Drugs Details

Drugs Info of Namenda
Drugs Details
  • Drugs Type  : FDA
  • Date : 21st Feb 2015 06:00 am
  • Brand Name : Namenda
  • Generic Name : memantine (Pronunciation: meh MAN teen)
Descriptions

NAMENDA (memantine hydrochloride) is an orally active NMDA receptor antagonist. The chemical name for memantine hydrochloride is 1-amino-3,5-dimethyladamantane hydrochloride with the following structural formula:

 

NAMENDA (memantine HCl) Structural Formula Illustration

The molecular formula is C12H21N•HCl and the molecular weight is 215.76. Memantine HCl occurs as a fine white to off-white powder and is soluble in water.

NAMENDA oral solution contains memantine hydrochloride in a strength equivalent to 2 mg of memantine hydrochloride in each mL. The oral solution also contains the following inactive ingredients: sorbitol solution (70%), methylparaben, propylparaben, propylene glycol, glycerin, natural peppermint flavor #104, citric acid, sodium citrate, and purified water.

What are the possible side effects of memantine (Namenda)?

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.

Stop using memantine and call your doctor at once if you have any of these serious side effects:

  • cough, chest tightness, fever, trouble breathing;
  • chest pain, fast heart rate;
  • confusion, hallucinations;
  • sudden numbness or weakness, especially on one side of the body;
  • lack of coordination;
  • fainting or seizure (convulsions);
  • urinating less than usual or not at...

Read All Potential Side Effects and See Pictures of Namenda »

What are the precautions when taking memantine hcl (Namenda)?

Before taking memantine, tell your doctor or pharmacist if you are allergic to it; or if you have any other allergies. This product may contain inactive ingredients which can cause allergic reactions or other problems. Talk to your pharmacist for more details.

Before using this medication, tell your doctor or pharmacist your medical history, especially of: kidney problems, severe urinary tract infections, recent dietary change (from a high-protein diet to a vegetarian diet).

This drug may make you dizzy. Do not drive, use machinery, or do any activity that requires alertness until you are sure you can perform such activities safely. Limit alcoholic beverages.

Before having surgery, tell your doctor or dentist about all the products you use (including prescription...

Read All Potential Precautions of Namenda »

This monograph has been modified to include the generic and brand name in many instances.

Indications

NAMENDA (memantine hydrochloride) is indicated for the treatment of moderate to severe dementia of the Alzheimer's type.

Dosage Administration

The recommended starting dose of NAMENDA is 5 mg (2.5 mL) once daily. The dose should be increased in 5 mg increments to 10 mg/day (2.5 mL twice daily), 15 mg/day (2.5 mL and 5 mL as separate doses), and 20 mg/day (5 mL twice daily). The minimum recommended interval between dose increases is one week. The dosage shown to be effective in controlled clinical trials is 20 mg/day (5 mL twice daily).

Dosing Titration Schedule

  Total daily dose Strength per dose (mg)
Starting Dose 5 mg 5mg
Dose after week 1 10 mg 5 mg (first daily dose)
5 mg (second daily dose)
Dose after week 2 15 mg 5 mg (first daily dose)
10 mg (second daily dose)
Dose after week 3 20 mg 10 mg (first daily dose)
10 mg (second daily dose)

NAMENDA can be taken with or without food. If a patient misses a single dose of NAMENDA, that patient should not double up on the next dose. The next dose should be taken as scheduled. If a patient fails to take NAMENDA for several days, dosing may need to be resumed at lower doses and retitrated as described above.

Do not mix NAMENDA oral solution with any other liquid. NAMENDA is administered with a dosing device that comes with the drug and consists of a syringe, syringe adaptor cap, tubing and other supplies a patient needs to administer the drug. The supplied syringe should be used to withdraw the correct volume of oral solution and the oral solution should be slowly squirted into the corner of the patient's mouth.

Special Populations

Renal Impairment

A target dose of 5 mg (2.5 mL) twice daily is recommended in patients with severe renal impairment (creatinine clearance of 5 – 29 mL/min based on the Cockcroft-Gault equation).

Hepatic Impairment

NAMENDA should be administered with caution to patients with severe hepatic impairment [see CLINICAL PHARMACOLOGY].

How Supplied

Dosage Forms And Strengths

NAMENDA 2 mg/mL oral solution: clear, alcohol-free, sugar-free, and peppermint flavored.

Storage And Handling

2 mg/mL Oral Solution

12 fl. oz. (360 mL) bottle NDC #0456-3202-12

Store NAMENDA oral solution at 25°C (77°F); excursions permitted to 15-30°C (59-86°F) [see USP Controlled Room Temperature].

Manufactured for: Forest Pharmaceuticals, Inc. Subsidiary of Forest Laboratories, LLC St. Louis, MO 63045. Manufactured by: Forest Laboratories Ireland Ltd. Revised August 2014

This monograph has been modified to include the generic and brand name in many instances.

Side Effects

Clinical Trials Experience

NAMENDA was evaluated in eight double-blind placebo-controlled trials involving a total of 1862 dementia (Alzheimer's disease, vascular dementia) patients (940 patients treated with NAMENDA and 922 patients treated with placebo) for a treatment period up to 28 weeks.

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

Adverse Events Leading to Discontinuation

In placebo-controlled trials in which dementia patients received doses of NAMENDA up to 20 mg/day, the likelihood of discontinuation because of an adverse reaction was the same in the NAMENDA group (10.1%) as in the placebo group (11.5%). No individual adverse reaction was associated with the discontinuation of treatment in 1% or more of NAMENDA-treated patients and at a rate greater than placebo.

Most Common Adverse Reactions

In double-blind placebo-controlled trials involving dementia patients, the most common adverse reactions (incidence ≥ 5% and higher than placebo) in patients treated with NAMENDA were dizziness, headache, confusion and constipation. Table 1 lists all adverse reactions that occurred in at least 2% of patients treated with NAMENDA and at an incidence greater than placebo.

