Label: COLESEVELAM HYDROCHLORIDE - colesevelam hydrochloride powder, for suspension

  • NDC Code(s): 67877-523-30
  • Packager: Ascend Laboratories, LLC
  • Category: HUMAN PRESCRIPTION DRUG LABEL
  • DEA Schedule: None
  • Marketing Status: Abbreviated New Drug Application

Drug Label Information

Updated September 11, 2019

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  • HIGHLIGHTS OF PRESCRIBING INFORMATION
    These highlights do not include all the information needed to use COLESEVELAM HYDROCHLORIDE FOR ORAL SUSPENSION safely and effectively. See full prescribing information for COLESEVELAM HYDROCHLORIDE FOR ORAL SUSPENSION.
    COLESEVELAM HYDROCHLORIDE for oral suspension
    Initial U.S. Approval: 2000

    RECENT MAJOR CHANGES

    Indications and Usage (1)                        04/2019

    Dosage and Administration (2)               04/2019

    Warnings and Precautions (5)                 04/2019

    INDICATIONS AND USAGE

    Colesevelam hydrochloride is a bile acid sequestrant indicated as an adjunct to diet and exercise to:

    • reduce elevated low-density lipoprotein cholesterol (LDL-C) in adults with primary hyperlipidemia (1.1).
    • reduce LDL-C levels in boys and postmenarchal girls, 10 to 17 years of age, with heteroz ygous familial hypercholesterolemia (HeFH) (1.1).

    Limitations of Use (1.3):

    • Do not use for treatment of  type 1 diabetes or for diabetic ketoacidosis.
    • The effect on cardiovascular morbidity and mortality has not been determined.
    • Not studied in type 2 diabetes with a dipeptidyl peptidase 4 inhibitor.
    • Not studied in Fredrickson Type I, III, IV, and V dyslipidemias.
    • Not studied in children less than 10 years of age or in pre-menarchal girls.

    DOSAGE AND ADMINISTRATION

    • Obtain lipid parameters, including serum triglyceride (TG) levels and non-HDL C, before starting colesevelam hydrochloride for oral suspension (2.1)
    • The recommended dosage for adults and children 10 to 17 years old with primary hyperlipidemia is 3.75 grams daily. The recommended dosage for adults with type 2 diabetes mellitus is 3.75 grams daily. Colesevelam hydrochloride for oral suspension should be taken as follows (2.2, 2.4):

    For Oral Suspension

    Take one packet once daily with a meal. To prepare, empty the entire contents of one packet into a glass or cup. Add 1 cup of water, fruit juice, or diet soft drinks. Stir well and drink.

    DOSAGE FORMS AND STRENGTHS

    For oral suspension: 3.75 gram packet (3)

    CONTRAINDICATIONS

    • Patients with serum triglyceride levels greater than 500 mg/dL (4).
    • Patients with a history of hypertriglyceridemia-induced pancreatitis (4).
    • Patients with a history of bowel obstruction (4).

    WARNINGS AND PRECAUTIONS

    • Hypertriglyceridemia and Pancreatitis: Colesevelam hydrochoride can increase TG. Hypertriglyceridemia can cause acute pancreatitis. Monitor lipids, including TG and non-high density lipoprotein cholesterol (non-HDL-C). Instruct patients to discontinue colesevelam hydrochoride and seek prompt medical attention if the symptoms of acute pancreatitis occur (5.1).
    • Gastrointestinal Obstruction: Cases of bowel obstruction have occurred. Colesevelam hydrochoride is not recommended in patients with gastroparesis, other gastrointestinal motility disorders, and in those who have had major gastrointestinal tract surgery and who may be at risk for bowel obstruction (5.2).
    • Vitamin K or Fat-Soluble Vitamin Deficiencies: Colesevelam hydrochoride may decrease absorption of fat-soluble vitamins. Patients with a susceptibility to deficiencies of vitamin K (e.g., patients on warfarin, patients with malabsorption syndromes) or other fat-soluble vitamins may be at increased risk. Patients on oral vitamin supplementation should take their vitamins at least 4 hours prior to colesevelam hydrochoride (5.3).
    • Drug Interactions: Due to the potential for decreased absorption of other drugs that have not been tested for interaction, consider administering at least 4 hours prior to colesevelam hydrochoride (5.4,7, 12.3).
    •  Risks in Patients with Phenylketonuria: Phenylalanine can be harmful to patients with phenylketonuria (PKU). Colesevelam hydrochloride for oral suspension contains 27 mg phenylalanine per 3.75 gram packet (5.5, 11).

    ADVERSE REACTIONS

    In clinical trials, the most common (incidence ≥2% and greater than placebo) adverse reactions with Colesevelam hydrochloride included constipation, dyspepsia, and nausea. (6.1)

    To report SUSPECTED ADVERSE REACTIONS, contact Ascend Laboratories, LLC at 1-877-ASC-RX01 (877-272-7901) or FDA at 1-800-332-1088 or www.fda.gov/medwatch.

    DRUG INTERACTIONS

    Concomitant use with colesevelam hydrochoride may decrease the exposure of the following drugs: Drugs with a narrow therapeutic index (e.g., cyclosporine), phenytoin, thyroid hormone replacement therapy, warfarin, oral contraceptives containing ethinyl estradiol and norethindrone, olmesartan medoxomil, and sulfonylureas (glimepiride, glipizide, glyburide). Administer these drugs 4 hours prior to colesevelam hydrochloride tablets. For patients on warfarin, monitor INR frequently during initiation then periodically (7.1).

    Concomitant use with colesevelam hydrochoride may increase the exposure of the following drugs: Metformin extended release. Monitor patients glycemic control (7.2).

    See 17 for PATIENT COUNSELING INFORMATION.

