WARNINGS SECTION.

WARNINGS. Cardiovascular Effects. Cardiovascular Thrombotic Events. Clinical trials of several COX-2 selective and nonselective NSAIDs of up to three years duration have shown an increased risk of serious cardiovascular (CV) thrombotic events, myocardial infarction, and stroke, which can be fatal. All NSAIDs, both COX-2 selective and nonselective, may have similar risk. Patients with known CV disease or risk factors for CV disease may be at greater risk. To minimize the potential risk for an adverse CV event in patients treated with an NSAID, the lowest effective dose should be used for the shortest duration possible. Physicians and patients should remain alert for the development of such events, even in the absence of previous CV symptoms. Patients should be informed about the signs and/or symptoms of serious CV events and the steps to take if they occur. There is no consistent evidence that concurrent use of aspirin mitigates the increased risk of serious CV thrombotic events associated with NSAID use. The concurrent use of aspirin and an NSAID does increase the risk of serious GI events (see WARNINGS: Gastrointestinal Effects). Two large, controlled, clinical trials of COX-2 selective NSAID for the treatment of pain in the first 10 to 14 days following CABG surgery found an increased incidence of myocardial infarction and stroke (see CONTRAINDICATIONS).. Hypertension. NSAIDs, including flurbiprofen, can lead to onset of new hypertension or worsening of preexisting hypertension, either of which may contribute to the increased incidence of CV events. Patients taking thiazides or loop diuretics may have impaired response to these therapies when taking NSAIDs. NSAIDs, including flurbiprofen, should be used with caution in patients with hypertension. Blood pressure (BP) should be monitored closely during the initiation of NSAID treatment and throughout the course of therapy.. Congestive Heart Failure and Edema. Fluid retention and edema have been observed in some patients taking NSAIDs. Flurbiprofen should be used with caution in patients with fluid retention or heart failure.. Gastrointestinal Effects. Risk of Ulceration, Bleeding, and Perforation. NSAIDs, including flurbiprofen, can cause serious gastrointestinal (GI) adverse events including inflammation, bleeding, ulceration, and perforation of the stomach, small intestine, or large intestine, which can be fatal. These serious adverse events can occur at any time, with or without warning symptoms, in patients treated with NSAIDs. Only one in five patients, who develop serious upper GI adverse event on NSAID therapy is symptomatic. Upper GI ulcers, gross bleeding, or perforation caused by NSAIDs occur in approximately 1% of patients treated for to months, and in about 2% to 4% of patients treated for one year. These trends continue with longer duration of use, increasing the likelihood of developing serious GI event at some time during the course of therapy. However, even short-term therapy is not without risk. NSAIDs should be prescribed with extreme caution in those with prior history of ulcer disease or gastrointestinal bleeding. Patients with prior history of peptic ulcer disease and/or gastrointestinal bleeding who use NSAIDs have greater than 10-fold increased risk for developing GI bleed compared to patients treated with neither of these risk factors. Other factors that increase the risk of GI bleeding in patients treated with NSAIDs include concomitant use of oral corticosteroids or anticoagulants, longer duration of NSAID therapy, smoking, use of alcohol, older age, and poor general health status. Most spontaneous reports of fatal GI events are in elderly or debilitated patients and therefore, special care should be taken in treating this population. To minimize the potential risk for an adverse GI event in patients treated with an NSAID, the lowest effective dose should be used for the shortest possible duration. Patients and physicians should remain alert for signs and symptoms of GI ulcerations and bleeding during NSAID therapy and promptly initiate additional evaluation and treatment if serious GI event is suspected. This should include discontinuation of the NSAID until serious GI adverse event is ruled out. For high risk patients, alternate therapies that do not involve NSAIDs should be considered. Renal Effects. Long-term administration of NSAIDs has resulted in renal papillary necrosis and other renal injury. Renal toxicity has also been seen in patients in whom renal prostaglandins have compensatory role in the maintenance of renal perfusion. In these patients, administration of non-steroidal anti-inflammatory drug may cause dose dependent reduction in prostaglandin formation and, secondarily, in renal blood flow, which may precipitate overt renal decompensation. Patients at greatest risk of this reaction are those with impaired renal function, heart failure, liver dysfunction, those taking diuretics and ACE inhibitors, and the elderly. Discontinuation of NSAID therapy is usually followed by recovery to the pretreatment state.. Advanced Renal Disease. In clinical studies, the elimination half-life of flurbiprofen was unchanged in patients with renal impairment. Flurbiprofen metabolites are eliminated primarily by the kidneys. Elimination of 4-hydroxy-flurbiprofen was reduced in patients with moderate to severe renal impairment. Therefore, treatment with flurbiprofen is not recommended in these patients with advanced renal disease. If flurbiprofen therapy must be initiated, close monitoring of the patients renal function is advisable (see CLINICAL PHARMACOLOGY).. Anaphylactoid Reactions. As with other NSAIDs, anaphylactoid reactions may occur in patients without known prior exposure to flurbiprofen. Flurbiprofen should not be given to patients with the aspirin triad. This symptom complex typically occurs in asthmatic patients who experience rhinitis with or without nasal polyps, or who exhibit severe, potentially fatal bronchospasm after taking aspirin or other NSAIDs (see CONTRAINDICATIONS and PRECAUTIONS: General: Preexisting Asthma). Emergency help should be sought in cases where an anaphylactoid reaction occurs.. Pregnancy. In late pregnancy, as with other NSAIDs, flurbiprofen should be avoided because it may cause premature closure of the ductus arteriosus.

SPL MEDGUIDE SECTION.

