Adoxa

Name: Adoxa

What is doxycycline?

Doxycycline is a synthetic (man-made) antibiotic derived from tetracycline.

Which drugs or supplements interact with doxycycline?

  • It is recommended that doxycycline not be taken at the same time as aluminum, magnesium, or calcium based antacids, such as Mylanta, Maalox, Tums, or Rolaids because, like food, these medications bind doxycycline in the intestine and prevent its absorption. Similarly, doxycycline should not be taken with minerals (such as calcium or iron) or with bismuth subsalicylate (Pepto Bismol).
  • Doxycycline may enhance the activity of warfarin (Jantoven, Coumadin) and cause excessive "thinning" of the blood leading to exaggerated bleeding, necessitating a reduction in the dose of warfarin. Phenytoin (Dilantin), carbamazepine (Tegretol), and barbiturates (such as phenobarbital) may enhance the metabolism (destruction) of doxycycline thus making it less effective.
  • Doxycycline may interfere with the action of penicillins and should not be combined with penicillins. It may also reduce the effect of oral contraceptives. Combining tetracycline and methoxyflurane (Penthrane) may reduce kidney function.

What else should I know about doxycycline?

What preparations of doxycycline are available?
  • Capsules: 50, 75, 100 and 150 mg.
  • Capsule (Delayed Release): 40 mg.
  • Tablets: 20, 50, 75, 100 and 150 mg.
  • Tablets (Delayed Release): 50, 60, 75, 80, 100, 120, 150, and 200 mg.
  • Syrup: 50 mg/5 ml (teaspoon)
  • Oral Suspension: 25 mg/5ml
  • Powder for injection: 100and 200 mg.
  • Periodontal Extended Release Liquid: 10%
How should I keep doxycycline stored?

  • Tablets, capsules, and syrup should be kept at room temperature 15 C to 30 C (59 F to 86 F) in tight, light resistant containers.
  • Powder for injection should be stored at or below 25 C (77 F) and protected from light.
  • Atridox (doxycycline in a gel used for subgingival application) should be stored at 2 C to 8 C (36 F to 46 F).

How does doxycycline work?
  • Doxycycline works by interrupting the production of proteins by bacteria. It is effective against a wide variety of bacteria, such as Hemophilus influenzae, Streptococcus pneumoniae, Mycoplasma pneumoniae, Chlamydia psittaci, Chlamydia trachomatis, Neisseria gonorrhoea, and many others.
When was doxycycline approved by the FDA?

The FDA approved doxycycline in December 1967.

Adoxa Overview

Doxycycline is a prescription medication used to treat certain bacterial infections and to prevent malaria infections. Doxycycline belongs to a group of drugs called tetracycline antibiotics, which prevent the growth and spread of certain bacteria by inhibiting protein production.

This medication comes in tablet, capsule, and oral suspension (liquid) forms, and is typically taken once or twice a day. The tablets and capsules should be taken with a glass of water, with or without food. However, taking doxycycline with milk or food may decrease the amount of medication absorbed from your stomach. Do not crush or break the delayed-release tablets or capsule.

Doxycycline also comes as a gel to be administered by a dentist in a clinic setting.

This medication is also available in an injectable form to be given directly into a vein (IV) by a healthcare professional.

Common side effects of doxycycline include nausea, sunlight sensitivity, and rash.  

Adoxa Interactions

Tell your doctor about all the medications you take including prescription and non-prescription medications, vitamins, and herbal supplements. Especially tell your doctor if you take:

  • anticoagulants, or blood thinners
  • penicillin antibiotics such as amoxicillin (Moxatag) and ampicillin
  • antacids containing aluminum, calcium, magnesium, or iron
  • bismuth subsalicylate (Pepto-Bismol)
  • barbiturates such as phenobarbital (Donnatal)
  • carbamazepine (Tegretol)
  • phenytoin (Dilantin)
  • methoxyflurane (Penthrane)
  • oral contraceptives

This is not a complete list of doxycycline drug interactions.  Ask your doctor or pharmacist for more information.

Adoxa Food Interactions

Medicines can interact with certain foods. In some cases, this may be harmful and your doctor may advise you to avoid certain foods.

Food, especially food and beverages high in calcium, can slightly decrease the absorption of tetracycline antibiotics, including doxycycline.  However, the absorption of doxycycline is not strongly influenced by food interactions.

