Mesna

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution, Intravenous:

Mesnex: 100 mg/mL (10 mL) [contains benzyl alcohol, edetate disodium]

Generic: 100 mg/mL (10 mL)

Tablet, Oral:

Mesnex: 400 mg [scored]

Pharmacology

Mechanism of Action

In blood, mesna is oxidized to dimesna which in turn is reduced in the kidney back to mesna, supplying a free thiol group which binds to and inactivates acrolein, the urotoxic metabolite of ifosfamide and cyclophosphamide

Pharmacokinetics/Pharmacodynamics

Distribution

0.65 ± 0.24 L/kg; distributed to total body water.

Metabolism

Rapidly oxidized to mesna disulfide (dimesna) in the intravascular compartment. Mesna and dimesna do not undergo hepatic metabolism.

Excretion

Urine (32% as mesna; 33% as dimesna).

Time to Peak

Plasma: Oral: Free mesna: 1.5 to 4 hours; Total mesna: 3 to 7 hours.

Half-Life Elimination

Mesna: ~22 minutes; Dimesna: ~70 minutes.

Protein Binding

69% to 75%.

Use: Labeled Indications

Prevention of ifosfamide-induced hemorrhagic cystitis: Preventive agent to reduce the incidence of ifosfamide-induced hemorrhagic cystitis

Limitations of use: Mesna is not indicated to reduce the risk of hematuria due to other conditions such as thrombocytopenia

Use: Off Label

Prevention of cyclophosphamide-induced hemorrhagic cystitis (with high-dose cyclophosphamide)ayes

Data from an acute lymphocytic leukemia study utilizing high-dose cyclophosphamide and from an Ewing sarcoma study support the use of mesna as a preventative agent to reduce the incidence of hemorrhagic cystitis due to cyclophosphamide Kantarjian 2000, Kolb 2003.

Based on the American Society of Clinical Oncology, Clinical Practice Guidelines (ASCO): Use of Chemotherapy and Radiotherapy Protectants, mesna (plus saline diuresis) is recommended as a preventative agent to reduce the incidence of hemorrhagic cystitis due to high-dose cyclophosphamide in the stem cell transplant setting.

Prevention of cyclophosphamide-induced hemorrhagic cystitis in patients with rheumatic or autoimmune disordersc

Clinical experience suggests mesna may be of benefit in the prevention of hemorrhagic cystitis associated with a repeat course of cyclophosphamide when treating rheumatic diseases Monach 2010. Clinical experience and a small study suggest the use of mesna with cyclophosphamide may be of benefit in the management of severe, refractory autoimmune hemolytic anemia Go 2017, Moyo 2002.

Contraindications

Known hypersensitivity to mesna or any component of the formulation.

Dosage and Administration

Dosing: Adult

Note: Mesna dosing schedule should be repeated each day ifosfamide is administered. If the ifosfamide dose is adjusted (decreased or increased), the mesna dose should also be modified to maintain the mesna-to-ifosfamide ratio.

Prevention of ifosfamide-induced hemorrhagic cystitis:

Standard-dose ifosfamide (manufacturer’s labeling): IV: Each mesna dose is equal to 20% of the daily ifosfamide dose given for 3 doses: With the ifosfamide dose (hour 0), hour 4, and at hour 8 after the ifosfamide dose (total daily mesna dose is 60% of the daily ifosfamide dose).

Oral mesna (following IV mesna; for ifosfamide doses ≤2 g/m²/day): Mesna dose (IV) is equal to 20% of the daily ifosfamide dose at hour 0, followed by 2 mesna doses (orally), each equal to 40% of the daily ifosfamide dose given 2 and 6 hours after the ifosfamide dose (total daily mesna dose is 100% of the daily ifosfamide dose). Note: If the oral mesna dose is vomited within 2 hours of administration, repeat the oral mesna dose or administer IV mesna.

Short infusion standard-dose ifosfamide (<2.5 g/m²/day): ASCO guidelines: IV: Total mesna dose is equal to 60% of the ifosfamide dose, in 3 divided doses (each mesna dose as 20% of daily ifosfamide dose), given 15 minutes before the ifosfamide dose, and 4 and 8 hours after each dose of ifosfamide (ASCO [Hensley 2009]).

