Lansoprazol Pensa
SUMMARY OF PRODUCT CHARACTERISTICS
1. NAME OF THE MEDICINAL PRODUCT
Lansoprazol Pensa 15 mg gastro-resistant capsules, hard
Lansoprazol Pensa 30 mg gastro-resistant capsules, hard
2. QUALITATIVE AND QUANTITATIVE COMPOSITION
15 mg:One capsule contains lansoprazole 15 mg
30 mg:One capsule contains lansoprazole 30 mg
Excipient with known effect:
15 mg:One capsule contains 103 mg sucrose
30 mg:One capsule contains 206 mg sucrose.
For the full list of excipients, see section 6.1.
3. PHARMACEUTICAL form
15 mg:Opaque, hard, white capsule.
Each capsule has the print ”LAN 15” and contains white to beige granules with gastro-resistant coating
30 mg:Opaque, hard, white capsule.
Each capsule has the print ”LAN 30” and contains white to beige granules with gastro-resistant coating
4. Clinical particulars
4.1 Therapeutic indications
• Treatment of duodenal and gastric ulcer
• Treatment of refluxoesophagitis
• Prophylaxis of reflux oesophagitis
• Treatment of NSAID-associated benign gastric and duodenal ulcers in patients requiring continued NSAID treatment
• Prophylaxis of NSAID-associated gastric ulcers and duodenal ulcers in patients at risk (see section 4.2) requiring continued therapy
• Symptomaticgastroesophagealreflux disease
• Zollinger-Ellison syndrome
Posology and method of administration
Posology
For optimal effect lansoprazole should be taken once daily in the morning.
Treatment of duodenal ulcer:
The recommended dose is 30mg once daily for 2 weeks. In patients not fully healed within this time, the medication is continued at the same dose for another two weeks.
Treatment of gastric ulcer:
The recommended dose is 30mg once daily for 4 weeks. The ulcer usually heals within 4 weeks, but in patients not fully healed within this time, the medication may be continued at the same dose for another 4 weeks.
Reflux oesophagitis:
The recommended dose is 30mg once daily for 4 weeks. In patients not fully healed within this time, the treatment may be continued at the same dose for another 4 weeks.
Prophylaxis of reflux oesophagitis:
15mg once daily. The dose may be increased up to 30mg daily as necessary.
Treatment of NSAID associated gastric and duodenal ulcers in patients requiring continued NSAID treatment:
30mg once daily for four weeks. In patients not fully healed the treatment may be continued for another four weeks. For patients at risk or with ulcers that are difficult to heal, a longer course of treatment and/or a higher dose should probably be used.
Prophylaxis of NSAID associated gastric and duodenal ulcers in patients at risk (such as age 65 or history of gastric or duodenal ulcer) requiring prolonged NSAID treatment:
15mg once daily. If the treatment fails the dose 30mg once daily should be used.
Symptomatic gastro-oesophageal reflux disease:
The recommended dose is 15mg or 30mg daily. Relief of symptoms is obtained rapidly. Individual adjustment of dosage should be considered. If the symptoms are not relieved within 4 weeks with a daily dose of 30mg, further examinations are recommended.
Zollinger-Ellison syndrome:
The recommended initial dose is 60mg once daily. The dose should be individually adjusted and the treatment should be continued for as long as necessary. Daily doses of up to 180mg have been used. If the required daily dose exceeds 120mg, it should be given in two divided doses.
Impaired hepatic or renal function:
There is no need for a dose adjustment in patients with impaired renal function. Patients with moderate or severe liver disease should be kept under regular supervision and a 50% reduction of the daily dose is recommended (see section 4.4 and 5.2).
Elderly:
Due to reduced clearance of lansoprazole in the elderly an adjustment of dose may be necessary based on individual requirements. A daily dose of 30mg should not be exceeded in the elderly unless there are compelling clinical indications.
Paediatric population:
The use of lansoprazole is not recommended in children as clinical data are limited (see also section 5.2). Treatment of small children below one year of age should be avoided as available data have not shown beneficial effects in the treatment of gastro-oesophageal reflux disease.
