BUDESONIDE capsule, coated pellets

budesonide by

Drug Labeling and Warnings

budesonide by is a Prescription medication manufactured, distributed, or labeled by Northstar Rx LLC., Zydus Pharmaceuticals USA Inc., Zydus Lifesciences Limited. Drug facts, warnings, and ingredients follow.

Drug Details [pdf]

  • 1 INDICATIONS AND USAGE

    1.1 Treatment of Mild to Moderate Active Crohn’s Disease

    Budesonide capsules (enteric coated) are indicated for the treatment of mild to moderate active Crohn's disease involving the ileum and/or the ascending colon in patients 8 years of age and older.

    1.2 Maintenance of Clinical Remission of Mild to Moderate Crohn’s Disease

    Budesonide capsules (enteric coated) are indicated for the maintenance of clinical remission of mild to moderate Crohn's disease involving the ileum and/or the ascending colon for up to 3 months in adults.

  • 2 DOSAGE AND ADMINISTRATION

    2.1 Administration Instructions

    • Take budesonide capsules (enteric coated) once daily in the morning.
    • Swallow budesonide extended-release capsules (enteric coated) whole. Do not chew or crush.
    • Avoid consumption of grapefruit juice for the duration of budesonide capsules (enteric coated) therapy [see Drug Interactions (7.1)] .

    2.2 Treatment of Mild to Moderate Active Crohn’s Disease

    The recommended dosage of budesonide capsules (enteric coated) is:

    Adults

    9 mg orally once daily for up to 8 weeks. Repeated 8 week courses of budesonide capsules (enteric coated)can be given for recurring episodes of active disease.

    Pediatric patients 8 to 17 years who weigh more than 25 kg

    9 mg orally once daily for up to 8 weeks, followed by 6 mg once daily for 2 weeks.

    2.3 Maintenance of Clinical Remission of Mild to Moderate Crohn’s Disease

    The recommended dosage in adults, following an 8 week course(s) of treatment for active disease and once the patient's symptoms are controlled (CDAI less than 150), is budesonide capsules(enteric coated) 6 mg orally once daily for maintenance of clinical remission up to 3 months. If symptom control is still maintained at 3 months an attempt to taper to complete cessation is recommended. Continued treatment with budesonide capsules (enteric coated) 6 mg for more than 3 months has not been shown to provide substantial clinical benefit.

    Patients with mild to moderate active Crohn's disease involving the ileum and/or ascending colon have been switched from oral prednisolone to budesonide capsules (enteric coated) with no reported episodes of adrenal insufficiency. Since prednisolone should not be stopped abruptly, tapering should begin concomitantly with initiating budesonide capsules (enteric coated) treatment.

    2.4 Dosage Adjustment in Adult Patients with Hepatic Impairment

    Consider reducing the dosage of budesonide capsules (enteric coated) to 3 mg once daily for adult patients with moderate hepatic impairment (Child-Pugh Class B). Avoid use in patients with severe hepatic impairment (Child-Pugh Class C) [see Warnings and Precautions (5.1), Use in Specific Populations (8.6)].

  • 3 DOSAGE FORMS AND STRENGTHS

    Budesonide extended-release capsules (enteric coated), 3 mg are white to off-white, free flowing pellets, filled in size '1' hard gelatin capsules having opaque light-orange colored cap printed with "720" in black ink and opaque white body.

  • 4 CONTRAINDICATIONS

    Budesonide extended-release capsules (enteric coated) are contraindicated in patients with hypersensitivity to budesonide or any of the ingredients of budesonide capsules (enteric coated). Serious hypersensitivity reactions, including anaphylaxis have occurred [see Adverse Reactions (6.2)].

  • 5 WARNINGS AND PRECAUTIONS

    5.1 Hypercorticism and Adrenal Axis Suppression

    When corticosteroids are used chronically, systemic effects such as hypercorticism and adrenal axis suppression may occur. Corticosteroids can reduce the response of the hypothalamus-pituitary-adrenal (HPA) axis to stress. In situations where patients are subject to surgery or other stress situations, supplementation with a systemic corticosteroid is recommended. Since budesonide capsules (enteric coated) contains a corticosteroid, general warnings concerning corticosteroids should be followed [see Warnings and Precautions (5.2), (5.3), (5.4)].

    Pediatric patients with Crohn's disease have a slightly higher systemic exposure of budesonide and increased cortisol suppression than adults with Crohn's disease [see Use in Specific Populations (8.4), Clinical Pharmacology (12.2)]. Patients with moderate to severe hepatic impairment (Child-Pugh Class B and C respectively) could be at an increased risk of hypercorticism and adrenal axis suppression due to an increased systemic exposure of oral budesonide. Avoid use in patients with severe hepatic impairment (Child-Pugh Class C). Monitor for increased signs and/or symptoms of hypercorticism and consider reducing the dosage in patients with moderate hepatic impairment (Child-Pugh Class B) [see Dosage and Administration (2.4), Use in Specific Populations (8.6), Clinical Pharmacology (12.3)].

    5.2 Symptoms of Steroid Withdrawal in Patients Transferred from Other Systemic Corticosteroids

    Monitor patients who are transferred from corticosteroid treatment with high systemic effects to corticosteroids with lower systemic availability, such as budesonide capsules (enteric coated), since symptoms attributed to withdrawal of steroid therapy, including those of acute adrenal axis suppression or benign intracranial hypertension, may develop. Adrenocortical function monitoring may be required in these patients and the dose of corticosteroid treatment with high systemic effects should be reduced cautiously.

    Replacement of systemic corticosteroids with budesonide capsules (enteric coated) may unmask allergies (e.g., rhinitis and eczema), which were previously controlled by the systemic drug.

    5.3 Increased Risk of Infection

    Patients who are on drugs that suppress the immune system are more susceptible to infection than healthy individuals. Chicken pox and measles, for example, can have a more serious or even fatal course in susceptible patients or patients on immunosuppressant doses of corticosteroids. In patients who have not had these diseases, particular care should be taken to avoid exposure.

    How the dose, route and duration of corticosteroid administration affect the risk of developing a disseminated infection is not known. The contribution of the underlying disease and/or prior corticosteroid treatment to the risk is also not known. If exposed, therapy with varicella zoster immune globulin (VZIG) or pooled intravenous immunoglobulin (IVIG), as appropriate, may be indicated. If exposed to measles, prophylaxis with pooled intramuscular immunoglobulin (IG) may be indicated. (See prescribing information for VZIG and IG). If chicken pox develops, treatment with antiviral agents may be considered.

    Corticosteroids should be used with caution, if at all, in patients with active or quiescent tuberculosis infection, untreated fungal, bacterial, systemic viral or parasitic infections, or ocular herpes simplex.

    5.4 Other Corticosteroid Effects

    Monitor patients with hypertension, diabetes mellitus, osteoporosis, peptic ulcer, glaucoma or cataracts, or with a family history of diabetes or glaucoma, or with any other condition where corticosteroids may have unwanted effects.

  • 6 ADVERSE REACTIONS

    The following clinically significant adverse reactions are described elsewhere in labeling:

    • Hypercorticism and adrenal axis suppression [see Warnings and Precautions (5.1)]
    • Symptoms of steroid withdrawal in those patients transferred from other systemic corticosteroids [see Warnings and Precautions (5.2)]
    • Increased risk of infection [see Warnings and Precautions (5.3)]
    • Other corticosteroid effects [see Warnings and Precautions (5.4)]

    6.1 Clinical Trials Experience

    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.

    Adults

    The data described below reflect exposure to budesonide capsules (enteric coated) in 520 patients with Crohn's disease, including 520 exposed to 9 mg per day (total daily dose) for 8 weeks and 145 exposed to 6 mg per day for one year in placebo controlled clinical trials. Of the 520 patients, 38% were males and the age range was 17 to 74 years.

