Summary of medicine characteristics - Controloc Control
1. NAME OF THE MEDICINAL PRODUCT
CONTROLOC Control 20 mg gastro-resistant tablets
2. QUALITATIVE AND QUANTITATIVE COMPOSITION
Each gastro-resistant tablet contains 20 mg pantoprazole (as sodium sesquihydrate).
For the full list of excipients, see section 6.1.
3. PHARMACEUTICAL FORM
Gastro-resistant tablet.
Yellow, oval, biconvex film-coated tablets imprinted with “P20” in brown ink on one side.
4. CLINICAL PARTICULARS4.1 Therapeutic indications
CONTROLOC Control is indicated for short-term treatment of reflux symptoms (e.g. heartburn, acid regurgitation) in adults.
4.2 Posology and method of administration
Posology
The recommended dose is 20 mg pantoprazole (one tablet) per day.
It might be necessary to take the tablets for 2–3 consecutive days to achieve improvement of symptoms. Once complete relief of symptoms has occurred, treatment should be discontinued.
The treatment should not exceed 4 weeks without consulting a doctor.
If no symptom relief is obtained within 2 weeks of continuous treatment, the patient should be instructed to consult a doctor.
Special populations
No dose adjustment is necessary in elderly patients or in those with impaired renal or liver function.
Paediatric population
CONTROLOC Control is not recommended for use in children and adolescents below 18 years of age due to insufficient data on safety and efficacy.
Method of administration
CONTROLOC Control 20 mg gastro-resistant tablets should not be chewed or crushed, and should be swallowed whole with liquid before a meal.
4.3 Contraindications
Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.
Co-administration of pantoprazole is not recommended with HIV protease inhibitors for which absorption is dependent on acidic intragastric pH such as atazanavir, nelfinavir; due to significant reduction in their bioavailability (see section 4.5).
4.4 Special warnings and precautions for use
Patients should be instructed to consult a doctor if:
- • They have unintentional weight loss, anaemia, gastrointestinal bleeding, dysphagia, persistent vomiting or vomiting with blood, since pantoprazole may alleviate symptoms and delay diagnosis of a severe condition. In these cases, malignancy should be excluded.
- • They have had previous gastric ulcer or gastrointestinal surgery.
- • They are on continuous symptomatic treatment of indigestion or heartburn for 4 or more weeks.
- • They have jaundice, hepatic impairment, or liver disease.
- • They have any other serious disease affecting general well-being.
- • They are aged over 55 years with new or recently changed symptoms.
4.5 Interaction with other medicinal products and other forms of interaction
Medicinal products with pH-dependent absorption pharmacokinetics
CONTROLOC Control may reduce the absorption of active substances whose bioavailability is dependent on the gastric pH (e.g. ketoconazole).
HIV protease inhibitors
Co-administration of pantoprazole is contraindicated with HIV protease inhibitors for which absorption is dependent on acidic intragastric pH such as atazanavir, nelfinavir; due to significant reduction in their bioavailability (see section 4.3).
Coumarin anticoagulants (phenprocoumon or warfarin)
Although no interaction during concomitant administration of phenprocoumon or warfarin has been observed in clinical pharmacokinetic studies, a few isolated cases of changes in International Normalised Ratio (INR) have been reported during concomitant treatment in the post-marketing period. Therefore, in patients treated with coumarin anticoagulants (e.g. phenprocoumon or warfarin), monitoring of prothrombin time/INR is recommended after initiation, termination or during irregular use of pantoprazole.
Methotrexate
Concomitant use of high-dose methotrexate (e.g. 300 mg) and proton pump inhibitors has been reported to increase methotrexate levels in some patients. Therefore in settings where high-dose methotrexate is used, for example cancer and psoriasis, a temporary withdrawal of pantoprazole may need to be considered.
Other interactions studies
Pantoprazole is metabolised in the liver via the cytochrome P450 enzyme system. Interaction studies with carbamazepine, caffeine, diazepam, diclofenac, digoxin, ethanol, glibenclamide, metoprolol, naproxen, nifedipine, phenytoin, piroxicam, theophylline and an oral contraceptive containing levonorgestrel and ethinyl oestradiol did not reveal clinically significant interactions. However, an interaction of pantoprazole with other substances which are metabolised by the same enzyme system cannot be excluded.
