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SUMMARY OF PRODUCT CHARACTERISTICS

1    NAME OF THE MEDICINAL PRODUCT

Quetiapine 200 mg Film-coated Tablets

2 QUALITATIVE AND QUANTITATIVE COMPOSITION

Each tablet contains 200 mg of quetiapine as quetiapine fumarate Excipient with known effect:

Lactose

For the 200 mg: 34.2 mg (anhydrous) per tablet For the full list of excipients, see Section 6.1.

3    PHARMACEUTICAL FORM

Film-coated tablet

Quetiapine 200 mg film-coated tablets

White, round, biconvex, film-coated tablet engraved ‘Q’ over ‘200’ on one side.

4    CLINICAL PARTICULARS

4.1    Therapeutic indications

Treatment of schizophrenia.

Treatment of bipolar disorder including::

-    manic episodes associated with bipolar disorder.

-    major depressive episodes in bipolar disorder

-    preventing recurrence in bipolar disorder in patients whose manic, mixed or depressive episode has responded to quetiapine treatment.

4.2 Posology and method of administration

Posology

Different dosing schedules exist for each indication. It must therefore be ensured that patients receive clear information on the appropriate dosage for their condition.

Adults

For the treatment of schizophrenia: Quetiapine should be administered twice a day. The total daily dose for the first four days of therapy is 50 mg (Day 1), 100 mg (Day 2), 200 mg (Day 3) and 300 mg (Day 4). From Day 4 onwards, the dose should be titrated to the usual effective dose of 300 to 450 mg/day. Depending on the clinical response and tolerability of the individual patient, the dose may be adjusted within the range 150 to 750 mg/day.

For the treatment of moderate to severe manic episodes associated with bipolar disorder: Quetiapine should be administered twice a day. As monotherapy or as adjunct therapy to mood stabilisers, the total daily dose for the first four days of therapy is 100 mg (Day 1), 200 mg (Day 2), 300 mg (Day 3) and 400 mg (Day 4). Further dosage adjustments up to 800 mg/day by Day 6 should be in increments of no greater than 200 mg/day.

The dose may be adjusted depending on clinical response and tolerability of the individual patient, within the range of 200 to 800mg/day. The usual effective dose is in the range of 400 to 800mg/day

For the treatment of depressive episodes in bipolar disorder: Quetiapine tablets should be administered once daily at bedtime. The total daily dose for the first four days of therapy is 50 mg (Day 1), 100 mg (Day 2), 200 mg (Day 3) and 300 mg (Day 4). The recommended daily dose is 300 mg. In clinical trials, no additional benefit was seen in the 600 mg group compared to the 300 mg group. Individual patients may benefit from a 600 mg dose. In individual patients, in the event of tolerance concerns, clinical trials have indicated that dose reduction to a minimum of 200 mg could be considered. When treating depressive episodes in bipolar disorder, treatment should be initiated by physicians experienced in treating bipolar disorder.

For preventing recurrence in bipolar disorder: For prevention of recurrence of manic, depressive and mixed episodes in bipolar disorder, patients who have responded to quetiapine for acute treatment of bipolar disorder should continue therapy at the same dose, The dose may be adjusted depending on clinical response and tolerability of the individual patient, within the range of 300 to 800 mg/day administered twice daily. It is important that the lowest effective dose is used for maintenance therapy.

Elderly

As with other antipsychotics and antidepressants, quetiapine should be used with caution in the elderly, especially during the initial dosing period. The rate of dose titration of quetiapine may need to be slower, and the daily therapeutic dose lower, than that used in younger patients, depending on the clinical response and tolerability of the individual patient. The mean plasma clearance of quetiapine was reduced by 30% to 50% in elderly patients when compared to younger patients.

Efficacy and safety has not been evaluated in patients over 65 years with depressive episodes in the framework of bipolar disorder

Paediatric population

Quetiapine is not recommended for use in children and adolescents below 18 years of age, due to a lack of data to support use in this age group. The available evidence from placebo-controlled clinical trials is presented in sections 4.4, 4.8, 5.1 and 5.2.

Renal Impairment

Dosage adjustment is not necessary in patients with renal impairment.

Hepatic Impairment

Quetiapine is extensively metabolised by the liver. Therefore, quetiapine should be used with caution in patients with known hepatic impairment, especially during the initial dosing period. Patients with hepatic impairment should be started with 25 mg/day. The dose can be increased in increments of 25 - 50 mg/day to an effective dose, depending on the clinical response and tolerability of the individual patient.

Method of administration

Quetiapine tablets can be administered with or without food.

4.3 Contraindications

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

Concomitant administration of cytochrome P450 3A4 inhibitors, such as HIV-protease inhibitors, azole-antifungal agents, erythromycin, clarithromycin and nefazodone, is contraindicated (see Section 4.5).

4.4 Special warnings and precautions for use

As quetiapine has several indications, the safety profile should be considered with respect to the individual patient’s diagnosis and the dose being administered.

Paediatric population

Quetiapine is not recommended for use in children and adolescents below 18 years of age, due to a lack of data to support use in this age group. Clinical trials have shown that in addition to the known safety profile identified in adults (see section 4.8), certain adverse events occurred at a higher frequency in children and adolescents compared to adults (increased appetite, elevations in serum prolactin, and extrapyramidal symptoms) and one was identified that has not been previously seen in adult studies (increases in blood pressure). Changes in thyroid function tests have also been observed in children and adolescents.

Furthermore, the long-term safety implications of treatment on growth and maturation have not been studied beyond 26 weeks. Long-term implications for cognitive and behavioural development are not known.

In placebo-controlled clinical trials with children and adolescent patients treated with quetiapine, quetiapine was associated with an increased incidence of extrapyramidal symptoms (EPS) compared to placebo in patients treated for schizophrenia and bipolar mania (see section 4.8).

Suicide/suicidal thoughts or clinical worsening

Depression is associated with an increased risk of suicidal thoughts, self-harm and suicide (suicide-related events). This risk persists until significant remission occurs. As improvement may not occur during the first few weeks or more of treatment, patients should be closely monitored until such improvement occurs. It is general clinical experience that the risk of suicide may increase in the early stages of recovery.

In addition, physicians should consider the potential risk of suicide-related events after abrupt cessation of quetiapine treatment, due to the known risk factors for the disease being treated.

Other psychiatric conditions for which quetiapine is prescribed can also be associated with an increased risk of suicide related events. In addition, these conditions may be co-morbid with major depressive episodes. The same precautions observed when treating patients with major depressive episodes should therefore be observed when treating patients with other psychiatric disorders.

