Posimir Side Effects Center

Medical Editor: John P. Cunha, DO, FACOEP

What Is Posimir?

Posimir (bupivacaine solution) contains an amide local anesthetic and is indicated in adults for administration into the subacromial space under direct arthroscopic visualization to produce post-surgical analgesia for up to 72 hours following arthroscopic subacromial decompression.

What Are Side Effects of Posimir?

Side effects of Posimir include:

dizziness,
changes in taste,
pain or discomfort when urinating,
headache,
numbness,
tingling,
ringing in the ears (tinnitus),
nausea,
vomiting,
anemia,
slow heart rate,
constipation,
increased C-reactive protein,
diarrhea,
post procedural bruising,
procedural pain,
itching,
fever,
drowsiness, and
surgical site bleeding

Seek medical care or call 911 at once if you have the following serious side effects:

Serious eye symptoms such as sudden vision loss, blurred vision, tunnel vision, eye pain or swelling, or seeing halos around lights;
Serious heart symptoms such as fast, irregular, or pounding heartbeats; fluttering in your chest; shortness of breath; and sudden dizziness, lightheartedness, or passing out;
Severe headache, confusion, slurred speech, arm or leg weakness, trouble walking, loss of coordination, feeling unsteady, very stiff muscles, high fever, profuse sweating, or tremors.

This document does not contain all possible side effects and others may occur. Check with your physician for additional information about side effects.

Dosage for Posimir

The recommended dose of Posimir is 660 mg (5 mL).

Posimir In Children

Safety and effectiveness of Posimir in pediatric patients below the age of 18 have not been established.

What Drugs, Substances, or Supplements Interact with Posimir?

Posimir may interact with other medicines such as:

local anesthetics,
nitrates/nitrites,
antineoplastic agents,
antibiotics,
antimalarials,
anticonvulsants,
acetaminophen,
metoclopramide,
quinine, and
sulfasalazine

Tell your doctor all medications and supplements you use.

Posimir During Pregnancy and Breastfeeding

Tell your doctor if you are pregnant or plan to become pregnant before using Posimir; it is unknown how it would affect a fetus. Both Posimir and benzyl alcohol (an inactive ingredient in Posimir) have been reported to pass in breast milk. Consult your doctor before breastfeeding.

Additional Information

Our Posimir (bupivacaine solution) for Infiltration Use Side Effects Drug Center provides a comprehensive view of available drug information on the potential side effects when taking this medication.

This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

QUESTION

Medically speaking, the term "myalgia" refers to what type of pain? See Answer

Posimir Consumer Information

Get emergency medical help if you have signs of an allergic reaction: hives, red rash, itching; sneezing, difficulty breathing; severe dizziness, vomiting; swelling of your face, lips, tongue, or throat.

Tell your caregivers at once if you have any of these serious side effects:

feeling anxious, restless, confused, dizzy, drowsy, or like you might pass out;
ringing in your ears, problems with speech or vision;
metallic taste in your mouth, numbness or tingling around your mouth;
muscle twitching, tremors, seizure (convulsions);
weak or shallow breathing;
fast heart rate, gasping, feeling unusually hot;
slow heart rate, weak pulse; or
little or no urination.

Seek medical attention right away if you develop a serious condition called methemoglobinemia. Symptoms include headache, fast heartbeats, shortness of breath, feeling tired or light-headed, or skin that looks pale, gray, or blue-colored.

Common side effects include:

weakness, long-lasting numbness or tingling;
feeling restless or drowsy;
tremors;
headache, blurred vision;
fast or slow heartbeats;
breathing problems;
chills or shivering;
back pain; or
nausea, vomiting.

This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

SLIDESHOW

Back Pain: 16 Back Pain Truths and Myths See Slideshow

Posimir Professional Information

SIDE EFFECTS

The following adverse reactions to bupivacaine hydrochloride are described in other sections of the prescribing information:

Systemic Toxicity with Intravascular Injection [see WARNINGS AND PRECAUTIONS]
Methemoglobinemia [see WARNINGS AND PRECAUTIONS]
Chondrolysis with Intra-Articular Infusion [see WARNINGS AND PRECAUTIONS]
Cardiovascular System Reactions [see WARNINGS AND PRECAUTIONS]

Clinical Trials Experience

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

The safety of POSIMIR, doses ranging from 2.5 mL to 5 mL, was evaluated in 10 randomized, double-blind, controlled trials. Overall, POSIMIR 5 mL, the recommended dose, has been administered to a total of 735 patients in clinical trials using a variety of administration methods, including the recommend method of infiltration. Three trials were controlled with bupivacaine HCl, two trials were controlled with bupivacaine HCl and vehicle placebo, and five trials were controlled with vehicle placebo. An additional 47 patients were treated with saline placebo in one of the bupivacaine HCl-controlled trials. The evaluated surgical procedures included inguinal hernia repair, subacromial decompression of the shoulder, abdominal hysterectomy, laparotomy, laparoscopic cholecystectomy, and laparoscopically-assisted colectomy.

