Naramig
SUMMARY OF PRODUCT CHARACTERISTICS
1. NAME OF THE MEDICINAL PRODUCT
Naramig, 2.5 mg, film-coated tablets.
2. QUALITATIVE AND QUANTITATIVE COMPOSITION
Tablets containing 2.5 mg of naratriptan (as naratriptan hydrochloride).
Excipient with known effect:
94.07 mg anhydrous lactose/film-coated tablet.
For the full list of excipients, see section 6.1.
3. PHARMACEUTICAL form
Film-coated tablet.
Green, film-coated, D-shaped, biconvex tablets engraved GX CE5 on one face.
4. Clinical particulars
4.1 Therapeutic indications
Acute treatment of the headache phase of migraine attacks with or without aura.
4.2 Posology and method of administration
Naramig Tablets should be taken as early as possible after the onset of a migraine headache but they are effective if taken at a later stage.
Naramig Tablets should not be used prophylactically.
Posology
Adults (18–65 years of age) The recommended dose of Naramig Tablets is a single 2.5 mg tablet.
If symptoms of migraine should recur, following an initial response, a second dose may be taken provided that there is a minimum interval of four hours between the two doses. The total dose should not exceed two 2.5 mg tablets in any 24-hour period.
If a patient does not respond to the first dose of Naramig Tablets a second dose should not be taken for the same attack as no benefit has been shown. Naramig Tablets may be used for subsequent migraine attacks.
Adolescents (12–17 years of age) In a clinical trial in adolescents, a very high placebo response was observed. The efficacy of naratriptan in this population has not been demonstrated and its use cannot be recommended.
Children (under 12 years of age) Naramig tablets are not recommended for use in children below 12 years due to a lack of data on safety and efficacy.
Elderly (over 65 years of age) The safety and effectiveness of naratriptan in individuals over age 65 have not been evaluated and therefore, its use in this age group cannot be recommended.
Renal Impairment The maximum total daily dose in patients with mild or moderate renal impairment is a single 2.5 mg tablet. The use of naratriptan is contraindicated in patients with severe renal impairment (see section 5.2).
Hepatic Impairment The maximum total daily dose in patients with mild or moderate hepatic impairment is a single 2.5 mg tablet. The use of naratriptan is contraindicated in patients with severe hepatic impairment (see section 5.2).
Method of administration
Naramig Tablets should be swallowed whole with water.
4.3 Contraindications
Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.
Previous myocardial infarction, ischaemic heart disease, Prinzmetal's angina/coronary vasospasm, peripheral vascular disease, patients who have symptoms or signs consistent with ischaemic heart disease.
History of cerebrovascular accident (CVA) or transient ischaemic attack (TIA).
Moderate or severe hypertension, mild uncontrolled hypertension.
Severely impaired renal (creatinine clearance <15 ml/min) or hepatic function (Child-Pugh grade C).
Concomitant administration of ergotamine, derivatives of ergotamine (including methysergide) and any triptan/5-hydroxytryptamine1 (5-HT1) receptor agonist with naratriptan.
4.4 Special warnings and precautions for use
Naratriptan should only be used where there is a clear diagnosis of migraine.
Naratriptan is not indicated for use in the management of hemiplegic, basilar or ophthalmoplegic migraine.
As with other acute migraine therapies, before treating headaches in patients not previously diagnosed as migraineurs, and in migraineurs who present with atypical symptoms, care should be taken to exclude other potentially serious neurological conditions. It should be noted that migraineurs may be at risk of certain cerebrovascular events (e.g. CVA or TIA).
The safety and efficacy of naratriptan when administered during the aura phase, prior to the onset of migraine headache, has yet to be established.
As with other 5-HT1 receptor agonists, naratriptan should not be given to patients with risk factors for ischaemic heart disease, including those patients who are heavy smokers or users of nicotine substitution therapy without prior cardiovascular evaluation (see section 4.3). Special consideration should be given to postmenopausal women and males over 40 with these risk factors.These evaluations however, may not identify every patient who has cardiac disease and, in very rare cases, serious cardiac events have occurred in patients without underlying cardiovascular disease when 5-HT1agonists have been administered.
