DOSAGE & ADMINISTRATION SECTION.

DOSAGE AND ADMINISTRATION. Major Depressive Disorder. Usual Initial Dosage. Paroxetine should be administered as single daily dose with or without food, usually in the morning. The recommended initial dose is 20 mg/day. Patients were dosed in range of 20 to 50 mg/day in the clinical trials demonstrating the effectiveness of paroxetine in the treatment of major depressive disorder. As with all drugs effective in the treatment of major depressive disorder, the full effect may be delayed. Some patients not responding to 20-mg dose may benefit from dose increases, in 10-mg/day increments, up to maximum of 50 mg/day. Dose changes should occur at intervals of at least week.. Maintenance Therapy. There is no body of evidence available to answer the question of how long the patient treated with paroxetine should remain on it. It is generally agreed that acute episodes of major depressive disorder require several months or longer of sustained pharmacologic therapy. Whether the dose needed to induce remission is identical to the dose needed to maintain and/or sustain euthymia is unknown. Systematic evaluation of the efficacy of paroxetine has shown that efficacy is maintained for periods of up to year with doses that averaged about 30 mg.. Systematic evaluation of the efficacy of paroxetine has shown that efficacy is maintained for periods of up to year with doses that averaged about 30 mg.. Obsessive Compulsive Disorder. Usual Initial Dosage. Paroxetine should be administered as single daily dose with or without food, usually in the morning. The recommended dose of paroxetine in the treatment of OCD is 40 mg daily. Patients should be started on 20 mg/day and the dose can be increased in 10-mg/day increments. Dose changes should occur at intervals of at least week. Patients were dosed in range of 20 to 60 mg/day in the clinical trials demonstrating the effectiveness of paroxetine in the treatment of OCD. The maximum dosage should not exceed 60 mg/day.. Maintenance Therapy. Long-term maintenance of efficacy was demonstrated in 6-month relapse prevention trial. In this trial, patients with OCD assigned to paroxetine demonstrated lower relapse rate compared to patients on placebo (see CLINICAL PHARMACOLOGY, Clinical Trials). OCD is chronic condition, and it is reasonable to consider continuation for responding patient. Dosage adjustments should be made to maintain the patient on the lowest effective dosage, and patients should be periodically reassessed to determine the need for continued treatment.. Panic Disorder. Usual Initial Dosage. Paroxetine should be administered as single daily dose with or without food, usually in the morning. The target dose of paroxetine in the treatment of panic disorder is 40 mg/day. Patients should be started on 10 mg/day. Dose changes should occur in 10-mg/day increments and at intervals of at least week. Patients were dosed in range of 10 to 60 mg/day in the clinical trials demonstrating the effectiveness of paroxetine. The maximum dosage should not exceed 60 mg/day.. Maintenance Therapy. Long-term maintenance of efficacy was demonstrated in 3-month relapse prevention trial. In this trial, patients with panic disorder assigned to paroxetine demonstrated lower relapse rate compared to patients on placebo (see CLINICAL PHARMACOLOGY, Clinical Trials). Panic disorder is chronic condition, and it is reasonable to consider continuation for responding patient. Dosage adjustments should be made to maintain the patient on the lowest effective dosage, and patients should be periodically reassessed to determine the need for continued treatment.. Social Anxiety Disorder. Usual Initial Dosage. Paroxetine should be administered as single daily dose with or without food, usually in the morning. The recommended and initial dosage is 20 mg/day. In clinical trials the effectiveness of paroxetine was demonstrated in patients dosed in range of 20 to 60 mg/day. While the safety of paroxetine has been evaluated in patients with social anxiety disorder at doses up to 60 mg/day, available information does not suggest any additional benefit for doses above 20 mg/day (see CLINICAL PHARMACOLOGY, Clinical Trials).. Maintenance Therapy. There is no body of evidence available to answer the question of how long the patient treated with paroxetine should remain on it. Although the efficacy of paroxetine beyond 12 weeks of dosing has not been demonstrated in controlled clinical trials, social anxiety disorder is recognized as chronic condition, and it is reasonable to consider continuation of treatment for responding patient. Dosage adjustments should be made to maintain the patient on the lowest effective dosage, and patients should be periodically reassessed to determine the need for continued treatment.. Generalized Anxiety Disorder. Usual Initial Dosage. Paroxetine should be administered as single daily dose with or without food, usually in the morning. In clinical trials the effectiveness of paroxetine was demonstrated in patients dosed in range of 20 to 50 mg/day. The recommended starting dosage and the established effective dosage is 20 mg/day. There is not sufficient evidence to suggest greater benefit to doses higher than 20 mg/day. Dose changes should occur in 10 mg/day increments and at intervals of at least week. Maintenance Therapy. Systematic evaluation of continuing paroxetine for periods of up to 24 weeks in patients with Generalized Anxiety Disorder who had responded while taking paroxetine during an 8-week acute treatment phase has demonstrated benefit of such maintenance (see CLINICAL PHARMACOLOGY, Clinical Trials). Nevertheless, patients should be periodically reassessed to determine the need for maintenance treatment.. Special Populations. Treatment of Pregnant Women During the Third Trimester. Neonates exposed to paroxetine and other SSRIs or SNRIs, late in the third trimester have developed complications requiring prolonged hospitalization, respiratory support, and tube feeding (see WARNINGS, Usage in Pregnancy). When treating pregnant women with paroxetine during the third trimester, the physician should carefully consider the potential risks and benefits of treatment. Dosage for Elderly or Debilitated Patients, and Patients With Severe Renal or Hepatic Impairment. The recommended initial dose is 10 mg/day for elderly patients, debilitated patients, and/or patients with severe renal or hepatic impairment. Increases may be made if indicated. Dosage should not exceed 40 mg/day.. Switching Patient to or From Monoamine Oxidase Inhibitor (MAOI) Intended to Treat Psychiatric Disorders: At least 14 days should elapse between discontinuation of an MAOI intended to treat psychiatric disorders and initiation of therapy with paroxetine Conversely, at least 14 days should be allowed after stopping paroxetine before starting an MAOI intended to treat psychiatric disorders (see CONTRAINDICATIONS).. Use of Paroxetine With Other MAOIs, Such as Linezolid or Methylene Blue. Do not start paroxetine tablets in patient who is being treated with linezolid or intravenous methylene blue because there is increased risk of serotonin syndrome. In patient who requires more urgent treatment of psychiatric condition, other interventions, including hospitalization, should be considered (see CONTRAINDICATIONS). In some cases, patient already receiving therapy with paroxetine tablets may require urgent treatment with linezolid or intravenous methylene blue. If acceptable alternatives to linezolid or intravenous methylene blue treatment are not available and the potential benefits of linezolid or intravenous methylene blue treatment are judged to outweigh the risks of serotonin syndrome in particular patient, paroxetine tablets should be stopped promptly, and linezolid or intravenous methylene blue can be administered. The patient should be monitored for symptoms of serotonin syndrome for weeks or until 24 hours after the last dose of linezolid or intravenous methylene blue, whichever comes first. Therapy with paroxetine tablets may be resumed 24 hours after the last dose of linezolid or intravenous methylene blue (see WARNINGS).The risk of administering methylene blue by non-intravenous routes (such as oral tablets or by local injection) or in intravenous doses much lower than mg/kg with paroxetine is unclear. The clinician should, nevertheless, be aware of the possibility of emergent symptoms of serotonin syndrome with such use (see WARNINGS).. Discontinuation of Treatment With Paroxetine. Symptoms associated with discontinuation of paroxetine have been reported (see PRECAUTIONS: Discontinuation of Treatment With Paroxetine). Patients should be monitored for these symptoms when discontinuing treatment, regardless of the indication for which paroxetine is being prescribed. gradual reduction in the dose rather than abrupt cessation is recommended whenever possible. If intolerable symptoms occur following decrease in the dose or upon discontinuation of treatment, then resuming the previously prescribed dose may be considered. Subsequently, the physician may continue decreasing the dose but at more gradual rate.

ADVERSE REACTIONS SECTION.

ADVERSE REACTIONS. Associated With Discontinuation of Treatment. Twenty percent (1,199/6,145) of patients treated with paroxetine in worldwide clinical trials in major depressive disorder and 16.1% (84/522), 11.8% (64/542), 9.4% (44/469), and 10.7% (79/735) of patients treated with paroxetine in worldwide trials in social anxiety disorder, OCD, panic disorder, and GAD respectively, discontinued treatment due to an adverse event. The most common events (>=1%) associated with discontinuation and considered to be drug related (i.e., those events associated with dropout at rate approximately twice or greater for paroxetine compared to placebo) included the following:Major Depressive DisorderOCDPanic DisorderSocial Anxiety DisorderGeneralized Anziety DisorderParoxetinePlaceboParoxetinePlaceboParoxetinePlaceboParoxetinePlaceboParoxetinePlaceboCNSSomnolence2.3%0.7%--1.9%0.3%3.4%0.3%2.0%0.2%Insomnia----1.7%0%1.3%0.3%3.1%0%Agitation1.1%0.5%--Tremor1.1%0.3%--1.7%0%Anxiety------1.1%0%Dizziness----1.5%0%1.9%0%1.0%0.2%GastrointestinalConstipation--1.1%0%Nausea3.2%1.1%1.9%0%3.2%1.2%4.0%0.3%2.0%0.2%Diarrhea1.0%0.3%--Dry mouth1.0%0.3%--Vomiting1.0%0.3%--1.0%0%Flatulence1.0%0.3%OtherAsthenia1.6%0.4%1.9%0.4%2.5%0.6%1.8%0.2%Abnormal Ejaculationa 1.6%0%2.1%0%4.9%0.6%2.5%0.5%Sweating1.0%0.3%--1.1%0%1.1%0.2%Impotencea --1.5%0%Libido Decreased1.0%0%Where numbers are not provided the incidence of the adverse events in patients treated with paroxetine was not >1% or was not greater than or equal to times the incidence of placebo.a. Incidence corrected for gender.. Commonly Observed Adverse Events. Major Depressive Disorder. The most commonly observed adverse events associated with the use of paroxetine (incidence of 5% or greater and incidence for paroxetine at least twice that for placebo, derived from Table 2) were: Asthenia, sweating, nausea, decreased appetite, somnolence, dizziness, insomnia, tremor, nervousness, ejaculatory disturbance, and other male genital disorders. Obsessive Compulsive Disorder. The most commonly observed adverse events associated with the use of paroxetine (incidence of 5% or greater and incidence for paroxetine at least twice that of placebo, derived from Table 3) were: Nausea, dry mouth, decreased appetite, constipation, dizziness, somnolence, tremor, sweating, impotence, and abnormal ejaculation.. Panic Disorder. The most commonly observed adverse events associated with the use of paroxetine (incidence of 5% or greater and incidence for paroxetine at least twice that for placebo, derived from Table 3) were: Asthenia, sweating, decreased appetite, libido decreased, tremor, abnormal ejaculation, female genital disorders, and impotence.. Social Anxiety Disorder. The most commonly observed adverse events associated with the use of paroxetine (incidence of 5% or greater and incidence for paroxetine at least twice that for placebo, derived from Table 3) were: Sweating, nausea, dry mouth, constipation, decreased appetite, somnolence, tremor, libido decreased, yawn, abnormal ejaculation, female genital disorders, and impotence.. Generalized Anxiety Disorder. The most commonly observed adverse events associated with the use of paroxetine (incidence of 5% or greater and incidence for paroxetine at least twice that for placebo, derived from Table 4) were: Asthenia, infection, constipation, decreased appetite, dry mouth, nausea, libido decreased, somnolence, tremor, sweating, and abnormal ejaculation.. Incidence in Controlled Clinical Trials. The prescriber should be aware that the figures in the tables following cannot be used to predict the incidence of side effects in the course of usual medical practice where patient characteristics and other factors differ from those that prevailed in the clinical trials. Similarly, the cited frequencies cannot be compared with figures obtained from other clinical investigations involving different treatments, uses, and investigators. The cited figures, however, do provide the prescribing physician with some basis for estimating the relative contribution of drug and nondrug factors to the side effect incidence rate in the populations studied.. Major Depressive Disorder. Table enumerates adverse events that occurred at an incidence of 1% or more among paroxetine-treated patients who participated in short-term (6-week) placebo-controlled trials in which patients were dosed in range of 20 mg to 50 mg/day. Reported adverse events were classified using standard COSTART-based Dictionary terminology. Table 2. Treatment-Emergent Adverse Experience Incidence in Placebo-Controlled Clinical Trials for Major Depressive Disordera Body SystemPreferred TermParoxetine (n 421)Placebo (n 421)Body as WholeHeadache18%17%Asthenia15%6%CardiovascularPalpitation3%1%Vasodilation3%1%DermatologicSweating11%2%Rash2%1%GastrointestinalNausea26%9%Dry Mouth18%12%Constipation14%9%Diarrhea12%8%Decreased Appetite6%2%Flatulence4%2%Oropharynx Disorderb 2%0%Dyspepsia2%1%MusculoskeletalMyopathy2%1%Myalgia2%1%Myasthenia1%0%Nervous SystemSomnolence23%9%Dizziness13%6%Insomnia13%6%Tremor8%2%Nervousness5%3%Anxiety5%3%Paresthesia4%2%Libido Decreased3%0%Drugged Feeling2%1%Confusion1%0%RespirationYawn4%0%Special SensesBlurred Vision4%1%Taste Perversion2%0%Urogenital SystemEjaculatory Disturbancec,d 13%0%Other Male Genital Disordersc,e 10%0%Urinary Frequency3%1%Urination Disorderf 3%0%Female Genital Disordersc,g 2%0%a. Events reported by at least 1% of patients treated with paroxetine are included, except the following events which had an incidence on placebo >= paroxetine: Abdominal pain, agitation, back pain, chest pain, CNS stimulation, fever, increased appetite, myoclonus, pharyngitis, postural hypotension, respiratory disorder (includes mostly cold symptoms or URI), trauma, and vomiting.b. Includes mostly lump in throat and tightness in throat.c. Percentage corrected for gender.d. Mostly ejaculatory delay.e. Includes anorgasmia, erectile difficulties, delayed ejaculation/orgasm, and sexual dysfunction, and impotence.f. Includes mostly difficulty with micturition and urinary hesitancy.g. Includes mostly anorgasmia and difficulty reaching climax/orgasm.. Obsessive Compulsive Disorder, Panic Disorder, and Social Anxiety Disorder. Table enumerates adverse events that occurred at frequency of 2% or more among OCD patients on paroxetine who participated in placebo-controlled trials of 12-weeks duration in which patients were dosed in range of 20 mg to 60 mg/day or among patients with panic disorder on paroxetine who participated in placebo-controlled trials of 10- to 12-weeks duration in which patients were dosed in range of 10 mg to 60 mg/day or among patients with social anxiety disorder on paroxetine who participated in placebo-controlled trials of 12-weeks duration in which patients were dosed in range of 20 mg to 50 mg/day.Table 3. Treatment-Emergent Adverse Experience Incidence in Placebo-Controlled Clinical Trials for Obsessive Compulsive Disorder, Panic Disorder, and Social Anxiety Disordera Body SystemPreferred TermObsessive Compulsive Disorder Panic Disorder Social Anxiety DisorderParoxetinePlacebo Paroxetine Placebo Paroxetine Placezbo(n= 542) (n= 265) (n= 469) (n= 324) (n= 425) (n=339)Body as WholeAsthenia22%14%14%5%22%14%Abdominal Pain----4%3%----Chest Pain3%2%--------Back Pain----3%2%----Chills2%1%2%1%----Trauma--------3%1%CardiovascularVasodilation4%1%--------Palpitation2%0%--------Dermatologic Sweating9%3%14%6%9%2%Rash3%2%--------GastrointestinalNausea23%10%23%17%25%7%Dry Mouth18%9%18%11%9%3%Constipation16%6%8%5%5%2%Diarrhea10%10%12%7%9%6%Decreased Appetite9%3%7%3%8%2%Dyspepsia--------4%2%Flatulence--------4%2%Increased Appetite4%3%2%1%----Vomiting--------2%1%MusculoskeletalMyalgia--------4%3%Nervous SystemInsomnia24%13%18%10%21%16%Somnolence24%7%19%11%22%5%Dizziness12%6%14%10%11%7%Tremor11%1%9%1%9%1%Nervousness9%8%----8%7%Libido Decreased7%4%9%1%12%1%Agitation----5%4%3%1%Anxiety----5%4%5%4%Abnormal Dreams4%1%--------Concentration Impaired3%2%----4%1%Depersonalization3%0%--------Myoclonus3%0%3%2%2%1%Amnesia2%1%--------Respiratory SystemRhinitis----3%0%----Pharyngitis--------4%2%Yawn--------5%1%Special SensesAbnormal Vision4%2%----4%1%Taste Perversion2%0%--------Urogenital SystemAbnormal Ejaculationb 23%1%21%1%28%1%Dysmenorrhea--------5%4%Female Genital Disorderb 3%0%9%1%9%1%Impotenceb 8%1%5%0%5%1%Urinary Frequency3%1%2%0%----Urination Impaired3%0%--------Urinary Tract Infection2%1%2%1%----a. Events reported by at least 2% of OCD, panic disorder, and social anxiety disorder in patients treated with paroxetine are included, except the following events which had an incidence on placebo >= paroxetine: [OCD]: Abdominal pain, agitation, anxiety, back pain, cough increased, depression, headache, hyperkinesia, infection, paresthesia, pharyngitis, respiratory disorder, rhinitis, and sinusitis. [panic disorder]: Abnormal dreams, abnormal vision, chest pain, cough increased, depersonalization, depression, dysmenorrhea, dyspepsia, flu syndrome, headache, infection, myalgia, nervousness, palpitation, paresthesia, pharyngitis, rash, respiratory disorder, sinusitis, taste perversion, trauma, urination impaired, and vasodilation. [social anxiety disorder]: Abdominal pain, depression, headache, infection, respiratory disorder, and sinusitis. b. Percentage corrected for gender. Generalized Anxiety Disorder. Table enumerates adverse events that occurred at frequency of 2% or more among GAD patients on paroxetine who participated in placebo-controlled trials of 8-weeks duration in which patients were dosed in range of 10 mg/day to 50 mg/day.Table 4. Treatment-Emergent Adverse Experience Incidence in Placebo-Controlled Clinical Trials for Generalized Anxiety Disordera Body SystemPreferred TermGeneralized Anxiety DisorderParoxetine (n 735) Placebo (n 529) Body as WholeAsthenia14%6%Headache17%14%Infection6%3%Abdominal PainTraumaCardiovascularVasodilation3%1%DermatologicSweating6%2%GastrointestinalNausea20%5%Dry Mouth11%5%Constipation10%2%Diarrhea9%7%Decreased Appetite5%1%Vomiting3%2%Dyspepsia----Nervous SystemInsomnia11%8%Somnolence15%5%Dizziness6%5%Tremor5%1%Nervousness4%3%Libido Decreased9%2%Abnormal DreamsRespiratory SystemRespiratory Disorder7%5%Sinusitis4%3%Yawn4%--Special SensesAbnormal Vision2%1%Urogenital SystemAbnormal Ejaculationb 25%2%Female Genital Disorderb 4%1%Impotenceb 4%3%a. Events reported by at least 2% of GAD in patients treated with paroxetine are included, except the following events which had an incidence on placebo >= paroxetine [GAD]: Abdominal pain, back pain, trauma, dyspepsia, myalgia, and pharyngitis. b. Percentage corrected for gender. Dose Dependency of Adverse Events. comparison of adverse event rates in fixed-dose study comparing 10, 20, 30, and 40 mg/day of paroxetine with placebo in the treatment of major depressive disorder revealed clear dose dependency for some of the more common adverse events associated with use of paroxetine, as shown in Table 5:Table 5. Treatment-Emergent Adverse Experience Incidence in Dose-Comparison Trial in the Treatment of Major Depressive Disordera Body System/Preferred TermPlaceboParoxetinen 5110 mg = 10220 mg = 10430 mg = 10140 mg = 102Body as WholeAsthenia0.0%2.9%10.6%13.9%12.7%DermatologySweating2.0%1.0%6.7%8.9%11.8%GastrointestinalConstipation5.9%4.9%7.7%9.9%12.7%Decreased Appetite2.0%2.0%5.8%4.0%4.9%Diarrhea7.8%9.8%19.2%7.9%14.7%Dry Mouth2.0%10.8%18.3%15.8%20.6%Nausea13.7%14.7%26.9%34.7%36.3%Nervous SystemAnxiety0.0%2.0%5.8%5.9%5.9%Dizziness3.9%6.9%6.7%8.9%12.7%Nervousness0.0%5.9%5.8%4.0%2.9%Paresthesia0.0%2.9%1.0%5.0%5.9%Somnolence7.8%12.7%18.3%20.8%21.6%Tremor0.0%0.0%7.7%7.9%14.7%Special SensesBlurred Vision2.0%2.9%2.9%2.0%7.8%Urogenital SystemAbnormal Ejaculation0.0%5.8%6.5%10.6%13.0%Impotence0.0%1.9%4.3%6.4%1.9%Male Genital Disorders0.0%3.8%8.7%6.4%3.7% aRule for including adverse events in table: Incidence at least 5% for of paroxetine groups and >= twice the placebo incidence for at least paroxetine group.In fixed-dose study comparing placebo and 20, 40, and 60 mg of paroxetine in the treatment of OCD, there was no clear relationship between adverse events and the dose of paroxetine to which patients were assigned. No new adverse events were observed in the group treated with 60 mg of paroxetine compared to any of the other treatment groups. In fixed-dose study comparing placebo and 10, 20, and 40 mg of paroxetine in the treatment of panic disorder, there was no clear relationship between adverse events and the dose of paroxetine to which patients were assigned, except for asthenia, dry mouth, anxiety, libido decreased, tremor, and abnormal ejaculation. In flexible-dose studies, no new adverse events were observed in patients receiving 60 mg of paroxetine compared to any of the other treatment groups. In fixed-dose study comparing placebo and 20, 40, and 60 mg of paroxetine in the treatment of social anxiety disorder, for most of the adverse events, there was no clear relationship between adverse events and the dose of paroxetine to which patients were assigned.In fixed-dose study comparing placebo and 20 and 40 mg of paroxetine in the treatment of generalized anxiety disorder, for most of the adverse events, there was no clear relationship between adverse events and the dose of paroxetine to which patients were assigned, except for the following adverse events: Asthenia, constipation, and abnormal ejaculation.. aRule for including adverse events in table: Incidence at least 5% for of paroxetine groups and >= twice the placebo incidence for at least paroxetine group.. Adaptation to Certain Adverse Events. Over 4- to 6-week period, there was evidence of adaptation to some adverse events with continued therapy (e.g., nausea and dizziness), but less to other effects (e.g., dry mouth, somnolence, and asthenia).. Male and Female Sexual Dysfunction With SSRIs. Although changes in sexual desire, sexual performance, and sexual satisfaction often occur as manifestations of psychiatric disorder, they may also be consequence of pharmacologic treatment. In particular, some evidence suggests that selective serotonin reuptake inhibitors (SSRIs) can cause such untoward sexual experiences. Reliable estimates of the incidence and severity of untoward experiences involving sexual desire, performance, and satisfaction are difficult to obtain, however, in part because patients and physicians may be reluctant to discuss them. Accordingly, estimates of the incidence of untoward sexual experience and performance cited in product labeling, are likely to underestimate their actual incidence.In placebo-controlled clinical trials involving more than 3,200 patients, the ranges for the reported incidence of sexual side effects in males and females with major depressive disorder, OCD, panic disorder, social anxiety disorder, and GAD are displayed in Table 6. Table 6. Incidence of Sexual Adverse Events in Controlled Clinical TrialsParoxetinePlacebon (males)14461042Decreased Libido6 to15%0 to 5%Ejaculatory Disturbance13 to 28%0 to -2%Impotence2 to 9%0 to 3%n (females)18221340Decreased Libido0 to 9%0 to 2%Orgasmic Disturbance2 to 9%0 to 1%There are no adequate and well-controlled studies examining sexual dysfunction with paroxetine treatment.Paroxetine treatment has been associated with several cases of priapism. In those cases with known outcome, patients recovered without sequelae. While it is difficult to know the precise risk of sexual dysfunction associated with the use of SSRIs, physicians should routinely inquire about such possible side effects.. While it is difficult to know the precise risk of sexual dysfunction associated with the use of SSRIs, physicians should routinely inquire about such possible side effects.. Weight and Vital Sign Changes. Significant weight loss may be an undesirable result of treatment with paroxetine for some patients but, on average, patients in controlled trials had minimal (about pound) weight loss versus smaller changes on placebo and active control. No significant changes in vital signs (systolic and diastolic blood pressure, pulse and temperature) were observed in patients treated with paroxetine in controlled clinical trials.. ECG Changes. In an analysis of ECGs obtained in 682 patients treated with paroxetine and 415 patients treated with placebo in controlled clinical trials, no clinically significant changes were seen in the ECGs of either group.. Liver Function Tests. In placebo-controlled clinical trials, patients treated with paroxetine exhibited abnormal values on liver function tests at no greater rate than that seen in placebo-treated patients. In particular, the paroxetine-versus-placebo comparisons for alkaline phosphatase, SGOT, SGPT, and bilirubin revealed no differences in the percentage of patients with marked abnormalities.. Hallucinations. In pooled clinical trials of immediate-release paroxetine hydrochloride, hallucinations were observed in 22 of 9089 patients receiving drug and of 3187 patients receiving placebo. Other Events Observed During the Premarketing Evaluation of Paroxetine. During its premarketing assessment in major depressive disorder, multiple doses of paroxetine were administered to 6,145 patients in phase and studies. The conditions and duration of exposure to paroxetine varied greatly and included (in overlapping categories) open and double-blind studies, uncontrolled and controlled studies, inpatient and outpatient studies, and fixed-dose, and titration studies. During premarketing clinical trials in OCD, panic disorder, social anxiety disorder, and generalized anxiety disorder, 542, 469, 522, and 735 patients, respectively, received multiple doses of paroxetine. Untoward events associated with this exposure were recorded by clinical investigators using terminology of their own choosing. Consequently, it is not possible to provide meaningful estimate of the proportion of individuals experiencing adverse events without first grouping similar types of untoward events into smaller number of standardized event categories.In the tabulations that follow, reported adverse events were classified using standard COSTART-based Dictionary terminology. The frequencies presented, therefore, represent the proportion of the 9,089 patients exposed to multiple doses of paroxetine who experienced an event of the type cited on at least occasion while receiving paroxetine. All reported events are included except those already listed in Tables to 5, those reported in terms so general as to be uninformative and those events where drug cause was remote. It is important to emphasize that although the events reported occurred during treatment with paroxetine, they were not necessarily caused by it.Events are further categorized by body system and listed in order of decreasing frequency according to the following definitions: Frequent adverse events are those occurring on or more occasions in at least 1/100 patients (only those not already listed in the tabulated results from placebo-controlled trials appear in this listing); infrequent adverse events are those occurring in 1/100 to 1/1,000 patients; rare events are those occurring in fewer than 1/1,000 patients. Events of major clinical importance are also described in the PRECAUTIONS section.. Body as Whole. Infrequent: Allergic reaction, chills, face edema, malaise, neck pain; rare: Adrenergic syndrome, cellulitis, moniliasis, neck rigidity, pelvic pain, peritonitis, sepsis, ulcer. Cardiovascular System. Frequent: Hypertension, tachycardia; infrequent: Bradycardia, hematoma, hypotension, migraine, postural hypotension, syncope; rare: Angina pectoris, arrhythmia nodal, atrial fibrillation, bundle branch block, cerebral ischemia, cerebrovascular accident, congestive heart failure, heart block, low cardiac output, myocardial infarct, myocardial ischemia, pallor, phlebitis, pulmonary embolus, supraventricular extrasystoles, thrombophlebitis, thrombosis, varicose vein, vascular headache, ventricular extrasystoles.. Digestive System. Infrequent: Bruxism, colitis, dysphagia, eructation, gastritis, gastroenteritis, gingivitis, glossitis, increased salivation, liver function tests abnormal, rectal hemorrhage, ulcerative stomatitis; rare: Aphthous stomatitis, bloody diarrhea, bulimia, cardiospasm, cholelithiasis, duodenitis, enteritis, esophagitis, fecal impactions, fecal incontinence, gum hemorrhage, hematemesis, hepatitis, ileitis, ileus, intestinal obstruction, jaundice, melena, mouth ulceration, peptic ulcer, salivary gland enlargement, sialadenitis, stomach ulcer, stomatitis, tongue discoloration, tongue edema, tooth caries.. Endocrine System. Rare: Diabetes mellitus, goiter, hyperthyroidism, hypothyroidism, thyroiditis.. Hemic and Lymphatic Systems. Infrequent: Anemia, leukopenia, lymphadenopathy, purpura; rare: Abnormal erythrocytes, basophilia, bleeding time increased, eosinophilia, hypochromic anemia, iron deficiency anemia, leukocytosis, lymphedema, abnormal lymphocytes, lymphocytosis, microcytic anemia, monocytosis, normocytic anemia, thrombocythemia, thrombocytopenia.. Metabolic and Nutritional. Frequent: Weight gain; infrequent: Edema, peripheral edema, SGOT increased, SGPT increased, thirst, weight loss; rare: Alkaline phosphatase increased, bilirubinemia, BUN increased, creatinine phosphokinase increased, dehydration, gamma globulins increased, gout, hypercalcemia, hypercholesteremia, hyperglycemia, hyperkalemia, hyperphosphatemia, hypocalcemia, hypoglycemia, hypokalemia, hyponatremia, ketosis, lactic dehydrogenase increased, non-protein nitrogen (NPN) increased.. Musculoskeletal System. Frequent: Arthralgia; infrequent: Arthritis, arthrosis; rare: Bursitis, myositis, osteoporosis, generalized spasm, tenosynovitis, tetany.. Nervous System. Frequent: Emotional lability, vertigo; infrequent: Abnormal thinking, alcohol abuse, ataxia, dystonia, dyskinesia, euphoria, hallucinations, hostility, hypertonia, hypesthesia, hypokinesia, incoordination, lack of emotion, libido increased, manic reaction, neurosis, paralysis, paranoid reaction; rare: Abnormal gait, akinesia, antisocial reaction, aphasia, choreoathetosis, circumoral paresthesias, convulsion, delirium, delusions, diplopia, drug dependence, dysarthria, extrapyramidal syndrome, fasciculations, grand mal convulsion, hyperalgesia, hysteria, manic-depressive reaction, meningitis, myelitis, neuralgia, neuropathy, nystagmus, peripheral neuritis, psychotic depression, psychosis, reflexes decreased, reflexes increased, stupor, torticollis, trismus, withdrawal syndrome.. Respiratory System. Infrequent: Asthma, bronchitis, dyspnea, epistaxis, hyperventilation, pneumonia, respiratory flu; rare: Emphysema, hemoptysis, hiccups, lung fibrosis, pulmonary edema, sputum increased, stridor, voice alteration.. Skin and Appendages. Frequent: Pruritus; infrequent: Acne, alopecia, contact dermatitis, dry skin, ecchymosis, eczema, herpes simplex, photosensitivity, urticaria; rare: Angioedema, erythema nodosum, erythema multiforme, exfoliative dermatitis, fungal dermatitis, furunculosis; herpes zoster, hirsutism, maculopapular rash, seborrhea, skin discoloration, skin hypertrophy, skin ulcer, sweating decreased, vesiculobullous rash.. Special Senses. Frequent: Tinnitus; infrequent: Abnormality of accommodation, conjunctivitis, ear pain, eye pain, keratoconjunctivitis, mydriasis, otitis media; rare: Amblyopia, anisocoria, blepharitis, cataract, conjunctival edema, corneal ulcer, deafness, exophthalmos, eye hemorrhage, glaucoma, hyperacusis, night blindness, otitis externa, parosmia, photophobia, ptosis, retinal hemorrhage, taste loss, visual field defect.. Urogenital System. Infrequent: Amenorrhea, breast pain, cystitis, dysuria, hematuria, menorrhagia, nocturia, polyuria, pyuria, urinary incontinence, urinary retention, urinary urgency, vaginitis; rare: Abortion, breast atrophy, breast enlargement, endometrial disorder, epididymitis, female lactation, fibrocystic breast, kidney calculus, kidney pain, leukorrhea, mastitis, metrorrhagia, nephritis, oliguria, salpingitis, urethritis, urinary casts, uterine spasm, urolith, vaginal hemorrhage, vaginal moniliasis.. Postmarketing Reports. Voluntary reports of adverse events in patients taking paroxetine that have been received since market introduction and not listed above that may have no causal relationship with the drug include acute pancreatitis, elevated liver function tests (the most severe cases were deaths due to liver necrosis, and grossly elevated transaminases associated with severe liver dysfunction), Guillain-Barre syndrome, Stevens-Johnson syndrome, toxic epidermal necrolysis, priapism, syndrome of inappropriate ADH secretion, symptoms suggestive of prolactinemia and galactorrhea; extrapyramidal symptoms which have included akathisia, bradykinesia, cogwheel rigidity, dystonia, hypertonia, oculogyric crisis which has been associated with concomitant use of pimozide; tremor and trismus; status epilepticus, acute renal failure, pulmonary hypertension, allergic alveolitis, anaphylaxis, eclampsia, laryngismus, optic neuritis, porphyria, restless legs syndrome (RLS), ventricular fibrillation, ventricular tachycardia (including torsade de pointes), thrombocytopenia, hemolytic anemia, events related to impaired hematopoiesis (including aplastic anemia, pancytopenia, bone marrow aplasia, and agranulocytosis), vasculitic syndromes (such as Henoch-Schonlein purpura), and premature births in pregnant women. There has been case report of an elevated phenytoin level after weeks of paroxetine and phenytoin coadministration. There has been case report of severe hypotension when paroxetine was added to chronic metoprolol treatment.

