DEPENDENCE SECTION.

9.3 Dependence. ToleranceTolerance (a state of adaptation in which exposure to drug results in reduction of the drugs desired and/or undesired effects over time) can occur during chronic therapy with CNS stimulants, including Ritalin and Ritalin-SR.DependencePhysical dependence (which is manifested by withdrawal syndrome produced by abrupt cessation, rapid dose reduction, or administration of an antagonist) may occur in patients treated with CNS stimulants, including Ritalin and Ritalin-SR. Withdrawal symptoms after abrupt cessation following prolonged high-dosage administration of CNS stimulants include dysphoric mood; fatigue; vivid, unpleasant dreams; insomnia or hypersomnia; increased appetite; and psychomotor retardation or agitation.

PACKAGE LABEL.PRINCIPAL DISPLAY PANEL.

PRINCIPAL DISPLAY PANEL. NDC 0078-0439-05Ritalin(R) HCLmethylphenidate HCL USP5 mg100 tabletsRx onlyDispense with Medication Guideattached or provided separately.NOVARTIS. PRINCIPAL DISPLAY PANELNDC 0078-0439-05Ritalin(R) HCLmethylphenidate HCL USP5 mg100 tabletsRx onlyDispense with Medication Guide attached or provided separately.NOVARTIS.

ABUSE SECTION.

9.2 Abuse. CNS stimulants, including Ritalin and Ritalin-SR, have high potential for abuse. Abuse is characterized by impaired control over drug use despite harm, and craving.Signs and symptoms of CNS stimulant abuse include increased heart rate, respiratory rate, blood pressure, and/or sweating, dilated pupils, hyperactivity, restlessness, insomnia, decreased appetite, loss of coordination, tremors, flushed skin, vomiting, and/or abdominal pain. Anxiety, psychosis, hostility, aggression, and suicidal or homicidal ideation have also been observed. Abusers of CNS stimulants may chew, snort, inject, or use other unapproved routes of administration which may result in overdose and death [see Overdosage (10)].To reduce the abuse of CNS stimulants, including Ritalin and Ritalin-SR, assess the risk of abuse prior to prescribing. After prescribing, keep careful prescription records, educate patients and their families about abuse and on proper storage and disposal of CNS stimulants [see How Supplied/Storage and Handling (16)], monitor for signs of abuse while on therapy, and reevaluate the need for Ritalin and Ritalin-SR use.

ADVERSE REACTIONS SECTION.

6 ADVERSE REACTIONS. The following are discussed in more detail in other sections of the labeling:Abuse and Dependence [see Boxed Warning, Warnings and Precautions (5.1), Drug Abuse and Dependence (9.2, 9.3)] Known hypersensitivity to methylphenidate or other ingredients of Ritalin and Ritalin-SR [see Contraindications (4)] Hypertensive crisis with Concomitant Use of Monoamine Oxidase Inhibitors [see Contraindications (4), Drug Interactions (7.1)] Serious Cardiovascular Reactions [see Warnings and Precautions (5.2)] Blood Pressure and Heart Rate Increases [see Warnings and Precautions (5.3)] Psychiatric Adverse Reactions [see Warnings and Precautions (5.4)] Priapism [see Warnings and Precautions (5.5)] Peripheral Vasculopathy, Including Raynauds Phenomenon [see Warnings and Precautions (5.6)] Long-Term Suppression of Growth [see Warnings and Precautions (5.7)] The following adverse reactions associated with the use of Ritalin, Ritalin-SR, and other methylphenidate products were identified in clinical trials, spontaneous reports, and literature. Because these reactions were reported voluntarily from population of uncertain size, it is not always possible to estimate their frequency reliably or to establish causal relationship to drug exposure.Adverse Reactions Reported With Ritalin and Ritalin-SRInfections and Infestations: nasopharyngitisBlood and the Lymphatic System Disorders: leukopenia, thrombocytopenia, anemiaImmune System Disorders: hypersensitivity reactions, including angioedema, and anaphylaxisMetabolism and Nutrition Disorders: decreased appetite, reduced weight gain, and suppression of growth during prolonged use in pediatric patientsPsychiatric Disorders: insomnia, anxiety, restlessness, agitation, psychosis (sometimes with visual and tactile hallucinations), depressed moodNervous System Disorders: headache, dizziness, tremor, dyskinesia, including choreoatheetoid movements, drowsiness, convulsions, cerebrovascular disorders (including vasculitis, cerebral hemorrhages and cerebrovascular accidents), serotonin syndrome in combination with serotonergic drugsEye Disorders: blurred vision, difficulties in visual accommodationCardiac Disorders: tachycardia, palpitations, increased blood pressure, arrhythmias, angina pectorisRespiratory, Thoracic, and Mediastinal Disorders: coughGastrointestinal Disorders: dry mouth, nausea, vomiting, abdominal pain, dyspepsiaHepatobiliary Disorders: abnormal liver function, ranging from transaminase elevation to severe hepatic injurySkin and Subcutaneous Tissue Disorders: hyperhidrosis, pruritus, urticaria, exfoliative dermatitis, scalp hair loss, erythema multiforme rash, thrombocytopenic purpuraMusculoskeletal and Connective Tissue Disorders: arthralgia, muscle cramps, rhabdomyolysisInvestigations: weight loss (adult ADHD patients)Additional Adverse Reactions Reported with Other Methylphenidate-Containing ProductsThe list below shows adverse reactions not listed for Ritalin and Ritalin-SR that have been reported with other methylphenidate-containing products.Blood and Lymphatic Disorders: pancytopeniaImmune System Disorders: hypersensitivity reactions, such as auricular swelling, bullous conditions, eruptions, exanthemasPsychiatric Disorders: affect lability, mania, disorientation, and libido changesNervous System Disorders: migraineEye Disorders: diplopia, mydriasisCardiac Disorders: sudden cardiac death, myocardial infarction, bradycardia, extrasystoleVascular Disorders: peripheral coldness, Raynauds phenomenonRespiratory, Thoracic, and Mediastinal Disorders: pharyngolaryngeal pain, dyspneaGastrointestinal Disorders: diarrhea, constipationSkin and Subcutaneous Tissue Disorders: angioneurotic edema, erythema, fixed drug eruptionMusculoskeletal, Connective Tissue, and Bone Disorders: myalgia, muscle twitchingRenal and Urinary Disorders: hematuriaReproductive System and Breast Disorders: gynecomastiaGeneral Disorders: fatigue, hyperpyrexiaUrogenital Disorders: priapism. Abuse and Dependence [see Boxed Warning, Warnings and Precautions (5.1), Drug Abuse and Dependence (9.2, 9.3)] Known hypersensitivity to methylphenidate or other ingredients of Ritalin and Ritalin-SR [see Contraindications (4)] Hypertensive crisis with Concomitant Use of Monoamine Oxidase Inhibitors [see Contraindications (4), Drug Interactions (7.1)] Serious Cardiovascular Reactions [see Warnings and Precautions (5.2)] Blood Pressure and Heart Rate Increases [see Warnings and Precautions (5.3)] Psychiatric Adverse Reactions [see Warnings and Precautions (5.4)] Priapism [see Warnings and Precautions (5.5)] Peripheral Vasculopathy, Including Raynauds Phenomenon [see Warnings and Precautions (5.6)] Long-Term Suppression of Growth [see Warnings and Precautions (5.7)] Common adverse reactions: tachycardia, palpitations, headache, insomnia, anxiety, hyperhidrosis, weight loss, decreased appetite, dry mouth, nausea, and abdominal pain. (6)To report SUSPECTED ADVERSE REACTIONS, contact Novartis Pharmaceuticals Corporation at 1-888-669-6682 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

BOXED WARNING SECTION.

WARNING: ABUSE AND DEPENDENCE. CNS stimulants, including Ritalin and Ritalin-SR, other methylphenidate-containing products, and amphetamines, have high potential for abuse and dependence. Assess the risk of abuse prior to prescribing, and monitor for signs of abuse and dependence while on therapy [see Warnings and Precautions (5.1), Drug Abuse and Dependence (9.2, 9.3)].. WARNING: ABUSE AND DEPENDENCESee full prescribing information for complete boxed warning.CNS stimulants, including Ritalin and Ritalin-SR, other methylphenidate-containing products, and amphetamines, have high potential for abuse and dependence. (5.1, 9.2, 9.3)Assess the risk of abuse prior to prescribing, and monitor for signs of abuse and dependence while on therapy. (5.1, 9.2). CNS stimulants, including Ritalin and Ritalin-SR, other methylphenidate-containing products, and amphetamines, have high potential for abuse and dependence. (5.1, 9.2, 9.3). Assess the risk of abuse prior to prescribing, and monitor for signs of abuse and dependence while on therapy. (5.1, 9.2).

