Nuelin

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Nuelin uses


DESCRIPTION

Nuelin® (theophylline, anhydrous) Tablets in a controlled-release system allows a 24-hour dosing interval for appropriate patients.

Nuelin is structurally classified as a methylxanthine. It occurs as a white, odorless, crystalline powder with a bitter taste. Anhydrous Nuelin has the chemical name 1H-Purine-2,6-dione, 3,7-dihydro-1,3-dimethyl-, and is represented by the following structural formula:

The molecular formula of anhydrous Nuelin is C7H8N4O2 with a molecular weight of 180.17.

Each controlled-release tablet for oral administration, contains 400 or 600 mg of anhydrous Nuelin.

Inactive Ingredients: cetostearyl alcohol, hydroxyethyl cellulose, magnesium stearate, povidone and talc.

Nuelin 400 mg

CLINICAL PHARMACOLOGY

Mechanism of Action

Nuelin has two distinct actions in the airways of patients with reversible obstruction; smooth muscle relaxation and suppression of the response of the airways to stimuli (i.e., non-bronchodilator prophylactic effects). While the mechanisms of action of Nuelin are not known with certainty, studies in animals suggest that bronchodilatation is mediated by the inhibition of two isozymes of phosphodiesterase (PDE III and, to a lesser extent, PDE IV) while non-bronchodilator prophylactic actions are probably mediated through one or more different molecular mechanisms, that do not involve inhibition of PDE III or antagonism of adenosine receptors. Some of the adverse effects associated with Nuelin appear to be mediated by inhibition of PDE III (e.g., hypotension, tachycardia, headache, and emesis) and adenosine receptor antagonism (e.g., alterations in cerebral blood flow).

Nuelin increases the force of contraction of diaphragmatic muscles. This action appears to be due to enhancement of calcium uptake through an adenosine-mediated channel.

Serum Concentration-Effect Relationship

Bronchodilation occurs over the serum Nuelin concentration range of 5-20 mcg/mL. Clinically important improvement in symptom control has been found in most studies to require peak serum Nuelin concentrations >10 mcg/mL, but patients with mild disease may benefit from lower concentrations. At serum Nuelin concentrations >20 mcg/mL, both the frequency and severity of adverse reactions increase. In general, maintaining peak serum Nuelin concentrations between 10 and 15 mcg/mL will achieve most of the drug’s potential therapeutic benefit while minimizing the risk of serious adverse events.

Pharmacokinetics

Overview: Nuelin is rapidly and completely absorbed after oral administration in solution or immediate-release solid oral dosage form. Nuelin does not undergo any appreciable pre-systemic elimination, distributes freely into fat-free tissues and is extensively metabolized in the liver.

The pharmacokinetics of Nuelin vary widely among similar patients and cannot be predicted by age, sex, body weight or other demographic characteristics. In addition, certain concurrent illnesses and alterations in normal physiology and co-administration of other drugs (see Table II ) can significantly alter the pharmacokinetic characteristics of Nuelin. Within-subject variability in metabolism has also been reported in some studies, especially in acutely ill patients. It is, therefore, recommended that serum Nuelin concentrations be measured frequently in acutely ill patients (e.g., at 24-hr intervals) and periodically in patients receiving long-term therapy, e.g., at 6-12 month intervals. More frequent measurements should be made in the presence of any condition that may significantly alter Nuelin clearance (see PRECAUTIONS, Laboratory Tests ).

Population Characteristics Total body clearance*

mean (range)††

(mL/kg/min)

Half-life mean (range)††

(hr)

For various North American patient populations from literature reports. Different rates of elimination and consequent dosage requirements have been observed among other peoples.
*Clearance represents the volume of blood completely cleared of Nuelin by the liver in one minute. Values listed were generally determined at serum Nuelin concentrations <20 mcg/mL; clearance may decrease and half-life may increase at higher serum concentrations due to non-linear pharmacokinetics.
††Reported range or estimated range (mean ±2 SD) where actual range not reported.
†NR=not reported or not reported in a comparable format.
**Median
Age
Premature neonates
postnatal age 3-15 days 0.29 (0.09-0.49) 30 (17-43)
postnatal age 25-57 days 0.64 (0.04-1.2) 20 (9.4-30.6)
Term infants
postnatal age 1-2 days NR 25.7 (25-26.5)
postnatal age 3-30 weeks NR 11 (6-29)
Children
1-4 years 1.7 (0.5-2.9) 3.4 (1.2-5.6)
4-12 years 1.6 (0.8-2.4) NR
13-15 years 0.9 (0.48-1.3) NR
6-17 years 1.4 (0.2-2.6) 3.7 (1.5-5.9)
Adults (16-60 years)
otherwise healthy
non-smoking asthmatics 0.65 (0.27-1.03) 8.7 (6.1-12.8)
Elderly (>60 years)
non-smokers with normal

cardiac,

liver, and renal function

0.41 (0.21-0.61) 9.8 (1.6-18)
Concurrent illness or altered physiological state
Acute pulmonary edema 0.33** (0.07-2.45) 19** (3.1-82)
COPD->60 years, stable
non-smoker >1 year 0.54 (0.44-0.64) 11 (9.4-12.6)
COPD with cor pulmonale 0.48 (0.08-0.88) NR
Cystic fibrosis (14-28 years) 1.25 (0.31-2.2) 6.0 (1.8-10.2)
Fever associated with
acute viral respiratory illness
(children 9-15 years) NR 7.0 (1.0-13)
Liver disease
cirrhosis 0.31** (0.1-0.7) 32** (10-56)
acute hepatitis 0.35 (0.25-0.45) 19.2 (16.6-21.8)
cholestasis 0.65 (0.25-1.45) 14.4 (5.7-31.8)
Pregnancy
1st trimester NR 8.5 (3.1-13.9)
2nd trimester NR 8.8 (3.8-13.8)
3rd trimester NR 13.0 (8.4-17.6)
Sepsis with multi-organ failure 0.47 (0.19-1.9) 18.8 (6.3-24.1)
Thyroid disease
hypothyroid 0.38 (0.13-0.57) 11.6 (8.2-25)
hyperthyroid 0.8 (0.68-0.97) 4.5 (3.7-5.6)

Note: In addition to the factors listed above, Nuelin clearance is increased and half-life decreased by low carbohydrate/high protein diets, parenteral nutrition, and daily consumption of charcoal-broiled beef. A high carbohydrate/low protein diet can decrease the clearance and prolong the half-life of Nuelin.

Absorption

Nuelin® administered in the fed state is completely absorbed after oral administration.

In a single-dose crossover study, two 400 mg Nuelin Tablets were administered to 19 normal volunteers in the morning or evening immediately following the same standardized meal (769 calories consisting of 97 grams carbohydrates, 33 grams protein and 27 grams fat). There was no evidence of dose dumping nor were there any significant differences in pharmacokinetic parameters attributable to time of drug administration. On the morning arm, the pharmacokinetic parameters were AUC=241.9±83.0 mcg hr/mL, Cmax=9.3±2.0 mcg/mL, Tmax=12.8±4.2 hours. On the evening arm, the pharmacokinetic parameters were AUC=219.7±83.0 mcg hr/mL, Cmax=9.2±2.0 mcg/mL, Tmax=12.5±4.2 hours.

A study in which Nuelin 400 mg Tablets were administered to 17 fed adult asthmatics produced similar Nuelin level-time curves when administered in the morning or evening. Serum levels were generally higher in the evening regimen but there were no statistically significant differences between the two regimens.

MORNING EVENING
AUC (0-24 hrs) (mcg hr/mL) 236.0±76.7 256.0±80.4
Cmax (mcg/mL) 14.5±4.1 16.3±4.5
Cmin (mcg/mL) 5.5±2.9 5.0±2.5
Tmax (hours) 8.1±3.7 10.1±4.1

A single-dose study in 15 normal fasting male volunteers whose Nuelin inherent mean elimination half-life was verified by a liquid Nuelin product to be 6.9±2.5 (SD) hours were administered two or three 400 mg Nuelin® Tablets. The relative bioavailability of Nuelin given in the fasting state in comparison to an immediate-release product was 59%. Peak serum Nuelin levels occurred at 6.9±5.2 (SD) hours, with a normalized (to 800 mg) peak level being 6.2±2.1 (SD). The apparent elimination half-life for the 400 mg Nuelin Tablets was 17.2±5.8 (SD) hours.