CLINICAL PHARMACOLOGY SECTION.

CLINICAL PHARMACOLOGY. Pharmacodynamics. The efficacy of paroxetine in the treatment of major depressive disorder, social anxiety disorder, obsessive compulsive disorder (OCD), panic disorder (PD), generalized anxiety disorder (GAD) is presumed to be linked to potentiation of serotonergic activity in the central nervous system resulting from inhibition of neuronal reuptake of serotonin (5-hydroxy-tryptamine, 5-HT). Studies at clinically relevant doses in humans have demonstrated that paroxetine blocks the uptake of serotonin into human platelets. In vitro studies in animals also suggest that paroxetine is potent and highly selective inhibitor of neuronal serotonin reuptake and has only very weak effects on norepinephrine and dopamine neuronal reuptake. In vitro radioligand binding studies indicate that paroxetine has little affinity for muscarinic, alpha1-, alpha2-, beta-adrenergic-, dopamine (D2)-, 5-HT1-, 5-HT2-, and histamine (H1)-receptors; antagonism of muscarinic, histaminergic, and alpha1-adrenergic receptors has been associated with various anticholinergic, sedative, and cardiovascular effects for other psychotropic drugs.Because the relative potencies of paroxetines major metabolites are at most 1/50 of the parent compound, they are essentially inactive.. Pharmacokinetics. Paroxetine hydrochloride is completely absorbed after oral dosing of solution of the hydrochloride salt. The mean elimination half-life is approximately 21 hours (CV 32%) after oral dosing of 30 mg tablets of paroxetine daily for 30 days. Paroxetine is extensively metabolized and the metabolites are considered to be inactive. Nonlinearity in pharmacokinetics is observed with increasing doses. Paroxetine metabolism is mediated in part by CYP2D6, and the metabolites are primarily excreted in the urine and to some extent in the feces. Pharmacokinetic behavior of paroxetine has not been evaluated in subjects who are deficient in CYP2D6 (poor metabolizers).In meta-analysis of paroxetine from studies done in healthy volunteers following multiple dosing of 20 mg/day to 40 mg/day, males did not exhibit significantly lower Cmax or AUC than females.. Absorption and Distribution. Paroxetine is equally bioavailable from the oral suspension and tablet.Paroxetine hydrochloride is completely absorbed after oral dosing of solution of the hydrochloride salt. In study in which normal male subjects (n 15) received 30 mg tablets daily for 30 days, steady-state paroxetine concentrations were achieved by approximately 10 days for most subjects, although it may take substantially longer in an occasional patient. At steady state, mean values of Cmax, Tmax, Cmin, and 1/2 were 61.7 ng/mL (CV 45%), 5.2 hr. (CV 10%), 30.7 ng/mL (CV 67%), and 21.0 hours (CV 32%), respectively. The steady-state Cmax and Cmin values were about and 14 times what would be predicted from single-dose studies. Steady-state drug exposure based on AUC0-24 was about times greater than would have been predicted from single-dose data in these subjects. The excess accumulation is consequence of the fact that of the enzymes that metabolizes paroxetine is readily saturable.The effects of food on the bioavailability of paroxetine were studied in subjects administered single dose with and without food. AUC was only slightly increased (6%) when drug was administered with food but the Cmax was 29% greater, while the time to reach peak plasma concentration decreased from 6.4 hours post-dosing to 4.9 hours.Paroxetine distributes throughout the body, including the CNS, with only 1% remaining in the plasma.Approximately 95% and 93% of paroxetine is bound to plasma protein at 100 ng/mL and 400 ng/mL, respectively. Under clinical conditions, paroxetine concentrations would normally be less than 400 ng/mL. Paroxetine does not alter the in vitro protein binding of phenytoin or warfarin. Metabolism and Excretion. The mean elimination half-life is approximately 21 hours (CV 32%) after oral dosing of 30 mg tablets daily for 30 days of Paroxetine hydrochloride. In steady-state dose proportionality studies involving elderly and nonelderly patients, at doses of 20 mg to 40 mg daily for the elderly and 20 mg to 50 mg daily for the nonelderly, some nonlinearity was observed in both populations, again reflecting saturable metabolic pathway. In comparison to Cmin values after 20 mg daily, values after 40 mg daily were only about to times greater than doubled.Paroxetine is extensively metabolized after oral administration. The principal metabolites are polar and conjugated products of oxidation and methylation, which are readily cleared. Conjugates with glucuronic acid and sulfate predominate, and major metabolites have been isolated and identified. Data indicate that the metabolites have no more than 1/50 the potency of the parent compound at inhibiting serotonin uptake. The metabolism of paroxetine is accomplished in part by CYP2D6. Saturation of this enzyme at clinical doses appears to account for the nonlinearity of paroxetine kinetics with increasing dose and increasing duration of treatment. The role of this enzyme in paroxetine metabolism also suggests potential drug-drug interactions (see PRECAUTIONS, Drugs Metabolized by CYP2D6).Approximately 64% of 30-mg oral solution dose of paroxetine was excreted in the urine with 2% as the parent compound and 62% as metabolites over 10-day post-dosing period. About 36% was excreted in the feces (probably via the bile), mostly as metabolites and less than 1% as the parent compound over the 10-day post-dosing period.. Other Clinical Pharmacology Information. Specific Populations. Renal and Liver Disease. Increased plasma concentrations of paroxetine occur in subjects with renal and hepatic impairment. The mean plasma concentrations in patients with creatinine clearance below 30 mL/min. were approximately times greater than seen in normal volunteers. Patients with creatinine clearance of 30 to 60 mL/min. and patients with hepatic functional impairment had about 2-fold increase in plasma concentrations (AUC, Cmax).The initial dosage should therefore be reduced in patients with severe renal or hepatic impairment, and upward titration, if necessary, should be at increased intervals (see DOSAGE AND ADMINISTRATION).. Elderly Patients. In multiple-dose study in the elderly at daily paroxetine doses of 20, 30, and 40 mg, Cmin concentrations were about 70% to 80% greater than the respective Cmin concentrations in nonelderly subjects. Therefore the initial dosage in the elderly should be reduced (see DOSAGE AND ADMINISTRATION).. Drug-Drug Interactions. In vitro drug interaction studies reveal that paroxetine inhibits CYP2D6. Clinical drug interaction studies have been performed with substrates of CYP2D6 and show that paroxetine can inhibit the metabolism of drugs metabolized by CYP2D6 including desipramine, risperidone, and atomoxetine (see PRECAUTIONS, Drug Interactions).. Clinical Trials. Major Depressive Disorder. The efficacy of paroxetine as treatment for major depressive disorder has been established in placebo-controlled studies of patients with major depressive disorder (aged 18 to 73). In these studies, paroxetine was shown to be significantly more effective than placebo in treating major depressive disorder by at least of the following measures: Hamilton Depression Rating Scale (HDRS), the Hamilton depressed mood text, and the Clinical Global Impression (CGI)-Severity of Illness. Paroxetine was significantly better than placebo in improvement of the HDRS sub-factor scores, including the depressed mood text, sleep disturbance factor, and anxiety factor.A study of outpatients with major depressive disorder who had responded to paroxetine (HDRS total score <8) during an initial 8-week open-treatment phase and were then randomized to continuation on paroxetine or placebo for year demonstrated significantly lower relapse rate for patients taking paroxetine (15%) compared to those on placebo (39%). Effectiveness was similar for male and female patients.. Obsessive Compulsive Disorder. The effectiveness of paroxetine in the treatment of obsessive compulsive disorder (OCD) was demonstrated in two 12-week multicenter placebo-controlled studies of adult outpatients (Studies and 2). Patients in all studies had moderate to severe OCD (DSM-IIIR) with mean baseline ratings on the Yale Brown Obsessive Compulsive Scale (YBOCS) total score ranging from 23 to 26. Study 1, dose-range finding study where patients were treated with fixed doses of 20, 40, or 60 mg of paroxetine/day demonstrated that daily doses of paroxetine 40 and 60 mg are effective in the treatment of OCD. Patients receiving doses of 40 and 60 mg paroxetine experienced mean reduction of approximately and points, respectively, on the YBOCS total score which was significantly greater than the approximate 4-point reduction at 20 mg and 3-point reduction in the placebo-treated patients. Study was flexible-dose study comparing paroxetine (20 to 60 mg daily) with clomipramine (25 to 250 mg daily). In this study, patients receiving paroxetine experienced mean reduction of approximately points on the YBOCS total score, which was significantly greater than the mean reduction of approximately points in placebo-treated patients.The following table provides the outcome classification by treatment group on Global Improvement texts of the Clinical Global Impression (CGI) scale for Study 1.Outcome Classification (%) on CGI-Global Improvement Item for Completers in Study 1Outcome ClassificationPlacebo(n=74)Paroxetine 20 mg Paroxetine 40 mgParoxetine 60 mg(n=75)(n=66)(n=66)Worse14%7%7%3%No Change44%35%22%19%Minimally Improved 24%33%29%34%Much Improved11%18%22%24%Very Much Improved7%7%20%20%Subgroup analyses did not indicate that there were any differences in treatment outcomes as function of age or gender.The long-term maintenance effects of paroxetine in OCD were demonstrated in long-term extension to Study 1. Patients who were responders on paroxetine during the 3-month double-blind phase and 6-month extension on open-label paroxetine (20 to 60 mg/day) were randomized to either paroxetine or placebo in 6-month double-blind relapse prevention phase. Patients randomized to paroxetine were significantly less likely to relapse than comparably treated patients who were randomized to placebo.. Panic Disorder. The effectiveness of paroxetine in the treatment of panic disorder was demonstrated in three 10- to 12-week multicenter, placebo-controlled studies of adult outpatients (Studies to 3). Patients in all studies had panic disorder (DSM-IIIR), with or without agoraphobia. In these studies, paroxetine was shown to be significantly more effective than placebo in treating panic disorder by at least out of measures of panic attack frequency and on the Clinical Global Impression Severity of Illness score.Study was 10-week dose-range finding study; patients were treated with fixed paroxetine doses of 10, 20, or 40 mg/day or placebo. significant difference from placebo was observed only for the 40 mg/day group. At endpoint, 76% of patients receiving paroxetine 40 mg/day were free of panic attacks, compared to 44% of placebo-treated patients.Study was 12-week flexible-dose study comparing paroxetine (10 to 60 mg daily) and placebo. At endpoint, 51% of paroxetine patients were free of panic attacks compared to 32% of placebo-treated patients.Study was 12-week flexible-dose study comparing paroxetine (10 to 60 mg daily) to placebo in patients concurrently receiving standardized cognitive behavioral therapy. At endpoint, 33% of the paroxetine-treated patients showed reduction to or panic attacks compared to 14% of placebo patients.In both Studies and 3, the mean paroxetine dose for completers at endpoint was approximately 40 mg/day of paroxetine.Long-term maintenance effects of paroxetine in panic disorder were demonstrated in an extension to Study 1. Patients who were responders during the 10-week double-blind phase and during 3-month double-blind extension phase were randomized to either paroxetine (10, 20, or 40 mg/day) or placebo in 3-month double-blind relapse prevention phase. Patients randomized to paroxetine were significantly less likely to relapse than comparably treated patients who were randomized to placebo.Subgroup analyses did not indicate that there were any differences in treatment outcomes as function of age or gender.. Social Anxiety Disorder. The effectiveness of paroxetine in the treatment of social anxiety disorder was demonstrated in three 12-week, multicenter, placebo-controlled studies (Studies 1, 2, and 3) of adult outpatients with social anxiety disorder (DSM-IV). In these studies, the effectiveness of paroxetine compared to placebo was evaluated on the basis of (1) the proportion of responders, as defined by Clinical Global Impression (CGI) Improvement score of (very much improved) or (much improved), and (2) change from baseline in the Liebowitz Social Anxiety Scale (LSAS).Studies and were flexible-dose studies comparing paroxetine (20 to 50 mg daily) and placebo. Paroxetine demonstrated statistically significant superiority over placebo on both the CGI Improvement responder criterion and the Liebowitz Social Anxiety Scale (LSAS). In Study 1, for patients who completed to week 12, 69% of paroxetine-treated patients compared to 29% of placebo-treated patients were CGI Improvement responders. In Study 2, CGI Improvement responders were 77% and 42% for the paroxetine- and placebo-treated patients, respectively.Study was 12-week study comparing fixed paroxetine doses of 20, 40, or 60 mg/day with placebo. Paroxetine 20 mg was demonstrated to be significantly superior to placebo on both the LSAS Total Score and the CGI Improvement responder criterion; there were trends for superiority over placebo for the 40 mg and 60 mg/day dose groups. There was no indication in this study of any additional benefit for doses higher than 20 mg/day.Subgroup analyses generally did not indicate differences in treatment outcomes as function of age, race, or gender.. Generalized Anxiety Disorder. The effectiveness of paroxetine in the treatment of Generalized Anxiety Disorder (GAD) was demonstrated in two 8-week, multicenter, placebo-controlled studies (Studies and 2) of adult outpatients with Generalized Anxiety Disorder (DSM-IV). Study was an 8-week study comparing fixed paroxetine doses of 20 mg or 40 mg/day with placebo. Doses of 20 mg or 40 mg of paroxetine were both demonstrated to be significantly superior to placebo on the Hamilton Rating Scale for Anxiety (HAM-A) total score. There was not sufficient evidence in this study to suggest greater benefit for the 40 mg/day dose compared to the 20 mg/day dose. Study was flexible-dose study comparing paroxetine (20 mg to 50 mg daily) and placebo. Paroxetine demonstrated statistically significant superiority over placebo on the Hamilton Rating Scale for Anxiety (HAM-A) total score. third study, also flexible-dose comparing paroxetine (20 mg to 50 mg daily), did not demonstrate statistically significant superiority of paroxetine over placebo on the Hamilton Rating Scale for Anxiety (HAM-A) total score, the primary outcome. Subgroup analyses did not indicate differences in treatment outcomes as function of race or gender. There were insufficient elderly patients to conduct subgroup analyses on the basis of age.In longer-term trial, 566 patients meeting DSM-IV criteria for Generalized Anxiety Disorder, who had responded during single-blind, 8-week acute treatment phase with 20 to 50 mg/day of paroxetine, were randomized to continuation of paroxetine at their same dose, or to placebo, for up to 24 weeks of observation for relapse. Response during the single-blind phase was defined by having decrease of >=2 points compared to baseline on the CGI-Severity of Illness scale, to score of <=3. Relapse during the double-blind phase was defined as an increase of >=2 points compared to baseline on the CGI-Severity of Illness scale to score of >=4, or withdrawal due to lack of efficacy. Patients receiving continued paroxetine experienced significantly lower relapse rate over the subsequent 24 weeks compared to those receiving placebo.

