Streptomycin is a water-soluble aminoglycoside derived from Streptomyces griseus. It is marketed as the sulfate salt of streptomycin. The chemical name of streptomycin sulfate is D-Streptamine, O-2-deoxy-2-(methylamino)-α-L-glucopyranosyl-(1→2)-O-5-deoxy-3-C-formyl-α-L-lyxofuranosyl-(1→4)-N,N¹-bis(aminoiminomethyl)-,sulfate (2:3) (salt).The molecular formula for Streptomycin Sulfate is (C₂₁H₃₉N₇O₁₂)₂-3H₂SO₄ and the molecular weight is 1457.41. It has the following structural formula:

Streptomycin for Injection, equivalent to 1 gram streptomycin /vial is supplied as a sterile nonpyrogenic lyophillized cake for intramuscular use after reconstitution. The lyophillized cake may reduce to a powder during shipping.

After reconstitution the pH range for Streptomycin for Injection should be between 4.5 and 7.0 in a solution containing 200 mg of streptomycin activity per mL.

*Each vial contains Sterile Streptomycin Sulfate USP equivalent to 1 gram of Streptomycin.

Last updated on RxList: 6/20/2008

Streptomycin is indicated for the treatment of individuals with moderate to severe infections caused by susceptible strains of microorganisms in the specific conditions listed below:

1. Mycobacterium tuberculosis: The Advisory Council for the Elimination of Tuberculosis, the American Thoracic Society, and the Center for Disease Control recommend that either streptomycin or ethambutol be added as a fourth drug in a regimen containing isoniazid (INH), rifampin and pyrazinamide for initial treatment of tuberculosis unless the likelihood of INH or rifampin resistance is very low. The need for a fourth drug should be reassessed when the results of susceptibility testing are known. In the past when the national rate of primary drug resistance to isoniazid was known to be less than 4% and was either stable or declining, therapy with two and three drug regimens was considered adequate. If community rates of INH resistance are currently less than 4%, an initial treatment regimen with less than four drugs may be considered.

Streptomycin is also indicated for therapy of tuberculosis when one or more of the above drugs is contraindicated because of toxicity or intolerance. The management of tuberculosis has become more complex as a consequence of increasing rates of drug resistance and concomitant HIV infection. Additional consultation from experts in the treatment of tuberculosis may be desirable in those settings.

2. Non-tuberculosis infections: The use of streptomycin should be limited to the treatment of infections caused by bacteria which have been shown to be susceptible to the antibacterial effects of streptomycin and which are not amenable to therapy with less potentially toxic agents.

1. Pasteurella pestis (plague),
2. Francisella tularensis (tularemia),
3. Brucella,
4. Calymmatobacterium granulomatis (donovanosis, granuloma inguinale),
5. H. ducreyi (chancroid),
6. H. influenzae (in respiratory, endocardial, and meningeal infections - concomitantly with another antibacterial agent),
7. K. pneumoniae pneumonia (concomitantly with another antibacterial agent),
8. E.coli, Proteus, A. aerogenes, K. pneumoniae, and Enterococcus faecalis in urinary tract infections,
9. Streptococcus viridans, Enterococcus faecalis (in endocardial infections - concomitantly with penicillin),
10. Gram-negative bacillary bacteremia (concomitantly with another antibacterial agent).

To reduce the development of drug-resistant bacteria and maintain the effectiveness of streptomycin and other antibacterial drugs, streptomycin should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria. When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to the empiric selection of therapy.

Intramuscular Route Only

Adults: The preferred site is the upper outer quadrant of the buttock, (i.e., gluteus maximus), or the mid-lateral thigh.

Children: It is recommended that intramuscular injections be given preferably in the mid-lateral muscles of the thigh. In infants and small children the periphery of the upper outer quadrant of the gluteal region should be used only when necessary, such as in burn patients, in order to minimize the possibility of damage to the sciatic nerve.

The deltoid area should be used only if well developed such as in certain adults and older children, and then only with caution to avoid radial nerve injury. Intramuscular injections should not be made into the lower and mid-third of the upper arm. As with all intramuscular injections, aspiration is necessary to help avoid inadvertent injection into a blood vessel.

