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Topiramate Cipla 200 Mg Film-Coated Tablets

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SUMMARY OF PRODUCT CHARACTERISTICS

1 NAME OF THE MEDICINAL PRODUCT

Topiramate Cipla 200 mg Film-coated Tablets.

2 QUALITATIVE AND QUANTITATIVE COMPOSITION

Each film-coated tablet contains 200 mg of topiramate.

Each film-coated tablet contains 198 mg of lactose monohydrate.

For a full list of excipients, see Section 6.1.

3 PHARMACEUTICAL FORM

Topiramate 200 mg Tablets are pink coloured, biconvex, caplet-shaped film-coated tablets.

4 CLINICAL PARTICULARS

4.1 Therapeutic indications

Epilepsy

Monotherapy in adults, adolescents and children over 6 years of age with partial seizures with or without secondary generalised seizures, and primary generalised tonic-clonic seizures.

Adjunctive therapy in children aged 2 years and above, adolescents and adults with partial onset seizures with or without secondary generalisation or primary generalised tonic-clonic seizures and for the treatment of seizures associated with Lennox-Gastaut syndrome.

Topiramate is indicated in adults for the prophylaxis of migraine headache after careful evaluation of possible alternative treatment options. Topiramate is not intended for acute treatment.

4.2 Posology and method of administration

General

It is recommended that therapy be initiated at a low dose followed by titration to an effective dose. Dose and titration rate should be guided by clinical response.

Topiramate Tablets are film-coated tablets. It is recommended that film-coated tablets should not be broken.

It is not necessary to monitor topiramate plasma concentrations to optimise therapy with Topiramate Tablets. On rare occasions, the addition of topiramate to phenytoin may require an adjustment of the dose of phenytoin to achieve optimal clinical outcome. Addition or withdrawal of phenytoin and carbamazepine to adjunctive therapy with Topiramate Tablets may require adjustment of the dose of Topiramate Tablets.

Topiramate Tablets can be taken without regard to meals.

In patients with or without a history of seizures or epilepsy, antiepileptic drugs including topiramate should be gradually withdrawn to minimize the potential for seizures or increased seizure frequency. In clinical trials, daily dosages were decreased in weekly intervals by 50-100 mg in adults with epilepsy and by 25-50 mg in adults receiving topiramate at doses up to 100 mg/day for migraine prophylaxis. In paediatric clinical trials, topiramate was gradually withdrawn over a 2-8 week period.

Monotherapy Epilepsy

General

When concomitant antiepileptic drugs (AEDs) are withdrawn to achieve monotherapy with topiramate, consideration should be given to the effects this may have on seizure control. Unless safety concerns require an abrupt withdrawal of the concomitant AED, a gradual discontinuation at the rate of approximately one-third of the concomitant AED dose every 2 weeks is recommended.

When enzyme inducing medicinal products are withdrawn, topiramate levels will increase. A decrease in topiramate dosage may be required if clinically indicated.

Adults

Dose and titration should be guided by clinical response. Titration should begin at 25 mg nightly for 1 week. The dosage should then be increased at 1- or 2-week intervals by increments of 25 or 50 mg/day, administered in two divided doses. If the patient is unable to tolerate the titration regimen, smaller increments or longer intervals between increments can be used.

The recommended initial target dose for topiramate monotherapy in adults is 100 mg/day to 200 mg/day in 2 divided doses. The maximum recommended daily dose is 500 mg/day in 2 divided doses. Some patients with refractory forms of epilepsy have tolerated topiramate monotherapy at doses of 1,000 mg/day. These dosing recommendations apply to all adults including the elderly in the absence of underlying renal disease.

Paediatric population (children over 6 years of age)

Dose and titration rate in children should be guided by clinical outcome. Treatment of children over 6 years of age should begin at 0.5 to 1 mg/kg nightly for the first week. The dosage should then be increased at 1- or 2-week intervals by increments of 0.5 to 1 mg/kg/day, administered in two divided doses. If the child is unable to tolerate the titration regimen, smaller increments or longer intervals between dose increments can be used.

The recommended initial target dose range for topiramate monotherapy in children over 6 years of age is 100mg/day depending on clinical response, (this is about 2.0mg/kg/day in children 6-16 years).

Adjunctive therapy epilepsy (partial onset seizures with or without secondary generalization, primary generalized tonic-clonic seizures, or seizures with Lennox-Gastaut syndrome)

Adults

Therapy should begin at 25-50 mg nightly for one week. Use of lower initial doses has been reported, but has not been studied systematically. Subsequently, at weekly or biweekly intervals, the dose should be increased by 25-50 mg/day and taken in two divided doses. Some patients may achieve efficacy with once-a-day dosing.

In clinical trials as adjunctive therapy, 200 mg was the lowest effective dose. The usual daily dose is 200-400 mg in two divided doses.

These dosing recommendations apply to all adults, including the elderly, in the absence of underlying renal disease (see section 4.4).

Paediatric population (children aged 2 years and above)

The recommended total daily dose of topiramate as adjunctive therapy is approximately 5 to 9 mg/kg/day in two divided doses. Titration should begin at 25 mg (or less, based on a range of 1 to 3 mg/kg/day) nightly for the first week. The dosage should then be increased at 1- or 2-week intervals by increments of 1 to 3 mg/kg/day (administered in two divided doses), to achieve optimal clinical response.

Daily doses up to 30 mg/kg/day have been studied and were generally well tolerated. Migraine

Adults

The recommended total daily dose of topiramate for prophylaxis of migraine headache is 100 mg/day administered in two divided doses. Titration should begin at 25 mg nightly for 1 week. The dosage should then be increased in increments of 25 mg/day administered at 1-week intervals. If the patient is unable to tolerate the titration regimen, longer intervals between dose adjustments can be used. Some patients may experience a benefit at a total daily dose of 50 mg/day. Patients have received a total daily dose up to 200 mg/day. This dose may be of benefit in some patients, nevertheless, caution is advised due to an increase incidence of side effects.

