• Patients & Caregivers

Xtampza® ER: engineered to deliver powerful pain relief and help mitigate the risks of abuse, misuse, and diversion

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Studies required by FDA to demonstrate the potential to help deter abuse

There are 4 categories (3 premarket and 1 postmarket) of studies FDA accepts to demonstrate a product’s potential to deter abuse.1

Lab‑based in vitro manipulation and extraction studies to evaluate the ease with which the potentially abuse‑deterrent properties of a formulation can be defeated or compromised

Pharmacokinetic (PK) studies to compare profiles of manipulated and intact product through one or more routes of administration to understand the in vivo properties of the formulation

Human abuse potential clinical studies, assessing the impact of potentially abuse-deterrent properties on Drug Liking and Take Drug Again measurements

Postmarket analysis assessing whether the marketing of a product with abuse-deterrent properties results in meaningful reductions in abuse, misuse, and related adverse clinical outcomes, such as addiction, overdose, and death

No product, including Xtampza ER, has Category 4 data sufficient to support a label claim that it reduces abuse, misuse, or deterrence in the real world

Category 1

Manipulation and Extraction studies

Results from in vitro physical and chemical manipulation studies support that Xtampza ER is less susceptible to the effects of grinding, crushing, and extraction using a variety of tools and solvents relative to oxycodone IR tablets.

Xtampza ER resisted attempts to pass the melted capsule contents or microspheres suspended in water through a hypodermic needle.2

Category 2

Pharmacokinetic studies

Only Xtampza ER maintained its extended‑release PK profile when crushed—OxyContin® did not

Xtampza ER intact and crushed
Oxycontin ER intact and crushed

In a randomized, open‑label, active‑controlled, 5‑treatment crossover study, Gudin et al compared the PK of crushed oxycodone IR to Xtampza ER (crushed and intact) and reformulated OxyContin (crushed and intact) taken orally in 42 healthy subjects.3

The findings above do not indicate that Xtampza ER can entirely prevent abuse via oral and nasal administration. Abuse of Xtampza ER by injection and by the oral and nasal routes is still possible.

The impact of the oral PK studies on diversion, misuse, and abuse of Xtampza ER has yet to be determined. Additional data, including epidemiological data, when available, may provide further information on the impact of the current formulation of Xtampza ER on the abuse liability of the drug.

How does this make you rethink your ER oxycodone of choice?

Category 3

Clinical Abuse Potential studies

Oral abuse: Xtampza ER demonstrated a statistically significant reduction in oral abuse potential vs oxycodone immediate‑release (IR)

The oral abuse potential of Xtampza ER was evaluated in two studies. Below are results from a study with 52 nondependent recreational opioid users who received active and placebo treatment orally. Drug Liking and Take Drug Again were measured on a visual analog scale (VAS).2

Mean maximum Drug Liking (Emax): oral administration² Mean maximum Drug Liking (Emax): oral administration²
77% of subjects had some reduction in Drug Liking with chewed Xtampza ER vs crushed IR oxycodone.⁴ 77% of subjects had some reduction in Drug Liking with chewed Xtampza ER vs crushed IR oxycodone.⁴
Mean maximum Take Drug Again (Emax): oral administration² Mean maximum Take Drug Again (Emax): oral administration²
  • The oral administration of both chewed and intact Xtampza ER in the fasted state was associated with statistically lower mean Drug Liking and Take Drug Again scores compared with crushed oxycodone IR
  • In addition, the Drug Liking and Take Drug Again scores were similar for Xtampza ER taken in the intact and chewed states

Abuse of Xtampza ER by injection and by the oral and nasal routes of administration is still possible.