    Treatment of Mild to Moderate Active Crohn's Disease

    The safety of budesonide capsules (enteric coated) was evaluated in 651 adult patients in five clinical trials of 8 weeks duration in patients with active mild to moderate Crohn's disease. The most common adverse reactions, occurring in greater than or equal to 5% of the patients, are listed in Table 1.

    Table 1 Common Adverse Reactions1 in 8-Week Treatment Clinical Trials

    1 Occurring in greater than or equal to 5% of the patients in any treated group.

    2 Prednisolone tapering scheme: either 40 mg in week 1 to 2, thereafter tapering with 5 mg per week; or 40 mg in week 1to 2, 30 mg in week 3 to 4, thereafter tapering with 5 mg per week.

    3 This drug is not approved for the treatment of Crohn's disease in the United States.
    Adverse Reaction
    		Budesonide
    9 mg
    n=520
    Number (%)
    		Placebo

    n=107
    Number (%)
    		Prednisolone2
    40 mg
    n=145
    Number (%)
    		Comparator3

    n=88
    Number (%)
    Headache
    		 107(21)
    		 19(18)
    		 31(21)
    		 11(13)
    Respiratory Infection
    		 55(11)
    		 7(7)
    		 20(14)
    		 5(6)
    Nausea
    		 57(11)
    		 10(9)
    		 18(12)
    		 7(8)
    Back Pain
    		 36(7)
    		 10(9)
    		 17(12)
    		 5(6)
    Dyspepsia
    		 31(6)
    		 4(4)
    		 17(12)
    		 3(3)
    Dizziness
    		 38(7)
    		 5(5)
    		 18(12)
    		 5(6)
    Abdominal Pain
    		 32(6)
    		 18(17)
    		 6(4)
    		 10(11)
    Flatulence
    		 30(6)
    		 6(6)
    		 12(8)
    		 5(6)
    Vomiting
    		 29(6)
    		 6(6)
    		 6(4)
    		 6(7)
    Fatigue
    		 25(5)
    		 8(7)
    		 11(8)
    		 0(0)
    Pain
    		 24(5)
    		 8(7)
    		 17(12)
    		 2(2)

    The incidence of signs and symptoms of hypercorticism reported by active questioning of patients in 4 of the 5 short-term clinical trials are displayed in Table 2.

    Table 2 Summary and Incidence of Signs/Symptoms of Hypercorticism in 8-Week Treatment ClinicalTrials

    1 Prednisolone tapering scheme: either 40 mg in week 1-2, thereafter tapering with 5 mg/week; or 40 mg in week 1 to 2, 30 mg in week 3 to 4, thereafter tapering with 5 mg/week.

    2 Statistically significantly different from budesonide capsules (enteric coated) 9 mg.

    3 including hair growth increased, local and hair growth increased, general.

    Header$
    		 Budesonide
    9 mg

    n=427
    		Placebo

    n=107
    		Prednisolone1
    40 mg
    n=145
    Signs/Symptom
    		Number (%)
    		Number (%)
    		Number (%)
    Total
    		 145 (34%)
    		 29 (27%)
    		 69 (48%)
    Acne
    		63(15)
    		 14(13)
    		 33(23)2
    Bruising Easily
    		 63(15)
    		 12(11)
    		 13(9)
    Moon Face
    		 46(11)
    		 4(4)
    		 53(37)2
    Swollen Ankles
    		 32(7)
    		 6(6)
    		 13(9)
    Hirsutism3
    		22(5)
    		 2(2)
    		 5(3)
    Buffalo hump
    		 6(1)
    		 2(2)
    		 5(3)
    Skin Striae
    		 4(1)
    		 2(2)
    		 0(0)

    Maintenance of Clinical Remission of Mild to Moderate Crohn's Disease

    The safety of budesonide capsules (enteric coated) were evaluated in 233 adult patients in four long-term clinical trials (52 weeks) of maintenance of clinical remission in patients with mild to moderate Crohn's disease. A total of 145 patients were treated with budesonide capsules (enteric coated) 6 mg once daily.

    The adverse reaction profile of budesonide capsules (enteric coated) 6 mg once daily in maintenance of Crohn's disease was similar to that of short-term treatment with budesonide capsules (enteric coated) 9 mg once daily in active Crohn's disease. In the long-term clinical trials, the following adverse reactions occurred in greater than or equal to 5% and are not listed in Table 1: diarrhea (10%); sinusitis (8%); infection viral (6%); and arthralgia (5%).

    Signs/symptoms of hypercorticism reported by active questioning of patients in the long-term maintenance clinical trials are displayed in Table 3.

    Table 3 Summary and Incidence of Signs/Symptoms of Hypercorticism in Long-Term Studies
    Header$
    		 Budesonide
    3 mg
    n=88
    		Budesonide
     6 mg
    n=145
    		Placebo
    n=143
    Signs/Symptom
    		Number (%)
    		Number (%)
    		Number (%)
    Bruising easily
    		 4(5)
    		 15(10)
    		 5(4)
    Acne
    		 4(5)
    		 14(10)
    		 3(2)
    Moon face
    		 3(3)
    		 6(4)
    		 0
    Hirsutism
    		 2(2)
    		 5(3)
    		 1(1)
    Swollen ankles
    		 2(2)
    		 3(2)
    		 3(2)
    Buffalo hump
    		 1(1)
    		 1(1)
    		 0
    Skin striae
    		 2(2)
    		 0(0)
    		 0

    The incidence of signs/symptoms of hypercorticism as described above in long-term maintenance clinical trials was similar to that seen in the short-term treatment clinical trials.

    Less Common Adverse Reactions in Treatment and Maintenance Clinical Trials

    Less common adverse reactions (less than 5%), occurring in adult patients treated with budesonide capsules (enteric coated) 9 mg (total daily dose) in short-term treatment clinical studies and/or budesonide capsules (enteric coated) 6 mg (total daily dose) in long-term maintenance clinical trials, with an incidence are listed below by system organ class:

    Cardiac disorders: palpitation, tachycardia

    Eye disorders: eye abnormality, vision abnormal

    General disorders and administration site conditions: asthenia, chest pain, dependent edema, face edema, flu-like disorder, malaise, fever

    Gastrointestinal disorders: anus disorder, enteritis, epigastric pain, gastrointestinal fistula, glossitis, hemorrhoids, intestinal obstruction, tongue edema, tooth disorder

    Infections and infestations: Ear infection - not otherwise specified, bronchitis, abscess, rhinitis, urinary tract infection, thrush

    Investigations: weight increased

    Metabolism and nutrition disorders: appetite increased

    Musculoskeletal and connective tissue disorders: arthritis, cramps, myalgia

    Nervous system disorders: hyperkinesia, paresthesia, tremor, vertigo, somnolence, amnesia

    Psychiatric disorders: agitation, confusion, insomnia, nervousness, sleep disorder

    Renal and urinary disorders: dysuria, micturition frequency, nocturia

    Reproductive system and breast disorders: intermenstrual bleeding, menstrual disorder

    Respiratory, thoracic and mediastinal disorders: dyspnea, pharynx disorder

    Skin and subcutaneous tissue disorders: alopecia, dermatitis, eczema, skin disorder, sweating increased, purpura

    Vascular disorders: flushing, hypertension

    Bone Mineral Density

    A randomized, open, parallel-group multicenter safety clinical trial specifically compared the effect of budesonide capsules (enteric coated) (less than 9 mg per day) and prednisolone (less than 40 mg per day) on bone mineral density over 2 years when used at doses adjusted to disease severity. Bone mineral density decreased significantly less with budesonide capsules (enteric coated) than with prednisolone in steroid-naïve patients, whereas no difference could be detected between treatment groups for steroid-dependent patients and previous steroid users. The incidence of symptoms associated with hypercorticism was significantly higher with prednisolone treatment.

