Delzicol

Medical Editor: John P. Cunha, DO, FACOEP Last updated on RxList: 11/29/2022
Drug Description

What is Delzicol and how is it used?

Delzicol is a prescription medicine used to treat the symptoms of Ulcerative Colitis. Delzicol may be used alone or with other medications.

Delzicol belongs to a class of drugs called 5-Aminosalicylic Acid Derivatives.

It is not known if Delzicol is safe and effective in children younger than 5 years of age.

What are the possible side effects of Delzicol?

Delzicol may cause serious side effects including:

  • hives,
  • difficulty breathing,
  • swelling of your face, lips, tongue, or throat,
  • severe stomach pain,
  • stomach cramping,
  • bloody diarrhea,
  • fever,
  • headache,
  • skin rash,
  • bloody or tarry stools,
  • coughing up blood,
  • vomit that looks like coffee grounds,
  • little or no urination,
  • painful or difficult urination,
  • swelling in your feet or ankles,
  • tiredness,
  • shortness of breath,
  • loss of appetite,
  • upper stomach pain,
  • tiredness,
  • easy bruising,
  • unusual bleeding,
  • dark urine,
  • clay-colored stools, and
  • yellowing of the skin or eyes (jaundice)

Get medical help right away, if you have any of the symptoms listed above.

The most common side effects of Delzicol include:

  • nausea,
  • vomiting,
  • stomach pain,
  • diarrhea,
  • indigestion,
  • gas,
  • headache,
  • rash, and
  • abnormal liver function tests

Tell the doctor if you have any side effect that bothers you or that does not go away.

These are not all the possible side effects of Delzicol. For more information, ask your doctor or pharmacist.

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

DESCRIPTION

Each DELZICOL (mesalamine) delayed-release capsule for oral administration contains 400 mg of mesalamine, an aminosalicylate. DELZICOL (mesalamine) delayed-release capsules contain acrylic based resin, Eudragit S (methacrylic acid copolymer type B, NF), which dissolves at pH 7 or greater and releases mesalamine in the terminal ileum and beyond for topical anti-inflammatory action in the colon. Mesalamine (also referred to as 5-aminosalicylic acid or 5-ASA) has the chemical name 5-amino-2hydroxybenzoic acid. Its structural formula is:

DELZICOL (mesalamine) Structural Formula Illustration

Inactive Ingredients: Each capsule contains colloidal silicon dioxide, dibutyl sebacate, ferric oxide red, ferric oxide yellow, lactose monohydrate, magnesium stearate, methacrylic acid copolymer type B (Eudragit S), polyethylene glycol, povidone, sodium starch glycolate, talc and hydroxypropyl methylcellulose (HPMC).

Indications & Dosage

INDICATIONS

Treatment Of Mildly To Moderately Active Ulcerative Colitis

DELZICOL® is indicated for the treatment of mildly to moderately active ulcerative colitis in patients 5 years of age and older.

Maintenance Of Remission Of Ulcerative Colitis

DELZICOL® is indicated for the maintenance of remission of ulcerative colitis in adults.

DOSAGE AND ADMINISTRATION

Important Administration Instructions

  • Two DELZICOL 400 mg capsules have not been shown to be interchangeable or substitutable with one mesalamine delayed-release 800 mg tablet.
  • Evaluate renal function prior to initiation of DELZICOL.
  • Take DELZICOL capsules with or without food.
  • Swallow the capsules whole; do not cut, break, crush or chew the capsules.
  • For patients who are unable to swallow the capsules whole, carefully open the capsule(s) and swallow the contents (four 100 mg tablets).
    • Open the number of capsules required to make up a complete dose [see DOSAGE AND ADMINISTRATION].
    • There are 4 tablets per capsule. Ensure all tablets per capsule are swallowed and no tablets are retained in the mouth.
    • Swallow the tablets whole; do not cut, break, crush or chew the tablets.
  • Drink an adequate amount of fluids [see WARNINGS AND PRECAUTIONS].
  • Intact, partially intact, and/or tablet shells have been reported in the stool; Instruct patients to contact their healthcare provider if this occurs repeatedly. Protect DELZICOL capsules from moisture. Close the container tightly and leave any desiccant pouches present in the bottle along with the tablets.

Dosage For Treatment Of Mildly To Moderately Active Ulcerative Colitis

Adults

For adults, the recommended dosage of DELZICOL is 800 mg (two 400 mg capsules) three times daily (total daily dosage of 2.4 grams) for a duration of 6 weeks [see Clinical Studies].

Pediatrics

For pediatric patients 5 years of age and older, the recommended total daily dosage of DELZICOL is weight-based (up to maximum of 2.4 grams per day) divided into two daily doses for a duration of 6 weeks (see Table 1).

Table 1: Pediatric Dosage by Weight

Weight Group (kg) Daily Dosage (mg/kg/day) Maximum Daily Dosage (grams per day) Morning Dosage Afternoon Dosage
17 to 32 36 to 71 1.2 two 400 mg capsules one 400 mg capsules
33 to 53 37 to 61 2 three 400 mg capsules two 400 mg capsules
54 to 90 27 to 44 2.4 three 400 mg capsules three 400 mg capsules

Dosage For Maintenance Of Remission Of Ulcerative Colitis

The recommended dosage of DELZICOL in adults is 1.6 grams (four 400 mg capsules) daily in two to four divided doses.

