Foradil

Overdose

Symptoms

There is no clinical experience to date on the management of overdose, however, an overdosage of Foradil would be likely to lead to effects that are typical of β2-adrenergic agonists: nausea, vomiting, headache, tremor, somnolence, palpitations, tachycardia, ventricular arrhythmias, metabolic acidosis, hypokalaemia, hyperglycaemia, prolonged QTc-interval, hypertension.

Treatment

Supportive and symptomatic treatment is indicated. Serious cases should be hospitalised.

Use of cardioselective beta-blockers may be considered, but only subject to extreme caution since the use of β-adrenergic blocker medication may provoke bronchospasm.

Serum potassium should be monitored.

Shelf life

2 years in Alu/Alu blisters.

Foradil price

Incompatibilities

None known.

List of excipients

Lactose, gelatin and black ink (containing shellac, black iron oxide (CI 77499, E 172), isopropyl alcohol, N-butyl alcohol, propylene glycol, purified water, dehydrated ethanol and ammonium hydroxide).

Undesirable effects

Adverse reactions (Table 1) are ranked in descending order of frequency, as follows: very common (> 1/10); common (> 1/100, < 1/10); uncommon (> 1/1,000, < 1/100); rare (> 1/10,000, <1/1,000); very rare (< 1/10,000); unknown (frequency cannot be estimated from available data). Within each frequency grouping, adverse reactions are ranked in order of decreasing seriousness.

Table 1

*The percent of patients with serious asthma exacerbations in clinical studies was higher for Foradil than for placebo, and the biggest numerical imbalance was observed in children 5-12 years old.

** These adverse events were reported in patients treated with Foradil during the post-marketing experience.

As with all inhalation therapy, paradoxical bronchospasm may occur in very rare cases. Treatment with β2-agonists may result in an increase in blood levels of insulin, free fatty acids, glycerol and ketone bodies. The excipient lactose contains small amounts of milk proteins. These may cause allergic reactions.

Reporting of suspected adverse reactions

Reporting 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.

Preclinical safety data

Mutagenicity

Mutagenicity tests covering a broad range of experimental endpoints have been conducted. No genotoxic effects were found in any of the in vitro or in vivo tests performed.

Carcinogenicity

Two-year studies in rats and mice did not show any carcinogenic potential.

Male mice treated at very high dose levels showed a slightly higher incidence of benign adrenal subcapsular cell tumours, which are considered to reflect alterations in the physiological ageing process.

Two studies in rats, covering different dose ranges, showed an increase in mesovarial leiomyomas. These benign neoplasms are typically associated with long-term treatment of rats at high doses of β2-adrenergic drugs. Increased incidences of ovarian cysts and benign granulosa/theca cell tumours were also seen; β-agonists are known to have effects on the ovary in rats in which are very likely specific to rodents. A few other tumour types noted in the first study using the higher doses were within the incidences of the historical control population, and were not seen in the lower-dose experiment.

None of the tumour incidences were increased to a statistically significant extent at the lowest dose of the second study, a dose leading to a systemic exposure 10 times higher than that expected from the maximum recommended dose of formoterol.

On the basis of these findings and the absence of a mutagenic potential, it is concluded that use of formoterol at therapeutic doses does not present a carcinogenic risk.

Reproductive toxicity

Animal tests have shown no teratogenic effects. Formoterol was evaluated for its effect on fertility and general reproductive performance in sexually mature male and female rats. Reproduction studies in rats revealed no impairment of fertility or effect on early embryonic development at oral doses up to 3 mg/kg (approximately 1200 times the maximum recommended daily inhalation powder dose in human on a mg/m2 basis).

After oral administration, formoterol was excreted in the milk of lactating rats.

Pharmacotherapeutic group

Pharmacodynamic properties

Pharmacotherapeutic group: Selective beta2-adrenergic agonist, ATC code: R03AC13.

Formoterol is a potent selective β2-adrenergic stimulant. It exerts a bronchodilator effect in patients with reversible airways obstruction. The effect sets in rapidly (within 1-3 minutes) and is still significant 12 hours after inhalation.

In man, Foradil has been shown to be effective in preventing bronchospasm induced by exercise and methacholine.

