ADVERSE REACTIONS SECTION.

6 ADVERSE REACTIONS. Most common adverse reactions (incidence >=3%) are headache, abdominal pain, diarrhea, nausea, vomiting, respiratory infection, and arthralgia. Adverse reactions in children were similar. (6.1) To report SUSPECTED ADVERSE REACTIONS, contact AvKARE at 1-855-361-3993 or FDA at 1-800-FDA-1088 orwww.fda.gov/medwatch.. 6.1 Clinical Studies Experience. Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice.Adult Ulcerative ColitisDuring clinical development, 259 adult patients with active ulcerative colitis were exposed to 6.75 g/day balsalazide in controlled trials.In the controlled clinical trials patients receiving balsalazide dose of 6.75 g/day most frequently reported the following adverse reactions: headache (8%), abdominal pain (6%), diarrhea (5%), nausea (5%), vomiting (4%), respiratory infection (4%), and arthralgia (4%). Withdrawal from therapy due to adverse reactions was comparable among patients on balsalazide and placebo.Adverse reactions reported by 1% or more of patients who participated in the well-controlled, Phase trials are presented by treatment group (Table 1).The number of placebo patients (35), however, is too small for valid comparisons. Some adverse reactions, such as abdominal pain, fatigue, and nausea were reported more frequently in women than in men. Abdominal pain, rectal bleeding, and anemia can be part of the clinical presentation of ulcerative colitis.Table 1: Adverse Reactions Occurring in >= % of Adult Balsalazide Patients in Controlled TrialsAdverse ReactionBalsalazide Capsules 6.75 g/ day[N 259]Placebo[N 35]Abdominal pain16 (6%)1 (3%)Diarrhea14 (5%)1 (3%)Arthralgia9 (4%)0%Rhinitis6 (2%)0%Insomnia6 (2%)0%Fatigue6 (2%)0%Flatulence5 (2%)0%Fever5 (2%)0%Dyspepsia5 (2%)0%Pharyngitis4 (2%)0%Coughing4 (2%)0%Anorexia4 (2%)0%Urinary tract infection3 (1%)0%Myalgia3 (1%)0%Flu-like disorder3 (1%)0%Dry mouth3 (1%)0%Cramps3 (1%)0%Constipation3 (1%)0%Adverse reactions occurring in at least 1% of Balsalazide Patients which were less frequent than placebo for the same event were not included in the table.Pediatric Ulcerative ColitisIn clinical trial in 68 pediatric patients aged to 17 years with mildly to moderately active ulcerative colitis who received 6.75 g/day or 2.25 g/day balsalazide disodium for weeks, the most frequently reported adverse reactions were headache (15%), abdominal pain upper (13%), abdominal pain (12%), vomiting (10%), diarrhea (9%), colitis ulcerative (6%), nasopharyngitis (6%), and pyrexia (6%). [see Table 2] One patient who received balsalazide disodium 6.75 g/day and patients who received balsalazide disodium 2.25 g/day discontinued treatment because of adverse reactions. In addition, patients in each dose group discontinued because of lack of efficacy. Adverse reactions reported by 3% or more of pediatric patients within either treatment group in the Phase trial are presented in Table 2.. 6.2 Postmarketing Experience. The following adverse reactions have been identified during post-approval use of balsalazide in clinical practice:myocarditis, pericarditis, vasculitis, pruritus, pleural effusion, pneumonia (with and without eosinophilia), alveolitis, renal failure, interstitial nephritis, pancreatitis, and alopecia.Because these reactions are reported voluntarily from population of unknown size, it is not always possible to reliably estimate their frequency or establish causal relationship to drug exposure. These adverse reactions have been chosen for inclusion due to combination of seriousness, frequency of reporting, or potential causal connection to balsalazide.HepaticPostmarketing adverse reactions of hepatotoxicity have been reported for products which contain (or are metabolized to) mesalamine, including elevated liver function tests (SGOT/AST, SGPT/ALT, GGT, LDH, alkaline phosphatase, bilirubin), jaundice, cholestatic jaundice, cirrhosis, hepatocellular damage including liver necrosis and liver failure. Some of these cases were fatal; however, no fatalities associated with these adverse reactions were reported in balsalazide clinical trials. One case of Kawasaki-like syndrome which included hepatic function changes was also reported, however, this adverse reaction was not reported in balsalazide clinical trials.

ANIMAL PHARMACOLOGY & OR TOXICOLOGY SECTION.

13.2 Animal Toxicology. Renal ToxicityIn animal studies conducted at doses up to 2000 mg/kg (approximately 21 times the recommended 6.75 g/day dose on mg/kg basis for 70 kg person), balsalazide demonstrated no nephrotoxic effects in rats or dogs.OverdosageA single oral dose of balsalazide disodium at g/kg or 4-aminobenzoyl--alanine, metabolite of balsalazide disodium, at g/kg was non-lethal in mice and rats. No symptoms of acute toxicity were seen at these doses.

CARCINOGENESIS & MUTAGENESIS & IMPAIRMENT OF FERTILITY SECTION.