Nasal abuse: Xtampza ER demonstrated a statistically significant reduction in nasal abuse potential vs oxycodone immediate-release (IR)

The nasal abuse potential of Xtampza ER was evaluated. Below are results from a study with 36 recreational opioid users with a history of intranasal drug abuse who received active and placebo via nasal administration. Drug Liking and Take Drug Again were measured on a VAS.2

Mean maximum Drug Liking (Emax): nasal administration² Mean maximum Drug Liking (Emax): nasal administration²
Mean maximum Take Drug Again (Emax): nasal administration² Mean maximum Take Drug Again (Emax): nasal administration²
  • Intranasal administration of crushed Xtampza ER was associated with statistically lower mean Drug Liking and Take Drug Again scores compared with crushed oxycodone IR

These findings do not indicate that Xtampza ER can entirely prevent abuse via nasal administration. Abuse of Xtampza ER by injection and by the oral and nasal routes of administration is still possible.

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INDICATIONS AND USAGE

Xtampza® ER (oxycodone) is indicated for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate.

Limitations of Use
  • Because of the risks of addiction, abuse, and misuse with opioids, even at recommended doses, and because of the greater risks of overdose and death with extended-release opioid formulations, reserve Xtampza ER for use in patients for whom alternative treatment options (eg, non-opioid analgesics or immediate-release opioids) are ineffective, not tolerated, or would be otherwise inadequate to provide sufficient management of pain
  • Xtampza ER is not indicated as an as-needed (prn) analgesic

IMPORTANT SAFETY INFORMATION

WARNING: ADDICTION, ABUSE, AND MISUSE; RISK EVALUATION AND MITIGATION STRATEGY (REMS); LIFE-THREATENING RESPIRATORY DEPRESSION; ACCIDENTAL INGESTION; NEONATAL OPIOID WITHDRAWAL SYNDROME; CYTOCHROME P450 3A4 INTERACTION; and RISKS FROM CONCOMITANT USE WITH BENZODIAZEPINES OR OTHER CNS DEPRESSANTS

Addiction, Abuse, and Misuse

Xtampza ER exposes patients and other users to the risks of opioid addiction, abuse, and misuse, which can lead to overdose and death. Assess each patient’s risk prior to prescribing Xtampza ER and monitor all patients regularly for the development of these behaviors or conditions.

Opioid Analgesic Risk Evaluation and Mitigation Strategy (REMS)

To ensure that the benefits of opioid analgesics outweigh the risks of addiction, abuse, and misuse, the Food and Drug Administration (FDA) has required a REMS for these products. Under the requirements of the REMS, drug companies with approved opioid analgesic products must make REMS-compliant education programs available to healthcare providers. Healthcare providers are strongly encouraged to

  • complete a REMS-compliant education program,
  • counsel patients and/or their caregivers, with every prescription, on safe use, serious risks, storage, and disposal of these products,
  • emphasize to patients and their caregivers the importance of reading the Medication Guide every time it is provided by their pharmacist, and
  • consider other tools to improve patient, household, and community safety.

Life-Threatening Respiratory Depression

Serious, life-threatening, or fatal respiratory depression may occur with use of Xtampza ER. Monitor for respiratory depression, especially during initiation of Xtampza ER or following a dose increase.

Accidental Ingestion

Accidental ingestion of even one dose of Xtampza ER, especially by children, can result in a fatal overdose of oxycodone.

Neonatal Opioid Withdrawal Syndrome

Prolonged use of Xtampza ER during pregnancy can result in neonatal opioid withdrawal syndrome, which may be life-threatening if not recognized and treated, and requires management according to protocols developed by neonatology experts. If opioid use is required for a prolonged period in a pregnant woman, advise the patient of the risk of neonatal opioid withdrawal syndrome and ensure that appropriate treatment will be available.

Cytochrome P450 3A4 Interaction

The concomitant use of Xtampza ER with all cytochrome P450 3A4 inhibitors may result in an increase in oxycodone plasma concentrations, which could increase or prolong adverse drug effects and may cause potentially fatal respiratory depression. In addition, discontinuation of a concomitantly used cytochrome P450 3A4 inducer may result in an increase in oxycodone plasma concentration. Monitor patients receiving Xtampza ER and any CYP3A4 inhibitor or inducer.

Risks From Concomitant Use With Benzodiazepines or Other CNS Depressants

Concomitant use of opioids with benzodiazepines or other central nervous system (CNS) depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death.

