Acnatac
1. NAME OF THE MEDICINAL PRODUCT
Acnatac 10 mg/g + 0.25 mg/g gel
2. QUALITATIVE AND QUANTITATIVE COMPOSITION
Each gram of gel contains 10 mg (1%)clindamycin (as clindamycin phosphate) and 0.25 mg (0.025%)tretinoin.
Excipients with known effect:
Methyl parahydroxybenzoate (E
218): 1.5 mg/g (0.15%)
Propyl parahydroxybenzoate (E216): 0.3 mg/g (0.03%)
Butylhydroxytoluene(E321): 0.2 mg/g
(0.02%)
For the full list of excipients, see section 6.1.
3. PHARMACEUTICAL form
Gel
Translucent yellow gel
4. Clinical particulars
4.1 Therapeutic indications
Acnatac is indicated for the topical treatment of acne vulgaris when comedones, papules and pustules are present in patients 12 years or older (see section 4.4 and 5.1).
Consideration should be given to official guidance on the appropriate use of antibacterial agents and acne treatment.
4.2 Posology and method of administration
Posology
Adults and adolescents (≥ 12 years)
Once daily at bedtime the entire face should be washed with mild soap and dried. A pea-sized amount of medication should be squeezed onto one fingertip, dot onto the chin; cheeks, nose, and forehead, then gently rub over the entire face.
Treatment with Acnatac should not exceed 12 weeks of continuous use without careful evaluation. It should be noted that therapeutic improvement may not be observed for several weeks after starting treatment.
In case of a missed dose of Acnatac, the patient should wait for the next dose at the usual time. Patients should not double the dose to make up for the forgotten dose.
Use in Children below 12 years of age
Acnatac is not recommended for use in children below 12 years of age, since safety and efficacyof Acnatac in children have not been established.
Use in the Elderly (>65 years of age)
Safety and efficacy of Acnatac in patients above the age of 65 years have not been established.
Renal and hepatic impairment
In view of the low systemic exposure to clindamycin and tretinoin following topical administration of Acnatac, moderate renal or hepatic impairment is not expected to result in systemic exposure of clinical concern. However, clindamycin and tretinoin serum concentrations have not been studied in patients with renal or hepatic disease following topical administration. Individual decisions are advisable in severe cases.
Method of administration
Acnatac is indicated for external (dermatological) use only. The application of Acnatac should avoid eyes, eyelids, lips and nostrils. After the application the patient should wash hands.
4.3 Contraindications
Acnatac is contraindicated:
-
In patients who have a history of hypersensitivity to the active substances clindamycin and/or tretinoin or to any of the excipients or lincomycin (see also Section 6.1).
-
In patients with regional enteritis, ulcerative colitis, or history of antibiotic-associated colitis.
-
In patients who have a personal or familial history of skin cancer.
-
In patients who have a history of acute eczemas, rosacea and perioral dermatitis
-
In patients with pustular and deep cystic nodular acne varieties (acne conglobata and acne fulminans)
4.4 Special warnings and precautions for use
Acnatac is not for oral, ophthalmic, intranasal or intravaginal use.
Acnatac is not recommended in treatment of mild acne vulgaris.
Acnatac should not be used in pregnancy, especially during the first trimester, and in women of childbearing potential not using contraception (see section 4.6).
Contact with the mouth, eyes and mucous membranes and with abraded or eczematous skinshould be avoided. Application to sensitive areas of skin should be made with caution. In the event of accidental contact with the eyes, bathe with large amounts of water.
Antibiotic-associated colitis (also known as Clostridium difficile-associated colitisor CDAD) has been reported with the use of some other topical clindamycin products. This is unlikely to occur with Acnatac, as plasma levels have been determined and the percutaneous absorption of clindamycin is clinically negligible.
If prolonged or significant diarrhoea occurs or the patient suffers from abdominal cramps, treatment with Acnatac should be discontinued immediately, as the symptoms may indicate antibiotic-associated colitis. Suitable diagnostic methods, such as the determination of Clostridium difficile and toxin and, if necessary, colonoscopy should be employed and treatment options for colitis considered.
