INHATEC 50 MICROGRAMS / 250 MICROGRAMS / DOSE INHALATION POWDER PRE-DISPENSED - summary of medicine characteristics

Inhatec 50 microgram/ 250 microgram/ dose inhalation powder, pre-dispensed

2 QUALITATIVE AND QUANTITATIVE COMPOSITION

Each single inhalation provides a delivered dose (the dose leaving the mouthpiece) of 45 micrograms of salmeterol (as salmeterol xinafoate) and 229 micrograms of fluticasone propionate. This corresponds to a pre-metered dose of 50 micrograms of salmeterol (as salmeterol xinafoate) and 250 micrograms fluticasone propionate.

Excipient with known effect:

Each delivered dose contains approximately 13 milligrams of lactose (as monohydrate).

For the full list of excipients, see section 6.1.

Inhalation powder, pre-dispensed.

Moulded plastic device containing a foil strip with 60 regularly placed blisters. Each blister contains pre-dispensed dose of white to off white inhalation powder.

4.1 Therapeutic indications

Inhatec is indicated in adults and adolescents 12 years of age and older in the regular treatment of asthma where use of a combination product (long- acting p2 agonist and inhaled corticosteroid) is appropriate:

– patients not adequately controlled with inhaled corticosteroids and ‚as needed‘ inhaled short-acting p2 agonist

or

– patients already adequately controlled on both inhaled corticosteroid and long-acting P2 agonist

Note: Inhatec 50 microgram /100 microgram strength is not appropriate in adults and children with severe asthma.

4.2 Posology and method of administration

Posology

Patients are to be made aware that Inhatec must be used daily for optimum benefit, even when asymptomatic.

Patients should be regularly reassessed by a doctor, so that the strength of Inhatec they are receiving remains optimal and is only changed on medical advice. The dose should be titrated to the lowest dose at which effective control of symptoms is maintained. Where the control of symptoms is maintained with the lowest strength of the combination given twice daily then the next step could include a test of inhaled corticosteroid alone. As an alternative, patients requiring a long-acting P2 agonist could be titrated to Inhatec given once daily if, in the opinion of the prescriber, it would be adequate to maintain disease control. In the event of once daily dosing when the patient has a history of nocturnal symptoms the dose should be given at night and when the patient has a history of mainly daytime symptoms the dose should be given in the morning.

Patients should be given the strength of Inhatec containing the appropriate fluticasone propionate dosage for the severity of their disease. If an individual patient should require dosages outside the recommended regimen, appropriate doses of P2 agonist and/or corticosteroid should be prescribed.

Recommended Doses:

Asthma

Adults and adolescents 12 years and older:

One inhalation of 50 micrograms salmeterol and 250 micrograms fluticasone propionate twice daily.

A short-term trial of Inhatec may be considered as initial maintenance therapy in adults or adolescents with moderate persistent asthma (defined as patients with daily symptoms, daily rescue use and moderate to severe airflow limitation) for whom rapid control of asthma is essential. In these cases, the recommended initial dose is one inhalation of 50 micrograms salmeterol and 100 micrograms fluticasone propionate twice daily. Once control of asthma is attained treatment should be reviewed and consideration given as to whether patients should be stepped down to an inhaled corticosteroid alone. Regular review of patients as treatment is stepped down is important.

A clear benefit has not been shown as compared to inhaled fluticasone propionate alone used as initial maintenance therapy when one or two of the criteria of severity are missing. In general, inhaled corticosteroids remain the first line treatment for most patients.

Inhatec is not intended for the initial management of mild asthma. Inhatec

50 microgram/100 micrograms strength is not appropriate in adults and children with severe asthma; it is recommended to establish the appropriate dosage of inhaled corticosteroid before any fixed-combination can be used in patients with severe asthma.

Paediatric population

Inhatec is not recommended for use in children aged under 12 years of age. The safety and efficacy of Inhatec in children aged less than 12 years of age has not been established.

Special patient groups

There is no need to adjust the dose in elderly patients or in those with renal impairment.