Injection sites should be alternated. As higher doses or more prolonged therapy with streptomycin may be indicated for more severe or fulminating infections (endocarditis, meningitis, etc.), the physician should always take adequate measures to be immediately aware of any toxic signs or symptoms occurring in the patient as a result of streptomycin therapy.

1. TUBERCULOSIS: The standard regimen for the treatment of drug susceptible tuberculosis has been two months of INH, rifampin and pyrazinamide followed by four months of INH and rifampin (patients with concomitant infection with tuberculosis and HIV may require treatment for a longer period).When streptomycin is added to this regimen because of suspected or proven drug resistance (see INDICATIONS AND USAGE section), the recommended dosing for streptomycin is as follows:

Streptomycin is usually administered daily as a single intramuscular injection. A total dose of not more than 120 g over the course of therapy should be given unless there are no other therapeutic options. In patients older than 60 years of age the drug should be used at a reduced dosage due to the risk of increased toxicity. (See BOXED WARNING.)

Therapy with streptomycin may be terminated when toxic symptoms have appeared, when impending toxicity is feared, when organisms become resistant, or when full treatment effect has been obtained. The total period of drug treatment of tuberculosis is a minimum of 1 year; however, indications for terminating therapy with streptomycin may occur at any time as noted above.

2. TULAREMIA: One to 2 g daily in divided doses for 7 to 14 days until the patient is afebrile for 5 to 7 days.

3. PLAGUE: Two grams of streptomycin daily in two divided doses should be administered intramuscularly. A minimum of 10 days of therapy is recommended.

4. BACTERIAL ENDOCARDITIS:

1. Streptococcal endocarditis; in penicillin-sensitive alpha and non-hemolytic streptococcal endocarditis (penicillin MIC ≤0.1 mcg/mL), streptomycin may be used for 2-week treatment concomitantly with penicillin. The streptomycin regimen is 1 g b.i.d. for the first week, and 500 mg b.i.d. for the second week. If the patient is over 60 years of age, the dosage should be 500 mg b.i.d. for the entire 2-week period.
2. Enterococcal endocarditis: Streptomycin in doses of 1 g b.i.d. for 2 weeks and 500 mg b.i.d. for an additional 4 weeks is given in combination with penicillin. Ototoxicity may require termination of the streptomycin prior to completion of the 6-week course of treatment.

5. CONCOMITANT USE WITH OTHER AGENTS: For concomitant use with other agents to which the infecting organism is also sensitive: Streptomycin is considered a second-line agent for the treatment of gram-negative bacillary bacteremia, meningitis, and pneumonia; brucellosis; granuloma inguinale; chancroid, and urinary tract infection.

For adults: 1 to 2 grams in divided doses every six to twelve hours for moderate to severe infections. Doses should generally not exceed 2 grams per day.

For children: 20 to 40 mg/kg/day (8 to 20 mg/lb/day) in divided doses every 6 to 12 hours. (Particular care should be taken to avoid excessive dosage in children.)

The dry lyophillized cake is dissolved by adding Water for Injection USP in an amount to yield the desired concentration as indicated in the following table:

Sterile reconstituted solutions should be protected from light and may be stored at room temperature for one week without significant loss of potency.

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.

Streptomycin for Injection USP is available in vials containing 1 gram NDC 39822-0706-1. Boxes of ten vials use NDC 39822-0706-2.

Store dry powder at 20°-25°C (68°-77°F) [see USP Controlled Room Temperature]. PROTECT FROM LIGHT.

Manufactured for: Northport, NY 11768. Revised September 2006. FDA revision date: 7/23/2001

Last updated on RxList: 6/20/2008

The following reactions are common: vestibular ototoxicity (nausea, vomiting, and vertigo); paresthesia of face; rash; fever; urticaria; angioneurotic edema; and eosinophilia.

The following reactions are less frequent: cochlear ototoxicity (deafness); exfoliative dermatitis; anaphylaxis; azotemia; leucopenia; thrombocytopenia; pancytopenia; hemolytic anemia; muscular weakness; and amblyopia.

