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Gastrointestinal (Other)

Alosetron (Lotronex®) Alvimopan - ENTEREG® capsule
infliximab (Remicade ®) Mesalamine (Asacol ®,Pentasa)
misoprostol (Cytotec ® ) Neomycin
octreotide (Sandostatin ®) olsalazine (Dipentum ® )
Orlistat (Xenical ®) sucralfate (Carafate ® )
Sulfasalazine (Azulfadine ®) Ursodiol (Actigall ®)
vasopressin (Pitressin ®) --
Please see package insert for additional information and possible updates. The authors make no claims of the accuracy of the information contained herein; and these suggested doses are not a substitute for clinical judgment. Neither GlobalRPh Inc. nor any other party involved in the preparation of this program shall be liable for any special, consequential, or exemplary damages resulting in whole or part from any user's use of or reliance upon this material. PLEASE READ THE DISCLAIMER CAREFULLY BEFORE ACCESSING OR USING THIS SITE. BY ACCESSING OR USING THIS SITE, YOU AGREE TO BE BOUND BY THE TERMS AND CONDITIONS SET FORTH IN THE DISCLAIMER.    [  Read the disclaimer    |   <<Back     ]

Alosetron (Lotronex®) top of page

Drug Category: Selective 5-HT3 Receptor Antagonist.  Indication: Treatment of women with severe diarrhea-predominant irritable bowel syndrome (IBS) who have failed to respond to conventional therapy

Dosing (Adults) IBS: Female: Oral: Initial: 0.5 mg twice daily for 4 weeks, with or without food; if tolerated, but response is inadequate, may be increased after 4 weeks to 1 mg twice daily. If response is inadequate after 4 weeks of 1 mg twice-daily dosing, discontinue treatment.  Note: Discontinue immediately if constipation or signs/symptoms of ischemic colitis occur. Do not reinitiate in patients who develop ischemic colitis.

Renal Dosing: The need for dosage adjustment has not been defined (due to limited information on activity of metabolites).


Supplied: Tablet: 0.5 mg, 1 mg

Alvimopan - ENTEREG® capsule top of page

Local monograph

infliximab (Remicade ®): top of page

CLINICAL PHARMACOLOGY
General
Infliximab neutralizes the biological activity of TNFalpha by binding with high affinity to the soluble and transmembrane forms of TNFalpha and inhibits binding of TNFalpha with its receptors. Infliximab does not neutralize TNFbeta (lymphotoxin alpha), a related cytokine that utilizes the same receptors as TNFalpha. Biological activities attributed to TNFalpha include: induction of pro-inflammatory cytokines such as interleukins (IL) 1 and 6, enhancement of leukocyte migration by increasing endothelial layer permeability and expression of adhesion molecules by endothelial cells and leukocytes, activation of neutrophil and eosinophil functional activity, induction of acute phase reactants and other liver proteins, as well as tissue degrading enzymes produced by synoviocytes and/or chondrocytes. Cells expressing transmembrane TNFalpha bound by infliximab can be lysed in vitro or in vivo. Infliximab inhibits the functional activity of TNFalpha in a wide variety of in vitro bioassays utilizing human fibroblasts, endothelial cells, neutrophils, B and T lymphocytes and epithelial cells. The relationship of these biological response markers to the mechanism(s) by which REMICADE exerts its clinical effects is unknown. Anti-TNFalpha antibodies reduce disease activity in the cotton-top tamarin colitis model, and decrease synovitis and joint erosions in a murine model of collagen-induced arthritis. Infliximab prevents disease in transgenic mice that develop polyarthritis as a result of constitutive expression of human TNFalpha, and when administered after disease onset, allows eroded joints to heal.


INDICATIONS AND USAGE
Rheumatoid Arthritis
REMICADE, in combination with methotrexate, is indicated for reducing signs and symptoms, inhibiting the progression of structural damage, and improving physical function in patients with moderately to severely active rheumatoid arthritis.

Crohn's Disease
REMICADE is indicated for reducing signs and symptoms and inducing and maintaining clinical remission in adult and pediatric patients with moderately to severely active Crohn's disease who have had an inadequate response to conventional therapy.