Medication Guide for Non-Steroidal Anti-Inflammatory Drugs (NSAIDs). (See the end of this Medication Guide for list of prescription NSAID medicines.)What is the most important information should know about medicines called Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) NSAID medicines may increase the chance of heart attack or stroke that can lead to death. This chance increases: with longer use of NSAID medicines in people who have heart disease NSAID medicines should never be used right before or after heart surgery called coronary artery bypass graft (CABG).NSAID medicines can cause ulcers and bleeding in the stomach and intestines at any time during treatment. Ulcers and bleeding: can happen without warning symptoms may cause death The chance of person getting an ulcer or bleeding increases with: taking medicines called corticosteroids and anticoagulants longer use smoking drinking alcohol older age having poor health NSAID medicines should only be used: exactly as prescribed at the lowest dose possible for your treatment for the shortest time needed What are Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) NSAID medicines are used to treat pain and redness, swelling, and heat (inflammation) from medical conditions such as: different types of arthritis menstrual cramps and other types of short-term painWho should not take Non-Steroidal Anti-Inflammatory Drug (NSAID)Do not take an NSAID medicine: if you had an asthma attack, hives, or other allergic reaction with aspirin or any other NSAID medicine for pain right before or after heart bypass surgeryTell your healthcare provider: about all of your medical conditions.about all of the medicines you take. NSAIDs and some other medicines can interact with each other and cause serious side effects. Keep list of your medicines to show to your healthcare provider and pharmacist. if you are pregnant. NSAID medicines should not be used by pregnant women late in their pregnancy. if you are breastfeeding. Talk to your doctor. What are the possible side effects of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Serious side effects include:heart attackstrokehigh blood pressureheart failure from body swelling (fluid retention)kidney problems including kidney failurebleeding and ulcers in the stomach and intestinelow red blood cells (anemia)life-threatening skin reactionslife-threatening allergic reactionsliver problems including liver failureasthma attacks in people who have asthmaOther side effects include:stomach painconstipationdiarrheagasheart burnnauseavomitingdizzinessGet emergency help right away if you have any of the following symptoms: shortness of breath or trouble breathing chest pain weakness in one part or side of your body slurred speech swelling of the face or throat Stop your NSAID medicine and call your healthcare provider right away if you have any of the following symptoms: nausea more tired or weaker than usual itching your skin or eyes look yellow stomach pain flu-like symptoms vomit blood there is blood in your bowel movement or it is black and sticky like tar unusual weight gain skin rash or blisters with fever swelling of the arms and legs, hands and feet These are not all the side effects with NSAID medicines. Talk to your healthcare provider or pharmacist for more information about NSAID medicines. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.Other information about Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Aspirin is an NSAID medicine but it does not increase the chance of heart attack. Aspirin can cause bleeding in the brain, stomach, and intestines. Aspirin can also cause ulcers in the stomach and intestines. Some of these NSAID medicines are sold in lower doses without prescription (over-the-counter). Talk to your healthcare provider before using over-the-counter NSAIDs for more than 10 days.NSAID medicines that need prescriptionGeneric NameTradenameCelecoxibCelebrexDiclofenacCataflam, Voltaren, Arthrotec (combined with misoprostol)DiflunisalDolobidEtodolacLodine, Lodine XLFenoprofenNalfon, Nalfon 200FlurbiprofenAnsaidIbuprofenMotrin, Tab-Profen, Vicoprofen (combined with hydrocodone), Combunox (combined with oxycodone)IndomethacinIndocin, Indocin SR, Indo-Lemmon, IndomethaganKetoprofenOruvailKetorolacToradolMefenamic AcidPonstelMeloxicamMobicNabumetoneRelafenNaproxenNaprosyn, Anaprox, Anaprox DS, EC-Naproxyn, Naprelan, Naprapac (copackaged with lansoprazole)OxaprozinDayproPiroxicamFeldeneSulindacClinorilTolmetinTolectin, Tolectin DS, Tolectin 600This Medication Guide has been approved by the U.S. Food and Drug Administration.Revised 06/2009. with longer use of NSAID medicines in people who have heart disease can happen without warning symptoms may cause death The chance of person getting an ulcer or bleeding increases with: taking medicines called corticosteroids and anticoagulants longer use smoking drinking alcohol older age having poor health The chance of person getting an ulcer or bleeding increases with: taking medicines called corticosteroids and anticoagulants longer use smoking drinking alcohol older age having poor health taking medicines called corticosteroids and anticoagulants longer use smoking drinking alcohol older age having poor health exactly as prescribed at the lowest dose possible for your treatment for the shortest time needed different types of arthritis menstrual cramps and other types of short-term pain. if you had an asthma attack, hives, or other allergic reaction with aspirin or any other NSAID medicine for pain right before or after heart bypass surgery. about all of your medical conditions.. about all of the medicines you take. NSAIDs and some other medicines can interact with each other and cause serious side effects. Keep list of your medicines to show to your healthcare provider and pharmacist. if you are pregnant. NSAID medicines should not be used by pregnant women late in their pregnancy. if you are breastfeeding. Talk to your doctor. heart attack. stroke. high blood pressure. heart failure from body swelling (fluid retention). kidney problems including kidney failure. bleeding and ulcers in the stomach and intestine. low red blood cells (anemia). life-threatening skin reactions. life-threatening allergic reactions. liver problems including liver failure. asthma attacks in people who have asthma. stomach pain. constipation. diarrhea. gas. heart burn. nausea. vomiting. dizziness. shortness of breath or trouble breathing chest pain weakness in one part or side of your body slurred speech swelling of the face or throat nausea more tired or weaker than usual itching your skin or eyes look yellow stomach pain flu-like symptoms vomit blood there is blood in your bowel movement or it is black and sticky like tar unusual weight gain skin rash or blisters with fever swelling of the arms and legs, hands and feet Aspirin is an NSAID medicine but it does not increase the chance of heart attack. Aspirin can cause bleeding in the brain, stomach, and intestines. Aspirin can also cause ulcers in the stomach and intestines. Some of these NSAID medicines are sold in lower doses without prescription (over-the-counter). Talk to your healthcare provider before using over-the-counter NSAIDs for more than 10 days.

ADVERSE REACTIONS SECTION.

