Sponsored by

Paul M. Karpecki, OD, FAAO Making Strides in Blepharitis Treatment How New Insights Can Help Doug Katsev, MD Clinicians Elevate Patient Care By Paul M. Karpecki, OD, FAAO; and Doug Katsev, MD

Drs. Karpecki and Katsev are paid consultants for Bausch + Lomb.

CHALLENGES OF BLEPHARITIS atients suffering from blepharitis Blepharitis is one of the most common ocular are a common, but unique, segment of pathologies encountered in the clinical settings.4 eye care patients. The chronic nature of Reports from US primary eye care providers es- blepharitis and sometimes-confound- timate that approximately 40% of patients seen Ping aspect of its diagnosis can create obstacles present with signs or symptoms of blepharitis.4 to treatment and management of the condition. However, the etiology of blepharitis is poorly In recent years, the Tear Film & Ocular Sur- understood.5 Pathogenesis is hypothesized to face Society Dry Eye Workshop II (DEWS II) re- be multifactorial, to include inflammatory skin port has offered foundational wisdom from 150 conditions, chronic lid margin infections, and worldwide experts on ocular surface care and parasitic infections.6 Symptoms can include a disease management, and provided guidance foreign body or burning sensation, excessive on best practices for management of condi- tearing, itching, , red and swollen tions such as blepharitis.1 , redness of the eye, , dry In addition, eye care professionals have ac- eye, and scurf on the .5 cess to treatments for blepharitis that address Blepharitis is categorized as acute or chronic, the inflammatory and sometimes bacterial as- and also by anatomic location: 1) anterior, which pects of the condition in order to relieve patient affects the exterior of the at the base of symptoms in a meaningful way. the eyelashes, and is frequently caused by bac- The availability of effective and timely treat- teria (Staphylococcal) and seborrheic dermati- ment can not only help to reduce the signs and tis;5 and 2) posterior blepharitis, which is found symptoms of blepharitis for sufferers, but it can at the posterior lid margin, and is frequently help to target unwanted physical manifesta- caused by dysfunction (MGD), tions of the condition that potentially weigh on infectious or allergic , acne, ro- the patient’s psyche and negatively impact on sacea and seborrheic .5 That said, in their social experience.2,3 patients with infectious blepharitis, the associat- As DEWS II and other consensus documents ed pathogens and resulting don’t continue to add to the collective body of eye tend to differentiate by location. care knowledge, clinicians can gain valuable Despite its prevalence, blepharitis can be a insights on the most effective ways to care for challenging condition to treat.7 If not adequately their blepharitis patients. With this new infor- addressed, long-term, unmanaged blepharitis mation in mind, they can hope to promptly help can lead to permanent changes to the eyelid alleviate the physical and social-emotional bur- morphology, and visual deficits due to keratop- dens of the condition for those who deal with it. athy and corneal ulceration.6 Blepharitis, in addition to yielding unwanted

Please see Important Safety Information on page 6 and full Prescribing Information for ZYLET® (loteprednol etabonate 0.5% and tobramycin 0.3% ophthalmic suspension) on pages 7-8. with BKC had worse meibomian gland function, Caring for the Blepharitis Patient poorer morphology, and a higher rate of medical Here is a short excerpt from our overall protocol histories related to the meibomian gland than a for managing the average blepharitis patient. healthy population.9 Evaluation & Diagnosis • Carefully evaluate the slit-lamp exam for MGD BLEPHARITIS MANAGEMENT & DEWS II and dry ; look for corneal staining The chronic nature of blepharitis and the fre- • Check for conjunctival involvement of follicles quent coexistence of ocular surface disease can and papilla make blepharitis difficult to manage. Foundation- ally, patients who are prone to getting blepharitis Classification should maintain good, routine eyelid hygiene in • Determine acute vs. chronic nature of con- order to prevent flareups. One goal of manage- dition (anterior vs. posterior determination is ment for blepharitis is to keep the lids clean and less critical) free of biofilm. Moreover, blepharitis patients who have concomitant acne should have the Lid Hygiene and Treatment Strategy • Acute blepharitis: Short burst of combination conditions treated simultaneously. topical - The importance of good lid hygiene was • Chronic blepharitis: Lid hygiene, hot com- stressed by the authors of the DEWS II report.1 presses, and lid scrubs; oral ; The report’s authors highlighted the importance and “episodic use” of combination topical of appropriately managing a variety of lid con- antibiotic-corticosteroids ditions that result in dry eye, particularly bleph- — Drs. Karpecki and Katsev aritis.1 Lid hygiene, if used correctly, the authors wrote, could reduce lipid byproducts and lipolytic physical for sufferers, can bacteria associated with these conditions.1 In ad- also take a negative emotional toll on patients. dition, the International Workshop on Meibomian One study, a retrospective analysis, found that Gland Dysfunction put forth that lid hygiene has blepharitis patients were at elevated risk of anxi- been widely considered an effective therapy for ety and depression, particularly during the period MGD and blepharitis.10 shortly after diagnosis.2 Another determined that persistently uncomfortable eyes, “an unattractive UPDATES IN LID HYGIENE PRACTICES appearance,” and uneasy feelings experienced by Applying warm compresses to the lids is often blepharitis patients might precipitate psychologi- accepted as an essential first step for maintaining cal stress and negative social implications.3 good lid hygiene. Traditionally, another hygiene strategy that had been employed for blepharitis BLEPHAROKERATOCONJUNCTIVITIS patients for many years had been light scrubbing Blepharokeratoconjunctivitis (BKC), similar to of the eyelids with a cotton swab coated with a blepharitis, is a chronic inflammatory condition mixture of water and baby shampoo. However, of the palpebral margin; however, it also features we have found that, over time, commercial sham- secondary conjunctival and corneal involvement.8 poos can remove natural oils and key mucopro- Signs and symptoms include tearing, photopho- teins from our patients’ meibomian glands. bia, , blepharitis (external hordeola or Furthermore, the DEWS II report noted that meibomian cysts), recurrent chalazia, phlyctenu- outdated lid hygiene practices such as using di- lar conjunctivitis, , as well as corneal com- luted baby shampoo should be updated by eye plications such as ulceration, neovascularization, care professionals. They specifically revealed that scarring, and perforation.8 diluted baby shampoo has been associated with In our experience, BKC frequently leads to as- reduced ocular surface MUC5AC levels and might sociated ocular surface inflammation, and it have an adverse effect on goblet cell function.11 can exacerbate symptoms of coexisting ocular As a result, the authors strongly advised that surface disease. One study found that patients clinicians utilize newer, more efficacious hygiene

