Xalatamax

Reduction of elevated intraocular pressure in patients with open angle glaucoma and ocular hypertension.

Reduction of elevated intraocular pressure in paediatric patients with elevated intraocular pressure and paediatric glaucoma.

Posology

Recommended dosage for adults (including the elderly):

Recommended therapy is one eye drop in the affected eye(s) once daily. Optimal effect is obtained if Xalatamax eye drops is administered in the evening.

The dosage of Xalatamax eye drops should not exceed once daily since it has been shown that more frequent administration decreases the intraocular pressure lowering effect.

If one dose is missed, treatment should continue with the next dose as normal.

Method of administration

As with any eye drops, to reduce possible systemic absorption, it is recommended that the lachrymal sac be compressed at the medial canthus (punctal occlusion) for one minute. This should be performed immediately following the instillation of each drop.

Contact lenses should be removed before instillation of the eye drops and may be reinserted after 15 minutes.

If more than one topical ophthalmic drug is being used, the drugs should be administered at least five minutes apart.

Paediatric population

Xalatamax eye drops may be used in paediatric patients at the same posology as in adults. No data are available for preterm infants (less than 36 weeks gestational age). Data in the age group < 1 year (4 patients) are limited.

Xalatamax eye drops may gradually change eye colour by increasing the amount of brown pigment in the iris. Before treatment is instituted, patients should be informed of the possibility of a permanent change in eye colour. Unilateral treatment can result in permanent heterochromia.

This change in eye colour has predominantly been seen in patients with mixed coloured irides, i.e. blue-brown, grey-brown, yellow-brown and green-brown. In clinical studies with Xalatamax, the onset of the change is usually within the first 8 months of treatment, rarely during the second or third year, and has not been seen after the fourth year of treatment. The rate of progression of iris pigmentation decreases with time and is stable for five years. The effect of increased pigmentation beyond five years has not been evaluated. In an open 5-year Xalatamax safety study, 33% of patients developed iris pigmentation. The iris colour change is slight in the majority of cases and often not observed clinically. The incidence in patients with mixed colour irides ranged from 7 to 85%, with yellow-brown irides having the highest incidence. In patients with homogeneously blue eyes, no change has been observed and in patients with homogeneously grey, green or brown eyes, the change has only rarely been seen.

The colour change is due to increased melanin content in the stromal melanocytes of the iris and not to an increase in number of melanocytes. Typically, the brown pigmentation around the pupil spreads concentrically towards the periphery in affected eyes, but the entire iris or parts of it may become more brownish. No further increase in brown iris pigment has been observed after discontinuation of treatment. It has not been associated with any symptom or pathological changes in clinical trials to date.

Neither naevi nor freckles of the iris have been affected by treatment. Accumulation of pigment in the trabecular meshwork or elsewhere in the anterior chamber has not been observed in clinical trials. Based on 5 years clinical experience, increased iris pigmentation has not been shown to have any negative clinical sequelae and Xalatamax eye drops can be continued if iris pigmentation ensues. However, patients should be monitored regularly and if the clinical situation warrants, Xalatamax eye drops treatment may be discontinued.

There is limited experience of Xalatamax in chronic angle closure glaucoma, open angle glaucoma of pseudophakic patients and in pigmentary glaucoma. There is no experience of Xalatamax in inflammatory and neovascular glaucoma or inflammatory ocular conditions. Xalatamax eye drops has no or little effect on the pupil, but there is no experience in acute attacks of closed angle glaucoma. Therefore, it is recommended that Xalatamax eye drops should be used with caution in these conditions until more experience is obtained.

There are limited study data on the use of Xalatamax during the peri-operative period of cataract surgery. Xalatamax eye drops should be used with caution in these patients.

Xalatamax eye drops should be used with caution in patients with a history of herpetic keratitis, and should be avoided in cases of active herpes simplex keratitis and in patients with a history of recurrent herpetic keratitis specifically associated with prostaglandin analogues.

