DETRUSITOL SR

Main information

  • Trade name:
  • DETRUSITOL SR
  • Dosage:
  • 4 Milligram
  • Pharmaceutical form:
  • Prolonged Release Capsules
  • Medicine domain:
  • Humans
  • Medicine type:
  • Allopathic drug

Documents

Localization

  • Available in:
  • DETRUSITOL SR
    Ireland
  • Language:
  • English

Status

  • Source:
  • HPRA - Health Products Regulatory Authority - Ireland
  • Authorization number:
  • PPA1562/060/001
  • Authorization date:
  • 09-09-2011
  • Last update:
  • 14-10-2016

Summary of Product characteristics: dosage, interactions, side effects

SummaryofProductCharacteristics

1NAMEOFTHEMEDICINALPRODUCT

DetrusitolSR4mgProlonged-releaseCapsules,Hard

2QUALITATIVEANDQUANTITATIVECOMPOSITION

Eachprolonged-releasecapsulecontainstolterodinetartrate4mgcorrespondingto2.74mgtolterodine.

Each4mgprolonged-releasecapsulecontainssucrose.

Forafulllistofexcipients,seesection6.1

3PHARMACEUTICALFORM

Prolonged-releaseCapsule,Hard

ProductimportedfromtheUK:

Bluecapsule,withwhiteprinting(symboland4)

4CLINICALPARTICULARS

4.1TherapeuticIndications

Symptomatictreatmentofurgeincontinenceand/orincreasedurinaryfrequencyandurgencyasmayoccurinpatients

withoveractivebladdersyndrome.

4.2Posologyandmethodofadministration

Adults(includingtheelderly):

Therecommendeddoseis4mgoncedailyexceptinpatientswithimpairedliverfunctionorseverelyimpairedrenal

function(GFR 30ml/min)forwhomtherecommendeddoseis2mgoncedaily(seesections4.4and5.2).Incaseof

troublesomeside-effectsthedosemaybereducedfrom4mgto2mgoncedaily.Theprolonged-releasecapsulescan

betakenwithorwithoutfoodandmustbeswallowedwhole.

Theeffectoftreatmentshouldbere-evaluatedafter2-3months(seesection5.1).

Paediatricpatients:

EfficacyofDetrusitolSRhasnotbeendemonstratedinchildren(Seesection5.1).Therefore,DetrusitolSRisnot

recommendedforchildren.

4.3Contraindications

Tolterodineiscontraindicatedinpatientswith

Urinaryretention

Uncontrollednarrowangleglaucoma

Myastheniagravis

Knownhypersensitivitytotolterodineorexcipients

Severeulcerativecolitis

Irish Medicines Board

______________________________________________________________________________________________________________________

Date Printed 13/04/2012 CRN 2111517 page number: 1

4.4Specialwarningsandprecautionsforuse

Tolterodineshallbeusedwithcautioninpatientswith:

Significantbladderoutletobstructionatriskofurinaryretention

Gastrointestinalobstructivedisorders,e.g.pyloricstenosis

Renalimpairment(seesections4.2and5.2)

Hepaticdisease(seesections4.2and5.2)

Autonomicneuropathy

Hiatushernia

Riskofdecreasedgastrointestinalmotility

Multipleoraltotaldailydosesofimmediaterelease4mg(therapeutic)and8mg(supratherapeutic)tolterodinehave

beenshowntoprolongtheQTcinterval(seesection5.1).Theclinicalrelevanceofthesefindingsisunclearandwill

dependonindividualpatientriskfactorsandsusceptibilitiespresent.

TolterodineshouldbeusedwithcautioninpatientswithriskfactorsforQT-prolongationincluding:

CongenitalordocumentedacquiredQTprolongation

Electrolytedisturbancessuchashypokalaemia,hypomagnesaemiaandhypocalcaemia

Bradycardia

Relevantpre-existingcardiacdiseases(i.e.cardiomyopathy,myocardialischaemia,arrhythmia,congestiveheart

failure)

ConcomitantadministrationofdrugsknowntoprolongQT-intervalincludingClassIA(e.g.quinidine,

procainamide)andClassIII(e.g.amiodarone,sotalol)anti-arrhythmics.

