In COPD patients, single doses of 10 times the maximum recommended therapeutic dose were associated with a moderate increase in pulse rate, systolic blood pressure and QTc interval.
An overdose of indacaterol is likely to lead to exaggerated effects typical of beta2-adrenergic stimulants, i.e. tachycardia, tremor, palpitations, headache, nausea, vomiting, drowsiness, ventricular arrhythmias, metabolic acidosis, hypokalaemia and hyperglycaemia.
Supportive and symptomatic treatment is indicated. In serious cases, patients should be hospitalised. Use of cardioselective beta blockers may be considered, but only under the supervision of a physician and with extreme caution since the use of beta-adrenergic blockers may provoke bronchospasm.
Not applicable.
Summary of the safety profile
The most common adverse reactions at the recommended doses were nasopharyngitis (14.3%), upper respiratory tract infection (14.2%), cough (8.2%), headache (3.7%) and muscle spasms (3.5%). These were in the vast majority mild or moderate and became less frequent if treatment was continued.
At the recommended doses, the adverse reaction profile of Onbrize in patients with COPD shows clinically insignificant systemic effects of beta2-adrenergic stimulation. Mean heart rate changes were less than one beat per minute, and tachycardia was infrequent and reported at a similar rate as under placebo treatment. Relevant prolongations of QTcF were not detectable in comparison to placebo. The frequency of notable QTcF intervals [i.e. >450 ms (males) and >470 ms (females)] and reports of hypokalaemia were similar to placebo. The mean of the maximum changes in blood glucose were similar between Onbrize and placebo.
Tabulated summary of adverse reactions
The Onbrize Phase III clinical development programme involved patients with a clinical diagnosis of moderate to severe COPD. 4,764 patients were exposed to indacaterol up to one year at doses up to twice the maximum recommended dose. Of these patients, 2,611 were on treatment with 150 microgram once daily and 1,157 on treatment with 300 microgram once daily. Approximately 41% of patients had severe COPD. The mean age of patients was 64 years, with 48% of patients aged 65 years or older, and the majority (80%) was Caucasian.
Adverse reactions in Table 1 are listed according to MedDRA system organ class in the COPD safety database. Within each system organ class, adverse reactions are ranked by frequency in descending order according to the following convention: 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), not known (cannot be estimated from the available data).
Table 1 Adverse reactions
| Adverse reactions | Frequency category |
| Infections and infestations | |
| Upper respiratory tract infection | Common |
| Nasopharyngitis | Common |
| Sinusitis | Common |
| Immune system disorders | |
| Hypersensitivity1 | Uncommon |
| Metabolism and nutrition disorders | |
| Diabetes mellitus and hyperglycaemia | Uncommon |
| Nervous system disorders | |
| Headache | Common |
| Dizziness | Common |
| Paraesthesia | Uncommon |
| Cardiac disorders | |
| Ischaemic heart disease | Uncommon |
| Atrial fibrillation | Uncommon |
| Palpitations | Uncommon |
| Tachycardia | Uncommon |
| Respiratory, thoracic and mediastinal disorders | |
| Cough | Common |
| Oropharyngeal pain including throat irritation | Common |
| Rhinorrhoea | Common |
| Paradoxical bronchospasm | Uncommon |
| Skin and subcutaneous tissue disorders | |
| Pruritus/rash | Uncommon |
| Musculoskeletal and connective tissue disorders | |
| Muscle spasm | Common |
| Myalgia | Uncommon |
| Musculoskeletal pain | Uncommon |
| General disorders and administration site conditions | |
| Chest pain | Common |
| Peripheral oedema | Common |
1 Reports of hypersensitivity have been received from post-approval marketing experience in association with the use of Onbrize. These were reported voluntarily from a population of uncertain size, and it is therefore not always possible to reliably estimate the frequency or establish a causal relationship to exposure to the medicinal product. Therefore the frequency was calculated from clinical trial experience.
At 600 microgram once-daily, the safety profile of Onbrize was overall similar to that of recommended doses. An additional adverse reaction was tremor (common).