ADVERSE REACTIONS. TABLE 2. Reported adverse events in patients receiving flurbiprofen or other non-steroidal anti-inflammatory drugsReported in patients treated with flurbiprofenReported in patientstreated with otherproducts but notflurbiprofenIncidence of 1%or greater Incidence 1% -Causal RelationshipProbable Incidence 1% -Causal RelationshipUnknown BODY AS WHOLE edemaanaphylactic reactionchillsfever< 1%:deathinfectionsepsisCARDIOVASCULAR SYSTEMcongestive heart failurehypertensionvascular diseasesvasodilationangina pectorisarrhythmiasmyocardial infarction< 1%:hypotensionpalpitationssyncopetachycardiavasculitisDIGESTIVE SYSTEM abdominal pain constipation diarrhea dyspepsia/heartburn elevated liver enzymes flatulence GI bleeding nausea vomitingbloody diarrheaesophageal diseasegastric/peptic ulcer diseasegastritisjaundice (cholestatic and noncholestatic)hematemesishepatitisstomatitis/glossitisappetite changescholecystitiscolitisdry mouthexacerbation of inflammatory bowel diseaseperiodontal abscesssmall intestine inflammation with loss of blood and protein> 1%:GI perforationGI ulcers (gastric/duodenal)< 1%:eructationliver failurepancreatitisHEMIC AND LYMPHATICSYSTEMaplastic anemia (including agranulocytosis or pancytopenia)decrease in hemoglobin and hematocrit ecchymosis/purpuraeosinophiliahemolytic anemiairon deficiency anemialeucopeniathrombocytopenialymphadenopathy> 1%:anemiaincreased bleeding time< 1%:melenarectal bleedingMETABOLIC ANDNUTRITIONAL SYSTEM body weight changeshyperuricemiahyperkalemia< 1%:hyperglycemiaNERVOUS SYSTEM headache nervousness and other manifestations of central nervous system (CNS) stimulation (e.g., anxiety, insomnia, increased reflexes, tremor) symptoms associated with CNS inhibition (e.g., amnesia, asthenia, depression, malaise, somnolence)ataxiacerebrovascular ischemiaconfusionparesthesiatwitchingconvulsioncerebrovascular accidentemotional labilityhypertoniameningitismyastheniasubarachnoid hemorrhage< 1%:comadream abnormalitiesdrowsinesshallucinationsRESPIRATORY SYSTEM rhinitisasthmaepistaxisbronchitis dyspneahyperventilationlaryngitispulmonary embolismpulmonary infarct< 1%:pneumoniarespiratory depressionSKIN AND APPENDAGES Rashangioedemaeczemaexfoliative dermatitisphotosensitivitypruritustoxic epidermal necrolysisurticariaalopeciadry skinherpes simplex/zosternail disordersweating< 1%:erythema multiformeStevens Johnson SyndromeSPECIAL SENSES changes in vision dizziness/vertigo tinnitusconjunctivitisparosmiachanges in tastecorneal opacityear diseaseglaucomaretinal hemorrhageretrobulbar neuritistransient hearing loss> 1%:pruritus< 1%:hearing impairmentUROGENITAL SYSTEM signs and symptoms suggesting urinary tract infectionhematuriainterstitial nephritisrenal failuremenstrual disturbancesprostate diseasevaginal and uterine hemorrhagevulvovaginitis> 1%:abnormal renal function< 1%:dysuriaoliguriapolyuriaproteinuria.

CLINICAL PHARMACOLOGY SECTION.

