DICHLORPHENAMIDE: 1,596 Adverse Event Reports & Safety Profile

Dichlorphenamide tablets USP contain dichlorphenamide, an oral carbonic anhydrase inhibitor. Dichlorphenamide USP, a dichlorinated benzenedisulfonamide, is known chemically as 4, 5– dichloro- 1,3-benzenedisulfonamide. Its empirical formula is C 6 H 6 Cl 2 N 2 O 4 S 2 and its structural formula is: Dichlorphenamide USP is a white or practically white crystalline powder with a molecular weight of 305.16. It is soluble in 10% w/v sodium hydroxide solution, sparingly soluble in 10% w/v sodium carbonate solution and very slightly to practically insoluble in water. Dichlorphenamide tablets USP are supplied as tablets, for oral administration, each containing 50 mg dichlorphenamide USP. Inactive ingredients are colloidal silicon dioxide, lactose monohydrate, magnesium stearate and pregelatinized starch. diclorophenamide-Label.jpg

AND USAGE Dichlorphenamide tablets are indicated for the treatment of primary hyperkalemic periodic paralysis, primary hypokalemic periodic paralysis, and related variants. Dichlorphenamide tablets are an oral carbonic anhydrase inhibitor indicated for the treatment of primary hyperkalemic periodic paralysis, primary hypokalemic periodic paralysis, and related variants ( 1 )

AND ADMINISTRATION

• Initiate dosing at 50 mg by mouth once or twice daily ( 2.1 )
• Titrate up or down dose based on individual response ( 2.1 )
• The minimum recommended dosage is 50 mg daily, and the maximum recommended dosage is 200 mg daily ( 2.1 )
• Evaluate response to dichlorphenamide tablets after 2 months of treatment ( 2.2 )

2.1 Dosage Information Initiate dosing at 50 mg by mouth once or twice daily. The dosage may be increased or decreased based on individual response, at weekly intervals (or sooner in case of adverse reaction). The minimum recommended total daily dosage is 50 mg, and the maximum recommended total daily dosage is 200 mg.

2.2 Monitoring to Assess Effectiveness Primary hyperkalemic periodic paralysis, primary hypokalemic periodic paralysis, and related variants are a heterogeneous group of conditions, for which the response to dichlorphenamide may vary. Therefore, prescribers should evaluate the patient's response to dichlorphenamide after 2 months of treatment to decide whether dichlorphenamide tablets should be continued.

2.3 Monitoring to Assess Safety Baseline and periodic measurements of serum potassium and sodium bicarbonate during dichlorphenamide treatment is recommended <span class="opacity-50 text-xs">[see Warnings and Precautions ( 5.3 , 5.4 )]</span> .

Dichlorphenamide is contraindicated in the following circumstances: Hypersensitivity to dichlorphenamide or other sulfonamides [see Warnings and Precautions ( 5.1 )] Concomitant use of dichlorphenamide and high dose aspirin [see Warnings and Precautions ( 5.2 ) and Drug Interactions ( 7.1 )] Severe pulmonary disease, limiting compensation to metabolic acidosis caused by dichlorphenamide [see Warnings and Precautions ( 5.4 )] Hepatic insufficiency: dichlorphenamide may aggravate hepatic encephalopathy. Hepatic insufficiency ( 4 ) Severe pulmonary obstruction ( 4 ) Hypersensitivity to dichlorphenamide or other sulfonamides ( 4 ) Concomitant use with high dose aspirin ( 4 )

REACTIONS The following serious adverse reactions are described elsewhere in labeling: Hypersensitivity and Other Life-Threatening Reactions [see Warnings and Precautions ( 5.1 )] Hypokalemia [see Warnings and Precautions ( 5.3 )]

Metabolic

Acidosis [see Warnings and Precautions ( 5.4 )] Falls [ see Warnings and Precautions ( 5.5 )] Most common adverse reactions (incidence at least 10% and greater than placebo) include paresthesias, cognitive disorder, dysgeusia, and confusional state ( 6.1 ) To report SUSPECTED ADVERSE REACTIONS, contact Cycle Pharmaceuticals Ltd at 1-857-437-3969 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

6.1 Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. In a 9-week randomized controlled trial in adults with hyperkalemic or hypokalemic periodic paralysis (Study 1), the most common adverse reactions in patients treated with dichlorphenamide, with rates greater than placebo, were paresthesia, cognitive disorder, dysgeusia, and confusional state. The mean dose of dichlorphenamide was 94 mg/day in patients with hypokalemic periodic paralysis and 82 mg/day in patients with hyperkalemic periodic paralysis.

