e.g., coronary artery disease, stroke, arrhythmias, congestive heart failure, uncontrolled hypertension) During or within 14 days following the administration of monoamine oxidase inhibitors Hyperthyroidism Glaucoma Agitated states History of drug abuse Pregnancy [see Use in Specific Populations (8.1)] Nursing [see Use in Specific Populations (8.3)] Known hypersensitivity, or idiosyncrasy to the sympathomimetic amines. History of cardiovascular disease (e.g., coronary artery disease, stroke, arrhythmias, congestive heart failure, uncontrolled hypertension) During or within 14 days following the administration of monoamine oxidase inhibitors Hyperthyroidism Glaucoma Agitated states History of drug abuse Pregnancy [see Use in Specific Populations (8.1)] Nursing [see Use in Specific Populations (8.3)] Known hypersensitivity, or idiosyncrasy to the sympathomimetic amines. History of cardiovascular disease (e.g., coronary artery disease, stroke, arrhythmias, congestive heart failure, uncontrolled hypertension) (4)During or within 14 days following the administration of monoamine oxidase inhibitors (4)Hyperthyroidism (4)Glaucoma (4)Agitated states (4)History of drug abuse (4)Pregnancy (4, 8.1)Nursing (4, 8.3)Known hypersensitivity, or idiosyncrasy to the sympathomimetic amines (4). History of cardiovascular disease (e.g., coronary artery disease, stroke, arrhythmias, congestive heart failure, uncontrolled hypertension) (4). During or within 14 days following the administration of monoamine oxidase inhibitors (4). Hyperthyroidism (4). Glaucoma (4). Agitated states (4). History of drug abuse (4). Pregnancy (4, 8.1). Nursing (4, 8.3). Known hypersensitivity, or idiosyncrasy to the sympathomimetic amines (4).

DESCRIPTION SECTION.

11 DESCRIPTION. Phentermine Resin Extended-Release Capsules contain 15 mg and 30 mg respectively of phentermine as the cationic exchange resin complex. Phentermine is -dimethyl phenethylamine (phenyl-tertiarybutylamine).Inactive Ingredients: dibasic calcium phosphate, talc, and magnesium stearate. The 15 mg capsule shell consists of D&C Yellow No. 10, FD&C Yellow No. 6, titanium dioxide, gelatin, FD&C Blue No. 1, FD&C Red No. 40, FDA /E172 black iron oxide. The capsule imprinting ink consists of shellac glaze in ethanol, black iron oxide, N-butyl alcohol, propylene glycol, FD&C Blue No. Aluminum Lake, FD&C Red No. 40 Aluminum Lake, FD&C Blue No. Aluminum Lake, D&C Yellow No. 10 Aluminum Lake, ethanol and methanol. The 30 mg capsule shell consists of D&C Yellow No. 10, FD&C Yellow No. 6, titanium dioxide, and gelatin. The capsule imprinting ink consists of shellac glaze in ethanol, black iron oxide, N-butyl alcohol, propylene glycol, FD&C Blue No. Aluminum Lake, FD&C Red No. 40 Aluminum Lake, FD&C Blue No. Aluminum Lake, D&C Yellow No. 10 Aluminum Lake, ethanol and methanol.

DOSAGE & ADMINISTRATION SECTION.