Table 1: Adverse Reactions Reported in Controlled Clinical Trials in at Least 2% of Patients Receiving NAMENDA and at a Higher Frequency than Placebo-treated Patients

Adverse Reaction Placebo
(N = 922) %
NAMENDA
(N = 940) %
Body as a Whole
  Fatigue 1 2
  Pain 1 3
Cardiovascular System
  Hypertension 2 4
Central and Peripheral Nervous System
  Dizziness 5 7
  Headache 3 6
Gastrointestinal System
  Constipation 3 5
  Vomiting 2 3
Musculoskeletal System
  Back pain 2 3
Psychiatric Disorders
  Confusion 5 6
  Somnolence 2 3
  Hallucination   2 3
Respiratory System
  Coughing 3 4
  Dyspnea 1 2

The overall profile of adverse reactions and the incidence rates for individual adverse reactions in the subpopulation of patients with moderate to severe Alzheimer's disease were not different from the profile and incidence rates described above for the overall dementia population.

Seizures

NAMENDA has not been systematically evaluated in patients with a seizure disorder. In clinical trials of NAMENDA, seizures occurred in 0.2% of patients treated with NAMENDA and 0.5% of patients treated with placebo.

Postmarketing Experience

The following adverse reactions have been identified during post-approval use of memantine. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. These reactions include:

Blood and Lymphatic System Disorders -agranulocytosis, leukopenia (including neutropenia), pancytopenia, thrombocytopenia, thrombotic thrombocytopenic purpura.

Cardiac Disorders -cardiac failure congestive.

Gastrointestinal Disorders -pancreatitis.

Hepatobiliary Disorders – hepatitis.

Psychiatric Disorders -suicidal ideation.

Renal and Urinary Disorders -acute renal failure (including increased creatinine and renal insufficiency).

Skin Disorders -Stevens Johnson syndrome.

Read the Namenda (memantine hcl) Side Effects Center for a complete guide to possible side effects

Learn More »

Interactions

Drugs That Make The Urine Alkaline

The clearance of memantine was reduced by about 80% under alkaline urine conditions at pH 8. Therefore, alterations of urine pH towards the alkaline condition may lead to an accumulation of the drug with a possible increase in adverse effects. Urine pH is altered by diet, drugs (e.g. carbonic anhydrase inhibitors, sodium bicarbonate) and clinical state of the patient (e.g. renal tubular acidosis or severe infections of the urinary tract). Hence, memantine should be used with caution under these conditions.

Use With Other N-methyl-D-aspartate (NMDA) Antagonists

The combined use of NAMENDA with other NMDA antagonists (amantadine, ketamine, and dextromethorphan) has not been systematically evaluated and such use should be approached with caution.

Read the Namenda Drug Interactions Center for a complete guide to possible interactions

Learn More »

This monograph has been modified to include the generic and brand name in many instances.

Warnings

Included as part of the PRECAUTIONS section.

Precautions

Genitourinary Conditions

Conditions that raise urine pH may decrease the urinary elimination of memantine resulting in increased plasma levels of memantine [see DRUG INTERACTIONS].

Patient Counseling Information

See FDA-approved patient labeling (PATIENT INFORMATION and Instructions for Use).

To assure safe and effective use of NAMENDA, the following information and instructions provided in the patient information section should be discussed with patients and caregivers.

Patients/caregivers should be instructed to follow the dose titration schedule provided by their physician or healthcare professional for NAMENDA.

If a patient misses a single dose of NAMENDA, that patient should not double up on the next dose. The next dose should be taken as scheduled. If a patient fails to take NAMENDA for several days, dosing should not be resumed without consulting that patient's healthcare professional.

Patients/caregivers should be instructed on how to use the NAMENDA oral solution dosing device. They should be made aware of the patient instruction sheet that is enclosed with the product. Patients/caregivers should be instructed to address any questions on the usage of the solution to their physician or pharmacist.

Nonclinical Toxicology

Carcinogenesis, Mutagenesis, Impairment Of Fertility

There was no evidence of carcinogenicity in a 113-week oral study in mice at doses up to 40 mg/kg/day (10 times the maximum recommended human dose [MRHD] on a mg/m² basis). There was also no evidence of carcinogenicity in rats orally dosed at up to 40 mg/kg/day for 71 weeks followed by 20 mg/kg/day (20 and 10 times the MRHD on a mg/m² basis, respectively) through 128 weeks.

Memantine produced no evidence of genotoxic potential when evaluated in the in vitro S. typhimurium or E. coli reverse mutation assay, an in vitro chromosomal aberration test in human lymphocytes, an in vivo cytogenetics assay for chromosome damage in rats, and the in vivo mouse micronucleus assay. The results were equivocal in an in vitro gene mutation assay using Chinese hamster V79 cells.

No impairment of fertility or reproductive performance was seen in rats administered up to 18 mg/kg/day (9 times the MRHD on a mg/m² basis) orally from 14 days prior to mating through gestation and lactation in females, or for 60 days prior to mating in males.

Use In Specific Populations

Pregnancy

Pregnancy Category B

There are no adequate and well-controlled studies of memantine in pregnant women. NAMENDA should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Memantine given orally to pregnant rats and pregnant rabbits during the period of organogenesis was not teratogenic up to the highest doses tested (18 mg/kg/day in rats and 30 mg/kg/day in rabbits, which are 9 and 30 times, respectively, the maximum recommended human dose [MRHD] on a mg/m² basis).

Slight maternal toxicity, decreased pup weights and an increased incidence of non-ossified cervical vertebrae were seen at an oral dose of 18 mg/kg/day in a study in which rats were given oral memantine beginning pre-mating and continuing through the postpartum period. Slight maternal toxicity and decreased pup weights were also seen at this dose in a study in which rats were treated from day 15 of gestation through the postpartum period. The no-effect dose for these effects was 6 mg/kg, which is 3 times the MRHD on a mg/m² basis.

Nursing Mothers

It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when NAMENDA is administered to a nursing mother.

Pediatric Use

Safety and effectiveness in pediatric patients have not been established.

Geriatric Use

The majority of people with Alzheimer's disease are 65 years and older. In the clinical studies of NAMENDA the mean age of patients was approximately 76; over 90% of patients were 65 years and older, 60% were 75 years and older, and 12% were at or above 85 years of age. The efficacy and safety data presented in the clinical trial sections were obtained from these patients. There were no clinically meaningful differences in most adverse events reported by patient groups ≥ 65 years old and < 65 year old.

