ADVIL MULTI-SYMPTOM COLD-FLU (chlorpheniramine maleate/phenylephrine hcl/ibuprofen)

There are 7 contraindications. Absolute contraindication.

Contraindication List
Aspirin exacerbated respiratory disease
Cerebrovascular accident
History of roux-en-Y gastric bypass
Post-operative from CABG surgery
Pregnancy
Renal transplant
Severe uncontrolled hypertension

There are 24 severe contraindications. Adequate patient monitoring is recommended for safer drug use.

Severe List
Acute myocardial infarction
Alcohol use disorder
Angle-closure glaucoma
Benign prostatic hyperplasia
Bladder outflow obstruction
Chronic idiopathic constipation
Chronic kidney disease stage 4 (severe) GFR 15-29 ml/min
Chronic kidney disease stage 5 (failure) GFr<15 ml/min
Coronary artery disease
CYp2c9 intermediate metabolizer (activity score 1)
CYp2c9 poor metabolizer
Gastrointestinal hemorrhage
Gastrointestinal obstruction
Gastrointestinal perforation
Gastrointestinal ulcer
History of kidney donation
Hypertension
Hyperthyroidism
Increased risk of bleeding
Nephrectomy
Stenosing peptic ulcer
Systemic mastocytosis
Thrombotic disorder
Urinary retention

There are 8 moderate contraindications. Clinically significant contraindication, where the condition can be managed or treated before the drug may be given safely.

Moderate List
Chronic heart failure
Chronic obstructive pulmonary disease
Disease of liver
Hypertension
Hyperthyroidism
Increased risk of bleeding due to coagulation disorder
Kidney disease with likely reduction in glomerular filtration rate (GFr)
Tobacco smoker

There are 94 severe adverse reactions.

More Frequent	Less Frequent
Skin rash	Body fluid retention Edema Pruritus of skin Tinnitus

Rare/Very Rare

Abnormal hepatic function tests Abnormal vaginal bleeding Acute cognitive impairment Acute myocardial infarction Acute pancreatitis Agranulocytosis Allergic dermatitis Altered mental status Anaphylaxis Anemia Angioedema Aphthous stomatitis Aplastic anemia Blood dyscrasias Bloody stools Bloody vomit Blurred vision Bronchospastic pulmonary disease Bullous dermatitis Cardiac arrhythmia Cerebrovascular accident Chest pain Chest tightness Chronic heart failure Conjunctivitis Cystitis Depression Diplopia Dizziness DRESS syndrome Drug-induced hepatitis Dry eye Dyspnea Eosinophilia Epistaxis Erythema multiforme Esophageal ulcer Exfoliative dermatitis Extrasystoles Gastric ulcer Gastritis Gastrointestinal hemorrhage Gastrointestinal perforation Gastrointestinal ulcer Hallucinations Headache disorder Hematuria Hemolytic anemia Hepatitis Hyperhidrosis Hyperkalemia Hypersensitivity drug reaction Hypertension Hypotension IgA vasculitis Insomnia Jaundice Kidney disease with reduction in glomerular filtration rate (GFr) Laryngeal edema Leukopenia Lupus-like syndrome Mood changes Nephrotoxicity Nervousness Neutropenic disorder Non-infective meningitis Pallor Pancytopenia Peptic ulcer Peripheral neuropathy Polyuria Renal failure Renal papillary necrosis Renal tubular necrosis Rhinitis Scotomata Seizure disorder Serum sickness Stevens-johnson syndrome Tachycardia Thrombocytopenic disorder Toxic amblyopia Toxic epidermal necrolysis Tremor Urticaria Vasculitis Visual changes Wheezing Worsening of chronic heart failure

There are 70 less severe adverse reactions.

More Frequent	Less Frequent
Anticholinergic toxicity Dizziness Drowsy Heartburn Nausea Thick bronchial secretions	Acute abdominal pain Anorexia Constipation Diarrhea Dyspepsia Flatulence Gastric acid hypersecretory conditions Headache disorder Irritability Muscle weakness Nervousness Sedation Vomiting

Rare/Very Rare

Abdominal distension Accidental fall Acute abdominal pain Acute cognitive impairment Agitation Anorexia Ataxia Blurred vision Chest discomfort Chills Constipation Diarrhea Diplopia Drowsy Dry nose Dry throat Dyspnea Dysuria Ecchymosis Euphoria Excitement Fatigue Flushing Headache disorder Hearing loss Hyperhidrosis Insomnia Irritability Maculopapular rash Malaise Migraine Mouth irritation Nausea Nervousness Nightmares Palpitations Paresthesia Pruritus of skin Skin photosensitivity Skin rash Symptoms of anxiety Tachycardia Tinnitus Tremor Urinary retention Urticaria Vertigo Visual changes Vomiting Wheezing Xerostomia

Reproduction studies in animals using dexchlorpheniramine have not been performed to date, but reproduction studies in rabbits and rats using chlorpheniramine maleate dosages up to 50 and 85 times the usual human dosage, respectively, have not revealed evidence of harm to the fetus. Decreased postnatal survival in offspring of rats receiving 33 and 67 times the usual human dosage of chlorpheniramine maleate has been reported. There are no adequate and controlled studies to date using chlorpheniramine or dexchlorpheniramine in pregnant women, and the drugs should be used during the first 2 trimesters only when clearly needed.