Shoulder Surgical Procedures

There were three studies evaluating the safety of POSIMIR administered during shoulder surgery.

In Study 1, one of three treatments was administered into the subacromial space at the end of surgery: POSIMIR, vehicle placebo, or bupivacaine HCl. Table 1 presents commonly-reported adverse reactions from Study 1.

Table 1. Commonly Reported Adverse Reactions from Study 1 (Incidence ≥ 2% and More Frequent than

Preferred Term, n (%)	Posimir (N=53)	Bupivacaine HCl (n=29)	Vehicle Placebo (N=25)
Headache	3 (5.7%)	1 (3.4%)	1 (4.0%)
Electrocardiogram T wave inversion	2 (3.8%)	0	0
Hypoesthesia	2 (3.8%)	1 (3.4%)	1 (4.0%)
Pruritus generalized	2 (3.8%)	0	0

In Study 2 and Study 3, patients were administered either POSIMIR or vehicle placebo into the subacromial space at the end of surgery. Table 2 presents commonly-reported adverse reactions from Studies 2 and 3.

Table 2. Commonly Reported Adverse Reactions Pooled from Study 2 and Study 3 (Incidence ≥ 2% and

Preferred Term, n (%)*	Posimir (N=75)	Vehicle Placebo (N=44)
Dizziness	30 (40.3%)	17 (38.3%)
Vomiting	22 (29.0%)	12 (26.6%)
Headache	17 (23.3%)	7 (16.3%)
Paresthesia	14 (18.4%)	7 (15.4%)
Dysgeusia	13 (17.3%)	7 (14.9%)
Hypoesthesia	13 (17.3%)	7 (15.8%)
Tinnitus	10 (13.2%)	3 (6.7%)
Dysuria	8 (10.1%)	4 (10.1%)
Pyrexia	7 (9.3%)	2 (4.6%)
Insomnia	5 (7.1%)	0
Dyspnea	3 (3.8%)	0
Muscle twitching	3 (3.8%)	0
Peripheral swelling	3 (3.9%)	0
Urinary retention	2 (2.7%)	1 (2.1%)
Contusion	2 (2.5%)	0
Dysmenorrhea	2 (2.7%)	0
Dysmenorrhea	2 (2.7%)	0
Nasal congestion	2 (2.5%)	0
Pruritus generalized	2 (2.5%)	0
* Percentages adjusted to account for the different sizes of the pooled studies.

Less common adverse reactions (incidence less than 2% and more frequent than either bupivacaine HCl or vehicle placebo) following POSIMIR administration in shoulder surgical procedures were angina pectoris, blepharospasm, electrocardiogram T wave amplitude decreased, fatigue, osteoarthritis, procedural nausea, proceduralpain, and pulmonary arterial hypertension.

Additional follow-up safety data consisting of shoulder MRI, physical examination of the shoulder, and assessments of wound healing were collected at 6 months in Study 1 and at 18 months in Study 2. There were no specific long-term follow-up evaluations for patients treated in Study 3; however, study investigators did not report any cases of chondrolysis in follow-up surveys. All surgical incisions were found to have healed as expected in all three studies. Table 3 presents the results of the MRIand physical examinations for Study 1. Table 4 presents the results of the MRI and physical examinations for Study 2.

Table 3. 6-Month Follow-up Safety Data from Subacromial Decompression Study 1.

Safety Evaluation	Posimir	Vehicle Placebo	Bupivacaine HCl
Number enrolled	53	25	29
Shoulder MRI
Number at 6-month follow-up	51	25	25
Improved , n (%)	6 (11.8%)	2 (8.0%)	6 (24.0%)
No change , n (%)	31 (60.8%)	14 (56.0%)	9 (36.0%)
Worsened , n (%)	14 (27.4%)	9 (36%)	10 (40%)
Constant-Murley score
Number at 6-month follow-up	52	25	26
Pre-surgery, mean (SD)	44.7 (12.5%)	41.7 (11.7%)	42 (11.3%)
Follow-up, mean (SD)	61.6 (15.2%)	63.2 (12.4%)	65.6 (6.8%)
Decreased from baseline. n (%)	5 (9.6%)	2 (8.0%)	0 (0%)
^[1] Compared with pre-surgical MRI

Table 4. 18-Month Follow-up Safety Data from Subacromial Decompression Study 2.