There were no interactions with concomitantly administered antacids.
4.6 Fertility, pregnancy and lactation
Pregnancy
There are no adequate data from the use of pantoprazole in pregnant women. Studies in animals have shown reproductive toxicity. Preclinical studies revealed no evidence of impaired fertility or teratogenic effects (see section 5.3). The potential risk for humans is unknown. Pantoprazole should not be used during pregnancy.
Breast-feeding
Pantoprazole/metabolites have been identified in human milk. The effect of pantoprazole on newborns/infants is unknown. CONTROLOC Control should not be used during breast-feeding.
Fertility
There was no evidence of impaired fertility following the administration of pantoprazole in animal studies (see section 5.3).
4.7 Effects on ability to drive and use machines
CONTROLOC Control has no or negligible influence on the ability to drive and use machines. However adverse reactions such as dizziness and visual disturbances may occur (see section 4.8). If affected, patients should not drive or use machines.
4.8 Undesirable effects
Summary of the safety profile
Approximately 5% of patients can be expected to experience adverse reactions.
Tabulated list of adverse reactions
The following adverse reactions have been reported with pantoprazole.
Within the following table, adverse reactions are ranked under the MedDRA frequency classification: 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). Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness.
Table 1. Adverse reactions with pantoprazole in clinical trials and post-marketing experience
| Frequency System organ class | Common | Uncommon | Rare | Very rare | Not known |
| Blood and lymphatic system disorders | Agranulocytosis | Thrombocytopenia, Leukopenia, Pancytopenia | |||
| Immune system disorders | Hypersensitivity (incl. anaphylactic reactions and anaphylactic shock) | ||||
| Metabolism and nutrition disorders | Hyperlipidaemias and lipid increases (triglycerides, cholesterol), Weight changes | Hyponatraemia, Hypomagnesaemia, Hypocalcaemia(1) Hypokalaemia(1) | |||
| Psychiatric disorders | Sleep disorders | Depression (and all aggravations) | Disorientation (and all aggravations) | Hallucination, Confusion (especially in pre-disposed patients, as well as the aggravation of these symptoms in case of pre-existence) | |
| Nervous system disorders | Headache, Dizziness | Taste disorders | Paraesthesia | ||
| Eye disorders | Disturbances in vision / blurred vision | ||||
| Gastrointestinal disorders | Fundic gland polyps (benign) | Diarrhoea, Nausea / vomiting, Abdominal distension and bloating, Constipation, Dry mouth, Abdominal pain and discomfort | Microscopic colitis |
| Frequency System organ class | Common | Uncommon | Rare | Very rare | Not known |
| Hepatobiliary disorders | Liver enzymes increased (transaminases, y-gt) | Bilirubin increased | Hepatocellular injury, Jaundice, Hepatocellular failure | ||
| Skin and subcutaneous tissue disorders | Rash / exanthema / eruption, Pruritus | Urticaria, Angioedema | Stevens-Johnson syndrome, Lyell syndrome, Erythema multiforme, Photosensitivity, Drug reaction with eosinophilia and systemic symptoms (DRESS), Subacute cutaneous lupus erythematosus (see section 4.4). | ||
| Musculoskeletal and connective tissue disorders | Fracture of wrist, hip and spine. | Arthralgia; Myalgia | |||
| Renal and urinary disorders | Interstitial nephritis | ||||
| Reproductive system and breast disorders | Gynaecomastia | ||||
| General disorders and administration site conditions | Asthenia, fatigue and malaise | Body temperature increased; Oedema peripheral |
(1) Hypocalcaemia and/or hypokalaemia may be related to the occurrence of hypomagnesaemia (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 national reporting system listed in
4.9 Overdose
Doses up to 240 mg administered intravenously over 2 minutes were well tolerated.
As pantoprazole is extensively protein bound, it is not readily dialysable.
In the case of overdose with clinical signs of intoxication, apart from symptomatic and supportive treatment, no specific therapeutic recommendations can be made.
5. PHARMACOLOGICAL PROPERTIES5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Proton pump inhibitors, ATC code: A02BC02
Mechanism of action
Pantoprazole is a substituted benzimidazole which inhibits the secretion of hydrochloric acid in the stomach by specific blockade of the proton pumps of the parietal cells.
