1. Name Of The Medicinal Product
Budenofalk® 2mg/dose rectal foam
2. Qualitative And Quantitative Composition
Each dose of 1.2 g foam contains 2 mg of budesonide
Excipients: cetyl alcohol, propylene glycol
For a full list of excipients, see section 6.1.
3. Pharmaceutical Form
Rectal foam, pressurised container
White to pale white, creamy firm foam
4. Clinical Particulars
4.1 Therapeutic Indications
For the treatment of active ulcerative colitis that is limited to the rectum and the sigmoid colon
4.2 Posology And Method Of Administration
Posology:
Adults aged> 18 years:
One actuation of 2 mg budesonide daily.
Children and adolescents:
Budenofalk® 2mg rectal foam should not be taken by children due to insufficient experience in this age group.
Method of Administration:
Budenofalk® 2mg rectal foam can be applied in the morning or evening.
The canister is first fitted with an applicator and then shaken for about 15 seconds before the applicator is inserted into the rectum as far as comfortable. Note that the dose is only sufficiently accurate when the pump dome is held downwards as vertically as possible. To administer a dose of Budenofalk®2mg rectal foam, the pump dome is fully pushed down and very slowly released. Following the activation the applicator should be held in position for 10-15 seconds before being withdrawn from the rectum.
The best results are obtained when the intestine is evacuated prior to administration of Budenofalk® 2mg rectal foam.
The attending physician determines the duration of use. An acute episode generally subsides after 6 to 8 weeks. Budenofalk® 2mg rectal foam should not be used after this time.
4.3 Contraindications
Budenofalk® 2mg rectal foam must not be used in:
- hypersensitivity to budesonide or any of the ingredients
- hepatic cirrhosis with signs of portal hypertension, e.g. late-stage primary biliary cirrhosis
4.4 Special Warnings And Precautions For Use
Treatment with Budenofalk® 2mg rectal foam results in lower systemic steroid levels than oral therapy with systemically acting corticoids. If a patient is transferred from systemic corticoids to Budenofalk, the theoretical risk of recurrence of symptoms due to differences in the pharmacokinetics has to be taken into account.
Caution is required in patients with tuberculosis, hypertension, diabetes mellitus, osteoporosis, peptic ulcer, glaucoma, cataracts, family history of diabetes, family history of glaucoma.
Infection:
Suppression of the inflammatory response and immune function increases the susceptibility to infections and their severity. The risk of deterioration of bacterial, fungal, amoebic, and viral infections during glucocorticoid treatment should be carefully considered. The clinical presentation may often be atypical and serious infections such as septicaemia and tuberculosis may be masked and may reach an advanced stage before being recognised.
Chickenpox: Chickenpox is of particular concern since this normally minor illness may be fatal in immunosuppressed patients. Patients without a definite history of chickenpox should be advised to avoid close personal contact with chickenpox or herpes zoster and if exposed they should seek urgent medical attention. If the patient is a child, parents must be given the above advice. Passive immunisation with varicella-zoster immunoglobulin (VZIG) is needed by exposed non-immune patients who are receiving systemic corticosteroids or who have used them within the previous 3 months; this should be given within 10 days of exposure to chickenpox. If a diagnosis of chickenpox is confirmed, the illness warrants specialist care and urgent treatment. In some cases corticosteroids should not be stopped and the dose may need to be increased.
Measles:Patients with compromised immunity who have come into contact with measles should, wherever possible, receive normal immunoglobulin as soon as possible after exposure.
Live vaccines: Live vaccines should not be given to individuals with impaired immune responsiveness. The antibody response to other vaccines may be diminished.
In patients with severe liver function disorders, the elimination of glucocorticoids including Budenofalk® 2mg rectal foam will be reduced, and their systemic bioavailability will be increased.
Caution should be exercised in patients with slight to moderate hepatic impairment.
Corticosteroids may cause suppression of the HPA axis and reduce the stress response. Where patients are subject to surgery or other stresses, supplementary systemic glucocorticoid treatment is recommended.
Concomitant treatment with ketoconazole or other CYP3A4 inhibitors should be avoided (see section 4.5).
4.5 Interaction With Other Medicinal Products And Other Forms Of Interaction
Pharmacodynamic interactions
Cardiac glycosides:
The action of the glycoside can be potentiated by potassium deficiency.
Saluretics:
Potassium excretion can be enhanced.
Pharmacokinetic interactions
Cytochrome P450:
- CYP3A4 inhibitors:
Ketoconazole 200 mg once daily p.o. increased the plasma concentrations of budesonide (3 mg single dose) approximately 6-fold during concomitant administration. When ketoconazole was administered 12 hours after budesonide, the concentrations increased approximately 3-fold. As there are not enough data to give dose recommendations, the combination should be avoided.
Other potent inhibitors of CYP3A4 such as ritonavir, itraconazole, and clarithromycin are also likely to give a marked increase of the plasma concentrations of budesonide. In addition, concomitant intake of grapefruit juice should be avoided.
- CYP3A4 inducers:
Compounds or drugs such as carbamazepine and rifampicin, which induce CYP3A4, might reduce the systemic but also the local exposure of budesonide at the gut mucosa. An adjustment of the budesonide dose might be necessary.
