Mild to moderate ulcerative colitis

Posology
Ulcerative colitis:
Adults
Active disease:
Individual dosage, up to 4 g mesalazine once daily or divided into 2-4 doses.
Maintenance treatment:
Individual dosage. Recommended dosage, 2 g mesalazine once daily.
Paediatric population
The safety and efficacy in children below 6 years of age have not been established.
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 /day in divided doses.
Maximum dose: 75 mg/kg/day in divided doses. The total dose should not exceed 4 g/day (maximum adult dose).
Maintenance treatment:
To be determined individually, starting with 15-30 mg/kg/day in divided doses. The total dose should not exceed
2 g/day (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
Oral use.
The granules must not be chewed. The contents of the sachet should be emptied onto the tongue and washed
down with some water or orange juice.

Caution is recommended when treating patients allergic to sulphasalazine (risk of allergy to salicylates). In case
of acute symptoms of intolerance, i.e. abdominal cramps, abdominal pain, fever, severe headache and rash, the
treatment should be discontinued immediately.
Caution is recommended in patients with impaired liver function. Liver function parameters like ALT or AST
should be assessed prior to and during treatment, at the discretion of the treating physician.
The drug is not recommended for use in patients with impaired renal function and in patients with haemorrhagic
diathesis. The renal function should be regularly monitored (e.g. serum creatinine), especially during the initial
phase of treatment. Urinary status (dip sticks) should be determined prior to and during treatment at the
discretion of the treating physician. Mesalazine induced nephrotoxicity should be suspected in patients
developing renal dysfunction during treatment. The concurrent use of other known nephrotoxic agents, such as
NSAIDs and azathioprine, may increase the risk of renal reactions.
Caution is recommended in patients with active peptic ulcer.
Patients with pulmonary disease, in particular asthma, should be very carefully monitored during a course of
treatment; see section 4.8.
Mesalazine-induced cardiac hypersensitivity reactions (myo- and pericarditis) have been reported rarely. Serious
blood dyscrasias have been reported very rarely with mesalazine (see section 4.5). Blood tests for differential
blood counts is recommended prior to and during treatment, at the discretion of the treating physician. Treatment
should be discontinued on suspicion or evidence of these adverse reactions.
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.

No interaction studies have been performed. Combination therapy with mesalazine and azathioprine or 6-
mercaptopurine or thioguanine has shown a higher frequency of myelosuppressive effects. An interaction cannot
be excluded, however, the mechanism of interaction is unknown. Regular monitoring of white blood cells is
recommended and dosage of thiopurines should be adjusted accordingly.
There is weak evidence that mesalazine might decrease the anticoagulant effect of warfarin.

PENTASA prolonged release granules should not be used during pregnancy and lactation except when the
potential benefits of the treatment outweigh the possible hazards in the opinion of the physician. The underlying
condition itself (Inflammatory bowel disease (IBD)) may increase risks for adverse pregnancy outcome.
Pregnancy:
Mesalazine is known to cross the placental barrier and its concentration in umbilical cord plasma is lower than
the concentration in maternal plasma. The metabolite acetyl-mesalazine is found at similar concentrations in
umbilical cord and maternal plasma. Animal studies on oral mesalazine do not indicate direct or indirect harmful
effects with respect to pregnancy, embryo/foetal development, parturition or postnatal development. There are no
adequate and well controlled studies of PENTASA use in pregnant women. Limited published human data on
mesalazine show no increase in the overall rate of congenital malformations. Some data show an increased rate of
preterm birth, stillbirth, and low birth weight; however, these adverse pregnancy outcomes are also associated
with active inflammatory bowel disease. Blood disorders (leucopenia, thrombocytopenia and anaemia) have been
reported in new-borns of mothers being treated with PENTASA prolonged release granules.
In one single case after long-term use of a high dose of mesalazine (2-4g, orally) during pregnancy, renal failure
in a neonate was reported.
Lactation:
Mesalazine is excreted in breast milk. The mesalazine concentration in breast milk is lower than in maternal
blood, whereas the metabolite - acetyl-mesalazine - appears in similar or increased concentrations. No controlled

studies with PENTASA prolonged release granules during breast-feeding have been carried out. Only limited
experience during lactation in women after oral application is available to date.
Hypersensitivity reactions like diarrhea in the infant cannot be excluded. If the infant develops diarrhoea, breastfeeding
should be discontinued.
Fertility:
Animal data on Mesalazine show no effect on male and female fertility

PENTASA prolonged release granules has no or negligible influence on the ability to drive or use machines.

The most frequent adverse reactions seen in clinical trials are diarrhoea, nausea, abdominal pain, headache,
vomiting, and rash.
Hypersensitivity reactions and drug fever may occasionally occur.
Frequency of adverse effects, based on clinical trials and reports from post-marketing surveillance:

(*)

The mechanism of mesalazine-induced myo- and pericarditis, pancreatitis, nephritis and hepatitis is unknown,
but it might be of allergic origin.
(**) Photosensitivity: More severe reactions are reported in patients with pre-existing skin conditions such as
atopic dermatitis and atopic eczema.
It is important to note that several of these disorders can also be attributed to the inflammatory bowel disease
itself.