Patients with a history of suicide related events, or those exhibiting a significant degree of suicidal ideation prior to commencement of treatment are known to be at greater risk of suicidal thoughts or suicide attempts, and should receive careful monitoring during treatment. A meta analysis of placebo controlled clinical trials of antidepressant drugs in adult patients with psychiatric disorders showed an increased risk of suicidal behaviour with antidepressants compared to placebo in patients less than 25 years old.

Close supervision of patients and in particular those at high risk should accompany drug therapy especially in early treatment and following dose changes. Patients (and caregivers of patients) should be alerted about the need to monitor for any clinical worsening, suicidal behaviour or thoughts and unusual changes in behaviour and to seek medical advice immediately if these symptoms present.

In shorter-term placebo controlled clinical studies of patients with major depressive episodes in bipolar disorder an increased risk of suicide-related events was observed in young adults patients (younger than 25 years of age) who were treated with quetiapine as compared to those treated with placebo (3.0% vs. 0%, respectively).

Somnolence and dizziness

Quetiapine treatment has been associated with somnolence and related symptoms, such as sedation (see Section 4.8). In clinical trials for treatment of patients with bipolar depression, onset was usually within the first 3 days of treatment and was predominantly of mild to moderate intensity. Bipolar depression patients experiencing somnolence of severe intensity may require more frequent contact for a minimum of 2 weeks from onset of somnolence, or until symptoms improve and treatment discontinuation may need to be considered.

Quetiapine treatment has been associated with orthostatic hypotension and related dizziness (see Section 4.8) which, like somnolence has onset usually during the initial dose-titration period. This could increase the occurrence of accidental injury (fall), especially in the elderly population. Therefore, patients should be advised to exercise caution until they are familiar with the potential effects of the medication.

Cardiovascular

Quetiapine should be used with caution in patients with known cardiovascular disease, cerebrovascular disease, or other conditions predisposing to hypotension. Quetiapine may induce orthostatic hypotension, especially during the initial dose-titration period. This is more common in elderly patients and in younger patients. Dose reduction or more gradual titration should be considered if this occurs. A slower titration regimen could be considered in patients with underlying cardiovascular disease.

Venous Thromboembolism (VTE)

Cases of venous thromboembolism (VTE) have been reported with antipsychotic drugs. Since patients treated with antipsychotics often present with acquired risk factors for VTE, all possible risk factors for VTE should be identified before and during treatment with quetiapine and preventative measures undertaken.

Seizures

In controlled clinical trials there was no difference in the incidence of seizures in patients treated with quetiapine or placebo. No data is available about the incidence of seizures in patients with a history of seizure disorder. As with other antipsychotics, caution is recommended when treating patients with a history of seizures (See Section 4.8).

Extrapyramidal symptoms

In placebo controlled clinical trials of adult patients quetiapine was associated with an increased incidence of extrapyramidal symptoms (EPS) compared to placebo in patients treated for major depressive episodes in bipolar disorder (see Section 4.8 and 5.1).

The use of quetiapine has been associated with the development of akathisia, characterised by a subjectively unpleasant or distressing restlessness and need to move often accompanied by an inability to sit or stand still. This is most likely to occur within the first few weeks of treatment. In patients who develop these symptoms, increasing the dose may be detrimental.

Tardive Dyskinesia

If signs and symptoms of tardive dyskinesia appear, dose reduction or discontinuation of quetiapine should be considered. The symptoms of tardive dyskinesia can worsen or even arise after discontinuation of treatment (see Section 4.8).

Neuroleptic Malignant Syndrome

Neuroleptic malignant syndrome has been associated with antipsychotic treatment, including quetiapine (see Section 4.8). Clinical manifestations include hyperthermia, altered mental status, muscular rigidity, autonomic instability, and increased creatinine phosphokinase. In such an event, quetiapine should be discontinued and appropriate medical treatment given.

Severe Neutropenia

Severe neutropenia (neutrophil count <0.5 x 10⁹/L) has been uncommonly reported in quetiapine clinical trials. Most cases of severe neutropenia have occurred within a couple of months of starting therapy with quetiapine. There was no apparent dose relationship. During post-marketing experience, resolution of leucopenia and/or neutropenia has followed cessation of therapy with quetiapine. Possible risk factors for neutropenia include pre-existing low white cell count (WBC) and history of drug induced neutropenia. Quetiapine should be discontinued in patients with a neutrophil count <1.0 x 10⁹/L. Patients should be observed for signs and symptoms of infection and neutrophil counts followed (until they exceed 1.5 x 10⁹/L) (see Section 5.1).

Weight:

Weight gain has been reported in patients who have been treated with quetiapine, and should be monitored and managed as clinically appropriate as in accordance with utilised antipsychotic guidelines (See Sections 4.8 and 5.1).

Hyperglycaemia

Hyperglycaemia and/ or development or exacerbation of diabetes occasionally associated with ketoacidosis or coma has been reported rarely, including some fatal cases (see section 4.8). In some cases, a prior increase in body weight has been reported which may be a predisposing factor. Appropriate clinical monitoring is advisable in accordance with utilised antipsychotic guidelines. Patients treated with any antipsychotic agent including quetiapine, should be observed for signs and symptoms of hyperglycaemia, (such as polydipsia, polyuria, polyphagia and weakness) and patients with diabetes mellitus or with risk factors for diabetes mellitus should be monitored regularly for worsening of glucose control. Weight should be monitored regularly.

Lipids

Increases in triglycerides, LDL and total cholesterol and decreases in HDL cholesterol have been observed in clinical trials with quetiapine (see Section 4.8). Lipid changes should be managed as clinically appropriate.

Metabolic Risk

Given the observed changes in weight, blood glucose (see hyperglycaemia) and lipids seen in clinical studies, patients (including those with normal baseline values) may experience worsening of their metabolic risk profile, which should be managed as clinically appropriate (see also section 4.8).

QT Prolongation

In clinical trials and use in accordance with the SPC, quetiapine was not associated with a persistent increase in absolute QT intervals. In post-marketing, QT prolongation was reported with quetiapine at the therapeutic doses (see Section 4.8) and in overdose (see Section 4.9). As with other antipsychotics, caution should be exercised when quetiapine is prescribed in patients with cardiovascular disease or family history of QT prolongation. Also caution should be exercised when quetiapine is prescribed either with medicines known to increase QT interval, or with concomitant neuroleptics, especially in the elderly, in patients with congenital long

QT syndrome, congestive heart failure, heart hypertrophy, hypokalaemia or hypomagnesaemia (see Section 4.5).