What should I discuss with my healthcare provider before taking Adoxa (doxycycline)?

You should not take this medicine if you are allergic to doxycycline or other tetracycline antibiotics such as demeclocycline, minocycline, tetracycline, or tigecycline.

To make sure doxycycline is safe for you, tell your doctor if you have ever had:

  • liver disease;

  • kidney disease;

  • asthma or sulfite allergy;

  • increased pressure inside your skull; or

  • if you also take isotretinoin, seizure medicine, or a blood thinner such as warfarin (Coumadin).

If you are using doxycycline to treat gonorrhea, your doctor may test you to make sure you do not also have syphilis, another sexually transmitted disease.

Taking this medicine during pregnancy may affect tooth and bone development in the unborn baby. Taking doxycycline during the last half of pregnancy can cause permanent tooth discoloration later in the baby's life. Tell your doctor if you are pregnant or if you become pregnant while using this medicine.

Doxycycline can make birth control pills less effective. Ask your doctor about using a non-hormonal birth control (condom, diaphragm with spermicide) to prevent pregnancy.

Doxycycline can pass into breast milk and may affect bone and tooth development in a nursing infant. Do not breast-feed while you are taking doxycycline.

Doxycycline can cause permanent yellowing or graying of the teeth in children younger than 8 years old. Children should use doxycycline only in cases of severe or life-threatening conditions such as anthrax or Rocky Mountain spotted fever. The benefit of treating a serious condition may outweigh any risks to the child's tooth development.

What should I avoid while taking Adoxa (doxycycline)?

Do not take iron supplements, multivitamins, calcium supplements, antacids, or laxatives within 2 hours before or after taking doxycycline.

Avoid taking any other antibiotics with doxycycline unless your doctor has told you to.

Avoid exposure to sunlight or tanning beds. Doxycycline can make you sunburn more easily. Wear protective clothing and use sunscreen (SPF 30 or higher) when you are outdoors.

Antibiotic medicines can cause diarrhea, which may be a sign of a new infection. If you have diarrhea that is watery or bloody, call your doctor. Do not use anti-diarrhea medicine unless your doctor tells you to.

What other drugs will affect Adoxa (doxycycline)?

Other drugs may interact with doxycycline, including prescription and over-the-counter medicines, vitamins, and herbal products. Tell your doctor about all your current medicines and any medicine you start or stop using.

Proper Use of doxycycline

This section provides information on the proper use of a number of products that contain doxycycline. It may not be specific to Adoxa. Please read with care.

Take this medicine exactly as directed by your doctor. Do not take more of it, do not take it more often, and do not take it for a longer time than your doctor ordered. To do so may increase the chance of side effects.

This medicine comes with patient instructions. Read and follow the instructions carefully. Ask your doctor if you have any questions.

If you are using delayed-release tablets or tablets:

  • It may be taken with food or milk, if it upsets your stomach.
  • You may take this medicine by breaking the tablets. Hold the tablet between your thumb and index fingers close to the appropriate score (separation) line. Then, apply enough pressure to snap the tablet segments apart. Do not use the tablet if it does not break on the scored lines.
  • You may also take this medicine by sprinkling the equally broken tablets onto cold, soft food, such as applesauce. This mixture must be swallowed immediately without chewing and followed with a glass of cool water to ensure complete swallowing of the pellets. Do not store the mixture for later use.

Swallow the capsule whole. Do not break, crush, chew, or open it.

Shake the oral liquid well just before each use. Measure the dose with a marked measuring spoon, oral syringe, or medicine cup.

Drink plenty of fluids to avoid throat irritation and ulceration.

If you are using this medicine to prevent malaria while traveling, start taking the medicine 1 or 2 days before you travel. Take the medicine every day during your trip and continue taking it for 4 weeks after you return. However, do not use the medicine for longer than 4 months.

If you are using Oracea™ delayed-release capsules:

  • You should take this medicine on an empty stomach, preferably at least 1 hour before or 2 hours after meals.
  • You should take this medicine with a full glass of water while sitting or standing.
  • To prevent throat irritation, do not lay down right after taking this medicine.

Use only the brand of this medicine that your doctor prescribed. Different brands may not work the same way.