2 DOSAGE AND ADMINISTRATION. Dosage should be individualized to obtain an adequate response with the lowest effective dose. (2.1)One capsule daily, before breakfast or 10-14 hours before retiring. (2.1)Late evening administration should be avoided (risk of insomnia) (2.1)Phentermine resin extended-release capsules can be taken with or without food (2.1)Limit the dosage to 15 mg daily for patients with severe renal impairment (eGFR 15 to 29 mL/min/1.73 m2). (2.2). Dosage should be individualized to obtain an adequate response with the lowest effective dose. (2.1). One capsule daily, before breakfast or 10-14 hours before retiring. (2.1). Late evening administration should be avoided (risk of insomnia) (2.1). Phentermine resin extended-release capsules can be taken with or without food (2.1). Limit the dosage to 15 mg daily for patients with severe renal impairment (eGFR 15 to 29 mL/min/1.73 m2). (2.2). 2.1 Exogenous Obesity. One capsule daily, before breakfast or 10-14 hours before retiring. For individuals exhibiting greater drug responsiveness, phentermine resin extended-release capsules, 15 mg, will usually suffice. Phentermine resin extended-release capsules, 30 mg, are recommended for less responsive patients. Phentermine resin extended-release capsules are not recommended for use in pediatric patients under 16 years of age.Phentermine resin extended-release capsules should be swallowed whole.Late evening medication should be avoided because of the possibility of resulting insomnia.. 2.2 Dosage in Patients With Renal Impairment. The recommended maximum dosage of phentermine is 15 mg daily for patients with severe renal impairment (eGFR 15 to 29 mL/min/1.73m2). Avoid use of phentermine in patients with eGFR less than 15 mL/min/1.73m2 or end-stage renal disease requiring dialysis [see Use in Specific Populations (8.6) and Clinical Pharmacology (12.3)].

DOSAGE FORMS & STRENGTHS SECTION.

3 DOSAGE FORMS AND STRENGTHS. Phentermine Resin Extended-Release Capsules are available in two strengths:15 mg: Size grey opaque/maize opaque capsules, imprinted with LCI on the cap and 1398 on the body.30 mg: Size maize/maize capsules, imprinted with LCI on the cap and 1366 on the body.. Capsules containing cationic resin complex equivalent to 15 mg or 30 mg phentermine base.. Capsules containing cationic resin complex equivalent to 15 mg or 30 mg phentermine base.

DRUG ABUSE AND DEPENDENCE SECTION.

9 DRUG ABUSE AND DEPENDENCE. 9.1 Controlled Substance. Phentermine is Schedule IV controlled substance.. 9.2 Abuse. Phentermine is related chemically and pharmacologically to the amphetamines. Amphetamines and other stimulant drugs have been extensively abused and the possibility of abuse of phentermine should be kept in mind when evaluating the desirability of including drug as part of weight reduction program.. 9.3 Dependence. Abuse of amphetamines and related drugs may be associated with intense psychological dependence and severe social dysfunction. There are reports of patients who have increased the dosage of these drugs to many times than recommended. Abrupt cessation following prolonged high dosage administration results in extreme fatigue and mental depression; changes are also noted on the sleep EEG. Manifestations of chronic intoxication with anorectic drugs include severe dermatoses, marked insomnia, irritability, hyperactivity and personality changes. severe manifestation of chronic intoxication is psychosis, often clinically indistinguishable from schizophrenia.

DRUG INTERACTIONS SECTION.

7 DRUG INTERACTIONS. Monoamine oxidase inhibitors: Risk of hypertensive crisis. (4, 7.1)Alcohol: Consider potential interaction (7.2)Insulin and oral hypoglycemics: Requirements may be altered. (7.3)Adrenergic neuron blocking drugs: Hypotensive effect may be decreased by phentermine. (7.4). Monoamine oxidase inhibitors: Risk of hypertensive crisis. (4, 7.1). Alcohol: Consider potential interaction (7.2). Insulin and oral hypoglycemics: Requirements may be altered. (7.3). Adrenergic neuron blocking drugs: Hypotensive effect may be decreased by phentermine. (7.4). 7.1 Monoamine Oxidase Inhibitors. Use of phentermine is contraindicated during or within 14 days following the administration of monoamine oxidase inhibitors because of the risk of hypertensive crisis.. 7.2 Alcohol. Concomitant use of alcohol with phentermine may result in an adverse drug reaction.. 7.3 Insulin and Oral Hypoglycemic Medications. Requirements may be altered [see Warnings and Precautions (5.9)].. 7.4 Adrenergic Neuron Blocking Drugs. Phentermine may decrease the hypotensive effect of adrenergic neuron blocking drugs.

GERIATRIC USE SECTION.

8.5 Geriatric Use. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.This drug is known to be substantially excreted by the kidney, and the risk of toxic reactions to this drug may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function.

HOW SUPPLIED SECTION.