Paediatric population

Topiramate is not recommended for treatment or prevention of migraine in children due to insufficient data on safety and efficacy.

General dosing recommendations for Topiramate Tablets in special patient populations

Renal impairment

In patients with impaired renal function (CLcr < 60mL/min) topiramate should be administered with caution as the plasma and renal clearance of topiramate are decreased. Subjects with known renal impairment may require a longer time to reach steady-state at each dose.

In patients with end-stage renal failure, since topiramate is removed from plasma by haemodialysis, a supplemental dose of Topiramate Tablets equal to approximately one-half the daily dose should be administered on haemodialysis days. The supplemental dose should be administered in divided doses at the beginning and completion of the haemodialysis procedure. The supplemental dose may differ based on the characteristics of the dialysis equipment being used.

Hepatic impairment

In patients with moderate to severe hepatic impairment topiramate should be administered with caution as the clearance of topiramate is decreased.

Elderly

No dose adjustment is required in the elderly population providing renal function is intact.

4.3 Contraindications

Hypersensitivity to the active substance or to any of the excipients.

Migraine prophylaxis in pregnancy and in women of child bearing potential if not using effective methods of contraception.

4.4 Special warnings and precautions for use

In situations where rapid withdrawal of topiramate is medically required, appropriate monitoring is recommended (see section 4.2 for further details).

As with other anti-epileptic drugs, some patients may experience an increase in seizure frequency or the onset of new types of seizures with topiramate. These phenomena may be the consequence of an overdose, a decrease in plasma concentrations of concomitantly used anti-epileptics, progress of the disease, or a paradoxical effect.

Adequate hydration while using topiramate is very important. Hydration can reduce the risk of nephrolithiasis (see below). Proper hydration prior to and during activities such as exercise or exposure to warm temperatures may reduce the risk of heat-related adverse reactions (see section 4.8).

Mood disturbances/depression

An increased incidence of mood disturbances and depression has been observed during topiramate treatment.

Suicide/suicide ideation

Suicidal ideation and behaviour have been reported in patients treated with antiepileptic agents in several indications. A meta-analysis of randomised placebo-controlled trials of anti-epileptic drugs has shown a small increased risk of suicidal ideation and behaviour. The mechanism of this risk is not known and the available data do not exclude the possibility of an increased risk for topiramate.

In double blind clinical trials, suicide related events (SREs) (suicidal ideation, suicide attempts and suicide) occurred at a frequency of 0.5% in topiramate treated patients (46 out of 8,652 patients treated) and at a nearly 3 fold higher incidence than those treated with placebo (0.2%; 8 out of 4,045 patients treated).

Patients therefore should be monitored for signs of suicidal ideation and behaviour and appropriate treatment should be considered. Patients (and caregivers of patients) should be advised to seek medical advice should signs of suicidal ideation or behaviour emerge.

Nephrolithiasis

Some patients, especially those with a predisposition to nephrolithiasis, may be at increased risk for renal stone formation and associated signs and symptoms such as renal colic, renal pain or flank pain.

Risk factors for nephrolithiasis include prior stone formation, a family history of nephrolithiasis and hypercalciuria. None of these risk factors can reliably predict stone formation during topiramate treatment. In addition, patients taking other medicinal products associated with nephrolithiasis may be at increased risk.

Decreased hepatic function

In hepatically-impaired patients, topiramate should be administered with caution as the clearance of topiramate may be decreased.

Acute myopia and secondary angle closure glaucoma

A syndrome consisting of acute myopia associated with secondary angle closure glaucoma has been reported in patients receiving topiramate. Symptoms include acute onset of decreased visual acuity and/or ocular pain. Ophthalmological findings include myopia, anterior chamber shallowing, ocular hyperaemia (redness) and increased intraocular pressure. Mydriasis may or may not be present. This syndrome may be associated with supraciliary effusion resulting in anterior displacement of the lens and iris, with secondary angle closure glaucoma. Symptoms typically occur within 1 month of the start of initiating topiramate therapy. In contrast to primary narrow angle glaucoma, which is rare under 40 years of age, secondary angle closure glaucoma associated with topiramate has been reported in paediatric patients as well as adults. Treatment includes discontinuation of topiramate, as rapidly as possible in the judgement of the treating physician, and appropriate measures to reduce intraocular pressure. These measures generally result in a decrease in intraocular pressure.

Elevated intraocular pressure of any aetiology, if left untreated, can lead to serious sequelae including permanent vision loss.

A determination should be made whether patients with a history of eye disorders should be treated with topiramate.

Metabolic Acidosis

Hyperchloraemic, non-anion gap, metabolic acidosis (i.e. decreased serum bicarbonate below the normal reference range in the absence of respiratory alkalosis) is associated with topiramate treatment. This decrease in serum bicarbonate is due to the inhibitory effect of topiramate on renal carbonic anhydrase. Generally, the decrease in bicarbonate occurs early in treatment although it can occur at any time during treatment. These decreases are usually mild to moderate (average decrease of 4 mmol/l at doses of 100 mg/day or above in adults and at approximately 6 mg/kg/day in paediatric patients).

Rarely, patients have experienced decreases to values below 10 mmol/l. Conditions or therapies that predispose to acidosis (such as renal disease, severe respiratory disorders, status epilepticus, diarrhoea, surgery, ketogenic diet, or certain medicinal products) may be additive to the bicarbonate lowering effects of topiramate.