Vestibular dysfunction resulting from the parenteral administration of streptomycin is cumulatively related to the total daily dose. When 1.8 to 2 g/day are given, symptoms are likely to develop in the large percentage of patients - especially in the elderly or patients with impaired renal function - within four weeks. Therefore, it is recommended that caloric and audiometric tests be done prior to, during, and following intensive therapy with streptomycin in order to facilitate detection of any vestibular dysfunction and/or impairment of hearing which may occur.

Vestibular symptoms generally appear early and usually are reversible with early detection and cessation of streptomycin administration. Two to three months after stopping the drug, gross vestibular symptoms usually disappear, except from the relative inability to walk in total darkness or on very rough terrain.

Although streptomycin is the least nephrotoxic of the aminoglycosides, nephrotoxicity does occur rarely.

Clinical judgment as to termination of therapy must be exercised when side effects occur.

The ototoxic effects of the aminoglycosides, including streptomycin, are potentiated by the co-administration of ethacrynic acid, furosemide, mannitol and possibly other diuretics.

Last updated on RxList: 6/20/2008

Ototoxicity: Both vestibular and auditory dysfunction can follow the administration of streptomycin. The degree of impairment is directly proportional to the dose and duration of streptomycin administration, to the age of the patient, to the level of renal function and to the amount of underlying existing auditory dysfunction. The ototoxic effects of the aminoglycosides, including streptomycin, are potentiated by the co-administration of ethacrynic acid, mannitol, furosemide and possibly other diuretics.

The vestibulotoxic potential of streptomycin exceeds that of its capacity for cochlear toxicity. Vestibular damage is heralded by headache, nausea, vomiting and disequilibrium. Early cochlear injury is demonstrated by the loss of high frequency hearing. Appropriate monitoring and early discontinuation of the drug may permit recovery prior to irreversible damage to the sensorineural cells.

Pregnancy: Streptomycin can cause fetal harm when administered to a pregnant woman. Because streptomycin readily crosses the placental barrier, caution in use of the drug is important to prevent ototoxicity in the fetus. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to the fetus.

General: Prescribing streptomycin in the absence of a proven or strongly suspected bacterial infection or a prophylactic indication is unlikely to provide benefit to the patient and increases the risk of the development of drug-resistant bacteria.

Baseline and periodic caloric stimulation tests and audiometric tests are advisable with extended streptomycin therapy. Tinnitus, roaring noises, or a sense of fullness in the ears indicates need for audiometric examination or termination of streptomycin therapy or both.

Care should be taken by individuals handling Streptomycin for Injection to avoid skin sensitivity reactions. As with all intramuscular preparations, Streptomycin for Injection should be injected well within the body of a relatively large muscle and care should be taken to minimize the possibility of damage to peripheral nerves. (See DOSAGE AND ADMINISTRATION.)

Extreme caution must be exercised in selecting a dosage regimen in the presence of preexisting renal insufficiency. In severely uremic patients a single dose may produce high blood levels for several days and the cumulative effect may produce ototoxic sequelae. When streptomycin must be given for prolonged periods of time alkalinization of the urine may minimize or prevent renal irritation.

A syndrome of apparent central nervous system depression, characterized by stupor and flaccidity, occasionally coma and deep respiratory depression, has been reported in very young infants in whom streptomycin dosage had exceeded the recommended limits. Thus, infants should not receive streptomycin in excess of the recommended dosage.

In the treatment of venereal infections such as granuloma inguinale, and chancroid, if concomitant syphilis is suspected, suitable laboratory procedures such as a dark field examination should be performed before the start of treatment, and monthly serologic tests should be done for at least four months.

As with other antibiotics, use of this drug may result in overgrowth of nonsusceptible organisms, including fungi. If superinfection occurs, appropriate therapy should be instituted.

Pregnancy: Category D: See WARNINGS section.

Nursing Mothers: Because of the potential for serious adverse reactions in nursing infants from streptomycin, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.

Pediatric Use: (See DOSAGE AND ADMINISTRATION.)

Last updated on RxList: 6/20/2008

No information provided.

A history of clinically significant hypersensitivity to streptomycin is a contraindication to its use. Clinically significant hypersensitivity to other aminoglycosides may contraindicate the use of streptomycin because of the known cross-sensitivity of patients to drugs in this class.

