ADVERSE REACTIONS SECTION.

6 ADVERSE REACTIONS The following adverse reactions are discussed elsewhere in the labeling:oIntestinal Necrosis [see Warnings and Precautions (5.1)]oElectrolyte Disturbances [see Warnings and Precautions (5.2, 5.3)]oAspiration [see Warnings and Precautions (5.4)]The following adverse reactions have been identified during post-approval use of Sodium Polystyrene Sulfonate Powder, for Suspension. Because these reactions are reported voluntarily from population of uncertain size, it is not always possible to estimate their frequency reliably or establish causal relationship to drug exposure.Gastrointestinal: anorexia, constipation, diarrhea, fecal impaction, gastrointestinal concretions (bezoars), ischemic colitis, nausea, ulcerations, vomiting, gastric irritation, intestinal obstruction (due to concentration of aluminium hydroxide)Metabolic: systemic alkalosis. oIntestinal Necrosis [see Warnings and Precautions (5.1)]. oElectrolyte Disturbances [see Warnings and Precautions (5.2, 5.3)]. oAspiration [see Warnings and Precautions (5.4)]. Adverse reactions reported include: anorexia, constipation, diarrhea, fecal impaction, gastrointestinal concretions (bezoars), ischemic colitis, nausea, vomiting (6).To report SUSPECTED ADVERSE REACTIONS, contact Epic Pharma, LLC 1-888-374-2791 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

CLINICAL PHARMACOLOGY SECTION.

12 CLINICAL PHARMACOLOGY 12.1 Mechanism of Action Sodium Polystyrene Sulfonate Powder, for Suspension is non-absorbed, cation exchange polymer that contains sodium counterion.Sodium Polystyrene Sulfonate Powder, for Suspension increases fecal potassium excretion through binding of potassium in the lumen of the gastrointestinal tract. Binding of potassium reduces the concentration of free potassium in the gastrointestinal lumen, resulting in reduction of serum potassium levels. The practical exchange ratio is mEq per gram of resin.As the resin passes along the intestine or is retained in the colon after administration by enema, the sodium ions are partially released and are replaced by potassium ions. This action occurs primarily in the large intestine, which excretes potassium ions to greater degree than does the small intestine. The efficiency of this process is limited and unpredictably variable.. 12.2 Pharmacodynamics The effective lowering of serum potassium with Sodium Polystyrene Sulfonate Powder, for Suspension may take hours to days.. 12.3 Pharmacokinetics The in vivo efficiency of sodium-potassium exchange resins is approximately 33 percent; hence, about one third of the resins actual sodium content is delivered to the body.Sodium Polystyrene Sulfonate Powder, for Suspension is not absorbed systemically.Drug InteractionsIn vitro binding studies showed that Sodium Polystyrene Sulfonate Powder, for Suspension bound significantly to the following tested drugs warfarin, metoprolol, phenytoin, furosemide, amlodipine and amoxicillin.

DESCRIPTION SECTION.

11 DESCRIPTION Sodium Polystyrene Sulfonate Powder, for Suspension is benzene, diethenyl-polymer, with ethenylbenzene, sulfonated, sodium salt and has the following structural formula:The drug is cream to light brown finely ground, powdered form of sodium polystyrene sulfonate, cation-exchange resin prepared in the sodium phase with an in vitro exchange capacity of approximately 3.1 mEq (in vivo approximately mEq) of potassium per gram. The sodium content is approximately 100 mg (4.1 mEq) per gram of the drug. It can be administered orally or rectally as an enema.One gram of Sodium Polystyrene Sulfonate Powder, for Suspension contains 4.1 mEq of sodium.. L:\Labeling Department\ANDA\Sodium Polystyrene SulfonateSZ- Done\Epic\Package Insert\2017.10 RLD update\Platimun\Docs for Submission\SBS\Structure.

DOSAGE & ADMINISTRATION SECTION.

2 DOSAGE AND ADMINISTRATION Oral: The average total daily adult dose of Sodium Polystyrene Sulfonate Powder, for Suspension is 15 to 60 g, administered as 15-g dose (four level teaspoons), one to four times daily (2.1).Rectal: The average adult dose is 30 to 50 every six hours (2.1).. 2.1 General Information Administer Sodium Polystyrene Sulfonate Powder, for Suspension at least hours before or hours after other oral medications. Patients with gastroparesis may require 6 hour separation [see Warnings and Precautions (5.5) and Drug Interaction (7) . 2.2 Recommended Dosage The intensity and duration of therapy depend upon the severity and resistance of hyperkalemia.OralThe average total daily adult dose of Sodium Polystyrene Sulfonate Powder, for Suspension is 15 to 60 g, administered as 15-g dose (four level teaspoons), one to four times daily.RectalThe average adult dose is 30 to 50 every six hours.. 2.3 Preparation and Administration Prepare suspension fresh and use within 24 hours.Do not heat Sodium Polystyrene Sulfonate Powder, for Suspension as it could alter the exchange properties of the resin.One level teaspoon contains approximately 3.5 of Sodium Polystyrene Sulfonate Powder, for Suspension and 15 mEq of sodium.Oral SuspensionSuspend each dose in small quantity of water or syrup, approximately to mL of liquid per gram of resin. Administer with patient in an upright position [SEE WARNINGS AND PRECAUTIONS (5.4)].EnemaAfter an initial cleansing enema, insert soft, large size (French 28) rubber tube into the rectum for distance of about 20 cm, with the tip well into the sigmoid colon, and tape in place.Administer as warm (body temperature) emulsion in 100 mL of aqueous vehicle and flush with 50 to 100 ml of fluid. somewhat thicker suspension may be used, but do not form paste.Agitate the emulsion gently during administration. The resin should be retained for as long as possible and follow by cleansing enema with nonsodium containing solution. Ensure an adequate volume of cleansing solution (up to liters) is utilized.