    Revised: 7/2019

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  • FULL PRESCRIBING INFORMATION: CONTENTS*

    1 INDICATIONS & USAGE

    1.1 Primary Hyperlipidemia

    1.3 Limitations of Use

    2 DOSAGE & ADMINISTRATION

    2.1 Testing Prior to Initiation of Colesevelam Hydrochloride

    2.2 Recommended Dosage in Primary Hyperlipidemia

    2.3 Important Dosing Information for Primary Hyperlipidemia

    2.4 Administration Instructions

    3 DOSAGE FORMS & STRENGTHS

    4 CONTRAINDICATIONS

    5 WARNINGS AND PRECAUTIONS

    5.1 Hypertriglyceridemia and Pancreatitis

    5.2 Gastrointestinal Obstruction

    5.3 Vitamin K or Fat-Soluble Vitamin Deficiencies

    5.4 Drug Interactions

    5.5 Risks in Patients with Phenylketonuria

    5.6 Macrovascular Outcomes

    6 ADVERSE REACTIONS

    6.1 Clinical Studies Experience

    6.2 Post-marketing Experience

    7 DRUG INTERACTIONS

    7.1 Colesevelam Hydrochloride Drug Interactions that Decrease the Exposure of the Concomitant Medication

    7.2 Colesevelam Hydrochloride Drug Interactions that Increase the Exposure of the Concomitant Medication

    8 USE IN SPECIFIC POPULATIONS

    8.1 Pregnancy

    8.2 Lactation

    8.3 Females and Males of Reproductive Potential

    8.4 Pediatric Use

    8.5 Geriatric Use

    10 OVERDOSAGE

    11 DESCRIPTION

    12 CLINICAL PHARMACOLOGY

    12.1 Mechanism of Action

    12.2 Pharmacodynamics

    12.3 Pharmacokinetics

    13 NONCLINICAL TOXICOLOGY

    13.1 Carcinogenesis, Mutagenesis, Impairment Of Fertility

    13.2 Animal Toxicology and/or Pharmacology 

    14 CLINICAL STUDIES

    14.1 Primary Hyperlipidemia

    16 HOW SUPPLIED/STORAGE AND HANDLING

    17 PATIENT COUNSELING INFORMATION

    *
    Sections or subsections omitted from the full prescribing information are not listed.
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  • 1 INDICATIONS & USAGE

    1.1 Primary Hyperlipidemia

    Colesevelam hydrochloride for oral suspension is indicated as an adjunct to diet and exercise to reduce elevated low-density lipoprotein cholesterol (LDL-C) in adults with primary hyperlipidemia

    Colesevelam hydrochloride for oral suspension is indicated to reduce LDL-C levels in boys and postmenarchal girls, 10 to 17 years of age, with heterozygous familial hypercholesterolemia (HeFH) who are unable to reach LDL-C target levels despite an adequate trial of dietary therapy and lifestyle modification.

    1.3 Limitations of Use

    • Colesevelam hydrochloride should not be used for the treatment of type 1 diabetes or for the treatment of diabetic ketoacidosis.
    • The effect of colesevelam hydrochloride on cardiovascular morbidity and mortality has not been determined.
    • Colesevelam hydrochloride has not been studied in type 2 diabetes in combination with a dipeptidyl peptidase 4 inhibitor.
    • Colesevelam hydrochloride has not been studied in Fredrickson Type I, III, IV, and V dyslipidemias.
    • Colesevelam hydrochloride has not been studied in children younger than 10 years of age or in premenarchal girls.
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  • 2 DOSAGE & ADMINISTRATION

    2.1 Testing Prior to Initiation of Colesevelam Hydrochloride

    Obtain lipid parameters, including TG levels and non-HDL-C, before starting colesevelam hydrochloride. Colesevelam hydrochloride is contraindicated in patients with TG levels greater than 500 mg/dL [see Contraindications (4) and Warnings and Precautions (5.1)].

    2.2 Recommended Dosage in Primary Hyperlipidemia

    The recommended dosage of colesevelam hydrochloride for oral suspension for adults and children 10 to 17 years old with primary hyperlipidemia is 3.75 grams daily.

    Colesevelam hydrochloride for oral suspension should be taken as follows:

    For Oral Suspension

    Take one packet once daily.

    2.3 Important Dosing Information for Primary Hyperlipidemia

    Colesevelam hydrochloride for oral suspension can be dosed at the same time as a statin or colesevelam hydrochloride for oral suspension and the statin can be dosed apart. Monitor lipid levels within 4 to 6 weeks after initiation of colesevelam hydrochloride for oral suspension.

    2.4 Administration Instructions

    For Oral Suspension:

    To prepare, empty the entire contents of one packet into a glass or cup. Add 1 cup (8 ounces) of water, fruit juice, or diet soft drinks. Stir well and drink. Take colesevelam hydrochloride for oral suspension with meals. Do not take colesevelam hydrochloride for oral suspension in its dry form. Due to tablet size, colesevelam hydrochloride for oral suspension is recommended for use in the pediatric population.

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  • 3 DOSAGE FORMS & STRENGTHS

    Colesevelam Hydrochloride for Oral Suspension: a white to yellow granular powder containing yellow granules packaged in singledose packets: 3.75 gram single-dose packet.

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  • 4 CONTRAINDICATIONS

    Colesevelam hydrochloride is contraindicated in patients with

    ·      A history of bowel obstruction [See Warnings and Precautions (5.4)]

    ·      Serum TG concentrations >500 mg/dL [See Warnings and Precautions (5.2)]

    ·      A history of hypertriglyceridemia-induced pancreatitis [See Warnings and Precautions (5.2)] 

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  • 5 WARNINGS AND PRECAUTIONS

    5.1 Hypertriglyceridemia and Pancreatitis

    Colesevelam hydrochloride, like other bile acid sequestrants, can increase serum TG concentrations. Hypertriglyceridemia can cause acute pancreatitis.

    Colesevelam hydrochloride had effects on serum TG (median increase 5% compared to placebo) in trials of patients with primary hyperlipidemia.

    Obtain lipid parameters, including TG levels and non-HDL-C, before starting colesevelam hydrochloride and periodically thereafter. Colesevelam hydrochloride is contraindicated in patients with TG levels greater than 500 mg/dL or patients with a history of hypertriglyceridemia-induced pancreatitis [see Contraindications (4)]. Patients with TG levels greater than 300 mg/dL could have greater increases in serum TG levels with colesevelam hydrochloride and may require additional TG monitoring. Instruct patients to discontinue colesevelam hydrochloride and seek prompt medical attention if the symptoms of acute pancreatitis occur (e.g., severe abdominal pain with or without nausea and vomiting). Discontinue colesevelam hydrochloride if TG levels exceed 500 mg/dL [see Adverse Reactions (6.1)].