Pantoprazole is converted to its active form, a cyclic sulphenamide, in the acidic environment in the parietal cells where it inhibits the H+, K±ATPase enzyme, i.e. the final stage in the production of hydrochloric acid in the stomach.
The inhibition is dose-dependent and affects both basal and stimulated acid secretion. In most patients, freedom from heartburn and acid reflux symptoms is achieved in 1 week. Pantoprazole reduces acidity in the stomach and thereby increases gastrin in proportion to the reduction in acidity. The increase in gastrin is reversible. Since pantoprazole binds to the enzyme distal to the receptor level, it can inhibit hydrochloric acid secretion independently of stimulation by other substances (acetylcholine, histamine, gastrin). The effect is the same whether the active substance is given orally or intravenously.
The fasting gastrin values increase under pantoprazole. On short-term use, in most cases they do not exceed the upper limit of normal. During long-term treatment, gastrin levels double in most cases. An excessive increase, however, occurs only in isolated cases. As a result, a mild to moderate increase in the number of specific endocrine (ECL) cells in the stomach is observed in a minority of cases during long-term treatment (simple to adenomatoid hyperplasia). However, according to the studies conducted so far, the formation of carcinoid precursors (atypical hyperplasia) or gastric carcinoids as were found in animal experiments (see section 5.3) have not been observed in humans.
During treatment with antisecretory medicinal products, serum gastrin increases in response to the decreased acid secretion. Also CgA increases due to decreased gastric acidity. The increased CgA level may interfere with investigations for neuroendocrine tumours.
Available published evidence suggests that proton pump inhibitors should be discontinued between 5 days and 2 weeks prior to CgA measurements. This is to allow CgA levels that might be spuriously elevated following PPI treatment to return to reference range.
Clinical efficacy and safety
In a retrospective analysis of 17 studies in 5960 patients with gastro-oesophageal reflux disease (GORD) who were treated with 20 mg pantoprazole monotherapy, the symptoms associated with acid reflux e.g. heartburn and acid regurgitation were evaluated according to a standardised methodology. Studies selected had to have at least one acid reflux symptom recording point at 2 weeks. GORD diagnosis in these studies was based on endoscopic assessment, with the exception of one study in which the inclusion of the patients was based on symptomatology alone.
In these studies, the percentage of patients experiencing complete relief from heartburn after 7 days was between 54.0% and 80.6% in the pantoprazole group. After 14 and 28 days, complete heartburn relief was experienced in 62.9% to 88.6% and 68.1% to 92.3% of the patients, respectively.
For the complete relief from acid regurgitation, similar results were obtained as for heartburn. After 7 days the percentage of patients experiencing complete relief from acid regurgitation was between 61.5% and 84.4%, after 14 days between 67.7% and 90.4%, and after 28 days between 75.2% and 94.5%, respectively.
Pantoprazole was consistently shown to be superior to placebo and H2RA and non-inferior to other PPIs. Acid-reflux symptom relief rates were largely independent of the initial GORD stage.
5.2 Pharmacokinetic properties
Pharmacokinetics do not vary after single or repeated administration. In the dose range of 10 to 80 mg, the plasma kinetics of pantoprazole are linear after both oral and intravenous administration.
Absorption
Pantoprazole is completely and rapidly absorbed after oral administration. The absolute bioavailability from the tablet was found to be about 77%. On average, at about 2.0 h – 2.5 h post administration (tmax) of a single 20 mg oral dose, the maximum serum concentrations (Cmax) of about 1–1.5 |Jg/mL are achieved, and these values remain constant after multiple administration.
Concomitant intake of food had no influence on bioavailability (AUC or Cmax), but increased the variability of the lag-time (tlag).
Distribution
Volume of distribution is about 0.15 L/kg and serum protein binding is about 98%.
Biotransformation
Pantoprazole is almost exclusively metabolised in the liver.
Elimination
Clearance is about 0.1 L/h/kg, and terminal half-life (t1/2) about 1 h. There were a few cases of subjects with delayed elimination. Due to the specific binding of pantoprazole to the proton pumps within the parietal cell, the elimination half-life does not correlate with the much longer duration of action (inhibition of acid secretion).
