Cabergoline Teva
SUMMARY OF PRODUCT CHARACTERISTICS
1 NAME OF THE MEDICINAL PRODUCT
Cabergoline Teva 2mg tablets
2 QUALITATIVE AND QUANTITATIVE COMPOSITION
Each tablet contains 2 mg cabergoline.
Excipient(s) with known effect: lactose 150.6 mg
For the full list of excipients, see section 6.1.
3 PHARMACEUTICAL FORM
Tablet
The tablet can be divided into equal doses.
White, capsule-shaped, biconvex tablets with scores on both sides. One side is debossed with ‘CBG’ and ‘2’ on either side of the score.
4 CLINICAL PARTICULARS
4.1 Therapeutic indications
Treatment of Parkinson’s disease:
If treatment with a dopamine agonist is being considered, cabergoline is indicated as second line therapy in patients who are intolerant or fail treatment with a non-ergot compound, as monotherapy, or as adjunctive treatment to levodopa plus dopa-decarboxylase inhibitor, in the management of the signs and symptoms of Parkinson's disease.
Treatment should be initiated under specialist supervision. The benefit of continued treatment should be regularly reassessed, taking into account the risk of fibrotic reactions and valvulopathy (see sections 4.3, 4.4 and 4.8).
4.2 Posology and method of administration
Posology
Adults and elderly patients:
As expected for dopamine agonists, dose response for both efficacy and undesirable effects appears to be linked to individual sensitivity. Optimization of dose should be obtained through slow initial dose titration, from starting doses of 0.5mg cabergoline (de novo patients) and 1 mg cabergoline (patients on L dopa) daily. The dosage of concurrent levodopa may be gradually decreased, while the dosage of cabergoline is increased, until the optimum balance is determined. In view of the long half-life of the compound, increments of the daily dose of 0.5-1 mg cabergoline should be done at weekly (initial weeks) or bi-weekly intervals, up to optimal doses.
The recommended therapeutic dosage is 2 to 3 mg cabergoline /day as adjuvant therapy to levodopa/carbidopa. The maximum dose of 3 mg/day of cabergoline must not be exceeded.Cabergoline should be given as a single daily dose.
Paediatric population:
The safety and efficacy of cabergoline has not been investigated in children or adolescents as Parkinson’s disease does not affect this population.
Use in patients with hepatic or renal dysfunction
For patients with severe hepatic dysfunction or end stage renal failure see section 4.4.
Method of administration
Cabergoline is to be administered by the oral route. In order to reduce the risk of gastrointestinal undesirable effects it is recommended that cabergoline is taken with meals for all therapeutic indications.
4.3 Contraindications
Pre-eclampsia, eclampsia
Post-partum hypertension or uncontrolled hypertension.
Hypersensitivity to the active substance, any ergot alkaloid or to any excipient listed in section 6.1.
History of pulmonary, pericardial and retroperitoneal fibrotic disorders.
History of psychosis or risk of post-partum psychosis
For long term treatment: evidence of cardiac valvulopathy of any valve as determined by pre-treatment echocardiography(See section 4.4 Special warnings and precautions for use – Fibrosis and cardiac valvulopathy and possibly related clinical phenomena).
4.4 Special warnings and precautions for use
General
As with other ergot derivatives, cabergoline should be given with caution to subjects with severe cardiovascular disease, hypotension, Raynaud's syndrome, peptic ulcer or gastrointestinal bleeding, or with a history of serious, particularly psychotic, mental disorders.
The effects of alcohol on overall tolerability of cabergoline are currently unknown.
Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.
Hepatic insufficiency:
Lower doses of cabergoline should be considered in patients with severe hepatic insufficiency. Compared to normal volunteers and those with lesser degrees of hepatic insufficiency, an increase in AUC has been seen in patients with severe hepatic insufficiency (Child-Pugh Class C) who received a single 1 mg dose.
Postural hypotension:
Postural hypotension can occur following administration of cabergoline, particularly during the first days of administration of cabergoline. Care should be exercised when administering cabergoline concomitantly with other drugs known to lower blood pressure.
