Document: Fluticasone Cipla pressurised inhalation, suspension ENG SmPC change

• Fluticason Cipla pressurised inhalation, suspension SmPC
• Fluticasone Cipla pressurised inhalation, suspension ENG SmPC

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SUMMARY OF PRODUCT CHARACTERISTICS

1. NAME OF THE MEDICINAL PRODUCT

[Nationally to be completed] 125 microgram per actuation pressurised inhalation, suspension

[Nationally to be completed] 250 microgram per actuation pressurised inhalation, suspension

2. QUALITATIVE AND QUANTITATIVE COMPOSITION

One metered dose (ex-valve) contains125 or 250 micrograms of fluticasone propionate respectively. This is equivalent to a delivered dose (ex-actuator) of 110 mcg or 220 mcg fluticasone propionate respectively.

For full list of excipients, see section 6.1.

3. PHARMACEUTICAL form

Pressurised inhalation, suspension

An inhaler comprising an aluminium alloy canister sealed with a metering valve, actuator and dust cap.

4. Clinical particulars

4.1 Therapeutic indications

Bronchial asthma

[Nationally to be completed] is indicated in adult and adolescent patients over 16 years of age.

4.2 Posology and method of administration

Posology:

[Nationally to be completed] is for oral inhalation use only.

Patients should be made aware of the prophylactic nature of therapy with [Nationally to be completed] and that it should be taken regularly even when they are asymptomatic.

If patients find that relief with short-acting bronchodilator treatment becomes less effective or they need more inhalations than usual, medical attention must be sought.

The dose may be adjusted until control is achieved or reduced to the minimum effective dose, according to the individual response.Where the control of symptoms is maintained with the lowest strength of [Nationally to be completed] (125 microgram/actuation), the next step could include a swap to a different inhaled fluticasone product available in a lower strength (50 micrograms/actuation). The onset of therapeutic effect is within 4 to 7 days.

Prescribers should be aware that fluticasone propionate is as effective as other inhaled steroids approximately at half the microgram daily dose. For example, a 100mcg of fluticasone propionate is approximately equivalent to 200mcg dose of beclometasone dipropionate (CFC containing) or budesonide.

Adult and adolescent patients over 16 years of age: 50 to 500 micrograms twice daily.

For patients with severe asthma and during asthma exacerbations, as an alternative to oral corticosteroid therapy, a temporary increase in dose may be needed (up to 2000 micrograms daily in adult patients). The treatment effect should be monitored and for maintenance therapy the lowest effective dose should be used.

[Nationally to be completed] may be used with a Volumatic spacer device by patients who find it difficult to synchronise inspiration with aerosol actuation.

Special patient groups:

There is no need to adjust the dose in elderly patients or in patients withrenal impairment. There is no experience in patients with hepatic impairment.

Method of Administration:

It is important to instruct the patient about correct inhalation technique (see package leaflet and instructions

for use).

Testing your inhaler

1 When using your inhaler for the first time, test it to ensure that it is working. Remove the mouthpiece cover by gently squeezing the sides with your thumb and forefinger and pull apart.

2 To make sure that it bworks, shake the inhaler well, point the mouthpiece away from you and press the canister to release a puff into the air. If you have not used the inhaler for a week or more, release two puffs of medicine into the air.

Using your inhaler

It is important to start to breathe as slowly as possible just before using your inhaler.

and free of objects (figure A).

the inhaler are evenly mixed (figure B).

comfortable (figure C). Do not breathe in again yet.

to release a puff of medicine. Do this while still breathing in steadily and deeply (figure D).

inhaler. Continue holding your breath for a few seconds, or as long as is comfortable (figure E).

Cleaning your Inhaler:

To prevent your inhaler blocking, it is important to clean it at least once a week.

To clean your inhaler:

• Remove the mouthpiece cover.

• Do not remove the metal canister from the plastic casing at any time.

• Wipe the inside and outside of the mouthpiece and the plastic casing with a dry cloth or tissue.

• Replace the mouthpiece cover.

Do not put the metal canister in water.

