Entocort
capsules containing 3 mg Budesonide
Presentation
Capsule 3 mg (19 mm x 7 mm): a two-piece, hard, gelatine capsule, size 1, with opaque, light grey body and opaque, pink cap. The cap has black radial print CIR/3 mg. Each capsule contains approx. 0.35 g of white to off-white budesonide Controlled Ileal Release (CIR) granules representing 3 mg budesonide active ingredient. Average gross mass approx. 0.42 g.
Uses
Actions
Budesonide is a glucocorticosteroid with high local anti-inflammatory effect. ENTOCORT capsules consist of gelatin capsules filled with gastro-resistant, prolonged release granules for oral use. The granules are practically insoluble in gastric juice, and have prolonged release properties adjusted to release budesonide in the small intestine through the colon.
The exact mechanism of action of glucocorticosteroids in the treatment of Crohn's disease is not fully understood. Anti-inflammatory actions, such as inhibition of inflammatory mediator release and inhibition of cytokine mediated immune responses, are probably important.
Data from clinical pharmacology studies and controlled clinical trials indicate that ENTOCORT capsules act topically. This is supported by an similar efficacy, but a significantly less impact on the HPA-axis and systemic inflammatory markers, compared with prednisolone.
At recommended doses, ENTOCORT capsules cause significantly less effect than prednisolone 20-40 mg daily on morning plasma cortisol, on 24-hour plasma cortisol (AUC 0-24 h) and on 24-hour urine cortisol. Also ACTH tests have shown that ENTOCORT capsules, compared with prednisolone, have significantly less impact on the adrenal function.
Pharmacokinetics
Absorption
After oral dosing of plain micronized budesonide, absorption is rapid and seems to be complete. After dosing of ENTOCORT capsules a major fraction of absorbed medicine is absorbed in the ileum and ascending colon. In patients with active Crohn's disease, the systemic availability after a single dose ranges from 12 to 20%. In healthy subjects the corresponding figures are 9 to 12%.
After repeated dosing for 8 weeks, the systemic availability approaches that in healthy subjects (about 10%).
Distribution
Budesonide has a volume of distribution of approximately 3 L/kg. Plasma protein binding averages 85-90%. Following oral dosing of ENTOCORT capsules 9 mg, mean maximal plasma concentration is approximately 5-10 nmol/L, attained between 3-5 hours.
Biotransformation
Budesonide then undergoes extensive biotransformation (≈ 90%) on first passage through the liver to metabolites of low glucocorticosteroid activity. The glucocorticosteroid activity of the major metabolites, 6β-hydroxybudesonide and 16α-hydroxyprednisolone, is less than 1% of that of budesonide. The metabolism of budesonide is primarily mediated by CYP3A4, a subfamily of cytochrome 450.
Elimination
Elimination of budesonide given as ENTOCORT capsules is rate limited by its absorption, and the plasma half-life averages 4 hours. The metabolites are excreted as such or in conjugated form, mainly via the kidneys. No intact budesonide has been detected in the urine. Budesonide has a high systemic clearance (approximately 1.2 L/min), and the plasma half-life after IV dosing averages 2-3 hours.
Linearity
The kinetics of budesonide are dose-proportional at clinically relevant doses.
Indications
ENTOCORT capsules are indicated for the induction of remission in patients with mild to moderate Crohn's disease affecting the ileum and/or the ascending colon.
Dosage and Administration
Adults
The recommended daily dose for induction of remission is 9 mg, administered once daily for up to eight weeks. The dose should be taken in the morning before breakfast. The capsules should be swallowed whole with water and must not be chewed. Full effect is usually achieved within 2-4 weeks. When treatment with ENTOCORT capsules is to be discontinued, the dose should be tapered for 2 to 4 weeks and not stopped abruptly.
Children
Experience with ENTOCORT capsules in children is limited.
Elderly
No special dose adjustment is recommended. However, experience with ENTOCORT capsules in the elderly is limited.
