Adverse Event Report

Report

reporttype1receiptdateformat102companynumbUS-TEVA-486074USAoccurcountryUSVersion of Safety Report ID1receivedateformat102duplicate1transmissiondateformat102fulfillexpeditecriteria2Safety Report ID10216696Date Received04/06/2014transmissiondate12/12/2014serious2Date Last Updated04/06/2014primarysourcecountryUS

Receiver

receivertype6receiverorganizationFDA

Primary Source

reportercountryUSqualification5

Sender

sendertype2senderorganizationFDA-Public Use

Patient

SexMale

Reaction

1)

reactionmeddraversionpt17.0ReactionLip dryOutcomeUnknown

2)

reactionmeddraversionpt17.0ReactionBack painOutcomeUnknown

3)

reactionmeddraversionpt17.0ReactionAnxietyOutcomeUnknown

4)

reactionmeddraversionpt17.0ReactionAlopeciaOutcomeUnknown

Drug

1)

drugcharacterization1medicinalproductCLARAVISdrugauthorizationnumb076135drugdosagetext60 MG EVERYDAY, 20 IN AM AND 40 PMdrugdosageformCAPSULEdrugadministrationroute048drugstartdateformat102drugstartdate12/05/2014actiondrug4

openFDA Info on Medication

Application NumberANDA076356, ANDA076135Brand NameCLARAVISGeneric NameISOTRETINOINManufacturersTeva Pharmaceuticals USA, Inc.product_ndc0555-1054, 0555-1055, 0555-1056, 0555-1057Product TypeHUMAN PRESCRIPTION DRUGRouteORALActive IngredientsISOTRETINOINRXCUI197843, 197844, 197845, 403930, 404059, 404062, 404065, 643488spl_ide462821c-84c4-4009-a26e-da92790126bfspl_set_ida31fd109-d0fd-4ab9-ba98-a3d64333c18dPackage NDC 0555-1054-60, 0555-1054-86, 0555-1054-56, 0555-1055-60, 0555-1055-86, 0555-1055- ... NUIN0000175607, M0018962Established Pharmacologic ClassRetinoid [EPC]Chemical StructureRetinoids [CS]UNIIEH28UP18IF

Report Duplicate

duplicatesourceTEVAduplicatenumbUS-TEVA-486074USA