Please see Important Safety Information on page 6 and full Prescribing Information for ZYLET® (loteprednol etabonate 0.5% 2 and tobramycin 0.3% ophthalmic suspension) on pages 7-8. strategies available on the market today that utilize a diversity of deliv- Diagnosing BKC vs. or ery mechanisms to improve patient Dry Eye outcomes when it comes to lid hy- It’s important to reduce the risk of ocular complications in con- giene.1 They noted that many new ditions such as BKC and rule out other ocular issues by confirm- products are available to improve ing diagnosis as soon as possible. If dry eye is suspected, a pos- lid health, including scrubs, foams, itive result to a screening questionnaire such as the 5-item Dry solutions, and wipes; however, more Eye Questionnaire (DEQ-5) or the Ocular Surface Disease Index specific information was beyond the (OSDI) should trigger further evaluation.15 Included are our rec- scope of the report.1 ommended steps to follow to try to confirm BKC diagnosis:

PATIENT ADHERENCE Medical History Review CHALLENGES Triaging questions16 Research has found that patients • Symptoms and signs who follow clinician-recommended • Time of day when symptoms are worse lid hygiene practices can see symp- • Duration of symptoms tom improvement. In a cross-sec- • Unilateral or bilateral presentation tional study, 207 subjects with dry Dry eye questionnaire15 eye symptoms and margin signs • OSDI were instructed to perform warm • Standard patient evaluation of eye dryness (SPEED) compresses and eyelid scrubs, and Risk factor analysis16 then complete a follow-up phone • Exacerbating conditions survey assessing adherence and • Systemic/autoimmune disease(s) that can contribute or subjective therapeutic response cause BKC 12 six weeks later. Patients who per- • Recent exposure to an infected individual formed the routine noted an im- Clinical examination16 12 provement in symptoms. • Eye chart or visual acuity test However, one challenge for cli- • Skin and eyelids changes nicians has been a lack of patient • exam with : adherence with lid hygiene recom- • Tear break-up time (<10 sec) mendations. The DEWS II authors • Anterior and posterior eyelid margin noted that adherence to provider • Eyelashes recommendations has been “no- • Eyelids 1 toriously poor.” In the aforemen- • Tarsal and bulbar tioned cross-sectional study, only • 55% of patients were compliant • Intraocular pressure (IOP) 12 after six weeks of use. So, while Diagnostic tests16 eye care professionals may do their There are no specific clinical diagnostic tests for blepharitis. due diligence in instructing patients • Cultures of the eyelid margins for: to maintain best practices with lid • Recurrent anterior blepharitis with severe inflammtion hygiene, it’s uncertain whether pa- • Patients who are not responding to therapy tients will follow through with clini- However, normal lids will often culture positive for normal cian instructions. bacterial flora, so this strategy may not always be optimal.

COMORBIDITY ISSUES 15. Wolffsohn JS, Arita R, Chalmers R, et al. TFOS DEWS II Diagnostic Methodology Report. Ocul Surf. 2017 Jul;15(3):539-574. Even with adherence to regular lid 16. Amescua G, Akpek EK, Farid M, et al. Blepharitis Preferred Practice Pattern®. Ophthal- hygiene practices, blepharitis may mology. 2019 Jan;126(1):P56-P93. develop in predisposed patients. In — Drs. Karpecki and Katsev these patients, the clinician must

3 first take steps to make the correct diagnosis. Yet, topical anti-inflammatory agents (e.g., corticoste- diagnosing blepharitis can be less than straight- roids, cyclosporine).16 These therapies are often forward at times. used in combination.16 Here is a more detailed list For example, patient complaints of ocular itching of some available treatments: may initially lead the eye care professional to sus- Over-The-Counter pect that ocular are involved. Histamine, • Artificial . Tear film instability often ac- which is released as a result of ongoing exposure companies blepharitis, so artificial tears may im- to an allergen, activates G protein-coupled hista- prove patient symptoms when used in conjunc- mine receptors on sensory neurons, signaling the tion with eyelid cleansing and medications.16 brain to perceive an “itch” sensation,13 commonly Prescription Drugs. Treatments for some cas- associated with ocular allergies. Yet, itching can es of blepharitis requiring a prescription include also be induced in a histamine-independent man- the following: ner by certain endogenous peptide fragments.14 • Anti-infectives available as antibiotic eye- And blepharitis, , as well as a host of drops, creams, and ointments, or oral antibiotics other conditions also share the symptom of itching, when indicated. more specifically on the eyelids. • Anti-inflammatory agents such as steroid Diagnosing BKC can also be difficult due to the eyedrops, creams, or ointments. overlap of symptoms with allergic conjunctivitis • Medications that affect the immune system and dry eye. However, key differences can help such as calcineurin inhibitors, which are designed indicate which condition a patient is presenting to offer relief of some signs and symptoms of with. For example, BKC symptoms tend to present blepharitis. in the eyelid either unilaterally or bilaterally, while • Treatments for underlying conditions, symptoms in patients with allergic conjunctivitis which are intended to control the issues leading are typically seen bilaterally and can also affect to blepharitis. the ocular surface.16,17 Dry eye, on the other hand, • Combination anti-infectives and anti-in- affects the ocular surface more than the eyelids.18 flammatory agents for patients in whom both Certain guidelines can help the clinician distin- therapies are indicated. guish between BKC and these other ocular condi- In-Office Procedures. In addition, a number of tions (see “Diagnosing BKC vs. Allergic Conjunctivitis in-office procedures can be conducted to help ad- or Dry Eye” on page 3.) dress blepharitis. They include the following: • Exfoliation of the lid margin, designed to TREATMENT STRATEGIES remove any mites and bacteria, and associated Beyond basic lid hygiene and after a diagnosis biofilm from the eyelids through debridement; as is made, choosing the right therapy to alleviate well as open any clogged meibomian glands symptoms and signs for the blepharitis patient • Thermal pulsation treatment, designed to is key to positive outcomes. The treatment land- melt and evacuate meibum, and any material that scape today offers eye care professionals various is obstructing the meibomian glands. tools to help manage or improve their blepharitis • Intense pulse light therapy, designed to patients’ signs and symptoms. As research contin- treat telangiectatic meibomian glands by bringing ues to expand the collective body of knowledge inflammatory mediators to the ocular surface. on best practices for managing conditions such as With in-office procedures, it is still important to blepharitis, eye care’s understanding of how best make sure to address the microbial growth as well to apply these potential therapies also evolves. as the inflammatory aspects of blepharitis. Importantly, the patient must understand that a cure for blepharitis is often not possible.16 Treat- SELECTION OF THERAPIES FOR THE ments that may be helpful include: warm com- BLEPHARITIS PATIENTS presses; eyelid cleansing, including eyelid mas- It is up to the clinician to select the appropriate sage in cases of MGD to express the meibomian therapy for their blepharitis patient in a medical glands; antibiotics (topical and/or systemic); and landscape offering multiple options. One prescrip-

