For the treatment of acute episodes and the maintenance of remission of ulcerative colitis

Posology:

Adults and the elderly

For the treatment of acute episodes of ulcerative colitis:

Once daily, 1 sachet of Salofalk^® 3000 mg, 1-2 sachets of Salofalk^® 1500 mg, 3 sachets of Salofalk^® 1000 mg or 3 sachets of Salofalk^® 500 mg (equivalent to 1.5-3.0 g mesalazine daily) preferably to be taken in the morning according to the individual clinical requirement.

It is also possible to take the prescribed daily dose in three divided doses (1 sachet of Salofalk^® 500 mg 3 times daily or 1 sachet of Salofalk^® 1000 mg 3 times daily) if this is more convenient to the patient.

For the maintenance of remission of ulcerative colitis:

The standard treatment is 0.5 g mesalazine 3 times daily (in the morning, at midday and in the evening) corresponding to a total dose of 1500 mg mesalazine per day.

For patients known to be at increased risk for relapse for medical reasons or due to difficulties to adhere to application of three daily doses, the dosing schedule can be adapted to 3.0 g mesalazine given as a single daily dose, preferably in the morning.

Paediatric population:

There is only limited documentation for an effect in children (age 6-18 years).

Children 6 years of age and older:

Active disease: To be determined individually, starting with 30-50 mg/kg bw/day once daily preferably in the morning or in divided doses. Maximum dose: 75 mg/kg bw/day. The total dose should not exceed the maximum adult dose.

Maintenance treatment: To be determined individually, starting with 15-30 mg/kg bw/day in divided doses. The total dose should not exceed the recommended adult dose.

It is generally recommended that half the adult dose may be given to children up to a body weight of 40 kg and the normal adult dose to those above 40 kg.

                               Method of administration

The contents of the sachets of Salofalk^® granules should not be chewed. The granules should be taken on the tongue and swallowed, without chewing, with plenty of liquid.

Both in the treatment of acute inflammatory episodes and during long term treatment, Salofalk^® granules should be used on a regular basis and consistently in order to achieve the desired therapeutic effects.

Duration of treatment

The treatment of acute episodes of ulcerative colitis usually lasts 8 weeks. The duration of use is determined by the physician.

Blood tests (differential blood count; liver function parameters such as ALT or AST; serum creatinine) and urinary status (dip sticks) should be determined prior to and during treatment, at the discretion of the treating physician. As a guideline, follow-up tests are recommended 14 days after commencement of treatment, then a further two to three tests at intervals of 4 weeks.

If the findings are normal, follow-up tests should be carried out every three months. If additional symptoms occur, these tests should be performed immediately.

Caution is recommended in patients with impaired hepatic function.

Mesalazine should not be used in patients with impaired renal function. Mesalazine-induced renal toxicity should be considered if renal function deteriorates during treatment. If this is the case, Salofalk^® granules should be discontinued immediately.

Cases of nephrolithiasis have been reported with the use of mesalazine including stones with a 100% mesalazine content. It is recommended to ensure adequate fluid intake during treatment.

Mesalazine may produce red-brown urine discoloration after contact with sodium hypochlorite bleach (e.g., in toilets cleaned with sodium hypochlorite contained in certain bleaches).

Serious blood dyscrasias have been reported very rarely with mesalazine. Hematological investigations should be performed if patients suffer from unexplained haemorrhages, bruises, purpura, anaemia, fever or pharyngolaryngeal pain. Salofalk^® granules should be discontinued in case of suspected or confirmed blood dyscrasia.

Cardiac hypersensitivity reactions (myocarditis, and pericarditis) induced by mesalazine have been rarely reported. Salofalk^® granules must then be discontinued immediately.

Patients with pulmonary disease, in particular asthma, should be very carefully monitored during a course of treatment with mesalazine.

Severe cutaneous adverse reactions

Severe cutaneous adverse reactions (SCARs), including drug reaction with eosinophilia and systemic symptoms (DRESS), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), have been reported in association with mesalazine treatment.

Mesalazine should be discontinued, at the first appearance of signs and symptoms of severe skin reactions, such as skin rash, mucosal lesions, or any other sign of hypersensitivity.

