DRUGS & SUPPLEMENTS
1 INDICATIONS AND USAGE
Adprazole Delayed-Release Capsules are a proton pump inhibitor indicated for:
The safety and effectiveness of Adprazole Delayed-Release Capsules in pediatric patients < 1 year of age have not been established (8.4).
1.1 Duodenal Ulcer (adults)
Adprazole Delayed-Release Capsules are indicated for short-term treatment of active duodenal ulcer in adults. Most patients heal within four weeks. Some patients may require an additional four weeks of therapy.
Adprazole Delayed-Release Capsules in combination with clarithromycin and amoxicillin, are indicated for treatment of patients with H. pylori infection and duodenal ulcer disease (active or up to 1-year history) to eradicate H. pylori in adults.
Adprazole Delayed-Release Capsules in combination with clarithromycin are indicated for treatment of patients with H. pylori infection and duodenal ulcer disease to eradicate H. pylori in adults.
Eradication of H. pylori has been shown to reduce the risk of duodenal ulcer recurrence [see Clinical Studies (14.1) and Dosage and Administration (2)].
Among patients who fail therapy, Adprazole Delayed-Release Capsules with clarithromycin is more likely to be associated with the development of clarithromycin resistance as compared with triple therapy. In patients who fail therapy, susceptibility testing should be done. If resistance to clarithromycin is demonstrated or susceptibility testing is not possible, alternative antimicrobial therapy should be instituted. [see Microbiology section (12.4 )], and the clarithromycin package insert, Microbiology section.
1.2 Gastric Ulcer
Adprazole Delayed-Release Capsules are indicated for short-term treatment (4-8 weeks) of active benign gastric ulcer in adults [see Clinical Studies (14.2)].
1.3 Treatment of Gastroesophageal Reflux Disease (adults and pediatric patients)
Adprazole Delayed-Release Capsules are indicated for the treatment of heartburn and other symptoms associated with GERD in pediatric patients and adults.
Adprazole Delayed-Release Capsules are indicated for the short-term treatment (4-8 weeks) of erosive esophagitis that has been diagnosed by endoscopy in pediatric patients and adults [see Clinical Studies (14.4)].
The efficacy of Adprazole Delayed-Release Capsules used for longer than 8 weeks in these patients has not been established. If a patient does not respond to 8 weeks of treatment, an additional 4 weeks of treatment may be given. If there is recurrence of erosive esophagitis or GERD symptoms (e.g., heartburn), additional 4-8 week courses of Adprazole may be considered.
1.4 Maintenance of Healing of Erosive Esophagitis
Adprazole Delayed-Release Capsules are indicated to maintain healing of erosive esophagitis in pediatric patients and adults.
Controlled studies do not extend beyond 12 months [see Clinical Studies ( 14.4 )].
1.5 Pathological Hypersecretory Conditions
Adprazole Delayed-Release Capsules are indicated for the long-term treatment of pathological hypersecretory conditions (e.g., Zollinger-Ellison syndrome, multiple endocrine adenomas and systemic mastocytosis) in adults.
2 DOSAGE AND ADMINISTRATION
Adprazole Delayed-Release Capsules should be taken before eating. In the clinical trials, antacids were used concomitantly with Adprazole Delayed-Release Capsules.
Patients should be informed that the Adprazole Delayed-Release Capsules should be swallowed whole.
For patients unable to swallow an intact capsule, alternative administration options are available [see Dosage and Administration ].
2.1 Short-Term Treatment of Active Duodenal Ulcer
The recommended adult oral dose of Adprazole Delayed-Release Capsules is 20 mg once daily. Most patients heal within four weeks. Some patients may require an additional four weeks of therapy.
2.2 H. pylori Eradication for the Reduction of the Risk of Duodenal Ulcer Recurrence
Triple Therapy - The recommended adult oral regimen is Adprazole Delayed-Release Capsules 20 mg plus clarithromycin 500 mg plus amoxicillin 1000 mg each given twice daily for 10 days. In patients with an ulcer present at the time of initiation of therapy, an additional 18 days of Adprazole Delayed-Release Capsules 20 mg once daily is recommended for ulcer healing and symptom relief.
Dual Therapy (Omeprazole Delayed-Release Capsules /clarithromycin) - The recommended adult oral regimen is Adprazole Delayed-Release Capsules 40 mg once daily plus clarithromycin 500 mg three times daily for 14 days. In patients with an ulcer present at the time of initiation of therapy, an additional 14 days of Adprazole Delayed-Release Capsules 20 mg once daily is recommended for ulcer healing and symptom relief.
2.3 Gastric Ulcer
The recommended adult oral dose is 40 mg once daily for 4-8 weeks.
2.4 Gastroesophageal Reflux Disease
The recommended adult oral dose for the treatment of patients with symptomatic GERD and no esophageal lesions is 20 mg daily for up to 4 weeks. The recommended adult oral dose for the treatment of patients with erosive esophagitis and accompanying symptoms due to GERD is 20 mg daily for 4 to 8 weeks.
2.5 Maintenance of Healing of Erosive Esophagitis
The recommended adult oral dose is 20 mg daily [see Clinical Studies ].
2.6 Pathological Hypersecretory Conditions
The dosage of Adprazole Delayed-Release Capsules in patients with pathological hypersecretory conditions varies with the individual patient. The recommended adult oral starting dose is 60 mg once daily. Doses should be adjusted to individual patient needs and should continue for as long as clinically indicated. Doses up to 120 mg three times daily have been administered. Daily dosages of greater than 80 mg should be administered in divided doses. Some patients with Zollinger-Ellison syndrome have been treated continuously with Adprazole Delayed-Release Capsules for more than 5 years.
2.7 Pediatric Patients
For the treatment of GERD and maintenance of healing of erosive esophagitis, the recommended daily dose for pediatric patients 2 to 16 years of age is as follows:
On a per kg basis, the doses of Adprazole required to heal erosive esophagitis in pediatric patients are greater than those for adults.
Alternative administrative options can be used for pediatric patients unable to swallow an intact capsule [see Dosage and Administration ].
2.8 Alternative Administration Options
Adprazole Delayed-Release Capsule is available as a delayed-release capsule.
For patients who have difficulty swallowing capsules, the contents of an Adprazole Delayed-Release Capsule can be added to applesauce. One tablespoon of applesauce should be added to an empty bowl and the capsule should be opened. All of the microtablets inside the capsule should be carefully emptied on the applesauce. The microtablets should be mixed with the applesauce and then swallowed immediately with a glass of cool water to ensure complete swallowing of the microtablets. The applesauce used should not be hot and should be soft enough to be swallowed without chewing. The microtablets should not be chewed or crushed. The microtablets/applesauce mixture should not be stored for future use.
2.9 Use with clopidogrel
Avoid concomitant use of clopidogrel and Adprazole. Co-administration of clopidogrel with 80 mg Adprazole, a proton pump inhibitor that is an inhibitor of CYP2C19, reduces the pharmacological activity of clopidogrel if given concomitantly or if given 12 hours apart [see Warnings and Precautions (5.4) and Drug Interactions (7.3) ].
3 DOSAGE FORMS AND STRENGTHS
Adprazole Delayed-Release Capsules, 10 mg, are opaque white cap and opaque white body capsules imprinted with "KU" and "114" in black ink.
Adprazole Delayed-Release Capsules, 20 mg, are opaque white cap and opaque gold body capsules imprinted with "KU" and "118" in black ink.
Adprazole Delayed-Release Capsules, 40 mg, are opaque gold cap and opaque gold body capsules imprinted with "KU" and "136" in black ink.
Adprazole Delayed-Release Capsules, 10 mg, 20 mg and 40 mg (3)
Adprazole Delayed-Release Capsules are contraindicated in patients with known hypersensitivity to substituted benzimidazoles or to any component of the formulation. Hypersensitivity reactions may include anaphylaxis, anaphylactic shock, angioedema, bronchospasm, interstitial nephritis, and urticaria [see Adverse Reactions ( 6 )].
Known hypersensitivity to any component of the formulation or substituted benzimidazoles (angioedema and anaphylaxis have occurred) (4)
5 WARNINGS AND PRECAUTIONS
5.1 Concomitant Gastric Malignancy
Symptomatic response to therapy with Adprazole does not preclude the presence of gastric malignancy.
5.2 Atrophic Gastritis
Atrophic gastritis has been noted occasionally in gastric corpus biopsies from patients treated long-term with Adprazole.
5.3 Bone Fracture
Several published observational studies suggest that proton pump inhibitor therapy may be associated with an increased risk for osteoporosis-related fractures of the hip, wrist, or spine. The risk of fracture was increased in patients who received high-dose, defined as multiple daily doses, and long-term PPI therapy (a year or longer). Patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated. Patients at risk for osteoporosis-related fractures should be managed according to established treatment guidelines [see Dosage and Administration (
5.4 Diminished Anti-platelet Activity of clopidogrel due to Impaired CYP2C19 Function by Adprazole
Clopidogrel is a prodrug. Inhibition of platelet aggregation by clopidogrel is entirely due to an active metabolite. The metabolism of clopidogrel to its active metabolite can be impaired by use with concomitant medications, such as Adprazole, that interfere with CYP2C19 activity. Avoid concomitant use of clopidogrel and Adprazole. Co-administration of clopidogrel with 80 mg Adprazole, a proton pump inhibitor that is an inhibitor of CYP2C19, reduces the pharmacological activity of clopidogrel if given concomitantly or if given 12 hours apart [see Drug Interactions (7) ].