HOW SUPPLIED

Dosage Forms And Strengths

DELZICOL (mesalamine) delayed-release capsules are clear capsules and imprinted “WC 400mg” in black ink. Each capsule contains four reddish-brown coated 100 mg mesalamine tablets.

Storage And Handling

DELZICOL (mesalamine) delayed-release capsules are available as clear capsules and imprinted with “WC 400mg” in black ink. Each capsule contains four reddish-brown coated 100 mg mesalamine tablets.

NDC 0023-5853-18 Bottle of 180 capsules

Store at controlled room temperature 20° to 25° C (68° to 77° F); excursions are permitted 15° to 30° C (59° to 86° F). [See USP Controlled Room Temperature]

Distributed by: Allergan USA, Inc. Madison, NJ 07940. Revised : Nov 2021

SLIDESHOW

Inflammatory Bowel Disease (IBD) Causes, Symptoms, Treatment See Slideshow
Side Effects

SIDE EFFECTS

The most serious adverse reactions seen in DELZICOL clinical trials or with other products that contain or are metabolized to mesalamine are:

  • Renal Impairment [see WARNINGS AND PRECAUTIONS]
  • Mesalamine-Induced Acute Intolerance Syndrome [see WARNINGS AND PRECAUTIONS]
  • Hypersensitivity Reactions [see WARNINGS AND PRECAUTIONS]
  • Hepatic Failure [see WARNINGS AND PRECAUTIONS]
  • Severe Cutaneous Adverse Reactions [see WARNINGS AND PRECAUTIONS]
  • Photosensitivity [see WARNINGS AND PRECAUTIONS]
  • Nephrolithiasis [see WARNINGS AND PRECAUTIONS]

Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

The safety of DELZICOL has been established based on adequate and well-controlled studies of mesalamine delayed-release tablets. In total, mesalamine delayed-release 400 mg tablets have been evaluated in 2690 patients with ulcerative colitis in controlled and open-label trials. Below is a description of the adverse reactions of mesalamine delayed-release tablets in these adequate and well-controlled studies.

Clinical studies supporting mesalamine delayed-release tablets use for the treatment of mildly to moderately active ulcerative colitis included two 6-week, placebo-controlled, randomized, double-blind studies in adults with mildly to moderately active ulcerative colitis (Studies 1 and 2), and one 6-week, randomized, double-blind, study of 2 dosage levels in children with mildly to moderately active ulcerative colitis (Study 3). Clinical studies supporting the use of mesalamine delayed-release tablets in the maintenance of remission of ulcerative colitis included a 6-month, randomized, double-blind, placebo-controlled, multi-center study (Study 4) and four active-controlled maintenance trials comparing mesalamine delayed-release with sulfasalazine. Mesalamine delayed-release tablets have been evaluated in 427 adults and 107 children with ulcerative colitis in these controlled studies.

Treatment Of Mildly To Moderately Active Ulcerative Colitis

Adults

In a 6-week placebo-controlled clinical study (Study 1) involving 105 patients, 53 of whom were randomized to mesalamine delayed-release tablets 2.4 grams per day [see Clinical Studies], 4% of the mesalamine delayed release tablets -treated patients in 2.4 grams per day group discontinued therapy because of adverse reactions as compared to 0% of the placebo-treated patients. The average age of patients was 41 years and 49 % of patients were male. Adverse reactions leading to withdrawal from mesalamine delayed-release tablets included (each in one patient): diarrhea and colitis flare; dizziness, nausea, joint pain, and headache.

The most common adverse reactions in patients treated with mesalamine delayed release tablets 2.4 grams per day in Study 1 are listed in Table 2 below.

Table 2: Most Common Adverse Reactions Reported in Study 1 for the Treatment of Mild to Moderate Ulcerative Colitis in Adults*

Adverse Reaction % of Patients with Adverse Reactions
Mesalamine Delayed release 2.4 grams per day
(n = 53)
Placebo
(n = 52)
Eructation 26 19
Abdominal pain 21 12
Constipation 11 0
Dizziness 9 8
Rhinitis 8 6
Back pain 6 4
Rash 6 4
Dyspepsia 4 0
Flu syndrome 4 2
* At Least 2% of Patients in the Mesalamine Delayed Release Tablets Group and at a Rate Greater than Placebo

Pediatric Patients 5 To 17 Years Old

A randomized, double-blind, 6-week study of 2 dosage levels of mesalamine delayed-release 400 mg tablets (Study 3) was conducted in 82 pediatric patients 5 to 17 years of age with mildly to moderately active ulcerative colitis. All patients were divided by body weight category (17 to less than 33 kg, 33 to less than 54 kg, and 54 to 90 kg) and randomly assigned to receive a low dosage (1.2, 2, and 2.4 grams per day for the respective body weight category) or a high dosage (2.0, 3.6, and 4.8 grams per day).

The high dosage regimen is not recommended because it was not found to be more effective than the recommended low dosage regimen [see DOSAGE AND ADMINISTRATION, Clinical Studies].