CARCINOGENESIS & MUTAGENESIS & IMPAIRMENT OF FERTILITY SECTION.

13.1 Carcinogenesis, Mutagenesis, and Impairment of Fertility. CarcinogenesisIn lifetime carcinogenicity study carried out in B6C3F1 mice, methylphenidate caused an increase in hepatocellular adenomas, and in males only, an increase in hepatoblastomas at daily dose of approximately 60 mg/kg/day. This dose is approximately times the MRHD of 60 mg/day given to children on mg/m2 basis. Hepatoblastoma is relatively rare rodent malignant tumor type. There was no increase in total malignant hepatic tumors. The mouse strain used is sensitive to the development of hepatic tumors and the significance of these results to humans is unknown.Methylphenidate did not cause any increase in tumors in lifetime carcinogenicity study carried out in F344 rats; the highest dose used was approximately 45 mg/kg/day, which is approximately times the MRHD (children) on mg/m2 basis.In 24-week carcinogenicity study in the transgenic mouse strain p53+/-, which is sensitive to genotoxic carcinogens, there was no evidence of carcinogenicity. Male and female mice were fed diets containing the same concentration of methylphenidate as in the lifetime carcinogenicity study; the high-dose groups were exposed to 60 to 74 mg/kg/day of methylphenidate.MutagenesisMethylphenidate was not mutagenic in the in vitro Ames reverse mutation assay, in the in vitro mouse lymphoma cell forward mutation assay, or in the in vitro chromosomal aberration assay using human lymphocytes. Sister chromatid exchanges and chromosome aberrations were increased, indicative of weak clastogenic response, in an in vitro assay in cultured Chinese Hamster Ovary cells. Methylphenidate was negative in vivo in males and females in the mouse bone marrow micronucleus assay.Impairment of FertilityNo human data on the effect of methylphenidate on fertility are available. Methylphenidate did not impair fertility in male or female mice that were fed diets containing the drug in an 18-week continuous breeding study. The study was conducted at doses up to 160 mg/kg/day, approximately 10times the MRHD of 60 mg/day given to adolescents on mg/m2 basis.

CLINICAL PHARMACOLOGY SECTION.

12 CLINICAL PHARMACOLOGY. 12.1 Mechanism of Action. Methylphenidate hydrochloride is CNS stimulant. The mode of therapeutic action in ADHD and narcolepsy is not known.. 12.2 Pharmacodynamics. Methylphenidate is racemic mixture comprised of the d- and l-threo enantiomers. The d-threo enantiomer is more pharmacologically active than the l-threo enantiomer. Methylphenidate blocks the reuptake of norepinephrine and dopamine into the presynaptic neuron and increase the release of these monoamines into the extraneuronal space.Cardiac ElectrophysiologyA formal QT study has not been conducted in patients taking Ritalin and Ritalin-SR.The effect of dexmethylphenidate, the pharmacologically active d-enantiomer of Ritalin, on the QT interval was evaluated in double-blind, placebo- and open-label active (moxifloxacin)-controlled study following single doses of dexmethlyphenidate XR 40 mg (maximum recommended adult total daily dosage) in 75 healthy volunteers. Electrocardiograms were collected up to 12 hours postdose. Fredericas method for heart rate correction was employed to derive the corrected QT interval (QTcF). The maximum mean prolongation of QTcF intervals was less than ms, and the upper limit of the 90% confidence interval was below 10 ms for all time-matched comparisons versus placebo. This was below the threshold of clinical concern and there was no evident exposure response relationship.. 12.3 Pharmacokinetics. AbsorptionRitalin in the SR tablets is more slowly but as extensively absorbed as in the regular tablets. Relative bioavailability of the SR tablet compared to the Ritalin tablet, measured by the urinary excretion of Ritalin major metabolite (-phenyl-2-piperidine acetic acid) was 105% (49% to 168%) in children and 101% (85% to 152%) in adults. The time to peak rate in children was 1.9 hours (0.3 to 4.4 hours) for the Ritalin tablets and 4.7 hours (1.3 to 8.2 hours) for the Ritalin-SR tablets. An average of 67% of SR tablet dose was excreted in children as compared to 86% in adults.Effect of FoodAfter high-fat meal, both area under the curve (by 25 %) and Cmax (by 27 %) are higher. Time to Cmax (Tmax) is faster after high-fat meal (median Tmax: 2.5 hours) as compared to without food (median Tmax: hours).DistributionBinding to plasma proteins is low (10% to 33%). The volume of distribution was 2.65 +- 1.11 L/kg for d-methylphenidate and 1.80 +- 0.91 L/kg for l-methylphenidate.EliminationThe systemic clearance is 0.40 +- 0.12 L/h/kg for d-methylphenidate and 0.73 +- 0.28 L/h/kg for l-methylphenidate.MetabolismMethylphenidate is metabolized primarily by de-esterification to alpha-phenyl-piperidine acetic acid (ritalinic acid), which has little or no pharmacologic activity.ExcretionAfter oral administration, 78% to 97% of the dose is excreted in the urine and 1% to 3% in feces in the form of metabolites within 48 to 96 hours. Most of the dose is excreted in the urine as alpha-phenyl-2-piperidine acetic acid (60% to 86%). The cumulative urinary excretion of alpha-phenyl-2-piperidine acetic acid are not significantly different for Ritalin-SR tablets.Studies in Specific PopulationsMale and Female PatientsIn clinical study involving adult subjects who received Ritalin-SR, plasma concentrations of Ritalins major metabolite appeared to be greater in females than in males. No gender differences were observed for Ritalin plasma concentration in the same subjects.Racial or Ethnic GroupsThere is insufficient experience with the use of Ritalin and Ritalin-SR to detect ethnic variations in pharmacokinetics.Patients with Renal ImpairmentRitalin has not been studied in renally-impaired patients. Renal impairment is expected to have minimal effect on the pharmacokinetics of methylphenidate since less than 1% of radiolabeled dose is excreted in the urine as unchanged compound, and the major metabolite (ritalinic acid), has little or no pharmacologic activity.Patients with Hepatic ImpairmentRitalin has not been studied in patients with hepatic impairment. Hepatic impairment is expected to have minimal effect on the pharmacokinetics of methylphenidate since it is metabolized primarily to ritalinic acid by nonmicrosomal hydrolytic esterases that are widely distributed throughout the body.

CONTRAINDICATIONS SECTION.

4 CONTRAINDICATIONS. Hypersensitivity to methylphenidate or other components of Ritalin or Ritalin-SR. Hypersensitivity reactions, such as angioedema and anaphylactic reactions, have been reported in patients treated with methylphenidate [see Adverse Reactions (6.1)].Concomitant treatment with monoamine oxidase inhibitors (MAOIs), or within 14 days following discontinuation of treatment with an MAOI, because of the risk of hypertensive crises [see Drug Interactions (7.1)].. Hypersensitivity to methylphenidate or other components of Ritalin or Ritalin-SR. Hypersensitivity reactions, such as angioedema and anaphylactic reactions, have been reported in patients treated with methylphenidate [see Adverse Reactions (6.1)].. Concomitant treatment with monoamine oxidase inhibitors (MAOIs), or within 14 days following discontinuation of treatment with an MAOI, because of the risk of hypertensive crises [see Drug Interactions (7.1)].. Known hypersensitivity to methylphenidate or other product components of Ritalin or Ritalin-SR. (4)Concurrent treatment with monoamine oxidase inhibitor (MAOI), or use of an MAOI within the preceding 14 days. (4). Known hypersensitivity to methylphenidate or other product components of Ritalin or Ritalin-SR. (4). Concurrent treatment with monoamine oxidase inhibitor (MAOI), or use of an MAOI within the preceding 14 days. (4).

CONTROLLED SUBSTANCE SECTION.

9.1 Controlled Substance. Ritalin and Ritalin-SR contain methylphenidate hydrochloride, Schedule II controlled substance.

DESCRIPTION SECTION.

11 DESCRIPTION. Ritalin contains methylphenidate hydrochloride, CNS stimulant. It is available as tablets of mg, 10 mg, and 20 mg strength for oral administration.Ritalin-SR contains methylphenidate hydrochloride, CNS stimulant. It is available as extended-release tablets of 20 mg strength for oral administration. Methylphenidate hydrochloride is methyl -phenyl-2-piperidineacetate hydrochloride, and its structural formula is: Methylphenidate hydrochloride USP is white, odorless, fine crystalline powder. Its solutions are acid to litmus. It is freely soluble in water and in methanol, soluble in alcohol, and slightly soluble in chloroform and in acetone. Its molecular weight is 269.77 g/mol.Ritalin tablets contains the following inactive ingredients: D&C Yellow No. 10 (5-mg and 20-mg tablets), FD&C Green No. (10-mg tablets), lactose, magnesium stearate, polyethylene glycol, starch (5-mg and 10-mg tablets), sucrose, talc, and tragacanth (20-mg tablets).Ritalin-SR extended-release tablets contains the following inactive ingredients: Cetostearyl alcohol, lactose, magnesium stearate, mineral oil, povidone, titanium dioxide, and zein.. Methylphenidate hydrochloride structural formula.