    5.2 Gastrointestinal Obstruction

    Postmarketing cases of bowel obstruction have occurred with colesevelam hydrochloride [see Adverse Reactions (6.2)]. Because of its constipating effects, colesevelam hydrochloride is not recommended in patients with gastroparesis, other gastrointestinal motility disorders, and in those who have had major gastrointestinal tract surgery and who may be at risk for bowel obstruction. Colesevelam hydrochloride is contraindicated in patients with a history of bowel obstruction [see Contraindications (4)]. Instruct patients to promptly discontinue colesevelam hydrochloride and seek medical attention if severe abdominal pain or severe constipation occurs.

    Because of the tablet size, colesevelam hydrochloride tablets can cause dysphagia or esophageal obstruction. For patients with difficulty swallowing tablets use colesevelam hydrochloride for oral suspension.

    5.3 Vitamin K or Fat-Soluble Vitamin Deficiencies

    Colesevelam hydrochloride may decrease the absorption of fat-soluble vitamins A, D, E, and K. Patients with a susceptibility to deficiencies of vitamin K (e.g., patients on warfarin, patients with malabsorption syndromes) or other fat-soluble vitamins may be at increased risk when taking colesevelam hydrochloride.

    Patients on oral vitamin supplementation should take their vitamins at least 4 hours prior to colesevelam hydrochloride.[see Drug Interactions (7.1)].

    5.4 Drug Interactions

    Colesevelam hydrochloride  reduces gastrointestinal absorption of some drugs. Administer drugs with a known interaction at least 4 hours prior to colesevelam hydrochloride[see Drug Interactions (7)].


    Due to the potential for decreased absorption of other drugs that have not been tested for interaction, especially those with a narrow therapeutic index, consider administering at least 4 hours prior to colesevelam hydrochloride[see Clinical Pharmacology (12.3)].

    5.5 Risks in Patients with Phenylketonuria

    Phenylalanine can be harmful to patients with phenylketonuria(PKU).Colesevelam hydrochloride for oral suspension contains phenylalanine, a component of aspartame. Each 3.75 gram packet contains 27 mg of phenylalanine. Before prescribing Colesevelam hydrochloride for oral suspension to a patient with PKU, consider the combined daily amount of phenylalanine from all sources, including colesevelam hydrochloride for oral suspension.

    5.6 Macrovascular Outcomes

    There have been no clinical studies establishing conclusive evidence of macrovascular disease risk reduction with colesevelam hydrochloride.

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  • 6 ADVERSE REACTIONS

    The following important adverse reactions are described below and elsewhere in the labeling:

    • Hypertriglyceridemia and Pancreatitis [see Warnings and Precautions (5.1)]
    • Gastrointestinal Obstruction [see Warnings and Precautions (5.2)]
    • Vitamin K or Fat-Soluble Vitamin Deficiencies [see Warnings and Precautions (5.3)]

    6.1 Clinical Studies Experience

    Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to rates in clinical studies of another drug and may not reflect the rates observed in practice.

    Primary Hyperlipidemia: In 7 double-blind, placebo-controlled, clinical trials, 807 patients with primary hyperlipidemia (age range 18-86 years, 50% women, 90% Caucasians, 7% Blacks, 2% Hispanics, 1% Asians) and elevated LDL-C were treated with colesevelam hydrochloride 1.5 g/day to 4.5 g/day from 4 to 24 weeks (total exposure 199 patient-years). 


    Table 1

    Clinical Studies of Colesevelam Hydrochloride for Primary Hyperlipidemia: Adverse Reactions Reported in ≥ 2% of Patients and More Commonly than in Placebo

     
    Colesevelam hydrochloride
    N = 807
    Placebo
    N = 258
    Constipation
    11.0%
    7.0%
    Dyspepsia
    8.3%
    3.5%
    Nausea
    4.2%
    3.9%
    Accidental injury
    3.7%
    2.7%
    Asthenia
    3.6%
    1.9%
    Pharyngitis
    3.2%
    1.9%
    Flu syndrome
    3.2%
    3.1%
    Rhinitis
    3.2%
    3.1%
    Myalgia
    2.1%
    0.4%

    Pediatric Patients 10 to 17 Years of Age: In an 8-week double-blind, placebo-controlled study boys and post-menarchal girls, 10 to 17 years of age, with HeFH (n=192), were treated with colesevelam hydrochloride tablets (1.9 to 3.8 g, daily) or placebo tablets


    Table 2

    Clinical Study of Colesevelam Hydrochloride for Primary Hyperlipidemia in HeFH Pediatric Patients: Adverse Reactions Reported in ≥2% of Patients and More Commonly than in Placebo


     
    Colesevelam Hydrochloride
    N = 129
    Placebo
    N = 65
    Nasopharyngitis
    6.2%
    4.6%
    Headache
    3.9%
    3.1%
    Fatigue
    3.9%
    1.5%
    Creatine Phosphokinase Increase
    2.3%
    0.0%
    Rhinitis
    2.3%
    0.0%
    Vomiting
    2.3%
    1.5%

    The reported adverse reactions during the additional 18-week open-label treatment period with colesevelam hydrochloride 3.8 g per day were similar to those during the double-blind period and included headache (7.6%), nasopharyngitis (5.4%), upper respiratory tract infection (4.9%), influenza (3.8%), and nausea (3.8%).

    6.2 Post-marketing Experience

    The following additional adverse reactions have been identified during post-approval use of colesevelam hydrochloride. Because these reactions are reported voluntarily from a population of uncertain size, it is generally not possible to reliably estimate their frequency or establish a causal relationship to drug exposure.


    Adverse Reactions Resulting from Drug Interactions [see Drug Interactions (7)]:

    • Increased seizure activity or decreased phenytoin levels in patients receiving phenytoin.
    • Reduced International Normalized Ratio (INR) in patients receiving warfarin therapy.
    • Elevated thyroid-stimulating hormone (TSH) in patients receiving thyroid hormone replacement therapy.

    Gastrointestinal:

    Bowel obstruction (in patients with a history of bowel obstruction or resection), dysphagia or esophageal obstruction (occasionally requiring medical intervention), fecal impaction, pancreatitis, abdominal distension, exacerbation of hemorrhoids, and increased transaminases.


    Laboratory Abnormalities:

    Hypertriglyceridemia

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  • 7 DRUG INTERACTIONS

    7.1 Colesevelam Hydrochloride Drug Interactions that Decrease the Exposure of the Concomitant Medication

    Table 4 includes a list of drugs that decrease exposure of the concomitant medication when administered concomitantly with colesevelam hydrochloride and instructions for preventing or managing them.

