Summary of medicine characteristics - Xydalba
1. NAME OF THE MEDICINAL PRODUCT
Xydalba 500 mg powder for concentrate for solution for infusion
2. QUALITATIVE AND QUANTITATIVE COMPOSITION
Each vial contains dalbavancin hydrochloride equivalent to 500 mg dalbavancin.
After reconstitution each ml contains 20 mg dalbavancin.
The diluted solution for infusion must have a final concentration of 1 to 5 mg/ml dalbavancin (see section 6.6).
For the full list of excipients, see section 6.1.
3. PHARMACEUTICAL FORM
Powder for concentrate for solution for infusion (powder for concentrate).
White to off-white to pale yellow powder.
4. CLINICAL PARTICULARS4.1 Therapeutic indications
Xydalba is indicated for the treatment of acute bacterial skin and skin structure infections (ABSSSI) in adults (see sections 4.4 and 5.1).
Consideration should be given to official guidance on the appropriate use of antibacterial agents.
4.2 Posology and method of administration
Posology
Recommended dose and duration of treatment for adults
The recommended dose of dalbavancin in adult patients with ABSSSI is 1,500 mg administered as either a single infusion of 1,500 mg or as 1,000 mg followed one week later by 500 mg (see sections 5.1 and 5.2).
Elderly
No dose adjustment is necessary (see section 5.2).
Renal impairment
Dose adjustments are not required for patients with mild or moderate renal impairment (creatinine clearance > 30 to 79 ml/min). Dose adjustments are not required for patients receiving regularly scheduled haemodialysis (3 times/week), and dalbavancinmay be administered without regard to the timing of haemodialysis.
In patients with chronic renal impairment whose creatinine clearance is < 30 ml/min and who are not receiving regularly scheduled haemodialysis, the recommended dose is reduced to either 1,000 mg administered as a single infusion or 750 mg followed one week later by 375 mg (see section 5.2).
Hepatic impairment
No dose adjustment of dalbavancin is recommended for patients with mild hepatic impairment (Child-Pugh A). Caution should be exercised when prescribing dalbavancin to patients with moderate or severe hepatic impairment (Child-Pugh B & C) as no data are available to determine appropriate dosing (see sections 5.2).
Paediatric population
The safety and efficacy of dalbavancin in children aged from birth to < 18 years has not yet been established. Currently available data are described in section 5.2, but no recommendation on a posology can be made.
Method of administration
Intravenous use
Xydalba must be reconstituted and then further diluted prior to administration by intravenous infusion over a 30 – minute period. For instructions on reconstitution and dilution of the medicinal product before administration, see section 6.6.
4.3 Contraindications
Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.
4.4 Special warnings and precautions for use
Hypersensitivity reactions
Dalbavancin should be administered with caution in patients known to be hypersensitive to other glycopeptides since cross-hypersensitivity may occur. If an allergic reaction to dalbavancin occurs, administration should be discontinued and appropriate therapy for the allergic reaction should be instituted.
Clostridioides (formerly Clostridium ) difficile -associated diarrhoea
Antibacterial-associated colitis and pseudomembranous colitis have been reported with the use of nearly all antibiotics and may range in severity from mild to life threatening. Therefore, it is important to consider this diagnosis in patients who present with diarrhoea during or subsequent to the treatment with dalbavancin (see section 4.8). In such circumstance, the discontinuation of dalbavancin and the use of supportive measures together with the administration of specific treatment for Clostridioides (formerly Clostridium ) difficile should be considered. These patients must never be treated with medicinal products that suppress the peristalsis.
Infusion-related reactions
Xydalba is to be administered via intravenous infusion, using a total infusion time of 30 minutes to minimise the risk of infusion-related reactions. Rapid intravenous infusions of glycopeptide antibacterial agents can cause reactions that resemble “Red-Man Syndrome”, including flushing of the upper body, urticaria, pruritus, and/or rash. Stopping or slowing the infusion may result in cessation of these reactions.
Renal impairment
Information on the efficacy and safety of dalbavancin in patients with creatinine clearance < 30 ml/min is limited. Based on simulations, dose adjustment is needed for patients with chronic renal impairment whose creatinine clearance is < 30 ml/min and who are not receiving regular haemodialysis (see sections 4.2 and 5.2).