Steady-state pharmacokinetics were determined in a study in 12 fasted patients with chronic reversible obstructive pulmonary disease. All were dosed with two 400 mg Nuelin Tablets given once daily in the morning and a reference controlled-release BID product administered as two 200 mg tablets given 12 hours apart. The pharmacokinetic parameters obtained for Nuelin Tablets given at doses of 800 mg once daily in the morning were virtually identical to the corresponding parameters for the reference drug when given as 400 mg BID. In particular, the AUC, Cmax and Cmin values obtained in this study were as follows:

Nuelin Tablets

800 mg

Q24h±SD

Reference Drug

400 mg

Q12h±SD

AUC, (0-24 hours), mcg hr/mL 288.9±21.5 283.5±38.4
Cmax, mcg/mL 15.7±2.8 15.2±2.1
Cmin, mcg/mL 7.9±1.6 7.8±1.7
Cmax-Cmin diff. 7.7±1.5 7.4±1.5

Single-dose studies in which subjects were fasted for twelve (12) hours prior to and an additional four (4) hours following dosing, demonstrated reduced bioavailability as compared to dosing with food. One single-dose study in 20 normal volunteers dosed with two (2) 400 mg tablets in the morning, compared dosing under these fasting conditions with dosing immediately prior to a standardized breakfast (769 calories, consisting of 97 grams carbohydrates, 33 grams protein and 27 grams fat). Under fed conditions, the pharmacokinetic parameters were: AUC=231.7±92.4 mcg hr/mL, Cmax=8.4±2.6 mcg/mL, Tmax=17.3±6.7 hours. Under fasting conditions, these parameters were AUC=141.2±6.53 mcg hr/mL, Cmax=5.5±1.5 mcg/mL, Tmax=6.5±2.1 hours.

Another single-dose study in 21 normal male volunteers, dosed in the evening, compared fasting to a standardized high calorie, high fat meal (870-1,020 calories, consisting of 33 grams protein, 55-75 grams fat, 58 grams carbohydrates). In the fasting arm subjects received one Nuelin® 400 mg Tablet at 8 p.m. after an eight hour fast followed by a further four hour fast. In the fed arm, subjects were again dosed with one 400 mg Nuelin Tablet, but at 8 p.m. immediately after the high fat content standardized meal cited above. The pharmacokinetic parameters (normalized to 800 mg) fed were AUC=221.8±40.9 mcg hr/mL, Cmax=10.9±1.7 mcg/mL, Tmax=11.8±2.2 hours. In the fasting arm, the pharmacokinetic parameters (normalized to 800 mg) were AUC=146.4±40.9 mcg hr/mL, Cmax=6.7±1.7 mcg/mL, Tmax=7.3±2.2 hours.

Thus, administration of single Nuelin doses to healthy normal volunteers, under prolonged fasted conditions (at least 10 hour overnight fast before dosing followed by an additional four (4) hour fast after dosing) results in decreased bioavailability. However, there was no failure of this delivery system leading to a sudden and unexpected release of a large quantity of Nuelin with Nuelin Tablets even when they are administered with a high fat, high calorie meal.

Similar studies were conducted with the 600 mg Nuelin Tablet. A single-dose study in 24 subjects with an established Nuelin clearance of ≤4 L/hr, compared the pharmacokinetic evaluation of one 600 mg Nuelin Tablet and one and one-half 400 mg Nuelin Tablets under fed (using a standard high fat diet) and fasted conditions. The results of this 4-way randomized crossover study demonstrate the bioequivalence of the 400 mg and 600 mg Nuelin Tablets. Under fed conditions, the pharmacokinetic results for the one and one-half 400 mg tablets were AUC=214.64±55.88 mcg hr/mL, Cmax=10.58±2.21 mcg/mL and Tmax=9.00±2.64 hours, and for the 600 mg tablet were AUC=207.85±48.9 mcg hr/mL, Cmax=10.39±1.91 mcg/mL and Tmax=9.58±1.86 hours. Under fasted conditions the pharmacokinetic results for the one and one-half 400 mg tablets were AUC=191.85 ±51.1 mcg hr/mL, Cmax= 7.37±1.83 mcg/mL and Tmax=8.08±4.39 hours; and for the 600 mg tablet were AUC=199.39±70.27 mcg hr/mL, Cmax=7.66±2.09 mcg/mL and Tmax=9.67±4.89 hours.

In this study the mean fed/fasted ratios for the one and one-half 400 mg tablets and the 600 mg tablet were about 112% and 104%, respectively.

In another study, the bioavailability of the 600 mg Nuelin Tablet was examined with morning and evening administration. This single-dose, crossover study in 22 healthy males was conducted under fed (standard high fat diet) conditions. The results demonstrated no clinically significant difference in the bioavailability of the 600 mg Nuelin Tablet administered in the morning or in the evening. The results were: AUC=233.6±45.1 mcg hr/mL, Cmax=10.6±1.3 mcg/mL and Tmax=12.5±3.2 hours with morning dosing; AUC=209.8±46.2 mcg hr/mL, Cmax=9.7±1.4 mcg/mL and Tmax=13.7±3.3 hours with evening dosing. The PM/AM ratio was 89.3%.

The absorption characteristics of Nuelin® Tablets (theophylline, anhydrous) have been extensively studied. A steady-state crossover bioavailability study in 22 normal males compared two Nuelin 400 mg Tablets administered q24h at 8 a.m. immediately after breakfast with a reference controlled-release Nuelin product administered BID in fed subjects at 8 a.m. immediately after breakfast and 8 p.m. immediately after dinner (769 calories, consisting of 97 grams carbohydrates, 33 grams protein and 27 grams fat).

The pharmacokinetic parameters for Nuelin 400 mg Tablets under these steady-state conditions were AUC=203.3±87.1 mcg hr/mL, Cmax=12.1±3.8 mcg/mL, Cmin=4.50±3.6, Tmax=8.8±4.6 hours. For the reference BID product, the pharmacokinetic parameters were AUC=219.2±88.4 mcg hr/mL, Cmax =11.0±4.1 mcg/mL, Cmin=7.28±3.5, Tmax=6.9±3.4 hours. The mean percent fluctuation [(Cmax-Cmin/Cmin)x100]=169% for the once-daily regimen and 51% for the reference product BID regimen.

The bioavailability of the 600 mg Nuelin Tablet was further evaluated in a multiple dose, steady-state study in 26 healthy males comparing the 600 mg Tablet to one and one-half 400 mg Nuelin Tablets. All subjects had previously established Nuelin clearances of ≤4 L/hr and were dosed once-daily for 6 days under fed conditions. The results showed no clinically significant difference between the 600 mg and one and one-half 400 mg Nuelin Tablet regimens. Steady-state results were:

600 MG TABLET

FED

600 MG

(ONE+ONE-HALF

400 MG TABLETS)

FED

AUC 0-24hrs (mcg hr/mL) 209.77±51.04 212.32±56.29
Cmax (mcg/mL) 12.91±2.46 13.17±3.11
Cmin (mcg/mL) 5.52±1.79 5.39±1.95
Tmax (hours) 8.62±3.21 7.23±2.35
Percent Fluctuation 183.73±54.02 179.72±28.86

The bioavailability ratio for the 600/400 mg tablets was 98.8%. Thus, under all study conditions the 600 mg tablet is bioequivalent to one and one-half 400 mg tablets.

Studies demonstrate that as long as subjects were either consistently fed or consistently fasted, there is similar bioavailability with once-daily administration of Nuelin Tablets whether dosed in the morning or evening.