Formoterol has been studied in the treatment of conditions associated with COPD, and has been shown to improve symptoms and pulmonary function and quality of life. Formoterol acts on the reversible component of the disease.

Serious asthma exacerbations

Placebo-controlled clinical studies of at least 4 weeks treatment duration with Foradil suggested a higher incidence of serious asthma exacerbations in patients who received Foradil than in those who received placebo, particularly in patients 5-12 years of age.

Experience in children aged 5-12 years with asthma

The safety of Foradil 12 microgram twice daily compared to Foradil 24 microgram twice daily and placebo was investigated in one large, multicenter, randomized, double-blind, 52-week clinical trial in 518 children with asthma (ages 5 to 12 years) in need of daily bronchodilators and anti-inflammatory treatment. More children who received Foradil 24 microgram twice daily (11/171, 6.4%) or Foradil 12 microgram twice daily (8/171, 4.7%) than children who received placebo (0/176, 0.0%) experienced serious asthma exacerbations.

Pharmacokinetic properties

Foradil has a therapeutic dose range of 12 to 24 micrograms b.i.d. Data on the plasma pharmacokinetics of formoterol were collected in healthy volunteers after inhalation of doses higher than the recommended range and in COPD patients after inhalation of therapeutic doses. Urinary excretion of unchanged formoterol, used as an indirect measure of systemic exposure, correlates with plasma drug disposition data. The elimination half-lives calculated for urine and plasma are similar.

Absorption

Following inhalation of a single 120 microgram dose of formoterol fumarate by healthy volunteers, formoterol was rapidly absorbed into plasma, reaching a maximum concentration of 266 pmol/l within 5 minutes of inhalation. In COPD patients treated for 12 weeks with formoterol fumarate 12 or 24 micrograms b.i.d. the plasma concentrations of formoterol ranged between 11.5 and 25.7 pmol/L and 23.3 and 50.3 pmol/L respectively at 10 minutes, 2 hours and 6 hours post inhalation.

Studies investigating the cumulative urinary excretion of formoterol and/or its (R,R) and (S,S)-enantiomers, after inhalation of dry powder (12-96 micrograms) or aerosol formulations (12-96 micrograms), showed that absorption increased linearly with the dose.

After 12 weeks administration of 12 micrograms or 24 micrograms formoterol powder b.i.d., the urinary excretion of unchanged formoterol increased by 63-73% in adult patients with asthma, by 19-38% in adult patients with COPD and by 18-84% in children, suggesting a modest and self-limiting accumulation of formoterol in plasma after repeated dosing.

As reported for other inhaled drugs, it is likely that about 90% of formoterol administered from an inhaler will be swallowed and then absorbed from the gastrointestinal tract. This means that the pharmacokinetic characteristics of the oral formulation largely apply also to the inhalation powder. When 80 micrograms of 3H-labelled formoterol fumarate was orally administered to two healthy volunteers, at least 65% of the drug was absorbed.

Distribution

The plasma protein binding of formoterol is 61-64% (34% primarily to albumin).

There is no saturation of binding sites in the concentration range reached with therapeutic doses.

Biotransformation

Formoterol is eliminated primarily by metabolism, direct glucuronidation being the major pathway of biotransformation, with O-demethylation followed by further glucuronidation being another pathway. Minor pathways involve sulphate conjugation of formoterol and deformylation followed by sulphate conjugation. Multiple isozymes catalyze the glucuronidation (UGT1A1, 1A3, 1A6, 1A7, 1A8, 1A9, 1A10, 2B7 and 2B15) and O-demethylation (CYP2D6, 2C19, 2C9, and 2A6) of formoterol, and so consequently the potential for metabolic drug-drug interaction is low. Formoterol did not inhibit cytochrome P450 isozymes at therapeutically relevant concentrations. The kinetics of formoterol are similar after single and repeated administration, indicating no auto-induction or inhibition of metabolism.

