Chronic overdosage may result in signs/symptoms of hypercorticism (see PRECAUTIONS). Inhalation by healthy volunteers of a single dose of 1,760 or 3,520 mcg of fluticasone propionate inhalation aerosol was well tolerated. Fluticasone propionate given by inhalation aerosol at doses of 1,320 mcg twice daily for 7 to 15 days to healthy human volunteers was also well tolerated. Repeat oral doses up to 80 mg daily for 10 days in healthy volunteers and repeat oral doses up to 20 mg daily for 42 days in patients were well tolerated. Adverse reactions were of mild or moderate severity, and incidences were similar in active and placebo treatment groups. The oral and subcutaneous median lethal doses in rats and mice were >1,000 mg/kg (>2,000 times the maximum human daily inhalation dose based on mg/m2).
FLOVENT (fluticasone propionate) Inhalation Aerosol is contraindicated in the primary treatment of status asthmaticus or other acute episodes of asthma where intensive measures are required.
Hypersensitivity to any of the ingredients of these preparations contraindicates their use (see DESCRIPTION).
The incidence of common adverse events in Table 1 is based upon 7 placebo-controlled US clinical trials in which 1,243 patients (509 female and 734 male adolescents and adults previously treated with as-needed bronchodilators and/or inhaled corticosteroids) were treated with FLOVENT (fluticasone propionate) Inhalation Aerosol (doses of 88 to 440 mcg twice daily for up to 12 weeks) or placebo.
Table 1. Overall Adverse Events With >3% Incidence in US Controlled Clinical Trials With FLOVENT Inhalation Aerosol in Patients Previously Receiving Bronchodilators and/or Inhaled Corticosteroids | ||||
Adverse Event | Placebo (N = 475) % | FLOVENT 88 mcg Twice Daily (N = 488) % | FLOVENT 220 mcg Twice Daily (N = 95) % | FLOVENT 440 mcg Twice Daily (N = 185) % |
Ear, nose, and throat | ||||
Pharyngitis | 7 | 10 | 14 | 14 |
Nasal congestion | 8 | 8 | 16 | 10 |
Sinusitis | 4 | 3 | 6 | 5 |
Nasal discharge | 3 | 5 | 4 | 4 |
Dysphonia | 1 | 4 | 3 | 8 |
Allergic rhinitis | 4 | 5 | 3 | 3 |
Oral candidiasis | 1 | 2 | 3 | 5 |
Respiratory | ||||
Upper respiratory infection | 12 | 15 | 22 | 16 |
Influenza | 2 | 3 | 8 | 5 |
Neurological | ||||
Headache | 14 | 17 | 22 | 17 |
Average duration of exposure (days) | 44 | 66 | 64 | 59 |
Table 1 includes all events (whether considered drug-related or nondrug-related by the investigator) that occurred at a rate of over 3% in groups treated with FLOVENT (fluticasone propionate) Inhalation Aerosol and were more common than in the placebo group. In considering these data, differences in average duration of exposure should be taken into account.
These adverse reactions were mostly mild to moderate in severity, with £2% of patients discontinuing the studies because of adverse events. Rare cases of immediate and delayed hypersensitivity reactions, including urticaria and rash and other rare events of angioedema and bronchospasm, have been reported.
Systemic glucocorticoid side effects were not reported during controlled clinical trials with FLOVENT (fluticasone propionate) Inhalation Aerosol. If recommended doses are exceeded, however, or if individuals are particularly sensitive, symptoms of hypercorticism, e.g., Cushing syndrome, could occur.
Other adverse events that occurred in these clinical trials using FLOVENT (fluticasone propionate) Inhalation Aerosol with an incidence of 1% to 3% and that occurred at a greater incidence than with placebo were:
Ear, Nose, and Throat: Pain in nasal sinus(es), rhinitis.
Eye: Irritation of the eye(s).
Gastrointestinal: Nausea and vomiting, diarrhea, dyspepsia and stomach disorder.
Miscellaneous: Fever.
Mouth and Teeth: Dental problem.
Musculoskeletal: Pain in joint, sprain/strain, aches and pains, pain in limb.
Neurological: Dizziness/giddiness.
Respiratory: Bronchitis, chest congestion.
Skin: Dermatitis, rash/skin eruption.
Urogenital: Dysmenorrhea.