Chronic metabolic acidosis increases the risk of renal stone formation and may potentially lead to osteopenia.

Chronic metabolic acidosis in paediatric patients can reduce growth rates. The effect of topiramate on bone-related sequelae has not been systematically investigated in paediatric or adult populations.

Depending on underlying conditions, appropriate evaluation including serum bicarbonate levels is recommended with topiramate therapy. If metabolic acidosis develops and persists, consideration should be given to reducing the dose or discontinuing topiramate (using dose tapering).

Topiramate should be used with caution in patients with conditions or treatment that represent a risk factor for the appearance of metabolic acidosis.

Nutritional supplementation

Some patients may experience weight loss whilst on treatment with topiramate. It is recommended that patients on topiramate treatment should be monitored for weight loss. A dietary supplement or increased food intake may be considered if the patient is losing weight while on topiramate.

Lactose intolerance

Topiramate Tablets contain lactose. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medication.

4.5 Interaction with other medicinal products and other forms of interaction

Effects of Topiramate Tablets on other antiepileptic drugs

The addition of topiramate to other antiepileptic drugs (phenytoin, carbamazepine, valproic acid, phenobarbital, primidone) has no effect on their steady-state plasma concentrations, except in the occasional patient, where the addition of topiramate to phenytoin may result in an increase of plasma concentrations of phenytoin. This is possibly due to inhibition of a specific enzyme polymorphic isoform (CYP2C19). Consequently, any patient on phenytoin showing clinical signs or symptoms of toxicity should have phenytoin levels monitored.

A pharmacokinetic interaction study of patients with epilepsy indicated the addition of topiramate to lamotrigine had no effect on steady state plasma concentration of lamotrigine at topiramate doses of 100 to 400 mg/day. In addition, there was no change in steady state plasma concentration of topiramate during or after removal of lamotrigine treatment (mean dose of 327 mg/day).

Topiramate inhibits the enzyme CYP 2C19 and may interfere with other substances metabolized via this enzyme (e.g. diazepam, imipramin, moclobemide, proguanil, omeprazol).

Effects of other antiepileptic medicinal products on Topiramate Tablets

Phenytoin and carbamazepine decrease the plasma concentration of topiramate. The

addition or withdrawal of phenytoin or carbamazepine to topiramate therapy may

require an adjustment in dosage of the latter. This should be done by titrating to clinical

effect.

The addition or withdrawal of valproic acid does not produce clinically significant changes in plasma concentrations of topiramate and, therefore, does not warrant dosage adjustment of topiramate. The results of these interactions are summarised in the following table:

AED Coadministered

AED Concentration

Topiramate

Concentration

Phenytoin

( )**

f

Carbamazepine (CBZ)

f

Valproic Acid

Lamotrigine

Phenobarbital

NS

Primidone

NS

^    =    No effect on plasma concentration (<15% change)

**    =    Plasma concentrations increase in individual patients

f    =    Plasma concentrations    decrease

NS    =    Not studied

AED    =    antiepileptic drug

Other medicinal product interactions

Digoxin

In a single-dose study, serum digoxin area under plasma concentration curve (AUC) decreased 12% due to concomitant administration of topiramate. The clinical relevance of this observation has not been established. When topiramate is added or withdrawn in patients on digoxin therapy, careful attention should be given to the routine monitoring of serum digoxin.

CNS Depressants

Concomitant administration of topiramate and alcohol or other CNS depressant medicinal products has not been evaluated in clinical studies. It is recommended that topiramate not be used concomitantly with alcohol or other CNS depressant medicinal products.

St John’s Wort (Hypericum perforatum)

A risk of decreased plasma concentrations resulting in a loss of efficacy could be observed with co-administration of topiramate and St John’s Wort. There have been no clinical studies evaluating this potential interaction.

Oral Contraceptives

In a pharmacokinetic interaction study in healthy volunteers with a concomitantly administered combination oral contraceptive product containing 1 mg norethindrone (NET) plus 35 pg ethinyl estradiol (EE), topiramate given in the absence of other medications at doses of 50 to 200 mg/day was not associated with statistically significant changes in mean exposure (AUC) to either component of the oral contraceptive. In another study, exposure to EE was statistically significantly decreased at doses of 200, 400 and 800 mg/day (18%, 21% and 30% respectively) when given as adjunctive therapy in epilepsy patients taking valproic acid. In both studies, topiramate (50-200 mg/day) in healthy volunteers and 200-800 mg/day in epilepsy patients) did not significantly affect exposure to NET. Although there was a dose dependent decrease in EE exposure for doses between 200-800 mg/day (in epilepsy patients), there was no significant dose dependent change in EE exposure for doses of 50-200 mg/day (in healthy volunteers). The clinical significance of the changes observed is not known. The possibility of decreased contraceptive efficacy and increased breakthrough bleeding should be considered in patients taking combination oral contraceptive products with topiramate. Patients taking estrogen containing contraceptives should be asked to report any change in their bleeding patterns. Contraceptive efficacy can be decreased even in the absence of breakthrough bleeding.

Lithium

In healthy volunteers, there was an observed reduction (18% for AUC) in systemic exposure for lithium during concomitant administration with topiramate 200 mg/day. In patients with bipolar disorder, the pharmacokinetics of lithium were unaffected during treatment with topiramate at doses of 200 mg/day; however, there was an observed increase in systemic exposure (26% for AUC) following topiramate doses of up to 600 mg/day. Lithium levels should be monitored when co-administered with topiramate.