16 HOW SUPPLIED/STORAGE AND HANDLING. Phentermine Resin Extended-Release Capsules are available in two strengths:15 mg: Size grey opaque/maize opaque capsules, imprinted with LCI on the cap and 1398 on the body, in bottles of 100 capsules (NDC 0527-1398-01).30 mg: Size maize/maize capsules, imprinted with LCI on the cap and 1366 on the body, in bottles of 100 capsules (NDC 0527-1366-01).Store at 20 to 25C (68 to 77F) [See USP Controlled Room Temperature].Dispense in tight, well-closed container as defined in the USP, with child-resistant closure (as required).Keep out of the reach of children.

PHARMACOKINETICS SECTION.

12.3 Pharmacokinetics. Following the administration of phentermine, phentermine reaches peak concentrations (Cmax) after to 4.4 hours. Drug InteractionsIn single-dose study comparing the exposures after oral administration of combination capsule of 15 mg phentermine and 92 mg topiramate to the exposures after oral administration of 15 mg phentermine capsule or 92 mg topiramate capsule, there is no significant topiramate exposure change in the presence of phentermine. However in the presence of topiramate, phentermine Cmax and AUC increase 13% and 42%, respectively.Specific PopulationsRenal ImpairmentCumulative urinary excretion of phentermine under uncontrolled urinary pH conditions was 62% 85%. Systemic exposure of phentermine may increase up to 91%, 45%, and 22% in patients with severe, moderate, and mild renal impairment, respectively [see Dosage and Administration (2.2) and Use in Specific Populations (8.6)].

INDICATIONS & USAGE SECTION.

1 INDICATIONS AND USAGE. Phentermine resin extended-release capsules are indicated as short-term (a few weeks) adjunct in regimen of weight reduction based on exercise, behavioral modification and caloric restriction in the management of exogenous obesity for patients with an initial body mass index >= 30 kg/m2, or >= 27 kg/m2 in the presence of other risk factors (e.g., controlled hypertension, diabetes, hyperlipidemia).Below is chart of body mass index (BMI) based on various heights and weights.BMI is calculated by taking the patients weight, in kilograms (kg), divided by the patients height, in meters (m), squared. Metric conversions are as follows: pounds 2.2 kg; inches 0.0254 meters.BODY MASS INDEX (BMI), kg/m2 Height (feet, inches) Weight (pounds)505356596063140272523211918150292724222019160312826242220170333028252321180353229272523190373431282624200393632302725210413734312926220433936333028230454137343129240474339363330250494440373431The limited usefulness of agents of this class, including phentermine, [see Clinical Pharmacology (12.1, 12.2)] should be measured against possible risk factors inherent in their use such as those described below.. Phentermine resin extended-release capsules are sympathomimetic amine anorectic indicated as short-term adjunct (a few weeks) in regimen of weight reduction based on exercise, behavioral modification and caloric restriction in the management of exogenous obesity for patients with an initial body mass index >= 30 kg/m2, or >= 27 kg/m2 in the presence of other risk factors (e.g., controlled hypertension, diabetes, hyperlipidemia). (1)The limited usefulness of agents of this class, including phentermine, should be measured against possible risk factors inherent in their use. (1).

INFORMATION FOR PATIENTS SECTION.