Renal elimination represents the major route of excretion (about 80%) for the metabolites of pantoprazole; the rest is excreted with the faeces. The main metabolite in both serum and urine is desmethylpantoprazole, which is conjugated with sulphate. The half-life of the main metabolite (about 1.5 h) is not much longer than that of pantoprazole.
Special populations
Renal impairment
No dose reduction is recommended when pantoprazole is administered to patients with impaired renal function (including patients on dialysis, which removes only negligible amounts of pantoprazole). As with healthy subjects, the half-life of pantoprazole is short. Although the main metabolite has a longer half-life (2–3 h), excretion is still rapid and thus accumulation does not occur.
Hepatic impairment
After administration of pantoprazole to patients with liver impairment (Child-Pugh classes A, B and C) the half-life values increased to between 3 and 7 h and the AUC values increased by a factor of 3–6, whereas the Cmax only increased slightly by a factor of 1.3 compared with healthy subjects.
Elderly
The slight increase in AUC and Cmax in elderly volunteers compared with younger subjects was not clinically relevant.
5.3 Preclinical safety data
Non-clinical data reveal no special hazard for humans based on conventional studies of safety pharmacology, repeated dose toxicity and genotoxicity.
In the 2-year carcinogenicity studies in rats, neuroendocrine neoplasms were found. In addition, squamous cell papillomas were found in the forestomach of rats in one study. The mechanism leading to the formation of gastric carcinoids by substituted benzimidazoles has been carefully investigated and allows the conclusion that it is a secondary reaction to the massively elevated serum gastrin levels occurring in the rat during chronic high-dose treatment.
In the 2-year rodent studies an increased number of liver tumours was observed in rats (in one rat study only) and in female mice and was interpreted as being due to pantoprazole's high metabolic rate in the liver.
A slight increase of neoplastic changes of the thyroid was observed in the group of rats receiving the highest dose (200 mg/kg) in one 2-year study. The occurrence of these neoplasms is associated with the pantoprazole-induced changes in the breakdown of thyroxine in the rat liver. As the therapeutic dose in man is low, no side effects on the thyroid glands are expected.
In a peri-postnatal rat reproduction study designed to assess bone development, signs of offspring toxicity (mortality, lower mean body weight, lower mean body weight gain and reduced bone growth) were observed at exposures (Cmax) approximately 2× the human clinical exposure. By the end of the recovery phase, bone parameters were similar across groups and body weights were also trending toward reversibility after a drug-free recovery period. The increased mortality has only been reported in pre-weaning rat pups (up to 21 days age) which is estimated to correspond to infants up to the age of 2 years old. The relevance of this finding to the paediatric population is unclear. A previous peri-postnatal study in rats at slightly lower doses found no adverse effects at 3 mg/kg compared with a low dose of 5 mg/kg in this study. Investigations revealed no evidence of impaired fertility or teratogenic effects.
Penetration of the placenta was investigated in the rat and was found to increase with advanced gestation. As a result, concentration of pantoprazole in the foetus is increased shortly before birth.
6. PHARMACEUTICAL PARTICULARS6.1 List of excipients
Core
Sodium carbonate, anhydrous
Mannitol (E421)
Crospovidone
Povidone K90
Calcium stearate
Coating
Hypromellose
Povidone K25
Titanium dioxide (E171)
Yellow iron oxide (E172)
Propylene glycol
Methacrylic acid-ethyl acrylate copolymer (1:1) Sodium laurilsulfate
Polysorbate 80 Triethyl citrate
Printing ink
Shellac
Red iron oxide (E172)
Black iron oxide (E172)
Yellow iron oxide (E172)
Ammonia solution, concentrated
6.2 Incompatibilities
Not applicable.
6.3 Shelf life
3 years
6.4 Special precautions for storage
Store in the original package in order to protect from moisture.
6.5 Nature and contents of container
Alu/Alu blisters with or without cardboard reinforcement containing 7 or 14 gastro-resistant tablets
Not all pack sizes may be marketed.
6.6 Special precautions for disposal
Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
7. MARKETING AUTHORISATION HOLDER
Takeda GmbH
Byk-Gulden-Str. 2
D-78467 Konstanz
Germany
Telephone: 0800 825332 4
Telefax: 0800 825332 9
8. MARKETING AUTHORISATION NUMBER(S)
EU/1/09/515/001–004
9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION
Date of first authorisation: 12 June 2009
Date of latest renewal: 21 February 2014