Table

1 lists the incidence of adverse reactions that occurred in 5% of patients treated with dichlorphenamide and more commonly than in patients treated with placebo in Study 1.

Table

1: Adverse Reactions in Patients Treated with Dichlorphenamide with Incidence 5% and more common than in Patients Treated with Placebo in Study 1 Adverse Reaction Dichlorphenamide N = 36 (%) Placebo N = 29 (%) Nervous system disorders Paresthesia 44 14 Cognitive disorder 1 14 7 Dysgeusia 14 0 Confusional state 11 0 Headache 8 7 Hypoesthesia 8 0 Lethargy 8 0 Dizziness 6 0 Gastrointestinal disorders Diarrhea 6 3 Nausea 6 0 General disorders and administration site conditions Fatigue 8 0 Malaise 6 0 Investigations Weight decreased 6 0 Musculoskeletal and connective tissue disorders Muscle spasms 8 0 Arthralgia 6 3 Muscle twitching 6 0 Respiratory Dyspnea 6 0 Pharyngolaryngeal pain 6 0 Skin Rash 8 0 Pruritus 6 0 1 Cognitive disorder combined cases with the preferred terms of cognitive disorder, disturbance in attention, and mental impairment.

6.2 Postmarketing Experience Adverse reactions have been identified during postapproval use of dichlorphenamide. 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. The following are adverse reactions which have been reported during postapproval use of dichlorphenamide and were serious or are not reported in the previous section of labeling <span class="opacity-50 text-xs">[see Clinical Trials Experience ( 6.1 ) ]</span> : amnesia, cardiac failure, condition aggravated, convulsion, hallucination, nephrolithiasis, pancytopenia, psychotic disorder, renal tubular necrosis, stupor, syncope, tremor.

AND PRECAUTIONS Hypersensitivity and Other Life-Threatening Reactions: discontinue dichlorphenamide at the first appearance of skin rash or any sign of immune- mediated or idiosyncratic adverse reaction ( 5.1 ) Hypokalemia: baseline and periodic measurements of serum potassium are recommended; if hypokalemia develops or persists, consider reducing the dose or discontinuing dichlorphenamide and correcting potassium levels ( 5.3 ) Metabolic acidosis: baseline and periodic measurements of serum bicarbonate are recommended; if metabolic acidosis develops or persists, consider reducing the dose or discontinuing dichlorphenamide ( 5.4 ) Falls: consider reducing the dose or discontinuing dichlorphenamide in patients who experience falls ( 5.5 )

5.1 Hypersensitivity and Other Life-Threatening Reactions Fatalities associated with the administration of sulfonamides have occurred because of adverse reactions including Stevens-Johnson syndrome, toxic epidermal necrolysis, fulminant hepatic necrosis, agranulocytosis, aplastic anemia, and other blood dyscrasias. Pulmonary involvement can occur in isolation or as part of a systemic reaction. Dichlorphenamide should be discontinued at the first appearance of skin rash or any sign of immune- mediated or other life-threatening adverse reaction.

5.2 Concomitant Use of Aspirin or Other Salicylates Carbonic anhydrase inhibitors, including dichlorphenamide, can cause metabolic acidosis <span class="opacity-50 text-xs">[see Warnings and Precautions ( 5.4 )]</span> , which can increase the risk of salicylate toxicity. Anorexia, tachypnea, lethargy, and coma have been reported with concomitant use of dichlorphenamide and high-dose aspirin. Therefore, the concomitant use of dichlorphenamide and high-dose aspirin is contraindicated. Patients with concomitant use of dichlorphenamide and low-dose aspirin should be carefully monitored.