17 PATIENT COUNSELING INFORMATION. Patients must be informed that phentermine is short-term (a few weeks) adjunct in regimen of weight reduction based on exercise, behavioral modification and caloric restriction in the management of exogenous obesity, and that coadministration of phentermine with other drugs for weight loss is not recommended [see Indications and Usage (1) and Warnings and Precautions (5.1)].Patients must be instructed on how much phentermine to take, and when and how to take it [see Dosage and Administration (3)].Advise pregnant women and nursing mothers not to use phentermine [see Use in Specific Populations (8.1, 8.3)].Patients must be informed about the risks of use of phentermine (including the risks discussed in Warnings and Precautions), about the symptoms of potential adverse reactions and when to contact physician and/or take other action. The risks include, but are not limited to:Development of primary pulmonary hypertension [see Warnings and Precautions (5.2)]Development of serious valvular heart disease [see Warnings and Precautions (5.3)]Effects on the ability to engage in potentially hazardous tasks [see Warnings and Precautions (5.5)]The risk of an increase in blood pressure [see Warnings and Precautions (5.8) and Adverse Reactions (6)]The risk of interactions [see Contraindications (4), Warnings and Precautions (5.7, 5.9) and Drug Interactions (7)]See also, for example, Adverse Reactions (6) and Use in Specific Populations (8).The patients must also be informed aboutthe potential for developing tolerance and actions if they suspect development of tolerance [see Warnings and Precautions (5.4)] andthe risk of dependence and the potential consequences of abuse [see Warnings and Precautions (5.6), Drug Abuse and Dependence (9), and Overdosage (10)].Tell patients to keep phentermine in safe place to prevent theft, accidental overdose, misuse or abuse. Selling or giving away phentermine may harm others and is against the law.Distributed by:Lannett Company, Inc,Philadelphia, PA 19154Made in the USAL6557Rev. 04/2017. Development of primary pulmonary hypertension [see Warnings and Precautions (5.2)]. Development of serious valvular heart disease [see Warnings and Precautions (5.3)]. Effects on the ability to engage in potentially hazardous tasks [see Warnings and Precautions (5.5)]. The risk of an increase in blood pressure [see Warnings and Precautions (5.8) and Adverse Reactions (6)]. The risk of interactions [see Contraindications (4), Warnings and Precautions (5.7, 5.9) and Drug Interactions (7)]. the potential for developing tolerance and actions if they suspect development of tolerance [see Warnings and Precautions (5.4)] and. the risk of dependence and the potential consequences of abuse [see Warnings and Precautions (5.6), Drug Abuse and Dependence (9), and Overdosage (10)].

MECHANISM OF ACTION SECTION.

12.1 Mechanism of Action. Phentermine is sympathomimetic amine with pharmacologic activity similar to the prototype drugs of this class used in obesity, amphetamine (d- and d/l-amphetamine). Drugs of this class used in obesity are commonly known as anorectics or anorexigenics. It has not been established that the primary action of such drugs in treating obesity is one of appetite suppression since other central nervous system actions, or metabolic effects, may also be involved.

NONCLINICAL TOXICOLOGY SECTION.

13 NONCLINICAL TOXICOLOGY. 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility. Studies have not been performed with phentermine to determine the potential for carcinogenesis, mutagenesis or impairment of fertility.

NURSING MOTHERS SECTION.

8.3 Nursing Mothers. It is not known if phentermine is excreted in human milk; however, other amphetamines are present in human milk. Because of the potential for serious adverse reactions in nursing infants, decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.

OVERDOSAGE SECTION.

10 OVERDOSAGE. The least amount feasible should be prescribed or dispensed at one time in order to minimize the possibility of overdosage.. 10.1 Acute Overdosage. Manifestations of acute overdosage include restlessness, tremor, hyperreflexia, rapid respiration, confusion, assaultiveness, hallucinations, and panic states. Fatigue and depression usually follow the central stimulation. Cardiovascular effects include arrhythmia, hypertension or hypotension, and circulatory collapse. Gastrointestinal symptoms include nausea, vomiting, diarrhea and abdominal cramps. Overdosage of pharmacologically similar compounds has resulted in fatal poisoning usually terminates in convulsions and coma.Management of acute phentermine intoxication is largely symptomatic and includes lavage and sedation with barbiturate. Experience with hemodialysis or peritoneal dialysis is inadequate to permit recommendations in this regard. Acidification of the urine increases phentermine excretion. Intravenous phentolamine (Regitine(R), CIBA) has been suggested on pharmacologic grounds for possible acute, severe hypertension, if this complicates overdosage.. 10.2 Chronic Intoxication. Manifestations of chronic intoxication with anorectic drugs include severe dermatoses, marked insomnia, irritability, hyperactivity and personality changes. The most severe manifestation of chronic intoxications is psychosis, often clinically indistinguishable from schizophrenia. See Drug Abuse and Dependence (9.3).

PACKAGE LABEL.PRINCIPAL DISPLAY PANEL.

PRINCIPAL DISPLAY PANEL 15 mg. NDC 0527-1398-01LannettPHENTERMINE RESIN CIVEXTENDED-RELEASECAPSULES15 mgRx Only100 CAPSULES. phentermine-resin-cap-15mg.

PEDIATRIC USE SECTION.