4.3 Contraindications

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

4.4 Special warnings and precautions for use

The management of asthma should follow a stepwise programme, and patient response should be monitored clinically and by lung function tests.

Before starting treatment, any bronchoconstriction should be treated, as otherwise the efficacy could be lesser than expected. Patients' inhaler technique should be checked regularly to make sure that inhaler actuation is synchronised with inspiration to ensure optimum delivery to the lungs. During inhalation, the patient should preferably sit or stand. The inhaler has been designed for use in a vertical position.

Fluticasone HFA Inhaler is not designed to relieve acute symptoms for which an inhaled short-acting bronchodilator is required. Patients should be advised to have such rescue medication available.

Increasing use of short-acting inhaled β₂-agonists to relieve symptoms indicates deterioration of asthma control. Under these conditions, the patient’s therapy plan should be reassessed.

Sudden and progressive deterioration in asthma control is potentially life-threatening and consideration should be given to increasing corticosteroid dosage. In patients considered at risk, daily peak flow monitoring may be instituted.

Lack of response or severe exacerbations of asthma should be treated by increasing the dose of inhaled fluticasone propionate and, if necessary, by giving a systemic steroid and/or an antibiotic if there is an infection.

Systemic effects of inhaled corticosteroids may occur, particularly at high doses prescribed for prolonged periods. These effects are much less likely to occur than with oral corticosteroids (see section 4.9). Possible systemic effects include Cushing's syndrome, Cushingoid features, adrenal suppression, growth retardation in children and adolescents, decrease in bone mineral density, cataract and glaucoma and more rarely, a range of psychological or behavioural effects including psychomotor hyperactivity, sleep disorders, anxiety, depression or aggression (particularly in children). It is important therefore that the dose of inhaled corticosteroid is reviewed regularly and reduced to the lowest dose at which effective control of asthma is maintained (see section 4.8).

Certain individuals can show greater susceptibility to the effects of inhaled corticosteroid than do most patients.

Prolonged treatment with high doses of inhaled corticosteroids may result in adrenal suppression and acute adrenal crisis. In very rare cases, adrenal suppression and acute adrenal crisis has occurred at doses of between 500 and 1000 micrograms of fluticasone propionate. Situations, which could potentially trigger acute adrenal crisis, include trauma, surgery, infection or any rapid reduction in dosage. Presenting symptoms are typically vague and may include anorexia, abdominal pain, weight loss, tiredness, headache, nausea, vomiting, decreased level of consciousness, hypoglycaemia, and seizures. The possibility of residual impaired adrenal response should always be considered in emergency (medical or surgical) and elective situations likely to produce stress, and appropriate corticosteroid treatment considered (see section 4.9).

As systemic absorption is largely through the lungs, the use of Volumatic spacer plus metered dose inhaler may increase drug delivery to the lungs. It should be noted that this could potentially lead to an increase in the risk of systemic adverse effects.

Treatment with Fluticasone HFA Inhaler should not be stopped abruptly due to the risk of exacerbations. Tapering of the dose should be done under medical supervision.

As with all inhaled corticosteroids, special care is necessary in patients with active or quiescent pulmonary tuberculosis.

There have been very rare reports of increases in blood glucose levels, (See 4.8 'Undesirable Effects'). This should be considered when prescribing to patients with a history of diabetes mellitus.

As with other inhalation therapy, paradoxical bronchospasm may occur with an immediate increase in wheezing after dosing. Fluticasone HFA Inhaler should be discontinued immediately, the patient assessed and alternative therapy instituted if necessary.

During post-marketing use, there have been reports of clinically significant drug interactions in patients receiving fluticasone propionate and ritonavir, resulting in systemic corticosteroid effects including Cushing’s syndrome and adrenal suppression. Therefore, concomitant use of fluticasone propionate and ritonavirshould be avoided, unless the potential benefit to the patient outweighs the risk of systemic corticosteroid side-effects. There is also an increased risk of systemic side effects when combining fluticasone propionate with other potent CYP3A inhibitors (see 4.5 Interaction with Other Medicinal Products and Other Forms of Interaction).