5.3 Hypokalemia Dichlorphenamide increases potassium excretion and can cause hypokalemia. The risk of hypokalemia is greater when dichlorphenamide is used in patients with conditions associated with hypokalemia (e.g., adrenocortical excess, renal tubular acidosis type 1 and 2), and in patients receiving other drugs that may cause hypokalemia <span class="opacity-50 text-xs">[see Drug Interactions ( 7.3 ]</span> . Baseline and periodic measurements of serum potassium during dichlorphenamide treatment is recommended. If hypokalemia develops or persists, consideration should be given to reducing the dose or discontinuing dichlorphenamide and correction of potassium levels.

5.4 Metabolic Acidosis Dichlorphenamide can cause hyperchloremic non-anion gap metabolic acidosis. Concomitant use of dichlorphenamide with other drugs that cause metabolic acidosis may increase the severity of acidosis. Concomitant use of dichlorphenamide in compensated patients with respiratory acidosis, such as in advanced lung diseases, may lead to respiratory decompensation. Baseline and periodic measurements of serum bicarbonate during dichlorphenamide treatment are recommended. If metabolic acidosis develops or persists, consideration should be given to reducing the dose or discontinuing dichlorphenamide <span class="opacity-50 text-xs">[see Drug Interactions ( 7.4) ]</span>.

5.5 Falls Dichlorphenamide increases the risk of falls. The risk of falls is greater in the elderly and with higher doses of dichlorphenamide. Consider dose reduction or discontinuation of dichlorphenamide in patients who experience falls while treated with dichlorphenamide.

INTERACTIONS Aspirin: anorexia, tachypnea, lethargy, and coma have been reported with concomitant use of dichlorphenamide and high-dose aspirin. The concomitant use of dichlorphenamide tablets and high-dose aspirin is contraindicated. Dichlorphenamide tablets should be used with caution in patients receiving lower doses of aspirin ( 4 , 5.2 , 7.1 )

7.1 Aspirin and Other Salicylates Carbonic anhydrase inhibitors, including dichlorphenamide, can cause metabolic acidosis <span class="opacity-50 text-xs">[see Warnings and Precautions ( 5.2 , 5.4 )]</span> , which can increase the risk of salicylate toxicity. Anorexia, tachypnea, lethargy, and coma have been reported with concomitant use of dichlorphenamide and high-dose aspirin. Therefore, concomitant use of dichlorphenamide and high-dose aspirin is contraindicated. Patients with concomitant use of dichlorphenamide and low-dose aspirin should be carefully monitored <span class="opacity-50 text-xs">[see Contraindications ( 4 ) and Warnings and Precautions ( 5.2 )]</span>.

7.2 Drugs that are Substrates of Organic Anion Transporter1 (OAT1) In vitro , dichlorphenamide is an inhibitor of OAT1 transporters. The concomitant administration of dichlorphenamide may increase the plasma exposures of OAT1 substrates. Use of dichlorphenamide with drugs that are sensitive to OAT1 inhibition (e.g., methotrexate, famotidine, oseltamivir) is not recommended <span class="opacity-50 text-xs">[see Clinical Pharmacology ( 12.3 )]</span>.

7.3 Drugs that Cause Hypokalemia The risk of hypokalemia is greater with coadministration of dichlorphenamide and other drugs that can cause hypokalemia (e.g., loop diuretics, thiazide diuretics, laxatives, antifungals, penicillins, and theophylline) <span class="opacity-50 text-xs">[see Warnings and Precautions ( 5.3 )]</span>.

7.4 Drugs that Cause Metabolic Acidosis Coadministration of dichlorphenamide and other drugs that can cause metabolic acidosis may increase the severity of the acidosis <span class="opacity-50 text-xs">[see Warnings and Precautions ( 5.4 )]</span>.

7.5 Drugs that are Inhibitors of OAT1 or OAT3 An in vitro transporter study indicated that dichlorphenamide is a substrate of human transporters OAT1 and OAT3 <span class="opacity-50 text-xs">[see Clinical Pharmacology ( 12.3 )]</span> . Therefore, signs of dichlorphenamide toxicity should be monitored when administered with OAT1 or OAT3 inhibitors.