Safety Evaluation	Posimir	Vehicle Placebo
Number enrolled	40	20
Shoulder MRI
Number at 18-month follow-up	27	14
Overall assessment
Unexpected injuries or findings compared with pre-surgical MRI, n (%)	0	0
New-onset cartilage or bone lesions of concern (not present at baseline and unrelated to surgery or natural disease progression), n (%)	0	0
Glenohumeral joint and humeral head
Presence of cartilage thinning - humeral head, n (%)
Grade 0: normal/none	26 (96.3%)	14 (100%)
Grade 1: mild	0	0
Grade 2: moderate	1 (3.7%)^[1]	0
Grade 3: severe	0	0
Rotator cuff and labrum
Supraspinatus tendon tear, n (%)
No tear	16 (59.3%)	5 (35.7%)
Partial	7 (25.9%)	7 (50.0%)
Full thickness	1 (3.7%)	0
Other findings	3 (11.1%)	2 (14.3%)
Supraspinatus - other findings, n (%)
Interstitial tear	0	0
Tendinosis	2 (7.4%)	1 (7.1%)
Surgically repaired tendon	0	1 (7.1%)
Interstitial tear/tendinosis	1 (3.7%)	0
(blank)	24 (88.9%)	12 (85.7%)
Subacromial space - acromion
Acromion bony spur, n (%)
Yes	1 (3.7%)	0
No	26 (96.3%)	14 (100%)
Acromion bone resection, n (%)
Yes	18 (66.7%)	9 (64.3%)
No	9 (33.3%)	5 (35.7%)
Acromion signal abnormality (edema, fibrosis), n (%)
Yes	2 (7.4%)^[2]	2 (14.3%)^[2]
No	25 (92.6%)^[2]	12 (85.7%)^[2]
Acromioclavicular joint
Bone resection at acromioclavicular joint/postoperative changes, n (%)
Yes	10 (37.0%)	4 (28.6%)
No	16 (59.3%)	10 (71.4%)
Not evaluable	1 (3.7%)	0
Joint effusion/synovitis, n (%)
Grade 0: normal/none	9 (33.3%)	2 (14.3%)
Grade 1: mild	9 (33.3%)^[3]	7 (50.0%)
Grade 2: moderate	3 (11.1%)^[3]	3 (21.4%)^[3]
Grade 3: severe	0	1 (7.1%)^[3]
Not evaluable	6 (22.2%)	1 (7.1%)
Bursa and Soft Tissue
Subacromial bursa - bursitis/excess fluid, n (%)
Grade 0: normal/none	18 (66.7%)	5 (35.7%)
Grade 1: mild	6 (22.2%)	9 (64.3%)^[4]
Grade 2: moderate	3 (11.1%)	0
Grade 3: severe	0	0
Physical Exam
Number at 18-month follow-up	31	16
Clinical assessment, n (%)
Normal	27 (87.1%)	13 (81.3%)
Abnormal	4 (12.9%)	3 (18.8%)
Pain intensity, 0-10 scale
Mean (SE)	0.9 (0.4%)	1.2 (0.6%)
Positive impingement sign, n (%)
Yes	3 (9.7%)	3 (18.8%)
No	28 (90.3%)	13 (81.3%)
Full passive range of motion, n (%)
Yes	27 (87.1%)	13 (81.3%)
No	4 (12.9%)	3 (18.8%)
^[1] The humeral head cartilage thinning was unchanged from baseline. ^[2] Two POSIMIR patients were positive for signal abnormalities at baseline and negative at 18 months. Two POSIMIR patients were negative for signal abnormalities at baseline and positive at 18 months. One placebo patient was positive for signal abnormality at baseline and negative at 18 months. Two placebo patients were positive for signal abnormalities at both baseline and 18 months. ^[3] Two POSIMIR patients had joint effusion/synovitis that improved from moderate at baseline to mild at 18 months. One POSIMIR patient had joint effusion/synovitis that improved from severe at baseline to mild at 18 months. Four patients (1 POSIMIR, 3 placebo) had joint effusion/synovitis that worsened from mild at baseline to moderate at 18 months. One placebo patient had joint effusion/synovitis that worsened from mild at baseline to severe at 18 months. ^[4] One placebo patient had bursitis/excess fluid that was severe at baseline and mild at 18 months.