For the transfer of patients being treated with oral corticosteroids:

Adrenal function and adrenal reserve usually remain within the normal range on recommended doses of fluticasone propionate therapy.The benefits of inhaled fluticasone propionate should minimise the need for oral steroids. However, the possibility of adverse effects in patients, resulting from prior or intermittent administration of oral steroids,may persist for some time. The extent of adrenal impairment may require specialist advice before elective procedures. The possibility of residual impaired adrenal response should always be considered in emergency (medical or surgical) and elective situations likely to produce stress, and appropriate corticosteroid treatment considered (see 4.9 Overdose).

Because of the possibility of impaired adrenal response, patients transferring from oral steroid therapy to inhaled fluticasone propionate therapy should be treated with special care, and adrenocortical function regularly monitored.

Following introduction of inhaled fluticasone propionate, withdrawal of systemic therapy should be gradual and patients encouraged to carry a steroid warning card indicating the possible need for additional therapy in times of stress.

For patients dependent on oral corticosteroids, fluticasone propionate should be administered concomitantly with systemic steroid therapy for 10 days.Thereafter, gradual withdrawal of the systemic steroid is commenced at a rate of 2.5 mg of prednisolone (or equivalent) per month, to the lowest possible level.

Some patients feel unwell in a non-specific way during the withdrawal phase despite maintenance or even improvement of the respiratory function. They should be encouraged to persevere with inhaled fluticasone propionate and to continue withdrawal of systemic steroid, unless there are objective signs of adrenal insufficiency.

Replacement of systemic steroid treatment with inhaled therapy sometimes unmasks allergies such as allergic rhinitis or eczema previously controlled by the systemic drug. These allergies should be symptomatically treated with antihistamine and/or topical preparations, including topical steroids.

4.5 Interaction with other medicinal products and other forms of interaction

Under normal circumstances, low plasma concentrations of fluticasone propionate are achieved after inhaled dosing, due to extensive first pass metabolism and high systemic clearance mediated by cytochrome P450 3A4 in the gut and liver. Hence, clinically significant drug interactions mediated by fluticasone propionate are unlikely.

In an interaction study in healthy subjects with intranasal fluticasone propionate, ritonavir (a highly potent cytochrome P450 3A4 inhibitor) 100 mg b.i.d. increased the fluticasone propionate plasma concentrations several hundred fold, resulting in markedly reduced serum cortisol concentrations.Information about this interaction is lacking for inhaled fluticasone propionate, but a marked increase in fluticasone propionate plasma levels is expected. Cases of Cushing's syndrome and adrenal suppression have been reported. The combination should be avoided unless the benefit outweighs the increased risk of systemic glucocorticoid side-effects.

In a small study in healthy volunteers, the slightly less potent CYP3A inhibitor ketoconazole increased the exposure of fluticasone propionate after a single inhalation by 150%. This resulted in a greater reduction of plasma cortisol as compared with fluticasone propionate alone. Co-treatment with other potent CYP3A inhibitors, such as itraconazole, clarithromycin, telithromycin, atazanavir, indinavir, nelfinavir or saquinavir is also expected to increase the systemic fluticasone propionate exposure and the risk of systemic side-effects. Caution is recommended and long-term treatment with such drugs should, if possible, be avoided.

4.6 Fertility, pregnancy and lactation

Fertility:

There is no clinical data available on effect of fluticasone propionate on fertility. No novel effects on

fertility were identified in repeat dose toxicity tests, reproductive studies, or teratology studies. As a

precautionary measure, it is preferable to avoid the use of fluticasone propionate when pregnancy is

planned.

Pregnancy:

There is inadequate evidence of safety of fluticasone propionate in human pregnancy. Data on a limited number (200) of exposed pregnancies indicate no adverse effects of Fluticasone pressurised Inhaler on pregnancy or the health of the foetus/new born child. To date no other relevant epidemiological data are available (see 5.3 ‘preclinical safety data’). Because Fluticasone HFA Inhaler delivers fluticasone propionate directly to the lungs by the inhaled route it avoids the high level of exposure that occurs when corticosteroids are given by systemic routes. Administration of fluticasone propionate during pregnancy should only be considered if the expected benefit to the mother is greater than any possible risk to the fetus.