In a 16-week study in patients with asthma requiring oral corticosteroids, the effects of FLOVENT (fluticasone propionate) Inhalation Aerosol, 660 mcg twice daily (N = 32) and 880 mcg twice daily (N = 32), were compared with placebo. Adverse events (whether considered drug-related or nondrug-related by the investigator) reported by more than 3 patients in either group treated with FLOVENT (fluticasone propionate) Inhalation Aerosol and that were more common with FLOVENT (fluticasone propionate) than placebo are shown below:
Ear, Nose, and Throat: Pharyngitis (9% and 25%), nasal congestion (19% and 22%), sinusitis (19% and 22%), nasal discharge (16% and 16%), dysphonia (19% and 9%), pain in nasal sinus(es) (13% and 0%), Candida-like oral lesions (16% and 9%), oropharyngeal candidiasis (25% and 19%).
Respiratory: Upper respiratory infection (31% and 19%), influenza (0% and 13%). Other: Headache (28% and 34%), pain in joint (19% and 13%), nausea and vomiting (22% and 16%), muscular soreness (22% and 13%), malaise/fatigue (22% and 28%), insomnia (3% and 13%).
Observed During Clinical Practice
In addition to adverse events reported from clinical trials, the following events have been identified during postapproval use of fluticasone propionate. Because they are reported voluntarily from a population of unknown size, estimates of frequency cannot be made. These events have been chosen for inclusion due to either their seriousness, frequency of reporting, or causal connection to fluticasone propionate or a combination of these factors.
Ear, Nose, and Throat: Aphonia, facial and oropharyngeal edema, hoarseness, laryngitis, and throat soreness and irritation.
Endocrine and Metabolic: Cushingoid features, growth velocity reduction in children/adolescents, hyperglycemia, osteoporosis, and weight gain.
Eye: Cataracts.
Non-Site Specific: Very rare anaphylactic reaction.
Psychiatry: Agitation, aggression, depression, and restlessness.
Respiratory: Asthma exacerbation, bronchospasm, chest tightness, cough, dyspnea, immediate bronchospasm, paradoxical bronchospasm, pneumonia, and wheeze.
Skin: Contusions, cutaneous hypersensitivity reactions, ecchymoses, and pruritus. Eosinophilic Conditions: In rare cases, patients on inhaled fluticasone propionate may present with systemic eosinophilic conditions, with some patients presenting with clinical features of vasculitis consistent with Churg-Strauss syndrome, a condition that is often treated with systemic corticosteroid therapy. These events usually, but not always, have been associated with the reduction and/or withdrawal of oral corticosteroid therapy following the introduction of fluticasone propionate. Cases of serious eosinophilic conditions have also been reported with other inhaled corticosteroids in this clinical setting. Physicians should be alert to eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications, and/or neuropathy presenting in their patients. A causal relationship between fluticasone propionate and these underlying conditions has not been established (see PRECAUTIONS: Eosinophilic Conditions).
FLOVENT (fluticasone propionate) Inhalation Aerosol is indicated for the maintenance treatment of asthma as prophylactic therapy. It is also indicated for patients requiring oral corticosteroid therapy for asthma. Many of these patients may be able to reduce or eliminate their requirement for oral corticosteroids over time.
FLOVENT (fluticasone propionate) Inhalation Aerosol is NOT indicated for the relief of acute bronchospasm.
FLOVENT (fluticasone propionate) 44 mcg Inhalation Aerosol is supplied in 7.9-g canisters containing 60 metered inhalations in institutional pack boxes of 1 (NDC 0173-0497-00) and in 13-g canisters containing 120 metered inhalations in boxes of 1 (NDC 0173-0491-00). Each canister is supplied with a dark orange oral actuator with a peach strapcap and patient s instructions. Each actuation of the inhaler delivers 44 mcg of fluticasone propionate from the actuator.
FLOVENT (fluticasone propionate) 110 mcg Inhalation Aerosol is supplied in 7.9-g canisters containing 60 metered inhalations in institutional pack boxes of 1 (NDC 0173-0498-00) and in 13-g canisters containing 120 metered inhalations in boxes of 1 (NDC 0173-0494-00). Each canister is supplied with a dark orange oral actuator with a peach strapcap and patient s instructions. Each actuation of the inhaler delivers 110 mcg of fluticasone propionate from the actuator.