8.4 Pediatric Use. Safety and effectiveness in pediatric patients have not been established. Because pediatric obesity is chronic condition requiring long-term treatment, the use of this product, approved for short-term therapy, is not recommended.

PHARMACODYNAMICS SECTION.

12.2 Pharmacodynamics. Typical of amphetamines include central nervous system stimulation and elevation of blood pressure. Tachyphylaxis and tolerance have been demonstrated with all drugs of this class in which these phenomena have been looked for.

USE IN SPECIFIC POPULATIONS SECTION.

8 USE IN SPECIFIC POPULATIONS. Nursing mothers: Discontinue drug or nursing taking into consideration importance of drug to mother. (4, 8.3) Pediatric use: Safety and effectiveness not established. (8.4)Geriatric use: Due to substantial renal excretion, use with caution. (8.5)Renal Impairment: Avoid use in patients with eGFR less than 15 mL/min/m2 or end-stage renal disease requiring dialysis. (8.6). Nursing mothers: Discontinue drug or nursing taking into consideration importance of drug to mother. (4, 8.3) Pediatric use: Safety and effectiveness not established. (8.4). Geriatric use: Due to substantial renal excretion, use with caution. (8.5). Renal Impairment: Avoid use in patients with eGFR less than 15 mL/min/m2 or end-stage renal disease requiring dialysis. (8.6). 8.1 Pregnancy. Pregnancy Category XPhentermine is contraindicated during pregnancy because weight loss offers no potential benefit to pregnant woman and may result in fetal harm. minimum weight gain, and no weight loss, is currently recommended for all pregnant women, including those who are already overweight or obese, due to obligatory weight gain that occurs in maternal tissues during pregnancy. Phentermine has pharmacologic activity similar to amphetamine (d- and d/l-amphetamine) [see Clinical Pharmacology (12.1)]. Animal reproduction studies have not been conducted with phentermine. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to fetus.. 8.3 Nursing Mothers. It is not known if phentermine is excreted in human milk; however, other amphetamines are present in human milk. Because of the potential for serious adverse reactions in nursing infants, decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.. 8.4 Pediatric Use. Safety and effectiveness in pediatric patients have not been established. Because pediatric obesity is chronic condition requiring long-term treatment, the use of this product, approved for short-term therapy, is not recommended.. 8.5 Geriatric Use. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.This drug is known to be substantially excreted by the kidney, and the risk of toxic reactions to this drug may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function.. 8.6 Renal Impairment. Based on the reported excretion of phentermine in urine, exposure increases can be expected in patients with renal impairment [see Clinical Pharmacology (12.3)].Use caution when administering phentermine to patients with renal impairment. In patients with severe renal impairment (eGFR 15 to 29 mL/min/1.73m2), limit the dosage of phentermine to 15 mg daily [see Dosage and Administration (2.2)]. Phentermine has not been studied in patients with eGFR less than 15 mL/min/1.73m2, including end-stage renal disease requiring dialysis; avoid use in these populations.

WARNINGS AND PRECAUTIONS SECTION.