DOSAGE & ADMINISTRATION SECTION.

2 DOSAGE AND ADMINISTRATION. Ritalin Tablets (2.2):Pediatric Patients Years and Older: Start with mg twice daily (before breakfast and lunch), titrating the dose weekly in 5- to 10-mg increments. Dosages above 60 mg/day are not recommended.Adults: Average daily dosage is 20 mg to 30 mg, administered or times daily, preferably 30 to 45 minutes before meals. Maximum total daily dosage is 60 mg.Ritalin-SR Extended-Release Tablets (2.2):May switch to Ritalin-SR when the 8-hour dosage of Ritalin-SR corresponds to the titrated 8-hour dosage of Ritalin.Must be swallowed whole and never crushed or chewed.. Pediatric Patients Years and Older: Start with mg twice daily (before breakfast and lunch), titrating the dose weekly in 5- to 10-mg increments. Dosages above 60 mg/day are not recommended.. Adults: Average daily dosage is 20 mg to 30 mg, administered or times daily, preferably 30 to 45 minutes before meals. Maximum total daily dosage is 60 mg.. May switch to Ritalin-SR when the 8-hour dosage of Ritalin-SR corresponds to the titrated 8-hour dosage of Ritalin.. Must be swallowed whole and never crushed or chewed.. 2.1 Pretreatment Screening. Prior to treating pediatric patients and adults with central nervous system (CNS) stimulants, including Ritalin or Ritalin-SR, assess for the presence of cardiac disease (i.e., perform careful history, including family history of sudden death or ventricular arrhythmia, and physical examination) [see Warnings and Precautions (5.2)].Assess the risk of abuse prior to prescribing, and monitor for signs of abuse and dependence while on therapy. Maintain careful prescription records, educate patients about abuse, monitor for signs of abuse and overdose, and periodically reevaluate the need for Ritalin or Ritalin-SR use [see Boxed Warning, Warnings and Precautions (5.1), Drug Abuse and Dependence (9.2, 9.3)].. 2.2 General Dosing Information. Ritalin TabletsPediatric Patients years and Older: Start with mg orally twice daily (before breakfast and lunch). Increase dosage gradually, in increments of 5-to 10-mg weekly. Daily dosage above 60 mg is not recommended.Adults: Average dosage is 20 to 30 mg daily. Administer orally in divided doses or times daily, preferably 30 to 45 minutes before meals. Maximum total daily dosage is 60 mg. Patients who are unable to sleep if medication is taken late in the day should take the last dose before p.m.Ritalin-SR TabletsRitalin-SR tablets have duration of action of approximately hours. Therefore, Ritalin-SR tablets may be used in place of Ritalin tablets when the 8-hour dosage of Ritalin-SR corresponds to the titrated 8-hour dosage of Ritalin. Ritalin-SR tablets must be swallowed whole and never crushed or chewed.Pharmacological treatment of ADHD may be needed for extended periods. Periodically reevaluate the long-term use of Ritalin and Ritalin-SR, and adjust dosage as needed.. 2.3 Dose Reduction and Discontinuation. If paradoxical worsening of symptoms or other adverse reactions occur, reduce the dosage, or, if necessary, discontinue Ritalin or Ritalin-SR. If improvement is not observed after appropriate dosage adjustment over one-month period, the drug should be discontinued.

DOSAGE FORMS & STRENGTHS SECTION.

3 DOSAGE FORMS AND STRENGTHS. Tablets5 mg, round, yellow, flat with CIBA monograpm on one side and NDC on the reverse side10 mg, round, pale green, biconvex with CIBA monograpm on one side and NDC and partial bisection on the reverse side20 mg, round, pale yellow, biconvex with CIBA monograpm on one side and NDC 34 and partial bisection on the reverse sideExtended-Release Tablets20 mg extended-release tablets, white to off-white, round, bicinvex, film coated with the CIBA monograpm and 16 on one side printed in black ink. mg, round, yellow, flat with CIBA monograpm on one side and NDC on the reverse side. 10 mg, round, pale green, biconvex with CIBA monograpm on one side and NDC and partial bisection on the reverse side. 20 mg, round, pale yellow, biconvex with CIBA monograpm on one side and NDC 34 and partial bisection on the reverse side. 20 mg extended-release tablets, white to off-white, round, bicinvex, film coated with the CIBA monograpm and 16 on one side printed in black ink. Tablets: mg, 10 mg, and 20 mg (3)Extended-Release Tablets: 20 mg (3). Tablets: mg, 10 mg, and 20 mg (3). Extended-Release Tablets: 20 mg (3).

DRUG ABUSE AND DEPENDENCE SECTION.

9 DRUG ABUSE AND DEPENDENCE. 9.1 Controlled Substance. Ritalin and Ritalin-SR contain methylphenidate hydrochloride, Schedule II controlled substance.. 9.2 Abuse. CNS stimulants, including Ritalin and Ritalin-SR, have high potential for abuse. Abuse is characterized by impaired control over drug use despite harm, and craving.Signs and symptoms of CNS stimulant abuse include increased heart rate, respiratory rate, blood pressure, and/or sweating, dilated pupils, hyperactivity, restlessness, insomnia, decreased appetite, loss of coordination, tremors, flushed skin, vomiting, and/or abdominal pain. Anxiety, psychosis, hostility, aggression, and suicidal or homicidal ideation have also been observed. Abusers of CNS stimulants may chew, snort, inject, or use other unapproved routes of administration which may result in overdose and death [see Overdosage (10)].To reduce the abuse of CNS stimulants, including Ritalin and Ritalin-SR, assess the risk of abuse prior to prescribing. After prescribing, keep careful prescription records, educate patients and their families about abuse and on proper storage and disposal of CNS stimulants [see How Supplied/Storage and Handling (16)], monitor for signs of abuse while on therapy, and reevaluate the need for Ritalin and Ritalin-SR use.. 9.3 Dependence. ToleranceTolerance (a state of adaptation in which exposure to drug results in reduction of the drugs desired and/or undesired effects over time) can occur during chronic therapy with CNS stimulants, including Ritalin and Ritalin-SR.DependencePhysical dependence (which is manifested by withdrawal syndrome produced by abrupt cessation, rapid dose reduction, or administration of an antagonist) may occur in patients treated with CNS stimulants, including Ritalin and Ritalin-SR. Withdrawal symptoms after abrupt cessation following prolonged high-dosage administration of CNS stimulants include dysphoric mood; fatigue; vivid, unpleasant dreams; insomnia or hypersomnia; increased appetite; and psychomotor retardation or agitation.

DRUG INTERACTIONS SECTION.

7 DRUG INTERACTIONS. Antihypertensive Drugs: Monitor blood pressure. Adjust dosage of antihypertensive drug as needed. (7.1)Halogenated Anesthetics: Avoid use of Ritalin or Ritalin-SR on the day of surgery if halogenated anesthetics will be used. (7.1). Antihypertensive Drugs: Monitor blood pressure. Adjust dosage of antihypertensive drug as needed. (7.1). Halogenated Anesthetics: Avoid use of Ritalin or Ritalin-SR on the day of surgery if halogenated anesthetics will be used. (7.1). 7.1 Clinically Important Drug Interactions With Ritalin and Ritalin-SR. Table presents clinically important drug interactions with Ritalin and Ritalin-SR.Table 1: Clinically Important Drug Interactions With Ritalin and Ritalin-SRMonoamine Oxidase Inhibitors (MAOIs)Clinical ImpactConcomitant use of MAOIs and CNS stimulants, including Ritalin and Ritalin-SR can cause hypertensive crisis. Potential outcomes include death, stroke, myocardial infarction, aortic dissection, ophthalmological complications, eclampsia, pulmonary edema, and renal failure [see Contraindications (4)].InterventionConcomitant use of Ritalin or Ritalin-SR with MAOIs or within 14 days after discontinuing MAOI treatment is contraindicated.Examplesselegiline, tranylcypromine, isocarboxazid, phenelzine, linezolid, methylene blueAntihypertensive DrugsClinical ImpactRitalin and Ritalin-SR may decrease the effectiveness of drugs used to treat hypertension [see Warnings and Precautions (5.3)].InterventionMonitor blood pressure and adjust the dosage of the antihypertensive drug as needed.ExamplesPotassium-sparing and thiazide diuretics, calcium channel blockers, angiotensin-converting-enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), beta blockers, centrally acting alpha-2 receptor agonistsHalogenated AnestheticsClinical ImpactConcomitant use of halogenated anesthetics and Ritalin or Ritalin-SR may increase the risk of sudden blood pressure and heart rate increase during surgery.InterventionAvoid use of Ritalin or Ritalin-SR in patients being treated with anesthetics on the day of surgery.Exampleshalothane, isoflurane, enflurane, desflurane, sevofluraneRisperidoneClinical ImpactCombined use of methylphenidate with risperidone when there is change, whether an increase or decrease, in dosage of either or both medications, may increase the risk of extrapyramidal symptoms (EPS)InterventionMonitor for signs of EPS.