Risperidone

Drug-drug interaction studies conducted under single dose conditions in healthy volunteers and multiple dose conditions in patients with bipolar disorder, yielded similar results. When administered concomitantly with topiramate at escalating doses of 100, 250 and 400 mg/day there was a reduction in risperidone (administered at doses ranging from 1 to 6 mg/day) systemic exposure (16% and 33% for steady-state AUC at the 250 and 400 mg/day doses, respectively). However, differences in AUC for the total active moiety between treatment with risperidone alone and combination treatment with topiramate were not statistically significant. Minimal alterations in the pharmacokinetics of the total active moiety (risperidone plus 9-hydroxyrisperidone) and no alterations for 9-hydroxyrisperidone were observed. There were no significant changes in the systemic exposure of the risperidone total active moiety or of topiramate. When topiramate was added to existing risperidone (1-6 mg/day) treatment, adverse events were reported more frequently than prior to topiramate (250400 mg/day) introduction (90% and 54% respectively). The most frequently reported AE’s when topiramate was added to risperidone treatment were somnolence (27% and 12%), paraesthesia (22% and 0%) and nausea (18% and 9% respectively).

Hydrochlorothiazide (HCTZ)

A drug-drug interaction study conducted in healthy volunteers evaluated the steady-state pharmacokinetics of HCTZ (25 mg q24h) and topiramate (96 mg q12h) when administered alone and concomitantly. The results of this study indicate that topiramate Cmax increased by 27% and AUC increased by 29% when HCTZ was added to topiramate. The clinical significance of this change is unknown. The addition of HCTZ to topiramate therapy may require an adjustment of the topiramate dose. The steady-state pharmacokinetics of HCTZ were not significantly influenced by the concomitant administration of topiramate. Clinical laboratory results indicated decreases in serum potassium after topiramate or HCTZ administration, which were greater when HCTZ and topiramate were administered in combination.

Metformin

A drug-drug interaction study conducted in healthy volunteers evaluated the steady-state pharmacokinetics of metformin and topiramate in plasma when metformin was given alone and when metformin and topiramate were given simultaneously. The results of this study indicated that metformin mean Cmax and mean AUC0-12h increased by 18% and 25%, respectively, while mean CL/F decreased 20% when metformin was co-administered with topiramate. Topiramate did not affect metformin tmax. The clinical significance of the effect of topiramate on metformin pharmacokinetics is unclear. Oral plasma clearance of topiramate appears to be reduced when administered with metformin. The extent of change in the clearance is unknown. The clinical significance of the effect of metformin on topiramate pharmacokinetics is unclear.

When topiramate is added or withdrawn in patients on metformin therapy, careful attention should be given to the routine monitoring for adequate control of their diabetic disease state.

Pioglitazone

A drug-drug interaction study conducted in healthy volunteers evaluated the steady-state pharmacokinetics of topiramate and pioglitazone when administered alone and concomitantly. A 15% decrease in the AUC ,ss of pioglitazone with no alteration in Cmax,ss was observed. This finding was not statistically significant. In addition, a 13% and 16% decrease in Cmax,ss and AUC ,ss respectively, of the active hydroxy-metabolite was noted as well as a 60% decrease in Cmax,ss and AUC ,ss of the active keto-metabolite. The clinical significance of these findings is not known. When topiramate is added to pioglitazone therapy or pioglitazone is added to topiramate therapy, careful attention should be given to the routine monitoring of patients for adequate control of their diabetic disease state.

Glyburide

A drug-drug interaction study conducted in patients with type 2 diabetes evaluated the steady-state pharmacokinetics of glyburide (5 mg/day) alone and concomitantly with topiramate (150 mg/day). There was a 25% reduction in glyburide AUC24 during topiramate administration. Systemic exposure of the active metabolites, 4-trans-hydroxy-glyburide (M1) and 3-cis-hydroxyglyburide (M2), were also reduced by 13% and 15%, respectively. The steady-state pharmacokinetics of topiramate were unaffected by concomitant administration of glyburide.

When topiramate is added to glyburide therapy or glyburide is added to topiramate therapy, careful attention should be given to the routine monitoring of patients for adequate control of their diabetic disease state.

Other forms of interactions

Agents predisposing to nephrolithiasis

Topiramate, when used concomitantly with other agents predisposing to nephrolithiasis, may increase the risk of nephrolithiasis. While using topiramate, agents like these should be avoided since they may create a physiological environment that increases the risk of renal stone formation.

Valproic Acid

Concomitant administration of topiramate and valproic acid has been associated with hyperammonemia with or without encephalopathy in patients who have tolerated either medicinal product alone. In most cases, symptoms and signs abated with discontinuation of either medicinal product. This adverse event is not due to a pharmacokinetic interaction. An association of hyperammonemia with topiramate monotherapy or concomitant treatment with other anti-epileptics has not been established.

Additional pharmacokinetic drug interaction studies

Clinical studies have been conducted to assess the potential pharmacokinetic drug interaction between topiramate and other agents. The changes in Cmax or AUC as a result of the interactions are summarized below. The second column (concomitant drug concentration) describes what happens to the concentration of the concomitant drug listed in the first column when topiramate is added. The third column (topiramate concentration) describes how the coadministration of a drug listed in the first column modifies the concentration of topiramate.

Summary of Results from Additional Clinical Pharmacokinetic Drug Interaction Studies

Concomitant Drug

Concomitant Drug Concentration3

Topiramate Concentration

Amitriptyline

NS

20% increase in Cmax and AUC of nortriptyline metabolite

Dihydroergotamine (Oral and Subcutaneous)

Haloperidol

31% increase in AUC of the reduced metabolite

NS

Propranolol

<->■ 17% increase in Cmax for 4-OH propranolol (TPM 50 mg q12h)

9% and 16% increase in Cmax,

9% and 17% increase in AUC (40 and 80 mg propranolol q12h respectively)

Sumatriptan (Oral and Subcutaneous)

NS

Pizotifen

Diltazem

25% decrease in AUC of diltiazem and 18% decrease in DEA, and for DEM*

20% increase in AUC

Venlafaxine

Flumarizine

16% increase in AUC (TPM 50 mg q12h) b

a % values are the changes in treatment mean Cmax or AUC with respect to monotherapy <->■    =No effect on Cmax and AUC (<15% change) of the parent compound

NS    =Not studied

*DEA = Des acetyl diltiazem, DEM = N-demethyl diltiazem

b    Flunarizine AUC increased 14% in subjects taking flunarizine alone. Increase

in exposure may be attributed to accumulation during achievement of steady state.

4.6 Fertility, pregnancy and lactation

Topiramate was teratogenic in mice, rats and rabbits. In rats, topiramate crosses the placental barrier.

Data from the U.K. pregnancy register and the North American Antiepileptic Drug (NAAED) pregnancy registry indicate that infants exposed to topiramate monotherapy in the first trimester have an increased risk of congenital malformations (e.g., craniofacial defects, such as cleft lip/palate, hypospadias, and anomalies involving various body systems). The NAAED pregnancy registry data for topiramate monotherapy showed an approximate 3-fold higher incidence of major congenital malformations, compared with a reference group not taking antiepileptic drugs. Furthermore, there was a higher prevalence of low birth weight (<2500 grams) following topiramate treatment than in the reference group.

In addition, data from these registries and other studies suggest that, compared with monotherapy, there may be an increased risk of teratogenic effects associated with the use of anti-epileptic drugs in combination therapy.

It is recommended that women of child bearing potential use adequate contraception and consider alternative therapeutic options.

Animal studies have shown excretion of topiramate in milk. The excretion of topiramate in human milk has not been evaluated in controlled studies. Limited observations in patients suggest an extensive excretion of topiramate into breast milk. Since many medicinal products are excreted into human milk, a decision must be made whether to suspend breast-feeding or to discontinue/ abstain from topiramate therapy, taking into account the importance of the medicinal product to the mother (section 4.4).

Indication Epilepsy

During pregnancy, topiramate should be prescribed after fully informing the woman of the known risks of uncontrolled epilepsy to the pregnancy and the potential risks of the medicinal product to the foetus.

Indication Migraine Prophylaxis

Topiramate is contraindicated in pregnancy, and in women of childbearing potential if an effective method of contraception is not used (see section 4.3 and 4.5 Interactions with oral contraceptives).

4.7 Effects on ability to drive and use machines

Topiramate acts on the central nervous system and may produce drowsiness, dizziness or other related symptoms. It may also cause visual disturbances and/or blurred vision. These adverse reactions could potentially be dangerous in patients driving a vehicle or operating machinery, particularly until such time as the individual patient’s experience with the medicinal products is established.

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

4.8 Undesirable effects

The safety of topiramate was evaluated from a clinical trial database consisting of 4,111 patients (3,182 on topiramate and 929 on placebo) who participated in 20 double-blind trials and 2,847 patients who participated in 34 open-label trials, respectively, for topiramate as adjunctive treatment of primary generalized tonic-clonic seizures, partial onset seizures, seizures associated with Lennox-Gastaut syndrome, monotherapy for newly or recently diagnosed epilepsy or migraine prophylaxis. The majority of ADRs were mild to moderate in severity. ADRs identified in clinical trials, and during post-

marketing experience (as indicated by”*”) are listed by their incidence in clinical trials in Table 1. Assigned frequencies are as follows:

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

cannot be estimated from the available data.


Not known

The most common ADRs (those with an incidence of >5% and greater than that observed in placebo in at least 1 indication in double-blind controlled studies with topiramate) include: anorexia, decreased appetite, bradyphrenia, depression, expressive language disorder, insomnia, coordination abnormal, disturbance in attention, dizziness, dysarthria, dysgeusia, hypoesthesia, lethargy, memory impairment, nystagmus, paresthesia, somnolence, tremor, diplopia, blurred vision, diarrhoea, nausea, fatigue, irritability, and weight decrease.

Paediatric population

ADRs reported more frequently (> 2-fold) in children than in adults in double-blind controlled studies include: decreased appetite, increased appetite, acidosis hyperchloraemic, hypokalaemia, abnormal behaviour, aggression, apathy, initial insomnia, suicidal ideation, disturbance in attention, lethargy, circadian rhythm sleep disorder, poor quality sleep, lacrimation increased, sinus bradycardia, feeling abnormal, and gait disturbance.

ADRs that were reported in children but not in adults in double-blind controlled studies include: eosinophilia, psychomotor hyperactivity, vertigo, vomiting, hyperthermia, pyrexia, and learning disability.