FLOVENT (fluticasone propionate) 220 mcg Inhalation Aerosol is supplied in 7.9-g canisters containing 60 metered inhalations in institutional pack boxes of 1 (NDC 0173-0499-00) and in 13-g canisters containing 120 metered inhalations in boxes of 1 (NDC 0173-0495-00). Each canister is supplied with a dark orange oral actuator with a peach strapcap and patient s instructions. Each actuation of the inhaler delivers 220 mcg of fluticasone propionate from the actuator.
FLOVENT (fluticasone propionate) canisters are for use with FLOVENT (fluticasone propionate) Inhalation Aerosol actuators only. The actuators should not be used with other aerosol medications.
The correct amount of medication in each inhalation cannot be assured after 60 inhalations from the 7.9-g canister or 120 inhalations from the 13-g canister even though the canister is not completely empty. The canister should be discarded when the labeled number of actuations has been used.
Store between 2° and 30°C (36° and 86°F). Store canister with mouthpiece down. Protect from freezing temperatures and direct sunlight.
Avoid spraying in eyes. Contents under pressure. Do not puncture or incinerate. Do not store at temperatures above 120°F. Keep out of reach of children. For best results, the canister should be at room temperature before use. Shake well before using.
Note
The indented statement below is required by the Federal Government s Clean Air Act for all products containing or manufactured with chlorofluorocarbons (CFCs).
Warning
Contains trichlorofluoromethane and dichlorodifluoromethane, substances that harm public health and environment by destroying ozone in the upper atmosphere.
A notice similar to the above WARNING has been placed in the patient information leaflet of this product pursuant to EPA regulations.
GlaxoSmithKline, Research Triangle Park, NC 27709, ©2004, GlaxoSmithKline. All rights reserved. March 2004 RL-2067
Particular care is needed for patients who are transferred from systemically active corticosteroids to FLOVENT (fluticasone propionate) Inhalation Aerosol because deaths due to adrenal insufficiency have occurred in patients with asthma during and after transfer from systemic corticosteroids to less systemically available inhaled corticosteroids. After withdrawal from systemic corticosteroids, a number of months are required for recovery of HPA function.
Patients who have been previously maintained on 20 mg or more per day of prednisone (or its equivalent) may be most susceptible, particularly when their systemic corticosteroids have been almost completely withdrawn. During this period of HPA suppression, patients may exhibit signs and symptoms of adrenal insufficiency when exposed to trauma, surgery, or infection (particularly gastroenteritis) or other conditions associated with severe electrolyte loss. Although FLOVENT (fluticasone propionate) Inhalation Aerosol may provide control of asthma symptoms during these episodes, in recommended doses it supplies less than normal physiological amounts of glucocorticoid systemically and does NOT provide the mineralocorticoid activity that is necessary for coping with these emergencies.
During periods of stress or a severe asthma attack, patients who have been withdrawn from systemic corticosteroids should be instructed to resume oral corticosteroids (in large doses) immediately and to contact their physicians for further instruction. These patients should also be instructed to carry a warning card indicating that they may need supplementary systemic corticosteroids during periods of stress or a severe asthma attack.
A drug interaction study in healthy subjects has shown that ritonavir (a highly potent cytochrome P450 3A4 inhibitor) can significantly increase plasma fluticasone propionate exposure, resulting in significantly reduced serum cortisol concentrations (see CLINICAL PHARMACOLOGY: Drug Interactions and PRECAUTIONS: Drug Interactions). During postmarketing use, there have been reports of clinically significant drug interactions in patients receiving fluticasone propionate and ritonavir, resulting in systemic corticosteroid effects including Cushing syndrome and adrenal suppression. Therefore, coadministration of fluticasone propionate and ritonavir is not recommended unless the potential benefit to the patient outweighs the risk of systemic corticosteroid side effects.
Patients requiring oral corticosteroids should be weaned slowly from systemic corticosteroid use after transferring to FLOVENT (fluticasone propionate) Inhalation Aerosol. In a trial of 96 patients, prednisone reduction was successfully accomplished by reducing the daily prednisone dose by 2.5 mg on a weekly basis during transfer to inhaled fluticasone propionate. Successive reduction of prednisone dose was allowed only when lung function, symptoms, and as-needed beta-agonist use were better than or comparable to that seen before initiation of prednisone dose reduction. Lung function (FEV1 or AM PEF), beta-agonist use, and asthma symptoms should be carefully monitored during withdrawal of oral corticosteroids. In addition to monitoring asthma signs and symptoms, patients should be observed for signs and symptoms of adrenal insufficiency such as fatigue, lassitude, weakness, nausea and vomiting, and hypotension.