  • Reserve concomitant prescribing of Xtampza ER and benzodiazepines or other CNS depressants for use in patients for whom alternative treatment options are inadequate.
  • Limit dosages and durations to the minimum required.
  • Follow patients for signs and symptoms of respiratory depression and sedation.

CONTRAINDICATIONS:

  • Xtampza ER is contraindicated in patients with significant respiratory depression, acute or severe bronchial asthma in an unmonitored setting or in the absence of resuscitative equipment, known or suspected gastrointestinal obstruction, including paralytic ileus, and hypersensitivity (eg, anaphylaxis) to oxycodone

WARNINGS AND PRECAUTIONS:

Addiction, Abuse, and Misuse

Xtampza ER contains oxycodone, a Schedule II controlled substance. As an opioid, Xtampza ER exposes users to the risks of addiction, abuse, and misuse. As extended-release products such as Xtampza ER deliver the opioid over an extended period of time, there is a greater risk for overdose and death due to the larger amount of oxycodone present.

Opioid Analgesic Risk Evaluation and Mitigation Strategy (REMS)

To ensure that the benefits of opioid analgesics outweigh the risks of addiction, abuse, and misuse, the Food and Drug Administration (FDA) has required a Risk Evaluation and Mitigation Strategy (REMS) for these products. Under the requirements of the REMS, drug companies with approved opioid analgesic products must make REMS-compliant education programs available to healthcare providers. Healthcare providers are strongly encouraged to do all of the following:

  • Complete a REMS-compliant education program offered by an accredited provider of continuing education (CE) or another education program that includes all the elements of the FDA Education Blueprint for Health Care Providers Involved in the Management or Support of Patients with Pain
  • Discuss with patients and/or their caregivers, with every prescription, the safe use, serious risks, and proper storage and disposal of these products. The Patient Counseling Guide (PCG) can be obtained at this link: www.fda.gov/Opioid
    AnalgesicREMSPCG
  • Emphasize to patients and their caregivers the importance of reading the Medication Guide every time it is provided by their pharmacist
  • Consider other tools to improve patient, household, and community safety such as patient-prescriber agreements that reinforce patient-prescriber responsibilities

For further information on the REMS and a list of accredited REMS CME/CE, call 1‑800‑503‑0784, or visit www.opioidanalgesicrems
.com
. The FDA Blueprint can be found at www.fda.gov/Opioid
AnalgesicREMS
Blueprint
.

Life‑Threatening Respiratory Depression
  • Serious, life-threatening, or fatal respiratory depression has been reported with the use of opioids, even when used as recommended. Respiratory depression, if not immediately recognized and treated, may lead to respiratory arrest and death. Management of respiratory depression may include close observation, supportive measures, and use of opioid antagonists, depending on the patient’s clinical status. Carbon dioxide (CO2) retention from opioid-induced respiratory depression can exacerbate the sedating effects of opioids
  • Opioids can cause sleep‑related breathing disorders, including central sleep apnea (CSA) and sleep‑related hypoxemia. Opioid use increases the risk of CSA in a dose‑dependent fashion. In patients who present with CSA, consider decreasing the opioid dosage using best practices for opioid taper
Neonatal Opioid Withdrawal Syndrome
  • Prolonged use of Xtampza ER during pregnancy can result in withdrawal in the neonate. Neonatal opioid withdrawal syndrome, unlike opioid withdrawal syndrome in adults, may be life-threatening if not recognized and treated, and requires management according to protocols developed by neonatology experts. Observe newborns for signs of neonatal opioid withdrawal syndrome and manage accordingly. Advise pregnant women using opioids for a prolonged period of the risk of neonatal opioid withdrawal syndrome, and ensure that appropriate treatment will be available

IMPORTANT SAFETY INFORMATION

WARNING: ADDICTION, ABUSE, AND MISUSE; RISK EVALUATION AND MITIGATION STRATEGY (REMS); LIFE-THREATENING RESPIRATORY DEPRESSION; ACCIDENTAL INGESTION; NEONATAL OPIOID WITHDRAWAL SYNDROME; CYTOCHROME P450 3A4 INTERACTION; and RISKS FROM CONCOMITANT USE WITH BENZODIAZEPINES OR OTHER CNS DEPRESSANTS

Addiction, Abuse, and Misuse

Xtampza ER exposes patients and other users to the risks of opioid addiction, abuse, and misuse, which can lead to overdose and death. Assess each patient’s risk prior to prescribing Xtampza ER and monitor all patients regularly for the development of these behaviors or conditions.

