ACUVAIL is indicated for the treatment of pain and inflammation following cataract surgery.

  Apply One Drop of ACUVAIL to the affected eye twice daily beginning 1 day   prior to cataract surgery, continued on the day of surgery, and through the first 2 weeks of the postoperative period.

ACUVAIL may be administered in conjunction with other topical ophthalmic medications such as alpha-agonists, beta-blockers, carbonic anhydrase inhibitors, cycloplegics, and mydriatics. Drops should be administered at least 5 minutes apart.

Pediatric Use:

The safety and effectiveness of ACUVAILL have not been established in pediatric patients younger than 2 years old.

Geriatric Use:

No overall differences in safety or effectiveness have been observed between elderly and other adult patients.

Delayed Healing

Topical nonsteroidal anti-inflammatory drugs (NSAIDs) may slow or delay healing. Topical corticosteroids are also known to slow or delay healing. Concomitant use of topical NSAIDs and topical steroids may increase the potential for healing problems.

Cross-Sensitivity or Hypersensitivity

There is the potential for cross-sensitivity to acetylsalicylic acid, phenylacetic acid derivatives, and other NSAIDs. There have been reports of bronchospasm or exacerbation of asthma associated with the use of ketorolac tromethamine ophthalmic solution in patients who either have a known hypersensitivity to aspirin/non-steroidal anti-inflammatory drugs, or a past medical history of asthma. Therefore, caution should be used when treating individuals who have previously exhibited sensitivities to these drugs.

 Increased Bleeding Time

With some NSAIDs, there exists the potential for increased bleeding time due to interference with thrombocyte aggregation. There have been reports that ocularly applied nonsteroidal anti-inflammatory drugs may cause increased bleeding of ocular tissues (including hyphemas) in conjunction with ocular surgery.

It is recommended that ACUVAIL be used with caution in patients with known bleeding tendencies or who are receiving other medications, which may prolong bleeding time.

Corneal Effects

Use of topical NSAIDs may result in keratitis. In some susceptible patients, continued use of topical NSAIDs may result in epithelial breakdown, corneal thinning, corneal erosion, corneal ulceration, or corneal perforation. These events may be sight threatening. Patients with evidence of corneal epithelial breakdown should immediately discontinue use of topical NSAIDs and should be closely monitored for corneal health.

Postmarketing experience with topical NSAIDs suggests that patients with complicated ocular surgeries, corneal denervation, corneal epithelial defects, diabetes mellitus, ocular surface diseases (e.g., dry eye syndrome), rheumatoid arthritis, or repeat ocular surgeries within a short period of time may be at increased risk for corneal adverse events which may become sight threatening.

Topical NSAIDs should be used with caution in these patients.

Postmarketing experience with topical NSAIDs also suggests that use more than 1 day prior to surgery or use beyond 14 days postsurgery may increase patient risk for the occurrence and severity of corneal adverse events.

Contact Lens Wear

ACUVAIL should not be administered while wearing contact lenses.

Risk of Contamination

Avoid allowing the tip of the single-dose vial to contact the eye or surrounding structures because this could cause the tip to become contaminated by common bacteria known to cause ocular infections or cause injury to the eye. Serious damage to the eye and subsequent loss of vision may result from using contaminated solutions.

PATIENT INFORMATION

Avoiding Contamination of the Product

Patients should be instructed that the solution from one individual single-use vial is to be used immediately after opening for administration to the affected eye. The remaining vial contents should be discarded.

The use of the same single-use vial of topical eye drops for both eyes following bilateral ocular surgery is not recommended. In these circumstances, advise patients to use one vial for each eye immediately after opening and discard the remaining contents after use.

Patients should be instructed to avoid allowing the tip of the vial to contact the eye or surrounding structures because this could cause the tip to become contaminated by common bacteria known to cause ocular infections or cause injury to the eye. Serious damage to the eye and subsequent loss of vision may result from using contaminated solutions.

Store the vials in the pouch, protected from light. Fold pouch ends closed.

 Intercurrent Ocular Conditions

Patients should be advised that if they develop an intercurrent ocular condition (e.g., trauma or infection) or have ocular surgery, they should immediately seek their physician’s advice concerning the continued use of ACUVAIL.

ACUVAIL ophthalmic solution may be administered in conjunction with other topical

ophthalmic medications such as alpha-agonists, antibiotics, beta blockers, carbonic anhydrase inhibitors, cycloplegics, and mydriatics.

Patients should be advised that if more than one topical ophthalmic medication is being used, the medicines should be administered at least 5 minutes apart.

Fertility

Ketorolac tromethamine did not impair fertility when administered orally to male and female rats at doses up to 9 mg/kg/day and 16 mg/kg/day, respectively. These doses are respectively 1500 and 2700 times higher than the typical human topical ophthalmic daily dose.

Pregnancy

Risk Summary

There are no adequate and well-controlled studies with ACUVAIL in pregnant women. No evidence of teratogenicity has been observed in rats or rabbits with ACUVAIL at clinically relevant doses.

