Budesonide
Budesonide Prescribing Information
Budesonide rectal foam is indicated for the induction of remission in patients with active mild to moderate distal ulcerative colitis extending up to 40 cm from the anal verge.
• The recommended dosage is 1 metered dose administered twice daily for 2 weeks followed by 1 metered dose administered once daily for 4 weeks. ()2.1 Recommended DosageThe recommended dosage regimen is 1 metered dose administered rectally twice daily for 2 weeks followed by 1 metered dose administered rectally once daily for 4 weeks.
• For rectal administration only. ()2.2 Administration InstructionsAdvise patients:
• Budesonide rectal foam is only to be applied rectally. It is not for oral use.• Before using budesonide rectal foam, use the bathroom to empty your bowels.• Each applicator is coated with a lubricant. If additional lubrication is needed, petrolatum or petroleum jelly can also be used.• Warm the canister in the hands while shaking it vigorously for 10 to 15 seconds prior to use.• Budesonide rectal foam can be used in a standing, lying or sitting position (e.g., while using the toilet).• Apply budesonide rectal foam in the morning and the evening for the first 2 weeks of treatment; then once daily in the evening for the next 4 weeks. When applied in the evening, use immediately prior to bedtime. Try not to empty your bowels again until the next morning.• Avoid concomitant use of CYP3A4 inhibitors (e.g., ketoconazole, grapefruit juice) during treatment with budesonide rectal foam.
• Warm the canister in the hands while shaking it vigorously for 10 to 15 seconds prior to use. ()2.2 Administration InstructionsAdvise patients:
• Budesonide rectal foam is only to be applied rectally. It is not for oral use.• Before using budesonide rectal foam, use the bathroom to empty your bowels.• Each applicator is coated with a lubricant. If additional lubrication is needed, petrolatum or petroleum jelly can also be used.• Warm the canister in the hands while shaking it vigorously for 10 to 15 seconds prior to use.• Budesonide rectal foam can be used in a standing, lying or sitting position (e.g., while using the toilet).• Apply budesonide rectal foam in the morning and the evening for the first 2 weeks of treatment; then once daily in the evening for the next 4 weeks. When applied in the evening, use immediately prior to bedtime. Try not to empty your bowels again until the next morning.• Avoid concomitant use of CYP3A4 inhibitors (e.g., ketoconazole, grapefruit juice) during treatment with budesonide rectal foam.
Budesonide rectal foam is formulated as an emulsion which is filled into an aluminum canister with an aerosol propellant. It is available in 1 strength: 2 mg budesonide per metered dose.
• Pregnancy:Based on animal data, may cause fetal harm. ()8.1 PregnancyRisk SummaryLimited 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, subcutaneous administration of budesonide during organogenesis at doses 1.2 times and 0.12 times, respectively, the human intrarectal dose of 4 mg/day, 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 of 2% to 4%, and 15% to 20%, respectively.
Clinical ConsiderationsDisease-Associated Maternal and/or Embryo/Fetal RiskPublished data suggest that increased disease activity is associated with the risk of developing adverse pregnancy outcomes in women with ulcerative colitis. Adverse pregnancy outcomes include preterm delivery (before 37 weeks of gestation), low birth weight (less than 2500 g) infants, and small for gestational age at birth.
Fetal/Neonatal Adverse ReactionsHypoadrenalism 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].DataAnimal DataBudesonide 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 1.2 times the recommended human intrarectal 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 6-18, 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 0.12 times the recommended human intrarectal dose of 4 mg/day 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 0.02 times the recommended human intrarectal dose on a body surface area basis) and 500 mcg/kg in rats (approximately 1.2 times the recommended human intrarectal dose of 4 mg/day on a body surface area basis).
In a pre-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 0.05 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.
• Hepatic Impairment:Monitor patients for signs and/or symptoms of hypercorticism. ()8.6 Hepatic ImpairmentNo dosage adjustment is needed for patients with mild (Child-Pugh Class A) hepatic impairment. Patients with moderate to severe hepatic impairment (Child-Pugh Class B or C) should be monitored for increased signs and/or symptoms of hypercorticism. Discontinuing the use of budesonide rectal foam should be considered in these patients if signs of hypercorticism are observed
[see Warnings and PrecautionsandClinical Pharmacology].
Budesonide rectal foam is contraindicated in patients with a history of a known hypersensitivity to budesonide or any of the ingredients of budesonide rectal foam. Reactions have included anaphylaxis
Serious and important adverse reactions include:
• Hypercorticism and adrenal axis suppression[see Warnings and Precautions]• Symptoms of steroid withdrawal in those patients transferring from systemic glucocorticosteroid therapy[see Warnings and Precautions]• Increased susceptibility to infection[see Warnings and Precautions]• Other glucocorticosteroid effects[see Warnings and Precautions]
Most common adverse reactions (≥ 2%) are decreased blood cortisol, adrenal insufficiency, and nausea.
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared with rates in the clinical trials of another drug and may not reflect the rates observed in practice.
The data described below reflect exposure to budesonide rectal foam in 332 patients with active mild to moderate distal ulcerative colitis extending up to 40 cm from the anal verge. The median duration of exposure was 42 days. This included 14 patients exposed for at least 6 months.