Pancreatitis

Pancreatitis has been reported in clinical trials and during the post marketing experience, however a causal relationship has not been established. Among the post marketing reports, many patients had factors which are known to be associated with pancreatitis such as increased triglycerides (see Section 4.4 Lipids), gallstones, and alcohol consumption.

Hepatic effects

If jaundice develops, quetiapine should be discontinued.

Dysphagia

Dysphagia (see Section 4.8) has been reported with quetiapine. Quetiapine should be used with caution in patients at risk for aspiration pneumonia.

Withdrawal

Acute withdrawal symptoms such as insomnia, nausea, headache, diarrhoea, vomiting, dizziness, and irritability have been described after abrupt cessation of quetiapine. Gradual withdrawal over a period of at least one to two weeks is advisable (see Section 4.8).

Interactions See also Section 4.5.

Concomitant use of quetiapine with a strong hepatic enzyme inducer such as carbamazepine or phenytoin substantially decreases quetiapine plasma concentrations, which could affect the efficacy of quetiapine therapy. In patients receiving a hepatic enzyme inducer, initiation of quetiapine should only occur if the physician considers that the benefits of quetiapine outweigh the risks of removing the hepatic enzyme inducer. It is important that any change in the inducer is gradual, and if required, replaced with a non-inducer (e.g. sodium valproate).

Additional information

Quetiapine data in combination with divalproex or lithium in acute moderate to severe manic episodes is limited; however, combination therapy was well tolerated (see Sections 4.8 and 5.1). The data showed an additive effect at week 3.

Elderly patients with dementia-related psychosis

Quetiapine is not approved for the treatment of dementia-related psychosis.

An approximately 3-fold increased risk of cerebrovascular adverse events has been seen in randomised placebo controlled trials in the dementia population with some atypical antipsychotics. The mechanism for this increased risk is not known. An increased risk cannot be excluded for other antipsychotics or other patient populations. Quetiapine should be used with caution in patients with risk factors for stroke.

In a meta-analysis of atypical antipsychotic medicinal products, it has been reported that elderly patients with dementia-related psychosis are at an increased risk of death compared to placebo. However in two 10-week placebo-controlled quetiapine studies in the same patient population (n=710; mean age: 83 years; range: 56-99 years) the incidence of mortality in quetiapine-treated patients was 5.5% versus 3.2% in the placebo group. The patients in these trials died from a variety of causes that were consistent with expectations for this population. These data do not establish a causal relationship between quetiapine treatment and death in elderly patients with dementia.

Lactose

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

4.5 Interaction with other medicinal products and other forms of interaction

Given the primary central nervous system effects, quetiapine should be used with caution in combination with other centrally acting medicinal products and alcohol.

Cytochrome P450 (CYP) 3A4 is the enzyme that is primarily responsible for the cytochrome P450 mediated metabolism of quetiapine. In an interaction study in healthy volunteers, concomitant administration of quetiapine (dosage of 25 mg) with ketoconazole, a CYP3A4 inhibitor, caused a 5- to 8-fold increase in the AUC of quetiapine. On the basis of this, concomitant use of quetiapine with CYP3A4 inhibitors is contraindicated. It is also not recommended to consume grapefruit juice while on quetiapine therapy.

In a multiple dose trial in patients to assess the pharmacokinetics of quetiapine given before and during treatment with carbamazepine (a known hepatic enzyme inducer), co-administration of carbamazepine significantly increased the clearance of quetiapine. This increase in clearance reduced systemic quetiapine exposure (as measured by AUC) to an average of 13% of the exposure during administration of quetiapine alone; although a greater effect was seen in some patients. As a consequence of this interaction, lower plasma concentrations can occur, which could affect the efficacy of quetiapine therapy.

Co-administration of quetiapine and phenytoin (another microsomal enzyme inducer) caused a greatly increased clearance of quetiapine by approx. 450%. In patients receiving a hepatic enzyme inducer, initiation of quetiapine treatment should only occur if the physician considers that the benefits of quetiapine outweigh the risks of removing the hepatic enzyme inducer. It is important that any change in the inducer is gradual, and if required, replaced with a non-inducer (e.g. sodium valproate) (see also Section 4.4).

The pharmacokinetics of quetiapine were not significantly altered by coadministration of the antidepressants imipramine (a known CYP 2D6 inhibitor) or fluoxetine (a known CYP 3A4 and CYP 2D6 inhibitor).

The pharmacokinetics of quetiapine were not significantly altered by coadministration of the antipsychotics risperidone or haloperidol. Concomitant use of quetiapine and thioridazine caused an increased clearance of quetiapine with approx. 70%.

The pharmacokinetics of quetiapine were not altered following co-administration with cimetidine.

The pharmacokinetics of lithium were not altered when co-administered with quetiapine.

The pharmacokinetics of sodium valproate and quetiapine were not altered to a clinically relevant extent when co-administered. A retrospective study of children and adolescents who received valproate, quetiapine, or both, found a higher incidence of leucopenia and neutropenia in the combination group versus the monotherapy groups.

Formal interaction studies with commonly used cardiovascular medicinal products have not been performed.

Caution should be exercised when quetiapine is used concomitantly with medicinal products known to cause electrolyte imbalance or to increase QT interval.

There have been reports of false positive results in enzyme immunoassays for methadone and tricyclic antidepressants in patients who have taken quetiapine. Confirmation of questionable immunoassay screening results by an appropriate chromatographic technique is recommended.

Paediatric population

Interaction studies have only been performed in adults.

4.6 Fertility, pregnancy and lactation

Pregnancy

The safety and efficacy of quetiapine during human pregnancy have not yet been established. Up to now there are no indications for harmfulness in animal tests, possible effects on the foetal eye have not been examined, though. Therefore, quetiapine should only be used during pregnancy if the benefits justify the potential risks. Following pregnancies in which quetiapine was used, neonatal withdrawal symptoms were observed.

Neonates exposed to antipsychotics (including quetiapine) during the third trimester of pregnancy are at risk of adverse reactions including extrapyramidal and /or withdrawal symptoms that may vary in severity and duration following delivery.

There have been reports of agitation, hypertonia, hypotonia, tremor, somnolence, respiratory distress, or feeding disorder. Consequently, newborns should be monitored carefully.