Continuous infusion standard-dose ifosfamide (<2.5 g/m²/day): ASCO guidelines: IV: Mesna dose (as a bolus) is equal to 20% of the daily ifosfamide dose, followed by a continuous infusion of mesna at 40% of the daily ifosfamide dose; continue mesna infusion for 12 to 24 hours after completion of ifosfamide infusion (ASCO [Hensley 2009]).

High-dose ifosfamide (>2.5 g/m²/day): ASCO guidelines: Evidence for use is inadequate; more frequent and prolonged mesna administration regimens may be required (ASCO [Hensley 2009]).

Other dosing strategies used in combination with ifosfamide (off-label dosing):

Mesna continuous infusion: IV: 1.8 g/m²/day to 5 g/m²/day as a continuous infusion (100% of the ifosfamide dose), repeated each day ifosfamide is received; see protocols for specific details (Bacci 2003; Kolb 2003; Moskowitz 2011).

Mesna bolus followed by continuous infusion: IV: 1 g/m² 1 hour prior to ifosfamide on day 1, followed by 3 g/m²/day continuous infusion (continuous infusion is 100% of the daily ifosfamide dose) on days 1, 2, and 3 (with sufficient hydration) every 3 weeks for 6 courses (Juergens 2006)

Prevention of cyclophosphamide-induced hemorrhagic cystitis (in patients with cancer; off-label use):

HDCAV/IE regimen for Ewing sarcoma: Adults <40 years of age: IV:

Cycles 1, 2, 3, and 6 (cyclophosphamide-containing regimen): 2.1 g/m²/day continuous infusion (mesna dose is equivalent to the daily cyclophosphamide dose) for 2 days with cyclophosphamide infusion during cycles 1, 2, 3, and 6 (Kolb 2003).

Cycles 4, 5, and 7 (ifosfamide-containing regimen): 1.8 g/m²/day continuous infusion (mesna dose is equivalent to the daily ifosfamide dose) for 5 days with ifosfamide infusion during cycles 4, 5, and 7 (Kolb 2003).

Hyper-CVAD regimen for acute lymphocytic leukemia: IV: 600 mg/m²/day continuous infusion (mesna continuous infusion is same total daily dose as cyclophosphamide) on days 1, 2, and 3, beginning with cyclophosphamide and ending 6 hours after the last cyclophosphamide dose during odd-numbered cycles (cycles 1, 3, 5, 7) of an 8-cycle phase (Kantarjian 2000).

Prevention of cyclophosphamide-induced hemorrhagic cystitis in patients with rheumatic or autoimmune disorders (off-label use; based on limited data): IV: Each mesna dose is equal to 20% of the daily cyclophosphamide dose given for 3 doses, 15 to 30 minutes prior to cyclophosphamide (hour 0), and 4 and 8 hours after cyclophosphamide (if administering mesna orally, each oral mesna dose is equal to 40% of the daily cyclophosphamide dose, with the first dose administered 2 hours prior to cyclophosphamide, and 4 and 8 hours after cyclophosphamide) (Monach 2010) or each mesna dose is equal to 20% of the daily cyclophosphamide dose given for 3 doses at 3, 6, and 8 hours following cyclophosphamide each day for 4 days (Moyo 2002).

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

Note: Dose, frequency, number of doses, and start date may vary by protocol and treatment phase. Refer to individual protocols.

Prevention of ifosfamide-induced hemorrhagic cystitis: Mesna dosing schedule should be repeated each day ifosfamide is received according to protocol. If ifosfamide dose is adjusted (decreased or increased), the mesna dose should also be modified to maintain the mesna-to-ifosfamide ratio; Infants, Children, and Adolescents:

Standard-dose ifosfamide: Note: ASCO defines standard-dose ifosfamide IV as <2500 mg/m²/day (Hensley, 2009); other pediatric oncology experts suggest ≤2000 mg/m²/day in protocols. ASCO defines standard-dose ifosfamide oral as ≤2000 mg/m²/day (Hensley, 2009; Schuchter, 2002).