GERIATRIC USE SECTION.

8.5 Geriatric Use. Ritalin has not been studied in the geriatric population.

HOW SUPPLIED SECTION.

16 HOW SUPPLIED/STORAGE AND HANDLING. Ritalin Tablets5 mg tablets (NDC 0078-0439-05) round, yellow, (imprinted CIBA 7) supplied in bottles of 10010 mg tablets (NDC 0078-0440-05) round, pale green, scored, (imprinted CIBA 3) supplied in bottles of 10020 mg tablets (NDC 0078-0441-05) round, pale yellow, scored, (imprinted CIBA 34) supplied in bottles of 100Store at 20C to 25C (68F to 77F); excursions permitted between 15C and 30C (59F and 86F) [see USP controlled room temperature].Protect from light.Dispense in tight, light-resistant container (USP).Ritalin-SR Extended-Release Tablets20 mg SR extended-release tablets (NDC 0078-0442-05), round, white, coated, (imprinted CIBA 16) supplied in bottles of 100Store at 20C to 25C (68F to 77F); excursions permitted between 15C and 30C (59F and 86F) [see USP controlled room temperature].Protect from moisture.Dispense in tight, light-resistant container (USP).DisposalComply with local laws and regulations on drug disposal of CNS stimulants. Dispose of remaining, unused, or expired Ritalin and Ritalin-SR by medicine take-back program or by an authorized collector registered with the Drug Enforcement Administration. If no take-back program or authorized collector is available, mix Ritalin or Ritalin-SR with an undesirable, nontoxic substance to make it less appealing to children and pets. Place the mixture in container, such as sealed plastic bag and discard Ritalin or Ritalin-SR in the household trash.. mg tablets (NDC 0078-0439-05) round, yellow, (imprinted CIBA 7) supplied in bottles of 100. 10 mg tablets (NDC 0078-0440-05) round, pale green, scored, (imprinted CIBA 3) supplied in bottles of 100. 20 mg tablets (NDC 0078-0441-05) round, pale yellow, scored, (imprinted CIBA 34) supplied in bottles of 100.

INDICATIONS & USAGE SECTION.

1 INDICATIONS AND USAGE. Ritalin and Ritalin-SR are indicated for the treatment of:Attention Deficit Hyperactivity Disorders (ADHD) in pediatric patients years and older and adultsNarcolepsy. Attention Deficit Hyperactivity Disorders (ADHD) in pediatric patients years and older and adults. Narcolepsy. Ritalin is central nervous system (CNS) stimulant indicated for the treatment of Attention Deficit Hyperactivity Disorders (ADHD) and Narcolepsy. (1).

INFORMATION FOR PATIENTS SECTION.

17 PATIENT COUNSELING INFORMATION. Advise the patient to read the FDA-approved patient labeling (Medication Guide).Controlled Substance Status/High Potential for Abuse and Dependence Advise patients that Ritalin and Ritalin-SR are controlled substances, and they can be abused and lead to dependence. Instruct patients that they should not give Ritalin or Ritalin-SR to anyone else. Advise patients to store Ritalin and Ritalin-SR in safe place, preferably locked, to prevent abuse. Advise patients to comply with laws and regulations on drug disposal. Advise patients to dispose of remaining, unused, or expired Ritalin and Ritalin-SR by medicine take-back program if available [see Boxed Warning, Warnings and Precautions (5.1), Drug Abuse and Dependence (9.1, 9.2, 9.3), How Supplied/Storage and Handling (16)].Serious Cardiovascular RisksAdvise patients that there is potential serious cardiovascular risk, including sudden death, myocardial infarction, stroke, and hypertension with Ritalin and Ritalin-SR use. Instruct patients to contact healthcare provider immediately if they develop symptoms, such as exertional chest pain, unexplained syncope, or other symptoms suggestive of cardiac disease [see Warnings and Precautions (5.2)].Blood Pressure and Heart Rate IncreasesInstruct patients that Ritalin and Ritalin-SR can cause elevations of their blood pressure and pulse rate [see Warnings and Precautions (5.3)].Psychiatric RisksAdvise patients that Ritalin and Ritalin-SR, at recommended doses, can cause psychotic or manic symptoms, even in patients without prior history of psychotic symptoms or mania [see Warnings and Precautions (5.4)].PriapismAdvise patients of the possibility of painful or prolonged penile erections (priapism). Instruct them to seek immediate medical attention in the event of priapism [see Warnings and Precautions (5.5)].Circulation Problems in Fingers and Toes [Peripheral Vasculopathy, Including Raynauds Phenomenon]Instruct patients about the risk of peripheral vasculopathy, including Raynauds phenomenon, and associated signs and symptoms: fingers or toes may feel numb, cool, painful, and/or may change color from pale, to blue, to red. Instruct patients to report to their physician any new numbness, pain, skin color change, or sensitivity to temperature in fingers or toes.Instruct patients to call their physician immediately with any signs of unexplained wounds appearing on fingers or toes while taking Ritalin and Ritalin-SR. Further clinical evaluation (e.g., rheumatology referral) may be appropriate for certain patients [see Warnings and Precautions (5.6)].Suppression of GrowthAdvise patients that Ritalin and Ritalin-SR may cause slowing of growth and weight loss [see Warnings and Precautions (5.7)].Pregnancy RegistryAdvise patients that there is pregnancy exposure registry that monitors pregnancy outcomes in patients exposed to ADHD medications, including Ritalin and Ritalin-SR, during pregnancy [see Use in Specific Populations (8.1)].Distributed by:Novartis Pharmaceuticals CorporationEast Hanover, New Jersey 07936T2021-87.

LACTATION SECTION.

8.2 Lactation. Risk SummaryLimited published literature, based on milk sampling from seven mothers reports that methylphenidate is present in human milk, which resulted in infant doses of 0.16% to 0.7% of the maternal weight-adjusted dosage and milk/plasma ratio ranging between 1.1 and 2.7. There are no reports of adverse effects on the breastfed infant and no effects on milk production. Long-term neurodevelopmental effects on infants from stimulant exposure are unknown. The developmental and health benefits of breastfeeding should be considered along with the mothers clinical need for Ritalin or Ritalin-SR and any potential adverse effects on the breastfed infant from Ritalin or Ritalin-SR or from the underlying maternal condition.Clinical ConsiderationsMonitor breastfeeding infants for adverse reactions, such as agitation, insomnia, anorexia, and reduced weight gain.

MECHANISM OF ACTION SECTION.

12.1 Mechanism of Action. Methylphenidate hydrochloride is CNS stimulant. The mode of therapeutic action in ADHD and narcolepsy is not known.

NONCLINICAL TOXICOLOGY SECTION.

13 NONCLINICAL TOXICOLOGY. 13.1 Carcinogenesis, Mutagenesis, and Impairment of Fertility. CarcinogenesisIn lifetime carcinogenicity study carried out in B6C3F1 mice, methylphenidate caused an increase in hepatocellular adenomas, and in males only, an increase in hepatoblastomas at daily dose of approximately 60 mg/kg/day. This dose is approximately times the MRHD of 60 mg/day given to children on mg/m2 basis. Hepatoblastoma is relatively rare rodent malignant tumor type. There was no increase in total malignant hepatic tumors. The mouse strain used is sensitive to the development of hepatic tumors and the significance of these results to humans is unknown.Methylphenidate did not cause any increase in tumors in lifetime carcinogenicity study carried out in F344 rats; the highest dose used was approximately 45 mg/kg/day, which is approximately times the MRHD (children) on mg/m2 basis.In 24-week carcinogenicity study in the transgenic mouse strain p53+/-, which is sensitive to genotoxic carcinogens, there was no evidence of carcinogenicity. Male and female mice were fed diets containing the same concentration of methylphenidate as in the lifetime carcinogenicity study; the high-dose groups were exposed to 60 to 74 mg/kg/day of methylphenidate.MutagenesisMethylphenidate was not mutagenic in the in vitro Ames reverse mutation assay, in the in vitro mouse lymphoma cell forward mutation assay, or in the in vitro chromosomal aberration assay using human lymphocytes. Sister chromatid exchanges and chromosome aberrations were increased, indicative of weak clastogenic response, in an in vitro assay in cultured Chinese Hamster Ovary cells. Methylphenidate was negative in vivo in males and females in the mouse bone marrow micronucleus assay.Impairment of FertilityNo human data on the effect of methylphenidate on fertility are available. Methylphenidate did not impair fertility in male or female mice that were fed diets containing the drug in an 18-week continuous breeding study. The study was conducted at doses up to 160 mg/kg/day, approximately 10times the MRHD of 60 mg/day given to adolescents on mg/m2 basis.

