Components:
Method of action:
Treatment option:
Medically reviewed by Kovalenko Svetlana Olegovna, PharmD. Last updated on 29.03.2022
Attention! Information on this page is intended only for medical professionals! Information is collected in open sources and may contain significant errors! Be careful and double-check all the information on this page!
Imiquimod cream is indicated for the topical treatment of:
- External genital and perianal warts (condylomata acuminata) in adults.
- Small superficial basal cell carcinomas (sBCCs) in adults.
- Clinically typical, nonhyperkeratotic, nonhypertrophic actinic keratoses (AKs) on the face or scalp in immunocompetent adult patients when size or number of lesions limit the efficacy and/or acceptability of cryotherapy and other topical treatment options are contraindicated or less appropriate.
Tian Rui is indicated for the topical treatment of clinically typical, nonhyperkeratotic, nonhypertrophic, visible or palpable actinic keratosis (AK) of the full face or balding scalp in immunocompetent adults when other topical treatment options are contraindicated or less appropriate.
Posology
The application frequency and duration of treatment with imiquimod cream is different for each indication.
External genital warts in adults:
Imiquimod cream should be applied 3 times per week (example: Monday, Wednesday, and Friday; or Tuesday, Thursday, and Saturday) prior to normal sleeping hours, and should remain on the skin for 6 to 10 hours.
Superficial basal cell carcinoma in adults:
Apply imiquimod cream for 6 weeks, 5 times per week (example: Monday to Friday) prior to normal sleeping hours, and leave on the skin for approximately 8 hours.
For quantity to be applied see 4.2 Method of administration.
Actinic keratosis in adults
Treatment should be initiated and monitored by a physician. Imiquimod cream should be applied 3 times per week (example: Monday, Wednesday and Friday) for four weeks prior to normal sleeping hours, and left on the skin for approximately 8 hours. Sufficient cream should be applied to cover the treatment area. After a 4-week treatment-free period, clearance of AKs should be assessed. If any lesions persist, treatment should be repeated for another four weeks.
An interruption of dosing should be considered if intense local inflammatory reactions occur or if infection is observed at the treatment site. In this latter case, appropriate other measures should be taken. Each treatment period should not be extended beyond 4 weeks due to missed doses or rest periods.
If the treated area does not show complete clearance at a follow-up examination about 8 weeks after the last 4-weeks course of treatment, an additional 4-weeks course of Tian Rui treatment may be considered.
A different therapy is recommended if the treated lesion(s) shows insufficient response to Tian Rui.
Actinic keratosis lesions that have cleared after one or two courses of treatment and subsequently recur can be re-treated with one or two further courses of Tian Rui cream following an at least 12 weeks treatment pause.
Information applicable to all indications:
If a dose is missed, the patient should apply the cream as soon as he/she remember and then he/she should continue with the regular schedule. However the cream should not be applied more than once a day.
Paediatric population
Use in the paediatric patient population is not recommended. There are no data available on the use of imiquimod in children and adolescents in the approved indications.
Tian Rui should not be used in children with molluscum contagiosum due to lack of efficacy in this indication.
Method of administration
External genital warts:
Imiquimod cream should be applied in a thin layer and rubbed on the clean wart area until the cream vanishes. Only apply to affected areas and avoid any application on internal surfaces. Imiquimod cream should be applied prior to normal sleeping hours. During the 6 to 10 hour treatment period, showering or bathing should be avoided. After this period it is essential that imiquimod cream is removed with mild soap and water. Application of an excess of cream or prolonged contact with the skin may result in a severe application site reaction. A single-use sachet is sufficient to cover a wart area of 20 cm2 (approx. 3 inches2). Sachets should not be re-used once opened. Hands should be washed carefully before and after application of cream.
Uncircumcised males treating warts under the foreskin should retract the foreskin and wash the area daily.
Superficial basal cell carcinoma:
Before applying imiquimod cream, patients should wash the treatment area with mild soap and water and dry thoroughly. Sufficient cream should be applied to cover the treatment area, including one centimetre of skin surrounding the tumour. The cream should be rubbed into the treatment area until the cream vanishes. The cream should be applied prior to normal sleeping hours and remain on the skin for approximately 8 hours. During this period, showering and bathing should be avoided. After this period it is essential that imiquimod cream is removed with mild soap and water.
Sachets should not be re-used once opened. Hands should be washed carefully before and after application of cream.
Response of the treated tumour to imiquimod cream should be assessed 12 weeks after the end of treatment. If the treated tumour shows an incomplete response, a different therapy should be used.
A rest period of several days may be taken if the local skin reaction to imiquimod cream causes excessive discomfort to the patient, or if infection is observed at the treatment site. In this latter case, appropriate other measures should be taken.
Actinic keratosis:
Before applying imiquimod cream, patients should wash the treatment area with mild soap and water and dry thoroughly. Sufficient cream should be applied to cover the treatment area. The cream should be rubbed into the treatment area until the cream vanishes. The cream should be applied prior to normal sleeping hours and remain on the skin for approximately 8 hours. During this period, showering and bathing should be avoided. After this period it is essential that imiquimod cream is removed with mild soap and water. Sachets should not be re-used once opened. Hands should be washed carefully before and after application of cream.
Posology
Tian Rui (per application: up to 2 sachets, 250 mg imiquimod cream per sachet) should be applied once daily before bedtime to the skin of the affected treatment field (area) for two treatment cycles of 2 weeks each separated by a 2-week no-treatment cycle or as directed by the physician.
The treatment area is the full face or balding scalp.
Local skin reactions in the treatment area are in part anticipated and common due to its mode of action. A rest period of several days may be taken if required by the patient's discomfort or severity of the local skin reaction. However, neither 2-week treatment cycle should be extended due to missed doses or rest periods.
A transient increase in actinic keratosis counts may be observed during treatment due to the likely effect of imiquimod to reveal and treat subclinical lesions. Response to treatment cannot be adequately assessed until resolution of local skin reactions. Patients should continue treatment as prescribed. Treatment should be continued for the full treatment course even if all actinic keratosis appear to be gone.
The clinical outcome of therapy has to be determined after regeneration of the treated skin, approximately 8 weeks after the end of treatment and on appropriate intervals thereafter based on clinical judgment. Lesions that do not respond completely to treatment at 8 weeks after the second treatment cycle should be carefully re-evaluated and one additional 2-week treatment of Tian Rui may be considered.