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility. In 24-month rat (Sprague Dawley) carcinogenicity study, oral (dietary) balsalazide disodium at doses up to g/kg/day was not tumorigenic. For 50-kg person of average height this dose represents 2.4 times the recommended human dose on body surface area basis. Balsalazide disodium was not genotoxic in the following in vitro or in vivo tests: Ames test, human lymphocyte chromosomal aberration test, and mouse lymphoma cell (L5178Y/TK+/-) forward mutation test, or mouse micronucleus test. However, it was genotoxic in the in vitro Chinese hamster lung cell (CH V79/HGPRT) forward mutation test. 4-aminobenzoyl--alanine, metabolite of balsalazide disodium, was not genotoxic in the Ames test and the mouse lymphoma cell (L5178Y/TK+/-) forward mutation test but was positive in the human lymphocyte chromosomal aberration test. N-acetyl-4-aminobenzoyl--alanine, conjugated metabolite of balsalazide disodium, was not genotoxic in Ames test, the mouse lymphoma cell (L5178Y/TK+/-) forward mutation test, or the human lymphocyte chromosomal aberration test. Balsalazide disodium at oral doses up to g/kg/day, 2.4 times the recommended human dose based on body surface area, was found to have no effect on fertility and reproductive performance in rats.

CLINICAL PHARMACOLOGY SECTION.

12 CLINICAL PHARMACOLOGY. 12.1 Mechanism of Action. Balsalazide disodium is delivered intact to the colon where it is cleaved by bacterial azoreduction to release equimolar quantities of mesalamine, which is the therapeutically active portion of the molecule, and the 4-aminobenzoyl--alanine carrier moiety. The carrier moiety released when balsalazide disodium is cleaved is only minimally absorbed and is largely inert.The mechanism of action of 5-ASA is unknown, but appears to be local to the colonic mucosa rather than systemic. Mucosal production or arachidonic acid metabolites, both through the cyclooxygenase pathways, i.e., prostanoids, and through the lipoxygenase pathways, i.e., leukotrienes and hydroxyeicosatetraenoic acids, is increased in patients with chronic inflammatory bowel disease, and it is possible that 5-ASA diminishes inflammation by blocking production of arachidonic acid metabolites in the colon.. 12.3 Pharmacokinetics. Balsalazide disodium capsules contain powder of balsalazide disodium that is insoluble in acid and designed to be delivered to the colon as the intact prodrug. Upon reaching the colon, bacterial azoreductases cleave the compound to release 5-ASA, the therapeutically active portion of the molecule, and 4-aminobenzoyl--alanine. The 5-ASA is further metabolized to yield Nacetyl-5-aminosalicylic acid (N-Ac-5-ASA), second key metabolite.AbsorptionThe plasma pharmacokinetics of balsalazide and its key metabolites from crossover study in healthy volunteers are summarized in Table 3. In this study, single oral dose of balsalazide 2.25 was administered to healthy volunteers as intact capsules (3 750 mg) under fasting conditions, as intact capsules (3 750 mg) after high-fat meal, and unencapsulated (3 750 mg) as sprinkles on applesauce.Table 3: Plasma Pharmacokinetics for Balsalazide and Key Metabolites (5-ASA and N-Ac-5-ASA) with Administration of Balsalazide Following Fast, High-Fat Meal, and Drug Contents Sprinkled on Applesauce (Mean +- SD)Fastingn 17High-Fat Mealn 17Sprinkledn 17C max (mcg/mL) Balsalazide0.51 +- 0.320.45 +- 0.390.21 +- 0.125-ASA0.22 +- 0.120.11 +- 0.1360.29 +- 0.17N-Ac-5-ASA0.88 +- 0.390.64 +- 0.5341.04 +- 0.57AUC last mcg.hr/mL) Balsalazide1.35 +- 0.731.52 +- 1.010.87 +- 0.485-ASA2.59 +- 1.462.10 +- 2.582.99 +- 1.70N-Ac-5-ASA17.8 +- 8.1417.7 +- 13.720.0 +- 11.4T max (h) Balsalazide0.8 +- 0.851.2 +- 1.111.6 +- 0.445-ASA8.2 +- 1.9822.0 +- 8.238.7 +- 1.99N-Ac-5-ASA9.9 +- 2.4920.2 +- 8.9410.8 +- 5.39A relatively low systemic exposure was observed under all three administered conditions (fasting, fed with high-fat meal, sprinkled on applesauce), which reflects the variable, but minimal absorption of balsalazide disodium and its metabolites. The data indicate that both max and AUC last were lower, while tmax was markedly prolonged, under fed (high-fat meal) compared to fasted conditions. Moreover, the data suggest that dosing balsalazide disodium as sprinkle or as capsule provides highly variable, but relatively similar mean pharmacokinetic parameter values. No inference can be made as to how the systemic exposure differences of balsalazide and its metabolites in this study might predict the clinical efficacy under different dosing conditions (i.e., fasted, fed with high-fat meal, or sprinkled on applesauce) since clinical efficacy after balsalazide disodium administration is presumed to be primarily due to the local effects of 5- ASA on the colonic mucosa. In separate study of adult patients with ulcerative colitis, who received balsalazide, 1.5 twice daily, for over year, systemic drug exposure, based on mean AUC values, was up to 60 times greater (0.008 mcgohr/mL to 0.480 mcgohr/mL) when compared to that obtained in healthy subjects who received the same dose.DistributionThe binding of balsalazide to human plasma proteins was >=99%.MetabolismThe products of the azoreduction of this compound, 5-ASA and 4-aminobenzoyl--alanine, and their N-acetylated metabolites have been identified in plasma, urine and feces.EliminationFollowing single-dose administration of 2.25 balsalazide (three 750 mg capsules) under fasting conditions in healthy subjects, mean urinary recovery of balsalazide, 5-ASA, and N-Ac-5-ASA was 0.20%, 0.22% and 10.2%, respectively.In multiple-dose study in healthy subjects receiving balsalazide dose of two 750 mg capsules twice daily (3 g/day) for 10 days, mean urinary recovery of balsalazide, 5-ASA, and N-Ac-5-ASA was 0.1%, 0%, and 11.3%, respectively. During this study, subjects received their morning dose 0.5 hours after being fed standard meal, and subjects received their evening dose hours after being fed standard meal.In study with 10 healthy volunteers, 65% of single 2.25-gram dose of balsalazide was recovered as 5-ASA, 4-aminobenzoyl--alanine, and the N-acetylated metabolites in feces, while <1% of the dose was recovered as parent compound.In study that examined the disposition of balsalazide in patients who were taking to g of balsalazide daily for more than year and who were in remission from ulcerative colitis, less than 1% of an oral dose was recovered as intact balsalazide in the urine. Less than 4% of the dose was recovered as 5-ASA, while virtually no 4-aminobenzoyl--alanine was detected in urine. The mean urinary recovery of N-Ac-5-ASA and N-acetyl-4-aminobenzoyl--alanine comprised <16% and <12% of the balsalazide dose, respectively. No fecal recovery studies were performed in this population.Pediatric Population In studies of pediatric patients with mild-to-moderate active ulcerative colitis receiving three 750 mg balsalazide disodium capsules times daily (6.75 g/day) for weeks, steady state was reached within weeks, as observed in adult patients. Likewise, the pharmacokinetics of balsalazide, 5-ASA, and N-Ac-5-ASA were characterized by very large inter-patient variability, which is also similar to that seen in adult patients.The pro-drug moiety, balsalazide, appeared to exhibit dose-independent (i.e., doselinear) kinetics in children, and the systemic exposure parameters (C max and AUC to 8) increased in an almost dose-proportional fashion after the 6.75 g/day versus the 2.25 g/day doses. However, the absolute magnitude of these exposure parameters was greater relative to adults. The and AUC observed in max to pediatric patients were 26% and 102% greater than those observed in adult patients at the 6.75 g/day dosage level. In contrast, the systemic exposure parameters for the active metabolites, 5-ASA and N- Ac-5-ASA, in pediatric patients increased in less than dose-proportional manner after the 6.75 g/day dose versus the 2.25 g/day dose. Additionally, the magnitude of these exposure parameters was decreased for both metabolites relative to adults. For the metabolite of key safety concern from systemic exposure perspective, 5-ASA, the and AUC observed in pediatric patients were max to 67% and 64% lower than those observed in adult patients at the 6.75 g/day dosage level. Likewise, for N-Ac-5-ASA, the and AUC observed in pediatric patients were 68% and 55% lower than max to those observed in adult patients at the 6.75 g/day dosage level. All pharmacokinetic studies with balsalazide are characterized by large variability in the plasma concentration versus time profiles for balsalazide and its metabolites, thus half-life estimates of these analytes are indeterminate.