Distribution

Once Nuelin enters the systemic circulation, about 40% is bound to plasma protein, primarily albumin. Unbound Nuelin distributes throughout body water, but distributes poorly into body fat. The apparent volume of distribution of Nuelin is approximately 0.45 L/kg based on ideal body weight. Nuelin passes freely across the placenta, into breast milk and into the cerebrospinal fluid (CSF). Saliva Nuelin concentrations approximate unbound serum concentrations, but are not reliable for routine or therapeutic monitoring unless special techniques are used. An increase in the volume of distribution of Nuelin, primarily due to reduction in plasma protein binding, occurs in premature neonates, patients with hepatic cirrhosis, uncorrected acidemia, the elderly and in women during the third trimester of pregnancy. In such cases, the patient may show signs of toxicity at total (bound+unbound) serum concentrations of Nuelin in the therapeutic range (10-20 mcg/mL) due to elevated concentrations of the pharmacologically active unbound drug. Similarly, a patient with decreased Nuelin binding may have a sub-therapeutic total drug concentration while the pharmacologically active unbound concentration is in the therapeutic range. If only total serum Nuelin concentration is measured, this may lead to an unnecessary and potentially dangerous dose increase. In patients with reduced protein binding, measurement of unbound serum Nuelin concentration provides a more reliable means of dosage adjustment than measurement of total serum Nuelin concentration. Generally, concentrations of unbound Nuelin should be maintained in the range of 6-12 mcg/mL.

Metabolism

Following oral dosing, Nuelin does not undergo any measurable first-pass elimination. In adults and children beyond one year of age, approximately 90% of the dose is metabolized in the liver. Biotransformation takes place through demethylation to 1-methylxanthine and 3-methylxanthine and hydroxylation to 1,3-dimethyluric acid. 1-methylxanthine is further hydroxylated, by xanthine oxidase, to 1-methyluric acid. About 6% of a Nuelin dose is N-methylated to caffeine. Nuelin demethylation to 3-methylxanthine is catalyzed by cytochrome P-450 1A2, while cytochromes P-450 2E1 and P-450 3A3 catalyze the hydroxylation to 1,3-dimethyluric acid. Demethylation to 1-methylxanthine appears to be catalyzed either by cytochrome P-450 1A2 or a closely related cytochrome. In neonates, the N-demethylation pathway is absent while the function of the hydroxylation pathway is markedly deficient. The activity of these pathways slowly increases to maximal levels by one year of age.

Caffeine and 3-methylxanthine are the only Nuelin metabolites with pharmacologic activity. 3-methylxanthine has approximately one tenth the pharmacologic activity of Nuelin and serum concentrations in adults with normal renal function are <1 mcg/mL. In patients with end-stage renal disease, 3-methylxanthine may accumulate to concentrations that approximate the unmetabolized Nuelin concentration. Caffeine concentrations are usually undetectable in adults regardless of renal function. In neonates, caffeine may accumulate to concentrations that approximate the unmetabolized Nuelin concentration and thus, exert a pharmacologic effect.

Both the N-demethylation and hydroxylation pathways of Nuelin biotransformation are capacity-limited. Due to the wide intersubject variability of the rate of Nuelin metabolism, non-linearity of elimination may begin in some patients at serum Nuelin concentrations <10 mcg/mL. Since this non-linearity results in more than proportional changes in serum Nuelin concentrations with changes in dose, it is advisable to make increases or decreases in dose in small increments in order to achieve desired changes in serum Nuelin concentrations (see DOSAGE AND ADMINISTRATION, Table VI ). Accurate prediction of dose-dependency of Nuelin metabolism in patients a priori is not possible, but patients with very high initial clearance rates (i.e., low steady-state serum Nuelin concentrations at above average doses) have the greatest likelihood of experiencing large changes in serum Nuelin concentration in response to dosage changes.

Excretion

In neonates, approximately 50% of the Nuelin dose is excreted unchanged in the urine. Beyond the first three months of life, approximately 10% of the Nuelin dose is excreted unchanged in the urine. The remainder is excreted in the urine mainly as 1,3-dimethyluric acid, 1-methyluric acid (20-25%) and 3-methylxanthine (15-20%). Since little Nuelin is excreted unchanged in the urine and since active metabolites of Nuelin (i.e., caffeine, 3-methylxanthine) do not accumulate to clinically significant levels even in the face of end-stage renal disease, no dosage adjustment for renal insufficiency is necessary in adults and children >3 months of age. In contrast, the large fraction of the Nuelin dose excreted in the urine as unchanged Nuelin and caffeine in neonates requires careful attention to dose reduction and frequent monitoring of serum Nuelin concentrations in neonates with reduced renal function (See WARNINGS ).

Serum Concentrations at Steady-State

After multiple doses of Nuelin, steady-state is reached in 30-65 hours (average 40 hours) in adults. At steady-state, on a dosage regimen with 24-hour intervals, the expected mean trough concentration is approximately 50% of the mean peak concentration, assuming a mean Nuelin half-life of 8 hours. The difference between peak and trough concentrations is larger in patients with more rapid Nuelin clearance. In these patients administration of Nuelin® may be required more frequently (every 12 hours).

Special Populations


Geriatric

The clearance of Nuelin is decreased by an average of 30% in healthy elderly adults (>60 yrs) compared to healthy young adults. Careful attention to dose reduction and frequent monitoring of serum Nuelin concentrations are required in elderly patients (see WARNINGS ).

Pediatrics

The clearance of Nuelin is very low in neonates. Nuelin clearance reaches maximal values by one year of age, remains relatively constant until about 9 years of age and then slowly decreases by approximately 50% to adult values at about age 16. Renal excretion of unchanged Nuelin in neonates amounts to about 50% of the dose, compared to about 10% in children older than three months and in adults. Careful attention to dosage selection and monitoring of serum Nuelin concentrations are required in pediatric patients (see WARNINGS and DOSAGE AND ADMINISTRATION ).

Gender

Gender differences in Nuelin clearance are relatively small and unlikely to be of clinical significance. Significant reduction in Nuelin clearance, however, has been reported in women on the 20th day of the menstrual cycle and during the third trimester of pregnancy.

Race

Pharmacokinetic differences in Nuelin clearance due to race have not been studied.

Renal Insufficiency

Only a small fraction, e.g., about 10%, of the administered Nuelin dose is excreted unchanged in the urine of children greater than three months of age and adults. Since little Nuelin is excreted unchanged in the urine and since active metabolites of Nuelin do not accumulate to clinically significant levels even in the face of end-stage renal disease, no dosage adjustment for renal insufficiency is necessary in adults and children >3 months of age. In contrast, approximately 50% of the administered Nuelin dose is excreted unchanged in the urine in neonates. Careful attention to dose reduction and frequent monitoring of serum Nuelin concentrations are required in neonates with decreased renal function (see WARNINGS ).

Hepatic Insufficiency

Nuelin clearance is decreased by 50% or more in patients with hepatic insufficiency (e.g., cirrhosis, acute hepatitis, cholestasis). Careful attention to dose reduction and frequent monitoring of serum Nuelin concentrations are required in patients with reduced hepatic function (see WARNINGS ).

Congestive Heart Failure

Nuelin clearance is decreased by 50% or more in patients with CHF. The extent of reduction in Nuelin clearance in patients with CHF appears to be directly correlated to the severity of the cardiac disease. Since Nuelin clearance is independent of liver blood flow, the reduction in clearance appears to be due to impaired hepatocyte function rather than reduced perfusion. Careful attention to dose reduction and frequent monitoring of serum Nuelin concentrations are required in patients with CHF (see WARNINGS ).

Smokers

Tobacco and marijuana smoking appears to increase the clearance of Nuelin by induction of metabolic pathways. Nuelin clearance has been shown to increase by approximately 50% in young adult tobacco smokers and by approximately 80% in elderly tobacco smokers compared to non-smoking subjects. Passive smoke exposure has also been shown to increase Nuelin clearance by up to 50%. Abstinence from tobacco smoking for one week causes a reduction of approximately 40% in Nuelin clearance. Careful attention to dose reduction and frequent monitoring of serum Nuelin concentrations are required in patients who stop smoking. Use of nicotine gum has been shown to have no effect on Nuelin clearance.

Fever

Fever, regardless of its underlying cause, can decrease the clearance of Nuelin. The magnitude and duration of the fever appear to be directly correlated to the degree of decrease of Nuelin clearance. Precise data are lacking, but a temperature of 39°C (102°F) for at least 24 hours is probably required to produce a clinically significant increase in serum Nuelin concentrations. Children with rapid rates of Nuelin clearance (i.e., those who require a dose that is substantially larger than average [e.g., >22 mg/kg/day] to achieve a therapeutic peak serum Nuelin concentration when afebrile) may be at greater risk of toxic effects from decreased clearance during sustained fever. Careful attention to dose reduction and frequent monitoring of serum Nuelin concentrations are required in patients with sustained fever (see WARNINGS ).