Mixed infections
In mixed infections in which Gram-negative bacteria are suspected patients should also be treated with an appropriate antibacterial agent(s) against Gram-negative bacteria (see section 5.1).
Non-susceptible organisms
The use of antibiotics may promote the overgrowth of non-susceptible micro-organisms. If superinfection occurs during therapy, appropriate measures should be taken.
Limitations of the clinical data
There is limited data on safety and efficacy of dalbavancin when administered for more than two doses (one week apart). In the major trials in ABSSSI the types of infections treated were confined to cellulitis/erysipelas, abscesses and wound infections only. There is no experience with dalbavancin in the treatment of severely immunocompromised patients.
Excipients
This medicine contains less than 1 mmol sodium (23 mg) per dose, that is to say essentially ‘sodium-free’.
4.5 Interaction with other medicinal products and other forms of interaction
Results from an in vitro receptor screening study do not indicate a likely interaction with other therapeutic targets or a potential for clinically relevant pharmacodynamic interactions (see section 5.1).
Clinical drug-drug interaction studies with dalbavancin have not been conducted.
Potential for other medicinal products to affect the pharmacokinetics of dalbavancin.
Dalbavancin is not metabolised by CYP enzymes in vitro , therefore co-administered CYP inducers or inhibitors are unlikely to influence the pharmacokinetics of dalbavancin.
It is not known if dalbavancin is a substrate for hepatic uptake and efflux transporters. Co-administration with inhibitors of these transporters may increase the exposure to dalbavancin. Examples of such transporter inhibitors are boosted protease inhibitors, verapamil, quinidine, itraconazole, clarithromycin and cyclosporine.
Potential for dalbavancin to affect the pharmacokinetics of other medicinal products.
The interaction potential of dalbavancin on medicinal products metabolised by CYP enzymes is expected to be low since it is neither an inhibitor nor an inducer of CYP enzymes in vitro. There are no data on dalbavancin as an inhibitor of CYP2C8.
It is not known if dalbavancin is an inhibitor of transporters. Increased exposure to transporter substrates sensitive for inhibited transporter activity, such as statins and digoxin, cannot be excluded if combined with dalbavancin.
4.6 Fertility, pregnancy and lactation
Pregnancy
There are no data from the use of dalbavancin in pregnant women. Studies in animals have shown reproductive toxicity (see section 5.3).
Xydalba is not recommended during pregnancy, unless the potential expected benefit clearly justifies the potential risk to the foetus.
Breast-feeding
It is unknown whether dalbavancin is excreted in human milk. However, dalbavancin is excreted in the milk of lactating rats and may be excreted in human breast milk. Dalbavancin is not well absorbed orally; however, an impact on the gastrointestinal flora or mouth flora of a breast-feeding infant cannot be excluded. A decision must be made whether to continue/discontinue breast-feeding or to continue/discontinue therapy with Xydalba taking into account the benefit of breast-feeding for the child and the benefit of therapy for the woman.
Fertility
Studies in animals have shown reduced fertility (see section 5.3). The potential risk for humans is unknown.
4.7 Effects on ability to drive and use machines
Xydalba may have a minor influence on the ability to drive and use machines, as dizziness has been reported in a small number of patients (see section 4.8).
4.8 Undesirable effects
Summary of the safety profile
In Phase 2 / 3 clinical studies, 2,473 patients received dalbavancin administered as either a single infusion of 1,500 mg or as 1,000 mg followed one week later by 500 mg. The most common adverse reactions occurring in > 1 % of patients treated with dalbavancin were nausea (2.4 %), diarrhoea (1.9 %), and headache (1.3 %) and were generally of mild or moderate severity.
Tabulated list of adverse reactions (Table 1)
The following adverse reactions have been identified in Phase 2/3 clinical trials with dalbavancin. Adverse reactions are classified according to System Organ Class and frequency. Frequency categories are derived according to the following conventions: 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).
