ASCORBIC ACID: 6,595 Adverse Event Reports & Safety Profile

DESCRIPTION: Each capsule contains: Ferrous Fumarate (anhydrous) .....................................130 mg (Equivalent to about 42.5 mg of Elemental Iron) PolysaccharideIronComplex .....................................92.4mg (Equivalent to about 42.5 mg of Elemental Iron) Vitamin C (from ProAscorb C‡)..................................... 210 mg Folic Acid ................................................................................... 1 mg Thiamine Mononitrate (B1)................................................. 5 mg Riboflavin (B2).......................................................................... 5 mg Niacin (B3)...............................................................................20 mg d-Calcium Pantothenate (B5)............................................. 7 mg Pyridoxine HCl (B6) ..............................................................25 mg Biotin (B7)........................................................................... 300 mcg Cyanocobalamin (B12) .....................................................10 mcg Copper (as Copper Sulfate)..........................................800 mcg Magnesium (as Magnesium Sulfate)............................6.9 mg Manganese (as Manganese Sulfate).............................1.3 mg Zinc (as Zinc Sulfate) ....................................................... 18.2 mg Inactive Ingredients: Hypromellose, Silicon Dioxide, Magnesium Stearate, Carmine, and Candurin Silver Fine. CLINICAL PHARMACOLOGY: Concept OBTM also supplies important prenatal vitamin minerals in a formulation that was especially designed to supplement the nutritional needs of pregnant women, before, during and after pregnancy.

In

Concept OBTM, patients receive the balanced support of 14 essential vitamins and minerals, including 1 mg of folic acid. The essential role of iron supplementation for pregnant women has long been recognized. Concept OBTM is unique in that it utilizes two (2) different forms of iron, i.e., Ferrous Fumarate and Polysaccharide Iron Complex (as cell-contracted akaganèite), making available a total of 85 mg of elemental iron per capsule as follows: Ferrous Fumarate (anhydrous) 130 mg Polysaccharide iron complex (PIC) 92.4 mg Ferrous Fumarate: Provides about 42.5 mg of elemental iron per dose.

Ferrous

Fumarate is an anhydrous salt of a combination of ferrous iron and fumaric acid, containing 33% of iron per weight. The acute toxicity in experimental animals is low and Ferrous Fumarate is well tolerated clinically. As a ferrous salt, it is more efficiently absorbed in the duodenum.

Ferrous

Fumarate contrasts very favorably with the availability of the 20% of elemental iron of ferrous sulfate, and the 13% of elemental iron of ferrous gluconate.

Polysaccharide Iron

Complex: Provides about 42.5 mg elemental iron, as a cell-contracted akaganèite. It is a product of ferric iron complexed to a low molecular weight polysaccharide. This polysaccharide is produced by the extensive hydrolysis of starch and is a dark brown powder that dissolves in water to form a very dark brown solution, which is virtually odorless and tasteless. The most frequent cause of anemia in pregnant women is iron deficiency. Because of the continuous loss of iron due to monthly menstruation, most women enter pregnancy with less than optimal iron stores. Supplementation of iron must suffice to meet the needs for maternal and fetal erythropoisis, and account for daily maternal gastrointestinal losses and obligate fetal transfer and growth. Iron requirements during pregnancy usually cannot be met with the average diet. (ACOG technical bulletin (1993): Nutrition during Pregnancy. p.4.

Number

179-April 1993: The American College of Obstetricians and Gynecologists, Washington, D.C. 20024-2188). Concept OBTM does not contain calcium, as calcium may inhibit iron absorption because of the binding or conversion of ferrous salts by calcium and other minerals. Calcium salts can always be prescribed separately for women at high nutritional risk, including those who do not eat adequate amounts of dairy products. The recommendation of the National Academy of Sciences Tenth Ed. 1989 National Academy Press, Washington, D.C., suggests the supplementation of 1200 mg of calcium for pregnant and lactating women for the prevention of calcium deficiency. Folic acid is a hematopoetic vitamin and has been used extensively for the prevention of neural tube defects. The need for folic acid in pregnancy, with its increased demands of the fetus, or lactation, is not being met by normal dietary sources. Concept OBTM capsules contain 1 mg of folic acid. Neural tube defects (NTD's) are the most common birth defects that result in infant mortality and serious disability. For women with a previous pregnancy that resulted in a child with a neural tube malformation, the use of 4 mg/d of folic acid has been reported to be effective in preventing a recurrence (MRC Vitamin Study Research Group, 1991). However, earlier studies from the United Kingdom suggested that lower daily doses, for example 0.36 mg, might result in a comparable reduction of a recurrence of NTD's. Since neural tube closure is complete by four weeks following conception, beginning folic acid supplementation after that time is not likely to be of any value. It should be noted that a daily 4 mg dose of folic acid did not prevent all NTD's in the MRC study. Patients should be cautioned that folic acid supplementation does not preclude the need for consideration for prenatal testing for NTD's (ACOG Committee Opinion, Number 120, March 1993: The American College of Obstetricians and Gynecologists, Washington D.C. 20024-2188). The U.S.

Public Health

Service has recommended that all women of childbearing age in the United States who are capable of becoming pregnant should consume 0.4 mg of folic acid per day for reducing their risk of having a pregnancy affected with spina bifida or other NTD's (Center of Disease Control, 1992). Recommendation for the use of folic acid to reduce the number of cases of spina bifida and other neural tube defects: MMWR 1992: 41(RR14): 1-7). Concept OBTM has been formulated without the addition of vitamins A, D, E and K. These fat-soluble vitamins can accumulate and lead to birth defects. Supplementation of vitamins A, D, E and K should be based on an individual need assessment.

All

ConceptTM products include a unique patented source of iron, e.g.

