headache, chromaturia and nausea (≥2%). safety data were analyzed separately for 280 hiv-uninfected subjects ≥12 years of age receiving nitazoxanide at the recommended dose for at least three days in 5 placebo-controlled clinical trials and for 256 hiv-uninfected subjects 1 through 11 years of age in 7 controlled clinical trials. there were no differences between the adverse reactions reported for nitazoxanide-treated subjects based upon age. 6.2 postmarketing experience the following adverse reactions have been identified during post approval use of nitazoxanide. 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 is a list of adverse reactions spontaneously reported with nitazoxanide tablets which were not included in clinical trial listings: gastrointestinal disorders: diarrhea, gastroesophageal reflux disease nervous system disorders: dizziness respiratory, thoracic and mediastinal disorders: dyspnea skin and subcutaneous tissue disorders: rash, urticaria

nistered once daily via oral gavage to pregnant female rats at levels up to 3200 mg/kg/day during the period of organogenesis. in rabbits, nitazoxanide was administered at doses of 0, 25, 50, or 100 mg/kg/day on gestation days 7 to 20. oral treatment of pregnant rabbits with nitazoxanide during organogenesis resulted in minimal maternal toxicity and no external fetal anomalies. 8.2 lactation risk summary no information regarding the presence of nitazoxanide in human milk, the effects on the breastfed infant, or the effects on milk production is available. the development and health benefits of breastfeeding should be considered along with the mother’s clinical need for nitazoxanide and any potential adverse effects on the breastfed infant from nitazoxanide or from the underlying maternal condition. 8.4 pediatric use the safety and efficacy of alinia for oral suspension for the treatment of diarrhea caused by g. lamblia or c. parvum in pediatric patients 1 to 11 years of age has been established based on three (3) randomized, controlled studies with 104 pediatric subjects treated with alinia for oral suspension 100 mg/5 ml. furthermore, the safety and efficacy of alinia for oral suspension for the treatment of diarrhea caused by g. lamblia or c. parvum in pediatric patients 12 to 17 years of age has been established based on two (2) randomized controlled studies with 44 pediatric subjects treated with alinia for oral suspension 100 mg/5 ml. [ see clinical studies (14.1) ] the safety and efficacy of nitazoxanide tablets for the treatment of diarrhea caused by g. lamblia or c. parvum in pediatric patients 12 to 17 years of age has been established based on three (3) randomized controlled studies with 47 pediatric subjects treated with nitazoxanide tablets 500 mg. a single nitazoxanide tablet contains a greater amount of nitazoxanide than is recommended for use in pediatric patients 11 years or younger. [see dosage and administration (2.1) ]. safety and efficacy of alinia for oral suspension in pediatric patients less than one year of age has not been studied. 8.5 geriatric use clinical studies of nitazoxanide tablets and alinia for oral suspension did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. in general, the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy in elderly patients should be considered when prescribing nitazoxanide tablets and alinia for oral suspension. 8.6 renal and hepatic impairment the pharmacokinetics of nitazoxanide in patients with compromised renal or hepatic function has not been studied. 8.7 hiv-infected or immunodeficient patients nitazoxanide tablets and alinia for oral suspension have not been studied for the treatment of diarrhea caused by g. lamblia in hiv-infected or immunodeficient patients. nitazoxanide tablets and alinia for oral suspension have not been shown to be superior to placebo for the treatment of diarrhea caused by c. parvum in hiv-infected or immunodeficient patients [see clinical studies (14) ].

of 0, 25, 50, or 100 mg/kg/day on gestation days 7 to 20. oral treatment of pregnant rabbits with nitazoxanide during organogenesis resulted in minimal maternal toxicity and no external fetal anomalies.

de tablet contains a greater amount of nitazoxanide than is recommended for use in pediatric patients 11 years or younger. [see dosage and administration (2.1) ]. safety and efficacy of alinia for oral suspension in pediatric patients less than one year of age has not been studied.

lasma pharmacokinetic of tizoxanide and tizoxanide glucuronide parameter values following administration of a single dose of nitazoxanide for oral suspension with food to subjects ≥1 year of age tizoxanide tizoxanide glucuronide age dose c max (μg/ml) *t max (hr) auc inf (μg•hr/ml) c max (μg/ml) *t max (hr) auc inf (μg•hr/ml) 1-3 years 100 mg 3.11 (2.0) 3.5 (2-4) 11.7 (4.46) 3.64 (1.16) 4.0 (3-4) 19.0 (5.03) 4-11 years 200 mg 3.00 (0.99) 2.0 (1-4) 13.5 (3.3) 2.84 (0.97) 4.0 (2-4) 16.9 (5.00) ≥18 years 500 mg 5.49 (2.06) 2.5 (1-5) 30.2 (12.3) 3.21 (1.05) 4.0 (2.5-6) 22.8 (6.49) * t max is given as a mean (range) multiple dosing: following oral administration of a single nitazoxanide tablet every 12 hours for 7 consecutive days, there was no significant accumulation of nitazoxanide metabolites tizoxanide or tizoxanide glucuronide detected in plasma. bioavailability: nitazoxanide for oral suspension is not bioequivalent to nitazoxanide tablets. the relative bioavailability of the suspension compared to the tablet was 70%. when nitazoxanide tablets are administered with food, the auc ԏ of tizoxanide and tizoxanide glucuronide in plasma is increased almost two-fold and the c max is increased by almost 50%. when nitazoxanide for oral suspension was administered with food, the auc ԏ of tizoxanide and tizoxanide glucuronide increased by about 45-50% and the c max increased by ≤10%. nitazoxanide tablets and nitazoxanide for oral suspension were administered with food in clinical trials and hence they are recommended to be administered with food [ see dosage and administration (2.1) ]. distribution in plasma, more than 99% of tizoxanide is bound to proteins. elimination metabolism following oral administration in humans, nitazoxanide is rapidly hydrolyzed to an active metabolite, tizoxanide (desacetyl-nitazoxanide). tizoxanide then undergoes conjugation, primarily by glucuronidation. excretion tizoxanide is excreted in the urine, bile and feces, and tizoxanide glucuronide is excreted in urine and bile. approximately two-thirds of the oral dose of nitazoxanide is excreted in the feces and one-third in the urine. specific populations pediatric patients the pharmacokinetics of tizoxanide and tizoxanide glucuronide following administration of nitazoxanide tablets in pediatric patients 12-17 years of age are provided above in table 2.mean (±sd) plasma pharmacokinetic parameters of tizoxanide and tizoxanide glucuronide following administraton of a single dose of one 500 mg nitazoxanide tablet with food to subject ≥12 years of age. the pharmacokinetics of tizoxanide and tizoxanide glucuronide following administration of nitazoxanide for oral suspension in pediatric patients 1-11 years of age are provided above in table 3. mean (±sd) plasma pharmacokinetic of tizoxanide and tizoxanide glucuronide parameter values following administration of a single dose of alinia for oral suspension with food to subjects ≥1 year of age. drug interaction studies in vitro studies demonstrated that tizoxanide has no significant inhibitory effect on cytochrome p450 enzymes. 12.4 microbiology mechanism of action the antiprotozoal activity of nitazoxanide is believed to be due to interference with the pyruvate:ferredoxin oxidoreductase (pfor) enzyme-dependent electron transfer reaction which is essential to anaerobic energy metabolism. studies have shown that the pfor enzyme from g. lamblia directly reduces nitazoxanide by transfer of electrons in the absence of ferredoxin. the dna-derived pfor protein sequence of c. parvum appears to be similar to that of g. lamblia. interference with the pfor enzyme-dependent electron transfer reaction may not be the only pathway by which nitazoxanide exhibits antiprotozoal activity. resistance a potential for development of resistance by c. parvum or g. lamblia to nitazoxanide has not been examined. antimicrobial activity nitazoxanide and its metabolite, tizoxanide, are active in vitro in inhibiting the growth of (i) sporozoites and oocysts of c. parvum and (ii) trophozoites of g. lamblia. susceptibility test methods for protozoa such as c. parvum and g. lamblia , standardized tests for use in clinical microbiology laboratories are not available.