Manufacturer's labeling: IV: Mesna dose is equal to 20% of the ifosfamide dose given for 3 doses: With the ifosfamide dose (hour 0), at hour 4, and at hour 8 after the ifosfamide dose (total daily mesna dose is 60% of the ifosfamide dose). Note: Safety and efficacy not established for ifosfamide doses >2000 mg/m²/day.

Alternate dosing: Limited data available:

IV:

Short IV infusion (intermittent): ASCO guidelines: Mesna dose equal to 60% of the ifosfamide dose given in 3 divided doses (20% each) 15 minutes before the ifosfamide dose and at 4 and 8 hours after the start of ifosfamide (Hensley, 2009)

Continuous IV infusion: Dosing regimens variable: ASCO guidelines: Mesna dose (as an IV bolus) equal to 20% of the ifosfamide dose, followed by a continuous IV infusion of mesna at 40% of the ifosfamide dose; continue mesna infusion for 12 to 24 hours after completion of ifosfamide infusion (Hensley, 2009). Some centers have used a mesna dose equal to 60% to 100% of the ifosfamide dose as a continuous IV infusion beginning 15 to 30 minutes before the first ifosfamide dose and completed at least 8 hours after the end of the ifosfamide infusion (Moskowitz, 2001).

Oral: ASCO guidelines: Total mesna dose equal to 100% of the ifosfamide dose, begin with IV dose equal to 20% for initial dose followed by oral dose at 40% of the ifosfamide dose at 2 and 6 hours after start of ifosfamide (Hensley, 2009); Note: Typically, oral doses of mesna are twice the IV dose.

High-dose ifosfamide: Note: ASCO defines high dose as ifosfamide dosage ≥2500 mg/m²/day (Hensley, 2009); other pediatric oncology experts suggest ≥2000 mg/m²/day in protocols: Limited data available; dosing regimens variable: IV: ASCO considers evidence for use inadequate and dosing recommendations are not established; more frequent and prolonged mesna administration regimens may be required (Hensley, 2009). Some centers have used a mesna dose equal to 100% of the ifosfamide dose as a short IV infusions 5 divided doses (0, 3, 6, 9 and 12) hours after the start of ifosfamide) (Kliegman, 2007) or as a continuous IV infusion beginning 15 to 30 minutes before the first ifosfamide dose and completed at least 12 hours after the end of the ifosfamide infusion.

Other dosing strategies have been used in combination with ifosfamide for specific regimens/protocols: Limited data available:

Mesna continuous IV infusion: Children and Adolescents: IV: 1800 mg/m²/day to 5000 mg/m²/day as a continuous infusion (100% of the ifosfamide dose), repeated each day ifosfamide is received; see protocols for specific details (Bacci, 2003; Kolb, 2003; Moskowitz, 2001)

Mesna IV bolus followed by continuous IV infusion: Children and Adolescents: IV: 1000 mg/m² 1 hour prior to ifosfamide on day 1, followed by 3000 mg/m²/day continuous infusion (continuous infusion is 100% of the ifosfamide dose) on days 1, 2, and 3 (with sufficient hydration); administer with subsequent ifosfamide doses (Juergens, 2006)

Mesna (20% higher than ifosfamide) continuous IV infusion: Children and Adolescents: IV: 3600 mg/m²/day continuous infusion for 4 days (mesna dose is 20% higher than ifosfamide), with hydration, administer with subsequent ifosfamide doses (Le Deley, 2007)

Prevention of cyclophosphamide-induced hemorrhagic cystitis: Limited data available: Note: Specific protocols should be consulted for combination regimens with cyclophosphamide. Mesna dosing schedule is typically repeated with each day cyclophosphamide is received; mesna dosing should be adjusted if cyclophosphamide dose is adjusted (decreased or increased) to maintain the mesna-to-cyclophosphamide ratio for the protocol; Infants, Children, and Adolescents:

Standard (low)-dose cyclophosphamide: Note: Some pediatric oncology experts have defined as cyclophosphamide dose <1800 mg/m²/day in protocols.

IV: Reported regimens variable: Mesna doses equivalent usually 60% to 100% of the cyclophosphamide daily dose although some protocols have used up to 160%.

