NURSING MOTHERS SECTION.

Nursing Mothers: It is not known whether topical administration of corticosteroids could result in sufficient systemic absorption to produce detectable quantities in breast milk. Systemically administered corticosteroids appear in breast milk and could suppress growth, interfere with endogenous corticosteroid production, or cause untoward effects. Because of the potential for serious adverse reactions in nursing infants from PRED-G (R), decision should be made whether to discontinue nursing while the drug is being administered or to discontinue the medication.

PRECAUTIONS SECTION.

PRECAUTIONS. General: Ocular irritation and punctate keratitis have been associated with the use of PRED-G (R) ophthalmic ointment. The initial prescription and renewal of the medication order beyond grams should be made by physician only after examination of the patients intraocular pressure, examination of the patient with the aid of magnification, such as slit lamp biomicroscopy and, where appropriate, fluorescein staining.As fungal infections of the cornea are particularly prone to develop coincidentally with long term corticosteroid applications, fungal invasion should be suspected in any persistent corneal ulceration where corticosteroid has been used or is in use. Fungal cultures should be taken when appropriate.. Information for Patients: If inflammation or pain persists longer than 48 hours or becomes aggravated the patient should be advised to discontinue use of the medication and consult physician.This product is sterile when packaged. To prevent contamination care should be taken to avoid touching the tip of the tube to eyelids or to any other surface. The use of this tube by more than one person may spread infection. Keep out of reach of children.. Carcinogenesis, mutagenesis, impairment of fertility: There are no published carcinogenicity or impairment of fertility studies on gentamicin. Aminoglycoside antibiotics have been found to be non-mutagenic.There are no published mutagenicity or impairment of fertility studies on prednisolone. Prednisolone has been reported to be non-carcinogenic.. Pregnancy: Gentamicin has been shown to depress newborn body weights, kidney weights, and median glomerular counts in newborn rats when administered systemically to pregnant rats in daily doses of approximately 500 times the maximum recommended ophthalmic dose in humans. There are no adequate and well controlled studies in pregnant women. Gentamicin should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.Prednisolone has been shown to be teratogenic in mice when given in doses 1-10 times the human ocular dose. Dexamethasone, hydrocortisone and prednisolone were ocularly applied to both eyes of pregnant mice five times per day on days 10 through 13 of gestation. significant increase in the incidence of cleft palate was observed in the fetuses of the treated mice. There are no adequate well-controlled studies in pregnant women. PRED-G (R) ophthalmic ointment should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.. Nursing Mothers: It is not known whether topical administration of corticosteroids could result in sufficient systemic absorption to produce detectable quantities in breast milk. Systemically administered corticosteroids appear in breast milk and could suppress growth, interfere with endogenous corticosteroid production, or cause untoward effects. Because of the potential for serious adverse reactions in nursing infants from PRED-G (R), decision should be made whether to discontinue nursing while the drug is being administered or to discontinue the medication.. Pediatric Use: Safety and effectiveness in pediatric patients have not been established.. Geriatric Use: No overall differences in safety or effectiveness have been observed between elderly and young patients.

ADVERSE REACTIONS SECTION.

ADVERSE REACTIONS. Adverse reactions have occurred with steroid/anti-infective combination drugs which can be attributed to the steroid component, the anti-infective component, or the combination. Exact incidence figures are not available since no denominator of treated patients is available.The most frequent reactions observed include ocular discomfort, irritation upon instillation of the medication and punctate keratitis. These reactions have resolved upon discontinuation of the medication. Other reactions reported with PRED-G (R) include eye burning, eye stinging, ocular hyperemia, eye pain, eye discharge, lacrimation increased, eye edema, visual impairment, blurry vision, foreign body sensation in eyes, and dysgeusia. Hypersensitivity including signs and symptoms related to ocular allergy (e.g. conjunctivitis), angioedema (e.g. tongue edema) and allergic skin reactions (e.g. rash and contact allergy) has also been reported.Reactions occurring most often from the presence of the anti-infective ingredient are allergic sensitizations. The reactions due to the steroid component in decreasing order of frequency are: elevation of intraocular pressure (IOP) with possible development of glaucoma, and infrequent optic nerve damage; posterior subcapsular cataract formation; and delayed wound healing.Secondary Infection: The development of secondary ocular infection has occurred after use of combinations containing steroids and antimicrobials. Fungal and viral infections of the cornea are particularly prone to develop coincidentally with long-term applications of steroid. The possibility of fungal invasion must be considered in any persistent corneal ulceration where steroid treatment has been used. (See WARNINGS) Secondary bacterial ocular infection following suppression of host responses also occurs.

CLINICAL PHARMACOLOGY SECTION.