Ferrous

Fumarate and Polysaccharide Iron Complex (U.S. Patent No: 11/243,043 Pending). An increase in tolerability is observed with the (patented formulation) and is believed to occur as the result of distributing the total iron content in the composition among compounds that NDC 52747-620-30 Concept OBTM Prescription Prenatal Postnatal Vitamin Mineral Capsules 52747620300709 Back side Concept OB LC-10807 Rev 07/2009 provide iron to the patient's blood stream via two different mechanisms. The ferrous salts are readily absorbed in the upper gut, by direct dissolution and absorption of the ferrous iron by the bloodstream. However, the iron available from PIC is absorbed in the lower gut, via an active protein transport mechanism".

The

Concept OBTM formulation also supplies additional important prenatal vitamin and minerals, which supplement the nutritional needs of pregnant women, before, during and after pregnancy. Deficiencies of these ingredients are common during pregnancy and lactation.

Clinical

Studies: Because Ferrous Fumarate is an organic complex, it contains no free ions, either ferric or ferrous.

Polysaccharide Iron

Complex is clinically non-toxic. Prior studies in rats demonstrated that Polysaccharide Iron Complex (PIC), administered as a single oral dose to Sprague Dawley rats did not produce evidence of toxicity at a dosage level of 5000 mg Iron/kg: (An Acute Oral Toxicity Study in Rats with Polysaccharide-Iron Complex. T.N.Merriman, M. Aikman and R.E. Rush, Springborn Laboratories. Inc. Spencerville, Ohio Study No.

3340.1 March - April 1994). Other clinical studies had demonstrated that Polysaccharide Iron gives a good hematopoietic response with an almost complete absence of the side effects usually associated with oral iron therapy. Picinni and Ricciotti suggested in 1982, that "the therapeutic effectiveness of Polysaccharide Iron Complex when compared with iron fumarate in the treatment of iron deficiency anemia, appears to be as active as the iron fumarate and as well tolerated, however, it exerted a greater influence on the level of hemoglobin and on the number of red cells..." and that, "it has been exceptionally well tolerated by all patients" (Picinni, L.-Ricciotti, M. 1982. Therapeutic effectiveness of an iron-polysaccharide complex in comparison with iron fumarate in the treatment of iron deficiency anemias): PANMINERVA MEDICA-EUROPA MEDICA, Vol. 24, No. 3, pp. 213-220 (July - September 1982). As mentioned above, the patented source of iron used in Concept OBTM (Ferrous Fumarate and Polysaccharide Iron Complex) provides a high level of elemental iron with a low incidence of gastric distress. CONCLUSION: Based on the results of this study, the oral combination of Ferrous Fumarate and Polysaccharide Iron Complex was better tolerated and safer than the oral administration of Ferrous Fumarate alone. The conclusion of this research stated, that the addition of PIC to Ferrous Fumarate surprisingly allows the same concentration of Ferrous Fumarate to be better tolerated than the Ferrous Fumarate alone. INDICATIONS: Concept OBTM is a prenatal supplement designed to improve the nutritional status for women throughout pregnancy and during the postnatal period to lactating and non-lactating mothers. Concept OBTM may also be used to improve the nutritional status of women before conception. CONTRAINDICATIONS: Concept OBTM is contraindicated in patients with known hypersensitivity to any of its ingredients; also, all iron compounds are contraindicated in patients with hemosiderosis, hemochromatosis, or hemolytic anemias. Pernicious anemia is a contraindication, as folic acid may obscure its signs and symptoms. WARNING: Accidental overdose of iron-containing products is a leading cause of fatal poisoning in children under 6. Keep this product out of reach of children. In case of accidental overdose, call a doctor or poison control center immediately. WARNING: Folic acid alone is improper therapy in the treatment for pernicious anemia and other megaloblastic anemias where Vitamin B12 is deficient. PRECAUTIONS: General: Folic acid in doses above 0.1 mg - 0.4 mg daily may obscure pernicious anemia, in that hematological remission can occur while neurological manifestations remain progressive.

Pediatric

Use: Safety and effectiveness of this product have not been established in pediatric patients.

Geriatric

Use: No clinical studies have been performed in patients age 65 and over to determine whether older persons respond differently from younger persons. Dosage should always begin at the low end of the dosage scale and should consider that elderly persons may have decreased hepatic, renal, or cardiac function and or concomitant diseases.

Adverse

Reactions: Folic Acid: Allergic sensitizations have been reported following both oral and parenteral administration of folic acid.

Ferrous

Fumarate: Gastrointestinal disturbances (anorexia, nausea, diarrhea, constipation) occur occasionally, but are usually mild and may subside with continuation of therapy. Although the absorption of iron is best when taken between meals, giving Concept OBTM after meals may control occasional G.I. disturbances. Concept OBTM is best absorbed when taken at bedtime. OVERDOSE: Iron: Signs and Symptoms: Iron is toxic. Acute overdosage of iron may cause nausea and vomiting and, in severe cases, cardiovascular collapse and death. Other symptoms include pallor and cyanosis, melena, shock, drowsiness and coma. The estimated overdose of orally ingested iron is 300-mg/kg body weight. When overdoses are ingested by children, severe reactions, including fatalities, have resulted. Concept OBTM should be stored beyond the reach of children to prevent against accidental iron poisoning. Keep this and all other drugs out of the reach of children. Treatment: For specific therapy, exchange transfusion and chelating agents should be used. For general management, perform gastric lavage with sodium bicarbonate solution or milk. Administer intravenous fluids and electrolytes and use oxygen. DOSAGE AND ADMINISTRATION: Adults (persons over 12 years of age), One (1) capsule daily, between meals, or as prescribed by a physician. Do not exceed recommended dosage. Do not administer to children under the age of 12. HOW SUPPLIED: Concept OB TM are pearl red-orange opaque Vcaps ® capsules printed in white with "Concept OB" on the cap and "US" logo on the body. Packed in child-resistant cap and light resistant bottle of 30 capsules (52747-0620-30). The listed product number is not a National Drug Code. Instead, US Pharmaceutical Corporation has assigned this product code formatted according to standard industry practice to meet the formatting requirements of pharmacy and healthcare insurance computer systems. Store at room temperature 15º to 30ºC (59º to 86ºF) and dry place. These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease. Vcaps ® and the Vcaps ® Logo are trademarks used under license.

