MAGNESIUM ANHYDROUS: 13 Adverse Event Reports & Safety Profile

Sodium sulfate, potassium sulfate, and magnesium sulfate oral solution (for adults) is an osmotic laxative and is provided as two bottles each containing 6 ounces of solution. Each bottle contains: 17.5 grams sodium sulfate, USP, 3.13 grams potassium sulfate, and 1.6 grams magnesium sulfate, USP. Inactive ingredients include: citric acid anhydrous, malic acid, natural and artificial blueberry flavor, purified water, sodium benzoate, and sucralose.

Sodium

Sulfate, USP The chemical name is Na 2 SO 4 . The average molecular weight is 142.04 g/mol. The structural formula is: image description Potassium Sulfate, FCC, purified The chemical name is K 2 SO 4 . The average molecular weight is 174.26 g/mol. The structural formula is: image description Magnesium Sulfate, USP The chemical name is MgSO 4 . The average molecular weight: 120.37 g/mol. The structural formula is: Each sodium sulfate, potassium sulfate, and magnesium sulfate oral solution kit also contains a high density polyethylene (HDPE) mixing container. Pediatric use information is approved for Braintree Laboratories, Inc.’s SUPREP BOWEL PREP KIT (sodium sulfate, potassium sulfate, and magnesium sulfate) oral solution. However, due to Braintree Laboratories, Inc.’s marketing exclusivity rights, this drug product is not labeled with that pediatric information. image description

AND USAGE Sodium sulfate, potassium sulfate, and magnesium sulfate oral solution is indicated for cleansing of the colon as a preparation for colonoscopy in adult patients. Pediatric use information is approved for Braintree Laboratories, Inc.'s SUPREP BOWEL PREP KIT (sodium sulfate, potassium sulfate, and magnesium sulfate) oral solution. However, due to Braintree Laboratories, Inc.'s marketing exclusivity rights, this drug product is not labeled with that pediatric information. Sodium sulfate, potassium sulfate, and magnesium sulfate oral solution is an osmotic laxative indicated for cleansing of the colon in preparation for colonoscopy in adult patients. ( 1 )

AND ADMINISTRATION For complete information on preparation before colonoscopy and administration of the dosage regimen, see full prescribing information. ( 2.1 , 2.2 ) Preparation and Administration ( 2.1 ) Administration of two doses (24 tablets) are required for a complete preparation for colonoscopy. SUTAB is supplied as two bottles each containing 12 tablets. Twelve (12) tablets are equivalent to one dose. Each SUTAB bottle contains a desiccant. Remove and discard the desiccant from both bottles the evening prior to the colonoscopy. Must consume water with each dose and an additional 32 ounces of water after each dose. Do not take other laxatives. Administer oral medications at least 1 hour before starting each dose of SUTAB. If taking tetracycline or fluoroquinolone antibiotics, iron, digoxin, chlorpromazine, or penicillamine, take these medications at least 2 hours before and not less than 6 hours after administration of each dose.

Recommended Split

Dose (2-Day) Regimen ( 2.2 )

Day

1, Dose 1: On the Evening Prior to Colonoscopy Open 1 bottle of 12 tablets. Remove and discard the desiccant. Remove and discard the desiccant from the second bottle and close the bottle. Use the second bottle for the second dose on the morning of the colonoscopy. Fill the provided container with 16 ounces of water (up to the fill line). Swallow each tablet with a sip of water and drink the entire amount over 15 to 20 minutes. Approximately one hour after the last tablet is ingested, fill the provided container a second time with 16 ounces of water (up to the fill line) and drink the entire amount over 30 minutes.

Approximately

30 minutes after finishing the second container of water, fill the provided container with 16 ounces of water (up to the fill line) and drink the entire amount over 30 minutes.

Day

2, Dose 2: Morning of the Colonoscopy (5 to 8 hours prior to the colonoscopy and no sooner than 4 hours from starting Dose 1): Continue to consume only clear liquids until after the colonoscopy.

Repeat Step

2 to Step 4 from Day 1, Dose 1. If patients experience preparation-related symptoms (e.g., nausea, bloating, cramping), pause or slow the rate of drinking the additional water until symptoms diminish. Complete all SUTAB tablets and water at least two hours prior to colonoscopy.