ThisespeciallyholdstruewhentakingpotentCYP3A4inhibitors(seesection5.1).Concomitanttreatmentwithpotent

CYP3A4inhibitorsshouldbeavoided(seesection4.5,Interactions).

Aswithalltreatmentsforsymptomsofurgencyandurgeincontinence,organicreasonsforurgeandfrequencyshould

beconsideredbeforetreatment.

Patientswithrarehereditaryproblemsoffructoseintolerance,glucose-galactosemalabsorptionorsucrase-isomaltase

insufficiencyshouldnottakethismedicine.

4.5Interactionwithothermedicinalproductsandotherformsofinteraction

ConcomitantsystemicmedicationwithpotentCYP3A4inhibitorssuchasmacrolideantibiotics(erythromycinand

clarithromycin),antifungalagents(e.g.ketoconazoleanditraconazole)andantiproteasesisnotrecommendeddueto

increasedserumconcentrationsoftolterodineinpoorCYP2D6metaboliserswith(subsequent)riskofoverdosage(see

section4.4).

Concomitantmedicationwithotherdrugsthatpossessantimuscarinicpropertiesmayresultinmorepronounced

therapeuticeffectandside-effects.Conversely,thetherapeuticeffectoftolterodinemaybereducedbyconcomitant

administrationofmuscariniccholinergicreceptoragonists.

Theeffectofprokineticslikemetoclopramideandcisapridemaybedecreasedbytolterodine.

Concomitanttreatmentwithfluoxetine(apotentCYP2D6inhibitor)doesnotresultinaclinicallysignificant

interactionsincetolterodineanditsCYP2D6-dependentmetabolite,5-hydroxymethyltolterodineareequipotent.

Druginteractionstudieshaveshownnointeractionswithwarfarinorcombinedoralcontraceptives(ethinyl

estradiol/levonorgestrel).

AclinicalstudyhasindicatedthattolterodineisnotametabolicinhibitorofCYP2D6,2C19,2C9,3A4or1A2.

Thereforeanincreaseofplasmalevelsofdrugsmetabolisedbytheseisoenzymesisnotexpectedwhendosedin

Irish Medicines Board

______________________________________________________________________________________________________________________

Date Printed 13/04/2012 CRN 2111517 page number: 2

4.6Fertility,pregnancyandlactation

Pregnancy

Therearenoadequatedatafromtheuseoftolterodineinpregnantwomen.

Studiesinanimalshaveshownreproductivetoxicity(seesection5.3).Thepotentialriskforhumansisunknown.

Consequently,DetrusitolSRisnotrecommendedduringpregnancy.

Lactation

Nodataconcerningtheexcretionoftolterodineintohumanmilkareavailable.Tolterodineshouldbeavoidedduring

lactation.

4.7Effectsonabilitytodriveandusemachines

Sincethisdrugmaycauseaccommodationdisturbancesandinfluencereactiontime,theabilitytodriveanduse

machinesmaybenegativelyaffected.

4.8Undesirableeffects

Duetothepharmacologicaleffectoftolterodineitmaycausemildtomoderateantimuscariniceffects,likedrynessof

themouth,dyspepsiaanddryeyes.

ThetablebelowreflectsthedataobtainedwithDetrusitolSRinclinicaltrialsandfrompostmarketingexperience.The

mostcommonlyreportedadversereactionwasdrymouth,whichoccurredin23.4%ofpatientstreatedwithDetrusitol

SRandin7.7%ofplacebo-treatedpatients.