5.5 Combination Use of Adprazole Delayed-Release Capsules with Amoxicillin
Serious and occasionally fatal hypersensitivity reactions have been reported in patients on penicillin therapy. These reactions are more likely to occur in individuals with a history of penicillin hypersensitivity and/or a history of sensitivity to multiple allergens. Before initiating therapy with amoxicillin, careful inquiry should be made concerning previous hypersensitivity reactions to penicillins, cephalosporins or other allergens. If an allergic reaction occurs, amoxicillin should be discontinued and appropriate therapy instituted. Serious anaphylactic reactions require immediate emergency treatment with epinephrine. Oxygen, intravenous steroids and airway management, including intubation, should also be administered as indicated.
Pseudomembranous colitis has been reported with nearly all antibacterial agents and may range in severity from mild to life-threatening. Therefore, it is important to consider this diagnosis in patients who present with diarrhea subsequent to the administration of antibacterial agents.
Treatment with antibacterial agents alters the normal flora of the colon and may permit overgrowth of clostridia. Studies indicate that a toxin produced by Clostridium difficile is a primary cause of "antibiotic-associated colitis."
After the diagnosis of pseudomembranous colitis has been established, therapeutic measures should be initiated. Mild cases of pseudomembranous colitis usually respond to discontinuation of the drug alone. In moderate to severe cases, consideration should be given to management with fluids and electrolytes, protein supplementation, and treatment with an antibacterial drug clinically effective against Clostridium difficile colitis.
5.6 Combination Use of Adprazole Delayed-Release Capsules with Clarithromycin
Clarithromycin should not be used in pregnant women except in clinical circumstances where no alternative therapy is appropriate. If pregnancy occurs while taking clarithromycin, the patient should be apprised of the potential hazard to the fetus.
Co-administration of Adprazole and clarithromycin has resulted in increases in plasma levels of Adprazole, clarithromycin, and 14-hydroxy-clarithromycin [see Clinical Pharmacology (12)].
Concomitant administration of clarithromycin with cisapride or pimozide, is contraindicated.
Hypomagnesemia, symptomatic and asymptomatic, has been reported rarely in patients treated with PPIs for at least three months, in most cases after a year of therapy. Serious adverse events include tetany, arrhythmias, and seizures. In most patients, treatment of hypomagnesemia required magnesium replacement and discontinuation of the PPI.
For patients expected to be on prolonged treatment or who take PPIs with medications such as digoxin or drugs that may cause hypomagnesemia, health care professionals may consider monitoring magnesium levels prior to initiation of PPI treatment and periodically [see Adverse Reactions (6.3) ].
5.8 Concomitant Use of Adprazole Delayed-Release Capsules with St. John's Wort or rifampin
Drugs which induce CYP2C19 or CYP3A4 (such as St. John's Wort or rifampin) can substantially decrease Adprazole concentrations [see Drug Interactions (7.3) ]. Avoid concomitant use of Adprazole Delayed-Release Capsules with St. John's Wort or rifampin.
5.9 Interactions with Investigations for Neuroendocrine Tumors
Serum chromogranin A (CgA) levels increase secondary to drug-induced decreases in gastric acidity. The increased CgA level may cause false positive results in diagnostic investigations for neuroendocrine tumors. Providers should temporarily stop Adprazole treatment before assessing CgA levels and consider repeating the test if initial CgA levels are high. If serial tests are performed (e.g. for monitoring), the same commercial laboratory should be used for testing, as reference ranges between tests may vary.
6 ADVERSE REACTIONS
Adults: Most common adverse reactions in adults are
Pediatric patients (2 to 16 years of age):
To report SUSPECTED ADVERSE REACTIONS, contact UCB, Inc. (1-866-822-0068) or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch
6.1 Clinical Trials Experience with Adprazole Delayed-Release Capsules Monotherapy
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 data described below reflects exposure to Adprazole Delayed-Release Capsules in 3096 patients from worldwide clinical trials (465 patients from US studies and 2,631 patients from international studies). Indications clinically studied in US trials included duodenal ulcer, resistant ulcer, and Zollinger-Ellison syndrome. The international clinical trials were double blind and open-label in design. The most common adverse reactions reported (i.e., with an incidence rate ≥ 2%) from Adprazole Delayed-Release Capsules-treated patients enrolled in these studies included headache (6.9%), abdominal pain (5.2%), nausea (4.0%), diarrhea (3.7%), vomiting (3.2%), and flatulence (2.7%).
Additional adverse reactions that were reported with an incidence ≥1% included acid regurgitation (1.9%), upper respiratory infection (1.9%), constipation (1.5%), dizziness (1.5%), rash (1.5%), asthenia (1.3%), back pain (1.1%), and cough (1.1%).
The clinical trial safety profile in patients greater than 65 years of age was similar to that in patients 65 years of age or less.
The clinical trial safety profile in pediatric patients who received Adprazole Delayed-Release Capsules was similar to that in adult patients. Unique to the pediatric population, however, adverse reactions of the respiratory system were most frequently reported in the 2 to 16 year age group (18.5%). Similarly, accidental injuries were reported frequently in the 2 to 16 year age group (3.8%) [see Use in Specific Populations ( 8.4 )].
6.2 Clinical Trials Experience with Adprazole Delayed-Release Capsules in Combination Therapy for H. pylori Eradication
In clinical trials using either dual therapy with Adprazole Delayed-Release Capsules and clarithromycin, or triple therapy with Adprazole Delayed-Release Capsules, clarithromycin, and amoxicillin, no adverse reactions unique to these drug combinations were observed. Adverse reactions observed were limited to those previously reported with Adprazole, clarithromycin, or amoxicillin alone.
Adverse reactions observed in controlled clinical trials using combination therapy with Adprazole Delayed-Release Capsules and clarithromycin (n = 346) that differed from those previously described for Adprazole Delayed-Release Capsules alone were taste perversion (15%), tongue discoloration (2%), rhinitis (2%), pharyngitis (1%) and flu-syndrome (1%). (For more information on clarithromycin, refer to the clarithromycin prescribing information, Adverse Reactions section).
Triple Therapy (Omeprazole Delayed-Release Capsules/clarithromycin/amoxicillin)
The most frequent adverse reactions observed in clinical trials using combination therapy with Adprazole Delayed-Release Capsules, clarithromycin, and amoxicillin (n = 274) were diarrhea (14%), taste perversion (10%), and headache (7%). None of these occurred at a higher frequency than that reported by patients taking antimicrobial agents alone. (For more information on clarithromycin or amoxicillin, refer to the respective prescribing information, Adverse Reactions sections).
6.3 Post-marketing Experience
The following adverse reactions have been identified during post-approval use of Adprazole Delayed-Release Capsules. Because these reactions are voluntarily. reported from a population of uncertain size, it is not always possible to reliably estimate their actual frequency or establish a causal relationship to drug exposure.
Body As a Whole: Hypersensitivity reactions including anaphylaxis, anaphylactic shock, angioedema, bronchospasm, interstitial nephritis, urticaria, (see also Skin below); fever; pain; fatigue; malaise;
Cardiovascular: Chest pain or angina, tachycardia, bradycardia, palpitations, elevated blood pressure, peripheral edema
Gastrointestinal: Pancreatitis (some fatal), anorexia, irritable colon, fecal discoloration, esophageal candidiasis, mucosal atrophy of the tongue, stomatitis, abdominal swelling, dry mouth. During treatment with Adprazole, gastric fundic gland polyps have been noted rarely. These polyps are benign and appear to be reversible when treatment is discontinued. Gastroduodenal carcinoids have been reported in patients with ZE syndrome on long-term treatment with Adprazole Delayed-Release Capsules. This finding is believed to be a manifestation of the underlying condition, which is known to be associated with such tumors.