To switch from Doryx® delayed-release tablets to Doryx® MPC delayed-release tablets:

  • Replace a 50 milligram (mg) dose of Doryx® delayed-release tablet with a 60 mg dose of Doryx® MPC delayed-release tablet.
  • Replace a 100 mg dose of Doryx® delayed-release tablet with a 120 mg dose of Doryx® MPC delayed-release tablet.

To help clear up your infection completely, keep taking this medicine for the full time of treatment, even if you begin to feel better after a few days. If you stop taking this medicine too soon, your symptoms may return.

Dosing

The dose of this medicine will be different for different patients. Follow your doctor's orders or the directions on the label. The following information includes only the average doses of this medicine. If your dose is different, do not change it unless your doctor tells you to do so.

The amount of medicine that you take depends on the strength of the medicine. Also, the number of doses you take each day, the time allowed between doses, and the length of time you take the medicine depend on the medical problem for which you are using the medicine.

  • For oral dosage forms (capsules, Doryx® delayed-release tablets, suspension, syrup, tablets):
    • For infections:
      • Adults—100 milligrams (mg) every 12 hours on the first day, then 100 mg once a day or 50 to 100 mg every 12 hours.
      • Children older than 8 years of age and weighs 45 kilograms (kg) or more—100 mg every 12 hours on the first day, then 100 mg once a day or 50 to 100 mg every 12 hours.
      • Children older than 8 years of age and weighs less than 45 kg—Dose is based on body weight and must be determined by your doctor. The dose is usually 4.4 mg per kg of body weight per day and divided into 2 doses on the first day of treatment. This is followed by 2.2 mg per kg of body weight per day, taken as a single dose or divided into two doses on the following days.
      • Children up to 8 years of age—Use is not recommended.
    • For the prevention of malaria:
      • Adults—100 milligrams (mg) once a day. You should take the first dose 1 or 2 days before traveling to an area where malaria may occur, and continue taking the medicine every day throughout your travel and for 4 weeks after you leave the malarious area.
      • Children older than 8 years of age—Dose is based on body weight and must be determined by your doctor. The dose is usually 2 milligrams (mg) per kilogram (kg) of body weight per day, taken as a single dose. You should take the first dose 1 or 2 days before travel to an area where malaria may occur, and continue taking the medicine every day throughout travel and for 4 weeks after you leave the malarious area.
      • Children up to 8 years of age—Use is not recommended.
    • For anthrax after possible exposure:
      • Adults and children weighing 45 kilograms (kg) or more—100 milligrams (mg) two times a day (taken every 12 hours) for 60 days.
      • Children weighing less than 45 kg—Dose is based on body weight and must be determined by your doctor. The dose is usually 2.2 milligrams (mg) per kilogram (kg) of body weight per day, two times a day for 60 days.
  • For oral dosage form (delayed-release capsules):
    • For the treatment of pimples from rosacea:
      • Adults—40 milligrams (mg) or one capsule once a day, in the morning.
      • Children—Use and dose must be determined by your doctor.
  • For oral dosage form (Doryx® MPC delayed-release tablet):
    • For infections:
      • Adults and children older than 8 years of age and weighs 45 kilograms (kg) or more, with or without severe or life-threatening infections—120 milligrams (mg) every 12 hours on the first day, then 120 mg once a day or 60 to 120 mg every 12 hours.
      • Children older than 8 years of age and weighs less than 45 kg—Dose is based on body weight and must be determined by your doctor. The dose is usually 5.3 mg per kg of body weight per day and divided into 2 doses on the first day of treatment. This is followed by 2.6 mg per kg of body weight per day, taken as a single dose or divided into two doses on the following days.
      • Children weighing less than 45 kg with severe or life-threatening infections—Dose is based on body weight and must be determined by your doctor. The dose is usually 2.6 mg per kg of body weight per day given every 12 hours.
      • Children 8 years of age and younger—Use is not recommended.
    • For prevention of malaria:
      • Adults and children weighing more than 45 kilograms (kg)—120 milligrams (mg) once a day. You should take the first dose 1 or 2 days before traveling to an area where malaria may occur, and continue taking the medicine every day throughout your travel and for 4 weeks after you leave the malarious area.
      • Children 8 years of age and older—Dose is based on body weight and must be determined by your doctor. The dose is usually 2.4 milligrams (mg) per kilogram (kg) of body weight per day, taken as a single dose. You should take the first dose 1 or 2 days before traveling to an area where malaria may occur, and continue taking the medicine every day throughout your travel and for 4 weeks after you leave the malarious area.
      • Children up to 8 years of age—Use is not recommended.
    • For anthrax after possible exposure:
      • Adults and children weighing 45 kilograms (kg) or more—120 milligrams (mg) two times a day for 60 days.
      • Children weighing less than 45 kg—Dose is based on body weight and must be determined by your doctor. The dose is usually 2.6 milligrams (mg) per kilogram (kg) of body weight per day, two times a day for 60 days.

