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Naratriptan 2.5 Mg Film-Coated Tablets

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Document: spc-doc_PL 04569-1037 change

SUMMARY OF PRODUCT CHARACTERISTICS

1    NAME OF THE MEDICINAL PRODUCT

Naratriptan 2.5 mg Film-Coated Tablets.

2    QUALITATIVE AND QUANTITATIVE COMPOSITION

Each tablet contains 2.78 mg of naratriptan hydrochloride equivalent to 2.5mg of naratriptan.

Excipient with known effect:

94.22 mg lactose anhydrous/ film-coated tablet.

For the full list of excipients, see section 6.1.

3    PHARMACEUTICAL FORM

Film-coated tablet.

Green, round, biconvex beveled edged film-coated tablets debossed with “M” on one side and “NN2” on the other side.

4    CLINICAL PARTICULARS

4.1    Therapeutic indications

Acute treatment of the headache phase of migraine attacks with or without aura.

4.2    Posology and method of administration

Posology

Naratriptan tablets are recommended as monotherapy for the acute treatment of a migraine attack.

Naratriptan should not be used prophylactically.

Naratriptan tablets should be taken as early as possible after the onset of a migraine headache but they are effective if taken at a later stage.

Adults (18-65 years of age)

The recommended dose of Naratriptan is a single 2.5 mg tablet.

If symptoms of migraine should recur, following an initial response, a second dose may be taken provided that there is a minimum interval of four hours between the two doses. The total dose should not exceed two 2.5 mg tablets in any 24-hour period.

If a patient does not respond to the first dose of naratriptan a second dose should not be taken for the same attack as no benefit has been shown. Naratriptan may be used for subsequent migraine attacks.

Paediatric population

Adolescents (12-17 years of age)

In a clinical trial in adolescents, a very high placebo response was observed. The efficacy of naratriptan in this population has not been demonstrated and its use cannot be recommended.

Children (under 12 years of age)

Naratriptan tablets are not recommended for use in children below 12 years due to a lack of data on safety and efficacy.

Elderly patients (over 65 years of age)

The safety and effectiveness of naratriptan in individuals over age 65 have not been evaluated and therefore, its use in this age group cannot be recommended. There is a moderate decrease in clearance with age (see section 5.2).

Renal impairment

Naratriptan should be used with caution in patients with mild or moderate renal impairment. The maximum total daily dose in patients with mild or moderate renal impairment is a single 2.5 mg tablet.

The use of naratriptan is contraindicated in patients with severe renal impairment (see section 5.2).

Hepatic impairment

Naratriptan should be used with caution in patients with mild or moderate hepatic impairment. The maximum total daily dose in patients with mild or moderate hepatic impairment is a single 2.5 mg tablet.

The use of naratriptan is contraindicated in patients with severe hepatic impairment (see sections 4.3 and 5.2).

Method of administration Oral use.

Naratriptan should be swallowed whole with water.

4.3 Contraindications

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

Previous myocardial infarction, ischaemic heart disease, Prinzmetal's angina/coronary vasospasm, peripheral vascular disease, patients who have symptoms or signs consistent with ischaemic heart disease.

History of cerebrovascular accident (CVA) or transient ischaemic attack (TIA).

Moderate or severe hypertension, mild uncontrolled hypertension.

Severely impaired renal (creatinine clearance <15 ml/min) or hepatic function (Child-Pugh grade C).

Concomitant administration of ergotamine, derivatives of ergotamine (including methysergide) and any triptan/5-hydroxytryptamine1 (5-HT1) receptor agonist with naratriptan.

4.4 Special warnings and precautions for use

Naratriptan should only be used where there is a clear diagnosis of migraine.

Naratriptan is not indicated for use in the management of hemiplegic, basilar or ophthalmoplegic migraine.

As with other acute migraine therapies, before treating headaches in patients not previously diagnosed as migraineurs, and in migraineurs who present with atypical symptoms, care should be taken to exclude other potentially serious neurological conditions. It should be noted that migraineurs may be at risk of certain cerebrovascular events (e.g. CVA or TIA).