Table 1
| System Organ Class | Common | Uncommon | Rare |
| Infections and infestations | vulvovaginal mycotic infection, urinary tract infection, fungal infection, Clostridioides (formerly Clostridium ) difficile colitis, oral candidiasis | ||
| Blood and lymphatic system disorders | anaemia, thrombocytosis, eosinophilia, leucopenia, neutropenia | ||
| Immune system disorders | anaphylactoid reaction | ||
| Metabolism and nutrition disorders | decreased appetite | ||
| Psychiatric disorders | insomnia | ||
| Nervous system disorders | headache | dysgeusia, dizziness | |
| Vascular disorders | flushing, phlebitis | ||
| Respiratory, thoracic and mediastinal disorders | cough | bronchospasm | |
| Gastrointestinal disorders | nausea, diarrhoea, | constipation, abdominal pain, dyspepsia, abdominal discomfort, vomiting | |
| Skin and subcutaneous tissue disorders | pruritus, urticaria, rash |
| System Organ Class | Common | Uncommon | Rare |
| Reproductive system and breast disorders | vulvovaginal pruritus | ||
| General disorders and administration site conditions | infusion-related reactions | ||
| Investigations | blood lactate dehydrogenase increased, alanine aminotransferase increased, aspartate aminotransferase increased, blood uric acid increased, liver function test abnormal, transaminases increased, blood alkaline phosphatase increased, platelet count increased, body temperature increased, hepatic enzyme increased, gamma-glutamyl transferase increased, |
Description of selected adverse reactions
Class adverse reactions
Ototoxicity has been associated with glycopeptide use (vancomycin and teicoplanin); patients who are receiving concomitant therapy with an ototoxic medicinal product, such as an aminoglycoside, may be at increased risk.
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
No specific information is available on the treatment of overdose with dalbavancin, as dose-limiting toxicity has not been observed in clinical studies. In Phase 1 studies, healthy volunteers have been administered single doses of up to 1,500 mg, and cumulative doses up to 4,500 mg over a period of up to 8 weeks, with no signs of toxicity or laboratory results of clinical concern. In Phase 3 studies, patients have been administered single doses of up to 1,500 mg.
Treatment of overdose with dalbavancin should consist of observation and general supportive measures. Although no information is available specifically regarding the use of haemodialysis to treat overdose, it should be noted that in a Phase 1 study in patients with renal impairment, less than 6 % of the recommended dalbavancin dose was removed after 3 hours of haemodialysis.
5. PHARMACOLOGICAL PROPERTIES5.1 Pharmacodynamic properties
Pharmacotherapeutic group: antibacterials for systemic use, glycopeptide antibacterials, ATC code: J01XA04.
Mechanism of action
Dalbavancin is a bactericidal lipoglycopeptide.
Its mechanism of action in susceptible Gram-positive bacteria involves interruption of cell wall synthesis by binding to the terminal D-alanyl-D-alanine of the stem peptide in nascent cell wall peptidoglycan, preventing cross-linking (transpeptidation and transglycosylation) of disaccharide subunits resulting in bacterial cell death.
Mechanism of resistance
All Gram-negative bacteria are inherently resistant to dalbavancin.
Resistance to dalbavancin in Staphylococcus spp. and Enterococcus spp. is mediated by VanA, a genotype that results in modification of the target peptide in nascent cell wall. Based on in vitro studies the activity of dalbavancin is not affected by other classes of vancomycin resistance genes.
Dalbavancin MICs are higher for vancomycin-intermediate staphylococci (VISA) than for fully vancomycin susceptible strains. If the isolates with higher dalbavancin MICs represent stable phenotypes and are correlated with resistance to the other glycopeptides, then the likely mechanism would be an increase in the number of glycopeptide targets in nascent peptidoglycan.
Cross-resistance between dalbavancin and other classes of antibiotics was not seen in in vitro studies. Methicillin resistance has no impact on dalbavancin activity.
Interactions with other antibacterial agents
In in vitro studies, no antagonism has been observed between dalbavancin and other commonly used antibiotics (i.e. cefepime, ceftazidime, ceftriaxone, imipenem, meropenem, amikacin, aztreonam, ciprofloxacin, piperacillin/tazobactam and trimethoprim/sulfamethoxazole), when tested against 12 species of Gram-negative pathogens (see section 4.5).
