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Alosetron

Alosetron hydrochloride is a potent and selective serotonin 5-HT3 receptor antagonist indicated for the management of severe diarrhea-predominant irritable bowel syndrome (IBS-D) in women whose symptoms have not responded adequately to conventional therapies.^[1]^[2] By antagonizing 5-HT3 receptors in the enteric nervous system, alosetron modulates gastrointestinal motility, secretion, and sensation, thereby reducing diarrhea, urgency, and abdominal pain associated with IBS-D.^[3]^[4] Initially approved by the U.S. Food and Drug Administration in February 2000 under the brand name Lotronex, alosetron was voluntarily withdrawn from the market in November 2000 following reports of serious, potentially life-threatening gastrointestinal adverse events, including ischemic colitis and severe constipation leading to complications such as perforation and obstruction.^[5]^[6] In response to patient advocacy and evidence of clinical benefits outweighing risks under strict prescribing conditions, the FDA permitted its reintroduction in June 2002 with a restricted distribution program emphasizing prescriber education, patient informed consent, and immediate discontinuation protocols for adverse symptoms; this program was later converted to a less stringent Risk Evaluation and Mitigation Strategy (REMS) before its removal in 2023.^[5]^[3]^[7] Despite its efficacy in alleviating refractory IBS-D symptoms, alosetron's use remains limited to specialist oversight due to the black-box warnings for ischemic colitis and constipation-related risks, highlighting the trade-offs in its therapeutic profile.^[8]

Medical Uses

Indications

Alosetron is indicated solely for the treatment of severe diarrhea-predominant irritable bowel syndrome (IBS-D) in women whose symptoms include chronic diarrhea and abdominal pain or discomfort, with symptoms persisting for at least six months and failing to respond adequately to conventional management, such as dietary modifications, loperamide, or other antidiarrheal agents.^[2]^[9] Eligible patients must also lack identifiable anatomic or biochemical gastrointestinal tract abnormalities or alternative organic etiologies for their symptoms, as confirmed through appropriate diagnostic evaluation.^[2]^[10] The indication is restricted to women due to limited efficacy data and higher risks observed in men during clinical trials and post-marketing surveillance.^[2] Alosetron is not approved for constipation-predominant IBS, mixed-type IBS, or non-IBS diarrheal conditions, nor for use in patients with mild or moderate IBS-D symptoms responsive to standard therapies.^[5] Prescribing requires enrollment in a risk management program emphasizing patient education on ischemic colitis and constipation risks, with discontinuation mandated if symptoms do not improve within four weeks.^[2]

Efficacy Evidence

Alosetron demonstrates efficacy in alleviating core symptoms of diarrhea-predominant irritable bowel syndrome (IBS-D) in women, including abdominal pain, urgency, and stool inconsistency, as evidenced by multiple randomized, placebo-controlled trials. In a 12-week trial of 647 nonconstipated women with IBS, alosetron 1 mg twice daily resulted in 41% of patients reporting adequate relief of pain and discomfort at month 3, compared to 29% on placebo (P=0.02), alongside significant reductions in stool frequency and improvements in consistency.^[11] Similar results were observed in parallel pivotal trials supporting initial FDA approval, where alosetron increased the proportion of women achieving global symptom improvement by 15-20% over placebo across endpoints like pain relief and urgency reduction.^[12] A meta-analysis of six large, randomized, 12-week trials involving over 3,000 female patients without constipation found that alosetron 1 mg twice daily significantly improved adequate relief of abdominal pain (odds ratio 1.20; 95% CI 1.06-1.37) and global symptom improvement (odds ratio 1.72; 95% CI 1.39-2.14), with a number needed to treat of 8 for global benefit.^[13] These effects were consistent across studies, driven by 5-HT3 receptor antagonism reducing colonic motility and visceral hypersensitivity, though benefits were not sustained beyond 12 weeks in extension data without dose adjustment.^[14] Limited evidence extends to men with IBS-D; a phase II dose-ranging trial of 598 patients showed alosetron 1 mg twice daily provided adequate relief of pain and discomfort in 58% versus 49% on placebo (P=0.03), with stool consistency improvements, but regulatory approval remains restricted to women due to smaller male cohorts and historical trial focus.^[15] Post-reapproval studies in clinical practice confirmed sustained symptom relief using FDA composite endpoints (pain and stool consistency), with 50-60% response rates in refractory female patients.^[16] Overall, efficacy is modest but superior to placebo in targeted populations, with no evidence of benefit in constipation-predominant IBS.^[17]