Miscellaneous

Other factors associated with decreased Nuelin clearance include the third trimester of pregnancy, sepsis with multiple organ failure, and hypothyroidism. Careful attention to dose reduction and frequent monitoring of serum Nuelin concentrations are required in patients with any of these conditions (see WARNINGS ). Other factors associated with increased Nuelin clearance include hyperthyroidism and cystic fibrosis.

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CLINICAL STUDIES

In patients with chronic asthma, including patients with severe asthma requiring inhaled corticosteroids or alternate-day oral corticosteroids, many clinical studies have shown that Nuelin decreases the frequency and severity of symptoms, including nocturnal exacerbations, and decreases the “as needed” use of inhaled beta-2 agonists. Nuelin has also been shown to reduce the need for short courses of daily oral prednisone to relieve exacerbations of airway obstruction that are unresponsive to bronchodilators in asthmatics.

In patients with chronic obstructive pulmonary disease (COPD), clinical studies have shown that Nuelin decreases dyspnea, air trapping, the work of breathing, and improves contractility of diaphragmatic muscles with little or no improvement in pulmonary function measurements.

INDICATIONS AND USAGE

Nuelin is indicated for the treatment of the symptoms and reversible airflow obstruction associated with chronic asthma and other chronic lung diseases, e.g., emphysema and chronic bronchitis.

CONTRAINDICATIONS

Nuelin® is contraindicated in patients with a history of hypersensitivity to Nuelin or other components in the product.

WARNINGS

Concurrent Illness

Nuelin should be used with extreme caution in patients with the following clinical conditions due to the increased risk of exacerbation of the concurrent condition:

Active peptic ulcer disease

Seizure disorders

Cardiac arrhythmias

Conditions That Reduce Nuelin Clearance

There are several readily identifiable causes of reduced Nuelin clearance. If the total daily dose is not appropriately reduced in the presence of these risk factors, severe and potentially fatal Nuelin toxicity can occur . Careful consideration must be given to the benefits and risks of Nuelin use and the need for more intensive monitoring of serum Nuelin concentrations in patients with the following risk factors:

Age


Concurrent Diseases


Cessation of Smoking

Drug Interactions

Adding a drug that inhibits Nuelin metabolism or stopping a concurrently administered drug that enhances Nuelin metabolism (e.g., carbamazepine, rifampin). (see PRECAUTIONS, Drug Interactions, Table II ).

When Signs or Symptoms of Nuelin Toxicity Are Present

Whenever a patient receiving Nuelin develops nausea or vomiting, particularly repetitive vomiting, or other signs or symptoms consistent with Nuelin toxicity (even if another cause may be suspected), additional doses of Nuelin should be withheld and a serum Nuelin concentration measured immediately . Patients should be instructed not to continue any dosage that causes adverse effects and to withhold subsequent doses until the symptoms have resolved, at which time the healthcare professional may instruct the patient to resume the drug at a lower dosage (see DOSAGE AND ADMINISTRATION, Dosing Guidelines, Table VI ).

Dosage Increases

Increases in the dose of Nuelin should not be made in response to an acute exacerbation of symptoms of chronic lung disease since Nuelin provides little added benefit to inhaled beta2-selective agonists and systemically administered corticosteroids in this circumstance and increases the risk of adverse effects. A peak steady-state serum Nuelin concentration should be measured before increasing the dose in response to persistent chronic symptoms to ascertain whether an increase in dose is safe. Before increasing the Nuelin dose on the basis of a low serum concentration, the healthcare professional should consider whether the blood sample was obtained at an appropriate time in relationship to the dose and whether the patient has adhered to the prescribed regimen (see PRECAUTIONS, Laboratory Tests ).

As the rate of Nuelin clearance may be dose-dependent (i.e., steady-state serum concentrations may increase disproportionately to the increase in dose), an increase in dose based upon a sub-therapeutic serum concentration measurement should be conservative. In general, limiting dose increases to about 25% of the previous total daily dose will reduce the risk of unintended excessive increases in serum Nuelin concentration (see DOSAGE AND ADMINISTRATION, Table VI ).

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PRECAUTIONS

General

Careful consideration of the various interacting drugs and physiologic conditions that can alter Nuelin clearance and require dosage adjustment should occur prior to initiation of Nuelin therapy, prior to increases in Nuelin dose, and during follow up. The dose of Nuelin selected for initiation of therapy should be low and, if tolerated , increased slowly over a period of a week or longer with the final dose guided by monitoring serum Nuelin concentrations and the patient’s clinical response (see DOSAGE AND ADMINISTRATION , Table V).

Monitoring Serum Nuelin Concentrations

Serum Nuelin concentration measurements are readily available and should be used to determine whether the dosage is appropriate. Specifically, the serum Nuelin concentration should be measured as follows:


To guide a dose increase, the blood sample should be obtained at the time of the expected peak serum Nuelin concentration; 12 hours after an evening dose or 9 hours after a morning dose at steady-state. For most patients, steady-state will be reached after 3 days of dosing when no doses have been missed, no extra doses have been added, and none of the doses have been taken at unequal intervals. A trough concentration (i.e., at the end of the dosing interval) provides no additional useful information and may lead to an inappropriate dose increase since the peak serum Nuelin concentration can be two or more times greater than the trough concentration with an immediate-release formulation. If the serum sample is drawn more than 12 hours after the evening dose, or more than 9 hours after a morning dose, the results must be interpreted with caution since the concentration may not be reflective of the peak concentration. In contrast, when signs or symptoms of Nuelin toxicity are present, a serum sample should be obtained as soon as possible, analyzed immediately, and the result reported to the healthcare professional without delay. In patients in whom decreased serum protein binding is suspected (e.g., cirrhosis, women during the third trimester of pregnancy), the concentration of unbound Nuelin should be measured and the dosage adjusted to achieve an unbound concentration of 6-12 mcg/mL.

Saliva concentrations of Nuelin cannot be used reliably to adjust dosage without special techniques.

Effects on Laboratory Tests

As a result of its pharmacological effects, Nuelin at serum concentrations within the 10-20 mcg/mL range modestly increases plasma glucose, uric acid (from a mean of 4 mg/dL to 6 mg/dL), free fatty acids (from a mean of 451 µEq/L to 800 µEq/L, total cholesterol (from a mean of 140 vs 160 mg/dL), HDL (from a mean of 36 to 50 mg/dL), HDL/LDL ratio (from a mean of 0.5 to 0.7), and urinary free cortisol excretion (from a mean of 44 to 63 mcg/24 hr). Nuelin at serum concentrations within the 10-20 mcg/mL range may also transiently decrease serum concentrations of triiodothyronine (144 before, 131 after one week and 142 ng/dL after 4 weeks of Nuelin). The clinical importance of these changes should be weighed against the potential therapeutic benefit of Nuelin in individual patients.

Information for Patients

The patient (or parent/caregiver) should be instructed to seek medical advice whenever nausea, vomiting, persistent headache, insomnia or rapid heartbeat occurs during treatment with Nuelin, even if another cause is suspected. The patient should be instructed to contact their healthcare professional if they develop a new illness, especially if accompanied by a persistent fever, if they experience worsening of a chronic illness, if they start or stop smoking cigarettes or marijuana, or if another healthcare professional adds a new medication or discontinues a previously prescribed medication. Patients should be informed that Nuelin interacts with a wide variety of drugs. The dietary supplement St. John’s Wort (Hypericum perforatum) should not be taken at the same time as Nuelin, since it may result in decreased Nuelin levels. If patients are already taking St. John’s Wort and Nuelin together, they should consult their healthcare professional before stopping the St. John’s Wort, since their Nuelin concentrations may rise when this is done, resulting in toxicity. Patients should be instructed to inform all healthcare professionals involved in their care that they are taking Nuelin, especially when a medication is being added or deleted from their treatment. Patients should be instructed to not alter the dose, timing of the dose, or frequency of administration without first consulting their healthcare professional. If a dose is missed, the patient should be instructed to take the next dose at the usually scheduled time and to not attempt to make up for the missed dose.