Idiopathic intracranial hypertension

Idiopathic intracranial hypertension (pseudotumor cerebri) has been reported in patients receiving mesalazine. Patients should be warned for signs and symptoms of idiopathic intracranial hypertension, including severe or recurrent headache, visual disturbances or tinnitus. If idiopathic intracranial hypertension occurs, discontinuation of mesalazine should be considered.

Patients with a history of adverse drug reactions to preparations containing sulfasalazine should be kept under close medical surveillance on commencement of a course of treatment with mesalazine. Should Salofalk^® granules cause acute intolerance reactions, such as abdominal cramps, acute abdominal pain, fever, severe headache and rash, therapy should be discontinued immediately.

This medicine contains 1 mg/2 mg/3 mg/6 mg aspartame in each sachet of Salofalk^® 500 mg/1000 mg/1500 mg/3000 mg. Aspartame is a source of phenylalanine. It may be harmful in patients with phenylketonuria (PKU).

Salofalk granules contain sucrose. Patients with rare hereditary problems of fructose intolerance, glucose galactose malabsorption or sucrase-isomaltase insufficiency should not take these medicines.

This medicine contains less than 1 mmol sodium (23 mg) per sachet, that is to say essentially ‘sodium-free’.

Specific interaction studies have not been performed.

·      Lactulose or similar preparations          possible reduction of mesalazine which lower stool pH                                              release from granules due to    decreased pH caused by bacterial                             metabolism of lactulose

In patients who are concomitantly treated with azathioprine, 6-mercaptopurine or thioguanine, a possible increase in the myelosuppressive effects of azathioprine, 6-mercaptopurine or thioguanine should be taken into account.

There is weak evidence that mesalazine might decrease the anticoagulant effect of warfarin.

Pregnancy

There are no adequate data on the use of mesalazine in pregnant women. However, data on a limited number of exposed pregnancies indicate no adverse effect of mesalazine on pregnancy or on the health of the foetus/newborn child. To date no other relevant epidemiologic data are available. In one single case after long-term use of high dose mesalazine (2-4 g/day, orally) during pregnancy, renal failure in a neonate was reported.

Animal studies on oral mesalazine do not indicate direct or indirect harmful effects with respect to pregnancy, embryonic/foetal development, parturition or postnatal development.

Salofalk^® granules should only be used during pregnancy if the potential benefit outweighs the possible risk.

Breastfeeding

N-acetyl-5-aminosalicylic acid and to a lesser degree mesalazine are excreted in breast milk. Only limited experience during lactation in women is available to date. Hypersensitivity reactions, like diarrhoea in the infant, cannot be excluded. Therefore, Salofalk^® granules should only be used during breastfeeding if the potential benefit outweighs the possible risk. If the infant develops diarrhoea, the breastfeeding should be discontinued.

Mesalazine has no influence or negligible influence on the ability to drive and use machines.

* see section 4.4 for further information

Severe cutaneous adverse reactions (SCARs), including drug reaction with eosinophilia and systemic symptoms (DRESS), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), have been reported in association with mesalazine treatment (see section 4.4).

Photosensitivity

More severe reactions are reported in patients with pre-existing skin conditions such as atopic dermatitis and atopic eczema.

Reporting of suspected adverse reactions:

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions to

The National Pharmacovigilance Cetre (NPC):

SFDA Call Center: 19999

E-mail: npc.drug@sfda.gov.sa

Website: https://ade.sfda.gov.sa

There are rare data on overdosage (e.g. intended suicide with high oral doses of mesalazine), which do not indicate renal or hepatic toxicity. There is no specific antidote and treatment is symptomatic and supportive.

Pharmacotherapeutic group: Intestinal antiinflammatory agents; Aminosalicylic acid and similar agents

                          ATC code: A07EC02

Mechanism of action

The mechanism of the anti-inflammatory action is unknown. The results of in vitro studies indicate that inhibition of lipoxygenase may play a role.

Effects on prostaglandin concentrations in the intestinal mucosa have also been demonstrated. Mesalazine (5-aminosalicylic acid / 5-ASA) may also function as a radical scavenger of reactive oxygen compounds.