In one epidemiologic study, use of chlorpheniramine was not associated with an increased risk of teratogenic effects; however, only a limited number of pregnant women received the drug in this study. Because of the risk of severe reactions (e.g., seizures) to antihistamines in neonates, chlorpheniramine or dexchlorpheniramine should not be used during the third trimester. It is not known whether phenylephrine hydrochloride can cause fetal harm when administered to pregnant women; the drug should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Animal studies suggest a potential for adverse cardiovascular effects to the fetus if the drug is administered IV during pregnancy. Administration of phenylephrine to patients in late pregnancy or labor may cause fetal anoxia and bradycardia by increasing contractility of the uterus and decreasing uterine blood flow. In studies of IV phenylephrine in pregnant women undergoing cesarean delivery with neuraxial anesthesia, common adverse effects reported in the mother included nausea and vomiting, bradycardia, reactive hypertension, and transient arrhythmias.

The drug did not appear to affect neonatal Apgar scores or umbilical artery blood-gas status. If a vasopressor is used in conjunction with oxytocic drugs, the vasopressor effect is potentiated and may result in potentially serious adverse effects. (See Drug Interactions: Oxytocic Drugs.) Use of NSAIAs during pregnancy at about 30 weeks' gestation or later can cause premature closure of the fetal ductus arteriosus, and use at about 20 weeks' gestation or later has been associated with fetal renal dysfunction resulting in oligohydramnios and, in some cases, neonatal renal impairment.

Because of these risks, use of NSAIAs should be avoided in pregnant women at about 30 weeks' gestation or later; if NSAIA therapy is necessary between about 20 and 30 weeks' gestation, the lowest effective dosage and shortest possible duration of treatment should be used. Monitoring of amniotic fluid volume via ultrasound examination should be considered if the duration of NSAIA treatment exceeds 48 hours; if oligohydramnios occurs, the drug should be discontinued and follow-up instituted according to clinical practice. Pregnant women should be advised to avoid use of NSAIAs beginning at 20 weeks' gestation unless otherwise advised by a clinician; they also should be informed that NSAIAs should be avoided beginning at 30 weeks' gestation because of the risk of premature closure of the fetal ductus arteriosus and that monitoring for oligohydramnios may be necessary if NSAIA therapy is required for longer than 48 hours' duration between about 20 and 30 weeks of gestation.

Fetal renal dysfunction resulting in oligohydramnios and, in some cases, neonatal renal impairment has been observed, on average, following days to weeks of maternal NSAIA use, although oligohydramnios has been observed infrequently as early as 48 hours after initiation of NSAIA therapy. Oligohydramnios is often, but not always, reversible following discontinuance of NSAIA therapy. Complications of prolonged oligohydramnios may include limb contracture and delayed lung maturation.

A limited number of case reports have described maternal NSAIA use and neonatal renal dysfunction, in some cases irreversible, without oligohydramnios. Some cases of neonatal renal dysfunction have required treatment with invasive procedures such as exchange transfusion or dialysis. Methodologic limitations of these postmarketing studies and case reports include lack of a control group; limited information regarding dosage, duration, and timing of drug exposure; and concomitant use of other drugs.

These limitations preclude establishing a reliable estimate of the risk of adverse fetal and neonatal outcomes with maternal NSAIA use. Available data on neonatal outcomes generally involved preterm infants, and the extent to which certain reported risks can be generalized to full-term infants is uncertain. Animal data indicate that prostaglandins have an important role in endometrial vascular permeability, blastocyst implantation, and decidualization.

In animal studies, inhibitors of prostaglandin synthesis, such as ibuprofen, were associated with increased preimplantation and postimplantation losses. Prostaglandins also have an important role in fetal kidney development. In animal studies, inhibitors of prostaglandin synthesis impaired kidney development at clinically relevant doses.

There are no adequate and well-controlled studies of ibuprofen in pregnant women. In animal reproduction studies, no clear developmental effects were observed in rabbits or rats given ibuprofen throughout the gestational period at dosages up to 0.4 or 0.5

times, respectively, the maximum recommended human dosage (MRHD). An increase in membranous ventricular septal defects was reported in rats given ibuprofen on gestation days 9 and 10 at a dosage of 0.8 times the MRHD.

The effects of ibuprofen on labor and delivery are unknown. In studies in rats, drugs that inhibit prostaglandin synthesis, including NSAIAs, delayed parturition and increased the incidence of stillbirth.

It is not known whether chlorpheniramine or dexchlorpheniramine is distributed into milk, but other antihistamines (e.g., diphenhydramine) have been detected in milk. Because of the potential for serious adverse reactions to antihistamines in nursing infants, a decision should be made whether to discontinue nursing or chlorpheniramine or dexchlorpheniramine, taking into account the importance of the drug to the woman. It is not known whether phenylephrine is distributed into human milk following parenteral administration.

The drug should be used with caution in nursing women. Limited data indicate that ibuprofen is distributed into milk, resulting in infant exposures of 0.06-0.6%

of the maternal weight-adjusted daily dosage. Adverse effects on breast-fed infants or effects on milk production have not been reported to date. The developmental and health benefits of breast-feeding should be considered along with the mother's clinical need for ibuprofen and any potential adverse effects on the breast-fed infant from the drug or from the underlying maternal condition.

Geriatric patients are at increased risk for NSAIA-associated serious adverse cardiovascular, GI, and renal effects. Many of the spontaneous reports of fatal adverse GI effects in patients receiving NSAIAs involve geriatric individuals. If the anticipated benefits of ibuprofen therapy outweigh the potential risks, ibuprofen should be initiated at the lower end of the dosing range and patients should be monitored for adverse effects.

Clinical studies of IV ibuprofen did not include sufficient numbers of patients >=65 years of age to determine whether geriatric patients respond differently than younger adults. Dosage should be selected with caution, starting at the low end of the dosage range, because of the greater frequency of decreased hepatic, renal, and/or cardiac function and concomitant disease and drug therapy observed in the elderly.