TOVEDESO Prolonged-release tablet Ref.[7701] Active ingredients: Desfesoterodine

Tovedeso should be used with caution in patients with:

• Clinically significant bladder outflow obstruction at risk of urinary retention (e.g. clinically significant prostate enlargement due to benign prostatic hyperplasia, see section 4.3)
• Gastrointestinal obstructive disorders (e.g. pyloric stenosis)
• Gastro-oesophageal reflux and/or who are concurrently taking medicinal products (such as oral bisphosphonates) that can cause or exacerbate oesophagitis
• Decreased gastrointestinal motility
• Autonomic neuropathy
• Controlled narrow-angle glaucoma

Caution should be exercised when prescribing or uptitrating desfesoterodine to patients in whom an increased exposure (see section 5.1) is expected:

• Hepatic impairment (see sections 4.2, 4.3 and 5.2)
• Renal impairment (see sections 4.2, 4.3 and 5.2)
• Concomitant administration of potent or moderate CYP3A4 inhibitors (see sections 4.2 and 4.5)
• Concomitant administration of a potent CYP2D6 inhibitor (see sections 4.5 and 5.2).

Dose increases

In patients with a combination of these factors, additional exposure increases are expected. Dose dependent antimuscarinic adverse reactions are likely to occur. In populations where the dose may be increased to 7 mg once daily, the dose increase should be preceded by an evaluation of the individual response and tolerability.

Organic causes must be excluded before any treatment with antimuscarinics is considered. Safety and efficacy have not yet been established in patients with a neurogenic cause for detrusor overactivity.

Other causes of frequent urination (treatment of heart failure or renal disease) should be assessed before treatment with desfesoterodine. If urinary tract infection is present, an appropriate medical approach should be taken/antibacterial therapy should be started.

Angioedema

Angioedema has been reported with fesoterodine, prodrug of desfesoterodine, and has occurred after the first dose in some cases.

If angioedema occurs, desfesoterodine should be discontinued and appropriate therapy should be promptly provided.

Potent CYP3A4 inducers

The concomitant use of desfesoterodine with a potent CYP3A4 inducer (i.e. carbamazepine, rifampicin, phenobarbital, phenytoin, St John’s Wort) is not recommended (see section 4.5).

QT prolongation

Tovedeso should be used with caution in patients with risk for QTprolongation (e.g. hypokalaemia, bradycardia and concomitant administration of medicines known to prolong QT interval) and relevant pre-existing cardiac diseases (e.g. myocardial ischaemia, arrhythmia, congestive heart failure), (see section 4.8). This especially holds true when taking potent CYP3A4 inhibitors (see sections 4.2, 4.5 and 5.1).

Lactose

Tovedeso prolonged-release tablets contain lactose. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicinal product.

Pharmacological interactions

Caution should be exercised in coadministration of desfesoterodine with other antimuscarinics and medicinal products with anticholinergic properties (e.g. amantadine, tri-cyclic antidepressants, certain neuroleptics ) as this may lead to more pronounced therapeutic- and side-effects (e.g. constipation, dry mouth, drowsiness, urinary retention).

Desfesoterodine may reduce the effect of medicinal products that stimulate the motility of the gastro-intestinal tract, such as metoclopramide.

Pharmacokinetic interactions

In vitro data demonstrate that desfesoterodine does not inhibit CYP1A2, 2B6, 2C8, 2C9, 2C19, 2D6, 2E1, or 3A4, or induce CYP1A2, 2B6, 2C9, 2C19, or 3A4 at clinically relevant plasma concentrations. Thus desfesoterodine is unlikely to alter the clearance of medicinal products that are metabolised by these enzymes.

CYP3A4 inhibitors

Potent CYP3A4 inhibitors

Following inhibition of CYP3A4 by co-administration of ketoconazole 200 mg twice daily, C_max and AUC of desfesoterodine increased 2.0 and 2.3-fold in CYP2D6 extensive metabolisers and 2.1 and 2.5-fold in CYP2D6 poor metabolisers, respectively. Therefore, the maximum dose of desfesoterodine should be restricted to 3.5 mg when used concomitantly with potent CYP3A4 inhibitors (e.g. atazanavir, clarithromycin, indinavir, itraconazole, ketoconazole, nefazodone, nelfinavir, ritonavir (and all ritonavir boosted PIregimens), saquinavir and telithromycin (see sections 4.2 and 4.4)).

Moderate CYP3A4 inhibitors

Following blockade of CYP3A4 by coadministration of the moderate CYP3A4 inhibitor fluconazole 200 mg twice a day for 2 days, C_max and AUC of desfesoterodine increased approximately 19% and 27%, respectively. No dosing adjustments are recommended in the presence of moderate CYP3A4 inhibitors (e.g. erythromycin, fluconazole, diltiazem, verapamil and grapefruit juice).

Weak CYP3A4 inhibitors

The effect of weak CYP3A4 inhibitors (e.g. cimetidine), was not examined; it is not expected to be in excess of the effect of moderate inhibitor.

CYP3A4 inducers

Following induction of CYP3A4 by coadministration of rifampicin 600 mg once a day, C_max and AUC of desfesoterodine decreased by approximately 70% and 75%, respectively, after oral administration of the prodrug of desfesoterodinefesoterodine 8 mg.

Induction of CYP3A4 may lead to subtherapeutic plasma levels. Concomitant use with CYP3A4 inducers (e.g. carbamazepine, rifampicin, phenobarbital, phenytoin, St John’s Wort) is not recommended (see section 4.4).