Fibrosis and cardiac valvulopathy and possibly related clinical phenomena:
Fibrotic and serosal inflammatory disorders such as pleuritis, pleural effusion, pleural fibrosis, pulmonary fibrosis, pericarditis, pericardial effusion, cardiac valvulopathy involving one or more valves (aortic, mitral and tricuspid) or retroperitoneal fibrosis have occurred after prolonged usage of ergot derivatives with agonist activity at the serotonin 5HT2B receptor, such as cabergoline. In some cases, symptoms or manifestations of cardiac valvulopathy improved after discontinuation of cabergoline.
Erythrocyte sedimentation rate (ESR) has been found to be abnormally increased in association with pleural effusion/fibrosis. Chest x-ray examination is recommended in cases of unexplained ESR increases to abnormal values. Serum creatine measurements can also be used to help in the diagnosis of fibrotic disorder. Following diagnosis of pleural effusion/pulmonary fibrosis or valvulopathy, the discontinuance of cabergoline has been reported to result in improvement of signs and symptoms. (See section 4.3 Contraindications).
Valvulopathy has been associated with cumulative doses, therefore, patients should be treated with the lowest effective dose. At each visit, the risk benefit profile of cabergoline treatment for the patient should be reassessed to determine the suitability of continued treatment with cabergoline.
Before initiating long term treatment:
All patients should undergo a cardiovascular evaluation, including echocardiogram, to assess the potential presence of asymptomatic valvular disease. It is also appropriate to perform baseline investigations of erythrocyte sedimentation rate or other inflammatory markers, lung function/chest x-ray and renal function prior to initiation of therapy. In patients with valvular regurgitation, it is not known whether cabergoline treatment might worsen the underlying disease. If fibrotic valvular disease is detected, the patient should not be treated with cabergoline. (See Section 4.3 Contraindications).
During long term treatment:
Fibrotic disorders can have an insidious onset and patients should be regularly monitored for possible manifestations of progressive fibrosis. Therefore during treatment, attention should be paid to the signs and symptoms of:
-
Pleuropulmonary disease, such as dyspnoea, shortness of breath, persistent cough, or chest pain.
-
Renal insufficiency or ureteral/abdominal vascular obstruction that may occur with pain in the loin/flank, and lower limb oedema, as well as any possible abdominal masses or tenderness that may indicate retroperitoneal fibrosis.
-
Cardiac failure cases of valvular and pericardial fibrosis have often manifested as cardiac failure. Therefore, valvular fibrosis (and constrictive pericarditis should be excluded if such symptoms occur.
Clinical diagnostic monitoring for development of fibrotic disease, as appropriate, is essential. Following treatment initiation, the first echocardiogram must occur within 3-6 months, thereafter, the frequency of echocardiographic monitoring should be determined by appropriate individual clinical assessment with particular emphasis on the above-mentioned signs and symptoms, but must occur at a least every 6 to 12 months.
Cabergoline should be discontinued if an echocardiogram reveals new or worsened valvular regurgitation, valvular restriction or valve leaflet thickening. (See Section 4.3 Contraindications)
The need for other clinical monitoring (e.g., physical examination including cardiac auscultation, X-ray, CT scan) should be determined on an individual basis.
Additional appropriate investigations such as erythrocyte sedimentation rate, and serum creatinine measurements should be performed if necessary to support a diagnosis of fibrotic disorder.
Hypotension:
Symptomatic hypotension can occur within 6 hours following administration of cabergoline: particular attention should be paid when administering cabergoline concomitantly with other medicical product known to lower blood pressure. Because of its elimination half-life hypotensive effects may persist for a few days after cessation of therapy. Monitoring of treatment with regular checks of blood pressure is recommended in the first 3-4 days after initiation of treatment.
Somnolence/sudden sleep onset:
Cabergoline has been associated with somnolence and episodes of sudden sleep onset in patients with Parkinson's disease. Sudden onset of sleep during activities, in some cases without awareness or warning signs, has been reported. A reduction of dosage or termination of therapy may be considered (See section 4.7 Effects on ability to drive and use machines).
Psychiatric:
Patients should be regularly monitored for the development of impulse control disorders. Patients and carers should be made aware that behavioural symptoms of impulse control disorders including pathological gambling, increased libido, hypersexuality, compulsive spending or buying, binge eating and compulsive eating can occur in patients treated with dopamine agonists including cabergoline. Dose reduction/tapered discontinuation should be considered if such symptoms develop.
