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STALEVO (LEVODOPA WITH CARBIDOPA AND ENTACAPONE) TABLETS: SPECIAL PRECAUTIONS

The events listed below are rare events known to be associated with the use of drugs that increase dopaminergic activity, including Stalevo (Carbidopa, Levodopa, Entacapone) tablets, although they are most often associated with the use of direct dopamine agonists.

Rhabdomyolysis

Cases of severe rhabdomyolysis have been reported with entacapone when used in combination with levodopa. The complicated nature of these cases makes it impossible to determine what role, if any, entacapone played in their pathogenesis. Severe prolonged motor activity including dyskinesia may account for rhabdomyolysis. One case, however, included fever and alteration of consciousness. It is therefore possible that the rhabdomyolysis may be a result of the syndrome described in "Hyperpyrexia and Confusion".

Hyperpyrexia and Confusion

Cases of a symptom complex resembling the neuroleptic malignant syndrome characterized by elevated temperature, muscular rigidity, altered consciousness, and elevated CPK have been reported in association with the rapid dose reduction or withdrawal of other dopaminergic drugs. No cases have been reported following the abrupt withdrawal or dose reduction of entacapone treatment during clinical studies.

Prescribers should exercise caution when discontinuing Stalevo (Carbidopa, Levodopa, Entacapone) combination treatment. When considered necessary, withdrawal should proceed slowly. If a decision is made to discontinue treatment with Stalevo, recommendations include monitoring the patient closely and adjusting other dopaminergic treatments as needed. This syndrome should be considered in the differential diagnosis for any patient who develops a high fever or severe rigidity. Tapering entacapone has not been systematically evaluated.

Fibrotic Complications

Cases of retroperitoneal pulmonary infiltrates, fibrosis, pleural effusion, and pleural thickening have been reported in some patients treated with ergot derived dopaminergic agents. These complications may resolve when the drug is discontinued, but complete resolution does not always occur. Although these adverse events are believed to be related to the ergoline structure of these compounds, whether other, nonergot derived drugs (e.g., entacapone, levodopa) that increase dopaminergic activity can cause them is unknown. It should be noted that the expected incidence of fibrotic complications is so low that even if entacapone caused these complications at rates similar to those attributable to other dopaminergic therapies, it is unlikely that it would have been detected in a cohort of the size exposed to entacapone. Four cases of pulmonary fibrosis were reported during clinical development of entacapone; three of these patients were also treated with pergolide and one with bromocriptine. The duration of treatment with entacapone ranged from 7-17 months.

Melanoma

Epidemiological studies have shown that patients with Parkinson's disease have a higher risk (2- to approximately 6-fold higher) of developing melanoma than the general population. Whether the increased risk observed was due to Parkinson's disease or other factors, such as drugs used to treat Parkinson's disease, is unclear.

For the reasons stated above, patients and providers are advised to monitor for melanomas frequently and on a regular basis when using Stalevo for any indication. Ideally, periodic skin examination should be performed by appropriately qualified individuals (e.g., dermatologists).

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