Following administration, naratriptan can be associated with transient symptoms including chest pain and tightness which may be intense and involve the throat (see section 4.8). Where such symptoms are thought to indicate ischaemic heart disease, no further doses of naratriptan should be taken and appropriate evaluation should be carried out (see section 4.8).
Naratriptan contains a sulphonamide component therefore there is a theoretical risk of a hypersensitivity reaction in patients with known hypersensitivity to sulphonamides.
The recommended dose of naratriptan should not be exceeded.
Serotonin syndrome (including altered mental status, autonomic instability and neuromuscular abnormalities) has been reported following concomitant treatment with triptans and selective serotonin reuptake inhibitors (SSRIs) or serotonin noradrenaline reuptake inhibitors (SNRIs). If concomitant treatment with naratriptan and an SSRI or SNRI is clinically warranted, appropriate observation of the patient is advised, particularly during treatment initiation, with dose increases, or with addition of another serotonergic medication(see section 4.5).
Undesirable effects may be more common during concomitant use of triptans and herbal preparations containing St John’s Wort (Hypericum perforatum
Prolonged use of any type of painkiller for headaches can make them worse. If this situation is experienced or suspected, medical advice should be obtained and treatment should be discontinued. The diagnosis of medication overuse headache (MOH) should be suspected in patients who have frequent or daily headaches despite (or because of) the regular use of headache medications.
This medicinal product contains anhydrous lactose. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.
4.5 Interaction with other medicinal products and other forms of interaction
Clinical studies did not reveal any interaction with alcohol or food.
Naratriptan did not inhibit monoamine oxidase enzymes in vitro. Therefore in vivo interaction studies with monoamine oxidase inhibitors were not performed.
From in vitro studies it has been concluded that a wide range of cytochrome P450 isoenzymes are involved in the limited metabolism of naratriptan. Therefore, significant metabolic drug interactions involving specific cytochrome P450 enzymes are unlikely (see section 5.2).
In clinical studies no evidence of interaction was found with blockers, tricyclic antidepressants or selective serotonin reuptake inhibitors.
Oral contraceptives decrease the total clearance of naratriptan by 30%, and smoking increases total clearance by 30%. But no dosing adjustments are required.
Since 60% of naratriptan is excreted renally with active renal secretion representing approximately 30% of total clearance, interactions might be possible with other drugs that are also renally secreted. However due to the safety profile of naratriptan, inhibition of naratriptan secretion is probably of minor importance, while the possibility of naratriptan to inhibit other drugs actively secreted should be considered.
There are limited data on interactions with ergotamine, ergotamine containing preparations, dihydroergotamine (DHE), or sumatriptan. The increased risk of coronary vasospasm is a theoretical possibility with co-administration of these and 5-HT1 receptor agonists (see section 4.3).
At least 24 hours should elapse after the administration of naratriptan before an ergotamine-containing preparation or any triptan/5-HT1 receptor agonist is given. Conversely, at least 24 hours should elapse after the administration of an ergotamine-containing preparation before naratriptan is given.
There have been reports describing patients with symptoms compatible with serotonin syndrome (including altered mental status, autonomic instability and neuromuscular abnormalities) following the use of selective serotonin reuptake inhibitors (SSRIs) or serotonin noradrenaline reuptake inhibitors (SNRIs)and triptans (see section 4.4).
4.6 Fertility, pregnancy and lactation
Pregnancy
Evaluation of experimental animal studies does not indicate direct teratogenic effects. However delays in foetal ossification and possible effects on embryo viability have been observed in the rabbit.
Post-marketing data from prospective pregnancy registries have documented the pregnancy outcomes in less than 60women exposed to naratriptan. Due to a small sample size no definitive conclusion can be drawn regarding the risk of birth defects following exposure to naratriptan.
Administration of naratriptan should only be considered if the expected benefit to the mother is greater than any possible risk to the foetus.