Transfer of patients from systemic corticosteroid therapy to FLOVENT (fluticasone propionate) Inhalation Aerosol may unmask conditions previously suppressed by the systemic corticosteroid therapy, e.g., rhinitis, conjunctivitis, eczema, and arthritis.
Persons who are on drugs that suppress the immune system are more susceptible to infections than healthy individuals. Chickenpox and measles, for example, can have a more serious or even fatal course in susceptible children or adults on corticosteroids. In such children or adults who have not had these diseases, particular care should be taken to avoid exposure. How the dose, route, and duration of corticosteroid administration affect the risk of developing a disseminated infection is not known. The contribution of the underlying disease and/or prior corticosteroid treatment to the risk is also not known. If exposed to chickenpox, prophylaxis with varicella zoster immune globulin (VZIG) may be indicated. If exposed to measles, prophylaxis with pooled intramuscular immunoglobulin (IG) may be indicated. (See the respective package inserts for complete VZIG and IG prescribing information.) If chickenpox develops, treatment with antiviral agents may be considered.
FLOVENT (fluticasone propionate) Inhalation Aerosol is not to be regarded as a bronchodilator and is not indicated for rapid relief of bronchospasm.
As with other inhaled asthma medications, bronchospasm may occur with an immediate increase in wheezing after dosing. If bronchospasm occurs following dosing with FLOVENT (fluticasone propionate) Inhalation Aerosol, it should be treated immediately with a fast-acting inhaled bronchodilator. Treatment with FLOVENT (fluticasone propionate) Inhalation Aerosol should be discontinued and alternative therapy instituted.
Patients should be instructed to contact their physicians immediately when episodes of asthma that are not responsive to bronchodilators occur during the course of treatment with FLOVENT (fluticasone propionate) Inhalation Aerosol. During such episodes, patients may require therapy with oral corticosteroids.
PRECAUTIONSGeneral
During withdrawal from oral corticosteroids, some patients may experience symptoms of systemically active corticosteroid withdrawal, e.g., joint and/or muscular pain, lassitude, and depression, despite maintenance or even improvement of respiratory function.
Fluticasone propionate will often permit control of asthma symptoms with less suppression of HPA function than therapeutically equivalent oral doses of prednisone. Since fluticasone propionate is absorbed into the circulation and can be systemically active at higher doses, the beneficial effects of FLOVENT (fluticasone propionate) Inhalation Aerosol in minimizing HPA dysfunction may be expected only when recommended dosages are not exceeded and individual patients are titrated to the lowest effective dose. A relationship between plasma levels of fluticasone propionate and inhibitory effects on stimulated cortisol production has been shown after 4 weeks of treatment with FLOVENT (fluticasone propionate) Inhalation Aerosol. Since individual sensitivity to effects on cortisol production exists, physicians should consider this information when prescribing FLOVENT (fluticasone propionate) Inhalation Aerosol.
Because of the possibility of systemic absorption of inhaled corticosteroids, patients treated with these drugs should be observed carefully for any evidence of systemic corticosteroid effects. Particular care should be taken in observing patients postoperatively or during periods of stress for evidence of inadequate adrenal response.
It is possible that systemic corticosteroid effects such as hypercorticism and adrenal suppression (including adrenal crisis) may appear in a small number of patients, particularly when FLOVENT (fluticasone propionate) Inhalation Aerosol is administered at higher than recommended doses over prolonged periods of time. If such effects occur, fluticasone propionate inhalation aerosol should be reduced slowly, consistent with accepted procedures for reducing systemic corticosteroids and for management of asthma symptoms.
A reduction of growth velocity in children or teenagers may occur as a result of inadequate control of chronic diseases such as asthma or from use of corticosteroids for treatment. Physicians should closely follow the growth of adolescents taking corticosteroids by any route and weigh the benefits of corticosteroid therapy and asthma control against the possibility of growth suppression if an adolescent s growth appears slowed.