5 WARNINGS AND PRECAUTIONS. Coadministration with other drugs for weight loss is not recommended (safety and efficacy of combination not established). (5.1) Rare cases of primary pulmonary hypertension have been reported. Phentermine should be discontinued in case of new, unexplained symptoms of dyspnea, angina pectoris, syncope or lower extremity edema. (5.2) Rare cases of serious regurgitant cardiac valvular disease have been reported. (5.3) Tolerance to the anorectic effect usually develops within few weeks. If this occurs, phentermine should be discontinued. The recommended dose should not be exceeded. (5.4) Phentermine may impair the ability of the patient to engage in potentially hazardous activities such as operating machinery or driving motor vehicle. (5.5) Risk of abuse and dependence. The least amount feasible should be prescribed or dispensed at one time in order to minimize the possibility of overdosage. (5.6) Concomitant alcohol use may result in an adverse drug reaction. (5.7) Use caution in patients with even mild hypertension (risk of increase in blood pressure). (5.8) reduction in dose of insulin or oral hypoglycemic medication may be required in some patients. (5.9). Coadministration with other drugs for weight loss is not recommended (safety and efficacy of combination not established). (5.1) Rare cases of primary pulmonary hypertension have been reported. Phentermine should be discontinued in case of new, unexplained symptoms of dyspnea, angina pectoris, syncope or lower extremity edema. (5.2) Rare cases of serious regurgitant cardiac valvular disease have been reported. (5.3) Tolerance to the anorectic effect usually develops within few weeks. If this occurs, phentermine should be discontinued. The recommended dose should not be exceeded. (5.4) Phentermine may impair the ability of the patient to engage in potentially hazardous activities such as operating machinery or driving motor vehicle. (5.5) Risk of abuse and dependence. The least amount feasible should be prescribed or dispensed at one time in order to minimize the possibility of overdosage. (5.6) Concomitant alcohol use may result in an adverse drug reaction. (5.7) Use caution in patients with even mild hypertension (risk of increase in blood pressure). (5.8) A reduction in dose of insulin or oral hypoglycemic medication may be required in some patients. (5.9). 5.1 Coadministration with Other Drug Products for Weight Loss. Phentermine resin extended-release capsules are indicated only as short-term (a few weeks) monotherapy for the management of exogenous obesity. The safety and efficacy of combination therapy with phentermine and any other drug products for weight loss including prescribed drugs, over-the-counter preparations, and herbal products, or serotonergic agents such as selective serotonin reuptake inhibitors (e.g., fluoxetine, sertraline, fluvoxamine, paroxetine), have not been established. Therefore, coadministration of phentermine and these drug products is not recommended.. 5.2 Primary Pulmonary Hypertension. Primary Pulmonary Hypertension (PPH) a rare, frequently fatal disease of the lungs has been reported to occur in patients receiving combination of phentermine with fenfluramine or dexfenfluramine. The possibility of an association between PPH and the use of phentermine alone cannot be ruled out; there have been rare cases of PPH in patients who reportedly have taken phentermine alone. The initial symptom of PPH is usually dyspnea. Other initial symptoms may include angina pectoris, syncope or lower extremity edema. Patients should be advised to report immediately any deterioration in exercise tolerance. Treatment should be discontinued in patients who develop new, unexplained symptoms of dyspnea, angina pectoris, syncope or lower extremity edema, and patients should be evaluated for the possible presence of pulmonary hypertension.. 5.3 Valvular Heart Disease. Serious regurgitant cardiac valvular disease, primarily affecting the mitral, aortic and/or tricuspid valves, has been reported in otherwise healthy persons who had taken combination of phentermine with fenfluramine or dexfenfluramine for weight loss. The possible role of phentermine in the etiology of these valvulopathies has not been established and their course in individuals after the drugs are stopped is not known. The possibility of an association between valvular heart disease and the use of phentermine alone cannot be ruled out; there have been rare cases of valvular heart disease in patients who reportedly have taken phentermine alone.. 5.4 Development of Tolerance, Discontinuation in Case of Tolerance. When tolerance to the anorectant effect develops, the recommended dose should not be exceeded in an attempt to increase the effect; rather, the drug should be discontinued.. 5.5 Effect on the Ability to Engage in Potentially Hazardous Tasks. Phentermine may impair the ability of the patient to engage in potentially hazardous activities such as operating machinery or driving motor vehicle; the patient should therefore be cautioned accordingly.. 5.6 Risk of Abuse and Dependence. Phentermine is related chemically and pharmacologically to amphetamine (d- and d/l-amphetamine) and other related stimulant drugs that have been extensively abused. The possibility of abuse of phentermine should be kept in mind when evaluating the desirability of including drug as part of weight reduction program. See Drug Abuse and Dependence (9) and Overdosage (10).The least amount feasible should be prescribed or dispensed at one time in order to minimize the possibility of overdosage.. 5.7 Usage with Alcohol. Concomitant use of alcohol with phentermine may result in an adverse drug reaction.. 5.8 Use in Patients with Hypertension. Use caution in prescribing phentermine for patients with even mild hypertension (risk of increase in blood pressure).. 5.9 Use in Patients on Insulin or Oral Hypoglycemic Medications for Diabetes Mellitus. reduction in insulin or oral hypoglycemic medications in patients with diabetes mellitus may be required.