Budesonide rectal foam was studied primarily in 2 placebo-controlled, 6-week trials in patients with active disease (Study 1 and Study 2). In these trials, 268 patients received budesonide rectal foam 2 mg twice a day for 2 weeks followed by 2 mg once a day for 4 weeks
The most common adverse reactions (≥ 2% of the budesonide rectal foam or Placebo group and at higher frequency in the budesonide rectal foam group) were decreased blood cortisol, adrenal insufficiency, and nausea (
A total of 10% of budesonide rectal foam-treated patients discontinued treatment due to an adverse reaction compared with 4% of placebo-treated patients.
Adverse Reaction | Budesonide Rectal Foam 2 mg/25 mL N=268 n (%) | Placebo N=278 n (%) |
Decreased blood cortisolDecreased blood cortisol was defined as a morning cortisol level of <5 mcg/dL. | 46 (17) | 6 (2) |
Adrenal insufficiencyAdrenal insufficiency was defined as a cortisol level of <18 mcg/dL at 30 minutes post-challenge with ACTH. | 10 (4) | 2 (1) |
Nausea | 6 (2) | 2 (1) |
Of the 46 budesonide rectal foam treated patients with decreased blood cortisol (defined as a morning cortisol level of <5 mcg/dL) reported as an adverse event, none had adrenal insufficiency (defined as a cortisol level of <18 mcg/dL at 30 minutes post-challenge with ACTH) (see
Table 2 summarizes the percentages of patients reporting glucocorticoid related effects in the 2 placebo-controlled trials (Studies 1 and 2).
Adverse Reaction | Budesonide Rectal Foam 2 mg/25 mL N=268 n (%) | Placebo N=278 n (%) |
Overall | 60 (22) | 10 (4) |
Blood cortisol decreased | 46 (17)Decreases in serum cortisol levels associated with budesonide treatment were seen at Weeks 1 and 2 (twice daily treatment) in the budesonide rectal foam group, but gradually returned to baseline levels during the 4 weeks of once daily treatment. | 6 (2) |
Adrenal insufficiency | 10 (4) | 2 (1) |
Insomnia | 1 (0.4) | 1 (0.4) |
Sleep disorder | 1 (0.4) | 0 |
Acne | 1 (0.4) | 0 |
Depression | 1 (0.4) | 1 (0.4) |
Hyperglycemia | 1 (0.4) | 0 |
No clinically significant differences were observed with respect to the overall percentages of patients with any glucocorticoid related effects between budesonide rectal foam and placebo after 6 weeks of therapy.
For additional details on morning cortisol levels and the response to the ACTH stimulation test,
In addition to adverse reactions reported from clinical trials for budesonide rectal foam, the following adverse reactions have been identified during post-approval use of other oral and rectal formulations of budesonide. 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.
In addition to adverse reactions reported from clinical trials for budesonide rectal foam, the following adverse reactions have been identified during post-approval use of other oral and rectal formulations of budesonide. 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.
• Hypercorticism and adrenal suppression:Follow general warnings concerning glucocorticosteroids. ()5.1 Hypercorticism and Adrenal Axis SuppressionWhen glucocorticosteroids are used chronically, systemic effects such as hypercorticism and adrenal suppression may occur. Glucocorticosteroids 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 glucocorticosteroid is recommended. Since budesonide rectal foam contains a glucocorticosteroid, general warnings concerning glucocorticoids should be followed
[see Clinical Pharmacology].Reduced liver function affects the elimination of glucocorticosteroids, and increased systemic availability of oral budesonide has been demonstrated in patients with liver cirrhosis
[see Use in Specific Populations].• Impaired Adrenal Function in Patients Transferred from Other Glucocorticoids:Taper slowly from glucocorticosteroids with high systemic effects; monitor for withdrawal symptoms and unmasking of allergies (rhinitis, eczema). ()5.2 Impaired Adrenal Suppression in Patients Transferred from Other GlucocorticoidsMonitor patients who are transferred from glucocorticosteroid treatment with higher systemic effects to glucocorticosteroids with lower systemic effects, such as budesonide rectal foam, since symptoms attributed to withdrawal of steroid therapy, including those of acute adrenal suppression or benign intracranial hypertension, may develop. Adrenocortical function monitoring may be required in these patients and the dose of glucocorticosteroid treatment with high systemic effects should be reduced cautiously.
Replacement of systemic glucocorticosteroids with budesonide rectal foam may unmask allergies (e.g., rhinitis and eczema), which were previously controlled by the systemic drug.
• Increased Risk of Infection, including serious and fatal chicken pox and measles:Monitor patients with active or quiescent tuberculosis infection, untreated fungal, bacterial, systemic viral or parasitic infections, or ocular herpes simplex. ()5.3 Increased Risk of InfectionPatients 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 glucocorticosteroids. In patients who have not had these diseases, particular care should be taken to avoid exposure.
How the dose, route and duration of glucocorticosteroid administration affect the risk of developing a disseminated infection is not known. The contribution of the underlying disease and/or prior glucocorticosteroid 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.
Glucocorticosteroids 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.
• Other Glucocorticosteroid Effects:Monitor patients with other conditions where glucocorticoids may have unwanted effects. ()5.4 Other Glucocorticosteroid EffectsMonitor 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 glucocorticosteroids may have unwanted effects.
• Flammable Contents:The contents of budesonide rectal foam are flammable. Instruct the patient to avoid fire, flame and smoking during and immediately following administration. ()5.5 Flammable ContentsThe contents of budesonide rectal foam include n-butane, isobutane and propane as propellants which are flammable. Instruct the patient to avoid fire, flame, and smoking during and immediately following administration. Patients should temporarily discontinue use of budesonide rectal foam before initiation of bowel preparation for colonoscopy and consult their healthcare provider before resuming therapy.