ASACOL — mesalamine tablet, delayed release
State of Florida DOH Central Pharmacy
Each Asacol ® delayed-release tablet for oral administration contains 400 mg of mesalamine, an anti-inflammatory drug. The Asacol delayed-release tablets are coated with acrylic based resin, Eudragit S (methacrylic acid copolymer B, NF), which dissolves at pH 7 or greater, releasing mesalamine in the terminal ileum and beyond for topical anti-inflammatory action in the colon. Mesalamine has the chemical name 5-amino-2-hydroxybenzoic acid; its structural formula is:
Inactive Ingredients: Each tablet contains colloidal silicon dioxide, dibutyl phthalate, edible black ink, iron oxide red, iron oxide yellow, lactose monohydrate, magnesium stearate, methacrylic acid copolymer B (Eudragit S), polyethylene glycol, povidone, sodium starch glycolate, and talc.
Mesalamine is thought to be the major therapeutically active part of the sulfasalazine molecule in the treatment of ulcerative colitis. Sulfasalazine is converted to equimolar amounts of sulfapyridine and mesalamine by bacterial action in the colon. The usual oral dose of sulfasalazine for active ulcerative colitis is 3 to 4 grams daily in divided doses, which provides 1.2 to 1.6 grams of mesalamine to the colon.
The mechanism of action of mesalamine (and sulfasalazine) is unknown, but appears to be topical rather than systemic. Mucosal production of arachidonic acid (AA) metabolites, both through the cyclooxygenase pathways, i.e., prostanoids, and through the lipoxygenase pathways, i.e., leukotrienes (LTs) and hydroxyeicosatetraenoic acids (HETEs), is increased in patients with chronic inflammatory bowel disease, and it is possible that mesalamine diminishes inflammation by blocking cyclooxygenase and inhibiting prostaglandin (PG) production in the colon.
Asacol tablets are coated with an acrylic-based resin that delays release of mesalamine until it reaches the terminal ileum and beyond. This has been demonstrated in human studies conducted with radiological and serum markers. Approximately 28% of the mesalamine in Asacol tablets is absorbed after oral ingestion, leaving the remainder available for topical action and excretion in the feces. Absorption of mesalamine is similar in fasted and fed subjects. The absorbed mesalamine is rapidly acetylated in the gut mucosal wall and by the liver. It is excreted mainly by the kidney as N-acetyl-5-aminosalicylic acid.
Mesalamine from orally administered Asacol tablets appears to be more extensively absorbed than the mesalamine released from sulfasalazine. Maximum plasma levels of mesalamine and N-acetyl-5-aminosalicylic acid following multiple Asacol doses are about 1.5 to 2 times higher than those following an equivalent dose of mesalamine in the form of sulfasalazine. Combined mesalamine and N-acetyl-5-aminosalicylic acid AUC’s and urine drug dose recoveries following multiple doses of Asacol tablets are about 1.3 to 1.5 times higher than those following an equivalent dose of mesalamine in the form of sulfasalazine.
The tmax for mesalamine and its metabolite, N-acetyl-5-aminosalicylic acid, is usually delayed, reflecting the delayed release, and ranges from 4 to 12 hours. The half-lives of elimination (t1/2elm ) for mesalamine and N-acetyl-5-aminosalicylic acid are usually about 12 hours, but are variable, ranging from 2 to 15 hours. There is a large intersubject variability in the plasma concentrations of mesalamine and N-acetyl-5-aminosalicylic acid and in their elimination half-lives following administration of Asacol tablets.
Two placebo-controlled studies have demonstrated the efficacy of Asacol tablets in patients with mildly to moderately active ulcerative colitis. In one randomized, double-blind, multi-center trial of 158 patients, Asacol doses of 1.6 g/day and 2.4 g/day were compared to placebo. At the dose of 2.4 g/day, Asacol tablets reduced the disease activity, with 21 of 43 (49%) Asacol patients showing improvement in sigmoidoscopic appearance of the bowel compared to 12 of 44 (27%) placebo patients (p = 0.048). In addition, significantly more patients in the Asacol 2.4 g/day group showed improvement in rectal bleeding and stool frequency. The 1.6 g/day dose did not produce consistent evidence of effectiveness.