Nuelin® Tablets can be taken once a day in the morning or evening. It is recommended that Nuelin be taken with meals. Patients should be advised that if they choose to take Nuelin with food it should be taken consistently with food and if they take it in a fasted condition it should routinely be taken fasted. It is important that the product whenever dosed be dosed consistently with or without food.

Nuelin Tablets are not to be chewed or crushed because it may lead to a rapid release of Nuelin with the potential for toxicity. The scored tablet may be split. Patients receiving Nuelin Tablets may pass an intact matrix tablet in the stool or via colostomy. These matrix tablets usually contain little or no residual Nuelin.

Drug Interactions

Nuelin interacts with a wide variety of drugs. The interaction may be pharmacodynamic, i.e., alterations in the therapeutic response to Nuelin or another drug or occurrence of adverse effects without a change in serum Nuelin concentration. More frequently, however, the interaction is pharmacokinetic, i.e., the rate of Nuelin clearance is altered by another drug resulting in increased or decreased serum Nuelin concentrations. Nuelin only rarely alters the pharmacokinetics of other drugs.

The drugs listed in Table II have the potential to produce clinically significant pharmacodynamic or pharmacokinetic interactions with Nuelin. The information in the “Effect” column of Table II assumes that the interacting drug is being added to a steady-state Nuelin regimen. If Nuelin is being initiated in a patient who is already taking a drug that inhibits Nuelin clearance, the dose of Nuelin required to achieve a therapeutic serum Nuelin concentration will be smaller. Conversely, if Nuelin is being initiated in a patient who is already taking a drug that enhances Nuelin clearance (e.g., rifampin), the dose of Nuelin required to achieve a therapeutic serum Nuelin concentration will be larger. Discontinuation of a concomitant drug that increases Nuelin clearance will result in accumulation of Nuelin to potentially toxic levels, unless the Nuelin dose is appropriately reduced. Discontinuation of a concomitant drug that inhibits Nuelin clearance will result in decreased serum Nuelin concentrations, unless the Nuelin dose is appropriately increased.

The drugs listed in Table III have either been documented not to interact with Nuelin or do not produce a clinically significant interaction (i.e., <15% change in Nuelin clearance).

The listing of drugs in Tables II and III are current as of February 9, 1995. New interactions are continuously being reported for Nuelin, especially with new chemical entities. The healthcare professional should not assume that a drug does not interact with Nuelin if it is not listed in Table II. Before addition of a newly available drug in a patient receiving Nuelin, the package insert of the new drug and/or the medical literature should be consulted to determine if an interaction between the new drug and Nuelin has been reported.

Drug Type of Interaction Effect**
*Refer to PRECAUTIONS, Drug Interactions for further information regarding table.
**Average effect on steady-state Nuelin concentration or other clinical effect for pharmacologic interactions. Individual patients may experience larger changes in serum Nuelin concentration than the value listed.
Adenosine Nuelin blocks adenosine receptors. Higher doses of adenosine may be required to achieve desired effect.
Alcohol A single large dose of alcohol (3 mL/kg of whiskey) decreases Nuelin clearance for up to 24 hours. 30% increase
Allopurinol Decreases Nuelin clearance at allopurinol doses ≥600 mg/day. 25% increase
Aminoglutethimide Increases Nuelin clearance by induction of microsomal enzyme activity. 25% decrease
Carbamazepine Similar to aminoglutethimide. 30% decrease
Cimetidine Decreases Nuelin clearance by inhibiting cytochrome P450 1A2. 70% increase
Ciprofloxacin Similar to cimetidine. 40% increase
Clarithromycin Similar to erythromycin. 25% increase
Diazepam Benzodiazepines increase CNS concentrations of adenosine, a potent CNS depressant, while Nuelin blocks adenosine receptors. Larger diazepam doses may be required to produce desired level of sedation. Discontinuation of Nuelin without reduction of diazepam dose may result in respiratory depression.
Disulfiram Decreases Nuelin clearance by inhibiting hydroxylation and demethylation. 50% increase
Enoxacin Similar to cimetidine. 300% increase
Ephedrine Synergistic CNS effects. Increased frequency of nausea, nervousness, and insomnia.
Erythromycin Erythromycin metabolite decreases Nuelin clearance by inhibiting cytochrome P450 3A3. 35% increase. Erythromycin steady-state serum concentrations decrease by a similar amount.
Estrogen Estrogen containing oral contraceptives decrease Nuelin clearance in a dose-dependent fashion. The effect of progesterone on Nuelin clearance is unknown. 30% increase
Flurazepam Similar to diazepam. Similar to diazepam.
Fluvoxamine Similar to cimetidine. Similar to cimetidine.
Halothane Halothane sensitizes the myocardium to catecholamines, Nuelin increases release of endogenous catecholamines. Increased risk of ventricular arrhythmias.
Interferon, human recombinant alpha-A Decreases Nuelin clearance. 100% increase
Isoproterenol (IV) Increases Nuelin clearance. 20% decrease
Ketamine Pharmacologic May lower Nuelin seizure threshold.
Lithium Nuelin increases renal lithium clearance. Lithium dose required to achieve a therapeutic serum concentration increased an average of 60%.
Lorazepam Similar to diazepam. Similar to diazepam.
Methotrexate (MTX) Decreases Nuelin clearance. 20% increase after low dose MTX, higher dose MTX may have a greater effect.
Mexiletine Similar to disulfiram. 80% increase
Midazolam Similar to diazepam. Similar to diazepam.
Moricizine Increases Nuelin clearance. 25% decrease
Pancuronium Nuelin may antagonize non-depolarizing neuromuscular blocking effects; possibly due to phosphodiesterase inhibition. Larger dose of pancuronium may be required to achieve neuromuscular blockade.
Pentoxifylline Decreases Nuelin clearance. 30% increase
Phenobarbital (PB) Similar to aminoglutethimide. 25% decrease after two weeks of concurrent PB.
Phenytoin Phenytoin increases Nuelin clearance by increasing microsomal enzyme activity. Nuelin decreases phenytoin absorption. Serum Nuelin and phenytoin concentrations decrease about 40%.
Propafenone Decreases Nuelin clearance and pharmacologic interaction. 40% increase. Beta-2 blocking effect may decrease efficacy of Nuelin.
Propranolol Similar to cimetidine and pharmacologic interaction. 100% increase. Beta-2 blocking effect may decrease efficacy of Nuelin.
Rifampin Increases Nuelin clearance by increasing cytochrome P450 1A2 and 3A3 activity. 20-40% decrease
St. John’s Wort (Hypericum Perforatum) Decrease in Nuelin plasma concentrations. Higher doses of Nuelin may be required to achieve desired effect. Stopping St. John’s Wort may result in Nuelin toxicity.
Sulfinpyrazone Increases Nuelin clearance by increasing demethylation and hydroxylation. Decreases renal clearance of Nuelin. 20% decrease
Tacrine Similar to cimetidine, also increases renal clearance of Nuelin. 90% increase
Thiabendazole Decreases Nuelin clearance. 190% increase
Ticlopidine Decreases Nuelin clearance. 60% increase
Troleandomycin Similar to erythromycin. 33-100% increase depending on troleandomycin dose.
Verapamil Similar to disulfiram. 20% increase
*Refer to PRECAUTIONS, Drug Interactions for information regarding table.
albuterol, systemic and inhaled mebendazole
amoxicillin medroxyprogesterone
ampicillin, with or without

sulbactam

methylprednisolone

metronidazole

atenolol metoprolol
azithromycin nadolol
caffeine, dietary ingestion nifedipine
cefaclor nizatidine
co-trimoxazole (trimethoprim and

sulfamethoxazole)

norfloxacin

ofloxacin

diltiazem omeprazole
dirithromycin prednisone, prednisolone
enflurane ranitidine
famotidine rifabutin
felodipine roxithromycin
finasteride sorbitol (purgative doses do not inhibit
hydrocortisone Nuelin absorption)
isoflurane sucralfate
isoniazid terbutaline, systemic
isradipine terfenadine
influenza vaccine tetracycline
ketoconazole tocainide
lomefloxacin

Drug-Food Interactions

The bioavailability of Nuelin® Tablets (theophylline, anhydrous) has been studied with co-administration of food. In three single-dose studies, subjects given Nuelin 400 mg or 600 mg Tablets with a standardized high-fat meal were compared to fasted conditions. Under fed conditions, the peak plasma concentration and bioavailability were increased; however, a precipitous increase in the rate and extent of absorption was not evident (see Pharmacokinetics , Absorption). The increased peak and extent of absorption under fed conditions suggests that dosing should be ideally administered consistently either with or without food.