Last updated on RxList: 6/20/2008

Following intramuscular injection of 1 g of streptomycin as the sulfate, a peak serum level of 25 to 50 mcg/mL is reached within 1 hour, diminishing slowly to about 50 percent after 5 to 6 hours.

Appreciable concentrations are found in all organ tissues except the brain. Significant amounts have been found in pleural fluid and tuberculous cavities. Streptomycin passes through the placenta with serum levels in the cord blood similar to maternal levels. Small amounts are excreted in milk, saliva, and sweat.

Streptomycin is excreted by glomerular filtration. In patients with normal kidney function, between 29% and 89% of a single 600 mg dose is excreted in the urine within 24 hours. Any reduction of glomerular function results in decreased excretion of the drug and concurrent rise in serum and tissue levels.

Microbiology

Streptomycin sulfate is a bactericidal antibiotic. It acts by interfering with normal protein synthesis. Streptomycin has been shown to be active against most strains of the following organisms both in vitro and in clinical infection. (See INDICATIONS AND USAGE.):

Brucella (brucellosis),
Calymmatobacterium granulomatis (donovanosis, granuloma inguinale),
Escherichia coli, Proteus spp., Aerobacter aerogenes, Klebsiella pneumoniae, and Enterococcus faecalis in urinary tract infections,
Francisella tularensis,
Haemophilus ducreyi (chancroid),
Haemophilus influenzae (in respiratory, endocardial, and meningeal infections - concomitantly with another antibacterial agent),
Klebsiella pneumoniae pneumonia (concomitantly with another antibacterial agent),
Mycobacterium tuberculosis,
Pasteurella pestis
Streptococcus viridans, Enterococcus faecalis (in endocardial infectionsconcomitantly with penicillin).

SUSCEPTIBILITY TESTS: Diffusion Techniques

Quantitative methods that require measurement of zone diameters give the most precise estimate of the susceptibility of bacteria to antimicrobial agents. One such standard procedure1 which has been recommended for use with disks to test susceptibility of organisms to streptomycin uses the 10 mcg streptomycin disk. Interpretation involves the correlation of the diameter obtained in the disk test with the minimum inhibitory concentration (MIC) for streptomycin.

Reports from the laboratory giving results of the standard single disk susceptibility test with a 10 mcg streptomycin disk should be interpreted according to the following criteria:

A report of “Susceptible” indicates that the pathogen is likely to respond to monotherapy with streptomycin. A report of “Intermediate” indicates that the result be considered equivocal, and, if the organism is not fully susceptible to alternative clinically feasible drugs, the test should be repeated. This category provides a buffer zone which prevents small uncontrolled technical factors from causing major discrepancies in interpretations. A report of “Resistant” indicates that achievable drug concentrations are unlikely to be inhibitory and other therapy should be selected.

Standardized procedures require the use of laboratory control organisms. The 10 mcg streptomycin disk should give the following zone diameter:

Methods Section

Two standardized in vitro susceptibility methods are available for testing streptomycin against Mycobancerium tuberculosis organisms. The agar proportion method (CDC or NCCLS M24-P) utilizes middlebrook 7H10 medium impregnated with streptomycin at two final concentrations, 2.0 and 10.0 mcg/mL. MIC90 values are calculated by comparing the quantity of organisms growing in the medium containing drug to the control cultures. Mycobacterial growth in the presence of drug ≥1% of the control indicates resistance.

The radiometric broth method employs the BACTEC 460 machine to compare the growth index from untreated control cultures to cultures grown in the presence of 6.0 mcg/mL of streptomycin. Strict adherence to the manufacturer's instructions for sample processing and data interpretation is required for this assay.

Susceptibility test results obtained by these two different methods cannot be compared unless equivalent drug concentrations are evaluated.

The clinical relevance of in vitro susceptibility test results for mycobacterial species other than M. tuberculosis using either the BACTEC or the proportion method has not been determined.

REFERENCES

'National Committee for Clinical Laboratory Standards. Performance Standards for Antimicrobial Disk Susceptibility Tests-Fourth Edition. Approved Standard NCCLS Document M2-A4.Vol.10, No.7, NCCLS, Villanova, PA 1990.