Breast-feeding

There have been published reports of quetiapine excretion into human breast milk, however the degree of excretion was not consistent. Women who are breast-feeding should therefore be advised to avoid breast-feeding while taking quetiapine.

4.7 Effects on ability to drive and use machines

Given its primary central nervous system effects, quetiapine may interfere with activities requiring mental alertness. Therefore, patients should be advised not to drive or operate machinery, until individual susceptibility to this is known.

4.8 Undesirable effects

The most commonly reported Adverse Drug Reactions (ADRs) with quetiapine are somnolence, dizziness, dry mouth, mild asthenia, constipation, tachycardia, orthostatic hypotension and dyspepsia.

As with other antipsychotics, weight gain, syncope, neuroleptic malignant syndrome, leucopenia, neutropenia and peripheral oedema, have been associated with quetiapine.

The incidences of ADRs associated with quetiapine therapy, are tabulated below according to the format recommended by the Council for International Organisations of Medical Sciences (CIOMS III Working Group; 1995).

Decreased haemoglobin²³

Leucopenia ^{1 29}, Decreased neutrophil count, Eosinophils increased²⁸ Thrombocytopenia, Anaemia, Platelet count decreased¹⁴ Agranulocytosis²⁷ Neutropenia ¹ Immune system disorders

Uncommon:    Hypersensitivity (including allergic skin reactions)

Very rare:    Anaphylactic reaction⁶

Endocrine disorders

Hyperprolactinaemia¹⁶, Decreases in Total T₄²⁵, Decreases in Free T.

Decreases in free T₃ , Hypothyroidism Inappropriate antidiuretic hormone secretion

Metabolism and nutrition disorders

Very common:    Elevations in serum triglyceride level¹¹’³¹

Elevations in total cholesterol (predominantly LDL cholesterol)¹ Decrease in HDL cholesterol^18,31 , Weight gain ^9,13 Increased appetite, blood glucose increased to hyperglycaemic

Hyponatraemia, Diabetes Mellitus Metabolic syndrome³⁰

Common:    Abnormal dreams and nightmares

Suicidal ideation and suicidal behaviour²¹

Rare:    Somnambulism and related reactions such as sleep talking and sleep

_related eating disorder_

Nervous system disorders

Very Common:    Dizziness ^{4 17}, somnolence ^{2 17}, headache

Common:    Syncope ^{4 17}, Extrapyramidal symptoms ^{1 22}, Dysarthria

Uncommon:    Seizure ¹, Restless legs syndrome, Tardive dyskinesia^{1, 6}

Eye Disorders Common:	Vision blurred
Cardiac disorders
Common: Uncommon:	Tachycardia 4, Palpitations24 QT prolongation 11319 Bradycardia33
Vascular disorders
Common:	Orthostatic hypotension 417
Rare:	Venous thromboembolism1 2 3

Respiratory, thoracic and mediastinal disorder Common:_Rhinitis, Dyspnoea²⁴_

Gastrointestinal disorders

Very common: Dry mouth

Common:    Constipation,    dyspepsia,    vomiting²⁶

Uncommon:    Dysphagia⁸

Rare:    Pancreatitis¹

Hepatobiliary disorders

Common:    Elevations in serum transaminases (ALT, AST)^{4 5 6 7 8}, Elevations in gamma-

GT levels³

Rare:_Jaundice ⁶, Hepatitis_

Skin and subcutaneous tissue disorders

Very rare:    Angioedema ⁶, Stevens-Johnson syndrome⁶

Not known: Toxic Epidermal Necrolysis, Erythema Multiforme_

Musculoskeletal and connective tissue disorder

Very rare:_Rhabdomyolysis_

Pregnancy, puerperium and perinatal conditions

Not known:    Drug withdrawal syndrome neonatal³²_

Reproductive system and breast disorders Uncommon:    Sexual dysfunction

Rare:    Priapism, galactorrhoea, breast swelling, menstrual disorder

General disorders and administration site conditions Very common Withdrawal (discontinuation) symptoms ¹¹⁰ Common:    Mild asthenia, peripheral oedema, irritability, pyrexia

8.    An increase in the rate of dysphagia with quetiapine vs. placebo was only observed in the clinical trials in bipolar depression.

9.    Based on > 7% increase in body weight from baseline. Occurs predominantly during the early weeks of treatment.

10.    The following withdrawal symptoms have been observed most frequently in acute placebo-controlled, monotherapy clinical trials, which evaluated discontinuation symptoms: insomnia, nausea, headache, diarrhoea, vomiting, dizziness, and irritability. The incidence of these reactions had decreased significantly after 1 week post-discontinuation.

11.    Triglycerides >200mg/dL (>2.258 mmol/L) (patients >18 years of age) or >150 mg/dL (>1.694 mmol/L) (patients <18 years of age) on at least one occasion.

12.    Cholesterol >240mg/dL (>6.2064 mmol/L) (patients >18 years of age) or >200 mg/dL (>5.172 mmol/L) (patients <18 years of age) on at least one occasion. An increase in LDL cholesterol of >30 mg/dL (>0.769mmol/L) has been very commonly observed. Mean change among patients who had this increase was 41.7 mg/dL (>1.07 mmol/L).

13.    See text below

14.    Platelets <100 x 10⁹ /L on at least one occasion

15.    Based on clinical trial adverse event reports of blood creatine phosphokinase increase not associated with neuroleptic malignant syndrome

16.    Prolactin levels (patients >18 years of age): >20pg/L (>869.56pmol/L) males; >30 pg/L (>1304.34 pmol/L) females at any time

17.    May lead to falls

18.    HDL cholesterol: <40mg/dL (1.025mmol/L) males; <50mg/dL (1.282 mmol/L) females at any time.

19.    Incidence of patients who have a QTc shift from <450 msec to >450 msec with a >30 msec increase. In placebo-controlled trials with quetiapine the mean change and the incidence of patients who have a shift to a clinically significant level is similar between quetiapine and placebo

20.    Shift from >132 mmol/L to <132 mmol/L on at least one occasion

21.    Cases of suicidal ideation and suicidal behaviours have been reported during quetiapine therapy or early after treatment discontinuation (see Sections 4.4 and 5.1).

22.    See Section 5.1

23.    Decreased haemoglobin to <13 g/dL (8.07 mmol/L) males, <12 g/dL (7.45 mmol/L) females on at least one occasion occurred in 11% of quetiapine patients in all trials including open label extensions. For these patients, the mean maximum decrease in haemoglobin at any time was -1.50 g/dL.