Description of selected adverse reactions
In Phase III clinical studies, healthcare providers observed during clinic visits that on average 17-20% of patients experienced a sporadic cough that occurred usually within 15 seconds following inhalation and typically lasted for 5 seconds (about 10 seconds in current smokers). It was observed with a higher frequency in female than in male patients and in current smokers than in ex-smokers. This cough experienced post inhalation did not lead to any patient discontinuing from the studies at the recommended doses (cough is a symptom in COPD and only 8.2% of patients reported cough as an adverse event). There is no evidence that cough experienced post inhalation is associated with bronchospasm, exacerbations, deteriorations of disease or loss of efficacy.
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 or search for MHRA Yellow Card in the Google Play or Apple App Store.
Effects on the cardiovascular system attributable to the beta2-agonistic properties of indacaterol included tachycardia, arrhythmias and myocardial lesions in dogs. Mild irritancy of the nasal cavity and larynx were seen in rodents. All these findings occurred at exposures sufficiently in excess of those anticipated in humans.
Although indacaterol did not affect general reproductive performance in a rat fertility study, a decrease in the number of pregnant F1 offspring was observed in the peri- and post-developmental rat study at an exposure 14-fold higher than in humans treated with Onbrize. Indacaterol was not embryotoxic or teratogenic in rats or rabbits.
Genotoxicity studies did not reveal any mutagenic or clastogenic potential. Carcinogenicity was assessed in a two-year rat study and a six-month transgenic mouse study. Increased incidences of benign ovarian leiomyoma and focal hyperplasia of ovarian smooth muscle in rats were consistent with similar findings reported for other beta2-adrenergic agonists. No evidence of carcinogenicity was seen in mice. Systemic exposures (AUC) in rats and mice at the no-observed adverse effect levels in these studies were at least 7- and 49-fold higher, respectively, than in humans treated with Onbrize once a day at a dose of 300 microgram.
Onbrize is indicated for maintenance bronchodilator treatment of airflow obstruction in adult patients with chronic obstructive pulmonary disease (COPD).
Pharmacotherapeutic group: Drugs for obstructive airways diseases, selective beta-2-adrenoreceptor agonists, ATC code: R03AC18
Mechanism of action
The pharmacological effects of beta2-adrenoceptor agonists are at least in part attributable to stimulation of intracellular adenyl cyclase, the enzyme that catalyses the conversion of adenosine triphosphate (ATP) to cyclic-3', 5'-adenosine monophosphate (cyclic monophosphate). Increased cyclic AMP levels cause relaxation of bronchial smooth muscle. In vitro studies have shown that indacaterol, a long-acting beta2-adrenergic agonist, has more than 24-fold greater agonist activity at beta2-receptors compared to beta1-receptors and 20-fold greater agonist activity compared to beta3-receptors.
When inhaled, indacaterol acts locally in the lung as a bronchodilator. Indacaterol is a partial agonist at the human beta2-adrenergic receptor with nanomolar potency. In isolated human bronchus, indacaterol has a rapid onset of action and a long duration of action.
Although beta2-receptors are the predominant adrenergic receptors in bronchial smooth muscle and beta1-receptors are the predominant receptors in the human heart, there are also beta2-adrenergic receptors in the human heart comprising 10-50% of the total adrenergic receptors. The precise function of beta2-adrenergic receptors in the heart is not known, but their presence raises the possibility that even highly selective beta2-adrenergic agonists may have cardiac effects.
Pharmacodynamic effects
Onbrize, administered once a day at doses of 150 and 300 microgram consistently provided clinically significant improvements in lung function (as measured by the forced expiratory volume in one second, FEV1) over 24 hours across a number of clinical pharmacodynamic and efficacy studies. There was a rapid onset of action within 5 minutes after inhalation, with an increase in FEV1 relative to baseline of 110-160 ml, comparable to the effect of the fast-acting beta2-agonist salbutamol 200 microgram and statistically significantly faster compared to salmeterol/fluticasone 50/500 microgram. Mean peak improvements in FEV1 relative to baseline were 250-330 ml at steady state.