There are no data available for use of Inhatec in patients with hepatic impairment.

Method of administration:

Inhalation use.

Using Inhatec

Inhatec must be used correctly in order to achieve effective treatment. All patients must be advised to read the patient information leaflet carefully and follow the instructions for use as detailed in the leaflet. All patients must be trained by the prescribing health care professional on how to use Inhatec, especially if this is their first time in using this inhaler. This is to ensure that they understand how to use the inhaler correctly.

The use of Inhatec follows three simple steps, which are outlined below:

1. The device is opened by depressing the red safety lock and primed by sliding the pink (for 50/250 microgram strength) mouthpiece cover until a “click” is heard.

2. The mouthpiece is then placed in the mouth and the lips closed round it. The dose can then be inhaled through the inhaler by breathing in steadily and deeply. The inhaler is then removed from the mouth and the patient must hold their breath for about 10 seconds or as long as is comfortable.

3. The patient must then be instructed to breathe out gently and close the inhaler cover until a “click” is heard.

Patients must also be advised to rinse their mouth afterwards with water and spit it out and/or brush their teeth after inhaling.

4.3 Contraindications

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

4.4 Special warnings and precautions for use

Deterioration of disease

Inhatec should not be used to treat acute asthma symptoms for which a fast- and short- acting bronchodilator is required. Patients should be advised to have their inhaler to be used for relief in an acute asthma attack available at all times.

Patients should not be initiated on Inhatec during an exacerbation, or if they have significantly worsening or acutely deteriorating asthma.

Serious asthma-related adverse events and exacerbations may occur during treatment with Inhatec. Patients should be asked to continue treatment but to seek medical advice if asthma symptoms remain uncontrolled or worsen after initiation on Inhatec.

Increased requirements for use of reliever medication (short-acting bronchodilators), or decreased response to reliever medication indicate deterioration of control and patients should be reviewed by a physician.

Sudden and progressive deterioration in control of asthma is potentially lifethreatening and the patient should undergo urgent medical assessment. Consideration should be given to increasing corticosteroid therapy.

Once asthma symptoms are controlled, consideration may be given to gradually reducing the dose of Inhatec. Regular review of patients as treatment is stepped down is important. The lowest effective dose of Inhatec should be used (see section 4.2).

Cessation of therapy

Treatment with Inhatec should not be stopped abruptly in patients with asthma due to risk of exacerbation. Therapy should be down-titrated under physician supervision.

Caution with special diseases

As with all inhaled medication containing corticosteroids, Inhatec should be administered with caution in patients with active or quiescent pulmonary tuberculosis and fungal, viral or other infections of the airway. Appropriate treatment should be promptly instituted, if indicated.

Cardiovascular effects

Rarely, Inhatec may cause cardiac arrhythmias e.g. supraventricular tachycardia, extrasystoles and atrial fibrillation, and a mild transient reduction in serum potassium at high therapeutic doses Inhatec should be used with caution in patients with severe cardiovascular disorders or heart rhythm abnormalities and in patients with diabetes mellitus, thyrotoxicosis, uncorrected hypokalaemia or patients predisposed to low levels of serum potassium.

Hyperglycaemia

There have been very rare reports of increases in blood glucose levels (see section 4.8) and this should be considered when prescribing to patients with a history of diabetes mellitus.

Paradoxical bronchospasm

As with other inhalation therapy paradoxical bronchospasm may occur with an immediate increase in wheezing and shortness of breath after dosing. Paradoxical bronchospasm responds to a rapid-acting bronchodilator and should be treated straightaway. Inhatec should be discontinued immediately, the patient assessed and alternative therapy instituted if necessary.

Beta 2 adrenoreceptor agonists

The pharmacological side effects of P2 agonist treatment, such as tremor, palpitations and headache, have been reported, but tend to be transient and reduce with regular therapy.

Excipients

Inhatec contains lactose. Patients with rare hereditary problems of galactose intolerance, total lactase deficiency or glucose-galactose malabsorption should not take this medicinal product.