DRUG INTERACTIONS SECTION.

Drug Interactions. Tryptophan. As with other serotonin reuptake inhibitors, an interaction between paroxetine and tryptophan may occur when they are coadministered. Adverse experiences, consisting primarily of headache, nausea, sweating, and dizziness, have been reported when tryptophan was administered to patients taking paroxetine. Consequently, concomitant use of paroxetine with tryptophan is not recommended (see WARNINGS, Serotonin Syndrome).. Monoamine Oxidase Inhibitors. See CONTRAINDICATIONS and WARNINGS.. Pimozide. In controlled study of healthy volunteers, after paroxetine was titrated to 60 mg daily, co-administration of single dose of mg pimozide was associated with mean increases in pimozide AUC of 151% and Cmax of 62%, compared to pimozide administered alone. The increase in pimozide AUC and Cmax is due to the CYP2D6 inhibitory properties of paroxetine. Due to the narrow therapeutic index of pimozide and its known ability to prolong the QT interval, concomitant use of pimozide and paroxetine is contraindicated (see CONTRAINDICATIONS). Serotonergic Drugs. Based on the mechanism of action of SNRIs and SSRIs, including paroxetine hydrochloride, and the potential for serotonin syndrome, caution is advised when paroxetine is coadministered with other drugs that may affect the serotonergic neurotransmitter systems, such as triptans, lithium, fentanyl, tramadol, amphetamines, or St. Johns Wort (see WARNINGS, Serotonin Syndrome). The concomitant use of paroxetine with MAOIs (including linezolid and intravenous methylene blue) is contraindicated (see CONTRAINDICATIONS). The concomitant use of paroxetine with other SSRIs, SNRIs or tryptophan is not recommended (see PRECAUTIONS, Drug Interactions, Tryptophan).. Thioridazine. See CONTRAINDICATIONS and WARNINGS. Warfarin. Preliminary data suggest that there may be pharmacodynamic interaction (that causes an increased bleeding diathesis in the face of unaltered prothrombin time) between paroxetine and warfarin. Since there is little clinical experience, the concomitant administration of paroxetine and warfarin should be undertaken with caution (see PRECAUTIONS, Drugs That Interfere With Hemostasis). Triptans. There have been rare postmarketing reports of serotonin syndrome with the use of an SSRI and triptan. If concomitant use of paroxetine with triptan is clinically warranted, careful observation of the patient is advised, particularly during treatment initiation and dose increases (see WARNINGS, Serotonin Syndrome).. Drugs Affecting Hepatic Metabolism. The metabolism and pharmacokinetics of paroxetine may be affected by the induction or inhibition of drug-metabolizing enzymes.. Cimetidine. Cimetidine inhibits many cytochrome P450 (oxidative) enzymes. In study where paroxetine (30 mg once daily) was dosed orally for weeks, steady-state plasma concentrations of paroxetine were increased by approximately 50% during coadministration with oral cimetidine (300 mg three times daily) for the final week. Therefore, when these drugs are administered concurrently, dosage adjustment of paroxetine after the 20-mg starting dose should be guided by clinical effect. The effect of paroxetine on cimetidines pharmacokinetics was not studied.. Phenobarbital. Phenobarbital induces many cytochrome P450 (oxidative) enzymes. When single oral 30-mg dose of paroxetine was administered at phenobarbital steady state (100 mg once daily for 14 days), paroxetine AUC and 1/2 were reduced (by an average of 25% and 38%, respectively) compared to paroxetine administered alone. The effect of paroxetine on phenobarbital pharmacokinetics was not studied. Since paroxetine exhibits nonlinear pharmacokinetics, the results of this study may not address the case where the drugs are both being chronically dosed. No initial dosage adjustment of paroxetine is considered necessary when coadministered with phenobarbital; any subsequent adjustment should be guided by clinical effect.. Phenytoin. When single oral 30-mg dose of paroxetine was administered at phenytoin steady state (300 mg once daily for 14 days), paroxetine AUC and 1/2 were reduced (by an average of 50% and 35%, respectively) compared to paroxetine administered alone. In separate study, when single oral 300-mg dose of phenytoin was administered at paroxetine steady state (30 mg once daily for 14 days), phenytoin AUC was slightly reduced (12% on average) compared to phenytoin administered alone. Since both drugs exhibit nonlinear pharmacokinetics, the above studies may not address the case where the drugs are both being chronically dosed. No initial dosage adjustments are considered necessary when these drugs are coadministered; any subsequent adjustments should be guided by clinical effect (see ADVERSE REACTIONS, Postmarketing Reports).. Drugs Metabolized by CYP2D6. Many drugs, including most drugs effective in the treatment of major depressive disorder (paroxetine, other SSRIs and many tricyclics), are metabolized by the cytochrome P450 isozyme CYP2D6. Like other agents that are metabolized by CYP2D6, paroxetine may significantly inhibit the activity of this isozyme. In most patients (>90%), this CYP2D6 isozyme is saturated early during dosing with paroxetine. In study, daily dosing of paroxetine (20 mg once daily) under steady-state conditions increased single dose desipramine (100 mg) Cmax, AUC, and 1/2 by an average of approximately 2-, 5-, and 3-fold, respectively. Concomitant use of paroxetine with risperidone, CYP2D6 substrate has also been evaluated. In study, daily dosing of paroxetine 20 mg in patients stabilized on risperidone (4 to mg/day) increased mean plasma concentrations of risperidone approximately 4-fold, decreased 9-hydroxyrisperidone concentrations approximately 10%, and increased concentrations of the active moiety (the sum of risperidone plus 9-hydroxyrisperidone) approximately 1.4-fold. The effect of paroxetine on the pharmacokinetics of atomoxetine has been evaluated when both drugs were at steady state. In healthy volunteers who were extensive metabolizers of CYP2D6, paroxetine 20 mg daily was given in combination with 20 mg atomoxetine every 12 hours. This resulted in increases in steady state atomoxetine AUC values that were 6- to 8-fold greater and in atomoxetine Cmax values that were 3- to 4-fold greater than when atomoxetine was given alone. Dosage adjustment of atomoxetine may be necessary and it is recommended that atomoxetine be initiated at reduced dose when it is given with paroxetine.Concomitant use of paroxetine with other drugs metabolized by cytochrome CYP2D6 has not been formally studied but may require lower doses than usually prescribed for either paroxetine or the other drug.Therefore, coadministration of paroxetine with other drugs that are metabolized by this isozyme, including certain drugs effective in the treatment of major depressive disorder (e.g., nortriptyline, amitriptyline, imipramine, desipramine, and fluoxetine), phenothiazines, risperidone, and Type 1C antiarrhythmics (e.g., propafenone, flecainide, and encainide), or that inhibit this enzyme (e.g., quinidine), should be approached with caution.However, due to the risk of serious ventricular arrhythmias and sudden death potentially associated with elevated plasma levels of thioridazine, paroxetine and thioridazine should not be coadministered (see CONTRAINDICATIONS and WARNINGS).Tamoxifen is pro-drug requiring metabolic activation by CYP2D6. Inhibition of CYP2D6 by paroxetine may lead to reduced plasma concentrations of an active metabolite (endoxifen) and hence reduced efficacy of tamoxifen (see PRECAUTIONS). At steady state, when the CYP2D6 pathway is essentially saturated, paroxetine clearance is governed by alternative P450 isozymes that, unlike CYP2D6, show no evidence of saturation (see PRECAUTIONS, Tricyclic Antidepressants [TCAs]). Drugs Metabolized by Cytochrome CYP3A4. An in vivo interaction study involving the coadministration under steady-state conditions of paroxetine and terfenadine, substrate for cytochrome CYP3A4, revealed no effect of paroxetine on terfenadine pharmacokinetics. In addition, in vitro studies have shown ketoconazole, potent inhibitor of CYP3A4 activity, to be at least 100 times more potent than paroxetine as an inhibitor of the metabolism of several substrates for this enzyme, including terfenadine, astemizole, cisapride, triazolam, and cyclosporine. Based on the assumption that the relationship between paroxetines in vitro Ki and its lack of effect on terfenadines in vivo clearance predicts its effect on other CYP3A4 substrates, paroxetines extent of inhibition of CYP3A4 activity is not likely to be of clinical significance. Tricyclic Antidepressants (TCAs). Caution is indicated in the coadministration of tricyclic antidepressants (TCAs) with paroxetine, because paroxetine may inhibit TCA metabolism. Plasma TCA concentrations may need to be monitored, and the dose of TCA may need to be reduced, if TCA is coadministered with paroxetine (see PRECAUTIONS, Drugs Metabolized by Cytochrome CYP2D6).. Drugs Highly Bound to Plasma Protein. Because paroxetine is highly bound to plasma protein, administration of paroxetine to patient taking another drug that is highly protein bound may cause increased free concentrations of the other drug, potentially resulting in adverse events. Conversely, adverse effects could result from displacement of paroxetine by other highly bound drugs.. Drugs That Interfere With Hemostasis (e.g., NSAIDs, Aspirin, and Warfarin). Serotonin release by platelets plays an important role in hemostasis. Epidemiological studies of the case-control and cohort design that have demonstrated an association between use of psychotropic drugs that interfere with serotonin reuptake and the occurrence of upper gastrointestinal bleeding have also shown that concurrent use of an NSAID or aspirin may potentiate this risk of bleeding. Altered anticoagulant effects, including increased bleeding, have been reported when SSRIs or SNRIs are coadministered with warfarin. Patients receiving warfarin therapy should be carefully monitored when paroxetine is initiated or discontinued. Alcohol. Although paroxetine does not increase the impairment of mental and motor skills caused by alcohol, patients should be advised to avoid alcohol while taking paroxetine.. Lithium. multiple-dose study has shown that there is no pharmacokinetic interaction between paroxetine and lithium carbonate. However, due to the potential for serotonin syndrome, caution is advised when paroxetine is coadministered with lithium.. Digoxin. The steady-state pharmacokinetics of paroxetine was not altered when administered with digoxin at steady state. Mean digoxin AUC at steady state decreased by 15% in the presence of paroxetine. Since there is little clinical experience, the concurrent administration of paroxetine and digoxin should be undertaken with caution.. Diazepam. Under steady-state conditions, diazepam does not appear to affect paroxetine kinetics. The effects of paroxetine on diazepam were not evaluated.. Procyclidine. Daily oral dosing of paroxetine (30 mg once daily) increased steady-state AUC0-24, Cmax, and Cmin values of procyclidine (5 mg oral once daily) by 35%, 37% and 67%, respectively, compared to procyclidine alone at steady state. If anticholinergic effects are seen, the dose of procyclidine should be reduced.. Beta-Blockers. In study where propranolol (80 mg twice daily) was dosed orally for 18 days, the established steady-state plasma concentrations of propranolol were unaltered during coadministration with paroxetine (30 mg once daily) for the final 10 days. The effects of propranolol on paroxetine have not been evaluated (see ADVERSE REACTIONS, Postmarketing Reports). Theophylline. Reports of elevated theophylline levels associated with treatment with paroxetine have been reported. While this interaction has not been formally studied, it is recommended that theophylline levels be monitored when these drugs are concurrently administered.. Fosamprenavir/Ritonavir. Co-administration of fosamprenavir/ritonavir with paroxetine significantly decreased plasma levels of paroxetine. Any dose adjustment should be guided by clinical effect (tolerability and efficacy). Electroconvulsive Therapy (ECT). There are no clinical studies of the combined use of ECT and paroxetine.

GENERAL PRECAUTIONS SECTION.

General. Activation of Mania/Hypomania. During premarketing testing, hypomania or mania occurred in approximately 1.0% of unipolar patients treated with paroxetine compared to 1.1% of active-control and 0.3% of placebo-treated unipolar patients. In subset of patients classified as bipolar, the rate of manic episodes was 2.2% for paroxetine and 11.6% for the combined active-control groups. As with all drugs effective in the treatment of major depressive disorder, paroxetine should be used cautiously in patients with history of mania.. Seizures. During premarketing testing, seizures occurred in 0.1% of patients treated with paroxetine, rate similar to that associated with other drugs effective in the treatment of major depressive disorder. Paroxetine should be used cautiously in patients with history of seizures. It should be discontinued in any patient who develops seizures.. Discontinuation of Treatment With Paroxetine. Recent clinical trials supporting the various approved indications for paroxetine employed taper-phase regimen, rather than an abrupt discontinuation of treatment. The taper-phase regimen used in GAD clinical trials involved an incremental decrease in the daily dose by 10 mg/day at weekly intervals. When daily dose of 20 mg/day was reached, patients were continued on this dose for week before treatment was stopped. With this regimen in those studies, the following adverse events were reported at an incidence of 2% or greater for paroxetine and were at least twice that reported for placebo: Abnormal dreams, paresthesia, and dizziness. In the majority of patients, these events were mild to moderate and were self-limiting and did not require medical intervention. During marketing of paroxetine and other SSRIs and SNRIs, there have been spontaneous reports of adverse events occurring upon the discontinuation of these drugs (particularly when abrupt), including the following: Dysphoric mood, irritability, agitation, dizziness, sensory disturbances (e.g., paresthesias such as electric shock sensations and tinnitus), anxiety, confusion, headache, lethargy, emotional lability, insomnia, and hypomania. While these events are generally self-limiting, there have been reports of serious discontinuation symptoms. Patients should be monitored for these symptoms when discontinuing treatment with paroxetine. gradual reduction in the dose rather than abrupt cessation is recommended whenever possible. If intolerable symptoms occur following decrease in the dose or upon discontinuation of treatment, then resuming the previously prescribed dose may be considered. Subsequently, the physician may continue decreasing the dose but at more gradual rate (see DOSAGE AND ADMINISTRATION).See also PRECAUTIONS, Pediatric Use, for adverse events reported upon discontinuation of treatment with paroxetine in pediatric patients.. Tamoxifen. Some studies have shown that the efficacy of tamoxifen, as measured by the risk of breast cancer relapse/mortality, may be reduced when co-prescribed with paroxetine as result of paroxetines irreversible inhibition of CYP2D6 (see Drug Interactions). However, other studies have failed to demonstrate such risk. It is uncertain whether the coadministration of paroxetine and tamoxifen has significant adverse effect on the efficacy of tamoxifen. One study suggests that the risk may increase with longer duration of coadministration. When tamoxifen is used for the treatment or prevention of breast cancer, prescribers should consider using an alternative antidepressant with little or no CYP2D6 inhibition.. Akathisia. The use of paroxetine or other SSRIs has been associated with the development of akathisia, which is characterized by an inner sense of restlessness and psychomotor agitation such as an inability to sit or stand still usually associated with subjective distress. This is most likely to occur within the first few weeks of treatment.. Hyponatremia. Hyponatremia may occur as result of treatment with SSRIs and SNRIs, including paroxetine. In many cases, this hyponatremia appears to be the result of the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Cases with serum sodium lower than 110 mmol/L have been reported. Elderly patients may be at greater risk of developing hyponatremia with SSRIs and SNRIs. Also, patients taking diuretics or who are otherwise volume depleted may be at greater risk (see PRECAUTIONS, Geriatric Use). Discontinuation of paroxetine should be considered in patients with symptomatic hyponatremia and appropriate medical intervention should be instituted. Signs and symptoms of hyponatremia include headache, difficulty concentrating, memory impairment, confusion, weakness, and unsteadiness, which may lead to falls. Signs and symptoms associated with more severe and/or acute cases have included hallucination, syncope, seizure, coma, respiratory arrest, and death. Abnormal Bleeding. SSRIs and SNRIs, including paroxetine, may increase the risk of bleeding events. Concomitant use of aspirin, nonsteroidal anti-inflammatory drugs, warfarin, and other anticoagulants may add to this risk. Case reports and epidemiological studies (case-control and cohort design) have demonstrated an association between use of drugs that interfere with serotonin reuptake and the occurrence of gastrointestinal bleeding. Bleeding events related to SSRIs and SNRIs use have ranged from ecchymoses, hematomas, epistaxis, and petechiae to life-threatening hemorrhages. Patients should be cautioned about the risk of bleeding associated with the concomitant use of paroxetine and NSAIDs, aspirin, or other drugs that affect coagulation. Bone Fracture. Epidemiological studies on bone fracture risk following exposure to some antidepressants, including SSRIs, have reported an association between antidepressant treatment and fractures. There are multiple possible causes for this observation and it is unknown to what extent fracture risk is directly attributable to SSRI treatment. The possibility of pathological fracture, that is, fracture produced by minimal trauma in patient with decreased bone mineral density, should be considered in patients treated with paroxetine who present with unexplained bone pain, point tenderness, swelling, or bruising. Use in Patients With Concomitant Illness. Clinical experience with paroxetine in patients with certain concomitant systemic illness is limited. Caution is advisable in using paroxetine in patients with diseases or conditions that could affect metabolism or hemodynamic responses. As with other SSRIs, mydriasis has been infrequently reported in premarketing studies with paroxetine. few cases of acute angle closure glaucoma associated with paroxetine therapy have been reported in the literature. As mydriasis can cause acute angle closure in patients with narrow angle glaucoma, caution should be used when paroxetine is prescribed for patients with narrow angle glaucoma.Paroxetine has not been evaluated or used to any appreciable extent in patients with recent history of myocardial infarction or unstable heart disease. Patients with these diagnoses were excluded from clinical studies during the products premarket testing. Evaluation of electrocardiograms of 682 patients who received paroxetine in double-blind, placebo-controlled trials, however, did not indicate that paroxetine is associated with the development of significant ECG abnormalities. Similarly, paroxetine does not cause any clinically important changes in heart rate or blood pressure.Increased plasma concentrations of paroxetine occur in patients with severe renal impairment (creatinine clearance <30 mL/min.) or severe hepatic impairment. lower starting dose should be used in such patients (see DOSAGE AND ADMINISTRATION).