Opioid Analgesic Risk Evaluation and Mitigation Strategy (REMS)

To ensure that the benefits of opioid analgesics outweigh the risks of addiction, abuse, and misuse, the Food and Drug Administration (FDA) has required a REMS for these products. Under the requirements of the REMS, drug companies with approved opioid analgesic products must make REMS-compliant education programs available to healthcare providers. Healthcare providers are strongly encouraged to

  • complete a REMS-compliant education program,
  • counsel patients and/or their caregivers, with every prescription, on safe use, serious risks, storage, and disposal of these products,
  • emphasize to patients and their caregivers the importance of reading the Medication Guide every time it is provided by their pharmacist, and
  • consider other tools to improve patient, household, and community safety.

Life-Threatening Respiratory Depression

Serious, life-threatening, or fatal respiratory depression may occur with use of Xtampza ER. Monitor for respiratory depression, especially during initiation of Xtampza ER or following a dose increase.

Accidental Ingestion

Accidental ingestion of even one dose of Xtampza ER, especially by children, can result in a fatal overdose of oxycodone.

Neonatal Opioid Withdrawal Syndrome

Prolonged use of Xtampza ER during pregnancy can result in neonatal opioid withdrawal syndrome, which may be life-threatening if not recognized and treated, and requires management according to protocols developed by neonatology experts. If opioid use is required for a prolonged period in a pregnant woman, advise the patient of the risk of neonatal opioid withdrawal syndrome and ensure that appropriate treatment will be available.

Cytochrome P450 3A4 Interaction

The concomitant use of Xtampza ER with all cytochrome P450 3A4 inhibitors may result in an increase in oxycodone plasma concentrations, which could increase or prolong adverse drug effects and may cause potentially fatal respiratory depression. In addition, discontinuation of a concomitantly used cytochrome P450 3A4 inducer may result in an increase in oxycodone plasma concentration. Monitor patients receiving Xtampza ER and any CYP3A4 inhibitor or inducer.

Risks From Concomitant Use With Benzodiazepines or Other CNS Depressants

Concomitant use of opioids with benzodiazepines or other central nervous system (CNS) depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death.

  • Reserve concomitant prescribing of Xtampza ER and benzodiazepines or other CNS depressants for use in patients for whom alternative treatment options are inadequate.
  • Limit dosages and durations to the minimum required.
  • Follow patients for signs and symptoms of respiratory depression and sedation.
Risks of Concomitant Use or Discontinuation of Cytochrome P450 3A4 Inhibitors and Inducers
  • Concomitant use of Xtampza ER with a CYP3A4 inhibitor, such as macrolide antibiotics (eg, erythromycin), azole‑antifungal agents (eg, ketoconazole), and protease inhibitors (eg, ritonavir), may increase plasma concentrations of oxycodone and prolong opioid adverse reactions, which may cause potentially fatal respiratory depression, particularly when an inhibitor is added after a stable dose of Xtampza ER is achieved. Similarly, discontinuation of a CYP3A4 inducer, such as rifampin, carbamazepine, and phenytoin, in Xtampza ER‑treated patients may increase oxycodone plasma concentrations and prolong opioid adverse reactions. When using Xtampza ER with CYP3A4 inhibitors or discontinuing CYP3A4 inducers in Xtampza ER‑treated patients, monitor patients closely at frequent intervals and consider dosage reduction of Xtampza ER until stable drug effects are achieved
  • Concomitant use of Xtampza ER with CYP3A4 inducers or discontinuation of a CYP3A4 inhibitor could decrease oxycodone plasma concentrations, decrease opioid efficacy or, possibly, lead to a withdrawal syndrome in a patient who had developed physical dependence to oxycodone. When using Xtampza ER with CYP3A4 inducers or discontinuing CYP3A4 inhibitors, monitor patients closely at frequent intervals and consider increasing the opioid dosage if needed to maintain adequate analgesia or if symptoms of opioid withdrawal occur
Risks From Concomitant Use With Benzodiazepines or Other CNS Depressants
  • Profound sedation, respiratory depression, coma, and death may result from the concomitant use of Xtampza ER with benzodiazepines or other CNS depressants (eg, non‑benzodiazepine sedatives/hypnotics, anxiolytics, tranquilizers, muscle relaxants, general anesthetics, antipsychotics, other opioids, alcohol). Because of these risks, reserve concomitant prescribing of these drugs for use in patients for whom alternative treatment options are inadequate
  • Observational studies have demonstrated that concomitant use of opioid analgesics and benzodiazepines increases the risk of drug‑related mortality compared to use of opioid analgesics alone. Because of similar pharmacological properties, it is reasonable to expect similar risk with the concomitant use of other CNS depressant drugs with opioid analgesics
Risk of Life‑Threatening Respiratory Depression in Patients With Chronic Pulmonary Disease or in Elderly, Cachectic, or Debilitated Patients

The use of Xtampza ER in patients with acute or severe bronchial asthma in an unmonitored setting or in the absence of resuscitative equipment is contraindicated.

Patients with Chronic Pulmonary Disease: Xtampza ER‑treated patients with significant chronic obstructive pulmonary disease or cor pulmonale, and those with a substantially decreased respiratory reserve, hypoxia, hypercapnia, or pre‑existing respiratory depression are at increased risk of decreased respiratory drive, including apnea, even at recommended dosages of Xtampza ER.

Elderly, Cachectic, or Debilitated Patients: Life‑threatening respiratory depression is more likely to occur in elderly, cachectic, or debilitated patients as they may have altered pharmacokinetics or altered clearance compared to younger, healthier patients.

Monitor such patients closely, particularly when initiating and titrating Xtampza ER and when Xtampza ER is given concomitantly with other drugs that depress respiration. Alternatively, consider the use of non‑opioid analgesics in these patients. Use an alternative analgesic for patients who require a dose of Xtampza ER less than 9 mg.