Renal insufficiency:
No overall differences in the pharmacokinetics of cabergoline were observed in moderate to severe renal disease. The pharmacokinetics of cabergoline has not been studied in patients having end-stage renal failure, or in patients on haemodialysis; these patients should be treated with caution.
4.5 Interactions with other medicinal products and other forms of interactions
Concomitant use not recommended
No information is available about interaction between cabergoline and other ergot alkaloids; therefore, the concomitant use of these medications during long-term treatment with cabergoline is not recommended.
Since cabergoline exerts its therapeutic effect by direct stimulation of dopamine receptors, it should not be concurrently administered with drugs that have dopamine-antagonist activity (such as phenothiazines, butyrophenones, thioxanthenes, metoclopramide) since these might reduce the therapeutic effect of cabergoline.
As with other ergot derivatives, cabergoline should not be used in association with macrolide antibiotics (eg, erythromycin) due to increased systemic bioavailability.
Precautions
Interactions with other medicinal products that reduce blood pressure should be taken into consideration.
The concomitant use of antiparkinson non-dopamine agonists (eg, selegiline, amantadine, biperiden, trihexyphenidyl) was allowed in clinical studies for patients receiving cabergoline. In studies where the pharmacokinetic interactions of cabergoline with L-dopa or selegiline were evaluated, no interactions were observed. Pharmacokinetic interactions with other medicinal products cannot be predicted based on available information about the metabolism of cabergoline.
4.6 Fertility, pregnancy and lactation
Pregnancy
There are no adequate and well-controlled studies from the use of cabergoline in pregnant women. Animal studies have not demonstrated teratogenic effects, but reduced fertility and embryo-toxicity were observed in association with pharmacodynamic activity (see section 5.3).
Before cabergoline administration, pregnancy should be excluded and after treatment should be prevented for at least one month.
In a twelve year observational study on pregnancy outcomes following cabergoline therapy, information is available on 256 pregnancies. Seventeen of these 256 pregnancies (6.6%) eventuated in major congenital malformations or abortion. Information is available on 23/258 infants who had a total of 27 neonatal abnormalities, both major and minor. Musculoskeletal malformations were the most common neonatal abormality (10), followed by cardio-pulmonary abnormalities (5). There is no information on perinatal disorders or long-term development of infants exposed to intra-uterine cabergoline. Based on recent published literature, the prevalence of major congenital malformations in the general population has been reported to be 6.9% or greater. Rates of congenital abnormality vary between different populations. It is not possible to accurately determine if there is an increased risk as no control group was included.
It is recommended that contraception is used whilst on treatment with cabergoline.
Cabergoline should only be used during pregnancy if clearly indicated and after an accurate benefit/risk evaluation.
Due to the long half-life of the drug and limited data on in utero exposure, women planning to become pregnant should discontinue cabergoline one month before intended conception. If conception occurs during therapy, treatment should be discontinued as soon as pregnancy is confirmed to limit foetal exposure to the drug.
Contraception should be continued for at least 4 weeks after stopping cabergoline.
Breast-feeding
In rats, cabergoline and/or its metabolites are excreted in milk. No information is available on excretion in breast milk in humans; however, lactation is expected to be inhibited/suppressed by cabergoline, in view of its dopamine agonist properties. Mothers should be advised not to breast-feed while being treated with cabergoline.
Fertility
Cabergoline restores ovulation and fertility in women with hyperprolactinaemic hypogonadism: since pregnancy might occur prior to reinitiation of menses, pregnancy testing is recommended as appropriate during the amenorrhoeic period and, once menses are reinitiated, every time a menstrual period is delayed by more than three days. Women not seeking pregnancy should be advised to use effective non-hormonal contraception during treatment and after cabergoline withdrawal. Because of limited experience on the safety of foetal exposure to cabergoline, it is advisable that women seeking pregnancy conceive at least one month after cabergoline discontinuation given that ovulatory cycles persist in some patients for 6 months after withdrawal. Should pregnancy occur during treatment, cabergoline is to be discontinued. As a precautionary measure, women who become pregnant should be monitored to detect signs of pituitary enlargement since expansion of pre-existing pituitary tumours may occur during gestation.