INDICATIONS & USAGE SECTION.

INDICATIONS AND USAGE. Major Depressive Disorder. Paroxetine tablets are indicated for the treatment of major depressive disorder.The efficacy of paroxetine in the treatment of major depressive episode was established in 6-week controlled trials of outpatients whose diagnoses corresponded most closely to the DSM-III category of major depressive disorder (see CLINICAL PHARMACOLOGY, Clinical Trials). major depressive episode implies prominent and relatively persistent depressed or dysphoric mood that usually interferes with daily functioning (nearly every day for at least weeks); it should include at least of the following symptoms: Change in appetite, change in sleep, psychomotor agitation or retardation, loss of interest in usual activities or decrease in sexual drive, increased fatigue, feelings of guilt or worthlessness, slowed thinking or impaired concentration, and suicide attempt or suicidal ideation.The effects of paroxetine in hospitalized depressed patients have not been adequately studied.The efficacy of paroxetine in maintaining response in major depressive disorder for up to year was demonstrated in placebo-controlled trial (see CLINICAL PHARMACOLOGY, Clinical Trials). Nevertheless, the physician who elects to use paroxetine for extended periods should periodically re-evaluate the long-term usefulness of the drug for the individual patient.. Obsessive Compulsive Disorder. Paroxetine tablets are indicated for the treatment of obsessions and compulsions in patients with obsessive compulsive disorder (OCD) as defined in the DSM-IV. The obsessions or compulsions cause marked distress, are time-consuming, or significantly interfere with social or occupational functioning.The efficacy of paroxetine was established in two 12-week trials with obsessive compulsive outpatients whose diagnoses corresponded most closely to the DSM-IIIR category of obsessive compulsive disorder (see CLINICAL PHARMACOLOGY, Clinical Trials).Obsessive compulsive disorder is characterized by recurrent and persistent ideas, thoughts, impulses, or images (obsessions) that are ego-dystonic and/or repetitive, purposeful, and intentional behaviors (compulsions) that are recognized by the person as excessive or unreasonable.Long-term maintenance of efficacy was demonstrated in 6-month relapse prevention trial. In this trial, patients assigned to paroxetine showed lower relapse rate compared to patients on placebo (see CLINICAL PHARMACOLOGY, Clinical Trials). Nevertheless, the physician who elects to use paroxetine for extended periods should periodically re-evaluate the long-term usefulness of the drug for the individual patient (see DOSAGE AND ADMINISTRATION).. Panic Disorder. Paroxetine tablets are indicated for the treatment of panic disorder, with or without agoraphobia, as defined in DSM-IV. Panic disorder is characterized by the occurrence of unexpected panic attacks and associated concern about having additional attacks, worry about the implications or consequences of the attacks, and/or significant change in behavior related to the attacks.The efficacy of paroxetine was established in three 10- to 12-week trials in panic disorder patients whose diagnoses corresponded to the DSM-IIIR category of panic disorder (see CLINICAL PHARMACOLOGY, Clinical Trials).Panic disorder (DSM-IV) is characterized by recurrent unexpected panic attacks, i.e., discrete period of intense fear or discomfort in which (or more) of the following symptoms develop abruptly and reach peak within 10 minutes: (1) palpitations, pounding heart, or accelerated heart rate; (2) sweating; (3) trembling or shaking; (4) sensations of shortness of breath or smothering; (5) feeling of choking; (6) chest pain or discomfort; (7) nausea or abdominal distress; (8) feeling dizzy, unsteady, lightheaded, or faint; (9) derealization (feelings of unreality) or depersonalization (being detached from oneself); (10) fear of losing control; (11) fear of dying; (12) paresthesias (numbness or tingling sensations); (13) chills or hot flushes.Long-term maintenance of efficacy was demonstrated in 3-month relapse prevention trial. In this trial, patients with panic disorder assigned to paroxetine demonstrated lower relapse rate compared to patients on placebo (see CLINICAL PHARMACOLOGY, Clinical Trials). Nevertheless, the physician who prescribes paroxetine for extended periods should periodically re-evaluate the long-term usefulness of the drug for the individual patient (see DOSAGE AND ADMINISTRATION).. Social Anxiety Disorder. Paroxetine tablets are indicated for the treatment of social anxiety disorder, also known as social phobia, as defined in DSM-IV (300.23). Social anxiety disorder is characterized by marked and persistent fear of or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. Exposure to the feared situation almost invariably provokes anxiety, which may approach the intensity of panic attack. The feared situations are avoided or endured with intense anxiety or distress. The avoidance, anxious anticipation, or distress in the feared situation(s) interferes significantly with the persons normal routine, occupational or academic functioning, or social activities or relationships, or there is marked distress about having the phobias. Lesser degrees of performance anxiety or shyness generally do not require psychopharmacological treatment.The efficacy of paroxetine was established in three 12-week trials in adult patients with social anxiety disorder (DSM-IV). Paroxetine has not been studied in children or adolescents with social phobia (see CLINICAL PHARMACOLOGY, Clinical Trials).The effectiveness of paroxetine in long-term treatment of social anxiety disorder, i.e., for more than 12 weeks, has not been systematically evaluated in adequate and well-controlled trials. Therefore, the physician who elects to prescribe paroxetine for extended periods should periodically re-evaluate the long-term usefulness of the drug for the individual patient (see DOSAGE AND ADMINISTRATION).. Generalized Anxiety Disorder. Paroxetine tablets are indicated for the treatment of Generalized Anxiety Disorder (GAD), as defined in DSM-IV. Anxiety or tension associated with the stress of everyday life usually does not require treatment with an anxiolytic.The efficacy of paroxetine in the treatment of GAD was established in two 8-week placebo-controlled trials in adults with GAD. Paroxetine has not been studied in children or adolescents with Generalized Anxiety Disorder (see CLINICAL PHARMACOLOGY, Clinical Trials). Generalized Anxiety Disorder (DSM-IV) is characterized by excessive anxiety and worry (apprehensive expectation) that is persistent for at least months and which the person finds difficult to control. It must be associated with at least of the following symptoms: Restlessness or feeling keyed up or on edge, being easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, sleep disturbance.The efficacy of paroxetine in maintaining response in patients with Generalized Anxiety Disorder, who responded during an 8-week acute treatment phase while taking paroxetine and were then observed for relapse during period of up to 24 weeks, was demonstrated in placebo-controlled trial (see CLINICAL PHARMACOLOGY, Clinical Trials). Nevertheless, the physician who elects to use paroxetine for extended periods should periodically re-evaluate the long-term usefulness of the drug for the individual patient (see DOSAGE AND ADMINISTRATION).

PRECAUTIONS SECTION.