Systemic corticosteroid effects

Systemic effects may occur with any inhaled corticosteroid, particularly at high doses prescribed for long periods. These effects are much less likely to occur than with oral corticosteroids. Possible systemic effects include Cushing's syndrome, Cushingoid features, adrenal suppression, 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) (see Paediatric population sub-heading below for information on the systemic effects of inhaled corticosteroids in children and adolescents). It is important, therefore, that the patient is reviewed regularly and the dose of inhaled corticosteroid is reduced to the lowest dose at which effective control of asthma is maintained.

Adrenal function

Prolonged treatment of patients with high doses of inhaled corticosteroids may result in adrenal suppression and acute adrenal crisis. Very rare cases of adrenal suppression and acute adrenal crisis have also been described with doses of fluticasone propionate between 500 and less than 1,000 micrograms. 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, hypotension, decreased level of consciousness, hypoglycaemia, and seizures. Additional systemic corticosteroid cover should be considered during periods of stress or elective surgery.

The benefits of inhaled fluticasone propionate therapy should minimise the need for oral steroids, but patients transferring from oral steroids may remain at risk of impaired adrenal reserve for a considerable time. Therefore these patients should be treated with special care and adrenocortical function regularly monitored. Patients who have required high dose emergency corticosteroid therapy in the past may also be at risk. This possibility of residual impairment should always be borne in mind in emergency and elective situations likely to produce stress, and appropriate corticosteroid treatment must be considered. The extent of the adrenal impairment may require specialist advice before elective procedures.

Interactions with other medicinal products

Ritonavir can greatly increase the concentration of fluticasone propionate in plasma. Therefore, concomitant use should 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 section 4.5).

Concomitant use of systemic ketoconazole significantly increases systemic exposure to salmeterol. This may lead to an increase in the incidence of systemic effects (e.g. prolongation in the QTc interval and palpitations). Concomitant treatment with ketoconazole or other potent CYP3A4 inhibitors should therefore, be avoided unless the benefits outweigh the potentially increased risk of systemic side effects of salmeterol treatment (see section 4.5).

Visual disturbance

Visual disturbance may be reported with systemic and topical corticosteroid use. If a patient presents with symptoms such as blurred vision or other visual disturbances, the patient should be considered for referral to an ophthalmologist for evaluation of possible causes which may include cataract, glaucoma or rare diseases such as central serous chorioretinopathy (CSCR) which have been reported after use of systemic and topical corticosteroids.

Paediatric population

Inhatec is not recommended for use in children under 12 years of age (see Section 4.2).

Adolescents <16 years taking high doses of fluticasone propionate (typically > 1000 micrograms/day) may be at particular risk. Systemic effects may occur, particularly at high doses prescribed for long periods. Possible systemic effects include Cushing's syndrome, Cushingoid features, adrenal suppression, acute adrenal crisis and growth retardation in children and adolescents and more rarely, a range of psychological or behavioural effects including psychomotor hyperactivity, sleep disorders, anxiety, depression or aggression. Consideration should be given to referring the child or adolescent to a paediatric respiratory specialist.

It is recommended that the height of children receiving prolonged treatment with inhaled corticosteroid is regularly monitored. The dose of inhaled corticosteroid should be reduced to the lowest dose at which effective control of asthma is maintained

4.5 Interaction with other medicinal products and other forms of interaction

ß adrenergic blockers may weaken or antagonise the effect of salmeterol. Both non-selective and selective ß blockers should be avoided unless there are compelling reasons for their use. Potentially serious hypokalaemia may result from ß2 agonist therapy. Particular caution is advised in acute severe asthma as this effect may be potentiated by concomitant treatment with xanthine derivatives, steroids and diuretics.

Concomitant use of other ß adrenergic containing medicinal products can have a potentially additive effect.

Fluticasone Propionate

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 CYP 3A4 in the gut and liver. Hence, clinically significant interactions with other active substances mediated by fluticasone propionate are unlikely.