A different therapy is recommended if the treated lesion(s) show(s) insufficient response to Tian Rui.
Actinic keratosis lesions that have cleared after two Tian Rui treatment cycles of 2 weeks and subsequently recur can be re-treated with one or two further Tian Rui treatment cycles of 2 weeks following an at least 12 weeks treatment pause.
Hepatic or renal impairment
Patients with hepatic or renal impairment were not included in clinical trials. These patients should be monitored under the close supervision of an experienced physician.
Paediatric population
The safety and efficacy of imiquimod in actinic keratosis in children and adolescents below the age of 18 years have not been established. No data are available.
Method of administration
Tian Rui is for external use only. Contact with eyes, lips, and nostrils should be avoided.
The treatment area should not be bandaged or otherwise occluded.
The prescriber should demonstrate the proper application technique to the patient to maximise the benefit of Tian Rui therapy.
Tian Rui should be applied once daily before bedtime to the skin of the affected treatment field (area) and remain on the skin for approximately 8 hours. During this period, showering and bathing should be avoided. Before applying the cream, the patient should wash the treatment area with mild soap and water and allow the area to dry thoroughly. Tian Rui should be applied as a thin film to the entire treatment area and rubbed in until the cream vanishes. Up to 2 sachets of Tian Rui may be applied to the treatment area (full face or scalp, but not both) at each daily application. Partially-used sachets should be discarded and not reused. Tian Rui should be left on the skin for approximately 8 hours; after this time it is essential that the cream is removed by washing the area and the hands with mild soap and water.
Hands should be washed carefully before and after application of cream.
Missed dose
In case a dose is missed, patients should wait until the forthcoming night to apply Tian Rui and then continue with the regular schedule. The cream should not be applied more than once daily. Each treatment cycle should not be extended beyond 2 weeks due to missed doses or rest periods.
External genital warts, superficial basal cell carcinoma and actinic keratosis:
Avoid contact with the eyes, lips and nostrils.
Imiquimod has the potential to exacerbate inflammatory conditions of the skin.
). Consideration should be given to balancing the benefit of imiquimod treatment for these patients with the risk associated with a possible worsening of their autoimmune condition.
). Consideration should be given to balancing the benefit of imiquimod treatment for these patients with the risk associated with the possibility of organ rejection or graft-versus-host disease.
Imiquimod cream therapy is not recommended until the skin has healed after any previous drug or surgical treatment.9)
The use of an occlusive dressing is not recommended with imiquimod cream therapy.
The excipients methyl hydroxybenzoate (E 218) and propyl hydroxybenzoate (E 216) may cause allergic reactions (possibly delayed). Cetyl alcohol and stearyl alcohol may cause local skin reactions (e.g. contact dermatitis).
Rarely, intense local inflammatory reactions including skin weeping or erosion can occur after only a few applications of imiquimod cream. Local inflammatory reactions may be accompanied, or even preceded, by flu-like systemic signs and symptoms including malaise, pyrexia, nausea, myalgias and rigors. An interruption of dosing should be considered.
).
External genital warts:
There is limited experience in the use of imiquimod cream in the treatment of men with foreskin-associated warts. The safety database in uncircumcised men treated with imiquimod cream three times weekly and carrying out a daily foreskin hygiene routine is less than 100 patients. In other studies, in which a daily foreskin hygiene routine was not followed, there were two cases of severe phimosis and one case of stricture leading to circumcision. Treatment in this patient population is therefore recommended only in men who are able or willing to follow the daily foreskin hygiene routine. Early signs of stricture may include local skin reactions (e.g. erosion, ulceration, oedema, induration), or increasing difficulty in retracting the foreskin. If these symptoms occur, the treatment should be stopped immediately. Based on current knowledge, treating urethral, intra-vaginal, cervical, rectal or intra-anal warts is not recommended. Imiquimod cream therapy should not be initiated in tissues where open sores or wounds exist until after the area has healed.
Local skin reactions such as erythema, erosion, excoriation, flaking and oedema are common. Other local reactions such as induration, ulceration, scabbing, and vesicles have also been reported. Should an intolerable skin reaction occur, the cream should be removed by washing the area with mild soap and water. Treatment with imiquimod cream can be resumed after the skin reaction has moderated.
The risk of severe local skin reactions may be increased when imiquimod is used at higher than recommended doses. However, in rare cases severe local reactions that have required treatment and/or caused temporary incapacitation have been observed in patients who have used imiquimod according to the instructions. Where such reactions have occurred at the urethral meatus, some women have experienced difficulty in urinating, sometimes requiring emergency catheterisation and treatment of the affected area.
No clinical experience exists with imiquimod cream immediately following treatment with other cutaneously applied drugs for treatment of external genital or perianal warts. Imiquimod cream should be washed from the skin before sexual activity. Imiquimod cream may weaken condoms and diaphragms, therefore concurrent use with imiquimod cream is not recommended. Alternative forms of contraception should be considered.
In immunocompromised patients, repeat treatment with imiquimod cream is not recommended.
While limited data have shown an increased rate of wart reduction in HIV positive patients, imiquimod cream has not been shown to be as effective in terms of wart clearance in this patient group.
Superficial basal cell carcinoma:
Imiquimod has not been evaluated for the treatment of basal cell carcinoma within 1 cm of the eyelids, nose, lips or hairline.
During therapy and until healed, affected skin is likely to appear noticeably different from normal skin. Local skin reactions are common but these reactions generally decrease in intensity during therapy or resolve after cessation of imiquimod cream therapy. There is an association between the complete clearance rate and the intensity of local skin reactions (e.g. erythema). These local skin reactions may be related to the stimulation of local immune response. If required by the patient's discomfort or the severity of the local skin reaction, a rest period of several days may be taken. Treatment with imiquimod cream can be resumed after the skin reaction has moderated.
The clinical outcome of therapy can be determined after regeneration of the treated skin, approximately 12 weeks after the end of treatment.
No clinical experience exists with the use of imiquimod cream in immunocompromised patients.
No clinical experience exists in patients with recurrent and previously treated BCCs, therefore use for previously treated tumours is not recommended.
Data from an open label clinical trial suggest that large tumours (>7.25 cm2) are less likely to respond to imiquimod therapy.