Duration of exposure to mesalamine among the 82 patients in the study ranged from 12 to 50 days (mean of 40 days in each dosage group). The majority (88%) of patients in each group were treated for more than 5 weeks. Table 3 provides a summary of the specific reported adverse reactions.

Table 3: Adverse Reactions ≥ 5% Reported in Study 3 for the Treatment of Mild to ModerateUlcerative Colitis in Pediatric Patients*

Adverse Reaction % of Patients with Adverse Reactions
Low Dosage
(n=41)
High Dosage
(n=41)
Nasopharyngitis 15 12
Headache 10 5
Abdominal pain 10 2
Dizziness 7 2
Sinusitis 7 0
Rash 5 5
Cough 5 0
Diarrhea 5 0
Fatigue 2 10
Pyrexia 0 7
Increased Lipase 0 5
Low Dosage = mesalamine 400 mg delayed-release tablet 1.2 to 2.4 grams/day; High Dosage = mesalamine 400 mg delayed-release tablet 2.0 to 4.8 grams/day. Dosage was dependent on body weight. Adverse Reactions reported at the 1-week telephone follow-up visit are included.
* At Least 5% of Patients in the low dosage or high dosage group

Twelve percent of the patients in the low dosage group (5 patients) and 2% of the patients in the high dosage group (1 patient) had serious adverse reactions. The serious adverse reactions consisted of sinusitis, adenovirus infection, and pancreatitis in one patient each in the low dosage group. Abdominal pain and decreased body mass index occurred in one patient and bloody diarrhea and sclerosing cholangitis also occurred in one patient in the low dosage group. Anemia and syncope occurred in one patient in the high dosage group.

Five patients were withdrawn from the study due to adverse reactions: 3 (7%) in the low dosage group (1 patient each with adenovirus infection, sclerosing cholangitis, and pancreatitis) and 2 patients (5%) in the high dosage group (1 patient with increased amylase and increased lipase, and 1 patient with upper abdominal pain).

In general, the nature and severity of reactions in the pediatric population was similar to those reported in adult populations of patients with ulcerative colitis.

Maintenance Of Remission Of Ulcerative Colitis

Clinical studies supporting the use of mesalamine delayed release tablets in the maintenance of remission of ulcerative colitis in adults included a randomized, double-blind, multi-center, placebo-controlled clinical trial of 6 months' duration in 264 patients (Study 4) [see Clinical Studies].

In Study 4, a randomized, double-blind, multi-center, placebo-controlled clinical trial of 6 months' duration, 87 patients were randomized to receive mesalamine delayed release tablets 1.6 grams per /day compared to 87 patients randomized to placebo. The average age of patients in Study 4 was 42 years and 55% of patients were male. Adverse reactions leading to study withdrawal in patients using mesalamine delayed release tablets included (each in one patient): anxiety, stomatitis and asthenia.

In addition to the adverse reactions listed in Table 2, the following occurred at a frequency of 2% or greater in patients who received mesalamine delayed-release tablets in Study 4: abdominal enlargement, gastroenteritis, gastrointestinal hemorrhage, infection, joint disorder, nervousness, paresthesia, hemorrhoids, tenesmus, urinary frequency and vision abnormalities.

Postmarketing Experience

The following adverse reactions have been identified during post-approval use of DELZICOL or other mesalamine-containing products. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

Body as a Whole: Neck pain, facial edema, edema, lupus-like syndrome, drug fever.

Cardiovascular: Pericarditis, myocarditis [see WARNINGS AND PRECAUTIONS].

Endocrine: Nephrogenic diabetes insipidus.

Gastrointestinal: Anorexia, pancreatitis, gastritis, increased appetite, cholecystitis, dry mouth, oral ulcers, perforated peptic ulcer, bloody diarrhea.

Hematologic: Agranulocytosis, aplastic anemia, thrombocytopenia, eosinophilia, leukopenia, anemia, lymphadenopathy.

Musculoskeletal: Gout.

Nervous: Depression, somnolence, emotional lability, hyperesthesia, vertigo, confusion, tremor, peripheral neuropathy, transverse myelitis, Guillain-Barré syndrome, intracranial hypertension.

Renal: Renal failure, interstitial nephritis, minimal change disease, nephrolithiasis [see WARNINGS AND PRECAUTIONS].

Respiratory/Pulmonary: Eosinophilic pneumonia, interstitial pneumonitis, asthma exacerbation, pleurisy/pleurtitis.

Skin: Alopecia, psoriasis, pyoderma gangrenosum, dry skin, erythema nodosum, urticaria, SJS/TEN, DRESS, and AGEP [see WARNINGS AND PRECAUTIONS].

Special Senses: Eye pain, taste perversion, blurred vision, tinnitus.

Urogenital: Dysuria, urinary urgency, hematuria, epididymitis, menorrhagia, reversible oligospermia.

Laboratory Abnormalities: Elevated AST (SGOT) or ALT (SGPT), elevated alkaline phosphatase, elevated GGT, elevated LDH, elevated bilirubin, elevated serum creatinine and BUN.

