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| DESCRIPTION: NUBAIN (nalbuphine hydrochloride) is a synthetic narcotic agonist-antagonist analgesic of the phenanthrene series. It is chemically related to both the widely used narcotic antagonist, naloxone, and the potent narcotic analgesic, oxymorphone. NALBUPHINE HYDROCHLORIDE Nalbuphine hydrochloride is (-)-17-(cyclobutylmethyl)-4, 5alpha- epoxymorphinan-3,6alpha,14-triol hydrochloride. NUBAIN is available in two concentrations, 10 mg and 20 mg of nalbuphine hydrochloride per mL. Both strengths contain 0.94% sodium citrate hydrous, 1.26% citric acid anhydrous, 0.1% sodium metabisulfite, and 0.2% of a 9:1 mixture of methylparaben and propylparaben as preservatives; pH is adjusted, if necessary, with hydrochloric acid. The 10 mg/mL strength contains 0.1% sodium chloride. NUBAIN is also available in a sulfite and paraben-free formulation in two concentrations, 10 mg and 20 mg of nalbuphine hydrochloride per mL. One mL of each strength contains 0.94% sodium citrate hydrous, 1.26% citric acid anhydrous; pH is adjusted, if necessary, with hydrochloric acid. The 10 mg/mL strength contains 0.2% sodium chloride. ACTIONS/CLINICAL PHARMACOLOGY: NUBAIN is a potent analgesic. Its analgesic potency is essentially equivalent to that of morphine on a milligram basis. Its onset of action occurs within 2 to 3 minutes Its onset of action occurs within 2 to 3 minutes after intravenous administration, and in less than 15 minutes following subcutaneous or intramuscular injection. The plasma half-life of nalbuphine is 5 hours and in clinical studies the duration of analgesic activity has been reported to range from 3 to 6 hours. The narcotic antagonist activity of NUBAIN is one-fourth as potent as nalorphine and 10 times that of pentazocine. INDICATIONS AND USAGE: NUBAIN (nalbuphine hydrochloride) is indicated for the relief of moderate to severe pain. NUBAIN can also be used as a supplement to balanced anesthesia, for preoperative and postoperative analgesia, and for obstetrical analgesia during labor and delivery. CONTRAINDICATIONS: NUBAIN should not be administered to patients who are hypersensitive to it. WARNINGS: NUBAIN SHOULD BE ADMINISTERED AS A SUPPLEMENT TO GENERAL ANESTHESIA ONLY BY PERSONS SPECIFICALLY TRAINED IN THE USE OF INTRAVENOUS ANESTHETICS AND MANAGEMENT OF THE RESPIRATORY EFFECTS OF POTENT OPIOIDS. NALOXONE, RESUSCITATIVE AND INTUBATION EQUIPMENT AND OXYGEN SHOULD BE READILY AVAILABLE. DRUG DEPENDENCE NUBAIN has been shown to have a low abuse potential. When compared with drugs which are not mixed agonist-antagonists, it has been reported that nalbuphine's potential for abuse would be less than that of codeine and propoxyphene. Psychological and physical dependence and tolerance may follow the abuse or misuse of nalbuphine. Therefore, caution should be observed in prescribing it for emotionally unstable patients, or for individuals with a history of narcotic abuse. Such patients should be closely supervised when long-term therapy is contemplated. Care should be taken to avoid increases in dosage or frequency of administration which in susceptible individuals might result in physical dependence. Abrupt discontinuation of NUBAIN following prolonged use has been followed by symptoms of narcotic withdrawal, i.e., abdominal cramps, nausea and vomiting, rhinorrhea, lacrimation, restlessness, anxiety, elevated temperature and piloerection. USE IN AMBULATORY PATIENTS NUBAIN may impair the mental or physical abilities required for the performance of potentially dangerous tasks such as driving a car or operating machinery. Therefore, NUBAIN should be administered with caution to ambulatory patients who should be warned to avoid such hazards. USE IN EMERGENCY PROCEDURES Maintain patient under observation until recovered from NUBAIN effects that would affect driving or other potentially dangerous tasks. USE IN CHILDREN Clinical experience to support