The skin surface area treated should be protected from solar exposure.
Actinic keratosis
Lesions clinically atypical for AK or suspicious for malignancy should be biopsied to determine appropriate treatment.
Imiquimod has not been evaluated for the treatment of actinic keratoses on the eyelids, the inside of the nostrils or ears, or the lip area inside the vermilion border.
There are very limited data available on the use of imiquimod for the treatment of actinic keratoses in anatomical locations other than the face and scalp. The available data on actinic keratosis on the forearms and hands do not support efficacy in this indication and therefore such use is not recommended.
Imiquimod is not recommended for the treatment of AK lesions with marked hyperkeratosis or hypertrophy as seen in cutaneous horns.
During therapy and until healed, affected skin is likely to appear noticeably different from normal skin. Local skin reactions are common but these reactions generally decrease in intensity during therapy or resolve after cessation of imiquimod cream therapy. There is an association between the complete clearance rate and the intensity of local skin reactions (e.g. erythema). These local skin reactions may be related to the stimulation of local immune response. If required by the patient's discomfort or the intensity of the local skin reaction, a rest period of several days may be taken. Treatment with imiquimod cream can be resumed after the skin reaction has moderated.
Each treatment period should not be extended beyond 4 weeks due to missed doses or rest periods.
The clinical outcome of therapy can be determined after regeneration of the treated skin, approximately 4-8 weeks after the end of treatment.
No clinical experience exists with the use of imiquimod cream in immunocompromised patients.
Information on re-treating actinic keratosis lesions that have cleared after one or two courses of treatment and subsequently recur is given in section 4.2 and 5.1.
Data from an open-label clinical trial suggest that subjects with more than 8 AK lesions showed a decreased rate of complete clearance compared to patients with less than 8 lesions.
The skin surface area treated should be protected from solar exposure.
General instructions for treatment
Lesions clinically atypical for AK or suspicious for malignancy should be biopsied to determine appropriate treatment.
Contact with eyes, lips and nostrils should be avoided as imiquimod has not been evaluated for the treatment of actinic keratosis on the eyelids, the inside of the nostrils or ears, or the lip area inside the vermilion border.
Imiquimod cream therapy is not recommended until the skin has healed after any previous medicinal products or surgical treatment. Application to broken skin could result in increased systemic absorption of imiquimod leading to a greater risk of adverse events.
Because of concern for heightened sunburn susceptibility, use of sunscreen is encouraged, and patients should minimise or avoid exposure to natural or artificial sunlight (tanning beds or UVA/B treatment) while using Tian Rui. The skin surface area treated should be protected from solar exposure.
Imiquimod is not recommended for the treatment of AK lesions with marked hyperkeratosis or hypertrophy as seen in cutaneous horns.
Local skin reactions
During therapy and until healed, affected skin is likely to appear noticeably different from normal skin. Local skin reactions are common but these reactions generally decrease in intensity during therapy or resolve after cessation of imiquimod cream therapy. Rarely, intense local inflammatory reactions including skin weeping or erosion can occur after only a few applications of imiquimod cream.
There is an association between the complete clearance rate and the intensity of local skin reactions (e.g. erythema). These local skin reactions may be related to the stimulation of local immune response. Furthermore, imiquimod has the potential to exacerbate inflammatory conditions of the skin. If required by the patient's discomfort or the intensity of the local skin reaction, a rest period of several days may be taken. Treatment with imiquimod cream can be resumed after the skin reaction has moderated. The intensity of the local skin reactions tend to be lower in the second cycle than in the first treatment cycle with Tian Rui.
Systemic reactions
Flu-like systemic signs and symptoms may accompany, or even precede, intense local skin reactions and may include fatigue, nausea, fever, myalgias, arthralgias, and chills. An interruption of dosing or dose adjustment should be considered.
Patients with reduced haematologic reserve should be monitored under the close supervision of an experienced physician.
Special populations
Patients with cardiac, hepatic or renal impairment were not included in clinical trials. These patients should be monitored under the close supervision of an experienced physician.
Use in immunocompromised patients and/or in patients with autoimmune conditions
The safety and efficacy of Tian Rui in immunocompromised patients (e.g. organ transplant patients) and/or patients with autoimmune conditions have not been established. Therefore, imiquimod cream should be used with caution in these patients. Consideration should be given to balancing the benefit of imiquimod treatment for these patients with the risk associated either with the possibility of organ rejection or graft-versus-host disease or a possible worsening of their autoimmune condition.
Re-treatment
Information on re-treating actinic keratosis lesions that have cleared after two 1.
Excipients
Stearyl alcohol and cetyl alcohol may cause local skin reactions (e.g. contact dermatitis). Benzyl alcohol may cause allergic reactions and mild local irritation.
Methyl parahydroxybenzoate (E 218), and propyl parahydroxybenzoate (E 216) may cause allergic reactions (possibly delayed).
Tian Rui cream has no or negligible influence on the ability to drive and use machines.
Tian Rui has no or negligible influence on the ability to drive and use machines.
a) General Description:
External genital warts:
In the pivotal trials with 3 times a week dosing, the most frequently reported adverse drug reactions judged to be probably or possibly related to imiquimod cream treatment were application site reactions at the wart treatment site (33.7% of imiquimod treated patients). Some systemic adverse reactions, including headache (3.7%), influenza-like symptoms (1.1%), and myalgia (1.5%) were also reported.
Patient reported adverse reactions from 2292 patients treated with imiquimod cream in placebo controlled and open clinical studies are presented below. These adverse events are considered at least possibly causally related to treatment with imiquimod.
Superficial basal cell carcinoma:
In trials with 5 times per week dosing 58% of patients experienced at least one adverse event. The most frequently reported adverse events from the trials judged probably or possibly related to imiquimod cream are application site disorders, with a frequency of 28.1%. Some systemic adverse reactions, including back pain (1.1%) and influenza-like symptoms (0.5%) were reported by imiquimod cream patients.
Patient reported adverse reactions from 185 patients treated with imiquimod cream in placebo controlled phase III clinical studies for superficial basal cell carcinoma are presented below. These adverse events are considered at least possibly causally related to treatment with imiquimod.