In an interaction study in healthy subjects with intranasal fluticasone propionate, ritonavir (a highly potent cytochrome CYP 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 and cobicistat-containing products, and moderate CYP3A inhibitors, such as erythromycin, is also expected to increase the systemic fluticasone propionate exposure and the risk of systemic side effects. Combinations should be avoided unless the benefit outweighs the potential increased risk of systemic corticosteroid side-effects, in which case patients should be monitored for systemic corticosteroid side-effects.

Salmeterol

Potent CYP3A4 inhibitors

Co-administration of ketoconazole (400 mg orally once daily) and salmeterol (50 micrograms inhaled twice daily) in 15 healthy subjects for 7 days resulted in a significant increase in plasma salmeterol exposure (1.4-fold Cmax and 15-fold AUC). This may lead to an increase in the incidence of other systemic effects of salmeterol treatment (e.g. prolongation of QTc interval and palpitations) compared with salmeterol or ketoconazole treatment alone (see section 4.4).

Clinically significant effects were not seen on blood pressure, heart rate, blood glucose and blood potassium levels. Co-administration with ketoconazole did not increase the elimination half-life of salmeterol or increase salmeterol accumulation with repeat dosing.

The concomitant administration of ketoconazole should be avoided, unless the benefits outweigh the potentially increased risk of systemic side effects of salmeterol treatment. There is likely to be a similar risk of interaction with other potent CYP3A4 inhibitors (e.g. itraconazole, telithromycin, ritonavir).

Moderate CYP 3A4 inhibitors

Co-administration of erythromycin (500 mg orally three times a day) and salmeterol (50 micrograms inhaled twice daily) in 15 healthy subjects for 6 days resulted in a small but non-statistically significant increase in salmeterol exposure (1.4-fold Cmax and 1.2-fold AUC). Co-administration with erythromycin was not associated with any serious adverse reactions.

4.6 Fertility, pregnancy and lactation

Fertility

There are no data in humans. However, animal studies showed no effects of salmeterol or fluticasone propionate on fertility.

Pregnancy

A large amount of data on pregnant women (more than 1,000 pregnancy outcomes) indicates no malformative or feto/neonatal toxicity related to salmeterol and fluticasone propionate. Animal studies have shown reproductive toxicity after administration of P2 adrenoreceptor agonists and glucocorticos­teroids (see section 5.3).

Administration of Inhatec to pregnant women should only be considered if the expected benefit to the mother is greater than any possible risk to the fetus.

The lowest effective dose of fluticasone propionate needed to maintain adequate asthma control should be used in the treatment of pregnant women.

Breast-feeding

It is unknown whether salmeterol and fluticasone propionate/me­tabolites are excreted in human milk.

Studies have shown that salmeterol and fluticasone propionate, and their metabolites, are excreted into the milk of lactating rats.

A risk to breastfed newborns/infants cannot be excluded. A decision must be made whether to discontinue breastfeeding or to discontinue Inhatec therapy taking into account the benefit of breastfeeding for the child and the benefit of therapy for the woman.

4.7 Effects on ability to drive and use machines

Inhatec has no or negligible influence on the ability to drive and use machines.

4.8 Undesirable effects

Summary of safety profile

As Inhatec contains salmeterol and fluticasone propionate, the type and severity of adverse reactions associated with each of the compounds may be expected. There is no incidence of additional adverse events following concurrent administration of the two compounds.

Adverse events which have been associated with salmeterol/flu­ticasone propionate are given below, listed by system organ class and frequency. Frequencies are defined as: 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) and not known (cannot be estimated from the available data). Frequencies were derived from clinical trial data. The incidence in placebo was not taken into account.

2. See section 4.4

Description of selected adverse reactions

The pharmacological side effects of p2 agonist treatment, such as tremor, palpitations and headache, have been reported, but tend to be transient and reduce with regular therapy.

As with other inhalation therapy paradoxical bronchospasm may occur with an immediate increase in wheezing and shortness of breath after dosing. Paradoxical bronchospasm responds to a rapid-acting bronchodilator and should be treated straightaway. Inhatec should be discontinued immediately, the patient assessed, and alternative therapy instituted if necessary.