Renal Impairment

No dosage adjustment is needed in patients with mild or moderate renal impairment. A dosage reduction is recommended in patients with severe renal impairment [see DOSAGE AND ADMINISTRATION and CLINICAL PHARMACOLOGY].

Hepatic Impairment

No dosage adjustment is needed in patients with mild or moderate hepatic impairment. NAMENDA should be administered with caution to patients with severe hepatic impairment [see DOSAGE AND ADMINISTRATION and CLINICAL PHARMACOLOGY].

This monograph has been modified to include the generic and brand name in many instances.

OverDose

Signs and symptoms most often accompanying memantine overdosage in clinical trials and from worldwide marketing experience, alone or in combination with other drugs and/or alcohol, include agitation, asthenia, bradycardia, confusion, coma, dizziness, ECG changes, increased blood pressure, lethargy, loss of consciousness, psychosis, restlessness, slowed movement, somnolence, stupor, unsteady gait, visual hallucinations, vertigo, vomiting, and weakness. The largest known ingestion of memantine worldwide was 2.0 grams in a patient who took memantine in conjunction with unspecified antidiabetic medications. The patient experienced coma, diplopia, and agitation, but subsequently recovered. Fatal outcome has been very rarely reported with memantine, and the relationship to memantine was unclear.

Because strategies for the management of overdose are continually evolving, it is advisable to contact a poison control center to determine the latest recommendations for the management of an overdose of any drug. As in any cases of overdose, general supportive measures should be utilized, and treatment should be symptomatic. Elimination of memantine can be enhanced by acidification of urine.

ContrainDications

NAMENDA (memantine hydrochloride) is contraindicated in patients with known hypersensitivity to memantine hydrochloride or to any excipients used in the formulation.

This monograph has been modified to include the generic and brand name in many instances.

Clinical Pharamacology

Mechanism Of Action

Persistent activation of central nervous system N-methyl-D-aspartate (NMDA) receptors by the excitatory amino acid glutamate has been hypothesized to contribute to the symptomatology of Alzheimer's disease. Memantine is postulated to exert its therapeutic effect through its action as a low to moderate affinity uncompetitive (open-channel) NMDA receptor antagonist which binds preferentially to the NMDA receptor-operated cation channels. There is no evidence that memantine prevents or slows neurodegeneration in patients with Alzheimer's disease.

Pharmacodynamics

Memantine showed low to negligible affinity for GABA, benzodiazepine, dopamine, adrenergic, histamine and glycine receptors and for voltage-dependent Ca2+, Na+ or K+ channels. Memantine also showed antagonistic effects at the 5HT3 receptor with a potency similar to that for the NMDA receptor and blocked nicotinic acetylcholine receptors with one-sixth to one-tenth the potency.

In vitro studies have shown that memantine does not affect the reversible inhibition of acetylcholinesterase by donepezil, galantamine, or tacrine.

Pharmacokinetics

Absorption

Following oral administration memantine is highly absorbed with peak concentrations reached in about 3-7 hours. Memantine has linear pharmacokinetics over the therapeutic dose range. Food has no effect on the absorption of memantine.

Distribution

The mean volume of distribution of memantine is 9-11 L/kg and the plasma protein binding is low (45%).

Metabolism

Memantine undergoes partial hepatic metabolism. The hepatic microsomal CYP450 enzyme system does not play a significant role in the metabolism of memantine.

Elimination

Memantine is excreted predominantly (about 48%) unchanged in urine and has a terminal elimination half-life of about 60-80 hours.

The remainder is converted primarily to three polar metabolites which possess minimal NMDA receptor antagonistic activity: the N-glucuronide conjugate, 6-hydroxy memantine, and 1-nitroso-deaminated memantine. A total of 74% of the administered dose is excreted as the sum of the parent drug and the Nglucuronide conjugate. Renal clearance involves active tubular secretion moderated by pH dependent tubular reabsorption.

Pharmacokinetics in Specific Populations

Gender

Following multiple dose administration of NAMENDA 20 mg daily, females had about 45% higher exposure than males, but there was no difference in exposure when body weight was taken into account.

Elderly

The pharmacokinetics of NAMENDA in young and elderly subjects are similar.

Renal Impairment

Memantine pharmacokinetics were evaluated following single oral administration of 20 mg memantine HCl in 8 subjects with mild renal impairment (creatinine clearance, CLcr, > 50 – 80 mL/min), 8 subjects with moderate renal impairment (CLcr 30 – 49 mL/min), 7 subjects with severe renal impairment (CLcr 5 – 29 mL/min) and 8 healthy subjects (CLcr > 80 mL/min) matched as closely as possible by age, weight and gender to the subjects with renal impairment. Mean AUC0-∞ increased by 4%, 60%, and 115% in subjects with mild, moderate, and severe renal impairment, respectively, compared to healthy subjects. The terminal elimination half-life increased by 18%, 41%, and 95% in subjects with mild, moderate, and severe renal impairment, respectively, compared to healthy subjects.

No dosage adjustment is recommended for patients with mild and moderate renal impairment. Dosage should be reduced in patients with severe renal impairment [see DOSAGE AND ADMINISTRATION].

Hepatic Impairment

Memantine pharmacokinetics were evaluated following the administration of single oral doses of 20 mg in 8 subjects with moderate hepatic impairment (Child-Pugh Class B, score 7-9) and 8 subjects who were age-, gender-, and weight-matched to the hepatically-impaired subjects. There was no change in memantine exposure (based on Cmax and AUC) in subjects with moderate hepatic impairment as compared with healthy subjects. However, terminal elimination half-life increased by about 16% in subjects with moderate hepatic impairment as compared with healthy subjects. No dose adjustment is recommended for patients with mild and moderate hepatic impairment. Memantine should be administered with caution to patients with severe hepatic impairment as the pharmacokinetics of memantine have not been evaluated in that population.