- CYP3A4 substrates:
Compounds or drugs which are metabolized by CYP3A4 might be in competition with budesonide. This might lead to an increased budesonide plasma concentration if the competing substance has a stronger affinity to CYP3A4, or - if budesonide binds stronger to CYP3A4 - the competing substance might be increased in plasma and a dose-adaptation/reduction of this drug might be required.
Elevated plasma concentrations and enhanced effects of corticosteroids have been reported in women also receiving oestrogens or oral contraceptives, but this has not been observed with oral low dose combination contraceptives.
4.6 Pregnancy And Lactation
Administration during pregnancy should be avoided unless there are compelling reasons for Budenofalk® 2mg rectal foam therapy. In pregnant animals, budesonide, like other glucocorticosteroids, has been shown to cause abnormalities of foetal development. The relevance of this to man has not been established.
It is not known if budesonide passes into breastmilk. A decision on whether to continue/discontinue breast-feeding or to continue/discontinue therapy with Budenofalk 2mg rectal foam should be made taking into account the benefit of breast-feeding to the child and the benefit of the therapy to the woman.
4.7 Effects On Ability To Drive And Use Machines
No effects are known.
4.8 Undesirable Effects
The assessment of undesirable effects is based on the following frequencies.
Very common: (
Common: (
Uncommon: (
Rare: (
Very rare: (<1/10,000), not known (cannot be estimated from the available data)
Undesirable effects were reported in 8% of patients in clinical trials with Budenofalk rectal foam. Burning in the rectum or pain were common and nausea, headache, increase in liver enzymes were uncommon.
The details of the side effects observed during clinical trials are as follows:
Infections and parasitic diseases
Uncommon: urinary tract infections
Blood and lymphatic system disorders
Uncommon: anaemia, increase in erythrocyte sedimentation rate, leukocytosis
Metabolism and nutrition disorders
Uncommon: increased appetite
Psychiatric disorders
Uncommon: insomnia
Nervous system disorders
Uncommon: headache, dizziness, disturbances of smell
Vascular disorders
Uncommon: hypertension
Gastrointestinal disorders
Uncommon: nausea, abdominal pain, dyspepsia, flatulence, paraesthesias in the abdominal region, anal fissure, aphthous stomatitis, frequent urge to defecate, haemorrhoids, rectal bleeding
Hepatobiliary disorders
Uncommon: increase in transaminases (GOT, GPT), increase in parameters of cholestasis (GGT, AP)
Skin and subcutaneous tissue disorders
Uncommon: acne, increased sweating
Investigations
Uncommon: increase in amylase, change in cortisol
General disorders and administration site conditions
Common: burning in the rectum and pain
Uncommon: asthenia, increase in body weight
Occasionally side effects may occur which are typical for systemically acting glucocorticosteroids. The side effects listed below depend on the dosage, the period of treatment, concomitant or previous treatment with other glucocorticosteroids and the individual sensitivity.
Immune system disorders:
Interference with the immune response (e.g. increase in risk of infections).
An exacerbation or the reappearance of extraintestinal manifestations (especially affecting skin and joints) can occur on switching a patient from the systemically acting glucocorticosteroids to the locally acting budesonide.
Metabolism and nutrition disorders:
Cushing's syndrome: moon-face, truncal obesity, reduced glucose tolerance, diabetes mellitus, sodium retention with oedema formation, increased excretion of potassium, inactivity or atrophy of the adrenal cortex, growth retardation in children, disturbance of sex hormone secretion (e.g. amenorrhoea, hirsutism, impotence)
Nervous system disorders:
depression, irritability, euphoria
in isolated cases (< 1/10,000): pseudotumor cerebri (including papilloedema) in adolescents.
Eye disorders:
glaucoma, cataract
Vascular disorders:
hypertension, increased risk of thrombosis, vasculitis (withdrawal syndrome after long-term therapy)
Gastro intestinal disorders:
stomach complaints, duodenal ulcer, pancreatitis, constipation
Skin and subcutaneous tissue disorders:
allergic exanthema, red striae, petechiae, ecchymoses, steroid acne, delayed wound healing.
Due to the cetyl alcohol and propylene glycol content local skin reactions may occur, e.g. contact dermatitis.
Musculoskeletal, connective tissue and bone disorders :
aseptic necrosis of bone (femur and head of the humerus), diffuse muscle pain and weakness, osteoporosis.
General disorders:
Tiredness, malaise.
Some of the undesired effects were reported after long-term use of orally administered budesonide.
Due to its local action, the risk of unwanted effects of Budenofalk® 2mg rectal foam is generally lower than when taking systemically acting glucocorticoids.
4.9 Overdose
To date, no cases of overdosage with budesonide are known. In view of the properties of budesonide contained in Budenofalk® 2mg rectal foam, an overdose resulting in toxic damage is extremely unlikely.