REMICADE is indicated for reducing the number of draining enterocutaneous and rectovaginal fistulas and maintaining fistula closure in adult patients with fistulizing Crohn's disease.

Ankylosing Spondylitis
REMICADE is indicated for reducing signs and symptoms in patients with active ankylosing spondylitis.

Psoriatic Arthritis
REMICADE is indicated for reducing signs and symptoms of active arthritis, inhibiting the progression of structural damage, and improving physical function in patients with psoriatic arthritis.

Plaque Psoriasis
REMICADE is indicated for the treatment of adult patients with chronic severe (i.e., extensive and /or disabling) plaque psoriasis who are candidates for systemic therapy and when other systemic therapies are medically less appropriate. REMICADE should only be administered to patients who will be closely monitored and have regular follow-up visits with a physician (See package insert for Boxed WARNINGS, WARNINGS, and PRECAUTIONS).

Ulcerative Colitis
REMICADE is indicated for reducing signs and symptoms, inducing and maintaining clinical remission and mucosal healing, and eliminating corticosteroid use in patients with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy

Dosing (Adults):
Ankylosing spondylitis: 5 mg/kg IV at 0, 2, and 6 weeks, followed by 5 mg/kg every 6 weeks thereafter.

Crohn's disease: Induction regimen: 5 mg/kg IV over 2 hours. Repeat dose at 2 and 6 weeks, followed by 5 mg/kg every 8 weeks. Dose may be increased to 10 mg/kg in patients who respond but then lose their response. If no response by week 14, consider discontinuing therapy.

Psoriatic arthritis (with or without methotrexate): 5 mg/kg IV at 0, 2, and 6 weeks, then every 8 weeks.

Rheumatoid arthritis: (In combination with methotrexate therapy): 3 mg/kg IV at 0, 2, and 6 weeks then every 8 weeks thereafter. Doses have ranged from 3-10 mg/kg intravenous infusion repeated at 4 to 8 week intervals.

Dosage adjustment with CHF: Weigh risk versus benefits for individual patient:
NYHA Class III or IV: </=5 mg/kg

Mesalamine  (Asacol ® , Pentasa) top of page

CLINICAL PHARMACOLOGY
Mesalamine is thought to be the major therapeutically active part of the sulfasalazine molecule in the treatment of ulcerative colitis. Sulfasalazine is converted to equimolar amounts of sulfapyridine and mesalamine by bacterial action in the colon. The usual oral dose of sulfasalazine for active ulcerative colitis is 3 to 4 grams daily in divided doses, which provides 1.2 to 1.6 grams of mesalamine to the colon.

The mechanism of action of mesalamine (and sulfasalazine) is unknown, but appears to be topical rather than systemic. Mucosal production of arachidonic acid (AA) metabolites, both through the cyclooxygenase pathways, i.e., prostanoids, and through the lipoxygenase pathways, i.e., leukotrienes (LTs) and hydroxyeicosatetraenoic acids (HETEs), is increased in patients with chronic inflammatory bowel disease, and it is possible that mesalamine diminishes inflammation by blocking cyclooxygenase and inhibiting prostaglandin (PG) production in the colon.


Adults (usual course of therapy is 3-8 weeks):
Oral:
Treatment of ulcerative colitis:
Capsule: 1 g 4 times/day
Tablet: Initial: 800 mg (2 tablets) 3 times/day for 6 weeks

Maintenance of remission of ulcerative colitis:
Capsule: 1 g 4 times/day
Tablet: 1.6 g/day in divided doses

Rectal:
Retention enema: 60 mL (4 g) at bedtime, retained overnight, approximately 8 hours

Rectal suppository (Canasa™):
500 mg: Insert 1 suppository in rectum twice daily; may increase to 3 times/day if inadequate response is seen after 2 weeks.
1000 mg: Insert 1 suppository in rectum daily at bedtime

Note: Suppositories should be retained for at least 1-3 hours to achieve maximum benefit.
Note: Some patients may require rectal and oral therapy concurrently.