    Table 4

    Colesevelam Hydrochloride Drug Interactions that Decrease the Exposure of the

    Concomitant Medication

    Drugs with a Narrow Therapeutic Index
    Clinical Impact:
    Concomitant use with colesevelam hydrochloride may decrease the exposure of the narrow therapeutic index drug. In vivo drug interactions studies showed a decrease in exposure of cyclosporine when coadministered with colesevelam hydrochloride [see Clinical Pharmacology (12.3)].
    Intervention:
    Administer the narrow therapeutic index drug at least 4 hours prior to colesevelam hydrochloride. Monitor drug levels when appropriate.
    Examples:
    Cyclosporine
    Phenytoin
    Clinical Impact:
    There have been postmarketing reports of increased seizure activity or decreased phenytoin levels in patients receiving phenytoin [see Adverse Reactions (6.2)].
     
    Intervention:
    Administer phenytoin 4 hours prior to colesevelam hydrochloride.
    Thyroid Hormone Replacement Therapy
    Clinical Impact:
    In vivo drug interactions studies showed a decrease in exposure of levothyroxine when coadministered with colesevelam hydrochloride [see Clinical Pharmacology (12.3)]. There have been postmarketing reports of elevated thyroid-stimulating hormone (TSH) in patients receiving thyroid hormone replacement therapy [see Adverse Reactions (6.2)].
    Intervention:
    Administer thyroid hormone replacement therapy 4 hours prior to colesevelam hydrochloride.
    Warfarin
    Clinical Impact:
    There have been postmarketing reports of reduced International Normalized Ratio (INR) in patients receiving warfarin therapy [see Adverse Reactions (6.2)].
    Intervention:
    Monitor INR frequently during colesevelam hydrochloride initiation then periodically thereafter.
    Oral Contraceptives Containing Ethinyl Estradiol and Norethindrone
    Clinical Impact:
    In vivo drug interactions studies showed a decrease in exposure of ethinyl estradiol and norethindrone when coadministered with colesevelam hydrochloride [see Clinical Pharmacology (12.3)].
    Intervention:
    Administer oral contraceptives containing ethinyl estradiol and norethindrone 4 hours prior to colesevelam hydrochloride.
    Olmesartan Medoxomil
    Clinical Impact:
    In vivo drug interactions studies showed a decrease in olmesartan medoxomil when coadministered with colesevelam hydrochloride [see Clinical Pharmacology (12.3)].
    Intervention:
    Administer olmesartan medoxomil 4 hours prior to colesevelam hydrochloride.
    Sulfonylureas
    Clinical Impact:
    In vivo drug interactions studies showed a decrease in sulfonylureas when coadministered with colesevelam hydrochloride [see Clinical Pharmacology (12.3)].
    Intervention:
    Administer sulfonylureas 4 hours prior to colesevelam hydrochloride.
    Examples:
    Glimepiride, glipizide, and glyburide
    Oral Vitamin Supplements
    Clinical Impact:
    Colesevelam hydrochloride may decrease the absorption of fat-soluble vitamins A, D, E, and K [see Warnings and Precautions (5.3)].
    Intervention:
    Patients on oral vitamin supplementation should take their vitamins at least 4 hours prior to colesevelam hydrochloride.

    7.2 Colesevelam Hydrochloride Drug Interactions that Increase the Exposure of the Concomitant Medication

    Table 5

    Colesevelam Hydrochloride Drug Interactions that Increase the Exposure of the Concomitant Medication

    Metformin Extended-Release (ER)
    Clinical Impact:
    In vivo drug interactions studies showed an increase in metformin extended release (ER) when coadministered with colesevelam hydrochloride [see Clinical Pharmacology (12.3)].
    Intervention:
    Monitor patients glycemic control.
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  • 8 USE IN SPECIFIC POPULATIONS

    8.1 Pregnancy

    Risk Summary

    Colesevelam hydrochloride is not absorbed systemically following oral administration, and maternal use is not expected to result in fetal exposure to the drug. Limited available data on the use of colesevelam hydrochloride are insufficient to determine a drug-associated risk of major congenital malformations or miscarriage. In animal reproduction studies, no evidence of either maternal or fetal toxicity was found in rats or rabbits exposed to colesevelam hydrochloride during the period of fetal organogenesis at 5 and 8 times, respectively, the maximum recommended human dose (MRHD) of 3.75 g/day, based on body surface area (mg/m2). No adverse effects on offspring survival and development were observed in rats administered 5 times the MRHD (see Data).Colesevelam hydrochloride may decrease the absorption of fat-soluble vitamins [see Warnings and Precautions (5.3)]. There are no data available on the effect of colesevelam hydrochloride on the absorption of fat-soluble vitamins in pregnant women. If the patient becomes pregnant while taking colesevelam hydrochloride, the patient should be advised of the lack of known clinical benefit with continued use during pregnancy.


    The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. In the US 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.


    Data

    Human Data

    There are no adequate and well-controlled studies of colesevelam hydrochloride use in pregnant women.

    In the postmarketing setting there have been infrequent reports of pregnancy with use of colesevelam hydrochloride and a causal association with congenital anomalies has not been established.


    Animal Data

    In pregnant rats given dietary doses of 0.3, 1.0, 3.0 g/kg/day colesevelam hydrochloride from gestation days 7 through 17, no teratogenic effects were observed. Exposures at 3.0 g/kg/day were 8 times the human exposure at 3.75 g/day MRHD, based on body surface area (mg/m2).


    In pregnant rabbits given an oral gavage doses of 0.1, 0.5, 1.0 g/kg/day colesevelam hydrochloride from gestation days 6 through 18, no teratogenic effects were observed. Exposures at 1.0 g/kg/day were 5 times the human exposure at 3.75 g/day MRHD, based on body surface area (mg/m2).


    In pregnant rats given oral gavage doses of 0.1, 0.3, 1.0 g/kg/day colesevelam hydrochloride from gestation day 6 through lactation day 21 (weaning), no adverse effects on survival and development were observed. Exposures at 1.0 g/kg/day were 5 times the human exposure at 3.75 g/day MRHD, based on body surface area (mg/m2).