Please see Important Safety Information on page 6 and full Prescribing Information for ZYLET® (loteprednol etabonate 0.5% 4 and tobramycin 0.3% ophthalmic suspension) on pages 7-8. in clinical trials. Subject in each study group with IOP Data from one randomized, double-masked, par- changes >10 mmHg over baseline allel-group study with healthy volunteers evaluated 19 8 the safety and tolerability of ZYLET and TobraDex. A total of 306 healthy volunteers received either 7 loteprednol etabonate/tobramycin (n=156) or dexa- methasone/tobramycin (n=150) at four-hour in- 6 tervals, four times a day in both eyes for 28 days. Researchers found that ZYLET was significantly less 5 likely to produce elevations in IOP than TobraDex was in healthy subjects treated for 28 days.19 Both 4 drugs showed similar efficacy and were well-toler- ated, with low risks for systemic and ocular adverse 3 events other than elevation in IOP for dexametha- sone/tobramycin.19 Percentage of Subjects % Subjects Percentage of 2 In a multicenter, randomized, investiga- 1 tor-masked, parallel-group study, investigators com- pared the safety and efficacy ofZYLET and TobraDex 0 in the treatment of ocular inflammation associated ZYLET TobraDex with BKC.21 Subjects with clinically diagnosed bleph- (n=3/156) (n=11/150) arokeratoconjunctivitis in at least one eye were In a randomized, double-masked, paral- randomized to ZYLET (n=138) or TobraDex (n=138) lel-group study with healthy volunteers administered four times per day, for 14 days. The designed to evaluate the safety and tolera- primary efficacy endpoint was the change from bility of ZYLET and TobraDex, treatment was baseline to Day 15 (±1 day) in the signs and symp- administered four times a day in both eyes, for 28 days.19 The primary endpoint was an toms composite score using a non-inferiority metric increase in IOP ≥10 mmHg over baseline. IOP to compare ZYLET to TobraDex. Safety endpoints in- elevations at or above 10 mmHg were seen in cluded visual acuity (VA), biomicroscopy, IOP assess- 2% of ZYLET-treated participants and 7.5% of ments, and adverse events. At Day 15, the mean (SD) TobraDex-treated participants. change from baseline in the signs and symptoms If ZYLET is used for 10 days or longer, IOP should be monitored.20 composite score was -15.2 (7.3) for ZYLET-treated subjects and -15.6 (7.7) for TobraDex-treated sub- 19. Holland EJ, Bartlett JD, Paterno MR, et al. Effects of loteprednol/ jects.21 Subjects treated with TobraDex experienced tobramycin versus dexamethasone/tobramycin on intraocular pres- sure in healthy volunteers. Cornea. 2008;27:50-5. a significant increase in IOP vs. those treated with 20. ZYLET. Prescribing Information. Available at: https://www. ZYLET at Day 7, Day 15, and overall.21 accessdata.fda.gov/drugsatfda_docs/label/2013/050804s018lbl.pdf (last accessed Aug. 28, 2019). In some patients, we have found an “episodic treatment” strategy with ZYLET to be particularly effective, although we caution patients about the tion therapy intended to help patients with bleph- possibility of IOP spikes with prolonged use of cor- aritis is a topical anti-infective and steroid combi- ticosteroids and without proper monitoring after nation for steroid responsive inflammatory ocular 10 days. That withstanding, we choose to employ a conditions for which a is indicated drug such as ZYLET, with established efficacy, two and where superficial bacterial ocular infection or moisturizing ingredients that may be soothing, and a risk of bacterial ocular infection exists. The agent, with less of a proclivity to elevate IOP. ZYLET® (loteprednol etabonate 0.5% and tobramy- cin 0.3% ophthalmic suspension), is formulated Dr. Karpecki is a practicing optometrist at the Ken- with the known moisturizing ingredients povidone tucky Eye Institute in Lexington, Ky., and Dr. Katsev is and glycerin. Initially approved for use in the US in a cornea, cararact and refractive surgeon at the San- 2004,20 ZYLET and its attributes have been studied sum Clinic in Santa Barbara, Calif.

5 INDICATIONS AND USAGE ZYLET® (loteprednol etabonate 0.5% and tobramycin 0.3% ophthalmic suspension) is a topical anti infective and corticosteroid combi- nation for steroid-responsive inflammatory ocular conditions for which a corticosteroid is indicated and where superficial bacterial ocular infection or a risk of bacterial ocular infection exists. Ocular steroids are indicated in inflammatory conditions of the palpebral and bulbar conjunctiva, cornea and anterior segmentof the such as allergic conjuncti-vitis, acne rosacea, superficial punctate keratitis, herpes zoster keratitis, iritis, cyclitis, and where the inherent risk of steroid use in certain infective conjunctivitides is accepted to obtain a diminution in and inflammation. They are also indicated in chronic anterior and corneal injury from chemical, radiation or thermal burns, or penetration of foreign bodies. The use of a combination drug with an anti-infective component is indicated where the risk of superficial ocular infection is high or where there is an expectation that potentially dangerous numbers of bacteria will be present in the eye. The particular anti-infective drug in this product (tobramycin) is active against the following common bacterial eye pathogens: Staph- ylococci, including S. aureus and S. epidermidis (coagulase-positive and coagulase-negative), including penicillin-resistant strains. Strepto- cocci, including some of the Group A-beta-hemolytic species, some nonhemolytic species, and some Streptococcus pneumoniae, Pseudomo- nas aeruginosa, Escherichia coli, Klebsiella pneumoniae, Enterobacter aerogenes, Proteus mirabilis, Morganella morganii, most Proteus vulgaris strains, Haemophilus influenzae, and H. aegyptius, Moraxella lacunata, Acinetobacter calcoaceticus and some Neisseria species.

IMPORTANT SAFETY INFORMATION • ZYLET is contraindicated in most viral diseases of the cornea and conjunctiva, including epithelial keratitis (den- dritic keratitis), , and varicella, and also in mycobacterial infections of the eye and fungal diseases of ocular structures. • Prolonged use of corticosteroids may result in with damage to the , and defects in visual acuity and fields of vision. Steroids should be used with caution in the presence of glaucoma. If this product is used for 10 days or longer, intraocular pressure should be monitored. • Use of corticosteroids may result in posterior subcapsular formation. • The use of steroids after cataract may delay healing and increase the incidence of bleb formation. In those diseases caus- ing thinning of the cornea or , perforations have been known to occur with the use of topical steroids. The initial prescription and renewal of the medication order should be made by a physician only after examination of the patient with the aid of magnifi- cation such as a slit lamp biomicroscopy and, where appropriate, fluorescein staining. • Prolonged use of corticosteroids may suppress the host response and thus increase the hazard of secondary ocular infections. In acute purulent conditions, steroids may mask infection or enhance existing infections. If signs and symptoms fail to improve after 2 days, the patient should be re-evaluated. • Employment of corticosteroid medication in the treatment of patients with a history of herpes simplex requires great caution. Use of ocular steroids may prolong the course and exacerbate the severity of many viral infections of the eye (including herpes simplex). • Fungal infections of the cornea are particularly prone to develop coincidentally with long-term, local steroid application. Fungus invasion must be considered in any persistent corneal ulceration where a steroid has been used or is in use. • Most common adverse reactions reported in patients were injection and superficial punctate keratitis, increased intraocular pres- sure, and burning and stinging upon instillation.