    Clinical Laboratory Test Findings

    The following potentially clinically significant laboratory changes in clinical trials, irrespective of relationship to budesonide capsules (enteric coated), were reported in greater than or equal to 1% of patients: hypokalemia, leukocytosis, anemia, hematuria, pyuria, erythrocyte sedimentation rate increased, alkaline phosphatase increased, atypical neutrophils, c-reactive protein increased and adrenal insufficiency.

    Pediatrics-Treatment of Mild to Moderate Active Crohn's Disease

    Adverse reactions reported in pediatric patients 8 to 17 years of age, who weigh more than 25 kg, were similar to those reactions described above in adult patients.

    6.2 Postmarketing Experience

    The following adverse reactions have been reported during post-approval use of budesonide capsules (enteric coated). Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

    Immune System Disorders: Anaphylactic reactions

    Nervous System Disorders: Benign intracranial hypertension

    Psychiatric Disorders: Mood swings

  • 7 DRUG INTERACTIONS

    7.1 CYP3A4 Inhibitors

    Budesonide is a substrate for CYP3A4. Avoid use with CYP3A4 inhibitors. Concomitant oral administration of a strong CYP3A4 inhibitor (ketoconazole) caused an eight-fold increase of the systemic exposure to oral budesonide. Inhibitors of CYP3A4 (e.g., ketoconazole, itraconazole, ritonavir, indinavir, saquinavir, erythromycin, and cyclosporine) can increase systemic budesonide concentrations [see Clinical Pharmacology (12.3)].

    Grapefruit Juice

    Avoid ingestion of grapefruit juice with budesonide. Intake of grapefruit juice which inhibits CYP3A4 activity with budesonide can increase the systemic exposure for budesonide [see Clinical Pharmacology (12.3)].

  • 8 USE IN SPECIFIC POPULATIONS

    8.1 Pregnancy

    Risk Summary

    Limited published studies report on the use of budesonide in pregnant women; however, the data are insufficient to inform a drug-associated risk for major birth defects and miscarriage. There are clinical considerations [see Clinical Considerations]. In animal reproduction studies with pregnant rats and rabbits, administration of subcutaneous budesonide during organogenesis at doses approximately 0.5 times or 0.05 times, respectively, the maximum recommended human dose, resulted in increased fetal loss, decreased pup weights, and skeletal abnormalities. Maternal toxicity was observed in both rats and rabbits at these dose levels [see Data]. Based on animal data, advise pregnant women of the potential risk to a fetus.

    The estimated background risk of major birth defects and miscarriage of the indicated population is unknown. All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.

    Clinical Considerations

    Disease-Associated Maternal and/or Embryo/Fetal Risk

    Some published epidemiological studies show an association of adverse pregnancy outcomes in women with Crohn's disease, including preterm birth and low birth weight infants, during periods of increased disease activity (including increased stool frequency and abdominal pain). Pregnant women with Crohn's disease should be counseled regarding the importance of controlling disease.

    Fetal/Neonatal adverse reactions

    Hypoadrenalism may occur in infants born of mothers receiving corticosteroids during pregnancy. Infants should be carefully observed for signs of hypoadrenalism, such as poor feeding, irritability, weakness, and vomiting, and managed accordingly [see Warnings and Precautions (5.1)].

    Data

    Animal Data

    Budesonide was teratogenic and embryolethal in rabbits and rats.

    In an embryo-fetal development study in pregnant rats dosed subcutaneously with budesonide during the period of organogenesis from gestation days 6-15 there were effects on fetal development and survival at subcutaneous doses up to approximately 500 mcg/kg in rats (approximately 0.5 times the maximum recommended human dose on a body surface area basis). In an embryo-fetal development study in pregnant rabbits dosed during the period of organogenesis from gestation days 6 to 18, there was an increase in maternal abortion, and effects on fetal development and reduction in litter weights at subcutaneous doses up to approximately 25 mcg/kg in rabbits (approximately 0.05 times the maximum recommended human dose on a body surface area basis). Maternal toxicity, including reduction in body weight gain, was observed at subcutaneous doses of 5 mcg/kg in rabbits (approximately 0.01 times the maximum recommended human dose on a body surface area basis) and 500 mcg/kg in rats (approximately 0.5 times the maximum recommended human dose on a body surface area basis).

    In a peri-and post-natal development study, rats dosed subcutaneously with budesonide during the period of Day 15 post coitum to Day 21 postpartum, budesonide had no effects on delivery but did have an effect on growth and development of offspring. In addition, offspring survival was reduced and surviving offspring had decreased mean body weights at birth and during lactation at exposures 0.02 times the MRHD (on a mg/m2basis at maternal subcutaneous doses of 20 mcg/kg/day and higher). These findings occurred in the presence of maternal toxicity.

    8.2 Lactation

    Risk Summary

    Lactation studies have not been conducted with oral budesonide, including budesonide capsules (enteric coated), and no information is available on the effects of the drug on the breastfed infant or the effects of the drug on milk production. One published study reports that budesonide is present in human milk following maternal inhalation of budesonide [see Data]. The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for budesonide capsules (enteric coated) and any potential adverse effects on the breastfed infant from budesonide capsules (enteric coated), or from the underlying maternal condition.

    Data

    One published study reports that budesonide is present in human milk following maternal inhalation of budesonide which resulted in infant doses approximately 0.3% to 1% of the maternal weight-adjusted dosage and a milk/plasma ratio ranging between 0.4 and 0.5. Budesonide plasma concentrations were not detected and no adverse events were noted in the breastfed infants following maternal use of inhaled budesonide. The recommended daily dose of budesonide capsules (enteric coated) are higher (up to 9 mg daily) compared with inhaled budesonide (up to 800 mcg daily) given to mothers in the above described study. The maximum budesonide plasma concentration following a 9 mg daily dose (in both single- and repeated-dose pharmacokinetic studies) of oral budesonide is approximately 2.15 to 4.31  ng/mL which is up to 10 times higher than the 0.43 to 0.86 ng/mL for a 800 mcg daily dose of inhaled budesonide at steady state in the above inhalation study. Assuming the coefficient of extrapolation between the inhaled and oral doses is constant across all dose levels, at therapeutic doses of budesonide capsules (enteric coated), budesonide exposure to the nursing child may be up to 10 times higher than that by budesonide inhalation.  

    8.4 Pediatric Use

    The safety and effectiveness of budesonide capsules (enteric coated) have been established in pediatric patients 8 to 17 years of age who weigh more than 25 kg for the treatment of mild to moderate active Crohn's disease involving the ileum and/or the ascending colon. Use of budesonide capsules (enteric coated) in this age group is supported by evidence from adequate and well controlled studies of budesonide capsules (enteric coated) in adults, with additional data from 2 clinical studies in 149 pediatric patients treated up to 8 weeks and one pharmacokinetic study in 8 pediatric patients [see Adverse Reactions (6.1), Clinical Pharmacology (12.3), and Clinical Studies (14.1)].

    The observed safety profile of budesonide capsules (enteric coated) in pediatric patients is consistent with its known safety profile in adults and no new safety concerns were identified [see Adverse Reactions (6.1)].

    The safety and effectiveness of budesonide capsules (enteric coated) have not been established in pediatric patients less than 8 years of age for the treatment of mild to moderate active Crohn's disease involving the ileum and/or the ascending colon.

    The safety and effectiveness of budesonide capsules (enteric coated) have not been established in pediatric patients for the maintenance of clinical remission of mild to moderate Crohn's disease. An open-label study to evaluate the safety and tolerability of budesonide capsules (enteric coated) as maintenance treatment in pediatric patients aged 5 to 17 years was conducted, and did not establish the safety and efficacy of maintenance of clinical remission.