Missed Dose

If you miss a dose of this medicine, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not double doses.

Storage

Store the medicine in a closed container at room temperature, away from heat, moisture, and direct light. Keep from freezing.

Keep out of the reach of children.

Do not keep outdated medicine or medicine no longer needed.

Ask your healthcare professional how you should dispose of any medicine you do not use.

Adoxa - Clinical Pharmacology

Tetracyclines are readily absorbed and are bound to plasma proteins in varying degrees. They are concentrated by the liver in the bile and excreted in the urine and feces at high concentrations in a biologically active form. Doxycycline is virtually completely absorbed after oral administration.

Following a 200 mg dose of doxycycline monohydrate, 24 normal adult volunteers averaged the following serum concentration values:

Time (hr): 0.5 1.0 1.5 2.0 3.0 4.0 8.0 12.0 24.0 48.0 72.0
Conc:(mcg/mL) 1.02 2.26 2.67 3.01 3.16 3.03 2.03 1.62 0.95 0.37 0.15
Average Observed Values
Maximum Concentration 3.61 mcg/mL (± 0.9 sd)
Time of Maximum Concentration 2.60 hr (± 1.10 sd)
Elimination Rate Constant 0.049 per hr (± 0.030 sd)
Half-Life 16.33 hr (± 4.53 sd)

Excretion of doxycycline by the kidney is about 40%/72 hours in individuals with normal function (creatinine clearance about 75 mL/min). This percentage excretion may fall as low as 1 to 5%/72 hours in individuals with severe renal insufficiency (creatinine clearance below 10 mL/min). Studies have shown no significant difference in serum half-life of doxycycline (range 18 to 22 hours) in individuals with normal and severely impaired renal function.

Hemodialysis does not alter serum half-life.

Microbiology : The tetracyclines are primarily bacteriostatic and are thought to exert their antimicrobial effect by the inhibition of protein synthesis. The tetracyclines, including doxycycline, have a similar antimicrobial spectrum of activity against a wide range of gram-positive and gram-negative microorganisms. Cross-resistance of these microorganisms to tetracyclines is common.

Doxycycline has been shown to be active against most strains of the following microorganisms, both in vitro and in clinical infections as described in the INDICATIONS AND USAGE section.

Aerobic Gram-Positive Microorganisms:

Because many strains of the following groups of gram-positive microorganisms have been shown to be resistant to tetracyclines, culture and susceptibility testing are recommended:

Bacillus anthracis

Listeria monocytogenes

Staphylococcus aureus*

*Doxycycline is not the drug of choice in the treatment of any type of staphylococcal infection.

Up to 44 percent of strains of Streptococcus pyogenes and 74 percent of Streptococcus faecalis have been found to be resistant to tetracycline drugs. Therefore, tetracyclines should not be used to treat streptococcal infections unless the microorganism has been demonstrated to be susceptible.

Streptococcus pneumoniae

Aerobic Gram-Negative Microorganisms:
Bartonella bacilliformis
Brucella species
Calymmatobacterium granulomatis
Campylobacter fetus
Francisella tularensis
Haemophilus ducreyi
Haemophilus influenzae
Neisseria gonorrhoeae
Vibrio cholerae
Yersinia pestis

Because many strains of the following groups of gram-negative microorganisms have been shown to be resistant to tetracyclines, culture and susceptibility testing are recommended:

Acinetobacter species
Enterobacter aerogenes
Escherichia coli
Klebsiella species
Shigella species

Anaerobic Microorganisms:
Actinomyces israelii
Clostridium species
Fusobacterium fusiforme