ingle dose of nitazoxanide for oral suspension with food to subjects ≥1 year of age tizoxanide tizoxanide glucuronide age dose c max (μg/ml) *t max (hr) auc inf (μg•hr/ml) c max (μg/ml) *t max (hr) auc inf (μg•hr/ml) 1-3 years 100 mg 3.11 (2.0) 3.5 (2-4) 11.7 (4.46) 3.64 (1.16) 4.0 (3-4) 19.0 (5.03) 4-11 years 200 mg 3.00 (0.99) 2.0 (1-4) 13.5 (3.3) 2.84 (0.97) 4.0 (2-4) 16.9 (5.00) ≥18 years 500 mg 5.49 (2.06) 2.5 (1-5) 30.2 (12.3) 3.21 (1.05) 4.0 (2.5-6) 22.8 (6.49) * t max is given as a mean (range) multiple dosing: following oral administration of a single nitazoxanide tablet every 12 hours for 7 consecutive days, there was no significant accumulation of nitazoxanide metabolites tizoxanide or tizoxanide glucuronide detected in plasma. bioavailability: nitazoxanide for oral suspension is not bioequivalent to nitazoxanide tablets. the relative bioavailability of the suspension compared to the tablet was 70%. when nitazoxanide tablets are administered with food, the auc ԏ of tizoxanide and tizoxanide glucuronide in plasma is increased almost two-fold and the c max is increased by almost 50%. when nitazoxanide for oral suspension was administered with food, the auc ԏ of tizoxanide and tizoxanide glucuronide increased by about 45-50% and the c max increased by ≤10%. nitazoxanide tablets and nitazoxanide for oral suspension were administered with food in clinical trials and hence they are recommended to be administered with food [ see dosage and administration (2.1) ]. distribution in plasma, more than 99% of tizoxanide is bound to proteins. elimination metabolism following oral administration in humans, nitazoxanide is rapidly hydrolyzed to an active metabolite, tizoxanide (desacetyl-nitazoxanide). tizoxanide then undergoes conjugation, primarily by glucuronidation. excretion tizoxanide is excreted in the urine, bile and feces, and tizoxanide glucuronide is excreted in urine and bile. approximately two-thirds of the oral dose of nitazoxanide is excreted in the feces and one-third in the urine. specific populations pediatric patients the pharmacokinetics of tizoxanide and tizoxanide glucuronide following administration of nitazoxanide tablets in pediatric patients 12-17 years of age are provided above in table 2.mean (±sd) plasma pharmacokinetic parameters of tizoxanide and tizoxanide glucuronide following administraton of a single dose of one 500 mg nitazoxanide tablet with food to subject ≥12 years of age. the pharmacokinetics of tizoxanide and tizoxanide glucuronide following administration of nitazoxanide for oral suspension in pediatric patients 1-11 years of age are provided above in table 3. mean (±sd) plasma pharmacokinetic of tizoxanide and tizoxanide glucuronide parameter values following administration of a single dose of alinia for oral suspension with food to subjects ≥1 year of age. drug interaction studies in vitro studies demonstrated that tizoxanide has no significant inhibitory effect on cytochrome p450 enzymes.

nistered 500 mg twice daily for 3 days to a placebo tablet. for both of these studies, clinical response was evaluated 4 to 7 days following the end of treatment. a clinical response of ‘well’ was defined as ‘no symptoms, no watery stools and no more than 2 soft stools with no hematochezia within the past 24 hours’ or ‘no symptoms and no unformed stools within the past 48 hours.’ the following clinical response rates were obtained: table 4. adult and adolescent patients with diarrhea caused by g. lamblia clinical response rates* 4 to 7 days post-therapy % (number of successes/total) nitazoxanide tablets nitazoxanide for oral suspension placebo tablets study 1 85% (46/54) ¶ § 83% (45/54) ¶ § 44% (12/27) study 2 100% (8/8) - 30% (3/10) * includes all patients randomized with g. lamblia as the sole pathogen. patients failing to complete the studies were treated as failures. ¶ clinical response rates statistically significantly higher when compared to placebo. § the 95% confidence interval of the difference in response rates for the tablet and suspension is (-14%, 17%). some patients with ‘well’ clinical responses had g. lamblia cysts in their stool samples 4 to 7 days following the end of treatment. the relevance of stool examination results in these patients is unknown. patients should be managed based upon clinical response to treatment. diarrhea caused by g. lamblia in pediatric patients 1 through 11 years of age: in a randomized, controlled trial conducted in peru in 110 pediatric patients with diarrhea and with or without enteric symptoms (e.g., abdominal distention, right iliac fossa tenderness) caused by g. lamblia , a three-day course of treatment with nitazoxanide (100 mg twice daily in pediatric patients ages 24-47 months, 200 mg twice daily in pediatric patients ages 4 through 11 years) was compared to a five-day course of treatment with metronidazole (125 mg twice daily in pediatric patients ages 2 through 5 years, 250 mg twice daily in pediatric patients ages 6 through 11 years). clinical response was evaluated 7 to 10 days following initiation of treatment with a ‘well’ response defined as ‘no symptoms, no watery stools and no more than 2 soft stools with no hematochezia within the past 24 hours’ or ‘no symptoms and no unformed stools within the past 48 hours.’ the following clinical response rates were obtained: table 5. clinical response rates in pediatric patients 7 to 10 days following initiation of therapy intent-to-treat and per protocol analyses % (number of successes/total), [95% confidence interval] population nitazoxanide (3 days) metronidazole (5 days) 95% ci diff § intent-to-treat analysis † 85% (47/55) 80% (44/55) [-9%, 20%] per protocol analysis ¶ 90% (43/48) 83% (39/47) [-8%, 21%] † intent-to-treat analysis includes all patients randomized with patients not completing the study treated as failures. ¶ per protocol analysis includes only patients who took all of their medication and completed the study. seven patients in each treatment group missed at least one dose of medication and one in the metronidazole treatment group was lost to follow-up. § 95% confidence interval on the difference in response rates (nitazoxanide-metronidazole). some patients with ‘well’ clinical responses had g. lamblia cysts in their stool samples 4 to 7 days following the end of treatment. the relevance of stool examination results in these patients is unknown. patients should be managed based upon clinical response to treatment. 14.2 diarrhea caused by c. parvum diarrhea caused by c. parvum in adults and adolescents 12 years of age or older: in a double-blind, controlled trial conducted in egypt in adults and adolescents with diarrhea and with or without enteric symptoms (e.g., abdominal pain/cramps, nausea, vomiting) caused by c. parvum , a three-day course of treatment with nitazoxanide tablets administered 500 mg twice daily was compared with a placebo tablet for 3 days. a third group of patients received open-label nitazoxanide for oral suspension administered 500 mg/25 ml of suspension twice daily for 3 days. clinical response was evaluated 4 to 7 days following the end of treatment. a clinical response of ‘well’ was defined as ‘no symptoms, no watery stools and no more than 2 soft stools within the past 24 hours’ or ‘no symptoms and no unformed stools within the past 48 hours.’ the following clinical response rates were obtained: table 6. clinical response rates in adult and adolescent patients 4 to 7 days post-therapy % (number of successes/total) nitazoxanide tablets nitazoxanide suspension placebo tablets intent-to-treat analysis* 96% (27/28) ¶ § 87% (27/31) ¶ § 41% (11/27) *includes all patients randomized with c. parvum as the sole pathogen. patients failing to complete the study were treated as failures. ¶ clinical response rates statistically significantly higher when compared to placebo. § the 95% confidence interval of the difference in response rates for the tablet and suspension is ( -10%, 28%). in a second double-blind, placebo-controlled trial of nitazoxanide tablets conducted in egypt in adults and adolescents with diarrhea and with or without enteric symptoms (e.g., abdominal colic, abdominal cramps, epigastric pain) caused by c. parvum as the sole pathogen, clinical and parasitological response rates showed a similar trend to the first study. clinical response rates, evaluated 2 to 6 days following the end of treatment, were 71% (15/21) in the nitazoxanide group and 42.9% (9/21) in the placebo group. some patients with ‘well’ clinical responses had c. parvum oocysts in their stool samples 4 to 7 days following the end of treatment. the relevance of stool examination results in these patients is unknown. patients should be managed based upon clinical response to treatment. diarrhea caused by c. parvum in pediatric patients 1 through 11 years of age: in two double-blind, controlled trials in pediatric patients with diarrhea and with or without enteric symptoms (e.g., abdominal distention, colic, left iliac fossa tenderness) caused by c. parvum , a three-day course of treatment with nitazoxanide (100 mg twice daily in pediatric patients ages 12-47 months, 200 mg twice daily in pediatric patients ages 4 through 11 years) was compared with a placebo. one study was conducted in egypt in outpatients ages 1 through 11 years with diarrhea caused by c. parvum . another study was conducted in zambia in malnourished pediatric patients admitted to the hospital with diarrhea caused by c. parvum . clinical response was evaluated 3 to 7 days post-therapy with a ‘well’ response defined as ‘no symptoms, no watery stools and no more than 2 soft stools within the past 24 hours’ or ‘no symptoms and no unformed stools within the past 48 hours.’ the following clinical response rates were obtained: table 7. clinical response rates in pediatric patients 3 to 7 days post-therapy intent-to-treat analyses % (number of successes/total) population nitazoxanide* placebo outpatient study, age 1 -11 years 88% (21/24) 38% (9/24) inpatient study, malnourished ¶ , age 12-35 months 56% (14/25) 23% (5/22) * clinical response rates statistically significantly higher compared to placebo. ¶ 60% considered severely underweight, 19% moderately underweight, 17% mild underweight. some patients with ‘well’ clinical responses had c. parvum oocysts in their stool samples 3 to 7 days following the end of treatment. the relevance of stool examination results in these patients is unknown. patients should be managed based upon clinical response to treatment. diarrhea caused by c. parvum in acquired immune deficiency syndrome (aids) patients: a double-blind, placebo-controlled trial did not produce clinical cure rates that were significantly different from the placebo control when conducted in hospitalized, severely malnourished pediatric patients with acquired immune deficiency syndrome (aids) in zambia. in this study, the pediatric patients received a three day course of nitazoxanide suspension (100 mg twice daily in pediatric patients ages 12-47 months, 200 mg twice daily in pediatric patients ages 4 through 11 years) and were evaluated for response four days after the end of treatment.