Please see full Prescribing Information for ZYLET (loteprednol etabonate 0.5% and tobramycin 0.3% ophthalmic suspension) on pages 7 & 8.

REFERENCES 1. Jones L, Downie LE, Korb D, et al. TFOS DEWS II Management and 2018;16(1):77-83. Therapy Report. Ocul Surf. 2017 Jul;15(3):575-628. 12. Alghamdi YA, Camp A, Feuer W, et al. Compliance and sub- 2. Chiang CC, Lin CL, Tsai YY, et al. Patients with blepharitis are jective patient responses to eyelid hygiene. Eye Contact . at elevated risk of anxiety and depression. PLoS One. 2013 Dec 2017;43(4):213-17. 30;8(12):e83335. 13. Xiao B, Patapoutian A. Scratching the surface: a role of pain-sens- 3. McDonald MB. The patient’s experience of blepharitis. Ocul Surf. ing TRPA1 in itch. Nat Neurosci. 2011 May;14(5):540-2. 2009 Apr; 7(2 Suppl):S17-8. 14. Sikand P, Dong X, Lamotte RH. BAM8-22 peptide produces itch 4. Lemp MA, Nichols KK. Blepharitis in the United States 2009: a and nocicep-tive sensations in humans independent of histamine survey-based perspective on prevalence and treatment. Ocul Surf. release. J Neurosci. 2011 May 18;31(20):7563-7. 2009;7(Suppl 2):1–14. 15. Wolffsohn JS, Arita R, Chalmers R, et al. TFOS DEWS II Diagnostic 5. Lindsley K, Matsumura S, Hatef E, et al. Interventions for chronic Methodology report. Ocul Surf. 2017 Jul;15(3):539-74. blepharitis. Cochrane Database Syst Rev. 2012 May 16;(5):CD005556. 16. Amescua G, Akpek EK, Farid M, et al. Blepharitis Preferred Prac- 6. Putnam CM. Diagnosis and management of blepharitis: an optom- tice Pat-tern®. 2019 Jan;126(1):P56-93. etrist’s per-spective. Clin Optom (Auckl). 2016 Aug 8;8:71-8. 17. Ackerman S, Smith LM, Gomes PJ. Ocular itch associated with 7. Duncan K, Jeng BH. Medical management of blepharitis. Curr Opin allergic conjunctivitis: latest evidence and clinical management. Ther Ophthal-mol. 2015 Jul;26(4):289-94. Adv Chronic Dis. 2016;7:52-67. 8. Rodríguez-García A, González-Godínez S, López-Rubio S. Bleph- 18. Abelson MB, Lilyestrom L. Is it dry eye or ? Review of Op- arokeratocon-junctivitis in childhood: corneal involvement and visual tometry. 2007; Aug. 15. Available at: https://www.reviewofoptometry. outcome. Eye (Lond). 2016 Mar;30(3):438-46. com/article/is-it-dry-eye-or-allergy (last accessed Aug. 28, 2019). 9. Yin Y, Gong L. The evaluation of meibomian gland function, mor- 19. Holland EJ, Bartlett JD, Paterno MR, et al. Effects of loteprednol/ phology and related medical history in Asian adult blepharokerato- tobramycin versus dexamethasone/tobramycin on intraocular pres- conjunctivitis patients. Acta Ophthalmol. 2017 Sep;95(6):634-8. (last sure in healthy volunteers. Cornea. 2008;27:50-5. accessed Aug. 28, 2019). 20. ZYLET. Prescribing Information. Available at: https://www.access- 10. Geerling G, Tauber J, Baudouin C, et al. The international work- data.fda.gov/drugsatfda_docs/label/2013/050804s018lbl.pdf (last shop on meibomian gland dysfunction: report of the subcommittee accessed Aug. 28, 2019). on management and treatment of meibomian gland dysfunction. 21. White EM, Macy JI, Bateman KM, et al. Comparison of the safety Invest Ophthalmol Vis Sci 2011;52(4):2050-64. and effica-cy of loteprednol 0.5%/tobramycin 0.3% with dexametha- 11. Sung J, Wang MTM, Lee SH, et al. Randomized double-masked sone 0.1%/tobramycin 0.3% in the treatment of blepharokeratocon- trial of eyelid cleansing treatments for blepharitis. Ocul Surf. junctivitis. Curr Med Res Opin. 2008 Jan;24(1):287-96.