Actinic keratosis
In the pivotal trials with 3 times per week dosing for up to 2 courses each of 4 weeks, 56% of imiquimod patients reported at least one adverse event. The most frequently reported adverse event from these trials judged probably or possibly related to imiquimod cream was application site reactions (22% of imiquimod treated patients). Some systemic adverse reactions, including myalgia (2%) were reported by imiquimod treated patients.
Patient reported adverse reactions from 252 patients treated with imiquimod cream in vehicle controlled phase III clinical studies for actinic keratosis are presented below. These adverse events are considered at least possibly causally related to treatment with imiquimod.
b) Tabular Listing of adverse events:
Frequencies are defined as Very common (>1/10), Common (>1/100 to <1/10) and Uncommon (>1/1,000 to <1/100). Lower frequencies from clinical trials are not reported here.
| External genital warts (3x/ wk,16wks) N = 2292 | Superficial basal cell carcinoma (5x/wk, 6 wks) N = 185 | Actinic keratosis (3x/wk, 4 or 8 wks) N = 252 | |
| Infections and infestations: | |||
| Infection | Common | Common | Uncommon |
| Pustules | Common | Uncommon | |
| Herpes simplex | Uncommon | ||
| Genital candidiasis | Uncommon | ||
| Vaginitis | Uncommon | ||
| Bacterial infection | Uncommon | ||
| Fungal infection | Uncommon | ||
| Upper respiratory tract infection | Uncommon | ||
| Vulvitis | Uncommon | ||
| Rhinitis | Uncommon | ||
| Influenza | Uncommon | ||
| Blood and lymphatic system disorders: | |||
| Lymphadenopathy | Uncommon | Common | Uncommon |
| Metabolism and nutrition disorders: | |||
| Anorexia | Uncommon | Common | |
| Psychiatric disorders: | |||
| Insomnia | Uncommon | ||
| Depression | Uncommon | Uncommon | |
| Irritability | Uncommon | ||
| Nervous system disorders: | |||
| Headache | Common | Common | |
| Paraesthesia | Uncommon | ||
| Dizziness | Uncommon | ||
| Migraine | Uncommon | ||
| Somnolence | Uncommon | ||
| Eye disorders | |||
| Conjunctival irritation | Uncommon | ||
| Eyelid oedema | Uncommon | ||
| Ear and labyrinth disorders: | |||
| Tinnitus | Uncommon | ||
| Vascular disorders: | |||
| Flushing | Uncommon | ||
| Respiratory, thoracic and mediastinal disorders: | |||
| Pharyngitis | Uncommon | ||
| Rhinitis | Uncommon | ||
| Nasal congestion | Uncommon | ||
| Pharyngo laryngeal pain | Uncommon | ||
| Gastrointestinal disorders: | |||
| Nausea | Common | Uncommon | Common |
| Abdominal pain | Uncommon | ||
| Diarrhoea | Uncommon | Uncommon | |
| Vomiting | Uncommon | ||
| Rectal disorder | Uncommon | ||
| Rectal tenesmus | Uncommon | ||
| Dry mouth | Uncommon | ||
| Skin and subcutaneous tissue disorders: | |||
| Pruritus | Uncommon | ||
| Dermatitis | Uncommon | Uncommon | |
| Folliculitis | Uncommon | ||
| Rash erythematous | Uncommon | ||
| Eczema | Uncommon | ||
| Rash | Uncommon | ||
| Sweating increased | Uncommon | ||
| Urticaria | Uncommon | ||
| Actinic keratosis | Uncommon | ||
| Erythema | Uncommon | ||
| Face oedema | Uncommon | ||
| Skin ulcer | Uncommon | ||
| Musculoskeletal and connective tissue disorders: | |||
| Myalgia | Common | Common | |
| Arthralgia | Uncommon | Common | |
| Back pain | Uncommon | Common | |
| Pain in extremity | Uncommon | ||
| Renal and urinary disorders: | |||
| Dysuria | Uncommon | ||
| Reproductive system and breast disorders: | |||
| Genital pain male | Uncommon | ||
| Penile disorder | Uncommon | ||
| Dyspareunia | Uncommon | ||
| Erectile dysfunction | Uncommon | ||
| Uterovaginal prolapse | Uncommon | ||
| Vaginal pain | Uncommon | ||
| Vaginitis atrophic | Uncommon | ||
| Vulval disorder | Uncommon | ||
| General disorders and administration site conditions: | |||
| Application site pruritus | Very common | Very common | Very common |
| Application site pain | Very common | Common | Common |
| Application site burning | Common | Common | Common |
| Application site irritation | Common | Common | Common |
| Application site erythema | Common | Common | |
| Application site reaction | Common | ||
| Application site bleeding | Common | Uncommon | |
| Application site papules | Common | Uncommon | |
| Application site paraesthesia | Common | Uncommon | |
| Application site rash | Common | ||
| Fatigue | Common | Common | |
| Pyrexia | Uncommon | Uncommon | |
| Influenza-like illness | Uncommon | Uncommon | |
| Pain | Uncommon | ||
| Asthenia | Uncommon | Uncommon | |
| Malaise | Uncommon | ||
| Rigors | Uncommon | Uncommon | |
| Application site dermatitis | Uncommon | ||
| Application site discharge | Uncommon | Uncommon | |
| Application site hyperaesthesia | Uncommon | ||
| Application site inflammation | Uncommon | ||
| Application site oedema | Uncommon | Uncommon | |
| Application site scabbing | Uncommon | Uncommon | |
| Application site scar | Uncommon | ||
| Application site skin breakdown | Uncommon | ||
| Application site swelling | Uncommon | Uncommon | |
| Application site ulcer | Uncommon | ||
| Application site vesicles | Uncommon | Uncommon | |
| Application site warmth | Uncommon | ||
| Lethargy | Uncommon | ||
| Discomfort | Uncommon | ||
| Inflammation | Uncommon |
c) Frequently occurring adverse events:
External genital warts:
Investigators of placebo controlled trials were required to evaluate protocol mandated clinical signs (skin reactions). These protocol mandated clinical sign assessments indicate that local skin reactions including erythema (61%), erosion (30%), excoriation/flaking/scaling (23%) and oedema (14%) were common in these placebo controlled clinical trials with imiquimod cream applied three times weekly. Local skin reactions, such as erythema, are probably an extension of the pharmacologic effects of imiquimod cream.