OVERDOSAGE SECTION.

10 OVERDOSAGE. Human ExperienceSigns and symptoms of acute overdosage, resulting principally from overstimulation of the central nervous system and from excessive sympathomimetic effects, may include the following: nausea, vomiting, diarrhea, restlessness, anxiety, agitation, tremors, hyperreflexia, muscle twitching, convulsions (which may be followed by coma), euphoria, confusion, hallucinations, delirium, sweating, flushing, headache, hyperpyrexia, tachycardia, palpitations, cardiac arrhythmias, hypertension, hypotension, tachypnea, mydriasis, dryness of mucous membranes, and rhabdomyolysis.Overdose ManagementConsult with Certified Poison Control Center (1-800-222-1222) for the latest recommendations.

PEDIATRIC USE SECTION.

8.4 Pediatric Use. The safety and effectiveness of Ritalin and Ritalin-SR for the treatment of ADHD have been established in pediatric patients to 17 years.The safety and effectiveness of Ritalin and Ritalin-SR in pediatric patients less than years have not been established.The long-term efficacy of Ritalin and Ritalin-SR in pediatric patients has not been established.Long-Term Suppression of GrowthGrowth should be monitored during treatment with stimulants, including Ritalin and Ritalin-SR. Pediatric patients who are not growing or gaining weight as expected may need to have their treatment interrupted [see Warnings and Precautions (5.7)].Juvenile Animal Toxicity DataRats treated with methylphenidate early in the postnatal period through sexual maturation demonstrated decrease in spontaneous locomotor activity in adulthood. deficit in acquisition of specific learning task was observed in females only. The doses at which these findings were observed are at least times the MRHD of 60 mg/day given to children on mg/m2 basis.In study conducted in young rats, methylphenidate was administered orally at doses of up to 100 mg/kg/day for weeks, starting early in the postnatal period (postnatal Day 7) and continuing through sexual maturity (postnatal Week 10). When these animals were tested as adults (postnatal Weeks 13 to 14), decreased spontaneous locomotor activity was observed in males and females previously treated with 50 mg/kg/day (approximately times the MRHD of 60 mg/day given to children on mg/m2 basis) or greater, and deficit in the acquisition of specific learning task was seen in females exposed to the highest dose (8 times the MRHD given to children on mg/m2 basis). The no effect level for juvenile neurobehavioral development in rats was mg/kg/day approximately 0.5 timesthe MRHD given to children on mg/m2 basis). The clinical significance of the long-term behavioral effects observed in rats is unknown.

PHARMACODYNAMICS SECTION.

12.2 Pharmacodynamics. Methylphenidate is racemic mixture comprised of the d- and l-threo enantiomers. The d-threo enantiomer is more pharmacologically active than the l-threo enantiomer. Methylphenidate blocks the reuptake of norepinephrine and dopamine into the presynaptic neuron and increase the release of these monoamines into the extraneuronal space.Cardiac ElectrophysiologyA formal QT study has not been conducted in patients taking Ritalin and Ritalin-SR.The effect of dexmethylphenidate, the pharmacologically active d-enantiomer of Ritalin, on the QT interval was evaluated in double-blind, placebo- and open-label active (moxifloxacin)-controlled study following single doses of dexmethlyphenidate XR 40 mg (maximum recommended adult total daily dosage) in 75 healthy volunteers. Electrocardiograms were collected up to 12 hours postdose. Fredericas method for heart rate correction was employed to derive the corrected QT interval (QTcF). The maximum mean prolongation of QTcF intervals was less than ms, and the upper limit of the 90% confidence interval was below 10 ms for all time-matched comparisons versus placebo. This was below the threshold of clinical concern and there was no evident exposure response relationship.

PHARMACOKINETICS SECTION.

12.3 Pharmacokinetics. AbsorptionRitalin in the SR tablets is more slowly but as extensively absorbed as in the regular tablets. Relative bioavailability of the SR tablet compared to the Ritalin tablet, measured by the urinary excretion of Ritalin major metabolite (-phenyl-2-piperidine acetic acid) was 105% (49% to 168%) in children and 101% (85% to 152%) in adults. The time to peak rate in children was 1.9 hours (0.3 to 4.4 hours) for the Ritalin tablets and 4.7 hours (1.3 to 8.2 hours) for the Ritalin-SR tablets. An average of 67% of SR tablet dose was excreted in children as compared to 86% in adults.Effect of FoodAfter high-fat meal, both area under the curve (by 25 %) and Cmax (by 27 %) are higher. Time to Cmax (Tmax) is faster after high-fat meal (median Tmax: 2.5 hours) as compared to without food (median Tmax: hours).DistributionBinding to plasma proteins is low (10% to 33%). The volume of distribution was 2.65 +- 1.11 L/kg for d-methylphenidate and 1.80 +- 0.91 L/kg for l-methylphenidate.EliminationThe systemic clearance is 0.40 +- 0.12 L/h/kg for d-methylphenidate and 0.73 +- 0.28 L/h/kg for l-methylphenidate.MetabolismMethylphenidate is metabolized primarily by de-esterification to alpha-phenyl-piperidine acetic acid (ritalinic acid), which has little or no pharmacologic activity.ExcretionAfter oral administration, 78% to 97% of the dose is excreted in the urine and 1% to 3% in feces in the form of metabolites within 48 to 96 hours. Most of the dose is excreted in the urine as alpha-phenyl-2-piperidine acetic acid (60% to 86%). The cumulative urinary excretion of alpha-phenyl-2-piperidine acetic acid are not significantly different for Ritalin-SR tablets.Studies in Specific PopulationsMale and Female PatientsIn clinical study involving adult subjects who received Ritalin-SR, plasma concentrations of Ritalins major metabolite appeared to be greater in females than in males. No gender differences were observed for Ritalin plasma concentration in the same subjects.Racial or Ethnic GroupsThere is insufficient experience with the use of Ritalin and Ritalin-SR to detect ethnic variations in pharmacokinetics.Patients with Renal ImpairmentRitalin has not been studied in renally-impaired patients. Renal impairment is expected to have minimal effect on the pharmacokinetics of methylphenidate since less than 1% of radiolabeled dose is excreted in the urine as unchanged compound, and the major metabolite (ritalinic acid), has little or no pharmacologic activity.Patients with Hepatic ImpairmentRitalin has not been studied in patients with hepatic impairment. Hepatic impairment is expected to have minimal effect on the pharmacokinetics of methylphenidate since it is metabolized primarily to ritalinic acid by nonmicrosomal hydrolytic esterases that are widely distributed throughout the body.

PREGNANCY SECTION.

8.1 Pregnancy. Pregnancy Exposure RegistryThere is pregnancy exposure registry that monitors pregnancy outcomes in women exposed to ADHD medications, including Ritalin and Ritalin-SR, during pregnancy. Healthcare providers are encouraged to register patients by calling the National Pregnancy Registry for ADHD Medications at 1-866-961-2388 or visit https://womensmentalhealth.org/adhd-medications/.Risk SummaryPublished studies and postmarketing reports on methylphenidate use during pregnancy have not identified drug-associated risk of major birth defects, miscarriage or adverse maternal or fetal outcomes. There may be risks to the fetus associated with the use of CNS stimulants use during pregnancy (see Clinical Considerations).No effects on morphological development were observed in embryo-fetal development studies with oral administration of methylphenidate to pregnant rats and rabbits during organogenesis at doses up to 10 and 15 times, respectively, the maximum recommended human dose (MRHD) of 60 mg/day given to adolescents on mg/m2 basis. However, spina bifida was observed in rabbits at dose 52 times the MRHD given to adolescents. decrease in pup body weight was observed in pre- and post-natal development study with oral administration of methylphenidate to rats throughout pregnancy and lactation at doses times the MRHD given to adolescents (see Data).The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.Clinical ConsiderationsFetal/Neonatal Adverse ReactionsCNS stimulants, such as Ritalin and Ritalin-SR, can cause vasoconstriction and thereby decrease placental perfusion. No fetal and/or neonatal adverse reactions have been reported with the use of therapeutic doses of methylphenidate during pregnancy; however, premature delivery and low birth weight infants have been reported in amphetamine-dependent mothers.DataAnimal DataIn embryo-fetal development studies conducted in rats and rabbits, methylphenidate was administered orally at doses of up to 75 and 200 mg/kg/day, respectively, during the period of organogenesis. Malformations (increased incidence of fetal spina bifida) were observed in rabbits at the highest dose, which is approximately 52 times the MRHD of 60 mg/day given to adolescents on mg/m2 basis. The no effect level for embryo-fetal development in rabbits was 60 mg/kg/day (15times the MRHD given to adolescents on mg/m2 basis). There was no evidence of morphological development effects in rats, although increased incidences of fetal skeletal variations were seen at the highest dose level (10 times the MRHD of 60 mg/day given to adolescents on mg/m2 basis), which was also maternally toxic. The no effect level for embryo-fetal development in rats was 25 mg/kg/day (3 times the MRHD on mg/m2 basis). When methylphenidate was administered to rats throughout pregnancy and lactation at doses of up to 45 mg/kg/day, offspring body weight gain was decreased at the highest dose (6 times the MRHD of 60 mg/day given to adolescents on mg/m2 basis), but no other effects on postnatal development were observed. The no effect level for pre- and postnatal development in rats was 15 mg/kg/day (~2 times the MRHD given to adolescents on mg/m2 basis).