DRUG INTERACTIONS SECTION.

7 DRUG INTERACTIONS oTake other orally administered drugs at least hours before or hours after Sodium Polystyrene Sulfonate Powder, for Suspension (7.1).oCation-Donating Antacids: may reduce the resins potassium exchange capability and increase risk of systemic alkalosis (7.2).oSorbitol: Concomitant use may contribute to the risk of intestinal necrosis and is not recommended (7.3).. oTake other orally administered drugs at least hours before or hours after Sodium Polystyrene Sulfonate Powder, for Suspension (7.1).. oCation-Donating Antacids: may reduce the resins potassium exchange capability and increase risk of systemic alkalosis (7.2).. oSorbitol: Concomitant use may contribute to the risk of intestinal necrosis and is not recommended (7.3).. 7.1 General Interactions No formal drug interaction studies have been conducted in humans.Sodium Polystyrene Sulfonate Powder, for Suspension has the potential to bind other drugs. In in vitro binding studies, Sodium Polystyrene Sulfonate Powder, for Suspension was shown to significantly bind the oral medications (n=6) that were tested. Decreased absorption of lithium and thyroxine have also been reported with co-administration of Sodium Polystyrene Sulfonate Powder, for Suspension. Binding of Sodium Polystyrene Sulfonate Powder, for Suspension to other oral medications could cause decreased gastrointestinal absorption and loss of efficacy when taken close to the time Sodium Polystyrene Sulfonate Powder, for Suspension is administered. Administer Sodium Polystyrene Sulfonate Powder, for Suspension at least hours before or hours after other oral medications. Patients with gastroparesis may require 6 hour separation. Monitor for clinical response and/or blood levels where possible.. 7.2 Cation-Donating Antacids The simultaneous oral administration of Sodium Polystyrene Sulfonate Powder, for Suspension with nonabsorbable cation-donating antacids and laxatives may reduce the resins potassium exchange capability and increase the risk of systemic alkalosis. 7.3 Sorbitol Sorbitol may contribute to the risk of intestinal necrosis [see Warnings and Precautions (5.1)] and concomitant use is not recommended.

INDICATIONS & USAGE SECTION.

1 INDICATIONS AND USAGE Sodium Polystyrene Sulfonate Powder, for Suspension is indicated for the treatment of hyperkalemia.Limitation of Use:Sodium Polystyrene Sulfonate Powder, for Suspension should not be used as an emergency treatment for life-threatening hyperkalemia because of its delayed onset of action [see Clinical Pharmacology (12.2)].. Sodium Polystyrene Sulfonate Powder, for Suspension is indicated for the treatment of hyperkalemia (1).Limitation of Use:Sodium Polystyrene Sulfonate Powder, for Suspension should not be used as an emergency treatment for life-threatening hyperkalemia because of its delayed onset of action (1).

MECHANISM OF ACTION SECTION.

12.1 Mechanism of Action Sodium Polystyrene Sulfonate Powder, for Suspension is non-absorbed, cation exchange polymer that contains sodium counterion.Sodium Polystyrene Sulfonate Powder, for Suspension increases fecal potassium excretion through binding of potassium in the lumen of the gastrointestinal tract. Binding of potassium reduces the concentration of free potassium in the gastrointestinal lumen, resulting in reduction of serum potassium levels. The practical exchange ratio is mEq per gram of resin.As the resin passes along the intestine or is retained in the colon after administration by enema, the sodium ions are partially released and are replaced by potassium ions. This action occurs primarily in the large intestine, which excretes potassium ions to greater degree than does the small intestine. The efficiency of this process is limited and unpredictably variable.

PEDIATRIC USE SECTION.

8.4 Pediatric Use Studies of safety and efficacy have not been conducted in pediatric patients.In pediatric patients, as in adults, Sodium Polystyrene Sulfonate Powder, for Suspension is expected to bind potassium at the practical exchange ratio of 1mEq potassium per gram of resin.In neonates, Sodium Polystyrene Sulfonate Powder, for Suspension should not be given by the oral route. In both children and neonates, excessive dosage or inadequate dilution could result in impaction of the resin. Premature infants or low birth weight infants may have an increased risk for gastrointestinal adverse effects with Sodium Polystyrene Sulfonate Powder, for Suspension use [see Warnings and Precautions (5.4)].