Use of more than the recommended amount or too frequent application may cause redness, stinging and discomfort. If severe irritation occurs, especially in the early stage of therapy, patient should be advised to discontinue temporarily or reduce the frequency of application.
Acnatac should be prescribed with caution in atopic subjects.
Acnatac should not be applied at the same time as other topical preparations (including cosmetics) because of possible incompatibility and interaction with tretinoin. Particular caution should be exercised in the use of keratolytic agents such as sulphur, salicylic acid, benzoyl peroxide or resorcinol and chemical abrasives. If the patient has been treated with such preparations, the effect of the peeling agents must subside before any commencement of Acnatac therapy.
Some medicated cleansers and scrubbing solutions have a strong drying effect. They should not be used in patients receiving tretinoin topical therapy.Abrasive soaps, soaps and cosmetics as well as spices or lime should be used with caution.
Because of increased susceptibility to UV radiation, photosensitivity may occur during treatment with Acnatac Gel. Exposure to sunlight should therefore be minimised and appropriate sunscreen products with a SPF (Sun Protection Factor) of at least 30, together with suitable protective apparel (e.g. a hat), should be used. Use of sun lamps or sun beds should be avoided during treatment and patients with sunburn should not use this product until recovered
Patients who may be required to have considerable sun exposure due to occupation and those with inherent sensitivity to the sun should exercise particular caution. If sunburn occurs, discontinue therapy with Acnatac until the severe erythema and peeling subside.
Occasional gram-negative folliculitis has been reported during treatment with clindamycin 1% topical products. If this should occur, therapy with Acnatac should be discontinued and alternative therapy should be initiated.
Long-term use of clindamycin may cause resistance and/or overgrowth of non susceptible dermal bacteria or fungi although this is a rare occurrence.
Cross resistance may occur with other antibiotics such as lincomycin or erythromycin (see section 4.5).
Simultaneous use of oral and topical antibiotics should be avoided, particularly if chemically different.
The excipients methyl parahydroxybenzoate (E218) and propyl parahydroxybenzoate (E216) may cause allergic reactions (possibly delayed). The excipient butylhydroxytoluene (E321) may cause local skin reactions (e.g. contact dermatitis), or irritation to the eyes and mucous membranes.
Interaction with other medicinal products and other forms of interaction
Concomitant topical medication as well as medicated soaps and cleansers that have a strong drying effect and products with high concentrations of alcohol as well as astringents should be used with caution. The concomitant treatment with corticosteroids should be avoided.
In vitro, antagonism has been demonstrated between erythromycin and clindamycin, synergy has been shown with metronidazole, both antagonistic and synergistic effects have been observed with aminoglycosides and agonistic action has been described with neuromuscular blocking agents.
Vitamin K antagonists
Increased coagulation tests (PT/INR) and/or bleeding, have been reported in patients treated with clindamycin in combination with a vitamin K antagonist (e.g. warfarin, acenocoumarol and fluindione). Coagulation tests, therefore, should be frequently monitored in patients treated with vitamin K antagonists.
Tretinoin causes enhanced permeability for other topically applied medicinal agents.
4.6 Fertility, pregnancy and lactation
Acnatac should be given to women of childbearing potential only if effective contraception is used during treatment and for 1 month after discontinuation of treatment.
Pregnancy
There are no
adequate data from the use of Acnatac in pregnant women. Acnatac
did not cause any reprotoxic effects in a topical study on
developmental toxicity in rabbits (see section 5.3).
Clindamycin
A limited number of pregnancies exposed in the first trimester to clindamycin indicate no adverse effects of clindamycin on pregnancy or on the health of the fetus/new-born child. Clindamycin was not teratogenic in reproduction studies in rats and mice, using subcutaneous and oral doses of clindamycin (see section 5.3).
Tretinoin
Tretinoin is a well-known human teratogen following systemic administration but the available data after topical administration in pregnant women is limited. Oral doses of tretinoin are teratogenic in animals and there is evidence of embryotoxicity from studies where tretinoin is applied dermally (see section 5.3). Acnatac should not be used in pregnancy, especially during the first trimester, and in women who may become pregnant.