SPL MEDGUIDE SECTION.

This Medication Guide has been approved by the U.S. Food and Drug Administration.Revised: June 2021MEDICATION GUIDERITALIN(R) (rit-ah-lin)(methylphenidate hydrochloride)tablets CIIWhat is the most important information should know about RITALINRITALIN is federal controlled substance (CII) because it can be abused or lead to dependence. Keep RITALIN in safe place to prevent misuse and abuse. Selling or giving away RITALIN may harm others and is against the law.Tell your doctor if you or your child have abused or been dependent on alcohol, prescription medicines, or street drugs.The following have been reported with use of methylphenidate hydrochloride and other stimulant medicines:1. Heart-related problems: sudden death in patients who have heart problems or heart defectsstroke and heart attack in adultsincreased blood pressure and heart rate Tell your doctor if you or your child have any heart problems, heart defects, high blood pressure, or family history of these problems. Your doctor should check you or your child carefully for heart problems before starting RITALIN. Your doctor should check you or your childs blood pressure and heart rate regularly during treatment with RITALIN. Call your doctor right away if you or your child has any signs of heart problems, such as chest pain, shortness of breath, or fainting while taking RITALIN. 2. Mental (psychiatric) problems: All Patients new or worse behavior and thought problemsnew or worse bipolar illnessnew or worse aggressive behavior or hostilitynew psychotic symptoms (such as hearing voices, believing things that are not true, are suspicious) or new manic symptoms Tell your doctor about any mental problems you or your child have, or about family history of suicide, bipolar illness, or depression. Call your doctor right away if you or your child have any new or worsening mental symptoms or problems while taking RITALIN, especially seeing or hearing things that are not real, believing things that are not real, or are suspicious. What is RITALINRITALIN is central nervous system (CNS) stimulant prescription medicine. It is used for the treatment of Attention Deficit Hyperactivity Disorder (ADHD). RITALIN may help increase attention and decrease impulsiveness and hyperactivity in patients with ADHD.RITALIN should be used as part of total treatment program for ADHD that may include counseling or other therapies.RITALIN is also used in the treatment of sleep disorder called narcolepsy.It is not known if RITALIN is safe and effective in children under years of age.Who should not take RITALINRITALIN should not be taken if you or your child:are allergic to methylphenidate hydrochloride, or any of the ingredients in RITALIN. See the end of this Medication Guide for complete list of ingredients in RITALIN.are taking or have taken within the past 14 days an anti-depression medicine called monoamine oxidase inhibitor (MAOI).RITALIN may not be right for you or your child. Before starting RITALIN, tell your or your childs doctor about all health conditions (or family history of), including:heart problems, heart defects, high blood pressuremental problems, including psychosis, mania, bipolar illness, or depressioncirculation problems in fingers or toesif you are pregnant or plan to become pregnant. It is not known if RITALIN will harm your unborn baby.There is pregnancy registry for females who are exposed to ADHD medications, including RITALIN, during pregnancy. The purpose of the registry is to collect information about the health of females exposed to RITALIN and their baby. If you or your child becomes pregnant during treatment with RITALIN, talk to your healthcare provider about registering with the National Pregnancy Registry of ADHD Medications at 1-866-961-2388 or visit online at https://womensmentalhealth.org/adhd-medications/. if you are breastfeeding or plan to breastfeed. RITALIN passes into your breast milk. Talk to your healthcare provider about the best way to feed your baby during treatment with RITALIN.Tell your doctor about all of the medicines that you or your child takes, including prescription and over-the-counter medicines, vitamins, and herbal supplements. RITALIN and some medicines may interact with each other and cause serious side effects. Sometimes the doses of other medicines will need to be adjusted while taking RITALIN.Your doctor will decide whether RITALIN can be taken with other medicines.Especially tell your doctor if you or your child takes:anti-depression medicines, including MAOIsblood pressure medicines (anti-hypertensives)Know the medicines that you or your child takes. Keep list of your medicines with you to show your doctor and pharmacist.You should not take RITALIN on the day of your operation if certain type of anesthetic is used. This is because there is chance of sudden rise in blood pressure and heart rate during the operation.Do not start any new medicine while taking RITALIN without talking to your doctor first.How should RITALIN be takenTake RITALIN exactly as prescribed. Your doctor may adjust the dose until it is right for you or your child.RITALIN is usually taken to times day.Take RITALIN 30 to 45 minutes before meal.From time-to-time, your doctor may stop RITALIN treatment for while to check ADHD symptoms.Your doctor may do regular checks of the blood, heart, and blood pressure while taking RITALIN. Children should have their height and weight checked often while taking RITALIN. RITALIN treatment may be stopped if problem is found during these check-ups.In case of poisoning, call your poison control center at 1-800-222-1222 right away, or go to the nearest hospital emergency room.What are the possible side effects of RITALINRITALIN may cause serious side effects, including:see What is the most important information should know about RITALIN for information on reported heart and mental problems.painful and prolonged erections (priapism) have occurred with methylphenidate. If you or your child develops priapism, seek medical help right away. Because of the potential for lasting damage, priapism should be evaluated by doctor immediately.circulation problems in fingers and toes (peripheral vasculopathy, including Raynauds phenomenon):fingers or toes may feel numb, cool, painfulfingers or toes may change color from pale, to blue, to redTell your doctor if you or your child have, numbness, pain, skin color change, or sensitivity to temperature in the fingers or toes. Call your doctor right away if you have or your child has any signs of unexplained wounds appearing on fingers or toes while taking RITALIN.Slowing of growth (height and weight) in childrenCommon side effects include: ofast heart beat osweating lot oabnormal heartbeat (palpitations)odecreased appetite oheadacheodry mouth otrouble sleepingonauseaonervousnessostomach painCall your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. How should store RITALINStore RITALIN in safe place and in tightly closed container at room temperature between 68F to 77F (20C to 25C).Protect from light.Dispose of remaining, unused, or expired RITALIN by medicine take-back program at authorized collection sites, such as retail pharmacies, hospital or clinic pharmacies, and law enforcement locations. If no take-back program or authorized collector is available, mix RITALIN with an undesirable, nontoxic substance, such as dirt, cat litter, or used coffee grounds to make it less appealing to children and pets. Place the mixture in container, such as sealed plastic bag and throw away (discard) RITALIN in the household trash.Keep RITALIN and all medicines out of the reach of children.General information about the safe and effective use of RITALIN.Medicines are sometimes prescribed for purposes other than those listed in Medication Guide. You can ask your pharmacist or doctor for information about RITALIN that is written for healthcare professionals. Do not use RITALIN for condition for which it was not prescribed. Do not give RITALIN to other people, even if they have the same symptoms that you have. It may harm them and it is against the law.What are the ingredients in RITALINActive ingredient: methylphenidate HCl Inactive ingredients: D&C Yellow No.10 (5-mg and 20-mg tablets), FD&C Green No.3 (10-mg tablets), lactose, magnesium stearate, polyethylene glycol, starch (5-mg and 10-mg tablets), sucrose, talc, and tragacanth (20-mg tablets) Distributed by:Novartis Pharmaceuticals CorporationEast Hanover, New Jersey 07936(C) NovartisFor more information and request for additional copies of the Medication Guide, call 1-888-669-6682.T2021-88. sudden death in patients who have heart problems or heart defects. stroke and heart attack in adults. increased blood pressure and heart rate. new or worse behavior and thought problems. new or worse bipolar illness. new or worse aggressive behavior or hostility. new psychotic symptoms (such as hearing voices, believing things that are not true, are suspicious) or new manic symptoms. RITALIN is central nervous system (CNS) stimulant prescription medicine. It is used for the treatment of Attention Deficit Hyperactivity Disorder (ADHD). RITALIN may help increase attention and decrease impulsiveness and hyperactivity in patients with ADHD.. RITALIN should be used as part of total treatment program for ADHD that may include counseling or other therapies.. RITALIN is also used in the treatment of sleep disorder called narcolepsy.. are allergic to methylphenidate hydrochloride, or any of the ingredients in RITALIN. See the end of this Medication Guide for complete list of ingredients in RITALIN.. are taking or have taken within the past 14 days an anti-depression medicine called monoamine oxidase inhibitor (MAOI).. heart problems, heart defects, high blood pressure. mental problems, including psychosis, mania, bipolar illness, or depression. circulation problems in fingers or toes. if you are pregnant or plan to become pregnant. It is not known if RITALIN will harm your unborn baby.There is pregnancy registry for females who are exposed to ADHD medications, including RITALIN, during pregnancy. The purpose of the registry is to collect information about the health of females exposed to RITALIN and their baby. If you or your child becomes pregnant during treatment with RITALIN, talk to your healthcare provider about registering with the National Pregnancy Registry of ADHD Medications at 1-866-961-2388 or visit online at https://womensmentalhealth.org/adhd-medications/. There is pregnancy registry for females who are exposed to ADHD medications, including RITALIN, during pregnancy. The purpose of the registry is to collect information about the health of females exposed to RITALIN and their baby. If you or your child becomes pregnant during treatment with RITALIN, talk to your healthcare provider about registering with the National Pregnancy Registry of ADHD Medications at 1-866-961-2388 or visit online at https://womensmentalhealth.org/adhd-medications/.. if you are breastfeeding or plan to breastfeed. RITALIN passes into your breast milk. Talk to your healthcare provider about the best way to feed your baby during treatment with RITALIN.. anti-depression medicines, including MAOIs. blood pressure medicines (anti-hypertensives). You should not take RITALIN on the day of your operation if certain type of anesthetic is used. This is because there is chance of sudden rise in blood pressure and heart rate during the operation.. Take RITALIN exactly as prescribed. Your doctor may adjust the dose until it is right for you or your child.. RITALIN is usually taken to times day.. Take RITALIN 30 to 45 minutes before meal.. From time-to-time, your doctor may stop RITALIN treatment for while to check ADHD symptoms.. Your doctor may do regular checks of the blood, heart, and blood pressure while taking RITALIN. Children should have their height and weight checked often while taking RITALIN. RITALIN treatment may be stopped if problem is found during these check-ups.. In case of poisoning, call your poison control center at 1-800-222-1222 right away, or go to the nearest hospital emergency room.. see What is the most important information should know about RITALIN for information on reported heart and mental problems.. painful and prolonged erections (priapism) have occurred with methylphenidate. If you or your child develops priapism, seek medical help right away. Because of the potential for lasting damage, priapism should be evaluated by doctor immediately.. circulation problems in fingers and toes (peripheral vasculopathy, including Raynauds phenomenon):fingers or toes may feel numb, cool, painfulfingers or toes may change color from pale, to blue, to redTell your doctor if you or your child have, numbness, pain, skin color change, or sensitivity to temperature in the fingers or toes. fingers or toes may feel numb, cool, painful. fingers or toes may change color from pale, to blue, to redTell your doctor if you or your child have, numbness, pain, skin color change, or sensitivity to temperature in the fingers or toes.. Call your doctor right away if you have or your child has any signs of unexplained wounds appearing on fingers or toes while taking RITALIN.. Slowing of growth (height and weight) in children. Store RITALIN in safe place and in tightly closed container at room temperature between 68F to 77F (20C to 25C).. Protect from light.. Dispose of remaining, unused, or expired RITALIN by medicine take-back program at authorized collection sites, such as retail pharmacies, hospital or clinic pharmacies, and law enforcement locations. If no take-back program or authorized collector is available, mix RITALIN with an undesirable, nontoxic substance, such as dirt, cat litter, or used coffee grounds to make it less appealing to children and pets. Place the mixture in container, such as sealed plastic bag and throw away (discard) RITALIN in the household trash.. Keep RITALIN and all medicines out of the reach of children.