Drug Interactions

DRUG INTERACTIONS

Nephrotoxic Agents, Including Non-Steroidal Anti-Inflammatory Drugs

The concurrent use of mesalamine with known nephrotoxic agents, including non-steroidal anti-inflammatory drugs (NSAIDs) may increase the risk of nephrotoxicity. Monitor patients taking nephrotoxic drugs for changes in renal function and mesalamine-related adverse reactions [see WARNINGS AND PRECAUTIONS].

Azathioprine Or 6-Mercaptopurine

The concurrent use of mesalamine with azathioprine or 6-mercaptopurine and/or other drugs known to cause myelotoxicity may increase the risk for blood disorders, bone marrow failure, and associated complications. If concomitant use of DELZICOL and azathioprine or 6-mercaptopurine cannot be avoided, monitor blood tests, including complete blood cell counts and platelet counts.

Interference With Urinary Normetanephrine Measurements

Use of DELZICOL may lead to spuriously elevated test results when measuring urinary normetanephrine by liquid chromatography with electrochemical detection [see WARNINGS AND PRECAUTIONS]. Consider an alternative, selective assay for normetanephrine.

Warnings & Precautions

WARNINGS

Included as part of the "PRECAUTIONS" Section

PRECAUTIONS

Renal Impairment

Renal impairment, including minimal change disease, acute and chronic interstitial nephritis, and renal failure, has been reported in patients given products such as APRISO that contain mesalamine or are converted to mesalamine. In animal studies, the kidney was the principal organ of mesalamine toxicity [see ADVERSE REACTIONS, Nonclinical Toxicology].

Evaluate renal function prior to initiation of APRISO therapy and periodically while on therapy. Evaluate the risks and benefits of using APRISO in patients with known renal impairment or a history of renal disease or taking concomitant nephrotoxic drugs [see DRUG INTERACTIONS, Use In Specific Populations].

Mesalamine-Induced Acute Intolerance Syndrome

Mesalamine has been associated with an acute intolerance syndrome that may be difficult to distinguish from an exacerbation of ulcerative colitis. Although the exact frequency of occurrence has not been determined, it has occurred in 3% of patients in controlled clinical trials of mesalamine or sulfasalazine. Symptoms include cramping, acute abdominal pain and bloody diarrhea, sometimes fever, headache, and rash. Monitor patients for worsening of these symptoms while on treatment. If acute intolerance syndrome is suspected, promptly discontinue treatment with APRISO.

Hypersensitivity Reactions

Some patients have experienced a hypersensitivity reaction to sulfasalazine. Some patients may have a similar reaction to APRISO or to other compounds that contain or are converted to mesalamine.

As with sulfasalazine, mesalamine-induced hypersensitivity reactions may present as internal organ involvement, including myocarditis, pericarditis, nephritis, hepatitis, pneumonitis and hematologic abnormalities. Evaluate patients immediately if signs or symptoms of a hypersensitivity reaction are present. Discontinue APRISO if an alternative etiology for the signs and symptoms cannot be established.

Hepatic Failure

There have been reports of hepatic failure in patients with pre-existing liver disease who have been administered mesalamine. Evaluate the risks and benefits of using APRISO in patients with known liver impairment.

Severe Cutaneous Adverse Reactions

Severe cutaneous adverse reactions, including Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), and acute generalized exanthematous pustulosis (AGEP) have been reported with the use of mesalamine [see ADVERSE REACTIONS]. Discontinue APRISO at the first signs or symptoms of severe cutaneous adverse reactions or other signs of hypersensitivity and consider further evaluation.

Photosensitivity

Patients with pre-existing skin conditions such as atopic dermatitis and atopic eczema have reported more severe photosensitivity reactions. Advise patients to avoid sun exposure, wear protective clothing, and use a broad-spectrum sunscreen when outdoors.

Nephrolithiasis

Cases of nephrolithiasis have been reported with the use of mesalamine, including stones with 100% mesalamine content. Mesalamine-containing stones are radiotransparent and undetectable by standard radiography or computed tomography (CT). Ensure adequate fluid intake during treatment with APRISO.

Risks In Patients With Phenylketonuria

Phenylalanine can be harmful to patients with phenylketonuria (PKU). APRISO contains phenylalanine, a component of aspartame. Each APRISO 0.375 g capsule contains 0.56 mg of phenylalanine. Before prescribing APRISO to a patient with PKU, consider the combined daily amount of phenylalanine from all sources, including APRISO.

Interference With Laboratory Tests

Use of APRISO may lead to spuriously elevated test results when measuring urinary normetanephrine by liquid chromatography with electrochemical detection because of the similarity in the chromatograms of normetanephrine and the main metabolite of mesalamine, N-acetyl-5-aminosalicylic acid (N-Ac-5-ASA). Consider an alternative, selective assay for normetanephrine.

Nonclinical Toxicology

Carcinogenesis, Mutagenesis, Impairment Of Fertility

Dietary mesalamine was not carcinogenic in rats at doses as high as 480 mg/kg/day, or in mice at 2000 mg/kg/day. These doses are about 2.6 and 5.4 times the recommended human dose of granulated mesalamine capsules of 1.5 g/day (30 mg/kg if 50 kg body weight assumed or 1110 mg/m2), respectively, based on body surface area.