Drug-Drug Interactions

Use with Cholinesterase Inhibitors

Coadministration of memantine with the AChE inhibitor donepezil HCl did not affect the pharmacokinetics of either compound. Furthermore, memantine did not affect AChE inhibition by donepezil. In a 24-week controlled clinical study in patients with moderate to severe Alzheimer's disease, the adverse event profile observed with a combination of NAMENDA and donepezil was similar to that of donepezil alone.

Effect of NAMENDA on the Metabolism of Other Drugs

In vitro studies conducted with marker substrates of CYP450 enzymes (CYP1A2, -2A6, -2C9, -2D6, 2E1, -3A4) showed minimal inhibition of these enzymes by memantine. In addition, in vitro studies indicate that at concentrations exceeding those associated with efficacy, memantine does not induce the cytochrome P450 isozymes CYP1A2, -2C9, -2E1 and -3A4/5. No pharmacokinetic interactions with drugs metabolized by these enzymes are expected.

Pharmacokinetic studies evaluated the potential of memantine for interaction with warfarin, and buproprion. Memantine did not affect the pharmacokinetics of the CYP2B6 substrate buproprion or its metabolite hydroxybuproprion. Furthermore, memantine did not affect the pharmacokinetics or pharmacodynamics of warfarin as assessed by the prothrombin INR.

Effect of Other Drugs on NAMENDA

Memantine is predominantly renally eliminated, and drugs that are substrates and/or inhibitors of the CYP450 system are not expected to alter the metabolism of memantine.

Drugs Eliminated via Renal Mechanisms

Because memantine is eliminated in part by tubular secretion, coadministration of drugs that use the same renal cationic system, including hydrochlorothiazide (HCTZ), triamterene (TA), metformin, cimetidine, ranitidine, quinidine, and nicotine, could potentially result in altered plasma levels of both agents. However, coadministration of NAMENDA and HCTZ/TA did not affect the bioavailability of either memantine or TA, and the bioavailability of HCTZ decreased by 20%. In addition, coadministration of memantine with the antihyperglycemic drug Glucovance® (glyburide and metformin HCl) did not affect the pharmacokinetics of memantine, metformin and glyburide. Furthermore, memantine did not modify the serum glucose lowering effect of Glucovance®, indicating the absence of a pharmacodynamic interaction.

Drugs Highly Bound to Plasma Proteins

Because the plasma protein binding of memantine is low (45%), an interaction with drugs that are highly bound to plasma proteins, such as warfarin and digoxin, is unlikely.

Animal Toxicology And/Or Pharmacology

Memantine induced neuronal lesions (vacuolation and necrosis) in the multipolar and pyramidal cells in cortical layers III and IV of the posterior cingulate and retrosplenial neocortices in rats, similar to those which are known to occur in rodents administered other NMDA receptor antagonists. Lesions were seen after a single dose of memantine. In a study in which rats were given daily oral doses of memantine for 14 days, the no-effect dose for neuronal necrosis was 6 times the maximum recommended human dose of 20 mg/day on a mg/m² basis

In acute and repeat-dose neurotoxicity studies in female rats, oral administration of memantine and donepezil in combination resulted in increased incidence, severity, and distribution of neurodegeneration compared with memantine alone. The no-effect levels of the combination were associated with clinically relevant plasma memantine and donepezil exposures.

The relevance of these findings to humans is unknown.

Clinical Studies

The clinical efficacy studies described below were conducted with NAMENDA tablets and not with NAMENDA oral solution; however, bioequivalence of NAMENDA oral solution with NAMENDA tablets has been demonstrated.

The effectiveness of NAMENDA as a treatment for patients with moderate to severe Alzheimer's disease was demonstrated in 2 randomized, double-blind, placebo-controlled clinical studies (Studies 1 and 2) conducted in the United States that assessed both cognitive function and day to day function. The mean age of patients participating in these two trials was 76 with a range of 50-93 years. Approximately 66% of patients were female and 91% of patients were Caucasian. A third study (Study 3), carried out in Latvia, enrolled patients with severe dementia, but did not assess cognitive function as a planned endpoint. Study Outcome Measures: In each U.S. study, the effectiveness of NAMENDA was determined using both an instrument designed to evaluate overall function through caregiver-related assessment, and an instrument that measures cognition. Both studies showed that patients on NAMENDA experienced significant improvement on both measures compared to placebo.

Day-to-day function was assessed in both studies using the modified Alzheimer's disease Cooperative Study -Activities of Daily Living inventory (ADCS-ADL). The ADCS-ADL consists of a comprehensive battery of ADL questions used to measure the functional capabilities of patients. Each ADL item is rated from the highest level of independent performance to complete loss. The investigator performs the inventory by interviewing a caregiver familiar with the behavior of the patient. A subset of 19 items, including ratings of the patient's ability to eat, dress, bathe, telephone, travel, shop, and perform other household chores has been validated for the assessment of patients with moderate to severe dementia. This is the modified ADCS-ADL, which has a scoring range of 0 to 54, with the lower scores indicating greater functional impairment.

The ability of NAMENDA to improve cognitive performance was assessed in both studies with the Severe Impairment Battery (SIB), a multi-item instrument that has been validated for the evaluation of cognitive function in patients with moderate to severe dementia. The SIB examines selected aspects of cognitive performance, including elements of attention, orientation, language, memory, visuospatial ability, construction, praxis, and social interaction. The SIB scoring range is from 0 to 100, with lower scores indicating greater cognitive impairment.

Study 1 (Twenty-Eight-Week Study)

In a study of 28 weeks duration, 252 patients with moderate to severe probable Alzheimer's disease (diagnosed by DSM-IV and NINCDS-ADRDA criteria, with Mini-Mental State Examination scores ≥ 3 and ≤ 14 and Global Deterioration Scale Stages 5-6) were randomized to NAMENDA or placebo. For patients randomized to NAMENDA, treatment was initiated at 5 mg once daily and increased weekly by 5 mg/day in divided doses to a dose of 20 mg/day (10 mg twice a day).

Effects on the ADCS-ADL

Figure 1 shows the time course for the change from baseline in the ADCS-ADL score for patients in the two treatment groups completing the 28 weeks of the study. At 28 weeks of treatment, the mean difference in the ADCS-ADL change scores for the NAMENDA-treated patients compared to the patients on placebo was 3.4 units. Using an analysis based on all patients and carrying their last study observation forward (LOCF analysis), NAMENDA treatment was statistically significantly superior to placebo.

