Questran Powder for Oral Suspension 4g & Questran Light

1. Name Of The Medicinal Product

Questran Light

2. Qualitative And Quantitative Composition

Each sachet contains 4g anhydrous colestyramine (a basic anion-exchange resin).

3. Pharmaceutical Form

Powder for Oral administration.

4. Clinical Particulars

4.1 Therapeutic Indications

Questran is used for:

1.	Primary prevention of coronary heart disease in men between 35 and 59 years of age and with primary hypercholesterolaemia who have not responded to diet and other appropriate measures.
2.	Reduction of plasma cholesterol in hypercholesterolaemia, particularly in those patients who have been diagnosed as Fredrickson's Type II (high plasma cholesterol with normal or slightly elevated triglycerides).
3.	Relief of pruritus associated with partial biliary obstruction and primary biliary cirrhosis.
4.	Relief of diarrhoea associated with ileal resection, Crohn's disease, vagotomy and diabetic vagal neuropathy.
5.	Management of radiation-induced diarrhoea.

4.2 Posology And Method Of Administration

Adults:

As a precautionary measure, where concurrent drug therapy exists then such drugs should be administered at least one hour before or 4-6 hours after Questran.

Questran should not be taken in its dry form.

Questran should be administered mixed with water or a suitable liquid, such as fruit juice, and stirred to a uniform consistency.

Questran may also be mixed with skimmed milk, thin soups, pulpy fruits with high moisture content, e.g. apple sauce, etc.

1. For primary prevention of coronary heart disease and to reduce cholesterol: After initial introduction over a three to four week period, 3 to 6 Questran sachets per day, administered either as a single daily dose or in divided doses up to four times daily, according to dosage requirements and patient acceptability. Dosage may be modified according to response and can be increased to 9 sachets per day if necessary.

Occasional slight gastro-intestinal upsets, e.g. constipation, may occur when starting Questran. These usually pass with continued usage of Questran and are minimised by starting therapy gradually.

Final dose required	Week1	Week 2	Week 3	Week 4
	Sachets per day
3	1	2	3	3
4	1	2	3	4
6	1	2	3	6

2. To relieve pruritus: One or two sachets daily are usually sufficient.

3. To relieve diarrhoea: As for reduction of cholesterol but it may be possible to reduce this dosage. In all patients presenting with diarrhoea induced by bile acid malabsorption, if a response is not seen within 3 days, then alternative therapy should be initiated.

Children 6 - 12 years:

The initial dose is determined by the following formula:

Subsequent dosage adjustment may be necessary where clinically indicated.

Children under 6 years:

Questran should not be used in children under 6. There are no data to support its use.

Elderly:

No dosage adjustment is necessary.

4.3 Contraindications

Questran is contra-indicated in patients who have shown hypersensitivity to any of the product ingredients.

In patients with complete biliary obstruction, since Questran cannot be effective where bile is not secreted into the intestine.

4.4 Special Warnings And Precautions For Use

Reduction of serum folate concentrations has been reported in children with familial hypercholesterolaemia. Supplementation with folic acid should be considered in these cases.

Questran Light contains aspartame, a source of phenylalanine.

4.5 Interaction With Other Medicinal Products And Other Forms Of Interaction

Questran may delay or reduce the absorption of certain drugs (such as digitalis, tetracycline, chlorothiazide, warfarin and thyroxine). The response to concomitant medication should be closely monitored and appropriate adjustments made if necessary.

Questran may interfere with the pharmacokinetics of drugs that undergo enterohepatic recirculation.

Patients should take other drugs at least one hour before or 4-6 hours after Questran to minimise possible interference with their absorption.

4.6 Pregnancy And Lactation

The safety of colestyramine in pregnancy and lactation has not been established and the possibility of interference with absorption of fat soluble vitamins should be considered.

4.7 Effects On Ability To Drive And Use Machines

None.

4.8 Undesirable Effects

Since Questran may interfere with the absorption of fat soluble vitamins, the diet may require supplementation with Vitamins A, D and K during prolonged high dose administration.

Chronic use of Questran may be associated with increased bleeding tendency due to hyperprothrombinaemia associated with Vitamin K deficiency. This will usually respond promptly to parenteral Vitamin K administration; recurrences can be prevented by oral administration of Vitamin K.

Hyperchloraemic acidosis has occasionally been reported following the prolonged use of anion exchange resins.

Gastro-intestinal side effects are those most frequently reported. The principal complaint is constipation which may be controlled with the usual remedies, and frequently disappears on continued usage of Questran. Large doses of Questran can cause diarrhoea.

Taste disturbance and skin irritation have been reported rarely but causal relationship to colestyramine remains undetermined. Rare reports of intestinal obstruction have been received.

4.9 Overdose

One case of medication error experienced heartburn and nausea after taking colestyramine 27g t.i.d. for a week. The potential problem in overdosage would be obstruction of the gastrointestinal tract.

5. Pharmacological Properties

5.1 Pharmacodynamic Properties

Cholesterol is a major, if not the sole precursor of bile acids. During normal digestion, bile acids are secreted via the bile from the liver and gall bladder into the small intestine. Bile acids emulsify the fat and lipid materials present in foods, thus facilitating absorption. A major portion of the bile acids secreted are reabsorbed from the ileum and returned via the portal vein to the liver, thus completing the enterohepatic cycle. Only very small amounts of bile acids are found in normal serum.

Colestyramine resin absorbs and combines with the bile acids in the intestine to form an insoluble complex which is excreted in the faeces. This results in a continuous, though partial, removal of bile acids from the enterohepatic circulation by preventing their reabsorption. The increased faecal loss of bile acids leads to an increased oxidation of cholesterol to bile acids and a decrease in serum cholesterol levels and low density lipoprotein serum levels. Colestyramine is hydrophilic but it is not soluble in water, nor is it hydrolysed by digestive enzymes.

In patients with partial biliary obstruction, the reduction of serum bile acid levels reduces excess bile acids deposited in the dermal tissue with resultant decrease in pruritus.

5.2 Pharmacokinetic Properties

The colestyramine resin in Questran Light is not absorbed from the digestive tract.

5.3 Preclinical Safety Data

No further significant information.

6. Pharmaceutical Particulars

6.1 List Of Excipients

Aspartame,

Citric acid anhydrous

Colloidal anhydrous silica

Orange juice flavour

Propylene glycol alginate

Xanthan gum

6.2 Incompatibilities

None known.

6.3 Shelf Life

36 months

6.4 Special Precautions For Storage

Do not store above 30°C. Store in a dry place.

6.5 Nature And Contents Of Container

Original packs containing 50 or 60 laminate sachets composed of paper, polyethylene and aluminium.

6.6 Special Precautions For Disposal And Other Handling

No special instructions.

7. Marketing Authorisation Holder

Bristol-Myers Squibb Holdings Limited

t/a Bristol-Myers Pharmaceuticals

Uxbridge Business Park

Sanderson Road

Uxbridge

Middlesex UB8 1DH

8. Marketing Authorisation Number(S)

PL 0125/0192

9. Date Of First Authorisation/Renewal Of The Authorisation

25 July 1988 / 26 November 1998

10. Date Of Revision Of The Text

22^nd July 2005