PRODUCT MONOGRAPH INCLUDING PATIENT MEDICATION INFORMATION PrMINT-TRAMADOL/ACET Acetaminophen and Tramadol hydrochloride tablets, House Std 37.5 mg tramadol hydrochloride/325 mg acetaminophen Centrally Acting Analgesic Mint Pharmaceuticals Inc. Date of Revision: 1093 Meyerside Drive, Unit 1, July 16, 2018 Mississauga, Ontario L5T 1J6 Control # 217285 1 | P a g e Table of Contents PART I: HEALTH PROFESSIONAL INFORMATION ......................................................... 3 SUMMARY PRODUCT INFORMATION ............................................................................... 3 INDICATIONS AND CLINICAL USE ..................................................................................... 3 CONTRAINDICATIONS ........................................................................................................... 4 WARNINGS AND PRECAUTIONS ......................................................................................... 4 ADVERSE REACTIONS ......................................................................................................... 17 DRUG INTERACTIONS ......................................................................................................... 21 DOSAGE AND ADMINISTRATION ..................................................................................... 25 OVERDOSAGE ........................................................................................................................ 27 ACTION AND CLINICAL PHARMACOLOGY .................................................................... 29 STORAGE AND STABILITY ................................................................................................. 35 SPECIAL HANDLING INSTRUCTIONS ............................................................................... 35 DOSAGE FORMS, COMPOSITION AND PACKAGING .................................................... 36 PART II: SCIENTIFIC INFORMATION ............................................................................... 37 PHARMACEUTICAL INFORMATION ................................................................................. 37 CLINICAL TRIALS ................................................................................................................. 38 DETAILED PHARMACOLOGY ............................................................................................ 42 TOXICOLOGY ......................................................................................................................... 45 REFERENCES .......................................................................................................................... 53 PATIENT MEDICATION INFORMATION .......................................................................... 55 2 | P a g e PrMINT -TRAMADOL/ACET Acetaminophen and Tramadol hydrochloride tablets, House Std 37.5 mg tramadol hydrochloride/325 mg acetaminophen Centrally Acting Analgesic PART I: HEALTH PROFESSIONAL INFORMATION SUMMARY PRODUCT INFORMATION Route of Dosage Form/ Nonmedicinal Ingredients Administration Strength Oral 37.5 mg tramadol Hydroxyl propyl methyl cellulose, titanium hydrochloride/325 mg dioxide, polyethylene glycol, iron oxide acetaminophen tablets yellow, polysorbate 80, Pregelatinized starch, Powdered cellulose, Sodium starch glycolate, Maize starch and Magnesium stearate INDICATIONS AND CLINICAL USE Adults: MINT-TRAMADOL/ACET (acetaminophen and tramadol hydrochloride) is indicated for the management of moderate to moderately severe pain. MINT-TRAMADOL/ACET has not been systematically evaluated beyond 12 weeks in controlled clinical trials. Therefore, the physician who elects to use MINT- TRAMADOL/ACET for extended periods should periodically re-evaluate the long-term usefulness of the drug for the individual patient. Geriatrics (> 65 years of age): In general dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range reflecting the greater frequency of decreased hepatic renal or cardiac function concomitant disease or other drug therapy. Healthy elderly subjects aged 65 to 75 years administered tramadol have plasma concentrations and elimination half-lives comparable to those observed in healthy subjects less than 65 years of age. MINT-TRAMADOL/ACET should be administered with greater caution in patients older than 75 years, due to the greater potential for adverse events in this population (see WARNINGS AND PRECAUTIONS and DOSAGE AND ADMINISTRATION). 