Aemcolo

AEMCOLO- rifamycin tablet, delayed release
RedHill Biopharma Ltd

1 INDICATIONS AND USAGE

1.1 Travelers’ Diarrhea

AEMCOLO is indicated for the treatment of travelers’ diarrhea (TD) caused by non-invasive strains of Escherichia coli in adults.

Limitations of Use

AEMCOLO is not indicated in patients with diarrhea complicated by fever or bloody stool or due to pathogens other than noninvasive strains of Escherichia coli [see Warnings and Precautions (5), Clinical Studies (14)].

1.2 Usage

To reduce the development of drug-resistant bacteria and maintain the effectiveness of AEMCOLO and other antibacterial drugs, AEMCOLO should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria. When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to the empiric selection of therapy.

2 DOSAGE AND ADMINISTRATION

2.1 Basic Dosing Information

The recommended dose of AEMCOLO is 388 mg (two tablets) orally twice daily (in the morning and evening) for three days. Take each dose with a glass of liquid (6-8 ounces). Do NOT take AEMCOLO concomitantly with alcohol. AEMCOLO can be taken with or without food.

2.2 Important Administration Instructions

AEMCOLO must be taken orally. Swallow the tablets whole. Do NOT crush, break or chew the delayed-release tablets.

3 DOSAGE FORMS AND STRENGTHS

AEMCOLO is a yellow-brown, ellipsoidal, film-coated, delayed-release tablet debossed on one side with “SV2”. Each delayed-release tablet contains 194 mg of rifamycin.

4 CONTRAINDICATIONS

AEMCOLO is contraindicated in patients with a known hypersensitivity to rifamycin, any of the other rifamycin class antimicrobial agents (e.g. rifaximin), or any of the components in AEMCOLO.

5 WARNINGS AND PRECAUTIONS

5.1 Risk of Persistent or Worsening of Diarrhea Complicated by Fever and/or Bloody Stool

AEMCOLO was not shown to be effective in patients with diarrhea complicated by fever and/or bloody stool. Patients with these conditions treated with AEMCOLO had prolonged time to last unformed stool (TLUS). The effectiveness of AEMCOLO in travelers’ diarrhea caused by pathogens other than E. coli has not been demonstrated. AEMCOLO is not recommended for use in patients with diarrhea accompanied by fever or bloody stools or due to pathogens other than noninvasive strains of E. coli [see Indications and Usage (1), Clinical Studies (14)].

Discontinue AEMCOLO if diarrhea gets worse or persists more than 48 hours and consider alternative antibacterial therapy.

5.2 Clostridium difficile -Associated Diarrhea

Clostridium difficile -associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, and may range in severity from mild diarrhea to fatal colitis. Treatment with antibacterial agents alters the normal flora of the colon which may lead to overgrowth of C. difficile.

C. difficile produces toxins A and B which contribute to the development of CDAD. Hypertoxin producing strains of C. difficile may cause increased morbidity and mortality, as these infections can be refractory to antimicrobial therapy and may require colectomy. CDAD must be considered in all patients who present with diarrhea following antibacterial drug use. Careful medical history is necessary since CDAD has been reported to occur over two months after the administration of antibacterial agents.

If CDAD is suspected or confirmed, antibacterial drug use not directed against C. difficile may need to be discontinued. Appropriate fluid and electrolyte management, protein supplementation, specific antibacterial treatment of C. difficile , and/or surgical evaluation should be instituted as clinically indicated.

5.3 Development of Drug-Resistant Bacteria

Prescribing AEMCOLO in the absence of a proven or strongly suspected bacterial infection or a prophylactic indication is unlikely to provide benefit to the patient and increases the risk of the development of drug-resistant bacteria.

6 ADVERSE REACTIONS

6.1 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 oral AEMCOLO 388 mg twice daily was assessed in 619 adults with travelers’ diarrhea in two controlled clinical trials (Trial 1 and Trial 2) with 96% of patients receiving three or four days of treatment. These patients had a mean age of 36.2 years (range 18 to 87 years) with 7% ≥ 65 years old; 49% were male, 84% were White, and 4% were Hispanic.

Discontinuation of AEMCOLO due to adverse reactions occurred in 1% of patients. The most frequent adverse reactions leading to discontinuation of AEMCOLO were abdominal pain (0.5%) and pyrexia (0.3%).

In Trial 1 (placebo-controlled), the adverse reaction that occurred in at least 2% of AEMCOLO-treated patients (n = 199) and with an incidence higher than in the placebo group was constipation (3.5% AEMCOLO, 1.5% placebo)

In Trial 2 (active comparator), the adverse reaction that occurred in at least 2% of AEMCOLO-treated patients (n = 420) and with an incidence higher than in the ciprofloxacin group was headache (3.3% AEMCOLO, 1.9% ciprofloxacin)

Adverse reactions reported in <2% of patients receiving AEMCOLO 388 mg twice daily with a higher incidence than the comparator group was dyspepsia.

7 DRUG INTERACTIONS

No clinical Drug-Drug Interactions (DDIs) have been studied. Based on the minimal systemic rifamycin concentrations observed after the recommended dose of AEMCOLO, clinically relevant DDIs are not expected [see Clinical Pharmacology (12.3)]

8 USE IN SPECIFIC POPULATIONS

8.1 Pregnancy

Risk Summary

There are no available data on AEMCOLO use in pregnant women to inform any drug associated risks for major birth defects, miscarriage, or adverse maternal or fetal outcomes. Systemic absorption of AEMCOLO in humans is negligible following oral administration of the recommended dose of AEMCOLO [see Clinical Pharmacology (12.3)]. Due to the negligible systemic exposure, it is not expected that maternal use of AEMCOLO will result in fetal exposure to the drug.

In animal reproduction studies, no malformations were observed in pregnant rats or rabbits at exposures 25,000 and 500 times (based on AUC), respectively, the human exposure achieved with the recommended clinical dose of AEMCOLO. Treatment of pregnant rats with AEMCOLO at more than 1,000 times the maximum plasma concentration (Cmax ) and 25,000 times the systemic exposure (based on AUC) during the period of organogenesis resulted in maternal toxicity, decreased fetal weight, and variations in diaphragm formation. Similarly, treatment of pregnant rabbits with AEMCOLO at more than 10 times the maximum human plasma concentration (Cmax ), resulted in maternal toxicity, decreased fetal weight, and slightly delayed fetal ossifications [See Data].

All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated risk of major birth defects and miscarriage in clinically recognized pregnancies is 2 to 4% and 15 to 20%, respectively. Advise pregnant women of the potential risk to a fetus.

Animal Data

Embryofetal toxicity studies in rats and rabbits did not show malformations up to the maximum tested doses of 855 and 85.5 mg/kg, (25,000 and 500 times greater plasma exposure based on AUC), respectively, of rifamycin given orally during the period of organogenesis (gestational days 6-17/18). In rats, the high dose of 855 mg/kg/day caused reduction in maternal food consumption, reduced fetal weight and a higher number of fetuses with thin tendinous diaphragm. In rabbits, the high dose of 85.5 mg/kg/day caused a reduction in food consumption and bodyweight gain in pregnant dams, as well as reduced fetal weights and slight delay in ossification, including slightly higher incidences of fetuses with skull suture bone variations, enlarged skull fontanelle and incompletely ossified digit 5 medial phalanx of both forelimbs. No adverse fetal effects were observed in rats and rabbits administered lower doses of oral rifamycin.

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