PRECAUTIONS. General. Activation of Mania/Hypomania. During premarketing testing, hypomania or mania occurred in approximately 1.0% of unipolar patients treated with paroxetine compared to 1.1% of active-control and 0.3% of placebo-treated unipolar patients. In subset of patients classified as bipolar, the rate of manic episodes was 2.2% for paroxetine and 11.6% for the combined active-control groups. As with all drugs effective in the treatment of major depressive disorder, paroxetine should be used cautiously in patients with history of mania.. Seizures. During premarketing testing, seizures occurred in 0.1% of patients treated with paroxetine, rate similar to that associated with other drugs effective in the treatment of major depressive disorder. Paroxetine should be used cautiously in patients with history of seizures. It should be discontinued in any patient who develops seizures.. Discontinuation of Treatment With Paroxetine. Recent clinical trials supporting the various approved indications for paroxetine employed taper-phase regimen, rather than an abrupt discontinuation of treatment. The taper-phase regimen used in GAD clinical trials involved an incremental decrease in the daily dose by 10 mg/day at weekly intervals. When daily dose of 20 mg/day was reached, patients were continued on this dose for week before treatment was stopped. With this regimen in those studies, the following adverse events were reported at an incidence of 2% or greater for paroxetine and were at least twice that reported for placebo: Abnormal dreams, paresthesia, and dizziness. In the majority of patients, these events were mild to moderate and were self-limiting and did not require medical intervention. During marketing of paroxetine and other SSRIs and SNRIs, there have been spontaneous reports of adverse events occurring upon the discontinuation of these drugs (particularly when abrupt), including the following: Dysphoric mood, irritability, agitation, dizziness, sensory disturbances (e.g., paresthesias such as electric shock sensations and tinnitus), anxiety, confusion, headache, lethargy, emotional lability, insomnia, and hypomania. While these events are generally self-limiting, there have been reports of serious discontinuation symptoms. Patients should be monitored for these symptoms when discontinuing treatment with paroxetine. gradual reduction in the dose rather than abrupt cessation is recommended whenever possible. If intolerable symptoms occur following decrease in the dose or upon discontinuation of treatment, then resuming the previously prescribed dose may be considered. Subsequently, the physician may continue decreasing the dose but at more gradual rate (see DOSAGE AND ADMINISTRATION).See also PRECAUTIONS, Pediatric Use, for adverse events reported upon discontinuation of treatment with paroxetine in pediatric patients.. Tamoxifen. Some studies have shown that the efficacy of tamoxifen, as measured by the risk of breast cancer relapse/mortality, may be reduced when co-prescribed with paroxetine as result of paroxetines irreversible inhibition of CYP2D6 (see Drug Interactions). However, other studies have failed to demonstrate such risk. It is uncertain whether the coadministration of paroxetine and tamoxifen has significant adverse effect on the efficacy of tamoxifen. One study suggests that the risk may increase with longer duration of coadministration. When tamoxifen is used for the treatment or prevention of breast cancer, prescribers should consider using an alternative antidepressant with little or no CYP2D6 inhibition.. Akathisia. The use of paroxetine or other SSRIs has been associated with the development of akathisia, which is characterized by an inner sense of restlessness and psychomotor agitation such as an inability to sit or stand still usually associated with subjective distress. This is most likely to occur within the first few weeks of treatment.. Hyponatremia. Hyponatremia may occur as result of treatment with SSRIs and SNRIs, including paroxetine. In many cases, this hyponatremia appears to be the result of the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Cases with serum sodium lower than 110 mmol/L have been reported. Elderly patients may be at greater risk of developing hyponatremia with SSRIs and SNRIs. Also, patients taking diuretics or who are otherwise volume depleted may be at greater risk (see PRECAUTIONS, Geriatric Use). Discontinuation of paroxetine should be considered in patients with symptomatic hyponatremia and appropriate medical intervention should be instituted. Signs and symptoms of hyponatremia include headache, difficulty concentrating, memory impairment, confusion, weakness, and unsteadiness, which may lead to falls. Signs and symptoms associated with more severe and/or acute cases have included hallucination, syncope, seizure, coma, respiratory arrest, and death. Abnormal Bleeding. SSRIs and SNRIs, including paroxetine, may increase the risk of bleeding events. Concomitant use of aspirin, nonsteroidal anti-inflammatory drugs, warfarin, and other anticoagulants may add to this risk. Case reports and epidemiological studies (case-control and cohort design) have demonstrated an association between use of drugs that interfere with serotonin reuptake and the occurrence of gastrointestinal bleeding. Bleeding events related to SSRIs and SNRIs use have ranged from ecchymoses, hematomas, epistaxis, and petechiae to life-threatening hemorrhages. Patients should be cautioned about the risk of bleeding associated with the concomitant use of paroxetine and NSAIDs, aspirin, or other drugs that affect coagulation. Bone Fracture. Epidemiological studies on bone fracture risk following exposure to some antidepressants, including SSRIs, have reported an association between antidepressant treatment and fractures. There are multiple possible causes for this observation and it is unknown to what extent fracture risk is directly attributable to SSRI treatment. The possibility of pathological fracture, that is, fracture produced by minimal trauma in patient with decreased bone mineral density, should be considered in patients treated with paroxetine who present with unexplained bone pain, point tenderness, swelling, or bruising. Use in Patients With Concomitant Illness. Clinical experience with paroxetine in patients with certain concomitant systemic illness is limited. Caution is advisable in using paroxetine in patients with diseases or conditions that could affect metabolism or hemodynamic responses. As with other SSRIs, mydriasis has been infrequently reported in premarketing studies with paroxetine. few cases of acute angle closure glaucoma associated with paroxetine therapy have been reported in the literature. As mydriasis can cause acute angle closure in patients with narrow angle glaucoma, caution should be used when paroxetine is prescribed for patients with narrow angle glaucoma.Paroxetine has not been evaluated or used to any appreciable extent in patients with recent history of myocardial infarction or unstable heart disease. Patients with these diagnoses were excluded from clinical studies during the products premarket testing. Evaluation of electrocardiograms of 682 patients who received paroxetine in double-blind, placebo-controlled trials, however, did not indicate that paroxetine is associated with the development of significant ECG abnormalities. Similarly, paroxetine does not cause any clinically important changes in heart rate or blood pressure.Increased plasma concentrations of paroxetine occur in patients with severe renal impairment (creatinine clearance <30 mL/min.) or severe hepatic impairment. lower starting dose should be used in such patients (see DOSAGE AND ADMINISTRATION).. Information for Patients. Paroxetine tablets should not be chewed or crushed, and should be swallowed whole. Patients should be cautioned about the risk of serotonin syndrome with the concomitant use of paroxetine and triptans, tramadol, or other serotonergic agents.Patients should be advised that taking paroxetine tablets can cause mild pupillary dilation, which in susceptible individuals, can lead to an episode of angle closure glaucoma. Pre-existing glaucoma is almost always open-angle glaucoma because angle closure glaucoma, when diagnosed, can be treated definitively with iridectomy. Open-angle glaucoma is not risk factor for angle closure glaucoma. Patients may wish to be examined to determine whether they are susceptible to angle closure, and have prophylactic procedure (e.g., iridectomy), if they are susceptible.Prescribers or other health professionals should inform patients, their families, and their caregivers about the benefits and risks associated with treatment with paroxetine and should counsel them in its appropriate use. patient Medication Guide is available for paroxetine tablets. The prescriber or health professional should instruct patients, their families, and their caregivers to read the Medication Guide and should assist them in understanding its contents. Patients should be given the opportunity to discuss the contents of the Medication Guide and to obtain answers to any questions they may have. The complete text of the Medication Guide is reprinted at the end of this document.Patients should be advised of the following issues and asked to alert their prescriber if these occur while taking paroxetine tablets. Clinical Worsening and Suicide Risk. Patients, their families, and their caregivers should be encouraged to be alert to the emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, mania, other unusual changes in behavior, worsening of depression, and suicidal ideation, especially early during antidepressant treatment and when the dose is adjusted up or down. Families and caregivers of patients should be advised to look for the emergence of such symptoms on day-to-day basis, since changes may be abrupt. Such symptoms should be reported to the patients prescriber or health professional, especially if they are severe, abrupt in onset, or were not part of the patients presenting symptoms. Symptoms such as these may be associated with an increased risk for suicidal thinking and behavior and indicate need for very close monitoring and possibly changes in the medication.. Drugs That Interfere With Hemostasis (e.g., NSAIDs, Aspirin, and Warfarin). Patients should be cautioned about the concomitant use of paroxetine and NSAIDs, aspirin, warfarin, or other drugs that affect coagulation since combined use of psychotropic drugs that interfere with serotonin reuptake and these agents has been associated with an increased risk of bleeding.. Interference With Cognitive and Motor Performance. Any psychoactive drug may impair judgment, thinking, or motor skills. Although in controlled studies paroxetine has not been shown to impair psychomotor performance, patients should be cautioned about operating hazardous machinery, including automobiles, until they are reasonably certain that therapy with paroxetine does not affect their ability to engage in such activities.. Completing Course of Therapy. While patients may notice improvement with treatment with paroxetine in to weeks, they should be advised to continue therapy as directed.. Concomitant Medication. Patients should be advised to inform their physician if they are taking, or plan to take, any prescription or over-the-counter drugs, since there is potential for interactions.. Alcohol. Although paroxetine has not been shown to increase the impairment of mental and motor skills caused by alcohol, patients should be advised to avoid alcohol while taking paroxetine.. Pregnancy. Patients should be advised to notify their physician if they become pregnant or intend to become pregnant during therapy (see WARNINGS, Usage in Pregnancy: Teratogenic Effects and Nonteratogenic Effects).. Nursing. Patients should be advised to notify their physician if they are breastfeeding an infant (see PRECAUTIONS, Nursing Mothers). Laboratory Tests. There are no specific laboratory tests recommended.. Drug Interactions. Tryptophan. As with other serotonin reuptake inhibitors, an interaction between paroxetine and tryptophan may occur when they are coadministered. Adverse experiences, consisting primarily of headache, nausea, sweating, and dizziness, have been reported when tryptophan was administered to patients taking paroxetine. Consequently, concomitant use of paroxetine with tryptophan is not recommended (see WARNINGS, Serotonin Syndrome).. Monoamine Oxidase Inhibitors. See CONTRAINDICATIONS and WARNINGS.. Pimozide. In controlled study of healthy volunteers, after paroxetine was titrated to 60 mg daily, co-administration of single dose of mg pimozide was associated with mean increases in pimozide AUC of 151% and Cmax of 62%, compared to pimozide administered alone. The increase in pimozide AUC and Cmax is due to the CYP2D6 inhibitory properties of paroxetine. Due to the narrow therapeutic index of pimozide and its known ability to prolong the QT interval, concomitant use of pimozide and paroxetine is contraindicated (see CONTRAINDICATIONS). Serotonergic Drugs. Based on the mechanism of action of SNRIs and SSRIs, including paroxetine hydrochloride, and the potential for serotonin syndrome, caution is advised when paroxetine is coadministered with other drugs that may affect the serotonergic neurotransmitter systems, such as triptans, lithium, fentanyl, tramadol, amphetamines, or St. Johns Wort (see WARNINGS, Serotonin Syndrome). The concomitant use of paroxetine with MAOIs (including linezolid and intravenous methylene blue) is contraindicated (see CONTRAINDICATIONS). The concomitant use of paroxetine with other SSRIs, SNRIs or tryptophan is not recommended (see PRECAUTIONS, Drug Interactions, Tryptophan).. Thioridazine. See CONTRAINDICATIONS and WARNINGS. Warfarin. Preliminary data suggest that there may be pharmacodynamic interaction (that causes an increased bleeding diathesis in the face of unaltered prothrombin time) between paroxetine and warfarin. Since there is little clinical experience, the concomitant administration of paroxetine and warfarin should be undertaken with caution (see PRECAUTIONS, Drugs That Interfere With Hemostasis). Triptans. There have been rare postmarketing reports of serotonin syndrome with the use of an SSRI and triptan. If concomitant use of paroxetine with triptan is clinically warranted, careful observation of the patient is advised, particularly during treatment initiation and dose increases (see WARNINGS, Serotonin Syndrome).. Drugs Affecting Hepatic Metabolism. The metabolism and pharmacokinetics of paroxetine may be affected by the induction or inhibition of drug-metabolizing enzymes.. Cimetidine. Cimetidine inhibits many cytochrome P450 (oxidative) enzymes. In study where paroxetine (30 mg once daily) was dosed orally for weeks, steady-state plasma concentrations of paroxetine were increased by approximately 50% during coadministration with oral cimetidine (300 mg three times daily) for the final week. Therefore, when these drugs are administered concurrently, dosage adjustment of paroxetine after the 20-mg starting dose should be guided by clinical effect. The effect of paroxetine on cimetidines pharmacokinetics was not studied.. Phenobarbital. Phenobarbital induces many cytochrome P450 (oxidative) enzymes. When single oral 30-mg dose of paroxetine was administered at phenobarbital steady state (100 mg once daily for 14 days), paroxetine AUC and 1/2 were reduced (by an average of 25% and 38%, respectively) compared to paroxetine administered alone. The effect of paroxetine on phenobarbital pharmacokinetics was not studied. Since paroxetine exhibits nonlinear pharmacokinetics, the results of this study may not address the case where the drugs are both being chronically dosed. No initial dosage adjustment of paroxetine is considered necessary when coadministered with phenobarbital; any subsequent adjustment should be guided by clinical effect.. Phenytoin. When single oral 30-mg dose of paroxetine was administered at phenytoin steady state (300 mg once daily for 14 days), paroxetine AUC and 1/2 were reduced (by an average of 50% and 35%, respectively) compared to paroxetine administered alone. In separate study, when single oral 300-mg dose of phenytoin was administered at paroxetine steady state (30 mg once daily for 14 days), phenytoin AUC was slightly reduced (12% on average) compared to phenytoin administered alone. Since both drugs exhibit nonlinear pharmacokinetics, the above studies may not address the case where the drugs are both being chronically dosed. No initial dosage adjustments are considered necessary when these drugs are coadministered; any subsequent adjustments should be guided by clinical effect (see ADVERSE REACTIONS, Postmarketing Reports).. Drugs Metabolized by CYP2D6. Many drugs, including most drugs effective in the treatment of major depressive disorder (paroxetine, other SSRIs and many tricyclics), are metabolized by the cytochrome P450 isozyme CYP2D6. Like other agents that are metabolized by CYP2D6, paroxetine may significantly inhibit the activity of this isozyme. In most patients (>90%), this CYP2D6 isozyme is saturated early during dosing with paroxetine. In study, daily dosing of paroxetine (20 mg once daily) under steady-state conditions increased single dose desipramine (100 mg) Cmax, AUC, and 1/2 by an average of approximately 2-, 5-, and 3-fold, respectively. Concomitant use of paroxetine with risperidone, CYP2D6 substrate has also been evaluated. In study, daily dosing of paroxetine 20 mg in patients stabilized on risperidone (4 to mg/day) increased mean plasma concentrations of risperidone approximately 4-fold, decreased 9-hydroxyrisperidone concentrations approximately 10%, and increased concentrations of the active moiety (the sum of risperidone plus 9-hydroxyrisperidone) approximately 1.4-fold. The effect of paroxetine on the pharmacokinetics of atomoxetine has been evaluated when both drugs were at steady state. In healthy volunteers who were extensive metabolizers of CYP2D6, paroxetine 20 mg daily was given in combination with 20 mg atomoxetine every 12 hours. This resulted in increases in steady state atomoxetine AUC values that were 6- to 8-fold greater and in atomoxetine Cmax values that were 3- to 4-fold greater than when atomoxetine was given alone. Dosage adjustment of atomoxetine may be necessary and it is recommended that atomoxetine be initiated at reduced dose when it is given with paroxetine.Concomitant use of paroxetine with other drugs metabolized by cytochrome CYP2D6 has not been formally studied but may require lower doses than usually prescribed for either paroxetine or the other drug.Therefore, coadministration of paroxetine with other drugs that are metabolized by this isozyme, including certain drugs effective in the treatment of major depressive disorder (e.g., nortriptyline, amitriptyline, imipramine, desipramine, and fluoxetine), phenothiazines, risperidone, and Type 1C antiarrhythmics (e.g., propafenone, flecainide, and encainide), or that inhibit this enzyme (e.g., quinidine), should be approached with caution.However, due to the risk of serious ventricular arrhythmias and sudden death potentially associated with elevated plasma levels of thioridazine, paroxetine and thioridazine should not be coadministered (see CONTRAINDICATIONS and WARNINGS).Tamoxifen is pro-drug requiring metabolic activation by CYP2D6. Inhibition of CYP2D6 by paroxetine may lead to reduced plasma concentrations of an active metabolite (endoxifen) and hence reduced efficacy of tamoxifen (see PRECAUTIONS). At steady state, when the CYP2D6 pathway is essentially saturated, paroxetine clearance is governed by alternative P450 isozymes that, unlike CYP2D6, show no evidence of saturation (see PRECAUTIONS, Tricyclic Antidepressants [TCAs]). Drugs Metabolized by Cytochrome CYP3A4. An in vivo interaction study involving the coadministration under steady-state conditions of paroxetine and terfenadine, substrate for cytochrome CYP3A4, revealed no effect of paroxetine on terfenadine pharmacokinetics. In addition, in vitro studies have shown ketoconazole, potent inhibitor of CYP3A4 activity, to be at least 100 times more potent than paroxetine as an inhibitor of the metabolism of several substrates for this enzyme, including terfenadine, astemizole, cisapride, triazolam, and cyclosporine. Based on the assumption that the relationship between paroxetines in vitro Ki and its lack of effect on terfenadines in vivo clearance predicts its effect on other CYP3A4 substrates, paroxetines extent of inhibition of CYP3A4 activity is not likely to be of clinical significance. Tricyclic Antidepressants (TCAs). Caution is indicated in the coadministration of tricyclic antidepressants (TCAs) with paroxetine, because paroxetine may inhibit TCA metabolism. Plasma TCA concentrations may need to be monitored, and the dose of TCA may need to be reduced, if TCA is coadministered with paroxetine (see PRECAUTIONS, Drugs Metabolized by Cytochrome CYP2D6).. Drugs Highly Bound to Plasma Protein. Because paroxetine is highly bound to plasma protein, administration of paroxetine to patient taking another drug that is highly protein bound may cause increased free concentrations of the other drug, potentially resulting in adverse events. Conversely, adverse effects could result from displacement of paroxetine by other highly bound drugs.. Drugs That Interfere With Hemostasis (e.g., NSAIDs, Aspirin, and Warfarin). Serotonin release by platelets plays an important role in hemostasis. Epidemiological studies of the case-control and cohort design that have demonstrated an association between use of psychotropic drugs that interfere with serotonin reuptake and the occurrence of upper gastrointestinal bleeding have also shown that concurrent use of an NSAID or aspirin may potentiate this risk of bleeding. Altered anticoagulant effects, including increased bleeding, have been reported when SSRIs or SNRIs are coadministered with warfarin. Patients receiving warfarin therapy should be carefully monitored when paroxetine is initiated or discontinued. Alcohol. Although paroxetine does not increase the impairment of mental and motor skills caused by alcohol, patients should be advised to avoid alcohol while taking paroxetine.. Lithium. multiple-dose study has shown that there is no pharmacokinetic interaction between paroxetine and lithium carbonate. However, due to the potential for serotonin syndrome, caution is advised when paroxetine is coadministered with lithium.. Digoxin. The steady-state pharmacokinetics of paroxetine was not altered when administered with digoxin at steady state. Mean digoxin AUC at steady state decreased by 15% in the presence of paroxetine. Since there is little clinical experience, the concurrent administration of paroxetine and digoxin should be undertaken with caution.. Diazepam. Under steady-state conditions, diazepam does not appear to affect paroxetine kinetics. The effects of paroxetine on diazepam were not evaluated.. Procyclidine. Daily oral dosing of paroxetine (30 mg once daily) increased steady-state AUC0-24, Cmax, and Cmin values of procyclidine (5 mg oral once daily) by 35%, 37% and 67%, respectively, compared to procyclidine alone at steady state. If anticholinergic effects are seen, the dose of procyclidine should be reduced.. Beta-Blockers. In study where propranolol (80 mg twice daily) was dosed orally for 18 days, the established steady-state plasma concentrations of propranolol were unaltered during coadministration with paroxetine (30 mg once daily) for the final 10 days. The effects of propranolol on paroxetine have not been evaluated (see ADVERSE REACTIONS, Postmarketing Reports). Theophylline. Reports of elevated theophylline levels associated with treatment with paroxetine have been reported. While this interaction has not been formally studied, it is recommended that theophylline levels be monitored when these drugs are concurrently administered.. Fosamprenavir/Ritonavir. Co-administration of fosamprenavir/ritonavir with paroxetine significantly decreased plasma levels of paroxetine. Any dose adjustment should be guided by clinical effect (tolerability and efficacy). Electroconvulsive Therapy (ECT). There are no clinical studies of the combined use of ECT and paroxetine.. Carcinogenesis, Mutagenesis, Impairment of Fertility. Carcinogenesis. Two-year carcinogenicity studies were conducted in rodents given paroxetine in the diet at 1, 5, and 25 mg/kg/day (mice) and 1, 5, and 20 mg/kg/day (rats). These doses are up to 2.4 (mouse) and 3.9 (rat) times the MRHD for major depressive disorder, social anxiety disorder, and GAD on mg/m2 basis. Because the MRHD for major depressive disorder is slightly less than that for OCD (50 mg versus 60 mg), the doses used in these carcinogenicity studies were only 2.0 (mouse) and 3.2 (rat) times the MRHD for OCD. There was significantly greater number of male rats in the high-dose group with reticulum cell sarcomas (1/100, 0/50, 0/50, and 4/50 for control, low-, middle-, and high-dose groups, respectively) and significantly increased linear trend across dose groups for the occurrence of lymphoreticular tumors in male rats. Female rats were not affected. Although there was dose-related increase in the number of tumors in mice, there was no drug-related increase in the number of mice with tumors. The relevance of these findings to humans is unknown.. Mutagenesis. Paroxetine produced no genotoxic effects in battery of in vitro and in vivo assays that included the following: Bacterial mutation assay, mouse lymphoma mutation assay, unscheduled DNA synthesis assay, and tests for cytogenetic aberrations in vivo in mouse bone marrow and in vitro in human lymphocytes and in dominant lethal test in rats.. Impairment of Fertility. Some clinical studies have shown that SSRIs (including paroxetine) may affect sperm quality during SSRI treatment, which may affect fertility in some men. reduced pregnancy rate was found in reproduction studies in rats at dose of paroxetine of 15 mg/kg/day, which is 2.9 times the MRHD for major depressive disorder, social anxiety disorder, and GAD or 2.4 times the MRHD for OCD on mg/m2 basis. Irreversible lesions occurred in the reproductive tract of male rats after dosing in toxicity studies for to 52 weeks. These lesions consisted of vacuolation of epididymal tubular epithelium at 50 mg/kg/day and atrophic changes in the seminiferous tubules of the testes with arrested spermatogenesis at 25 mg/kg/day (9.8 and 4.9 times the MRHD for major depressive disorder, social anxiety disorder, and GAD; 8.2 and 4.1 times the MRHD for OCD and PD on mg/m2 basis).. Pregnancy. Pregnancy Category D.. See WARNINGS, Usage in Pregnancy: Teratogenic Effects and Nonteratogenic Effects.. Labor and Delivery. The effect of paroxetine on labor and delivery in humans is unknown.. Nursing Mothers. Like many other drugs, paroxetine is secreted in human milk, and caution should be exercised when paroxetine is administered to nursing woman. Pediatric Use. Safety and effectiveness in the pediatric population have not been established (see BOX WARNING and WARNINGS, Clinical Worsening and Suicide Risk). Three placebo-controlled trials in 752 pediatric patients with MDD have been conducted with paroxetine, and the data were not sufficient to support claim for use in pediatric patients. Anyone considering the use of paroxetine in child or adolescent must balance the potential risks with the clinical need. Decreased appetite and weight loss have been observed in association with the use of SSRIs. Consequently, regular monitoring of weight and growth should be performed in children and adolescents treated with an SSRI such as paroxetine.In placebo-controlled clinical trials conducted with pediatric patients, the following adverse events were reported in at least 2% of pediatric patients treated with paroxetine and occurred at rate at least twice that for pediatric patients receiving placebo: emotional lability (including self-harm, suicidal thoughts, attempted suicide, crying, and mood fluctuations), hostility, decreased appetite, tremor, sweating, hyperkinesia, and agitation.Events reported upon discontinuation of treatment with paroxetine in the pediatric clinical trials that included taper phase regimen, which occurred in at least 2% of patients who received paroxetine and which occurred at rate at least twice that of placebo, were: emotional lability (including suicidal ideation, suicide attempt, mood changes, and tearfulness), nervousness, dizziness, nausea, and abdominal pain (see DOSAGE AND ADMINISTRATION, Discontinuation of Treatment With Paroxetine).. Geriatric Use. SSRIs and SNRIs, including paroxetine, have been associated with cases of clinically significant hyponatremia in elderly patients, who may be at greater risk for this adverse event (see PRECAUTIONS, Hyponatremia). In worldwide premarketing clinical trials with paroxetine, 17% of patients treated with paroxetine (approximately 700) were 65 years of age or older. Pharmacokinetic studies revealed decreased clearance in the elderly, and lower starting dose is recommended; there were, however, no overall differences in the adverse event profile between elderly and younger patients, and effectiveness was similar in younger and older patients (see CLINICAL PHARMACOLOGY and DOSAGE AND ADMINISTRATION).

PREGNANCY SECTION.

Usage in Pregnancy. Teratogenic Effects. Epidemiological studies have shown that infants exposed to paroxetine in the first trimester of pregnancy have an increased risk of congenital malformations, particularly cardiovascular malformations. The findings from these studies are summarized below: 1.A study based on Swedish national registry data demonstrated that infants exposed to paroxetine during pregnancy (n 815) had an increased risk of cardiovascular malformations (2% risk in paroxetine-exposed infants) compared to the entire registry population (1% risk), for an odds ratio (OR) of 1.8 (95% confidence interval 1.1 to 2.8). No increase in the risk of overall congenital malformations was seen in the paroxetine-exposed infants. The cardiac malformations in the paroxetine-exposed infants were primarily ventricular septal defects (VSDs) and atrial septal defects (ASDs). Septal defects range in severity from those that resolve spontaneously to those which require surgery. 2.A separate retrospective cohort study from the United States (United Healthcare data) evaluated 5,956 infants of mothers dispensed antidepressants during the first trimester (n 815 for paroxetine). This study showed trend towards an increased risk for cardiovascular malformations for paroxetine (risk of 1.5%) compared to other antidepressants (risk of 1%), for an OR of 1.5 (95% confidence interval 0.8 to 2.9). Of the 12 paroxetine-exposed infants with cardiovascular malformations, had VSDs. This study also suggested an increased risk of overall major congenital malformations including cardiovascular defects for paroxetine (4% risk) compared to other (2% risk) antidepressants (OR 1.8; 95% confidence interval 1.2 to 2.8). 3.Two large case-control studies using separate databases, each with >9,000 birth defect cases and >4,000 controls, found that maternal use of paroxetine during the first trimester of pregnancy was associated with 2- to 3-fold increased risk of right ventricular outflow tract obstructions. In one study the odds ratio was 2.5 (95% confidence interval, 1.0 to 6.0, exposed infants) and in the other study the odds ratio was 3.3 (95% confidence interval, 1.3 to 8.8, exposed infants). Other studies have found varying results as to whether there was an increased risk of overall, cardiovascular, or specific congenital malformations. meta-analysis of epidemiological data over 16-year period (1992 to 2008) on first trimester paroxetine use in pregnancy and congenital malformations included the above-noted studies in addition to others (n 17 studies that included overall malformations and = 14 studies that included cardiovascular malformations; = 20 distinct studies). While subject to limitations, this meta-analysis suggested an increased occurrence of cardiovascular malformations (prevalence odds ratio [POR] 1.5; 95% confidence interval 1.2 to 1.9) and overall malformations (POR 1.2; 95% confidence interval 1.1 to 1.4) with paroxetine use during the first trimester. It was not possible in this meta-analysis to determine the extent to which the observed prevalence of cardiovascular malformations might have contributed to that of overall malformations, nor was it possible to determine whether any specific types of cardiovascular malformations might have contributed to the observed prevalence of all cardiovascular malformations. If patient becomes pregnant while taking paroxetine, she should be advised of the potential harm to the fetus. Unless the benefits of paroxetine to the mother justify continuing treatment, consideration should be given to either discontinuing paroxetine therapy or switching to another antidepressant (see PRECAUTIONS, Discontinuation of Treatment With Paroxetine). For women who intend to become pregnant or are in their first trimester of pregnancy, paroxetine should only be initiated after consideration of the other available treatment options. 1.A study based on Swedish national registry data demonstrated that infants exposed to paroxetine during pregnancy (n 815) had an increased risk of cardiovascular malformations (2% risk in paroxetine-exposed infants) compared to the entire registry population (1% risk), for an odds ratio (OR) of 1.8 (95% confidence interval 1.1 to 2.8). No increase in the risk of overall congenital malformations was seen in the paroxetine-exposed infants. The cardiac malformations in the paroxetine-exposed infants were primarily ventricular septal defects (VSDs) and atrial septal defects (ASDs). Septal defects range in severity from those that resolve spontaneously to those which require surgery. 2.A separate retrospective cohort study from the United States (United Healthcare data) evaluated 5,956 infants of mothers dispensed antidepressants during the first trimester (n 815 for paroxetine). This study showed trend towards an increased risk for cardiovascular malformations for paroxetine (risk of 1.5%) compared to other antidepressants (risk of 1%), for an OR of 1.5 (95% confidence interval 0.8 to 2.9). Of the 12 paroxetine-exposed infants with cardiovascular malformations, had VSDs. This study also suggested an increased risk of overall major congenital malformations including cardiovascular defects for paroxetine (4% risk) compared to other (2% risk) antidepressants (OR 1.8; 95% confidence interval 1.2 to 2.8). 3.Two large case-control studies using separate databases, each with >9,000 birth defect cases and >4,000 controls, found that maternal use of paroxetine during the first trimester of pregnancy was associated with 2- to 3-fold increased risk of right ventricular outflow tract obstructions. In one study the odds ratio was 2.5 (95% confidence interval, 1.0 to 6.0, exposed infants) and in the other study the odds ratio was 3.3 (95% confidence interval, 1.3 to 8.8, exposed infants). Animal Findings. Reproduction studies were performed at doses up to 50 mg/kg/day in rats and mg/kg/day in rabbits administered during organogenesis. These doses are approximately (rat) and (rabbit) times the maximum recommended human dose (MRHD) on an mg/m2 basis. These studies have revealed no evidence of teratogenic effects. However, in rats, there was an increase in pup deaths during the first days of lactation when dosing occurred during the last trimester of gestation and continued throughout lactation. This effect occurred at dose of mg/kg/day or approximately one-sixth of the MRHD on an mg/m2 basis. The no-effect dose for rat pup mortality was not determined. The cause of these deaths is not known. Nonteratogenic Effects. Neonates exposed to paroxetine hydrochloride and other SSRIs or serotonin and norepinephrine reuptake inhibitors (SNRIs), late in the third trimester have developed complications requiring prolonged hospitalization, respiratory support, and tube feeding. Such complications can arise immediately upon delivery. Reported clinical findings have included respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting, hypoglycemia, hypotonia, hypertonia, hyperreflexia, tremor, jitteriness, irritability, and constant crying. These features are consistent with either direct toxic effect of SSRIs and SNRIs or, possibly, drug discontinuation syndrome. It should be noted that, in some cases, the clinical picture is consistent with serotonin syndrome (see WARNINGS, Serotonin Syndrome). Infants exposed to SSRIs in pregnancy may have an increased risk for persistent pulmonary hypertension of the newborn (PPHN). PPHN occurs in to per 1,000 live births in the general population and is associated with substantial neonatal morbidity and mortality. Several recent epidemiologic studies suggest positive statistical association between SSRI use (including paroxetine tablets) in pregnancy and PPHN. Other studies do not show significant statistical association. Physicians should also note the results of prospective longitudinal study of 201 pregnant women with history of major depression, who were either on antidepressants or had received antidepressants less than 12 weeks prior to their last menstrual period, and were in remission. Women who discontinued antidepressant medication during pregnancy showed significant increase in relapse of their major depression compared to those women who remained on antidepressant medication throughout pregnancy. When treating pregnant woman with paroxetine tablets, the physician should carefully consider both the potential risks of taking an SSRI, along with the established benefits of treating depression with an antidepressant. This decision can only be made on case by case basis (see DOSAGE AND ADMINISTRATION and ADVERSE REACTIONS, Postmarketing Reports).

SPL MEDGUIDE SECTION.