    8.2 Lactation

    Risk Summary

    Colesevelam hydrochloride is not absorbed systemically by the mother following oral administration, and breastfeeding is not expected to result in exposure of the child to colesevelam hydrochloride.

    8.3 Females and Males of Reproductive Potential

    Contraception 

    Use of colesevelam hydrochloride may reduce the efficacy of oral contraceptives. Advise patients to take oral contraceptives at least 4 hours prior to taking colesevelam hydrochloride [see Drug Interactions (7)].

    8.4 Pediatric Use

    The safety and effectiveness of colesevelam hydrochloride as monotherapy or in combination with a statin were evaluated in children, 10 to 17 years of age with HeFH [see Clinical Studies (14.1)]. The adverse reaction profile was similar to that of patients treated with placebo. In this limited controlled study, there were no significant effects on growth, sexual maturation, fat-soluble vitamin levels or clotting factors in the adolescent boys or girls relative to placebo see Adverse Reactions (6.1)].


    Due to tablet size, colesevelam hydrochloride for oral suspension is recommended for use in the pediatric population. Dose adjustments are not required when colesevelam hydrochloride is administered to children 10 to 17 years of age.


    Colesevelam hydrochloride has not been studied in children younger than 10 years of age or in pre-menarchal girls.

    8.5 Geriatric Use

    Primary Hyperlipidemia: Of the 1350 patients enrolled in the hyperlipidemia clinical studies, 349 (26%) were ≥65 years old, and 58 (4%) were ≥75 years old. No overall differences in safety or effectiveness were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out.

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  • 10 OVERDOSAGE

    Colesevelam hydrochloride is not absorbed and the risk of systemic toxicity is low. Excessive doses of colesevelam hydrochloride may cause more severe local gastrointestinal effects (e.g., constipation).

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  • 11 DESCRIPTION

    Colesevelam hydrochloride is a non-absorbed, polymeric, lipid-lowering and glucose-lowering agent for oral administration. Colesevelam hydrochloride is a high-capacity bile acid-binding molecule.

    Colesevelam hydrochloride is poly(allylamine hydrochloride) cross-linked with epichlorohydrin and alkylated with 1-bromodecane and (6-bromohexyl)-trimethylammonium bromide. The chemical name (IUPAC) of colesevelam hydrochloride is allylamine polymer with 1-chloro-2,3-epoxypropane, [6-(allylamino)-hexyl]trimethylammonium chloride and N-allyldecylamine, hydrochloride. The chemical structure of colesevelam hydrochloride is represented by the following formula:
    colese-struc

    wherein (a) represents allyl amine monomer units that have not been alkylated by either of the 1-bromodecane or (6-bromohexyl)-trimethylammonium bromide alkylating agents or cross-linked by epichlorohydrin; (b) represents allyl amine units that have undergone cross-linking with epichlorohydrin; (c) represents allyl amine units that have been alkylated with a decyl group; (d) represents allyl amine units that have been alkylated with a (6-trimethylammonium) hexyl group, and m represents a number ≥ 100 to indicate an extended polymer network. A small amount of the amines are dialkylated, and are not depicted in the formula above. No regular order of the groups is implied by the structure; cross-linking and alkylation are expected to occur randomly along the polymer chains. A large amount of the amines are protonated. The polymer is depicted in the hydrochloride form; a small amount of the halides are bromide. Colesevelam hydrochloride is hydrophilic and insoluble in water.

    Colesevelam hydrochloride for oral suspension is a citrus-flavored, a white to yellow granular powder containing yellow granules packaged in single-dose packets containing 3.75 gram colesevelam hydrochloride. In addition, each packet contains the following inactive ingredients: microcrystalline cellulose, medium chain triglycerides, simethicone emulsion, colloidal silicon dioxide, propylene glycol alginate, magnesium trisilicate, lemon-lime flavor, orange flavor, citric acid monohydrate, and aspartame (<5 calories per 3.75 gram single dose packet).    . PHENYLKETONURICS: colesevelam hydrochloride for oral suspension contains 27 mg phenylalanine per 3.75 gram dose.


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  • 12 CLINICAL PHARMACOLOGY

    12.1 Mechanism of Action

    Primary Hyperlipidemia: Colesevelam hydrochloride, the active pharmaceutical ingredient in colesevelam hydrochloride, is a non-absorbed, lipid-lowering polymer that binds bile acids in the intestine, impeding their reabsorption. As the bile acid pool becomes depleted, the hepatic enzyme, cholesterol 7-α-hydroxylase, is upregulated, which increases the conversion of cholesterol to bile acids. This causes an increased demand for cholesterol in the liver cells, resulting in the dual effect of increasing transcription and activity of the cholesterol biosynthetic enzyme, HMG-CoA reductase, and increasing the number of hepatic LDL receptors. These compensatory effects result in increased clearance of LDL-C from the blood, resulting in decreased serum LDL-C levels. Serum TG levels may increase or remain unchanged.

    12.2 Pharmacodynamics

    A maximum therapeutic response to the lipid-lowering effects of colesevelam hydrochloride was achieved within 2 weeks and was maintained during long-term therapy. In the diabetes clinical studies, a therapeutic response to colesevelam hydrochloride, as reflected by a reduction in hemoglobin A1C (A1C), was initially noted following 4 to 6 weeks of treatment and reached maximal or near-maximal effect after 12 to 18 weeks of treatment.

    12.3 Pharmacokinetics

    Absorption: Colesevelam hydrochloride is a hydrophilic, water-insoluble polymer that is not hydrolyzed by digestive enzymes and is not absorbed.


    Distribution: Colesevelam hydrochloride is not absorbed, and therefore, its distribution is limited to the gastrointestinal tract.


    Metabolism: Colesevelam hydrochloride is not metabolized systemically and does not interfere with systemic drug-metabolizing enzymes such as cytochrome P-450.


    Excretion: In 16 healthy volunteers, an average of 0.05% of administered radioactivity from a single 14C-labeled colesevelam hydrochloride dose was excreted in the urine.