The capsules must not be chewed. They must be swallowed whole with water.
Contraindications
Hypersensitivity to any of the ingredients.
Warnings and Precautions
NOTE: Some patients have been treated continuously for up to a year or more with ENTOCORT and although corticosteroid side effects are expected to be less than with prednisolone, caution should be exercised.
Caution should be taken in patients with infections, hypertension, diabetes mellitus, osteoporosis, peptic ulcer, glaucoma or cataracts, or with a family history of diabetes or glaucoma, or with any other condition where glucocorticosteroids may have unwanted effects.
Particular care is needed in patients who are transferred from systemic glucocorticosteroid treatment with a higher systemic effect to ENTOCORT Capsules. These patients may have adrenocortical suppression. Therefore, monitoring of adrenocortical function may be considered in these patients and their dose of systemic steroid should be reduced cautiously.
Some patients feel unwell in a non-specific way during the withdrawal phase e.g. pain in muscles and joints. A general insufficient glucocorticosteroid effect should be suspected if, in rare cases, symptoms such as tiredness, headache, nausea and vomiting should occur. In these cases, a temporary increase in the dose of systemic glucocorticosteroids is sometimes necessary.
Glucocorticosteroids can reduce the response of the hypothalamus-pituitary-adrenal (HPA) axis to stress. In situations where patients are subject to surgery or other stress situations, supplementation with a systemic glucocorticosteroid is recommended.
Replacement of systemic glucocorticosteroid treatment with higher systemic effect with ENTOCORT Capsules, sometimes unmasks allergies, e.g. rhinitis and eczema, which were previously controlled by the systemic medication.
Chicken pox and measles can have a more serious course in patients on oral glucocorticosteroids. In patients who have not had these diseases, particular care should be taken to avoid exposure. If exposed, therapy with varicella zoster immune globulin (VZIG) or pooled intravenous immunoglobulin (IVIG), as appropriate, may be indicated. If chicken pox develops, treatment with antiviral agents may be considered.
Reduced liver function may affect the elimination of glucocorticosteroids. The intravenous pharmacokinetics of budesonide however was similar in cirrhotic patients and in healthy subjects. The pharmacokinetics after oral ingestion of budesonide was affected by compromised liver function as evidenced by increased systemic availability.
In vivo studies have shown that oral administration of ketoconazole (a known inhibitor of CYP3A4 activity in the liver and in the intestinal mucosa, also see INTERACTIONS) caused a several-fold increase of the systemic exposure to oral budesonide. If treatment with ketoconazole together with budesonide is indicated, reduction of the budesonide dose should be considered if side effects typical of systemic glucocorticosteroids occur. After extensive intake of grapefruit juice (which inhbits CYP3A4 activity predominantly in the intestinal mucosa), the systemic exposure for oral budesonide increased about two times. As with other drugs primarily being metabolized through CYP3A4, regular ingestion of grapefruit or grapefruit juice, should be avoided in connection with budesonide administration (other juices such as orange juice or apple juice do not inhibit CYP3A4). Also see INTERACTIONS.
When ENTOCORT capsules are used chronically in excessive doses, systemic glucocorticosteroid effects such as hypercorticism and adrenal suppression may appear.
Pregnancy and Lactation
In pregnant animals, administration of budesonide, like other glucocorticosteroids, is associated with abnormalities of foetal development. The relevance of this finding to humans has not been established. However, as with other agents, the administration of ENTOCORT capsules during pregnancy requires that the benefits for the mother are weighed against the risks for the foetus.
There is no information regarding the passage of budesonide into breast milk and it is therefore recommended that breastfeeding be avoided in women receiving ENTOCORT.
Effects on ability to drive and use machines
ENTOCORT capsules do not affect the ability to drive and use machines.
