SUMMARY OF PRODUCT CHARACTERISTICS

1    NAME OF THE MEDICINAL PRODUCT

Eskazole Tablets 400 mg

2    QUALITATIVE AND QUANTITATIVE COMPOSITION

Albendazole 400 mg

Excipients with known effect:

Lactose, sunset yellow lake

For the full list of excipients, see section 6.1

3    PHARMACEUTICAL FORM

Tablet

4    CLINICAL PARTICULARS

4.1    Therapeutic indications

‘Eskazole’ is a benzimidazole carbamate anthelmintic for use in the treatment of hydatid cysts caused by:

Echinococcosis

‘Eskazole’ shows greatest efficacy in the treatment of liver, lung and peritoneal cysts. Experience with bone cysts and those in the heart and central nervous system is limited.

Cystic Echinococcosis (caused by Echinococcus granulosus)

‘Eskazole’ is used in patients with cystic echinococcosis:

1.    Where surgical intervention is not feasible.

2.    Prior to surgical intervention.

3.    Post-operatively if pre-operative treatment was too short, if spillage has occurred

or if viable material was found at surgery.

4. Following percutaneous drainage of cysts for diagnostic or therapeutic reasons.

Alveolar Echinococcosis (caused by Echinococcus multilocularis) ‘Eskazole’ is used in patients with alveolar echinococcosis:

1.    In inoperable disease, particularly in cases of local or distant metastasis.

2.    Following palliative surgery.

3.    Following radical surgery or liver transplantation.

4.2 Posology and Method of Administration

Route of administration: Oral.

Dosage: Dosages are dependent on the parasite involved, the weight of the patient, and the severity of the infection:

Cystic Echinococcosis

Patients weighing >60 kg

Total daily dose: 800 mg given in two divided doses of 400 mg for a total of 28 days.

Patients weighing <60 kg

Total daily dose: 12 mg/kg given in two equally divided doses (maximum dose 800 mg/day) as above.

This 28-day treatment period may be repeated after a 14-day period without treatment for a total of three cycles.

Alveolar Echinococcosis

Patients weighing >60 kg

Total daily dose: 800 mg given in two equally divided doses for cycles of 28 days with 14 days between cycles.

Patients weighing <60 kg

Total daily dose: 12 mg/kg given in two equally divided doses (maximum dose 800 mg/day) as above.

Treatment may need to be prolonged for months or years. Continuous treatment at the same dose has been used for periods of up to 20 months.

Method of administration

Albendazole should be taken with meals. Some people, particularly young children, may experience difficulties swallowing the tablets whole and should be encouraged to chew the tablets with a little water, alternatively tablets may be crushed.

Cystic Echinococcosis

1.    Inoperable and multiple cysts

Up to three 28-day cycles of albendazole may be given for the treatment of liver, lung and peritoneal cysts. More prolonged treatment may be required for sites such as bone and brain.

2.    Pre-operative

Two 28-day cycles should be given where possible prior to surgery. Where surgical intervention is necessary before completion of two cycles, albendazole should be given for as long as possible.

3.    Post-operative

Where only a short pre-operative course has been given (less than 14 days) and in cases where emergency surgery is required, albendazole should be given post-operatively for two 28-day cycles separated by 14 drug-free days.

Additionally, where cysts are found to be viable following pre-surgical treatment or where spillage has occurred, a full two-cycle course should be given.

4.    After percutaneous cyst drainage.

Treatment as for post-surgery above.

Alveolar Echinococcosis

Treatment is normally given in 28 day cycles as for cystic echinococcosis. It may have to be continued for months or even years. Current follow up suggests that survival times are substantially improved following prolonged treatment. Continuous treatment has been shown in a limited number of patients to lead to apparent cure.

Special Populations

Children

There has been limited experience to date with the use of albendazole in children under six years of age; therefore, usage in children less than six years is not recommended. The recommended dose for older children is 12 mg/kg body weight/day in divided doses.

Elderly

Experience in patients 65 years of age or older is limited. Reports indicate that no dosage adjustment is required; however, albendazole should be used with caution in elderly patients with evidence of hepatic dysfunction (see ‘Hepatic impairment’ below and ‘5.2 Pharmacokinetic Properties’).

Renal impairment

Since renal elimination of albendazole and its primary metabolite, albendazole sulfoxide, is negligible, it is unlikely that clearance of these compounds would be altered in these patients. No dosage adjustment is required; however, patients with evidence of renal impairment should be carefully monitored.

Hepatic impairment

Since Albendazole is rapidly metabolised by the liver to the primary pharmacologically active metabolite, albendazole sulfoxide, hepatic impairment would be expected to have significant effects on the pharmacokinetics of albendazole sulfoxide. Patients with abnormal liver function test results (transaminases) prior to commencing albendazole therapy should be carefully evaluated and therapy should be discontinued if liver enzymes are significantly increased or full blood count decreased by a clinically significant level (see ‘4.4 Special Warnings and Precautions for Use’ and ‘4.8 Undesirable Effects’).