Breast-feeding
Naratriptan and/or drug related metabolites are excreted into the milk of lactating rats. Transient effects in the pre and post-natal development of neonatal rats were observed only at maternal exposures sufficiently in excess of maximum human exposure. No studies have been conducted to determine the level of transference of naratriptan into breast milk of nursing women. It is recommended that infant exposure be minimised by avoiding breast-feeding for 24 hours after treatment.
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.
Drowsiness may occur as a result of migraine or its treatment with naratriptan. Caution is recommended when skilled tasks are to be performed e.g. driving or operating machinery.
Undesirable effects
Some of the symptoms reported as adverse events may be part of the migraine attack.
Undesirable effects are ranked under headings of frequency using the following convention: common (>1/100, <1/10); uncommon (>1/1,000, <1/100); rare (>1/10,000, <1/1,000); very rare (<1/10,000).
|
Immune system disorders |
|
|
Rare |
Anaphylaxis |
|
Nervous system disorders |
|
|
Common |
Sensations of tingling, dizziness, drowsiness |
|
Rare |
Somnolence |
|
Eye disorders |
|
|
Uncommon |
Visual disturbance |
|
Cardiac disorders |
|
|
Uncommon |
Bradycardia, tachycardia, palpitations |
|
Very rare |
Coronary artery vasospasm, angina, myocardial infarction |
|
Vascular disorders |
|
|
Very rare |
Peripheral vascular ischaemia |
|
Gastrointestinal disorders |
|
|
Common |
Nausea, vomiting |
|
Rare |
Ischaemic colitis |
|
Skin and subcutaneous tissue disorders |
|
|
Rare |
Rash, urticaria, pruritis, facial oedema |
|
General disorders and administration site disorders |
|
|
Common |
Sensations of heat, malaise/fatigue |
|
Uncommon |
Pain, sensations of heaviness, pressure or tightness These symptoms are usually transient, may be intense and can affect any part of the body, including the chest and throat |
|
Investigations |
|
|
Uncommon |
Increase in blood pressure of
approximately |
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 [To be completed nationally]
4.9 Overdose
Administration of a high dose of 25 mg naratriptan in one healthy male subject increased blood pressure by up to 71 mmHg and resulted in adverse events including light-headedness, tension in the neck, tiredness and a loss of co-ordination. Blood pressure returned to baseline by 8 hours after dosing without other pharmacological intervention.
It is unknown what effect haemodialysis or peritoneal dialysis has on the plasma concentrations of naratriptan.
Treatment If overdosage with naratriptan occurs, the patient should be monitored for at least 24 hours and standard supportive treatment applied as required.
5. PHARMACOLOGICAL PROPERTIES
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Selective 5-HT1 receptor agonists, ATC code: N02CC02.
Mechanism of action
Naratriptan has been shown to be
a selective agonist for 5 hydroxytryptamine1
(5-HT1) receptors mediating vascular contraction.
Naratriptan has high affinity for human cloned 5-HT1B
and 5-HT1D receptors, the human 5-HT1B
receptor is thought to correspond to the vascular 5-HT1
receptor mediating contraction of intracranial blood vessels.
Naratriptan has little or no effect at other 5-HT receptor
(5-HT2, 5-HT3,
5-HT4 and 5-HT7) subtypes.
In animals, naratriptan constricts the carotid arterial circulation. In addition experimental studies in animals suggest that naratriptan inhibits trigeminal nerve activity. Both these actions may contribute to the anti-migraine action of naratriptan in humans.
Clinical efficacy
In clinical studies the onset of efficacy is from one hour and peak efficacy is reached in 4 hours. The initial efficacy of naratriptan 2.5 mg was slightly lower than sumatriptan 100 mg. However, the efficacy over 24 hours was similar for both drugs and the incidence of adverse events in the clinical studies was slightly lower after naratriptan 2.5 mg than after sumatriptan 100 mg. No studies have been performed comparing naratriptan 2.5 mg with sumatriptan 50 mg.
5.2 Pharmacokinetic properties
Absorption
Following oral administration, naratriptan is absorbed with maximum plasma concentrations observed at 2–3 hours. After administration of a 2.5 mg naratriptan tablet Cmax is approximately 8.3 ng/ml (95% Cl: 6.5 to 10.5 ng/ml) in women and 5.4 ng/ml (95% Cl: 4.7 to 6.1 ng/ml) in men.