INDICATIONS AND USAGE Supplementation of the diet with vitamins A, C and D. Tri-Vite Drops with Fluoride 0.25 mg also provides fluoride for caries prophylaxis.

The American

Academy of Pediatrics recommends that children up to age 16, in areas where drinking water contains less than optimal levels of fluoride, receive daily fluoride supplementation.

The American

Academy of Pediatrics recommend that infants and young children 6 months to 3 years of age, in areas where the drinking water contains less than 0.3 ppm of fluoride, and children 3-6 years of age, in areas where the drinking water contains 0.3 through 0.6 ppm of fluoride, receive 0.25 mg of supplemental fluoride daily which is provided in a dose of 1 mL of Tri-Vite Drops with Fluoride 0.25 mg (See Dosage and Administration ). Tri-Vite Drops with Fluoride 0.25 mg supply significant amounts of vitamins A, C and D to supplement the diet, and to help assure that nutritional deficiencies of these vitamins will not develop. Thus, in a single easy-to-use preparation, children obtain essential vitamins and fluoride.

2.

Dosage And Administration

Supplied in Pharmacy Bulk Package (PBP). Dispense single doses to multiple patients in a pharmacy admixture program; use within 4 hours of puncture. (2.1) Must be diluted prior to use (2.1) Administer as a slow intravenous infusion (2.1)

See Full Prescribing

Information for important administration instructions (2.1) Maximum recommended duration is one week (2.2) Population ​ (2.2)

Recommended Doses

Pediatric patients age 5 months to less than 12 months 50 mg once daily Pediatric patients age 1 year to less than 11 years 100 mg once daily Adults and pediatric patients age 11 years and older 200 mg once daily Specific Populations ​(2.3, 8.1, 8.2) Pregnant women, lactating women, patients with glucose-6-phosphate dehydrogenase deficiency Should not exceed the U.S.

Recommended Dietary

Allowance (RDA) Supplied in Pharmacy Bulk Package (PBP). Dispense single doses to multiple patients in a pharmacy admixture program; use within 4 hours of puncture. (2.1) Must be diluted prior to use (2.1) Administer as a slow intravenous infusion (2.1)

See Full Prescribing

Information for important administration instructions (2.1) Maximum recommended duration is one week (2.2) Population ​ (2.2) ​Recommended Doses Pediatric patients age 5 months to less than 12 months 50 mg once daily Pediatric patients age 1 year to less than 11 years 100 mg once daily Adults and pediatric patients age 11 years and older 200 mg once daily ​Specific Populations ​(2.3 , 8.1 , 8.2) Pregnant women, lactating women, patients with glucose-6-phosphate dehydrogenase deficiency Should not exceed the U.S.

Recommended Dietary

Allowance (RDA)

2.1 Important Preparation and Administration Instructions ASCOR vials contain 25, 000 mg of ascorbic acid and the largest recommended single dose is 200 mg. Do not give the entire contents of the vial to a single patient. Do not administer ASCOR as an undiluted intravenous sensitive. Minimize exposure to light because ASCOR is light sensitive. ASCOR is supplied as a Pharmacy Bulk Package (PBP) which is intended for dispensing of single doses to multiple patients in a pharmacy admixture program and is restricted to the preparation of admixtures for infusion: a. Use only in a suitable ISO Class 5 work area such as a laminar flow hood (or an equivalent clean air compounding area) b. Penetrate each PBP vial closure only one time with a suitable sterile transfer device or dispensing set that allows measured dispensing of the contents. Given that pressure may develop within the vial during storage, excercise caution when withdrawing contents from the vial. c. Once the closure system has been penetrated, complete all dispensing from the PBP vial within 4 hours. Each dose must be used immediately . Discard unused portion. d. Prior to administration, ASCOR must be diluted in a suitable infusion solution and the final solution for infusion must be isotonic (undiluted the osmolarity of ASCOR is approximately 5,900 mOsmol/L). Prior to preparing the admixture for infusion, calculate the osmolarity of the intended admixture for infusion. Add one daily dose of ASCOR directly to an appropriate volume of a suitable infusion solution (e.g., 5% Dextrose Injection, Sterile Water for Injection) and add appropriate solutes, as necessary, to make final solution isotonic.