4.3 Contraindications

Albendazole should not be administered during pregnancy or in women thought to be pregnant. Women of childbearing age should be advised to take effective precautions, with non hormonal contraceptive measures, against conception during and within one month of completion of treatment with ‘Eskazole’.

Albendazole is contra-indicated in patients with a known history of hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

4.4 Special warnings and precautions for use

Albendazole has been associated with mild to moderate elevations of hepatic enzymes. Hepatic enzymes generally normalise on discontinuation of treatment. Case reports of hepatitis have also been received (see ‘4.8 Undesirable Effects’). Liver function tests should be obtained before the start of each treatment cycle and at least every two weeks during treatment. If hepatic enzymes are significantly increased (greater than twice the upper limit of normal), albendazole should be discontinued. Treatment may be restarted when hepatic enzymes have returned to normal limits, but patients should be monitored for recurrence.

Albendazole has been shown to cause bone marrow suppression and therefore blood counts should be performed at the start and every two weeks during each 28-day cycle. Patients with liver disease, including hepatic echinococcosis, appear to be more susceptible to bone marrow suppression leading to pancytopenia, aplastic anaemia, agranulocytosis and leucopenia and therefore warrant closer monitoring of blood counts. Albendazole should be discontinued if clinically significant decreases in blood cell counts occur (see ‘4.2 Posology and Method of Administration’ and ‘4.8 Undesirable Effects’).

Precautions:

In order to avoid administering albendazole during early pregnancy, women of childbearing age should:

-    initiate treatment only after a negative pregnancy test. These tests should be repeated at least once before initiating the next cycle.

-    be advised to take effective precautions against conception during and within one month of completion of treatment with albendazole for a systemic infection.

Symptoms associated with an inflammatory reaction following death of the parasite may occur in patients receiving albendazole treatment for neurocysticercosis (e.g. seizures, raised intracranial pressure, focal signs). These should be treated with appropriate steroid and anticonvulsant therapy. Oral or intravenous corticosteroids are recommended to prevent cerebral hypertensive episodes during the first week of treatment.

Pre-existing neurocysticercosis may also be uncovered in patients treated with albendazole for other conditions, particularly in areas with high taenosis infection. Patients may experience neurological symptoms e.g. seizures, increased intracranial pressure and focal signs as a result of an inflammatory reaction caused by death of the parasite within the brain. Symptoms may occur soon after treatment, appropriate steroid and anticonvulsant therapy should be started immediately.

Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.

4.5 Interactions with other Medicaments and other Forms of Interactions

Albendazole has been shown to induce liver enzymes of the cytochrome P450 system responsible for its own metabolism.

Drugs that can reduce the effectiveness of albendazole - monitor effect - other dose regimens or therapies may be required.

•    Anticonvulsants (eg phenytoin: fosphenytoin: carbamazepine: phenobarbital: primidone)

•    Levamisole

•    Ritonavir

Drugs that may increase levels of the active metabolite of albendazole -monitor to possible increased albendazole adverse effects.

•    Cimetidine

•    Dexamethasone (continuous use raises albendazole levels by 50%)

•    Praziquantel

Grapefruit juice also increases the plasma levels of albendazole sulfoxide. Other possible interactions

Because of possible alterations in cytochrome P450 activity, there is a theoretical risk of an interaction with the following

•    Oral contraceptives

•    Anticoagulants

•    Oral hypoglycaemics

•    Theophylline

Care should be exercised when albendazole is given to patients taking these medicines.

4.6 Fertility, pregnancy and lactation

Pregnancy:

‘Eskazole’ should not be administered during pregnancy or in women thought to be pregnant (see contra-indications).

Breast-feeding:

It is not known whether albendazole or its metabolites are secreted in human breast milk. Thus ‘Eskazole’ should not be used during lactation unless the potential benefits are considered to outweigh the potential risks associated with treatment.

4.7 Effects on ability to drive and use machines

Dizziness is reported as a common reaction. Patients should be advised that if affected they should not drive, operate machinery or take part in activities where this could put them or others at risk.

4.8 Undesirable effects

Data from large clinical studies were used to determine the frequency of very common to rare undesirable reactions. The frequencies assigned to all other undesirable reactions (i.e. those occurring at < 1/1000) were mainly determined using post-marketing data and refer to a reporting rate rather than a true frequency.