administration to patients under 18 years is not available at present. USE IN PREGNANCY (OTHER THAN LABOR) Safe use of NUBAIN in pregnancy has not been established. Although animal reproductive studies have not revealed teratogenic or embryotoxic effects, nalbuphine should only be administered to pregnant women when, in the judgement of the physician, the potential benefits outweigh the possible hazards. USE DURING LABOR AND DELIVERY NUBAIN can produce respiratory depression in the neonate. It should be used with caution in women delivering premature infants. HEAD INJURY AND INCREASED INTRACRANIAL PRESSURE The possible respiratory depressant effects and the potential of potent analgesics to elevate cerebrospinal fluid pressure (resulting from vasodilation following CO2 retention) may be markedly exaggerated in the presence of head injury, intracranial lesions or a pre-existing increase in intracranial pressure. Furthermore, potent analgesics can produce effects which may obscure the clinical course of patients with head injuries. Therefore, NUBAIN should be used in these circumstances only when essential, and then should be administered with extreme caution. INTERACTION WITH OTHER CENTRAL NERVOUS SYSTEM DEPRESSANTS Although NUBAIN possesses narcotic antagonist activity, there is evidence that in nondependent patients it will not antagonize a narcotic analgesic administered just before, concurrently, or just after an injection of NUBAIN. Therefore, patients receiving a narcotic analgesic, general anesthetics, phenothiazines, or other tranquilizers, sedatives, hypnotics, or other CNS depressants (including alcohol) concomitantly with NUBAIN may exhibit an additive effect. When such combined therapy is contemplated, the dose of one or both agents should be reduced. SULFITES SENSITIVITY NUBAIN contains sodium metabisulfite, a sulfite that may cause allergic- type reactions including anaphylactic symptoms and life-threatening or less severe asthmatic episodes in certain susceptible people. The overall prevalence of sulfite sensitivity in the general population is unknown and probably low. Sulfite sensitivity is seen more frequently in asthmatic than in nonasthmatic people. PRECAUTIONS: IMPAIRED RESPIRATION At the usual adult dose of 10 mg/70 kg, NUBAIN causes some respiratory depression approximately equal to that produced by equal doses of morphine. However, in contrast to morphine, respiratory depression is not appreciably increased with higher doses of NUBAIN. Respiratory depression induced by NUBAIN can be reversed by NARCAN(R) (naloxone hydrochloride) when indicated. NUBAIN should be administered with caution at low doses to patients with impaired respiration (e.g., from other medication, uremia, bronchial asthma, severe infection, cyanosis or respiratory obstructions). IMPAIRED RENAL OR HEPATIC FUNCTION Because NUBAIN is metabolized in the liver and excreted by the kidneys, patients with renal or liver dysfunction may over-react to customary doses. Therefore, in these individuals, NUBAIN should be used with caution and administered in reduced amounts. MYOCARDIAL INFARCTION As with all potent analgesics, NUBAIN should be used with caution in patients with myocardial infarction who have nausea or vomiting. BILIARY TRACT SURGERY As with all narcotic analgesics, NUBAIN should be used with caution in patients about to undergo surgery of the biliary tract since it may cause spasm of the sphincter of Oddi. CARDIOVASCULAR SYSTEM During evaluation of NUBAIN in anesthesia, a higher incidence of bradycardia has been reported in patients who did not receive atropine pre-operatively or in the pre-operative period. DRUG INTERACTIONS: INTERACTION WITH OTHER CENTRAL NERVOUS SYSTEM DEPRESSANTS Although NUBAIN possesses narcotic antagonist activity, there is evidence that in nondependent patients it will not antagonize a narcotic analgesic administered just before, concurrently, or just after an injection of