5. Pharmacological Properties
5.1 Pharmacodynamic Properties
Pharmacotherapeutic group: Corticosteroids acting locally
ATC code: A07EA06
The exact mechanism of action of budesonide in the treatment of ulcerative colitis/procto-sigmoiditis is not fully understood. Data from clinical pharmacology studies and controlled clinical trials strongly indicate that the mode of action of budesonide is predominantly based on a local action in the gut. Budesonide is a glucocorticosteroid with a high local anti-inflammatory effect. At a dosage of 2 mg budesonide, applied rectally, budesonide leads to practically no suppression of the hypothalamus-hypophysis-adrenal cortex axis.
Budenofalk® 2mg rectal foam investigated up to the daily dosage of 4 mg budesonide showed virtually no influence on the plasma cortisol level.
5.2 Pharmacokinetic Properties
Absorption:
After oral application the systemic availability of budesonide is about 10%. After rectal administration the areas under the concentration time curves are about 1.5-fold higher than in historical controls considering the identical oral budesonide dose. Peak levels are obtained after an average of 2-3 hours after administering Budenofalk® 2mg rectal foam.
Distribution:
Budesonide has a high volume of distribution (about 3 l/kg). Plasma protein binding averages 85 -90%.
Biotransformation:
Budesonide undergoes extensive biotransformation in the liver (approximately 90 %) to metabolites of low glucocorticosteroid activity. The glucocorticosteroid activity of the major metabolites, 6β-hydroxybudesonide and 16α-hydroxyprednisolone, is less than 1 % of that of budesonide.
Elimination:
The average elimination half-life is about 3 - 4 hours. The mean clearance rate is about 10 -15 l/min for budesonide, determined by HPLC-based methods.
Spread:
A scintigraphic investigation with technetium-marked Budenofalk® 2mg rectal foam on patients with ulcerative colitis showed that the foam spreads out over the entire sigmoid.
Specific patient populations (liver diseases):
Dependent on the type and severity of liver diseases the metabolism of budesonide might be decreased.
5.3 Preclinical Safety Data
Preclinical investigations on dogs have shown that Budenofalk® 2mg rectal foam is well tolerated locally.
Preclinical data in acute, subchronic and chronic toxicological studies with budesonide showed atrophies of the thymus gland and adrenal cortex and a reduction especially of lymphocytes. These effects were less pronounced or at the same magnitude as observed with other glucocorticosteroids. These steroid effects might also be of relevance in man.
Budesonide had no mutagenic effects in a number of in vitro and in vivo tests.
A slightly increased number of basophilic hepatic foci were observed in chronic rat studies with budesonide, and in carcinogenicity studies there was an increased incidence of primary hepatocellular neoplasms, astrocytomas (in male rats) and mammary tumours (female rats) observed. These tumours are probably due to the specific steroid receptor action, increased metabolic burden on the liver and anabolic effects, effects which are also known from other glucocorticosteroids in rat studies and therefore represent a class effect. No similar effects have ever been observed in man for budesonide, neither in clinical trials nor from spontaneous reports.
In general, preclinical data reveal no special hazard for humans based on conventional studies of safety pharmacology, repeated dose toxicity, genotoxicity, carcinogenic potential.
In pregnant animals, budesonide, like other glucocorticosteroids, has been shown to cause abnormalities of foetal development, but the relevance to man has not been established (see also section 4.6).
6. Pharmaceutical Particulars
6.1 List Of Excipients
Cetyl alcohol
Citric acid monohydrate
Disodium edetate
Emulsifying wax
Macrogol stearyl ether
Propylene glycol
Purified water
Propellant:
n-Butane
Isobutane
Propane
6.2 Incompatibilities
Not applicable.
6.3 Shelf Life
2 years
After first opening: 4 weeks.
6.4 Special Precautions For Storage
Do not store above 25 °C.
Do not refrigerate or freeze.
This is a pressurised container, containing of inflammable propellant.
Do not expose to temperature higher than 50°C, protect from direct sunlight. Do not pierce or burn even when empty.
6.5 Nature And Contents Of Container
Aluminium pressurised container with metering valve together with 14 PVC applicators coated with white soft paraffin and liquid paraffin for administration of the foam and 14 plastic bags for hygienic disposal of the applicators.
Pack sizes:
Original pack with 1 pressurised container, contains at least 14 doses of 1.2 g rectal foam each.
Original pack with 2 pressurised containers, contains at least 2 x 14 doses of 1.2 g rectal foam each.
Hospital pack with 1 pressurised container, contains at least 14 doses of 1.2 g rectal foam each.
Not all pack sizes may be marketed.
6.6 Special Precautions For Disposal And Other Handling
No special requirements
7. Marketing Authorisation Holder
Dr. Falk Pharma GmbH
Leinenweberstr. 5
Postfach 6529
D-79041 Freiburg
Germany
8. Marketing Authorisation Number(S)
PL 08637/0011
9. Date Of First Authorisation/Renewal Of The Authorisation
15/06/2006
10. Date Of Revision Of The Text
July 2009.
11 DOSIMETRY (IF APPLICABLE)
Not applicable
12 INSTRUCTIONS FOR PREPARATION OF RADIOPHARMACEUTICALS (IF APPLICABLE)
Not applicable