The safety and efficacy of naratriptan when administered during the aura phase, prior to the onset ofmigraine headache, has yet to be established.

As with other 5-HT1 receptor agonists, naratriptan should not be given to patients with risk factors for ischaemic heart disease, including those patients who are heavy smokers or users of nicotine substitution therapy without prior cardiovascular evaluation (see section 4.3). Special consideration should be given to postmenopausal women and males over 40 with these risk factors. These evaluations however, may not identify every patient who has cardiac disease and, in very rare cases, serious cardiac events have occurred in patients without underlying cardiovascular disease when 5-HT1 agonists have been administered.

Following administration, naratriptan can be associated with transient symptoms including chest pain and tightness which may be intense and involve the throat (see section 4.8). Where such symptoms are thought to indicate ischaemic heart disease, no further doses of naratriptan should be taken and appropriate evaluation should be carried out (see section 4.8).

Naratriptan contains a sulfonamide component therefore there is a theoretical risk of a hypersensitivity reaction in patients with known hypersensitivity to sulfonamides.

The recommended dose of naratriptan should not be exceeded.

Serotonin syndrome (including altered mental status, autonomic instability and neuromuscular abnormalities) has been reported following concomitant treatment with triptans and selective serotonin reuptake inhibitors (SSRIs) or serotonin

noradrenaline reuptake inhibitors (SNRIs). If concomitant treatment with naratriptan and an SSRI or SNRI is clinically warranted, appropriate observation of the patient is advised, particularly during treatment initiation, with dose increases, or with addition of another serotonergic medication (see section 4.5).

Undesirable effects may be more common during concomitant use of triptans and herbal preparations

containing St John’s Wort (Hypericum perforatum)

Prolonged use of any type of painkiller for headaches can make them worse. If this situation is experienced or suspected, medical advice should be obtained and treatment should be discontinued. The diagnosis of medication overuse headache (MOH) should be suspected in patients who have frequent or daily headaches despite (or because of) the regular use of headache medications.

Naratriptan contains lactose anhydrous, patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.

4.5 Interaction with other medicinal products and other forms of interaction

Clinical studies did not reveal any pharmacokinetic interaction with alcohol or food.

Naratriptan did not inhibit monoamine oxidase enzymes in vitro. Therefore in vivo interaction studies with monoamine oxidase inhibitors were not performed.

From in vitro studies it has been concluded that a wide range of cytochrome P450 isoenzymes are involved in the limited metabolism of naratriptan. Therefore, significant metabolic drug interactions involving specific cytochrome P450 enzymes are unlikely (see section 5.2).

In clinical studies no evidence of pharmacokinetic interaction was found with B blockers, tricyclic antidepressants or selective serotonin reuptake inhibitors.

Oral contraceptives decrease the total clearance of naratriptan by 30%, and smoking increases total clearance by 30%. But no dosing adjustments are required.

Since 60% of naratriptan is excreted renally with active renal secretion representing approximately 30% of total clearance, interactions might be possible with other drugs that are also renally secreted. However due to the safety profile of naratriptan, inhibition of naratriptan secretion is probably of minor importance, while the possibility of naratriptan to inhibit other drugs actively secreted should be considered.

There are limited data on interactions with ergotamine, ergotamine containing preparations, dihydroergotamine (DHE), or sumatriptan. The increased risk of coronary vasospasm is a theoretical possibility with co-administration of these and 5-HT1 receptor agonists (see section 4.3).

At least 24 hours should elapse after the administration of naratriptan before an ergotamine containing

preparation or any triptan/5-HT1 receptor agonist is given. Conversely, at least 24 hours should elapse after the administration of an ergotamine-containing preparation before naratriptan is given.

There have been reports describing patients with symptoms compatible with serotonin syndrome (including altered mental status, autonomic instability and neuromuscular abnormalities) following the use of selective serotonin reuptake inhibitors (SSRIs) or serotonin noradrenaline reuptake inhibitors (SNRIs) and triptans (see section 4.4).