Method of administration
Lansoprazole Pensa should be taken at least 30 minutes before food (see section 5.2). Capsules should be swallowed whole with liquid.
Patients that have problems with swallowing can open the capsule and remove the granules before administration, and swallow these with water. Please note that the granules must be swallowed whole and may not be crushed or chewed, and should not be mixed with water before administration.
4.3 Contraindications
Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.
Lansoprazole should not be administered with atazanavir (see section 4.5)
4.4 Special warnings and precautions for use
In common with other anti-ulcer therapies, the possibility of malignant gastrictumour should be excluded when treating a gastric ulcer with lansoprazole because lansoprazole can mask the symptoms and delay the diagnosis.
Lansoprazole should be used with caution in patients with moderate and severe hepatic dysfunction (see sections 4.2 and 5.2).
Decreased gastric acidity due to lansoprazole might be expected to increase gastric counts of bacteria normally present in the gastrointestinal tract. Treatment with lansoprazole may lead to a slightly increased risk of gastrointestinal infections such as Salmonella and Campylobacter.
Hypomagnesaemia
Severe hypomagnesaemia has been reported in patients treated with PPIs like lansoprazole for at least three months, and in most cases for a year. Serious manifestations of hypomagnesaemia such as fatigue, tetany, delirium, convulsions, dizziness and ventricular arrhythmia can occur but they may begin insidiously and be overlooked. In most affected patients, hypomagnesaemia improved after magnesium replacement and discontinuation of the PPI.
For patients expected to be on prolonged treatment or who take PPIs with digoxin or drugs that may cause hypomagnesaemia (e.g., diuretics), health care professionals should consider measuring magnesium levels before starting PPI treatment and periodically during treatment.
Subacute cutaneous lupus erythematosus (SCLE)
Proton pump inhibitors are associated with very infrequent cases of SCLE. If lesions occur, especially in sun-exposed areas of the skin, and if accompanied by arthralgia, the patient should seek medical help promptly and the health care professional should consider stopping Lansoprazol Pensa. SCLE after previous treatment with a proton pump inhibitor may increase the risk of SCLE with other proton pump inhibitors.
In patients suffering from gastro-duodenal ulcers, the possibility of H.pylori infection as an etiological factor should be considered.
Because of limited safety data for patients on maintenance treatment for longer than 1 year, regular review of the treatment and a thorough risk/benefit assessment should be regularly performed in these patients.
Proton pump inhibitors, especially if used in high doses and over long durations (>1 year), may modestly increase the risk of hip, wrist and spine fracture, predominantly in the elderly or in presence of other recognised risk factors. Observational studies suggest that proton pump inhibitors may increase the overall risk of fracture by 10–40%. Some of this increase may be due to other risk factors. Patients at risk of osteoporosis should receive care according to current clinical guidelines and they should have an adequate intake of vitamin D and calcium.
Very rarely cases of colitis have been reported in patients taking lansoprazole. Therefore, in the case of severe and/or persistent diarrhea, discontinuation of therapy should be considered.
The treatment for the prevention of peptic ulceration of patients in need of continuous NSAID treatment should be restricted to high risk patients (e.g. previous gastrointestinal bleeding, perforation or ulcer, advanced age, concomitant use of medication known to increase the likelihood of upper GI adverse events [e.g. corticosteroids or anticoagulants], the presence of a serious co-morbidity factor or the prolonged use of NSAID maximum recommended doses).
Lansoprazol Pensa contains sucrose. Patients with rare hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucrase-isomaltase insufficiency should not take this medicine.
4.5 Interaction with other medicinal products and other forms of interaction
Effects of lansoprazole on other drugs
Medicinal products with pH dependent absorption
Lansoprazole may interfere with the absorption of drugs where gastric pH is critical to bioavailability.
Atazanavir:
A study has shown that co-administration of lansoprazole (60mg once daily) with atazanavir 400mg to healthy volunteers resulted in a substantial reduction in atazanavir exposure (approximately 90% decrease in AUC and Cmax). Lansoprazole should not be co-administered with atazanavir (see section 4.3).