Other Microorganisms:
Borrelia recurrentis
Chlamydia psittaci
Chlamydia trachomatis
Mycoplasma pneumoniae
Rickettsiae
Treponema pallidum
Treponema pertenue

Susceptibility Tests:

Dilution techniques:

Quantitative methods are used to determine antimicrobial minimum inhibitory concentrations (MIC’s). These MIC’s provide estimates of the susceptibility of bacteria to antimicrobial compounds. The MIC’s should be determined using a standardized procedure. Standardized procedures are based on a dilution method1,3 (broth or agar) or equivalent with standardized inoculum concentrations and standardized concentrations of tetracycline powder. The MIC values should be interpreted according to the following criteria for indicated aerobic microorganisms other than Haemophilus species, Neisseria gonorrhoeae, and Streptococcus pneumoniae:

a. Interpretative criteria applicable only to tests performed by broth microdilution method using Haemophilus Test Medium (HTM). 1,3

b. Interpretative criteria applicable only to tests performed by agar dilution method using GC agar base with 1% defined growth supplement. 1,3

c. Interpretative criteria applicable only to tests performed by broth microdilution method using cation-adjusted Mueller-Hinton broth with 2 to 5% lysed horse blood. 1,3

MIC (mcg/mL) Interpretation
≤4 Susceptible (S)
8 Intermediate (I)
≥16 Resistant (R)
When testing Haemophilus spp.a  
MIC (mcg/mL) Interpretation
≤2 Susceptible (S)
4 Intermediate (I)
≥8 Resistant (R)
When testing Neisseria gonorrhoeaeb
MIC (mcg/mL) Interpretation
≤0.25 Susceptible (S)
0.5-1 Intermediate (I)
≥2 Resistant (R)
When testing Streptococcus pneumoniaec
MIC (mcg/mL) Interpretation
≤2 Susceptible (S)
4 Intermediate (I)
≥8 Resistant (R)

A report of “Susceptible” indicates that the pathogen is likely to be inhibited if the antimicrobial compound in the blood reaches the concentrations usually achievable. A report of “Intermediate” indicates that the result should be considered equivocal, and, if the microorganism is not fully susceptible to alternative, clinically feasible drugs, the test should be repeated. This category implies possible clinical applicability in body sites where the drug is physiologically concentrated or in situations where high dosage of drug can be used. This category also provides a buffer zone which prevents small uncontrolled technical factors from causing major discrepancies in interpretation. A report of “Resistant” indicates that the pathogen is not likely to be inhibited if the antimicrobial compound in the blood reaches the concentrations usually achievable; other therapy should be selected.

Standardized susceptibility test procedures require the use of laboratory control microorganisms to control the technical aspects of the laboratory procedures. Standard tetracycline powder should provide the following MIC values:

a. Range applicable only to tests performed by broth microdilution method using Haemophilus Test Medium (HTM).1,3

b. Range applicable only to tests performed by agar dilution method using GC agar base with 1% defined growth supplement. 1,3

c. Range applicable only to tests performed by broth microdilution method using cation-adjusted Mueller-Hinton broth with 2 to 5% lysed horse blood. 1,3

Microorganism MIC (mcg/mL)
Enterococcus faecalis ATCC 29212 8-32
Escherichia coli ATCC 25922 0.5-2
Haemophilus influenzaea ATCC 49247 4-32
Neisseria gonorrhoeaeb ATCC 49226 0.25-1
Pseudomonas aeruginosa ATCC 27853 8-32
Staphylococcus aureus ATCC 29213 0.12-1
Streptococcus pneumoniaec ATCC 49619 0.12-0.5

Diffusion techniques:

Quantitative methods that require measurement of zone diameters also provide reproducible estimates of the susceptibility of bacteria to antimicrobial compounds. One such standardized procedure 2,3 requires the use of standardized inoculum concentrations. This procedure uses paper disks impregnated with 30 mcg tetracycline or 30 mcg doxycycline to test the susceptibility of microorganisms to doxycycline.