Sterile

Water for Injection is highly hypotonic; adjust solute content, as necessary, to make thet final infusion solution isotonic prior to injection. Do not mix ASCOR with solutions containing elemental compounds that can be reduced (e.g., copper). The concentration of ascorbic acid in the final, admixture solution for infusion is to be the range of 1 to 25 mg of ascorbic acid per mL. For example, for the largest recommended dose: Add 200 mg of ascorbic acid (equivalent to 0.4 mL of ASCOR) to 7.5 mL of Sterile Water for Injection to produce an infusion solution having an approximate osmolarity of 290 mOsmol/L. In this specific example, addition of solute is NOT necessary because the solution is isotonic. e. Prepare the recommended dose based on the patient population [ see Dosage and Administration (2.2) , (2.3) ]. f. Visually inspect for particulate matter and discoloration prior to administration (the diluted ASCOR solution should appear colorless to pale yellow). g. Immediately administer the admixture for infusion as a slow intravenous infusion [ see Recommended Dosage, (2.2) ] ASCOR vials contain 25, 000 mg of ascorbic acid and the largest recommended single dose is 200 mg. Do not give the entire contents of the vial to a single patient. Do not administer ASCOR as an undiluted intravenous sensitive. Minimize exposure to light because ASCOR is light sensitive. ASCOR is supplied as a Pharmacy Bulk Package (PBP) which is intended for dispensing of single doses to multiple patients in a pharmacy admixture program and is restricted to the preparation of admixtures for infusion: a. Use only in a suitable ISO Class 5 work area such as a laminar flow hood (or an equivalent clean air compounding area) b. Penetrate each PBP vial closure only one time with a suitable sterile transfer device or dispensing set that allows measured dispensing of the contents. Given that pressure may develop within the vial during storage, excercise caution when withdrawing contents from the vial. c. Once the closure system has been penetrated, complete all dispensing from the PBP vial within 4 hours. Each dose must be used immediately. Discard unused portion. d. Prior to administration, ASCOR must be diluted in a suitable infusion solution and the final solution for infusion must be isotonic (undiluted the osmolarity of ASCOR is approximately 5,900 mOsmol/L). Prior to preparing the admixture for infusion, calculate the osmolarity of the intended admixture for infusion. Add one daily dose of ASCOR directly to an appropriate volume of a suitable infusion solution (e.g., 5% Dextrose Injection, Sterile Water for Injection) and add appropriate solutes, as necessary, to make final solution isotonic.

Sterile

Water for Injection is highly hypotonic; adjust solute content, as necessary, to make thet final infusion solution isotonic prior to injection. Do not mix ASCOR with solutions containing elemental compounds that can be reduced (e.g., copper). The concentration of ascorbic acid in the final, admixture solution for infusion is to be the range of 1 to 25 mg of ascorbic acid per mL. For example, for the largest recommended dose: Add 200 mg of ascorbic acid (equivalent to 0.4 mL of ASCOR) to 7.5 mL of Sterile Water for Injection to produce an infusion solution having an approximate osmolarity of 290 mOsmol/L. In this specific example, addition of solute is NOT necessary because the solution is isotonic. e. Prepare the recommended dose based on the patient population [ see Dosage and Administration (2.2), (2.3)]. f. Visually inspect for particulate matter and discoloration prior to administration (the diluted ASCOR solution should appear colorless to pale yellow). g. Immediately administer the admixture for infusion as a slow intravenous infusion [ see Recommended Dosage, (2.2)]

2.2 Recommended Dosage Table 1 provides recommended doses of ASCOR based on patient population and infusion rates of diluted ASCOR solution.

Table

1: Recommended Dose of ASCOR and Infusion Rate of Diluted ASCOR Solution Patient Population ASCOR Once Daily Dose (mg)

Infusion

Rate of Diluted ASCOR Solution (mg/minute)

Pediatric

Patients age 5 months to less than 12 months 50

1.3 Pediatric Patients age 1 year to less than 11 years 100

3.3 Adults and Pediatric Patients 11 years and older 200 33 The recommended maximum duration of daily treatment with ASCOR is seven days. If no improvement in scorbutic symptoms is observed after one week of treatment, retreat until resolution of scorbutic symptoms is observed. Repeat dosing is not recommended in pediatric patients less than 11 years of age.

2.3 Dosage Reductions in Specific Populations Women who are pregnant or lactating and patients with glucose-6-dehydrogenase deficiency should not exceed the U.S.

Recommended Dietary

Allowance (RDA) or daily Adequate Intake (AI) level for ascorbic acid for their age group and condition [ ​ see Warnings and Precautions (5.2) and Use in Specific Populations (8.1 , 8.2) ].

2.1 Important Preparation and Administration Instructions ASCOR vials contain 25, 000 mg of ascorbic acid and the largest recommended single dose is 200 mg. Do not give the entire contents of the vial to a single patient. Do not administer ASCOR as an undiluted intravenous sensitive. Minimize exposure to light because ASCOR is light sensitive. ASCOR is supplied as a Pharmacy Bulk Package (PBP) which is intended for dispensing of single doses to multiple patients in a pharmacy admixture program and is restricted to the preparation of admixtures for infusion: a. Use only in a suitable ISO Class 5 work area such as a laminar flow hood (or an equivalent clean air compounding area) b. Penetrate each PBP vial closure only one time with a suitable sterile transfer device or dispensing set that allows measured dispensing of the contents. Given that pressure may develop within the vial during storage, excercise caution when withdrawing contents from the vial. c. Once the closure system has been penetrated, complete all dispensing from the PBP vial within 4 hours. Each dose must be used immediately . Discard unused portion. d. Prior to administration, ASCOR must be diluted in a suitable infusion solution and the final solution for infusion must be isotonic (undiluted the osmolarity of ASCOR is approximately 5,900 mOsmol/L). Prior to preparing the admixture for infusion, calculate the osmolarity of the intended admixture for infusion. Add one daily dose of ASCOR directly to an appropriate volume of a suitable infusion solution (e.g., 5% Dextrose Injection, Sterile Water for Injection) and add appropriate solutes, as necessary, to make final solution isotonic.

