glucagon intranasal (Rx)

Brand and Other Names:Baqsimi
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

intranasal powder

  • 3mg/actuation

Hypoglycemia

Indicated for severe hypoglycemic reactions in patients with diabetes

3 mg administered as 1 actuation using the intranasal device into 1 nostril

If no response after 15 minutes, administer an additional 3-mg dose from a new device while waiting for emergency assistance

Dosage Forms & Strengths

intranasal powder

  • 3mg/actuation

Hypoglycemia

Indicated for severe hypoglycemic reactions in children aged ≥4 years with diabetes

<4 years: Safety and efficacy not established

≥4 years: 3 mg administered as 1 actuation using the intranasal device into 1 nostril

If no response after 15 minutes, administer an additional 3-mg dose from a new device while waiting for emergency assistance

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Interactions

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              Serious - Use Alternative (18)

              • aclidinium

                glucagon intranasal increases toxicity of aclidinium by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration of anticholinergic drugs and glucagon increase the risk of gastrointestinal adverse reactions due to additive effects on inhibition of gastrointestinal motility. .

              • atropine

                glucagon intranasal increases effects of atropine by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration of anticholinergic drugs and glucagon increase the risk of gastrointestinal adverse reactions due to additive effects on inhibition of gastrointestinal motility. .

              • benztropine

                glucagon intranasal increases toxicity of benztropine by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration of anticholinergic drugs and glucagon increase the risk of gastrointestinal adverse reactions due to additive effects on inhibition of gastrointestinal motility. .

              • dicyclomine

                glucagon intranasal increases toxicity of dicyclomine by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration of anticholinergic drugs and glucagon increase the risk of gastrointestinal adverse reactions due to additive effects on inhibition of gastrointestinal motility. .

              • glycopyrrolate

                glucagon intranasal increases toxicity of glycopyrrolate by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration of anticholinergic drugs and glucagon increase the risk of gastrointestinal adverse reactions due to additive effects on inhibition of gastrointestinal motility. .

              • glycopyrrolate inhaled

                glucagon intranasal increases toxicity of glycopyrrolate inhaled by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration of anticholinergic drugs and glucagon increase the risk of gastrointestinal adverse reactions due to additive effects on inhibition of gastrointestinal motility. .

              • hyoscyamine

                glucagon intranasal increases toxicity of hyoscyamine by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration of anticholinergic drugs and glucagon increase the risk of gastrointestinal adverse reactions due to additive effects on inhibition of gastrointestinal motility. .

              • hyoscyamine spray

                glucagon intranasal increases toxicity of hyoscyamine spray by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration of anticholinergic drugs and glucagon increase the risk of gastrointestinal adverse reactions due to additive effects on inhibition of gastrointestinal motility. .

              • ipratropium

                glucagon intranasal increases toxicity of ipratropium by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration of anticholinergic drugs and glucagon increase the risk of gastrointestinal adverse reactions due to additive effects on inhibition of gastrointestinal motility. .

              • methscopolamine

                glucagon intranasal increases toxicity of methscopolamine by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration of anticholinergic drugs and glucagon increase the risk of gastrointestinal adverse reactions due to additive effects on inhibition of gastrointestinal motility. .

              • orphenadrine

                glucagon intranasal increases toxicity of orphenadrine by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration of anticholinergic drugs and glucagon increase the risk of gastrointestinal adverse reactions due to additive effects on inhibition of gastrointestinal motility. .

              • propantheline

                glucagon intranasal increases toxicity of propantheline by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration of anticholinergic drugs and glucagon increase the risk of gastrointestinal adverse reactions due to additive effects on inhibition of gastrointestinal motility. .

              • scopolamine

                glucagon intranasal increases toxicity of scopolamine by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration of anticholinergic drugs and glucagon increase the risk of gastrointestinal adverse reactions due to additive effects on inhibition of gastrointestinal motility. .

              • tiotropium

                glucagon intranasal increases toxicity of tiotropium by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration of anticholinergic drugs and glucagon increase the risk of gastrointestinal adverse reactions due to additive effects on inhibition of gastrointestinal motility. .

              • trihexyphenidyl

                glucagon intranasal increases toxicity of trihexyphenidyl by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration of anticholinergic drugs and glucagon increase the risk of gastrointestinal adverse reactions due to additive effects on inhibition of gastrointestinal motility. .

              • tropicamide

                glucagon intranasal increases toxicity of tropicamide by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration of anticholinergic drugs and glucagon increase the risk of gastrointestinal adverse reactions due to additive effects on inhibition of gastrointestinal motility. .

              • umeclidinium bromide

                glucagon intranasal increases toxicity of umeclidinium bromide by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration of anticholinergic drugs and glucagon increase the risk of gastrointestinal adverse reactions due to additive effects on inhibition of gastrointestinal motility. .

              • umeclidinium bromide/vilanterol inhaled

                glucagon intranasal increases toxicity of umeclidinium bromide/vilanterol inhaled by Other (see comment). Avoid or Use Alternate Drug. Comment: Coadministration of anticholinergic drugs and glucagon increase the risk of gastrointestinal adverse reactions due to additive effects on inhibition of gastrointestinal motility. .

              Monitor Closely (44)

              • acebutolol

                glucagon intranasal decreases toxicity of acebutolol by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor. Coadministration of glucagon with beta-blockers may have transiently increased pulse and blood pressure.

              • antithrombin alfa

                glucagon intranasal increases effects of antithrombin alfa by unknown mechanism. Use Caution/Monitor.

              • antithrombin III

                glucagon intranasal increases effects of antithrombin III by unknown mechanism. Use Caution/Monitor.

              • argatroban

                glucagon intranasal increases effects of argatroban by unknown mechanism. Use Caution/Monitor.

              • atenolol

                glucagon intranasal decreases toxicity of atenolol by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor. Coadministration of glucagon with beta-blockers may have transiently increased pulse and blood pressure.

              • bemiparin

                glucagon intranasal increases effects of bemiparin by unknown mechanism. Use Caution/Monitor.

              • betaxolol

                glucagon intranasal decreases toxicity of betaxolol by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor. Coadministration of glucagon with beta-blockers may have transiently increased pulse and blood pressure.

              • bisoprolol

                glucagon intranasal decreases toxicity of bisoprolol by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor. Coadministration of glucagon with beta-blockers may have transiently increased pulse and blood pressure.

              • bivalirudin

                glucagon intranasal increases effects of bivalirudin by unknown mechanism. Use Caution/Monitor.

              • carvedilol

                glucagon intranasal decreases toxicity of carvedilol by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor. Coadministration of glucagon with beta-blockers may have transiently increased pulse and blood pressure.

              • celiprolol

                glucagon intranasal decreases toxicity of celiprolol by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor. Coadministration of glucagon with beta-blockers may have transiently increased pulse and blood pressure.

              • dalteparin

                glucagon intranasal increases effects of dalteparin by unknown mechanism. Use Caution/Monitor.

              • dichlorphenamide

                dichlorphenamide and glucagon intranasal both decrease serum potassium. Use Caution/Monitor.

              • enoxaparin

                glucagon intranasal increases effects of enoxaparin by unknown mechanism. Use Caution/Monitor.

              • esmolol

                glucagon intranasal decreases toxicity of esmolol by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor. Coadministration of glucagon with beta-blockers may have transiently increased pulse and blood pressure.

              • fondaparinux

                glucagon intranasal increases effects of fondaparinux by unknown mechanism. Use Caution/Monitor.

              • heparin

                glucagon intranasal increases effects of heparin by unknown mechanism. Use Caution/Monitor.

              • indomethacin

                indomethacin decreases effects of glucagon intranasal by unknown mechanism. Use Caution/Monitor. In patients taking indomethacin, glucagon may lose its ability to raise blood glucose or may even produce hypoglycemia.

              • insulin aspart

                glucagon intranasal decreases effects of insulin aspart by pharmacodynamic antagonism. Use Caution/Monitor. Endogenous glucagon is a regulatory hormone that increases blood glucose levels; exogenous glucagon is often used to treat hypoglycemia in patients with diabetes mellitus.

              • insulin aspart protamine/insulin aspart

                glucagon intranasal decreases effects of insulin aspart protamine/insulin aspart by pharmacodynamic antagonism. Use Caution/Monitor. Endogenous glucagon is a regulatory hormone that increases blood glucose levels; exogenous glucagon is often used to treat hypoglycemia in patients with diabetes mellitus.

              • insulin degludec

                glucagon intranasal decreases effects of insulin degludec by pharmacodynamic antagonism. Use Caution/Monitor. Endogenous glucagon is a regulatory hormone that increases blood glucose levels; exogenous glucagon is often used to treat hypoglycemia in patients with diabetes mellitus.

              • insulin degludec/insulin aspart

                glucagon intranasal decreases effects of insulin degludec/insulin aspart by pharmacodynamic antagonism. Use Caution/Monitor. Endogenous glucagon is a regulatory hormone that increases blood glucose levels; exogenous glucagon is often used to treat hypoglycemia in patients with diabetes mellitus.

              • insulin detemir

                glucagon intranasal decreases effects of insulin detemir by pharmacodynamic antagonism. Use Caution/Monitor. Endogenous glucagon is a regulatory hormone that increases blood glucose levels; exogenous glucagon is often used to treat hypoglycemia in patients with diabetes mellitus.

              • insulin glargine

                glucagon intranasal decreases effects of insulin glargine by pharmacodynamic antagonism. Use Caution/Monitor. Endogenous glucagon is a regulatory hormone that increases blood glucose levels; exogenous glucagon is often used to treat hypoglycemia in patients with diabetes mellitus.

              • insulin glulisine

                glucagon intranasal decreases effects of insulin glulisine by pharmacodynamic antagonism. Use Caution/Monitor. Endogenous glucagon is a regulatory hormone that increases blood glucose levels; exogenous glucagon is often used to treat hypoglycemia in patients with diabetes mellitus.

              • insulin inhaled

                glucagon intranasal decreases effects of insulin inhaled by pharmacodynamic antagonism. Use Caution/Monitor. Endogenous glucagon is a regulatory hormone that increases blood glucose levels; exogenous glucagon is often used to treat hypoglycemia in patients with diabetes mellitus.

              • insulin isophane human/insulin regular human

                glucagon intranasal decreases effects of insulin isophane human/insulin regular human by pharmacodynamic antagonism. Use Caution/Monitor. Endogenous glucagon is a regulatory hormone that increases blood glucose levels; exogenous glucagon is often used to treat hypoglycemia in patients with diabetes mellitus.

              • insulin lispro

                glucagon intranasal decreases effects of insulin lispro by pharmacodynamic antagonism. Use Caution/Monitor. Endogenous glucagon is a regulatory hormone that increases blood glucose levels; exogenous glucagon is often used to treat hypoglycemia in patients with diabetes mellitus.

              • insulin lispro protamine/insulin lispro

                glucagon intranasal decreases effects of insulin lispro protamine/insulin lispro by pharmacodynamic antagonism. Use Caution/Monitor. Endogenous glucagon is a regulatory hormone that increases blood glucose levels; exogenous glucagon is often used to treat hypoglycemia in patients with diabetes mellitus.

              • insulin NPH

                glucagon intranasal decreases effects of insulin NPH by pharmacodynamic antagonism. Use Caution/Monitor. Endogenous glucagon is a regulatory hormone that increases blood glucose levels; exogenous glucagon is often used to treat hypoglycemia in patients with diabetes mellitus.

              • insulin regular human

                glucagon intranasal decreases effects of insulin regular human by pharmacodynamic antagonism. Use Caution/Monitor. Endogenous glucagon is a regulatory hormone that increases blood glucose levels; exogenous glucagon is often used to treat hypoglycemia in patients with diabetes mellitus.

              • labetalol

                glucagon intranasal decreases toxicity of labetalol by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor. Coadministration of glucagon with beta-blockers may have transiently increased pulse and blood pressure.

              • metformin

                glucagon intranasal decreases effects of metformin by pharmacodynamic antagonism. Use Caution/Monitor.

              • metoprolol

                glucagon intranasal decreases toxicity of metoprolol by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor. Coadministration of glucagon with beta-blockers may have transiently increased pulse and blood pressure.

              • nadolol

                glucagon intranasal decreases toxicity of nadolol by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor. Coadministration of glucagon with beta-blockers may have transiently increased pulse and blood pressure.

              • nebivolol

                glucagon intranasal decreases toxicity of nebivolol by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor. Coadministration of glucagon with beta-blockers may have transiently increased pulse and blood pressure.

              • penbutolol

                glucagon intranasal decreases toxicity of penbutolol by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor. Coadministration of glucagon with beta-blockers may have transiently increased pulse and blood pressure.

              • phenindione

                glucagon intranasal increases effects of phenindione by unknown mechanism. Use Caution/Monitor.

              • pindolol

                glucagon intranasal decreases toxicity of pindolol by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor. Coadministration of glucagon with beta-blockers may have transiently increased pulse and blood pressure.

              • propranolol

                glucagon intranasal decreases toxicity of propranolol by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor. Coadministration of glucagon with beta-blockers may have transiently increased pulse and blood pressure.

              • protamine

                glucagon intranasal increases effects of protamine by unknown mechanism. Use Caution/Monitor.

              • sotalol

                glucagon intranasal decreases toxicity of sotalol by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor. Coadministration of glucagon with beta-blockers may have transiently increased pulse and blood pressure.

              • timolol

                glucagon intranasal decreases toxicity of timolol by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor. Coadministration of glucagon with beta-blockers may have transiently increased pulse and blood pressure.

              • warfarin

                glucagon intranasal increases effects of warfarin by unknown mechanism. Use Caution/Monitor.

              Minor (5)

              • magnesium chloride

                glucagon intranasal increases levels of magnesium chloride by decreasing renal clearance. Minor/Significance Unknown.

              • magnesium citrate

                glucagon intranasal increases levels of magnesium citrate by decreasing renal clearance. Minor/Significance Unknown.

              • magnesium hydroxide

                glucagon intranasal increases levels of magnesium hydroxide by decreasing renal clearance. Minor/Significance Unknown.

              • magnesium oxide

                glucagon intranasal increases levels of magnesium oxide by decreasing renal clearance. Minor/Significance Unknown.

              • magnesium sulfate

                glucagon intranasal increases levels of magnesium sulfate by decreasing renal clearance. Minor/Significance Unknown.

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              Adverse Effects

              >10%

              Adults

              • Watery eyes (58.8%)
              • Nasal congestion (42.5%)
              • Nasal itching (39.2%)
              • Nausea (26.1%)
              • Eye redness (24.8%)
              • Itchy eyes (21.6%)
              • Sneezing (19.6%)
              • Headache (18.3%)
              • Vomiting (15%)
              • Upper respiratory tract irritation (12.4%)
              • Throat itching (12.4%)

              Children

              • Watery eyes (47.2%)
              • Nasal congestion (41.7%)
              • Vomiting (30.6%)
              • Nasal itching (27.8%)
              • Headache (25%)
              • Runny nose (25%)
              • Sneezing (19.4%)
              • Upper respiratory tract irritation (16.7%)
              • Itchy eyes (16.7%)
              • Eye redness (13.9%)

              1-10%

              Children

              • Throat itching (2.8%)
              • Ears itching (2.8%)

              Adults

              • Ears itching (3.3%)

              Frequency Not Defined

              Adults and children

              • Dysgeusia
              • Pruritus
              • Tachycardia
              • Hypertension
              • Additional upper respiratory tract irritation (nasal pruritus, throat irritation, parosmia)
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              Warnings

              Contraindications

              Pheochromocytoma

              Insulinoma

              Hypersensitivity to glucagon or to any excipients

              Cautions

              Allergic reactions reported including anaphylactic shock with breathing difficulties and hypotension

              Contraindicated with pheochromocytoma; glucagon may stimulate catecholamine release from the tumor; if blood pressure (BP) increases dramatically and undiagnosed pheochromocytoma is suspected, administer phentolamine 5-10 mg IV to lower BP

              Contraindicated with insulinoma; glucagon administration may produce initial increase in blood glucose; however, glucagon may directly or indirectly (through an initial rise in blood glucose) stimulate exaggerated insulin release from an insulinoma and cause hypoglycemia; treat with glucose PO or IV

              Effective for hypoglycemia only if sufficient hepatic glycogen is present; patients in states of starvation, with adrenal insufficiency, or chronic hypoglycemia may not have adequate levels of hepatic glycogen for glucagon to be effective; treat these patients with glucose

              Drug interaction overview

              • Patients taking beta-blockers may have transiently increased pulse and BP when administered glucagon
              • In patients taking indomethacin, glucagon may lose its ability to raise blood glucose or may even produce hypoglycemia
              • Glucagon may increase anticoagulant effect of warfarin
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              Pregnancy & Lactation

              Pregnancy

              Available data from case reports and a small number of observational studies with glucagon use in pregnant women over decades of use have not identified a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes

              Multiple small studies have demonstrated a lack of transfer of pancreatic glucagon across the human placental barrier during early gestation

              Lactation

              There is no information available on the presence of glucagon in human or animal milk, the effects of the drug on the breastfed infant, or the effects of the drug on milk production

              However, glucagon is a peptide and would be expected to be broken down to its constituent amino acids in the infant's digestive tract and is therefore unlikely to cause harm to an exposed infant

              Pregnancy Categories

              A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

              B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

              C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

              D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

              X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

              NA: Information not available.

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              Pharmacology

              Mechanism of Action

              Insulin antagonist

              Activates hepatic glucagon receptors that stimulate cAMP synthesis; this accelerates hepatic glycogenolysis and gluconeogenesis, causing an increase in blood glucose levels

              Preexisting hepatic glycogen stores necessary to be effective in treating hypoglycemia

              Mean maximum glucose increase from baseline

              • Adults: 140 mg/dL
              • Children aged 4 yr to <8 yr: 138 mg/dL
              • Children aged 8 yr to <12 yr: 133 mg/dL
              • Children aged 12 yr to <17 yr: 102 mg/dL

              Absorption

              Peak plasma concentration: 6130 pg/mL

              Peak plasma time: 15 minutes (adults); 15-20 minutes (children)

              Distribution

              Vd: 885 L

              Metabolism

              Degraded in the liver, kidneys, and plasma

              Elimination

              Half-life: ~35 minutes (adults); 21-31 minutes (children)

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              Administration

              Intranasal Administration

              For intranasal use only

              Instruct patients and their caregivers on the signs and symptoms of severe hypoglycemia

              Severe hypoglycemia requires help of others to recover; instruct the patient to inform those around them about intranasal glucagon and how to use it

              Administer as soon as possible when severe hypoglycemia is recognized

              Emphasize the following instructions to the patient or caregiver

              • Do not push plunger or test the device before administering
              • Administer according to instructions on the shrink-wrapped tube label
              • Administer by inserting the tip into 1 nostril and pressing the device plunger all the way in until the green line is no longer showing; dose does not need to be inhaled
              • Call for emergency assistance immediately after administering
              • When patient responds to treatment, give oral carbohydrates to restore the liver glycogen and prevent recurrence of hypoglycemia
              • Do not attempt to reuse the glucagon intranasal device; each device contains 1 dose of glucagon and cannot be reused

              Storage

              May store up to 86ºF (30ºC) in the shrink-wrapped tube provided

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              Patient Handout

              A Patient Handout is not currently available for this monograph.
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              Formulary

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              The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

              Tier Description
              1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
              2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
              3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
              4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
              5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
              6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
              NC NOT COVERED – Drugs that are not covered by the plan.
              Code Definition
              PA Prior Authorization
              Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
              QL Quantity Limits
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              ST Step Therapy
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              OR Other Restrictions
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              Medscape prescription drug monographs are based on FDA-approved labeling information, unless otherwise noted, combined with additional data derived from primary medical literature.