Short IV infusion (intermittent): Mesna dose equal to 60% of the cyclophosphamide dose given in 3 divided doses (0, 4, and 8 hours after the start of cyclophosphamide) has been used by some centers; others have used a mesna dose equal to 100% of the cyclophosphamide dose as short IV infusions in 5 divided doses (0, 3, 6, 9, and 12 hours after the start of cyclophosphamide) (Kliegman, 2007)

Continuous IV infusion: Some centers have used a mesna dose equal to 60% of the cyclophosphamide dose as a continuous IV infusion beginning 15 to 30 minutes before the first cyclophosphamide dose and completed at least 8 hours after the end of the cyclophosphamide infusion.

Oral: Some centers have used a total mesna dose equal to 100% of the cyclophosphamide dose, begin with IV dose equal to 20% for initial dose followed by oral dose at 40% of the cyclophosphamide dose at 2 and 6 hours after start of cyclophosphamide; Note: Typically, oral doses of mesna are twice the IV dose.

High-dose cyclophosphamide: Note: Some pediatric oncology experts have defined cyclophosphamide dose ≥1800 mg/m²/day in protocols: IV: Some centers have used a mesna dose equal to 100% of the cyclophosphamide dose as short IV infusions in 5 divided doses (0, 3, 6, 9, and 12 hours after the start of) (Kliegman, 2007) or as a continuous IV infusion beginning 15 to 30 minutes before the first cyclophosphamide dose

Other dosing strategies have been used in combination with cyclophosphamide for specific regimens/protocols: Limited data available: HDCAV/IE regimen for Ewing sarcoma: Children and Adolescents: IV: 2100 mg/m²/day continuous infusion (mesna dose is equivalent to the cyclophosphamide dose) for 2 days with cyclophosphamide infusion during cycles 1, 2, 3, and 6 (Kolb, 2003)

Reconstitution

IV: Dilute in D5W, NS, D5¹/₄NS, D5¹/₃NS, D5¹/₂NS, or lactated Ringer's to a final concentration of 20 mg/mL.

Extemporaneously Prepared

An oral solution may be prepared from mesna solution for injection. Dilute solution for injection to 20 mg/mL or 50 mg/mL with orange or grape syrup. Prior to administration, syrup-diluted solutions may be diluted to a final concentration of 1, 10, or 50 mg/mL with any of the following: Carbonated beverages, apple juice, orange juice, or milk. Mesna injection prepared for oral administration is stable for at least 9 days undiluted in polypropylene syringes and stored at 5°C, 24°C, 35°C; for 7 days when diluted 1:2 or 1:5 with syrups and stored at 24°C in capped tubes; or for 24 hours at 5°C when diluted to 1:2, 1:10, and 1:100 in orange or apple juice, milk, or carbonated beverages. Dilution of mesna with diet or sugar-free preparations has not been evaluated.

Goren MP, Lyman BA, Li JT. The stability of mesna in beverages and syrup for oral administration. Cancer Chemother Pharmacol. 1991;28(4):298-301.1908750

Administration

Maintain adequate hydration and urinary output during ifosfamide (or cyclophosphamide) treatment.

IV: Administer as an IV bolus (per manufacturer); may also be administered by short infusion or continuous infusion (maintain continuous infusion for 12 to 24 hours after completion of ifosfamide infusion) (ASCO [Hensley 2009]); refer to specific protocol for administration rate/details.

Oral: Administer orally in tablet formulation; patients who vomit within 2 hours after taking oral mesna should repeat the dose or receive IV mesna. A solution may be prepared from solution for injection by dilution in syrup, juice, carbonate beverages, or milk (Goren 1991); see Extemporaneously Prepared section.

Storage

Store intact vials and tablets at 20°C to 25°C (68°F to 77°F); excursions are permitted between 15°C and 30°C (59°F and 86°F). Multidose vials may be stored and used for up to 8 days after initial puncture. Solutions diluted for infusion in D5W, NS, D5¹/₄NS, D5¹/₃NS, D5¹/₂NS, or lactated Ringer's and stored at room temperature should be used within 24 hours. According to the manufacturer, mesna and ifosfamide may be mixed in the same bag if the final ifosfamide concentration is ≤50 mg/mL. Solutions of mesna and ifosfamide (1:1) in NS at a concentration of up to 20 mg/mL are stable for 14 days in PVC bags (Zhang 2014). Solutions of mesna (0.5 to 3.2 mg/mL) and cyclophosphamide (1.8 to 10.8 mg/mL) in D5W are stable for 48 hours refrigerated or 6 hours at room temperature (Menard 2003). Mesna injection prepared for oral administration is stable for at least 9 days undiluted in polypropylene syringes and stored at 5°C, 24°C, 35°C; for 7 days when diluted 1:2 or 1:5 with syrups and stored at 24°C in capped tubes; or for 24 hours at 5°C when diluted to 1:2, 1:10, and 1:100 in orange or apple juice, milk, or carbonated beverages (Goren 1991).