Ketoconazole and itraconazole:
The absorption of ketoconazole and itraconazole from the gastrointestinal tract is enhanced by the presence of gastric acid. Administration of lansoprazole may result in sub-therapeutic concentrations of ketoconazole and itraconazole and the combination should be avoided.
Digoxin:
Co-administration of lansoprazole and digoxin may lead to increased digoxin plasma levels. The plasma levels of digoxin should therefore be monitored and the dose of digoxin adjusted if necessary when initiating and ending lansoprazole treatment.
Medicinal products metabolised by P450 enzymes
Lansoprazole may increase plasma concentrations of drugs that are metabolised by CYP3A4. Caution is advised when combining lansoprazole with drugs which are metabolised by this enzyme and have a narrow therapeutic window.
Theophylline:
Lansoprazole reduces the plasma concentration of theophylline, which may decrease the expected clinical effect at the dose. Caution is advised when combining the two drugs.
Tacrolimus:
Co-administration of lansoprazole increases the plasma concentrations of tacrolimus (a CYP3A and P-gp substrate). Lansoprazole exposure increased the mean exposure of tacrolimus by up to 81%. Monitoring of tacrolimus plasma concentrations is advised when concomitant treatment with lanzoprazole is initiated or ended.
Medicinal products transported by P-glycoprotein
Lansoprazole has been observed to inhibit the transport protein, P-glycoprotein (P-gp) in vitro. The clinical relevance of this is unknown.
Effects of other drugs on lansoprazole
Drugs which inhibit CYP2C19
Fluvoxamine:
A dose reduction may be considered when combining lansoprazole with the CYP2C19 inhibitor fluvoxamine. A study shows that the plasma concentrations of lansoprazole increase up to 4-fold.
Drugs which induces CYP2C19 and CYP3A4
Enzyme inducers affecting CYP2C19 and CYP3A4 such as rifampicin, and St John´s wort (Hypericum perforatum) can markedly reduce the plasma concentrations of lansoprazole.
Others
Sucralfate/Antacids:
Sucralfate/Antacids may decrease the bioavailability of lansoprazole. Therefore lansoprazole should be taken at least 1 hour after taking these drugs.
No clinically significant interactions of lansoprazole with non-steroidal anti-inflammatory drugs have been demonstrated, although no formal interactions studies have been performed.
4.6 Fertility, pregnancy and lactation
Pregnancy:
For lansoprazole no clinical data on exposed pregnancies are available. Animal studies do not indicate direct or indirect harmful effects with respect to pregnancy, embryonal/foetal development, parturition or postnatal development.
Therefore, the use of lansoprazole during pregnancy is not recommended.
Breastfeeding:
It is not known whether lansoprazole is excreted in human breast milk. Animal studies have shown excretion of lansoprazole in milk.
A decision on whether to continue/discontinue breast-feeding or to continue/discontinue therapy with lansoprazole should be made taking into account the benefit of breastfeeding to the child and the benefit of lansoprazole therapy to the woman.
Effects on ability to drive and use machines
Adverse drug reactions such as dizziness, vertigo, visual disturbances and somnolence may occur (see section 4.8). Under these conditions the ability to react may be decreased.
4.8 Undesirable effects
Frequencies are defined as common (> 1/100, < 1/10); uncommon (> 1/1,000, < 1/100); rare (>1/10,000, <1/1,000); very rare (<1/10,000).