Susceptibility testing breakpoints
Minimum inhibitory concentration (MIC) breakpoints determined by the European Committee on Antimicrobial Susceptibility Testing (EUCAST) are:
- • Staphylococcus spp.: Susceptible < 0.125 mg/l; Resistant > 0.125 mg/l,
- • Beta-haemolytic streptococci of Groups A, B, C, G: Susceptible < 0.125 mg/l; Resistant
> 0.125 mg/l,
- • Viridans group streptococci (Streptococcus anginosus group only): Susceptible
< 0.125 mg/l; Resistant > 0.125 mg/l.
PK/PD relationship
Bactericidal activity against staphylococci in vitro is time-dependent at serum concentrations of dalbavancin similar to those obtained at the recommended dose in humans. In vivo PK/PD relationship of dalbavancin for S. aureus was investigated using a neutropenic model of animal infection that showed that net reduction in the log10 of colony-forming units (CFU) was greatest when larger doses were given less frequently.
Clinical efficacy against specific pathogens
Efficacy has been demonstrated in clinical studies against the pathogens listed for ABSSSI that were susceptible to dalbavancin in vitro:
- • Staphylococcus aureus,
- • Streptococcus pyogenes,
- • Streptococcus agalactiae,
- • Streptococcus dysgalactiae,
- • Streptococcus anginosus group (includes S. anginosus, S. intermedius, and S.
constellatus).
Antibacterial activity against other relevant pathogens
Clinical efficacy has not been established against the following pathogens although in vitro studies suggest that they would be susceptible to dalbavancin in the absence of acquired mechanisms of resistance:
- • Group G streptococci
- • Clostridium perfringens
- • Peptostreptococcus spp.
Paediatric population
The European Medicines Agency has deferred the obligation to submit the results of studies with Xydalba in one or more subsets of the paediatric population in ABSSSI (see sections 4.2 and 5.2 for information on paediatric use).
5.2 Pharmacokinetic properties
The pharmacokinetics of dalbavancin have been characterised in healthy subjects, patients, and special populations. Systemic exposures to dalbavancin are dose proportional following single doses over a range of 140 to 1120 mg, indicating linear pharmacokinetics of dalbavancin. No accumulation of dalbavancin was observed following multiple intravenous infusions administered once-weekly for up to 8 weeks (1,000 mg on Day 1, followed by up to 7 weekly 500 mg doses) in healthy adults.
The mean terminal elimination half-life (t1/2) was 372 (range 333 to 405) hours. The pharmacokinetics of dalbavancin are best described using a three-compartment model (a and p distributional phases followed by a terminal elimination phase). Thus, the distributional half-life (ti/zp), which constitutes most of the clinically-relevant concentration-time profile, ranged from 5 to 7 days and is consistent with once-weekly dosing.
Estimated pharmacokinetic parameters of dalbavancin following the two-dose regimen and the single-dose regimen, respectively, are shown in Table 2 below.
Table 2
Mean (SD) dalbavancin pharmacokinetic parameters using population PK analysis1
| Parameter | Two-dose regimen 2 | Single-dose regimen 3 |
| Cmax (mg/L) | Day 1: 281 (52) Day 8: 141 (26) | Day 1: 411 (86) |
| AUC0-Day14 (mg«h/L) | 18100 (4600) | 20300 (5300) |
| CL (L/h) | 0.048 (0.0086) | 0.049 (0.0096) |
| ||
The dalbavancin plasma concentration-time following the two-dose and the single-dose regimens, respectively, are shown in Figure 1.
Figure 1. Dalbavancin Plasma Concentrations versus time in a typical ABSSSI patient (simulation using population pharmacokinetic model) for both the single and the two-dose regimens.
Distribution
Clearance and volume of distribution at steady state are comparable between healthy subjects and patients with infections. The volume of distribution at steady state was similar to the volume of extracellular fluid. Dalbavancin is reversibly bound to human plasma proteins, primarily to albumin. The plasma protein binding of dalbavancin is 93 % and is not altered as a function of drug concentration, renal insufficiency, or hepatic insufficiency. Following a single intravenous dose of 1,000 mg in healthy volunteers AUC in skin blister fluid amounted (bound and unbound dalbavancin) to approximately 60 % of the plasma AUC at day 7 post-dose.