24.    These reports often occurred in the setting of tachycardia, dizziness, orthostatic hypotension, and/or underlying cardiac/respiratory disease.

25.    Based on shifts from normal baseline to potentially clinically important value at anytime post-baseline in all trials. Shifts in total T4, free T4, total T3 and free T3 are defined as <0.8 x LLN (pmol/L) and shift in TSH is > 5 mlU/L at any time.

26.    Based upon the increased rate of vomiting in elderly patients (>65 years of age).

27.    Shift in neutrophils from >=1.5 x 10^A9/L at baseline to <0.5 x 10^A9/L at any time during treatment.

28.    Based on shifts from normal baseline to potentially clinically important value at anytime post-baseline in all trials. Shifts in eosinophils are defined as >1x 10⁹ cells/L at any time.

29.    Based on shifts from normal baseline to potentially clinically important value at anytime post-baseline in all trials. Shifts in WBCs are defined as < 3X10⁹cells/L at any time.

30.    Based on adverse event reports of metabolic syndrome from all clinical trials with quetiapine.

31.    In some patients, a worsening of more than one of the metabolic factors of weight, blood glucose and lipids was observed in clinical studies (See Section 4.4).

32.    See section 4.6

33.    May occur at or near initiation of treatment and be associated with hypotension and/or syncope. Frequency based on adverse reports of bradycardia and related events in all clinical trials with quetiapine.

Cases of QT prolongation, ventricular arrhythmia, sudden unexplained death, cardiac arrest and torsades de pointes have been reported very rarely with the use of neuroleptics and are considered class effects (see Section 4.4).

Paediatric population

The same ADRs described above for adults should be considered for children and adolescents. The following table summarises ADRs that occur in a higher frequency category in children and adolescents patients (10-17 years of age) than in the adult population or ADRs that have not been identified in the adult population.

Overdose

In general, reported signs and symptoms were those resulting from an exaggeration of the active substance's known pharmacological effects, i.e., drowsiness and sedation, tachycardia and hypotension.

Fatal outcome has been reported in clinical trials following an acute overdose at 13.6 grams, and in post-marketing on doses as low as 6 grams of quetiapine alone. However, survival has also been reported following acute overdoses of up to 30 grams. In post-marketing experience, there have been reports of overdose of quetiapine alone resulting in death or coma. Additionally, the following events have been reported in the setting of monotherapy overdose with quetiapine: QT-prolongation, seizures, status epilepticus, rhabdomyolysis, respiratory depression, urinary retention, confusion, delirium, and/or agitation.

Patients with pre-existing severe cardiovascular disease may be at an increased risk of the effects of overdose (see Section 4.4).

Management of overdose

There is no specific antidote to quetiapine. In cases of severe signs, the possibility of multiple drug involvement should be considered, and intensive care procedures are recommended, including establishing and maintaining a patent airway, ensuring adequate oxygenation and ventilation, and monitoring and support of the cardiovascular system. Whilst the prevention of absorption in overdose has not been investigated, gastric lavage can be indicated in severe poisoning and if possible to perform within one hour of ingestion. The administration of activated charcoal should be considered.

In cases of quetiapine overdose, refractory hypotension should be treated with appropriate measures such as intravenous fluids and/or sympathomimetic agents. Epinephrine and dopamine should be avoided, since beta stimulation may worsen hypotension in the setting of quetiapine-induced alpha blockade.

Close medical supervision and monitoring should be continued until the patient recovers.

5 PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Antipsychotics; Diazepines, oxazepines and thiazepines ATC code: N05A H04

Mechanism of Action

Quetiapine is an atypical antipsychotic agent. Quetiapine and the active human plasma metabolite, norquetiapine interact with a broad range of neurotransmitter receptors. Quetiapine and norquetiapine exhibit affinity for brain serotonin (5HT₂) and dopamine D₁- and D₂- receptors. It is this combination of receptor antagonism with a higher selectivity for 5HT₂ relative to dopamine D₂- receptors, which is believed to contribute to the clinical antipsychotic properties and low extrapyramidal side effect (EPS) liability of quetiapine compared to typical antipsychotics. Additionally, nor quetiapine has high affinity for the norepinephrine transporter (NET). Quetiapine and nor quetiapine also have high affinity at histaminergic and adrenergic a1 receptors, with a lower affinity at adrenergic a₂ and serotonin 5HT₁A receptors. Quetiapine has no appreciable affinity at cholinergic muscarinic or benzodiazepine receptors.

Pharmacodynamic Effect

Quetiapine is active in tests for antipsychotic activity, such as conditioned avoidance. It also blocks the action of dopamine agonists, measured either behaviourally or electrophysiologically, and elevates dopamine metabolite concentrations, a neurochemical index of D₂-receptor blockade.

In pre-clinical tests predictive of EPS, quetiapine is unlike typical antipsychotics and has an atypical profile. Quetiapine does not produce dopamine D₂-receptor supersensitivity after chronic administration. Quetiapine produces only weak catalepsy at effective dopamine D₂-receptor blocking doses. Quetiapine demonstrates selectivity for the limbic system by producing depolarisation blockade of the A10 mesolimbic but not the A9 nigrostriatal dopamine-containing neurones following chronic administration. Quetiapine exhibits minimal dystonic liability in haloperidol-sensitised or drug-naive Cebus monkeys after acute and chronic administration. The results of these tests predict that quetiapine should have minimal EPS liability, and it has been hypothesised that agents with a lower EPS liability may also have a lower liability to produce tardive dyskinesia (see Section 4.8). The extent to which the nor quetiapine metabolite contributes to the pharmacological activity of Quetiapine in humans is not known.

Clinical Efficacy Schizophrenia

The results of three placebo-controlled clinical trials, in patients with schizophrenia, including one that used a dose range of quetiapine of 75 to 750 mg/day identified no difference between the quetiapine and placebo treatment groups in the incidence of EPS or concomitant use of anticholinergics. The long-term efficacy of quetiapine IR in prevention of schizophrenic relapses has not been verified in blinded clinical trials. In open label trials, in patients with schizophrenia, quetiapine was effective in maintaining the clinical improvement during continuation therapy in patients who showed an initial treatment response, suggesting some long-term efficacy.

Bipolar DisorderIn four placebo-controlled clinical trials, evaluating doses of quetiapine up to 800 mg/day for the treatment of bipolar mania, two each in monotherapy and as adjunct therapy to lithium or valproate semisodium, there were no differences between the quetiapine and placebo treatment groups in the incidence of EPS or concomitant use of anticholinergics.