Soft Tissue Surgical Procedures

There were two studies evaluating the safety of POSIMIR in patients undergoing inguinal hernia repair (hernioplasty). Patients in these studies were administered either POSIMIR 5 mL or vehicle placebo; 2.5 mL administered into the floor of the inguinal canal and 2.5 mL administered into the subcutaneous space. Table 5 presents commonly-reported adverse reactions from these studies.

Table 5. Commonly Reported Adverse Reactions Pooled from Studies in Inguinal Hernia Repair (Incidence ≥ 2% and More Frequent than Placebo)

Preferred Term, n (%)*	Posimir (N=69)	Vehicle Placebo (N=53)
Bradycardia	16 (22.9%)	7 (14.2%)
Pruritus^†	15 (21.6%)	9 (17.5%)
Post procedural contusion (bruising)	10 (14.0%)	5 (10.1%)
Vomiting	6 (9.4%)	4 (7.4%)
Incision site swelling	4 (6.0%)	3 (5.7%)
Dyspepsia	4 (5.7%)	2 (3.7%)
Pyrexia	4 (6.0%)	2 (4.0%)
Contusion	4 (5.7%)	0
Back pain	3 (4.1%)	2 (3.4%)
Viral infection	3 (4.1%)	2 (4.0%)
Incision site erythema	3 (4.1%)	0
Oropharyngeal pain	3 (4.6%)	0
Tachycardia	3 (4.6%)	0
Upper respiratory tract infection	2 (3.0%)	1 (2.0%)
Dry throat	2 (3.2%)	0
Hyperhidrosis	2 (3.0%)	0
Hypertension	2 (2.8%)	0
Local swelling	2 (3.0%)	0
Testicular swelling	2 (3.2%)	0
* Percentages adjusted to account for the different sizes of the pooled studies. ^† Incision site pruritus, generalized pruritus, and genital pruritus were also reported, but none had incidence ≥2% and more frequent than placebo.

There were five studies evaluating the safety of POSIMIR in laparoscopic, laparoscopically-assisted, or open abdominal surgeries.

In two studies in patients undergoing laparoscopic cholecystectomy, POSIMIR or bupivacaine HCl was administered into the laparoscopic port incisions at the end of surgery. In one of these studies, a subset of patients received either POSIMIR or saline placebo. In a study of patients undergoing laparoscopically-assisted colectomy, POSIMIR or vehicle placebo was administered predominantly into the hand port incision at the end of surgery. In a study of patients undergoing laparotomy, POSIMIR or bupivacaine HCl was administered into the full length of the surgical incision at the end of surgery. Table 6 presents commonly-reported adverse reactions from these four studies. Table 7 and Table 8 present, respectively, surgical-site adverse reactions and early-occurring central nervous system (CNS)-related adverse reactions from the laparoscopic cholecystectomy study that included a saline placebo control arm.

Table 6. Commonly Reported Adverse Reactions Pooled from Laparoscopic, Laparoscopically-Assisted, and Open Abdominal Surgery Studies (Incidence ≥2% and More Frequent than Bupivacaine HCl or Placebo).