Adrenal Insufficiency
  • Cases of adrenal insufficiency have been reported with opioid use, more often following greater than one month of use. Presentation of adrenal insufficiency may include non‑specific symptoms and signs, including nausea, vomiting, anorexia, fatigue, weakness, dizziness, and low blood pressure. If adrenal insufficiency is suspected, confirm the diagnosis with diagnostic testing as soon as possible. If adrenal insufficiency is diagnosed, treat with physiologic replacement doses of corticosteroids. Wean the patient off of the opioid to allow adrenal function to recover, and continue corticosteroid treatment until adrenal function recovers. Other opioids may be tried as some cases reported use of a different opioid without recurrence of adrenal insufficiency. The information available does not identify any particular opioids as being more likely to be associated with adrenal insufficiency
Severe Hypotension
  • Xtampza ER may cause severe hypotension, including orthostatic hypotension and syncope in ambulatory patients. There is an increased risk in patients whose ability to maintain blood pressure has already been compromised by a reduced blood volume or concurrent administration of certain CNS depressant drugs (eg, phenothiazines or general anesthetics). Monitor these patients for signs of hypotension after initiating or titrating the dosage of Xtampza ER. In patients with circulatory shock, Xtampza ER may cause vasodilation that can further reduce cardiac output and blood pressure. Avoid the use of Xtampza ER in patients with circulatory shock
Risks of Use in Patients With Increased Intracranial Pressure, Brain Tumors, Head Injury, or Impaired Consciousness
  • In patients who may be susceptible to the intracranial effects of CO2 retention (eg, those with evidence of increased intracranial pressure or brain tumors), Xtampza ER may reduce respiratory drive, and the resultant CO2 retention can further increase intracranial pressure. Monitor such patients for signs of sedation and respiratory depression, particularly when initiating therapy with Xtampza ER
  • Opioids may also obscure the clinical course in a patient with a head injury. Avoid the use of Xtampza ER in patients with impaired consciousness or coma
Risks of Use in Patients With Gastrointestinal Conditions
  • Xtampza ER is contraindicated in patients with gastrointestinal obstruction, including paralytic ileus
  • The oxycodone in Xtampza ER may cause spasm of the sphincter of Oddi. Opioids may cause increases in the serum amylase. Monitor patients with biliary tract disease, including acute pancreatitis, for worsening symptoms
Risk of Use in Patients With Seizure Disorders
  • The oxycodone in Xtampza ER may increase the frequency of seizures in patients with seizure disorders and may increase the risk of seizures in other clinical settings associated with seizures. Monitor patients with a history of seizure disorders for worsened seizure control during Xtampza ER therapy
Withdrawal
  • Do not abruptly discontinue Xtampza ER in a patient physically dependent on opioids. When discontinuing Xtampza ER in a physically dependent patient, gradually taper the dosage. Rapid tapering of oxycodone in a patient physically dependent on opioids may lead to a withdrawal syndrome and return of pain
  • Additionally, avoid the use of mixed agonist/antagonist (eg, pentazocine, nalbuphine, and butorphanol) or partial agonist (eg, buprenorphine) analgesics in patients who have received or are receiving a course of therapy with a full opioid agonist analgesic, including Xtampza ER. In these patients, mixed agonist/antagonist and partial agonist analgesics may reduce the analgesic effect and/or may precipitate withdrawal symptoms
Risks of Driving and Operating Machinery
  • Xtampza ER may impair the mental or physical abilities needed to perform potentially hazardous activities, such as driving a car or operating machinery. Warn patients not to drive or operate dangerous machinery unless they are tolerant to the effects of Xtampza ER and know how they will react to the medication
Laboratory Monitoring
  • Not every urine drug test for “opioids” or “opiates” detects oxycodone reliably, especially those designed for in‑office use. Further, many laboratories will report urine drug concentrations below a specified “cut‑off” value as “negative.” Therefore, if urine testing for oxycodone is considered in the clinical management of an individual patient, ensure that the sensitivity and specificity of the assay is appropriate, and consider the limitations of the testing used when interpreting results
ADMINISTRATION WITH FOOD:
  • Instruct patients to always take Xtampza ER capsules with food and with approximately the same amount of food in order to ensure consistent plasma levels are achieved. For patients who have difficulty swallowing, Xtampza ER can also be taken as a sprinkle on soft foods or sprinkled into a cup and administered directly into the mouth, or through a nasogastric or gastric feeding tube
ADVERSE REACTIONS:
  • The most common adverse reactions (>5%) reported by patients in the Phase 3 clinical trial comparing Xtampza ER with placebo were nausea, headache, constipation, somnolence, pruritus, vomiting, and dizziness

Please see full Prescribing Information, including Boxed Warning.

References: 1. US Department of Health and Human Services. Food and Drug Administration Center for Drug Evaluation and Research (CDER). Abuse-deterrent opioids—evaluation and labeling: guidance for industry. Published April 2015. Accessed January 22, 2020. https://www.fda.gov/regulatory-information/search-fda-guidance-documents/abuse-deterrent-opioids-evaluation-and-labeling. 2. Xtampza ER [package insert]. Stoughton, MA: Collegium Pharmaceutical, Inc.; 2019 3. Gudin J, Levy-Cooperman N, Kopecky EA, et al. Comparing the effect of tampering on the oral pharmacokinetic profiles of two extended-release oxycodone formulations with abuse-deterrent properties. Pain Med. 2015;16(11):2142-2151. doi:10.1111/pme.12834. 4. Data on file. Collegium Pharmaceutical, Inc.

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