Table 1: Topiramate Adverse Drug Reactions

System Organ Class

Very common

Common

Uncommon

Rare

Not known

Investigation

s

Weight

decreased

Weight

increased*

Crystal urine present,

Tandem gait test abnormal,

White blood cell count decreased

Blood bicarbonate decreased

Cardiac

disorders

Bradycardia,

Sinus bradycardia, Palpitations

Blood and lymphatic system disorders

Anaemia

Leucopenia, Thrombocytop enia, Lymphadenopathy, Eosinophilia

Neutropenia*

Nervous

system

disorders

Paraesthesia,

Somnolence,

Dizziness

Disturbance in

attention,

Memory

impairment,

Amnesia,

Cognitive

Depressed level of consciousness, Grand mal convulsion,

Visual field defect, Complex partial

Apraxia,

Circadian rhythm sleep disorder, Hyperaesthesia, Hyposmia, Anosmia,

disorder,

Mental

impairment,

Psychomotor

skills

impaired,

Convulsion,

Coordination

abnormal,

Tremor,

Lethargy,

Hypoaesthesia,

Nystagmus,

Dysgeusia,

Balance

disorder,

Dysarthria,

Intention

tremor,

Sedation

seizures,

Speech disorder, Psychomotor hyperactivity, Syncope,

Sensory

disturbance,

Drooling,

Hypersomnia,

Aphasia,

Repetitive speech,

Hypokinesia,

Dyskinesia,

Dizziness postural,

Poor quality sleep,

Burning sensation,

Sensory loss,

Parosmia,

Cerebellar

syndrome,

Dysaesthesia,

Hypogeusia,

Stupor,

Clumsiness,

Aura,

Ageusia,

Dysgraphia,

Dysphasia,

Neuropathy

peripheral,

Presyncope,

Dystonia

formication

Essential tremor, Akinesia, Unresponsive to stimuli

Eye disorders

Vision blurred, Diplopia, Visual disturbance

Visual acuity reduced,

Scotoma,

Myopia*,

Abnormal sensation in eye*,

Dry eye,

Photophobia,

Blepharospasm,

Lacrimation

increased,

Photopsia,

Mydriasis,

Presbyopia

Blindness

unilateral,

Blindness

transient,

Glaucoma,

Accommodation

disorder,

Altered visual depth perception, Scintillating scotoma,

Eyelid oedema*, Night blindness, Amblyopia

Angle

closure

glaucoma*,

Maculopath

y*,

Eye

movement

disorder*

Ear and

Labyrinth

disorders

Vertigo, Tinnitus, Ear pain

Deafness,

Deafness unilateral,

Deafness

neurosensory,

Ear discomfort, Hearing impaired

Respiratory thoracic and mediastinal disorders

Dyspnoea,

Epistaxis,

Nasal

congestion,

Rhinorrhoea

Dyspnoea exertional, Paranasal sinus, Hypersecretion, Dysphonia

Gastrointesti nal disorders

Nausea,

Diarrhoea

Vomiting,

Constipation,

Abdominal

pain upper,

Dyspepsia,

Abdominal

pain,

Dry mouth,

Stomach

discomfort,

Paraesthesia

oral,

Gastritis,

Abdominal

discomfort

Pancreatitis, Flatulence, Gastrooesophageal reflux disease, Abdominal pain lower,

Hypoaesthesia oral,

Gingival bleeding,

Abdominal

distention,

Epigastric

discomfort,

Abdominal

tenderness,

Salivary

hypersecretion,

Oral pain,

Breath odour, Glossodynia

Renal and

urinary

disorders

Nephrolithiasi

s,

Pollakiuria,

Dysuria

Calculus urinary,

Urinary

incontinence,

Haematuria,

Incontinence,

Micturition

urgency,

Renal colic, Renal pain

Calculus ureteric, Renal tubular acidosis*

Skin and subcutaneous tissue disorders

Alopecia,

Rash,

Pruritus

Anhidrosis,

Hypoaesthesia

facial,

Urticaria,

Erythema,

Pruritus

generalised,

Rash macular,

Skin discolouration, Dermatitis allergic, Swelling face

Stevens-Johnson

syndrome*

Erythema

multiforme*,

Skin odour abnormal, Periorbital oedema*,

Urticaria localised

Toxic

epidermal

necrolysis*

Musculoskele tal and connective tissue disorders

Arthralgia,

Muscle

spasms,

Myalgia,

Muscle

twitching,

Muscular

weakness,

Musculoskelet

al chest pain

Joint swelling*,

Musculoskeletal

stiffness,

Flank pain, Muscle fatigue

Limb discomfort*

Metabolism and nutrition disorders

Anorexia,

Decreased

appetite

Metabolic acidosis, Hypokalaemia, Increased appetite, Polydipsia

Acidosis

hyperchloraemic

Infections

and

infestations

Nasopharyngitis

*

Vascular

disorders

Hypotension,

Orthostatic

hypotension,

Flushing,

Hot flush

Raynaud’s

phenomenon

General disorders and administratio n site conditions

Fatigue

Pyrexia,

Asthenia,

Irritability,

Gait

disturbance,

Feeling

abnormal,

Malaise

Hyperthermia,

Thirst,

Influenza like illness*, Sluggishness, Peripheral coldness, Feeling drunk, Feeling jittery

Face oedema, Calcinosis

Social

circumstance

s

Learning disability

Immune

system

disorders

Hypersensitivi

ty

Allergic oedema*, Conjunctiva l oedema*

Reproductive system and breast

Erectile

dysfunction,

Sexual dysfunction

disorders

Psychiatric

disorders

Depression

Bradyphrenia,

Insomnia,

Expressive

language

disorder,

Anxiety,

Confusional

state,

Disorientation,

Aggression,

Mood altered,

Agitation,

Mood swings,

Depressed

mood,

Anger,

Abnormal

behaviour

Suicidal ideation, Suicide attempt, Hallucination, Psychotic disorder, Hallucination auditory, Hallucination visual,

Apathy Lack of spontaneous speech,

Sleep disorder, Affect lability, Libido decreased, Restlessness, Crying,

Dysphemia, Euphoric mood, Paranoia, Perseveration,

Panic attack, Tearfulness, Reading disorder, Initial insomnia, Flat affect,

Thinking abnormal, Loss of libido, Listless,

Middle insomnia, Distractability, Early morning awakening,

Panic reaction, Elevated mood

Mania,

Anorgasmia,

Panic disorder, Disturbance in sexual arousal, Feeling of despair*,

Orgasm abnormal,

Hypomania,

Orgasmic

sensation

decreased.