Biotransformation
Metabolites have not been observed in significant amounts in human plasma. The metabolites hydroxy-dalbavancin and mannosyl aglycone have been detected in urine (< 25 % of administered dose). The metabolic pathways responsible for producing these metabolites have not been identified; however, due to the relatively minor contribution of metabolism to the overall elimination of dalbavancin, drug-drug interactions via inhibition or induction of metabolism of dalbavancin are not anticipated. Hydroxy-dalbavancin and mannosyl aglycone show significantly less antibacterial activity compared to dalbavancin.
Elimination
Following administration of a single 1,000 mg dose in healthy subjects, an average of 19 % to 33 % of the administered dalbavancin dose was excreted in urine as dalbavancin and 8 % to 12 % as the metabolite hydroxy-dalbavancin. Approximately 20 % of the administered dose was excreted in faeces.
Special populations
Renal impairment
The pharmacokinetics of dalbavancin were evaluated in 28 subjects with varying degrees of renal impairment and in 15 matched control subjects with normal renal function. Following a single dose of 500 mg or 1,000 mg dalbavancin, the mean plasma clearance (CLT) was reduced 11 %, 35 %, and 47 % in subjects with mild (CLcr 50 – 79 ml/min), moderate (CLcr 30 – 49 ml/min), and severe (CLCR < 30 ml/min) renal impairment, respectively, compared to subjects with normal renal function. The mean AUC for subjects with creatinine clearance < 30 ml/min was approximately 2 – fold higher. The clinical significance of the decrease in mean plasma CLt, and the associated increase in AUC0– / noted in these pharmacokinetic studies of dalbavancin in subjects with severe renal impairment has not been established. Dalbavancin pharmacokinetics in subjects with end-stage renal disease receiving regularly scheduled renal dialysis (3 times/week) were similar to those observed in subjects with mild to moderate renal impairment, and less than 6 % of an administered dose is removed after 3 hours of haemodialysis. For dosing instructions in subjects with renal impairment refer to section 4.2.
Hepatic impairment
The pharmacokinetics of dalbavancin were evaluated in 17 subjects with mild, moderate, or severe hepatic impairment and compared to 9 matched healthy subjects with normal hepatic function. The mean AUC was unchanged in subjects with mild hepatic impairment compared to subjects with normal hepatic function; however, the mean AUC decreased by 28 % and 31 %, respectively, in subjects with moderate and severe hepatic impairment. The cause and the clinical significance of the decreased exposure in subjects with moderate and severe hepatic function are unknown. For dosing instructions in subjects with hepatic impairment refer to section 4.2.
Gender
Clinically significant gender-related differences in dalbavancin pharmacokinetics have not been observed in healthy subjects or in patients with infections. No dose adjustment is recommended based on gender.
Elderly
The pharmacokinetics of dalbavancin were not significantly altered with age; therefore, dose adjustment is not necessary based on age (see section 4.2). The experience with dalbavancin in elderly is limited: 276 patients > 75 years of age were included in the Phase 2/3 clinical studies, of which 173 received dalbavancin. Patients up to 93 years of age have been included in clinical studies.
Paediatric population
The safety and efficacy of Xydalba in children aged from birth to < 18 years have not yet been established.
A total of 10 paediatric patients with ages 12 to 16 years who had resolving infections were given single doses of either dalbavancin 1,000 mg (body weight > 60 kg) or dalbavancin 15 mg/kg (body weight < 60 kg).
- Mean plasma exposures for dalbavancin, based on AUCinf (17,495 gg^h/ml and 16,248 gg •h/ml) and Cmax (212 gg/ml and 191 gg/ml) were similar when administered as 1,000 mg to paediatric subjects (12–16 years) weighing > 60 kg (61.9 – 105.2 kg) or as 15 mg/kg to paediatric subjects weighing < 60 kg (47.9–58.9 kg). Apparent terminal t'A was similar for dalbavancin doses of 1,000 mg and 15 mg/kg, with mean values of 227 and 202 hours, respectively. The safety profile of dalbavancin in the subjects aged between 12 and 16 years in this study was consistent with the safety profile observed in adults treated with dalbavancin.