Pharmacology

Mechanism of Action

Alosetron is a potent and selective antagonist of the 5-hydroxytryptamine type 3 (5-HT3) receptor, a ligand-gated cation channel primarily expressed on intrinsic primary afferent neurons in the enteric nervous system and central neurons.^[2] ^[3] These receptors mediate serotonin-induced depolarization, facilitating gastrointestinal processes such as peristalsis, fluid secretion, and visceral sensation.^[2] By competitively binding to 5-HT3 receptors with high affinity, alosetron inhibits serotonin signaling, thereby attenuating excitatory neural pathways in the gut without significant central nervous system penetration due to its pharmacokinetic profile.^[2] ^[18] The antagonism reduces fasted small bowel and colonic transit times, decreases colonic tone, and inhibits fluid secretion in response to serotonergic stimulation, effects demonstrated in human studies where alosetron delayed overall gastrointestinal transit.^[2] This modulation normalizes hypermotility in conditions like diarrhea-predominant irritable bowel syndrome by dampening the release of neurotransmitters from sensory afferents and altering smooth muscle contractility.^[18] ^[19] Unlike non-selective agents, alosetron's selectivity for 5-HT3 over other serotonin subtypes minimizes off-target effects on broader serotonergic pathways.^[3] While the precise downstream effects on visceral hypersensitivity remain under investigation, preclinical data indicate blockade of non-selective cation currents activated by 5-HT3 stimulation in enteric neurons.^[2]

Safety Profile

Contraindications

Alosetron is contraindicated in patients with known hypersensitivity to alosetron hydrochloride or any component of the formulation.^[2] It must not be initiated in individuals currently experiencing constipation, as this increases the risk of serious complications.^[2] The drug is also contraindicated in patients with a history of chronic or severe constipation or any sequelae thereof, including intestinal obstruction, stricture, toxic megacolon, gastrointestinal perforation, or adhesions.^[2] Contraindications extend to those with prior ischemic colitis, impaired intestinal circulation, thrombophlebitis, or hypercoagulable states, due to heightened vulnerability to ischemic events.^[2] Inflammatory bowel conditions such as Crohn's disease, ulcerative colitis, or diverticulitis similarly preclude use, as alosetron may exacerbate these disorders.^[2] Severe hepatic impairment (Child-Pugh class C) represents an absolute contraindication owing to altered drug metabolism and potential toxicity.^[2] Concomitant administration with fluvoxamine, a potent CYP1A2 inhibitor, is contraindicated because it substantially elevates alosetron plasma levels, amplifying adverse effect risks.^[2] These restrictions stem from post-marketing surveillance revealing severe gastrointestinal events, including fatalities, in patients with predisposing factors.^[2]

Adverse Effects

The most frequently reported adverse effect of alosetron is constipation, occurring in a dose-dependent manner with incidences of 29% at 1 mg twice daily and 11% at 0.5 mg twice daily in clinical trials involving over 8,000 patients; approximately 11% of patients on the higher dose discontinued due to this effect, with median onset at 8 days and most cases resolving as single episodes.^[2] Other common adverse reactions, reported in more than 2% of patients and exceeding placebo rates, include abdominal discomfort or pain (7%), nausea (6%), and gastrointestinal discomfort or pain (5%).^[2] Ischemic colitis, a serious reduction in colonic blood flow, has been associated with alosetron use, with a cumulative incidence of 0.3% (3 per 1,000 patients) after 6 months in clinical trials (95% confidence interval: 1-4 per 1,000) compared to 0% in placebo groups.^[2] Post-marketing surveillance data indicate a lower adjudicated rate of 1.1 cases per 1,000 patient-years, with clinical trials showing 0.15% incidence versus 0% for placebo; nearly all reported cases in trials were reversible without long-term sequelae.^[20]^[2] Serious complications of constipation, including impaction, obstruction, perforation, and ulceration, occurred in approximately 0.1% (1 per 1,000) of alosetron-treated patients in clinical trials versus similar rates in placebo, with post-marketing rates of 0.66 per 1,000 patient-years; these events have occasionally required hospitalization, surgical intervention, or resulted in death, though overall incidence remains low and rarely leads to serious morbidity.^[2]^[20] Additional post-marketing reports include small bowel mesenteric ischemia and thrombotic events, underscoring the need for prompt discontinuation upon symptom onset such as new or worsening abdominal pain or bloody stools.^[2]