Breast-feeding
It is not known whether tretinoin and clindamycin are secreted in breast milk following the use of Acnatac. Oral and parenteral administration of clindamycin has been reported to result in the appearance of clindamycin in breast milk. It is known that orally administered retinoids and their metabolites are secreted in breast milk. Therefore, Acnatac should not be used in women who are breast feeding.
Fertility
There are no available data on fertility on Acnatac.
Clindamycin
Reproduction studies in rats and mice, using subcutaneous and oral doses of clindamycin, revealed no evidence of impaired fertility.
Tretinoin
Systemically administered tretinoin severely affects fertility. Available data regarding fertility after topical administration in humans are limited.
4.7 Effects on ability to drive and use machines
No studies on the effects on the ability to drive and use machines have been performed. It is unlikely that treatment with Acnatac will have any effect on the ability to drive and use machines.
Undesirable effects
Within the system organ classes, adverse reactions are listed under headings of frequency (number of patients expected to experience the reaction), using the following categories:
Very common (1/10)
Common (1/100 to <1/10)
Uncommon (1/1,000 to <1/100)
Rare (1/10,000 to <1/1,000)
Very rare (<1/10,000)
Not known (cannot be estimated from the available data)
Reported frequencies in clinical trials are as following:
Immune system disorders:
Rare:Hypersensitivity
Endocrine disorders:
Rare: Hypothyroidism
Nervous system disorders:
Rare: Headache
Eye disorders:
Rare: Eye irritation
Gastrointestinal disorders:
Rare:Gastroenteritis, nausea
Skin and subcutaneous tissue disorders:
Uncommon: Acne, dry skin, erythema, seborrhoea, photosensitivity reaction, pruritis, rash, exfoliative rash, skin exfoliation, sunburn
Rare: Dermatitis, herpes simplex, rash macular, skin bleeding, skin burning sensation, skin depigmentation, skin irritation.
General disorders and administration site conditions:
Uncommon:Application site reaction, application site burning, application site dermatitis, application site dryness, application site erythema,
Rare: Application site irritation, application site swelling, application site erosion, application site discolouration, application site pruritis, application site desquamation, feeling hot, pain
Paediatric population
The proportion of paediatric patients (12-17 years) reporting a specific drug-related adverse reaction was consistent with that which was reported in the overall population. The incidence of dry skin in adolescent population (12-17 years) was slightly higher in clinical trials than in the overall population.
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the national reporting system listed in Appendix V
4.9 Overdose
Acnatac Gel is for topical use only. If Acnatac Gel is applied excessively, marked redness, peeling or discomfort can occur. If excess application occurs accidentally or through over-enthusiastic use, the face should be gently washed with a mild soap and lukewarm water. Acnatac should be discontinued for several days before resuming therapy.
In the case of overdosage, topically applied clindamycin phosphate from Acnatac can be absorbed in sufficient amounts to cause systemic effects. Gastrointestinal side effects including abdominal pain, nausea, vomiting and diarrhoea may occur (see section 4.4).
In the event of accidental ingestion, treatment should be symptomatic. The same adverse reactions effects as those expected with clindamycin (i.e. abdominal pain, nausea, vomiting and diarrhoea) and tretinoin (including teratogenesis in women of childbearing years) are expected. In such cases, Acnatac Gel should be discontinued and pregnancy testing should be carried out in women of childbearing potential.
5. PHARMACOLOGICAL PROPERTIES
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Anti-Acne Preparations for
Topical Use;
clindamycin, combinations
ATC code: D10AF51
Acnatac combines two active substances, which act through different mechanisms of action (see below).
Clindamycin:
Clindamycin is a semisynthetic derivativeof the parent compound lincomycin that is produced by Streptomyces lincolnensis and is predominantly bacteriostatic. Clindamycin binds to the 50S ribosomal subunitsof susceptible bacteria and prevents elongation of peptide chains by interfering with peptidyl transfer, thereby suppressing bacterial protein synthesis. Although clindamycin phosphate is inactive in-vitro, rapid in-vivo hydrolysis converts this compound to the antibacterial active clindamycin.