4.6 Fertility, pregnancy and lactation

Pregnancy

The safe use of naratriptan in pregnant women has not been established. Evaluation of experimental animal studies does not indicate any direct teratogenic effects or harmful effects on peri- and postnatal development. However, delays in foetal ossification and possible effects on embryo viability have been observed in the rabbit. Because animal reproduction studies are not always predictive of human response administration of naratriptan should only be considered if the expected benefit to the mother is greater than any possible risk to the foetus.

Breast-feeding

Naratriptan and/or drug related metabolites are secreted into the milk of lactating rats. Transient effects in the pre and post-natal development of neonatal rats were observed only at maternal exposures sufficiently in excess of maximum human exposure. No studies have been conducted to determine the level of transference of naratriptan into breast milk of nursing women. It is recommended that infant exposure be minimised by avoiding breast-feeding for 24 hours after treatment.

4.7 Effects on ability to drive and use machines

No studies on the effects on the ability to drive and use machines have been performed.

Caution is recommended in patients performing skilled tasks (e.g. driving or operating machinery) as drowsiness or other symptoms may occur during a migraine attack or with naratriptan treatment.

4.8 Undesirable effects

Some of the symptoms reported as adverse events may be part of the migraine attack.

Undesirable effects are ranked under headings of frequency using the following convention: common

(>1/100 to <1/10); uncommon (>1/1,000 to <1/100); rare (>1/10,000 to <1/1,000); very rare (<1/10,000).

Immune system disorders

Rare:    Hypersensitivity reactions ranging from cutaneous

hypersensitivity to rare cases of anaphylaxis

Nervous system disorders

Common:    Sensations of tingling, dizziness, somnolence

Eye disorders

Uncommon:    Visual disturbance

Cardiac disorders

Uncommon:    Bradycardia, tachycardia, palpitations

Very rare:    Coronary artery vasospasm, transient ischaemic ECG changes,

angina, myocardial infarction (see section 4.3 and 4.4)

Vascular disorders

Very rare:    Peripheral vascular ischaemia

Gastrointestinal disorders Common:    Nausea, vomiting

Rare:    Ischaemic colitis

Skin and subcutaneous tissue disorders

Rare:    Rash, urticaria, pruritis,    facial oedema

General disorders and administration site conditions Common:    Sensations of heat, malaise/fatigue

Uncommon:    Pain, sensations of heaviness, pressure or tightness. These symptoms

are usually transient, may be intense and can affect any part of the body, including the chest and throat.

Investigations

Uncommon:    Increase in blood pressure of approximately 5 mmHg (systolic) and 3

mmHg (diastolic) in a period of up to 12 hours after administration.

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

Symptoms

Administration of a high dose of 25 mg naratriptan in one healthy male subject increased blood pressure by up to 71 mmHg and resulted in adverse events including light-headedness, tension in the neck, tiredness and a loss of co-ordination. Blood pressure returned to baseline by 8 hours after dosing without other pharmacological intervention.

Treatment

It is unknown what effect haemodialysis or peritoneal dialysis has on the plasma

concentrations of

naratriptan.

If overdosage with naratriptan occurs, the patient should be monitored for at least 24 hours and standard supportive treatment applied as required.

5 PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Antimigraine preparations, selective serotonin (5HT1) agonists,

ATC code: N02CC02.

Mechanism of action

Naratriptan has been shown to be a selective agonist for 5 hydroxytryptamine1 (5-HT1) receptors mediating vascular contraction. Naratriptan has high affinity for human cloned 5-HTm and 5-HTid receptors, the human 5-HTm receptor is thought to correspond to the vascular 5-HT1 receptor mediating contraction of intracranial blood vessels. Naratriptan has little or no effect at other 5-HT receptor (5-HT2, 5-HT3, 5-HT4 and 5-HT7) subtypes.

Pharmacodynamic effects

In animals, naratriptan constricts the carotid arterial circulation. In addition experimental studies in animals suggest that naratriptan inhibits trigeminal nerve activity. Both these actions may contribute to the antimigraine action of naratriptan in humans.

Clinical efficacy and safety

In man, a meta-analysis of BP recordings in 15 studies showed that the population average maximum increases in systolic and diastolic blood pressure after a 2.5mg dose of naratriptan tablets would be less than 5mmHg and 3mmHG respectively. The blood pressure response was unaffected by age, weight, hepatic or renal impairment.