CLINICAL STUDIES SECTION.

6.1 Clinical Studies Experience. Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice.Adult Ulcerative ColitisDuring clinical development, 259 adult patients with active ulcerative colitis were exposed to 6.75 g/day balsalazide in controlled trials.In the controlled clinical trials patients receiving balsalazide dose of 6.75 g/day most frequently reported the following adverse reactions: headache (8%), abdominal pain (6%), diarrhea (5%), nausea (5%), vomiting (4%), respiratory infection (4%), and arthralgia (4%). Withdrawal from therapy due to adverse reactions was comparable among patients on balsalazide and placebo.Adverse reactions reported by 1% or more of patients who participated in the well-controlled, Phase trials are presented by treatment group (Table 1).The number of placebo patients (35), however, is too small for valid comparisons. Some adverse reactions, such as abdominal pain, fatigue, and nausea were reported more frequently in women than in men. Abdominal pain, rectal bleeding, and anemia can be part of the clinical presentation of ulcerative colitis.Table 1: Adverse Reactions Occurring in >= % of Adult Balsalazide Patients in Controlled TrialsAdverse ReactionBalsalazide Capsules 6.75 g/ day[N 259]Placebo[N 35]Abdominal pain16 (6%)1 (3%)Diarrhea14 (5%)1 (3%)Arthralgia9 (4%)0%Rhinitis6 (2%)0%Insomnia6 (2%)0%Fatigue6 (2%)0%Flatulence5 (2%)0%Fever5 (2%)0%Dyspepsia5 (2%)0%Pharyngitis4 (2%)0%Coughing4 (2%)0%Anorexia4 (2%)0%Urinary tract infection3 (1%)0%Myalgia3 (1%)0%Flu-like disorder3 (1%)0%Dry mouth3 (1%)0%Cramps3 (1%)0%Constipation3 (1%)0%Adverse reactions occurring in at least 1% of Balsalazide Patients which were less frequent than placebo for the same event were not included in the table.Pediatric Ulcerative ColitisIn clinical trial in 68 pediatric patients aged to 17 years with mildly to moderately active ulcerative colitis who received 6.75 g/day or 2.25 g/day balsalazide disodium for weeks, the most frequently reported adverse reactions were headache (15%), abdominal pain upper (13%), abdominal pain (12%), vomiting (10%), diarrhea (9%), colitis ulcerative (6%), nasopharyngitis (6%), and pyrexia (6%). [see Table 2] One patient who received balsalazide disodium 6.75 g/day and patients who received balsalazide disodium 2.25 g/day discontinued treatment because of adverse reactions. In addition, patients in each dose group discontinued because of lack of efficacy. Adverse reactions reported by 3% or more of pediatric patients within either treatment group in the Phase trial are presented in Table 2.