4.7 Effects on ability to drive and use machines
Patients should be careful when performing actions which require fast and accurate reaction during treatment initiation.
Cabergoline reduces blood pressure, which may impair the reactions of certain patients. This should be taken into account in situations requiring intense awareness, such as when driving a car or operating machinery.
Patients treated with cabergoline and presenting with somnolence and/or sudden sleep episodes must be informed to refrain from driving or engaging in activities where impaired alertness may put themselves or others at risk of serious injury or death (eg, operating machines) until such episodes and somnolence have resolved (See section 4.4 Special warnings and precautions for use – Somnolence/sudden sleep onset).
4.8 Undesirable effects
About 1070 parkinsonian patients have received cabergoline as adjuvant therapy to L-dopa in clinical studies; of these 74% had at least one adverse event, mainly of mild to moderate severity and transient in nature, and requiring discontinuation in a small proportion of cases.
The following undesirable effects have been observed and reported during treatment with cabergoline with the following frequencies: 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).
|
MedDRA System Organ Class |
Frequency |
Undesirable Effects |
|
Cardiac disorders |
Very Common |
Valvulopathy (including regurgitation) and related disorders (pericarditis and pericardial effusion) |
|
Common* |
Angina pectoris |
|
|
Respiratory, thoracic and mediastinal disorders |
Common |
Dyspnoea |
|
Uncommon |
Pleural effusion, pulmonary fibrosis |
|
|
Very rare |
Fibrosis (including pleural fibrosis) |
|
|
Not Known |
Respiratory disorder, respiratory failure, pleuritis, chest pain |
|
|
Immune system disorders |
Uncommon |
Hypersensitivity reaction |
|
Nervous system disorders |
Common |
Headache, somnolence, dizziness/vertigo, dyskinesia |
|
Uncommon |
Hyperkinesia |
|
|
Not Known |
Sudden sleep onset, syncope, tremor |
|
|
Eye disorders |
Not Known |
Visual impairment |
|
Psychiatric disorders |
Common |
Hallucinations, sleep disturbances, increased libido, confusion |
|
Uncommon |
Delusions, psychotic disorder |
|
|
Not Known |
Aggression, hypersexuality, pathological gambling |
|
|
Vascular disorders |
Common |
Cabergoline generally exerts a hypotensive effect in patients on long-term treatment; postural hypotension |
|
Uncommon |
Erythromelalgia |
|
|
Not Known |
Digital vasospasm |
|
|
Gastrointestinal disorders |
Very common |
Nausea |
|
Common |
Constipation, dyspepsia, gastritis, vomiting |
|
|
General disorders and administration site conditions |
Very common |
Peripheral oedema |
|
Common |
Asthenia |
|
|
Uncommon |
Oedema, fatigue |
|
|
Hepato-biliary disorders |
Uncommon |
Hepatic function abnormal |
|
Skin and subcutaneous tissue disorders |
Uncommon |
Rash |
|
Not Known |
Alopecia |
|
|
Musculoskeletal and connective tissue disorders |
Not Known |
Leg cramps |
|
Investigations |
Common |
Liver function tests abnormal, decreased hemoglobin, hematocrit, and/or red blood cell (>15% vs baseline) |
|
Not Known |
Blood creatinine phosphokinase increased |
* When concomitant use with levodopa therapy
Impulse control disorders
Pathological gambling, increased libido, hypersexuality, compulsive spending or buying, binge eating and compulsive eating can occur in patients treated with dopamine agonists including cabergoline (see section „Special warnings and precautions for use“).
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
Symptoms of overdose would likely be those of over-stimulation of dopamine receptors, eg, nausea, vomiting, gastric complaints, postural hypotension, reduced blood pressure, confusion/psychosis or hallucinations.
Supportive measures should be taken to remove unabsorbed drug and maintain blood pressure, if necessary. In addition, the administration of dopamine antagonist drugs may be advisable.
5 PHARMACOLOGICAL PROPERTIES
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Dopamine agonist
ATC code: N04BC06
Cabergoline is a synthetic ergot alkaloid and an ergoline derivate with long-acting dopamine agonist and prolactin-inhibiting properties. A central dopaminergic effect via D2-receptor stimulation is achieved through higher doses than doses that reduce the levels of serum prolactin.