Last updated on RxList: 6/20/2008

Patients should be counseled that antibacterial drugs including streptomycin should only be used to treat bacterial infections. They do not treat viral infections (e.g., the common cold).When streptomycin is prescribed to treat a bacterial infection, patients should be told that although it is common to feel better early in the course of therapy, the medication should be taken exactly as directed. Skipping doses or not completing the full course of therapy may (1) decrease the effectiveness of the immediate treatment and (2) increase the likelihood that bacteria will develop resistance and will not be treatable by streptomycin or other antibacterial drugs in the future.

Last updated on RxList: 6/20/2008

IMPORTANT NOTE: This is a summary and does not contain all possible information about this product. For complete information about this product or your specific health needs, ask your health care professional. Always seek the advice of your health care professional if you have any questions about this product or your medical condition. This information is not intended as individual medical advice and does not substitute for the knowledge and judgment of your health care professional. This information does not contain any assurances that this product is safe, effective, or appropriate for you.

STREPTOMYCIN - INJECTION

(strep-toe-MYE-sin)

WARNING: This medication can sometimes cause serious nerve damage, possibly resulting in permanent hearing loss and balance problems. The risk is higher if you have kidney disease, if you are receiving high doses of this medication, if you use this drug for a long time, if you are an older adult (e.g., older than 60 years), or if you develop a severe loss of body water (become dehydrated). To reduce the risk of dehydration, drink plenty of fluids while using this medication unless your doctor directs you otherwise. Before starting streptomycin, tell your doctor if you already have kidney or hearing problems.

Tell your doctor immediately if you notice ringing/roaring in the ears, headache, hearing loss, balance problems, unusual drowsiness, dizziness, vision changes, or numbness/tingling of the skin.

Your doctor will monitor your progress to reduce the risk of these side effects and may test your hearing, kidneys, and streptomycin blood level. This medication may be stopped if you develop kidney problems or hearing problems.

If possible, you should avoid using any other medications that may harm the kidneys or nerves while using streptomycin (e.g., cidofovir, cisplatin, cyclosporine, aminoglycoside antibiotics such as gentamicin/tobramycin, among others). Strong "water pills"/diuretics (e.g., furosemide, ethacrynic acid) should also be avoided if possible.

Before having surgery, tell your doctor or dentist that you are using this medication. This drug may affect many of the drugs used during surgery and may increase your risk of side effects.

USES: This medication is used with other medications to treat active tuberculosis (TB) infection if you cannot take other drugs for TB or if you have a type of TB that cannot be treated with other drugs (drug-resistant TB). Streptomycin belongs to a class of drugs known as aminoglycoside antibiotics. It works by killing the organisms that cause the infection.

This drug may also be used to treat other serious infections (e.g., Mycobacterium avium complex-MAC, tularemia, endocarditis, plague) along with other medications.

HOW TO USE: This medication is given by injection, usually into a muscle, by a health care professional. When you start treatment for TB, it is usually given once a day or as directed by your doctor. Health care professionals must follow all the manufacturer's instructions for properly mixing and giving this drug. It is important to change the location of the injection site daily to avoid problem areas under the skin. If you have any questions about using this medication properly, consult your doctor or pharmacist.

Dosage is based on the kind of infection, your weight, medical condition, streptomycin blood levels, and side effects. How often you receive injections and the length of your treatment will depend on the type of infection you have and your response to treatment.

Medication to treat tuberculosis is usually used for 9 months or longer. After you receive streptomycin daily for 1 to 2 months, your doctor may direct you to receive this medication less often (e.g., 2 to 3 times a week). Your doctor may direct you to stop using this medication before stopping your other TB medications. It is very important to continue using streptomycin and your other medications exactly as prescribed by your doctor.

Do not stop taking this medication (or other TB medicines/antibiotics) even for a short time unless directed to do so by your doctor. Skipping or changing your dose without approval from your doctor may worsen side effects or make the infection (especially TB) more difficult to treat (resistant). If TB becomes resistant to this medication, it might also become resistant to other TB medications. This medication works best when the amount of drug in your body is kept at a constant level. Therefore, be sure to keep all appointments for receiving this drug.