ZYLET is a trademark of Bausch & Lomb Incorporated or its affiliates. Please see Important Safety Information on page 6 and ©2020 Bausch & Lomb Incorporated or its affiliates. Created in the USA. All rights Reserved. 6 full Prescribing Information for ZYLET® on pages 7-8. 1/20. ZYL.0055.USA.19 HIGHLIGHTS OF OF PRESCRIBING PRESCRIBING INFORMATION INFORMATION • -Use of corticosteroids may result in posterior subcapsular These highlights do do not not include include all all the the information information needed needed to to cataract formation. (5.2)FULL PRESCRIBING INFORMATION use ZYLET®® (loteprednol (loteprednol etabonate etabonate and and tobramycin tobramycin ophthalmic ophthalmic suspension)• Delayed healing–The use1. of INDICATIONSsteroids after cataract AND USAGE surgery may safelysuspension) and effectively. safely and effectively. See full prescribing See full prescribing information information for ZYLET (loteprednoldelay healing and increase theZylet® incidence is a topical of bleb anti-infective formation. and In those corticosteroid combination for steroid-respon- etabonatefor ZYLET (loteprednol and tobramycin etabonate ophthalmic and tobramycin suspension, ophthalmic 0.5%/0.3%). diseases causing thinning ofsive the inflammatory cornea or sclera, ocular perforations conditions have for which a corticosteroid is indicated and suspension, 0.5%/0.3%). been known to occur with thewhere use superficialof topical steroids. bacterial Theocular initial infection or a risk of bacterial ocular infection prescription and renewal of the medication order should be made Zylet (loteprednol etabonate etabonate and and tobramycin tobramycin ophthalmic ophthalmic suspension) 0.5%/0.3% exists. Initial U.S. Approval: 2004 by a physician only after examinationOcular steroids of the are patient indicated with inthe inflammatory aid conditions of the palpebral and suspension) 0.5%/0.3% of a magnification such as slit lamp biomicroscopy and, where Initial U.S. Approval: 2004 appropriate, fluorescein staining.bulbar (5.3) conjunctiva, cornea and anterior segment of the globe such as allergic con- INDICATIONS AND USAGE junctivitis, acne rosacea, superficial punctate keratitis, herpes zoster keratitis, iritis, ------INDICATIONS AND USAGE ------• Bacterial infections–Prolonged use of corticosteroids may suppress Zylet isis aa topicaltopical anti-infective anti-infective and and steroid steroid combination combination for for s steroid-teroid-responsivethe inflammato host response- and thus cyclitis,increase and the where hazard the of inherentsecondary risk ocular of steroid use in certain infective conjunctiviti- ryresponsive ocular conditions inflammatory for which ocular a corticosteroidconditions for iswhich indicated a corticosteroid and where issuperficial infection. bacterial In acute purulent desconditions, is accepted steroids to obtain may maska diminution infection in edema and inflammation. They are also ocularindicated infection and where or a risk superficial of bacterial bacterial ocular ocular infection infection exists. or (1) a risk of or enhance existing infection.indicated If signs in and chronic symptoms anterior fail uveitis to improve and corneal injury from chemical, radiation or DOSAGEbacterial ocularAND ADMINISTRATION infection exists. (1) after 2 days, the patient shouldthermal be re-evaluated. burns, or penetration (5.4) of foreign bodies. Apply- - - -- one - - -- or - two- -- -drops -DOSAGE of Zylet AND into ADMINISTRATION the conjunctival - sac- - -- of- th- --e affected------eye• Vireveryal infections–Employment four to The of ause corticosteroid of a combination medication drug within the an anti-infective component is indicated where sixApply hours. one (2.1) or two drops of Zylet into the conjunctival sac of the treatment of patients with athe history risk of of superficial herpes simplex ocular requires infection great is high or where there is an expectation that DOSAGEaffected eye FORMS every AND four STRENGTHSto six hours. (2.1) caution. Use of ocular steroidspotentially may prolong dangerous the course numbers and ofmay bacteria will be present in the eye. Zylet- - - -- contains ------5-- mg/mL - DOSAGE loteprednol FORMS AND etabonate STRENGTHS and -3--- mg/mL---- tobramycin.------(3)exacerbate the severity of manyThe particular viral infections anti-infective of the eyedrug (including in this product (tobramycin) is active against the CONTRAINDICATIONSZylet contains 5 mg/mL loteprednol etabonate and 3 mg/mL herpes simplex). (5.5) following common bacterial eye pathogens: Zylet,tobramycin. as with (3) other steroid anti-infective ophthalmic combination drugs, is •contraindicatedFungal infections–Fungal infectionsStaphylococci, of the cornea including are particularlyS. aureus and prone S. epidermidis (coagulase-positive and in- - most - -- - viral- -- -diseases ------of - theCONTRAINDICATIONS cornea and conjunctiva -- - -- including------epithelial------herpesto develop simplex coincidentally withcoagulase-negative), long-term local steroid including application. penicillin-resistant strains. Streptococci, including keratitisZylet, as (dendritic with other keratitis), steroid anti-infectivevaccinia, and varicella,ophthalmic and combination also in mycobacterial Fungusinfection invasion of must be consideredsome of thein any Group persistent A-beta-hemolytic corneal species, some nonhemolytic species, and thedrugs, eye is and contraindicated fungal diseases in mostof ocular viral structures. diseases of (4.1) the cornea and ulceration where a steroid hassome been Streptococcus used or is inpneumoniae, use. (5.6) Pseudomonas aeruginosa, Escherichia coli, Klebsiella WARNINGSconjunctiva including AND PRECAUTIONS epithelial (dendritic ------ADVERSEpneumoniae, REACTIONS Enterobacter ------aerogenes,------Proteus--- - mirabilis, Morganella morganii, most keratitis),• Intraocular vaccinia, pressure and varicella, (IOP)-Prolonged and also use in mycobacterialof corticosteroids infection may result of Most in glaucoma common adverse reactionsProteus reported vulgaris in patientsstrains, Haemophilus were injection influenzae, and H. aegyptius, Moraxella lacunata, the witheye anddamage fungal to diseasesthe optic ofnerve, ocular defects structures. in visual (4.1) acuity and fields of vision.and superficialIf this punctate keratitis,Acinetobacter increased calcoaceticus intraocular pressure,and some Neisseria species. - - -product ------is - used -- - - forWARNINGS 10 days orAND longer, PRECAUTIONS IOP should -- be - -- monitored.------(5.1)- - burning and stinging upon2. instillation. DOSAGE (6) AND ADMINISTRATION • •Intr Cataracts-Useaocular pressure of corticosteroids (IOP)-Prolonged may use result of corticosteroids in posterior subcapsular may result cataractTo report forma SUSPECTED- ADVERSE2.1 REACTIONS, Recommended contact Dosing Bausch + Lomb, intion. glaucoma (5.2) with damage to the optic nerve, defects in visual acuity a division of Valeant PharmaceuticalsApply one Northor two America drops of LLC, Zylet at into the conjunctival sac of the affected eye every 1-800-321-4576 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. •and Delayed fields healing–Theof vision. If this use product of steroids is used after for cataract 10 days surgery or longer, may IOPdelay healing and four to six hours. During the initial 24 to 48 hours, the dosing may be increased, to shouldincrease be monitored.the incidence (5.1) of bleb formation. In those diseases causing thinningSee 17 of for the PATIENT cor- COUNSELINGevery INFORMATION. one to two hours. Frequency should be decreased gradually as warranted nea or sclera, perforations have been known to occur with the use of topical steroids. by improvement in clinicalRevised: signs. Care 08/2016 should be taken not to discontinue therapy The initial prescription and renewal of the medication order should be made by a prematurely. FULLphysician PRESCRIBING only after INFORMATION: examination CONTENTS* of the patient with the aid of a magnification such as 2.2 Prescription Guideline 1 slitINDIC lampATIONS biomicroscopy AND USAGE and, where appropriate, fluorescein staining. 