CONTRAINDICATIONS SECTION.

4 CONTRAINDICATIONS. Patients with hypersensitivity to salicylates or to any of the components of balsalazide disodium capsules or balsalazide metabolites. Hypersensitivity reactions may include, but are not limited to the following: anaphylaxis, bronchospasm, and skin reaction.. Patients with hypersensitivity to salicylates or to any of the components of balsalazide disodium capsules or balsalazide metabolites. Hypersensitivity reactions may include, but are not limited to the following: anaphylaxis, bronchospasm, and skin reaction. (4).

DESCRIPTION SECTION.

11 DESCRIPTION. Each balsalazide disodium capsule, USP contains 750 mg of balsalazide disodium, prodrug that is enzymatically cleaved in the colon to produce mesalamine (5-aminosalicylic acid or 5-ASA), an anti-inflammatory drug. Each capsule of balsalazide (750 mg) is equivalent to 267 mg of mesalamine. Balsalazide disodium has the chemical name (E)-5-[[-4-[[(2- carboxyethyl)amino]carbonyl] phenyl]azo]-2-hydroxybenzoic acid, disodium salt, dihydrate. Its structural formula is:Molecular Weight: 437.32Molecular Formula: 17H 13N 3O 6Na 2o2H 2O Balsalazide disodium is stable, odorless orange to yellow microcrystalline powder. It is freely soluble in water and isotonic saline, sparingly soluble in methanol and ethanol, and practically insoluble in all other organic solvents.Inactive Ingredients: Each hard gelatin capsule contains colloidal silicon dioxide, magnesium stearate and titanium dioxide. The capsule imprinting ink contains propylene glycol, strong ammonia solution, shellac and red iron oxide. The sodium content of each capsule is approximately 86 mg.. structural-formula.

DOSAGE & ADMINISTRATION SECTION.

2 DOSAGE AND ADMINISTRATION. Adult dose is three 750 mg balsalazide disodium capsules times day (6.75 g/day) with or without food for weeks. Some adult patients required treatment for up to 12 weeks. (2.1) Pediatric dose is EITHER: (2.2, 8.4) 1. Three 750 mg balsalazide disodium capsules times day (6.75 g/day) with or without food for weeks. OR: 2. One 750 mg balsalazide disodium capsule times day (2.25 g/day) with or without food for up to weeks. Capsules may be swallowed whole or may be opened and sprinkled on applesauce, then chewed or swallowed immediately. (2.3, 12.3). Adult dose is three 750 mg balsalazide disodium capsules times day (6.75 g/day) with or without food for weeks. Some adult patients required treatment for up to 12 weeks. (2.1) Pediatric dose is EITHER: (2.2, 8.4) 2.1 Adult Dose. For treatment of active ulcerative colitis in adult patients, the usual dose is three 750 mg balsalazide disodium capsules to be taken times day (6.75 per day) for up to weeks. Some patients in the adult clinical trials required treatment for up to 12 weeks.. 2.2 Pediatric Dose. For treatment of active ulcerative colitis in pediatric patients, aged to 17 years, the usual dose is EITHER:three 750 mg balsalazide disodium capsules times day (6.75 per day) for up to weeks; OR: one 750 mg balsalazide disodium capsule times day (2.25 per day) for up to weeks.Use of balsalazide in the pediatric population for more than weeks has not been evaluated in clinical trials. [See Clinical Studies Section (14)] three 750 mg balsalazide disodium capsules times day (6.75 per day) for up to weeks; OR: one 750 mg balsalazide disodium capsule times day (2.25 per day) for up to weeks.. 2.3 Administration Alternatives. Balsalazide disodium capsules may also be administered by carefully opening the capsule and sprinkling the capsule contents on applesauce. The entire drug/applesauce mixture should be swallowed immediately; the contents may be chewed, if necessary, since contents of balsalazide disodium capsules are NOT coated beads/granules. Patients should be instructed not to store any drug/applesauce mixture for future use.If the capsules are opened for sprinkling, color variation of the powder inside the capsules ranges from orange to yellow and is expected due to color variation of the active pharmaceutical ingredient.Teeth and/or tongue staining may occur in some patients who use balsalazide disodium capsules in sprinkle form with food.