CLINICAL PHARMACOLOGY. Pharmacodynamics. Flurbiprofen is non-steroidal anti-inflammatory drug that exhibits anti-inflammatory, analgesic, and antipyretic activities in animal models. The mechanism of action of flurbiprofen, like that of other non-steroidal anti-inflammatory drugs, is not completely understood but may be related to prostaglandin synthetase inhibition.. Pharmacokinetics. Absorption. The mean oral bioavailability of flurbiprofen 100 mg tablets is 96% relative to an oral solution. Flurbiprofen is rapidly and non-stereoselectively absorbed with peak plasma concentrations occurring at about hours (see Table 1). Administration of flurbiprofen with either food or antacids may alter the rate but not the extent of flurbiprofen absorption. Ranitidine has been shown to have no effect on either the rate or extent of flurbiprofen absorption.. Distribution. The apparent volume of distribution (Vz/F) of both R- and S-flurbiprofen is approximately 0.12 L/Kg. Both flurbiprofen enantiomers are more than 99% bound to plasma proteins, primarily albumin. Plasma protein binding is relatively constant for the typical average steady-state concentrations (<= 10 mcg/mL) achieved with recommended doses. Flurbiprofen is poorly excreted into human milk. The nursing infant dose is predicted to be approximately 0.1 mg/day in the established milk of woman taking flurbiprofen 200 mg/day (see PRECAUTIONS: Nursing Mothers).. Metabolism. Several flurbiprofen metabolites have been identified in human plasma and urine. These metabolites include 4-hydroxy-flurbiprofen, 3, 4-dihydroxy-flurbiprofen, 3-hydroxy-4-methoxy-flurbiprofen, their conjugates, and conjugated flurbiprofen. Unlike other arylpropionic acid derivatives (e.g., ibuprofen), metabolism of R-flurbiprofen to S-flurbiprofen is minimal. In vitro studies have demonstrated that cytochrome P450 2C9 plays an important role in the metabolism of flurbiprofen to its major metabolite, 4-hydroxy-flurbiprofen. The 4-hydroxy-flurbiprofen metabolite showed little anti-inflammatory activity in animal models of inflammation. Flurbiprofen does not induce enzymes that alter its metabolism.The total plasma clearance of unbound flurbiprofen is not stereoselective, and clearance of flurbiprofen is independent of dose when used within the therapeutic range.. Excretion. Following dosing with flurbiprofen, less than 3% of flurbiprofen is excreted unchanged in the urine, with about 70% of the dose eliminated in the urine as parent drug and metabolites. Because renal elimination is significant pathway of elimination of flurbiprofen metabolites, dosing adjustment in patients with moderate or severe renal dysfunction may be necessary to avoid accumulation of flurbiprofen metabolites. The mean terminal disposition half-lives (t1/2) of R- and S-flurbiprofen are similar, about 4.7 and 5.7 hours, respectively. There is little accumulation of flurbiprofen following multiple doses of flurbiprofen.Table 1. Mean (SD) R, S-Flurbiprofen Pharmacokinetic Parameters Normalized to 100 mg Dose of FlurbiprofenPharmacokineticParameterNormal HealthyAdults (18 to 40 years)N 15GeriatricArthritis Patients (65 to 83 years)N 13End Stage RenalDisease Patients (23 to 42 years)N 8AlcoholicCirrhosis Patients (31 to 61 years)N 8PeakConcentration(Tg/mL)14 (4)16 (5)9 Time of PeakConcentration(h)1.9 (1.5)2.2 (3)2.3 1.2 Urinary Recoveryof UnchangedFlurbiprofen(% of Dose)2.9 (1.3)0.6 (0.6)0.02 (0.02)NA Area Under theCurve (AUC) (Tg h/mL)83 (20)77 (24)44 50 Apparent Volumeof Distribution(Vz/F, L)14 (3)12 (5)10 14 TerminalDispositionHalf-life (t1/2, h)7.5 (0.8)5.8 (1.9)3.3 5.4TH Special Populations. Pediatric. The pharmacokinetics of flurbiprofen have not been investigated in pediatric patients.. Race. No pharmacokinetic differences due to race have been identified.. Geriatric. Flurbiprofen pharmacokinetics were similar in geriatric arthritis patients, younger arthritis patients, and young healthy volunteers receiving flurbiprofen tablets 100 mg as either single or multiple doses.. Hepatic Insufficiency. Hepatic metabolism may account for 90% of flurbiprofen elimination, so patients with hepatic disease may require reduced doses of flurbiprofen tablets compared to patients with normal hepatic function. The pharmacokinetics of R- and S-flurbiprofen were similar, however, in alcoholic cirrhosis patients (N 8) and young healthy volunteers (N 8) following administration of single 200 mg dose of flurbiprofen tablets. Flurbiprofen plasma protein binding may be decreased in patients with liver disease and serum albumin concentrations below 3.1 g/dL (see PRECAUTIONS: General: Hepatic Effects).. Renal Insufficiency. Renal clearance is an important route of elimination for flurbiprofen metabolites, but minor route of elimination for unchanged flurbiprofen (<= 3% of total clearance). The unbound clearances of R- and S-flurbiprofen did not differ significantly between normal healthy volunteers (N 6, 50 mg single dose) and patients with renal impairment (N 8, inulin clearances ranging from 11 to 43 mL/min, 50 mg multiple doses). Flurbiprofen plasma protein binding may be decreased in patients with renal impairment and serum albumin concentrations below 3.9 g/dL. Elimination of flurbiprofen metabolites may be reduced in patients with renal impairment (see PRECAUTIONS: General: Renal Effects).Flurbiprofen is not significantly removed from the blood into dialysate in patients undergoing continuous ambulatory peritoneal dialysis.. Drug-Drug Interactions. (see also PRECAUTIONS: Drug Interactions). Antacids. Administration of flurbiprofen to volunteers under fasting conditions or with antacid suspension yielded similar serum flurbiprofen-time profiles in young adult subjects (n 12). In geriatric subjects (n 7), there was reduction in the rate but not the extent of flurbiprofen absorption.. Aspirin. Concurrent administration of flurbiprofen and aspirin resulted in 50% lower serum flurbiprofen concentrations. This effect of aspirin (which is also seen with other non-steroidal anti-inflammatory drugs) has been demonstrated in patients with rheumatoid arthritis (n 15) and in healthy volunteers (n 16) (see PRECAUTIONS: Drug Interactions).. Beta-Adrenergic Blocking Agents. The effect of flurbiprofen on blood pressure response to propranolol and atenolol was evaluated in men with mild uncomplicated hypertension (n 10). Flurbiprofen pretreatment attenuated the hypotensive effect of single dose of propranolol but not atenolol. Flurbiprofen did not appear to affect the beta-blocker-mediated reduction in heart rate. Flurbiprofen did not affect the pharmacokinetic profile of either drug (see PRECAUTIONS: Drug Interactions).. Cimetidine, Ranitidine. In normal volunteers (n 9), pretreatment with cimetidine or ranitidine did not affect flurbiprofen pharmacokinetics, except for small (13%) but statistically significant increase in the area under the serum concentration curve of flurbiprofen in subjects who received cimetidine.. Digoxin. In studies of healthy males (n 14), concomitant administration of flurbiprofen and digoxin did not change the steady-state serum levels of either drug.. Diuretics. Studies in healthy volunteers have shown that, like other non-steroidal anti-inflammatory drugs, flurbiprofen can interfere with the effects of furosemide. Although results have varied from study to study, effects have been shown on furosemide-stimulated diuresis, natriuresis, and kaliuresis. Other non-steroidal anti-inflammatory drugs that inhibit prostaglandin synthesis have been shown to interfere with thiazide and potassium-sparing diuretics (see PRECAUTIONS: Drug Interactions).. Lithium. In study of 11 women with bipolar disorder receiving lithium carbonate at dosage of 600 mg to 1200 mg/day, administration of 100 mg flurbiprofen every 12 hours increased plasma lithium concentrations by 19%. Four of 11 patients experienced clinically important increase (> 25% or 0.2 mmol/L). Non-steroidal anti-inflammatory drugs have also been reported to decrease the renal clearance of lithium by about 20% (see PRECAUTIONS: Drug Interactions).. Methotrexate. In study of six adult arthritis patients, coadministration of methotrexate (10 to 25 mg/dose) and flurbiprofen (300 mg/day) resulted in no observable interaction between these two drugs.. Oral Hypoglycemic Agents. In clinical study, flurbiprofen was administered to adult diabetics who were already receiving glyburide (n 4), metformin (n 2), chlorpropamide with phenformin (n 3), or glyburide with phenformin (n 6). Although there was slight reduction in blood sugar concentrations during concomitant administration of flurbiprofen and hypoglycemic agents, there were no signs or symptoms of hypoglycemia.