Drug Interactions

There are no known significant interactions.

Test Interactions

Urinary ketones: False-positive tests for urinary ketones may occur in patients receiving mesna with the use of nitroprusside-based urine tests, including dipstick tests.

CPK activity: Mesna may interfere with enzymatic creatine kinase (CPK) activity tests which use a thiol compound (eg, N-acetylcysteine) for CPK reactivation; may result in a falsely low CPK level.

Ascorbic acid: Mesna may result in false-positive reactions in Tillman’s reagent-based urine screening tests for ascorbic acid.

Adverse Reactions

Mesna alone (frequency not defined):

Cardiovascular: Flushing

Central nervous system: Dizziness, drowsiness, headache, hyperesthesia, rigors

Dermatologic: Skin rash

Gastrointestinal: Anorexia, constipation, diarrhea, dysgeusia (with oral administration), flatulence, nausea, unpleasant taste (with oral administration), vomiting

Local: Injection site reaction

Neuromuscular & skeletal: Arthralgia, back pain

Ophthalmic: Conjunctivitis

Respiratory: Cough, flu-like symptoms, pharyngitis, rhinitis

Miscellaneous: Fever

<1%, postmarketing and/or case reports (mesna alone or in combination): Anaphylaxis, erythema at injection site, hypersensitivity reaction, hypertension, hypotension, increased serum transaminases, increased ST segment on ECG, limb pain, malaise, myalgia, pain at injection site, tachycardia, tachypnea, thrombocytopenia

Warnings/Precautions

Concerns related to adverse effects:

• Dermatologic toxicity: Drug rash with eosinophilia and systemic symptoms and bullous/ulcerative skin, and mucosal reactions consistent with Stevens-Johnson syndrome or toxic epidermal necrolysis have been reported. The skin and mucosal reactions may be characterized by rash, pruritus, urticaria, erythema, burning sensation, angioedema, periorbital edema, flushing, and stomatitis. Reactions may occur with the first mesna exposure, or after several months of treatment. If severe dermatologic toxicity occurs, discontinue mesna and manage with supportive care.
• Hematuria: Monitor urine for hematuria. Severe hematuria despite utilization of mesna may require ifosfamide (or cyclophosphamide) dose reduction or discontinuation. Examine urine specimen for hematuria prior to ifosfamide (or cyclophosphamide) treatment; if hematuria (>50 RBC/HPF) develops, reduce the ifosfamide/cyclophosphamide dose or discontinue; mesna may not prevent hemorrhagic cystitis in all patients. Patients should receive adequate hydration during treatment.
• Hypersensitivity: Hypersensitivity reactions (including anaphylaxis) have been reported. Reactions may also include fever, hypotension, tachycardia, acute renal impairment, hypoxia, respiratory distress, urticaria, angioedema, signs of disseminated intravascular coagulation, hematologic abnormalities, increased liver enzymes, nausea, vomiting, arthralgia, and myalgia. Reactions may occur with the first mesna exposure, or after several months of treatment. Monitor for signs/symptoms of reactions. If hypersensitivity occurs, discontinue mesna and manage with supportive care. Mesna is a thiol compound; it is unknown if the risk for reaction is increased in patients who have had a reaction to other thiol compounds (eg, amifostine).
• Ifosfamide/cyclophosphamide toxicities: Mesna is intended for the prevention of hemorrhagic cystitis and will not prevent or alleviate other toxicities associated with ifosfamide or cyclophosphamide.