MEDICATION GUIDE. Paroxetine Tablets, USP (pa rox teen) Read the Medication Guide that comes with paroxetine before you start taking it and each time you get refill. There may be new information. This Medication Guide does not take the place of talking to your healthcare provider about your medical condition or treatment. Talk with your healthcare provider if there is something you do not understand or want to learn more about. What is the most important information should know about paroxetine Paroxetine and other antidepressant medicines may cause serious side effects, including: 1. Suicidal thoughts or actions: 1.Paroxetine and other antidepressant medicines may increase suicidal thoughts or actions in some children, teenagers, or young adults within the first few months of treatment or when the dose is changed. 2.Depression or other serious mental illnesses are the most important causes of suicidal thoughts or actions.3.Watch for these changes and call your healthcare provider right away if you notice: 1.New or sudden changes in mood, behavior, actions, thoughts, or feelings, especially if severe.2.Pay particular attention to such changes when paroxetine is started or when the dose is changed. Keep all follow-up visits with your healthcare provider and call between visits if you are worried about symptoms. Call your healthcare provider right away if you have any of the following symptoms, or call 911 if an emergency, especially if they are new, worse, or worry you: 1.attempts to commit suicide 2.acting on dangerous impulses 3.acting aggressive or violent 4.thoughts about suicide or dying5.new or worse depression 6.new or worse anxiety or panic attacks 7.feeling agitated, restless, angry, or irritable 8.trouble sleeping 9.an increase in activity or talking more than what is normal for you 10.other unusual changes in behavior or mood Call your healthcare provider right away if you have any of the following symptoms, or call 911 if an emergency. Paroxetine may be associated with these serious side effects: 2. Serotonin Syndrome or Neuroleptic Malignant Syndrome-like reactions. This condition can be life-threatening and may include: 1.agitation, hallucinations, coma, or other changes in mental status 2.coordination problems or muscle twitching (overactive reflexes) 3.racing heartbeat, high or low blood pressure 4.sweating or fever 5.nausea, vomiting, or diarrhea 6.muscle rigidity 3. Visual problems 1.eye pain2.changes in vision3.swelling or redness in or around the eyeOnly some people are at risk for these problems. You may want to undergo an eye examination to see if you are at risk and receive preventative treatment if you are.4. Severe allergic reactions: 1.trouble breathing 2.swelling of the face, tongue, eyes, or mouth 3.rash, itchy welts (hives), or blisters, alone or with fever or joint pain 5. Abnormal bleeding: Paroxetine and other antidepressant medicines may increase your risk of bleeding or bruising, especially if you take the blood thinner warfarin (Coumadin(R), Jantoven(R)), non-steroidal anti-inflammatory drug (NSAIDs, like ibuprofen or naproxen), or aspirin. 6. Seizures or convulsions 7. Manic episodes: 1.greatly increased energy 2.severe trouble sleeping 3.racing thoughts 4.reckless behavior 5.unusually grand ideas 6.excessive happiness or irritability 7.talking more or faster than usual 8. Changes in appetite or weight. Children and adolescents should have height and weight monitored during treatment. 9. Low salt (sodium) levels in the blood. Elderly people may be at greater risk for this. Symptoms may include: 1.headache 2.weakness or feeling unsteady 3.confusion, problems concentrating or thinking, or memory problemsDo not stop paroxetine without first talking to your healthcare provider. Stopping paroxetine too quickly may cause serious symptoms including: 1.anxiety, irritability, high or low mood, feeling restless, or changes in sleep habits 2.headache, sweating, nausea, dizziness 3.electric shock-like sensations, shaking, confusion What is paroxetine Paroxetine is prescription medicine used to treat depression. It is important to talk with your healthcare provider about the risks of treating depression and also the risks of not treating it. You should discuss all treatment choices with your healthcare provider. Paroxetine is also used to treat: 1.Major Depressive Disorder (MDD) 2.Obsessive Compulsive Disorder (OCD) 3.Panic Disorder 4.Social Anxiety Disorder 5.Generalized Anxiety Disorder (GAD) Talk to your healthcare provider if you do not think that your condition is getting better with treatment using paroxetine. Who should not take paroxetine Do not take paroxetine if you: 1.are allergic to paroxetine or any of the ingredients in paroxetine tablets. See the end of this Medication Guide for complete list of ingredients in paroxetine tablets.2.take monoamine oxidase inhibitor (MAOI). Ask your healthcare provider or pharmacist if you are not sure if you take an MAOI, including the antibiotic linezolid.1.Do not take an MAOI within weeks of stopping paroxetine unless directed to do so by your physician. 2.Do not start paroxetine if you stopped taking an MAOI in the last weeks unless directed to do so by your physician. 3.People who take paroxetine close in time to an MAOI may have serious or even life-threatening side effects. Get medical help right away if you have any of these symptoms:1.high fever 2.uncontrolled muscle spasms3.stiff muscles4.rapid changes in heart rate or blood pressure 5.confusion6.loss of consciousness (pass out) 1.take MELLARIL(R) (thioridazine). Do not take MELLARIL(R) together with paroxetine because this can cause serious heart rhythm problems or sudden death. 2.take the antipsychotic medicine pimozide (ORAP(R)) because this can cause serious heart problems. What should tell my healthcare provider before taking paroxetine Ask if you are not sure. Before starting paroxetine, tell your healthcare provider if you: 1.are pregnant, may be pregnant, or plan to become pregnant. There is possibility that paroxetine may harm your unborn baby, including an increased risk of birth defects, particularly heart defects. Other risks may include serious condition in which there is not enough oxygen in the babys blood. Your baby may also have certain other symptoms shortly after birth. Premature births have also been reported in some women who used paroxetine during pregnancy. 2.are breastfeeding. Paroxetine passes into your milk. Talk to your healthcare provider about the best way to feed your baby while taking paroxetine. 3.are taking certain drugs such as: 1.triptans used to treat migraine headache 2.other antidepressants (SSRIs, SNRIs, tricyclics, or lithium) or antipsychotics 3.drugs that affect serotonin, such as lithium, tramadol, tryptophan, St. Johns wort 4.certain drugs used to treat irregular heart beats 5.certain drugs used to treat schizophrenia 6.certain drugs used to treat HIV infection7.certain drugs that affect the blood, such as warfarin, aspirin, and ibuprofen 8.certain drugs used to treat epilepsy 9.atomoxetine10.cimetidine11.fentanyl 12.metoprolol 13.pimozide14.procyclidine15.tamoxifen16.have liver problems 17.have kidney problems 18.have heart problems 19.have or had seizures or convulsions 20.have bipolar disorder or mania 21.have low sodium levels in your blood 22.have history of stroke 23.have high blood pressure 24.have or had bleeding problems 25.have glaucoma (high pressure in the eye) Tell your healthcare provider about all the medicines you take, including prescription and non-prescription medicines, vitamins, and herbal supplements. Paroxetine and some medicines may interact with each other, may not work as well, or may cause serious side effects. Your healthcare provider or pharmacist can tell you if it is safe to take paroxetine with your other medicines. Do not start or stop any medicine while taking paroxetine without talking to your healthcare provider first. If you take paroxetine, you should not take any other medicines that contain paroxetine hydrochloride, including PAXIL CR and PEXEVA(R) (paroxetine mesylate).How should take paroxetine 1.Take paroxetine exactly as prescribed. Your healthcare provider may need to change the dose of paroxetine until it is the right dose for you. 2.Paroxetine may be taken with or without food. 3.If you are taking paroxetine oral suspension, shake the suspension well before use.4.If you miss dose of paroxetine, take the missed dose as soon as you remember. If it is almost time for the next dose, skip the missed dose and take your next dose at the regular time. Do not take two doses of paroxetine at the same time.5.If you take too much paroxetine, call your healthcare provider or poison control center right away, or get emergency treatment.6.Do not stop taking paroxetine suddenly without talking to your doctor (unless you have symptoms of severe allergic reaction). If you need to stop taking paroxetine, your healthcare provider can tell you how to safely stop taking it. What should avoid while taking paroxetine Paroxetine can cause sleepiness or may affect your ability to make decisions, think clearly, or react quickly. You should not drive, operate heavy machinery, or do other dangerous activities until you know how paroxetine affects you. Do not drink alcohol while using paroxetine. What are possible side effects of paroxetine Paroxetine may cause serious side effects, including all of those described in the section entextd What is the most important information should know about paroxetine Common possible side effects in people who take paroxetine include: 1.nausea 2.sleepiness3.weakness4.dizziness5.feeling anxious or trouble sleeping 6.sexual problems 7.sweating8.shaking 9.not feeling hungry 10.dry mouth 11.constipation12.infection 13.yawningTell your healthcare provider if you have any side effect that bothers you or that does not go away. These are not all the possible side effects of paroxetine. For more information, ask your healthcare provider or pharmacist. CALL YOUR DOCTOR FOR MEDICAL ADVICE ABOUT SIDE EFFECTS. YOU MAY REPORT SIDE EFFECTS TO THE FDA AT 1-800-FDA--1088 or 1-800-332-1088. How should store paroxetine 1.Store at 20oC to 25oC (68oF to 77oF). 2.Keep paroxetine away from light. 3.Keep bottle of paroxetine closed tightly. Keep paroxetine and all medicines out of the reach of children. General information about paroxetine Medicines are sometimes prescribed for purposes other than those listed in Medication Guide. Do not use paroxetine for condition for which it was not prescribed. Do not give paroxetine to other people, even if they have the same condition. It may harm them. This Medication Guide summarizes the most important information about paroxetine. If you would like more information, talk with your healthcare provider. You may ask your healthcare provider or pharmacist for information about paroxetine that is written for healthcare professionals. For more information about paroxetine call Apotex Drug Information at 1--800-706-5575. What are the ingredients in paroxetine tablets Active ingredient: paroxetine hydrochloride Inactive ingredients: anhydrous lactose, hydroxypropyl cellulose, hypromellose, magnesium stearate, polyethylene glycol, sodium starch glycolate and titanium dioxide. PAXIL and PAXIL CR are registered trademarks of GlaxoSmithKline. The other brands listed are trademarks of their respective owners. This Medication Guide has been approved by the U.S. Food and Drug Administration. APOTEX INC. PAROXETINE TABLETS, USP 10 mg, 20 mg, 30 mg and 40 mgManufactured by Manufactured for Apotex Inc. Apotex Corp. Toronto, Ontario Weston, FL Canada M9L 1T9 33326 Distributed By:MAJOR(R) PHARMACEUTICALSLivonia, MI 48152Refer to package label for Distributors NDC Number Revised: January 2017 1.Paroxetine and other antidepressant medicines may increase suicidal thoughts or actions in some children, teenagers, or young adults within the first few months of treatment or when the dose is changed. 2.Depression or other serious mental illnesses are the most important causes of suicidal thoughts or actions.. 3.Watch for these changes and call your healthcare provider right away if you notice: 1.New or sudden changes in mood, behavior, actions, thoughts, or feelings, especially if severe.2.Pay particular attention to such changes when paroxetine is started or when the dose is changed. 1.New or sudden changes in mood, behavior, actions, thoughts, or feelings, especially if severe.. 2.Pay particular attention to such changes when paroxetine is started or when the dose is changed. 1.attempts to commit suicide 2.acting on dangerous impulses 3.acting aggressive or violent 4.thoughts about suicide or dying. 5.new or worse depression 6.new or worse anxiety or panic attacks 7.feeling agitated, restless, angry, or irritable 8.trouble sleeping 9.an increase in activity or talking more than what is normal for you 10.other unusual changes in behavior or mood 1.agitation, hallucinations, coma, or other changes in mental status 2.coordination problems or muscle twitching (overactive reflexes) 3.racing heartbeat, high or low blood pressure 4.sweating or fever 5.nausea, vomiting, or diarrhea 6.muscle rigidity 1.eye pain. 2.changes in vision. 3.swelling or redness in or around the eye. 1.trouble breathing 2.swelling of the face, tongue, eyes, or mouth 3.rash, itchy welts (hives), or blisters, alone or with fever or joint pain 1.greatly increased energy 2.severe trouble sleeping 3.racing thoughts 4.reckless behavior 5.unusually grand ideas 6.excessive happiness or irritability 7.talking more or faster than usual 1.headache 2.weakness or feeling unsteady 3.confusion, problems concentrating or thinking, or memory problems. 1.anxiety, irritability, high or low mood, feeling restless, or changes in sleep habits 2.headache, sweating, nausea, dizziness 3.electric shock-like sensations, shaking, confusion 1.Major Depressive Disorder (MDD) 2.Obsessive Compulsive Disorder (OCD) 3.Panic Disorder 4.Social Anxiety Disorder 5.Generalized Anxiety Disorder (GAD) 1.are allergic to paroxetine or any of the ingredients in paroxetine tablets. See the end of this Medication Guide for complete list of ingredients in paroxetine tablets.. 2.take monoamine oxidase inhibitor (MAOI). Ask your healthcare provider or pharmacist if you are not sure if you take an MAOI, including the antibiotic linezolid.1.Do not take an MAOI within weeks of stopping paroxetine unless directed to do so by your physician. 2.Do not start paroxetine if you stopped taking an MAOI in the last weeks unless directed to do so by your physician. 3.People who take paroxetine close in time to an MAOI may have serious or even life-threatening side effects. Get medical help right away if you have any of these symptoms:1.high fever 2.uncontrolled muscle spasms3.stiff muscles4.rapid changes in heart rate or blood pressure 5.confusion6.loss of consciousness (pass out) 1.Do not take an MAOI within weeks of stopping paroxetine unless directed to do so by your physician. 2.Do not start paroxetine if you stopped taking an MAOI in the last weeks unless directed to do so by your physician. 3.People who take paroxetine close in time to an MAOI may have serious or even life-threatening side effects. Get medical help right away if you have any of these symptoms:1.high fever 2.uncontrolled muscle spasms3.stiff muscles4.rapid changes in heart rate or blood pressure 5.confusion6.loss of consciousness (pass out) 1.high fever 2.uncontrolled muscle spasms. 3.stiff muscles. 4.rapid changes in heart rate or blood pressure 5.confusion. 6.loss of consciousness (pass out) 1.take MELLARIL(R) (thioridazine). Do not take MELLARIL(R) together with paroxetine because this can cause serious heart rhythm problems or sudden death. 2.take the antipsychotic medicine pimozide (ORAP(R)) because this can cause serious heart problems. 1.are pregnant, may be pregnant, or plan to become pregnant. There is possibility that paroxetine may harm your unborn baby, including an increased risk of birth defects, particularly heart defects. Other risks may include serious condition in which there is not enough oxygen in the babys blood. Your baby may also have certain other symptoms shortly after birth. Premature births have also been reported in some women who used paroxetine during pregnancy. 2.are breastfeeding. Paroxetine passes into your milk. Talk to your healthcare provider about the best way to feed your baby while taking paroxetine. 3.are taking certain drugs such as: 1.triptans used to treat migraine headache 2.other antidepressants (SSRIs, SNRIs, tricyclics, or lithium) or antipsychotics 3.drugs that affect serotonin, such as lithium, tramadol, tryptophan, St. Johns wort 4.certain drugs used to treat irregular heart beats 5.certain drugs used to treat schizophrenia 6.certain drugs used to treat HIV infection7.certain drugs that affect the blood, such as warfarin, aspirin, and ibuprofen 8.certain drugs used to treat epilepsy 9.atomoxetine10.cimetidine11.fentanyl 12.metoprolol 13.pimozide14.procyclidine15.tamoxifen16.have liver problems 17.have kidney problems 18.have heart problems 19.have or had seizures or convulsions 20.have bipolar disorder or mania 21.have low sodium levels in your blood 22.have history of stroke 23.have high blood pressure 24.have or had bleeding problems 25.have glaucoma (high pressure in the eye) 1.triptans used to treat migraine headache 2.other antidepressants (SSRIs, SNRIs, tricyclics, or lithium) or antipsychotics 3.drugs that affect serotonin, such as lithium, tramadol, tryptophan, St. Johns wort 4.certain drugs used to treat irregular heart beats 5.certain drugs used to treat schizophrenia 6.certain drugs used to treat HIV infection. 7.certain drugs that affect the blood, such as warfarin, aspirin, and ibuprofen 8.certain drugs used to treat epilepsy 9.atomoxetine. 10.cimetidine. 11.fentanyl 12.metoprolol 13.pimozide. 14.procyclidine. 15.tamoxifen. 16.have liver problems 17.have kidney problems 18.have heart problems 19.have or had seizures or convulsions 20.have bipolar disorder or mania 21.have low sodium levels in your blood 22.have history of stroke 23.have high blood pressure 24.have or had bleeding problems 25.have glaucoma (high pressure in the eye) 1.Take paroxetine exactly as prescribed. Your healthcare provider may need to change the dose of paroxetine until it is the right dose for you. 2.Paroxetine may be taken with or without food. 3.If you are taking paroxetine oral suspension, shake the suspension well before use.. 4.If you miss dose of paroxetine, take the missed dose as soon as you remember. If it is almost time for the next dose, skip the missed dose and take your next dose at the regular time. Do not take two doses of paroxetine at the same time.. 5.If you take too much paroxetine, call your healthcare provider or poison control center right away, or get emergency treatment.. 6.Do not stop taking paroxetine suddenly without talking to your doctor (unless you have symptoms of severe allergic reaction). If you need to stop taking paroxetine, your healthcare provider can tell you how to safely stop taking it. 1.nausea 2.sleepiness. 3.weakness. 4.dizziness. 5.feeling anxious or trouble sleeping 6.sexual problems 7.sweating. 8.shaking 9.not feeling hungry 10.dry mouth 11.constipation. 12.infection 13.yawning. 1.Store at 20oC to 25oC (68oF to 77oF). 2.Keep paroxetine away from light. 3.Keep bottle of paroxetine closed tightly.

WARNINGS SECTION.