Elderly: See adult dosing; use with caution

Administration
Oral: Swallow capsules or tablets whole, do not chew or crush.
Rectal enema: Shake bottle well. Retain enemas for 8 hours or as long as practical.
Suppository: Remove foil wrapper; avoid excessive handling. Should be retained for at least 1-3 hours to achieve maximum benefit.

Supplied
Capsule, controlled release (Pentasa®): 250 mg
    Extended-release capsules: 0.375 g APRISO™
Suppository, rectal (Canasa™): 500 mg, 1000 mg [contains saturated vegetable fatty acid esters]
Suspension, rectal: 4 g/60 mL (7s) [contains potassium metabisulfite and sodium benzoate]
Rowasa®: 4 g/60 mL (7s, 28s) [contains potassium metabisulfite and sodium benzoate]
Tablet, delayed release [enteric coated] (Asacol®): 400 mg
Asacol® HD -800 mg delayed-release tablet

 SELECTED INDIVIDUAL PRODUCT MONOGRAPHS (Mesalamine)

APRISO™ (mesalamine) extended-release capsules:
APRISO is a locally-acting aminosalicylate indicated for the maintenance of remission of ulcerative colitis in adults.

DOSAGE AND ADMINISTRATION
Four APRISO capsules once daily (1.5 g/day) in the morning with or without food. Do not co-administer with antacids.

DOSAGE FORMS AND STRENGTHS
Extended-release capsules: 0.375 g

--------------------
CANASA® (mesalamine, USP) 1000 mg suppositories
DOSAGE AND ADMINISTRATION
The usual dosage of CANASA® (mesalamine, USP) 1000 mg suppositories is one rectal suppository 1 time daily at bedtime.

The suppository should be retained for one to three hours or longer, if possible, to achieve the maximum benefit. While the effect of CANASA® suppositories may be seen within three to twenty-one days, the usual course of therapy would be from three to six weeks depending on symptoms and sigmoidoscopic findings. Studies have suggested that CANASA® suppositories will delay relapse after the six-week short-term treatment.

--------------------
LIALDA® is a locally acting 5-aminosalicylic acid (5-ASA) indicated for the induction of remission in adults with active, mild to moderate ulcerative colitis and for the maintenance of remission of ulcerative colitis.

DOSAGE AND ADMINISTRATION:  
For induction of remission of active, mild to moderate ulcerative colitis, two to four 1.2 g tablets taken once daily with food.
For maintenance of remission of ulcerative colitis, two 1.2 g tablets taken once daily with food. (1, 2)

DOSAGE FORMS AND STRENGTHS
Delayed-Release Tablets: 1.2 g
------------------------

Asacol®
DOSAGE AND ADMINISTRATION
For the treatment of mildly to moderately active ulcerative colitis: The usual dosage in adults is two 400-mg tablets to be taken three times a day for a total daily dose of 2.4 grams for a duration of 6 weeks.

For the maintenance of remission of ulcerative colitis: The recommended dosage in adults is 1.6 grams daily, in divided doses. Treatment duration in the prospective, well-controlled trial was 6 months.

Two Asacol 400 mg tablets have not been shown to be bioequivalent to one Asacol HD 800 mg tablet.
------------------------
Asacol® HD (mesalamine) delayed-release tablet for oral administration

DOSAGE AND ADMINISTRATION
Two 800 mg tablets three times daily for 6 weeks.
Asacol HD should be swallowed whole without cutting, breaking, or chewing.
One Asacol HD 800 mg tablet has not been shown to be bioequivalent to two Asacol® (mesalamine) delayed-release 400 mg tablets.

misoprostol  (Cytotec ® ) top of page

Pharmacodynamics
Misoprostol has both antisecretory (inhibiting gastric acid secretion) and (in animals) mucosal protective properties. NSAIDs inhibit prostaglandin synthesis, and a deficiency of prostaglandins within the gastric mucosa may lead to diminishing bicarbonate and mucus secretion and may contribute to the mucosal damage caused by these agents. Misoprostol can increase bicarbonate and mucus production, but in man this has been shown at doses 200 mcg and above that are also antisecretory. It is therefore not possible to tell whether the ability of misoprostol to reduce the risk of gastric ulcer is the result of its antisecretory effect, its mucosal protective effect, or both.