CYP2D6 inhibitors

The interaction with CYP2D6 inhibitors was not tested clinically. Mean C_max and AUC of desfesoterodine are 1.7 and 2-fold higher, respectively, in CYP2D6 poor metabolisers as compared to extensive metabolisers. Coadministration of a potent CYP2D6 inhibitor may result in increased exposure and adverse events. A dose reduction to 3.5 mg may be needed (see section 4.4).

Oral contraceptives

Fesoterodine, prodrug of desfesoterodine, does not impair the suppression of ovulation by oral hormonal contraception. In the presence of fesoterodine, prodrug of desfesoterodine, there are no changes in the plasma concentrations of combined oral contraceptives containing ethinylestradiol and levonorgestrel.

Warfarin

A clinical study in healthy volunteers has shown that fesoterodine, prodrug of desfesoterodine, 8 mg once daily has no significant effect on the pharmacokinetics or the anticoagulant activity of a single dose of warfarin.

Paediatric population

Interaction studies have only been performed in adults.

Pregnancy

There are no adequate data from the use of fesoterodine, prodrug of desfesoterodine in pregnant women. Reproductive toxicity studies with fesoterodine in animals show minor embryotoxicity (see section 5.3). The potential risk for humans is unknown. Tovedeso is not recommended during pregnancy.

Breast-feeding

It is unknown whether fesoterodine or desfesoterodine is excreted into human milk; therefore, breast-feeding is not recommended during treatment with Tovedeso.

Fertility

No clinical trials have been conducted to assess the effect of fesoterodine on human fertility.

Fesoterodine fumarate had no effect on male or female fertility in mice or any effects on reproductive function, or early embryonic development of the foetus in mice at non-maternally toxic doses (for details see section 5.3). Women of child bearing potential should be made aware of the lack of human fertility data, and Tovedeso should only be given after consideration of individual risks and benefits.

Tovedeso has minor influence on the ability to drive and use machines. Caution should be exercised when driving or using machines due to possible occurrence of side effects such as blurred vision, dizziness, and somnolence (see section 4.8).

Summary of the safety profile

The safety of fesoterodine, prodrug of desfesoterodine, was evaluated in placebo-controlled clinical studies in a total of 2859 patients with overactive bladder, of which 780 received placebo.

Due to the pharmacological properties of fesoterodine, treatment may cause mild to moderate antimuscarinic effects like dry mouth, dry eye, dyspepsia and constipation. Urinary retention may occur uncommonly.

Dry mouth, the only very common adverse reactions, occurred with a frequency of 28.8% in the fesoterodine group compared to 8.5% in the placebo group. The majority of adverse reactions occurred during the first month of treatment with the exception of cases classified as urinary retention or post void residual urine greater than 200 ml, which could occur after long term treatment and was more common in male than female subjects.

Tabulated list of adverse reactions

The table below gives the frequency of treatment emergent adverse reactions from placebo-controlled clinical trials and from post-marketing experience with fesoterodine, prodrug of desfesoterodine. The adverse reactions are reported in this table with the following frequency convention: 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).

Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness.

Infections and infestations

Uncommon: Urinary tract infection

Psychiatric disorders

Common: Insomnia

Rare: Confusional state

Nervous system disorders

Common: Dizziness; Headache

Uncommon: Dysgeusia; Somnolence

Eye disorders

Common: Dry eye

Uncommon: Blurred vision

Ear and labyrinth disorders

Uncommon: Vertigo

Cardiac disorders

Uncommon: Tachycardia; Palpitations

Respiratory, thoracic and mediastinal disorders

Common: Dry throat

Uncommon: Pharyngolaryngeal pain; Cough; Nasal dryness

Gastrointestinal disorders

Very common: Dry mouth

Common: Abdominal pain; Diarrhoea; Dyspepsia; Constipation; Nausea

Uncommon: Abdominal discomfort; Flatulence, Gastroesophageal reflux

Hepatobiliary disorders

Uncommon: ALT increased; GGT increased

Skin and subcutaneous tissue disorders

Uncommon: Rash; Dry skin; Pruritus

Rare: Angioedema; Urticaria

Renal and urinary disorders

Common: Dysuria

Uncommon: Urinary retention (including feeling of residual urine; micturition disorder); Urinary hesitation

General disorders and administration site conditions

Uncommon: Fatigue

Description of selected adverse reactions

In clinical trials of fesoterodine, prodrug of desfesoterodine, cases of markedly elevated liver enzymes were reported with the occurrence frequency no different from the placebo group. The relation to desfesoterodine treatment is unclear.

Electrocardiograms were obtained from 782 patients treated with 4 mg, 785 treated with 8 mg, 222 treated with 12 mg fesoterodine, prodrug of desfesoterodine, and 780 with placebo. The heart rate corrected QT interval in fesoterodine treated patients did not differ from that seen in placebo treated patients. The incidence rates of QTc ≥500 ms post baseline or QTc increase of ≥60 ms is 1.9%, 1.3%, 1.4% and 1.5%, for fesoterodine 4 mg, 8 mg, 12 mg and placebo, respectively. The clinical relevance of these findings will depend on individual patient risk factors and susceptibilities present (see section 4.4).

Post-marketing cases of urinary retention requiring catheterisation have been described, generally within the first week of treatment with fesoterodine, prodrug of desfesoterodine. They have mainly involved elderly (≥ 65 years) male patients with a history consistent with benign prostatic hyperplasia (see section 4.4).

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 Yellow Card Scheme at: www.mhra.gov.uk/yellowcard.

Not applicable.