WARNINGS. Clinical Worsening and Suicide Risk. Patients with major depressive disorder (MDD), both adult and pediatric, may experience worsening of their depression and/or the emergence of suicidal ideation and behavior (suicidality) or unusual changes in behavior, whether or not they are taking antidepressant medications, and this risk may persist until significant remission occurs. Suicide is known risk of depression and certain other psychiatric disorders, and these disorders themselves are the strongest predictors of suicide. There has been long-standing concern, however, that antidepressants may have role in inducing worsening of depression and the emergence of suicidality in certain patients during the early phases of treatment. Pooled analyses of short-term placebo-controlled trials of antidepressant drugs (SSRIs and others) showed that these drugs increase the risk of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults (ages 18 to 24) with major depressive disorder (MDD) and other psychiatric disorders. Short-term studies did not show an increase in the risk of suicidality with antidepressants compared to placebo in adults beyond age 24; there was reduction with antidepressants compared to placebo in adults aged 65 and older.The pooled analyses of placebo-controlled trials in children and adolescents with MDD, obsessive compulsive disorder (OCD), or other psychiatric disorders included total of 24 short-term trials of antidepressant drugs in over 4,400 patients. The pooled analyses of placebo-controlled trials in adults with MDD or other psychiatric disorders included total of 295 short-term trials (median duration of months) of 11 antidepressant drugs in over 77,000 patients. There was considerable variation in risk of suicidality among drugs, but tendency toward an increase in the younger patients for almost all drugs studied. There were differences in absolute risk of suicidality across the different indications, with the highest incidence in MDD. The risk differences (drug vs placebo), however, were relatively stable within age strata and across indications. These risk differences (drug-placebo difference in the number of cases of suicidality per 1,000 patients treated) are provided in Table 1. Table 1Age RangeDrug-Placebo Difference in Number of Cases of Suicidality per 1,000 Patients Treated Increases Compared to Placebo<1814 additional cases18 to 245 additional cases Decreases Compared to Placebo25 to 641 fewer case>=656 fewer casesNo suicides occurred in any of the pediatric trials. There were suicides in the adult trials, but the number was not sufficient to reach any conclusion about drug effect on suicide. It is unknown whether the suicidality risk extends to longer-term use, i.e., beyond several months. However, there is substantial evidence from placebo-controlled maintenance trials in adults with depression that the use of antidepressants can delay the recurrence of depression. All patients being treated with antidepressants for any indication should be monitored appropriately and observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of course of drug therapy, or at times of dose changes, either increases or decreases. The following symptoms, anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, and mania, have been reported in adult and pediatric patients being treated with antidepressants for major depressive disorder as well as for other indications, both psychiatric and nonpsychiatric. Although causal link between the emergence of such symptoms and either the worsening of depression and/or the emergence of suicidal impulses has not been established, there is concern that such symptoms may represent precursors to emerging suicidality. Consideration should be given to changing the therapeutic regimen, including possibly discontinuing the medication, in patients whose depression is persistently worse, or who are experiencing emergent suicidality or symptoms that might be precursors to worsening depression or suicidality, especially if these symptoms are severe, abrupt in onset, or were not part of the patients presenting symptoms.If the decision has been made to discontinue treatment, medication should be tapered, as rapidly as is feasible, but with recognition that abrupt discontinuation can be associated with certain symptoms (see PRECAUTIONS and DOSAGE AND ADMINISTRATION, Discontinuation of Treatment With Paroxetine, for description of the risks of discontinuation of paroxetine).Families and caregivers of patients being treated with antidepressants for major depressive disorder or other indications, both psychiatric and nonpsychiatric, should be alerted about the need to monitor patients for the emergence of agitation, irritability, unusual changes in behavior, and the other symptoms described above, as well as the emergence of suicidality, and to report such symptoms immediately to healthcare providers. Such monitoring should include daily observation by families and caregivers. Prescriptions for paroxetine should be written for the smallest quantity of tablets consistent with good patient management, in order to reduce the risk of overdose. Screening Patients for Bipolar Disorder. major depressive episode may be the initial presentation of bipolar disorder. It is generally believed (though not established in controlled trials) that treating such an episode with an antidepressant alone may increase the likelihood of precipitation of mixed/manic episode in patients at risk for bipolar disorder. Whether any of the symptoms described above represent such conversion is unknown. However, prior to initiating treatment with an antidepressant, patients with depressive symptoms should be adequately screened to determine if they are at risk for bipolar disorder; such screening should include detailed psychiatric history, including family history of suicide, bipolar disorder, and depression. It should be noted that paroxetine is not approved for use in treating bipolar depression.. Serotonin Syndrome. The development of potentially life-threatening serotonin syndrome has been reported with SNRIs and SSRIs, including paroxetine tablets, alone but particularly with concomitant use of other serotonergic drugs (including triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, amphetamines, and St. Johns Wort) and with drugs that impair metabolism of serotonin (in particular, MAOIs, both those intended to treat psychiatric disorders and also others, such as linezolid and intravenous methylene blue). Serotonin syndrome symptoms may include mental status changes (e.g., agitation, hallucinations, delirium, and coma), autonomic instability (e.g., tachycardia, labile blood pressure, dizziness, diaphoresis, flushing, hyperthermia), neuromuscular symptoms (e.g., tremor, rigidity, myoclonus, hyperreflexia, incoordination), seizures, and/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea). Patients should be monitored for the emergence of serotonin syndrome. The concomitant use of paroxetine with MAOIs intended to treat psychiatric disorders is contraindicated. Paroxetine should also not be started in patient who is being treated with MAOIs such as linezolid or intravenous methylene blue. All reports with methylene blue that provided information on the route of administration involved intravenous administration in the dose range of mg/kg to mg/kg. No reports involved the administration of methylene blue by other routes (such as oral tablets or local tissue injection) or at lower doses. There may be circumstances when it is necessary to initiate treatment with an MAOI such as linezolid or intravenous methylene blue in patient taking paroxetine. Paroxetine should be discontinued before initiating treatment with the MAOI (see CONTRAINDICATIONS and DOSAGE AND ADMINISTRATION).If concomitant use of paroxetine tablets with certain other serotonergic drugs, i.e., triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, buspirone, tryptophan, amphetamines, and St. Johns Wort is clinically warranted, be aware of potential increased risk for serotonin syndrome, particularly during treatment initiation and dose increases. Treatment with paroxetine tablets and any concomitant serotonergic agents should be discontinued immediately if the above events occur and supportive symptomatic treatment should be initiated. Angle-Closure Glaucoma. The pupillary dilation that occurs following use of many antidepressant drugs including paroxetine tablets may trigger an angle closure attack in patient with anatomically narrow angles who does not have patent iridectomy.. Potential Interaction With Thioridazine. Thioridazine administration alone produces prolongation of the QTc interval, which is associated with serious ventricular arrhythmias, such as torsade de pointes-type arrhythmias, and sudden death. This effect appears to be dose related. An in vivo study suggests that drugs which inhibit CYP2D6, such as paroxetine, will elevate plasma levels of thioridazine. Therefore, it is recommended that paroxetine not be used in combination with thioridazine (see CONTRAINDICATIONS and PRECAUTIONS). Usage in Pregnancy. Teratogenic Effects. Epidemiological studies have shown that infants exposed to paroxetine in the first trimester of pregnancy have an increased risk of congenital malformations, particularly cardiovascular malformations. The findings from these studies are summarized below: 1.A study based on Swedish national registry data demonstrated that infants exposed to paroxetine during pregnancy (n 815) had an increased risk of cardiovascular malformations (2% risk in paroxetine-exposed infants) compared to the entire registry population (1% risk), for an odds ratio (OR) of 1.8 (95% confidence interval 1.1 to 2.8). No increase in the risk of overall congenital malformations was seen in the paroxetine-exposed infants. The cardiac malformations in the paroxetine-exposed infants were primarily ventricular septal defects (VSDs) and atrial septal defects (ASDs). Septal defects range in severity from those that resolve spontaneously to those which require surgery. 2.A separate retrospective cohort study from the United States (United Healthcare data) evaluated 5,956 infants of mothers dispensed antidepressants during the first trimester (n 815 for paroxetine). This study showed trend towards an increased risk for cardiovascular malformations for paroxetine (risk of 1.5%) compared to other antidepressants (risk of 1%), for an OR of 1.5 (95% confidence interval 0.8 to 2.9). Of the 12 paroxetine-exposed infants with cardiovascular malformations, had VSDs. This study also suggested an increased risk of overall major congenital malformations including cardiovascular defects for paroxetine (4% risk) compared to other (2% risk) antidepressants (OR 1.8; 95% confidence interval 1.2 to 2.8). 3.Two large case-control studies using separate databases, each with >9,000 birth defect cases and >4,000 controls, found that maternal use of paroxetine during the first trimester of pregnancy was associated with 2- to 3-fold increased risk of right ventricular outflow tract obstructions. In one study the odds ratio was 2.5 (95% confidence interval, 1.0 to 6.0, exposed infants) and in the other study the odds ratio was 3.3 (95% confidence interval, 1.3 to 8.8, exposed infants). Other studies have found varying results as to whether there was an increased risk of overall, cardiovascular, or specific congenital malformations. meta-analysis of epidemiological data over 16-year period (1992 to 2008) on first trimester paroxetine use in pregnancy and congenital malformations included the above-noted studies in addition to others (n 17 studies that included overall malformations and = 14 studies that included cardiovascular malformations; = 20 distinct studies). While subject to limitations, this meta-analysis suggested an increased occurrence of cardiovascular malformations (prevalence odds ratio [POR] 1.5; 95% confidence interval 1.2 to 1.9) and overall malformations (POR 1.2; 95% confidence interval 1.1 to 1.4) with paroxetine use during the first trimester. It was not possible in this meta-analysis to determine the extent to which the observed prevalence of cardiovascular malformations might have contributed to that of overall malformations, nor was it possible to determine whether any specific types of cardiovascular malformations might have contributed to the observed prevalence of all cardiovascular malformations. If patient becomes pregnant while taking paroxetine, she should be advised of the potential harm to the fetus. Unless the benefits of paroxetine to the mother justify continuing treatment, consideration should be given to either discontinuing paroxetine therapy or switching to another antidepressant (see PRECAUTIONS, Discontinuation of Treatment With Paroxetine). For women who intend to become pregnant or are in their first trimester of pregnancy, paroxetine should only be initiated after consideration of the other available treatment options. 1.A study based on Swedish national registry data demonstrated that infants exposed to paroxetine during pregnancy (n 815) had an increased risk of cardiovascular malformations (2% risk in paroxetine-exposed infants) compared to the entire registry population (1% risk), for an odds ratio (OR) of 1.8 (95% confidence interval 1.1 to 2.8). No increase in the risk of overall congenital malformations was seen in the paroxetine-exposed infants. The cardiac malformations in the paroxetine-exposed infants were primarily ventricular septal defects (VSDs) and atrial septal defects (ASDs). Septal defects range in severity from those that resolve spontaneously to those which require surgery. 2.A separate retrospective cohort study from the United States (United Healthcare data) evaluated 5,956 infants of mothers dispensed antidepressants during the first trimester (n 815 for paroxetine). This study showed trend towards an increased risk for cardiovascular malformations for paroxetine (risk of 1.5%) compared to other antidepressants (risk of 1%), for an OR of 1.5 (95% confidence interval 0.8 to 2.9). Of the 12 paroxetine-exposed infants with cardiovascular malformations, had VSDs. This study also suggested an increased risk of overall major congenital malformations including cardiovascular defects for paroxetine (4% risk) compared to other (2% risk) antidepressants (OR 1.8; 95% confidence interval 1.2 to 2.8). 3.Two large case-control studies using separate databases, each with >9,000 birth defect cases and >4,000 controls, found that maternal use of paroxetine during the first trimester of pregnancy was associated with 2- to 3-fold increased risk of right ventricular outflow tract obstructions. In one study the odds ratio was 2.5 (95% confidence interval, 1.0 to 6.0, exposed infants) and in the other study the odds ratio was 3.3 (95% confidence interval, 1.3 to 8.8, exposed infants). Animal Findings. Reproduction studies were performed at doses up to 50 mg/kg/day in rats and mg/kg/day in rabbits administered during organogenesis. These doses are approximately (rat) and (rabbit) times the maximum recommended human dose (MRHD) on an mg/m2 basis. These studies have revealed no evidence of teratogenic effects. However, in rats, there was an increase in pup deaths during the first days of lactation when dosing occurred during the last trimester of gestation and continued throughout lactation. This effect occurred at dose of mg/kg/day or approximately one-sixth of the MRHD on an mg/m2 basis. The no-effect dose for rat pup mortality was not determined. The cause of these deaths is not known. Nonteratogenic Effects. Neonates exposed to paroxetine hydrochloride and other SSRIs or serotonin and norepinephrine reuptake inhibitors (SNRIs), late in the third trimester have developed complications requiring prolonged hospitalization, respiratory support, and tube feeding. Such complications can arise immediately upon delivery. Reported clinical findings have included respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting, hypoglycemia, hypotonia, hypertonia, hyperreflexia, tremor, jitteriness, irritability, and constant crying. These features are consistent with either direct toxic effect of SSRIs and SNRIs or, possibly, drug discontinuation syndrome. It should be noted that, in some cases, the clinical picture is consistent with serotonin syndrome (see WARNINGS, Serotonin Syndrome). Infants exposed to SSRIs in pregnancy may have an increased risk for persistent pulmonary hypertension of the newborn (PPHN). PPHN occurs in to per 1,000 live births in the general population and is associated with substantial neonatal morbidity and mortality. Several recent epidemiologic studies suggest positive statistical association between SSRI use (including paroxetine tablets) in pregnancy and PPHN. Other studies do not show significant statistical association. Physicians should also note the results of prospective longitudinal study of 201 pregnant women with history of major depression, who were either on antidepressants or had received antidepressants less than 12 weeks prior to their last menstrual period, and were in remission. Women who discontinued antidepressant medication during pregnancy showed significant increase in relapse of their major depression compared to those women who remained on antidepressant medication throughout pregnancy. When treating pregnant woman with paroxetine tablets, the physician should carefully consider both the potential risks of taking an SSRI, along with the established benefits of treating depression with an antidepressant. This decision can only be made on case by case basis (see DOSAGE AND ADMINISTRATION and ADVERSE REACTIONS, Postmarketing Reports).

CLINICAL STUDIES SECTION.

14 CLINICAL STUDIES. 14.1 Major Depressive Disorder. The efficacy of paroxetine as treatment for major depressive disorder (MDD) has been established in placebo-controlled studies of patients with MDD (aged 18 to 73). In these studies, paroxetine was shown to be statistically significantly more effective than placebo in treating MDD by at least of the following measures: Hamilton Depression Rating Scale (HDRS), the Hamilton depressed mood text, and the Clinical Global Impression (CGI)-Severity of Illness. paroxetine was statistically significantly better than placebo in improvement of the HDRS sub-factor scores, including the depressed mood text, sleep disturbance factor, and anxiety factor. Long-term efficacy of paroxetine for treatment of MDD in outpatients was demonstrated in randomized withdrawal study. Patients who responded to paroxetine (HDRS total score <8) during an initial 8-week open-label treatment phase were then randomized to continue paroxetine or placebo, for up to year. Patients treated with paroxetine demonstrated statistically significant lower relapse rate during the withdrawal phase (15%) compared to those on placebo (39%). Effectiveness was similar for male and female patients.. 14.2 Obsessive Compulsive Disorder. The effectiveness of paroxetine in the treatment of obsessive compulsive disorder (OCD) was demonstrated in two 12-week multicenter placebo-controlled studies of adult outpatients (Studies and 2). Patients had moderate to severe OCD (DSM-IIIR) with mean baseline ratings on the Yale Brown Obsessive Compulsive Scale (YBOCS) total score ranging from 23 to 26. In study 1, dose-range finding study, patients received fixed daily doses of paroxetine 20 mg, 40 mg, or 60 mg. Study demonstrated that daily doses of paroxetine 40 mg and 60 mg are effective in the treatment of OCD. Patients receiving doses of paroxetine 40 mg and 60 mg experienced mean reduction of approximately and points, respectively, on the YBOCS total score which was statistically significantly greater than the approximate 4-point reduction at 20 mg and 3-point reduction in the placebo-treated patients. Study was flexible-dose study comparing paroxetine 20 mg to 60 mg daily with clomipramine 25 mg to 250 mg daily or placebo). In this study, patients receiving paroxetine experienced mean reduction of approximately points on the YBOCS total score, which was statistically significantly greater than the mean reduction of approximately points in placebo-treated patients. The following table provides the outcome classification by treatment group on Global Improvement texts of the Clinical Global Impression (CGI) scale for Study 1.Table 10: Outcome Classification (%) on CGI-Global Improvement Item for Completers in Study in Patients with OCD OutcomePlaceboParoxetine Tablets 20 mgParoxetine Tablets 40 mgParoxetine Tablets 60 mgClassification(n 74)(n 75)(n 66)(n 66) %%%%Worse14773No Change44352219Minimally Improved24332934Much Improved11182224Very Much Improved772020Subgroup analyses did not indicate that there were any differences in treatment outcomes as function of age or gender.The long-term efficacy of paroxetine for the treatment of OCD was established in long-term extension to Study 1. Patients who responded to paroxetine during the 3-month double-blind phase and 6-month extension on open-label paroxetine 20 mg to 60 mg daily were randomized to either paroxetine or placebo in 6-month double-blind relapse prevention phase. Patients randomized to paroxetine were statistically significantly less likely to relapse than placebo-treated patients.. 14.3 Panic Disorder. The effectiveness of paroxetine in the treatment of panic disorder (PD) was demonstrated in three 10 to 12-week multicenter, placebo-controlled studies of adult outpatients (Studies 1, 2, and 3). Patients had PD (DSM-IIIR), with or without agoraphobia. In these studies, paroxetine was shown to be statistically significantly more effective than placebo in treating PD by at least out of measures of panic attack frequency and on the Clinical Global Impression Severity of Illness score. Study was 10-week dose-range finding study; patients received fixed doses of paroxetine 10 mg, 20 mg, or 40 mg daily or placebo. statistically significant difference from placebo was observed only for the paroxetine 40 mg daily group. At endpoint, 76% of patients receiving paroxetine 40 mg daily were free of panic attacks, compared to 44% of placebo-treated patients. Study was 12-week flexible-dose study comparing paroxetine 10 mg to 60 mg daily and placebo. At endpoint, 51% of paroxetine-treated patients were free of panic attacks compared to 32% of placebo-treated patients. Study was 12-week flexible-dose study comparing paroxetine 10 mg to 60 mg daily to placebo in patients concurrently receiving standardized cognitive behavioral therapy. At endpoint, 33% of the paroxetine-treated patients showed reduction to or panic attacks compared to 14% of placebo-treated patients. In Studies and 3, the mean paroxetine dose for completers at endpoint was approximately 40 mg daily. Long-term efficacy of paroxetine in PD was demonstrated in an extension to Study 1. Patients who responded to paroxetine during the 10-week double-blind phase and during 3-month double-blind extension phase were randomized to either paroxetine 10 mg, 20 mg, or 40 mg daily or placebo in 3-month double-blind relapse prevention phase. Patients randomized to paroxetine were statistically significantly less likely to relapse than placebo-treated patients. Subgroup analyses did not indicate that there were any differences in treatment outcomes as function of age or gender.. 14.4 Social Anxiety Disorder. The effectiveness of paroxetine in the treatment of social anxiety disorder (SAD) was demonstrated in three 12-week, multicenter, placebo-controlled studies (Studies 1, 2, and 3) of adult outpatients with SAD (DSM-IV). In these studies, the effectiveness of paroxetine compared to placebo was evaluated on the basis of (1) the proportion of responders, as defined by Clinical Global Impression (CGI) Improvement score of (very much improved) or (much improved), and (2) change from baseline in the Liebowitz Social Anxiety Scale (LSAS).Studies and were flexible-dose studies comparing paroxetine 20 mg to 50 mg daily and placebo. paroxetine demonstrated statistically significant superiority over placebo on both the CGI Improvement responder criterion and the Liebowitz Social Anxiety Scale (LSAS). In Study 1, for patients who completed to week 12, 69% of paroxetine-treated patients compared to 29% of placebo-treated patients were CGI Improvement responders. In Study 2, CGI Improvement responders were 77% and 42% for the paroxetine- and placebo-treated patients, respectively.Study was 12-week study comparing fixed doses of paroxetine 20 mg, 40 mg, or 60 mg daily with placebo. Paroxetine 20 mg was statistically significantly superior to placebo on both the LSAS Total Score and the CGI Improvement responder criterion; there were trends for superiority over placebo for the paroxetine 40 mg and 60 mg daily dose groups. There was no indication in this study of any additional benefit for doses higher than 20 mg daily.Subgroup analyses generally did not indicate differences in treatment outcomes as function of age, race, or gender.. 14.5 Generalized Anxiety Disorder. The effectiveness of paroxetine in the treatment of generalized anxiety disorder (GAD) was demonstrated in two 8-week, multicenter, placebo-controlled studies (Studies and 2) of adult outpatients with GAD (DSM-IV).Study was an 8-week study comparing fixed doses of paroxetine 20 mg or 40 mg daily with placebo. Doses of paroxetine 20 mg or 40 mg were both demonstrated to be statistically significantly superior to placebo on the Hamilton Rating Scale for Anxiety (HAM-A) total score.There was not sufficient evidence in this study to suggest greater benefit for the paroxetine 40 mg daily dose compared to the 20 mg daily dose.Study was flexible-dose study comparing paroxetine 20 mg to 50 mg daily and placebo. Paroxetine demonstrated statistically significant superiority over placebo on the Hamilton Rating Scale for Anxiety (HAM-A) total score.A third study, flexible-dose study comparing paroxetine 20 mg to 50 mg daily to placebo, did not demonstrate statistically significant superiority of paroxetine over placebo on the Hamilton Rating Scale for Anxiety (HAM-A) total score, the primary outcome.Subgroup analyses did not indicate differences in treatment outcomes as function of race or gender. There were insufficient elderly patients to conduct subgroup analyses on the basis of age.In long-term trial, 566 patients meeting DSM-IV criteria for GAD, who had responded during single-blind, 8-week acute treatment phase with paroxetine 20 mg to 50 mg daily, were randomized to continuation of paroxetine at their same dose, or to placebo, for up to 24 weeks of observation for relapse. Response during the single-blind phase was defined by having decrease of >=2 points compared to baseline on the CGI-Severity of Illness scale, to score of <=3. Relapse during the double-blind phase was defined as an increase of >=2 points compared to baseline on the CGI- Severity of Illness scale to score of >=4, or withdrawal due to lack of efficacy. Patients continuing to receive paroxetine experienced statistically significantly lower relapse rate over the subsequent 24 weeks compared to those receiving placebo.. 14.6 Posttraumatic Stress Disorder. The effectiveness of paroxetine in the treatment of Posttraumatic Stress Disorder (PTSD) was demonstrated in two 12-week, multicenter, placebo-controlled studies (Studies and 2) of adult outpatients who met DSM-IV criteria for PTSD. The mean duration of PTSD symptoms for the studies combined was 13 years (ranging from 0.1 year to 57 years). The percentage of patients with secondary MDD or non-PTSD anxiety disorders in the combined studies was 41% (356 out of 858 patients) and 40% (345 out of 858 patients), respectively. Study outcome was assessed by (1) the Clinician-Administered PTSD Scale Part (CAPS-2) score and (2) the Clinical Global Impression-Global Improvement Scale (CGI-I). The CAPS-2 is multi-text instrument that measures aspects of PTSD with the following symptom clusters: Reexperiencing/intrusion, avoidance/numbing and hyperarousal. The primary outcomes for each trial were (1) change from baseline to endpoint on the CAPS-2 total score (17 texts), and (2) proportion of responders on the CGI-I, where responders were defined as patients having score of (very much improved) or (much improved).Study was 12-week study comparing fixed doses of paroxetine 20 mg or 40 mg daily to placebo. Doses of paroxetine 20 mg and 40 mg were demonstrated to be statistically significantly superior to placebo on change from baseline for the CAPS-2 total score and on proportion of responders on the CGI-I. There was not sufficient evidence in this study to suggest greater benefit for the 40 mg daily dose compared to the 20 mg daily dose. Study was 12-week flexible-dose study comparing paroxetine 20 mg to 50 mg daily to placebo. Paroxetine was demonstrated to be significantly superior to placebo on change from baseline for the CAPS-2 total score and on proportion of responders on the CGI-I.A third study, flexible-dose study comparing paroxetine 20 mg to 50 mg daily to placebo, demonstrated paroxetine to be statistically significantly superior to placebo on change from baseline for CAPS-2 total score, but not on proportion of responders on the CGI-I.The majority of patients in these trials were women (68% women: 377 out of 551 subjects in Study and 66% women: 202 out of 303 subjects in Study 2). Subgroup analyses did not indicate differences in treatment outcomes as function of gender. There were an insufficient number of patients who were 65 years and older or were non-Caucasian to conduct subgroup analyses on the basis of age or race, respectively.

USE IN SPECIFIC POPULATIONS SECTION.