In vitro studies on canine parietal cells using tritiated misoprostol acid as the ligand have led to the identification and characterization of specific prostaglandin receptors. Receptor binding is saturable, reversible, and stereospecific. The sites have a high affinity for misoprostol, for its acid metabolite, and for other E type prostaglandins, but not for F or I prostaglandins and other unrelated compounds, such as histamine or cimetidine. Receptor-site affinity for misoprostol correlates well with an indirect index of antisecretory activity. It is likely that these specific receptors allow misoprostol taken with food to be effective topically, despite the lower serum concentrations attained.

Misoprostol produces a moderate decrease in pepsin concentration during basal conditions, but not during histamine stimulation. It has no significant effect on fasting or postprandial gastrin nor on intrinsic factor output.

----------------------
Effects on gastric acid secretion
Misoprostol, over the range of 50–200 mcg, inhibits basal and nocturnal gastric acid secretion, and acid secretion in response to a variety of stimuli, including meals, histamine, pentagastrin, and coffee. Activity is apparent 30 minutes after oral administration and persists for at least 3 hours. In general, the effects of 50 mcg were modest and shorter lived, and only the 200-mcg dose had substantial effects on nocturnal secretion or on histamine and meal-stimulated secretion.

Uterine effects
Misoprostol has been shown to produce uterine contractions that may endanger pregnancy.

Other pharmacologic effects
Misoprostol does not produce clinically significant effects on serum levels of prolactin, gonadotropins, thyroid-stimulating hormone, growth hormone, thyroxine, cortisol, gastrointestinal hormones (somatostatin, gastrin, vasoactive intestinal polypeptide, and motilin), creatinine, or uric acid. Gastric emptying, immunologic competence, platelet aggregation, pulmonary function, or the cardiovascular system are not modified by recommended doses of misoprostol


Dosage - Oral:
Adults:
Prevention of NSAID-induced gastric ulcers: 200 mcg 4 times/day with food; if not tolerated, may decrease dose to 100 mcg 4 times/day with food or 200 mcg twice daily with food; last dose of the day should be taken at bedtime

Medical termination of pregnancy: Refer to Mifepristone monograph.

Intravaginal: Adults: Labor induction or cervical ripening (unlabeled use): 25 mcg ( 1 /4 of 100 mcg tablet); may repeat at intervals no more frequent than every 3-6 hours. Do not use in patients with previous cesarean delivery or prior major uterine surgery.

Administration
Incidence of diarrhea may be lessened by having patient take dose right after meals. Therapy is usually begun on the second or third day of the next normal menstrual period.

Supplied
Tablet: 100 mcg, 200 mcg

Neomycin: top of page

INDICATIONS
Orally to prepare GI tract for surgery; topically to treat minor skin infections; treatment of diarrhea caused by E. coli ; adjunct in the treatment of hepatic encephalopathy; bladder irrigation

Dosage
Children: Oral:
Preoperative intestinal antisepsis: 90 mg/kg/day divided every 4 hours for 2 days; or 25 mg/kg at 1 PM, 2 PM, and 11 PM on the day preceding surgery as an adjunct to mechanical cleansing of the intestine and in combination with erythromycin base

Hepatic encephalopathy: 50-100 mg/kg/day in divided doses every 6-8 hours or 2.5-7 g/m 2 /day divided every 4-6 hours for 5-6 days not to exceed 12 g/day

Children and Adults: Topical: Topical solutions containing 0.1% to 1% neomycin have been used for irrigation
===================
Adults: Oral:

Preoperative intestinal antisepsis: 1 g each hour for 4 doses then 1 g every 4 hours for 5 doses; or 1 g at 1 PM, 2 PM, and 11 PM on day preceding surgery as an adjunct to mechanical cleansing of the bowel and oral erythromycin; or 6 g/day divided every 4 hours for 2-3 days

Hepatic encephalopathy: 500-2000 mg every 6-8 hours or 4-12 g/day divided every 4-6 hours for 5-6 days