In clinical trials, quetiapine has been shown to be effective in the treatment of both positive and negative symptoms of schizophrenia, In one trial against chlorpromazine, and two against haloperidol, quetiapine showed similar short-term efficacy.

In clinical trials, quetiapine has been shown to be effective as monotherapy or as adjunct therapy in reducing manic symptoms in patients with bipolar mania. The mean last week median dose of quetiapine in responders, was approximately 600 mg and approximately 85% of the responders were in the dose range of 400 to 800 mg per day.

Unlike many other antipsychotics, quetiapine does not produce sustained elevations in prolactin, which is considered a feature of atypical antipsychotics. In a multiple fixed-dose clinical trial, in patients with schizophrenia, there were no differences in prolactin levels at study completion, for quetiapine across the recommended dose range, and placebo.

In 4 clinical trials in patients with depressive episodes in bipolar I or bipolar II disorder, with or without rapid cycling courses, 51% of quetiapine treated patients had at least a 50% improvement in MADRS total score at week 8 compared to 37% of the placebo treated patients. The anti-depressant effect was significant at Day 8 (week 1). There were fewer episodes of treatment emergent mania with quetiapine than with placebo.

In continuation treatment, the anti-depressant effect was maintained for patients on quetiapine (mean duration of treatment 30 weeks). Quetiapine reduced the risk of recurrent mood (manic and depressed) event by 49%. Quetiapine was superior to placebo in treating the anxiety symptoms associated with bipolar depression as assessed by mean change from baseline to week 8 in HAM-A total score.

In one long-term study (up to 2 years treatment, mean quetiapine exposure 191 days) evaluating recurrence prevention in patients with manic, depressed or mixed mood episodes quetiapine was superior to placebo in increasing the time to recurrence of any mood event (manic, mixed or depressed), in patients with bipolar I disorder. The number of patients with a mood event was 91 (22.5%) in the quetiapine group, 208 (51.5%) in the placebo group and 95 (26.1%) in the lithium treatment groups respectively. In patients who responded to quetiapine, when comparing continued treatment with quetiapine to switching to lithium, the results indicated that a switch to lithium treatment does not appear to be associated with an increased time to recurrence of a mood event.

In two recurrence prevention studies evaluating quetiapine in combination with mood stabilisers, in patients with manic, depressed or mixed mood episodes, the combination with quetiapine was superior to mood stabilisers monotherapy in increasing the time to recurrence of any mood event (manic, mixed or depressed).

The risk of a recurrent event was reduced by 70%. Quetiapine was administered twice-daily totalling 400 mg to 800 mg a day as combination therapy to lithium or valproate.

Clinical safety

In short-term, placebo-controlled clinical trials in schizophrenia and bipolar mania the aggregated incidence of extrapyramidal symptoms was similar to placebo (schizophrenia: 7.8% for quetiapine and 8.0% for placebo; bipolar mania: 11.2% for quetiapine and 11.4% for placebo). Higher rates of extrapyramidal symptoms were seen in quetiapine treated patients compared to those treated with placebo in shortterm, placebo-controlled clinical trials in MDD and bipolar depression. In short-term, placebo-controlled bipolar depression trials the aggregated incidence of extrapyramidal symptoms was 8.9% for quetiapine compared to 3.8% for placebo. In short-term, placebo-controlled monotherapy clinical trials in major depressive disorder the aggregated incidence of extrapyramidal symptoms was 5.4% for Quetiapine Prolonged-Release Tablets and 3.2% for placebo. In a short-term placebo-controlled monotherapy trial in elderly patients with major depressive disorder, the

aggregated incidence of extrapyramidal symptoms was 9.0% for Quetiapine Prolonged-Release Tablets and 2.3% for placebo. In both bipolar depression and MDD, the incidence of the individual adverse events (eg, akathisia, extrapyramidal disorder, tremor, dyskinesia, dystonia, restlessness, muscle contractions involuntary, psychomotor hyperactivity and muscle rigidity) did not exceed 4% in any treatment group. In long-term studies of schizophrenia and bipolar disorder the aggregated incidence of treatment-emergent extrapyramidal symptoms was similar between quetiapine and placebo.

In short term, fixed dose (50mg/d to 800 mg/d), placebo-controlled studies (ranging from 3 to 8 weeks), the mean weight gain for quetiapine-treated patients ranged from 0.8 kg for the 50 mg daily dose to 1.4 kg for the 600 mg daily dose (with lower gain for the 800 mg daily dose), compared to 0.2 kg for the placebo treated patients. The percentage of quetiapine treated patients who gained £7% of body weight ranged from 5.3% for the 50 mg daily dose to 15.5% for the 400 mg daily dose (with lower gain for the 600 and 800 mg daily doses), compared to 3.7% for placebo treated patients.

Longer term relapse prevention trials had an open label period (ranging from 4 to 36 weeks) during which patients were treated with quetiapine, followed by a randomized withdrawal period during which patients were randomized to quetiapine or placebo. For patients who were randomized to quetiapine, the mean weight gain during the open label period was 2.56 kg, and by week 48 of the randomized period, the mean weight gain was 3.22 kg, compared to open label baseline. For patients who were randomized to placebo, the mean weight gain during the open label period was 2.39 kg, and by week 48 of the randomized period the mean weight gain was 0.89 kg, compared to open label baseline.

In placebo-controlled studies in elderly patients with dementia-related psychosis, the incidence of cerebrovascular adverse events per 100 patient years was not higher in quetiapine-treated patients than in placebo-treated patients

In all short-term placebo-controlled monotherapy trials in patients with a baseline neutrophil count > 1.5 x 10⁹/L, the incidence of at least one occurrence of neutrophil count <1.5 x 10⁹/L, was 1.9% in patients treated with quetiapine compared to 1.3% in placebo-treated patients. The incidence of shifts to >0.5 - <1.0 X 1⁹/L was the same (0.2%) in patients treated with quetiapine as with placebo-treated patients.In all clinical trials (placebo-controlled, open-label, active comparator; patients with a baseline neutrophil count >1.5 x 10⁹/L), the incidence of at least one occurrence of neutrophil count <0.5 x 10⁹/L was 0.21% in patients treated with quetiapine. and 0% in placebo treated patients and the incidence >0.5 - <1.0 x 10⁹/L was 0.75% in patients treated with quetiapine and 0.11% in placebo-treated patients.