SPL UNCLASSIFIED SECTION.

2.1 Pretreatment Screening. Prior to treating pediatric patients and adults with central nervous system (CNS) stimulants, including Ritalin or Ritalin-SR, assess for the presence of cardiac disease (i.e., perform careful history, including family history of sudden death or ventricular arrhythmia, and physical examination) [see Warnings and Precautions (5.2)].Assess the risk of abuse prior to prescribing, and monitor for signs of abuse and dependence while on therapy. Maintain careful prescription records, educate patients about abuse, monitor for signs of abuse and overdose, and periodically reevaluate the need for Ritalin or Ritalin-SR use [see Boxed Warning, Warnings and Precautions (5.1), Drug Abuse and Dependence (9.2, 9.3)].

USE IN SPECIFIC POPULATIONS SECTION.

8 USE IN SPECIFIC POPULATIONS. 8.1 Pregnancy. Pregnancy Exposure RegistryThere is pregnancy exposure registry that monitors pregnancy outcomes in women exposed to ADHD medications, including Ritalin and Ritalin-SR, during pregnancy. Healthcare providers are encouraged to register patients by calling the National Pregnancy Registry for ADHD Medications at 1-866-961-2388 or visit https://womensmentalhealth.org/adhd-medications/.Risk SummaryPublished studies and postmarketing reports on methylphenidate use during pregnancy have not identified drug-associated risk of major birth defects, miscarriage or adverse maternal or fetal outcomes. There may be risks to the fetus associated with the use of CNS stimulants use during pregnancy (see Clinical Considerations).No effects on morphological development were observed in embryo-fetal development studies with oral administration of methylphenidate to pregnant rats and rabbits during organogenesis at doses up to 10 and 15 times, respectively, the maximum recommended human dose (MRHD) of 60 mg/day given to adolescents on mg/m2 basis. However, spina bifida was observed in rabbits at dose 52 times the MRHD given to adolescents. decrease in pup body weight was observed in pre- and post-natal development study with oral administration of methylphenidate to rats throughout pregnancy and lactation at doses times the MRHD given to adolescents (see Data).The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.Clinical ConsiderationsFetal/Neonatal Adverse ReactionsCNS stimulants, such as Ritalin and Ritalin-SR, can cause vasoconstriction and thereby decrease placental perfusion. No fetal and/or neonatal adverse reactions have been reported with the use of therapeutic doses of methylphenidate during pregnancy; however, premature delivery and low birth weight infants have been reported in amphetamine-dependent mothers.DataAnimal DataIn embryo-fetal development studies conducted in rats and rabbits, methylphenidate was administered orally at doses of up to 75 and 200 mg/kg/day, respectively, during the period of organogenesis. Malformations (increased incidence of fetal spina bifida) were observed in rabbits at the highest dose, which is approximately 52 times the MRHD of 60 mg/day given to adolescents on mg/m2 basis. The no effect level for embryo-fetal development in rabbits was 60 mg/kg/day (15times the MRHD given to adolescents on mg/m2 basis). There was no evidence of morphological development effects in rats, although increased incidences of fetal skeletal variations were seen at the highest dose level (10 times the MRHD of 60 mg/day given to adolescents on mg/m2 basis), which was also maternally toxic. The no effect level for embryo-fetal development in rats was 25 mg/kg/day (3 times the MRHD on mg/m2 basis). When methylphenidate was administered to rats throughout pregnancy and lactation at doses of up to 45 mg/kg/day, offspring body weight gain was decreased at the highest dose (6 times the MRHD of 60 mg/day given to adolescents on mg/m2 basis), but no other effects on postnatal development were observed. The no effect level for pre- and postnatal development in rats was 15 mg/kg/day (~2 times the MRHD given to adolescents on mg/m2 basis).. 8.2 Lactation. Risk SummaryLimited published literature, based on milk sampling from seven mothers reports that methylphenidate is present in human milk, which resulted in infant doses of 0.16% to 0.7% of the maternal weight-adjusted dosage and milk/plasma ratio ranging between 1.1 and 2.7. There are no reports of adverse effects on the breastfed infant and no effects on milk production. Long-term neurodevelopmental effects on infants from stimulant exposure are unknown. The developmental and health benefits of breastfeeding should be considered along with the mothers clinical need for Ritalin or Ritalin-SR and any potential adverse effects on the breastfed infant from Ritalin or Ritalin-SR or from the underlying maternal condition.Clinical ConsiderationsMonitor breastfeeding infants for adverse reactions, such as agitation, insomnia, anorexia, and reduced weight gain.. 8.4 Pediatric Use. The safety and effectiveness of Ritalin and Ritalin-SR for the treatment of ADHD have been established in pediatric patients to 17 years.The safety and effectiveness of Ritalin and Ritalin-SR in pediatric patients less than years have not been established.The long-term efficacy of Ritalin and Ritalin-SR in pediatric patients has not been established.Long-Term Suppression of GrowthGrowth should be monitored during treatment with stimulants, including Ritalin and Ritalin-SR. Pediatric patients who are not growing or gaining weight as expected may need to have their treatment interrupted [see Warnings and Precautions (5.7)].Juvenile Animal Toxicity DataRats treated with methylphenidate early in the postnatal period through sexual maturation demonstrated decrease in spontaneous locomotor activity in adulthood. deficit in acquisition of specific learning task was observed in females only. The doses at which these findings were observed are at least times the MRHD of 60 mg/day given to children on mg/m2 basis.In study conducted in young rats, methylphenidate was administered orally at doses of up to 100 mg/kg/day for weeks, starting early in the postnatal period (postnatal Day 7) and continuing through sexual maturity (postnatal Week 10). When these animals were tested as adults (postnatal Weeks 13 to 14), decreased spontaneous locomotor activity was observed in males and females previously treated with 50 mg/kg/day (approximately times the MRHD of 60 mg/day given to children on mg/m2 basis) or greater, and deficit in the acquisition of specific learning task was seen in females exposed to the highest dose (8 times the MRHD given to children on mg/m2 basis). The no effect level for juvenile neurobehavioral development in rats was mg/kg/day approximately 0.5 timesthe MRHD given to children on mg/m2 basis). The clinical significance of the long-term behavioral effects observed in rats is unknown.. 8.5 Geriatric Use. Ritalin has not been studied in the geriatric population.