Due to the fluticasone propionate component, hoarseness and candidiasis (thrush) of the mouth and throat and, rarely, of the oesophagus can occur in some patients. Both hoarseness and incidence of candidiasis may be relieved by rinsing the mouth with water and/or brushing the teeth after using the product. Symptomatic mouth and throat candidiasis can be treated with topical anti-fungal therapy whilst still continuing with Inhatec.

Paediatric population

Possible systemic effects include Cushing's syndrome, Cushingoid features, adrenal suppression and growth retardation in children and adolescents (see section 4.4). Children may also experience anxiety, sleep disorders and behavioural changes, including hyperactivity and irritability.

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 or search for MHRA Yellow Card in the Google Play or Apple App Store.

4.9 Overdose

There are no data available from clinical trials on overdose with Inhatec, however data on overdose with both active substances are given below:

Salmeterol

The signs and symptoms of salmeterol overdose are dizziness, increases in systolic blood pressure, tremor, headache and tachycardia. If Inhatec therapy has to be withdrawn due to overdose of the P agonist component of the medicinal product, provision of appropriate replacement steroid therapy should be considered.

Additionally, hypokalaemia can occur and therefore serum potassium levels should be monitored. Potassium replacement should be considered.

Fluticasone propionate

Acute: Acute inhalation of fluticasone propionate doses in excess of those recommended may lead to temporary suppression of adrenal function. This does not need emergency action as adrenal function is recovered in a few days, as verified by plasma cortisol measurements.

Chronic overdose of inhaled fluticasone propionate: Adrenal reserve should be monitored and treatment with a systemic corticosteroid may be necessary. When stabilised, treatment should be continued with an inhaled corticosteroid at the recommended dose. Refer to section 4.4: risk of adrenal suppression.

In cases of both acute and chronic fluticasone propionate overdose, Inhatec therapy should be continued at a suitable dosage for symptom control.

5.1

Pharmacotherapeutic            Adre­nergics in combination with corticosteroids or

group:                             ­other drugs, excl. anticholinergics.

ATC code:

R03AK06

Mechanism of action and pharmacodynamic effects

Inhatec contains salmeterol and fluticasone propionate which have differing modes of action. The respective mechanisms of action of both active substances are discussed below:

Salmeterol:

Salmeterol is a selective long-acting (12 hour) P2 adrenoceptor agonist with a long side chain which binds to the exo-site of the receptor.

Salmeterol produces a longer duration of bronchodilation, lasting for at least 12 hours, than recommended doses of conventional short-acting P2 agonists.

Fluticasone propionate:

Fluticasone propionate given by inhalation at recommended doses has a glucocorticoid anti-inflammatory action within the lungs, resulting in reduced symptoms and exacerbations of asthma, with less adverse reactions than when corticosteroids are administered systemically.

Clinical e fficacy and safety

The studies described below (GOAL and SMART) were carried out with this same fixed dose combination(s), salmeterol xinafoate and fluticasone propionate, but studied a previously authorised product; the studies described were not carried out with Inhatec.

Salmeterol/flu­ticasone propionate – Asthma clinical trials

A twelve month study (Gaining Optimal Asthma ControL, GOAL), in 3,416 adult and adolescent patients with persistent asthma, compared the safety and efficacy of salmeterol/flu­ticasone propionate versus inhaled corticosteroid (fluticasone propionate) alone to determine whether the goals of asthma management were achievable. Treatment was stepped up every 12 weeks until total control was achieved or the highest dose of study drug was reached. GOAL showed more patients treated with salmeterol/flu­ticasone propionate achieved asthma control than patients treated with inhaled corticosteroid (ICS) alone and this control was attained at a lower corticosteroid do­se.

*Well controlled asthma was achieved more rapidly with salmeterol/flu­ticasone propionate than with ICS alone. The time on treatment for 50 % of subjects to achieve a first individual well controlled week was 16 days for salmeterol/flu­ticasone propionate compared to 37 days for the ICS group. In the subset of steroid naive asthmatics the time to an individual well controlled week was 16 days in the salmeterol/flu­ticasone propionate treatment compared to 23 days following treatment with ICS.