Preferred Term, n (%)*	Posimir (N=337)	Bupivacaine HCl (N=186)	Vehicle Placebo (N=78)
Post procedural contusion (bruising)	231 (71.2%)	119 (61.8%)	41 (52.6%)
Nausea	189 (55.8%)	111 (59.6%)	40 (51.3%)
Constipation	112 (35.2%)	80 (41.8%)	8 (10.3%)
Somnolence	92 (30.4%)	80 (41.0%)	3 (3.8%)
Headache	86 (27.2%)	63 (32.3%)	12 (15.4%)
Dizziness	75 (23.5%)	58 (30.1%)	6 (7.7%)
Vomiting	66 (19.4%)	39 (21.0%)	6 (7.7%)
Dysgeusia	50 (16.2%)	33 (16.9%)	2 (2.6%)
Pruritus^†	45 (14.3%)	36 (18.7%)	5 (6.4%)
Procedural pain	35 (11.4%)	35 (17.8%)	0
Diarrhea	34 (9.8%)	10 (5.5%)	10 (12.8%)
Incision site hemorrhage	30 (8.7%)	6 (3.0%)	3 (3.8%)
Pyrexia	29 (8.2%)	10 (5.7%)	11 (14.1%)
Abdominal distension	29 (8.2%)	8 (4.8%)	12 (15.4%)
Incision site erythema	29 (8.1%)	5 (2.7%)	10 (12.8%)
Post procedural discharge	26 (7.5%)	8 (4.4%)	7 (9.0%)
Paresthesia	22 (5.9%)	25 (13.1%)	2 (2.6%)
Hypokalemia	18 (5.2%)	2 (1.4%)	10 (12.8%)
Incision site hematoma	17 (4.5%)	3 (1.7%)	4 (5.1%)
Anemia	16 (4.6%)	1 (0.7%)	7 (9.0%)
Flatulence	16 (4.6%)	7 (4.0%)	8 (10.3%)
Hypertension	16 (4.5%)	7 (3.6%)	1 (1.3%)
Incision site infection	15 (4.2%)	4 (2.5%)	2 (2.6%)
Musculoskeletal pain	15 (4.4%)	8 (4.9%)	0
Abdominal pain	14 (3.9%)	1 (0.5%)	1 (1.3%)
Insomnia	13 (3.8%)	5 (2.9%)	7 (9.0%)
Dyspepsia	13 (3.6%)	3 (1.9%)	4 (5.1%)
Wound dehiscence	13 (3.6%)	3 (1.5%)	5 (6.4%)
Cough	12 (3.6%)	3 (1.8%)	1 (1.3%)
Oropharyngeal pain	12 (3.5%)	2 (1.0%)	0
Urinary retention	10 (2.8%)	2 (1.2%)	4 (5.1%)
Chest pain	10 (2.9%)	1 (0.5%)	1 (1.3%)
Ileus	10 (2.7%)	1 (0.7%)	3 (3.8%)
Body temperature increased	9 (2.4%)	0	2 (2.6%)
Abdominal pain upper	8 (2.5%)	2 (1.0%)	0
Rash	7 (2.1%)	7 (3.8%)	1 (1.3%)
Pain in extremity	7 (2.1%)	5 (2.8%)	1 (1.3%)
Dry mouth	7 (2.2%)	2 (1.0%)	1 (1.3%)
Nasopharyngitis	7 (2.1%)	0	0
* Percentages adjusted to account for the different sizes of the pooled studies. ^† Incision site pruritus, generalized pruritus, eye pruritus, anal pruritus, and infusion site pruritus were also reported, but none had incidence ≥2% and more frequent than placebo.

Table 7. Incidence of Surgical Site Adverse Reactions from Laparoscopic Cholecystectomy Study with Saline Placebo and Bupivacaine HCl Controls.

Prespecified Term*, n (%)	Saline Placebo Control		Bupivacaine HCl Control
Prespecified Term*, n (%)	Posimir (N=45)	Saline Placebo (N=47)	Posimir (N=148)	Bupivacaine HCl (N=148)
Visible bruising	41 (91.1%)	33 (70.2%)	142 (95.9%)	105 (70.9%)
Surgical site bleeding	22 (48.9%)	20 (42.6%)	19 (12.8%)	24 (16.2%)
Drainage from surgical incision(s)	2 (4.4%)	3 (6.4%)	11 (7.4%)	6 (4.1%)
Wound hematoma	0	0	6 (4.1%)	2 (1.4%)
Wound dehiscence	0	0	2 (1.4%)	3 (2.0%)
Surgical site infection	0	0	2 (1.4%)	1 (0.7%)
* Terms were prespecified for examination by a blinded assessor on postoperative days 0, 4, 7, 14, 28, and 59.

Table 8. CNS-related Adverse Reactions Solicited from Subjects at 6 Hours Post-surgery in Laparoscopic Cholecystectomy Study with Saline Placebo andBupivacaine HCl Controls.