|
|
Common |
Uncommon |
Rare |
Very rare |
Not known |
|
Blood and lymphatic system disorders |
|
Thrombocytopenia, eosinophilia, leucopenia |
Anaemia |
Agranulocytosis, pancytopenia |
|
|
Immune system disorders |
|
|
|
Anaphylactic shock |
|
|
Metabolism and nutritional disorders |
|
|
|
|
hypomagnesaemia. [See Special warnings and precautions for use (4.4)] |
|
Psychiatric disorders |
|
Depression |
Insomnia, hallucination, confusion |
|
|
|
Nervous system disorders |
Headache, dizziness |
|
Restlessness, vertigo, paraesthesia, somnolence, tremor |
|
|
|
Eye disorders |
|
|
Visual disturbances |
|
|
|
Gastrointestinal disorders |
Nausea, diarrhea, stomach ache, constipation, vomiting, flatulence, dry mouth or throat |
|
Glossitis, candidiasis of the oeso-phagus, pancreatitis, taste disturb-ances |
Colitis, stomatitis |
|
|
Hepatobiliary disorders |
Increase in liver enzyme levels |
|
Hepatitis, jaundice |
|
|
|
Skin and subcutaneous tissue disorders |
Urticaria, itching, rash |
|
Petechiae, purpura, hair loss, erythema multiforme, photosensi-tivity |
Steven-Johnson syndrome, toxic epidermal necrolysis |
Subacute cutaneous lupus erythematosus (see section 4.4). |
|
Musculoskeletal and connective tissue disorders |
|
Arthralgia, myalgia, fracture of the hip, wrist or spine (see section 4.4) |
|
|
|
|
Renal and urinary disorders |
|
|
Interstitial nephritis |
|
|
|
Reproductive system and breast disorders |
|
|
Gynaecomastia |
|
|
|
General disorders and administration site conditions |
Fatigue |
Oedema |
Fever, hyperhid-rosis, an-gioedema, anorexia, impotence |
|
|
|
Investigations |
|
|
|
Increase in cholesterol and triglyceride levels, hyponatraemia |
|
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
The effects of overdose on lansoprazole in humans are not known (although the acute toxicity is likely to be low) and, consequently, instruction for treatment cannot be given. However, daily doses of up to 180mg of lansoprazole orally and up to 90mg of lansoprazole intravenously have been administered in trials without significant undesirable effects.
Please refer to section 4.8 for possible symptoms of lansoprazole overdose.
In the case of suspected overdose the patient should be monitored. Lansoprazole is not significantly eliminated by haemodialysis. If necessary, gastric emptying, charcoal and symptomatic therapy is recommended.
5. PHARMACOLOGICAL PROPERTIES
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Proton pump inhibitors, ATC code: A02BC03
Lansoprazole is a gastric proton pump inhibitor. It inhibits the final stage of gastric acid formation by inhibiting the activity of H+/K+ ATPase of the parietal cells in the stomach. The inhibition is dose-dependent and reversible, and the effect applies to both basal and stimulated secretion of gastric acid. Lansoprazole is concentrated in the parietal cells and becomes active in their acidic environment, whereupon it reacts with the sulphydryl group of H+/K+ATPase causing inhibition of the enzyme activity.
Effect on gastric acid secretion:
Lansoprazole is a specific inhibitor of the parietal cell proton pump. A single oral 30mg dose of lansoprazole inhibits pentagastrin-stimulated gastric acid secretion by about 80%. After repeated daily administration for seven days, about 90% inhibition of gastric acid secretion is achieved. It has a corresponding effect on the basal secretion of gastric acid. A single oral dose of 30mg reduces basal secretion by about 70%, and the patients' symptoms are consequently relieved starting from the very first dose. After eight days of repeated administration the reduction is about 85%. A rapid relief of symptoms is obtained by 30mg daily, and most patients with duodenal ulcer recover within 2 weeks, patients with gastric ulcer and reflux oesophagitis within 4 weeks.
5.2 Pharmacokinetic properties
Lansoprazole is a racemate of two active enantiomers that are biotransformed into the active form in the acidic environment of the parietal cells. As lansoprazole is rapidly inactivated by gastric acid, it is administered orally in enteric-coated form(s) for systemic absorption.
Absorption and distribution
Lansoprazole exhibits high (80-90%) bioavailability with a single dose. Peak plasma levels occur within 1.5 to 2.0 hours. Intake of food slows the absorption rate of lansoprazole and reduces the bioavailabilty by about 50%. The plasma protein binding is 97%.