CLINICAL PHARMACOLOGY. Corticosteroids suppress the inflammatory response to variety of agents and they probably delay or slow healing. Since corticosteroids may inhibit the bodys defense mechanism against infection, concomitant antimicrobial drug may be used when this inhibition is considered to be clinically significant in particular case.The anti-infective component in PRED-G (R) ophthalmic ointment is included to provide action against specific organisms susceptible to it. Gentamicin sulfate is active in vitro against susceptible strains of the following microorganisms: Staphylococcus aureus, Streptococcus pyogenes, Streptococcus pneumoniae, Enterobacter aerogenes, Escherichia coli, Haemophilus influenzae, Klebsiella pneumoniae, Neisseria gonorrhoeae, Pseudomonas aeruginosa, and Serratia marcescens.When decision to administer both corticosteroid and an antimicrobial is made, the administration of such drugs in combination has the advantage of greater patient compliance and convenience, with the added assurance that the appropriate dosage of both drugs is administered. When both types of drugs are in the same formulation, compatibility of ingredients is assured and the correct volume of drug is delivered and retained.The relative potency of corticosteroids depends on the molecular structure, concentration, and release from the vehicle.

GENERAL PRECAUTIONS SECTION.

General: Ocular irritation and punctate keratitis have been associated with the use of PRED-G (R) ophthalmic ointment. The initial prescription and renewal of the medication order beyond grams should be made by physician only after examination of the patients intraocular pressure, examination of the patient with the aid of magnification, such as slit lamp biomicroscopy and, where appropriate, fluorescein staining.As fungal infections of the cornea are particularly prone to develop coincidentally with long term corticosteroid applications, fungal invasion should be suspected in any persistent corneal ulceration where corticosteroid has been used or is in use. Fungal cultures should be taken when appropriate.

INDICATIONS & USAGE SECTION.

INDICATIONS AND USAGE. PRED-G(R) ophthalmic ointment is indicated for steroid-responsive inflammatory ocular conditions for which corticosteroid is indicated and where superficial bacterial ocular infection or risk of bacterial ocular infection exists.Ocular steroids are indicated in inflammatory conditions of the palpebral and bulbar conjunctiva, cornea, and anterior segment of the globe where the inherent risk of steroid use in certain infective conjunctivitides is accepted to obtain diminution in edema and inflammation. They are also indicated in chronic anterior uveitis and corneal injury from chemical, radiation, or thermal burns or penetration of foreign bodies.The use of combination drug with an anti-infective component is indicated where the risk of superficial ocular infection is high or where there is an expectation that potentially dangerous numbers of bacteria will be present in the eye.The particular anti-infective drug in this product is active against the following common bacterial eye pathogens: Staphylococcus aureaus, Streptococcus pyogenes, Streptococcus pneumoniae, Enterobacter aerogenes, Escherichia coli, Haemophilus influenzae, Klebsiella pneumoniae, Neisseria gonorrhoeae, Pseudomonas aeruginosa, and Serratia marcescens.

PREGNANCY SECTION.

Pregnancy: Gentamicin has been shown to depress newborn body weights, kidney weights, and median glomerular counts in newborn rats when administered systemically to pregnant rats in daily doses of approximately 500 times the maximum recommended ophthalmic dose in humans. There are no adequate and well controlled studies in pregnant women. Gentamicin should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.Prednisolone has been shown to be teratogenic in mice when given in doses 1-10 times the human ocular dose. Dexamethasone, hydrocortisone and prednisolone were ocularly applied to both eyes of pregnant mice five times per day on days 10 through 13 of gestation. significant increase in the incidence of cleft palate was observed in the fetuses of the treated mice. There are no adequate well-controlled studies in pregnant women. PRED-G (R) ophthalmic ointment should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

SPL UNCLASSIFIED SECTION.

PRED-G(R)(gentamicin and prednisolone acetate ophthalmic ointment, USP) 0.3%/0.6%sterilePRED-G(R) sterile ophthalmic ointment is topical anti-inflammatory/anti-infective combination product for ophthalmic use.Structural Formulas:Chemical Names: Prednisolone acetate: 11ss,17,21-Trihydroxypregna-1,4-diene-3,20-dione 21-acetate.Gentamicin sulfate is the sulfate salt of gentamicin C1, gentamicin C2, and gentamicin C1A which are produced by the growth of Micromonospora purpurea.Contains: Actives: gentamicin sulfate equivalent to 0.3% gentamicin base, prednisolone acetate 0.6%; Preservative: chlorobutanol (chloral derivative) 0.5%; Inactives: mineral oil; petrolatum (and) lanolin alcohol; purified water; and white petrolatum.. Structural Formulas.

WARNINGS SECTION.

WARNINGS. Prolonged use of corticosteroids may result in glaucoma, with damage to the optic nerve, defects in visual acuity and fields of vision, and in posterior subcapsular cataract formation. Prolonged use of corticosteroids may suppress the host immune response and thus increase the hazard of secondary ocular infections. Various ocular diseases and long term use of topical corticosteroids have been known to cause corneal and scleral thinning. Use of topical corticosteroids in the presence of thin corneal or scleral tissue may lead to perforation. Acute purulent infections of the eye may be masked or enhanced by the presence of corticosteroid medication. If these products are used for 10 days or longer, intraocular pressure should be routinely monitored even though it may be difficult in children and uncooperative patients. Steroids should be used with caution in the presence of glaucoma. Intraocular pressure should be checked frequently.The use of steroids after cataract surgery may delay healing and increase the incidence of bleb formation.Use of ocular steroids may prolong the course and may exacerbate the severity of many viral infections of the eye (including herpes simplex). Employment of corticosteroid medication in the treatment of patients with history of herpes simplex requires great caution, frequent slit lamp microscopy is recommended.