Chronic hepatic insufficiency: 4 g/day for an indefinite period
===================
Supplied
Powder, micronized, as sulfate [for prescription compounding] (Neo-Rx): (10 g, 100 g)
Solution, oral, as sulfate (Neo-Fradin™): 125 mg/5 mL (60 mL, 480 mL) [contains benzoic acid; cherry flavor]
Tablet, as sulfate: 500 mg

octreotide  (Sandostatin ®) top of page

CLINICAL PHARMACOLOGY
Octreotide acetate exerts pharmacologic actions similar to the natural hormone, somatostatin. It is an even more potent inhibitor of growth hormone, glucagon, and insulin than somatostatin. Like somatostatin, it also suppresses LH response to GnRH, decreases splanchnic blood flow, and inhibits release of serotonin, gastrin, vasoactive intestinal peptide, secretin, motilin, and pancreatic polypeptide.

By virtue of these pharmacological actions, octreotide acetate has been used to treat the symptoms associated with metastatic carcinoid tumors (flushing and diarrhea), and Vasoactive Intestinal Peptide (VIP) secreting adenomas (watery diarrhea).

Octreotide acetate substantially reduces growth hormone and/or IGF-I (somatomedin C) levels in patients with acromegaly.

Single doses of octreotide acetate have been shown to inhibit gallbladder contractility and to decrease bile secretion in normal volunteers. In controlled clinical trials the incidence of gallstone or biliary sludge formation was markedly increased.

Octreotide acetate suppresses secretion of thyroid stimulating hormone (TSH).

Adults: SubQ: Initial: 50 mcg 1-2 times/day and titrate dose based on patient tolerance and response

Carcinoid: 100-600 mcg/day in 2-4 divided doses

VIPomas: 200-300 mcg/day in 2-4 divided doses

Diarrhea: Initial: I.V.: 50-100 mcg every 8 hours; increase by 100 mcg/dose at 48-hour intervals; maximum dose: 500 mcg every 8 hours

Esophageal varices bleeding: I.V. bolus: 25-50 mcg followed by continuous I.V. infusion of 25-50 mcg/hour

Acromegaly: Initial: SubQ: 50 mcg 3 times/day; titrate to achieve growth hormone levels <5 ng/mL or IGF-I (somatomedin C) levels <1.9 U/mL in males and <2.2 U/mL in females; usual effective dose 100 mcg 3 times/day; range 300-1500 mcg/day

Note: Should be withdrawn yearly for a 4-week interval in patients who have received irradiation. Resume if levels increase and signs/symptoms recur.

===================
Acromegaly, carcinoid tumors, and VIPomas (depot injection): Patients must be stabilized on subcutaneous octreotide for at least 2 weeks before switching to the long-acting depot: Upon switch: 20 mg I.M. intragluteally every 4 weeks for 2-3 months, then the dose may be modified based upon response
===================
Dosage adjustment for acromegaly: After 3 months of depot injections the dosage may be continued or modified as follows:
GH </= 2.5 ng/mL, IGF-1 is normal, symptoms controlled: Maintain octreotide LAR® at 20 mg I.M. every 4 weeks

GH >2.5 ng/mL, IGF-1 is elevated, and/or symptoms uncontrolled: Increase octreotide LAR® to 30 mg I.M. every 4 weeks

GH </= 1 ng/mL, IGF-1 is normal, symptoms controlled: Reduce octreotide LAR® to 10 mg I.M. every 4 weeks
Dosages >40 mg are not recommended
===================

Dosage adjustment for carcinoid tumors and VIPomas: After 2 months of depot injections the dosage may be continued or modified as follows:
Increase to 30 mg I.M. every 4 weeks if symptoms are inadequately controlled.
Decrease to 10 mg I.M. every 4 weeks, for a trial period, if initially responsive to 20 mg dose.
Dosage >30 mg is not recommended.