USE IN SPECIFIC POPULATIONS SECTION.

8 USE IN SPECIFIC POPULATIONS 8.1 Pregnancy Risk SummarySodium Polystyrene Sulfonate Powder, for Suspension is not absorbed systemically following oral or rectal administration and maternal use is not expected to result in fetal risk.. 8.2 Labor and Delivery Risk SummarySodium Polystyrene Sulfonate Powder, for Suspension is not absorbed systemically by the mother, so breastfeeding is not expected to result in risk to the infant.. 8.4 Pediatric Use Studies of safety and efficacy have not been conducted in pediatric patients.In pediatric patients, as in adults, Sodium Polystyrene Sulfonate Powder, for Suspension is expected to bind potassium at the practical exchange ratio of 1mEq potassium per gram of resin.In neonates, Sodium Polystyrene Sulfonate Powder, for Suspension should not be given by the oral route. In both children and neonates, excessive dosage or inadequate dilution could result in impaction of the resin. Premature infants or low birth weight infants may have an increased risk for gastrointestinal adverse effects with Sodium Polystyrene Sulfonate Powder, for Suspension use [see Warnings and Precautions (5.4)].

WARNINGS AND PRECAUTIONS SECTION.

5 WARNINGS AND PRECAUTIONS oIntestinal Necrosis: cases of intestinal necrosis and other serious gastrointestinal events have been reported (5.1).oElectrolyte Disturbances: Severe hypokalemia can occur. (5.2).oFluid overload in patient sensitive to high sodium intake: Monitor patients who are sensitive to sodium intake for signs of fluid overload. (5.3).oRisk of aspiration: Acute bronchitis or bronchopneumonia caused by inhalation of sodium polystyrene sulfonate particles has been reported. (5.4). oIntestinal Necrosis: cases of intestinal necrosis and other serious gastrointestinal events have been reported (5.1).. oElectrolyte Disturbances: Severe hypokalemia can occur. (5.2).. oFluid overload in patient sensitive to high sodium intake: Monitor patients who are sensitive to sodium intake for signs of fluid overload. (5.3).. oRisk of aspiration: Acute bronchitis or bronchopneumonia caused by inhalation of sodium polystyrene sulfonate particles has been reported. (5.4). 5.1 Intestinal Necrosis Cases of intestinal necrosis, some fatal, and other serious gastrointestinal adverse events (bleeding, ischemic colitis, perforation) have been reported in association with Sodium Polystyrene Sulfonate Powder, for Suspension use. The majority of these cases reported the concomitant use of sorbitol. Risk factors for gastrointestinal adverse events were present in many of the cases including prematurity, history of intestinal disease or surgery, hypovolemia, and renal insufficiency and failure. Concomitant administration of sorbitol is not recommended.oUse only in patients who have normal bowel function. Avoid use in patients who have not had bowel movement post-surgery.oAvoid use in patients who are at risk for developing constipation or impaction (including those with history of impaction, chronic constipation, inflammatory bowel disease, ischemic colitis, vascular intestinal atherosclerosis, previous bowel resection, or bowel obstruction).Discontinue use in patients who develop constipation.. 5.2 Electrolyte Disturbances Monitor serum potassium during therapy because severe hypokalemia may occur.Sodium Polystyrene Sulfonate Powder, for Suspension is not totally selective for potassium, and small amounts of other cations such as magnesium and calcium can also be lost during treatment. Monitor calcium and magnesium in patients receiving Sodium Polystyrene Sulfonate Powder, for Suspension.. 5.3 Fluid Overload in Patients Sensitive to High Sodium Intake Each 15 dose of Sodium Polystyrene Sulfonate Powder, for Suspension contains 1500 mg (60 mEq) of sodium. Monitor patients who are sensitive to sodium intake (heart failure, hypertension, edema) for signs of fluid overload. Adjustment of other sources of sodium may be required.. 5.4 Risk of Aspiration Cases of acute bronchitis or bronchopneumonia caused by inhalation of sodium polystyrene sulfonate particles have been reported. Patients with impaired gag reflex, altered level of consciousness, or patients prone to regurgitation may be at increased risk. Administer Sodium Polystyrene Sulfonate Powder, for Suspension with the patient in an upright position.. 5.5 Binding to Other Orally Administered Medications Sodium Polystyrene Sulfonate Powder, for Suspension may bind orally administered medications, which could decrease their gastrointestinal absorption and lead to reduced efficacy. Administer other oral medications at least hours before or hours after Sodium Polystyrene Sulfonate Powder, for Suspension. Patients with gastroparesis may require 6 hour separation. [SEE DOSAGE AND ADMINISTRATION (2.1) and DRUG INTERACTIONS (7)].