Pharmacodynamic effects

Mesalazine, orally administered, acts predominantly locally at the gut mucosa and in the submucosal tissue from the luminal side of the intestine. It is important, therefore, that mesalazine is available at the regions of inflammation. Systemic bioavailability/plasma concentrations of mesalazine are therefore of no relevance for therapeutic efficacy, but rather a factor for safety. In order to realise this, Salofalk^® granules are gastric juice resistant and release mesalazine in a pH dependent manner, due to an Eudragit L coating, and prolonged manner, due to the matrix granule structure.

General considerations of mesalazine

Absorption

Mesalazine absorption is highest in proximal and lowest in distal gut areas.

Biotransformation

Mesalazine is metabolised both pre-systemically by the intestinal mucosa and the liver to the pharmacologically inactive N-acetyl-5-aminosalicylic acid (N-Ac-5-ASA). The acetylation seems to be independent of the acetylator phenotype of the patient. Some acetylation also occurs through the action of colonic bacteria. Protein binding of mesalazine and N-Ac-5-ASA is 43 % and 78 %, respectively.

Elimination

Mesalazine and its metabolite N-Ac-5-ASA are eliminated via the faeces (major part), renally (varies between 20 and 50 %, depending on the kind of application, pharmaceutical preparation and route of mesalazine release, respectively), and biliary (minor part). Renal excretion predominantly occurs as N-Ac-5-ASA. About 1 % of the total orally administered mesalazine dose is excreted into the breast milk mainly as N-Ac-5-ASA.

Salofalk^® Granules specific

Distribution

Owing to the granule size of approx. 1 mm, transit from the stomach to the small intestine is fast.

A combined pharmacoscintigraphic/pharmacokinetic study showed that the compound reaches the ileocaecal region within approx. 3 hours and the ascending colon within approx. 4 hours. The total transit time in the colon amounts to about 20 hours.

Approximately 80 % of an administered oral dose is estimated to be available in the colon, sigmoid colon and rectum.

Absorption

Mesalazine release from Salofalk^® granules starts after a lag phase of about 2-3 hours. Peak plasma concentrations are reached at about 4-5 hours. The systemic bioavailability of mesalazine after oral administration is estimated to be approximately 15-25 %.

Food intake delays absorption by 1 to 2 hours but does not change the rate and extent of absorption.

Elimination

From a 3 x 500 mg daily mesalazine dose in long-term therapy, a total renal elimination of mesalazine and N-Ac-5-ASA under steady state conditions was calculated to be about 25 %. The unmetabolised excreted mesalazine part was less than 1 % of the oral dose. The terminal elimination half-life observed after single dose administration of 3 * 500 mg or 3 * 1000 mg Salofalk^® granules was 10.5 hours.

Preclinical data reveal no special hazard for humans based on conventional studies of safety pharmacology, genotoxicity, carcinogenicity (rat) or toxicity to reproduction.

Kidney toxicity (renal papillary necrosis and epithelial damage in the proximal convoluted tubule or the whole nephron) has been seen in repeat-dose toxicity studies with high oral doses of mesalazine. The clinical relevance of this finding is unknown.

List of excipients

1.      Aspartame (E 951)

2.      Carmellose sodium

3.      Citric acid

4.      Silica, colloidal anhydrous

5.      Hypromellose

6.      Magnesium stearate

7.      Methacrylic acid-methyl methacrylate copolymer (1:1) (MW approx. 135000) (Eudragit L 100),

8.      Methylcellulose

9.      Cellulose, microcrystalline

10.  Polyacrylate dispersion 40 % (Eudragit NE 40 D containing 2 % Nonoxynol 100)

11.  Povidone K 25

12.  Simeticone

13.  Sorbic acid

14.  Talc

15.  Titanium dioxide (E 171)

16.  Triethyl citrate

17.  Vanilla custard flavouring (containing sucrose)

Not applicable.

Do not store above 30 °C.

Sachet of polyester/aluminium/polyethylene foil.

Each sachet of Salofalk^® 1500 mg contains 2.79 g granules.

Pack sizes:

60 sachets Salofalk^® 1500 mg.

No special requirements.