6(5.3) ADVERSE REACTIONS Not more than 20 mL should be prescribed initially and the prescription should 2 • BacterialDOSAGE infections–Prolonged AND ADMINISTRATION use of corticosteroids may suppress the8 hostUSE response IN SPECIFIC POPULATIONSnot be refilled without further evaluation [see Warnings and Precautions (5.3)]. and2.1 thus R ecommendedincrease the hazard Dosing of secondary ocular infection. In acute purulent8.1 condiPregnancy- 3. DOSAGE FORMS AND STRENGTHS tions,2.2 steroidsPrescription may mask Guideline infection or enhance existing infection. If signs and8.3 symptoms Nursing Mothers Zylet (loteprednol etabonate and tobramycin ophthalmic suspension) 0.5%/0.3% 3 failDOSA to improveGE FORMS after AND 2 days, STRENGTHS the patient should be re-evaluated. (5.4) 8.4 Pediatric Use contains 5 mg/mL loteprednol etabonate and 3 mg/mL tobramycin. 4 • ViralCONTRAINDICATIONS infections–Employment of a corticosteroid medication in the treatment8.5 of Geriatric Use 4. CONTRAINDICATIONS patients4.1 Nonbact with a historyerial Etiology of herpes simplex requires great caution. Use of11 ocular DESCRIPTION steroids 4.1 Nonbacterial Etiology 5 mayWARNINGS prolong theAND course PRECAUTIONS and may exacerbate the severity of many viral12 infections CLINIC ALof PHARMACOLOGYZylet, as with other steroid anti-infective ophthalmic combination drugs, is contra- the5.1 eye Intr(includingaocular herpes Pressure simplex). (IOP) Increase (5.5) 12.1 Mechanism of Actionindicated in most viral diseases of the cornea and conjunctiva including epithelial • Fungal5.2 infections–FungalCataracts infections of the cornea are particularly prone to 12.3develop Pharmacokinetics herpes simplex keratitis (dendritic keratitis), vaccinia, and varicella, and also in coincidentally5.3 Delayed with Healing long-term local steroid application. Fungus invasion13 must NONCLINIC be AL TOXICOLOGYmycobacterial infection of the eye and fungal diseases of ocular structures. considered5.4 Bact inerial any Infections persistent corneal ulceration where a steroid has been used13.1 orC arcinogenesis,is 5. Mutagenesis, WARNINGS Impairment AND PRECAUTIONS of Fertility in5.5 use. (5.6)Viral Infections 16 HOW SUPPLIED/STORAGE5.1 AND Intraocular HANDLING Pressure (IOP) Increase ADVERSE5.6 REACTIONSFungal Infections 17 PATIENT COUNSELING INFORMATIONProlonged use of corticosteroids may result in glaucoma with damage to the optic Most 5.7common Aminogly adversecoside reactions Hypersensitivity reported in patients were injection and *superficial Sections or puncsubsections- omittednerve, from defects the full in prescribing visual acuity information and fields of vision. Steroids should be used with tate keratitis, increased intraocular pressure, burning and stinging upon instillation.are not listed. (6) caution in the presence of glaucoma. To report SUSPECTED ADVERSE REACTIONS, contact Bausch + Lomb, a division of If this product is used for 10 days or longer, intraocular pressure should be ValeantFULL PRESCRIBING Pharmaceuticals INFORMATION North America LLC, at monitored. 1-800-321-45761 INDICATIONS or AND FDA USAGE at 1-800-FDA-1088 or www.fda.gov/medwatch. 5.2 Cataracts See 17Zylet for® PATIENTis a topical COUNSELING anti-infective INFORMATION.and corticosteroid combination for steroid-responsive inflammatoryUse ocular of corticosteroids conditions for maywhich result a in posterior subcapsular cataract formation. corticosteroid is indicated and where superficial bacterial ocular infectionRevised: or 08/2016a risk of bacterial ocular5.3 Delayedinfection Healingexists. FULLOcular PRESCRIBING steroids are INFORMATION: indicated in inflammatory CONTENTS* conditions of the palpebral and bulbar conjunctiva, corneaThe use and of anteriorsteroids segmentafter cataract of the surgery globe may delay healing and increase the 1. INDICATIONSsuch as allergic AND conjunctivitis, USAGE acne rosacea, superficial punctate keratitis, herpes zoster keratitis, iritis,incidence cyclitis, of bleband formation.where the Ininherent those diseasesrisk causing thinning of the cornea or 2. DOSAGEof steroid AND use ADMINISTRATION in certain infective conjunctivitides is accepted to obtain a diminution in edema andsclera, inflammation. perforations They have are alsobeen indicated known to in occur with the use of topical steroids. 2.1chronic Recommended anterior uveitis Dosing and corneal injury from chemical, radiation or thermal burns, or penetrationThe of initial foreign prescription bodies. and renewal of the medication order should be made by a 2.2The Prescription use of a combination Guideline drug with an anti-infective component is indicated where the risk of superficialphysician ocular only afterinfection examination is high or of where the patient with the aid of magnification such 3. DOSAGEthere is FORMS an expectation AND STRENGTHS that potentially dangerous numbers of bacteria will be present in the eye.as a slit lamp biomicroscopy and, where appropriate, fluorescein staining. 4. CONTRAINDICATIONSThe particular anti-infective drug in this product (tobramycin) is active against the following common5.4 Bacterialbacterial eyeInfections pathogens: 4.1Staphylococci, Nonbacterial including Etiology S. aureus and S. epidermidis (coagulase-positive and coagulase-negative), includingProlonged penicillin-resistant use of corticosteroids strains. may suppress the host response and thus 5. WARNINGSStreptococci, AND including PRECAUTIONS some of the Group A-beta-hemolytic species, some nonhemolytic species, andincrease some the Streptococcus hazard of secondary pneumoniae, ocular infections. In acute purulent conditions 5.1Pseudomonas Intraocular Pressure aeruginosa, (IOP) EscherichiaIncrease coli, Klebsiella pneumoniae, Enterobacter aerogenes, Proteusof the mirabilis, eye, steroids Morganella may mask morganii infection, most or enhance existing infection. If signs and 5.2Proteus Cataracts vulgaris strains, Haemophilus influenzae, and H. aegyptius, Moraxella lacunata, Acinetobactersymptoms calcoaceticus fail toand improve some Neisseria after 2 days, species. the patient should be re-evaluated. 2 5.3DOSA DelayedGE AND Healing ADMINISTRATION 5.5 Viral Infections 5.42.1 Bacterial Recommended Infections Dosing Employment of a corticosteroid medication in the treatment of patients with 5.5Apply Viral Infectionsone or two drops of Zylet into the conjunctival sac of the affected eye every four to six hours.a history During of the herpes initial simplex 24 to 48 requires hours, thegreat caution. Use of ocular steroids may 5.6dosing Fungal may Infections be increased, to every one to two hours. Frequency should be decreased gradually as prolongwarranted the by course improvement and may inexacerbate clinical the severity of many viral infections of the 5.7signs. Aminoglycoside Care should Hypersensitivity be taken not to discontinue therapy prematurely. eye (including herpes simplex). 6. ADVERSE2.2 Pr REACTIONSescription Guideline 5.6 Fungal Infections 8. USENot IN more SPECIFIC than POPULATIONS20 mL should be prescribed initially and the prescription should not be refilled withoutFungal further infections evaluation of the [seecornea Warnings are particularly and prone to develop coincidentally Precautions (5.3)]. 8.1 Pregnancy with long-term local steroid application. Fungus invasion must be considered 3 8.3DOSA NursingGE FORMS Mothers AND STRENGTHS in any persistent corneal ulceration where a steroid has been used or is in use. 8.4Zylet Pediatric (loteprednol Use etabonate and tobramycin ophthalmic suspension) 0.5%/0.3% contains 5 mg/mL loteprednolFungal culturesetabonate should and 3 bemg/mL taken tobramycin. when appropriate. 