PHARMACOKINETICS SECTION.

Pharmacokinetics. Absorption. The mean oral bioavailability of flurbiprofen 100 mg tablets is 96% relative to an oral solution. Flurbiprofen is rapidly and non-stereoselectively absorbed with peak plasma concentrations occurring at about hours (see Table 1). Administration of flurbiprofen with either food or antacids may alter the rate but not the extent of flurbiprofen absorption. Ranitidine has been shown to have no effect on either the rate or extent of flurbiprofen absorption.. Distribution. The apparent volume of distribution (Vz/F) of both R- and S-flurbiprofen is approximately 0.12 L/Kg. Both flurbiprofen enantiomers are more than 99% bound to plasma proteins, primarily albumin. Plasma protein binding is relatively constant for the typical average steady-state concentrations (<= 10 mcg/mL) achieved with recommended doses. Flurbiprofen is poorly excreted into human milk. The nursing infant dose is predicted to be approximately 0.1 mg/day in the established milk of woman taking flurbiprofen 200 mg/day (see PRECAUTIONS: Nursing Mothers).. Metabolism. Several flurbiprofen metabolites have been identified in human plasma and urine. These metabolites include 4-hydroxy-flurbiprofen, 3, 4-dihydroxy-flurbiprofen, 3-hydroxy-4-methoxy-flurbiprofen, their conjugates, and conjugated flurbiprofen. Unlike other arylpropionic acid derivatives (e.g., ibuprofen), metabolism of R-flurbiprofen to S-flurbiprofen is minimal. In vitro studies have demonstrated that cytochrome P450 2C9 plays an important role in the metabolism of flurbiprofen to its major metabolite, 4-hydroxy-flurbiprofen. The 4-hydroxy-flurbiprofen metabolite showed little anti-inflammatory activity in animal models of inflammation. Flurbiprofen does not induce enzymes that alter its metabolism.The total plasma clearance of unbound flurbiprofen is not stereoselective, and clearance of flurbiprofen is independent of dose when used within the therapeutic range.. Excretion. Following dosing with flurbiprofen, less than 3% of flurbiprofen is excreted unchanged in the urine, with about 70% of the dose eliminated in the urine as parent drug and metabolites. Because renal elimination is significant pathway of elimination of flurbiprofen metabolites, dosing adjustment in patients with moderate or severe renal dysfunction may be necessary to avoid accumulation of flurbiprofen metabolites. The mean terminal disposition half-lives (t1/2) of R- and S-flurbiprofen are similar, about 4.7 and 5.7 hours, respectively. There is little accumulation of flurbiprofen following multiple doses of flurbiprofen.Table 1. Mean (SD) R, S-Flurbiprofen Pharmacokinetic Parameters Normalized to 100 mg Dose of FlurbiprofenPharmacokineticParameterNormal HealthyAdults (18 to 40 years)N 15GeriatricArthritis Patients (65 to 83 years)N 13End Stage RenalDisease Patients (23 to 42 years)N 8AlcoholicCirrhosis Patients (31 to 61 years)N 8PeakConcentration(Tg/mL)14 (4)16 (5)9 Time of PeakConcentration(h)1.9 (1.5)2.2 (3)2.3 1.2 Urinary Recoveryof UnchangedFlurbiprofen(% of Dose)2.9 (1.3)0.6 (0.6)0.02 (0.02)NA Area Under theCurve (AUC) (Tg h/mL)83 (20)77 (24)44 50 Apparent Volumeof Distribution(Vz/F, L)14 (3)12 (5)10 14 TerminalDispositionHalf-life (t1/2, h)7.5 (0.8)5.8 (1.9)3.3 5.4TH.

PRECAUTIONS SECTION.