    Drug Interactions: Drug interactions between colesevelam and concomitantly administered drugs were screened through in vitro studies and confirmed in in vivo studies. In vitro studies demonstrated that cephalexin, metformin, and ciprofloxacin had negligible binding to colesevelam hydrochloride. Therefore, an in vivo pharmacokinetic interaction of colesevelam hydrochloride with these drugs is unlikely. Colesevelam hydrochloride was found to have no significant effect on the bioavailability of aspirin, atenolol, digoxin, enalapril, fenofibrate, lovastatin, metoprolol, phenytoin, pioglitazone, quinidine, rosiglitazone, sitagliptin, valproic acid, and warfarin. The results of additional in vivo drug interactions of colesevelam hydrochloride are presented in Table 6.

    Table 6

    Mean Change in Drug Exposure (AUC0 to ∞ and Cmax) when Administered with Colesevelam Hydrochloride (3.75 g)a

    Drug
    Dose
    Co-administered
    1 hr prior to
    colesevelam hydrochloride 
    4 hr prior to
    colesevelam hydrochloride 
     
     
    AUC0 to ∞
    Cmax
    AUC0 to ∞
    Cmax
    AUC0 to ∞
    Cmax
    Cyclosporine
    200 mg
    -34%
    -44%
    N/A
    N/A
    N/A
    N/A
    Ethinyl
    Estradiol*
    0.035 mg
    -24%
    -24%
    -18%
    -1%
    -12%
    0%
    Glimepiride
    4 mg
    -18%
    -8%
    N/A
    N/A
    -6%
    3%
    Glipizide
    20 mg
    -12%
    -13%
    N/A
    N/A
    -4%
    0%
    Glyburide
    3 mg
    -32%
    -47%
    -20%
    -15%
    -7%
    4%
    Levothyroxine
    600 μg
    -22%
    -33%
    6%
    -2%
    1%
    8%
    Metformin ER
    1500 mg
    44%
    8%
    N/A
    N/A
    N/A
    N/A
    Norethindrone*
    1 mg
    -1%
    -20%
    5%
    -3%
    6%
    7%
    Olmesartan Medoxomil
    40 mg
    -39%
    -28%
    N/A
    N/A
    -15%
    -4%
    Repaglinide
    2 mg
    -7%
    -19%
    -6%
    -1%
    N/A
    N/A
    Verapamil sustained-release
    240 mg
    -31%
    -11%
    N/A
    N/A
    N/A
    N/A

    a With verapamil, the dose of colesevelam hydrochloride was 4.5 g

    * Oral contraceptive containing norethindrone and ethinyl estradiol.

    N/A – Not Available

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  • 13 NONCLINICAL TOXICOLOGY

    13.1 Carcinogenesis, Mutagenesis, Impairment Of Fertility

    Carcinogenesis: A 104-week carcinogenicity study with colesevelam hydrochloride was conducted in CD-1 mice, at oral dietary doses up to 3 g/kg/day. This dose was approximately 50 times the maximum recommended human dose of 4.5 g/day, based on body weight, mg/kg. There were no significant drug-induced tumor findings in male or female mice. In a 104-week carcinogenicity study with colesevelam hydrochloride in Harlan Sprague-Dawley rats, a statistically significant increase in the incidence of pancreatic acinar cell adenoma was seen in male rats at doses greater than 1.2 g/kg/day (approximately 20 times the maximum human dose, based on body weight, mg/kg) (trend test only). A statistically significant increase in thyroid C-cell adenoma was seen in female rats at 2.4 g/kg/day (approximately 40 times the maximum human dose, based on body weight, mg/kg).

    Mutagenesis: Colesevelam hydrochloride and 4 degradants present in the drug substance have been evaluated for mutagenicity in the Ames test and a mammalian chromosomal aberration test. The 4 degradants and an extract of the parent compound did not exhibit genetic toxicity in an in vitro bacterial mutagenesis assay in S. typhimurium and E. coli (Ames assay) with or without rat liver metabolic activation. An extract of the parent compound was positive in the Chinese Hamster Ovary (CHO) cell chromosomal aberration assay in the presence of metabolic activation and negative in the absence of metabolic activation. The results of the CHO cell chromosomal aberration assay with 2 of the 4 degradants, decylamine HCl and aminohexyltrimethyl ammonium chloride HCl, were equivocal in the absence of metabolic activation and negative in the presence of metabolic activation. The other 2 degradants, didecylamine HCl and 6-decylamino-hexyltrimethyl ammonium chloride HCl, were negative in the presence and absence of metabolic activation.


    Impairment of Fertility: Colesevelam hydrochloride did not impair fertility in rats at doses up to 3 g/kg/day (approximately 50 times the maximum human dose, based on body weight, mg/kg).

    13.2 Animal Toxicology and/or Pharmacology 

    Reproductive Toxicology Studies

    Reproduction studies have been performed in rats and rabbits at doses up to 3 g/kg/day and 1 g/kg/day, respectively (approximately 50 and 17 times the maximum human dose, based on body weight, mg/kg) and have revealed no evidence of harm to the fetus due to colesevelam hydrochloride.

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  • 14 CLINICAL STUDIES

    14.1 Primary Hyperlipidemia

    Colesevelam hydrochloride reduces TC, LDL-C, apolipoprotein B (Apo B), and non-HDL-C when administered alone or in combination with a statin in patients with primary hyperlipidemia.


    Approximately 1600 patients were studied in 9 clinical trials with treatment durations ranging from 4 to 50 weeks. With the exception of one open-label, uncontrolled, long-term extension study, all studies were multicenter, randomized, double-blind, and placebo-controlled. A maximum therapeutic response to colesevelam hydrochloride was achieved within 2 weeks and was maintained during long-term therapy.

    Monotherapy: In a study in patients with LDL-C between 130 mg/dL and 220 mg/dL (mean 158 mg/dL), colesevelam hydrochloride was given for 24 weeks in divided doses with the morning and evening meals.


    As shown in Table 7, the mean LDL-C reductions were 15% and 18% at the 3.8 g and 4.5 g doses. The respective mean TC reductions were 7% and 10%. The mean Apo B reductions were 12% in both treatment groups. colesevelam hydrochloride at both doses increased HDL-C by 3%. Increases in TG of 9 to 10% were observed at both colesevelam hydrochloride doses but the changes were not statistically different from placebo.