Dosage form specific issues:

• Benzyl alcohol and derivatives: Some dosage forms may contain benzyl alcohol; large amounts of benzyl alcohol (≥99 mg/kg/day) have been associated with a potentially fatal toxicity (“gasping syndrome”) in neonates; the “gasping syndrome” consists of metabolic acidosis, respiratory distress, gasping respirations, CNS dysfunction (including convulsions, intracranial hemorrhage), hypotension, and cardiovascular collapse (AAP ["Inactive" 1997]; CDC 1982); some data suggests that benzoate displaces bilirubin from protein binding sites (Ahlfors 2001); avoid or use dosage forms containing benzyl alcohol with caution in neonates. See manufacturer’s labeling.

Other warnings/precautions:

• Appropriate use: Guidelines from the American Society of Clinical Oncology (ASCO) for the use of chemotherapy and radiotherapy protectants (ASCO [Hensley 2009]; ASCO [Schuchter 2002]) recommend mesna to decrease the incidence of ifosfamide-induced urotoxicity associated with short infusion and continuous infusion standard-dose ifosfamide (<2.5 g/m²/day). Although evidence is inadequate regarding mesna’s uroprotective effects with high-dose ifosfamide (>2.5 g/m²/day), the guidelines suggest more frequent and prolonged mesna administration times may be required. For prevention of high-dose cyclophosphamide-induced urotoxicity (associated with stem cell transplantation; off-label use), the guidelines recommend mesna in conjunction with saline diuresis (or forced saline diuresis alone).

Monitoring Parameters

Monitor urine for signs of hematuria; monitor urine output and hydration status; verify pregnancy status prior to treatment initiation in females of reproductive potential. Monitor for signs/symptoms of hypersensitivity or dermatologic toxicity.

Pregnancy

Pregnancy Considerations

Use of mesna to reduce ifosfamide-induced hemorrhagic cystitis in pregnancy has been reported (Lam 2006; Merimsky 1999; Mir 2012).

Mesna injection contains benzyl alcohol as a preservative; exposure to the fetus is expected to be unlikely due to rapid maternal metabolism.

Mesna is administered in combination with cytotoxic agents that may cause fetal harm (refer to specific monographs for additional information).

Verify pregnancy status prior to treatment initiation in females of reproductive potential. Females of reproductive potential should use effective contraception during mesna/ifosfamide treatment and for 6 months after the final mesna/ifosfamide dose. Males with female partners of reproductive potential should use effective contraception during mesna/ifosfamide treatment and for 3 months after the final mesna/ifosfamide dose.

Patient Education

What is this drug used for?

• It is used to lower the bad effects of some cancer drugs on the bladder.
• This drug is used with ifosfamide. Talk with the doctor about the risks and side effects that may happen with ifosfamide.

Frequently reported side effects of this drug

• Diarrhea
• Constipation
• Fatigue
• Trouble sleeping
• Sore throat
• Stuffy nose
• Passing gas
• Back pain
• Dry mouth
• Sweating a lot
• Lack of appetite
• Hair loss
• Headache
• Injection site irritation

Other side effects of this drug: Talk with your doctor right away if you have any of these signs of:

• Low potassium like muscle pain or weakness, muscle cramps, or an abnormal heartbeat.
• Burning or numbness feeling
• Unable to pass urine
• Change in amount of urine passed
• Flushing
• Muscle pain
• Severe abdominal pain
• Excessive weight gain
• Swelling in the arms or legs
• Joint pain
• Nausea
• Vomiting
• Severe loss of strength and energy
• Sensitivity to light
• Chest pain
• Shortness of breath
• Fast heartbeat
• Blood in the urine
• Bruising
• Bleeding
• Painful urination
• Anxiety
• Confusion
• Dizziness
• Passing out
• Flu-like syndrome
• Chills
• Swollen glands
• Stevens-Johnson syndrome/toxic epidermal necrolysis like swollen, blistered, or peeling skin [with or without fever]; red or irritated eyes; or sores in mouth, throat, nose, or eyes.
• Signs of a significant reaction like wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat.

Note: This is not a comprehensive list of all side effects. Talk to your doctor if you have questions.

Consumer Information Use and Disclaimer: This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a brief summary of general information about this medicine. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not specific medical advice and does not replace information you receive from the healthcare provider. You must talk with the healthcare provider for complete information about the risks and benefits of using this medicine.