Controlled clinical studies have demonstrated that cabergoline is effective at an average dose of 4 mg/day following titration (up to 5-6 mg cabergoline/day in the different studies). Cabergoline reduces daily fluctuations in the motor function in patients with Parkinson’s disease that are being treated with levodopa/carbidopa. In newly diagnosed patients, cabergoline administered as monotherapy has been shown to produce somewhat less frequent clinical improvement compared with levodopa/carbidopa.
With regard to the endocrine effects of Cabergoline not related to the antiprolactinaemic effect, available data from humans confirm the experimental findings in animals indicating that the test compound is endowed with a very selective action with no effect on basal secretion of other pituitary hormones or cortisol.
The pharmacodynamic actions of cabergoline not correlated with the therapeutic effect only relate to blood pressure decrease. The maximal hypotensive effect of cabergoline as single dose usually occurs during the first 6 hours after active substance intake and is dose-dependent both in terms of maximal decrease and frequency.
5.2 Pharmacokinetic properties
Absorption
After oral administration cabergoline is rapidly absorbed from the gastrointestinal tract as the peak plasma concentration is received within 0.5 to 4 hours.
Food does not appear to affect absorption and disposition of cabergoline.
Distribution
“In-vitro” experiments showed that cabergoline at concentrations of 0.1 – 10 ng/ml is 41-42% bound to plasma proteins.
Biotransformation
In urine, the main metabolite identified is 6-allyl-8ß-carboxy-ergoline, which accounts for 4-6% of the dose. Three additional metabolites are identified in urine, which account overall for less than 3% of the dose. The metabolites have been found to be much less potent than cabergoline in inhibiting prolactin secretion “in-vitro”.
Elimination
The elimination half-life of cabergoline, is long; (63-68 hours in healthy volunteers and 79-115 hours in hyperprolactinaemic patients.
On the basis of the elimination half-life, steady state conditions should be achieved after 4 weeks, as confirmed by the mean peak plasma levels of cabergoline obtained after a single dose (37 ± 8 pg/ml) and after a 4 week multiple-regimen (101 ± 43 pg/ml) for 0.5 cabergoline dose.
Ten days after administration about 18% and 72% of the dose is recovered in urine and faeces, respectively. Unchanged cabergoline in urine accounts for 2-3% of the dose.
Linearity/Non-linearity
The pharmacokinetic profile is linear up to 7 mg per day.
5.3 Preclinical safety data
Almost all the findings noted throughout the series of preclinical safety studies are a consequence of the central dopaminergic effects or the long-lasting inhibition of PRL in species (rodents) with a specific hormonal physiology different to man.
Preclinical safety studies of cabergoline indicate a large safety margin for this compound in rodents and in monkeys, as well as a lack of teratogenic, mutagenic or carcinogenic potential.
6 PHARMACEUTICAL PARTICULARS
6.1 List of excipients
Anhydrous lactose
L-Leucin
Magnesium stearate (E572)
6.2 Incompatibilities
Not applicable.
6.3 Shelf life
2 years.
6.4 Special precautions for storage
Do not store above 30°C. Store in the original package in order to protect from moisture. The drying capsule or bag with silica gel must not be removed from the bottle.
6.5 Nature and contents of container
Brown glass bottles (type III) that contain a desiccation capsule or bag with silica gel. The brown glass bottle has an induction-sealed childproof aluminium membrane and a childproof HDPE or PP top. External box.
Packaging sizes: 2, 8, 14, 15, 16, 20, 28, 30, 32, 40, 48, 50, 60, 90, 96, 100.
Not all pack sizes may be marketed.
6.6 Special precautions for disposal
No special requirements for disposal.
7 MARKETING AUTHORISATION HOLDER
<To be completed nationally>
8 MARKETING AUTHORISATION NUMBER
<To be completed nationally>
9 DATE OF FIRST AUTHORISATION/RENEWAL OF AUTHORISATION
Date of first authorisation: 2004-05-07
Date of last renewal: 2009-05-07
10 DATE OF REVISION OF SUMMARY OF PRODUCT CHARACTERISTICS
2015-04-02
11