Figure 1: Time course of the change from baseline in ADCS-ADL score for patients completing 28 weeks of treatment.

View Enlarged Table

Figure 2 shows the cumulative percentages of patients from each of the treatment groups who had attained at least the change in the ADCS-ADL shown on the X axis. The curves show that both patients assigned to NAMENDA and placebo have a wide range of responses and generally show deterioration (a negative change in ADCS-ADL compared to baseline), but that the NAMENDA group is more likely to show a smaller decline or an improvement. (In a cumulative distribution display, a curve for an effective treatment would be shifted to the left of the curve for placebo, while an ineffective or deleterious treatment would be superimposed upon or shifted to the right of the curve for placebo).

Figure 2: Cumulative percentage of patients completing 28 weeks of double-blind treatment with specified changes from baseline in ADCS-ADL scores.

View Enlarged Table
Effects on the SIB

Figure 3 shows the time course for the change from baseline in SIB score for the two treatment groups over the 28 weeks of the study. At 28 weeks of treatment, the mean difference in the SIB change scores for the NAMENDA-treated patients compared to the patients on placebo was 5.7 units. Using an LOCF analysis, NAMENDA treatment was statistically significantly superior to placebo.

Figure 3: Time course of the change from baseline in SIB score for patients completing 28 weeks of treatment.

Time course of the change from baseline in SIB score - Illustration

Figure 4 shows the cumulative percentages of patients from each treatment group who had attained at least the measure of change in SIB score shown on the X axis. The curves show that both patients assigned to NAMENDA and placebo have a wide range of responses and generally show deterioration, but that the NAMENDA group is more likely to show a smaller decline or an improvement.

Figure 4: Cumulative percentage of patients completing 28 weeks of double-blind treatment with specified changes from baseline in SIB scores.

View Enlarged Table
Study 2 (Twenty-Four-Week Study)

In a study of 24 weeks duration, 404 patients with moderate to severe probable Alzheimer's disease (diagnosed by NINCDS-ADRDA criteria, with Mini-Mental State Examination scores ≥ 5 and ≤ 14) who had been treated with donepezil for at least 6 months and who had been on a stable dose of donepezil for the last 3 months were randomized to NAMENDA or placebo while still receiving donepezil. For patients randomized to NAMENDA, treatment was initiated at 5 mg once daily and increased weekly by 5 mg/day in divided doses to a dose of 20 mg/day (10 mg twice a day).

Effects on the ADCS-ADL

Figure 5 shows the time course for the change from baseline in the ADCS-ADL score for the two treatment groups over the 24 weeks of the study. At 24 weeks of treatment, the mean difference in the ADCS-ADL change scores for the NAMENDA/donepezil treated patients (combination therapy) compared to the patients on placebo/donepezil (monotherapy) was 1.6 units. Using an LOCF analysis, NAMENDA/donepezil treatment was statistically significantly superior to placebo/donepezil.

Figure 5: Time course of the change from baseline in ADCS-ADL score for patients completing 24 weeks of treatment.

Time course of the change from baseline in ADCS-ADL score -  Illustration

Figure 6 shows the cumulative percentages of patients from each of the treatment groups who had attained at least the measure of improvement in the ADCS-ADL shown on the X axis. The curves show that both patients assigned to NAMENDA/donepezil and placebo/donepezil have a wide range of responses and generally show deterioration, but that the NAMENDA/donepezil group is more likely to show a smaller decline or an improvement.

Figure 6: Cumulative percentage of patients completing 24 weeks of double-blind treatment with specified changes from baseline in ADCS-ADL scores.

View Enlarged Table
Effects on the SIB

Figure 7 shows the time course for the change from baseline in SIB score for the two treatment groups over the 24 weeks of the study. At 24 weeks of treatment, the mean difference in the SIB change scores for the NAMENDA/donepezil-treated patients compared to the patients on placebo/donepezil was 3.3 units. Using an LOCF analysis, NAMENDA/donepezil treatment was statistically significantly superior to placebo/donepezil.

Figure 7: Time course of the change from baseline in SIB score for patients completing 24 weeks of treatment.

Time course of the change from baseline in SIB score - Illustration

Figure 8 shows the cumulative percentages of patients from each treatment group who had attained at least the measure of improvement in SIB score shown on the X axis. The curves show that both patients assigned to NAMENDA/donepezil and placebo/donepezil have a wide range of responses, but that the NAMENDA/donepezil group is more likely to show an improvement or a smaller decline.

Figure 8: Cumulative percentage of patients completing 24 weeks of double-blind treatment with specified changes from baseline in SIB scores.

View Enlarged Table
Study 3 (Twelve-Week Study)

In a double-blind study of 12 weeks duration, conducted in nursing homes in Latvia, 166 patients with dementia according to DSM-III-R, a Mini-Mental State Examination score of < 10, and Global Deterioration Scale staging of 5 to 7 were randomized to either NAMENDA or placebo. For patients randomized to NAMENDA, treatment was initiated at 5 mg once daily and increased to 10 mg once daily after 1 week. The primary efficacy measures were the care dependency subscale of the Behavioral Rating Scale for Geriatric Patients (BGP), a measure of day-to-day function, and a Clinical Global Impression of Change (CGI-C), a measure of overall clinical effect. No valid measure of cognitive function was used in this study. A statistically significant treatment difference at 12 weeks that favored NAMENDA over placebo was seen on both primary efficacy measures. Because the patients entered were a mixture of Alzheimer's disease and vascular dementia, an attempt was made to distinguish the two groups and all patients were later designated as having either vascular dementia or Alzheimer's disease, based on their scores on the Hachinski Ischemic Scale at study entry. Only about 50% of the patients had computerized tomography of the brain. For the subset designated as having Alzheimer's disease, a statistically significant treatment effect favoring NAMENDA over placebo at 12 weeks was seen on both the BGP and CGI-C.

This monograph has been modified to include the generic and brand name in many instances.