The bronchodilator effect did not depend on the time of dosing, morning or evening.
Onbrize was shown to reduce lung hyperinflation, resulting in increased inspiratory capacity during exercise and at rest, compared to placebo.
Effects on cardiac electrophysiology
A double-blind, placebo- and active (moxifloxacin)-controlled study for 2 weeks in 404 healthy volunteers demonstrated maximum mean (90% confidence intervals) prolongations of the QTcF interval (in milliseconds) of 2.66 (0.55, 4.77) 2.98 (1.02, 4.93) and 3.34 (0.86, 5.82) following multiple doses of 150 microgram, 300 microgram and 600 microgram, respectively. Therefore, this shows no concern for a pro-arrhythmic potential related to QT-interval prolongations at recommended therapeutic doses or at twice the maximum recommended dose. There was no evidence of a concentration-delta QTc relationship in the range of doses evaluated.
As demonstrated in 605 patients with COPD in a 26-week, double-blind, placebo-controlled Phase III study, there was no clinically relevant difference in the development of arrhythmic events monitored over 24 hours, at baseline and up to 3 times during the 26-week treatment period, between patients receiving recommended doses of Onbrize treatment and those patients who received placebo or treatment with tiotropium.
Clinical efficacy and safety
The clinical development programme included one 12-week, two six-month (one of which was extended to one year to evaluate safety and tolerability) and one one-year randomised controlled studies in patients with a clinical diagnosis of COPD. These studies included measures of lung function and of health outcomes such as dyspnoea, exacerbations and health-related quality of life.
Lung function
Onbrize, administered once a day at doses of 150 microgram and 300 microgram, showed clinically meaningful improvements in lung function. At the 12-week primary endpoint (24-hour trough FEV1), the 150 microgram dose resulted in a 130-180 ml increase compared to placebo (p<0.001) and a 60 ml increase compared to salmeterol 50 microgram twice a day (p<0.001). The 300 microgram dose resulted in a 170-180 ml increase compared to placebo (p<0.001) and a 100 ml increase compared to formoterol 12 microgram twice a day (p<0.001). Both doses resulted in an increase of 40-50 ml over open-label tiotropium 18 microgram once a day (150 microgram, p=0.004; 300 microgram, p=0.01). The 24-hour bronchodilator effect of Onbrize was maintained from the first dose throughout a one-year treatment period with no evidence of loss in efficacy (tachyphylaxis).
Symptomatic benefits
Both doses demonstrated statistically significant improvements in symptom relief over placebo for dyspnoea and health status (as evaluated by Transitional Dyspnoea Index [TDI] and St. George's Respiratory Questionnaire [SGRQ], respectively). The magnitude of response was generally greater than seen with active comparators (Table 2). In addition, patients treated with Onbrize required significantly less rescue medication, had more days when no rescue medication was needed compared to placebo and had a significantly improved percentage of days with no daytime symptoms.
Pooled efficacy analysis over 6 months' treatment demonstrated that the rate of COPD exacerbations was statistically significantly lower than the placebo rate. Treatment comparison compared to placebo showed a ratio of rates of 0.68 (95% CI [ 0.47, 0.98]; p-value 0.036) and 0.74 (95% CI [0.56, 0.96]; p-value 0.026) for 150 microgram and 300 microgram, respectively.
Limited treatment experience is available in individuals of African descent.