The long-term effects of fluticasone propionate in human subjects are not fully known. In particular, the effects resulting from chronic use of fluticasone propionate on developmental or immunologic processes in the mouth, pharynx, trachea, and lung are unknown. Some patients have received fluticasone propionate inhalation aerosol on a continuous basis for periods of 3 years or longer. In clinical studies with patients treated for nearly 2 years with inhaled fluticasone propionate, no apparent differences in the type or severity of adverse reactions were observed after long- versus short-term treatment.
Rare instances of glaucoma, increased intraocular pressure, and cataracts have been reported following the inhaled administration of corticosteroids, including fluticasone propionate.
In clinical studies with inhaled fluticasone propionate, the development of localized infections of the pharynx with Candida albicans has occurred. When such an infection develops, it should be treated with appropriate local or systemic (i.e., oral antifungal) therapy while remaining on treatment with FLOVENT (fluticasone propionate) Inhalation Aerosol, but at times therapy with FLOVENT (fluticasone propionate) Inhalation Aerosol may need to be interrupted.
Inhaled corticosteroids should be used with caution, if at all, in patients with active or quiescent tuberculosis infection of the respiratory tract; untreated systemic fungal, bacterial, viral or parasitic infections; or ocular herpes simplex.
Eosinophilic Conditions
In rare cases, patients on inhaled fluticasone propionate may present with systemic eosinophilic conditions, with some patients presenting with clinical features of vasculitis consistent with Churg-Strauss syndrome, a condition that is often treated with systemic corticosteroid therapy. These events usually, but not always, have been associated with the reduction and/or withdrawal of oral corticosteroid therapy following the introduction of fluticasone propionate. Cases of serious eosinophilic conditions have also been reported with other inhaled corticosteroids in this clinical setting. Physicians should be alert to eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications, and/or neuropathy presenting in their patients. A causal relationship between fluticasone propionate and these underlying conditions has not been established (see ADVERSE REACTIONS).
Information for Patients
Patients being treated with FLOVENT (fluticasone propionate) Inhalation Aerosol should receive the following information and instructions. This information is intended to aid them in the safe and effective use of this medication. It is not a disclosure of all possible adverse or intended effects.
Patients should use FLOVENT (fluticasone propionate) Inhalation Aerosol at regular intervals as directed. Results of clinical trials indicated significant improvement may occur within the first day or two of treatment; however, the full benefit may not be achieved until treatment has been administered for 1 to 2 weeks or longer. The patient should not increase the prescribed dosage but should contact the physician if symptoms do not improve or if the condition worsens.
After inhalation, rinse the mouth with water without swallowing.
Patients should be warned to avoid exposure to chickenpox or measles and, if they are exposed, to consult the physician without delay.
For the proper use of FLOVENT (fluticasone propionate) Inhalation Aerosol and to attain maximum improvement, the patient should read and follow carefully the Patient s Instructions for Use accompanying the product.
Carcinogenesis, Mutagenesis, Impairment of Fertility
Fluticasone propionate demonstrated no tumorigenic potential in studies of oral doses up to 1,000 mcg/kg (approximately 2 times the maximum human daily inhalation dose based on mcg/m2) for 78 weeks in the mouse or inhalation of up to 57 mcg/kg (approximately 1/4 the maximum human daily inhalation dose based on mcg/m2) for 104 weeks in the rat.
Fluticasone propionate did not induce gene mutation in prokaryotic or eukaryotic cells in vitro. No significant clastogenic effect was seen in cultured human peripheral lymphocytes in vitro or in the mouse micronucleus test when administered at high doses by the oral or subcutaneous routes. Furthermore, the compound did not delay erythroblast division in bone marrow.
No evidence of impairment of fertility was observed in reproductive studies conducted in rats dosed subcutaneously with doses up to 50 mcg/kg (approximately 1/4 the maximum human daily inhalation dose based on mcg/m2) in males and females. However, prostate weight was significantly reduced in rats.
Pregnancy
Teratogenic Effects: Pregnancy Category C. Subcutaneous studies in the mouse and rat at 45 and 100 mcg/kg, respectively (approximately 1/10 and 1/2 the maximum human daily inhalation dose based on mcg/m2, respectively), revealed fetal toxicity characteristic of potent glucocorticoid compounds, including embryonic growth retardation, omphalocele, cleft palate, and retarded cranial ossification.