3 | P a g e Pediatrics (<18 years of age): The safety and efficacy of MINT-TRAMADOL/ACET has not been studied in the pediatric population. Therefore, use of MINT-TRAMADOL/ACET tablets is not recommended in patients under 18 years of age. CONTRAINDICATIONS MINT-TRAMADOL/ACET (acetaminophen and tramadol hydrochloride) is contraindicated in: • Patients who are hypersensitive to the active substance tramadol and acetaminophen or other opioid analgesics or to any ingredient in the formulation. For complete listing see the DOSAGE FORMS, COMPOSITION AND PACKAGING section of the Product Monograph. • Patients with known or suspected mechanical gastrointestinal obstruction (e.g., bowel obstruction or strictures) or any diseases/conditions that affect bowel transit (e.g., ileus of any type). • Patients with suspected surgical abdomen (e.g., acute appendicitis or pancreatitis). • Patients with severe hepatic or renal impairment (creatinine clearance of less than 30ml/min and/or Child-Pugh Class C). • Patients with mild pain that can be managed with other pain medications. • Patients with acute or severe bronchial asthma, chronic obstructive airway, or status asthmaticus. • Patients with acute respiratory depression, elevated carbon dioxide levels in the blood, and cor pulmonale. • Patients with acute alcoholism, delirium tremens, and convulsive disorders. • Patients with severe CNS depression, increased cerebrospinal or intracranial pressure, and head injury. • Patients taking monoamine oxidase (MAO) inhibitors (or within 14 days following discontinuation of such therapy). • Women who are pregnant, nursing or during labour and delivery. • Any situation where opioids are contraindicated, including acute intoxication with any of the following: alcohol, hypnotics, centrally acting analgesics, opioids or psychotropic drugs. MINT-TRAMADOL/ACET may worsen central nervous system and respiratory depression in these patients. • Pediatric patients less than 18 years of age who have undergone tonsillectomy and/or adenoidectomy for obstructive sleep apnea syndrome. • Pediatric patients less than 12 years of age. WARNINGS AND PRECAUTIONS SERIOUS WARNINGS AND PRECAUTIONS Limitations of Use Because of the risks of addiction, abuse, and misuse with opioids, even at recommended doses, and because of the risks of overdose and death with immediate release opioid formulations, MINT-TRAMADOL/ACET (acetaminophen and tramadol hydrochloride) should only be used in patients for whom alternative treatment options (e.g., non-opioid analgesics) are ineffective, not tolerated, or would be otherwise inadequate to provide appropriate management of pain (see DOSAGE 4 | P a g e AND ADMINISTRATION). Addiction, Abuse, and Misuse MINT-TRAMADOL/ACET poses risks of opioid addiction, abuse, and misuse, which can lead to overdose and death. Each patient’s risk should be assessed prior to prescribing MINT-TRAMADOL/ACET, and all patients should be monitored regularly for the development of these behaviours or conditions (see WARNINGS AND PRECAUTIONS). MINT-TRAMADOL/ACET should be stored securely to avoid theft or misuse. Life-threatening Respiratory Depression: OVERDOSE Serious, life-threatening, or fatal respiratory depression may occur with use of MINT- TRAMADOL/ACET. Infants exposed in-utero or through breast milk are at risk of life-threatening respiratory depression upon delivery or when nursed. Patients should be monitored for respiratory depression, especially during initiation of MINT- TRAMADOL/ACET or following a dose increase. MINT-TRAMADOL/ACET must be swallowed whole. Cutting, breaking, crushing, chewing or dissolving MINT-TRAMADOL/ACET can lead to dangerous adverse events including death (see WARNINGS AND PRECAUTIONS). Further, instruct patients of the hazards related to taking opioids including fatal overdose. Accidental Exposure Accidental ingestion of even one dose of MINT-TRAMADOL/ACET, especially by children, can result in a fatal overdose of tramadol and acetaminophen (see DOSAGE AND ADMINISTRATION, Disposal, for instructions on proper disposal). Neonatal Opioid Withdrawal Syndrome Prolonged maternal use of MINT-TRAMADOL/ACET during pregnancy can result in neonatal opioid withdrawal syndrome, which may be life-threatening (see WARNINGS AND PRECAUTIONS). Interaction with Alcohol The co-ingestion of alcohol with MINT-TRAMADOL/ACET should be avoided as it may result in dangerous additive effects, causing serious injury or death (see WARNINGS AND PRECAUTIONS and DRUG INTERACTIONS). Hepatotoxicity MINT-TRAMADOL/ACET contains acetaminophen. Acetaminophen has been associated with cases of acute liver failure, at times resulting in liver transplant and death. Most of the cases of liver injury are associated with the use of acetaminophen at doses that exceed the maximum daily limits, and often involve more than one acetaminophen-containing product. Risks From Concomitant Use With Benzodiazepines or Other CNS Depressants Concomitant use of opioids with benzodiazepines or other central nervous system 5 | P a g e (CNS) depressants, including alcohol, may