Reports of macular oedema have occurred mainly in aphakic patients, in pseudophakic patients with torn posterior lens capsule or anterior chamber lenses, or in patients with known risk factors for cystoid macular oedema (such as diabetic retinopathy and retinal vein occlusion). Xalatamax eye drops should be used with caution in aphakic patients, in pseudophakic patients with torn posterior lens capsule or anterior chamber lenses, or in patients with known risk factors for cystoid macular oedema.

In patients with known predisposing risk factors for iritis/uveitis, Xalatamax eye drops can be used with caution.

There is limited experience from patients with asthma, but some cases of exacerbation of asthma and/or dyspnoea were reported in post marketing experience.).

Periorbital skin discolouration has been observed, the majority of reports being in Japanese patients. Experience to date shows that periorbital skin discolouration is not permanent and in some cases has reversed while continuing treatment with Xalatamax.

Xalatamax may gradually change eyelashes and vellus hair in the treated eye and surrounding areas; these changes include increased length, thickness, pigmentation, number of lashes or hairs and misdirected growth of eyelashes. Eyelash changes are reversible upon discontinuation of treatment.

Xalatamax eye drops contains benzalkonium chloride, which is commonly used as a preservative in ophthalmic products. Benzalkonium chloride has been reported to cause punctuate keratopathy and/or toxic ulcerative keratopathy, may cause eye irritation and is known to discolour soft contact lenses. Close monitoring is required with frequent or prolonged use of Xalatamax eye drops in dry eye patients, or in conditions where the cornea is compromised. Contact lenses may absorb benzalkonium chloride and these should be removed before applying Xalatamax eye drops but may be reinserted after 15 minutes.

Paediatric population

Efficacy and safety data in the age group < 1 year (4 patients) are very limited. No data are available for preterm infants (less than 36 weeks gestational age).

In children from 0 to < 3 years old that mainly suffer from PCG (primary congenital glaucoma), surgery (e.g. trabeculotomy/goniotomy) remains the first line treatment.

Long-term safety in children has not yet been established.

In common with other eye preparations, instillation of eye drops may cause transient blurring of vision. Until this has resolved, patients should not drive or use machines.

a. Summary of the safety profile

The majority of adverse events relate to the ocular system. In an open 5-year Xalatamax safety study, 33% of patients developed iris pigmentation. Other ocular adverse events are generally transient and occur on dose administration.

b. Tabulated list of adverse reactions

Adverse events are categorized by frequency as follows: very common (>1/10), common (>1/100, <1/10), uncommon (>1/1000, <1/100), rare (>1/10,000, <1/1000) and very rare (<1/10,000). Not known (cannot be estimated from the available data).

c. Description of selected adverse reactions

No information is provided.

d. Paediatric Population

In two short term clinical trials (≤ 12 weeks), involving 93 (25 and 68) paediatric patients the safety profile was similar to that in adults and no new adverse events were identified. The short term safety profiles in the different paediatric subsets were also similar. Adverse events seen more frequently in the paediatric population as compared to adults are: nasopharyngitis and pyrexia.

Cases of corneal calcification have been reported very rarely in association with the use of phosphate containing eye drops in some patients with significantly damaged corneas.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme Website: www.mhra.gov.uk/yellowcard.

Apart from ocular irritation and conjunctival hyperaemia, no other ocular side effects are known if Xalatamax eye drops is overdosed.

If Xalatamax eye drops is accidentally ingested the following information may be useful: One bottle contains 125 micrograms Xalatamax. More than 90% is metabolised during the first pass through the liver. Intravenous infusion of 3 micrograms/kg in healthy volunteers induced no symptoms, but a dose of 5.5-10 micrograms/kg caused nausea, abdominal pain, dizziness, fatigue, hot flushes and sweating. In monkeys, Xalatamax has been infused intravenously in doses of up to 500 micrograms/kg without major effects on the cardiovascular system.