Tell your doctor immediately if your infection symptoms return (e.g., fever, chills, body aches) while you are using this medication or after you stop using it.

Nausea, vomiting, stomach upset, or loss of appetite may occur. Pain/irritation/redness may occur at the injection site. 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.

Tell your doctor immediately if any of these unlikely but serious side effects occur: muscle weakness, persistent diarrhea even after stopping this medication.

Tell your doctor immediately if any of these rare but very serious side effects occur: easy bleeding/bruising, fast heartbeat, new signs of infections (e.g., high fever, persistent cough), change in the amount of urine, unusual tiredness.

Use of this medication for prolonged or repeated periods may result in oral thrush or a new vaginal yeast infection. Contact your doctor if you notice white patches in your mouth, a change in vaginal discharge, or other new symptoms.

A very serious allergic reaction to this drug is rare. However, seek immediate medical attention if you notice any symptoms of a serious allergic reaction, including: rash, itching/swelling (especially of the tongue/lips/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.

Contact your doctor for medical advice about side effects. The following numbers do not provide medical advice, but in the US you may report side effects to the Food and Drug Administration (FDA) at 1-800-FDA-1088. In Canada, you may call Health Canada at 1-866-234-2345.

PRECAUTIONS: See also Warning section.

Before using streptomycin injection, tell your doctor or pharmacist if you are allergic to it; or to other aminoglycoside antibiotics (e.g., tobramycin, gentamicin); or if you have any other allergies.

Before using this medication, tell your doctor or pharmacist your medical history, especially of: kidney problems, hearing problems, severe loss of body water (dehydration), a certain muscle problem (myasthenia gravis), burns over a large area of skin, cystic fibrosis.

Before having surgery, tell your doctor or dentist that you are taking this medication.

Caution is advised when using this drug in older adults because they may have decreased kidney function. Therefore, older adults may be more sensitive to the kidney and hearing side effects.

Streptomycin is not recommended for use during pregnancy. Consult your doctor for more details.

This medication passes into breast milk. Therefore, breast-feeding while using this medication is not recommended. Consult your doctor before breast-feeding.

Your doctor or pharmacist may already be aware of any possible drug interactions and may be monitoring you for them. Do not start, stop, or change the dosage of any medicine before checking with your doctor or pharmacist first.

This drug should not be used with certain live bacterial vaccines (e.g., BCG, typhoid) because the vaccines may not be effective. If you have recently received or are planning to receive any vaccinations, tell your doctor or pharmacist before starting streptomycin.

Before using this medication, tell your doctor or pharmacist of all prescription and nonprescription/herbal products you may use, especially of: amphotericin B, "water pills"/diuretics (e.g., hydrochlorothiazide), high doses of aspirin/NSAIDs such as ibuprofen/naproxen.

If your doctor has directed you to take low doses of aspirin to prevent heart attack or stroke (usually at dosages of 81-325 milligrams a day), you should continue to take the aspirin. Consult your doctor or pharmacist for more details.

This document does not contain all possible interactions. Therefore, before using this product, tell your doctor or pharmacist of all the products you use. Keep a list of all your medications with you, and share the list with your doctor and pharmacist.

OVERDOSE: If overdose is suspected, contact your local poison control center or emergency room immediately. US residents can call the US National Poison Hotline at 1-800-222-1222. Canada residents can call a provincial poison control center. Symptoms may include: extreme drowsiness, slow/shallow breathing, inability to move.

NOTES: Laboratory and/or medical tests (e.g., kidney tests, hearing tests, streptomycin levels) should be performed periodically to monitor your progress or check for side effects. Consult your doctor for more details.

MISSED DOSE: If you miss a dose, contact your doctor immediately to establish a new dosing schedule. Do not double the dose to catch up.

STORAGE: Store the unmixed powder at room temperature between 59-86 degrees F (15-30 degrees C) away from light and moisture. Do not store in the bathroom. Keep all medicines away from children and pets.

After mixing, you may store the liquid at room temperature for up to 7 days. Consult your pharmacist for details.

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 for more details about how to safely discard your product.

Information last revised July 2008 Copyright(c) 2008 First DataBank, Inc.