===================

Supplied
Injection, microspheres for suspension, as acetate [depot formulation] (Sandostatin LAR®): 10 mg, 20 mg, 30 mg [with diluent and syringe]

Injection, solution, as acetate (Sandostatin®): 0.05 mg/mL (1 mL); 0.1 mg/mL (1 mL); 0.2 mg/mL (5 mL); 0.5 mg/mL (1 mL); 1 mg/mL (5 mL)

olsalazine  (Dipentum ® ) top of page

CLINICAL PHARMACOLOGY
After oral administration, olsalazine has limited systemic bioavailability. Based on oral and intravenous dosing studies, approximately 2.4% of a single 1.0 g oral dose is absorbed. Less than 1% of olsalazine is recovered in the urine. The remaining 98 to 99% of an oral dose will reach the colon, where each molecule is rapidly converted into two molecules of 5-aminosalicylic acid (5-ASA) by colonic bacteria and the low prevailing redox potential found in this environment. The liberated 5-ASA is absorbed slowly resulting in very high local concentrations in the colon.

The conversion of olsalazine to mesalamine (5-ASA) in the colon is similar to that of sulfasalazine, which is converted into sulfapyridine and mesalamine. It is thought that the mesalamine component is therapeutically active in ulcerative colitis (A.K. Azad-Kahn et al, LANCET, 2: 892-895, 1977). The usual dose of sulfasalazine for maintenance of remission in patients with ulcerative colitis is 2 grams daily, which would provide approximately 0.8 grams of mesalamine to the colon. More than 0.9 grams of mesalamine would usually be made available in the colon from 1 gram of olsalazine.

The mechanism of action of mesalamine (and sulfasalazine) is unknown, but appears to be topical rather than systemic. Mucosal production of arachidonic acid (AA) metabolites, both through the cyclooxygenase pathways (i.e., prostanoids) and through the lipoxygenase pathways (i.e., leukotrienes [LTs] and hydroxyeicosatetraenoic acids [HETEs]) is increased in patients with chronic inflammatory bowel disease, and it is possible that mesalamine diminishes inflammation by blocking cyclooxygenase and inhibiting prostaglandin (PG) production in the colon.

INDICATIONS AND USAGE
Olsalazine is indicated for the maintenance of remission of ulcerative colitis in patients who are intolerant of sulfasalazine.

CONTRAINDICATIONS
Hypersensitivity to olsalazine, other salicylates, or any of the excipients.

Dosing (Adults): Ulcerative colitis: 500mg orally bid.

Administration
Take with food in evenly divided doses.
Supplied
Capsule, as sodium: 250 mg

Orlistat  (Xenical ®) top of page

Mechanism of Action
Orlistat is a reversible inhibitor of lipases. It exerts its therapeutic activity in the lumen of the stomach and small intestine by forming a covalent bond with the active serine residue site of gastric and pancreatic lipases. The inactivated enzymes are thus unavailable to hydrolyze dietary fat in the form of triglycerides into absorbable free fatty acids and monoglycerides. As undigested triglycerides are not absorbed, the resulting caloric deficit may have a positive effect on weight control. Systemic absorption of the drug is therefore not needed for activity. At the recommended therapeutic dose of 120 mg three times a day, orlistat inhibits dietary fat absorption by approximately 30%.

Dosing (Adults):  Weight loss:
Oral: Children >/= 12 years and Adults: 120 mg 3 times/day with each main meal containing fat (during or up to 1 hour after the meal); omit dose if meal is occasionally missed or contains no fat.

Supplied
Capsule: 120 mg

sucralfate  (Carafate ® ) top of page

CLINICAL PHARMACOLOGY
Sucralfate is only minimally absorbed from the gastrointestinal tract. The small amounts of the sulfated disaccharide that are absorbed are excreted primarily in the urine.

Although the mechanism of sucralfate’s ability to accelerate healing of duodenal ulcers remains to be fully defined, it is known that it exerts its effect through a local, rather than systemic, action. The following observations also appear pertinent:

1]Studies in human subjects and with animal models of ulcer disease have shown that sucralfate forms an ulcer-adherent complex with proteinaceous exudate at the ulcer site.
2]In vitro, a sucralfate-albumin film provides a barrier to diffusion of hydrogen ions.
3]In human subjects, sucralfate given in doses recommended for ulcer therapy inhibits pepsin activity in gastric juice by 32%.
4]In vitro, sucralfate absorbs bile salts.