4 8.5CONTRAINDICATIONS Geriatric Use 5.7 Aminoglycoside Hypersensitivity 11. DESCRIPTION4.1 Nonbacterial Etiology Sensitivity to topically applied aminoglycosides may occur in some patients. If hy- 12. CLINICALZylet, as withPHARMACOLOGY other steroid anti-infective ophthalmic combination drugs, is contraindicated in mostpersensitivity viral diseases develops of the cornea with this and product, discontinue use and institute appropriate 12.1conjunctiva Mechanism including of Action epithelial herpes simplex keratitis (dendritic keratitis), vaccinia, and varicella,therapy. and also in mycobacterial infection of the eye and fungal diseases of ocular structures. 12.3 Pharmacokinetics 6. ADVERSE REACTIONS 5 WARNINGS AND PRECAUTIONS 13. NONCLINICAL TOXICOLOGY Adverse reactions have occurred with steroid/anti-infective combination drugs 5.1 Intraocular Pressure (IOP) Increase 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility which can be attributed to the steroid component, the anti-infective component, or 16. HOWProlonged SUPPLIED/STORAGE use of corticosteroids AND may HANDLING result in glaucoma with damage to the optic nerve, defects inthe visual combination. acuity and fields of vision. Steroids should be used with caution in the presence of glaucoma. 17. PATIENT COUNSELING INFORMATION Zylet: If this product is used for 10 days or longer, intraocular pressure should be monitored. *Sections or subsections omitted from the full prescribing information are not listed. In a 42-day safety study comparing Zylet to placebo, ocular adverse reactions 5.2 Cataracts Use of corticosteroids may result in posterior subcapsular cataract formation. 5.3 Delayed Healing 7 The use of steroids after cataract surgery may delay healing and increase the incidence of bleb formation. In those diseases causing thinning of the cornea or sclera, perforations have been known to occur with the use of topical steroids. The initial prescription and renewal of the medication order should be made by a physician only after examination of the patient with the aid of magnification such as a slit lamp biomicroscopy and, where appropriate, fluorescein staining. 5.4 Bacterial Infections Prolonged use of corticosteroids may suppress the host response and thus increase the hazard of secondary ocular infections. In acute purulent conditions of the eye, steroids may mask infection or enhance existing infection. If signs and symptoms fail to improve after 2 days, the patient should be re-evaluated. 5.5 Viral Infections Employment of a corticosteroid medication in the treatment of patients with a history of herpes simplex requires great caution. Use of ocular steroids may prolong the course and may exacerbate the severity of many viral infections of the eye (including herpes simplex). 5.6 Fungal Infections Fungal infections of the cornea are particularly prone to develop coincidentally with long-term local steroid application. Fungus invasion must be considered in any persistent corneal ulceration where a steroid has been used or is in use. Fungal cultures should be taken when appropriate. 5.7 Aminoglycoside Hypersensitivity Sensitivity to topically applied aminoglycosides may occur in some patients. If hypersensitivity develops with this product, discontinue use and institute appropriate therapy. 6 ADVERSE REACTIONS Adverse reactions have occurred with steroid/anti-infective combination drugs which can be attributed to the steroid component, the anti-infective component, or the combination. Zylet: In a 42-day safety study comparing Zylet to placebo, ocular adverse reactions included injection (approximately 20%) and superficial punctate keratitis (approximately 15%). Increased intraocular pressure was reported in 10% (Zylet) and 4% (placebo) of subjects. Nine percent (9%) of Zylet subjects reported burning and stinging upon instillation. included injection (approximately 20%) and superficial punctate keratitis (approx- imately 15%). Increased intraocular pressure was reported in 10% (Zylet) and 4% Loteprednol etabonate: (placebo) of subjects. Nine percent (9%) of Zylet subjects reported burning and Chemical name: chloromethyl 17α-[(e- stinging upon instillation. thoxycarbonyl)oxy]-11β-hydroxy-3-oxoan- C24H31ClO7 Ocular reactions reported with an incidence less than 4% include vision disorders, drosta-1,4-diene-17β-carboxylate Mol. Wt. 466.96 discharge, itching, lacrimation disorder, photophobia, corneal deposits, ocular discomfort, eyelid disorder, and other unspecified eye disorders. Tobramycin: The incidence of non-ocular reactions reported in approximately 14% of subjects Chemical Name: was headache; all other non-ocular reactions had an incidence of less than 5%. O-3-Amino-3-deoxy-α-D-glucopyranosyl- Loteprednol etabonate ophthalmic suspension 0.2% - 0.5%: (1→4)-O-[2,6-diamino- Reactions associated with ophthalmic steroids include elevated intraocular pres- 2,3,6-trideoxy-α-D-ribo-hexopyrano- C H N O sure, which may be associated with infrequent optic nerve damage, visual acuity syl-(1 6)]-2-deoxystreptamine 18 37 5 9 → Mol. Wt. 467.52 and field defects, posterior subcapsular cataract formation, delayed wound healing Each mL contains: Actives: Loteprednol and secondary ocular infection from pathogens including herpes simplex, and Etabonate 5 mg (0.5%) and Tobramycin perforation of the globe where there is thinning of the cornea or sclera. 3 mg (0.3%). Inactives: Edetate Disodium, In a summation of controlled, randomized studies of individuals treated for 28 Glycerin, Povidone, Purified Water, Tyloxapol, and Benzalkonium Chloride 0.01% days or longer with loteprednol etabonate, the incidence of significant elevation (preservative). Sulfuric Acid and/or Sodium Hydroxide may be added to adjust the of intraocular pressure (≥10 mm Hg) was 2% (15/901) among patients receiving pH to 5.7-5.9. The suspension is essentially isotonic with a tonicity of 260 to 320 loteprednol etabonate, 7% (11/164) among patients receiving 1% prednisolone mOsm/kg. acetate and 0.5% (3/583) among patients receiving placebo. 12. CLINICAL PHARMACOLOGY Tobramycin ophthalmic solution 0.3%: 12.1 Mechanism of Action The most frequent adverse reactions to topical tobramycin are hypersensitivity and Corticosteroids inhibit the inflammatory response to a variety of inciting agents and localized ocular toxicity, including lid itching and swelling and conjunctival . probably delay or slow healing. They inhibit the edema, fibrin deposition, capillary di- These reactions occur in less than 4% of patients. Similar reactions may occur with lation, leukocyte migration, capillary proliferation, fibroblast proliferation, deposition the topical use of other aminoglycoside antibiotics. of collagen, and scar formation associated with inflammation. There is no generally Secondary Infection: accepted explanation for the mechanism of action of ocular corticosteroids. Howev- The development of secondary infection has occurred after use of combinations er, corticosteroids are thought to act by the induction of phospholipase A inhibitory containing steroids and antimicrobials. Fungal infections of the cornea are particu- 2 proteins, collectively called lipocortins. It is postulated that these proteins control larly prone to develop coincidentally with long-term applications of steroids. the biosynthesis of potent mediators of inflammation such as prostaglandins and The possibility of fungal invasion must be considered in any persistent corneal ulceration where steroid treatment has been used. leukotrienes by inhibiting the release of their common precursor arachidonic acid. Arachidonic acid is released from membrane phospholipids