Remote site skin reactions, mainly erythema (44%), were also reported in the placebo controlled trials. These reactions were at non-wart sites which may have been in contact with imiquimod cream. Most skin reactions were mild to moderate in severity and resolved within 2 weeks of treatment discontinuation. However, in some cases these reactions have been severe, requiring treatment and/or causing incapacitation. In very rare cases, severe reactions at the urethral meatus have resulted in dysuria in women.
Superficial basal cell carcinoma:
Investigators of the placebo controlled clinical trials were required to evaluate protocol mandated clinical signs (skin reactions). These protocol mandated clinical sign assessments indicate that severe erythema (31%) severe erosions (13%) and severe scabbing and crusting (19%) were very common in these trials with imiquimod cream applied 5 times weekly. Local skin reactions, such as erythema, are probably an extension of the pharmacologic effect of imiquimod cream.
Skin infections during treatment with imiquimod have been observed. While serious sequelae have not resulted, the possibility of infection in broken skin should always be considered.
Actinic keratosis
In clinical trials of imiquimod cream 3 times weekly for 4 or 8 weeks the most frequently occurring application site reactions were itching at the target site (14%) and burning at the target site (5%). Severe erythema (24%) and severe scabbing and crusting (20%) were very common. Local skin reactions, such as erythema, are probably an extension of the pharmacologic effect of imiquimod cream. See 4.2 and 4.4 for information on rest periods.
Skin infections during treatment with imiquimod have been observed. While serious sequelae have not resulted, the possibility of infection in broken skin should always be considered.
d) Adverse events applicable to all indications:
Reports have been received of localised hypopigmentation and hyperpigmentation following imiquimod cream use. Follow-up information suggests that these skin colour changes may be permanent in some patients. In a follow-up of 162 patients five years after treatment for sBCC a mild hypopigmentation was observed in 37% of the patients and a moderate hypopigmentation was observed in 6% of the patients. 56% of the patients have been free of hypopigmentation; hyperpigmentation has not been reported.
Clinical studies investigating the use of imiquimod for the treatment of actinic keratosis have detected a 0.4% (5/1214) frequency of alopecia at the treatment site or surrounding area. Postmarketing reports of suspected alopecia occurring during the treatment of sBCC and EGW have been received.
Reductions in haemoglobin, white blood cell count, absolute neutrophils and platelets have been observed in clinical trials. These reductions are not considered to be clinically significant in patients with normal haematologic reserve. Patients with reduced haematologic reserve have not been studied in clinical trials. Reductions in haematological parameters requiring clinical intervention have been reported from postmarketing experience. There have been postmarketing reports of elevated liver enzymes.
Rare reports have been received of exacerbation of autoimmune conditions.
Rare cases of remote site dermatologic drug reactions, including erythema multiforme, have been reported from clinical trials. Serious skin reactions reported from postmarketing experience include erythema multiforme, Stevens Johnson syndrome and cutaneous lupus erythematosus.
e) Paediatric population:
Imiquimod was investigated in controlled clinical studies with paediatric patients. There was no evidence for systemic reactions. Application site reactions occurred more frequently after imiquimod than after vehicle, however, incidence and intensity of these reactions were not different from that seen in the licensed indications in adults. There was no evidence for serious adverse reaction caused by imiquimod in paediatric patients.
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard.
Summary of the safety profile:
The data described below reflect exposure to Tian Rui or vehicle in 319 subjects enrolled in two double-blind studies. Subjects applied up to two sachets of Tian Rui 3.75% cream or vehicle daily to the skin of the affected area (either entire face or balding scalp, but not both) for two 2-week treatment cycles separated by a 2-week no-treatment cycle.
In clinical trials most patients (159/160) using Tian Rui for the treatment of AK experience local skin reactions (most frequently erythema, scab, and exfoliation/application site dryness) at the application site. However, only 11% (17/160) of patients in clinical trials with Tian Rui required rest periods (treatment interruption) due to local adverse reactions. Some systemic adverse reactions, including headache 6% (10/160), fatigue 4% (7/160), were reported by Tian Rui treated patients in clinical trials.
Tabulated list of adverse reactions
Data presented in the table below reflects:
- exposure to Tian Rui or vehicle in above mentioned studies (frequencies very common to uncommon and at greater frequency after vehicle).
- experience with imiquimod 5% cream
Frequencies are defined as:
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) and not known (cannot be estimated from the available data)
| System organ class | Frequency | Adverse reactions |
| Infections and infestations | Common | Herpes simplex |
| Uncommon | Infection | |
| Pustules | ||
| Frequency not known | Skin infection | |
| Blood and lymphatic system disorders | Common | Lymphadenopathy |
| Frequency not known | Haemoglobin decreased | |
| White blood cell count decreased | ||
| Neutrophil count decreased | ||
| Platelet count decreased | ||
| Immune system disorders | Rare | Exacerbation of autoimmune conditions |
| Metabolism and nutrition disorders | Common | Anorexia |
| Blood glucose increased | ||
| Psychiatric disorders | Common | Insomnia |
| Uncommon | Depression | |
| Irritability | ||
| Nervous system disorders | Common | Headache |
| Dizziness | ||
| Eye disorders | Uncommon | Conjunctival irritation |
| Eyelid oedema | ||
| Respiratory, thoracic and mediastinal disorders | Uncommon | Nasal congestion |
| Pharyngo laryngeal pain | ||
| Hepatobiliary disorders | Frequency not known | Hepatic enzyme increased |
| Gastrointestinal disorders | Common | Nausea |
| Diarrhoea | ||
| Vomiting | ||
| Uncommon | Dry mouth | |
| Abdominal pain | ||
| Skin and subcutaneous tissue disorders | Very common | Erythema |
| Scab | ||
| Skin exfoliation | ||
| Skin oedema | ||
| Skin ulcer | ||
| Skin hypopigmentation | ||
| Common | Dermatitis | |
| Uncommon | Face oedema | |
| Rare | Remote site dermatologic reaction | |
| Frequency not known | Alopecia | |
| Erythema multiforme | ||
| Stevens Johnson syndrome | ||
| Cutaneous lupus erythematosus | ||
| Skin hyperpigmentation | ||
| Musculoskeletal and connective tissue disorders | Common | Myalgia |
| Arthralgia | ||
| Uncommon | Back pain | |
| Pain in extremity | ||
| General disorders and administration site conditions | Very common | Application site erythema |
| Application site scabbing | ||
| Application site exfoliation | ||
| Application site dryness | ||
| Application site oedema | ||
| Application site ulcer | ||
| Application site discharge | ||
| Common | Application site reaction | |
| Application site pruritus | ||
| Application site pain | ||
| Application site swelling | ||
| Application site burning | ||
| Application site irritation | ||
| Application site rash | ||
| Fatigue | ||
| Pyrexia | ||
| Influenza-like illness | ||
| Pain | ||
| Chest pain | ||
| Uncommon | Application site dermatitis | |
| Application site bleeding | ||
| Application site papules | ||
| Application site paraesthesia | ||
| Application site hyperaesthesia | ||
| Application site inflammation | ||
| Application site scar | ||
| Application site skin breakdown | ||
| Application site vesicles | ||
| Application site warmth | ||
| Asthenia | ||
| Chills | ||
| Lethargy | ||
| Discomfort | ||
| Inflammation |
Description of selected adverse reactions
Blood system disorders
Reductions in haemoglobin, white blood cell count, absolute neutrophils and platelets have been observed in clinical trials investigating the use of imiquimod 5% cream. These reductions are not considered to be clinically significant in patients with normal haematologic reserve. Patients with reduced haematologic reserve have not been studied in clinical trials. Reductions in haematological parameters requiring clinical intervention have been reported from postmarketing experience.