Elimination

In asthmatic and COPD patients treated for 12 weeks with 12 or 24 micrograms formoterol fumarate b.i.d., approximately 10% and 7% of the dose, respectively, were recovered in the urine as unchanged formoterol. In asthmatic children, approximately 6% of the dose was recovered in the urine as unchanged formoterol after multiple dosing of 12 and 24 micrograms. The (R,R) and (S,S)-enantiomers accounted, respectively, for 40% and 60% of urinary recovery of unchanged formoterol, after single doses (12 to 120 micrograms) in healthy volunteers and after single and repeated doses in asthma patients.

After a single oral dose of 3H-formoterol, 59-62% of the dose was recovered in the urine and 32-34% in the faeces. Renal clearance of formoterol is 150 mL/min.

After inhalation, plasma formoterol kinetics and urinary excretion rate data in healthy volunteers indicate a biphasic elimination, with the terminal elimination half-lives of the (R,R)- and (S,S)-enantiomers being 13.9 and 12.3 hours, respectively.

Approximately 6.4-8% of the dose was recovered in the urine as unchanged formoterol, with the (R,R) and (S,S)-enantiomers contributing 40% and 60% respectively.

Date of revision of the text

07 October 2016

Marketing authorisation holder

Novartis Pharmaceuticals UK Ltd

Frimley Business Park,

Frimley

Camberley

Surrey

GU16 7SR

UK

Special precautions for storage

In Alu/Alu blisters: Store below 25°C. Store in the original container in order to protect from moisture.

Nature and contents of container

Blister calendar packs of 60 capsules, with an inhaler device in each pack.

Marketing authorisation number(s)

PL 00101/0494

Fertility, pregnancy and lactation

Pregnancy

There were no teratogenic effects revealed in animal tests. In animal studies formoterol has caused implantation losses as well as decreased early postnatal survival and birth weight. The effects appeared at considerably higher systemic exposures than those reached during clinical use of formoterol. However, until further experience is gained, Foradil is not recommended for use during pregnancy (particularly at the end of pregnancy or during labour) unless there is no more established alternative. As with any medicine, use during pregnancy should only be considered if the expected benefit to the mother is greater than any risk to the foetus.

Breast feeding

The substance has been detected in the milk of lactating rats, but it is not known whether formoterol passes into human breast milk, therefore mothers using Foradil should refrain from breast feeding their infants.

Fertility

There is no available data on the effect of formoterol on human fertility. No impairment of

fertility was observed in studies performed in male and female rats.

Special warnings and precautions for use

Asthma-related death

Formoterol fumarate dihydrate, the active ingredient of Foradil, belongs to the class of long-acting beta2-adrenergic agonists (LABAs). In a study with salmeterol, a different long-acting beta2-agonist, a higher rate of death due to asthma was observed in the patients treated with salmeterol (13/13,176) than in the placebo group (3/13,179). No study adequate to determine whether the rate of asthma-related death is increased with Foradil has been conducted.

In the treatment of asthma

Foradil should not be used (and is not sufficient) as the first treatment for asthma.

When treating patients with asthma, use Foradil only as an add-on to an inhaled corticosteroid (ICS) for patients who are not adequately controlled on an ICS alone or whose disease severity clearly warrants initiation of treatment with both an ICS and a LABA.

Children up to the age of 6 years should not be treated with Foradil as sufficient experience is not available for this group. For children 6-12 years of age, when treatment with an ICS and LABA is required, it is recommended to use a combination product, except in cases where a separate ICS and LABA are more appropriate.

Foradil should not be used in conjunction with another LABA

Whenever Foradil is prescribed, patients should be evaluated for the adequacy of the anti-inflammatory therapy they receive. Patients must be advised to continue taking anti-inflammatory therapy unchanged after the introduction of Foradil, even when their symptoms improve.

The daily dose of Foradil should not be increased beyond the maximum recommended dose.

Once asthma symptoms are controlled, consideration may be given to gradually reducing the dose of Foradil. Regular review of patients as treatment is stepped down is important. The lowest effective dose of Foradil should be used.

Serious asthma-related adverse events and exacerbations may occur during treatment with Foradil. Clinical studies with Foradil suggested a higher incidence of serious asthma exacerbations in patients who received Foradil than in those who received placebo, particularly in patients 5-12 years of age. These studies do not allow precise quantification of the differences in serious asthma exacerbation rates between treatment groups.