Breast-feeding:
The secretion of fluticasone propionate in human breast milk has not been investigated. Subcutaneous administration of fluticasone propionate to lactating laboratory rats produced measurable plasma levels and evidence of fluticasone propionate in the milk However, plasma levels in humans after inhalation at recommended doses are likely to be low. When fluticasone propionate is used in breast-feeding mothers the therapeutic benefits must be weighed against the potential hazards to mother and baby.

4.7 Effects on ability to drive and use machines

Fluticasone propionate is unlikely to produce an effect.

Adverse events are listed below by system organ class and frequency. Frequencies are defined as: very common ( 1/10), common ( 1/100 and <1/10), uncommon ( 1/1000 and <1/100), rare ( 1/10,000 and <1/1000), very rare (<1/10,000) including isolated reportsand not known (cannot be estimated from the available data). Very common, common and uncommon events were generally determined from clinical trial data. Rare and very rare events were generally determined from spontaneous data.

System Organ Class	Adverse Event	Frequency
Infections and infestations	Candidiasis of the mouth and throat	Very Common
Immune system disorders	Hypersensitivity reactions with the following manifestations:
	Cutaneous hypersensitivity reactions	Uncommon
	Angioedema (mainly facial and oropharyngeal oedema)	Very Rare
	Respiratory symptoms (dyspnoea and/or bronchospasm)	Very Rare
	Anaphylactic reactions	Very Rare
Endocrine disorders	Cushing's syndrome, Cushingoid features, adrenal suppression, growth retardation in children and adolescents, decreased bone mineral density, cataract, glaucoma	Very Rare
Metabolism and nutrition disorders	Hyperglycaemia (see 4.4 'Special Warnings and Precautions for Use')	Very Rare
Psychiatric disorders	Anxiety, sleep disorders, behavioural changes, including hyperactivity and irritability (predominantly in children)	Very Rare
	Depression, aggression (predominantly in children)	Not known
Respiratory, thoracic and mediastinal disorders	Hoarseness/dysphonia Epistaxis	Common Not known
Skin and subcutaneous tissue disorders	Contusions	Common

Hoarseness and candidiasis of the mouth and throat (thrush) occurs in some patients. Such patients may find it helpful to rinse out their mouth with water after using the inhaler. Symptomatic candidiasis can be treated with topical anti-fungal therapy whilst still continuing with Fluticasone HFA Inhaler.

Possible systemic effects include Cushing's syndrome, Cushingoid features, adrenal suppression, growth retardation, decreased bone mineral density, cataract, glaucoma (see 4.4 Special Warning and Special Precautions for Use).

As with other inhalation therapy, paradoxical bronchospasm may occur (see 4.4 '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

Acute:Inhalation of the drug in doses in excess of those approvedmay lead to temporary suppression of adrenal function. This does not necessitate emergency action being taken. In these patients treatment with fluticasone propionate by inhalation should be continued at a dose sufficient to control asthma adrenal function recovers in a few days and can be verified by measuring plasma cortisol.

Chronic: If higher than approved doses are continued over prolonged periods, significant adrenocortical suppression is possible. There have been very rare reports of acute adrenal crisis occurring in children exposed to higher than approved doses (typically 1000 micrograms daily and above), over prolonged periods (several months or years); observed features included hypoglycaemia and sequelae of decreased consciousness and/or convulsions. Situations which could potentially trigger acute adrenal crisis include exposure to trauma, surgery infection or any rapid reduction in dosage. Monitoring of adrenal reserve may be indicated. Treatment with inhaled fluticasone propionate should be continued at a dose sufficient to control asthma.

5. PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Fluticasone propionate is a glucocorticoid with anti-inflammatory effects. Fluticasone propionate given by inhalation at recommended doses has a potent glucocorticoid anti-inflammatory action within the lungs, resulting in a reduction of both symptoms and exacerbations of asthma, with a lower incidence and severity of adverse effects than those observed when corticosteroids are administered systemically. Treatment with fluticasone propionate is a prophylactic treatment. Full effect is achieved after 4-7 days of treatment. The majority of particles are less than 5 micrometers.

5.2 Pharmacokinetic properties

Absorption

In healthy subjects the mean systemic bioavailability of Fluticasone HFA Inhaler is 5-11% of the nominal dose, depending on the inhalation device used. In patients with asthma (FEV 1 < 75% predicted) the mean systemic absolute bioavailability is reduced as compared to healthy volunteers. Systemic absorption occurs mainly through the lungs and has been shown to be linearly related to dose over the dose range 500 to 2000 micrograms. Absorption is initially rapid then prolonged.

Absolute oral bioavailability is negligible (<1%) due to a combination of incomplete absorption from the GI tract and extensive first-pass metabolism.

Distribution

After an intravenous dose, fluticasone propionate is extensively distributed in the body. Plasma clearance is high (approximately 1150 ml/min) and volume of distribution at steady state is large (approximately 300 L). The binding of fluticasone to plasma proteins is 91%.

Biotransformation

Fluticasone is metabolized by the enzyme CYP3A4 to an inactive major carboxyacid metabolite.

Elimination

87-100% of an oral dose is excreted in the faeces, up to 75% as parent compound. Other metabolites with unknown structure have also been identified in faeces. The terminal half-life is about 8 hours.

5.3 Preclinical safety data

Administration of corticosteroids to pregnant animals can cause abnormalities of fetal development, including cleft palate and intra-uterine growth retardation. There may therefore be a very small risk of such effects in the human fetus. It should be noted, however, that the fetal changes in animals occur after relatively high systemic exposure.

Toxicology has shown only those class effects typical of potent corticosteroids, and these only at doses greatly in excess of that proposed for therapeutic use. No novel effects or effects on fertility were identified inrepeat dose toxicity tests, reproductive studies or teratology studies. Fluticasone propionate is devoid of mutagenic activity in vitro and in vivo and showed no tumorigenic potential in rodents. It is both non-irritant and non-sensitising in animal models.

The non-CFC propellant, HFA 134a, has been shown to have no toxic effect at very high vapour concentrations, far in excess of those likely to be experienced by patients, in a wide range of animal species exposed daily for periods of two years.

The use of HFA 134a as a propellant has not altered the toxicity profile of fluticasone propionate compared to that using the conventional CFC propellant.

6. PHARMACEUTICAL PARTICULARS

6.1 List of excipients

Norflurane (HFA 134a)

6.2 Incompatibilities

Not applicable

6.3 Shelf life

2 years

6.4 Special precautions for storage

The canister contains a pressurized liquid. Do not expose to temperatures higher than 50C. Do not pierce the canister. Do not refrigerate or freeze. Protect from frost and direct sunlight.

As with most medicines in pressurised canisters, the therapeutic effect of this medication may decrease when the canister is cold.

The canister should not be punctured, broken or burnt even when apparently empty.

Replace the mouthpiece cover firmly and snap into position.

An inhaler comprising an aluminium alloy canister sealed with a metering valve, actuator and dust cap. Each canister contains 120 metered actuations of either 125 or 250 micrograms of fluticasone propionate.

Pack sizes:

1 or 2 (bundled package 2x1) canisters containing 120 metered doses.

Not all pack sizes may be marketed.

6.6 Special precautions for disposal <and other handling>

The aerosol spray is inhaled through the mouth into the lungs. After shaking the inhaler the patient should exhale, the mouthpiece should be placed in the mouth and the lips closed around it. The actuator is depressed to release a spray, which must coincide with inspiration of breath.

For detailed instructions for use refer to the package leaflet in every pack.

7. MARKETING AUTHORISATION HOLDER

[To be completed nationally]

8. MARKETING AUTHORISATION NUMBER(S)

XXXXX/XXXX

9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

<[To be completed nationally]>

10. DATE OF REVISION OF THE TEXT11 November 2015