Skin infections
Skin infections during treatment with imiquimod have been observed. While serious sequelae have not resulted, the possibility of infection in broken skin should always be considered.
Hypopigmentation and hyperpigmentation
Reports have been received of localised hypopigmentation and hyperpigmentation following imiquimod 5 % cream use. Follow-up information suggests that these skin colour changes may be permanent in some patients.
Remote site dermatologic reactions
Rare cases of remote site dermatologic reactions, including erythema multiforme, have been reported from clinical trials with imiquimod 5% cream therapy.
Alopecia
Clinical studies investigating the use of imiquimod 5% cream for the treatment of actinic keratosis have detected a 0.4% (5/1214) frequency of alopecia at the treatment site or surrounding area.
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard.
When applied topically, systemic overdosage with imiquimod cream is unlikely due to minimal percutaneous absorption. Studies in rabbits reveal a dermal lethal dose of greater than 5 g/kg. Persistent dermal overdosing of imiquimod cream could result in severe local skin reactions.
Following accidental ingestion, nausea, emesis, headache, myalgia and fever could occur after a single dose of 200 mg imiquimod which corresponds to the content of approximately 16 sachets. The most clinically serious adverse event reported following multiple oral doses of > 200 mg was hypotension which resolved following oral or intravenous fluid administration.
When applied topically, systemic overdose with imiquimod cream is unlikely due to minimal percutaneous absorption. Studies in rabbits reveal a dermal lethal imiquimod dose of greater than 5 g/kg. Persistent topical overdosing of imiquimod cream could result in severe local skin reactions and may increase the risk for systemic reactions.
Following accidental ingestion, nausea, emesis, headache, myalgia and fever could occur after a single dose of 200 mg imiquimod which corresponds to the content of more than 21 sachets of Tian Rui. The most clinically serious adverse event reported following multiple oral doses of > 200 mg was hypotension which resolved following oral or intravenous fluid administration.
Management of overdose should consist of treatment of clinical symptoms.
Pharmacotherapeutic group: Chemotherapeutics for topical use, antivirals, ATC Code: D06BB10
Imiquimod is an immune response modifier. Saturable binding studies suggest a membrane receptor for imiquimod exists on responding immune cells. Imiquimod has no direct antiviral activity. In animal models imiquimod is effective against viral infections and acts as an antitumour agent principally by induction of alpha interferon and other cytokines. The induction of alpha interferon and other cytokines following imiquimod cream application to genital wart tissue has also been demonstrated in clinical studies.
Increases in systemic levels of alpha interferon and other cytokines following topical application of imiquimod were demonstrated in a pharmacokinetic study.
External genital warts:
Clinical Efficacy
The results of 3 phase III pivotal efficacy studies showed that treatment with imiquimod for sixteen weeks was significantly more effective than treatment with vehicle as measured by total clearance of treated warts.
In 119 imiquimod-treated female patients, the combined total clearance rate was 60% as compared to 20% in 105 vehicle-treated patients (95% CI for rate difference: 20% to 61%, p<0.001). In those imiquimod patients who achieved total clearance of their warts, the median time to clearance was 8 weeks.
In 157 imiquimod-treated male patients, the combined total clearance rate was 23% as compared to 5% in 161 vehicle-treated patients (95%CI for rate difference: 3% to 36%, p<0.001). In those imiquimod patients who achieved total clearance of their warts, the median time to clearance was 12 weeks.
Superficial basal cell carcinoma:
Clinical efficacy:
The efficacy of imiquimod 5 times per week for 6 weeks was studied in two double-blind vehicle controlled clinical trials. Target tumours were histologically confirmed single primary superficial basal cell carcinomas with a minimum size of 0.5 cm2 and a maximum diameter of 2 cm. Tumours located within 1 cm of the eyes, nose, mouth, ears or hairline were excluded. In a pooled analysis of these two studies, histological clearance was noted in 82% (152/185) of patients. When clinical assessment was also included, clearance judged by this composite endpoint was noted in 75% (139/185) of patients. These results were statistically significant (p<0.001) by comparison with the vehicle group, 3% (6/179) and 2% (3/179) respectively. There was a significant association between the intensity of local skin reactions (e.g. erythema) seen during the treatment period and complete clearance of the basal cell carcinoma.
Five -year data from a long-term open-label uncontrolled study indicate that an estimated 77.9% [95% CI (71.9%, 83.8%)] of all the subjects who initially received treatment became clinically clear and remained clear at 60 months.
Actinic keratosis:
Clinical efficacy:
The efficacy of imiquimod applied 3 times per week for one or two courses of 4 weeks, separated by a 4 week treatment-free period, was studied in two double-blind vehicle controlled clinical trials. Patients had clinically typical, visible, discrete, nonhyperkeratotic, nonhypertrophic AK lesions on the balding scalp or face within a contiguous 25 cm2 treatment area. 4-8 AK lesions were treated. The complete clearance rate (imiquimod minus placebo) for the combined trials was 46.1% (CI 39.0%, 53.1%).