    Systemic corticosteroids, including budesonide capsules (enteric coated), may cause a reduction of growth velocity in pediatric patients. Pediatric patients with Crohn's disease have a 17% higher mean systemic exposure and cortisol suppression than adults with Crohn's disease [see Warnings and Precautions (5.1) and Clinical Pharmacology (12.2)].

    8.5 Geriatric Use

    Clinical studies of budesonide capsules (enteric coated) did not include sufficient numbers of patients aged 65 and over to determine whether they respond differently from younger patients. Of the 651 patients treated with budesonide capsules (enteric coated) in clinical studies, 17 (3%) were greater than or equal to 65 years of age and none were greater than 74 years of age. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.

    8.6 Hepatic Impairment

    Patients with moderate to severe hepatic impairment (Child-Pugh Class B and C, respectively) could be at an increased risk of hypercorticism and adrenal axis suppression due to an increased systemic exposure to budesonide [see Warnings and Precautions (5.1) and Clinical Pharmacology (12.3)]. Avoid use in patients with severe hepatic impairment (Child-Pugh Class C). Monitor for increased signs and/or symptoms of hypercorticism and consider dosage reduction in patients with moderate hepatic impairment (Child-Pugh Class B) [see Dosage and Administration (2.4)]. No dosage adjustment is needed in patients with mild hepatic impairment (Child-Pugh Class A).

  • 10 OVERDOSAGE

    Reports of acute toxicity and/or death following overdosage of glucocorticoids  are rare. Treatment consists of immediate gastric lavage or emesis followed by supportive and symptomatic therapy.

    If corticosteroids are used at excessive doses for prolonged periods, systemic corticosteroid effects such as hypercorticism and adrenal axis suppression may occur. For chronic overdosage in the case of severe disease requiring continuous steroid therapy, the dosage may be reduced temporarily.

    Single oral doses of 200 and 400 mg/kg were lethal in female and male mice, respectively. The signs of acute toxicity were decreased motor activity, piloerection and generalized edema.

  • 11 DESCRIPTION

    Budesonide USP, the active ingredient of budesonide extended-release capsules (enteric coated), is a synthetic corticosteroid. Budesonide is designated chemically as (RS)-11β, 16α, 17,21- tetrahydroxypregna-1,4-diene-3,20-dione cyclic 16,17-acetal with butyraldehyde. Budesonide is provided as a mixture of two epimers (22R and 22S). The molecular formula of budesonide is C25H34O6 and its molecular weight is 430.5.  Its structural formula is:

    budesonide

    Budesonide, USP is a white to off-white, odorless, crystalline powder that is practically insoluble in water and heptane, sparingly soluble in ethanol, and freely soluble in chloroform. Its partition coefficient between octanol and water at pH 5 is 1.6 x 10 3 ionic strength 0.01.

    Each capsule for oral administration contains 3 mg of micronized budesonide with the following inactive ingredients: acetyltributyl citrate, ethylcellulose aqueous dispersion, gelatin, iron oxide red, iron oxide yellow, methacrylic acid copolymer dispersion, polysorbate 80, simethicone emulsion, sodium lauryl sulfate, sugar spheres, talc, titanium dioxide and triethyl citrate.The capsule shell is printed with black pharmaceutical ink which contains following ingredients: butyl alcohol, dehydrated alcohol, iron oxide black, isopropyl alcohol, potassium hydroxide, propylene glycol, shellac and strong ammonia solution and purified water.

  • 12 CLINICAL PHARMACOLOGY

    12.1 Mechanism of Action

    Budesonide is an anti-inflammatory corticosteroid and has a high glucocorticoid effect and a weak mineralocorticoid effect, and the affinity of budesonide to glucocorticoid receptors, which reflects the intrinsic potency of the drug, is about 200-fold that of cortisol and 15-fold that of prednisolone.

    12.2 Pharmacodynamics

    Treatment with glucocorticoids, including budesonide capsules (enteric coated) are associated with a suppression of endogenous cortisol concentrations and an impairment of the hypothalamus-pituitary-adrenal (HPA) axis function. There was a positive correlation between the percent (%) reduction of AUC 0-24 of plasma cortisol and systemic exposure to budesonide both in pediatric and adult patients.

    Adults

    Plasma cortisol suppression was compared following five days' administration of budesonide capsules (enteric coated) and prednisolone in a crossover study in healthy volunteers. The mean decrease in the area under the plasma cortisol concentration-time curve over 24 hour (AUC0-24) was greater (78%) with prednisolone 20 mg per day compared to 45% with budesonide capsules (enteric coated) 9 mg per day.

    Pediatrics

    The effect of budesonide on endogenous cortisol concentrations was compared between pediatrics (n=8, aged 9 to 14 years) and adults (n=6) with active Crohn's disease following administration of budesonide capsules (enteric coated) 9 mg once daily for 7 days. Compared to baseline values before treatment, the mean decrease in the AUC0-24 of cortisol was 64% (±18%) in pediatrics and 50% (±27%) in adults after budesonide capsules (enteric coated) treatment [see Warnings and Precautions (5.1), Adverse Reactions (6.1) and Use in Specific Populations (8.4)].

    The responses to adrenocorticotropin challenge (i.e., ACTH stimulation test) was studied in pediatric patients aged 8 to 17 years, with mild to moderate active Crohn's disease in randomized, double-blind, active control study [see Clinical Studies (14.1)]. After 8 weeks of treatment with 9 mg once daily budesonide capsules (enteric coated) or with prednisolone, administered at tapering doses starting from 1 mg/kg, the proportion of patients with normal response to the ACTH challenge was 6% in the budesonide group compared to none in the prednisolone group; the proportion of patients with morning p-cortisol of greater than 5 mcg/dL was 50% in the budesonide group compared to 22% in the prednisolone group. The mean morning p-cortisol was 6.3 mcg/dL in the budesonide group and 2.6 mcg/dL in the prednisolone group (Table 4).

    Table 4 Proportion of Pediatric Patients 8 to 17 years old with Peak Endogenous Cortisol Levels (above 18 mcg/dL) after ACTH Stimulation and Normal Response* to ACTH Challenge Following Administration of Budesonide or Prednisolone for 8 weeks

    *The normal response to ACTH challenge included 3 criteria, as defined in the cosyntropin label:

    1) morning cortisol level above 5 mcg/dL; 2) increase in cortisol level by at least 7 mcg/dL above the morning (pre-challenge) level following ACTH challenge; and cortisol level of above 18 mcg/dL following ACTH challenge. Cortisol concentration was measured at 30 min after intravenous or intramuscular injection of 0.25 mg cosyntropin at baseline and at week 8 after treatment.

    		Budesonide
    		 Prednisolone
    Peak plasma cortisol above 18 mcg/dL
    At baseline
    		91% (20/22)
    		91% (21/23)
    At week 8
    		25% (4/16)
    		0% (0/18)
    Normal response* to ACTH challenge
    At baseline
    		73% (16/22)
    		78% (18/23)
    At week 8
    		6% (1/16)
    		0% (0/18)

    12.3 Pharmacokinetics

    Absorption

    Following administration of budesonide capsules (enteric coated), the time to peak concentration varied in individual patients between 30 and 600 minutes. Mean oral bioavailability of budesonide ranged from 9% to 21% both in patients and in healthy subjects, demonstrating a high first-pass elimination of the drug.

    Budesonide pharmacokinetics were dose-proportional following repeated administration in the dose range of 3 to 15 mg. No accumulation of budesonide was observed following repeated dosing.

    Following oral administration of a single dose of 9 mg budesonide capsules (enteric coated) in healthy subjects under fasting condition, the mean peak plasma concentration (Cmax) and the area under the plasma concentration time curve (AUC) for budesonide were 1.50 ± 0.79 ng/mL and 14.13 ± 7.33 nghr/mL, respectively. The time to peak concentration (Tmax) varied between 2 and 8 hours with a median value of 3.5 hours. In a different study, following oral administration of 9 mg budesonide capsules (enteric coated)  for five days in healthy subjects, the mean Cmax and the steady state AUC for budesonide were 2.28 ± 0.77 ng/mL and 15.93 ± 6.29 nghr/mL, respectively.

    Following administration of 9 mg budesonide capsules (enteric coated) once daily in patients with active Crohn's disease, the mean Cmax and AUC were 1.72 ± 0.90 ng/mL and 15.07 ± 8.52 nghr/mL, respectively.

    Concomitant administration of a high-fat meal delayed the Tmax of budesonide from budesonide capsules (enteric coated) by 2.3 hours but did not significantly affect the AUC in healthy subjects. The Cmax and AUC to budesonide was similar when single dose of budesonide capsules (enteric coated) (9 mg) were administered after opening capsule and sprinkling granules on applesauce versus as intact capsules in the fasted state (N=24) in healthy subjects.

    Distribution

    The mean volume of distribution (Vss) of budesonide varied between 2.2 and 3.9 L/kg in healthy subjects and in patients. Plasma protein binding was estimated to be 85% to 90% in the concentration range 0.43 to 99.02 ng/mL , independent of gender. The erythrocyte/plasma partition ratio at clinically relevant concentrations was about 0.8.

    Elimination

    Budesonide had a plasma clearance, 0.9 to 1.8 L/min in healthy adults. Mean plasma clearance after intravenous administration of budesonide in patients with Crohn's disease was 1.0 L/min. These plasma clearance values approached the estimated liver blood flow, and, accordingly, suggest that budesonide is a high hepatic clearance drug. The plasma elimination half-life, after administration of intravenous doses ranged between 2 and 3.6 hours, and did not differ between healthy adults and patients with Crohn's disease.

    Metabolism

    Following absorption, budesonide is subject to high first pass metabolism (80% to 90%). In vitro experiments in human liver microsomes demonstrated that budesonide is rapidly and extensively biotransformed, mainly by CYP3A4, to its 2 major metabolites, 6β-hydroxy budesonide and 16α-hydroxy prednisolone. The corticosteroid activity of these metabolites was negligible (less than 1/100) in relation to that of the parent compound. In vivo investigations with intravenous doses in healthy subjects were in agreement with the in vitro findings.

    Excretion

    Budesonide was excreted in urine and feces in the form of metabolites. After oral as well as intravenous administration of micronized [3H]-budesonide, approximately 60% of the recovered radioactivity was found in urine. The major metabolites, including 6β-hydroxy budesonide and 16α-hydroxy prednisolone, are mainly renally excreted, intact or in conjugated forms. No unchanged budesonide was detected in urine.

    Specific Populations

    Age: Pediatric Population (8 years and older)

    The pharmacokinetics of budesonide were investigated in pediatric patients aged 9 to 14 years (n=8) after oral administration of budesonide capsules (enteric coated) and intravenous administration of budesonide. Following administration of 9 mg budesonide capsules (enteric coated) once daily for 7 days, the median time to peak plasma concentration of budesonide was 5 hours and the mean peak plasma concentration was 2.58 ± 1.51 ng/mL. The mean AUC was 17.78 ± 5.25 nghr/mL and 17% higher than that in adult patients with Crohn's disease in the same study. The mean absolute oral availability was 9.2% (3 to 17%; n=4) in pediatric patients.

    After single dose administration of intravenous budesonide (n=4), the mean volume of distribution (Vss) was 2.2 ± 0.4 L/kg and mean clearance was 0.81 ± 0.2 L/min. The mean elimination half-life was 1.9 hours in pediatric patients. The body-weight normalized clearance in pediatric patients was 20.5 mL/min/kg in comparison to 15.9 mL/min/kg in adult patients after intravenous administration [see Warnings and Precautions (5.1), Use in Specific Population (8.4)].

    Hepatic Impairment

    In patients with mild (Child-Pugh Class A, n=4) or moderate (Child-Pugh Class B, n=4) hepatic impairment, budesonide 4 mg was administered orally as a single dose. The patients with moderate hepatic impairment had a 3.5-fold higher AUC compared to the healthy subjects with normal hepatic function while the patients with mild hepatic impairment had an approximately 1.4-fold higher AUC. The Cmax values demonstrated similar increases [see Dosage and Administration (2.4), Warnings and Precautions (5.1)]. The increased systemic exposure in patients with mild hepatic impairment was not considered to be clinically relevant. Patients with severe liver impairment (Child-Pugh Class C) were not studied.

    Drug Interaction Studies

    Budesonide is metabolized via CYP3A4. Potent inhibitors of CYP3A4 can increase the plasma concentrations of budesonide several-fold. Conversely, induction of CYP3A4 potentially could result in the lowering of budesonide plasma concentrations.

    Effects of Other Drugs on Budesonide

    Ketoconazole

    In an open, non-randomized, cross-over study, 6 healthy subjects were given budesonide 10 mg as a single dose, either alone or concomitantly with the last ketoconazole dose of 3 days treatment with ketoconazole 100 mg twice daily. Coadministration of ketoconazole resulted in an eight-fold increase in AUC of budesonide, compared to budesonide alone [see Drug Interactions (7.1)].

    Grapefruit Juice

    In an open, randomized, cross-over study, 8 healthy subjects were given budesonide capsules (enteric coated) 3 mg, either alone, or concomitantly with 600 mL concentrated grapefruit juice (which inhibits CYP3A4 activity predominantly in the intestinal mucosa), on the last of 4 daily administrations. Concomitant administration of grapefruit juice resulted in a 2-fold increase of the bioavailability of budesonide compared to budesonide alone [see Drug Interactions (7.1)].

    Oral Contraceptives (CYP3A4 Substrates)

    In a parallel study, the pharmacokinetics of budesonide were not significantly different between healthy female subjects who received oral contraceptives containing desogestrel 0.15 mg and ethinyl estradiol 30 μg and healthy female subjects who did not receive oral contraceptives. Budesonide 4.5 mg once daily (one-half the recommended dose) for one week did not affect the plasma concentrations of ethinyl estradiol, a CYP3A4 substrate. The effect of budesonide 9 mg once daily on the plasma concentrations of ethinyl estradiol was not studied.

    Omeprazole

    In a study in 11 healthy subjects, performed in a double-blind, randomized, placebo controlled manner, the effect of 5 to 6 days treatment with omeprazole 20 mg once daily on the pharmacokinetics of budesonide administered as budesonide capsules (enteric coated) 9 mg as a single dose was investigated. Omeprazole 20 mg once daily did not affect the absorption or pharmacokinetics of budesonide.

    Cimetidine

    In an open, non-randomized, cross-over study, the potential effect of cimetidine on the pharmacokinetics of budesonide was studied. Six healthy subjects received cimetidine 1 gram daily (200 mg with meals and 400 mg at night) for 2 separate 3-day periods. Budesonide 4 mg was administered either alone or on the last day of one of the cimetidine treatment periods. Coadministration of cimetidine resulted in a 52% and 31% increase in the budesonide peak plasma concentration and the AUC of budesonide, respectively.

  • 13 NONCLINICAL TOXICOLOGY

    13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

    Carcinogenicity studies with budesonide were conducted in rats and mice. In a two-year study in Sprague-Dawley rats, budesonide caused a statistically significant increase in the incidence of gliomas in male rats at an oral dose of 50 mcg/kg (approximately 0.05 times the maximum recommended human dose on a body surface area basis). In addition, there were increased incidences of primary hepatocellular tumors in male rats at 25 mcg/kg (approximately 0.023 times the maximum recommended human dose on a body surface area basis) and above. No tumorigenicity was seen in female rats at oral doses up to 50 mcg/kg (approximately 0.05 times the maximum recommended human dose on a body surface area basis). In an additional two-year study in male Sprague-Dawley rats, budesonide caused no gliomas at an oral dose of 50 mcg/kg (approximately 0.05 times the maximum recommended human dose on a body surface area basis). However, it caused a statistically significant increase in the incidence of hepatocellular tumors at an oral dose of 50 mcg/kg (approximately 0.05 times the maximum recommended human dose on a body surface area basis). The concurrent reference corticosteroids (prednisolone and triamcinolone acetonide) showed similar findings.  In a 91-week study in mice, budesonide caused no treatment-related carcinogenicity at oral doses up to 200 mcg/kg (approximately 0.1 times the maximum recommended human dose on a body surface area basis).

    Budesonide was not genotoxic in the Ames test, the mouse lymphoma cell forward gene mutation (TK+/-) test, the human lymphocyte chromosome aberration test, the Drosophila melanogaster sex-linked recessive lethality test, the rat hepatocyte UDS test and the mouse micronucleus test.

    In rats, budesonide had no effect on fertility at subcutaneous doses up to 80 mcg/kg (approximately 0.07 times the maximum recommended human dose on a body surface area basis). However, it caused a decrease in prenatal viability and viability in pups at birth and during lactation, along with a decrease in maternal body-weight gain, at subcutaneous doses of 20 mcg/kg (approximately 0.02 times the maximum recommended human dose on a body surface area basis) and above. No such effects were noted at 5 mcg/kg (approximately 0.005 times the maximum recommended human dose on a body surface area basis).

  • 14 CLINICAL STUDIES

    14.1 Treatment of Mild to Moderate Active Crohn’s Disease

    Adults

    The efficacy of budesonide capsules (enteric coated) were evaluated in 994 patients with mild to moderate active Crohn's disease of the ileum and/or ascending colon in 5 randomized and double-blind studies of 8 weeks duration. The study patients ranged in age from 17 to 85 (mean 35), 40% were male and 97% were white. The Crohn's Disease Activity Index (CDAI) was the main clinical assessment used for determining efficacy in these 5 studies.1The CDAI is a validated index based on subjective aspects rated by the patient (frequency of liquid or very soft stools, abdominal pain rating and general well-being) and objective observations (number of extraintestinal symptoms, need for antidiarrheal drugs, presence of abdominal mass, body weight and hematocrit). Clinical improvement, defined as a CDAI score of less than or equal to 150 assessed after 8 weeks of treatment, was the primary efficacy variable in these 5 comparative efficacy studies of budesonide capsules (enteric coated). Safety assessments in these studies included monitoring of adverse reactions. A checklist of potential symptoms of hypercorticism was used.

    One study (Study 1) compared the efficacy of budesonide capsules (enteric coated) 9 mg daily in the morning to a comparator. At baseline, the median CDAI was 272. budesonide capsules (enteric coated) 9 mg daily resulted in a significantly higher clinical improvement rate at Week 8 than the comparator. See Table 5.

    Table 5 Clinical Improvement Rates (CDAI less than or equal to 150) After 8 weeks of Treatment

    1. p=0.0004 compared to comparator.

    2. p=0.001 compared to placebo.

    3. This drug is not approved for the treatment of Crohn's disease in the United States.
    C li n i cal Study
    		Budesonide 9 mg Daily
    		Budesonide 4.5 mg Twice Daily

    C o m parator3
    		Placebo
    		Prednisolone
    1
    		 62/91 (69%)1
    		37/83 (45%)
    2
    		 31/61 (51%)2
    		13/64 (20%)
    3
    		 38/79 (48%)
    		 41/78 (53%)
    		 13/40 (33%)
    4
    		 35/58 (60%)
    		 25/60 (42%)
    		 35/58 (60%)
    5
    		 45/86 (52%)
    		 56/85 (65%)

    Two placebo-controlled clinical trials (Studies 2 and 3) were conducted. Study 2 involved 258 patients and tested the effects of graded doses of budesonide capsules (enteric coated) (1.5 mg twice daily, 4.5 mg twice daily, or 7.5 mg twice daily) versus placebo. At baseline, the median CDAI was 290. The 1.5 mg twice daily arm (data not shown) could not be differentiated from placebo. The 4.5 mg twice daily arm was statistically different from placebo (Table 5), while no additional benefit was seen when the daily budesonide capsules (enteric coated) dose was increased to 15 mg per day (data not shown). Study 3 was a 3-armed parallel group study. The groups were treated with budesonide capsules (enteric coated) 9 mg once daily, budesonide capsules (enteric coated) 4.5 mg twice daily and placebo for 8 weeks, followed by a 2-week double-blind taper phase. The median CDAI at baseline was 263. Neither 9 mg daily nor 4.5 mg twice daily budesonide capsules (enteric coated) dose levels were statistically different from placebo (Table 5). The recommended dosage of budesonide capsules (enteric coated) for the treatment of mild to moderate active Crohn's disease involving the ileum and/or the ascending colon in adults is 9 mg once daily in the morning for up to 8 weeks [see Dosage and Administration (2.1)].

    Two clinical trials (Studies 4 and 5) compared budesonide capsules (enteric coated) with oral prednisolone (initial dose 40 mg per day). Study 4 was a 3-armed parallel group study. The groups were treated with budesonide capsules (enteric coated) 9 mg once daily, budesonide capsules (enteric coated) 4.5 mg twice daily and prednisolone 40 mg (tapered dose) for 8 weeks, followed by a 4-week double blind taper phase. At baseline, the median CDAI was 277. Equal clinical improvement rates (60%) were seen in the budesonide capsules (enteric coated) 9 mg daily and the prednisolone groups in Study 4. In Study 5, 13% fewer patients in the budesonide capsules (enteric coated) group experienced clinical improvement than in the prednisolone group (no statistical difference) (Table 5).

    The proportion of patients with normal plasma cortisol values (greater than 64.58 ng/mL) was significantly higher in the budesonide capsules (enteric coated) groups in both trials (60% to 66%) than in the prednisolone groups (26% to 28%) at Week 8.

    Pediatrics (8 to 17 Years of Age)

    The effectiveness of budesonide capsules (enteric coated), in pediatric patients aged 8 to 17 years, who weigh more than 25 kg with mild to moderate active Crohn's disease (defined as Crohn's Disease Activity Index (CDAI) ≥ 200) involving the ileum and/or the ascending colon, was assessed in one randomized, double-blind, active control study. This study compared budesonide capsules (enteric coated) 9 mg once daily, with prednisolone, administered at tapering doses starting from 1 mg/kg. Twenty-two (22) patients were treated with budesonide capsules (enteric coated) capsules and 24 patients were treated with prednisolone. After 8 weeks of treatment, 55% (95% CI: 32%, 77%) of patients treated with budesonide capsules (enteric coated) reached the endpoint (CDAI ≤150), as compared to 68% (95% CI: 47%, 89%) of patients treated with prednisolone. The average number of liquid or very soft stools per day (assessed over 7 days) decreased from 1.49 at baseline to 0.96 after treatment with budesonide capsules (enteric coated) and 2.00 at baseline to 0.52 after treatment with prednisolone. The average daily abdominal pain rating (where 0=none, 1=mild, 2=moderate, and 3=severe) decreased from 1.49 at baseline to 0.54 after treatment with budesonide capsules (enteric coated) and 1.64 at baseline to 0.38 after 8 weeks of treatment with prednisolone.