Patients should be advised that if, after initiation of Foradil, their symptoms persist, or if the number of doses of Foradil required to control their symptoms increases, this usually indicates a worsening of the underlying condition. In these circumstances, they should be advised to continue treatment but to seek medical advice as soon as possible.

Patients should not be initiated on Foradil or the dose increased during an acute severe asthma exacerbation, or if they have significantly worsening or acutely deteriorating asthma.

Foradil must not be used to relieve acute asthma symptoms. In the event of an acute attack, a short-acting beta2-agonist should be used. Patients must be informed of the need to seek medical treatment immediately if their asthma deteriorates suddenly.

Concomitant conditions

Special care and supervision, with particular emphasis on dosage limits, is required in patients receiving Foradil when the following conditions may exist:

Ischaemic heart disease, cardiac arrhythmias, especially third degree atrioventricular block, severe cardiac decompensation, idiopathic subvalvular aortic stenosis, severe hypertension, aneurysm, phaeochromocytoma, hypertrophic obstructive cardiomyopathy, thyrotoxicosis, or other severe cardiovascular disorders, such as tachyarrhythmias or severe heart failure.

Formoterol may induce prolongation of the QTc-interval. Caution should be observed when treating patients with prolongation of the QTc-interval and in patients treated with drugs affecting the QTc-interval.

Caution should be used when co-administering theophylline and formoterol in patients with pre-existing cardiac conditions

Due to the hyperglycaemic effect of β2-stimulants, including formoterol, additional blood glucose controls are recommended in diabetic patients.

Hypokalaemia

Potentially serious hypokalaemia may result from β2-agonist therapy, including formoterol. Particular caution is advised in severe asthma as this effect may be potentiated by hypoxia and concomitant treatment. It is recommended that serum potassium levels be monitored in such situations.

Paradoxical bronchospasm

As with other inhalation therapy, the potential for paradoxical bronchospasm should be kept in mind. If it occurs, the preparation should be discontinued immediately and alternative therapy substituted.

Foradil contains lactose monohydrate less than 500 micrograms per delivered dose. This amount does not normally cause problems in lactose intolerant patients. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.

Incorrect route of administration

There have been reports of patients who have mistakenly swallowed Foradil capsules instead of placing the capsules in the inhalation device. The majority of these ingestions were not associated with side effects. Healthcare providers should discuss with the patient how to correctly use Foradil. If a patient who is prescribed Foradil does not experience breathing improvement, the healthcare provider should ask how the patient is using Foradil.

Effects on ability to drive and use machines

Patients experiencing dizziness or other similar side effects should be advised to refrain from driving or using machines.

Special precautions for disposal and other handling

Any unused medicinal product or waste material should be disposed of in accordance with local requirements.

Date of first authorisation/renewal of the authorisation

Date of first authorisation: 17 August 1995

Date of latest renewal: 21 March 2003

Interaction with other medicinal products and other forms of interaction

There are no clinical data to support the advice given below, but from consideration of first principles one might expect the following interactions:

Drugs such as quinidine, disopyramide, procainamide, phenothiazines, antihistamines, tricyclic antidepressants and erythromycin may be associated with QT-interval prolongation and an increased risk of ventricular arrhythmia.

Concomitant administration of other sympathomimetic agents may potentiate the undesirable effects of Foradil and may require titration of the dose.

Administration of Foradil to patients being treated with monoamine oxidase inhibitors, macrolides or tricyclic antidepressants should be performed with caution, since the action of ß2-adrenergic stimulants on the cardiovascular system may be potentiated.

Concomitant treatment with xanthine derivatives, steroids, or diuretics may potentiate a possible hypokalaemic effect of β2-agonists. Hypokalaemia may increase susceptibility to cardiac arrhythmias (for example, in patients treated with digitalis).

There is an elevated risk of arrhythmias in patients receiving concomitant anaesthesia with halogenated hydrocarbons.

The bronchodilating effects of formoterol can be enhanced by anticholinergic drugs.

β-adrenergic blockers may weaken or antagonise the effect of Foradil. Therefore Foradil should not be given together with ß-adrenergic blockers (including eye drops) unless there are compelling reasons for their use.