Risk-Benefit Analysis

Alosetron provides significant symptom relief in women with severe diarrhea-predominant irritable bowel syndrome (IBS-D), including reductions in abdominal pain, urgency, and stool frequency, with clinical trials demonstrating adequate relief in 41-57% of patients compared to 29-40% on placebo over 12 weeks.^[21] Long-term studies indicate sustained efficacy, with global symptom improvement and decreased disability in daily activities for responders.^[16] Economic modeling estimates a net benefit of 34.1 risk-adjusted value-adjusted life years per 1000 patients treated over 52 weeks relative to placebo, supporting its utility in refractory cases where conventional therapies fail.^[22] However, alosetron carries risks of serious gastrointestinal adverse events, primarily ischemic colitis (incidence approximately 1 in 800 patients in post-marketing data) and complications of constipation such as obstruction, perforation, or toxic megacolon, with rare fatalities reported, prompting initial market withdrawal in 2000.^[6] Constipation occurs in 20-30% of users, often resolving with discontinuation, but severe cases necessitate hospitalization in about 1 in 1000 patients.^[1] These risks are dose-dependent and more prevalent at higher doses or with prolonged use without symptom improvement.^[2] In the target population of women with severe, refractory IBS-D, the benefits outweigh risks when prescribed under restricted conditions, including starting at 0.5 mg daily, rapid discontinuation for inadequate response or adverse effects, and exclusion of contraindicated patients (e.g., those with constipation history or ischemic disease).^[5] FDA reapproval in 2002 and removal of the Risk Evaluation and Mitigation Strategy in 2023 reflect post-marketing evidence that serious events are infrequent (fewer than 1 per 1000 patient-years) and manageable with prescriber education and patient monitoring, affirming net clinical value for those with substantial symptom burden.^[7] Patient counseling on symptoms of ischemia or severe constipation is essential to mitigate harms.^[8]

Regulatory History

Development and Initial Approval

Alosetron, a selective serotonin 5-HT3 receptor antagonist, was developed by GlaxoSmithKline (then Glaxo Wellcome) as a targeted therapy for severe diarrhea-predominant irritable bowel syndrome (IBS-D) in women, addressing a condition lacking specific pharmacological treatments at the time.^[23] The drug's development focused on its ability to inhibit visceral afferent nerve activation and reduce colonic motility, based on preclinical and early-phase studies demonstrating antagonism of 5-HT3 receptors in the gastrointestinal tract.^[3] Pivotal phase III clinical trials, involving thousands of female patients, provided evidence of symptom relief, including reductions in abdominal pain and bowel frequency, which supported the new drug application submitted to the U.S. Food and Drug Administration (FDA).^[24] On November 16, 1999, an FDA gastrointestinal drugs advisory committee voted to recommend approval of alosetron hydrochloride (branded as Lotronex), citing the unmet need in IBS-D treatment despite concerns over potential rare adverse events like ischemic colitis observed in trials.^[25] The FDA completed its review in approximately seven months, granting initial marketing approval on February 9, 2000, as the first agent specifically indicated for women with severe IBS-D unresponsive to conventional therapies.^[26]^[1] Approval included requirements for patient medication guides under newly implemented 1999 regulations, emphasizing informed consent on risks such as constipation.^[27] This marked a milestone in functional gastrointestinal disorder management, though post-approval surveillance later revealed limitations in the initial risk assessment.^[28]