The Effect of Other Drugs on Nuelin Serum Concentration Measurements

Most serum Nuelin assays in clinical use are immunoassays which are specific for Nuelin. Other xanthines such as caffeine, dyphylline, and pentoxifylline are not detected by these assays. Some drugs, however, may interfere with certain HPLC techniques. Caffeine and xanthine metabolites in neonates or patients with renal dysfunction may cause the reading from some dry reagent office methods to be higher than the actual serum Nuelin concentration.

Carcinogenesis, Mutagenesis, and Impairment of Fertility

Long term carcinogenicity studies have been carried out in mice (oral doses 30-150 mg/kg) and rats (oral doses 5-75 mg/kg). Results are pending.

Nuelin has been studied in Ames salmonella, in vivo and in vitro cytogenetics, micronucleus and Chinese hamster ovary test systems and has not been shown to be genotoxic.

In a 14 week continuous breeding study, Nuelin, administered to mating pairs of B6C3F1 mice at oral doses of 120, 270 and 500 mg/kg (approximately 1.0-3.0 times the human dose on a mg/m2 basis) impaired fertility, as evidenced by decreases in the number of live pups per litter, decreases in the mean number of litters per fertile pair, and increases in the gestation period at the high dose as well as decreases in the proportion of pups born alive at the mid and high dose. In 13 week toxicity studies, Nuelin was administered to F344 rats and B6C3F1 mice at oral doses of 40-300 mg/kg (approximately 2.0 times the human dose on a mg/m2 basis). At the high dose, systemic toxicity was observed in both species including decreases in testicular weight.

Pregnancy: Teratogenic Effects: Category C

In studies in which pregnant mice, rats and rabbits were dosed during the period of organogenesis, Nuelin produced teratogenic effects.

In studies with mice, a single intraperitoneal dose at and above 100 mg/kg during organogenesis produced cleft palate and digital abnormalities. Micromelia, micrognathia, clubfoot, subcutaneous hematoma, open eyelids, and embryolethality were observed at doses that are approximately 2 times the maximum recommended oral dose for adults on a mg/m2 basis.

In a study with rats dosed from conception through organogenesis, an oral dose of 150 mg/kg/day (approximately 2 times the maximum recommended oral dose for adults on a mg/m2 basis) produced digital abnormalities. Embryolethality was observed with a subcutaneous dose of 200 mg/kg/day (approximately 4 times the maximum recommended oral dose for adults on a mg/m2 basis).

In a study in which pregnant rabbits were dosed throughout organogenesis, an intravenous dose of 60 mg/kg/day (approximately 2 times the maximum recommended oral dose for adults on a mg/m2 basis), which caused the death of one doe and clinical signs in others, produced cleft palate and was embryolethal. Doses at and above 15 mg/kg/day (less than the maximum recommended oral dose for adults on a mg/m2 basis) increased the incidence of skeletal variations.

There are no adequate and well-controlled studies in pregnant women. Nuelin should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Nursing Mothers

Nuelin is excreted into breast milk and may cause irritability or other signs of mild toxicity in nursing human infants. The concentration of Nuelin in breast milk is about equivalent to the maternal serum concentration. An infant ingesting a liter of breast milk containing 10-20 mcg/mL of Nuelin per day is likely to receive 10-20 mg of Nuelin per day. Serious adverse effects in the infant are unlikely unless the mother has toxic serum Nuelin concentrations.

Pediatric Use

Nuelin is safe and effective for the approved indications in pediatric patients. The maintenance dose of Nuelin must be selected with caution in pediatric patients since the rate of Nuelin clearance is highly variable across the pediatric age range.

Geriatric Use

Elderly patients are at a significantly greater risk of experiencing serious toxicity from Nuelin than younger patients due to pharmacokinetic and pharmacodynamic changes associated with aging. The clearance of Nuelin is decreased by an average of 30% in healthy elderly adults (>60 yrs) compared to healthy young adults. Nuelin clearance may be further reduced by concomitant diseases prevalent in the elderly, which further impair clearance of this drug and have the potential to increase serum levels and potential toxicity. These conditions include impaired renal function, chronic obstructive pulmonary disease, congestive heart failure, hepatic disease and an increased prevalence of use of certain medications (see PRECAUTIONS: Drug Interactions ) with the potential for pharmacokinetic and pharmacodynamic interaction. Protein binding may be decreased in the elderly resulting in an increased proportion of the total serum Nuelin concentration in the pharmacologically active unbound form. Elderly patients also appear to be more sensitive to the toxic effects of Nuelin after chronic overdosage than younger patients. Careful attention to dose reduction and frequent monitoring of serum Nuelin concentrations are required in elderly patients (see PRECAUTIONS, Monitoring Serum Nuelin Concentrations, and DOSAGE AND ADMINISTRATION ). The maximum daily dose of Nuelin in patients greater than 60 years of age ordinarily should not exceed 400 mg/day unless the patient continues to be symptomatic and the peak steady-state serum Nuelin concentration is <10 mcg/mL (see DOSAGE AND ADMINISTRATION ). Nuelin doses greater than 400 mg/d should be prescribed with caution in elderly patients. Nuelin should be prescribed with caution in elderly male patients with pre-existing partial outflow obstruction, such as prostatic enlargement, due to the risk of urinary retention.

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ADVERSE REACTIONS

Adverse reactions associated with Nuelin are generally mild when peak serum Nuelin concentrations are <20 mcg/mL and mainly consist of transient caffeine-like adverse effects such as nausea, vomiting, headache, and insomnia. When peak serum Nuelin concentrations exceed 20 mcg/mL, however, Nuelin produces a wide range of adverse reactions including persistent vomiting, cardiac arrhythmias, and intractable seizures which can be lethal (see OVERDOSAGE ). The transient caffeine-like adverse reactions occur in about 50% of patients when Nuelin therapy is initiated at doses higher than recommended initial doses (e.g., >300 mg/day in adults and >12 mg/kg/day in children beyond >1 year of age). During the initiation of Nuelin therapy, caffeine-like adverse effects may transiently alter patient behavior, especially in school age children, but this response rarely persists. Initiation of Nuelin therapy at a low dose with subsequent slow titration to a predetermined age-related maximum dose will significantly reduce the frequency of these transient adverse effects (see DOSAGE AND ADMINISTRATION, Table V ). In a small percentage of patients (<3% of children and <10% of adults) the caffeine-like adverse effects persist during maintenance therapy, even at peak serum Nuelin concentrations within the therapeutic range (i.e., 10-20 mcg/mL). Dosage reduction may alleviate the caffeine-like adverse effects in these patients, however, persistent adverse effects should result in a reevaluation of the need for continued Nuelin therapy and the potential therapeutic benefit of alternative treatment.

Other adverse reactions that have been reported at serum Nuelin concentrations <20 mcg/mL include abdominal pain, agitation, anaphylactic reaction, anaphylactoid reaction, anxiety, cardiac arrhythmias, diarrhea, dizziness, fine skeletal muscle tremors, gastric irritation, gastroesophageal reflux, hyperuricemia, irritability, palpitations, pruritus, rash, sinus tachycardia, restlessness, transient diuresis, urinary retention and urticaria. In patients with hypoxia secondary to COPD, multifocal atrial tachycardia and flutter have been reported at serum Nuelin concentrations ≥15 mcg/mL. There have been a few isolated reports of seizures at serum Nuelin concentrations <20 mcg/mL in patients with an underlying neurological disease or in elderly patients. The occurrence of seizures in elderly patients with serum Nuelin concentrations <20 mcg/mL may be secondary to decreased protein binding resulting in a larger proportion of the total serum Nuelin concentration in the pharmacologically active unbound form. The clinical characteristics of the seizures reported in patients with serum Nuelin concentrations <20 mcg/mL have generally been milder than seizures associated with excessive serum Nuelin concentrations resulting from an overdose (i.e., they have generally been transient, often stopped without anticonvulsant therapy, and did not result in neurological residua).