These observations suggest that sucralfate’s antiulcer activity is the result of formation of an ulcer-adherent complex that covers the ulcer site and protects it against further attack by acid, pepsin, and bile salts. There are approximately 14-16 mEq of acid-neutralizing capacity per 1 g dose of sucralfate



Dosing
Oral:
Adults:

Stress ulcer prophylaxis: 1 g 4 times/day
Stress ulcer treatment: 1 g every 4 hours

Duodenal ulcer:
Treatment: 1 g 4 times/day on an empty stomach and at bedtime for 4-8 weeks, or alternatively 2 g twice daily; treatment is recommended for 4-8 weeks in adults, the elderly may require 12 weeks

Maintenance: Prophylaxis: 1 g twice daily

Stomatitis (unlabeled use): 1 g/10 mL suspension, swish and spit or swish and swallow 4 times/day

Dosage comment in renal impairment: Aluminum salt is minimally absorbed (<5%), however, may accumulate in renal failure

Administration
Tablet may be broken or dissolved in water before ingestion. Administer with water on an empty stomach.
Supplied
Suspension, oral: 1 g/10 mL (10 mL)
Carafate®: 1 g/10 mL (420 mL)
Tablet (Carafate®): 1 g

Sulfasalazine   (Azulfadine ®) top of page

CLINICAL PHARMACOLOGY
Pharmacodynamics
The mode of action of sulfasalazine (SSZ) or its metabolites, 5-amino­salicylic acid (5-ASA) and sulfapyridine (SP), is still under investigation, but may be related to the anti-inflammatory and/or immunomodulatory properties that have been observed in animal and in vitro models, to its affinity for connective tissue, and/or to the relatively high concentration it reaches in serous fluids, the liver and intestinal walls, as demonstrated in autoradiographic studies in animals. In ulcerative colitis, clinical studies utilizing rectal administration of SSZ, SP, and 5-ASA have indicated that the major therapeutic action may reside in the 5-ASA moiety.

INDICATIONS AND USAGE
Sulfasalazine tablets are indicated:

a. in the treatment of mild to moderate ulcerative colitis, and as adjunctive therapy in severe ulcerative colitis; and
b. for the prolongation of the remission period between acute attacks of ulcerative colitis.

CONTRAINDICATIONS
Sulfasalazine tablets are contraindicated in:

Patients with intestinal or urinary obstruction,
Patients with porphyria,
Patients hypersensitive to sulfasalazine, its metabolites, sulfonamides or salicylates

Adults:
Ulcerative colitis: Initial: 1 g 3-4 times/day, 2 g/day maintenance in divided doses; may initiate therapy with 0.5-1 g/day

Rheumatoid arthritis: Enteric coated tablet: Initial: 0.5-1 g/day; increase weekly to maintenance dose of 2 g/day in 2 divided doses; maximum: 3 g/day (if response to 2 g/day is inadequate after 12 weeks of treatment)

Dosing interval in renal impairment:
Clcr 10-30 mL/minute: Administer twice daily
Clcr<10 mL/minute: Administer once daily
Dosing adjustment in hepatic impairment: Avoid use

Supplied
Tablet (Azulfidine®): 500 mg
Tablet, delayed release, enteric coated (Azulfidine® EN-tabs®): 500 mg

Ursodiol  (Actigall ®) top of page

Gallstone dissolution: Oral: 8-10 mg/kg/day in 2-3 divided doses; use beyond 24 months is not established; obtain ultrasound images at 6-month intervals for the first year of therapy; 30% of patients have stone recurrence after dissolution.
Gallstone prevention: Oral: 300 mg twice daily.
Primary biliary cirrhosis: Oral: 13-15 mg/kg/day in 2-4 divided doses (with food).

Supplied: [Supplied: 300 capsule]

vasopressin  (Pitressin ®) top of page

CLINICAL PHARMACOLOGY
The antidiuretic action of vasopressin is ascribed to increasing reabsorption of water by the renal tubules.

Vasopressin can cause contraction of smooth muscle of the gastrointestinal tract and of all parts of the vascular bed, especially the capillaries, small arterioles and venules with less effect on the smooth musculature of the large veins. The direct effect on the contractile elements is neither antagonized by adrenergic blocking agents nor prevented by vascular denervation.