2.1 Important Preparation and Administration Instructions Correct fluid and electrolyte abnormalities before treatment with SUTAB <span class="opacity-50 text-xs">[see Warnings and Precautions ( 5.1 )]</span> Administration of two doses of SUTAB (24 tablets) are required for a complete preparation for colonoscopy. SUTAB is supplied as two bottles each containing 12 tablets. Twelve (12) tablets are equivalent to one dose. Each SUTAB bottle contains a desiccant. Remove and discard the desiccant from both bottles of SUTAB the evening prior to the colonoscopy <span class="opacity-50 text-xs">[see Dosage and Administration ( 2.2 )]</span> . Must consume water with each dose of SUTAB and an additional 32 ounces of water must be consumed after each dose <span class="opacity-50 text-xs">[see Dosage and Administration (2.2) and Warnings and Precautions ( 5.1 )]</span> . Consume a low residue breakfast on the day before colonoscopy, followed by clear liquids up to 2 hours prior to colonoscopy. Do not drink milk or eat or drink anything colored red or purple. Do not drink alcohol. Do not take other laxatives while taking SUTAB. Administer oral medications at least 1 hour before starting each dose of SUTAB. If taking tetracycline or fluoroquinolone antibiotics, iron, digoxin, chlorpromazine, or penicillamine, take these medications at least 2 hours before and not less than 6 hours after administration of each dose of SUTAB. Stop consumption of all fluids at least 2 hours prior to the colonoscopy.

2.2 Recommended Split-Dose (2-Day)

Dosage Regimen

The recommended Split-Dose (2-day) dosage regimen for adults consists of two doses of SUTAB: the first dose during the evening prior to colonoscopy and the second dose the next day, during the morning of the colonoscopy. Instruct patients: On the Day Prior to Colonoscopy : A low residue breakfast may be consumed. Examples of low residue foods are eggs, white bread, cottage cheese, yogurt, grits, coffee, tea. After breakfast, only clear liquids may be consumed until after the colonoscopy. Examples of clear liquids are coffee or tea (no cream or non-dairy creamer), fruit juices (without pulp), gelatin desserts (no fruit or topping), water, chicken broth, clear soda (such as ginger ale).

Day

1, Dose 1 - On the Evening Prior to Colonoscopy: Early in the evening prior to colonoscopy, open one bottle of 12 tablets. Remove and discard the desiccant. Remove and discard the desiccant from the second bottle and close the bottle. Use the second bottle for the second dose on the morning of the colonoscopy. Fill the provided container with 16 ounces of water (up to the fill line). Swallow one tablet at a time with a sip of water. Finish taking the 12 tablets and drinking the entire amount of water within 15 to 20 minutes. Approximately one hour after the last tablet is ingested, fill the provided container a second time with 16 ounces of water (up to the fill line) and drink the entire amount over 30 minutes.

Approximately

30 minutes after finishing the second container of water, fill the provided container again with 16 ounces of water (up to the fill line) and drink the entire amount over 30 minutes. If patients experience preparation-related symptoms (e.g. nausea, bloating, cramping), pause or slow the rate of drinking the additional water until symptoms diminish.

Day

2, Dose 2 – The Morning of the Colonoscopy (5 to 8 hours prior to the colonoscopy and no sooner than 4 hours from starting Dose 1): Continue to consume only clear liquids until after the colonoscopy.

Repeat Step

2 to Step 4 from Day 1, Dose 1. If patients experience preparation-related symptoms (e.g., nausea, bloating, cramping), pause or slow the rate of drinking the additional water until symptoms diminish. Complete taking all SUTAB tablets and water at least two hours prior to colonoscopy.

Sodium sulfate, potassium sulfate, and magnesium sulfate oral solution is contraindicated in the following conditions: Gastrointestinal obstruction or ileus [see Warnings and Precautions (5.6) ] Bowel perforation [see Warnings and Precaution (5.6) ] Toxic colitis or toxic megacolon Gastric retention Hypersensitivity to any of the ingredients in sodium sulfate, potassium sulfate, and magnesium sulfate oral solution Gastrointestinal obstruction or ileus ( 4 , 5.6 ) Bowel perforation ( 4 , 5.6 ) Toxic colitis or toxic megacolon ( 4 ) Gastric retention ( 4 ) Hypersensitivity to any ingredient ( 4 )

REACTIONS The following serious or otherwise important adverse reactions for bowel preparations are described elsewhere in the labeling: Serious Fluid and Electrolyte Abnormalities [see Warnings and Precautions ( 5.1 )]

Cardiac

Arrhythmias [see Warnings and Precautions ( 5.2 )] Seizures [see Warnings and Precautions ( 5.3 )] Patients with Risk of Renal Injury [see Warnings and Precautions ( 5.4 )]

Colonic Mucosal

Ulceration and Ischemic Colitis [see Warnings and Precautions ( 5.5 )] Patients with Significant Gastrointestinal Disease [see Warnings and Precautions ( 5.6 )]

Hypersensitivity

Reactions [see Warnings and Precautions ( 5.7 )] Risk of Gastrointestinal Complications with Ingestion of Desiccant [see Warnings and Precautions ( 5.8 )] Most common gastrointestinal adverse reactions are nausea, abdominal distension, vomiting and upper abdominal pain. ( 6.1 ) To report SUSPECTED ADVERSE REACTIONS, contact Braintree Laboratories, Inc. at 1-800-874-6756 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch .

6.1 Clinical Trials 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. The safety of SUTAB was evaluated in two randomized, parallel group, multicenter, investigator blinded clinical trials in 941 adult patients undergoing colonoscopy. The active comparators were polyethylene glycol 3350, sodium sulfate, sodium chloride, potassium chloride, ascorbic acid and sodium ascorbate for oral solution in Study 1 and sodium picosulfate, magnesium oxide, and anhydrous citric acid for oral solution in Study 2 <span class="opacity-50 text-xs">[see Clinical Studies ( 14 )]</span> .

Adverse Gastrointestinal Reactions

Reported by Symptom Questionnaire In Studies 1 and 2, patients were queried for selected gastrointestinal adverse reactions of stomach cramping (upper abdominal pain), stomach bloating (abdominal distention), nausea and vomiting using a standard questionnaire following completion of study drug and prior to colonoscopy on the day of colonoscopy. Patients reporting selected gastrointestinal symptom(s) rated the intensity as mild, moderate or severe. A total of 52% (287/552) of patients in Study 1 and 52% (202/389) in Study 2 reported at least one selected gastrointestinal adverse reaction when queried using the standard questionnaire.

Tables

1 and 2 show results for each gastrointestinal adverse reaction reported by patients using the standard questionnaire, including severity.

Table

1: Gastrointestinal Symptoms by Severity a From Symptom Questionnaire in Adult Patients Following Colon Cleansing and Prior to Colonoscopy – Study 1 b a Mild : barely noticeable, does not influence functioning causing no limitations of usual activities; Moderate : makes participant uncomfortable, influences functioning causing some limitations of usual activities; Severe : severe discomfort, treatment needed, severe and undesirable, causing inability to carry out usual activities b Study 1 was not designed to support comparative claims for SUTAB for the adverse reactions reported in this table. c Percentage represents n/N for patients who experienced each gastrointestinal adverse reaction on the symptom questionnaire based on the total number of patients per treatment arm. Symptom SUTAB Polyethylene glycol 3350, sodium sulfate, sodium chloride, potassium chloride, ascorbic acid and sodium ascorbate Total Number or Patients per Treatment Arm (N) 281 271 Patients with at Least One Gastrointestinal Adverse Reaction from Symptom Questionnaire 163 124 % Nausea c 48 26 Mild 71 77 Moderate 27 23 Severe 2 0 % Abdominal Distension c,d 29 22 Mild 68 71 Moderate 30 29 Severe 1 0 % Vomiting c 23 5 Mild 48 46 Moderate 52 54 Severe 0 0 % Upper Abdominal Pain c 16 18 Mild 65 71 Moderate 35 29 Severe 0 0 Total Number of Patients per Treatment Arm (N) 281 271 Table 2: Gastrointestinal Symptoms by Severity a From Symptom Questionnaire in Adult Patients Following Colon Cleansing and Prior to Colonoscopy – Study 2 b a Mild : barely noticeable, does not influence functioning causing no limitations of usual activities; Moderate : makes participant uncomfortable, influences functioning causing some limitations of usual activities; Severe : severe discomfort, treatment needed, severe and undesirable, causing inability to carry out usual activities b Study 2 was not designed to support comparative claims for SUTAB for the adverse reactions reported in this table. c Percentage represents n/N for patients who experienced each gastrointestinal adverse reaction on the symptom questionnaire based on the total number of patients per treatment arm. Symptom SUTAB Sodium picosulfate, magnesium oxide, and anhydrous citric acid Total Number or Patients per Treatment Arm (N) 190 199 Patients with at Least One Gastrointestinal Adverse Reaction from Symptom Questionnaire 135 67 % Nausea c 52 18 Mild 74 94 Moderate 20 6 Severe 6 0 % Abdominal Distension c 34 15 Mild 73 69 Moderate 27 31 Severe 0 0 % Vomiting c 16 2 Mild 53 33 Moderate 47 67 Severe 0 0 % Upper Abdominal Pain c 23 13 Mild 82 100 Moderate 16 0 Severe 2 0 Total Number of Patients per Treatment Arm (N) 190 199 Patients with at Least One Gastrointestinal Adverse Reaction from Symptom Questionnaire 135 67 Additional Adverse Reactions Reported in Studies 1 and 2 In addition to the gastrointestinal symptoms reported on the standard questionnaire (Tables 1 and 2), other adverse reactions reported in at least 2% of patients in either treatment arm in Studies 1 and 2 were: dizziness in Study 1 (0% SUTAB and 2% comparator); and hypermagnesemia (2% SUTAB and 2% comparator) and increased liver function test (including ALT, AST and bilirubin) (3% SUTAB and 1% comparator) in Study 2.

