Durlaza

Overdose

Salicylate toxicity may result from acute ingestion (overdose) or chronic intoxication. The early signs of salicylic overdose (salicylism), including tinnitus (ringing in the ears), occur at plasma concentrations approaching 200 mcg/mL. Plasma concentrations of aspirin above 300 mcg/mL are clearly toxic. Severe toxic effects are associated with levels above 400 mcg/mL . A single lethal dose of aspirin in adults is not known with certainty but death may be expected at 30 g. For real or suspected overdose, contact a Poison Control Center immediately.

In acute overdose, severe acid-base and electrolyte disturbances may occur and are complicated by hyperthermia and dehydration. Respiratory alkalosis occurs early while hyperventilation is present, but is quickly followed by metabolic acidosis.

Treatment consists primarily of supporting vital functions, increasing salicylate elimination, and correcting the acid-base disturbance. Gastric emptying or lavage is recommended as soon as possible after ingestion, even if the patient has vomited spontaneously. After lavage or emesis, administer activated charcoal, as a slurry, if less than 3 hours have passed since ingestion.

Severity of aspirin intoxication is determined by measuring the blood salicylate level. Monitor acid-base status with serial blood gas and serum pH measurements. Maintain fluid and electrolyte balance.

In severe cases, hyperthermia and hypovolemia are the major immediate threats to life. Replace fluid intravenously and correct acidosis. Monitor plasma electrolytes and pH to promote alkaline diuresis of salicylate if renal function is normal. Glucose may be required to control hypoglycemia.

Hemodialysis and peritoneal dialysis can reduce the body aspirin content. In patients with renal insufficiency or in cases of life-threatening intoxication, dialysis is usually required. Exchange transfusion may be indicated in infants and young children.

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Contraindications

DURLAZA is contraindicated:

• In patients with a hypersensitivity to nonsteroidal anti-inflammatory drugs (NSAIDs).
• In patients with the syndrome of asthma, rhinitis, and nasal polyps. DURLAZA may cause severe urticaria, angioedema, or bronchospasm.

Undesirable effects

The following is a list of adverse reactions that have been reported in the literature for products containing low dose aspirin.

Central Nervous System: Agitation, cerebral edema, coma, confusion, dizziness, headache, lethargy, seizures.

Fluid and Electrolyte: Hyperkalemia, metabolic acidosis, respiratory alkalosis.

Gastrointestinal: Dyspepsia, hepatic enzyme elevation, hepatitis, Reye's Syndrome

Renal: Interstitial nephritis, papillary necrosis, proteinuria, renal insufficiency and failure.

Therapeutic indications

DURLAZA is indicated to:

1. Reduce the risk of death and myocardial infarction (MI) in patients with chronic coronary artery disease, such as patients with a history of MI or unstable angina pectoris or with chronic stable angina
2. Reduce the risk of death and recurrent stroke in patients who have had an ischemic stroke or transient ischemic attack

Use immediate-release aspirin, not DURLAZA in situations where a rapid onset of action is required (such as acute treatment of myocardial infarction or before percutaneous coronary intervention).

Pharmacodynamic properties

The dose-response relationship for DURLAZA and immediate release (IR) aspirin towards COX-1 inhibition was characterized by examining the inhibition of serum TXB2 and urine 11dehydro-TXB2 at 24 h following a single dose. Doses over the range of 20 mg to 325 mg for DURLAZA and 5 mg to 81 mg for IR aspirin respectively were studied. Half-maximal inhibition of serum TXB2 and urine 11-dehydro-TXB2 occurred with doses of DURLAZA (ID50) about 2-fold the dose of immediate release (IR) aspirin. Based on this relationship, the pharmacodynamic effect of DURLAZA 162.5 mg is similar to that attained with IR aspirin 81 mg. The mean inhibition of serum TXB2 following DURLAZA (82%) is lower when compared to IR aspirin 81 mg (93%) following the first dose. However, upon repeat administration, near maximal inhibition of serum TXB2 is achieved, similar to what is achieved following repeated daily doses of IR aspirin.

Pharmacokinetic properties

Following oral administration, DURLAZA exhibits extended release of aspirin from the encapsulated microparticles, thereby prolonging the absorption of aspirin across the GI tract compared to IR aspirin (Figure 1). Once absorbed, aspirin is metabolized, distributed, and excreted in a manner similar to that of aspirin absorbed from IR dosage forms.

Figure 1: Mean acetylsalicylic acid concentration-time profile following single dose administration of 162.5 mg DURLAZA or 81 mg immediate release ASA

Following administration of DURLAZA, the time to reach peak plasma concentration of aspirin is slightly longer compared to following IR aspirin dosage form. Median Tmax for DURLAZA is about 2 h when compared to 1 h following IR aspirin (see Figure 1). The mean Cmax for DURLAZA is approximately 35% of that following IR aspirin 81 mg. The area under the plasma concentration-time curve for aspirin following administration of DURLAZA is approximately 70% of that following IR aspirin. The rate of DURLAZA absorption is dependent on food, alcohol, and gastric pH.

The volume of distribution of usual doses of aspirin in normal subjects averages approximately 170 mL/kg of body weight.

Aspirin is rapidly hydrolyzed in the plasma to salicylic acid such that plasma levels of aspirin following DURLAZA administration are essentially undetectable 4-8 hours after dosing. In contrast to immediate release aspirin, measurable levels of salicyclic acid at 24 hours following a single dose of DURLAZA were observed. Salicylic acid is primarily conjugated in the liver to form salicyluric acid, a phenolic glucuronide, an acyl glucuronide, and a number of minor metabolites.