Table 2 Symptom relief at 6 months treatment duration
| Treatment Dose (microgram) | Indacaterol 150 once a day | Indacaterol 300 once a day | Tiotropium 18 once a day | Salmeterol 50 twice a day | Formoterol 12 twice a day | Placebo |
| Percentage of patients who achieved MCID TDI†| 57 a 62 b |
71 b 59 c |
57 b | 54 a |
54 c | 45 a 47 b 41 c |
| Percentage of patients who achieved MCID SGRQ†| 53 a 58 b |
53 b 55 c |
47 b | 49 a |
51 c | 38 a 46 b 40 c |
| Reduction in puffs/day of rescue medication use vs. baseline | 1.3 a 1.5 b |
1.6 b |
1.0 b | 1.2 a |
n/e | 0.3 a 0.4 b |
| Percentage of days with no rescue medication use | 60 a 57 b |
58 b |
46 b | 55 a |
n/e | 42 a 42 b |
Study design with a: indacaterol 150 microgram, salmeterol and placebo; b: indacaterol 150 and 300 microgram, tiotropium and placebo; c: indacaterol 300 microgram, formoterol and placebo
†MCID = minimal clinically important difference (>1 point change in TDI, >4 point change in SGRQ)
n/e= not evaluated at six months
Paediatric population
Indacaterol is a chiral molecule with R-configuration.
Pharmacokinetic data were obtained from a number of clinical studies, from healthy volunteers and COPD patients.
Absorption
The median time to reach peak serum concentrations of indacaterol was approximately 15 min after single or repeated inhaled doses. Systemic exposure to indacaterol increased with increasing dose (150 microgram to 600 microgram) in a dose proportional manner. Absolute bioavailability of indacaterol after an inhaled dose was on average 43% to 45%. Systemic exposure results from a composite of pulmonary and gastrointestinal absorption; about 75% of systemic exposure was from pulmonary absorption and about 25% from gastrointestinal absorption.
Indacaterol serum concentrations increased with repeated once-daily administration. Steady state was achieved within 12 to 14 days. The mean accumulation ratio of indacaterol, i.e. AUC over the 24-h dosing interval on Day 14 compared to Day 1, was in the range of 2.9 to 3.5 for once-daily inhaled doses between 150 microgram and 600 microgram.
Distribution
After intravenous infusion the volume of distribution of indacaterol during the terminal elimination phase was 2557 litres indicating an extensive distribution. The in vitro human serum and plasma protein binding was 94.1-95.3% and 95.1-96.2%, respectively.
Biotransformation
After oral administration of radiolabelled indacaterol in a human ADME (absorption, distribution, metabolism, excretion) study, unchanged indacaterol was the main component in serum, accounting for about one third of total drug-related AUC over 24 hours. A hydroxylated derivative was the most prominent metabolite in serum. Phenolic O-glucuronides of indacaterol and hydroxylated indacaterol were further prominent metabolites. A diastereomer of the hydroxylated derivative, a N-glucuronide of indacaterol, and C- and N-dealkylated products were further metabolites identified.
In vitro investigations indicated that UGT1A1 is the only UGT isoform that metabolised indacaterol to the phenolic O-glucuronide. The oxidative metabolites were found in incubations with recombinant CYP1A1, CYP2D6, and CYP3A4. CYP3A4 is concluded to be the predominant isoenzyme responsible for hydroxylation of indacaterol. In vitro investigations further indicated that indacaterol is a low affinity substrate for the efflux pump P-gp.
Elimination
In clinical studies which included urine collection, the amount of indacaterol excreted unchanged via urine was generally lower than 2% of the dose. Renal clearance of indacaterol was, on average, between 0.46 and 1.20 litres/hour. When compared with the serum clearance of indacaterol of 23.3 litres/hour, it is evident that renal clearance plays a minor role (about 2 to 5% of systemic clearance) in the elimination of systemically available indacaterol.
In a human ADME study where indacaterol was given orally, the faecal route of excretion was dominant over the urinary route. Indacaterol was excreted into human faeces primarily as unchanged parent substance (54% of the dose) and, to a lesser extent, hydroxylated indacaterol metabolites (23% of the dose). Mass balance was complete with >90% of the dose recovered in the excreta.
Indacaterol serum concentrations declined in a multi-phasic manner with an average terminal half-life ranging from 45.5 to 126 hours. The effective half-life, calculated from the accumulation of indacaterol after repeated dosing ranged from 40 to 52 hours which is consistent with the observed time-to-steady state of approximately 12-14 days.