Mesalamine was negative in the Ames test, the mouse lymphoma cell (L5178Y/TK+/-) forward mutation test, the sister chromatid exchange assay in the Chinese hamster bone marrow test, and the mouse bone marrow micronucleus test.

No effects on fertility or reproductive performance in male and female rats were observed with oral mesalamine doses up to 320 mg/kg (about 1.7 times the recommended human dose based on body surface area).

Use In Specific Populations

Pregnancy

Risk Summary

Published data from meta-analyses, cohort studies and case series on the use of mesalamine during pregnancy have not reliably informed an association with mesalamine and major birth defects, miscarriage, or adverse maternal or fetal outcomes (see Data).

In animal reproduction studies, there were no adverse developmental outcomes with administration of oral mesalamine during organogenesis to pregnant rats and rabbits at doses 1.7 and 5.4 times, respectively, the maximum recommended human dose (see Data).

The estimated background risk of major birth defects and miscarriage for the indicated populations is unknown. Adverse outcomes in pregnancy occur regardless of the health of the mother or the use of medications. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2 to 4% and 15 to 20%, respectively.

Clinical Considerations

Disease-associated Maternal and Embryo/fetal Risk

Published data suggest that increased disease activity is associated with the risk of developing adverse pregnancy outcomes in women with ulcerative colitis. Adverse pregnancy outcomes include preterm delivery (before 37 weeks of gestation), low birth weight (less than 2500 g) infants, and small for gestational age at birth.

Data

Human Data

Published data from meta-analyses, cohort studies and case series on the use of mesalamine during early pregnancy (first trimester) and throughout pregnancy have not reliably informed an association of mesalamine and major birth defects, miscarriage, or adverse maternal or fetal outcomes. There is no clear evidence that mesalamine exposure in early pregnancy is associated with an increased risk in major congenital malformations, including cardiac malformations. Published epidemiologic studies have important methodological limitations which hinder interpretation of the data, including inability to control for confounders, such as underlying maternal disease, and maternal use of concomitant medications, and missing information on the dose and duration of use for mesalamine products.

Animal Data

Reproduction studies with mesalamine during organogenesis have been performed in rats at oral doses up to 320 mg/kg/day (about 1.7 times the recommended human dose based on a body surface area comparison) and rabbits at doses up to 495 mg/kg/day (about 5.4 times the recommended human dose based on a body surface area comparison) and have revealed no evidence of harm to the fetus due to mesalamine.

Lactation

Risk Summary

Data from published literature report the presence of mesalamine and its metabolite, N-acetyl 5-aminosalicylic acid in human milk in small amounts with relative infant doses (RID) of 2% or less (see Data). There are case reports of diarrhea in breastfed infants exposed to mesalamine (see Clinical Considerations). There is no information on the effects of the drug on milk production. The lack of clinical data during lactation precludes a clear determination of the risk of APRISO to an infant during lactation; therefore, the developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for APRISO and any potential adverse effects on the breastfed child from APRISO or from the underlying maternal condition.

Clinical Considerations

Advise the caregiver to monitor the breastfed infant for diarrhea.

Data

In published lactation studies, maternal mesalamine doses from various oral and rectal formulations and products ranged from 500 mg to 4.8 g daily. The average concentration of mesalamine in milk ranged from non-detectable to 0.5 mg/L. The average concentration of the N-acetyl-5-aminosalicylic acid in milk ranged from 0.2 to 9.3 mg/L. Based on these concentrations, estimated infant daily dosages for an exclusively breastfed infant are 0 to 0.075 mg/kg/day (RID 0 to 0.1%) of mesalamine and 0.03 to 1.4 mg/kg/day of N-acetyl-5-aminosalicylic acid.

Pediatric Use

Safety and effectiveness of APRISO in pediatric patients have not been established.

Geriatric Use

Clinical studies of APRISO did not include sufficient numbers of subjects aged 65 years and over to determine whether they respond differently than younger subjects. Reports from uncontrolled clinical studies and postmarketing reporting systems suggested a higher incidence of blood dyscrasias (i.e., agranulocytosis, neutropenia and pancytopenia) in patients who were 65 years or older compared to younger patients taking mesalamine-containing products such as APRISO. Monitor complete blood cell counts and platelet counts in elderly patients during treatment with APRISO. In general, consider the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy in elderly patients when prescribing APRISO [see Renal Impairment].

Renal Impairment

Mesalamine is known to be substantially excreted by the kidney, and the risk of adverse reactions to this drug may be greater in patients with impaired renal function. Evaluate renal function in all patients prior to initiation and periodically while on APRISO therapy. Monitor patients with known renal impairment or history of renal disease or taking nephrotoxic drugs for decreased renal function and mesalamine-related adverse reactions [see WARNINGS AND PRECAUTIONS, ADVERSE REACTIONS, DRUG INTERACTIONS].