In a second randomized, double-blind, placebo-controlled clinical trial of 6 weeks duration in 87 ulcerative colitis patients, Asacol tablets, at a dose of 4.8 g/day, gave sigmoidoscopic improvement in 28 of 38 (74%) patients compared to 10 of 38 (26%) placebo patients (p < 0.001). Also, more patients in the Asacol 4.8 g/day group showed improvement in overall symptoms.
A 6-month, randomized, double-blind, placebo-controlled, multi-center study involved 264 patients treated with Asacol 0.8 g/day (n = 90), 1.6 g/day (n = 87), or placebo (n = 87). The proportion of patients treated with 0.8 g/day who maintained endoscopic remission was not statistically significant compared to placebo. In the intention to treat (ITT) analysis of all 174 patients treated with Asacol 1.6 g/day or placebo, Asacol maintained endoscopic remission of ulcerative colitis in 61 of 87 (70.1%) of patients, compared to 42 of 87 (48.3%) of placebo recipients (p = 0.005).
A pooled efficacy analysis of 4 maintenance trials compared Asacol , at doses of 0.8 g/day to 2.8 g/day, with sulfasalazine, at doses of 2 g/day to 4 g/day (n = 200). Treatment success was 59 of 98 (59%) for Asacol and 70 of 102 (69%) for sulfasalazine, a non-significant difference.
The effect of Asacol (mesalamine) on sulfasalazine-induced impairment of male fertility was examined in an open-label study. Nine patients (age < 40 years) with chronic ulcerative colitis in clinical remission on sulfasalazine 2 g/day to 3 g/day were crossed over to an equivalent Asacol dose (0.8 g/day to 1.2 g/day) for 3 months. Improvement in sperm count (p < 0.02) and morphology (p < 0.02) occurred in all cases. Improvement in sperm motility (p < 0.001) occurred in 8 of the 9 patients.
Asacol tablets are indicated for the treatment of mildly to moderately active ulcerative colitis and for the maintenance of remission of ulcerative colitis.
Asacol tablets are contraindicated in patients with hypersensitivity to salicylates or to any of the components of the Asacol tablet.
Patients with pyloric stenosis may have prolonged gastric retention of Asacol tablets which could delay release of mesalamine in the colon.
Exacerbation of the symptoms of colitis has been reported in 3% of Asacol -treated patients in controlled clinical trials. This acute reaction, characterized by cramping, abdominal pain, bloody diarrhea, and occasionally by fever, headache, malaise, pruritus, rash, and conjunctivitis, has been reported after the initiation of Asacol tablets as well as other mesalamine products. Symptoms usually abate when Asacol tablets are discontinued.
Some patients who have experienced a hypersensitivity reaction to sulfasalazine may have a similar reaction to Asacol tablets or to other compounds which contain or are converted to mesalamine.
Renal impairment, including minimal change nephropathy, acute and chronic interstitial nephritis, and, rarely, renal failure has been reported in patients taking Asacol tablets as well as other compounds which contain or are converted to mesalamine. In animal studies (rats, dogs), the kidney is the principal target organ for toxicity. At doses of approximately 750 mg/kg to 1000 mg/kg [15 to 20 times the administered recommended human dose (based on a 50 kg person) on a mg/kg basis and 3 to 4 times on a mg/m2 basis], mesalamine causes renal papillary necrosis. Therefore, caution should be exercised when using Asacol (or other compounds which contain or are converted to mesalamine or its metabolites) in patients with known renal dysfunction or history of renal disease. It is recommended that all patients have an evaluation of renal function prior to initiation of Asacol tablets and periodically while on Asacol therapy.
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