Special populations
A population pharmacokinetic analysis showed that there is no clinically relevant effect of age (adults up to 88 years), sex, weight (32-168 kg) or race on the pharmacokinetics of indacaterol. It did not suggest any difference between ethnic subgroups in this population.
Patients with mild and moderate hepatic impairment showed no relevant changes in Cmax or AUC of indacaterol, nor did protein binding differ between mild and moderate hepatic impaired subjects and their healthy controls. Studies in subjects with severe hepatic impairment were not performed.
Due to the very low contribution of the urinary pathway to total body elimination, a study in renally impaired subjects was not performed.
Asthma
Onbrize is a long-acting beta2-adrenergic agonist, which is only indicated for COPD and should not be used in asthma due to the absence of long-term outcome data in asthma.
Long-acting beta2-adrenergic agonists may increase the risk of asthma-related serious adverse events, including asthma-related deaths, when used for the treatment of asthma.
Hypersensitivity
Immediate hypersensitivity reactions have been reported after administration of Onbrize. If signs suggesting allergic reactions (in particular, difficulties in breathing or swallowing, swelling of tongue, lips and face, urticaria, skin rash) occur, Onbrize should be discontinued immediately and alternative therapy instituted.
Paradoxical bronchospasm
As with other inhalation therapy, administration of Onbrize may result in paradoxical bronchospasm that may be life-threatening. If paradoxical bronchospasm occurs Onbrize should be discontinued immediately and alternative therapy substituted.
Deterioration of disease
Onbrize is not indicated for the treatment of acute episodes of bronchospasm, i.e. as rescue therapy. In the event of deterioration of COPD during treatment with Onbrize, a re-evaluation of the patient and of the COPD treatment regimen should be undertaken. An increase in the daily dose of Onbrize beyond the maximum dose of 300 microgram is not appropriate.
Systemic effects
Although no clinically relevant effect on the cardiovascular system is usually seen after the administration of Onbrize at the recommended doses, as with other beta2-adrenergic agonists, indacaterol should be used with caution in patients with cardiovascular disorders (coronary artery disease, acute myocardial infarction, cardiac arrhythmias, hypertension), in patients with convulsive disorders or thyrotoxicosis, and in patients who are unusually responsive to beta2-adrenergic agonists.
Cardiovascular effects
Like other beta2-adrenergic agonists, indacaterol may produce a clinically significant cardiovascular effect in some patients as measured by increases in pulse rate, blood pressure, and/or symptoms. In case such effects occur, treatment may need to be discontinued. In addition, beta-adrenergic agonists have been reported to produce electrocardiogram (ECG) changes, such as flattening of the T wave, prolongation of QT interval and ST segment depression, although the clinical significance of these observations is unknown. Therefore, long-acting beta2-adrenergic agonists such as Onbrize should be used with caution in patients with known or suspected prolongation of the QT interval or treated with medicinal products affecting the QT interval.
Clinically relevant effects on prolongation of the QTc-interval have not been observed in clinical studies of Onbrize at recommended therapeutic doses.
Hypokalaemia
Beta2-adrenergic agonists may produce significant hypokalaemia in some patients, which has the potential to produce adverse cardiovascular effects. The decrease in serum potassium is usually transient, not requiring supplementation. In patients with severe COPD, hypokalaemia may be potentiated by hypoxia and concomitant treatment , which may increase the susceptibility to cardiac arrhythmias.
Hyperglycaemia
Inhalation of high doses of beta2-adrenergic agonists may produce increases in plasma glucose. Upon initiation of treatment with Onbrize plasma glucose should be monitored more closely in diabetic patients.
During clinical studies, clinically notable changes in blood glucose were generally more frequent by 1-2% on Onbrize at the recommended doses than on placebo. Onbrize has not been investigated in patients with not well controlled diabetes mellitus.
Excipients
The capsules contain lactose. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicinal product.
Onbrize has no or negligible influence on the ability to drive and use machines.
Posology
The recommended dose is the inhalation of the content of one 150 microgram capsule once a day, using the Onbrize inhaler. The dose should only be increased on medical advice.