Overdose & Contraindications

OVERDOSE

DELZICOL is an aminosalicylate, and symptoms of salicylate toxicity include nausea, vomiting and abdominal pain, tachypnea, hyperpnea, tinnitus, and neurologic symptoms (headache, dizziness, confusion, seizures). Severe salicylate intoxication may lead to electrolyte and blood pH imbalance and potentially to other organ (e.g., renal and liver) involvement. There is no specific antidote for mesalamine overdose; however, conventional therapy for salicylate toxicity may be beneficial in the event of acute overdosage and may include gastrointestinal tract decontamination to prevent of further absorption. Correct fluid and electrolyte imbalance by the administration of appropriate intravenous therapy and maintain adequate renal function.

DELZICOL is a pH dependent delayed-release product and this factor should be considered when treating a suspected overdose.

CONTRAINDICATIONS

DELZICOL is contraindicated in patients with known or suspected hypersensitivity to salicylates or aminosalicylates or to any of the ingredients of DELZICOL [see WARNINGS AND PRECAUTIONS, ADVERSE REACTIONS, DESCRIPTION].

Clinical Pharmacology

CLINICAL PHARMACOLOGY

Mechanism Of Action

The mechanism of action of mesalamine is not fully understood, but appears to be a topical anti-inflammatory effect on colonic epithelial cells. Mucosal production of arachidonic acid metabolites, both through the cyclooxygenase pathways, that is, prostanoids, and through the lipoxygenase pathways, that is, leukotrienes and hydroxyeicosatetraenoic acids, is increased in patients with ulcerative colitis, and it is possible that mesalamine diminishes inflammation by blocking cyclooxygenase and inhibiting prostaglandin production in the colon.

Pharmacokinetics

Absorption

Approximately 28% of mesalamine in mesalamine delayed-release formulation is absorbed after oral ingestion. Following replicate single dose oral administration of DELZICOL 400 mg capsule containing four 100 mg tablets in healthy subjects (N = 146) under fasted conditions, the mean Cmax, AUC8-48 and AUCtldc values were 150 ± 235 ng/mL, 640 ± 521 ng.h/mL, and 909 ± 777 ng.h/mL, respectively. The median [range] Tmax for mesalamine following DELZICOL 400 mg capsule containing four 100 mg tablets was approximately 10 hours [5.5 – 48 hours], reflecting the delayed-release characteristics of the formulation.

A high fat meal increased systemic exposure of mesalamine (geometric mean Cmax: ↑ 32%; AUC8-48 h: ↑ 46 %; AUC: ↑ 29%) and delayed the median tmax by approximately 4 hours compared to results in the fasted state. The observed differences in mesalamine exposure due to concomitant food intake are not considered to be clinically relevant at the total daily dosage of 2.4 grams per day.

Elimination

Metabolism

The absorbed mesalamine is rapidly acetylated in the gut mucosal wall and by the liver to N-acetyl-5aminosalicylic acid.

Excretion

Absorbed mesalamine is excreted mainly by the kidney as N-acetyl-5-aminosalicylic acid. Unabsorbed mesalamine is excreted in feces.

After intravenous administration, the elimination half-life of mesalamine is reported to be approximately 40 minutes. After oral dosing, the median terminal t½ values for mesalamine are usually about 25 hours, but are variable, ranging from 1.5 to 296 hours. There is a large inter-subject and intra-subject variability in the plasma concentrations of mesalamine and N-acetyl-5-aminosalicylic acid and in their terminal half-lives following administration of DELZICOL.

Specific Populations

Pediatric Patients

In a dose-ranging pharmacokinetic study evaluating 30, 60 and 90 mg/kg per day doses of mesalamine delayed-release 400 mg tablets administered twice daily for four weeks, the mean Cavg values of mesalamine in pediatric ulcerative colitis patients ranged from approximately 400 ng/mL to 2100 ng/mL based on data from all dose levels.

In a study evaluating mesalamine delayed-release tablets in pediatric ulcerative colitis patients (Study 3), mean plasma concentrations of mesalamine (based on sparse sampling) were 820 to 988 ng/mL at the low dose level (that is, 1.2, 2 or 2.4 grams/day based on body weight strata of 17 to less than 33 kg, 33 to less than 54 kg, and 54 to 90 kg, respectively).

Animal Toxicology And/Or Pharmacology

In animal studies (rats, mice, dogs), the kidney was the principal organ for toxicity. (In the following, comparisons of animal dosing to recommended human dosing are based on body surface area and a 2.4 grams per day dose for a 60 kg person.)

Mesalamine causes renal papillary necrosis in rats at single doses of approximately 750 mg/kg to 1000 mg/kg (approximately 3 to 4 times the recommended human dose based on body surface area). Doses of 170 and 360 mg/kg/day (about 0.7 and 1.5 times the recommended human dose based on body surface area) given to rats for six months produced papillary necrosis, papillary edema, tubular degeneration, tubular mineralization, and urothelial hyperplasia.

In mice, oral doses of 4000 mg/kg/day mesalamine (approximately 8 times the recommended human dose based on body surface area) for three months produced tubular nephrosis, multifocal/diffuse tubulointerstitial inflammation, and multifocal/diffuse papillary necrosis.

In dogs, single doses of 6000 mg (approximately 8 times the recommended human dose based on body surface area) of delayed-release mesalamine tablets resulted in renal papillary necrosis but were not fatal. Renal changes have occurred in dogs given chronic administration of mesalamine at doses of 80 mg/kg/day (1.1 times the recommended human dose based on body surface area).