DOSAGE FORMS & STRENGTHS SECTION.

3 DOSAGE FORMS AND STRENGTHS. Balsalazide disodium capsules, USP are available as opaque white capsules containing 750 mg balsalazide disodium, imprinted with APO B750 in red ink.. Capsules: 750 mg (3).

DRUG INTERACTIONS SECTION.

7 DRUG INTERACTIONS. In an in vitro study using human liver microsomes, balsalazide and its metabolites [5-aminosalicylic acid (5-ASA), N-acetyl-5-aminosalicylic acid (N-Ac-5-ASA), 4-aminobenzoyl--alanine (4-ABA) and N-acetyl-4-aminobenzoyl--alanine (N-Ac-4-ABA)] were not shown to inhibit the major CYP enzymes evaluated (CYP1A2, CYP2C9, CYP2C19, CYP2D6, and CYP3A4/5). Therefore, balsalazide and its metabolites are not expected to inhibit the metabolism of other drugs which are substrates of CYP1A2, CYP2C9, CYP2C19, CYP2D6, or CYP3A4/5.. In an in vitro study using human liver microsomes, balsalazide and its metabolites were notshown to inhibit the major CYP enzymes evaluated (CYP1A2, CYP2C9, CYP2C19, CYP2D6, and CYP3A4/5). (7).

HOW SUPPLIED SECTION.

16 HOW SUPPLIED/STORAGE AND HANDLING. Balsalazide Disodium Capsules, USP are available as white, opaque capsules imprinted APO B750 in red ink.Balsalazide Disodium Capsules, USP are supplied as follows:NDC 50268-102-13 10 capsules per car, cards per cartonDispensed in Unit Dose package. For Institutional Use Only.StorageStore at 20o to 25oC (68o to 77oF); excursions permitted between 15o and 30oC (59o and 86oF).See USP Controlled Room Temperature.

INDICATIONS & USAGE SECTION.

1 INDICATIONS AND USAGE. Balsalazide disodium capsules are indicated for the treatment of mildly to moderately active ulcerative colitis in patients years of age and older. Safety and effectiveness of balsalazide beyond weeks in children (ages to 17 years) and 12 weeks in adults have not been established.. Balsalazide is locally acting aminosalicylate indicated for the treatment of mildly to moderately active ulcerative colitis in patients years of age and older. (1) Safety and effectiveness of balsalazide beyond weeks in children (ages to 17 years) and 12 weeks in adults have not been established. (1) Balsalazide is locally acting aminosalicylate indicated for the treatment of mildly to moderately active ulcerative colitis in patients years of age and older. (1) Safety and effectiveness of balsalazide beyond weeks in children (ages to 17 years) and 12 weeks in adults have not been established. (1).

INFORMATION FOR PATIENTS SECTION.

17 PATIENT COUNSELING INFORMATION. 17.1 Important Precautions Regarding Balsalazide. Instruct patients not to take balsalazide if they have hypersensitivity to salicylates (e.g., aspirin).Patients should be instructed to contact their health care provider under the following circumstances: If they experience worsening of their ulcerative colitis symptoms. If they are diagnosed with pyloric stenosis, because balsalazide disodium capsules may be slow to pass through their digestive tract. If they are diagnosed with renal dysfunction. Damage to the kidney has been observed in people given medications similar to balsalazide. Instruct patients not to take balsalazide if they have hypersensitivity to salicylates (e.g., aspirin).. Patients should be instructed to contact their health care provider under the following circumstances: If they experience worsening of their ulcerative colitis symptoms. If they are diagnosed with pyloric stenosis, because balsalazide disodium capsules may be slow to pass through their digestive tract. If they are diagnosed with renal dysfunction. Damage to the kidney has been observed in people given medications similar to balsalazide. 17.2 What Patients Should Know About Adverse Reactions. In adult clinical trials the most common adverse reactions were headache, abdominal pain, diarrhea, nausea, vomiting, respiratory infection, and arthralgia.In the pediatric clinical trial the most common adverse reactions were headache, abdominal pain, vomiting, diarrhea, ulcerative colitis, nasopharyngitis, and pyrexia.Inform patients that this listing of adverse reactions is not complete and not all adverse reactions can be anticipated. If appropriate, more comprehensive list of adverse reactions can be discussed with patients.. In adult clinical trials the most common adverse reactions were headache, abdominal pain, diarrhea, nausea, vomiting, respiratory infection, and arthralgia.. In the pediatric clinical trial the most common adverse reactions were headache, abdominal pain, vomiting, diarrhea, ulcerative colitis, nasopharyngitis, and pyrexia.. Inform patients that this listing of adverse reactions is not complete and not all adverse reactions can be anticipated. If appropriate, more comprehensive list of adverse reactions can be discussed with patients.. 17.3 What Patients Should Know About Taking Balsalazide with Other Medication. Based upon limited studies conducted in test tube, balsalazide is not believed to interfere with other drugs by preventing how the liver functions. However, as the studies were limited in scope, you should always consult your doctor and discuss potential interactions prior to initiating any new drug.BALSALAZIDE DISODIUM CAPSULES, USP 750 mgManufactured for:AvKARE, Inc.Pulaski, TN 38478Mfg. Rev. 03/16AV Rev. 09/17 (P) AvPAK Based upon limited studies conducted in test tube, balsalazide is not believed to interfere with other drugs by preventing how the liver functions. However, as the studies were limited in scope, you should always consult your doctor and discuss potential interactions prior to initiating any new drug.