The oral bioavailability is 74% in women and 63% in men with no differences in efficacy and tolerability in clinical use. Therefore a gender related dose adjustment is not required.
Distribution
Naratriptan is distributed in a volume of 170 litres. Plasma protein binding is low (29%).
Biotransformation
Mean clearance after intravenous administration was 470 ml/min in men and 380 ml/min in women. Renal clearance is similar in men and women at 220 ml/min and is higher than the glomerular filtration rate suggesting that naratriptan is actively secreted in the renal tubules. Naratriptan is predominantly excreted in the urine with 50% of the dose recovered as unchanged naratriptan and 30% recovered as inactive metabolites. In vitro naratriptan was metabolised by a wide range of cytochrome P450 isoenzymes. Consequently, significant metabolic drug interactions with naratriptan are not anticipated (see section 4.5).
Naratriptan does not inhibit cytochrome P450 enzymes. Whether naratriptan has any inducing potential on human isoenzymes is unknown, however it was not shown to produce significant changes in the expression of hepatic cytochrome P450 isoforms in rats.
Elimination
The mean elimination half-life (t1/2) is 6 hours.
Special Patient Populations
Elderly In healthy elderly subjects (n=12), clearance was decreased by 26% and AUC was increased by 30% when compared to healthy young subjects (n=12) in the same study (see section 4.2).
Gender The naratriptan AUC and Cmax were approximately 35% lower in males compared to females, possibly due to the concomitant use of oral contraceptives, however, with no differences in efficacy and tolerability in clinical use. Therefore, a gender-related dose adjustment is not required (see section 4.2).
Renal Impairment Renal excretion is the major route for the elimination of naratriptan. Accordingly exposure to naratriptan may be increased in patients with renal disease. In a study in male and female renally impaired patients (creatinine clearance 18 to 115 ml/min; n=15) matched for sex, age and weight with healthy subjects (n=8), renally impaired patients had an approximately 80% increase in t1/2 and an approximately 50% reduction in clearance (see section 4.2).
Hepatic Impairment The liver plays a lesser role in the clearance of orally administered naratriptan. In a study in male and female hepatically impaired patients (Child-Pugh grade A or B n=8) matched for sex, age and weight with healthy subjects who received oral naratriptan, hepatically impaired patients had an approximately 40% increase in t1/2 and an approximately 30% reduction in clearance (see section 4.2).
5.3 Preclinical safety data
Preclinical effects in single and repeat dose toxicity studies were observed only at exposures sufficiently in excess of maximum human exposure.
A standard battery of genotoxicity tests did not indicate any genotoxic potential of naratriptan.
No tumours relevant to clinical use were found in mouse and rat carcinogenicity studies.
6. PHARMACEUTICAL PARTICULARS
6.1 List of excipients
Tablet core:
Microcrystalline cellulose.
Anhydrous lactose.
Croscarmellose sodium.
Magnesium stearate.
Film-coat:
Hypromellose.
Titanium dioxide (E171).
Triacetin.
Iron oxide yellow (E172)
Indigo carmine aluminium lake (E132).
6.2 Incompatibilities
Not applicable.
6.3 Shelf life
3 years
6.4 Special precautions for storage
Do not store above 30C.
Nature and contents of container
Child-resistant aluminium foil blister pack faced with PVC and paper/aluminium/polybutyl methacrylate/PVC lidding.The blister packs contain 2, 3, 4, 6, 12, or 18 Naramig Tablets.
Not all pack sizes may be marketed.
6.6 Special precautions for disposal <and other handling>
No special requirements for disposal.
7. MARKETING AUTHORISATION HOLDER
[To be completed nationally]
8. MARKETING AUTHORISATION NUMBER(S)
[To be completed nationally]
9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION
Date of first authorisation: [To be completed nationally]
Date of last renewal: 10/03/2002
10. DATE OF REVISION OF THE TEXT
18 July 2016
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