One-year data from two combined observational studies indicate a recurrence rate of 27% (35/128 patients) in those patients who became clinically clear after one or two courses of treatment. The recurrence rate for individual lesions was 5.6% (41/737). Corresponding recurrence rates for vehicle were 47% (8/17 patients) and 7.5% (6/80 lesions).
Two open-label, randomised, controlled clinical trials compared the long-term effects of imiquimod with those of topical diclofenac in patients with actinic keratosis with respect to the risk of progression to in situ or invasive squamous cell carcinoma (SCC). Treatments were given as officially recommended. If the treated AK field was not completely cleared of lesions, additional treatment cycles could be started. All patients were followed-up until withdrawal or up to 3 years after randomisation. Results are emerged from a meta-analysis of both trials.
A total of 482 patients were included into the trials, of these 481 patients received study treatments, and of these 243 patients were treated with imiquimod and 238 patients with topical diclofenac. The treated AK field was located on the balding scalp or face with a contiguous area of about 40 cm2 for both treatment groups presenting with a median number of 7 clinically typical AK lesions at baseline. There is clinical experience from 90 patients who got 3 or more imiquimod treatment cycles, 80 patients received 5 or more courses of imiquimod treatment over the 3-year study period.
Regarding the primary endpoint, histological progression, overall 13 of 242 patients (5.4%) of the imiquimod group and 26 of 237 patients (11.0%) of the diclofenac group were found to have a histological progression to in situ or invasive SCC within 3 years, a difference of -5.6% (95% CI: -10.7% to -0.7%). Thereof 4 of 242 patients (1.7%) of the imiquimod and 7 of 237 patients (3.0%) of the diclofenac group were found to have a histological progression to invasive SCC within the 3-year period.
A total of 126 of 242 patients treated with imiquimod (52.1%) and 84 of 237 patients treated with topical diclofenac (35.4%) showed complete clinical clearance of the treated AK field at week 20 (i.e. about 8 weeks after the end of the initial treatment cycle); a difference of 16.6% (95% CI: 7.7% to 25.1%). For those patients with complete clinical clearance of the treated AK field recurrence of AK lesions was evaluated. A patient was counted as recurrent in these trials if at least one AK lesion was observed in the completely cleared field whereby a recurrent lesion could be a lesion which occurred at the same location as a formerly cleared lesion or a newly identified lesion anywhere in the treated AK field. The risk for recurrence of AK lesions in the treated field (as defined above) was 39.7% (50 of 126 patients) until month 12 for patients treated with imiquimod compared with 50.0% (42 of 84 patients) for patients treated with topical diclofenac, a difference of -10.3% (95% CI: -23.6% to 3.3%); and 66.7% (84 of 126 patients) for a treatment with imiquimod and 73.8% (62 of 84 patients) for topical diclofenac until month 36, a difference of -7.1% (95% CI: -19.0% to 5.7%).
A patient with recurrent AK lesions (as defined above) in the completely cleared field had a chance of about 80% to become completely cleared again following an additional imiquimod treatment cycle compared with a chance of about 50% for a re-treatment with topical diclofenac.
Paediatric population
The approved indications genital warts, actinic keratosis and superficial basal cell carcinoma are conditions not generally seen within the paediatric population and were not studied.
Tian Rui Cream has been evaluated in four randomised, vehicle controlled, double-blind trials in children aged 2 to 15 years with molluscum contagiosum (imiquimod n = 576, vehicle n = 313). These trials failed to demonstrate efficacy of imiquimod at any of the tested dosage regimens (3x/week for ≤16 weeks and 7x/week for ≤8 weeks).
Pharmacotherapeutic group: Antibiotics and chemotherapeutics for dermatological use, antivirals, ATC Code: D06BB10
Pharmacodynamic effects
Imiquimod is an immune response modifier. It is the lead compound of the imidazoline family. Saturable binding studies suggest membrane receptors for imiquimod exists on responding cells; these are called toll-like receptor 7 and 8. Imiquimod induces the release of interferon alpha (IFN-α) and other cytokines from a variety of human and animal cells (e.g. from human monocytes/macrophages and keratinocytes). Topical in vivo application of imiquimod cream on mouse skin resulted in increased concentrations of IFN and tumour necrosis factor (TNF) compared with skin of untreated mice. The panel of induced cytokines varies with the cell's tissue origin. In addition, release of cytokines was induced following dermal application and oral administration of imiquimod in various laboratory animals and in human studies. In animal models imiquimod is effective against viral infections and acts as an antitumour agent principally by inducing release of alpha interferon and other cytokines.
Increases in systemic levels of alpha interferon and other cytokines following topical application of imiquimod were also observed in human data.
Clinical efficacy and safety
The efficacy of Tian Rui was studied in two double-blind, randomized, vehicle-controlled clinical studies. Patients had 5-20 typical visible or palpable AK lesions in an area that exceeded 25 cm2 on either the face or balding scalp. 319 subjects with AK were treated with up to 2 sachets once daily of imiquimod 3.75% cream, or a matching vehicle cream for two treatment cycles of 2 weeks separated by a 2-week no-treatment cycle. For the combined trials the complete clearance rate of the full face or balding scalp under imiquimod 3.75% cream was 35.6% (57/160 patients, CI 28.2%, 43.6 %) under vehicle 6.3% (10/159 patients, CI 3.1%, 11.3%) at the 8-week post-treatment visit. No overall differences in safety or effectiveness were observed between patients 65 years or older and the younger patients. Squamous cell carcinoma (SCC) was reported in 1.3% (2/160) of patients treated with imiquimod 3.75%, in 0.6% (1/159) treated with vehicle. This difference was not statistically significant.
In a follow-up study where initially cleared patients with imiquimod 3.75% were followed for at least 14 months without any further AK-treatment, 40.5% of the patients showed sustained complete clearance of the whole treatment area (either full face or scalp) There are no data for imiquimod 3.75% on long-term clearance beyond that.