The following convention has been used for the classification of frequency:

Very common    >1/10

Common    >1/100 to <1/10

Uncommon    > 1/1000 to < 1/100

Rare    > 1/10,000 to < 1/1000

Blood and the lymphatic system disorders Uncommon:    Leucopenia

Very rare:    Pancytopenia, aplastic anaemia, agranulocytosis

Patients with liver disease, including hepatic echinococcosis, appear to be more susceptible to bone marrow suppression (see ‘4.2 Posology and Method of Administration’ and ‘4.4 Special Warnings and Precautions for Use’).

Immune system disorders

Uncommon:    Hypersensitivity reactions including rash, pruritus and

urticaria

Nervous system disorders Very common:    Headache

Common:    Dizziness

Gastrointestinal disorders

Common:    Gastrointestinal disturbances (abdominal pain, nausea,

vomiting)

Gastrointestinal disturbances have been associated with albendazole when treating patients with echinococcosis.

Hepato-biliary disorders

Very common:    Mild to moderate elevations of hepatic enzymes

Uncommon:    Hepatitis

Skin and subcutaneous tissue disorders

Common:    Reversible alopecia (thinning of hair, and moderate hair loss)

Very rare:    Erythema    multiforme, Stevens-Johnson syndrome

General disorders and administrative site conditions Common:    Fever

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

4.9 Overdose

In case of overdosage, symptomatic therapy (gastric lavage) and general supportive measures should be undertaken.

5 PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Benzimidazole derivatives, ATC code: P02CA03

Albendazole is a benzimidazole carbamate with anthelmintic effects against tissue parasites.

Albendazole exhibits larvicidal, ovicidal and vermicidal activity, and it is thought to exert its anthelmintic effect by inhibiting tubulin polymerisation. This causes the disruption of the helminth metabolism, including energy depletion, which immobilises and then kills the susceptible helminth.

Albendazole is effective in the treatment of tissue parasites including cystic echinococcosis and alveolar echinococcosis caused by infestation of Echinococcus granulosus and Echinococcus multilocularis, respectively.

In the treatment of cysts due to E. multilocularis, a minority of patients were considered to be cured and a majority had an improvement or stabilisation of disease due to albendazole.

5.2 Pharmacokinetic properties Absorption and metabolism

In man, albendazole is poorly absorbed (<5%) following oral administration. Albendazole rapidly undergoes extensive first-pass metabolism in the liver, and is generally not detected in plasma. Albendazole sulfoxide is the primary metabolite, which is thought to be the active moiety in effectiveness against systemic tissue infections. The plasma half-life of albendazole sulfoxide is 8'A hours.

Following oral administration of a single dose of 400 mg albendazole, the pharmacologically active metabolite, albendazole sulfoxide, has been reported to achieve plasma concentrations from 1.6 to 6.0 micromol/litre when taken with breakfast. The systemic pharmacological effect of albendazole is augmented if the dose is administered with a fatty meal, which enhances the absorption by approximately 5-fold.

Excretion

Albendazole sulfoxide and its metabolites appear to be principally eliminated in bile, with only a small proportion appearing in the urine. Elimination from cysts has been shown to occur over several weeks following high and prolonged dosing.

Special Patient Populations

Elderly

Although no studies have investigated the effect of age on albendazole sulfoxide pharmacokinetics, data in 26 hydatid cyst patients (up to 79 years) suggest pharmacokinetics similar to those in young healthy subjects. The number of elderly patients treated for either hydatid disease or neurocysticercosis is limited, but no problems associated with an older population have been observed.

Renal Impairment

The pharmacokinetics of albendazole in patients with impaired renal function have not been studied.

Hepatic Impairment

The pharmacokinetics of albendazole in patients with impaired hepatic function have not been studied.

5.3 Preclinical safety data

There are no pre-clinical data of relevance to the prescriber which are additional to that already included in other sections of the SPC.

6    PHARMACEUTICAL PARTICULARS

6.1    List of excipients

Lactose

Maize starch

Sunset yellow lake

Sodium lauryl sulphate

Polyvinylpyrrolidone

Microcrystalline cellulose

Sodium saccharin

Sodium starch glycollate

Vanilla flavour

Orange flavour

Passion fruit flavour

Magnesium stearate

Hydroxypropylmethylcellulose

Propylene glycol

Purified water

Incompatibilities

None

6.3    Shelf life

5 years

6.4    Special    precautions for    storage

Store at    or below 30°C

6.5    Nature    and contents of    container

Polypropylene 'securitainer' with polyethylene lid, each pack containing 60 tablets

6.6    Special    precautions for    disposal

No special instructions.

7 MARKETING AUTHORISATION HOLDER

Smith Kline & French Laboratories Ltd.

980 Great West Road,

Brentford,

Middlesex TW8 9GS

MARKETING AUTHORISATION NUMBER(S)

PL 00002/0202

DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

13 August 2003

DATE OF REVISION OF THE TEXT

13/10/2014