URSODIOL

Ursodiol, USP is a bile acid available as 300 mg capsules suitable for oral administration. Ursodiol, USP (ursodeoxycholic acid), is a naturally occurring bile acid found in small quantities in normal human bile and in the biles of certain other mammals. Ursodiol, USP is a white or almost white crystalline powder, practically insoluble in water, freely soluble in ethanol (96%), slightly soluble in acetone and practically insoluble in methylene chloride. The chemical name for ursodiol is 3α,7β-Dihydroxy-5β-cholan-24-oic acid (C 24 H 40 O 4 ). Ursodiol, USP has a molecular weight of 392.6 g/mol. Its structure is shown below: Inactive Ingredients : Colloidal silicon dioxide, gelatin, iron oxide red, magnesium stearate, starch (biological source: maize), titanium dioxide and water. Each capsule is imprinted with black pharmaceutical ink which contains butyl alcohol, dehydrated alcohol, ferrosoferric oxide, isopropyl alcohol, purified water, potassium hydroxide, propylene glycol, shellac and strong ammonia solution. 10

Ursodiol capsules are indicated for patients with radiolucent, noncalcified gallbladder stones < 20 mm in greatest diameter in whom elective cholecystectomy would be undertaken except for the presence of increased surgical risk due to systemic disease, advanced age, idiosyncratic reaction to general anesthesia, or for those patients who refuse surgery. Safety of use of ursodiol capsules beyond 24 months is not established. Ursodiol capsules are indicated for the prevention of gallstone formation in obese patients experiencing rapid weight loss.

Gallstone Dissolution The recommended dose for ursodiol capsules treatment of radiolucent gallbladder stones is 8 to 10 mg/kg/day given in 2 or 3 divided doses. Ultrasound images of the gallbladder should be obtained at 6-month intervals for the first year of ursodiol capsules therapy to monitor gallstone response. If gallstones appear to have dissolved, ursodiol capsules therapy should be continued and dissolution confirmed on a repeat ultrasound examination within 1 to 3 months. Most patients who eventually achieve complete stone dissolution will show partial or complete dissolution at the first on-treatment reevaluation. If partial stone dissolution is not seen by 12 months of ursodiol capsules therapy, the likelihood of success is greatly reduced. Gallstone Prevention The recommended dosage of ursodiol capsules for gallstone prevention in patients undergoing rapid weight loss is 600 mg/day (300 mg b.i.d.).

Ursodiol will not dissolve calcified cholesterol stones, radiopaque stones, or radiolucent bile pigment stones. Hence, patients with such stones are not candidates for ursodiol therapy. Patients with compelling reasons for cholecystectomy including unremitting acute cholecystitis, cholangitis, biliary obstruction, gallstone pancreatitis, or biliary-gastrointestinal fistula are not candidates for ursodiol therapy. Allergy to bile acids.

The nature and frequency of adverse experiences were similar across all groups. The following tables provide comprehensive listings of the adverse experiences reported that occurred with a 5% incidence level: GALLSTONE DISSOLUTION Ursodiol 8 mg/kg/day to 10 mg/kg/day(N = 155) Placebo(N = 159) N (%) N (%) Body as a Whole Allergy Chest Pain Fatigue Infection Viral 8 5 7 30 (5.2) (3.2) (4.5) (19.4) 7 10 8 41 (4.4) (6.3) (5.0) (25.8) Digestive System Abdominal Pain Cholecystitis Constipation Diarrhea Dyspepsia Flatulence Gastrointestinal Disorder Nausea Vomiting 67 8 15 42 26 12 6 22 15 (43.2) (5.2) (9.7) (27.1) (16.8) (7.7) (3.9) (14.2) (9.7) 70 7 14 34 18 12 8 27 11 (44.0) (4.4) (8.8) (21.4) (11.3) (7.5) (5.0) (17.0) (6.9) Musculoskeletal System Arthralgia Arthritis Back Pain Myalgia 12 9 11 9 (7.7) (5.8) (7.1) (5.8) 24 4 18 9 (15.1) (2.5) (11.3) (5.7) Nervous System Headache Insomnia 28 3 (18.1) (1.9) 34 8 (21.4) (5.0) Respiratory System Bronchitis Coughing Pharyngitis Rhinitis Sinusitis Upper Respiratory Tract Infection 10 11 13 8 17 24 (6.5) (7.1) (8.4) (5.2) (11.0) (15.5) 6 7 5 11 18 21 (3.8) (4.4) (3.1) (6.9) (11.3) (13.2) Urogenital System Urinary Tract Infection 10 (6.5) 7 (4.4) GALLSTONE PREVENTION Ursodiol 600 mg (N = 322) Placebo (N = 325) N (%) N (%) Body as a Whole Fatigue Infection Viral Influenza-like Symptoms 25 29 21 (7.8) (9.0) (6.5) 33 29 19 (10.2) (8.9) (5.8) Digestive System Abdominal Pain Constipation Diarrhea Flatulence Nausea Vomiting 20 85 81 15 56 44 (6.2) (26.4) (25.2) (4.7) (17.4) (13.7) 39 72 68 24 43 44 (12.0) (22.2) (20.9) (7.4) (13.2) (13.5) Musculoskeletal System Back Pain Musculoskeletal Pain 38 19 (11.8) (5.9) 21 15 (6.5) (4.6) Nervous System Dizziness Headache 53 80 (16.5) (24.8) 42 78 (12.9) (24.0) Respiratory System Pharyngitis Sinusitis Upper Respiratory Tract Infection 10 17 40 (3.1) (5.3) (12.4) 19 18 35 (5.8) (5.5) (10.8) Skin and Appendages Alopecia 17 (5.3) 8 (2.5) Urogenital System Dysmenorrhea 18 (5.6) 19 (5.8) Post-marketing Experience The following adverse reactions, presented by system organ class in alphabetical order, have been identified during post-approval use of ursodiol. 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 disorders : enteroliths (bezoars) To report SUSPECTED ADVERSE REACTIONS, contact Amneal Pharmaceuticals at 1-877-835-5472 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

Bile acid sequestering agents such as cholestyramine and colestipol may interfere with the action of ursodiol by reducing its absorption. Aluminum-based antacids have been shown to adsorb bile acids in vitro and may be expected to interfere with ursodiol in the same manner as the bile acid sequestering agents. Estrogens, oral contraceptives, and clofibrate (and perhaps other lipid-lowering drugs) increase hepatic cholesterol secretion, and encourage cholesterol gallstone formation and hence may counteract the effectiveness of ursodiol.