5.3 Preclinical safety data
Dalbavancin toxicity has been evaluated after daily intravenous administration for durations of up to 3 months in rats and dogs. Dose-dependent toxicity included serum chemistry and histological evidence of renal and hepatic injury, reduced red blood cell parameters and injection site irritation. In dogs only, infusion reactions characterised by skin swelling and/or redness (not associated with the injection site), mucosal pallor, salivation, vomiting, sedation, and modest declines in blood pressure and increases in heart rate were observed in a dose-dependent manner. These infusion reactions were transient (resolved within 1 hour post-dosing) and were attributed to histamine release. Dalbavancin toxicity profile in juvenile rats was consistent with that previously observed in adult rats at the same dose (mg/kg /day) levels.
Reproductive toxicity studies in rats and rabbits showed no evidence of a teratogenic effect. In rats, at exposures approximately 3 times above clinical exposure, there was reduced fertility and an increased incidence of embryo-lethality, reductions in foetal weight and skeletal ossification and increased neonatal mortality. In rabbits, abortion occurred in conjunction with maternal toxicity at exposures below the human therapeutic range.
Long-term carcinogenicity studies have not been conducted. Dalbavancin was not mutagenic or clastogenic in a battery of in vitro and in vivo genotoxicity tests.
6. PHARMACEUTICAL PARTICULARS6.1 List of excipients
Mannitol (E421)
Lactose monohydrate
Hydrochloric acid (for pH-adjustment)
Sodium hydroxide (for pH-adjustment)
6.2 Incompatibilities
Sodium chloride solutions may cause precipitation and must not be used for reconstitution or dilution (see section 6.6).
This medicinal product must not be mixed with other medicinal products or intravenous solutions other than those mentioned in section 6.6.
6.3 Shelf life
Dry powder: 4 years
Chemical and physical in-use stability of Xydalba has been demonstrated for both the reconstituted concentrate and for the diluted solution for 48 hours at or below 25 °C. The total in-use stability from reconstitution to administration should not exceed 48 hours.
From a microbiological point of view, the product should be used immediately. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and would normally not be longer than 24 hours at 2 to 8 °C, unless reconstitution/dilution has taken place in controlled and validated aseptic conditions. Do not freeze.
6.4 Special precautions for storage
This medicinal product does not require any special storage conditions.
For storage conditions after reconstitution and dilution of the medicinal product, see section 6.3.
6.5 Nature and contents of container
Single-use 48 ml type I glass vial with an elastomeric stopper and a green flip off seal.
Each pack contains 1 vial.
6.6 Special precautions for disposal and other handling
Xydalba must be reconstituted with sterile water for injections and subsequently diluted with
50 mg/ml (5 %) glucose solution for infusion.
Xydalba vials are for single-use only.
Instructions for reconstitution and dilution
Aseptic technique must be used for reconstitution and dilution of Xydalba.
-
1. The content of each vial must be reconstituted by slowly adding 25 ml of water for injections.
-
2. Do not shake. To avoid foaming, alternate between gentle swirling and inversion of the vial, until its contents are completely dissolved. The reconstitution time may be up to 5 minutes.
-
3. The reconstituted concentrate in the vial contains 20 mg/ml dalbavancin.
-
4. The reconstituted concentrate must be a clear, colourless to yellow solution with no
visible particles.
-
5. The reconstituted concentrate must be further diluted with 50 mg/ml (5 %) glucose solution for infusion.
-
6. To dilute the reconstituted concentrate, the appropriate volume of the 20 mg / ml concentrate must be transferred from the vial to an intravenous bag or bottle containing 50 mg/ml (5 %) glucose solution for infusion. For example: 25 ml of the concentrate contains 500 mg dalbavancin.
-
7. After dilution the solution for infusion must have a final concentration of 1 to 5 mg/ml dalbavancin
-
8. The solution for infusion must be clear, colourless to yellow solution with no visible particles.
-
9. If particulate matter or discoloration is identified, the solution must be discarded.
7. MARKETING AUTHORISATION HOLDER
Allergan Pharmaceuticals International Ltd.,
Clonshaugh Business & Technology Park,
Dublin 17, D17 E400, Ireland
8. MARKETING AUTHORISATION NUMBER(S)
EU/1/14/986/001
9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION
Date of first authorisation: 19 February 2015
Date of latest authorisation: