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New Zealand white rabbits were treated with Retin-A Micro (tretinoin gel) microsphere, 0.1%,
at doses of 0.2, 0.5, and 1.0 mg/kg/day, administered topical y for 24 hours a day while
wearing Elizabethan col ars to prevent ingestion of the drug. There appeared to be increased
incidences of certain alterations, including domed head and hydrocephaly, typical of retinoid-
induced fetal malformations in this species, at 0.5 and 1.0 mg/kg/day. Similar malformations
were not observed at 0.2 mg/kg/day, 3 times the maximum human systemic dose of tretinoin
after topical administration of Retin-A Micro (tretinoin gel) microsphere, 0.1%, normalized
FOR TOPICAL USE ONLY. NOT FOR OPHTHALMIC, ORAL, OR INTRAVAGINAL USE.
for total body surface area. In a repeat study of the highest topical dose (1.0 mg/kg/day) in
pregnant rabbits, these effects were not seen, but a few alterations that may be associated
Retin-A Micro® (tretinoin gel) microsphere, 0.1% and 0.04% is a formulation containing 0.1%
with tretinoin exposure were seen. Other pregnant rabbits exposed topical y for six hours to
or 0.04%, by weight, tretinoin for topical treatment of acne vulgaris. This formulation uses
0.5 or 0.1 mg/kg/day tretinoin while restrained in stocks to prevent ingestion, did not show
patented methyl methacrylate/glycol dimethacrylate crosspolymer porous microspheres
any teratogenic effects at doses up to 17 times (1.0 mg/kg/day) the maximum human systemic
(MICROSPONGE® System) to enable inclusion of the active ingredient, tretinoin, in an aqueous
dose after topical administration of Retin-A Micro (tretinoin gel) microsphere, 0.1%, adjusted for
total body surface area, but fetal resorptions were increased at 0.5 mg/kg. In addition, topical
IMPORTANT NOTE: This information is a BRIEF SUMMARY of the complete prescribing
tretinoin in non Retin-A Micro (tretinoin gel) microsphere formulations was not teratogenic in
information provided with the product and therefore should not be used as the basis
rats and rabbits when given in doses of 42 and 27 times the maximum human systemic dose
for prescribing the product. This summary has been prepared by deleting information
after topical administration of Retin-A Micro (tretinoin gel) microsphere, 0.1%, normalized for total
from the complete prescribing information such as certain text, tables, and references.
body surface area, respectively, (assuming a 50 kg adult applied a daily dose of 1.0 g of 0.1%
The physician should be thoroughly familiar with the complete prescribing information
gel topical y). At these topical doses, however, delayed ossification of several bones occurred
before prescribing the product.
in rabbits. In rats, a dose-dependent increase of supernumerary ribs was observed.
INDICATIONS AND USAGE:
Retin-A Micro (tretinoin gel) microsphere, 0.1% and 0.04%, is
Oral tretinoin has been shown to be teratogenic in rats, mice, rabbits, hamsters, and subhu-
indicated for topical application in the treatment of acne vulgaris. The safety and efficacy of the
man primates. Tretinoin was teratogenic in Wistar rats when given oral y or topical y in doses
use of this product in the treatment of other disorders have not been established.
greater than 1 mg/kg/day (8 times the maximum human systemic dose normalized for total
This drug is contraindicated in individuals with a history of sensitivity
body surface area). However, variations in teratogenic doses among various strains of rats have
reactions to any of its components. It should be discontinued if hypersensitivity to any of its
been reported. In the cynomolgus monkey, which metabolical y is more similar to humans than
other species in its handling of tretinoin, fetal malformations were reported for doses of 10
mg/kg/day or greater, but none were observed at 5 mg/kg/day (83 times the maximum human
systemic dose normalized for total body surface area), although increased skeletal variations
were observed at al doses. Dose-related increases in embryolethality and abortion also were
• The skin of certain individuals may become excessively dry, red, swol en, or blistered. If the
reported. Similar results have also been reported in pigtail macaques.
degree of irritation warrants, patients should be directed to temporarily reduce the amount
Topical tretinoin in animal teratogenicity tests has generated equivocal results. There is evidence
or frequency of application of the medication, discontinue use temporarily, or discontinue
for teratogenicity (shortened or kinked tail) of topical tretinoin in Wistar rats at doses greater
use al together. Efficacy at reduced frequencies of application has not been established.
than 1 mg/kg/day (8 times the maximum human systemic dose normalized for total body surface
If a reaction suggesting sensitivity occurs, use of the medication should be discontinued.
area). Anomalies (humerus: short 13%, bent 6%, os parietal incompletely ossified 14%) have
Excessive skin dryness may also be experienced; if so, use of an appropriate emol ient
also been reported when 10 mg/kg/day was topical y applied. Supernumerary ribs have been
a consistent finding in rats when dams were treated topical y or oral y with retinoids.