PRECAUTIONS. General. Flurbiprofen cannot be expected to substitute for corticosteroids or to treat corticosteroid insufficiency. Abrupt discontinuation of corticosteroids may lead to disease exacerbation. Patients on prolonged corticosteroid therapy should have their therapy tapered slowly if decision is made to discontinue corticosteroids. The pharmacological activity of flurbiprofen in reducing fever and inflammation may diminish the utility of these diagnostic signs in detecting complications of presumed noninfectious, painful conditions.. Hepatic Effects. Borderline elevations of one or more liver tests may occur in up to 15% of patients taking non-steroidal anti-inflammatory drugs, including flurbiprofen. These laboratory abnormalities may progress, may remain unchanged, or may be transient with continuing therapy. Notable elevations of ALT or AST (approximately three or more times the upper limit of normal) have been reported in approximately 1% of patients in clinical trials with non-steroidal anti-inflammatory drugs. In addition, rare cases of severe hepatic reactions, including jaundice, fulminant hepatitis, liver necrosis, and hepatic failure, some of them with fatal outcomes have been reported. patient with symptoms and/or signs suggesting liver dysfunction, or with abnormal liver test values, should be evaluated for evidence of the development of more severe hepatic reaction while on therapy with flurbiprofen. If clinical signs and symptoms consistent with liver disease develop, or if systemic manifestations occur (e.g., eosinophilia, rash, etc.), flurbiprofen should be discontinued. Hematological Effects. Anemia is sometimes seen in patients receiving non-steroidal anti-inflammatory drugs, including flurbiprofen. This may be due to fluid retention, GI blood loss, or an incompletely described effect upon erythropoiesis. Patients on long-term treatment with non-steroidal anti-inflammatory drugs, including flurbiprofen, should have their hemoglobin or hematocrit checked periodically even if they do not exhibit any signs or symptoms of anemia. Non-steroidal anti-inflammatory drugs inhibit platelet aggregation and have been shown to prolong bleeding time in some patients. Unlike aspirin, their effect on platelet function is quantitatively less, of shorter duration, and reversible. Flurbiprofen does not generally affect platelet counts, prothrombin time (PT), or partial thromboplastin time (PTT). Patients receiving flurbiprofen who may be adversely affected by alterations in platelet function, such as those with coagulation disorders or patients receiving anticoagulants, should be carefully monitored.. Preexisting Asthma. Patients with asthma may have aspirin-sensitive asthma. The use of aspirin in patients with aspirin-sensitive asthma has been associated with severe bronchospasm which can be fatal. Since cross-reactivity, including bronchospasm, between aspirin and other non-steroidal anti-inflammatory drugs has been reported in such aspirin-sensitive patients, flurbiprofen should not be administered to patients with this form of aspirin sensitivity and should be used with caution in patients with preexisting asthma.. Vision Changes. Blurred and/or diminished vision has been reported with the use of flurbiprofen and other non-steroidal anti-inflammatory drugs. Patients experiencing eye complaints should have ophthalmologic examinations.. Information for Patients. Patients should be informed of the following information before initiating therapy with an NSAID and periodically during the course of ongoing therapy. Patients should also be encouraged to read the NSAID Medication Guide that accompanies each prescription dispensed.Flurbiprofen, like other NSAIDs, may cause CV side effects, such as MI or stroke, which may result in hospitalization and even death. Although serious CV events can occur without warning symptoms, patients should be alert for the signs and symptoms of chest pain, shortness of breath, weakness, slurring of speech, and should ask for medical advice when observing any indicative sign or symptoms. Patients should be apprised of the importance of this follow-up (see WARNINGS: Cardiovascular Effects).Flurbiprofen, like other NSAIDs, can cause GI discomfort and, rarely, serious GI side effects, such as ulcers and bleeding, which may result in hospitalization and even death. Although serious GI tract ulcerations and bleeding can occur without warning symptoms, patients should be alert for the signs and symptoms of ulcerations and bleeding, and should ask for medical advice when observing any indicative sign or symptoms including epigastric pain, dyspepsia, melena, and hematemesis. Patients should be apprised of the importance of this follow-up (see WARNINGS: Gastrointestinal Effects: Risk of Ulceration, Bleeding, and Perforation).Flurbiprofen, like other NSAIDs, can cause serious skin side effects such as exfoliative dermatitis, SJS, and TEN, which may result in hospitalizations and even death. Although serious skin reactions may occur without warning, patients should be alert for the signs and symptoms of skin rash and blisters, fever, or other signs of hypersensitivity such as itching, and should ask for medical advice when observing any indicative signs or symptoms. Patients should be advised to stop the drug immediately if they develop any type of rash and contact their physicians as soon as possible. Patients should promptly report signs or symptoms of unexplained weight gain or edema to their physicians.Patients should be informed of the warning signs and symptoms of hepatotoxicity (e.g., nausea, fatigue, lethargy, pruritus, jaundice, right upper quadrant tenderness and flu-like symptoms). If these occur, patients should be instructed to stop therapy and seek immediate medical therapy.Patients should be informed of the signs of an anaphylactoid reaction (e.g. difficulty breathing, swelling of the face or throat). If these occur, patients should be instructed to seek immediate emergency help (see WARNINGS).In late pregnancy, as with other NSAIDs, flurbiprofen should be avoided because it may cause premature closure of the ductus arteriosus.. Flurbiprofen, like other NSAIDs, may cause CV side effects, such as MI or stroke, which may result in hospitalization and even death. Although serious CV events can occur without warning symptoms, patients should be alert for the signs and symptoms of chest pain, shortness of breath, weakness, slurring of speech, and should ask for medical advice when observing any indicative sign or symptoms. Patients should be apprised of the importance of this follow-up (see WARNINGS: Cardiovascular Effects).. Flurbiprofen, like other NSAIDs, can cause GI discomfort and, rarely, serious GI side effects, such as ulcers and bleeding, which may result in hospitalization and even death. Although serious GI tract ulcerations and bleeding can occur without warning symptoms, patients should be alert for the signs and symptoms of ulcerations and bleeding, and should ask for medical advice when observing any indicative sign or symptoms including epigastric pain, dyspepsia, melena, and hematemesis. Patients should be apprised of the importance of this follow-up (see WARNINGS: Gastrointestinal Effects: Risk of Ulceration, Bleeding, and Perforation).. Flurbiprofen, like other NSAIDs, can cause serious skin side effects such as exfoliative dermatitis, SJS, and TEN, which may result in hospitalizations and even death. Although serious skin reactions may occur without warning, patients should be alert for the signs and symptoms of skin rash and blisters, fever, or other signs of hypersensitivity such as itching, and should ask for medical advice when observing any indicative signs or symptoms. Patients should be advised to stop the drug immediately if they develop any type of rash and contact their physicians as soon as possible. Patients should promptly report signs or symptoms of unexplained weight gain or edema to their physicians.. Patients should be informed of the warning signs and symptoms of hepatotoxicity (e.g., nausea, fatigue, lethargy, pruritus, jaundice, right upper quadrant tenderness and flu-like symptoms). If these occur, patients should be instructed to stop therapy and seek immediate medical therapy.. Patients should be informed of the signs of an anaphylactoid reaction (e.g. difficulty breathing, swelling of the face or throat). If these occur, patients should be instructed to seek immediate emergency help (see WARNINGS).. In late pregnancy, as with other NSAIDs, flurbiprofen should be avoided because it may cause premature closure of the ductus arteriosus.. Laboratory Tests. Because serious GI tract ulcerations and bleeding can occur without warning symptoms, physicians should monitor for signs or symptoms of GI bleeding. Patients on long-term treatment with non-steroidal anti-inflammatory drugs should have their CBC and chemistry profile checked periodically. If clinical signs and symptoms consistent with liver or renal disease develop, systemic manifestations occur (e.g., eosinophilia, rash, etc.) or abnormal liver tests persist or worsen, flurbiprofen should be discontinued.. Drug Interactions. ACE Inhibitors. Reports suggest that non-steroidal anti-inflammatory drugs may diminish the antihypertensive effect of ACE inhibitors. These interactions should be given consideration in patients taking non-steroidal anti-inflammatory drugs concomitantly with ACE inhibitors.. Anticoagulants. The effects of warfarin and NSAIDs on GI bleeding are synergistic, such that users of both drugs together have risk of serious GI bleeding higher than users of either drug alone. The physician should be cautious when administering flurbiprofen to patients taking warfarin or other anticoagulants.. Aspirin. Concurrent administration of aspirin lowers serum flurbiprofen concentrations (see CLINICAL PHARMACOLOGY: Drug-Drug Interactions). The clinical significance of this interaction is not known; however, as with other NSAIDs, concomitant administration of flurbiprofen and aspirin is not generally recommended because of the potential for increased adverse effects.. Beta-Adrenergic Blocking Agents. Flurbiprofen attenuated the hypotensive effect of propranolol but not atenolol (see CLINICAL PHARMACOLOGY: Drug-Drug Interactions). The mechanism underlying this interference is unknown. Patients taking both flurbiprofen and beta-blocker should be monitored to ensure that satisfactory hypotensive effect is achieved.. Diuretics. Clinical studies, as well as post-marketing observations, have shown that flurbiprofen can reduce the natriuretic effect of furosemide and thiazides in some patients. This response has been attributed to inhibition of renal prostaglandin synthesis. During concomitant therapy with NSAIDs, the patient should be observed closely for signs of renal failure (see WARNINGS: Renal Effects), as well as diuretic efficacy.. Lithium. NSAIDs have produced an elevation of plasma lithium levels and reduction in renal lithium clearance. The mean minimum lithium concentration increased 15% and the renal clearance was decreased by approximately 20%. These effects have been attributed to inhibition of renal prostaglandin synthesis by the non-steroidal anti-inflammatory drugs. Thus, when non-steroidal anti-inflammatory drugs and lithium are administered concurrently, subjects should be observed carefully for signs of lithium toxicity.. Methotrexate. Non-steroidal anti-inflammatory drugs have been reported to competitively inhibit methotrexate accumulation in rabbit kidney slices. This may indicate that they could enhance the toxicity of methotrexate. Caution should be used when non-steroidal anti-inflammatory drugs are administered concomitantly with methotrexate.. Pregnancy. Teratogenic Effects. Pregnancy Category C. Reproductive studies conducted in rats and rabbits have not demonstrated evidence of developmental abnormalities. However, animal reproduction studies are not always predictive of human response. There are no adequate and well controlled studies in pregnant women. Flurbiprofen should be used in pregnancy only if the potential benefit justifies the potential risk to the fetus.. Nonteratogenic Effects. Because of the known effects of non-steroidal anti-inflammatory drugs on the fetal cardiovascular system (closure of ductus arteriosus), use during late pregnancy should be avoided.. Labor and Delivery. In rat studies with non-steroidal anti-inflammatory drugs, as with other drugs known to inhibit prostaglandin synthesis, an increased incidence of dystocia, delayed parturition, and decreased pup survival occurred. The effects of flurbiprofen on labor and delivery in pregnant women are unknown.. Nursing Mothers. Concentrations of flurbiprofen in breast milk and plasma of nursing mothers suggest that nursing infant could receive approximately 0.10 mg flurbiprofen per day in the established milk of woman taking flurbiprofen 200 mg/day. Because of possible adverse effects of prostaglandin-inhibiting drugs on neonates, decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.. Pediatric Use. Safety and effectiveness in pediatric patients have not been established.. Geriatric Use. As with any NSAID, caution should be exercised in treating the elderly (65 years and older). Clinical experience with flurbiprofen suggests that elderly patients may have higher incidence of gastrointestinal complaints than younger patients, including ulceration, bleeding, flatulence, bloating, and abdominal pain. To minimize the potential risk for gastrointestinal events, the lowest effective dose should be used for the shortest possible duration (see WARNINGS: Gastrointestinal Effects). Likewise, elderly patients are at greater risk of developing renal decompensation (see WARNINGS: Renal Effects). The pharmacokinetics of flurbiprofen do not seem to differ in elderly patients from those in younger individuals (see CLINICAL PHARMACOLOGY: Special Populations). The rate of absorption of flurbiprofen was reduced in elderly patients who also received antacids, although the extent of absorption was not affected (see CLINICAL PHARMACOLOGY: Drug-Drug Interactions).