Hepatic: Liver disease including hepatic failure (some fatal), liver necrosis (some fatal), hepatic encephalopathy hepatocellular disease, cholestatic disease, mixed hepatitis, jaundice, and elevations of liver function tests [ALT, AST, GGT, alkaline phosphatase, and bilirubin]
Metabolic/Nutritional: Hypoglycemia, hypomagnesemia, hyponatremia, weight gain
Musculoskeletal: Muscle weakness, myalgia, muscle cramps, joint pain, leg pain, bone fracture
Nervous System/Psychiatric: Psychiatric and sleep disturbances including depression, agitation, aggression, hallucinations, confusion, insomnia, nervousness, apathy, somnolence, anxiety, and dream abnormalities; tremors, paresthesia; vertigo
Respiratory: Epistaxis, pharyngeal pain
Skin: Severe generalized skin reactions including toxic epidermal necrolysis (some fatal), Stevens-Johnson syndrome, and erythema multiforme; photosensitivity; urticaria; rash; skin inflammation; pruritus; petechiae; purpura; alopecia; dry skin; hyperhidrosis
Special Senses: Tinnitus, taste perversion
Ocular: Optic atrophy, anterior ischemic optic neuropathy, optic neuritis, dry eye syndrome, ocular irritation, blurred vision, double vision
Urogenital: Interstitial nephritis, hematuria, proteinuria, elevated serum creatinine, microscopic pyuria, urinary tract infection, glycosuria, urinary frequency, testicular pain
Hematologic: Agranulocytosis (some fatal), hemolytic anemia, pancytopenia, neutropenia, anemia, thrombocytopenia, leukopenia, leucocytosis
7 DRUG INTERACTIONS
7.1 Interference with Antiretroviral Therapy
Concomitant use of atazanavir and nelfinavir with proton pump inhibitors is not recommended. Co-administration of atazanavir with proton pump inhibitors is expected to substantially decrease atazanavir plasma concentrations and may result in a loss of therapeutic effect and the development of drug resistance. Coadministration of saquinavir with proton pump inhibitors is expected to increase saquinavir concentrations, which may increase toxicity and require dose reduction.
Adprazole has been reported to interact with some antiretroviral drugs. The clinical importance and the mechanisms behind these interactions are not always known. Increased gastric pH during Adprazole treatment may change the absorption of the antiretroviral drug. Other possible interaction mechanisms are via CYP 2C19.
Reduced concentrations of atazanavir and nelfinavir
For some antiretroviral drugs, such as atazanavir and nelfinavir, decreased serum levels have been reported when given together with Adprazole. Following multiple doses of nelfinavir (1250 mg, twice daily) and Adprazole (40 mg daily), AUC was decreased by 36% and 92%,
Cmax by 37% and 89% and Cmin by 39% and 75% respectively for nelfinavir and M8. Following multiple doses of atazanavir (400 mg, daily) and Adprazole (40 mg, daily, 2 hr before atazanavir), AUC was decreased by 94%, Cmax by 96%, and Cmin by 95%. Concomitant administration with Adprazole and drugs such as atazanavir and nelfinavir is therefore not recommended.
Increased concentrations of saquinavir
For other antiretroviral drugs, such as saquinavir, elevated serum levels have been reported, with an increase in AUC by 82%, in Cmax by 75%, and in Cmin by 106%, following multiple dosing of saquinavir/ritonavir (1000/100 mg) twice daily for 15 days with Adprazole 40 mg daily co-administered days 11 to 15. Therefore, clinical and laboratory monitoring for saquinavir toxicity is recommended during concurrent use with Adprazole Delayed-Release Capsules. Dose reduction of saquinavir should be considered from the safety perspective for individual patients.
There are also some antiretroviral drugs of which unchanged serum levels have been reported when given with Adprazole.
7.2 Drugs for Which Gastric pH Can Affect Bioavailablity
Because of its profound and long lasting inhibition of gastric acid secretion, it is theoretically possible that Adprazole may interfere with absorption of drugs where gastric pH is an important determinant of their bioavailability. The absorption of digoxin can increase during treatment with Adprazole. Concomitant treatment with Adprazole (20 mg daily) and digoxin in healthy subjects increased the bioavailability of digoxin by 10% (30% in two subjects). Therefore patients may need to be monitored when digoxin is taken concomitantly with Adprazole. In the clinical trials, antacids were used concomitantly with the administration of Adprazole Delayed-Release Capsules.
7.3 Effects on Hepatic Metabolism/Cytochrome P-450 Pathways
Adprazole can prolong the elimination of diazepam, warfarin and phenytoin, drugs that are metabolized by oxidation in the liver. There have been reports of increased INR and prothrombin time in patients receiving proton pump inhibitors, including Adprazole, and warfarin concomitantly. Increases in INR and prothrombin time may lead to abnormal bleeding and even death. Patients treated with proton pump inhibitors and warfarin may need to be monitored for increases in INR and prothrombin time.
Although in normal subjects no interaction with theophylline or propranolol was found, there have been clinical reports of interaction with other drugs metabolized via the cytochrome P450 system (e.g., cyclosporine, dandulfiram, benzodiazepines). Patients should be monitored to determine if it is necessary to adjust the dosage of these drugs when taken concomitantly with Adprazole Delayed-Release Capsules.
Concomitant administration of Adprazole and voriconazole (a combined inhibitor of CYP2C19 and CYP3A4) resulted in more than doubling of the Adprazole exposure. Dose adjustment of Adprazole is not normally required. However, in patients with Zollinger-Ellison syndrome, who may require higher doses up to 240 mg/day, dose adjustment may be considered. When voriconazole (400 mg Q12h x 1 day, then 200 mg x 6 days) was given with Adprazole (40 mg once daily x 7 days) to healthy subjects, it significantly increased the steady-state Cmax and AUC0-24 of Adprazole, an average of 2 times (90% CI: 1.8, 2.6) and 4 times (90% CI: 3.3, 4.4) respectively as compared to when Adprazole was given without voriconazole.
Adprazole acts as an inhibitor of CYP 2C19. Adprazole, given in doses of 40 mg daily for one week to 20 healthy subjects in crossover study, increased Cmax and AUC of cilostazol by 18% and 26% respectively. Cmax and AUC of one of its active metabolites, 3,4-dihydro-cilostazol, which has 4-7 times the activity of cilostazol, were increased by 29% and 69% respectively. Co-administration of cilostazol with Adprazole is expected to increase concentrations of cilostazol and its above mentioned active metabolite. Therefore a dose reduction of cilostazol from 100 mg b.i.d. to 50 mg b.i.d. should be considered.
Adprazole is an inhibitor of CYP2C19 enzyme. Clopidogrel is metabolized to its active metabolite in part by CYP2C19. Concomitant use of Adprazole 80 mg results in reduced plasma concentrations of the active metabolite of clopidogel and a reduction in platelet inhibition [see Warnings and Precautions (5.4) ].
In a crossover clinical study, 72 healthy subjects were administered clopidogrel (300 mg loading dose followed by 75 mg per day) alone with Adprazole (80 mg at the same time as clopidogrel) for 5 days. The exposure to the active metabolite of clopidogrel was decreased by 46% (Day 1) and 42% (Day 5) when clopidogrel and Adprazole were administered together. The active metabolite of clopidogrel selectively and irreversibly inhibits the binding of adenosine diphosphate (ADP) to its platelet P2Y12 receptor, thereby inhibiting platelet aggregation. The mean inhibition of platelet aggregation at 5 mcM ADP was diminished by 39% (Day 1) and 21% ( Day 5) when clopidogrel and Adprazole were administered together.
In another study, 72 healthy subjects were given the same doses of clopidogrel and 80 mg Adprazole but the drugs were administered 12 hours apart; the results were similar, indicating that administering clopidogrel and Adprazole at different times does not prevent their interaction [see Warnings and Precautions (5.4) ].
There are no adequate combination studies of a lower dose of Adprazole or a higher dose of clopidogrel in comparison with the approved dose of clopidogrel.
Concomitant administration of Adprazole and tacrolimus may increase the serum levels of tacrolimus.
7.5 Interactions with Investigations of Neurodocrine Tumors
Drug-induced decrease in gastric acidity results in enterochromaffin-like cell hyperplasia and increased Chromogranin A levels which may interfere with investigations for neuroendocrine tumors.
8 USE IN SPECIFIC POPULATIONS
Patients with hepatic impairment:
Pregnancy Category C
Reproductive studies in rats and rabbits with Adprazole and multiple cohort studies in pregnant women with Adprazole use during the first trimester do not show an increased risk of congenital anomalies or adverse pregnancy outcomes. There are no adequate and well -controlled studies on the use of Adprazole 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. The vast majority of reported experience with Adprazole during human pregnancy is first trimester exposure and the duration of use is rarely specified, e.g., intermittent vs. chronic. An expert review of published data on experiences with Adprazole use during pregnancy by TERIS – the Teratogen Information System – concluded that therapeutic doses during pregnancy are unlikely to pose a substantial teratogenic risk (the quantity and quality of data were assessed as fair). Three epidemiological studies compared the frequency of congenital abnormalities among infants born to women who used Adprazole during pregnancy with the frequency of abnormalities among infants of women exposed to H2–receptor antagonists or other controls. A population-based prospective cohort epidemiological study from the Swedish Medical Birth Registry, covering approximately 99% of pregnancies, reported on 955 infants (824 exposed during the first trimester with 39 of these exposed beyond first trimester, and 131 exposed after the first trimester) whose mothers used Adprazole during pregnancy. In utero exposure to Adprazole was not associated with increased risk of any malformation (odds ratio 0.82, 95% CI 0.50–1.34), low birth weight or low Apgar score. The number of infants born with ventricular septal defects and the number of stillborn infants was slightly higher in the omeprazole-exposed infants than the expected number in the normal population. The author concluded that both effects may be random.
A retrospective cohort study reported on 689 pregnant women exposed to either H2–blockers or Adprazole in the first trimester (134 exposed to Adprazole). The overall malformation rate was 4.4% (95% CI 3.6–5.3) and the malformation rate for first trimester exposure to Adprazole was 3.6% (95% CI 1.5–8.1). The relative risk of malformations associated with first trimester exposure to Adprazole compared with non-exposed women was 0.9 (95% CI 0.3–2.2).