Market Withdrawal

Alosetron, marketed as Lotronex by Glaxo Wellcome, was voluntarily withdrawn from the United States market on November 28, 2000, immediately following a meeting with the Food and Drug Administration (FDA) to discuss postmarketing reports of serious adverse gastrointestinal events.^[29]^[30] The manufacturer initiated the withdrawal after FDA analysis revealed patterns of severe complications not fully anticipated during preapproval clinical trials, including ischemic colitis and life-threatening constipation-related issues such as bowel obstruction, perforation, and impaction.^[27]^[26] By the date of withdrawal, postmarketing surveillance had documented at least 70 cases of serious adverse events associated with alosetron use: 49 instances of ischemic colitis, a condition involving reduced blood flow to the colon leading to tissue damage, and 21 cases of severe constipation resulting in obstructed or ruptured bowels.^[27] Of these, 34 patients required hospitalization, with two deaths attributed to ischemic colitis and one to complications of constipation.^[27] These events occurred despite the drug's targeted use in women with severe diarrhea-predominant irritable bowel syndrome (IBS), highlighting a disproportionate risk in real-world application compared to controlled trial data.^[29] The withdrawal was precipitated by advocacy groups, including Public Citizen, which petitioned the FDA in August 2000 to revoke approval, citing evidence of ischemic colitis as a direct causal risk without identifiable predisposing factors.^[31] FDA's Office of Post-Marketing Drug Risk Assessment concluded that no reliable predictors existed for either ischemic colitis or severe constipation, underscoring the challenges in early detection and the need for immediate market removal to prevent further harm.^[32] Glaxo Wellcome's decision aligned with FDA recommendations, though the agency expressed willingness to collaborate on potential reintroduction under stricter controls.^[29] The action effectively halted all distribution and sales, with patient notifications issued to discontinue use promptly.^[26]

Reapproval and Restrictions

Following voluntary withdrawal from the U.S. market in November 2000 amid reports of ischemic colitis and severe constipation complications, alosetron (marketed as Lotronex) was reapproved by the FDA on June 7, 2002, via a supplemental New Drug Application permitting restricted marketing to address safety concerns.^[33]^[5] The reapproval narrowed the indication from the original 2000 approval, confining use to adult women with severe diarrhea-predominant irritable bowel syndrome (IBS-D) meeting specific criteria: chronic symptoms for at least 6 months, no identifiable anatomic or biochemical abnormalities explaining the condition, and documented failure of conventional therapies.^[1]^[34] Distribution was limited through a physician-based risk management program requiring prescribers to attest in writing to their qualifications, including familiarity with IBS-D diagnosis and commitment to educating patients on risks such as ischemic colitis, complicated constipation, and symptoms necessitating immediate discontinuation (e.g., rectal bleeding, severe or worsening abdominal pain, or constipation unresponsive to laxatives).^[33]^[5] Prescribers were mandated to report all serious adverse events to the manufacturer (GlaxoSmithKline at the time) and the FDA within specified timelines, with patients required to sign a consent form acknowledging these risks and agreeing to comply with monitoring.^[33]^[1] These measures aimed to select patients likely to derive benefit while minimizing exposure in those at higher risk, reflecting FDA's determination—based on post-withdrawal data review and advisory committee input—that alosetron's efficacy in refractory cases justified controlled reintroduction despite persistent rare but serious gastrointestinal risks.^[5]^[1] The program excluded men, patients with mild symptoms, and those with contraindications like a history of constipation or ischemic events, with dosing starting at 0.5 mg once or twice daily and titrated only if tolerated.^[33]^[34]

Post-2010 Updates

In 2010, the U.S. Food and Drug Administration (FDA) approved a Risk Evaluation and Mitigation Strategy (REMS) program for alosetron (marketed as Lotronex), mandating prescriber training, enrollment in the program, and a patient-provider agreement form to ensure safe use amid ongoing concerns over ischemic colitis and severe constipation.^[5] This measure built on prior restrictions following the drug's 2002 reapproval, aiming to balance access for women with severe diarrhea-predominant irritable bowel syndrome (IBS-D) against rare but serious adverse events.^[5] By 2016, postmarketing surveillance data prompted FDA modifications to the alosetron REMS, rendering prescriber training voluntary and eliminating the requirement for patient-provider agreements, while retaining elements like a medication guide and communication plan to educate on risks.^[5] ^[35] A concurrent safety update emphasized the program's evolution, reflecting accumulated evidence of low incidence rates for adjudicated cases of ischemic colitis (stable at approximately 1 in 1,000 patients) and complications of constipation (decreasing over time from post-2002 reintroduction).^[24] ^[35] In 2023, the FDA fully discontinued the alosetron REMS program for Lotronex and its approved generics, citing stable adverse event reporting patterns from 2002 through 2016 that confirmed the benefits outweighed risks when used as indicated in women with severe IBS-D unresponsive to other therapies.^[1] ^[7] This decision aligned with long-term postmarketing data showing no escalation in serious events, supporting continued restricted prescribing without mandatory risk mitigation elements.^[24] Clinical research post-2010 has reinforced alosetron's efficacy in symptom relief, including reductions in abdominal pain, urgency, and stool inconsistency, as demonstrated in a 2012 randomized trial assessing quality-of-life improvements and workplace productivity.^[36] A 2018 retrospective analysis of real-world use further confirmed benefits across FDA-defined composite endpoints for IBS-D, with adverse event rates remaining consistent with historical profiles.^[16] Exploratory studies, such as a 2013 trial in Japanese patients with severe IBS-D, explored tolerability and dosing feasibility without identifying new safety signals.^[37] These findings have informed prescribing guidelines emphasizing alosetron's role in refractory cases, absent major regulatory reversals or expanded indications through 2025.^[1]

Controversies

FDA Oversight and Decision-Making

The U.S. Food and Drug Administration (FDA) approved alosetron hydrochloride (Lotronex) on February 9, 2000, for the management of women with severe diarrhea-predominant irritable bowel syndrome (IBS) who had failed conventional therapies, based on clinical trials demonstrating efficacy in symptom relief but with limited pre-approval data on rare adverse events like ischemic colitis, of which only four possible cases were identified during development.^[5]^[38] Postmarketing surveillance, initiated immediately after launch, rapidly identified serious risks including ischemic colitis (with at least four associated deaths by mid-2000) and complications from severe constipation (such as bowel obstruction, perforation, and additional fatalities), prompting Glaxo Wellcome to voluntarily withdraw the drug from the market on November 28, 2000, in coordination with FDA recommendations to mitigate ongoing harm.^[5]^[27] The FDA's oversight during this period involved active review of adverse event reports through its MedWatch system, which highlighted the challenges of approving drugs for niche conditions where trial populations may not fully capture low-incidence risks, leading to criticism that the agency's initial benefit-risk assessment underestimated post-approval real-world harms despite the drug's targeted labeling.^[5]^[39] In response to patient advocacy and manufacturer petitions, the FDA convened a Gastrointestinal Drugs Advisory Committee in April 2002 to reassess alosetron's risk-benefit profile, where a majority recommended conditional reapproval despite dissenting views from some senior advisors warning of potential additional deaths based on unresolved mechanistic concerns about 5-HT3 receptor antagonism causing vascular and motility issues.^[39]^[40] The agency approved the drug's reintroduction on June 7, 2002, imposing stringent restrictions including a mandatory Prescribing Program for Lotronex (PPL), which required prescribers to complete training, document severe refractory disease, obtain patient informed consent acknowledging risks like ischemic colitis (incidence estimated at 1 in 1,000 users post-reapproval), and discontinue at the first sign of complications.^[5]^[34] This decision reflected FDA's emphasis on postmarketing data integration and risk mitigation strategies over outright denial, though it drew scrutiny for perceived regulatory capture, with former agency officials citing close pharmaceutical industry ties as influencing leniency, contrasted by evidence that patient desperation for IBS relief—evidenced by thousands of supportive letters—played a key role in balancing access against documented low event rates under controlled use.^[25]^[29] Subsequent FDA oversight included ongoing surveillance, approving generic alosetron in 2016 while retaining the evolved Risk Evaluation and Mitigation Strategy (REMS), which mandated education on risks.^[5] By 2023, after analyzing nine years of post-reapproval data showing ischemic colitis rates of approximately 1.1 per 1,000 patient-years and serious constipation complications reduced to rare levels (with no utilization uptick), the FDA determined the REMS no longer necessary, affirming that restricted access ensured benefits outweighed risks without evidence of systemic oversight failures.^[5]^[24] This evolution underscores the agency's adaptive decision-making framework, reliant on empirical postmarketing evidence rather than static pre-approval assumptions, though debates persist on whether earlier withdrawal signals or stricter initial hurdles could have prevented initial harms.^[41]^[25]

Stakeholder Perspectives

Patients with severe diarrhea-predominant irritable bowel syndrome (IBS-D) have strongly advocated for alosetron's availability, reporting substantial symptom relief including reduced bowel urgency, improved stool consistency, and enhanced quality of life when other treatments failed.^[42] Following its 2000 withdrawal, the FDA received thousands of letters from patients emphasizing alosetron's transformative benefits and pleading for reaccess, with advocacy groups like the International Foundation for Functional Gastrointestinal Disorders (IFFGD) and the Lotronex Action Group submitting petitions highlighting its role in managing refractory cases.^[29] ^[43] User reviews from clinical practice indicate high satisfaction, with an average rating of 9.5 out of 10 for IBS-D symptom control among responders.^[44] Gastroenterologists and other physicians prescribing alosetron post-reapproval in 2002 view it as effective for select women with severe, chronic IBS-D unresponsive to conventional therapies, citing clinical trial data showing improvements in global symptoms, abdominal pain, and defecation patterns.^[16] ^[45] However, many express caution due to rare but serious risks like ischemic colitis and severe constipation, supporting the FDA-mandated Risk Management Program that requires physician certification, patient consent, and close monitoring to mitigate adverse events.^[24] Post-marketing data from 2002 to 2011 confirmed a significant decline in complications under these restrictions, reinforcing its utility in targeted high-need populations.^[24] Pharmaceutical stakeholders, including original developer GlaxoSmithKline (GSK) and subsequent marketer Prometheus Laboratories, justified the 2000 voluntary withdrawal amid reports of 84 hospitalizations and at least five deaths linked to complications like ischemic colitis, prioritizing patient safety over continued sales despite initial disagreement with FDA on event causality.^[46] ^[47] Prometheus pursued reapproval, collaborating with the FDA to implement educational and prescribing safeguards, arguing that the drug's benefits for severe IBS-D patients outweighed risks when used restrictively, as evidenced by reduced adverse event rates after 2002.^[42] ^[48] FDA regulators balanced post-approval surveillance data showing elevated risks against patient and physician demands, leading to reapproval in June 2002 under stringent conditions for women with severe IBS-D who failed other treatments.^[5] Critics, including Public Citizen, contended that alosetron's marginal efficacy— with only about 15% absolute benefit over placebo in trials—and potential for life-threatening complications warranted permanent withdrawal, accusing the agency of undue influence from patient advocacy and industry.^[49] ^[50] This debate framed reapproval as either regulatory responsiveness to real-world needs or a lapse in prioritizing verifiable safety data over anecdotal benefits.^[25]

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Alosetron controls bowel urgency and provides global symptom ...
Alosetron is effective at managing bowel urgency in women with diarrhea-predominant IBS. The IBS Global Improvement assessment correlated with improvements in ...Alosetron Controls Bowel... · Abstract · Introduction
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Alosetron for irritable bowel syndrome: Senior vice president of ...
We have worked with the Food and Drug Administration to find a way forward for this drug that will balance safety concerns and practicality in prescribing.
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Drug for irritable bowel syndrome taken off the market - The BMJ
Dec 9, 2000 · Dr Wolfe said, “Once again the FDA approved a drug that should not have been approved and waited far too long to withdraw it from the market.”.Missing: pharma perspectives reapproval
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Alosetron: a case study in regulatory capture, or a victory for patients ...
Sep 14, 2002 · Having withdrawn the drug it was not our intention to reintroduce it. However, thousands of patients contacted both us and the FDA to stress the
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Petition to Ban Alosetron (Lotronex) - Public Citizen
There was some evidence of alosetron efficacy in this trial. For the full study population, more patients on alosetron (41%) than placebo (26%) had ...Missing: perspectives | Show results with:perspectives
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Testimony Concerning Alosetron (Lotronex) - Public Citizen
Testimony Concerning Alosetron (Lotronex) · Alosetron Risk Information · History of Incidence of Alosetron-induced Ischemic Colitis · Regulatory Options.<|separator|>