The mean plasma half-life of aspirin may range from 20 to 60 min. Following therapeutic doses, approximately 10% is found excreted in the urine as salicylic acid, 75% as salicylic acid, and 10% phenolic and 5% acyl glucuronides of salicylic acid.

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Fertility, pregnancy and lactation

Avoid use during the third trimester of pregnancy because NSAIDs such as DURLAZA may cause premature closure of the fetal ductus arteriosus. Salicylate products have also been associated with alterations in maternal and neonatal hemostasis mechanisms, decreased birth weight, and with perinatal mortality.

Qualitative and quantitative composition

DURLAZA (aspirin) Extended Release Capsules are supplied as white to off-white opaque capsules each containing 162.5 mg of aspirin.

DURLAZA Capsules, 162.5 mg, are supplied as follows:

Size 2 white to off-white opaque capsules imprinted with the name Durlaza

Bottles of 30 capsules NDC 58487-001-01
Bottles of 90 capsules NDC 58487-001-02

Special Precautions for Storage: Store at 25 °C (77 °F); excursions permitted to 15 - 30°C (59 86°F).

Manufactured for New Haven Pharmaceuticals, Inc. North Haven, CT 06473. DURLAZA Capsules manufactured in USA. Distributed by Cardinal Health 105, Inc. Revised: Sep 2015

Special warnings and precautions for use

Included as part of the PRECAUTIONS section.

DURLAZA increases the risk of bleeding. Risk factors for bleeding include the use of other drugs that increase the risk of bleeding (e.g., anticoagulants, antiplatelet agents, and chronic use of NSAIDs).

DURLAZA may cause gastric ulceration and bleeding. Avoid DURLAZA in patients with active peptic ulcer disease.

DURLAZA can cause fetal harm when administered to a pregnant woman. Maternal aspirin use during later stages of pregnancy may cause low birth weight, increased incidence for intracranial hemorrhage in premature infants, stillbirths and neonatal death. Because NSAIDs may cause premature closure of the fetal ductus arteriosus, avoid DURLAZA in the third trimester of pregnancy.

No carcinogenesis, mutagenesis or impairment of fertility studies were conducted with DURLAZA. Aspirin is not considered to be genotoxic or carcinogenic. Studies with oral aspirin in pregnant rats demonstrated the occurrence of fetal malformations at oral doses at or above 250 mg/kg [Human equivalent dose (HED) 40 mg/kg].

Avoid use during the third trimester of pregnancy because NSAIDs such as DURLAZA may cause premature closure of the fetal ductus arteriosus. Salicylate products have also been associated with alterations in maternal and neonatal hemostasis mechanisms, decreased birth weight, and with perinatal mortality.

Avoid DURLAZA 1 week prior to and during labor and delivery because it can result in excessive blood loss at delivery. Prolonged gestation and prolonged labor due to prostaglandin inhibition have been reported.

Because of the potential for serious adverse reactions in nursing infants from DURLAZA, choose either to discontinue DURLAZA or discontinue nursing.

Safety and effectiveness in pediatric patients have not been established.

In a large collaborative overview of aspirin for vascular event prevention, including over 14000 patients over 65 years of age, 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.

Avoid DURLAZA in patients with severe hepatic insufficiency.

Avoid DURLAZA in patients with severe renal failure (glomerular filtration rate less than 10 mL/minute).

Dosage (Posology) and method of administration

The recommended dose of DURLAZA is one capsule (162.5 mg) once daily. Take the capsules with a full glass of water at the same time each day.

Swallow DURLAZA capsules whole. Do not cut, crush or chew capsules.

Do not take DURLAZA 2 hours before or 1 hour after consuming alcohol.

Interaction with other medicinal products and other forms of interaction

The following is a list of adverse reactions that have been reported in the literature for products containing low dose aspirin.

Central Nervous System: Agitation, cerebral edema, coma, confusion, dizziness, headache, lethargy, seizures.

Fluid and Electrolyte: Hyperkalemia, metabolic acidosis, respiratory alkalosis.

Gastrointestinal: Dyspepsia, hepatic enzyme elevation, hepatitis, Reye's Syndrome

Renal: Interstitial nephritis, papillary necrosis, proteinuria, renal insufficiency and failure.

Alcohol: Do not take DURLAZA 2 hours before or 1 hour after consuming alcohol. Alcohol can interfere with the controlled release properties of DURLAZA.

Renin-angiotensin system (RAS) inhibitors: In patients who are elderly, volume-depleted (including those on diuretic therapy), or who have compromised renal function, coadministration of NSAIDs, including DURLAZA, with RAS inhibitors may result in deterioration of renal function, including possible acute renal failure. These effects are usually reversible. Monitor renal function periodically in patients receiving RAS inhibitors and DURLAZA.

NSAIDs, including DURLAZA may attenuate the antihypertensive effects of RAS inhibitors.

Anticoagulant and antiplatelets: Increased risk of bleeding

Anticonvulsants: Salicylate can displace protein-bound phenytoin and valproic acid, leading to a decrease in the total concentration of phenytoin and an increase in serum valproic acid levels.

Methotrexate: Salicylate can inhibit renal clearance of methotrexate, leading to bone marrow toxicity, especially in the elderly or renal impaired.

Nonsteroidal Anti-inflammatory Drugs (NSAIDs): The concurrent use of DURLAZA with other NSAIDs increases the risk of bleeding and may result in renal impairment.

Ibuprofen can interfere with the anti-platelet effect of low dose aspirin. Patients who use DURLAZA and take a single dose of ibuprofen 400 mg should dose the ibuprofen at least 2-4 hours or longer after ingestion of DURLAZA. Wait 8 hours after ibuprofen dosing, before giving aspirin, to avoid significant interference.

Nonselective NSAIDs may interfere with the antiplatelet effect of low-dose aspirin.