• Unprotected exposure to sunlight, including sunlamps, should be minimized during the use of
Retin-A Micro (tretinoin gel) microsphere, 0.1% and 0.04%, and patients with sunburn should
There are no adequate and wel -control ed studies in pregnant women. Retin-A Micro should be
be advised not to use the product until ful y recovered because of heightened susceptibility to
used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
sunlight as a result of the use of tretinoin. Patients who may be required to have considerable
With widespread use of any drug, a smal number of birth defect reports associated temporal y
sun exposure due to occupation and those with inherent sensitivity to the sun should exercise
with the administration of the drug would be expected by chance alone. Thirty human cases
particular caution. Use of sunscreen products (SPF 15) and protective clothing over treated
of temporal y associated congenital malformations have been reported during two decades of
areas are recommended when exposure cannot be avoided.
clinical use of Retin-A. Although no definite pattern of teratogenicity and no causal association
• Weather extremes, such as wind or cold, also may be irritating to patients under treatment
has been established from these cases, five of the reports describe the rare birth defect category
holoprosencephaly (defects associated with incomplete midline development of the forebrain). The
• Retin-A Micro (tretinoin gel) microsphere, 0.1% and 0.04%, should be kept away from the
significance of these spontaneous reports in terms of risk to the fetus is not known.
eyes, the mouth, paranasal creases of the nose, and mucous membranes.
Topical tretinoin has been shown to be fetotoxic in rabbits when
• Tretinoin has been reported to cause severe irritation on eczematous skin and should be used
administered 0.5 mg/kg/day (8 times the maximum human systemic dose applied topical y and
with utmost caution in patients with this condition.
normalized for total body surface area), resulting in fetal resorptions and variations in ossifica-
tion. Oral tretinoin has been shown to be fetotoxic, resulting in skeletal variations and increased
Information for Patients:
A Patient Information Leaflet has been prepared and is included with
intrauterine death in rats when administered 2.5 mg/kg/day (21 times the maximum human
each package of Retin-A Micro (tretinoin gel) microsphere, 0.1% and 0.04%.
systemic dose applied topical y and normalized for total body surface area).
Concomitant topical medication, medicated or abrasive soaps and cleansers,
products that have a strong drying effect, products with high concentrations of alcohol, astringents,
There are, however no adequate and wel -control ed studies in pregnant women.
or spices should be used with caution because of possible interaction with tretinoin. Avoid contact
Animal Toxicity Studies:
In male mice treated topical y with Retin-A Micro (tretinoin gel)
with the peel of limes. Particular caution should be exercised with the concomitant use of topical
microsphere 0.1%, at 0.5, 2.0, or 5.0 mg/kg/day tretinoin (2, 8, or 21 times the maximum
over-the-counter acne preparations containing benzoyl peroxide, sulfur, resorcinol, or salicylic acid
human systemic dose after topical administration of Retin-A Micro (tretinoin gel) microsphere,
with Retin-A Micro (tretinoin gel) microsphere, 0.1% and 0.04%. It also is advisable to al ow the
0.1%, normalized for total body surface area) for 90 days, a reduction in testicular weight, but
effects of such preparations to subside before use of Retin-A Micro (tretinoin gel) microsphere,
with no pathological changes were observed at the two highest doses. Similarly, in female mice
there was a reduction in ovarian weights, but without any underlying pathological changes, at
Carcinogenesis, Mutagenesis, Impairment of Fertility:
In a 91-week dermal study in which
5.0 mg/kg/day (21 times the maximum human dose). In this study there was a dose-related
CD-1 mice were administered 0.017% and 0.035% formulations of tretinoin, cutaneous squa-
increase in the plasma concentration of tretinoin 4 hours after the first dose. A separate toxi-
mous cel carcinomas and papil omas in the treatment area were observed in some female
cokinetic study in mice indicates that systemic exposure is greater after topical application to
mice. These concentrations are near the tretinoin concentration of these clinical formulations
unrestrained animals than to restrained animals, suggesting that the systemic toxicity observed
(0.04% and 0.1%). A dose-related incidence of liver tumors in male mice was observed at
is probably related to ingestion. Male and female dogs treated with Retin-A Micro (tretinoin gel)
those same doses. The maximum systemic doses associated with the administered 0.017%
microsphere, 0.1%, at 0.2, 0.5, or 1.0 mg/kg/day tretinoin (5, 12, or 25 times the maximum
and 0.035% formulations are 0.5 and 1.0 mg/kg/day, respectively. These doses are two and
human systemic dose after topical administration of Retin-A Micro (tretinoin gel) microsphere,
four times the maximum human systemic dose applied topical y, when normalized for total
0.1%, normalized for total body surface area, respectively) for 90 days showed no evidence of
body surface area. The biological significance of these findings is not clear because they
reduced testicular or ovarian weights or pathological changes.