5.2 Pharmacokinetic properties

Absorption

Following oral administration, naratriptan is absorbed with maximum plasma concentrations observed at 2-3 hours. After administration of a 2.5 mg naratriptan tablet Cmax is approximately 8.3 ng/ml (95% Cl: 6.5 to 10.5 ng/ml) in women and 5.4 ng/ml (95% Cl: 4.7 to 6.1 ng/ml) in men.

The oral bioavailability is 74% in women and 63% in men with no differences in efficacy and tolerability in clinical use. Therefore a gender related dose adjustment is not required.

Distribution

Naratriptan is distributed in a volume of 170 litres. Plasma protein binding is low (29%).

Biotransformation

In vitro naratriptan was metabolised by a wide range of cytochrome P450 isoenzymes. Consequently, significant metabolic drug interactions with naratriptan are not anticipated (see section 4.5).

Elimination

The mean elimination half-life (t1/2) is 6 hours.

Mean clearance after intravenous administration was 470 ml/min in men and 380 ml/min in women. Renal clearance is similar in men and women at 220 ml/min and is higher than the glomerular filtration rate suggesting that naratriptan is actively secreted in the renal tubules. Naratriptan is predominantly excreted in the urine with 50% of the dose recovered as unchanged naratriptan and 30% recovered as inactive metabolites.

Special Patient Populations

Elderly

In healthy elderly subjects (n=12), clearance was decreased by 26% and AUC was increased by 30% when compared to healthy young subjects (n=12) in the same study (see section 4.2).

Gender

The naratriptan AUC and Cmax were approximately 35% lower in males compared to females, possibly due to the concomitant use of oral contraceptives, however, with no differences in efficacy and tolerability in clinical use. Therefore, a gender-related dose adjustment is not required (see section 4.2).

Renal Impairment

Renal excretion is the major route for the elimination of naratriptan. Accordingly exposure to naratriptan may be increased in patients with renal disease. In a study in male and female renally impaired patients (creatinine clearance 18 to 115 ml/min; n=15) matched for sex, age and weight with healthy subjects (n=8), renally impaired patients had an approximately 80% increase in t1/2 and an approximately 50% reduction in clearance (see section 4.2).

Hepatic Impairment

The liver plays a lesser role in the clearance of orally administered naratriptan. In a study in male and female hepatically impaired patients (Child-Pugh grade A or B n=8) matched for sex, age and weight with healthy subjects who received oral naratriptan, hepatically impaired patients had an approximately 40% increase in t1/2 and an approximately 30% reduction in clearance (see section 4.2).

5.3 Preclinical safety data

No clinically relevant findings were observed in preclinical studies.

6 PHARMACEUTICAL PARTICULARS

6.1 List of excipients

Tablet core:

Cellulose, microcrystalline.

Lactose anhydrous.

Croscarmellose sodium.

Magnesium stearate.

Film-coating:

Hypromellose.

Titanium dioxide (E171).

Triacetin.

Yellow iron oxide (E172)

Indigo carmine aluminium lake (E132).

6.2 Incompatibilities

Not applicable.

6.3 Shelf life 3 years

6.4    Special precautions for storage

This medicinal product does not require any special storage conditions

6.5    Nature and contents of container

Cold form blister pack comprising of aluminium foil laminated to oriented polyamide that is laminated to PVC on the side and plain aluminium foil on the other side with heat seal coating.

The blister packs contain 2, 3, 4, 6, 12, or 18 Naratriptan Film-Coated Tablets. Not all pack sizes may be marketed.

6.6    Special precautions for disposal

No special requirements.

7    MARKETING AUTHORISATION HOLDER

Generics [UK] Ltd t/a Mylan Station Close, Potters Bar Hertfordshire EN6 1TL United Kingdom

8    MARKETING AUTHORISATION NUMBER(S)

PL 04569/1037

9    DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

12/05/2011

10    DATE OF REVISION OF THE TEXT

07/10/2015