    Table 7

    Response to Colesevelam Hydrochloride Monotherapy in a 24-Week Trial -Percent Change in Lipid Parameters from Baseline


    Grams/
    Day
    N
    TC
    LDL-C
    Apo B
    HDL-Ca
    Non-HDL-C
    TGa
    Placebo
    88
    +1
    0
    0
    –1
    +1
    +5
    3.8 g
    (6 tablets)
    95
    –7*
    –15*
    –12*
    +3*
    –10*
    +10
    4.5 g
    (7 tablets)
    94
    –10*
    –18*
    –12*
    +3
    –13*
    +9

    *p less than 0.05 for lipid parameters compared to placebo, for Apo B compared to baseline.

     a Median % change from baseline.


    In a study in 98 patients with LDL-C between 145 mg/dL and 250 mg/dL (mean 169 mg/dL), colesevelam hydrochloride 3.8 g was given for 6 weeks as a single dose with breakfast, as a single dose with dinner, or as divided doses with breakfast and dinner. The mean LDL-C reductions were 18%, 15%, and 18% for the 3 dosing regimens, respectively. The reductions with these 3 regimens were not statistically different from one another.


    Combination Therapy: Co-administration of colesevelam hydrochloride and a statin (atorvastatin, lovastatin, or simvastatin) in 3 clinical studies demonstrated an additive reduction of LDL-C. The mean baseline LDL-C was 184 mg/dL in the atorvastatin study (range 156 to 236 mg/dL), 171 mg/dL in the lovastatin study (range 115 to 247 mg/dL), and 188 mg/dL in the simvastatin study (range 148 to 352 mg/dL). As demonstrated in Table 8, colesevelam hydrochloride doses of 2.3 g to 3.8 g resulted in an additional 8% to 16% reduction in LDL-C above that seen with the statin alone.

    Table 8

    Response to Colesevelam Hydrochloride in Combination with Atorvastatin, Simvastatin, or Lovastatin -Percent Change in Lipid Parameters

    Dose/Day
    N
    TC
    LDL-C
    Apo B
    HDL-Ca
    Non-HDL-C
    TGa
    Atorvastatin Trial (4-week)
    Placebo
    19
    +4
    +3
    –3
    +4
    +4
    +10
    Atorvastatin 10 mg
    18
    –27*
    –38*
    –32*
    +8
    –35*
    –24*
    Colesevelam hydrochloride 3.8 g/
    Atorvastatin 10 mg
    18
    –31*
    –48*
    –38*
    +11
    –40*
    –1
    Atorvastatin 80 mg
    20
    –39*
    –53*
    –46*
    +6
    –50*
    –33*
    Simvastatin Trial (6-week)
    Placebo
    33
    –2
    –4
    –4*
    –3
    –2
    +6*
    Simvastatin 10 mg
    35
    –19*
    –26*
    –20*
    +3*
    –24*
    –17*
    Colesevelam hydrochloride 3.8 g/
    Simvastatin 10 mg
    34
    –28*
    –42*
    –33*
    +10*
    –37*
    –12*
    Simvastatin 20 mg
    39
    –23*
    –34*
    –26*
    +7*
    –30*
    –12*
    Colesevelam hydrochloride 2.3 g/
    Simvastatin 20 mg
    37
    –29*
    –42*
    –32*
    +4*
    –37*
    –12*
    Lovastatin Trial (4-week)
    Placebo
    26
    +1
    0
    0
    +1
    +1
    +1
    Lovastatin 10 mg
    26
    –14*
    –22*
    –16*
    +5
    –19*
    0
    Colesevelam hydrochloride 2.3 g/ Lovastatin 10 mg Together
    27
    –21*
    –34*
    –24*
    +4
    –27*
    –1
    Colesevelam hydrochloride 2.3 g/ Lovastatin 10 mg Apart
    23
    –21*
    –32*
    –24*
    +2
    –28*
    –2

    *p less than 0.05 for lipid parameters compared to placebo, for Apo B compared to baseline.

     a Median % change from baseline.


    In all 3 studies, the LDL-C reduction achieved with the combination of colesevelam hydrochloride and any given dose of statin therapy was statistically superior to that achieved with colesevelam hydrochloride or that dose of the statin alone. The LDL-C reduction with atorvastatin 80 mg was not statistically significantly different from the combination of colesevelam hydrochloride 3.8 g and atorvastatin 10 mg.

    Pediatric Therapy: The safety and efficacy of colesevelam hydrochloride in pediatric patients were evaluated in an 8-week, multi-center, randomized, double-blind, placebo-controlled, parallel-group study followed by an open-label phase, in 194 boys and postmenarchal girls 10 to 17 years of age (mean age 14.1 years) with (HeFH), taking a stable dose of an FDA-approved statin (with LDL-C greater than 130 mg/dL) or naïve to lipid-lowering therapy (with LDL-C greater than 160 mg/dL). This study had 3 periods: a single-blind, placebo stabilization period; an 8-week, randomized, double-blind, parallel-group, placebo-controlled treatment period; and an 18-week, open-label treatment period. Forty-seven (24%) patients were taking statins and 147 (76%) patients were statin-naïve at screening. The mean baseline LDL-C at Day 1 was approximately 199 mg/dL.


    During the double-blind treatment period, patients were assigned randomly to treatment: colesevelam hydrochloride 3.8 g/day (n=64), colesevelam hydrochloride 1.9 g/day (n=65), or placebo (n=65). In total, 186 patients completed the double-blind treatment period. After 8 weeks of treatment, colesevelam hydrochloride 3.8 g/day significantly decreased plasma levels of LDL-C, non-HDL-C, TC, and Apo B and significantly increased HDL-C. A moderate, non-statistically significant increase in TG was observed versus placebo (Table 9).

    Table 9

    Response to Colesevelam Hydrochloride 3.8 g Compared to Placebo in Pediatric Patients 10 to 17 Years of Age – Mean Percent Change in Lipid Parameters from Baseline to Week 8

    Treatment
    Difference
    TC
    (N=128)
    LDL-C
    (N=128)
    Apo B
    (N=12
    4)
    HDL-C
    (N=128)
    Non-HDL-C
    (N=128)
    TGa (N=128)
    Colesevelam Hydrochloride 
    3.8 g vs Placebo
    -7*
    -13*
    -8*
    +6*
    -11*
     +5

    *p≤0.05 for lipid parameters compared to placebo Values represent LS mean. Only patients with values at both study baseline and endpoint are included in this table. Study baseline was defined as the last value measured before or on Day 1 prior to the first dose of randomized study medication.

    a For triglycerides, median % change from baseline. Results were based on the ITT population with LOCF


    During the open-label treatment period patients were treated with colesevelam hydrochloride 3.8 g/day. In total, 173 (89%) patients completed 26 weeks of treatment. Results at Week 26 were consistent with those at Week 8.