Lactation:

Risk Summary

It is not known whether are whether ketorolac when given topically is present in human milk. Because many drugs are excreted in human milk, caution should be exercised when ACUVAIL is administered to a nursing woman.

There are no reported effects of topical ophthalmic drugs on driving or using machinery. However, caution should be exercised. If transient blurred vision occurs during installation, the patient should wait until the vision is restored.

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to the rates in the clinical trials of another drug and may not reflect the rates observed in practice.

Frequency categories: Very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to ≤1/100); rare (≥1/10,000 to ≤1/1,000); very rare (≤1/10,000), not known (cannot be estimated from the available data).

Clinical Studies Experience

The most common adverse reactions were reported in 1% to 6% of patients.

Common:

·        Increased intraocular pressure

·        Conjunctival hyperemia and/or hemorrhage

·        Corneal edema

·        Ocular pain

·        Headache

·        Tearing and vision blurred

·        Increased intraocular pressure

Other adverse reactions occurring during treatment with ketorolac tromethamine ophthalmic solutions included allergic reactions (including eye swelling, hyperemia, and pruritis).

Postmarketing Experience

The following adverse reactions have been identified during postapproval use of ketorolac tromethamine ophthalmic solutions in clinical practice. Because these reactions are reported voluntarily from a population uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relation to the drug.

Unknown:

Eye Disorders:

· Corneal erosion

· Corneal perforation

· Corneal thinning & corneal melt

· Epithelial breakdown

· Ulcerative keratitis

Respiratory, Thoracic and Mediastinal Disorders:

· Bronchospasm

· Exacerbation of asthma

To reports any side effect(s):

Saudi Arabia:

Other GCC States:

No overdosage has been reported after ophthalmic use. In case of an overdosage, symptomatic and supportive treatment should be instituted and must be diluted with plenty of water.

Pharmacotherapeutic group: Non-steroidal anti-inflammatory (NSAID) ATC Code: S01BC05

Mechanism of Action

Ketorolac tromethamine is a nonsteroidal anti-inflammatory drug which, when administered systemically, has demonstrated analgesic, anti-inflammatory, and anti-pyretic activity. The mechanism of its action is thought to be due to its ability to inhibit prostaglandin biosynthesis.

CLINICAL STUDIES

Two multicenter, randomized, double-masked, parallel group comparison studies including approximately 500 patients were conducted to evaluate the effects of ACUVAIL on anterior chamber cell and flare, and ocular pain relief following cataract extraction with posterior chamber intraocular lens (IOL) implantation. Results of these studies indicated that patients receiving ACUVAILL™ had a significantly higher incidence of clearing of anterior chamber inflammation 53% (167/318) vs. patients receiving vehicle 26% (41/155) at day 14.

ACUVAIL was also significantly superior to vehicle in resolving ocular pain. On Day 1 post cataract surgery, 72% (233/322) of patients in the ACUVAIL group were pain free compared to 40% (62/156) of patients in the vehicle group.

Results from clinical studies indicate that ketorolac tromethamine has no significant effect upon intraocular pressure; however, changes in intraocular pressure may occur following cataract surgery.

Two drops of 0.5% ketorolac tromethamine ophthalmic solution instilled into the eyes of patients 12 hours and 1 hour prior to cataract extraction achieved a mean ketorolac concentration of 95 ng/mL in the aqueous humor of 8 of 9 eyes tested (range 40 to 170 ng/mL).

One drop of 0.5% ketorolac tromethamine ophthalmic solution was instilled into 1 eye and 1 drop of vehicle into the other eye three times daily in 26 healthy subjects. Five (5) of 26 subjects had detectable concentrations of ketorolac in their plasma (range 11 to 23 ng/mL) at Day 10 during topical ocular treatment. The range of concentrations following three times daily dosing of 0.5% ketorolac tromethamine ophthalmic solution are approximately 4 to 8% of the steady state mean minimum plasma concentration observed following four times daily oral administration of 10 mg ketorolac in humans (290 ± 70 ng/mL).

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Carboxymethylcellulose sodium

 Sodium chloride

 Sodium citrate dehydrate

 Purified water

 Sodium hydroxide and/or hydrochloric acid to adjust ph.

Not known.

Store below 30° C. Store the vials in the pouch, protected from light. Fold pouch ends closed. The solution from one individual single-dose vial is to be used immediately after opening. The remaining vial contents should be discarded.

ACUVAIL (ketorolac tromethamine ophthalmic solution) 0.45% is supplied as sterile, clear, and colorless to pale yellow ophthalmic solution in clear low density polyethylene (LDPE), single-dose vials packaged in 3 flow wrap pouches, 10 vials per flow Wrap pouch:

30 Single-dose Vials 0.4 mL each (Carton containing 3 flow wraps).

No special requirements.

Any unused medicinal product or waste material should be disposed of in accordance with local requirements