    Use of budesonide capsules (enteric coated) in this age group is supported by evidence from adequate and well-controlled studies of budesonide capsules (enteric coated) in adults, and by safety and pharmacokinetic studies performed in pediatric patients.

    14.2 Maintenance of Clinical Remission of Mild to Moderate Crohn’s Disease

    Adults

    The efficacy of budesonide capsules (enteric coated) for maintenance of clinical remission were evaluated in four double-blind, placebo-controlled, 12-month trials in which 380 patients were randomized and treated once daily with 3 mg or 6 mg budesonide capsules (enteric coated) or placebo. Patients ranged in age from 18 to 73 (mean 37)  years. Sixty percent of the patients were female and 99% were Caucasian. The mean CDAI at entry was 96. Among the four clinical trials, approximately 75% of the patients enrolled had exclusively ileal disease. Colonoscopy was not performed following treatment. Budesonide capsules (enteric coated) 6 mg per day prolonged the time to relapse, defined as an increase in CDAI of at least 60 units to a total score greater than 150 or withdrawal due to disease deterioration. The median time to relapse in the pooled population of the 4 studies was 154 days for patients taking placebo, and 268 days for patients taking budesonide capsules (enteric coated) 6 mg per day. Budesonide capsules (enteric coated) 6 mg per day reduced the proportion of patients with loss of symptom control relative to placebo in the pooled population for the 4 studies at 3 months (28% versus 45% for placebo).

  • 15 REFERENCES

    1. Best WR, Becktel JM, Singleton JW, Kern F: Development of a Crohn's Disease Activity Index, National Cooperative Crohn's Disease Study. Gastroenterology 1976; 70(3): 439-444.
  • 16 HOW SUPPLIED/STORAGE AND HANDLING

    Budesonide Extended-Release Capsules (Enteric Coated) 3 mg are white to off-white, free flowing pellets, filled in size '1' hard gelatin capsules having opaque light-orange colored cap printed with "720" in black ink and opaque white body and are supplied as follows:

    NDC: 16714-829-01 in bottle of 100 capsules

    Store at 20°C to 25°C (68°F to 77°F) [See USP Controlled Room Temperature].

    Keep container tightly closed.

  • 17 PATIENT COUNSELING INFORMATION

    Advise Patients to read the FDA-Approved patient labeling (Patient Information).

    Hypercorticism and Adrenal Axis Suppression

    Advise patients that budesonide capsules (enteric coated) may cause hypercorticism and adrenal axis suppression and to follow a taper schedule, as instructed by their healthcare provider if transferring to budesonide capsules (enteric coated) from systemic corticosteroids [see Warnings and Precautions (5.1), (5.2)]. Advise patients that replacement of systemic corticosteroids with budesonide capsules (enteric coated) may unmask allergies (e.g., rhinitis and eczema), which were previously controlled by the systemic drug.

    Increased Risk of Infection

    Advise patients to avoid exposure to people with chicken pox or measles and, if exposed, to consult their healthcare provider immediately. Inform patients that they are at increased risk of developing a variety of infections; including worsening of existing tuberculosis, fungal, bacterial, viral or parasitic infections or ocular herpes simplex and to contact their healthcare provider if they develop any symptoms of infection [see Warnings and Precautions (5.3)].

    Pregnancy

    Advise female patients that budesonide capsules (enteric coated) may cause fetal harm and to inform their healthcare provider with a known or suspected pregnancy [see Use in Specific Populations (8.1)].

    Administration

    • Take budesonide capsules (enteric coated) once daily in the morning.
    • Swallow budesonide extended-release capsules (enteric coated) capsules whole. Do not chew or crush.
    • Avoid consumption of grapefruit juice for the duration of their budesonide capsules (enteric coated) therapy [see Drug Interactions (7.1)] .

    Manufactured for:

    Northstar Rx LLC

    Memphis, TN 38141

    Manufactured by:

    Cadila Healthcare Ltd.

    Ahmedabad, India.

    Rev.05/2019

    PATIENT INFORMATION

    Budesonide (bew-DEH-so-nide) Extended-Release Capsules (Enteric Coated)

    Read this Patient Information before you start taking budesonide capsules (enteric coated) and each time you get a refill. There may be new information. This information does not take the place of talking to your healthcare provider about your medical condition or your treatment.

    What are Budesonide Capsules (enteric coated)?

    Budesonide capsules (enteric coated) are prescription corticosteroid medicine used to treat mild to moderate Crohn's disease that affects part of the small intestine (ileum) and part of the large intestine (ascending colon):

    • in people 8 years of age and older with active Crohn's disease
    • in adults to help keep symptoms from coming back for up to 3 months

    It is not known if budesonide capsules (enteric coated) are safe and effective in children under 8 years of age, or in children 8 to 17 years of age who weigh 55 pounds (25 kg) or less, for the treatment of mild to moderate active Crohn's disease that affects part of the small intestine (ileum) and part of the large intestine (ascending colon).

    It is not known if budesonide capsules (enteric coated) are safe and effective in children to help keep symptoms of mild to moderate Crohn's disease that affects part of the small intestine (ileum) and part of the large intestine (ascending colon) from coming back.

    Who should not take Budesonide Capsules (enteric coated)?

    Do not take Budesonide Capsules (enteric coated) if:

    • you are allergic to budesonide or any of the ingredients in budesonide capsules (enteric coated). See the end of this leaflet for a complete list of ingredients in budesonide capsules (enteric coated).

    What should I tell my healthcare provider before taking Budesonide Capsules (enteric coated)?

    Before you take Budesonide Capsules (enteric coated) tell your healthcare provider if you have any other medical conditions including if you:

    • have liver problems.
    • are planning to have surgery.
    • have chicken pox or measles or have recently been near anyone with chicken pox or measles.
    • have an infection.
    • have diabetes or glaucoma or have a family history of diabetes or glaucoma.
    • have cataracts.
    • have or had tuberculosis.
    • have high blood pressure (hypertension).
    • have decreased bone mineral density (osteoporosis).
    • have stomach ulcers.
    • have any other medical condition.
    • are pregnant or plan to become pregnant. Budesonide capsules (enteric coated) may harm your unborn baby. Talk to your healthcare provider about the possible risk to your unborn baby if you take budesonide capsules (enteric coated) when you are pregnant. Tell your healthcare provider right away if you become pregnant or think you may be pregnant during your treatment with budesonide capsules (enteric coated).
    • are breastfeeding or plan to breastfeed. It is not known if budesonide capsules (enteric coated) passes into your breast milk or if it will affect your baby. Talk to your healthcare provider about the best way to feed your baby if you take budesonide capsules (enteric coated).

    Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. Budesonide capsules (enteric coated) and other medicines may affect each other causing side effects.

    How should I take Budesonide Capsules (enteric coated)?

    • Take budesonide capsules (enteric coated) exactly as your healthcare provider tells you.
    • Your healthcare provider will tell you how many budesonide capsules (enteric coated) to take. Your healthcare provider may change your dose if needed.
    • Take budesonide capsules (enteric coated) 1 time each day in the morning.
    • Take budesonide capsules (enteric coated) whole. Do not chew or crush budesonide capsules (enteric coated) before swallowing.
    • If you take too much budesonide capsules (enteric coated) call your healthcare provider right away or go to the nearest hospital emergency room.

    What should I avoid while taking Budesonide Capsules (enteric coated)?

    • Do not drink grapefruit juice during your treatment with budesonide capsules (enteric coated). Drinking grapefruit juice can increase the level of budesonide capsules (enteric coated) in your blood.

    What are the possible side effects of Budesonide Capsules (enteric coated)?