Laboratory Changes Electrolyte Abnormalities

Shifts in serum electrolytes from normal at baseline to above the upper end of normal following study drug on the day of colonoscopy in at least 2% of patients in either treatment arm and at least 2% greater in patients treated with SUTAB than treated with comparator in either Study 1 or Study 2 were: magnesium (27% SUTAB and 5% comparator in Study 1), and serum osmolality (44% SUTAB and 28% comparator in Study 2). These changes were transient and resolved without intervention.

Renal Function Parameters

Decreases in creatinine clearance and increases in blood urea nitrogen (BUN) were reported in less than 1% of patients in both SUTAB and comparator arms in both trials.

6.2 Postmarketing Experience The following adverse reactions have been identified during post-approval use of SUTAB. 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. Gastrointestinal : gastric ulceration, gastritis Hypersensitivity : anaphylaxis, angioedema, dyspnea, rash, pruritus, urticaria <span class="opacity-50 text-xs">[see Warnings and Precautions ( 5.7 )]</span>

AND PRECAUTIONS Risk of fluid and electrolyte abnormalities : Encourage adequate hydration, assess concurrent medications, and consider laboratory assessments prior to and after each use. ( 5.1 , 7.1 ) Cardiac arrhythmias : Consider pre-dose and post-colonoscopy ECGs in patients at increased risk. ( 5.2 ) Seizures : Use caution in patients with a history of seizures and patients at increased risk of seizures, including medications that lower the seizure threshold. ( 5.3 , 7.1 ) Patients with renal impairment or taking concomitant medications that affect renal function : Use caution, ensure adequate hydration and consider laboratory testing. ( 5.4 , 7.1 ) Suspected GI obstruction or perforation : Rule out the diagnosis before administration. ( 4 , 5.6 ) Patients at risk for aspiration : Observe during administration. ( 5.7 )

5.1 Serious Fluid and Serum Chemistry Abnormalities Advise all patients to hydrate adequately before, during, and after the use of sodium sulfate, potassium sulfate, and magnesium sulfate oral solution. If a patient develops significant vomiting or signs of dehydration after taking sodium sulfate, potassium sulfate, and magnesium sulfate oral solution, consider performing post-colonoscopy lab tests (electrolytes, creatinine, and BUN). Fluid and electrolyte disturbances can lead to serious adverse events including cardiac arrhythmias, seizures and renal impairment. Correct fluid and electrolyte abnormalities before treatment with sodium sulfate, potassium sulfate, and magnesium sulfate oral solution. Use sodium sulfate, potassium sulfate, and magnesium sulfate oral solution with caution in patients with conditions, or who are using medications, that increase the risk for fluid and electrolyte disturbances or may increase the risk of adverse events of seizure, arrhythmias, and renal impairment <span class="opacity-50 text-xs">[see Drug Interactions (7.1) ]</span> . Sodium sulfate, potassium sulfate, and magnesium sulfate oral solution can cause temporary elevations in uric acid <span class="opacity-50 text-xs">[see Adverse Reactions (6.1) ]</span> . Uric acid fluctuations in patients with gout may precipitate an acute flare. The potential for uric acid elevation should be considered before administering sodium sulfate, potassium sulfate, and magnesium sulfate oral solution to patients with gout or other disorders of uric acid metabolism.

5.2 Cardiac Arrhythmias There have been rare reports of serious arrhythmias associated with the use of ionic osmotic laxative products for bowel preparation. Use caution when prescribing sodium sulfate, potassium sulfate, and magnesium sulfate oral solution for patients at increased risk of arrhythmias (e.g., patients with a history of prolonged QT, uncontrolled arrhythmias, recent myocardial infarction, unstable angina, congestive heart failure, or cardiomyopathy). Consider pre-dose and post-colonoscopy ECGs in patients at increased risk of serious cardiac arrhythmias.