Percentage of patients reported with sign or symptom
Sign/Symptom Acute Overdose Chronic Overdosage
(Large Single Ingestion) (Multiple Excessive Doses)
Study 1 Study 2 Study 1 Study 2
(n=157) (n=14) (n=92) (n=102)
*These data are derived from two studies in patients with serum Nuelin concentrations >30 mcg/mL. In the first study (Study #1-Shanon, Ann Intern Med 1993;119:1161-67), data were prospectively collected from 249 consecutive cases of Nuelin toxicity referred to a regional poison center for consultation. In the second study (Study #2-Sessler, Am J Med 1990;88:567-76), data were retrospectively collected from 116 cases with serum Nuelin concentrations >30 mcg/mL among 6000 blood samples obtained for measurement of serum Nuelin concentrations in three emergency departments. Differences in the incidence of manifestations of Nuelin toxicity between the two studies may reflect sample selection as a result of study design (e.g., in Study #1, 48% of the patients had acute intoxications versus only 10% in Study #2) and different methods of reporting results.
**NR=Not reported in a comparable manner.
Asymptomatic NR** 0 NR** 6
Gastrointestinal
Vomiting 73 93 30 61
Abdominal Pain NR** 21 NR** 12
Diarrhea NR** 0 NR** 14
Hematemesis NR** 0 NR** 2
Metabolic/Other
Hypokalemia 85 79 44 43
Hyperglycemia 98 NR** 18 NR**
Acid/base disturbance 34 21 9 5
Rhabdomyolysis NR** 7 NR** 0
Cardiovascular
Sinus tachycardia 100 86 100 62
Other supraventricular
tachycardias 2 21 12 14
Ventricular premature beats 3 21 10 19
Atrial fibrillation or flutter 1 NR** 12 NR**
Multifocal atrial tachycardia 0 NR** 2 NR**
Ventricular arrhythmias with

hemodynamic instability

7 14 40 0
Hypotension/shock NR** 21 NR** 8
Neurologic
Nervousness NR** 64 NR** 21
Tremors 38 29 16 14
Disorientation NR** 7 NR** 11
Seizures 5 14 14 5
Death 3 21 10 4
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OVERDOSAGE

General

The chronicity and pattern of Nuelin overdosage significantly influences clinical manifestations of toxicity, management and outcome. There are two common presentations: acute overdose, i.e., ingestion of a single large excessive dose (>10 mg/kg), as occurs in the context of an attempted suicide or isolated medication error, and (2) chronic overdosage, i.e., ingestion of repeated doses that are excessive for the patient’s rate of Nuelin clearance. The most common causes of chronic Nuelin overdosage include patient or caregiver error in dosing, healthcare professional prescribing of an excessive dose or a normal dose in the presence of factors known to decrease the rate of Nuelin clearance, and increasing the dose in response to an exacerbation of symptoms without first measuring the serum Nuelin concentration to determine whether a dose increase is safe.

Severe toxicity from Nuelin overdose is a relatively rare event. In one health maintenance organization, the frequency of hospital admissions for chronic overdosage of Nuelin was about 1 per 1000 person-years exposure. In another study, among 6000 blood samples obtained for measurement of serum Nuelin concentration, for any reason, from patients treated in an emergency department, 7% were in the 20-30 mcg/mL range and 3% were >30 mcg/mL. Approximately two-thirds of the patients with serum Nuelin concentrations in the 20-30 mcg/mL range had one or more manifestations of toxicity while >90% of patients with serum Nuelin concentrations >30 mcg/mL were clinically intoxicated. Similarly, in other reports, serious toxicity from Nuelin is seen principally at serum concentrations >30 mcg/mL.

Several studies have described the clinical manifestations of Nuelin overdose and attempted to determine the factors that predict life-threatening toxicity. In general, patients who experience an acute overdose are less likely to experience seizures than patients who have experienced a chronic overdosage, unless the peak serum Nuelin concentration is >100 mcg/mL. After a chronic overdosage, generalized seizures, life-threatening cardiac arrhythmias, and death may occur at serum Nuelin concentrations >30 mcg/mL. The severity of toxicity after chronic overdosage is more strongly correlated with the patient’s age than the peak serum Nuelin concentration; patients >60 years are at the greatest risk for severe toxicity and mortality after a chronic overdosage. Pre-existing or concurrent disease may also significantly increase the susceptibility of a patient to a particular toxic manifestation, e.g., patients with neurologic disorders have an increased risk of seizures and patients with cardiac disease have an increased risk of cardiac arrhythmias for a given serum Nuelin concentration compared to patients without the underlying disease.

The frequency of various reported manifestations of Nuelin overdose according to the mode of overdose are listed in Table IV.

Other manifestations of Nuelin toxicity include increases in serum calcium, creatine kinase, myoglobin and leukocyte count, decreases in serum phosphate and magnesium, acute myocardial infarction, and urinary retention in men with obstructive uropathy.

Seizures associated with serum Nuelin concentrations >30 mcg/mL are often resistant to anticonvulsant therapy and may result in irreversible brain injury if not rapidly controlled. Death from Nuelin toxicity is most often secondary to cardiorespiratory arrest and/or hypoxic encephalopathy following prolonged generalized seizures or intractable cardiac arrhythmias causing hemodynamic compromise.

Overdose Management

General Recommendations for Patients with Symptoms of Nuelin Overdose or Serum Nuelin Concentrations >30 mcg/mL (Note: Serum Nuelin concentrations may continue to increase after presentation of the patient for medical care.)

Specific Recommendations

Acute Overdose


Chronic Overdosage

Extracorporeal Removal

Increasing the rate of Nuelin clearance by extracorporeal methods may rapidly decrease serum concentrations, but the risks of the procedure must be weighed against the potential benefit. Charcoal hemoperfusion is the most effective method of extracorporeal removal, increasing Nuelin clearance up to sixfold, but serious complications, including hypotension, hypocalcemia, platelet consumption and bleeding diatheses may occur. Hemodialysis is about as efficient as multiple-dose oral activated charcoal and has a lower risk of serious complications than charcoal hemoperfusion. Hemodialysis should be considered as an alternative when charcoal hemoperfusion is not feasible and multiple-dose oral charcoal is ineffective because of intractable emesis. Serum Nuelin concentrations may rebound 5-10 mcg/mL after discontinuation of charcoal hemoperfusion or hemodialysis due to redistribution of Nuelin from the tissue compartment. Peritoneal dialysis is ineffective for Nuelin removal; exchange transfusions in neonates have been minimally effective.

DOSAGE AND ADMINISTRATION

Nuelin® 400 or 600 mg Tablets can be taken once a day in the morning or evening. It is recommended that Nuelin be taken with meals. Patients should be advised that if they choose to take Nuelin with food it should be taken consistently with food and if they take it in a fasted condition it should routinely be taken fasted. It is important that the product whenever dosed be dosed consistently with or without food.

Nuelin® Tablets are not to be chewed or crushed because it may lead to a rapid release of Nuelin with the potential for toxicity. The scored tablet may be split. Infrequently, patients receiving Nuelin 400 or 600 mg Tablets may pass an intact matrix tablet in the stool or via colostomy. These matrix tablets usually contain little or no residual Nuelin.

Stabilized patients, 12 years of age or older, who are taking an immediate-release or controlled-release Nuelin product may be transferred to once-daily administration of 400 mg or 600 mg Nuelin Tablets on a mg-for-mg basis.

It must be recognized that the peak and trough serum Nuelin levels produced by the once-daily dosing may vary from those produced by the previous product and/or regimen.

General Considerations

The steady-state peak serum Nuelin concentration is a function of the dose, the dosing interval, and the rate of Nuelin absorption and clearance in the individual patient. Because of marked individual differences in the rate of Nuelin clearance, the dose required to achieve a peak serum Nuelin concentration in the 10-20 mcg/mL range varies fourfold among otherwise similar patients in the absence of factors known to alter Nuelin clearance (e.g., 400-1600 mg/day in adults <60 years old and 10-36 mg/kg/day in children 1-9 years old). For a given population there is no single Nuelin dose that will provide both safe and effective serum concentrations for all patients. Administration of the median Nuelin dose required to achieve a therapeutic serum Nuelin concentration in a given population may result in either sub-therapeutic or potentially toxic serum Nuelin concentrations in individual patients. For example, at a dose of 900 mg/d in adults <60 years or 22 mg/kg/d in children 1-9 years, the steady-state peak serum Nuelin concentration will be <10 mcg/mL in about 30% of patients, 10-20 mcg/mL in about 50% and 20-30 mcg/mL in about 20% of patients. The dose of Nuelin must be individualized on the basis of peak serum Nuelin concentration measurements in order to achieve a dose that will provide maximum potential benefit with minimal risk of adverse effects.