WARNINGS AND PRECAUTIONS SECTION.

5 WARNINGS AND PRECAUTIONS. Serious Cardiovascular Events: Sudden death has been reported in association with CNS-stimulant treatment at usual doses in pediatric patients with structural cardiac abnormalities or other serious heart problems. In adults, sudden death, stroke, and myocardial infarction have been reported. Avoid use in patients with known structural cardiac abnormalities, cardiomyopathy, serious heart rhythm arrhythmias, or coronary artery disease. (5.2)Blood Pressure and Heart Rate Increases: Monitor blood pressure and pulse. Consider the benefits and risk in patients for whom an increase in blood pressure or heart rate would be problematic. (5.3)Psychiatric Adverse Reactions: Use of stimulants may cause psychotic or manic symptoms in patients with no prior history or exacerbation of symptoms in patients with preexisting psychiatric illness. Evaluate for preexisting psychotic or bipolar disorder prior to Ritalin and Ritalin-SR use. (5.4)Priapism: Cases of painful and prolonged penile erections, and priapism have been reported with methylphenidate products. Immediate medical attention should be sought if signs or symptoms of prolonged penile erections or priapism are observed. (5.5)Peripheral Vasculopathy, Including Raynauds Phenomenon: Stimulants used to treat ADHD are associated with peripheral vasculopathy, including Raynauds phenomenon. Careful observation for digital changes is necessary during treatment with ADHD stimulants. (5.6)Long-Term Suppression of Growth: Monitor height and weight at appropriate intervals in pediatric patients. (5.7). Serious Cardiovascular Events: Sudden death has been reported in association with CNS-stimulant treatment at usual doses in pediatric patients with structural cardiac abnormalities or other serious heart problems. In adults, sudden death, stroke, and myocardial infarction have been reported. Avoid use in patients with known structural cardiac abnormalities, cardiomyopathy, serious heart rhythm arrhythmias, or coronary artery disease. (5.2). Blood Pressure and Heart Rate Increases: Monitor blood pressure and pulse. Consider the benefits and risk in patients for whom an increase in blood pressure or heart rate would be problematic. (5.3). Psychiatric Adverse Reactions: Use of stimulants may cause psychotic or manic symptoms in patients with no prior history or exacerbation of symptoms in patients with preexisting psychiatric illness. Evaluate for preexisting psychotic or bipolar disorder prior to Ritalin and Ritalin-SR use. (5.4). Priapism: Cases of painful and prolonged penile erections, and priapism have been reported with methylphenidate products. Immediate medical attention should be sought if signs or symptoms of prolonged penile erections or priapism are observed. (5.5). Peripheral Vasculopathy, Including Raynauds Phenomenon: Stimulants used to treat ADHD are associated with peripheral vasculopathy, including Raynauds phenomenon. Careful observation for digital changes is necessary during treatment with ADHD stimulants. (5.6). Long-Term Suppression of Growth: Monitor height and weight at appropriate intervals in pediatric patients. (5.7). 5.1 Potential for Abuse and Dependence. CNS stimulants, including Ritalin and Ritalin-SR, other methylphenidate-containing products, and amphetamines, have high potential for abuse and dependence. Assess the risk of abuse prior to prescribing, and monitor for signs of abuse and dependence while on therapy [see Boxed Warning, Drug Abuse and Dependence (9.2, 9.3)].. 5.2 Serious Cardiovascular Reactions. Sudden death, stroke, and myocardial infarction have been reported in adults with CNS stimulant treatment at recommended doses. Sudden death has been reported in pediatric patients with structural cardiac abnormalities and other serious heart problems taking CNS stimulants at recommended doses for ADHD. Avoid use in patients with known serious structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities, coronary artery disease, and other serious heart problems. Further evaluate patients who develop exertional chest pain, unexplained syncope, or arrhythmias during Ritalin and Ritalin-SR treatment.. 5.3 Blood Pressure and Heart Rate Increases. CNS stimulants cause an increase in blood pressure (mean increase approximately to mmHg) and heart rate (mean increase approximately to beats per minute). Individuals may have larger increases. Monitor all patients for hypertension and tachycardia.. 5.4 Psychiatric Adverse Reactions. Exacerbation of Preexisting PsychosisCNS stimulants may exacerbate symptoms of behavior disturbance and thought disorder in patients with preexisting psychotic disorder.Induction of Manic Episode in Patients with Bipolar DisorderCNS stimulants may induce manic or mixed mood episode in patients. Prior to initiating treatment, screen patients for risk factors for developing manic episode (e.g., comorbid or history of depressive symptoms or family history of suicide, bipolar disorder, or depression).New Psychotic or Manic SymptomsCNS stimulants, at recommended doses, may cause psychotic or manic symptoms (e.g., hallucinations, delusional thinking, or mania) in patients without prior history of psychotic illness or mania. If such symptoms occur, consider discontinuing Ritalin and Ritalin-SR. In pooled analysis of multiple short-term, placebo-controlled studies of CNS stimulants, psychotic or manic symptoms occurred in approximately 0.1% of CNS stimulant-treated patients, compared to in placebo-treated patients.. 5.5 Priapism. Prolonged and painful erections, sometimes requiring surgical intervention, have been reported with methylphenidate products in both pediatric and adult patients. Priapism was not reported with drug initiation but developed after some time on the drug, often subsequent to an increase in dose. Priapism has also appeared during period of drug withdrawal (drug holidays or during discontinuation). Patients who develop abnormally sustained or frequent and painful erections should seek immediate medical attention.. 5.6 Peripheral Vasculopathy, Including Raynauds Phenomenon CNS stimulants, including Ritalin and Ritalin-SR, used to treat ADHD are associated with peripheral vasculopathy, including Raynauds phenomenon. Signs and symptoms are usually intermittent and mild; however, very rare sequelae include digital ulceration and/or soft tissue breakdown. Effects of peripheral vasculopathy, including Raynauds phenomenon, were observed in postmarketing reports at different times and at therapeutic doses in all age groups throughout the course of treatment. Signs and symptoms generally improve after reduction in dose or discontinuation of drug. Careful observation for digital changes is necessary during treatment with ADHD stimulants. Further clinical evaluation (e.g., rheumatology referral) may be appropriate for certain patients.. 5.7 Long-Term Suppression of Growth. CNS stimulants have been associated with weight loss and slowing of growth rate in pediatric patients.Careful follow-up of weight and height in pediatric patients ages to 10 years who were randomized to either methylphenidate or non-medication treatment groups over 14 months, as well as in naturalistic subgroups of newly methylphenidate-treated and non-medication treated patients over 36 months (to the ages of 10 to 13 years), suggests that consistently medicated pediatric patients (i.e., treatment for days per week throughout the year) have temporary slowing in growth rate (on average, total of about cm less growth in height and 2.7 kg less growth in weight over years), without evidence of growth rebound during this period of development.Closely monitor growth (weight and height) in pediatric patients treated with CNS stimulants, including Ritalin and Ritalin-SR. Patients who are not growing or gaining height or weight as expected may need to have their treatment interrupted.