NUBAIN. Therefore, patients receiving a narcotic analgesic, general anesthetics, phenothiazines, or other tranquilizers, sedatives, hypnotics, or other CNS depressants (including alcohol) concomitantly with NUBAIN may exhibit an additive effect. When such combined therapy is contemplated, the dose of one or both agents should be reduced. (See Also WARNINGS) ADVERSE REACTIONS: The most frequent adverse reaction in 1066 patients treated with NUBAIN is sedation 381(36%). Less frequent reactions are: sweaty/clammy 99(9%), nausea/vomiting 68(6%), dizziness/vertigo 58(5%), dry mouth 44(4%), and headache 27(3%). Other adverse reactions which may occur (reported incidence of 1% or less) are: CNS EFFECTS Nervousness, depression, restlessness, crying, euphoria, floating, hostility, unusual dreams, confusion, faintness, hallucinations, dysphoria, feeling of heaviness, numbness, tingling, unreality. The incidence of psychotomimetic effects, such as unreality, depersonalization, delusions, dysphoria and hallucinations has been shown to be less than that which occurs with pentazocine. CARDIOVASCULAR Hypertension, hypotension, bradycardia, tachycardia, pulmonary edema. GASTROINTESTINAL Cramps, dyspepsia, bitter taste. RESPIRATION Depression, dyspnea, asthma. DERMATOLOGICAL Itching, burning, urticaria. MISCELLANEOUS Speech difficulty, urinary urgency, blurred vision, flushing and warmth. DRUG ABUSE AND DEPENDENCE:ATION OVERDOSAGE: MANAGEMENT OF OVERDOSAGE The immediate intravenous administration of NARCAN(R) (naloxone hydrochloride) is a specific antidote. Oxygen, intravenous fluids, vasopressors and other supportive measures should be used as indicated. supportive measures should be used as indicated. The administration of single doses of 72 mg of NUBAIN subcutaneously to eight normal subjects has been reported to have resulted primarily in symptoms of sleepiness and mild dysphoria. DOSAGE AND ADMINISTRATION: The usual recommended adult dose is 10 mg for a 70 kg individual, administered subcutaneously, intramuscularly or intravenously; this dose may be repeated every 3 to 6 hours as necessary. Dosage should be adjusted according to the severity of the pain, physical status of the patient, and other medications which the patient may be receiving. (See Interaction with Other Central Nervous System Depressants under WARNINGS). In non-tolerant individuals, the Central Nervous System Depressants under WARNINGS). In non-tolerant individuals, the recommended single maximum dose is 20 mg, with a maximum total daily dose of 160 mg. The use of NUBAIN as a supplement to balanced anesthesia requires larger doses than those recommended for analgesia. Induction doses of NUBAIN range from 0.3 mg/kg to 3.0 mg/kg intravenously to be administered over a 10 to 15 minute period with maintenance doses of 0.25 to 0.50 mg/kg in single intravenous administrations as required. The use of NUBAIN may be followed by respiratory depression which can be reversed with the narcotic antagonist NARCAN(R) (naloxone hydrochloride). PATIENTS DEPENDENT ON NARCOTICS Patients who have been taking narcotics chronically may experience withdrawal symptoms can be controlled by the slow intravenous administration of small increments of morphine, until relief occurs. If the previous analgesic was morphine, meperidine, codeine, or other narcotic with similar duration of activity, one-fourth of the anticipated dose of NUBAIN can be administered initially and the patient observed for signs of withdrawal, i.e., abdominal cramps, nausea and vomiting, lacrimation, rhinorrhea, anxiety, restlessness, elevation of temperature or piloerection. If untoward symptoms do not occur, progressively larger doses may be tried at appropriate intervals until the desired level of analgesia is obtained with NUBAIN. HOW SUPPLIED: NUBAIN(R) (nalbuphine hydrochloride) for intramuscular, subcutaneous, or intravenous use is available in:
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