The inhalation of the content of one 300 microgram capsule once a day, using the Onbrize inhaler has been shown to provide additional clinical benefit with regard to breathlessness, particularly for patients with severe COPD. The maximum dose is 300 microgram once daily.
Onbrize should be administered at the same time of the day each day.
If a dose is missed the next dose should be taken at the usual time the next day.
Special populations
Elderly population
Maximum plasma concentration and overall systemic exposure increase with age but no dose adjustment is required in elderly patients.
Hepatic impairment
No dose adjustment is required for patients with mild and moderate hepatic impairment. There are no data available for use of Onbrize in patients with severe hepatic impairment.
Renal impairment
No dose adjustment is required for patients with renal impairment.
Paediatric population
There is no relevant use of Onbrize in the paediatric population (under 18 years).
Method of administration
For inhalation use only. Onbrize capsules must not be swallowed.
The capsules must only be removed from the blister immediately before use.
The capsules must be administered only using the Onbrize inhaler. The Onbrize inhaler provided with each new prescription should be used.
Patients should be instructed on how to administer the product correctly. Patients who do not experience improvement in breathing should be asked if they are swallowing the medicine rather than inhaling it.
Each inhaler should be disposed of after 30 days of use.
Instructions for handling and use
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| Pull off the cap. |
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| Open inhaler: Hold the base of the inhaler firmly and tilt the mouthpiece. This opens the inhaler. |
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| Prepare capsule: Immediately before use, with dry hands, remove one capsule from the blister. |
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| Insert capsule: Place the capsule into the capsule chamber. Never place a capsule directly into the mouthpiece. |
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| Close the inhaler: Close the inhaler until you hear a “clickâ€. |
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| Pierce the capsule: - Hold the inhaler upright with the mouthpiece pointing up. - Pierce the capsule by firmly pressing together both side buttons at the same time. Do this only once. - You should hear a “click†as the capsule is being pierced. |
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| Release the side buttons fully. |
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| Breathe out: Before placing the mouthpiece in your mouth, breathe out fully. Do not blow into the mouthpiece. |
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| Inhale the medicine To breathe the medicine deeply into your airways: - Hold the inhaler as shown in the picture. The side buttons should be facing left and right. Do not press the side buttons. - Place the mouthpiece in your mouth and close your lips firmly around it. - Breathe in rapidly but steadily and as deeply as you can. |
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| Note: As you breathe in through the inhaler, the capsule spins around in the chamber and you should hear a whirring noise. You will experience a sweet flavour as the medicine goes into your lungs. Additional information Occasionally, very small pieces of the capsule can get past the screen and enter your mouth. If this happens, you may be able to feel these pieces on your tongue. It is not harmful if these pieces are swallowed or inhaled. The chances of the capsule shattering will be increased if the capsule is accidentally pierced more than once (step 6). If you do not hear a whirring noise: The capsule may be stuck in the capsule chamber. If this happens: - Open the inhaler and carefully loosen the capsule by tapping the base of the inhaler. Do not press the side buttons. - Inhale the medicine again by repeating steps 8 and 9. |
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| Hold breath: After you have inhaled the medicine: - Hold your breath for at least 5-10 seconds or as long as you comfortably can while taking the inhaler out of your mouth. - Then breathe out. - Open the inhaler to see if any powder is left in the capsule. If there is powder left in the capsule: - Close the inhaler. - Repeat steps 8, 9, 10 and 11. Most people are able to empty the capsule with one or two inhalations. Additional information Some people may occasionally cough briefly soon after inhaling the medicine. If you do, don't worry. As long as the capsule is empty, you have received enough of your medicine. |
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| After you have finished taking your medicine: - Open the mouthpiece again, and remove the empty capsule by tipping it out of the capsule chamber. Put the empty capsule in your household waste. - Close the inhaler and replace the cap. Do not store the capsules in the Onbrize inhaler. |
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| Mark daily dose tracker: On the inside of the pack there is a daily dose tracker. Put a mark in today's box if it helps to remind you of when your next dose is due. |