GENERAL PRECAUTIONS SECTION.

General. Flurbiprofen cannot be expected to substitute for corticosteroids or to treat corticosteroid insufficiency. Abrupt discontinuation of corticosteroids may lead to disease exacerbation. Patients on prolonged corticosteroid therapy should have their therapy tapered slowly if decision is made to discontinue corticosteroids. The pharmacological activity of flurbiprofen in reducing fever and inflammation may diminish the utility of these diagnostic signs in detecting complications of presumed noninfectious, painful conditions.. Hepatic Effects. Borderline elevations of one or more liver tests may occur in up to 15% of patients taking non-steroidal anti-inflammatory drugs, including flurbiprofen. These laboratory abnormalities may progress, may remain unchanged, or may be transient with continuing therapy. Notable elevations of ALT or AST (approximately three or more times the upper limit of normal) have been reported in approximately 1% of patients in clinical trials with non-steroidal anti-inflammatory drugs. In addition, rare cases of severe hepatic reactions, including jaundice, fulminant hepatitis, liver necrosis, and hepatic failure, some of them with fatal outcomes have been reported. patient with symptoms and/or signs suggesting liver dysfunction, or with abnormal liver test values, should be evaluated for evidence of the development of more severe hepatic reaction while on therapy with flurbiprofen. If clinical signs and symptoms consistent with liver disease develop, or if systemic manifestations occur (e.g., eosinophilia, rash, etc.), flurbiprofen should be discontinued. Hematological Effects. Anemia is sometimes seen in patients receiving non-steroidal anti-inflammatory drugs, including flurbiprofen. This may be due to fluid retention, GI blood loss, or an incompletely described effect upon erythropoiesis. Patients on long-term treatment with non-steroidal anti-inflammatory drugs, including flurbiprofen, should have their hemoglobin or hematocrit checked periodically even if they do not exhibit any signs or symptoms of anemia. Non-steroidal anti-inflammatory drugs inhibit platelet aggregation and have been shown to prolong bleeding time in some patients. Unlike aspirin, their effect on platelet function is quantitatively less, of shorter duration, and reversible. Flurbiprofen does not generally affect platelet counts, prothrombin time (PT), or partial thromboplastin time (PTT). Patients receiving flurbiprofen who may be adversely affected by alterations in platelet function, such as those with coagulation disorders or patients receiving anticoagulants, should be carefully monitored.. Preexisting Asthma. Patients with asthma may have aspirin-sensitive asthma. The use of aspirin in patients with aspirin-sensitive asthma has been associated with severe bronchospasm which can be fatal. Since cross-reactivity, including bronchospasm, between aspirin and other non-steroidal anti-inflammatory drugs has been reported in such aspirin-sensitive patients, flurbiprofen should not be administered to patients with this form of aspirin sensitivity and should be used with caution in patients with preexisting asthma.. Vision Changes. Blurred and/or diminished vision has been reported with the use of flurbiprofen and other non-steroidal anti-inflammatory drugs. Patients experiencing eye complaints should have ophthalmologic examinations.