Clinical Studies

The safety and efficacy of DELZICOL has been established based on adequate and well-controlled studies of mesalamine delayed-release tablets. Below is a description of the results of the adequate and well-controlled studies of mesalamine delayed-release tablets for the treatment of mildly to moderately active ulcerative colitis in adults and pediatric patients 5 to 17 years of age and the maintenance of remission of ulcerative colitis in adults.

Treatment Of Mildly To Moderately Active Ulcerative Colitis

Adults

Two placebo-controlled studies (Studies 1 and 2) have demonstrated the efficacy of mesalamine delayed-release tablets in patients with mildly to moderately active ulcerative colitis.

In one randomized, double-blind, multi-center, placebo-controlled clinical trial of 6 weeks’ duration in 158 patients (Study 1), patients received mesalamine delayed release dosages of 1.6 grams per day (800 mg twice a day; n=53) and 2.4 grams per day (800 mg three times a day; n=53), compared to placebo (n=52). The scoring system for determination of treatment efficacy included assessment of stool frequency, rectal bleeding, sigmoidoscopic findings, patient’s functional assessment, and physician global assessment. At the dosage of 2.4 grams per day, 21 of 43 (49%) patients using mesalamine delayed release tablets showed an improvement in sigmoidoscopic appearance of the bowel compared to 12 of 44 (27%) patients using placebo (p = 0.048). In addition, significantly more patients in the mesalamine delayed release tablets 2.4 grams per day group showed improvement in rectal bleeding and stool frequency. The 1.6 grams per day dosage regimen is not recommended because it did not produce consistent evidence of effectiveness [see DOSAGE AND ADMINISTRATION].

In a second randomized, double-blind, placebo-controlled clinical trial of 6 weeks’ duration in 87 patients (Study 2), patients received mesalamine delayed release tablets of 1.6 grams per day (400 mg four times a day; n=11) and 4.8 grams per day (1.2 grams four times a day; n=38), compared to placebo four times a day (n=38). mesalamine delayed release tablets 4.8 grams per day for 6 weeks resulted in sigmoidoscopic improvement in 28 of 38 (74%) patients compared to 10 of 38 (26%) placebo patients (p less than 0.001). Also, more patients in the mesalamine delayed release tablets 4.8 grams per day group than the placebo group showed improvement in overall symptoms. The 4.8 grams per day dosage regimen is not recommended because greater efficacy was not demonstrated with this dosage compared to the 2.4 grams per day dosage [see DOSAGE AND ADMINISTRATION].

Pediatrics

The safety and effectiveness of mesalamine delayed release in pediatric patients 5 to 17 years of age for treatment of mildly to moderately active ulcerative colitis are supported by evidence from adequate and well controlled studies of mesalamine delayed release in adults and a single study in pediatric patients.

A randomized, double-blind, 6-week study of two dosage levels of mesalamine delayed release tablets (Study 3) was conducted in 82 pediatric patients 5 to 17 years of age with mildly or moderately active ulcerative colitis defined as a score of 10 to 55 on the Pediatric Ulcerative Colitis Activity Index (PUCAI) (which includes assessment of abdominal pain, rectal bleeding, stool consistency, number of stools per 24 hours, presence of nocturnal bowel movement and activity level, and has a total maximum score of 85; each of the subscales are scored from 0 to 10 except rectal bleeding which is scored from 0 to 30, and number of stools per 24 hours which is scored from 0 to 15) and rectal bleeding and stool frequency Mayo subscale scores of ≥1 (each of these subscales are scored from zero (normal) to three (most severe).

All patients were divided by weight category (17 to less than 33 kg, 33 to less than 54 kg, and 54 to 90 kg) and randomly assigned to receive a low dosage (1.2, 2, and 2.4 grams per day for the respective weight category) or a high dosage (2, 3.6, and 4.8 grams per day). Doses were administered every 12 hours.

The proportion of patients who achieved success based on the Truncated Mayo Score (TM-Mayo) (based on the stool frequency and rectal bleeding subscores of the Mayo Score) and based on the PUCAI was measured after 6 weeks of treatment. Success based on TM-Mayo was defined as either partial response (improvement from baseline in stool frequency or rectal bleeding subscores with no worsening in the other) or complete response (both stool frequency and rectal bleeding subscores equal 0). Success based on PUCAI was defined as either partial response (PUCAI reduction of greater than or equal to 20 points from Baseline to Week 6 with Week 6 score greater than or equal to 10) or complete response (PUCAI less than 10 at Week 6).

There were 41 patients in the low dosage group and 41 patients in the high dosage group who received at least one dose of mesalamine delayed-release 400 mg tablets; 36 patients in each dosage group completed the study. Patients were considered treatment failures if they did not achieve success or dropped out due to adverse reaction or lack of efficacy.

At Week 6, 73% of the patients in the low dosage group, and 70% of the patients in the high dosage group achieved success based on the TM-Mayo; 34% of the patients in the low dosage group and 43% of the patients in the high dosage group achieved complete response. At Week 6, 56% of the patients in the low dosage group, and 55% of the patients in the high dosage group achieved success based on the PUCAI; 46% of the patients in the low dosage group and 43% of the patients in the high dosage group achieved complete response.