Transient caffeine-like adverse effects and excessive serum concentrations in slow metabolizers can be avoided in most patients by starting with a sufficiently low dose and slowly increasing the dose, if judged to be clinically indicated, in small increments (see Table V ). Dose increases should only be made if the previous dosage is well tolerated and at intervals of no less than 3 days to allow serum Nuelin concentrations to reach the new steady-state. Dosage adjustment should be guided by serum Nuelin concentration measurement (see PRECAUTIONS, Laboratory Tests and DOSAGE AND ADMINISTRATION, Table VI ). Healthcare providers should instruct patients and caregivers to discontinue any dosage that causes adverse effects, to withhold the medication until these symptoms are gone and to then resume therapy at a lower, previously tolerated dosage (see WARNINGS ).

If the patient’s symptoms are well controlled, there are no apparent adverse effects, and no intervening factors that might alter dosage requirements (see WARNINGS and PRECAUTIONS ), serum Nuelin concentrations should be monitored at 6 month intervals for rapidly growing children and at yearly intervals for all others. In acutely ill patients, serum Nuelin concentrations should be monitored at frequent intervals, e.g., every 24 hours.

Nuelin distributes poorly into body fat, therefore, mg/kg dose should be calculated on the basis of ideal body weight.

Table V contains Nuelin dosing titration schema recommended for patients in various age groups and clinical circumstances. Table VI contains recommendations for Nuelin dosage adjustment based upon serum Nuelin concentrations. Application of these general dosing recommendations to individual patients must take into account the unique clinical characteristics of each patient. In general, these recommendations should serve as the upper limit for dosage adjustments in order to decrease the risk of potentially serious adverse events associated with unexpected large increases in serum Nuelin concentration.

Table V. Dosing initiation and titration (as anhydrous Nuelin). *

Titration Step Children <45 kg Children >45 kg and adults
1If caffeine-like adverse effects occur, then consideration should be given to a lower dose and titrating the dose more slowly (see ADVERSE REACTIONS ).
  • Starting Dosage
12-14 mg/kg/day up to a maximum of 300 mg/day admin. QD* 300-400 mg/day1 admin. QD*
  • After 3 days, if tolerated, increase dose to:
16 mg/kg/day up to a maximum of 400 mg/day admin. QD* 400-600 mg/day1 admin. QD*
  • After 3 more days, if tolerated, and if needed increase dose to:
20 mg/kg/day up to a maximum of 600 mg/day admin. QD* As with all Nuelin products, doses greater than 600 mg should be titrated according to blood level

*Patients with more rapid metabolism clinically identified by higher than average dose requirements, should receive a smaller dose more frequently (every 12 hours) to prevent breakthrough symptoms resulting from low trough concentrations before the next dose.

Peak Serum

Concentration

Dosage Adjustment
¶Dose reduction and/or serum Nuelin concentration measurement is indicated whenever adverse effects are present physiologic abnormalities that can reduce Nuelin clearance occur (e.g. sustained fever), or a drug that interacts with Nuelin is added or discontinued (see WARNINGS ).
<9.9 mcg/mL If symptoms are not controlled and current dosage is tolerated, increase dose about 25%. Recheck serum concentration after three days for further dosage adjustment.
10-14.9 mcg/mL If symptoms are controlled and current dosage is tolerated, maintain dose and recheck serum concentration at 6-12 month intervals.¶ If symptoms are not controlled and current dosage is tolerated consider adding additional medication(s) to treatment regimen.
15-19.9 mcg/mL Consider 10% decrease in dose to provide greater margin of safety even if current dosage is tolerated. ¶
20-24.9 mcg/mL Decrease dose by 25% even if no adverse effects are present. Recheck serum concentration after 3 days to guide further dosage adjustment.
25-30 mcg/mL Skip next dose and decrease subsequent doses at least 25% even if no adverse effects are present. Recheck serum concentration after 3 days to guide further dosage adjustment. If symptomatic, consider whether overdose treatment is indicated.
>30 mcg/mL Treat overdose as indicated. If Nuelin is subsequently resumed, decrease dose by at least 50% and recheck serum concentration after 3 days to guide further dosage adjustment.

HOW SUPPLIED

Nuelin® (theophylline, anhydrous) Controlled-Release Tablets 400 mg are supplied in white, opaque plastic, child-resistant bottles containing 100 tablets (NDC 67781-251-01) or 500 tablets (NDC 67781-251-05). Each round, white 400 mg tablet bears the symbol PF on the scored side and U400 on the other side.

Nuelin® (theophylline, anhydrous) Controlled-Release Tablets 600 mg are supplied in white, opaque plastic, child-resistant bottles containing 100 tablets (NDC 67781-252-01). Each rectangular, concave, white 600 mg tablet bears the symbol PF on the scored side and U 600 on the other side.

Store at 25°C (77°F); excursions permitted between 15°-30°C (59°-86°F).

Dispense in a tight, light-resistant container.

©2011, Purdue Pharmaceutical Products L.P.

Dist. by: Purdue Pharmaceutical Products L.P.

Stamford, CT 06901-3431

Revised 10/2011

300945-0B

Nuelin Tablets

400 mg Tablets

NDC 677781-251-01

Nuelin Tablets 400 mg Tablets NDC 677781-251-01

Nuelin Tablets

600 mg Tablets

NDC 677781-252-01

Nuelin Tablets 600 mg Tablets NDC 677781-252-01

Nuelin 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.


Nuelin 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.


Nuelin 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.


Nuelin 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.


Nuelin 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.


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References

  1. Dailymed."THEOPHYLLINE SOLUTION [SILARX PHARMACEUTICALS, INC]". https://dailymed.nlm.nih.gov/dailym... (accessed August 28, 2018).
  2. Dailymed."THEOPHYLLINE: DailyMed provides trustworthy information about marketed drugs in the United States. DailyMed is the official provider of FDA label information (package inserts).". https://dailymed.nlm.nih.gov/dailym... (accessed August 28, 2018).
  3. "theophylline". https://pubchem.ncbi.nlm.nih.gov/co... (accessed August 28, 2018).

Frequently asked Questions

Can i drive or operate heavy machine after consuming Nuelin?

Depending on the reaction of the Nuelin after taken, if you are feeling dizziness, drowsiness or any weakness as a reaction on your body, Then consider Nuelin 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 Nuelin 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.

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Review

sdrugs.com conducted a study on Nuelin, 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 Nuelin 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.

Visitor reports

Visitor reported useful

No survey data has been collected yet

Visitor reported side effects

No survey data has been collected yet

Visitor reported price estimates

No survey data has been collected yet

Two visitors reported frequency of use

How often in a day do you take the medicine?
Are you taking the Nuelin drug as prescribed by the doctor?

Few medications can be taken Once in a day more than prescribed when the doctor's advice mentions the medicine can be taken according to frequency or severity of symptoms. Most times, be very careful and clear about the number of times you are taking the medication. The report of sdrugs.com website users about the frequency of taking the drug Nuelin is mentioned below.
Visitors%
Once in a day1
50.0%
Twice in a day1
50.0%

Two visitors reported doses

What is the dose of Nuelin drug you are taking?
According to the survey conducted among sdrugs.com website users, the maximum number of people are using the following dose 201-500mg. Few medications come in only one or two doses. Few are specific for adult dose and child dose. The dose of the medicine given to the patient depends on the severity of the symptom/disease. There can be dose adjustments made by the doctor, based on the progression of the disease. Follow-up is important.
Visitors%
201-500mg1
50.0%
101-200mg1
50.0%

Visitor reported time for results

No survey data has been collected yet

Visitor reported administration

No survey data has been collected yet

Three visitors reported age

Visitors%
16-291
33.3%
46-601
33.3%
1-51
33.3%

Visitor reviews


There are no reviews yet. Be the first to write one!


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The information was verified by Dr. Rachana Salvi, MD Pharmacology

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