In the rabbit, fetal weight reduction and cleft palate were observed following subcutaneous doses of 4 mcg/kg (approximately 1/25 the maximum human daily inhalation dose based on mcg/m2). However, following oral administration of up to 300 mcg/kg (approximately 3 times the maximum human daily inhalation dose based on mcg/m2) of fluticasone propionate to the rabbit, there were no maternal effects nor increased incidence of external, visceral, or skeletal fetal defects. No fluticasone propionate was detected in the plasma in this study, consistent with the established low bioavailability following oral administration (see CLINICAL PHARMACOLOGY).
Less than 0.008% of the administered dose crossed the placenta following oral administration of 100 mcg/kg to rats or 300 mcg/kg to rabbits (approximately 1/2 and 3 times the maximum human daily inhalation dose based on mcg/m2, respectively).
There are no adequate and well-controlled studies in pregnant women. FLOVENT (fluticasone propionate) Inhalation Aerosol should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
Experience with oral glucocorticoids since their introduction in pharmacologic, as opposed to physiologic, doses suggests that rodents are more prone to teratogenic effects from glucocorticoids than humans. In addition, because there is a natural increase in glucocorticoid production during pregnancy, most women will require a lower exogenous glucocorticoid dose and many will not need glucocorticoid treatment during pregnancy.
Nursing Mothers
It is not known whether fluticasone propionate is excreted in human breast milk. Subcutaneous administration of 10 mcg/kg tritiated drug to lactating rats (approximately 1/20 the maximum human daily inhalation dose based on mcg/m2) resulted in measurable radioactivity in both plasma and milk. Because glucocorticoids are excreted in human milk, caution should be exercised when fluticasone propionate inhalation aerosol is administered to a nursing woman.
Pediatric Use
One hundred thirty-seven (137) patients between the ages of 12 and 16 years were treated with FLOVENT (fluticasone propionate) Inhalation Aerosol in the US pivotal clinical trials. The safety and effectiveness of FLOVENT (fluticasone propionate) Inhalation Aerosol in children below 12 years of age have not been established. Oral corticosteroids have been shown to cause a reduction in growth velocity in children and teenagers with extended use. If a child or teenager on any corticosteroid appears to have growth suppression, the possibility that they are particularly sensitive to this effect of corticosteroids should be considered (see PRECAUTIONS).
Geriatric Use
Five hundred seventy-four (574) patients 65 years of age or older have been treated with FLOVENT (fluticasone propionate) Inhalation Aerosol in US and non-US clinical trials. There were no differences in adverse reactions compared to those reported by younger patients.
FLOVENT (fluticasone propionate) Inhalation Aerosol should be administered by the orally inhaled route in patients 12 years of age and older. Individual patients will experience a variable time to onset and degree of symptom relief. Generally, FLOVENT (fluticasone propionate) Inhalation Aerosol has a relatively rapid onset of action for an inhaled glucocorticoid. Improvement in asthma control following inhaled administration of fluticasone propionate can occur within 24 hours of beginning treatment, although maximum benefit may not be achieved for 1 to 2 weeks or longer after starting treatment.
After asthma stability has been achieved (see Table 2), it is always desirable to titrate to the lowest effective dosage to reduce the possibility of side effects. For patients who do not respond adequately to the starting dosage after 2 weeks of therapy, higher dosages may provide additional asthma control. The safety and efficacy of FLOVENT (fluticasone propionate) Inhalation Aerosol when administered in excess of recommended dosages have not been established.
The recommended starting dosage and the highest recommended dosage of FLOVENT (fluticasone propionate) Inhalation Aerosol, based on prior antiasthma therapy, are listed in Table 2.