Clindamycin has been shown to have in vitro activityagainst Propionibacterium acnes, one pathophysiological factor thatinfluence the development ofacne vulgaris. Clindamycin also exerts an anti-inflammatory effect on the acne vulgaris lesions.
The break-point for susceptibility testing of clindamycin is 4 mg/ml for P. acnes as a representative ofGram-positive anaerobes (breakpointsfor susceptibility recommended by the European Committee on Antimicrobial SusceptibilityTesting-EUCAST).
Tretinoin:
Topical tretinoin has both comedolytic and anti-inflammatory effects. Tretinoin decreases cohesiveness of follicular epithelial cells resulting in decreased microcomedone formation. Additionally, tretinoin stimulates mitotic activity and increased turnover of follicular epithelial cells, causing extrusion of the comedones. The comedolytic activity is related to a normalisation of the desquamation of the follicular epithelium. Tretinoin exerts anti-inflammatory effect via suppression of toll-like receptors (TLRs).
A combination therapy of clindamycin and tretinoin, as in Acnatac Gel, not only combines the individual actions of both active agents but also complements their certain actions. There is also evidence in the literature to show that when applied together, tretinoin increases the penetration of clindamycin. Thus, this combination therapy targets multiple pathogenic factors: abnormal follicular keratinization, P.acnesproliferation, inflammation and increased sebum production.
Clinical efficacy of Acnatac
Three randomised double-blind clinical studies, including a total of 4550 patients with acne vulgaris with both inflammatory and non-inflammatory lesions were performed. Of these 1853 patients were treated with Acnatac Gel, 846 with tretinoin, 1428 with clindamycin phosphate and 423 with Acnatac Gel vehicle.
Patients with 20-50 facial acne inflammatory lesions (papules and pustules), 20-100 facial acne non-inflammatory lesions (open and closed comedones), two or fewer nodules (defined as an inflammatory lesion greater than or equal to 5 mm in diameter) and without cysts were included. Lesions were counted at baseline and at weeks 2, 4, 8 and 12.
Primary measurements of efficacy for studies 7001.G2HP-06-02 and 7001.G2HP-07-02 were (1) mean percent change from baseline at Week 12 in inflammatory lesion counts, (2) mean percent change from baseline at Week 12 in non inflammatory lesion counts, (3) mean percent change from baseline at Week 12 in total lesion counts, and (4) the percent of subjects who were clear or almost clear, at Week 12 as judged by an Evaluator’s Global Severity Score (EGSS). Superiority vs. monotherapies was concluded if two of three lesion count variables and dichotomized EGSS were significant.
Treatment was applied once daily for 12 weeks and patients were evaluated and lesions counted at week 12.
Studies 7001.G2HP-06-02 and 7001.G2HP-07-02 compared Acnatac to both mono treatments (clindamycin phosphate 1.2% gel and tretinoin 0.025% gel) and vehicle using a double-blind treatment regimen. The third clinical study (MP1501-02) was conducted to compare Acnatac to clindamycin alone.
The distribution of percent change in lesion counts was skewed, therefore the median percent change is shown in the following tables.