The high dosage regimen is not recommended because it was not more effective than the low dosage regimen [see DOSAGE AND ADMINISTRATION].

Maintenance Of Remission Of Ulcerative Colitis

Adults

In a randomized, double-blind, multi-center, placebo-controlled clinical trial of 6 months’ duration in 264 patients (Study 4), patients received mesalamine delayed-release tablets of 0.8 grams per day (400 mg twice a day; n = 90) and 1.6 grams per day (400 mg four times a day; n = 87), compared to placebo four times a day (n = 87). The proportion of patients treated with 0.8 grams per day who maintained endoscopic remission was not statistically significant compared to placebo; the 0.8 grams per day dosage regimen is not recommended [see DOSAGE AND ADMINISTRATION]. The number of patients using mesalamine delayed-release tablets 1.6 grams per day who maintained endoscopic remission of ulcerative colitis was 61 of 87 (70%) compared with 42 of 87 (48%) of placebo patients (p = 0.005).

A pooled efficacy analysis of 4 maintenance trials compared mesalamine delayed release tablets at dosages of 0.8 to 2.8 grams per day, in divided doses ranging from twice daily to four times per day, with sulfasalazine, at dosages of 2 to 4 grams per day. Treatment success was seen in 59 of 98 (59%) patients using mesalamine delayed release tablets and 70 of 102 (69%) patients using sulfasalazine, a non-significant difference.

Medication Guide

PATIENT INFORMATION

Administration

  • Inform patients that if they are switching from a previous oral mesalamine therapy to DELZICOL to discontinue their previous oral mesalamine therapy and follow the dosing instructions for DELZICOL. Inform patients that two DELZICOL 400 mg capsules cannot be substituted for one mesalamine delayed-release 800 mg tablet.
  • Inform patients that DELZICOL capsules can be taken with or without food.
  • Instruct patients to swallow the DELZICOL capsules whole. Do not cut, break, crush or chew the capsules.
  • For patients who are unable to swallow the capsules whole, carefully open the capsules and swallow the contents (four 100 mg tablets).
    • Open the number of capsules required to make up a complete dose.
    • There are 4 tablets per capsule. Ensure all tablets per capsule are swallowed and no tablets are retained in the mouth.
    • Swallow the tablets whole; do not cut, break, crush or chew the tablets.
  • Drink an adequate amount of fluids.
  • Inform patients that intact, partially intact, and/or tablet shells have been reported in the stool. Instruct patients to contact their healthcare provider if this occurs repeatedly.
  • Instruct patients to protect DELZICOL capsules from moisture. Instruct patients to close the container tightly and to leave any desiccant pouches present in the bottle along with the capsules.

Renal Impairment

  • Inform patients that DELZICOL may decrease their renal function, especially if they have known renal impairment or are taking nephrotoxic drugs, including NSAIDs, and periodic monitoring of renal function will be performed while they are on therapy. Advise patients to complete all blood tests ordered by their healthcare provider [see WARNINGS AND PRECAUTIONS, DRUG INTERACTIONS].

Mesalamine-Induced Acute Intolerance Syndrome And Other Hypersensitivity Reactions

Inform patients of the signs and symptoms of hypersensitivity reactions. Instruct patients to stop taking DELZICOL and report to their healthcare provider if they experience new or worsening symptoms of Acute Intolerance Syndrome (cramping, abdominal pain, bloody diarrhea, fever, headache, malaise, conjunctivitis and rash) or other symptoms suggestive of mesalamine-induced hypersensitivity [see WARNINGS AND PRECAUTIONS].

Hepatic Failure

Inform patients with known liver disease of the signs and symptoms of worsening liver function and advise them to report to their healthcare provider if they experience such signs or symptoms [see WARNINGS AND PRECAUTIONS].

Severe Cutaneous Adverse Reactions

Inform patients of the signs and symptoms of severe cutaneous adverse reactions. Instruct patients to stop taking DELZICOL and report to their healthcare provider at first appearance of a severe cutaneous adverse reaction or other sign of hypersensitivity [see WARNINGS AND PRECAUTIONS].

Photosensitivity

Advise patients with pre-existing skin conditions to avoid sun exposure, wear protective clothing, and use a broad-spectrum sunscreen when outdoors [see WARNINGS AND PRECAUTIONS].

Nephrolithiasis

Instruct patients to maintain an adequate fluid intake during treatment in order to minimize the risk of kidney stone formation and to contact their healthcare provider if they experience signs or symptoms of a kidney stone (e.g., severe side or back pain, blood in the urine) [see WARNINGS AND PRECAUTIONS].

Iron Content Of DELZICOL

Advise patients to inform their healthcare provider if they take iron-containing supplements [see WARNINGS AND PRECAUTIONS].

Blood Disorders

Inform elderly patients and those taking azathioprine or 6-mercaptopurine of the risk for blood disorders and the need for periodic monitoring of complete blood cell counts and platelet counts while on therapy. Advise patients to complete all blood tests ordered by their healthcare provider [see DRUG INTERACTIONS, Use In Specific Populations].

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