Reports from the laboratory providing results of the standard single-disk susceptibility test with 30 mcg tetracycline-class disk or the 30 mcg doxycycline disk should be interpreted according to the following criteria for indicated aerobic microorganisms other than Haemophilus species, Neisseria gonorrhoeae, and Streptococcus pneumoniae:

a. Interpretative criteria applicable only to tests performed by disk diffusion method using a 30 mcg tetracycline-class disk and using Haemophilus Test Medium (HTM).2,3

b. Interpretative criteria applicable only to tests performed by disk diffusion method using a 30 mcg tetracycline-class disk and using GC agar base with 1% defined growth supplement.2,3

c. Interpretative criteria applicable only to tests performed by disk diffusion method using a 30 mcg tetracycline-class disk and using Mueller-Hinton agar with 5% defibrinated sheep blood and incubated with 5% CO2.2,3

Zone Diameter (mm) Interpretation
Tetracycline Doxycycline
≥15 ≥14 Susceptible (S)
12-14 11-13 Intermediate (I)
≤11 ≤10 Resistant (R)
When testing Haemophilus spp.a
Zone Diameter (mm) Interpretation
tetracycline
≥29 Susceptible (S)
26-28 Intermediate (I)
≤25 Resistant (R)
When testing Neisseria gonorrhoeaeb
Zone Diameter (mm) Interpretation
tetracycline
≥38 Susceptible (S)
31-37 Intermediate (I)
≤30 Resistant (R)
Zone diameters ≤19 mm may indicate a plasmid-mediated tetracycline-resistant Neisseria gonorrhoeae (TRNG) isolate. These TRNG strains should be confirmed by the dilution test (MIC ≥16 mcg/mL).
When testing Streptococcus pneumoniae c
Zone Diameter (mm) Interpretation
tetracycline
≥23 Susceptible (S)
19-22 Intermediate (I)
≤18 Resistant (R)

Interpretation should be as stated above for results using dilution techniques. Interpretation involves correlation of the diameter obtained in the disk test with the MIC for tetracycline or doxycycline, respectively.

As with standardized dilution techniques, diffusion methods require the use of laboratory control microorganisms that are used to control the technical aspects of the laboratory procedures. For the diffusion technique, the 30 mcg tetracycline-class disk or the 30 mcg doxycycline disk should provide the following zone diameters in these laboratory test quality control strains:

a. Range applicable only to tests performed by disk diffusion method using a 30 mcg tetracycline-class disk and using Haemophilus Test Medium (HTM). 2,3

b. Range applicable only to tests performed by disk diffusion method using a 30 mcg tetracycline-class disk and using GC agar base with 1% defined growth supplement.2,3

c. Range applicable only to tests performed by disk diffusion method using a 30 mcg tetracycline-class disk and using Mueller-Hinton agar with 5% defibrinated sheep blood and incubated with 5% CO2.2,3

Microorganism Zone Diameter (mm)
tetracycline doxycycline
Escherichia coli ATCC 25922 18-25 18-24
Haemophilus influenzaea ATCC 49247 14-22 ---
Neisseria gonorrhoeaeb ATCC 49226 30-42 ---
Staphylococcus aureus ATCC 25923 24-30 23-29
Streptococcus pneumoniaec ATCC 49619 27-31 ---

Anaerobic techniques:

For anaerobic bacteria, the susceptibility to tetracycline as MIC’s can be determined by standardized test methods.4 The MIC values obtained should be interpreted according to the following criteria:

MIC (mcg/mL) Interpretation
≤4 Susceptible (S)
8 Intermediate (I)
≥16 Resistant (R)

Interpretation is identical to that stated above for results using dilution techniques.

As with other susceptibility techniques, the use of laboratory control microorganisms is required to control the technical aspects of the laboratory standardized procedures. Standardized tetracycline powder should provide the following MIC values:

a. Range applicable only to tests performed by the reference agar dilution method.

Microorganism MIC (mcg/mL)
Bacteroides fragilisa ATCC 25285 0.12-0.5
Bacteroides thetaiotaomicrona ATCC 29741 8-32

Geriatric

Many medicines have not been studied specifically in older people. Therefore, it may not be known whether they work exactly the same way they do in younger adults or if they cause different side effects or problems in older people. There is no specific information comparing use of tetracyclines in the elderly with use in other age groups.

Pregnancy

Use is not recommended during the last half of pregnancy. If tetracyclines are taken during that time, they may cause the unborn infant's teeth to become discolored and may slow down the growth of the infant's teeth and bones. In addition, liver problems may occur in pregnant women, especially those receiving high doses by injection into a vein.

Missed Dose

If you miss a dose of this medicine, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not double doses.

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