Sterile

Water for Injection is highly hypotonic; adjust solute content, as necessary, to make thet final infusion solution isotonic prior to injection. Do not mix ASCOR with solutions containing elemental compounds that can be reduced (e.g., copper). The concentration of ascorbic acid in the final, admixture solution for infusion is to be the range of 1 to 25 mg of ascorbic acid per mL. For example, for the largest recommended dose: Add 200 mg of ascorbic acid (equivalent to 0.4 mL of ASCOR) to 7.5 mL of Sterile Water for Injection to produce an infusion solution having an approximate osmolarity of 290 mOsmol/L. In this specific example, addition of solute is NOT necessary because the solution is isotonic. e. Prepare the recommended dose based on the patient population [ see Dosage and Administration (2.2) , (2.3) ]. f. Visually inspect for particulate matter and discoloration prior to administration (the diluted ASCOR solution should appear colorless to pale yellow). g. Immediately administer the admixture for infusion as a slow intravenous infusion [ see Recommended Dosage, (2.2) ] ASCOR vials contain 25, 000 mg of ascorbic acid and the largest recommended single dose is 200 mg. Do not give the entire contents of the vial to a single patient. Do not administer ASCOR as an undiluted intravenous sensitive. Minimize exposure to light because ASCOR is light sensitive. ASCOR is supplied as a Pharmacy Bulk Package (PBP) which is intended for dispensing of single doses to multiple patients in a pharmacy admixture program and is restricted to the preparation of admixtures for infusion: a. Use only in a suitable ISO Class 5 work area such as a laminar flow hood (or an equivalent clean air compounding area) b. Penetrate each PBP vial closure only one time with a suitable sterile transfer device or dispensing set that allows measured dispensing of the contents. Given that pressure may develop within the vial during storage, excercise caution when withdrawing contents from the vial. c. Once the closure system has been penetrated, complete all dispensing from the PBP vial within 4 hours. Each dose must be used immediately. Discard unused portion. d. Prior to administration, ASCOR must be diluted in a suitable infusion solution and the final solution for infusion must be isotonic (undiluted the osmolarity of ASCOR is approximately 5,900 mOsmol/L). Prior to preparing the admixture for infusion, calculate the osmolarity of the intended admixture for infusion. Add one daily dose of ASCOR directly to an appropriate volume of a suitable infusion solution (e.g., 5% Dextrose Injection, Sterile Water for Injection) and add appropriate solutes, as necessary, to make final solution isotonic.

Sterile

Water for Injection is highly hypotonic; adjust solute content, as necessary, to make thet final infusion solution isotonic prior to injection. Do not mix ASCOR with solutions containing elemental compounds that can be reduced (e.g., copper). The concentration of ascorbic acid in the final, admixture solution for infusion is to be the range of 1 to 25 mg of ascorbic acid per mL. For example, for the largest recommended dose: Add 200 mg of ascorbic acid (equivalent to 0.4 mL of ASCOR) to 7.5 mL of Sterile Water for Injection to produce an infusion solution having an approximate osmolarity of 290 mOsmol/L. In this specific example, addition of solute is NOT necessary because the solution is isotonic. e. Prepare the recommended dose based on the patient population [ see Dosage and Administration (2.2), (2.3)]. f. Visually inspect for particulate matter and discoloration prior to administration (the diluted ASCOR solution should appear colorless to pale yellow). g. Immediately administer the admixture for infusion as a slow intravenous infusion [ see Recommended Dosage, (2.2)]

CONTRAINDICATIONS: Integra PlusTM is contraindicated in patients with a known hypersensitivity to any of its ingredients; also, all iron compounds are contraindicated in patients with hemosiderosis, hemochromatosis, or hemolytic anemias. Pernicious anemia is a contraindication, as folic acid may obscure its signs and symptoms.

REACTIONS The following adverse reactions are discussed in greater detail in other sections of the labeling:

• Oxalate nephropathy and Nephrolithiasis [see Warnings and Precautions (5.1) ].
• Hemolysis in patients with glucose-6-phosphate dehydrogenase deficiency [see Warnings and Precautions (5.2) ]. The following adverse reactions associated with the use of ascorbic acid were identified in the literature. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to estimate their frequency reliably or to establish a causal relationship to drug exposure: Administration site reactions: pain and swelling. Ascorbic acid injection should not be rapidly administered. Rapid intravenous administration (>250 mg/minute) of ascorbic acid injection may cause temporary faintness or nausea, lethargy, flushing, dizziness, and headache (the recommended infusion rates of diluted ascorbic acid injection solution are 1.3 mg/minute (Pediatric Patients age 5 months to less than 12 months), 3.3 mg/minute (Pediatric Patients age 1 year to less than 11 years) and 33 mg/minute (Adults and Pediatric Patients 11 years and older) [see Dosage and Administration (2.2) ]). Acute and chronic oxalate nephropathy have occurred with prolonged administration of high doses of ascorbic acid [see Warnings and Precautions (5.1) ]. In patients with glucose-6-phosphate dehydrogenase deficiency, severe hemolysis has occurred [see Warnings and Precautions (5.2) ]. Most common adverse reactions are pain and swelling at the site of infusion ( 6 ) To report SUSPECTED ADVERSE REACTIONS, contact [Fresenius Kabi USA, LLC at 1-800-551-7176] or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

AND PRECAUTIONS

• Oxalate nephropathy and Nephrolithiasis : Ascorbic acid has been associated with development of acute or chronic oxalate nephropathy following prolonged use of high doses of ascorbic acid infusion. Patients with renal disease including renal impairment, history of oxalate kidney stones, geriatric patients, and pediatric patients less than 2 years old may be at increased risk ( 5.1 ).
• Hemolysis : Patients with glucose-6-phosphate dehydrogenase deficiency are at risk of severe hemolysis; a reduced dose is recommended ( 5.2 ).
• Laboratory Test Interference: Ascorbic acid may interfere with laboratory tests based on oxidation-reduction reactions, including blood and urine glucose testing ( 5.3 ).