Following subcutaneous or intramuscular administration of vasopressin injection, the duration of antidiuretic activity is variable but effects are usually maintained for 2-8 hours.

The majority of a dose of vasopressin is metabolized and rapidly destroyed in the liver and kidneys. Vasopressin has a plasma half-life of about 10 to 20 minutes. Approximately 5% of a subcutaneous dose of vasopressin is excreted in urine unchanged after four hours.

INDICATIONS
Vasopressin is indicated for prevention and treatment of postoperative abdominal distention, in abdominal roentgenography to dispel interfering gas shadows, and in diabetes insipidus.

DOSING
Diabetes insipidus (highly variable dosage; titrated based on serum and urine sodium and osmolality in addition to fluid balance and urine output):

I.M., SubQ:
Children: 2.5-10 units 2-4 times/day as needed
Adults: 5-10 units 2-4 times/day as needed (dosage range 5-60 units/day)

Continuous I.V. infusion: Children and Adults: 0.5 milliunit/kg/hour (0.0005 unit/kg/hour); double dosage as needed every 30 minutes to a maximum of 0.01 unit/kg/hour.

Intranasal: Administer on cotton pledget, as nasal spray, or by dropper.
======================

Abdominal distention: Adults: I.M.: 5 units stat, 10 units every 3-4 hours

======================
GI hemorrhage (unlabeled use): I.V. infusion: Dilute in NS or D5W to 0.1-1 unit/mL

Children: Initial: 0.002-0.005 units/kg/minute; titrate dose as needed; maximum: 0.01 unit/kg/minute; continue at same dosage (if bleeding stops) for 12 hours, then taper off over 24-48 hours

AdAdults: Initial: 0.2-0.4 unit/minute, then titrate dose as needed, if bleeding stops; continue at same dose for 12 hours, taper off over 24-48 hours
======================

Out-of-hospital asystole (unlabeled use): Adults: I.V.: 40 units; if spontaneous circulation is not restored in 3 minutes, then repeat dose

Pulseless VT/VF (ACLS protocol): I.V.: 40 units (as a single dose only); if no I.V. access, administer 40 units diluted with NS (to a total volume of 10 mL) endotracheally

Vasodilatory shock/septic shock (unlabeled use): Adults: I.V.: Vasopressin has been used in doses of 0.01-0.1 units/minute for the treatment of septic shock. Doses >0.05 units/minute may have more cardiovascular side effects. Most case reports have used 0.04 units/minute continuous infusion as a fixed dose.
======================

Administration
I.V.: Use extreme caution to avoid travasation because of risk of necrosis and gangrene. In treatment of varices, infusions are often supplemented with nitroglycerin infusions to minimize cardiac effects.

GIGI hemorrhage: Administration requires the use of an infusion pump and should be administered in a peripheral line.

Vasodilatory shock: Administration through a central catheter is recommended.
======================
Supplied
Injection, solution: 20 units/mL (0.5 mL, 1 mL, 10 mL)
Pitressin®: 20 units/mL (1 mL)
 

Reference(s)

National Institutes of Health, U.S. National Library of Medicine, DailyMed Database.
Provides access to the latest drug monographs submitted to the Food and Drug Administration (FDA). Please review the latest applicable package insert for additional information and possible updates.  A local search option of this data can be found here.

Disclaimer

Listed dosages are for - Adult patients ONLY. PLEASE READ THE DISCLAIMER CAREFULLY BEFORE ACCESSING OR USING THIS SITE. BY ACCESSING OR USING THIS SITE, YOU AGREE TO BE BOUND BY THE TERMS AND CONDITIONS SET FORTH IN THE DISCLAIMER. GlobalRPH does not directly or indirectly practice medicine or provide medical services and therefore assumes no liability whatsoever of any kind for the information and data accessed through the Service or for any diagnosis or treatment made in reliance thereon.

David F. McAuley, Pharm.D., R.Ph.  GlobalRPh Inc.
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Medical Calculators - A thru Z
Lab Values - A thru Z