Two open-label randomized, controlled studies investigated the long-term effects of imiquimod 5% (and not with this 3.75% product) in comparison to topical diclofenac (3% gel). In these studies, the treated AK field was located on the balding scalp or face with a contiguous area of about 40 cm2 and presenting with a median number of 7 clinically typical AK lesions at baseline. Study treatments were given as officially recommended. These studies showed that imiquimod was better than topical diclofenac in preventing the histological progression of AK lesions to in-situ or invasive squamous cell carcinoma (SCC). In addition, these studies supported the use of up to two additional treatment cycles of imiquimod when the AK lesions are not completely cleared or if the AK lesions recurred after successful initial treatment with imiquimod.
Paediatric population
).
External genital warts, superficial basal cell carcinoma and actinic keratosis:
Less than 0.9% of a topically applied single dose of radiolabelled imiquimod was absorbed through the skin of human subjects. The small amount of drug which was absorbed into the systemic circulation was promptly excreted by both urinary and faecal routes at a mean ratio of approximately 3 to 1. No quantifiable levels (>5 ng/ml) of drug were detected in serum after single or multiple topical doses.
Systemic exposure (percutaneous penetration) was calculated from recovery of carbon-14 from [14C] imiquimod in urine and faeces.
Minimal systemic absorption of imiquimod 5% cream across the skin of 58 patients with actinic keratosis was observed with 3 times per week dosing for 16 weeks. The extent of percutaneous absorption did not change significantly between the first and last doses of this study. Peak serum drug concentrations at the end of week 16 were observed between 9 and 12 hours and were 0.1, 0.2, and 1.6 ng/mL for the applications to face (12.5 mg, 1 single-use sachet), scalp (25 mg, 2 sachets) and hands/arms (75 mg, 6 sachets), respectively. The application surface area was not controlled in the scalp and hands/ arms groups. Dose proportionality was not observed. An apparent half-life was calculated that was approximately 10 times greater than the 2 hour half-life seen following subcutaneous dosing in a previous study, suggesting prolonged retention of drug in the skin. Urinary recovery was less than 0.6% of the applied dose at week 16 in these patients.
Paediatric population
The pharmacokinetic properties of imiquimod following single and multiple topical application in paediatric patients with molluscum contagiosum (MC) have been investigated. The systemic exposure data demonstrated that the extent of absorption of imiquimod following topical application to the MC lesional skin of the paediatric patients aged 6-12 years was low and comparable to that observed in healthy adults and adults with actinic keratosis or superficial basal cell carcinoma. In younger patients aged 2-5 years absorption, based on Cmax values, was higher compared to adults.
Absorption
Less than 0.9% of a topically applied single dose of radiolabelled imiquimod was absorbed through the skin of human subjects.
Systemic exposure (percutaneous penetration) was calculated from recovery of carbon-14 from [14C] imiquimod in urine and faeces.
During a pharmacokinetic study with imiquimod 3.75% cream following application of 2 sachets once daily (18.75 mg imiquimod/day) for up to three weeks to the entire face and/or scalp (approximately 200 cm2), low systemic absorption of imiquimod was observed in patients with AK. Steady-state levels were achieved in 2 weeks and time to maximal concentrations (Tmax) ranged between 6 and 9 hours after last application.
Distribution
The mean peak serum imiquimod concentration at the end of the pharmacokinetic study was 0.323 ng/mL.
Biotransformation
Orally administered imiquimod is rapidly and extensively metabolised into two main metabolites.
Elimination
The small amount of medicinal product which was absorbed into the systemic circulation was promptly excreted by both urinary and faecal routes at a mean ratio of approximately 3 to 1.
The apparent half-life following topical dosing of 3.75% imiquimod cream in the pharmacokinetic study was calculated as approximately 29 hours.
Non-clinical data revealed no special hazard for humans based on conventional studies of safety pharmacology, mutagenicity and teratogenicity.
In a four-month rat dermal toxicity study, significantly decreased body weight and increased spleen weight were observed at 0.5 and 2.5 mg/kg; similar effects were not seen in a four month mouse dermal study. Local dermal irritation, especially at higher doses, was observed in both species.
A two-year mouse carcinogenicity study by dermal administration on three days a week did not induce tumours at the application site. However, the incidences of hepatocellular tumours among treated animals were greater than those for controls. The mechanism for this is not known, but as imiquimod has low systemic absorption from human skin, and is not mutagenic, any risk to humans from systemic exposure is likely to be low. Furthermore, tumours were not seen at any site in a 2-year oral carcinogenicity study in rats.
Imiquimod cream was evaluated in a photocarcinogenicity bioassay in albino hairless mice exposed to simulated solar ultraviolet radiation (UVR). Animals were administered imiquimod cream three times per week and were irradiated 5 days per week for 40 weeks. Mice were maintained for an additional 12 weeks for a total of 52 weeks. Tumours occurred earlier and in greater number in the group of mice administered the vehicle cream in comparison with the low UVR control group. The significance for man is unknown. Topical administration of imiquimod cream resulted in no tumour enhancement at any dose, in comparison with the vehicle cream group.
Non-clinical data revealed no special hazard for humans based on conventional studies of safety pharmacology, mutagenicity and teratogenicity.
In a four-month rat dermal toxicity study, significantly decreased body weight and increased spleen weight were observed at 0.5 and 2.5 mg/kg; similar effects were not seen in a four-month mouse dermal study. Local dermal irritation, especially at higher doses, was observed in both species.
A 18-month mouse carcinogenicity study by dermal administration on three days a week did not induce tumours at the application site. Only in female mice, the incidences of hepatocellular adenomas were slightly greater than those for controls. The incidence corresponds well with the spectrum of spontaneous tumours, as is known in mice in correspondence with their age. Therefore, these findings are considered to be incidental. As imiquimod has low systemic absorption from human skin, and is not mutagenic, any risk to humans from systemic exposure is likely to be low. Furthermore, tumours were not seen at any site in a 2-year oral carcinogenicity study in rats.
Imiquimod cream was evaluated in a photocarcinogenicity bioassay in albino hairless mice exposed to simulated solar ultraviolet radiation (UVR). Animals were administered imiquimod cream three times per week and were irradiated 5 days per week for 40 weeks. Mice were maintained for an additional 12 weeks. Tumours occurred earlier and in greater number in the group of mice administered the vehicle cream in comparison with the low UVR control group. The significance for man is unknown. Topical administration of imiquimod cream resulted in no tumour enhancement at any dose, in comparison with the vehicle cream group.
Not applicable.
No special requirements.
However, we will provide data for each active ingredient