The overall study results showed:

*Well controlled asthma; less than or equal to 2 days with symptom score greater than 1 (symptom score 1 defined as ‘symptoms for one short period during the day’), SABA use on less than or equal to 2 days and less than or equal to 4 occasions/week, greater than or equal to 80 % predicted morning peak

expiratory flow, no night-time awakenings, no exacerbations and side effects enforcing a change in therapy.

Total control of asthma; no symptoms, no SABA use, greater than or equal to 80 % predicted morning peak expiratory flow, no night-time awakenings, no exacerbations and no side effects enforcing a change in therapy.

The results of this study suggest that salmeterol/flu­ticasone propionate 50/100 micrograms bd may be considered as initial maintenance therapy in patients with moderate persistent asthma for whom rapid control of asthma is deemed essential (see section 4.2).

A double blind, randomised, parallel group study in 318 patients with persistent asthma aged > 18 years evaluated the safety and tolerability of administering two inhalations twice daily (double dose) of salmeterol/flu­ticasone propionate for two weeks. The study showed that doubling the inhalations of each strength of salmeterol/flu­ticasone propionate for up to 14 days resulted in a small increase in P agonist-related adverse events (tremor; 1 patient [1 %] vs 0, palpitations; 6 [3 %] vs 1 [<1 %], muscle cramps; 6[3 %] vs 1 [<1 %]) and a similar incidence of inhaled corticosteroid-related adverse events (e.g. oral candidiasis; 6 [6 %] vs 16 [8 %], hoarseness; 2 [2 %] vs 4 [2 %]) compared to one inhalation twice daily. The small increase in P agonist-related adverse events should be taken into account if doubling the dose of salmeterol/flu­ticasone propionate is considered by the physician in adult patients requiring additional short-term (up to 14 days) inhaled corticosteroid therapy.

Asthma

The SalmeterolMulti-center Asthma Research Trial (SMART)

The Salmeterol Multi-center Asthma Research Trial (SMART) was a 28-week US study that evaluated the safety of salmeterol compared to placebo added to usual therapy in adult and adolescent subjects. Although there were no significant differences in the primary endpoint of the combined number of respiratory-related deaths and respiratory-related life-threatening experiences, the study showed a significant increase in asthma-related deaths in patients receiving salmeterol (13 deaths out of 13,176 patients treated with salmeterol versus 3 deaths out of 13,179 patients on placebo). The study was not designed to assess the impact of concurrent inhaled corticosteroid use, and only 47 % of subjects reported ICS use at baseline.

Safety and efficacy of salmeterol-FP versus FP alone in asthma

Two multi-centre 26-week studies were conducted to compare the safety and efficacy of salmeterol-FP versus FP alone, one in adult and adolescent subjects (AUSTRI trial), and the other in paediatric subjects 4–11 years of age (VESTRI trial). For both studies, enrolled subjects had moderate to severe persistent asthma with history of asthma-related hospitalisation or asthma exacerbation in the previous year. The primary objective of each study was to determine whether the addition of LABA to ICS therapy (salmeterol-FP) was non-inferior to ICS (FP) alone in terms of the risk of serious asthma related events (asthma-related hospitalisation, endotracheal intubation, and death). A secondary efficacy objective of these studies was to evaluate whether ICS/LABA (salmeterol-FP) was superior to ICS therapy alone (FP) in terms of severe asthma exacerbation (defined as deterioration of asthma requiring the use of systemic corticosteroids for at least 3 days or an in-patient hospitalisation or emergency department visit due to asthma that required systemic corticosteroids).

A total of 11,679 and 6,208 subjects were randomized and received treatment in the AUSTRI and VESTRI trials, respectively. For the primary safety endpoint, noninferiority was achieved for both trials (see Table below).