INFORMATION FOR PATIENTS SECTION.

Information for Patients. Patients should be informed of the following information before initiating therapy with an NSAID and periodically during the course of ongoing therapy. Patients should also be encouraged to read the NSAID Medication Guide that accompanies each prescription dispensed.Flurbiprofen, like other NSAIDs, may cause CV side effects, such as MI or stroke, which may result in hospitalization and even death. Although serious CV events can occur without warning symptoms, patients should be alert for the signs and symptoms of chest pain, shortness of breath, weakness, slurring of speech, and should ask for medical advice when observing any indicative sign or symptoms. Patients should be apprised of the importance of this follow-up (see WARNINGS: Cardiovascular Effects).Flurbiprofen, like other NSAIDs, can cause GI discomfort and, rarely, serious GI side effects, such as ulcers and bleeding, which may result in hospitalization and even death. Although serious GI tract ulcerations and bleeding can occur without warning symptoms, patients should be alert for the signs and symptoms of ulcerations and bleeding, and should ask for medical advice when observing any indicative sign or symptoms including epigastric pain, dyspepsia, melena, and hematemesis. Patients should be apprised of the importance of this follow-up (see WARNINGS: Gastrointestinal Effects: Risk of Ulceration, Bleeding, and Perforation).Flurbiprofen, like other NSAIDs, can cause serious skin side effects such as exfoliative dermatitis, SJS, and TEN, which may result in hospitalizations and even death. Although serious skin reactions may occur without warning, patients should be alert for the signs and symptoms of skin rash and blisters, fever, or other signs of hypersensitivity such as itching, and should ask for medical advice when observing any indicative signs or symptoms. Patients should be advised to stop the drug immediately if they develop any type of rash and contact their physicians as soon as possible. Patients should promptly report signs or symptoms of unexplained weight gain or edema to their physicians.Patients should be informed of the warning signs and symptoms of hepatotoxicity (e.g., nausea, fatigue, lethargy, pruritus, jaundice, right upper quadrant tenderness and flu-like symptoms). If these occur, patients should be instructed to stop therapy and seek immediate medical therapy.Patients should be informed of the signs of an anaphylactoid reaction (e.g. difficulty breathing, swelling of the face or throat). If these occur, patients should be instructed to seek immediate emergency help (see WARNINGS).In late pregnancy, as with other NSAIDs, flurbiprofen should be avoided because it may cause premature closure of the ductus arteriosus.. Flurbiprofen, like other NSAIDs, may cause CV side effects, such as MI or stroke, which may result in hospitalization and even death. Although serious CV events can occur without warning symptoms, patients should be alert for the signs and symptoms of chest pain, shortness of breath, weakness, slurring of speech, and should ask for medical advice when observing any indicative sign or symptoms. Patients should be apprised of the importance of this follow-up (see WARNINGS: Cardiovascular Effects).. Flurbiprofen, like other NSAIDs, can cause GI discomfort and, rarely, serious GI side effects, such as ulcers and bleeding, which may result in hospitalization and even death. Although serious GI tract ulcerations and bleeding can occur without warning symptoms, patients should be alert for the signs and symptoms of ulcerations and bleeding, and should ask for medical advice when observing any indicative sign or symptoms including epigastric pain, dyspepsia, melena, and hematemesis. Patients should be apprised of the importance of this follow-up (see WARNINGS: Gastrointestinal Effects: Risk of Ulceration, Bleeding, and Perforation).. Flurbiprofen, like other NSAIDs, can cause serious skin side effects such as exfoliative dermatitis, SJS, and TEN, which may result in hospitalizations and even death. Although serious skin reactions may occur without warning, patients should be alert for the signs and symptoms of skin rash and blisters, fever, or other signs of hypersensitivity such as itching, and should ask for medical advice when observing any indicative signs or symptoms. Patients should be advised to stop the drug immediately if they develop any type of rash and contact their physicians as soon as possible. Patients should promptly report signs or symptoms of unexplained weight gain or edema to their physicians.. Patients should be informed of the warning signs and symptoms of hepatotoxicity (e.g., nausea, fatigue, lethargy, pruritus, jaundice, right upper quadrant tenderness and flu-like symptoms). If these occur, patients should be instructed to stop therapy and seek immediate medical therapy.. Patients should be informed of the signs of an anaphylactoid reaction (e.g. difficulty breathing, swelling of the face or throat). If these occur, patients should be instructed to seek immediate emergency help (see WARNINGS).. In late pregnancy, as with other NSAIDs, flurbiprofen should be avoided because it may cause premature closure of the ductus arteriosus.