The study could effectively rule out a relative risk greater than 2.5 for all malformations. Rates of preterm delivery or growth retardation did not differ between the groups.
A controlled prospective observational study followed 113 women exposed to Adprazole during pregnancy (89% first trimester exposures). The reported rates of major congenital malformations was 4% for the Adprazole group, 2% for controls exposed to non-teratogens, and 2.8% in disease-paired controls (background incidence of major malformations 1–5%). Rates of spontaneous and elective abortions, preterm deliveries, gestational age at delivery, and mean birth weight did not differ between the groups. The sample size in this study has 80% power to detect a 5–fold increase in the rate of major malformation.
Several studies have reported no apparent adverse short-term effects on the infant when single dose oral or intravenous Adprazole was administered to over 200 pregnant women as premedication for cesarean section under general anesthesia.
Reproductive studies conducted with Adprazole on rats at oral doses up to 56 times the human dose and in rabbits at doses up to 56 times the human dose did not show any evidence of teratogenicity. In pregnant rabbits, Adprazole at doses about 5.5 to 56 times the human dose produced dose-related increases in embryo-lethality, fetal resorptions, and pregnancy loss. In rats treated with Adprazole at doses about 5.6 to 56 times the human dose, dose-related embryo/fetal toxicity and postnatal developmental toxicity occurred in offspring [see Animal Toxicology and/or Pharmacology (13.2)].
8.3 Nursing Mothers
Adprazole concentrations have been measured in breast milk of a woman following oral administration of 20 mg. The peak concentration of Adprazole in breast milk was less than 7% of the peak serum concentration. This concentration would correspond to 0.004 mg of Adprazole in 200 mL of milk. Because Adprazole is excreted in human milk, because of the potential for serious adverse reactions in nursing infants from Adprazole, and because of the potential for tumorigenicity shown for Adprazole in rat carcinogenicity studies, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.
8.4 Pediatric Use
Use of Adprazole Delayed-Release Capsules in pediatric and adolescent patients 2 to 16 years of age for the treatment of GERD is supported by a) extrapolation of results, already included in the currently approved labeling, from adequate and well-controlled studies that supported the approval of Adprazole Delayed-Release Capsules for adults, and b) safety and pharmacokinetic studies performed in pediatric and adolescent patients. [see Clinical Pharmacology, Pharmacokinetics, Pediatric for pharmacokinetic information and Dosage and Administration ( 2 ), Adverse Reactions ( 6.1 ) and Clinicial Studies ( 14.6 )]. The safety and effectiveness of Adprazole Delayed-Release Capsules for the treatment of GERD in patients < 1 year of age have not been established. The safety and effectiveness of Adprazole Delayed-Release Capsules for other pediatric uses have not been established.
8.5 Geriatric Use
Adprazole was administered to over 2000 elderly individuals (≥ 65 years of age) in clinical trials in the U.S. and Europe. There were no differences in safety and effectiveness between the elderly and younger subjects. Other reported clinical experience has not identified differences in response between the elderly and younger subjects, but greater sensitivity of some older individuals cannot be ruled out.
Pharmacokinetic studies have shown the elimination rate was somewhat decreased in the elderly and bioavailability was increased. The plasma clearance of Adprazole was 250 mL/min (about half that of young volunteers) and its plasma half-life averaged one hour, about twice that of young healthy volunteers. However, no dosage adjustment is necessary in the elderly [see Clinical Pharmacology ( 12.3 )].
8.6 Hepatic Impairment
Consider dose reduction, particularly for maintenance of healing of erosive esophagitis .
8.7 Renal Impairment
No dosage reduction is necessary [see Clinical Pharmacology ( 12.3 )].
8.8 Asian Population
Consider dose reduction, particularly for maintenance of healing of erosive esophagitis [see Clinical Pharmacology ( 12.3 )].
Reports have been received of overdosage with Adprazole in humans. Doses ranged up to 2400 mg (120 times the usual recommended clinical dose). Manifestations were variable, but included confusion, drowsiness, blurred vision, tachycardia, nausea, vomiting, diaphoresis, flushing, headache, dry mouth, and other adverse reactions similar to those seen in normal clinical experience [ see Adverse Reactions ( 6 )]. Symptoms were transient, and no serious clinical outcome has been reported when Adprazole Delayed-Release Capsules were taken alone. No specific antidote for Adprazole overdosage is known. Adprazole is extensively protein bound and is, therefore, not readily dialyzable. In the event of overdosage, treatment should be symptomatic and supportive.
As with the management of any overdose, the possibility of multiple drug ingestion should be considered. For current information on treatment of any drug overdose, contact a Poison Control Center at 1-800-222-1222.
Single oral doses of Adprazole at 1350, 1339, and 1200 mg/kg were lethal to mice, rats, and dogs, respectively. Animals given these doses showed sedation, ptosis, tremors, convulsions, and decreased activity, body temperature, and respiratory rate and increased depth of respiration.
The active ingredient in Adprazole Delayed-Release Capsules is a substituted benzimidazole, 5-methoxy-2-[[(4-methoxy-3, 5-dimethyl-2-pyridinyl) methyl] sulfinyl]-1H-benzimidazole, a compound that inhibits gastric acid secretion. Its empirical formula is C17H19N3O3S, with a molecular weight of 345.42. The structural formula is:
Adprazole is a white to off-white crystalline powder that melts with decomposition at about 155°C. It is a weak base, freely soluble in ethanol and methanol, and slightly soluble in acetone and isopropanol and very slightly soluble in water. The stability of Adprazole is a function of pH; it is rapidly degraded in acid media, but has acceptable stability under alkaline conditions.
Adprazole Delayed-Release Capsules meet USP Dissolution Test 2.
Adprazole Delayed-Release Capsules are supplied as delayed-release capsules for oral administration. Each delayed-release capsule contains either 10 mg, 20 mg, or 40 mg of Adprazole in the form of enteric-coated microtablets with the following inactive ingredients: crospovidone, glyceryl behenate, hypromellose, lactose monohydrate, methacrylic acid copolymer dispersion, silicon dioxide, talc, titanium dioxide and triethyl citrate. In addition, the capsule shells contain gelatin and may contain sodium lauryl sulfate. In addition, the 20 mg and 40 mg capsule shells also contain yellow iron oxide. The imprinting ink also contains ammonium hydroxide, butyl alcohol, black iron oxide, isopropyl alcohol, propylene glycol and shellac glaze. The ink may also contain dehydrated alcohol.
12 CLINICAL PHARMACOLOGY
12.1 Mechanism of Action
Adprazole belongs to a class of antisecretory compounds, the substituted benzimidazoles, that suppress gastric acid secretion by specific inhibition of the H+/K+ ATPase enzyme system at the secretory surface of the gastric parietal cell. Because this enzyme system is regarded as the acid pump within the gastric mucosa, Adprazole has been characterized as a gastric acid-pump inhibitor, in that it blocks the final step of acid production. This effect is dose-related and leads to inhibition of both basal and stimulated acid secretion irrespective of the stimulus. Animal studies indicate that after rapid disappearance from plasma, Adprazole can be found within the gastric mucosa for a day or more.
After oral administration, the onset of the antisecretory effect of Adprazole occurs within one hour, with the maximum effect occurring within two hours. Inhibition of secretion is about 50% of maximum at 24 hours and the duration of inhibition lasts up to 72 hours. The antisecretory effect thus lasts far longer than would be expected from the very short (less than one hour) plasma half-life, apparently due to prolonged binding to the parietal H+/K+ ATPase enzyme. When the drug is discontinued, secretory activity returns gradually, over 3 to 5 days. The inhibitory effect of Adprazole on acid secretion increases with repeated once-daily dosing, reaching a plateau after four days.
Results from numerous studies of the antisecretory effect of multiple doses of 20 mg and 40 mg of Adprazole in normal volunteers and patients are shown below. The "max" value represents determinations at a time of maximum effect (2-6 hours after dosing), while "min" values are those 24 hours after the last dose of Adprazole.
Single daily oral doses of Adprazole ranging from a dose of 10 mg to 40 mg have produced 100% inhibition of 24-hour intragastric acidity in some patients.
Serum Gastric Effects
In studies involving more than 200 patients, serum gastrin levels increased during the first 1 to 2 weeks of once-daily administration of therapeutic doses of Adprazole in parallel with inhibition of acid secretion. No further increase in serum gastrin occurred with continued treatment. In comparison with histamine H2-receptor antagonists, the median increases produced by 20 mg doses of Adprazole were higher (1.3 to 3.6 fold vs. 1.1 to 1.8 fold increase). Gastrin values returned to pretreatment levels, usually within 1 to 2 weeks after discontinuation of therapy.
Enterochromaffin-like (ECL) Cell Effects
Human gastric biopsy specimens have been obtained from more than 3000 patients treated with Adprazole in long-term clinical trials. The incidence of ECL cell hyperplasia in these studies increased with time; however, no case of ECL cell carcinoids, dysplasia, or neoplasia has been found in these patients [see Clinical Pharmacology ( 12 )]. However, these studies are of insufficient duration and size to rule out the possible influence of long-term administration of Adprazole on the development of any premalignant or malignant conditions.