VeryCommon

(1/10) Common

(1/100and

<1/10) Uncommon

(1/1000and

<1/100) Notknown(cannot

beestimatedfromthe

availabledata)

Infectionsand

infestations Sinusitis

Immunesystem

disorders Hypersensitivitynot

otherwisespecified Anaphylactoid

reactions

Psychiatric

disorders Nervousness Confusion,

hallucinations,

Disorientation

Nervoussystem

disorders Dizziness,

somnolence,

headache Paresthesia,

memoryimpairment

Eyedisorders Dryeyes,

abnormalvision

(including

abnormal

accomodation)

Earandlabyrinth

Irish Medicines Board

______________________________________________________________________________________________________________________

Date Printed 13/04/2012 CRN 2111517 page number: 3

Casesofaggravationofsymptomsofdementia(e.g.confusion,disorientation,delusion)havebeenreportedafter

tolterodinetherapywasinitiatedinpatientstakingcholinesteraseinhibitorsforthetreatmentofdementia.

Paediatricpatients

IntwopaediatricphaseIIIrandomised,placebo-controlled,double-blindstudiesconductedover12weekswhereatotal

of710paediatricpatientswererecruited,theproportionofpatientswithurinarytractinfections,diarrhoeaand

abnormalbehaviourwashigherinpatientstreatedwithtolterodinethanplacebo(urinarytractinfection:tolterodine6.8

%,placebo3.6%;diarrhoea:tolterodine3.3%,placebo0.9%;abnormalbehaviour:tolterodine1.6%,placebo0.4%).

(Seesection5.1).

4.9Overdose

Thehighestdosegiventohumanvolunteersoftolterodinetartrateis12.8mgasasingledoseoftheimmediaterelease

formulation.Themostsevereadverseeventsobservedwereaccommodationdisturbancesandmicturitiondifficulties.

Intheeventoftolterodineoverdose,treatwithgastriclavageandgiveactivatedcharcoal.

Treatsymptomsasfollows:

Severecentralanticholinergiceffects(e.g.hallucinations,severeexcitation):treatwithphysostigmine

Convulsionsorpronouncedexcitation:treatwithbenzodiazepines

Respiratoryinsufficiency:treatwithartificialrespiration

Tachycardia:treatwithbeta-blockers

Urinaryretention:treatwithcatheterisation

Mydriasis:treatwithpilocarpineeyedropsand/orplacepatientindarkroom.

AnincreaseinQTintervalwasobservedatatotaldailydoseof8mgimmediatereleasetolterodine(twicethe

recommendeddailydoseoftheimmediatereleaseformulationandequivalenttothreetimesthepeakexposureofthe

prolongedreleasecapsuleformulation)administeredoverfourdays.Intheeventoftolterodineoverdose,standard

Cardiacdisorders Palpitations,

cardiacfailure,

arrhythmia Tachycardia

Vasculardisorders Flushing

Gastrointestinal

disorders Drymouth Dyspepsia,

constipation,

abdominalpain,

flatulence,

diarrhoea Gastroesophageal

reflux,

vomiting

Skinand

subcutaneoustissue

disorders Angioedema,

dryskin

Renalandurinary

disorders Dysuria Urinaryretention

Generaldisorders

andadministration

siteconditions Fatigue,peripheral

Irish Medicines Board

______________________________________________________________________________________________________________________

Date Printed 13/04/2012 CRN 2111517 page number: 4

5PHARMACOLOGICALPROPERTIES

5.1Pharmacodynamicproperties

Pharmacotherapeuticgroup:Urinaryantispasmodics

ATCcode:G04BD07

Tolterodineisacompetitive,specificmuscarinicreceptorantagonistwithaselectivityfortheurinarybladderover

salivaryglandsinvivo.Oneofthetolterodinemetabolites(5-hydroxymethylderivative)exhibitsapharmacological

profilesimilartothatoftheparentcompound.Inextensivemetabolisersthismetabolitecontributessignificantlytothe

therapeuticeffect(see5.2).

Effectofthetreatmentcanbeexpectedwithin4weeks.