Dictionary-Derived Term (Symptom)*	Saline Placebo Control		Bupivacaine HCl Control
Dictionary-Derived Term (Symptom)*	Posimir (N=45)	Saline Placebo (N=47)	Posimir (N=148)	Bupivacaine HCl (N=148)
Entire study, n (%)
Somnolence (Drowsiness)	18 (40.0%)	16 (34.0%)	60 (40.5%)	48 (32.4%)
Nausea (Nausea)	9 (20.0%)	13 (27.7%)	48 (32.4%)	57 (38.5%)
Dizziness (Dizziness)	3 (6.7%)	3 (6.4%)	28 (18.9%)	31 (20.9%)
Headache (Headache)	5 (11.1%)	4 (8.5%)	23 (15.5%)	18 (12.2%)
Vomiting (Vomiting)	2 (4.4%)	3 (6.4%)	10 (6.8%)	15 (10.1%)
Constipation (Constipation)	0 (0.0%)	4 (8.5%)	9 (6.1%)	10 (6.8%)
Pruritus (Itching)	1 (2.2%)	1 (2.1%)	6 (4.1%)	5 (3.4%)
Subset of study, n (%)N=23N=22
Dysgeusia (Metallic taste in mouth)	3 (13.0%)	2 (9.1%)	26 (17.6%)	22 (14.9%)
Paresthesia (Tingling)	0	0	2 (1.4%)	6 (4.1%)
Hypoesthesia (Numbness)	0	0	1 (0.7%)	1 (0.7%)
* Patients responded to a 10-symptom checklist (7 symptoms for part of the saline placebo-controlled portion of the study).

In a study of patients undergoing total abdominal hysterectomy, POSIMIR, vehicle placebo, or bupivacaine HCl was administered into the surgical incision at the end of surgery. Table 9 presents commonly-reported adverse reactions from this study.

Table 9. Commonly Reported Adverse Reactions from Total Abdominal Hysterectomy Study (Incidence ≥ 2% and More Frequent than Bupivacaine HCl).

Preferred Term	Posimir (N=60)	Bupivacaine HCl (N=27)	Vehicle Placebo (N=27)
Post procedural contusion (bruising)	36 (60.0%)	0	9 (33.3%)
Anemia	10 (16.7%)	3 (11.1%)	4 (14.8%)
Dizziness	9 (15.0%)	4 (14.8%)	3 (11.1%)
Vomiting	9 (15.0%)	4 (14.8%)	8 (29.6%)
C-reactive protein increased	7 (11.7%)	1 (3.7%)	0
Pyrexia	7 (11.7%)	7 (25.9%)	3 (11.1%)
Somnolence	5 (8.3%)	2 (7.4%)	0
Blood potassium decreased	4 (6.7%)	0	1 (3.7%)
Hypertension	4 (6.7%)	2 (7.4%)	1 (3.7%)
Incision site hematoma	3 (5.0%)	0	0
Electrocardiogram change	2 (3.3%)	0	0
Procedural hemorrhage	2 (3.3%)	0	0
Vaginal hematoma	2 (3.3%)	0	0

Less common adverse reactions (incidence less than 2% and more frequent than either bupivacaine HCl or placebo) following POSIMIR administration in soft tissue surgical procedures were: application site irritation, atrial fibrillation, drug eruption, electrocardiogram QT prolonged, eructation, erythema, excessive granulation tissue, fatigue, genital pain, heart rate increased, hiccups, hypoesthesia, hypogeusia, incision site cellulitis, incision site erosion, incision site hypoesthesia, incision siteinflammation, incision site edema, incision site pain, incision site rash, mean arterial pressure increased, micturition urgency, night sweats, overdose, palpitations, procedural hypertension, pruritus generalized, rash generalized, seroma, sinus tachycardia, skin discoloration, tinnitus, and wound hemorrhage.

DRUG INTERACTIONS

Do not dilute or mix POSIMIR with local anesthetics or other drugs or diluents.

Avoid additional use of local anesthetics within 168 hours following administration of POSIMIR.

Drugs Associated With Methemoglobinemia

Patients who are administered POSIMIR are at increased risk of developing methemoglobinemia when concurrently exposed to following drugs, which could include other local anesthetics [see WARNINGS AND PRECAUTIONS].

Examples of Drugs Associated with Methemoglobinemia:

Class	Examples
Nitrates/Nitrites	nitric oxide, nitroglycerin, nitroprusside, nitrous oxide
Local anesthetics	articaine, benzocaine, bupivacaine, lidocaine, mepivacaine, prilocaine, procaine, ropivacaine, tetracaine
Antineoplastic agents	cyclophosphamide, flutamide, hydroxyurea, ifosfamide, rasburicase
Antibiotics	dapsone, nitrofurantoin, para-aminosalicylic acid, sulfonamides
Antimalarials	chloroquine, primaquine
Anticonvulsants	phenobarbital, phenytoin, sodium valproate
Other drugs	acetaminophen, metoclopramide, quinine, sulfasalazine

Read the entire FDA prescribing information for Posimir (Bupivacaine Solution)