5.1 Oxalate Nephropathy and Nephrolithiasis Acute and chronic oxalate nephropathy have been reported with prolonged administration of high doses of ascorbic acid. Acidification of the urine by ascorbic acid may cause precipitation of cysteine, urate or oxalate stones. Patients with renal disease including renal impairment, history of oxalate kidney stones, and geriatric patients may be at increased risk for oxalate nephropathy while receiving treatment with ascorbic acid. Pediatric patients less than 2 years of age may be at increased risk for oxalate nephropathy during treatment with ascorbic acid because their kidneys are immature <span class="opacity-50 text-xs">[see Use in Specific Populations (8.4, 8.5, 8.6) ]</span> . Monitor renal function in patients at increased risk receiving ascorbic Acid Injection. Discontinue ascorbic acid injection in patients who develop oxalate nephropathy and treat any suspected oxalate nephropathy. Ascorbic acid injection is not indicated for prolonged administration (the maximum recommended duration is one week) <span class="opacity-50 text-xs">[see Dosage and Administration (2.1) ]</span>.

5.2 Hemolysis in Patients with Glucose-6-Phosphate Dehydrogenase Deficiency Hemolysis has been reported with administration of ascorbic acid in patients with glucose-6-phosphate dehydrogenase deficiency. Patients with glucose-6-phosphate dehydrogenase deficiency may be at increased risk for severe hemolysis during treatment with ascorbic acid. Monitor hemoglobin and blood count and use a reduced dose of Ascorbic acid injection in patients with glucose-6-phosphate dehydrogenase deficiency <span class="opacity-50 text-xs">[see Dosage and Administration (2.3) ]</span> . Discontinue treatment with ascorbic acid injection if hemolysis is suspected and treat as needed.

5.3 Laboratory Test Interference Ascorbic acid may interfere with laboratory tests based on oxidation-reduction reactions, including blood and urine glucose testing, nitrite and bilirubin levels, and leucocyte count testing. If possible, laboratory tests based on oxidation-reduction reactions should be delayed until 24 hours after infusion of ascorbic acid injection <span class="opacity-50 text-xs">[see Drug Interactions (7.4) ]</span>.

5.1 Oxalate Nephropathy and Nephrolithiasis Acute and chronic oxalate nephropathy have been reported with prolonged administration of high doses of ascorbic acid. Acidification of the urine by ascorbic acid may cause precipitation of cysteine, urate or oxalate stones. Patients with renal disease including renal impairment, history of oxalate kidney stones, and geriatric patients may be at increased risk for oxalate nephropathy while receiving treatment with ascorbic acid. Pediatric patients less than 2 years of age may be at increased risk for oxalate nephropathy during treatment with ascorbic acid because their kidneys are immature <span class="opacity-50 text-xs">[see Use in Specific Populations (8.4, 8.5, 8.6) ]</span> . Monitor renal function in patients at increased risk receiving ascorbic Acid Injection. Discontinue ascorbic acid injection in patients who develop oxalate nephropathy and treat any suspected oxalate nephropathy. Ascorbic acid injection is not indicated for prolonged administration (the maximum recommended duration is one week) <span class="opacity-50 text-xs">[see Dosage and Administration (2.1) ]</span>.

5.2 Hemolysis in Patients with Glucose-6-Phosphate Dehydrogenase Deficiency Hemolysis has been reported with administration of ascorbic acid in patients with glucose-6-phosphate dehydrogenase deficiency. Patients with glucose-6-phosphate dehydrogenase deficiency may be at increased risk for severe hemolysis during treatment with ascorbic acid. Monitor hemoglobin and blood count and use a reduced dose of Ascorbic acid injection in patients with glucose-6-phosphate dehydrogenase deficiency <span class="opacity-50 text-xs">[see Dosage and Administration (2.3) ]</span> . Discontinue treatment with ascorbic acid injection if hemolysis is suspected and treat as needed.

5.3 Laboratory Test Interference Ascorbic acid may interfere with laboratory tests based on oxidation-reduction reactions, including blood and urine glucose testing, nitrite and bilirubin levels, and leucocyte count testing. If possible, laboratory tests based on oxidation-reduction reactions should be delayed until 24 hours after infusion of ascorbic acid injection <span class="opacity-50 text-xs">[see Drug Interactions (7.4) ]</span>.

PRECAUTIONS General Anemia is a manifestation that requires appropriate investigation to determine its cause or causes. Folic acid alone is unwarranted in the treatment of pure vitamin B12 deficiency states, such as pernicious anemia. Folic acid may obscure pernicious anemia in that the blood picture may revert to normal while neurological manifestations remain progressive. As with all preparations containing intrinsic factor, resistance may develop in some cases of pernicious anemia to the potentiation of absorption of physiologic doses of vitamin B12. If resistance occurs, parenteral therapy or oral therapy with so-called massive doses of vitamin B12 may be necessary for adequate treatment of the patient. No single regimen fits all cases, and the status of the patient observed in follow-up is the final criterion for adequacy of therapy. Periodic clinical and laboratory studies are considered essential and are recommended.

Pregnancy Teratogenic Effects Pregnancy

Category C: Animal reproduction studies have not been conducted with TRICON™ Capsules. It is also not known whether TRICON™ Capsules can cause fetal harm when administered to pregnant women or can affect reproduction capacity. TRICON™ Capsules should be given to pregnant women only if clearly needed.

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 TRICON™ is administered to a nursing woman.

Pediatric Use

Safety and effectiveness in pediatric patients below the age of 10 have not been established.

Geriatric Use Geriatric

Use: Clinical studies on this product have not been performed in sufficient numbers of subjects aged 65 and over to determine whether elderly subjects respond differently from younger subjects. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal or cardiac function and of concomitant disease or other drug therapy.