Intravenous administration of Xalatamax in monkeys has been associated with transient bronchoconstriction. However, in patients with moderate bronchial asthma, bronchoconstriction was not induced by Xalatamax when applied topically on the eyes in a dose of seven times the clinical dose of Xalatamax.

If overdosage with Xalatamax eye drops occurs, treatment should be symptomatic.

Pharmacotherapeutic group: Prostaglandin analogues

ATC code: S01EE01

The active substance Xalatamax, a prostaglandin F2α analogue, is a selective prostanoid FP receptor agonist which reduces the intraocular pressure by increasing the outflow of aqueous humour. Reduction of the intraocular pressure in man starts about three to four hours after administration and maximum effect is reached after eight to twelve hours. Pressure reduction is maintained for at least 24 hours.

Studies in animals and man indicate that the main mechanism of action is increased uveoscleral outflow, although some increase in outflow facility (decrease in outflow resistance) has been reported in man.

Pivotal studies have demonstrated that Xalatamax is effective as monotherapy. In addition, clinical trials investigating combination use have been performed. These include studies that show that Xalatamax is effective in combination with beta-adrenergic antagonists (timolol). Short-term (1 or 2 weeks) studies suggest that the effect of Xalatamax is additive in combination with adrenergic agonists (dipivalyl epinephrine), oral carbonic anhydrase inhibitors (acetazolamide) and at least partly additive with cholinergic agonists (pilocarpine).

Clinical trials have shown that Xalatamax has no significant effect on the production of aqueous humour. Xalatamax has not been found to have any effect on the blood-aqueous barrier.

Xalatamax has no or negligible effects on the intraocular blood circulation when used at the clinical dose and studied in monkeys. However, mild to moderate conjunctival or episcleral hyperaemia may occur during topical treatment.

Chronic treatment with Xalatamax in monkey eyes, which had undergone extracapsular lens extraction, did not affect the retinal blood vessels as determined by fluorescein angiography.

Xalatamax has not induced fluorescein leakage in the posterior segment of pseudophakic human eyes during short-term treatment.

Xalatamax in clinical doses has not been found to have any significant pharmacological effects on the cardiovascular or respiratory system.

Paediatric population

The efficacy of Xalatamax in paediatric patients ≤ 18 years of age was demonstrated in a 12-week, double-masked clinical study of Xalatamax compared with timolol in 107 patients diagnosed with ocular hypertension and paediatric glaucoma. Neonates were required to be at least 36 weeks gestational age. Patients received at random either Xalatamax 50 mcg/ml once daily or timolol 0.5% (or optionally 0.25% for subjects younger than 3 years old) twice daily. The primary efficacy endpoint was the mean reduction in intraocular pressure (IOP) from baseline at Week 12 of the study. Mean IOP reductions in the Xalatamax and timolol groups were similar. In all age groups studied (0 to <3 years, 3 to < 12 years and 12 to 18 years of age) the mean IOP reduction at Week 12 in the Xalatamax group was similar to that in the timolol group. Nevertheless, efficacy data in the age group 0 to < 3 years were based on only 13 patients for Xalatamax and no relevant efficacy was shown from the 4 patients representing the age group 0 to < 1 year old in the clinical paediatric study. No data are available for preterm infants (less than 36 weeks gestational age).

IOP reductions among subjects in the primary congenital/infantile glaucoma (PCG) subgroup were similar between the Xalatamax group and the timolol group. The non-PCG (e.g. juvenile open angle glaucoma, aphakic glaucoma) subgroup showed similar results as the PCG subgroup.

The effect on IOP was seen after the first week of treatment (see table) and was maintained throughout the 12 week period of study, as in adults.

SE: standard error.

^†Adjusted estimate based on an analysis of covariance (ANCOVA) model.

Xalatamax (mw 432.58) is an isopropyl ester prodrug which per se is inactive, but after hydrolysis to the acid of Xalatamax becomes biologically active.