MECHANISM OF ACTION SECTION.

12.1 Mechanism of Action. Balsalazide disodium is delivered intact to the colon where it is cleaved by bacterial azoreduction to release equimolar quantities of mesalamine, which is the therapeutically active portion of the molecule, and the 4-aminobenzoyl--alanine carrier moiety. The carrier moiety released when balsalazide disodium is cleaved is only minimally absorbed and is largely inert.The mechanism of action of 5-ASA is unknown, but appears to be local to the colonic mucosa rather than systemic. Mucosal production or arachidonic acid metabolites, both through the cyclooxygenase pathways, i.e., prostanoids, and through the lipoxygenase pathways, i.e., leukotrienes and hydroxyeicosatetraenoic acids, is increased in patients with chronic inflammatory bowel disease, and it is possible that 5-ASA diminishes inflammation by blocking production of arachidonic acid metabolites in the colon.

NONCLINICAL TOXICOLOGY SECTION.

13 NONCLINICAL TOXICOLOGY. 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility. In 24-month rat (Sprague Dawley) carcinogenicity study, oral (dietary) balsalazide disodium at doses up to g/kg/day was not tumorigenic. For 50-kg person of average height this dose represents 2.4 times the recommended human dose on body surface area basis. Balsalazide disodium was not genotoxic in the following in vitro or in vivo tests: Ames test, human lymphocyte chromosomal aberration test, and mouse lymphoma cell (L5178Y/TK+/-) forward mutation test, or mouse micronucleus test. However, it was genotoxic in the in vitro Chinese hamster lung cell (CH V79/HGPRT) forward mutation test. 4-aminobenzoyl--alanine, metabolite of balsalazide disodium, was not genotoxic in the Ames test and the mouse lymphoma cell (L5178Y/TK+/-) forward mutation test but was positive in the human lymphocyte chromosomal aberration test. N-acetyl-4-aminobenzoyl--alanine, conjugated metabolite of balsalazide disodium, was not genotoxic in Ames test, the mouse lymphoma cell (L5178Y/TK+/-) forward mutation test, or the human lymphocyte chromosomal aberration test. Balsalazide disodium at oral doses up to g/kg/day, 2.4 times the recommended human dose based on body surface area, was found to have no effect on fertility and reproductive performance in rats.. 13.2 Animal Toxicology. Renal ToxicityIn animal studies conducted at doses up to 2000 mg/kg (approximately 21 times the recommended 6.75 g/day dose on mg/kg basis for 70 kg person), balsalazide demonstrated no nephrotoxic effects in rats or dogs.OverdosageA single oral dose of balsalazide disodium at g/kg or 4-aminobenzoyl--alanine, metabolite of balsalazide disodium, at g/kg was non-lethal in mice and rats. No symptoms of acute toxicity were seen at these doses.

NURSING MOTHERS SECTION.

8.3 Nursing Mothers. It is not known whether balsalazide disodium is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when balsalazide is administered to nursing woman.

OVERDOSAGE SECTION.

10 OVERDOSAGE. No case of overdose has occurred with balsalazide. 3-year-old boy is reported to have ingested g of another mesalamine product. He was treated with ipecac and activated charcoal with no adverse reactions.If an overdose occurs with balsalazide, treatment should be supportive, with particular attention to correction of electrolyte abnormalities.

PACKAGE LABEL.PRINCIPAL DISPLAY PANEL.

PACKAGE LABEL.PRINCIPAL DISPLAY PANEL. Label 1.

PEDIATRIC USE SECTION.

8.4 Pediatric Use. Use of balsalazide disodium in pediatric and adolescent patients to 17 years of age for the treatment of mildly to moderately active ulcerative colitis is supported by:extrapolation of results from clinical studies that supported the approval of balsalazide disodium for adults.a clinical trial of 68 patients ages to 17 years comparing two doses of balsalazide disodium (6.75 g/day and 2.25 g/day), anda pharmacokinetic study performed on subset of the pediatric study population. [See Adverse Reactions (6.1), Clinical Pharmacology (12.3), and Clinical Studies (14)]. Based on the limited data available, dosing can be initiated at either 6.75 or 2.25 g/day.Safety and efficacy of balsalazide disodium in pediatric patients below the age of years have not been established.. extrapolation of results from clinical studies that supported the approval of balsalazide disodium for adults.. clinical trial of 68 patients ages to 17 years comparing two doses of balsalazide disodium (6.75 g/day and 2.25 g/day), and. pharmacokinetic study performed on subset of the pediatric study population. [See Adverse Reactions (6.1), Clinical Pharmacology (12.3), and Clinical Studies (14)].

PHARMACOKINETICS SECTION.