by phospholipase A . Secondary bacterial ocular infection following suppression of host responses also 2 occurs. Corticosteroids are capable of producing a rise in intraocular pressure. Loteprednol 8. USE IN SPECIFIC POPULATIONS etabonate is structurally similar to other corticosteroids. However, the number 20 8.1 Pregnancy position ketone group is absent. Teratogenic effects: Loteprednol etabonate has been shown to be embryotoxic The anti-infective component in the combination (tobramycin) is included to provide (delayed ossification) and teratogenic (increased incidence of meningocele, action against susceptible organisms. In vitro studies have demonstrated that tobra- abnormal left common carotid artery, and limb fixtures) when administered orally mycin is active against susceptible strains of the following microorganisms: to rabbits during organogenesis at a dose of 3 mg/kg/day (35 times the maximum Staphylococci, including S. aureus and S. epidermidis (coagulase-positive and coagu- daily clinical dose), a dose which caused no maternal toxicity. The no-observed-ef- lase-negative), including penicillin-resistant strains. fect-level (NOEL) for these effects was 0.5 mg/kg/day (6 times the maximum daily Streptococci, including some of the Group A-beta-hemolytic species, some nonhe- clinical dose). Oral treatment of rats during organogenesis resulted in teratogenicity molytic species, and some Streptococcus pneumoniae. Pseudomonas aeruginosa, Esch- (absent innominate artery at ≥5 mg/kg/day doses, and cleft palate and umbilical erichia coli, Klebsiella pneumoniae, Enterobacter aerogenes, Proteus mirabilis, Morganella hernia at ≥50 mg/kg/day) and embryotoxicity (increased post-implantation losses at morganii, most Proteus vulgaris strains, Haemophilus influenzae and H. aegyptius, 100 mg/kg/day and decreased fetal body weight and skeletal ossification with ≥50 Moraxella lacunata, Acinetobacter calcoaceticus and some Neisseria species. mg/kg/day). Treatment of rats at 0.5 mg/kg/day (6 times the maximum daily clinical 12.3 Pharmacokinetics dose) during organogenesis did not result in any reproductive toxicity. Loteprednol In a controlled clinical study of ocular penetration, the levels of loteprednol etabon- etabonate was maternally toxic (significantly reduced body weight gain during ate in the aqueous humor were found to be comparable between Lotemax and treatment) when administered to pregnant rats during organogenesis at doses of ≥5 mg/kg/day. Zylet treatment groups. Oral exposure of female rats to 50 mg/kg/day of loteprednol etabonate from the Results from a bioavailability study in normal volunteers established that plasma start of the fetal period through the end of lactation, a maternally toxic treatment levels of loteprednol etabonate and Δ1 cortienic acid etabonate (PJ 91), its primary, regimen (significantly decreased body weight gain), gave rise to decreased growth inactive metabolite, were below the limit of quantitation (1 ng/mL) at all sampling and survival and retarded development in the offspring during lactation; the NOEL times. for these effects was 5 mg/kg/day. Loteprednol etabonate had no effect on the The results were obtained following the ocular administration of one drop in each duration of gestation or parturition when administered orally to pregnant rats at eye of 0.5% loteprednol etabonate ophthalmic suspension 8 times daily for 2 days doses up to 50 mg/kg/day during the fetal period. or 4 times daily for 42 days. This study suggests that limited (<1 ng/mL) systemic Reproductive studies have been performed in rats and rabbits with tobramycin at absorption occurs with 0.5% loteprednol etabonate. doses up to 100 mg/kg/day parenterally and have revealed no evidence of impaired 13. NONCLINICAL TOXICOLOGY fertility or harm to the fetus. There are no adequate and well-controlled studies 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility in pregnant women. Zylet should be used during pregnancy only if the potential Long-term animal studies have not been conducted to evaluate the carcinogenic benefit justifies the potential risk to the fetus. potential of loteprednol etabonate or tobramycin. Loteprednol etabonate was not 8.3 Nursing Mothers genotoxic in vitro in the Ames test, the mouse lymphoma TK assay, a chromosome It is not known whether topical ophthalmic administration of corticosteroids could aberration test in human lymphocytes, or in an in vivo mouse micronucleus assay. result in sufficient systemic absorption to produce detectable quantities in human Oral treatment of male and female rats at 50 mg/kg/day and 25 mg/kg/day of milk. Systemic steroids that appear in human milk could suppress growth, interfere loteprednol etabonate, respectively, (500 and 250 times the maximum clinical dose, with endogenous corticosteroid production, or cause other untoward effects. respectively) prior to and during mating did not impair fertility in either gender. No Caution should be exercised when Zylet is administered to a nursing woman. 8.4 Pediatric Use impairment of fertility was noted in studies of subcutaneous tobramycin in rats at Two trials were conducted to evaluate the safety and efficacy of Zylet® (loteprednol 100 mg/kg/day (1700 times the maximum daily clinical dose). etabonate and tobramycin ophthalmic suspension) in pediatric subjects age zero 16. HOW SUPPLIED/STORAGE AND HANDLING to six years; one was in subjects with lid inflammation and the other was in subjects Zylet (loteprednol etabonate and tobramycin ophthalmic suspension) is supplied in with blepharoconjunctivitis. a white low density polyethylene plastic bottle with a white controlled drop tip and a In the lid inflammation trial, Zylet with warm compresses did not demonstrate white polypropylene cap in the following sizes: efficacy compared to vehicle with warm compresses. Patients received warm 5 mL (NDC 24208-358-05) in a 7.5 mL bottle compress lid treatment plus Zylet or vehicle for 14 days. The majority of patients in 10 mL (NDC 24208-358-10) in a 10 mL bottle both treatment groups showed reduced lid inflammation. USE ONLY IF IMPRINTED NECKBAND IS INTACT. In the blepharoconjunctivitis trial, Zylet did not demonstrate efficacy compared to Storage: Store upright at 15º-25ºC (59º-77ºF). PROTECT FROM FREEZING. SHAKE vehicle, loteprednol etabonate ophthalmic suspension, or tobramycin ophthalmic VIGOROUSLY BEFORE USING. solution. There was no difference between treatment groups in mean change from 17. PATIENT COUNSELING INFORMATION baseline blepharoconjunctivitis score at Day 15. This product is sterile when packaged. Patients should be advised not to allow the There were no differences in safety assessments between the treatment groups dropper tip to touch any surface, as this may contaminate the suspension. If pain in either trial. develops, redness, itching or inflammation becomes aggravated, the patient should 8.5 Geriatric Use be advised to consult a physician. As with all ophthalmic preparations containing No overall differences in safety and effectiveness have been observed between benzalkonium chloride, patients should be advised not to wear soft contact lenses elderly and younger patients. when using Zylet. 11. DESCRIPTION Zylet (loteprednol etabonate and tobramycin ophthalmic suspension) is a sterile, multiple dose topical anti-inflammatory corticosteroid and anti-infective Bausch + Lomb, a division of Valeant Pharmaceuticals North America LLC Bridgewa- combination for ophthalmic use. Both loteprednol etabonate and tobramycin are ter, NJ 08807 USA white to off-white powders. The chemical structures of loteprednol etabonate and © Bausch & Lomb Incorporated tobramycin are shown below. Zylet is a trademark of Bausch & Lomb Incorporated or its affiliates.

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