5.3 Seizures There have been reports of generalized tonic-clonic seizures and/or loss of consciousness associated with use of bowel preparation products in patients with no prior history of seizures. The seizure cases were associated with electrolyte abnormalities (e.g., hyponatremia, hypokalemia, hypocalcemia, and hypomagnesemia) and low serum osmolality. The neurologic abnormalities resolved with correction of fluid and electrolyte abnormalities. Use caution when prescribing sodium sulfate, potassium sulfate, and magnesium sulfate oral solution for patients with a history of seizures and in patients at increased risk of seizure, such as patients taking medications that lower the seizure threshold (e.g., tricyclic antidepressants), patients withdrawing from alcohol or benzodiazepines, or patients with known or suspected hyponatremia <span class="opacity-50 text-xs">[see Drug Interactions (7.1) ]</span> .

5.4 Use in Patients with Risk of Renal Injury Use sodium sulfate, potassium sulfate, and magnesium sulfate oral solution with caution in patients with impaired renal function or patients taking concomitant medications that may affect renal function (such as diuretics, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, or non-steroidal anti-inflammatory drugs) <span class="opacity-50 text-xs">[see Drug Interactions (7.1) ]</span> . These patients may be at risk for renal injury. Advise these patients of the importance of adequate hydration with sodium sulfate, potassium sulfate, and magnesium sulfate oral solution and consider performing baseline and post-colonoscopy laboratory tests (electrolytes, creatinine, and BUN) in these patients <span class="opacity-50 text-xs">[see Use in Specific Populations (8.6) ]</span> .

5.5 Colonic Mucosal Ulcerations and Ischemic Colitis Osmotic laxative products may produce colonic mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Concurrent use of stimulant laxatives and sodium sulfate, potassium sulfate, and magnesium sulfate oral solution may increase these risks <span class="opacity-50 text-xs">[see Drug Interactions (7.3) ]</span> . Consider the potential for mucosal ulcerations resulting from the bowel preparation when interpreting colonoscopy findings in patients with known or suspect inflammatory bowel disease (IBD).

5.6 Use in Patients with Significant Gastrointestinal Disease If gastrointestinal obstruction or perforation is suspected, perform appropriate diagnostic studies to rule out these conditions before administering sodium sulfate, potassium sulfate, and magnesium sulfate oral solution <span class="opacity-50 text-xs">[see Contraindications (4) ]</span> . Use with caution in patients with severe active ulcerative colitis.

5.7 Aspiration Patients with impaired gag reflex or other swallowing abnormalities are at risk for regurgitation or aspiration of sodium sulfate, potassium sulfate, and magnesium sulfate oral solution. Observe these patients during administration of sodium sulfate, potassium sulfate, and magnesium sulfate oral solution. Use with caution in these patients.

INTERACTIONS Drugs that increase risk of fluid and electrolyte imbalance. ( 7.1 ) Pediatric use information is approved for Braintree Laboratories, Inc.'s SUPREP BOWEL PREP KIT (sodium sulfate, potassium sulfate, and magnesium sulfate) oral solution. However, due to Braintree Laboratories, Inc.'s marketing exclusivity rights, this drug product is not labeled with that pediatric information.

7.1 Drugs That May Increase Risks of Fluid and Electrolyte Abnormalities Use caution when prescribing sodium sulfate, potassium sulfate, and magnesium sulfate oral solution to patients taking medications that increase the risk of fluid and electrolyte disturbances or may increase the risk of adverse events of seizure, arrhythmias, and prolonged QT in the setting of fluid and electrolyte abnormalities <span class="opacity-50 text-xs">[see Warnings and Precautions (5.1 , 5.2 , 5.3 , 5.4) ]</span> .

7.2 Potential for Reduced Drug Absorption Sodium sulfate, potassium sulfate, and magnesium sulfate oral solution can reduce the absorption of other co-administered drugs <span class="opacity-50 text-xs">[see Dosage and Administration (2.1) ]</span> . Administer oral medications at least one hour before starting each dose of sodium sulfate, potassium sulfate, and magnesium sulfate oral solution. Administer tetracycline and fluoroquinolone antibiotics, iron, digoxin, chlorpromazine, and penicillamine at least 2 hours before and not less than 6 hours after administration of sodium sulfate, potassium sulfate, and magnesium sulfate oral solution to avoid chelation with magnesium.

7.3 Stimulant Laxatives Concurrent use of stimulant laxatives and sodium sulfate, potassium sulfate, and magnesium sulfate oral solution may increase the risk of mucosal ulceration or ischemic colitis. Avoid use of stimulant laxatives (e.g., bisacodyl, sodium picosulfate) while taking sodium sulfate, potassium sulfate, and magnesium sulfate oral solution <span class="opacity-50 text-xs">[see Warnings and Precautions (5.5) ]</span> .