Systemic effects of Adprazole in the CNS, cardiovascular and respiratory systems have not been found to date. Adprazole, given in oral doses of 30 or 40 mg for 2 to 4 weeks, had no effect on thyroid function, carbohydrate metabolism, or circulating levels of parathyroid hormone, cortisol, estradiol, testosterone, prolactin, cholecystokinin or secretin.
No effect on gastric emptying of the solid and liquid components of a test meal was demonstrated after a single dose of Adprazole 90 mg. In healthy subjects, a single I.V. dose of Adprazole (0.35 mg/kg) had no effect on intrinsic factor secretion. No systematic dose-dependent effect has been observed on basal or stimulated pepsin output in humans.
However, when intragastric pH is maintained at 4.0 or above, basal pepsin output is low, and pepsin activity is decreased.
As do other agents that elevate intragastric pH, Adprazole administered for 14 days in healthy subjects produced a significant increase in the intragastric concentrations of viable bacteria. The pattern of the bacterial species was unchanged from that commonly found in saliva. All changes resolved within three days of stopping treatment.
The course of Barrett's esophagus in 106 patients was evaluated in a U.S. double-blind controlled study of Adprazole Delayed-Release Capsules 40 mg twice daily for 12 months followed by 20 mg twice daily for 12 months or ranitidine 300 mg twice daily for 24 months. No clinically significant impact on Barrett's mucosa by antisecretory therapy was observed. Although neosquamous epithelium developed during antisecretory therapy, complete elimination of Barrett's mucosa was not achieved. No significant difference was observed between treatment groups in development of dysplasia in Barrett's mucosa and no patient developed esophageal carcinoma during treatment. No significant differences between treatment groups were observed in development of ECL cell hyperplasia, corpus atrophic gastritis, corpus intestinal metaplasia, or colon polyps exceeding 3 mm in diameter [see Clinical Pharmacology ( 12 )].
Adprazole Delayed-Release Capsules contain an enteric-coated microtablet formulation of Adprazole, so that absorption of Adprazole begins only after the microtablets leave the stomach. Absorption is rapid, with peak plasma levels of Adprazole occurring within 0.5 to 3.5 hours. Peak plasma concentrations of Adprazole and AUC are approximately proportional to doses up to 40 mg, but because of a saturable first-pass effect, a greater than linear response in peak plasma concentration and AUC occurs with doses greater than 40 mg. Absolute bioavailability (compared with intravenous administration) is about 30-40% at doses of 20-40 mg, due in large part to presystemic metabolism. In healthy subjects the plasma half-life is 0.5 to 1 hour, and the total body clearance is 500-600 mL/min.
The bioavailability of Adprazole increases slightly upon repeated administration of Adprazole Delayed-Release Capsules.
Adprazole Delayed-Release Capsules 40 mg was bioequivalent when administered with and without applesauce. However, Adprazole Delayed-Release Capsules 20 mg was not bioequivalent when administered with and without applesauce. When administered with applesauce, a mean 25% reduction in Cmax was observed without a significant change in AUC for Adprazole Delayed-Release Capsules 20 mg. The clinical relevance of this finding is unknown.
Protein binding is approximately 95%.
Adprazole is extensively metabolized by the cytochrome P450 (CYP) enzyme system.
Following single dose oral administration of a buffered solution of Adprazole, little if any unchanged drug was excreted in urine. The majority of the dose (about 77%) was eliminated in urine as at least six metabolites. Two were identified as hydroxyomeprazole and the corresponding carboxylic acid. The remainder of the dose was recoverable in feces. This implies a significant biliary excretion of the metabolites of Adprazole. Three metabolites have been identified in plasma - the sulfide and sulfone derivatives of Adprazole, and hydroxyomeprazole. These metabolites have very little or no antisecretory activity.
Combination Therapy with Antimicrobials
Adprazole 40 mg daily was given in combination with clarithromycin 500 mg every 8 hours to healthy adult male subjects. The steady state plasma concentrations of Adprazole were increased (Cmax, AUC0-24, and T1/2 increases of 30%, 89% and 34% respectively) by the concomitant administration of clarithromycin. The observed increases in Adprazole plasma concentration were associated with the following pharmacological effects. The mean 24-hour gastric pH value was 5.2 when Adprazole was administered alone and 5.7 when co-administered with clarithromycin.
The plasma levels of clarithromycin and 14-hydroxy-clarithromycin were increased by the concomitant administration of Adprazole. For clarithromycin, the mean Cmax was 10% greater, the mean Cmin was 27% greater, and the mean AUC0-8 was 15% greater when clarithromycin was administered with Adprazole than when clarithromycin was administered alone. Similar results were seen for 14-hydroxy-clarithromycin, the mean Cmax was 45% greater, the mean Cmin was 57% greater, and the mean AUC0-8 was 45% greater. Clarithromycin concentrations in the gastric tissue and mucus were also increased by concomitant administration of Adprazole.
The elimination rate of Adprazole was somewhat decreased in the elderly, and bioavailability was increased. Adprazole was 76% bioavailable when a single 40 mg oral dose of Adprazole (buffered solution) was administered to healthy elderly volunteers, versus 58% in young volunteers given the same dose. Nearly 70% of the dose was recovered in urine as metabolites of Adprazole and no unchanged drug was detected. The plasma clearance of Adprazole was 250 mL/min (about half that of young volunteers) and its plasma half-life averaged one hour, about twice that of young healthy volunteers.
The pharmacokinetics of Adprazole have been investigated in pediatric patients 2 to 16 years of age
Following comparable mg/kg doses of Adprazole, younger children (2 to 5 years of age) have lower AUCs than children 6 to16 years of age or adults; AUCs of the latter two groups did not differ [see Dosage and Administration ( 2 )].
In patients with chronic hepatic disease, the bioavailability increased to approximately 100% compared with an I.V. dose, reflecting decreased first-pass effect, and the plasma half-life of the drug increased to nearly 3 hours compared with the half-life in normals of 0.5-1 hour. Plasma clearance averaged 70 mL/min, compared with a value of 500-600 mL/min in normal subjects. Dose reduction, particularly where maintenance of healing of erosive esophagitis is indicated, for the hepatically impaired should be considered.
In patients with chronic renal impairment, whose creatinine clearance ranged between 10 and 62 mL/min/1.73 m2, the disposition of Adprazole was very similar to that in healthy volunteers, although there was a slight increase in bioavailability. Because urinary excretion is a primary route of excretion of Adprazole metabolites, their elimination slowed in proportion to the decreased creatinine clearance. No dose reduction is necessary in patients with renal impairment.
In pharmacokinetic studies of single 20 mg Adprazole doses, an increase in AUC of approximately four-fold was noted in Asian subjects compared with Caucasians. Dose reduction, particularly where maintenance of healing of erosive esophagitis is indicated, for Asian subjects should be considered.
Adprazole and clarithromycin dual therapy and Adprazole, clarithromycin and amoxicillin triple therapy have been shown to be active against most strains of Helicobacter pylori in vitro and in clinical infections as described in the Indications and Usage section ( 1.1 ).
Helicobacter pylori- Pretreatment Resistance
Clarithromycin pretreatment resistance rates were 3.5% (4/113) in the omeprazole/clarithromycin dual therapy studies (4 and 5) and 9.3% (41/439) in omeprazole/clarithromycin/amoxicillin triple therapy studies (1, 2, and 3).
Amoxicillin pretreatment susceptible isolates (≤ 0.25 mcg/mL) were found in 99.3% (436/439) of the patients in the omeprazole/clarithromycin/amoxicillin triple therapy studies (1, 2, and 3). Amoxicillin pretreatment minimum inhibitory concentrations (MICs) > 0.25 mcg/mL occurred in 0.7% (3/439) of the patients, all of whom were in the clarithromycin and amoxicillin study arm. One patient had an unconfirmed pretreatment amoxicillin minimum inhibitory concentration (MIC) of > 256 mcg/mL by Etest®.
Patients not eradicated of H. pylori following omeprazole/clarithromycin/amoxicillin triple therapy or omeprazole/clarithromycin dual therapy will likely have clarithromycin resistant H. pylori isolates. Therefore, clarithromycin susceptibility testing should be done, if possible. Patients with clarithromycin resistant H. pylori should not be treated with any of the following: omeprazole/clarithromycin dual therapy, omeprazole/clarithromycin/amoxicillin triple therapy, or other regimens which include clarithromycin as the sole antimicrobial agent.
Amoxicillin Susceptibility Test Results and Clinical/Bacteriological Outcomes
In the triple therapy clinical trials, 84.9% (157/185) of the patients in the omeprazole/clarithromycin/amoxicillin treatment group who had pretreatment amoxicillin susceptible MICs (≤ 0.25 mcg/mL) were eradicated of H. pylori and 15.1% (28/185) failed therapy. Of the 28 patients who failed triple therapy, 11 had no post-treatment susceptibility test results and 17 had post-treatment H. pylori isolates with amoxicillin susceptible MICs. Eleven of the patients who failed triple therapy also had post-treatment H. pylori isolates with clarithromycin resistant MICs.