7. DRUG INTERACTIONS ​Antibiotics:​ Ascorbic acid may decrease the activities of erythromycin, kanamycin, streptomycin, doxycycline, and lincomycin. Bleomycin is inactivated ​in vitro ​by ascorbic acid (7.1). ​Amphetamine and Other Drugs Affected by Urine Acidification:​ Ascorbic acid may cause acidification of the urine and result in decreased amphetamine serum levels affect excretion and plasma concentrations of other drugs sensitive to urine pH (7.2). ​Warfarin:​ Continue standard monitoring (7.3) ​ See 17 for PATIENT COUNSELING INFORMATION ​Antibiotics: ​ Ascorbic acid may decrease the activities of erythromycin, kanamycin, streptomycin, doxycycline, and lincomycin. Bleomycin is inactivated ​in vitro ​by ascorbic acid (7.1) . ​Amphetamine and Other Drugs Affected by Urine Acidification: ​ Ascorbic acid may cause acidification of the urine and result in decreased amphetamine serum levels affect excretion and plasma concentrations of other drugs sensitive to urine pH (7.2) . ​Warfarin: ​ Continue standard monitoring (7.3) ​ See 17 for PATIENT COUNSELING INFORMATION

7.1 Antibiotics

7.1 Antibiotics Ascorbic acid may decrease activities of erythromycin, kanamycin, streptomycin, doxycycline, and lincomycin. Bleomycin is inactivated in vitro by ascorbic acid. If the antibiotic efficacy is suspected to be decreased by concomitant administration of ASCOR, discontinue ASCOR administration.

7.1 Antibiotics Ascorbic acid may decrease activities of erythromycin, kanamycin, streptomycin, doxycycline, and lincomycin. Bleomycin is inactivated in vitro by ascorbic acid. If the antibiotic efficacy is suspected to be decreased by concomitant administration of ASCOR, discontinue ASCOR administration.

7.2 Amphetamine &amp; Other Drugs Affected by Urine Acidification

7.2 Amphetamine &amp; Other Drugs Affected by Urine Acidification Ascorbic acid may acidify the urine and lower serum concentrations of amphetamine by increasing renal excretion (as reflected by changes in amphetamine urine recovery rates). In case of decreased amphetamine efficacy discontinue ASCOR administration. Standard monitoring of therapy is warranted. In addition, acidification of urine by ascorbic acid will alter the excretion of certain drugs affected by the pH of the urine (e.g., fluphenazine) when administered concurrently. It has been reported that concurrent administration of ascorbic acid and fluphenazine has resulted in decreased fluphenazine plasma concentrations. Standard monitoring of therapy is warranted.

7.2 Amphetamine &amp; Other Drugs Affected by Urine Acidification Ascorbic acid may acidify the urine and lower serum concentrations of amphetamine by increasing renal excretion (as reflected by changes in amphetamine urine recovery rates). In case of decreased amphetamine efficacy discontinue ASCOR administration. Standard monitoring of therapy is warranted. In addition, acidification of urine by ascorbic acid will alter the excretion of certain drugs affected by the pH of the urine (e.g., fluphenazine) when administered concurrently. It has been reported that concurrent administration of ascorbic acid and fluphenazine has resulted in decreased fluphenazine plasma concentrations. Standard monitoring of therapy is warranted.

7.3 Warfarin

7.3 Warfarin Limited case reports have suggested interference of ascorbic acid with the anticoagulation effects of warfarin, however, patients on warfarin therapy treated with ascorbic acid doses up to 1000 mg/day (5 times the largest recommended single dose) for 2 weeks (twice the maximum recommended duration), no effect was observed. Standard monitoring for anti-coagulation therapy should continue during ascorbic acid treatment, as per standard of care.

7.3 Warfarin Limited case reports have suggested interference of ascorbic acid with the anticoagulation effects of warfarin, however, patients on warfarin therapy treated with ascorbic acid doses up to 1000 mg/day (5 times the largest recommended single dose) for 2 weeks (twice the maximum recommended duration), no effect was observed. Standard monitoring for anti-coagulation therapy should continue during ascorbic acid treatment, as per standard of care.

7.4 Laboratory Test Interference

7.4 Laboratory Test Interference Because ascorbic acid is a strong reducing agent, it can interfere with numerous laboratory tests based on oxidation-reduction reactions (e.g., glucose, nitrite and bilirubin levels, leukocyte count, etc.). Chemical detecting methods based on colorimetric reactions are generally those tests affected. Ascorbic acid may lead to inaccurate results (false negatives) obtained for checking blood or urinary glucose levels, nitrite, bilirubin, and leukocytes if tested during or within 24 hours after infusion <span class="opacity-50 text-xs">[see Warnings and Precautions (5.3) ]</span> .

7.4 Laboratory Test Interference Because ascorbic acid is a strong reducing agent, it can interfere with numerous laboratory tests based on oxidation-reduction reactions (e.g., glucose, nitrite and bilirubin levels, leukocyte count, etc.). Chemical detecting methods based on colorimetric reactions are generally those tests affected. Ascorbic acid may lead to inaccurate results (false negatives) obtained for checking blood or urinary glucose levels, nitrite, bilirubin, and leukocytes if tested during or within 24 hours after infusion <span class="opacity-50 text-xs">[see Warnings and Precautions (5.3)]</span> .

7.1 Antibiotics

7.1 Antibiotics Ascorbic acid may decrease activities of erythromycin, kanamycin, streptomycin, doxycycline, and lincomycin. Bleomycin is inactivated in vitro by ascorbic acid. If the antibiotic efficacy is suspected to be decreased by concomitant administration of ASCOR, discontinue ASCOR administration.

7.1 Antibiotics Ascorbic acid may decrease activities of erythromycin, kanamycin, streptomycin, doxycycline, and lincomycin. Bleomycin is inactivated in vitro by ascorbic acid. If the antibiotic efficacy is suspected to be decreased by concomitant administration of ASCOR, discontinue ASCOR administration.

7.2 Amphetamine &amp; Other Drugs Affected by Urine Acidification

7.2 Amphetamine &amp; Other Drugs Affected by Urine Acidification Ascorbic acid may acidify the urine and lower serum concentrations of amphetamine by increasing renal excretion (as reflected by changes in amphetamine urine recovery rates). In case of decreased amphetamine efficacy discontinue ASCOR administration. Standard monitoring of therapy is warranted. In addition, acidification of urine by ascorbic acid will alter the excretion of certain drugs affected by the pH of the urine (e.g., fluphenazine) when administered concurrently. It has been reported that concurrent administration of ascorbic acid and fluphenazine has resulted in decreased fluphenazine plasma concentrations. Standard monitoring of therapy is warranted.