InthePhaseIIIprogram,theprimaryendpointwasreductionofincontinenceepisodesperweekandthesecondary

endpointswerereductionofmicturitionsper24hoursandincreaseofmeanvolumevoidedpermicturition.These

parametersarepresentedinthefollowingtable.

EffectoftreatmentwithDetrusitolSR4mgoncedailyafter12weeks,comparedwithplacebo.Absolutechangeand

percentagechangerelativetobaseline.TreatmentdifferenceDetrusitolvs.placebo:LeastSquaresestimatedmean

changeand95%confidenceinterval.

*)97.5%confidenceintervalaccordingtoBonferroni

After12weeksoftreatment23.8%(121/507)intheDetrusitolSRgroupand15.7%(80/508)intheplacebogroup

reportedthattheysubjectivelyhadnoorminimalbladderproblems.

Theeffectoftolterodinewasevaluatedinpatients,examinedwithurodynamicassessmentatbaselineand,depending

ontheurodynamicresult,theywereallocatedtoaurodynamicpositive(motorurgency)oraurodynamicnegative

(sensoryurgency)group.Withineachgroup,thepatientswererandomisedtoreceiveeithertolterodineorplacebo.The

studycouldnotprovideconvincingevidencethattolterodinehadeffectsoverplaceboinpatientswithsensoryurgency.

TheclinicaleffectsoftolterodineonQTintervalwerestudiedinECGsobtainedfromover600treatedpatients,

includingtheelderlyandpatientswithpre-existingcardiovasculardisease.ThechangesinQTintervalsdidnot

Detrusitol

SR4mg

oncedaily

(n=507) Placebo

(n=508) Treatmentdifferencevs.

placebo:Meanchange

and95%CI Statistical

significance

vs.Placebo

(p-value)

Numberof

incontinence

episodesper

week -11.8

(-54%) -6.9

(-28%) -4.8

(-7.2;-2.5)* <0.001

Numberof

micturitionsper

24hours -1.8

(-13%) -1.2

(-8%) -0.6

(-1.0;-0.2) 0.005

Meanvolume

voidedper

micturition(ml) +34(+27%) +14(+12%) +20

Irish Medicines Board

______________________________________________________________________________________________________________________

Date Printed 13/04/2012 CRN 2111517 page number: 5

TheeffectoftolterodineonQT-prolongationwasinvestigatedfurtherin48healthymaleandfemalevolunteersaged

18-55years.Subjectswereadministered2mgBIDand4mgBIDtolterodineastheimmediatereleaseformulations.

Theresults(Fridericiacorrected)atpeaktolterodineconcentration(1hour)showedmeanQTcintervalincreasesof5.0

and11.8msecfortolterodinedosesof2mgBIDand4mgBIDrespectivelyand19.3msecformoxifloxacin(400mg)

whichwasusedasanactive,internalcontrol.Apharmacokinetic/pharmacodynamicmodelestimatedthatQTcinterval

increasesinpoormetabolisers(devoidofCYP2D6)treatedwithtolterodine2mgBIDarecomparabletothose

observedinextensivemetabolisersreceiving4mgBID.Atbothdosesoftolterodine,nosubject,irrespectiveoftheir

metabolicprofile,exceeded500msecforabsoluteQTcFor60msecforchangefrombaselinethatareconsidered

thresholdsofparticularconcern.The4mgBIDdosecorrespondstoapeakexposure(C

)ofthreetimesthat

obtainedwiththehighesttherapeuticdoseofDetrusitolSRcapsules.

Paediatricpatients

Efficacyinthepaediatricpopulationhasnotbeendemonstrated.Twopaediatricphase3randomised,placebo-

controlled,double-blind12weekstudieswereconductedusingtolterodineextendedreleasecapsules.Atotalof710

paediatricpatients(486ontolterodineand224onplacebo)aged5-10yearswithurinaryfrequencyandurgeurinary

incontinencewerestudied.Nosignificantdifferencebetweenthetwogroupswasobservedineitherstudywithregard

tochangefrombaselineintotalnumberofincontinenceepisodes/week.(Seesection4.8).