In fixed dose short-term placebo-controlled clinical trials, quetiapine treatment was associated with dose-related decreases in thyroid hormone levels. In short-term placebo-controlled clinical trials, the incidence of potentially clinically significant shifts in thyroid hormone levels were: total T4: 3.4% for quetiapine versus 0.6% for placebo; free T4: 0.7% for quetiapine versus 0.1% for placebo; total T3: 0.54% for quetiapine versus 0.0% for placebo and free T3: 0.2% for quetiapine versus 0.0% for placebo. The incidence of shifts in TSH was 3.2% for quetiapine versus 2.7% for placebo. In short-term placebo-controlled monotherapy trials, the incidence of reciprocal, potentially clinically significant shifts in T3 and TSH was 0.0% for both quetiapine and placebo and 0.1% for quetiapine versus 0.0% for placebo for shifts in T4 and TSH. These changes in thyroid hormone levels are generally not associated with clinically symptomatic hypothyroidism. The reduction in total and free T4 was

maximal within the first six weeks of quetiapine treatment, with no further reduction during long-term treatment. In nearly all cases, cessation of quetiapine treatment was associated with a reversal of the effects on total and free T4, irrespective of the duration of treatment. In eight patients, where TBG was measured, levels of TBG were unchanged.

Cataracts/lens opacities

In a clinical trial to evaluate the cataractogenic potential of quetiapine (200-800 mg/day) versus risperidone (2-8 mg) in patients with schizophrenia or schizoaffective disorder, the percentage of patients with increased lens opacity grade was not higher in quetiapine (4%) compared with risperidone (10%), for patients with at least 21 months of exposure.

Paediatric _ population

The efficacy and safety of quetiapine was studied in a 3-week placebo controlled study for the treatment of mania (n= 284 patients from the US, aged 10-17). About 45% of the patient population had an additional diagnosis of ADHD. In addition, a 6-week placebo controlled study for the treatment of schizophrenia (n = 222 patients, aged 13-17) was performed. In both studies, patients with known lack of response to quetiapine were excluded. Treatment with quetiapine was initiated at 50 mg/day and on day 2 increased to 100 mg/day; subsequently the dose was titrated to a target dose (mania 400-600 mg/day; schizophrenia 400-800 mg/day) using increments of 100 mg/day given two or three times daily.

In the mania study, the difference in LS mean change from baseline in YMRS total score (active minus placebo) was -5.21 for quetiapine 400 mg/day and -6.56 for quetiapine 600 mg/day. Responder rates (YMRS improvement >50%) were 64% for quetiapine 400 mg/day, 58% for 600 mg/day and 37% in the placebo arm.

In the schizophrenia study, the difference in LS mean change from baseline in PANSS total score (active minus placebo) was -8.16 for Quetiapine 400 mg/day and -9.29 for quetiapine 800 mg/day. Neither low dose (400 mg/day) nor high dose regimen (800 mg/day) quetiapine was superior to placebo with respect to the percentage of patients achieving response, defined as >30% reduction from baseline in PANSS total score. Both in mania and schizophrenia higher doses resulted in numerically lower response rates.

No data are available on maintenance of effect or recurrence prevention in this age group.

A 26-week open-label extension to the acute trials (n= 380 patients), with quetiapine flexibly dosed at 400-800 mg/day, provided additional safety data. Increases in blood pressure were reported in children and adolescents and increased appetite, extrapyramidal symptoms and elevations in serum prolactin were reported with higher frequency in children and adolescents than in adult patients (see sections 4.4 and 4.8).

Extrapyramidal Symptoms

In a short-term placebo-controlled monotherapy trial in adolescent patients (13-17 years of age) with schizophrenia, the aggregated incidence of extrapyramidal symptoms was 12.9% for quetiapine and 5.3% for placebo, though the incidence of the individual adverse events (e.g. akathisia, tremor, extrapyramidal disorder, hypokinesia, restlessness, psychomotor hyperactivity, muscle rigidity, dyskinesia) did not exceed 4.1% in any treatment group. In a short-term placebo-controlled monotherapy trial in children and adolescent patients (10-17 years of age) with

bipolar mania, the aggregated incidence of extrapyramidal symptoms was 3.6% for quetiapine and 1.1% for placebo. In a long-term open label study of schizophrenia and bipolar mania, the aggregated incidence of treatment-emergent EPS was 10%.

Weight Gain

In short-term clinical trials in paediatric patients (10-17 years of age), 17% of quetiapine-treated patients and 2.5% of placebo-treated patients gained >7% of their body weight. When adjusting for normal growth over longer term, an increase of at least 0.5 standard deviation from baseline in Body Mass Index (BMI) was used as a measure of a clinically significant change; 18.3% of patients who were treated with quetiapine for at least 26 weeks met this criterion.

Suicide/Suicidal thoughts or Clinical worsening

In short-term placebo-controlled clinical trials in paediatric patients with schizophrenia, the incidence of suicide related events was 1.4% (2/147) for quetiapine and 1.3% (1/75) for placebo in patients <18 years of age. In short-term placebo-controlled trials in paediatric patients with bipolar mania, the incidence of suicide related events was 1.0% (2/193) for quetiapine and 0% (0/90) for placebo in patients <18 years of age.

5.2 Pharmacokinetic properties

Absorption

Quetiapine is well absorbed and extensively metabolised following oral administration. The bioavailability of quetiapine is not significantly affected by administration with food.

Distribution

Quetiapine is approximately 83% bound to plasma proteins.

Biotransformation

Steady-state peak molar concentrations of the active metabolite nor quetiapine are 35% of that observed for quetiapine.

Clinical trials have demonstrated that quetiapine is effective when given twice a day. This is further supported by data from a positron emission tomography (PET) study which identified that 5HT₂ and D₂ receptor occupancy are maintained for up to 12 hours after dosing with quetiapine. The safety and efficacy of doses greater than 800 mg/day have not been evaluated.

Metabolism

Quetiapine is extensively metabolised by the liver, with parent compound accounting for less than 5% of unchanged drug-related material in the urine or faeces, following the administration of radiolabelled quetiapine. Approximately 73% of the radioactivity is excreted in the urine and 21% in the faeces.

In vitro investigations established that CYP3A4 is the primary enzyme responsible for cytochrome P450 mediated metabolism of quetiapine. Nor quetiapine is primarily formed and eliminated via CYP3A4.

In a multiple-dose trial in healthy volunteers to assess the pharmacokinetics of quetiapine given before and during treatment with ketoconazole, co-administration of ketoconazole resulted in an increase in mean C_max and AUC of quetiapine of 235% and 522%, respectively, with a corresponding decrease in mean oral clearance of 84%. The mean half-life of quetiapine increased from 2.6 to 6.8 hours, but the mean tm_ax was unchanged.