Susceptibility Test for Helicobacter pylori
The reference methodology for susceptibility testing of H. pylori is agar dilution MICs1. One to three microliters of an inoculum equivalent to a No. 2 McFarland standard (1 x 107 - 1 x 108 CFU/mL for H. pylori) are inoculated directly onto freshly prepared antimicrobial containing Mueller-Hinton agar plates with 5% aged defibrinated sheep blood (≥ 2 weeks old). The agar dilution plates are incubated at 35°C in a microaerobic environment produced by a gas generating system suitable for campylobacters. After 3 days of incubation, the MICs are recorded as the lowest concentration of antimicrobial agent required to inhibit growth of the organism. The clarithromycin and amoxicillin MIC values should be interpreted according to the following criteria:
Standardized susceptibility test procedures require the use of laboratory control microorganisms to control the technical aspects of the laboratory procedures. Standard clarithromycin and amoxicillin powders should provide the following MIC values:
Effects on Gastrointestinal Microbial Ecology
Decreased gastric acidity due to any means including proton pump inhibitors, increases gastric counts of bacteria normally present in the gastrointestinal tract. Treatment with proton pump inhibitors may lead to slightly increased risk of gastrointestinal infections such as Salmonella and Campylobacter and possibly Clostridium difficile in hospitalized patients.
13 NONCLINICAL TOXICOLOGY
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
In two 24-month carcinogenicity studies in rats, Adprazole at daily doses of 1.7, 3.4, 13.8, 44.0 and 140.8 mg/kg/day produced gastric ECL cell carcinoids in a dose-related manner in both male and female rats; the incidence of this effect was markedly higher in female rats, which had higher blood levels of Adprazole. Gastric carcinoids seldom occur in the untreated rat. In addition, ECL cell hyperplasia was present in all treated groups of both sexes. In one of these studies, female rats were treated with 13.8 mg omeprazole/kg/day (about 6 times a human dose of 20 mg/day, based on body surface area) for one year, and then followed for an additional year without the drug. No carcinoids were seen in these rats. An increased incidence of treatment-related ECL cell hyperplasia was observed at the end of one year (94% treated vs 10% controls). By the second year the difference between treated and control rats was much smaller (46% vs 26%) but still showed more hyperplasia in the treated group. Gastric adenocarcinoma was seen in one rat (2%). No similar tumor was seen in male or female rats treated for two years. For this strain of rat no similar tumor has been noted historically, but a finding involving only one tumor is difficult to interpret. In a 52-week toxicity study in Sprague-Dawley rats, brain astrocytomas were found in a small number of males that received Adprazole at dose levels of 0.4, 2, and 16 mg/kg/day (about 0.2 to 6.5 times the human dose on a body surface area basis). No astrocytomas were observed in female rats in this study. In a 2-year carcinogenicity study in Sprague-Dawley rats, no astrocytomas were found in males or females at the high dose of 140.8 mg/kg/day (about 57 times the human dose on a body surface area basis). A 78-week mouse carcinogenicity study of Adprazole did not show increased tumor occurrence, but the study was not conclusive. A 26-week p53 (+/-) transgenic mouse carcinogenicity study was not positive.
Adprazole was positive for clastogenic effects in an in vitro human lymphocyte chromosomal aberration assay, in one of two in vivo mouse micronucleus tests, and in an in vivo bone marrow cell chromosomal aberration assay. Adprazole was negative in the in vitro Ames test, an in vitro mouse lymphoma cell forward mutation assay, and an in vivo rat liver DNA damage assay.
Adprazole at oral doses up to 138 mg/kg/day in rats (about 56 times the human dose on a body surface area basis) was found to have no effect on fertility and reproductive performance.
In 24-month carcinogenicity studies in rats, a dose-related significant increase in gastric carcinoid tumors and ECL cell hyperplasia was observed in both male and female animals [see Warnings and Precautions (5)]. Carcinoid tumors have also been observed in rats subjected to fundectomy or long-term treatment with other proton pump inhibitors or high doses of H2-receptor antagonists.
13.2 Animal Toxicology and/or Pharmacology
Reproductive Toxicology Studies
Reproductive studies conducted with Adprazole in rats at oral doses up to 138 mg/kg/day (about 56 times the human dose on a body surface area basis) and in rabbits at doses up to 69 mg/kg/day (about 56 times the human dose on a body surface area basis) did not disclose any evidence for a teratogenic potential of Adprazole. In rabbits, Adprazole in a dose range of 6.9 to 69.1 mg/kg/day (about 5.5 to 56 times the human dose on a body surface area basis) produced dose-related increases in embryo-lethality, fetal resorptions, and pregnancy disruptions. In rats, dose-related embryo/fetal toxicity and postnatal developmental toxicity were observed in offspring resulting from parents treated with Adprazole at 13.8 to 138.0 mg/kg/day (about 5.6 to 56 times the human doses on a body surface area basis).
14 CLINICAL STUDIES
14.1 Duodenal Ulcer Disease
Active Duodenal Ulcer-In a multicenter, double-blind, placebo-controlled study of 147 patients with endoscopically documented duodenal ulcer, the percentage of patients healed at 2 and 4 weeks was significantly higher with Adprazole 20 mg once daily than with placebo (p ≤ 0.01).
Complete daytime and nighttime pain relief occurred significantly faster (p ≤ 0.01) in patients treated with Adprazole Delayed-Release Capsules 20 mg than in patients treated with placebo. At the end of the study, significantly more patients who had received Adprazole Delayed-Release Capsules had complete relief of daytime pain (p ≤ 0.05) and nighttime pain (p ≤ 0.01).
In a multicenter, double-blind study of 293 patients with endoscopically documented duodenal ulcer, the percentage of patients healed (per protocol) at 4 weeks was significantly higher with Adprazole Delayed-Release Capsules 20 mg once daily than with ranitidine 150 mg b.i.d. (p < 0.01).
Healing occurred significantly faster in patients treated with Adprazole Delayed-Release Capsules than in those treated with ranitidine 150 mg b.i.d. (p < 0.01).
In a foreign multinational randomized, double-blind study of 105 patients with endoscopically documented duodenal ulcer, 20 mg and 40 mg of Adprazole Delayed-Release Capsules were compared with 150 mg b.i.d. of ranitidine at 2, 4 and 8 weeks. At 2 and 4 weeks both doses of Adprazole Delayed-Release Capsules were statistically superior (per protocol) to ranitidine, but 40 mg was not superior to 20 mg of Adprazole Delayed-Release Capsules, and at 8 weeks there was no significant difference between any of the active drugs.
H. pylori Eradication in Patients with Duodenal Ulcer Disease
Triple Therapy (Omeprazole Delayed-Release Capsules/clarithromycin/amoxicillin)- Three U.S., randomized, double-blind clinical studies in patients with H. pylori infection and duodenal ulcer disease (n=558) compared Adprazole Delayed-Release Capsules plus clarithromycin plus amoxicillin with clarithromycin plus amoxicillin. Two studies (1 and 2) were conducted in patients with an active duodenal ulcer, and the other study (3) was conducted in patients with a history of a duodenal ulcer in the past 5 years but without an ulcer present at the time of enrollment. The dose regimen in the studies was Adprazole Delayed-Release Capsules 20 mg twice daily plus clarithromycin 500 mg twice daily plus amoxicillin 1 g twice daily for 10 days; or clarithromycin 500 mg twice daily, plus amoxicillin 1 g twice daily for 10 days. In studies 1 and 2, patients who took the Adprazole regimen also received an additional 18 days of Adprazole Delayed-Release Capsules 20 mg once daily. Endpoints studied were eradication of H. pylori and duodenal ulcer healing (studies 1 and 2 only). H. pylori status was determined by CLOtest®, histology and culture in all three studies. For a given patient, H. pylori was considered eradicated if at least two of these tests were negative, and none was positive.
The combination of Adprazole plus clarithromycin plus amoxicillin was effective in eradicating H. pylori.
Dual Therapy (Omeprazole Delayed-Release Capsules/clarithromycin)
Four randomized, double-blind, multi-center studies (4, 5, 6, and 7) evaluated Adprazole Delayed-Release Capsules 40 mg once daily plus clarithromycin 500 mg three times daily for 14 days, followed by Adprazole Delayed-Release Capsules 20 mg once daily, (studies 4, 5, and 7) or by Adprazole Delayed-Release Capsules 40 mg once daily (Study 6) for an additional 14 days in patients with active duodenal ulcer associated with H. pylori. Studies 4 and 5 were conducted in the U.S. and Canada and enrolled 242 and 256 patients, respectively. H. pylori infection and duodenal ulcer were confirmed in 219 patients in Study 4 and 228 patients in Study 5. These studies compared the combination regimen to Adprazole Delayed-Release Capsules and clarithromycin monotherapies. Studies 6 and 7 were conducted in Europe and enrolled 154 and 215 patients, respectively. H. pylori infection and duodenal ulcer were confirmed in 148 patients in study 6 and 208 patients in Study 7. These studies compared the combination regimen with Adprazole monotherapy. The results for the efficacy analyses for these studies are described below. H. pylori eradication was defined as no positive test (culture or histology) at 4 weeks following the end of treatment, and two negative tests were required to be considered eradicated of H. pylori. In the per-protocol analysis, the following patients were excluded: dropouts, patients with missing H. pylori tests post-treatment, and patients that were not assessed for H. pylori eradication because they were found to have an ulcer at the end of treatment.