Serious asthma-related events in the 26-Week AUSTRI and VESTRI trials

a If the resulting upper 95 % CI estimate for the relative risk was less than 2.0, then non-inferiority was concluded.

b If the resulting upper 95 % CI estimate for the relative risk was less than 2.675, then non-inferiority was concluded.

For the secondary efficacy endpoint, reduction in time to first asthma exacerbation for salmeterol-FP relative to FP was seen in both studies, however only AUSTRI met statistical significance:

Paediatric population

Inhatec is not indicated in children under 12 years of age (see section 4.2). The studies described below were carried out with a previously authorised product; the studies described were not carried out with Inhatec.

In trial SAM101667, in 158 children aged 6 to 16 years with symptomatic asthma, the combination of salmeterol/ fluticasone propionate is as efficacious as doubling the dose of fluticasone propionate in respect of symptom control and lung function. This study was not designed to investigate the effect on exacerbations.

In a 12-week trial of children aged 4 to 11 years [n = 257] treated with either salmeterol/flu­ticasone propionate 50/100 or salmeterol 50 micrograms + fluticasone propionate 100 micrograms both twice daily, both treatment arms experienced a 14 % increase in peak expiratory flow rate as well as improvements in symptom score and rescue salbutamol use. There were no differences between the two treatment arms. There were no differences in safety parameters between the two treatment arms.

In a 12-week trial of children 4 to 11 years of age [n = 203] randomized in a parallel-group study with persistent asthma and who were symptomatic on inhaled corticosteroid, safety was the primary objective. Children received either salmeterol/flu­ticasone propionate (50/100 micrograms) or fluticasone propionate (100 micrograms) alone twice daily. Two children on salmeterol/flu­ticasone propionate and 5 children on fluticasone propionate withdrew because of worsening asthma. After 12 weeks no children in either treatment arm had abnormally low 24-hour urinary cortisol excretion. There were no other differences in safety profile between the treatment arms.

Fluticasone propionate containing medications in asthma during pregnancy

An observational retrospective epidemiological cohort study utilising electronic health records from the United Kingdom was conducted to evaluate the risk of MCMs following first trimester exposure to inhaled FP alone and salmeterol-FP relative to non-FP containing ICS. No placebo comparator was included in this study.

Within the asthma cohort of 5,362 first trimester ICS-exposed pregnancies, 131 diagnosed MCMs were identified; 1,612 (30 %) were exposed to FP or salmeterol-FP of which 42 diagnosed MCMs were identified. The adjusted odds ratio for MCMs diagnosed by 1 year was 1.1 (95 %CI: 0.5–2.3) for FP exposed vs non-FP ICS exposed women with moderate asthma and 1.2 (95 %CI: 0.7–2.0) for women with considerable to severe asthma. No difference in the risk of MCMs was identified following first trimester exposure to FP alone versus salmeterol-FP. Absolute risks of MCM across the asthma severity strata ranged from 2.0 to 2.9 per 100 FP-exposed pregnancies which is comparable to results from a study of 15,840 pregnancies unexposed to asthma therapies in the General Practice Research Database (2.8 MCM events per 100 pregnancies).

5.2 Pharmacokinetic properties

For pharmacokinetic purposes each component can be considered separately.

Salmeterol

Salmeterol acts locally in the lung therefore plasma levels are not an indication of therapeutic effects. In addition there are only limited data available on the pharmacokinetics of salmeterol because of the technical difficulty of assaying the active substance in plasma due to the low plasma concentrations at therapeutic doses (approximately 200 picogram /mL or less) achieved after inhaled dosing.

Fluticasone propionate

The absolute bioavailability of a single dose of inhaled fluticasone propionate in healthy subjects varies between approximately 5 to 11 % of the nominal dose depending on the inhalation device used.

In patients with asthma a lesser degree of systemic exposure to inhaled fluticasone propionate has been observed.

Absorption

Systemic absorption occurs mainly through the lungs and is initially rapid then prolonged. The remainder of the inhaled dose may be swallowed but contributes minimally to systemic exposure due to the low aqueous solubility and pre-systemic metabolism, resulting in oral availability of less than 1 %. There is a linear increase in systemic exposure with increasing inhaled dose.