7.2 Amphetamine &amp; Other Drugs Affected by Urine Acidification Ascorbic acid may acidify the urine and lower serum concentrations of amphetamine by increasing renal excretion (as reflected by changes in amphetamine urine recovery rates). In case of decreased amphetamine efficacy discontinue ASCOR administration. Standard monitoring of therapy is warranted. In addition, acidification of urine by ascorbic acid will alter the excretion of certain drugs affected by the pH of the urine (e.g., fluphenazine) when administered concurrently. It has been reported that concurrent administration of ascorbic acid and fluphenazine has resulted in decreased fluphenazine plasma concentrations. Standard monitoring of therapy is warranted.

7.3 Warfarin

7.3 Warfarin Limited case reports have suggested interference of ascorbic acid with the anticoagulation effects of warfarin, however, patients on warfarin therapy treated with ascorbic acid doses up to 1000 mg/day (5 times the largest recommended single dose) for 2 weeks (twice the maximum recommended duration), no effect was observed. Standard monitoring for anti-coagulation therapy should continue during ascorbic acid treatment, as per standard of care.

7.3 Warfarin Limited case reports have suggested interference of ascorbic acid with the anticoagulation effects of warfarin, however, patients on warfarin therapy treated with ascorbic acid doses up to 1000 mg/day (5 times the largest recommended single dose) for 2 weeks (twice the maximum recommended duration), no effect was observed. Standard monitoring for anti-coagulation therapy should continue during ascorbic acid treatment, as per standard of care.

7.4 Laboratory Test Interference

7.4 Laboratory Test Interference Because ascorbic acid is a strong reducing agent, it can interfere with numerous laboratory tests based on oxidation-reduction reactions (e.g., glucose, nitrite and bilirubin levels, leukocyte count, etc.). Chemical detecting methods based on colorimetric reactions are generally those tests affected. Ascorbic acid may lead to inaccurate results (false negatives) obtained for checking blood or urinary glucose levels, nitrite, bilirubin, and leukocytes if tested during or within 24 hours after infusion <span class="opacity-50 text-xs">[see Warnings and Precautions (5.3) ]</span> .

7.4 Laboratory Test Interference Because ascorbic acid is a strong reducing agent, it can interfere with numerous laboratory tests based on oxidation-reduction reactions (e.g., glucose, nitrite and bilirubin levels, leukocyte count, etc.). Chemical detecting methods based on colorimetric reactions are generally those tests affected. Ascorbic acid may lead to inaccurate results (false negatives) obtained for checking blood or urinary glucose levels, nitrite, bilirubin, and leukocytes if tested during or within 24 hours after infusion <span class="opacity-50 text-xs">[see Warnings and Precautions (5.3)]</span> .

ACTIVE INGREDIENTS/PURPOSE ASCORBIC ACID 4X ANTIOXIDANT CONJUNCTIVA TISSUE 6X DETOXIFICATION DEHYDROEPIANDROSTERON 6X HORMONAL SUPPORT DL-MALIC ACID 6X PROMOTE CELL METABOLISM FUCUS VESICULOSUS 4X DETOXIFICATION HISTIDINE 4X ANTI-INFLAMMATORY HYALURONIDASE 6X ANTI-INFLAMMATORY INTERLEUKIN 6 4C IMMUNE SUPPORT LACTICUM ACIDUM 4X ANTIOXIDANT LYMPHATIC VESSEL 6X IMMUNE SUPPORT NADIDUM 6X METABOLIC SUPPORT NATRUM OXALACETICUM 6X ANTIOXIDANT NATRUM PYRUVICUM 6X ANTIOXIDANT NATRUM SULPHURICUM 6X, 8X, 12X, 30X, 200X ANTIOXIDANT PHENYLALANINE 4X IMPROVE CONCENTRATION PROLACTIN 6X IMPROVE CONCENTRATION PYROGENIUM 12X ANTI-INFLAMMATORY THUJA OCCIDENTALIS 6X, 8X, 12X, 30X, 200X DETOXIFICATION TRICHINOYL PHOSPHATE 6X ANTIOXIDANT TYROSINE 4X IMMUNE SUPPORT

Inactive ingredients WATER 34% ASCORBIC ACID 3% NIACINAMIDE 2% PROPYLENE GLYCOL 5% GLYCERIN 5% TREHALOSE 1% ALLANTOIN 0.3% SODIUM HYALURONATE 0.2% DIPOTASSIUM GLYCYRRHIZATE 0.5% LIMNANTHES ALBA (MEADOWFOAM) SEED OIL 2% MACADAMIA TERNIFOLIA SEED OIL 2% TRITICUM VULGARE (WHEAT) GERM OIL 2% ETHYLHEXYL SALICYLATE 3% C12-15 ALKYL BENZOATE 3% CETEARYL ALCOHOL 1% CETEARYL GLUCOSIDE 2% CETEARETH-21 1% DIMETHICONE 1% TOCOPHERYL ACETATE 2% BISABOLOL 0.3% XANTHAN GUM 0.4% ETHYLHEXYLGLYCERIN 0.1% CHLORPHENESIN 0.15% HYDROLYZED BETA-GLUCAN 3% PAEONIA ALBIFLORA ROOT EXTRACT 3% TRITICUM VULGARE (WHEAT) GERM EXTRACT 2% CENTELLA ASIATICA ROOT EXTRACT 2% ALOE FEROX LEAF EXTRACT 2% PARFUM 0.05