The combination of Adprazole and clarithromycin was effective in eradicating H. pylori.
Ulcer healing was not significantly different when clarithromycin was added to Adprazole therapy compared with Adprazole therapy alone.
The combination of Adprazole and clarithromycin was effective in eradicating H. pylori and reduced duodenal ulcer recurrence.
14.2 Gastric Ulcer
In a U.S. multicenter, double-blind, study of Adprazole 40 mg once daily, 20 mg once daily, and placebo in 520 patients with endoscopically diagnosed gastric ulcer, the following results were obtained.
For the stratified groups of patients with ulcer size less than or equal to 1 cm, no difference in healing rates between 40 mg and 20 mg was detected at either 4 or 8 weeks. For patients with ulcer size greater than 1 cm, 40 mg was significantly more effective than 20 mg at 8 weeks.
In a foreign, multinational, double-blind study of 602 patients with endoscopically diagnosed gastric ulcer, Adprazole 40 mg once daily, 20 mg once daily, and ranitidine 150 mg twice a day were evaluated.
14.3 Gastroesophageal Reflux Disease
A placebo-controlled study was conducted in Scandinavia to compare the efficacy of Adprazole 20 mg or 10 mg once daily for up to 4 weeks in the treatment of heartburn and other symptoms in GERD patients without erosive esophagitis.
Results are shown below.
14.4 Erosive Esophagitis
In a U.S. multicenter double-blind placebo controlled study of 20 mg or 40 mg of Adprazole Delayed-Release Capsules in patients with symptoms of GERD and endoscopically diagnosed erosive esophagitis of grade 2 or above, the percentage healing rates were as follows:
In this study, the 40 mg dose was not superior to the 20 mg dose of Adprazole Delayed-Release Capsules in the percentage healing rate. Other controlled clinical trials have also shown that Adprazole Delayed-Release Capsules are effective in severe GERD. In comparisons with histamine H2-receptor antagonists in patients with erosive esophagitis, grade 2 or above, Adprazole Delayed-Release Capsules in a dose of 20 mg was significantly more effective than the active controls. Complete daytime and nighttime heartburn relief occurred significantly faster (p < 0.01) in patients treated with Adprazole Delayed-Release Capsules than in those taking placebo or histamine H2- receptor antagonists.
In this and five other controlled GERD studies, significantly more patients taking 20 mg Adprazole (84%) reported complete relief of GERD symptoms than patients receiving placebo (12%).
Long Term Maintenance Of Healing of Erosive Esophagitis
In a U.S. double-blind, randomized, multicenter, placebo controlled study, two dose regimens of Adprazole Delayed-Release Capsules were studied in patients with endoscopically confirmed healed esophagitis. Results to determine maintenance of healing of erosive esophagitis are shown below.
In an international multicenter double-blind study, Adprazole Delayed-Release Capsules 20 mg daily and 10 mg daily were compared with ranitidine 150 mg twice daily in patients with endoscopically confirmed healed esophagitis. The table below provides the results of this study for maintenance of healing of erosive esophagitis.
In patients who initially had grades 3 or 4 erosive esophagitis, for maintenance after healing, 20 mg daily of Adprazole was effective, while 10 mg did not demonstrate effectiveness.
14.5 Pathological Hypersecretory Conditions
In open studies of 136 patients with pathological hypersecretory conditions, such as Zollinger-Ellison (ZE) syndrome with or without multiple endocrine adenomas, Adprazole Delayed-Release Capsules significantly inhibited gastric acid secretion and controlled associated symptoms of diarrhea, anorexia, and pain. Doses ranging from 20 mg every other day to 360 mg per day maintained basal acid secretion below 10 mEq/hr in patients without prior gastric surgery, and below 5 mEq/hr in patients with prior gastric surgery.
Initial doses were titrated to the individual patient need, and adjustments were necessary with time in some patients see Dosage and Administration ( 2 )]. Adprazole Delayed-Release Capsules were well tolerated at these high dose levels for prolonged periods (> 5 years in some patients). In most ZE patients, serum gastrin levels were not modified by Adprazole Delayed-Release Capsules. However, in some patients serum gastrin increased to levels greater than those present prior to initiation of Adprazole therapy. At least 11 patients with ZE syndrome on long-term treatment with Adprazole Delayed-Release Capsules developed gastric carcinoids. These findings are believed to be a manifestation of the underlying condition, which is known to be associated with such tumors, rather than the result of the administration of Adprazole Delayed-Release Capsules [see Adverse Reactions ( 6 )].
14.6 Pediatric GERD
The effectiveness of Adprazole Delayed-Release Capsules for the treatment of nonerosive GERD in pediatric patients 1 to 16 years of age is based in part on data obtained from pediatric patients in an uncontrolled Phase III study [see Use in Specific Populations ( 8.4 )].
The study enrolled 113 pediatric patients 2 to 16 years of age with a history of symptoms suggestive of nonerosive GERD. Patients were administered a single dose of Adprazole (10 mg or 20 mg, based on body weight) for 4 weeks either as an intact capsule or as an open capsule in applesauce. Successful response was defined as no moderate or severe episodes of either pain-related symptoms or vomiting/regurgitation during the last 4 days of treatment. Results showed success rates of 60% (9/15; 10 mg Adprazole) and 59% (58/98; 20 mg Adprazole), respectively.
Healing of Erosive Esophagitis
In an uncontrolled, open-label dose-titration study, healing of erosive esophagitis in pediatric patients 2 to 16 years of age required doses that ranged from 0.7 to 3.5 mg/kg/day (80 mg/day). Doses were initiated at 0.7 mg/kg/day. Doses were increased in increments of 0.7 mg/kg/day (if intraesophageal pH showed a pH of < 4 for less than 6% of a 24-hour study). After titration, patients remained on treatment for 3 months. Forty-four percent of the patients were healed on a dose of 0.7 mg/kg body weight; most of the remaining patients were healed with 1.4 mg/kg after an additional 3 months' treatment. Erosive esophagitis was healed in 51 of 57 (90%) children who completed the first course of treatment in the healing phase of the study. In addition, after 3 months of treatment, 33% of the children had no overall symptoms, 57% had mild reflux symptoms, and 40% had less frequent regurgitation/vomiting.
Maintenance of Healing of Erosive Esophagitis
In an uncontrolled, open-label study of maintenance of healing of erosive esophagitis in 46 pediatric patients, 54% of patients required half the healing dose. The remaining patients increased the healing dose (0.7 to a maximum of 2.8 mg/kg/day) either for the entire maintenance period, or returned to half the dose before completion. Of the 46 patients who entered the maintenance phase, 19 (41%) had no relapse. In addition, maintenance therapy in erosive esophagitis patients resulted in 63% of patients having no overall symptoms.
1. National Committee for Clinical Laboratory Standards. Methods for Dilution Antimicrobial Susceptibility Tests for Bacteria That Grow Aerobically-Fifth Edition. Approved Standard NCCLS Document M7-A5, Vol, 20, No. 2, NCCLS, Wayne, PA, January 2000.
16 HOW SUPPLIED/STORAGE AND HANDLING
Adprazole Delayed-Release Capsules, 10 mg, are opaque white cap and opaque white body capsules imprinted with "KU" and "114" in black ink. They are supplied as follows:
Bottles of 30 NDC 62175-114-32
Bottles of 100 NDC 62175-114-37
Adprazole Delayed-Release Capsules, 20 mg, are opaque white cap and opaque gold body capsules imprinted with "KU" and "118" in black ink. They are supplied as follows:
Bottles of 30 NDC 62175-118-32
Bottles of 100 NDC 62175-118-37
Bottles of 1000 NDC 62175-118-43
Adprazole Delayed-Release Capsules, 40 mg, are opaque gold cap and opaque gold body capsules imprinted with "KU" and "136" in black ink. They are supplied as follows:
Bottles of 30 NDC 62175-136-32
Bottles of 100 NDC 62175-136-37
Bottles of 1000 NDC 62175-136-43
Store Adprazole Delayed-Release Capsules in a tight container protected from light and moisture. Store at 20°-25°C (68°-77°F).
Dispense in a tight and light-resistant container.
17 PATIENT COUNSELING INFORMATION
Adprazole Delayed-Release Capsule should be taken before eating. Patients should be informed that the Adprazole Delayed-Release Capsule should be swallowed whole.
For patients who have difficulty swallowing capsules, the contents of an Adprazole Delayed-Release Capsule can be added to applesauce. One tablespoon of applesauce should be added to an empty bowl and the capsule should be opened. All of the microtablets inside the capsule should be carefully emptied on the applesauce. The microtablets should be mixed with the applesauce and then swallowed immediately with a glass of cool water to ensure complete swallowing of the microtablets. The applesauce used should not be hot and should be soft enough to be swallowed without chewing. The microtablets should not be chewed or crushed. The microtablets/applesauce mixture should not be stored for future use.