Adverse Effects
In clinical studies most adverse events were of mild to moderate intensity and of a non-serious character as reflected in the following paragraph:
Side effects typical of systemic glucocorticosteroids (cushingoid features and reduced growth velocity) may occur. These side effects are dependent on dose, treatment time, concomitant and previous glucocorticosteroid intake, and individual sensitivity. Other adverse reactions reported in clinical trials include dyspepsia, muscle cramps, tremor, palpitations, blurred vision, skin reactions (rash, urticaria), menstrual disorders, hypokalemia, and behavioural changes such as nervousness, insomnia and mood swings.
Clinical studies have shown that the frequency of glucorticosteroid associated side-effects is substantially reduced (approximately halved) with ENTOCORT capsules compared with prednisolone at therapeutically equivalent doses.
Interactions
Elevated plasma levels and enhanced effects of corticosteroids have been reported in women also receiving oestrogens or oral contraceptives. However, a low-dose combination oral contraceptive that more than doubled the plasma concentration of oral prednisolone, had no significant effect on the plasma concentration of oral budesonide.
At recommended doses, cimetidine has slight but clinically insignificant effect and omeprazole no effect on the pharmacokinetics of oral budesonide.
The metabolism of budesonide is primarily mediated by CYP3A4, a subfamily of cytochrome 450. Inhibition by budesonide on other drugs metabolism via CVP3A4 is unlikely, since budesonide has low affinity to the enzyme. Inhibition of CYP3A4 by e.g. ketoconazole and grapefruit juice can however increase the systemic exposure to budesonide. (See WARNINGS AND PRECAUTIONS).
Overdosage
Reports of acute toxicity and/or death following overdosage of glucocorticosteroids are rare. Thus, acute overdosage with ENTOCORT capsules, even in excessive doses, is not expected to be a clinical problem. In the event of acute overdosage, no specific antidote is available. Treatment consists of immediate gastric lavage or emesis followed by supportive and symptomatic therapy.
Pharmaceutical Precautions
Shelf-Life
36 months
Storage Conditions
The capsules should be stored below 30°C in the container. Replace the cap firmly after use. Store outside reach of children.
Incompatibilities
No known incompatibilities.
Package Quantities
HDPE tablet container, with polypropylene screw cap, including a desiccant.
Further Information
Preclinical Safety Data
Results from acute, subacute and chronic toxicity studies show that the systemic effects of budesonide, eg. decreased body-weight gain and atrophy of lymphoid tissues and adrenal cortex, are less severe or similar to those observed after administration of other glucocorticosteroids.
Budesonide evaluated in six different test systems did not show any mutagenic or clastogenic effects.
An increased incidence of brain gliomas in male rats in a carcinogenicity study could not be verified in a repeat study, in which the incidence of gliomas did not differ between any of the groups with active treatment (budesonide, prednisolone, triamcinolone acetonide) and the control groups.
Liver changes (primary hepatocellular neoplasms) found in male rats in the original carcinogenicity study were noted again in a repeat study with budesonide as well as with the reference glucocorticosteroids. These effects are most probably related to a receptor effect and thus represent a class-effect.
Available clinical experience shows that there are no indications that budesonide or other glucocorticosteroids induce brain gliomas or primary hepatocellular neoplasms in man.
The toxicity of ENTOCORT capsules, with focus on the gastrointestinal tract, has been studied in cynomolgus monkeys in doses up to 5 mg/kg (approximately 25 times the recommended daily dose in man) after repeated oral administration for up to 6 months. No effects were observed in the gastrointestinal tract, neither at gross pathology nor in the histopathological examination.
List of excipients
Capsule filling:
- Ethycellulose
- Acetyltributyl citrate
- Methacrylic acid copolymer
- Triethylcitrate (E1505)
- Antifoam M
- Polysorbate 80 (E433)
- Talc (E553b)
- Sugar spheres (consisting of sucrose and maize starch)
Capsule:
- Gelatin
- Titanium dioxide (E 171)
- Iron oxide (E 172)
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