Quetiapine and several of its metabolites (including nor quetiapine) were found to be weak inhibitors of human cytochrome P450 1A2, 2C9, 2C19, 2D6 and 3A4 activities in vitro. In vitro CYP inhibition is observed only at concentrations approximately 5 to 50 fold higher than those observed at a dose range of 300 to 800 mg/day in humans. Based on these in vitro results, it is unlikely that co-administration of quetiapine with other medicinal products will result in clinically significant medicinal product inhibition of cytochrome P450 mediated metabolism of the other drug. From animal studies it appears that quetiapine can induce cytochrome P450 enzymes. In a specific interaction study in psychotic patients, however, no increase in the cytochrome P450 activity was found after administration of quetiapine.

Elimination

The elimination half lives of quetiapine and nor quetiapine are approximately 7 and 12 hours, respectively.

The average molar dose fraction of free quetiapine and the active human plasma metabolite nor quetiapine is <5% excreted in the urine.

Linearity/non-linearity

The pharmacokinetics of quetiapine and N-desalkyl quetiapine are linear across the approved dosing range.

Special populations

Gender

The kinetics of quetiapine do not differ between men and women.

Elderly patients

The mean clearance of quetiapine in the elderly is approximately 30 to 50% lower than that seen in adults aged 18 to 65 years.

Renal impairment

The mean plasma clearance of quetiapine was reduced by approximately 25% in subjects with severe renal impairment (creatinine clearance less than 30 ml/min/1.73m²), but the individual clearance values are within the range for normal subjects.

Hepatic impairment

The mean quetiapine plasma clearance decreases with approx. 25% in persons with known hepatic impairment (stable alcohol cirrhosis). As quetiapine is extensively metabolised by the liver, elevated plasma levels are expected in the population with hepatic impairment. Dose adjustments may be necessary in these patients (see Section 4.2).

Paediatric population

Children and adolescents (10 to 17 years of age)

Pharmacokinetic data were sampled in 9 children aged 10-12 years old and 12 adolescents, who were on steady-state treatment with 400 mg quetiapine twice daily. At steady-state, the dose-normalised plasma levels of the parent compound, quetiapine, in children and adolescents (10-17 years of age) were in general similar to adults, though C_max in children was at the higher end of the range observed in adults. The AUC and Cmax for the active metabolite, norquetiapine, were higher, approximately 62% and 49% in children (10-12 years), respectively and 28% and 14% in adolescents (13-17 years), respectively, compared to adults.

5.3 Preclinical safety data

There was no evidence of genotoxicity in a series of in vitro and in vivo genotoxicity studies.

In laboratory animals at a clinically relevant exposure level the following deviations were seen, which as yet have not been confirmed in long-term clinical research:

In rats, pigment deposition in the thyroid gland has been observed; in cynomolgus monkeys thyroid follicular cell hypertrophy, a lowering in plasma T3 levels, decreased haemoglobin concentration and a decrease of red and white blood cell count have been observed; and in dogs lens opacity and cataracts. (For cataracts/lens opacities, see section 5.1)

Taking these findings into consideration, the benefits of the treatment with quetiapine need to be balanced against the safety risks for the patient.

6    PHARMACEUTICAL PARTICULARS

6.1    List of excipients

Tablet core

Lactose monohydrate Microcrystalline cellulose Povidone 30 Magnesium stearate Sodium starch glycolate (Type A)

Calcium hydrogen phosphate dihydrate

Tablet coating Hypromellose Titanium dioxide (E171)

In addition, the 200 mg tablets contain: Macrogol 400

Polysorbate 80

6.2 Incompatibilities

Not applicable.

6.3 Shelf life

36 months

6.4 Special precautions for storage

This medicinal product does not require any special storage conditions.

6.5 Nature and contents of container

PVC/PVdC Aluminium Blisters

1, 3, 6, 7, 10, 14, 20, 28, 30, 50, 56, 60, 84, 90, 98, 100 tablets per pack. Not all pack sizes may be marketed

HDPE Bottles with PP Caps

60, 84, 90, 98, 100, 250, 500, 1000 tablets per bottle.

Not all pack sizes may be marketed.

6.6 Special precautions for disposal

No special requirements.

7 MARKETING AUTHORISATION HOLDER

Generics [UK] Limited t/a Mylan

Station Close

Potters Bar

Hertfordshire

EN6 1TL

United Kingdom

8    MARKETING AUTHORISATION NUMBER(S)

PL 04569/1041

9    DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

24/06/2012

10    DATE OF REVISION OF THE TEXT

17/01/2014

1

Rare:_Neuroleptic malignant syndrome ² Hypothermia

Investigations

Rare    Elevations in blood creatine phosphokinase ¹⁵

2

   See Section 4.4.

3

   Somnolence may occur, usually during the first two weeks of treatment and generally resolves with the continued administration of quetiapine.

4

   Asymptomatic elevations (shift from normal to > 3X ULN at any time) in serum transaminase (ALT, AST) or gamma-GT-levels have been observed in some patients administered quetiapine. These elevations were usually reversible on continued quetiapine treatment.

5

   As with other antipsychotics with alphai adrenergic blocking activity, quetiapine may commonly induce orthostatic hypotension, associated with dizziness, tachycardia and, in some patients, syncope, especially during the initial dose-titration period (See Section 4.4).

6

   Exacerbation of pre-existing diabetes has been reported in very rare cases.

7

   Calculation of frequency for these ADR’s have only been taken from postmarketing data with the immediate release formulation of Quetiapine.

8

   Fasting blood glucose >126mg/dL (>7.0 mmol/L) or a non-fasting blood glucose >200mg/dL (>11.1 mmol/L) on at least one occasion.

9

The frequencies of adverse events are ranked according to the following: 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);

Very rare (<1/10,000);

not known (cannot be estimated from the available data)._

10

   Based on shifts above clinically significant thresholds (adapted from the National Institutes of Health criteria) or increases >20mmHg for systolic or >10 mmHg for diastolic blood pressure at any time in two acute (3-6 weeks) placebo-controlled trials in children and adolescents.

11

   See section 5.1

12

   Note: The frequency is consistent to that observed in adults, but irritability might be associated with different clinical implications in children and adolescents as compared to adults.

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, website: http://www.mhra.gov.uk/yellowcard.