Advise patients to immediately report and seek care for any cardiovascular or neurological symptoms including palpitations, dizziness, seizures, and tetany as these may be signs of hypomagnesemia [see Warnings and Precautions (5.7) ].
Kremers Urban, Pharmaceuticals Inc.
Princeton, NJ 08540, USA
Revised: 9E 07/2011
Adprazole Delayed-Release Capsules
Read the patient information that comes with Adprazole Delayed-Release Capsules before you start taking it and each time you get a refill. There may be new information. This leaflet does not take the place of talking with your doctor about your medical condition or your treatment.
If you have any questions about Adprazole Delayed-Release Capsules, ask your doctor.
WHAT ARE Adprazole DELAYED-RELEASE CAPSULES?
Adprazole Delayed-Release Capsules are a prescription medicine called a proton pump inhibitor (PPI). Adprazole Delayed-Release Capsules reduce the amount of acid in your stomach. Adprazole Delayed-Release Capsules are used in adults:
For children and adolescents 2 to 17 years of age, Adprazole Delayed-Release Capsules are used:
Adprazole Delayed-Release Capsules are not recommended for children under the age of 2 years Adprazole Delayed-Release Capsules may help your acid-related symptoms, but you could still have serious stomach problems. Talk with your doctor.
WHO SHOULD NOT TAKE Adprazole DELAYED-RELEASE CAPSULES?
Do not take Adprazole Delayed-Release Capsules if you:
WHAT SHOULD I TELL MY DOCTOR BEFORE TAKING Adprazole DELAYED-RELEASE CAPSULES?
Tell your doctor about all your medical conditions, including if you:
Tell your doctor about all of the medicines you take including prescription and non-prescription drugs, vitamins and herbal supplements. Adprazole Delayed-Release Capsules may affect how other medicines work, and other medicines may affect how Adprazole Delayed-Release Capsules works. Especially tell your doctor if you take:
HOW SHOULD I TAKE Adprazole DELAYED-RELEASE CAPSULES?
WHAT ARE THE POSSIBLE SIDE EFFECTS OF Adprazole DELAYED-RELEASE CAPSULES?
Your doctor may stop Adprazole Delayed-Release Capsules if these symptoms happen.
Tell your doctor right away if you have any of these symptoms;
Your doctor may check the level of magnesium in your body before you start taking Adprazole Delayed-Release Capsules or during treatment if you will be taking Adprazole Delayed-Release Capsules for a long period of time.
The most common side effects with Adprazole Delayed-Release Capsules in adults and children include:
People who are taking multiple daily doses of proton pump inhibitor medicines for a long period of time may have an increased risk of fractures of the hip, wrist or spine.
Tell your doctor about any side effects that bother you or that do not go away. These are not all the possible side effects with Adprazole Delayed-Release Capsules. Talk with your doctor or pharmacist if you have any questions about side effects. You may report side effects to the FDA at 1-800-FDA-1088.
HOW SHOULD I STORE Adprazole DELAYED-RELEASE CAPSULES?
Store Adprazole Delayed-Release Capsules at 68°F to 77°F (20°C to 25°C).
Keep the container of Adprazole Delayed-Release Capsules closed tightly.
Keep Adprazole Delayed-Release Capsules and all medicines out of the reach of children.
Medicines are sometimes prescribed for purposes other than those listed in the Patient Information leaflet. Do not use Adprazole Delayed-Release Capsules for a condition for which it was not prescribed. Do not give Adprazole Delayed-Release Capsules to other people, even if they have the same symptoms you have. It may harm them.
This Patient Information leaflet provides a summary of the most important information about Adprazole Delayed-Release Capsules. For more information, ask your doctor. You can ask your doctor or pharmacist for information that is written for healthcare professionals. For more information, go to www. kremersurban.com or call toll free 1-866-822-0068.
PATIENT INSTRUCTIONS FOR USE
For instructions on taking Delayed-Release Capsules, please see "HOW SHOULD I TAKE Adprazole DELAYED-RELEASE CAPSULES?"
WHAT ARE THE INGREDIENTS IN Adprazole DELAYED-RELEASE CAPSULES?
Active ingredient in Adprazole DELAYED-RELEASE CAPSULES:
Inactive ingredients in Adprazole DELAYED-RELEASE CAPSULES:
(including the capsule shells): crospovidone, glyceryl behenate, hypromellose, lactose monohydrate, methacrylic acid copolymer dispersion, silicon dioxide, talc, titanium dioxide and triethyl citrate. In addition, the capsule shells contain gelatin and may contain sodium lauryl sulfate. In addition, the 20 mg and 40 mg capsule shells also contain yellow iron oxide. The imprinting ink also contains ammonium hydroxide, butyl alcohol, black iron oxide, isopropyl alcohol, propylene glycol and shellac glaze. The ink may also contain dehydrated alcohol.
Kremers Urban Pharmaceuticals Inc.
Princeton, NJ 08540, USA
Revised: 9E 07/2011
Adprazole pharmaceutical active ingredients containing related brand and generic drugs:
Active ingredient is the part of the drug or medicine which is biologically active. This portion of the drug is responsible for the main action of the drug which is intended to cure or reduce the symptom or disease. The other portions of the drug which are inactive are called excipients; there role is to act as vehicle or binder. In contrast to active ingredient, the inactive ingredient's role is not significant in the cure or treatment of the disease. There can be one or more active ingredients in a drug.
Adprazole available forms, composition, doses:
Form of the medicine is the form in which the medicine is marketed in the market, for example, a medicine X can be in the form of capsule or the form of chewable tablet or the form of tablet. Sometimes same medicine can be available as injection form. Each medicine cannot be in all forms but can be marketed in 1, 2, or 3 forms which the pharmaceutical company decided based on various background research results.
Composition is the list of ingredients which combinedly form a medicine. Both active ingredients and inactive ingredients form the composition. The active ingredient gives the desired therapeutic effect whereas the inactive ingredient helps in making the medicine stable.
Doses are various strengths of the medicine like 10mg, 20mg, 30mg and so on. Each medicine comes in various doses which is decided by the manufacturer, that is, pharmaceutical company. The dose is decided on the severity of the symptom or disease.
Adprazole destination | category:
Destination is defined as the organism to which the drug or medicine is targeted. For most of the drugs what we discuss, human is the drug destination.
Drug category can be defined as major classification of the drug. For example, an antihistaminic or an antipyretic or anti anginal or pain killer, anti-inflammatory or so.
Adprazole Anatomical Therapeutic Chemical codes:
A medicine is classified depending on the organ or system it acts [Anatomical], based on what result it gives on what disease, symptom [Therapeutical], based on chemical composition [Chemical]. It is called as ATC code. The code is based on Active ingredients of the medicine. A medicine can have different codes as sometimes it acts on different organs for different indications. Same way, different brands with same active ingredients and same indications can have same ATC code.
Adprazole pharmaceutical companies:
Pharmaceutical companies are drug manufacturing companies that help in complete development of the drug from the background research to formation, clinical trials, release of the drug into the market and marketing of the drug.
Researchers are the persons who are responsible for the scientific research and is responsible for all the background clinical trials that resulted in the development of the drug.
Frequently asked QuestionsCan i drive or operate heavy machine after consuming Adprazole?
Depending on the reaction of the Adprazole after taken, if you are feeling dizziness, drowsiness or any weakness as a reaction on your body, Then consider Adprazole not safe to drive or operate heavy machine after consumption. Meaning that, do not drive or operate heavy duty machines after taking the capsule if the capsule has a strange reaction on your body like dizziness, drowsiness. As prescribed by a pharmacist, it is dangerous to take alcohol while taking medicines as it exposed patients to drowsiness and health risk. Please take note of such effect most especially when taking Primosa capsule. It's advisable to consult your doctor on time for a proper recommendation and medical consultations.Is Adprazole addictive or habit forming?
Medicines are not designed with the mind of creating an addiction or abuse on the health of the users. Addictive Medicine is categorically called Controlled substances by the government. For instance, Schedule H or X in India and schedule II-V in the US are controlled substances.
Please consult the medicine instruction manual on how to use and ensure it is not a controlled substance.In conclusion, self medication is a killer to your health. Consult your doctor for a proper prescription, recommendation, and guidiance.
ReviewsDrugs.com conducted a study on Adprazole, and the result of the survey is set out below. It is noteworthy that the product of the survey is based on the perception and impressions of the visitors of the website as well as the views of Adprazole consumers. We, as a result of this, advice that you do not base your therapeutic or medical decisions on this result, but rather consult your certified medical experts for their recommendations.
One visitor reported administrationThe drugs are administered in various routes, like oral or injection form. They are administered before food or after food. How are you taking Adprazole drug, before food or after food?
Click here to find out how other users of our website are taking it. For any doubts or queries on how and when the medicine is administered, contact your health care provider immediately.
One visitor reported age
The information was verified by Dr. Arunabha Ray, MD Pharmacology