12.3 Pharmacokinetics. Balsalazide disodium capsules contain powder of balsalazide disodium that is insoluble in acid and designed to be delivered to the colon as the intact prodrug. Upon reaching the colon, bacterial azoreductases cleave the compound to release 5-ASA, the therapeutically active portion of the molecule, and 4-aminobenzoyl--alanine. The 5-ASA is further metabolized to yield Nacetyl-5-aminosalicylic acid (N-Ac-5-ASA), second key metabolite.AbsorptionThe plasma pharmacokinetics of balsalazide and its key metabolites from crossover study in healthy volunteers are summarized in Table 3. In this study, single oral dose of balsalazide 2.25 was administered to healthy volunteers as intact capsules (3 750 mg) under fasting conditions, as intact capsules (3 750 mg) after high-fat meal, and unencapsulated (3 750 mg) as sprinkles on applesauce.Table 3: Plasma Pharmacokinetics for Balsalazide and Key Metabolites (5-ASA and N-Ac-5-ASA) with Administration of Balsalazide Following Fast, High-Fat Meal, and Drug Contents Sprinkled on Applesauce (Mean +- SD)Fastingn 17High-Fat Mealn 17Sprinkledn 17C max (mcg/mL) Balsalazide0.51 +- 0.320.45 +- 0.390.21 +- 0.125-ASA0.22 +- 0.120.11 +- 0.1360.29 +- 0.17N-Ac-5-ASA0.88 +- 0.390.64 +- 0.5341.04 +- 0.57AUC last mcg.hr/mL) Balsalazide1.35 +- 0.731.52 +- 1.010.87 +- 0.485-ASA2.59 +- 1.462.10 +- 2.582.99 +- 1.70N-Ac-5-ASA17.8 +- 8.1417.7 +- 13.720.0 +- 11.4T max (h) Balsalazide0.8 +- 0.851.2 +- 1.111.6 +- 0.445-ASA8.2 +- 1.9822.0 +- 8.238.7 +- 1.99N-Ac-5-ASA9.9 +- 2.4920.2 +- 8.9410.8 +- 5.39A relatively low systemic exposure was observed under all three administered conditions (fasting, fed with high-fat meal, sprinkled on applesauce), which reflects the variable, but minimal absorption of balsalazide disodium and its metabolites. The data indicate that both max and AUC last were lower, while tmax was markedly prolonged, under fed (high-fat meal) compared to fasted conditions. Moreover, the data suggest that dosing balsalazide disodium as sprinkle or as capsule provides highly variable, but relatively similar mean pharmacokinetic parameter values. No inference can be made as to how the systemic exposure differences of balsalazide and its metabolites in this study might predict the clinical efficacy under different dosing conditions (i.e., fasted, fed with high-fat meal, or sprinkled on applesauce) since clinical efficacy after balsalazide disodium administration is presumed to be primarily due to the local effects of 5- ASA on the colonic mucosa. In separate study of adult patients with ulcerative colitis, who received balsalazide, 1.5 twice daily, for over year, systemic drug exposure, based on mean AUC values, was up to 60 times greater (0.008 mcgohr/mL to 0.480 mcgohr/mL) when compared to that obtained in healthy subjects who received the same dose.DistributionThe binding of balsalazide to human plasma proteins was >=99%.MetabolismThe products of the azoreduction of this compound, 5-ASA and 4-aminobenzoyl--alanine, and their N-acetylated metabolites have been identified in plasma, urine and feces.EliminationFollowing single-dose administration of 2.25 balsalazide (three 750 mg capsules) under fasting conditions in healthy subjects, mean urinary recovery of balsalazide, 5-ASA, and N-Ac-5-ASA was 0.20%, 0.22% and 10.2%, respectively.In multiple-dose study in healthy subjects receiving balsalazide dose of two 750 mg capsules twice daily (3 g/day) for 10 days, mean urinary recovery of balsalazide, 5-ASA, and N-Ac-5-ASA was 0.1%, 0%, and 11.3%, respectively. During this study, subjects received their morning dose 0.5 hours after being fed standard meal, and subjects received their evening dose hours after being fed standard meal.In study with 10 healthy volunteers, 65% of single 2.25-gram dose of balsalazide was recovered as 5-ASA, 4-aminobenzoyl--alanine, and the N-acetylated metabolites in feces, while <1% of the dose was recovered as parent compound.In study that examined the disposition of balsalazide in patients who were taking to g of balsalazide daily for more than year and who were in remission from ulcerative colitis, less than 1% of an oral dose was recovered as intact balsalazide in the urine. Less than 4% of the dose was recovered as 5-ASA, while virtually no 4-aminobenzoyl--alanine was detected in urine. The mean urinary recovery of N-Ac-5-ASA and N-acetyl-4-aminobenzoyl--alanine comprised <16% and <12% of the balsalazide dose, respectively. No fecal recovery studies were performed in this population.Pediatric Population In studies of pediatric patients with mild-to-moderate active ulcerative colitis receiving three 750 mg balsalazide disodium capsules times daily (6.75 g/day) for weeks, steady state was reached within weeks, as observed in adult patients. Likewise, the pharmacokinetics of balsalazide, 5-ASA, and N-Ac-5-ASA were characterized by very large inter-patient variability, which is also similar to that seen in adult patients.The pro-drug moiety, balsalazide, appeared to exhibit dose-independent (i.e., doselinear) kinetics in children, and the systemic exposure parameters (C max and AUC to 8) increased in an almost dose-proportional fashion after the 6.75 g/day versus the 2.25 g/day doses. However, the absolute magnitude of these exposure parameters was greater relative to adults. The and AUC observed in max to pediatric patients were 26% and 102% greater than those observed in adult patients at the 6.75 g/day dosage level. In contrast, the systemic exposure parameters for the active metabolites, 5-ASA and N- Ac-5-ASA, in pediatric patients increased in less than dose-proportional manner after the 6.75 g/day dose versus the 2.25 g/day dose. Additionally, the magnitude of these exposure parameters was decreased for both metabolites relative to adults. For the metabolite of key safety concern from systemic exposure perspective, 5-ASA, the and AUC observed in pediatric patients were max to 67% and 64% lower than those observed in adult patients at the 6.75 g/day dosage level. Likewise, for N-Ac-5-ASA, the and AUC observed in pediatric patients were 68% and 55% lower than max to those observed in adult patients at the 6.75 g/day dosage level. All pharmacokinetic studies with balsalazide are characterized by large variability in the plasma concentration versus time profiles for balsalazide and its metabolites, thus half-life estimates of these analytes are indeterminate.