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  • 16 HOW SUPPLIED/STORAGE AND HANDLING

    Colesevelam hydrochloride for oral suspension is a white to yellow granular powder containing yellow granules.

    Colesevelam hydrochloride for oral suspension is available as follows:

    • 3.75 gram single-dose packet

    Cartons of 30 packets – NDC 67877-523-30

     
    Store at 25°C (68° to 77°F); excursions permitted between 15° to 30°C (59° to 86°F) [see USP Controlled Room Temperature].Protect from moisture.

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  • 17 PATIENT COUNSELING INFORMATION

    Hypertriglyceridemia and pancreatitis:
    Inform patients that colesevelam hydrochloride may increase their serum triglycerides which can lead to hypertriglyceridemia and pancreatitis. Instruct patients to discontinue colesevelam hydrochloride and seek prompt medical attention if the symptoms of acute pancreatitis occur (e.g., severe abdominal pain with or without nausea and vomiting) [see Warnings and Precautions (5.1)]

    Gastrointestinal:
    Inform patients that colesevelam hydrochloride may cause bowel obstruction. Instruct patients to promptly discontinue colesevelam hydrochloride and seek medical attention if severe abdominal pain or severe constipation occurs [see Warnings and Precautions (5.2)].

    Drug and Vitamin interactions:
    Advise patients that colesevelam hydrochloride has drug interactions and colesevelam hydrochloride may decrease the absorption of fat-soluble vitamins A, D, E, and K. Instruct patients to take oral vitamins at least 4 hours prior to colesevelam hydrochloride. Instruct patients to inform their physician about all the drugs and vitamins that they are prescribed or take over the counter [see Warnings and Precautions (5.3) and Drug Interactions (7)].

    Hypertriglyceridemia and cardiovascular disease:
    Inform patients that colesevelam hydrochloride may increase serum triglycerides and that the long-term effect of hypertriglyceridemia on the risk of coronary artery disease is uncertain [see Warnings and Precautions (5.1)]

    Administration [see Dosage and Administration (2.4)]:
    Tablets: Advise patients to take colesevelam hydrochloride tablets with a meal and liquid. Inform patients that colesevelam hydrochloride tablets can be taken as 6 tablets once daily or 3 tablets twice daily

    For Oral Suspension:
    Instruct patients to empty the entire contents of one packet into a glass or cup and add 1 cup (8 ounces) of water, fruit juice, or diet soft drinks. Stir well and drink. Advise patients to take colesevelam hydrochloride oral suspension with meals. Advise patient to not take colesevelam hydrochloride oral suspension in its dry form.

    Females of Reproductive Potential:
    Advise females of reproductive potential that colesevelam hydrochloride may reduce the effectiveness of oral contraceptives, and to take oral contraceptives at least 4 hours before taking colesevelam hydrochloride [see Drug Interactions (7) and Use in Specific Populations (8.3)].


    cole-logo


    Manufactured in India by:
    Alkem Laboratories Limited
    H.O.: ALKEM HOUSE,
    Senapati Bapat Marg, Lower Parel,
    Mumbai – 400 013, INDIA

    Distributed by:
    Ascend Laboratories, LLC
    Parsippany, NJ 07054

    Revised: July, 2019

    PT 2768-01

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  • PACKAGE LABEL.PRINCIPAL DISPLAY PANEL

    PACKAGE LABEL - PRINCIPAL DISPLAY PANEL

    ASCEND Laboratories, LLC
    NDC 67877-523-30

    Colesevelam Hydrochloride for Oral Suspension 3.75g/packet
    Rx only                                                                     
    Single Dose Packet
    Packet Label

    PACKAGE LABEL - PRINCIPAL DISPLAY PANEL

    ASCEND Laboratories, LLC
    NDC 67877-523-30
    Carton Label
    Colesevelam Hydrochloride for Oral Suspension 3.75 g/packet
    Rx only                                                                     
    30 Packets

    Carton Label

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  • INGREDIENTS AND APPEARANCE
    COLESEVELAM HYDROCHLORIDE 
    colesevelam hydrochloride powder, for suspension
    Product Information
    Product Type HUMAN PRESCRIPTION DRUG Item Code (Source) NDC:67877-523
    Route of Administration ORAL
    Active Ingredient/Active Moiety
    Ingredient Name Basis of Strength Strength
    COLESEVELAM HYDROCHLORIDE (UNII: P4SG24WI5Q) (COLESEVELAM - UNII:1XU104G55N) COLESEVELAM HYDROCHLORIDE 3.75 g
    Inactive Ingredients
    Ingredient Name Strength
    MICROCRYSTALLINE CELLULOSE (UNII: OP1R32D61U)  
    MEDIUM-CHAIN TRIGLYCERIDES (UNII: C9H2L21V7U)  
    SILICON DIOXIDE (UNII: ETJ7Z6XBU4)  
    MAGNESIUM TRISILICATE (UNII: C2E1CI501T)  
    CITRIC ACID MONOHYDRATE (UNII: 2968PHW8QP)  
    ASPARTAME (UNII: Z0H242BBR1)  
    DIMETHICONE (UNII: 92RU3N3Y1O)  
    LEMON (UNII: 24RS0A988O)  
    ORANGE (UNII: 5EVU04N5QU)  
    PROPYLENE GLYCOL ALGINATE (UNII: 26CD3J2R0C)  
    Product Characteristics
    Color YELLOW (White to Yellow Granular Powder) Score     
    Shape Size
    Flavor CITRUS (Lemon-Orange Flavor) Imprint Code
    Contains     
    Packaging
    # Item Code Package Description Marketing Start Date Marketing End Date
    1 NDC:67877-523-30 30 in 1 PACKET; Type 0: Not a Combination Product 05/09/2019
    Marketing Information
    Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date
    ANDA ANDA210316 05/09/2019
    Labeler - Ascend Laboratories, LLC (141250469)
    Establishment
    Name Address ID/FEI Business Operations
    Alkem Laboratories Limited 677605851 ANALYSIS(67877-523) , REPACK(67877-523) , MANUFACTURE(67877-523) , PACK(67877-523)
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