Metabolism and elimination
Lansoprazole is extensively metabolised by the liver and the metabolites are excreted by both the renal and biliary route. The metabolism of lansoprazole is mainly catalysed by the enzyme CYP2C19. The enzyme CYP3A4 also contributes to the metabolism. The plasma elimination half-life ranges from 1 to 2 hours following single or multiple doses in healthy subjects. There is no evidence of accumulation following multiple doses in healthy subjects. Sulphone, sulphide and 5-hydroxyl derivatives of lansoprazole have been identified in plasma. These metabolites have very little or no antisecretory activity.
A study with 14C labelled lansoprazole indicated that approximately one-third of the administered radiation was excreted in the urine and two-thirds was recovered in the faeces.
Pharmacokinetics in elderly patients
The clearance of lansoprazole is decreased in the elderly, with elimination half-life increased approximately 50% to 100%. Peak plasma levels were not increased in the elderly.
Pharmacokinetics in paediatric patients
The evaluation of the pharmacokinetics in children aged 1 –17 years of age showed a similar exposure as compared to adults with doses of 15mg for those below 30kg of weight and 30mg for those above. The investigation of a dose of 17mg/m2body surface or 1mg/kg body weight also resulted in comparable exposure of lansoprazole in children aged 2-3 months up to one year of age compared to adults.
Higher exposure to lansoprazole in comparison to adults has been seen in infants below the age of 2-3 months with doses of both 1.0mg/kg and 0.5mg/kg body weight given as a single dose.
Pharmacokinetics in hepatic insufficiency
The exposure of lansoprazole is doubled in patients with mild hepatic impairment and much more increased in patients with moderate and severe hepatic impairment.
CYP2C19 poor metabolisers
CYP2C19 is subject to genetic polymorphism and 2-6 % of the population, called poor metabolisers (PMs), are homozygote for a mutant CYP2C19 allele and therefore lacks a functional CYP2C19 enzyme. The exposure of lansoprazole is several-fold higher in PMs than in extensive metabolisers.
5.3 Preclinical safety data
Non-clinical data reveal no special hazards for humans based on conventional studies of safety pharmacology, repeated dose toxicity, toxicity to reproduction or genotoxicity.
In two rat carcinogenicity studies, lansoprazole produced dose-related gastric ECL cell hyperplasia and ECL cell carcinoids associated with hypergastrinaemia due to inhibition of acid secretion. Intestinal metaplasia was also observed, as were Leydig cell hyperplasia and benign Leydig cell tumours. After 18 months of treatment retinal atrophy was observed. This was not seen in monkeys, dogs or mice.
In mouse carcinogenicity studies dose-related gastric ECL cell hyperplasia developed as well as liver tumours and adenoma of rete testis.
The clinical relevance of these findings is unknown.
6. PHARMACEUTICAL PARTICULARS
6.1 List of excipients
Capsule contents:
Hypromellose (E-464),
Talc
Titanium dioxide (E-171),
Metacrylic acid-ethyl acrylate copolymer (1:1)
Triethylcitrate
Sugar spheres (sucrose and maize starch).
Capsule Shells:
Titanium dioxide (E-171)
Gelatine
Purified water
Printing ink:
Shellac
Black iron oxide (E-172).
6.2 Incompatibilities
Not applicable.
6.3 Shelf life
Blister and plastic jar: 2 years
6.4 Special precautions for storage
Blister:
Do not store above 25C.
Plastic jar:
Do not store above 30C.Keep the container tightly closed, in order to protect from moisture.
6.5 Nature and contents of container
The gastro-resistant capsules are available in aluminium/aluminium-blister or in a HDPE container and screw cap containing a desiccant capsule (LDPE and HDPE with silicon dioxide as the dessicant).
Blister: 7, 14, 28, 42 and 56 gastro-resistant capsules
Plastic jar: 7, 14, 28, 56 (2x 28) and 100 (2x 50) gastro-resistant capsules
Not all pack sizes may be marketed.
6.6 Special precautions for disposal
No special requirements.
7. MARKETING AUTHORISATION HOLDER
Pensa Pharma AB
Birger Jarlsgatan 22
114 34 Stockholm
Sweden
8. MARKETING AUTHORISATION NUMBER(S)
<to be completed nationally>
9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION
2010-02-19
10. DATE OF REVISION OF THE TEXT
2016-02-25