Experience in animals: A single intravenous dose of mesalazine in rats of 920 mg/kg and single oral doses of
mesalazine in pigs up to 5 g/kg were not lethal.
Human experience: There is limited clinical experience with overdose of PENTASA prolonged release granules
which does not indicate renal or hepatic toxicity. Since PENTASA is an amino salicylate, symptoms of salicylate
toxicity may occur. Symptoms of salicylate over dosage are well described in the literature.
There have been reports of patients taking daily oral doses of 8 g for a month without any adverse events

There is no specific antidote and treatment is symptomatic and supportive. The treatment at hospital includes
close monitoring of renal function

Pharmacotherapeutic group: Intestinal anti-inflammatory agents, aminosalicylic acid and similar agents
ATC code: A07E C02
Mesalazine is the active component of sulfasalazine, which has been used for a long time in the treatment of
ulcerative colitis and Crohn’s disease.
The therapeutic value of mesalazine appears to be due to local effect on the inflamed intestinal tissue, rather than
to systemic effect.
There is information suggesting that severity of colonic inflammation in ulcerative colitis patients treated with
mesalazine is inversely correlated with mucosal concentrations of mesalazine.
Increased leukocyte migration, abnormal cytokine production, increased production of arachidonic acid
metabolites, particularly leukotriene B4, and increased free radical formation in the inflamed intestinal tissue are
all present in patients with inflammatory bowel disease. The mechanism of action of mesalazine is not fully
understood although mechanisms such as activation of the γ-form of peroxisome proliferator-activated receptors
(PPAR-γ) and inhibition of nuclear factor-kappa B (NF-κB) in the intestinal mucosa have been implicated.
Mesalazine has in-vitro and in-vivo pharmacological effects that inhibit leukocyte chemotaxis, decrease cytokine
and leukotriene production and scavenge for free radicals. It is currently unknown which, if any, of these
mechanisms play a predominant role in the clinical efficacy of mesalazine.
The risk of colorectal cancer (CRC) is slightly increased in ulcerative colitis.
Observed effects of mesalazine in experimental models and patient biopsies support the role of mesalazine in
prevention of colitis-associated CRC, with down regulation of both inflammation dependent and noninflammation
dependent signalling pathways involved in the development of colitis-associated CRC. However
data from meta-analyses, including both referral and non-referral populations, provide inconsistent clinical
information regarding the benefit of mesalazine in the carcinogenesis risk associated with ulcerative colitis.

General characteristics of the active substance
Disposition and local availability:
The therapeutic activity of mesalazine most likely depends on a local contact of the drug with the diseased area
of the intestinal mucosa.
PENTASA prolonged release granules consist of ethylcellulose coated microgranules of mesalazine. The coated
microgranules enter the duodenum within an hour of administration, independent of food co-administration.
Mesalazine is continuously released from the coated microgranules throughout the gastrointestinal tract in any
enteral pH conditions.
Absorption: Bioavailability of PENTASA after oral administration can be estimated to approx. 30%, based on
urine recovery data in healthy volunteers. Maximum plasma concentrations are seen 1-6 hours post-dose. A oncedaily
dosing regimen of mesalazine (1 × 4 g/d) and a twice-daily dosage (2 × 2 g/d) results in a comparable
systemic exposure (AUC) over 24 hours and indicate a continuous release of mesalazine from the formulation
over the treatment period. Steady-state is reached after a treatment period of 5 days following oral administration.

The transit and release of mesalazine after oral administration are independent of food co-administration,
whereas the systemic exposure may be increased.

Distribution: Mesalazine and acetyl-mesalazine do not cross the blood-brain barrier. Protein binding of
mesalazine is approximately 50% and of acetyl-mesalazine about 80%.
Metabolism: Mesalazine is metabolised both pre-systemically by the intestinal mucosa and systemically in the
liver to N-acetyl-mesalazine (acetyl-mesalazine) principally by NAT-1. Some acetylation also occurs through the
action of colonic bacteria. The acetylation seems to be independent of the acetylator phenotype of the patient.
The metabolic ratio of acetyl-mesalazine to mesalazine in plasma after oral administration ranges from 3.5 to 1.3
after daily doses of 500 mg x 3 and 2 g x 3, respectively, implying a dose-dependent acetylation which may be
subject to saturation.
Elimination: Due to the continuous release of mesalazine throughout the gastrointestinal tract, the elimination
half-life cannot be determined after oral administration.
However, once the formulation is not present in the GI tract elimination will follow the plasma half-life of orally
or iv administered uncoated mesalazine, which is approximately 40 minutes and for acetyl-mesalazine
approximately 70 minutes.
Characteristics in patients
Pathophysiologic changes such as diarrhoea and increased bowel acidity observed during active inflammatory
bowel disease have only a minor impact on the delivery of mesalazine to the intestinal mucosa after oral
administration. A urine excretion 20-25% of the daily dose has been observed in patients with accelerated
intestinal transit. Likewise, a corresponding increase in faecal excretion has been seen.

Toxic renal effects have been demonstrated in all species tested. Rat and monkey dosages and plasma
concentrations at the No Observed Adverse Effect Levels (NOAELs) exceed those used in humans by a factor of
2-7.2.
In vitro test systems and in-vivo studies showed no evidence of mutagenic effects. Studies on the tumourigenic
potential carried out in rats showed no evidence of any substance-related increase in the incidence of tumours.
Animal studies on oral mesalazine do not indicate direct or indirect harmful effects with respect to fertility,
pregnancy, embryo-foetal development, parturition or postnatal development.

Ethylcellulose
Povidone

Not applicable

This medicinal product does not require any special storage conditions.

Polyester/Aluminium/LD polyethylene sachet.
Pack size:
1 x 50 sachets

Any unused product or waste material should be disposed of in accordance with local requirements.