8 USE IN SPECIFIC POPULATIONS. 3.Pregnancy: Can cause fetal and neonatal harm. Advise women of potential risk to the fetus. (8.1)4.Nursing Mothers: Discontinue drug or nursing, taking into consideration importance of drug to mother. (8.3). 3.Pregnancy: Can cause fetal and neonatal harm. Advise women of potential risk to the fetus. (8.1). 4.Nursing Mothers: Discontinue drug or nursing, taking into consideration importance of drug to mother. (8.3). 8.1 Pregnancy. Pregnancy Category [see Warnings and Precautions 5.4)]Epidemiological studies have shown that infants exposed to paroxetine in the first trimester of pregnancy have an increased risk of congenital malformations, particularly cardiovascular malformations. If paroxetine is used during pregnancy, or if the patient becomes pregnant while taking paroxetine, advise the patient of the potential hazard to the fetus.Clinical Considerations Unless the benefits of paroxetine to the mother justify continuing treatment, consideration should be given to either discontinuing paroxetine therapy or switching to another antidepressant [see Warnings and Precautions (5.7)]. For1.A study based on Swedish national registry data demonstrated that infants exposed to paroxetine during pregnancy (n 815) had an increased risk of cardiovascular malformations (2% risk in paroxetine-exposed infants) compared to the entire registry population (1% risk), for an odds ratio (OR) of 1.8 (95% confidence interval 1.1 to 2.8). No increase in the risk of overall congenital malformations was seen in the paroxetine-exposed infants. The cardiac malformations in the paroxetine-exposed infants were primarily ventricular septal defects (VSDs) and atrial septal defects (ASDs). Septal defects range in severity from those that resolve spontaneously to those which require surgery.2.A separate retrospective cohort study from the United States (United Healthcare data) evaluated 5,956 infants of mothers dispensed antidepressants during the first trimester (n 815 for paroxetine). This study showed trend towards an increased risk for cardiovascular malformations for paroxetine (risk of 1.5%) compared to other antidepressants (risk of 1%), for an OR of 1.5 (95% confidence interval 0.8 to 2.9). Of the 12 paroxetine-exposed infants with cardiovascular malformations, had VSDs. This study also suggested an increased risk of overall major congenital malformations including cardiovascular defects for paroxetine (4% risk) compared to other (2% risk) antidepressants (OR 1.8; 95% confidence interval 1.2 to 2.8).3. Two large case-control studies using separate databases, each with >9,000 birth defect cases and >4,000 controls, found that maternal use of paroxetine during the first trimester of pregnancy was associated with 2- to 3-fold increased risk of right ventricular outflow tract obstructions. In one study the OR was 2.5 (95% confidence interval, to 6, exposed infants) and in the other study the OR was 3.3 (95% confidence interval, 1.3 to 8.8, exposed infants).Other studies have found varying results as to whether there was an increased risk of overall, cardiovascular, or specific congenital malformations. meta-analysis of epidemiological data over 16-year period (1992 to 2008) on first trimester paroxetine use in pregnancy and congenital malformations included the above-noted studies in addition to others (n 17 studies that included overall malformations and = 14 studies that included cardiovascular malformations; = 20 distinct studies). While subject to limitations, this meta-analysis suggested an increased occurrence of cardiovascular malformations (prevalence odds ratio [POR] 1.5; 95% confidence interval 1.2 to 1.9) and overall malformations (POR 1.2; 95% confidence interval 1.1 to 1.4) with paroxetine use during the first trimester. It was not possible in this meta-analysis to determine the extent to which the observed prevalence of cardiovascular malformations might have contributed to that of overall malformations, nor was it possible to determine whether any specific types of cardiovascular malformations might have contributed to the observed prevalence of all cardiovascular malformations. Unless the benefits of paroxetine to the mother justify continuing treatment, consideration should be given to either discontinuing paroxetine therapy or switching to another antidepressant [see Warnings and Precautions (5.7)]. For women who intend to become pregnant or are in their first trimester of pregnancy, paroxetine should only be initiated after consideration of the other available treatment options [see Warnings and Precautions (5.4)]. Treatment of Pregnant Women During Their Third Trimester: Neonates exposed to SSRIs or serotonin and norepinephrine reuptake inhibitors (SNRIs), including paroxetine, late in the third trimester have developed complications requiring prolonged hospitalization, respiratory support, and tube feeding. Such complications can arise immediately upon delivery. Reported clinical findings have included respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting, hypoglycemia, hypotonia, hypertonia, hyperreflexia, tremor, jitteriness, irritability, and constant crying. These features are consistent with either direct toxic effect of SSRIs and SNRIs or, possibly, drug discontinuation syndrome. It should be noted that, in some cases, the clinical picture is consistent with serotonin syndrome [see Warnings and Precautions (5.2)]. Exposure to SSRIs in late pregnancy may have an increased risk for persistent pulmonary hypertension of the newborn (PPHN). PPHN occurs in to per 1,000 live births in the general population and is associated with substantial neonatal morbidity and mortality. In retrospective case-control study of 377 women whose infants were born with PPHN and 836 women whose infants were born healthy, the risk for developing PPHN was approximately six-fold higher for infants exposed to SSRIs after the 20th week of gestation compared to infants who had not been exposed to antidepressants during pregnancy.There have also been postmarketing reports of premature births in pregnant women exposed to paroxetine or other SSRIs. When treating pregnant woman with paroxetine during the third trimester, the physician should carefully consider both the potential risks and benefits of treatment. prospective longitudinal study of 201 women with history of major depression who were euthymic at the beginning of pregnancy. The women who discontinued antidepressant medication during pregnancy were more likely to experience relapse of major depression than women who continued antidepressant medication.Animal FindingsReproduction studies were performed at doses up to 50 mg/kg/day in rats and mg/kg/day in rabbits administered during organogenesis. These doses are approximately (rat) and less than (rabbit) times the maximum recommended human dose (MRHD 75 mg) on an mg/m2 basis. These studies have revealed no evidence of developmental effects. However, in rats, there was an increase in pup deaths during the first days of lactation when dosing occurred during the last trimester of gestation and continued throughout lactation. This effect occurred at dose of mg/kg/day which is than the MRHD on an mg/m2 basis. The no-effect dose for rat pup mortality was not determined. The cause of these deaths is not known.. 1.A study based on Swedish national registry data demonstrated that infants exposed to paroxetine during pregnancy (n 815) had an increased risk of cardiovascular malformations (2% risk in paroxetine-exposed infants) compared to the entire registry population (1% risk), for an odds ratio (OR) of 1.8 (95% confidence interval 1.1 to 2.8). No increase in the risk of overall congenital malformations was seen in the paroxetine-exposed infants. The cardiac malformations in the paroxetine-exposed infants were primarily ventricular septal defects (VSDs) and atrial septal defects (ASDs). Septal defects range in severity from those that resolve spontaneously to those which require surgery.. 2.A separate retrospective cohort study from the United States (United Healthcare data) evaluated 5,956 infants of mothers dispensed antidepressants during the first trimester (n 815 for paroxetine). This study showed trend towards an increased risk for cardiovascular malformations for paroxetine (risk of 1.5%) compared to other antidepressants (risk of 1%), for an OR of 1.5 (95% confidence interval 0.8 to 2.9). Of the 12 paroxetine-exposed infants with cardiovascular malformations, had VSDs. This study also suggested an increased risk of overall major congenital malformations including cardiovascular defects for paroxetine (4% risk) compared to other (2% risk) antidepressants (OR 1.8; 95% confidence interval 1.2 to 2.8).. 3. Two large case-control studies using separate databases, each with >9,000 birth defect cases and >4,000 controls, found that maternal use of paroxetine during the first trimester of pregnancy was associated with 2- to 3-fold increased risk of right ventricular outflow tract obstructions. In one study the OR was 2.5 (95% confidence interval, to 6, exposed infants) and in the other study the OR was 3.3 (95% confidence interval, 1.3 to 8.8, exposed infants).. 8.3 Nursing Mothers. Like many other drugs, paroxetine is secreted in human milk. Because of the potential for serious adverse reactions in nursing infants from paroxetine, decision should be made whether to discontinue nursing infants or to discontinue the drug, taking into account the importance of the drug to the mother.. 8.4 Pediatric Use. The safety and effectiveness of paroxetine in pediatric patients have not been established [see Box Warning]. Effectiveness was not demonstrated in three placebo-controlled trials in 752 paroxetine-treated pediatric patients with MDD.Antidepressants increase the risk of suicidal thoughts and behaviors in pediatric patients[see Boxed Warning, Warnings and Precautions (5.1)]. Decreased appetite and weight loss have been observed in association with the use of SSRIs. In placebo-controlled clinical trials conducted with pediatric patients, the following adverse reactions were reported in at least 2% of pediatric patients treated with paroxetine and occurred at rate at least twice that for pediatric patients receiving placebo: emotional lability (including self-harm, suicidal thoughts, attempted suicide, crying, and mood fluctuations), hostility, decreased appetite, tremor, sweating, hyperkinesia, and agitation. Adverse reactions upon discontinuation of treatment with paroxetine in the pediatric clinical trials that included taper phase regimen, which occurred in at least 2% of patients and at rate at least twice that of placebo, were: emotional lability (including suicidal ideation, suicide attempt, mood changes, and tearfulness), nervousness, dizziness, nausea, and abdominal pain.. 8.5 Geriatric Use. In premarketing clinical trials with paroxetine, 17% of patients treated with paroxetine (approximately 700) were 65 years of age or older. Pharmacokinetic studies revealed decreased clearance in the elderly, and lower starting dose is recommended;, however, no overall differences in safety or effectiveness were observed between elderly and younger patients [see Dosage and Administration (2.4), Clinical Pharmacology (12.3)]. SSRIs including paroxetine, have been associated with cases of clinically significant hyponatremia in elderly patients, who may be at greater risk for this adverse reaction [see Warnings and Precautions (5.7)]. 8.6 Renal and Hepatic Impairment. Increased plasma concentrations of paroxetine occur in patients with renal and hepatic impairment. The initial dosage of paroxetine should be reduced in patients with severe renal impairment and in patients with severe hepatic impairment [see Dosage and Administration (2.4), Clinical Pharmacology (12.3)].

WARNINGS AND PRECAUTIONS SECTION.

5 WARNINGS AND PRECAUTIONS. 8.Serotonin Syndrome: Increased risk when co-administered with other serotonergic agents (e.g., SSRI, SNRI, triptans), but also when taken alone. If occurs, discontinue paroxetine tablets and initiate supportive measures. (5.2)9.Embryofetal and Neonatal Toxicity: Can cause fetal and neonatal harm. Increased risk of cardiovascular malformations with exposure during the first trimester. Exposure in late pregnancy may lead to an increased risk for persistent pulmonary hypertension of the newborn. (5.4, 8.1)10.Increased Risk of Bleeding: Concomitant use of aspirin, nonsteroidal anti- inflammatory drugs, other antiplatelet drugs, warfarin, and other anticoagulant drugs may increase risk. (5.5)11.Activation of Mania/Hypomania: Screen patients for bipolar disorder. (5.6)12.Seizures: Use with caution in patients with seizure disorders. (5.8)13.Angle-Closure Glaucoma: Angle-closure glaucoma has occurred in patients with untreated anatomically narrow angles treated with antidepressants. (5.9)14.Sexual Dysfunction: Paroxetine may cause symptoms of sexual dysfunction. (5.13). 8.Serotonin Syndrome: Increased risk when co-administered with other serotonergic agents (e.g., SSRI, SNRI, triptans), but also when taken alone. If occurs, discontinue paroxetine tablets and initiate supportive measures. (5.2). 9.Embryofetal and Neonatal Toxicity: Can cause fetal and neonatal harm. Increased risk of cardiovascular malformations with exposure during the first trimester. Exposure in late pregnancy may lead to an increased risk for persistent pulmonary hypertension of the newborn. (5.4, 8.1). 10.Increased Risk of Bleeding: Concomitant use of aspirin, nonsteroidal anti- inflammatory drugs, other antiplatelet drugs, warfarin, and other anticoagulant drugs may increase risk. (5.5). 11.Activation of Mania/Hypomania: Screen patients for bipolar disorder. (5.6). 12.Seizures: Use with caution in patients with seizure disorders. (5.8). 13.Angle-Closure Glaucoma: Angle-closure glaucoma has occurred in patients with untreated anatomically narrow angles treated with antidepressants. (5.9). 14.Sexual Dysfunction: Paroxetine may cause symptoms of sexual dysfunction. (5.13). 5.1 Suicidal Thoughts and Behaviors in Adolescents and Young Adults. In pooled analyses of placebo-controlled trials of antidepressant drugs (SSRIs and other antidepressant classes) that included approximately 77,000 adult patients and 4,500 pediatric patients, the incidence of suicidal thoughts and behaviors in antidepressant-treated patients age 24 years and younger was greater than in placebo-treated patients. There was considerable variation in risk of suicidal thoughts and behaviors among drugs, but there was an increased risk identified in young patients for most drugs studied. There were differences in absolute risk of suicidal thoughts and behaviors across the different indications, with the highest incidence in patients with MDD. The drug-placebo differences in the number of cases of suicidal thoughts and behaviors per 1,000 patients treated are provided in Table 2.Table 2: Risk Differences of the Number of Patients with Suicidal Thoughts and Behaviors in the Pooled Placebo-Controlled Trials of Antidepressants in Pediatric and Adult Patients Age RangeDrug-Placebo Difference in Number of Patients with Suicidal Thoughts and Behaviors per 1,000 Patients Treated Increases Compared to Placebo<18 years old14 additional cases18 to 24 years old5 additional cases Decreases Compared to Placebo25 to 64 years old1 fewer case >=65 years old6 fewer casesParoxetine is not approved for use in pediatric patients.It is unknown whether the risk of suicidal thoughts and behaviors in children, adolescents, and young adults extends to longer-term use, i.e., beyond four months. However, there is substantial evidence from placebo-controlled maintenance trials in adults with MDD that antidepressants delay the recurrence of depression and that depression itself is risk factor for suicidal thoughts and behaviors. Monitor all antidepressant-treated patients for any indication for clinical worsening and emergence of suicidal thoughts and behaviors, especially during the initial few months of drug therapy, and at times of dosage changes. Counsel family members or caregivers of patients to monitor for changes in behavior and to alert the healthcare provider. Consider changing the therapeutic regimen, including possibly discontinuing paroxetine, in patients whose depression is persistently worse, or who are experiencing emergent suicidal thoughts or behaviors.. 5.2 Serotonin Syndrome. SSRIs, including paroxetine can precipitate serotonin syndrome, potentially life-threatening condition. The risk is increased with concomitant use of other serotonergic drugs (including triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, amphetamines and St. Johns Wort) and with drugs that impair metabolism of serotonin, i.e., MAOIs [see Contraindications (4), Drug Interactions (7.1)]. Serotonin syndrome can also occur when these drugs are used alone.Serotonin syndrome symptoms may include mental status changes (e.g., agitation, hallucinations, delirium, and coma), autonomic instability (e.g., tachycardia, labile blood pressure, dizziness, diaphoresis, flushing, hyperthermia), neuromuscular symptoms (e.g., tremor, rigidity, myoclonus, hyperreflexia, incoordination), seizures, and/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea). The concomitant use of paroxetine with MAOIs is contraindicated. In addition, do not initiate paroxetine in patient being treated with MAOIs such as linezolid or intravenous methylene blue. No reports involved the administration of methylene blue by other routes (such as oral tablets or local tissue injection) or at lower doses. If it is necessary to initiate treatment with an MAOI such as linezolid or intravenous methylene blue in patient taking paroxetine discontinue paroxetine before initiating treatment with the MAOI [see Contraindications (4), Drug Interactions (7)]. Monitor all patients taking paroxetine for the emergence of serotonin syndrome. Discontinue treatment with paroxetine and any concomitant serotonergic agents immediately if the above symptoms occur, and initiate supportive symptomatic treatment. If concomitant use of paroxetine with other serotonergic drugs is clinically warranted, inform patients of the increased risk for serotonin syndrome and monitor for symptoms.. 5.3 Drug Interactions Leading to QT Prolongation. The CYP2D6 inhibitory properties of paroxetine can elevate plasma levels of thioridazine and pimozide. Since thioridazine and pimozide given alone produce prolongation of the QTc interval and increase the risk of serious ventricular arrhythmias, the use of paroxetine is contraindicated in combination with thioridazine and pimozide [see Contraindications (4), Drug Interactions (7), Clinical Pharmacology (12.3)]. 5.4 Embryofetal and Neonatal Toxicity. Paroxetine can cause fetal harm when administered to pregnant woman. Epidemiological studies have shown that infants exposed to paroxetine in the first trimester of pregnancy have an increased risk of cardiovascular malformations. Exposure to paroxetine in late pregnancy may lead to an increased risk for persistent pulmonary hypertension of the newborn (PPNH) and/or neonatal complications requiring prolonged hospitalization, respiratory support, and tube feeding. If paroxetine are used during pregnancy, or if the patient becomes pregnant while taking paroxetine,the patient should be apprised of the potential hazard to the fetus [see Use in Specific Populations (8.1 )]. 5.5 Increased Risk of Bleeding. Drugs that interfere with serotonin reuptake inhibition, including paroxetine, increase the risk of bleeding events. Concomitant use of aspirin, nonsteroidal anti-inflammatory drugs (NSAIDS), other antiplatelet drugs, warfarin, and other anticoagulants may add to this risk. Case reports and epidemiological studies (case-control and cohort design) have demonstrated an association between use of drugs that interfere with serotonin reuptake and the occurrence of gastrointestinal bleeding. Bleeding events related to drugs that interfere with serotonin reuptake have ranged from ecchymoses, hematomas, epistaxis, and petechiae to life-threatening hemorrhages. Inform patients about the increased risk of bleeding associated with the concomitant use of paroxetine and antiplatelet agents or anticoagulants. For patients taking warfarin, carefully monitor the international normalized ratio.. 5.6 Activation of Mania or Hypomania. In patients with bipolar disorder, treating depressive episode with paroxetine tablet or another antidepressant may precipitate mixed/mani episode. During controlled clinical trials of paroxetine, hypomania or mania occurred in approximately 1% of paroxetine-treated unipolar patients compared to 1.1% of active-control and 0.3% of placebo-treated unipolar patients. Prior to initiating treatment with paroxetine, screen patients for any personal or family history of bipolar disorder, mania, or hypomania.. 5.7 Discontinuation Syndrome. Adverse reactions after discontinuation of serotonergic antidepressants, particularly after abrupt discontinuation, include: nausea, sweating, dysphoric mood, irritability, agitation, dizziness, sensory disturbances (e.g., paresthesia, such as electric shock sensations), tremor, anxiety, confusion, headache, lethargy, emotional lability, insomnia, hypomania, tinnitus, and seizures. gradual reduction in dosage rather than abrupt cessation is recommended whenever possible [see Dosage and Administration (2.7)]. During clinical trials of GAD and PTSD, gradual decreases in the daily dose by 10 mg/day at weekly intervals followed by week at 20 mg/day was used before treatment was discontinued. The following adverse reactions were reported at an incidence of 2% or greater for paroxetine and were at least twice that reported for placebo: Abnormal dreams, paresthesia, and dizziness Adverse reactions have been reported upon discontinuation of treatment with paroxetine in pediatric patients. The safety and effectiveness of paroxetine in pediatric patients have not been established [see Boxed Warning, Warnings and Precautions (5.1), Use in Specific Populations (8.4)]. 5.8 Seizures. Paroxetine tablets have not been systematically evaluated in patients with seizure disorders. Patients with history of seizures were excluded from clinical studies. During clinical studies, seizures occurred in 0.1% of patients treated with paroxetine. Paroxetine should be prescribed with caution in patients with seizure disorder. Discontinue paroxetine in any patient who develops seizures.. 5.9 Angle-Closure Glaucoma. The pupillary dilation that occurs following use of many antidepressant drugs including paroxetine may trigger an angle closure attack in patient with anatomically narrow angles who does not have patent iridectomy. Cases of angle-closure glaucoma associated with use of paroxetine have been reported. Avoid use of antidepressants, including paroxetine in patients with untreated anatomically narrow angles.. 5.10 Hyponatremia. Hyponatremia may occur as result of treatment with SSRIs, including paroxetine. Cases with serum sodium lower than 110 mmol/L have been reported. Signs and symptoms of hyponatremia include headache, difficulty concentrating, memory impairment, confusion, weakness, and unsteadiness, which may lead to falls. Signs and symptoms associated with more severe and/or acute cases have included hallucination, syncope, seizure, coma, respiratory arrest, and death. In many cases, this hyponatremia appears to be the result of the syndrome of inappropriate antidiuretic hormone secretion (SIADH).In patients with symptomatic hyponatremia, discontinue paroxetine tablet and institute appropriate medical intervention. Elderly patients, patients taking diuretics, and those who are volume-depleted may be at greater risk of developing hyponatremia with SSRIs [see Use in Specific Populations (8.5)]. 5.11 Reduction of Efficacy of Tamoxifen. Some studies have shown that the efficacy of tamoxifen, as measured by the risk of breast cancer relapse/mortality, may be reduced with concomitant use of paroxetine as result of paroxetines irreversible inhibition of CYP2D6 and lower blood levels of tamoxifen [see Drug Interactions (7)]. One study suggests that the risk may increase with longer duration of coadministration. However, other studies have failed to demonstrate such risk. When tamoxifen is used for the treatment or prevention of breast cancer, prescribers should consider using an alternative antidepressant with little or no CYP2D6 inhibition.. 5.12 Bone Fracture. Epidemiological studies on bone fracture risk during exposure to some antidepressants, including SSRIs, have reported an association between antidepressant treatment and fractures. There are multiple possible causes for this observation,and it is unknown to what extent fracture risk is directly attributable to SSRI treatment.. 5.13 Sexual Dysfunction Use of SSRIs, including paroxetine, may cause symptoms of sexual dysfunction [see Adverse Reactions (6.1)]. In male patients, SSRI use may result in ejaculatory delay or failure, decreased libido, and erectile dysfunction. In female patients, SSRI use may result in decreased libido and delayed or absent orgasm. It is important for prescribers to inquire about sexual function prior to initiation of paroxetine and to inquire specifically about changes in sexual function during treatment, because sexual function may not be spontaneously reported. When evaluating changes in sexual function, obtaining detailed history (including timing of symptom onset) is important because sexual symptoms may have other causes, including the underlying psychiatric disorder. Discuss potential management strategies to support patients in making informed decisions about treatment.