The prodrug is well absorbed through the cornea and all drug that enters the aqueous humour is hydrolysed during the passage through the cornea.

Studies in man indicate that the peak concentration in the aqueous humour is reached about two hours after topical administration. After topical application in monkeys, Xalatamax is distributed primarily in the anterior segment, the conjunctivae and the eyelids. Only minute quantities of the drug reach the posterior segment.

There is practically no metabolism of the acid of Xalatamax in the eye. The main metabolism occurs in the liver. The half life in plasma is 17 minutes in man. The main metabolites, the 1,2-dinor and 1,2,3,4-tetranor metabolites, exert no or only weak biological activity in animal studies and are excreted primarily in the urine.

Paediatric population

An open-label pharmacokinetic study of plasma Xalatamax acid concentrations was undertaken in 22 adults and 25 paediatric patients (from birth to < 18 years of age) with ocular hypertension and glaucoma. All age groups were treated with Xalatamax 50 mcg/ml, one drop daily in each eye for a minimum of 2 weeks. Xalatamax acid systemic exposure was approximately 2-fold higher in 3 to < 12 year olds and 6-fold higher in children < 3 years old compared with adults, but a wide safety margin for systemic adverse effects was maintained. Median time to reach peak plasma concentration was 5 minutes post-dose across all age groups. The median plasma elimination half-life was short (< 20 minutes), similar for paediatric and adult patients, and resulted in no accumulation of Xalatamax acid in the systemic circulation under steady-state conditions.

The ocular as well as systemic toxicity of Xalatamax has been investigated in several animal species. Generally, Xalatamax is well tolerated with a safety margin between clinical ocular dose and systemic toxicity of at least 1000 times. High doses of Xalatamax, approximately 100 times the clinical dose/kg body weight, administered intravenously to unanaesthetised monkeys have been shown to increase the respiration rate probably reflecting bronchoconstriction of short duration. In animal studies, Xalatamax has not been found to have sensitising properties.

In the eye, no toxic effects have been detected with doses of up to 100 micrograms/eye/day in rabbits or monkeys (clinical dose is approximately 1.5 micrograms/eye/day). In monkeys, however, Xalatamax has been shown to induce increased pigmentation of the iris.

The mechanism of increased pigmentation seems to be stimulation of melanin production in melanocytes of the iris with no proliferative changes observed. The change in iris colour may be permanent.

In chronic ocular toxicity studies, administration of Xalatamax 6 micrograms/eye/day has also been shown to induce increased palpebral fissure. This effect is reversible and occurs at doses above the clinical dose level. The effect has not been seen in humans.

Xalatamax was found negative in reverse mutation tests in bacteria, gene mutation in mouse lymphoma and mouse micronucleus test. Chromosome aberrations were observed in vitro with human lymphocytes. Similar effects were observed with prostaglandin F2α, a naturally occurring prostaglandin, and indicates that this is a class effect.

Additional mutagenicity studies on in vitro/in vivo unscheduled DNA synthesis in rats were negative and indicate that Xalatamax does not have mutagenic potency. Carcinogenicity studies in mice and rats were negative.

Xalatamax has not been found to have any effect on male or female fertility in animal studies. In the embryotoxicity study in rats, no embryotoxicity was observed at intravenous doses (5, 50 and 250 micrograms/kg/day) of Xalatamax. However, Xalatamax induced embryolethal effects in rabbits at doses of 5 micrograms/kg/day and above.

The dose of 5 micrograms/kg/day (approximately 100 times the clinical dose) caused significant embryofetal toxicity characterised by increased incidence of late resorption and abortion and by reduced fetal weight.

No teratogenic potential has been detected.

In vitro studies have shown that precipitation occurs when eye drops containing thiomersal are mixed with Xalatamax. If such drugs are used, the eye drops should be administered with an interval of at least five minutes.

No special requirements.