5.2Pharmacokineticproperties

Pharmacokineticcharacteristicsspecificforthisformulation:

Tolterodineprolonged-releasecapsulesgiveaslowerabsorptionoftolterodinethantheimmediate-releasetabletsdo.

Asaresult,themaximumserumconcentrationsareobserved4(2-6)hoursafteradministrationofthecapsules.The

apparenthalf-lifefortolterodinegivenasthecapsuleisabout6hoursinextensiveandabout10hoursinpoor

metabolisers(devoidofCYP2D6).Steadystateconcentrationsarereachedwithin4daysafteradministrationofthe

capsules.

Thereisnoeffectoffoodonthebioavailabilityofthecapsules.

Absorption:AfteroraladministrationtolterodineissubjecttoCYP2D6catalysedfirst-passmetabolismintheliver,

resultingintheformationofthe5-hydroxymethylderivative,amajorpharmacologicallyequipotentmetabolite.

Theabsolutebioavailabilityoftolterodineis17%inextensivemetabolisers,themajorityofthepatients,and65%in

poormetabolisers(devoidofCYP2D6).

Distribution:Tolterodineandthe5-hydroxymethylmetabolitebindprimarilytoorosomucoid.Theunboundfractions

are3.7%and36%,respectively.Thevolumeofdistributionoftolterodineis113l.

Elimination:Tolterodineisextensivelymetabolisedbytheliverfollowingoraldosing.Theprimarymetabolicrouteis

mediatedbythepolymorphicenzymeCYP2D6andleadstotheformationofthe5-hydroxymethylmetabolite.Further

metabolismleadstoformationofthe5-carboxylicacidandN-dealkylated5-carboxylicacidmetabolites,whichaccount

for51%and29%ofthemetabolitesrecoveredintheurine,respectively.Asubset(about7%)ofthepopulationis

devoidofCYP2D6activity.Theidentifiedpathwayofmetabolismfortheseindividuals(poormetabolisers)is

dealkylationviaCYP3A4toN-dealkylatedtolterodine,whichdoesnotcontributetotheclinicaleffect.Theremainder

ofthepopulationisreferredtoasextensivemetabolisers.Thesystemicclearanceoftolterodineinextensive

metabolisersisabout30L/h.

Inpoormetabolisersthereducedclearanceleadstosignificantlyhigherserumconcentrationsoftolterodine(about7-

fold)andnegligibleconcentrationsofthe5-hydroxymethylmetaboliteareobserved.

The5-hydroxymethylmetaboliteispharmacologicallyactiveandequipotentwithtolterodine.Becauseofthe

differencesintheprotein-bindingcharacteristicsoftolterodineandthe5-hydroxymethylmetabolite,theexposure

(AUC)ofunboundtolterodineinpoormetabolisersissimilartothecombinedexposureofunboundtolterodineandthe

5-hydroxymethylmetaboliteinpatientswithCYP2D6activitygiventhesamedosageregimen.Thesafety,tolerability

Irish Medicines Board

______________________________________________________________________________________________________________________

Date Printed 13/04/2012 CRN 2111517 page number: 6

Theexcretionofradioactivityafteradministrationof [ 14

-tolterodineisabout77%inurineand17%infaeces.Less

than1%ofthedoseisrecoveredasunchangeddrug,andabout4%asthe5-hydroxymethylmetabolite.The

carboxylatedmetaboliteandthecorrespondingdealkylatedmetaboliteaccountforabout51%and29%oftheurinary

recovery,respectively.

Thepharmacokineticsislinearinthetherapeuticdosagerange.

Specificpatientgroups:

Impairedliverfunction:About2-foldhigherexposureofunboundtolterodineandthe5-hydroxymethylmetaboliteis

foundinsubjectswithlivercirrhosis(seesection4.2and4.4).