|
Median percent change (decrease) in the number of lesions at week 12 |
|||||
|
Lesion type |
Treatment |
Study |
Meta-analysis |
||
|
G2HP_06_02 (n=1252) |
G2HP_07_02 (n=1288) |
MP1501_02 (n=2010) |
All studies1 (n=4550) |
||
|
Inflammatory |
Acnatac |
52.6 |
61.3 |
70.0 |
65.2 |
|
Clindamycin |
46.4* |
52.1* |
64.5* |
60.0* |
|
|
Tretinoin |
42.9* |
50.0* |
n.a. |
46.4* |
|
|
Vehicle |
25.0* |
38.9* |
n.a |
32.3* |
|
|
Non-inflammatory |
Acnatac |
43.8 |
42.3 |
57.6 |
51.6 |
|
Clindamycin |
27.5* |
32.2 |
48.2* |
43.5* |
|
|
Tretinoin |
36.2* |
40.0 |
n.a. |
37.3* |
|
|
Vehicle |
23.0* |
24.2* |
n.a. |
23.9* |
|
|
Total |
Acnatac |
46.3 |
48.4 |
62.0 |
54.5 |
|
Clindamycin |
33.9* |
40.9* |
53.1* |
48.1* |
|
|
Tretinoin |
39.6* |
39.7* |
n.a. |
39.6* |
|
|
Vehicle |
22.2* |
25.0* |
n.a. |
22.8* |
|
|
p-values from ranked ANOVA 1 for pairwise comparison vs. Tretinoin and Vehicle data from studies 7001-G2HP-06-02 and 7001-G2HP-07-02 were considered. * p 0.05 |
|||||
Global Severity Score at Week 12 –presented as dichotomised values
|
|
Acnatac |
Clindamycin |
Tretinoin |
Vehicle |
|
ITT-clear or almost clear * |
|
|
|
|
|
Success |
85 (20%) |
32 (15%) |
62 (15%) |
18 ( 9% ) |
|
Failure |
335 (80%) |
176 (85%) |
355 (85%) |
189 (91%) |
|
Total |
420 |
208 |
417 |
207 |
|
P-value |
|
0.147 |
0.037 |
<0.001 |
|
ITT-clear or almost clear ** |
|
|
|
|
||||
|
Success |
95 (22%) |
38 (17%) |
60 (14%) |
16 ( 7% ) |
||||
|
Failure |
330 (78%) |
180 (83%) |
369 (86%) |
200 (93%) |
||||
|
Total |
425 |
218 |
429 |
216 |
||||
|
P-value |
|
0.122 |
0.001 |
<0.001 |
||||
|
|
|
|
|
|
||||
|
ITT- clear, almost clear or at least 2-grade improvement*** |
|
|
|
|
||||
|
Success |
381 (38%) |
318 (32%) |
|
|
||||
|
Failure |
627 (62%) |
684 (68%) |
|
|
||||
|
Total |
1008 |
1002 |
|
|
||||
|
P-value |
|
0.002 |
|
|
||||
1missing values imputed as failures
* Study 7001-G2HP-06-02
** Study 7001-G2HP-07-02
*** Study MP-1501-02
Paediatric Population
The percentage change in the number of lesions at Week 12 for adolescents, between 12 and 17 years, in the individual trials and the metanalysis of these trials are provided below.
|
Median percent change (decrease) in the number of lesions at Week 12: Adolescents |
|||||
|
Lesion type |
Treatment |
Study |
Meta-analysis |
||
|
G2HP_06_02 (n = 800) |
G2HP_07_02 (n = 795) |
MP1501_02 (n = 1320) |
All studies1 (n = 2915) |
||
|
Inflammatory |
Acnatac |
50.0 |
56.2 |
66.7 |
62.5 |
|
Clindamycin |
40.4 |
46.7 |
64.0* |
58.3* |
|
|
Tretinoin |
38.5* |
47.3* |
n.a. |
40.7* |
|
|
Vehicle |
16.7* |
25.4* |
n.a. |
21.4* |
|
|
Non-inflammatory |
Acnatac |
43.4 |
40.2 |
55.6 |
50.0 |
|
Clindamycin |
23.4* |
26.5* |
48.7* |
42.2* |
|
|
Tretinoin |
30.2* |
36.9 |
n.a. |
32.8* |
|
|
Vehicle |
13.5* |
13.7* |
n.a. |
13.5* |
|
|
Total |
Acnatac |
42.0 |
44.8 |
59.4 |
52.5 |
|
Clindamycin |
31.3* |
34.2* |
53.0* |
46.4* |
|
|
Tretinoin |
31.9* |
38.1* |
n.a. |
35.6* |
|
|
Vehicle |
14.6* |
14.6* |
n.a. |
14.6* |
|
|
p-values from ranked ANOVA 1 for pairwise comparison vs. Tretinoin and Vehicle data from studies 7001-G2HP-06-02 and 7001-G2HP-07-02 were considered. * p 0.05 |
|||||
Although the studies were not powered for the subgroups and the results are not as consistent as for the changes in lesion counts, they also provide evidence for superiority of the combination product.