Distribution

The disposition of fluticasone propionate is characterised by high plasma clearance (1,150 mL/min), a large volume of distribution at steady-state (approximately 300 L) and a terminal half-life of approximately 8 hours. Plasma protein binding is 91 %.

Biotransformation

Fluticasone propionate is cleared very rapidly from the systemic circulation. The main pathway is metabolism to an inactive carboxylic acid metabolite, by the cytochrome P450 enzyme CYP3A4. Other unidentified metabolites are also found in the faeces.

Elimination

The renal clearance of fluticasone propionate is negligible. Less than 5 % of the dose is excreted in urine, mainly as metabolites. The main part of the dose is excreted in faeces as metabolites and unchanged active substance.

Paediatric population

Inhatec is not indicated for use in children under 12 years of age. The studies described below were carried out with a previously authorised product, the studies described were not carried out with Inhatec.

In a population pharmacokinetic analysis utilizing data from 9 controlled clinical trials with different devices (dry powder inhaler, metered dose inhaler) that included 350 patients with asthma aged 4 to 77 years (174 patients 4 to 11 years of age) higher fluticasone propionate systemic exposure following treatment with salmeterol/flu­ticasone dry powder inhaler 50/100 compared to fluticasone propionate dry powder inhaler 100 were seen.

Geometric Mean Ratio [90 % CI] for the salmeterol/flu­ticasone propionate vs. fluticasone propionate dry powder inhaler Comparison in Children and Adolescent/Adult Populations

The effect of 21 days of treatment with salmeterol/flu­ticasone inhaler 25/50 micrograms (2 inhalations twice daily with or without a spacer) or salmeterol/flu­ticasone dry powder inhaler 50/100 micrograms (1 inhalation twice daily) was evaluated in 31 children aged 4 to 11 years with mild asthma. Systemic exposure to salmeterol was similar for salmeterol/flu­ticasone inhaler, salmeterol/flu­ticasone inhaler with spacer, and salmeterol/flu­ticasone dry powder inhaler (126 pg hr/mL [95 % CI: 70, 225], 103 pg hr/mL [95 % CI: 54, 200], and 110 pg hr/mL [95 % CI: 55, 219], respectively). Systemic exposure to fluticasone propionate was similar for salmeterol/flu­ticasone inhaler with spacer (107 pg hr/mL [95 % CI: 45.7, 252.2]) and salmeterol/flu­ticasone dry powder inhaler (138 pg hr/mL [95 % CI: 69.3, 273.2]), but lower for salmeterol/flu­ticasone inhaler (24 pg hr/mL [95 % CI: 9.6, 60.2]).”

5.3 Preclinical safety data

6   PHARMACEUTICAL PARTICULARS

6.1 List of excipients

Lactose monohydrate (which contains milk proteins).

6.2 Incompatibilities

Not applicable.

6.3 Shelf life

2 years.

6.4 Special precautions for storage

Do not store above 30 °C.

Store in the original package in order to protect from moisture.

6.5 Nature and contents of container

The inhalation powder is contained in blister held on a formed aluminium/OPA/PVC base foil, with a peelable PETP-film/paper/PVC lidding foil. The blister is contained in a moulded white plastic device with a light pink (for 50/100 microgram strength) slidable mouthpiece cover, with a red safety lock.

The inhaler is packaged within triple laminated foil pouch consisting of Polyester/ADH/A­luminium/ADH/Po­lyethylene Fil­m.

The plastic devices are available in cardboard containers, which hold:

1 × 60 dose Inhatec

6.6 Special precautions for disposal

The Inhatec releases a powder which is inhaled into the lungs. A dose indicator on the Inhatec indicates the number of doses left. For detailed instructions for use see the Patient Information Leaflet.

Any unused medicinal product or waste material should be disposed of in accordance with local requirements.

Neutec Inhaler Ireland Limited 22 Northumberland Road Ballsbridge

Dublin 4

Ireland