| Table 2. Recommended Dosages of FLOVENT Inhalation Aerosol | ||
Previous Therapy Dosage | Recommended Starting | Highest Recommended Dosage |
Bronchodilators alone | 88 mcg twice daily | 440 mcg twice daily |
Inhaled corticosteroids | 88-220 mcg twice daily* | 440 mcg twice daily |
Oral corticosteroids † | 880 mcg twice daily | 880 mcg twice daily |
* Starting dosages above 88 mcg twice daily may be considered for patients with poorer asthma control or those who have previously required doses of inhaled corticosteroids that are in the higher range for that specific agent. | ||
NOTE: In all patients, it is desirable to titrate to the lowest effective dosage once asthma Stability is achieved. | ||
† For Patients Currently Receiving Chronic Oral Corticosteroid Therapy: Prednisone should be reduced no faster than 2.5 mg/day on a weekly basis, beginning after at least 1 week of therapy with FLOVENT Inhalation Aerosol. Patients should be carefully monitored for signs of asthma instability, including serial objective measures of airflow, and for signs of adrenal insufficiency (see WARNINGS). Once prednisone reduction is complete, the dosage of fluticasone propionate should be reduced to the lowest effective dosage. | ||
Geriatric Use
In studies where geriatric patients (65 years of age or older, see PRECAUTIONS) have been treated with FLOVENT (fluticasone propionate) Inhalation Aerosol, efficacy and safety did not differ from that in younger patients. Consequently, no dosage adjustment is recommended. Directions for Use
Illustrated Patient’s Instructions for Use accompany each package of FLOVENT (fluticasone propionate) Inhalation Aerosol.
The incidence of common adverse events in Table 1 is based upon 7 placebo-controlled US clinical trials in which 1,243 patients (509 female and 734 male adolescents and adults previously treated with as-needed bronchodilators and/or inhaled corticosteroids) were treated with FLOVENT (fluticasone propionate) Inhalation Aerosol (doses of 88 to 440 mcg twice daily for up to 12 weeks) or placebo.
Table 1. Overall Adverse Events With >3% Incidence in US Controlled Clinical Trials With FLOVENT Inhalation Aerosol in Patients Previously Receiving Bronchodilators and/or Inhaled Corticosteroids | ||||
Adverse Event | Placebo (N = 475) % | FLOVENT 88 mcg Twice Daily (N = 488) % | FLOVENT 220 mcg Twice Daily (N = 95) % | FLOVENT 440 mcg Twice Daily (N = 185) % |
Ear, nose, and throat | ||||
Pharyngitis | 7 | 10 | 14 | 14 |
Nasal congestion | 8 | 8 | 16 | 10 |
Sinusitis | 4 | 3 | 6 | 5 |
Nasal discharge | 3 | 5 | 4 | 4 |
Dysphonia | 1 | 4 | 3 | 8 |
Allergic rhinitis | 4 | 5 | 3 | 3 |
Oral candidiasis | 1 | 2 | 3 | 5 |
Respiratory | ||||
Upper respiratory infection | 12 | 15 | 22 | 16 |
Influenza | 2 | 3 | 8 | 5 |
Neurological | ||||
Headache | 14 | 17 | 22 | 17 |
Average duration of exposure (days) | 44 | 66 | 64 | 59 |
Table 1 includes all events (whether considered drug-related or nondrug-related by the investigator) that occurred at a rate of over 3% in groups treated with FLOVENT (fluticasone propionate) Inhalation Aerosol and were more common than in the placebo group. In considering these data, differences in average duration of exposure should be taken into account.
These adverse reactions were mostly mild to moderate in severity, with £2% of patients discontinuing the studies because of adverse events. Rare cases of immediate and delayed hypersensitivity reactions, including urticaria and rash and other rare events of angioedema and bronchospasm, have been reported.
Systemic glucocorticoid side effects were not reported during controlled clinical trials with FLOVENT (fluticasone propionate) Inhalation Aerosol. If recommended doses are exceeded, however, or if individuals are particularly sensitive, symptoms of hypercorticism, e.g., Cushing syndrome, could occur.
Other adverse events that occurred in these clinical trials using FLOVENT (fluticasone propionate) Inhalation Aerosol with an incidence of 1% to 3% and that occurred at a greater incidence than with placebo were:
Ear, Nose, and Throat: Pain in nasal sinus(es), rhinitis.
Eye: Irritation of the eye(s).
Gastrointestinal: Nausea and vomiting, diarrhea, dyspepsia and stomach disorder.
Miscellaneous: Fever.
Mouth and Teeth: Dental problem.
Musculoskeletal: Pain in joint, sprain/strain, aches and pains, pain in limb.
Neurological: Dizziness/giddiness.
Respiratory: Bronchitis, chest congestion.
Skin: Dermatitis, rash/skin eruption.