PREGNANCY SECTION.

8.1 Pregnancy. Pregnancy Category B. Reproduction studies were performed in rats and rabbits at oral doses up to g/kg/day, 2.4 and 4.7 times the recommended human dose based on body surface area for the rat and rabbit, respectively, and revealed no evidence of impaired fertility or harm to the fetus due to balsalazide disodium. There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.

SPL UNCLASSIFIED SECTION.

2.1 Adult Dose. For treatment of active ulcerative colitis in adult patients, the usual dose is three 750 mg balsalazide disodium capsules to be taken times day (6.75 per day) for up to weeks. Some patients in the adult clinical trials required treatment for up to 12 weeks.

USE IN SPECIFIC POPULATIONS SECTION.

8 USE IN SPECIFIC POPULATIONS. Renal impairment: Use balsalazide with caution in patients with history of renal disease. (5.3) 8.1 Pregnancy. Pregnancy Category B. Reproduction studies were performed in rats and rabbits at oral doses up to g/kg/day, 2.4 and 4.7 times the recommended human dose based on body surface area for the rat and rabbit, respectively, and revealed no evidence of impaired fertility or harm to the fetus due to balsalazide disodium. There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.. 8.3 Nursing Mothers. It is not known whether balsalazide disodium is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when balsalazide is administered to nursing woman.. 8.4 Pediatric Use. Use of balsalazide disodium in pediatric and adolescent patients to 17 years of age for the treatment of mildly to moderately active ulcerative colitis is supported by:extrapolation of results from clinical studies that supported the approval of balsalazide disodium for adults.a clinical trial of 68 patients ages to 17 years comparing two doses of balsalazide disodium (6.75 g/day and 2.25 g/day), anda pharmacokinetic study performed on subset of the pediatric study population. [See Adverse Reactions (6.1), Clinical Pharmacology (12.3), and Clinical Studies (14)]. Based on the limited data available, dosing can be initiated at either 6.75 or 2.25 g/day.Safety and efficacy of balsalazide disodium in pediatric patients below the age of years have not been established.. extrapolation of results from clinical studies that supported the approval of balsalazide disodium for adults.. clinical trial of 68 patients ages to 17 years comparing two doses of balsalazide disodium (6.75 g/day and 2.25 g/day), and. pharmacokinetic study performed on subset of the pediatric study population. [See Adverse Reactions (6.1), Clinical Pharmacology (12.3), and Clinical Studies (14)].

WARNINGS AND PRECAUTIONS SECTION.

5 WARNINGS AND PRECAUTIONS. Exacerbation of the symptoms of ulcerative colitis was reported in both adult and pediatric patients. Observe patients closely for worsening of these symptoms while on treatment. (5.1) Prolonged gastric retention of balsalazide may occur in patients with pyloric stenosis. (5.2) Exacerbation of the symptoms of ulcerative colitis was reported in both adult and pediatric patients. Observe patients closely for worsening of these symptoms while on treatment. (5.1) Prolonged gastric retention of balsalazide may occur in patients with pyloric stenosis. (5.2) 5.1 Exacerbations of Ulcerative Colitis. In the adult clinical trials, out of 259 patients reported exacerbation of the symptoms of ulcerative colitis. In the pediatric clinical trials, out of 68 patients reported exacerbation of the symptoms of ulcerative colitis.Observe patients closely for worsening of these symptoms while on treatment. 5.2 Pyloric Stenosis. Patients with pyloric stenosis may have prolonged gastric retention of balsalazide disodium capsules.. 5.3 Renal. Renal toxicity has been observed in animals and patients given other mesalamine products. Therefore, caution should be exercised when administering balsalazide capsules to patients with known renal dysfunction or history of renal disease. [See Nonclinical Toxicology (13.2)].