    Budesonide Capsules (enteric coated) may cause serious side effects, including:

    • Effects of having too much corticosteroid medicine in your blood (hypercorticism) . Long-time use of budesonide capsules (enteric coated) can cause you to have too much corticosteroid medicine in your blood. Tell your healthcare provider if you have any of the following signs and symptoms of hypercorticism:
    • acne
    • bruise easily
    • rounding of your face (moon face)
    • ankle swelling
    • thicker or more hair on your body and face
    • a fatty pad or hump between your shoulders (buffalo hump)
    • pink or purple stretch marks on the skin of your abdomen, thighs, breasts and arms
    • Adrenal suppression . When budesonide capsules (enteric coated) are taken for a long period of time (chronic use), adrenal suppression can happen. This is a condition in which the adrenal glands do not make enough steroid hormones. Symptoms of adrenal suppression include: tiredness, weakness, nausea and vomiting and low blood pressure. Tell your healthcare provider if you are under stress or have any symptoms of adrenal suppression during treatment with budesonide capsules (enteric coated).
    • Worsening of allergies . If you take certain other corticosteroid medicines to treat allergies, switching to budesonide capsules (enteric coated) may cause your allergies to come back. These allergies may include a skin condition called eczema or inflammation inside your nose (rhinitis). Tell your healthcare provider if any of your allergies become worse while taking budesonide capsules (enteric coated).
    • Increased risk of infection . Budesonide capsules (enteric coated) weakens your immune system. Taking medicines that weaken your immune system makes you more likely to get infections. Avoid contact with people who have contagious diseases, such as chicken pox or measles, while taking budesonide capsules (enteric coated). Tell your healthcare provider right away if you come in contact with anyone who has chicken pox or measles.

    Tell your healthcare provider about any signs or symptoms of infection during treatment with budesonide capsules (enteric coated), including:

    • fever
    • chills
    • pain
    • feeling tired
    • aches
    • nausea and vomiting

    The most common side effects of Budesonide Capsules (enteric coated) in adults include:

    • headache
    • stomach area (abdominal) pain
    • infection in your air passages (respiratory infection)
    • gas
    • nausea
    • vomiting
    • back pain
    • tiredness
    • indigestion
    • pain
    • dizziness

    The most common side effects of budesonide capsules (enteric coated) in children 8 to 17 years of age, who weigh more than 55 pounds (25 kg), are similar to the most common side effects in adults.

    Tell your healthcare provider if you have any side effect that bothers you or that does not go away. These are not all the possible side effects of budesonide capsules (enteric coated). For more information, ask your healthcare provider or pharmacist.

    Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

    How should I store Budesonide Capsules (enteric coated)?

    • Store budesonide capsules (enteric coated) at room temperature between 68°F to 77°F (20°C to 25°C).
    • Keep budesonide capsules (enteric coated) in a tightly closed container.

    Keep Budesonide Capsules (enteric coated) and all medicines out of the reach of children.

    General information about the safe and effective use of Budesonide Capsules (enteric coated).

    Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide or Patient Information leaflet. Do not use budesonide capsules (enteric coated) for a condition for which it was not prescribed. Do not give budesonide capsules (enteric coated) to other people, even if they have the same symptoms that you have. It may harm them. You can ask your pharmacist or healthcare provider for information about budesonide capsules (enteric coated) that is written for health professionals.

    Please address medical inquiries to, Northstar Rx LLC at Tel.: 1-800-206-7821.

    What are the ingredients in Budesonide Capsules (enteric coated)?

    Active ingredient: budesonide, USP

    Inactive ingredients: acetyltributyl citrate, ethylcellulose aqueous dispersion, gelatin, iron oxide red, iron oxide yellow, methacrylic acid copolymer dispersion, polysorbate 80, simethicone emulsion, sodium lauryl sulfate, sugar spheres, talc, titanium dioxide and triethyl citrate. The capsule shell is printed with black pharmaceutical ink which contains following ingredients: butyl alcohol, dehydrated alcohol, iron oxide black, isopropyl alcohol, potassium hydroxide, propylene glycol, shellac and strong ammonia solution and purified water.

    This Patient Information has been approved by the U.S. Food and Drug Administration.

  • SPL UNCLASSIFIED SECTION

    Manufactured for:

    Northstar Rx LLC

    Memphis, TN 38141

    Manufactured by:

    Cadila Healthcare Ltd.

    Ahmedabad, India.

    Rev.05/2019

  • PACKAGE LABEL.PRINCIPAL DISPLAY PANEL

    NDC: 16714-829-01 in bottle of 100 capsules

    Budesonide extended-release capsules (enteric coated) 3 mg

    Rx only

    Budesonide Capsules label
  • INGREDIENTS AND APPEARANCE
    BUDESONIDE 
    budesonide capsule, coated pellets
    Product Information
    Product TypeHUMAN PRESCRIPTION DRUGItem Code (Source)NDC: 16714-829
    Route of AdministrationORAL
    Active Ingredient/Active Moiety
    Ingredient NameBasis of StrengthStrength
    BUDESONIDE (UNII: Q3OKS62Q6X) (BUDESONIDE - UNII:Q3OKS62Q6X) BUDESONIDE3 mg
    Inactive Ingredients
    Ingredient NameStrength
    ACETYLTRIBUTYL CITRATE (UNII: 0ZBX0N59RZ)  
    ALCOHOL (UNII: 3K9958V90M)  
    AMMONIA (UNII: 5138Q19F1X)  
    BUTYL ALCOHOL (UNII: 8PJ61P6TS3)  
    DIMETHICONE (UNII: 92RU3N3Y1O)  
    ETHYLCELLULOSES (UNII: 7Z8S9VYZ4B)  
    FERRIC OXIDE RED (UNII: 1K09F3G675)  
    FERRIC OXIDE YELLOW (UNII: EX438O2MRT)  
    FERROSOFERRIC OXIDE (UNII: XM0M87F357)  
    GELATIN (UNII: 2G86QN327L)  
    ISOPROPYL ALCOHOL (UNII: ND2M416302)  
    METHACRYLIC ACID - ETHYL ACRYLATE COPOLYMER (1:1) TYPE A (UNII: NX76LV5T8J)  
    POLYSORBATE 80 (UNII: 6OZP39ZG8H)  
    POTASSIUM HYDROXIDE (UNII: WZH3C48M4T)  
    PROPYLENE GLYCOL (UNII: 6DC9Q167V3)  
    SHELLAC (UNII: 46N107B71O)  
    SODIUM LAURYL SULFATE (UNII: 368GB5141J)  
    SUCROSE (UNII: C151H8M554)  
    TALC (UNII: 7SEV7J4R1U)  
    TITANIUM DIOXIDE (UNII: 15FIX9V2JP)  
    TRIETHYL CITRATE (UNII: 8Z96QXD6UM)  
    WATER (UNII: 059QF0KO0R)  
    Product Characteristics
    ColorORANGE (OPAQUE LIGHT-ORANGE) , WHITE (OPAQUE WHITE) Scoreno score
    ShapeCAPSULE (CAPSULE) Size19mm
    FlavorImprint Code 720
    Contains    
    Packaging
    #Item CodePackage DescriptionMarketing Start DateMarketing End Date
    1NDC: 16714-829-01100 in 1 BOTTLE; Type 0: Not a Combination Product06/25/2018
    Marketing Information
    Marketing CategoryApplication Number or Monograph CitationMarketing Start DateMarketing End Date
    ANDAANDA20613406/25/2018
    Labeler - Northstar Rx LLC. (830546433)
    Registrant - Zydus Pharmaceuticals (USA) Inc. (156861945)
    Establishment
    NameAddressID/FEIBusiness Operations
    Cadila Healthcare Limited863362789ANALYSIS(16714-829) , MANUFACTURE(16714-829)
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