5.2 Pharmacokinetic properties
In an open-label, multiple-dose study treating 12 subjects with moderate to severe acne, the percutaneous absorption of tretinoin following 14 consecutive daily applications of approximately 4 g of Acnatac was minimal. Tretinoin plasma concentrations were below the lower limit of quantitation (LLOQ; 1 ng/mL) in 50% to 92% of subjects at any given time point following administration and were near the LLOQ in the remaining subjects, with values ranging from 1.0 to 1.6 ng/mL. The plasma concentrations of the key tretinoin metabolites, 13-cis-retinoic acid and 4-oxo-13-cis-retinoic acid, ranged from 1.0 to 1.4 ng/mL and from 1.6 to 6.5 ng/mL, respectively. Plasma concentrations for clindamycin generally did not exceed 3.5 ng/mL, with the exception of one subject whose plasma concentration reached 13.1 ng/mL.
Tretinoin
Tretinoin occurs in the body as a metabolite of retinol, and it exhibits a certain degree of Vitamin A growth-promoting activity. Representative well-controlled clinical studies conclude that topically applied tretinoin does not increase plasma alltrans retinoic acid (tretinoin). Following a single topical application of radiolabelled tretinoin, the blood concentration of retinoic acid was found to be unchanged from 2-48 hours. Neither single-dose nor longterm treatment with topical tretinoin formulations does alter systemic retinoid levels, which remain within the range of body’s natural endogenous levels.
Clindamycin
Clindamycin is converted within the skin by phosphatases, leading to the more potent from of clindamycin. Thus, conversion to clindamycin is a major determinant of antimicrobial activity in the skin layers following topical application of clindamycin phosphate.
5.3 Preclinical safety data
Following preclinical studies of Acnatac, clindamycin, and tretinoin support the safety of Acnatac.
Acnatac
A 13 week repeat-dose dermal toxicity study in minipigs revealed no toxic effects, apart from minor local irritation (erythema). Acnatac Gel was shown not to be a primary skin irritant or ocular irritant in two local tolerance studies in rabbits, and it was shown not to be a contact sensitizer in guinea pigs.
In a dermal developmental toxicity study in rabbits no reproductive toxicity was seen.
Clindamycin
Systemically administered clindamycin does not affect fertility, mating ability, embryonic development, or post-natal development. In-vitro and in-vivo studies did not reveal any mutagenic potential of clindamycin. Clindamycin was not carcinogenic in mice in a 2-year dermal study with 1.2% clindamycin phosphate and a 2-year oral study in rats.
Tretinoin
In-vitro and in-vivo studies did not reveal any mutagenic potential of tretinoin. Tretinoin was not carcinogenic in mice in a 2-year dermal study with 0.1% tretinoin (a higher strength than Acnatac). The systemic carcinogenic potential has not been studied. Oral tretinoin has been shown to be teratogenic in rats, mice, hamsters, rabbits, monkeys and humans. It severely affects fertility and peri-postnatal development. In animals, dermally applied tretinoin was not teratogenic at daily doses that were several times higher than the human recommended daily dose adjusted to body surface.
6. PHARMACEUTICAL PARTICULARS
6.1 List of excipients
purified water
glycerol
carbomers
methyl parahydroxybenzoate (E218)
propyl parahydroxybenzoate (E216)
polysorbate 80
disodium edetate
citric acid, anhydrous
butylhydroxytoluene (E321)
trometamol
6.2 Incompatibilities
Not applicable
6.3 Shelf life
18 months
After first opening: 3 months
6.4 Special precautions for storage
Do not store above 25C. Do not freeze.
Keep the tube tightly closed.
Nature and contents of container
The pack sizes are 30g and 60g.
Both packs comprise of an aluminium tube with an epoxyphenolic internal lacquer, fitted with a polyethylene cap.
Not all pack sizes may be marketed.
6.6 Special precautions for disposal and other handling
Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
7. MARKETING AUTHORISATION HOLDER
<[To be completed nationally]>
{Name and address}
<{tel}>
<{fax}>
<{e-mail}>
8. MARKETING AUTHORISATION NUMBER(S)
<[To be completed nationally]>
9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION
Date of first authorisation: 28 February 2013
<[To be completed nationally]>
10. DATE OF REVISION OF THE TEXT
2016-08-05
12