* identified as an ADR from postmarketing spontaneous reports. Its frequency was calculated based on clinical trial data.

4.9 Overdose

Signs and Symptoms

Overdoses of topiramate have been reported. Signs and symptoms included convulsions, drowsiness, speech disturbances, blurred vision, diplopia, impaired mentation, lethargy, abnormal co-ordination, stupor, hypotension, abdominal pain, agitation, dizziness and depression. The clinical consequences were not severe in most cases, but deaths have been reported after overdoses with multiple medicinal products including topiramate.

Topiramate overdose can result in severe metabolic acidosis (see section 4.4).

In acute topiramate overdose, if the ingestion is recent, the stomach should be emptied immediately by lavage or by induction of emesis. Activated charcoal has been shown to adsorb topiramate in vitro. Treatment should be appropriately supportive and the patient should be well hydrated. Haemodialysis has been shown to be an effective means of removing topiramate from the body.

5 PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: other antiepileptics, antimigraine preparations. ATC code: N03AX11

Topiramate is classified as a sulphamate-substituted monosaccharide. The precise mechanism by which topiramate exerts its antiseizure and migraine prophylaxis effects are unknown. Electrophysiological and biochemical studies on cultured neurons have identified three properties that may contribute to the antiepileptic efficacy of topiramate.

Action potentials elicited repetitively by a sustained depolarization of the neurons were blocked by topiramate in a time-dependent manner, suggestive of a state-dependent sodium channel blocking action. Topiramate increased the frequency at which Y-aminobuyrate (GABA) activated GABAa receptors, and enhanced the ability of GABA to induce a flux of chloride ions into neurons, suggesting that topiramate potentiates the activity of this inhibitory neurotransmitter.

The effect was not blocked by flumazenil, a benzodiazepine antagonist, nor did topiramate increase the duration of the channel open time, differentiating topiramate from barbiturates that modulate GABAa receptors.

Because the antiepileptic profile of topiramate differs markedly from that of the benzodiazepines, it may modulate a benzodiazepine-insensitive subtype of GABAreceptor. Topiramate antagonized the ability of kainate to activate the kainate/AMPA (a-amino-3-hydroxy-5-methylisoxazole-4-propionic acid) subtype of excitatory amino acid (glutamate) receptor, but had no apparent effect on the activity of N-methyl-D-aspartate (NMDA) at the NMDA receptor subtype. These effects of topiramate were concentration-dependent over a range of 1 pM to 200 pM, with minimum acitivity observed at 1 pM to 10 pM.

In addition topiramate inhibits some isoenzymes of carbonic anhydrase. This pharmacologic effect is much weaker than that of acetazolamide, a known carbonic anhydrase inhibitor, and is not thought to be a major component of topiramate’s antiepileptic activity.

In animal studies, topiramate exhibits anticonvulsant activity in rat and mouse maximal electroshock seizure (MES) tests and is effective in rodent models of epilepsy, which include tonic and absence-like seizures in the spontaneous epileptic rat (SER) and tonic

and clonic seizures induced in rats by kindling of the amygdala or by global ischemia. Topiramate is only weakly effective in blocking clonic seizures induced by the GABAreceptor antagonist, pentylenetetrazole.

Studies in mice receiving concomitant administration of topiramate and carbamazepine or phenobarbital showed synergistic anticonvulsant activity, while combination with phenytoin showed additive anticonvulsant activity. In well-controlled add-on trials, no correlation has been demonstrated between trough plasma concentrations of topiramate and its clinical efficacy. No evidence of tolerance has been demonstrated in man.

5.2 Pharmacokinetic properties

The pharmacokinetic profile of topiramate compared to other antiepileptic drugs shows a long plasma half-life, linear pharmacokinetics, predominantly renal clearance, absence of significant protein binding, and lack of clinically relevant active metabolites.

Topiramate is not a potent inducer of drug metabolizing enzymes, can be administered without regard to meals, and routine monitoring of plasma topiramate concentrations is not necessary. In clinical studies, there was no consistent relationship between plasma concentrations and efficacy or adverse events.

Absorption

Topiramate is rapidly and well absorbed. Following oral administration of 100 mg topiramate to healthy subjects, a mean peak plasma concentration (Cmax) of 1.5 pg/ml was achieved within 2 to 3 hours (Tmax).

Based on the recovery of radioactivity from the urine, the mean extent of absorption of a 100 mg oral dose of 14C-topiramate was at least 81%. There is no clinically significant effect of food on the bioavailability of topiramate.

Distribution

Generally 13-17% of topiramate is bound to plasma proteins. A low capacity binding site for topiramate in/on erythrocytes that is saturable above plasma concentrations of 4 pg/ml has been observed. The volume of distribution varied inversely with the dose. The mean apparent volume of distribution was 0.80 to 0.55 l/kg for a single dose range of 100 to 1200 mg. An effect of gender on the volume of distribution was detected, with values for females circa 50% of those for males. This was attributed to the higher percent body fat in female patients and is of no clinical consequence.

Metabolism

Topiramate is not extensively metabolised (~20%) in healthy volunteers. It is metabolised up to 50% in patients receiving concomitant antiepileptic therapy with known inducers of drug metabolising enzymes. Six metabolites, formed through hydroxylation, hydrolysis and glucuronidation, have been isolated, characterised and identified from plasma, urine and faeces of humans. Each metabolite represents less than 3% of the total radioactivity excreted following administration of 14C-topiramate. Two metabolites, which retained most of the structure of topiramate, were tested and found to have little or no anticonvulsant activity.