Impairedrenalfunction:Themeanexposureofunboundtolterodineandits5-hydroxymethylmetaboliteisdoubledin

patientswithsevererenalimpairment(inulinclearanceGFR 30ml/min).Theplasmalevelsofothermetaboliteswere

markedly(upto12-fold)increasedinthesepatients.Theclinicalrelevanceoftheincreasedexposureofthese

metabolitesisunknown.Thereisnodatainmildtomoderaterenalimpairment(seesection4.2and4.4).

Paediatricpatients:

Theexposureoftheactivemoietypermgdoseissimilarinadultsandadolescents.Themeanexposureoftheactive

moietypermgdoseisapproximatelytwo-foldhigherinchildrenbetween5-10yearsthaninadults(Seesections4.2

and5.1).

5.3Preclinicalsafetydata

Intoxicity,genotoxicity,carcinogenicityandsafetypharmacologystudiesnoclinicallyrelevanteffectshavebeen

observedexceptthoserelatedtothepharmacologicaleffectofthedrug.

Reproductionstudieshavebeenperformedinmiceandrabbits.Inmice,therewasnoeffectoftolterodineonfertility

orreproductivefunction.Tolterodineproducedembryodeathandmalformationsatplasmaexposures(C

orAUC)

20or7timeshigherthanthoseseenintreatedhumans.Inrabbits,nomalformativeeffectwasseen,butthestudies

wereconductedat20or3timeshigherplasmaexposure(C

orAUC)thanthoseexpectedintreatedhumans.

Tolterodine,aswellasitsactivehumanmetabolitesprolongactionpotentialduration(90%repolarisation)incanine

purkinjefibres(14-75timestherapeuticlevels)andblocktheK+-currentinclonedhumanether-a-go-go-relatedgene

(hERG)channels(0,5-26,1timestherapeuticlevels).IndogsprolongationoftheQTintervalhasbeenobservedafter

applicationoftolterodineanditshumanmetabolites(3,1-61,0timestherapeuticlevels).Theclinicalrelevanceofthese

findingsisunknown.

6PHARMACEUTICALPARTICULARS

6.1Listofexcipients

Sucrose

Maizestartch

Hypromellose

Ethylcellulose

Mediumchaintriglycerides

Oleicacid

Gelatine

Indigocarmine(E132)

Titaniumdioxide(E171)

Shellacglaze

Propyleneglycol

Irish Medicines Board

______________________________________________________________________________________________________________________

Date Printed 13/04/2012 CRN 2111517 page number: 7

6.2Incompatibilities

Notapplicable.

6.3Shelflife

TheshelflifeexpirydateforthisproductshallbethedateshownontheBlisterandouterpackageoftheproductonthe

marketinthecountryoforigin.

6.4Specialprecautionsforstorage

Donotstoreabove30°C.

Blisters:Keeptheblisterintheoutercarton.

6.5Natureandcontentsofcontainer

DetrusitolSRprolonged-releasecapsulesarepackedinblistersmadeofPVC/PVDCandaluminiumfoilwithaheat

sealcoatingofPVDC.7capsulesperblister,4blistersand28capsulesperpack.

6.6Specialprecautionsfordisposalofausedmedicinalproductorwastematerialsderivedfrom

suchmedicinalproductandotherhandlingoftheproduct

Anyunusedproductorwastematerialshouldbedisposedofinaccordancewithlocalrequirements.

7PARALLELPRODUCTAUTHORISATIONHOLDER

LTTPharmaLimited

Unit18,OxleasowRoad

EastMoonsMoat

Redditch

Worcestershire

B980RE

UnitedKingdom

8PARALLELPRODUCTAUTHORISATIONNUMBER

PPA1562/060/001

9DATEOFFIRSTAUTHORISATION/RENEWALOFTHEAUTHORISATION

Dateoffirstauthorisation:9thSeptember2011.

Irish Medicines Board

______________________________________________________________________________________________________________________

Date Printed 13/04/2012 CRN 2111517 page number: 8