Patient Information

NAMENDA
(Nuh-MEN-dah)
(memantine hydrochloride) Oral Solution

Read this Patient Information that comes with NAMENDA before you start taking it and each time you get a refill. There may be new information. This information does not take the place of talking to your doctor about your medical condition or your treatment.

What is NAMENDA?

NAMENDA is a prescription medicine used for the treatment of moderate to severe dementia in people with Alzheimer's disease. NAMENDA belongs to a class of medicines called NMDA (N-methyl-Daspartate) inhibitors.

It is not known if NAMENDA is safe and effective in children.

Who should not take NAMENDA?

Do not take NAMENDA if you are allergic to memantine or any of the ingredients in NAMENDA. See the end of this leaflet for a complete list of ingredients in NAMENDA.

What should I tell my doctor before taking NAMENDA?

Before you take NAMENDA, tell your doctor if you:

  • have or have had seizures
  • have or have had problems passing urine
  • have or have had bladder or kidney problems
  • have liver problems
  • have any other medical conditions
  • are pregnant or plan to become pregnant. It is not known if NAMENDA will harm your unborn baby.
  • are breastfeeding or plan to breastfeed. It is not known if NAMENDA passes into your breast milk. You and your doctor should decide if you will take NAMENDA or breastfeed.

Tell your doctor about all the medicines you take, including prescription and non-prescription medicines, vitamins, and herbal supplements.

Taking NAMENDA with certain other medicines may affect each other. Taking NAMENDA with other medicines can cause serious side effects.

Especially tell your doctor if you take:

  • other NMDA antagonists such as amantadine, ketamine, and dextromethorphan
  • medicines that make your urine alkaline such as carbonic anhydrase inhibitors and sodium bicarbonate

Ask your doctor or pharmacist for a list of these medicines, if you are not sure.

Know the medicines you take. Keep a list of them to show your doctor and pharmacist when you get a new medicine.

How should I take NAMENDA?

  • See the step-by-step instructions for taking NAMENDA at the end of this Patient Information.
  • Your doctor will tell you how much NAMENDA to take and when to take it.
  • Your doctor may change your dose if needed.
  • NAMENDA can be taken with food or without food.
  • If you forget to take one dose of NAMENDA, do not double up on the next dose. You should take only the next dose as scheduled.
  • If you have forgotten to take NAMENDA for several days, you should not take the next dose until you talk to your doctor.
  • If you take too much NAMENDA, call your doctor or poison control center at 1-800-222-1222 right away, or go to the nearest hospital emergency room.

What are the possible side effects of NAMENDA?

NAMENDA may cause side effects, including:

The most common side effects of NAMENDA include:

  • dizziness
  • headache
  • confusion
  • constipation

These are not all the possible side effects of NAMENDA. For more information, ask your doctor or pharmacist.

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1800-FDA-1088.

How should I store NAMENDA?

  • Store NAMENDA at room temperature between 68°F to 77°F (20°C to 25°C).

What are the ingredients in NAMENDA?

Active ingredients: memantine hydrochloride

Inactive ingredients: sorbitol solution (70%), methyl paraben, propylparaben, propylene glycol, glycerin, natural peppermint flavor #104, citric acid, sodium citrate, and purified water

Keep NAMENDA and all medicines out of the reach of children.

General information about the safe and effective use of NAMENDA.

Medicines are sometimes prescribed for purposes other than those listed in a Patient Information leaflet. Do not take NAMENDA for a condition for which it was not prescribed. Do not give NAMENDA to other people, even if they have the same condition. It may harm them.

This Patient Information leaflet summarizes the most important information about NAMENDA. If you would like more information, talk with your doctor. You can ask your doctor or pharmacist for information about NAMENDA that was written for healthcare professionals.

For more information about NAMENDA, go to www.namenda.com, or call Forest Laboratories, Inc. at 1-800-678-1605.

INSTRUCTIONS FOR USE

NAMENDA
(Nuh-MEN-dah)
(memantine hydrochloride) Oral Solution

Directions for Using your NAMENDA Oral Solution

Read these instructions before taking NAMENDA Oral Solution and each time you get a refill. There may be new information. This information does not take the place of talking to your doctor about your medical condition or your treatment.

Preparing your dose of NAMENDA Oral Solution.

You will need the following supplies:

  1. NAMENDA Oral Solution bottle with Child-resistant cap
  2. Green syringe adaptor cap with lid
  3. Oral dosing syringe
  4. Prescribing Information

 

pSupplies needed for Preparing your dose of NAMENDA Oral Solution - Illustration

1. Remove the oral dosing syringe, the green syringe adaptor cap, and remove the plastic tube from its protective plastic bag. Attach the tube to the green syringe adaptor cap if it is not already attached.

 

The green syringe adaptor cap - Illustration

2. The bottle comes with a child-resistant cap. To remove the cap, you should push down on the cap and at the same time; turn the cap counter-clockwise (to the left).

 

Child-resistant cap - Illustration

3. Carefully remove the seal from the bottle and throw away.

 

Remove the seal - Illustration

4. Insert the green syringe adaptor cap, with the attached tube, all the way into the bottle and tightly screw the cap onto the bottle by turning the cap clockwise (to the right).

 

Insert the green syringe adaptor cap - Illustration

5. The green syringe adaptor cap has an opening with an attached lid. The adaptor is used to withdraw the correct dose of medicine from the bottle with the syringe. The attached adaptor lid should be closed in between doses.

 

The green syringe adaptor cap has an opening with an attached lid - Illustration

6. Keep the bottle upright on a table. Open the syringe adaptor lid and insert the tip of syringe into the syringe adaptor opening

  • Make sure the syringe is pushed firmly into the adaptor opening.

 

syringe is pushed firmly into the adaptor opening - Illustration

7. While holding the syringe in place, gently pull the plunger of the syringe until you get to the correct mL (amount) of medicine you need.

  • Do not worry about a few tiny bubbles. This will not affect your dose.

 

gently pull the plunger - Illustration

8. Remove the syringe from the syringe adaptor cap.

 

Remove the syringe from the syringe adaptor cap - Illustration

9. Remove the syringe from the bottle and slowly squirt the NAMENDA Oral Solution into the corner of you or the patient's mouth. Do not mix NAMENDA Oral Solution with any other liquid.

 

Slowly squirt the NAMENDA Oral Solution into the corner of you or the patient’s mouth - Illustration

10. After use, reseal the bottle by snapping the attached syringe adaptor lid closed.

 

Reseal the bottle - Illustration

11. Rinse the empty syringe by inserting the open end of the syringe into a glass of water, pulling the plunger out to draw in water, and pushing the plunger in to remove the water. Repeat several times. Allow the syringe to air dry.

 

Rinse the empty syringe - Illustration

12. Store the bottle upright.

 

Store the bottle upright - Illustration

This monograph has been modified to include the generic and brand name in many instances.

Consumer Overview Uses

IMPORTANT: HOW TO USE THIS INFORMATION: This is a summary and does NOT have all possible information about this product. This information does not assure that this product is safe, effective, or appropriate for you. This information is not individual medical advice and does not substitute for the advice of your health care professional. Always ask your health care professional for complete information about this product and your specific health needs.

 

MEMANTINE - ORAL

 

(MEM-an-teen)

 

COMMON BRAND NAME(S): Namenda

 

USES: Memantine is used to treat moderate to severe confusion (dementia) related to Alzheimer's disease. It does not cure Alzheimer's disease, but it may improve memory, awareness, and the ability to perform daily functions. This medication works by blocking the action of a certain natural substance in the brain (glutamate) that is believed to be linked to symptoms of Alzheimer's disease.

 

HOW TO USE: Read the Patient Information Leaflet if available from your pharmacist before you start taking memantine and each time you get a refill. If you have any questions, ask your doctor or pharmacist.

Take this medication by mouth with or without food as directed by your doctor. The dosage is based on your medical condition and response to treatment. When you first start taking this medication, you will usually take it once daily. To reduce your risk of side effects, your doctor may direct you to start this medication at a low dose and gradually increase your dose. Follow your doctor's instructions carefully. Once your dose increases to more than 5 milligrams per day, take this medication twice daily or as directed by your doctor.

If you are taking memantine oral liquid, read the manufacturer's instruction sheet that comes with the bottle. Follow the directions exactly. Use the oral syringe that comes with the product to measure out your dose. Do not use a household spoon because you may not get the correct dose. Swallow the medication directly from the syringe. Do not mix it with water or other liquids. Rinse the syringe with water after each use. Consult your doctor or pharmacist if you have any questions.

Use this medication regularly to get the most benefit from it. To help you remember, take it at the same time(s) each day.

Tell your doctor if your condition worsens.

Consumer Overview Side Effect

SIDE EFFECTS: Body aches, dizziness, constipation, and headache may occur. If any of these effects persist or worsen, tell your doctor or pharmacist promptly.

Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.

A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.

This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.

In the US -

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.

 

Read the Namenda (memantine hcl) Side Effects Center for a complete guide to possible side effects

Learn More »

PRECAUTIONS: Before taking memantine, tell your doctor or pharmacist if you are allergic to it; or if you have any other allergies. This product may contain inactive ingredients which can cause allergic reactions or other problems. Talk to your pharmacist for more details.

Before using this medication, tell your doctor or pharmacist your medical history, especially of: kidney problems, severe urinary tract infections, recent dietary change (from a high-protein diet to a vegetarian diet).

This drug may make you dizzy. Do not drive, use machinery, or do any activity that requires alertness until you are sure you can perform such activities safely. Limit alcoholic beverages.

Before having surgery, tell your doctor or dentist about all the products you use (including prescription drugs, nonprescription drugs, and herbal products).

During pregnancy, this medication should be used only when clearly needed. Discuss the risks and benefits with your doctor.

It is unknown if this drug passes into breast milk. Consult your doctor before breast-feeding.

Consumer Overview Missed Dose

DRUG INTERACTIONS: Drug interactions may change how your medications work or increase your risk for serious side effects. This document does not contain all possible drug interactions. Keep a list of all the products you use (including prescription/nonprescription drugs and herbal products) and share it with your doctor and pharmacist. Do not start, stop, or change the dosage of any medicines without your doctor's approval.

Some products that may interact with this drug include: carbonic anhydrase inhibitors (such as acetazolamide, methazolamide), sodium bicarbonate.

 

OVERDOSE: If overdose is suspected, contact a poison control center or emergency room immediately. US residents can call their local poison control center at 1-800-222-1222. Canada residents can call a provincial poison control center. Symptoms of overdose may include: restlessness, personality change, hallucinations, drowsiness, loss of consciousness.

 

NOTES: Do not share this medication with others.

 

MISSED DOSE: If you miss a dose, use it as soon as you remember. If it is near the time of the next dose, skip the missed dose and resume your usual dosing schedule. Do not double the dose to catch up.

 

STORAGE: Store at room temperature away from light and moisture. Do not store in the bathroom. Keep all medications away from children and pets.

Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company.

 

Information last revised March 2013. Copyright(c) 2013 First Databank, Inc.

Patient Detailed Side Effect

Brand Names: Namenda

Generic Name: memantine (Pronunciation: meh MAN teen)

  • What is memantine (Namenda)?
  • What are the possible side effects of memantine (Namenda)?
  • What is the most important information I should know about memantine (Namenda)?
  • What should I discuss with my healthcare provider before taking memantine (Namenda)?
  • How should I take memantine (Namenda)?
  • What happens if I miss a dose (Namenda)?
  • What happens if I overdose (Namenda)?
  • What should I avoid while taking memantine (Namenda)?
  • What other drugs will affect memantine (Namenda)?
  • Where can I get more information?

What is memantine (Namenda)?

Memantine reduces the actions of chemicals in the brain that may contribute to the symptoms of Alzheimer's disease.

Memantine is used to treat moderate to severe dementia of the Alzheimer's type.

Memantine may also be used for other purposes not listed in this medication guide.

What are the possible side effects of memantine (Namenda)?

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.

Stop using memantine and call your doctor at once if you have any of these serious side effects:

  • cough, chest tightness, fever, trouble breathing;
  • chest pain, fast heart rate;
  • confusion, hallucinations;
  • sudden numbness or weakness, especially on one side of the body;
  • lack of coordination;
  • fainting or seizure (convulsions);
  • urinating less than usual or not at all;
  • pale skin, easy bruising or bleeding, unusual weakness; or
  • increased blood pressure (severe headache, blurred vision, trouble concentrating, chest pain, numbness, seizure).

Less serious side effects may include:

  • nausea, vomiting, diarrhea, constipation, loss of appetite;
  • dizziness, tired feeling;
  • weight loss;
  • swelling in your hands or feet;
  • fast heart rate;
  • easy bruising or bleeding, unusual weakness;
  • joint pain;
  • anxiety, aggression;
  • skin rash;
  • redness or swelling of or around your eyes; or
  • urinating more than usual.

This is not a complete list of side effects and others may occur. Tell your doctor about any unusual or bothersome side effect. You may report side effects to FDA at 1-800-FDA-1088.

Read the Namenda (memantine hcl) Side Effects Center for a complete guide to possible side effects

Learn More »

What is the most important information I should know about memantine (Namenda)?

Before using memantine, tell your doctor if you are allergic to any drugs, or if you have a seizure disorder, cataracts, liver or kidney disease, or a bladder or kidney infection.

Memantine can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert.

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Patient Detailed How Take

What should I discuss with my healthcare provider before taking memantine (Namenda)?

Do not use this medication if you are allergic to memantine.

Before using memantine, tell your doctor if you are allergic to any drugs, or if you have:

  • epilepsy or other seizure disorder;
  • cataracts;
  • liver disease;
  • kidney disease; or
  • a bladder or kidney infection.

If you have any of these conditions, you may need a dose adjustment or special tests to safely take memantine.

FDA pregnancy category B. This medication is not expected to be harmful to an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant during treatment.

It is not known whether memantine passes into breast milk or if it could harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby.

How should I take memantine (Namenda)?

Take this medication exactly as it was prescribed for you. Do not take the medication in larger amounts, or take it for longer than recommended by your doctor. Follow the directions on your prescription label.

Your doctor may occasionally change your dose to make sure you get the best results from this medication.

Take this medicine with a full glass of water.

Memantine can be taken with or without food.

The liquid (oral solution) form of this medication comes with patient instructions for safe and effective use. Follow these directions carefully. Ask your doctor or pharmacist if you have any questions.

Do not mix the oral solution with any other liquids.

Rinse the empty oral syringe with clean water and allow it to air dry after every use.

It is important to use memantine regularly to get the most benefit. Get your prescription refilled before you run out of medicine completely.

To be sure this medication is helping your condition, and is not causing harmful effects, doctor will need to check your progress on a regular basis. Do not miss any scheduled appointments.

Store memantine at room temperature away from moisture and heat. Keep the liquid medicine bottle tightly closed with the cap provided. Do not store the bottle with the oral syringe in it.

Side Effects Centers
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Patient Detailed Avoid Taking

What happens if I miss a dose (Namenda)?

Take the missed dose as soon as you remember. If it is almost time for your next dose, skip the missed dose and take the medicine at your next regularly scheduled time. Do not take extra medicine to make up the missed dose.

What happens if I overdose (Namenda)?

Seek emergency medical attention if you think you have used too much of this medicine.

Overdose symptoms may include restlessness, drowsiness, unusual behavior, hallucinations, feeling light-headed, or fainting.

What should I avoid while taking memantine (Namenda)?

Memantine can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert.

What other drugs will affect memantine (Namenda)?

Before taking memantine, tell your doctor if you are using any of the following drugs:

  • cimetidine (Tagamet);
  • nicotine (Commit, Habitrol, Nicoderm, Nicotrol, Nicorette);
  • ranitidine (Zantac);
  • quinidine (Cardioquin, Quinadex, Quinaglute);
  • sodium bicarbonate (Alka-Seltzer, baking soda antacid home remedy);
  • antiviral medication such as amantadine (Symmetrel) or rimantadine (Flumadine);
  • cold or cough medicine that contains dextromethorphan;
  • a diuretic (water pill) such as hydrochlorothiazide (HCTZ, HydroDiuril, Hyzaar, Lopressor, Vasoretic, Zestoretic) or triamterene (Dyrenium, Maxzide, Dyazide);
  • medicine to treat glaucoma, such as acetazolamide (Diamox), dichlorphenamide (Daranide), or methazolamide (Neptazane, MZM, Glauctabs); or
  • an oral diabetes medicine that contains metformin (such as Fortamet, Glucophage, Actoplus Met, Avanda met, Metaglip, Glucovance).

This list is not complete and there may be other drugs that can interact with memantine. Tell your doctor about all the prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor.

Where can I get more information?

Your pharmacist can provide more information about memantine.


Remember, keep this and all other medicines out of the reach of children, never share your medicines with others, and use this medication only for the indication prescribed.

Every effort has been made to ensure that the information provided by Cerner Multum, Inc. ('Multum') is accurate, up-to-date, and complete, but no guarantee is made to that effect. Drug information contained herein may be time sensitive. Multum information has been compiled for use by healthcare practitioners and consumers in the United States and therefore Multum does not warrant that uses outside of the United States are appropriate, unless specifically indicated otherwise. Multum's drug information does not endorse drugs, diagnose patients or recommend therapy. Multum's drug information is an informational resource designed to assist licensed healthcare practitioners in caring for their patients and/or to serve consumers viewing this service as a supplement to, and not a substitute for, the expertise, skill, knowledge and judgment of healthcare practitioners. The absence of a warning for a given drug or drug combination in no way should be construed to indicate that the drug or drug combination is safe, effective or appropriate for any given patient. Multum does not assume any responsibility for any aspect of healthcare administered with the aid of information Multum provides. The information contained herein is not intended to cover all possible uses, directions, precautions, warnings, drug interactions, allergic reactions, or adverse effects. If you have questions about the drugs you are taking, check with your doctor, nurse or pharmacist.

Copyright 1996-2013 Cerner Multum, Inc. Version: 2.07. Revision date: 12/15/2010.

Your use of the content provided in this service indicates that you have read,understood and agree to the End-User License Agreement,which can be accessed by clicking on this link.

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