occurred at doses that exceeded the dermal maximal y tolerated dose (MTD) of tretinoin and
It is not known whether this drug is excreted in human milk. Because many
because they were within the background natural occurrence rate for these tumors in this
drugs are excreted in human milk, caution should be exercised when Retin-A Micro (tretinoin
strain of mice. There was no evidence of carcinogenic potential when 0.025 mg/kg/day of
gel) microsphere, 0.1% or 0.04%, is administered to a nursing woman.
tretinoin was administered topical y to mice (0.1 times the maximum human systemic dose,
normalized for total body surface area). For purposes of comparisons of the animal exposure
Safety and effectiveness in children below the age of 12 have not been established.
to systemic human exposure, the maximum human systemic dose applied topical y is defined
Safety and effectiveness in a geriatric population have not been established.
as 1 gram of Retin-A Micro (tretinoin gel) microsphere, 0.1% applied daily to a 50 kg person
Clinical studies of Retin-A Micro did not include sufficient numbers of subjects aged 65 and
over to determine whether they respond differently from younger subjects.
Dermal carcinogenicity testing has not been performed with Retin-A Micro (tretinoin gel)
The skin of certain sensitive individuals may become excessively red, edematous, blistered, or
Studies in hairless albino mice suggest that concurrent exposure to tretinoin may enhance the
crusted. If these effects occur, the medication should either be discontinued until the integrity
tumorigenic potential of carcinogenic doses of UVB and UVA light from a solar simulator. This
of the skin is restored, or the medication should be adjusted to a level the patient can tolerate.
effect has been confirmed in a later study in pigmented mice, and dark pigmentation did not
However, efficacy has not been established for lower dosing frequencies.
overcome the enhancement of photocarcinogenesis by 0.05% tretinoin. Although the significance
True contact al ergy to topical tretinoin is rarely encountered. Temporary hyper- or hypopig-
of these studies to humans is not clear, patients should minimize exposure to sunlight or artificial
mentation has been reported with repeated application of tretinoin. Some individuals have been
reported to have heightened susceptibility to sunlight while under treatment with tretinoin.
The mutagenic potential of tretinoin was evaluated in the Ames assay and in the in vivo
Retin-A Micro (tretinoin gel) microsphere, 0.1% and 0.04%, is intended for topical
micronucleus assay, both of which were negative.
use only. If medication is applied excessively, no more rapid or better results wil be obtained and
The components of the microspheres have shown potential for genetic toxicity and teratogenesis.
marked redness, peeling, or discomfort may occur. Oral ingestion of large amounts of the drug
EGDMA, a component of the excipient acrylates copolymer, was positive for induction of structural
may lead to the same side effects as those associated with excessive oral intake of Vitamin A.
chromosomal aberrations in the in vitro
chromosomal aberration assay in mammalian cel s in
the absence of metabolic activation, and negative for genetic toxicity in the Ames assay, the
HGPRT forward mutation assay, and the mouse micronucleus assay.
Patent Nos.: 4,690,825; 5,145,675 & 5,955,109
In dermal Segment I fertility studies of another tretinoin formulation in rats, slight (not statisti-
cal y significant) decreases in sperm count and motility were seen at 0.5 mg/kg/day (4 times
the maximum human systemic dose applied topical y, and normalized for total body surface
area), and slight (not statistical y significant) increases in the number and percent of nonviable
embryos in females treated with 0.25 mg/kg/day (2 times the maximum human systemic dose
applied topical y and normalized for total body surface area) and above were observed. In oral
Segment I and Segment I I studies in rats with tretinoin, decreased survival of neonates and
growth retardation were observed at doses in excess of 2 mg/kg/day (17 times the human
topical dose normalized for total body surface area).
Dermal fertility and perinatal development studies with Retin-A Micro (tretinoin gel) microsphere,
0.1% or 0.04%, have not been performed in any species.
Pregnancy: Teratogenic Effects: Pregnancy Category C.
DIVISION OF ORTHO-MCNEIL PHARMACEUTICAL, INC.
In a study of pregnant rats treated with topical application of Retin-A Micro (tretinoin gel)
microsphere, 0.1%, at doses of 0.5 to 1 mg/kg/day on gestation days 6-15 (4 to 8
times the maximum human systemic dose of tretinoin normalized for total body sur-
face area after topical administration of Retin-A Micro (tretinoin gel) microsphere, 0.1%)
RETIN-A MICRO® is a registered trademark of Ortho-McNeil Pharmaceutical, Inc.
some alterations were seen in vertebrae and ribs of offspring. In another study, pregnant
MICROSPONGE® is a registered trademark of Cardinal Health, Inc., Dublin, OH.
2nd PROFESSIONAL MBBS EXAMINATION, 2011 College/Institute : A.N.MEDICAL COLLEGE, GAYA Roll No. : 201115206004 Registration No : 07201206050/2011 Name : ARVIND KUMAR Father's Name : RAM NARESH RAM Mother's Name : SUBJECT NAME COMPONENT Max.Marks Marks Obtained Theory P-1 Theory P-2 I.A. Theory PATHOLOGY Practical I.A.Practical Aggregate Theory P-
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