Urogenital: Dysmenorrhea.
In a 16-week study in patients with asthma requiring oral corticosteroids, the effects of FLOVENT (fluticasone propionate) Inhalation Aerosol, 660 mcg twice daily (N = 32) and 880 mcg twice daily (N = 32), were compared with placebo. Adverse events (whether considered drug-related or nondrug-related by the investigator) reported by more than 3 patients in either group treated with FLOVENT (fluticasone propionate) Inhalation Aerosol and that were more common with FLOVENT (fluticasone propionate) than placebo are shown below:
Ear, Nose, and Throat: Pharyngitis (9% and 25%), nasal congestion (19% and 22%), sinusitis (19% and 22%), nasal discharge (16% and 16%), dysphonia (19% and 9%), pain in nasal sinus(es) (13% and 0%), Candida-like oral lesions (16% and 9%), oropharyngeal candidiasis (25% and 19%).
Respiratory: Upper respiratory infection (31% and 19%), influenza (0% and 13%). Other: Headache (28% and 34%), pain in joint (19% and 13%), nausea and vomiting (22% and 16%), muscular soreness (22% and 13%), malaise/fatigue (22% and 28%), insomnia (3% and 13%).
Observed During Clinical Practice
In addition to adverse events reported from clinical trials, the following events have been identified during postapproval use of fluticasone propionate. Because they are reported voluntarily from a population of unknown size, estimates of frequency cannot be made. These events have been chosen for inclusion due to either their seriousness, frequency of reporting, or causal connection to fluticasone propionate or a combination of these factors.
Ear, Nose, and Throat: Aphonia, facial and oropharyngeal edema, hoarseness, laryngitis, and throat soreness and irritation.
Endocrine and Metabolic: Cushingoid features, growth velocity reduction in children/adolescents, hyperglycemia, osteoporosis, and weight gain.
Eye: Cataracts.
Non-Site Specific: Very rare anaphylactic reaction.
Psychiatry: Agitation, aggression, depression, and restlessness.
Respiratory: Asthma exacerbation, bronchospasm, chest tightness, cough, dyspnea, immediate bronchospasm, paradoxical bronchospasm, pneumonia, and wheeze.
Skin: Contusions, cutaneous hypersensitivity reactions, ecchymoses, and pruritus. Eosinophilic Conditions: In rare cases, patients on inhaled fluticasone propionate may present with systemic eosinophilic conditions, with some patients presenting with clinical features of vasculitis consistent with Churg-Strauss syndrome, a condition that is often treated with systemic corticosteroid therapy. These events usually, but not always, have been associated with the reduction and/or withdrawal of oral corticosteroid therapy following the introduction of fluticasone propionate. Cases of serious eosinophilic conditions have also been reported with other inhaled corticosteroids in this clinical setting. Physicians should be alert to eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications, and/or neuropathy presenting in their patients. A causal relationship between fluticasone propionate and these underlying conditions has not been established (see PRECAUTIONS: Eosinophilic Conditions).
DRUG INTERACTIONSFluticasone propionate is a substrate of cytochrome P450 3A4. A drug interaction study with fluticasone propionate aqueous nasal spray in healthy subjects has shown that ritonavir (a highly potent cytochrome P450 3A4 inhibitor) can significantly increase plasma fluticasone propionate exposure, resulting in significantly reduced serum cortisol concentrations (see CLINICAL PHARMACOLOGY: Drug Interactions). During postmarketing use, there have been reports of clinically significant drug interactions in patients receiving fluticasone propionate and ritonavir, resulting in systemic corticosteroid effects including Cushing syndrome and adrenal suppression. Therefore, coadministration of fluticasone propionate and ritonavir is not recommended unless the potential benefit to the patient outweighs the risk of systemic corticosteroid side effects.
In a placebo-controlled, crossover study in 8 healthy volunteers, coadministration of a single dose of orally inhaled fluticasone propionate (1,000 mcg) with multiple doses of ketoconazole (200 mg) to steady state resulted in increased mean plasma fluticasone propionate exposure, a reduction in plasma cortisol AUC, and no effect on urinary excretion of cortisol. Caution should be exercised when FLOVENT (fluticasone propionate) Inhalation Aerosol is coadministered with ketoconazole and other known potent cytochrome P450 3A4 inhibitors.