Elimination

In humans, the major route of elimination of unchanged topiramate and its metabolites is via the kidney (at least 81% of the dose). Approximately 66% of a dose of 14C-topiramate was excreted unchanged in the urine within four days. Following twice a day dosing with 50 mg and 100 mg of topiramate the mean renal clearance was approximately 18 ml/min and 17 ml/min respectively. There is evidence of renal tubular reabsorption of topiramate. This is supported by studies in rats where topiramate was co-administered with probenecid, and a significant increase in renal clearance of topiramate was observed. Overall, plasma clearance is approximately 20 to 30 ml/min in humans following oral administration.

Topiramate exhibits low intersubject variability in plasma concentrations and, therefore, has predictable pharmacokinetics. The pharmacokinetics of topiramate are linear with plasma clearance remaining constant and area under the plasma concentration curve increasing in a dose-proportional manner over a 100 to 400 mg single oral dose range in healthy subjects. Patients with normal renal function may take 4 to 8 days to reach steady-state plasma concentrations. The mean Cmax following multiple, twice a day oral doses of 100 mg to healthy subjects was 6.76 pg/ml. Following administration of multiple doses of 50 mg and 100 mg of topiramate twice a day, the mean plasma elimination half-life was approximately 21 hours.

Concomitant multiple-dose administration of topiramate, 100 to 400 mg twice a day, with phenytoin or carbamazepine shows dose proportional increases in plasma concentrations of topiramate.

The plasma and renal clearance of topiramate are decreased in patients with impaired renal function (CLCr < 60 ml/min), and the plasma clearance is decreased in patients with end-stage renal disease. As a result, higher steady-state topiramate plasma concentrations are expected for a given dose in renal-impaired patients as compared to those with normal renal function. Topiramate is effectively removed from plasma by haemodialysis.

Plasma clearance of topiramate is decreased in patients with moderate to severe hepatic impairment.

Plasma clearance of topiramate is unchanged in elderly subjects in the absence of underlying renal disease.

Paediatric population (pharmacokinetics, up to 12 years of age)

The pharmacokinetics of topiramate in children, as in adults receiving add-on therapy, are linear, with clearance independent of dose and steady-state plasma concentrations increasing in proportion to dose. Children, however, have a higher clearance and shorter elimination half-life. Consequently, the plasma concentrations of topiramate for the same mg/kg dose may be lower in children compared to adults. As in adults, hepatic enzyme inducing anti-epileptic drugs decrease the steady-state plasma concentrations.

5.3 Preclinical safety data

In non-clinical studies or fertility, despite maternal and paternal toxicity as low as 8 mg/kg/day, no effects on fertility were observed, in male or female rats with doses up to 100 mg/kg/day.

In preclinical studies, topiramate has been shown to have teratogenic effects in the species studied (mice, rats and rabbits). In mice, fetal weights and skeletal ossification were reduced at 500 mg/kg/day in conjunction with maternal toxicity. Overall numbers of fetal malformations in mice were increased for all drug-treated groups (20, 100 and 500 mg/kg/day).

In rats, dosage-related maternal and embryo/fetal toxicity (reduced fetal weights and/or skeletal ossification) were observed down to 20 mg/kg/day with teratogenic effects (limb and digit defects) at 400 mg/kg/day and above. In rabbits, dosage-related maternal toxicity was noted down to 10 mg/kg/day with embryo/fetal toxicity (increased lethality) down to 35 mg/kg/day, and teratogenic effects (rib and vertebral malformations) at 120 mg/kg/day.

The teratogenic effects seen in rats and rabbits were similar to those seen with carbonic anhydrase inhibitors, which have not been associated with malformations in humans. Effects on growth were also indicated by lower weights at birth and during lactation for pups from female rats treated with 20 or 100 mg/kg/day during gestation and lactation. In rats, topiramate crosses the placental barrier.

In juvenile rats, daily oral administration of topiramate at doses up to 300 mg/kg/day during the period of development corresponding to infancy, childhood, and adolescence resulted in toxicities similar to those in adult animals (decreased food consumption with decreased body weight gain, centrolobullar hepatocellular hypertrophy). There were no relevant effects on long bone (tibia) growth or bone (femur) mineral density, preweaning and reproductive development, neurological development (including assessments on memory and learning), mating and fertility or hysterotomy parameters.

In a battery of in vitro and in vivo mutagenicity assays, topiramate did not show genotoxic potential.

6 PHARMACEUTICAL PARTICULARS

6.1 List of excipients

Tablet core:

Pre-gelatinised Starch (PA 5PH)

Lactose monohydrate

Microcrystalline cellulose (Avicel PH 101)

Sodium starch glycolate (Type A)

Magnesium stearate

Film-coating Opadry Pink containing:

Titanium dioxide Hypromellose PEG 400 Polysorbate 80 Iron oxide red.

6.2 Incompatibilities

Not applicable.

6.3 Shelf life

2 years.

6.4 Special precautions for storage

This medicinal product does not require any special storage conditions. Store in the original package.

6.5 Nature and contents of container

Blisters:

Packed in push-through blister strips composed of 3-ply alu-alu laminated film and 25 micron plain aluminium foil (heat sealable against PVC with VMCH coating).

Pack sizes of 28, 56, 60 & 84 tablets.

Bottles:

Bottle packs of the following composition: Opaque, high density polyethylene bottles. White, opaque, polypropylene, child-resistant closures and a desiccant.

Pack sizes of 60, 100 & 200 tablets.

(Not all pack sizes will be marketed).

6.6 Special precautions for disposal

7. MARKETING AUTHORISATION HOLDER

Cipla (EU) Limited

Hillbrow House

Hillbrow Road

Esher

Surrey

KT10 9NW

8 MARKETING AUTHORISATION NUMBER(S)

PL 36390/0072

9 DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

24/01/2012

10 DATE OF REVISION OF THE TEXT

11/03/2014

23