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Finasteride 5mg Film Coated Tablets

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SUMMARY OF PRODUCT CHARACTERISTICS

1 NAME OF THE MEDICINAL PRODUCT

Finasteride 5 mg film-coated tablets

2 QUALITATIVE AND QUANTITATIVE COMPOSITION

One film-coated tablet contains 5 mg finasteride.

Excipient: lactose monohydrate (97.5 mg).

For a full list of excipients, see section 6.1.

3 PHARMACEUTICAL FORM

Film-coated tablet.

Blue coloured, circular, biconvex, beveled edged film-coated tablets debossed with ‘E’ on one side and ‘61’ on the other side.

4 CLINICAL PARTICULARS

4.1 Therapeutic indications

Finasteride 5 mg is indicated for the treatment and control of benign prostatic hyperplasia (BPH) to:

- cause regression of the enlarged prostate, improve urinary flow and improve the symptoms associated with BPH,

- reduce the incidence of acute urinary retention and reduce need for surgery including transurethral resection of the prostate (TURP) and prostatectomy.

Finasteride 5mg should be administered in patients with an enlarged prostate (prostate volume above ca. 40ml).

4.2 Posology and method of administration

Finasteride 5mg is for oral use only.

Dosage in adults

The recommended dosage is one 5 mg tablet daily with or without food. The tablet should be swallowed whole and must not be divided or crushed (see section 6.6).

Even though improvement can be seen within a short time, treatment for at least 6 months may be necessary in order to determine objectively whether a satisfactory response to treatment has been achieved. Thereafter, treatment should be continued long term.

Dosage in the elderly

Dosage adjustments are not necessary although pharmacokinetic studies have shown that the elimination rate of finasteride is slightly decreased in patients over the age of 70.

Dosage in hepatic insufficiency

There is no data available in patients with hepatic insufficiency (see section 4.4). Dosage in renal insufficiency

Dosage adjustments are not necessary in patients with varying degrees of renal insufficiency (starting from creatinine clearance as low as 9 ml/min) as in pharmacokinetic studies renal insufficiency was not found to affect the elimination of finasteride. Finasteride has not been studied in patients on haemodialysis.

Finasteride is contraindicated in children.

4.3 Contraindications

Finasteride is contraindicated in the following:

Hypersensitivity to finasteride or to any of the excipients.

Pregnancy-Use in women who are or may potentially be pregnant (see sections 4.6 Fertility, pregnancy and lactation, Exposure to finasteride-risk to male foetus).

Finasteride is indicated neither in women nor in children.

4.4 Special warnings and precautions for use

General:

• Patients with large residual urine volume and/or severely diminished urinary flow should be carefully monitored for obstructive uropathy. The possibility of surgery should be an option.

• Consultation of an urologist should be considered in patients treated with finasterides Obstruction due to trilobular growth pattern of the prostate should be excluded before starting treatment with finasteride.

Hepatic Insufficiency

There is no experience in patients with liver insufficiency. Since finasteride is metabolised in the liver (see section 5.2) caution is advised in patients with decreased hepatic function as the plasma-levels of finasteride may be increased in such patients.

Lactose

This medicinal product contains lactose-monohydrate. Patients with rare hereditary problems of galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.

Effects on prostate-specific antigen (PSA) and prostate cancer detection:

No clinical benefit has yet been demonstrated in patients with prostate cancer treated with finasteride. Patients with BPH and elevated serum prostate specific antigen (PSA) were monitored in controlled clinical studies with serial PSAs and prostate biopsies. In these BPH studies, finasteride did not appear to alter the rate of prostate cancer detection, and the overall incidence of prostate cancer was not significantly different in patients treated with finasteride or placebo.

Serum PSA concentration is correlated with patient age and prostatic volume, and prostatic volume is correlated with patient age.

Digital rectal examination, as well as other evaluations for prostate cancer, are recommended prior to initiating therapy with finasteride and periodically thereafter. Serum PSA is also used for prostate cancer detection. Generally, a baseline PSA >10 ng/mL (Hybritech) prompts further evaluation and consideration of biopsy; for PSA levels between 4 and 10 ng/mL, further evaluation is advisable. There is considerable overlap in PSA levels among men with and without prostate cancer. Therefore, in men with BPH, PSA values within the normal reference range do not rule out prostate cancer regardless of treatment with finasteride. A baseline PSA <4 ng/mL does not exclude prostate cancer.

Finasteride causes a decrease in serum PSA concentrations by approximately 50% in patients with BPH even in the presence of prostate cancer. This decrease in serum PSA levels in patients with BPH treated with finasteride should be considered when evaluating PSA data and does not rule out concomitant prostate cancer. This decrease is predictable over the entire range of PSA values, although it may vary in individual patients. In patients treated with finasteride for six months or more, PSA values should be doubled for comparison with normal ranges in untreated men. This adjustment preserves the sensitivity or specificity of the PSA assay and maintains its ability to detect prostate cancer.

Any sustained increase in PSA levels of patients treated with finasteride should be carefully evaluated, including consideration of non-compliance to finasteride therapy.

Percent free PSA (free to total PSA ratio) is not significantly decreased by finasteride and remains constant even under the influence of finasteride. When percent free PSA is used as an aid in the detection of prostate cancer, no adjustment is necessary.

Women who are pregnant or may become pregnant should not handle crushed or broken finasteride tablets because of the possibility of absorption of finasteride and the subsequent potential risk to a male foetus. Finasteride tablets have a film coating which prevents contact with the active ingredient provided that the tablets have not been broken or crushed (see sections 4.6 and 6.6).

Drug/laboratory test interactions

Effect on levels of PSA

Serum PSA concentration is correlated with patient age and prostatic volume, and prostatic volume is correlated with patient age. When PSA laboratory determinations are evaluated, consideration should be given to the fact that PSA levels decrease in patients treated with finasteride. In most patients, a rapid decrease in PSA is seen within the first months of therapy, after which time PSA levels stabilise to a new baseline. The post-treatment baseline approximates half of the pre-treatment value. Therefore, in typical patients treated with finasteride for six months or more, PSA values should be doubled for comparison to normal ranges in untreated men. For clinical interpretation, see 4.4 Special warnings and precautions for use, Effects on PSA and prostate cancer detection.

Percent free PSA (free to total PSA ratio) is not significantly decreased by Finasteride The ratio of free to total PSA remains constant even under the influence of ‘Finasteride ’ When percent free PSA is used as an aid in the detection of prostate cancer, no adjustment to its value is necessary.

Breast cancer in men

Breast cancer has been reported in men taking finasteride 5 mg during clinical trials and the post-marketing period. Physicians should instruct their patients to promptly report any changes in their breast tissue such as lumps, pain, gynaecomastia or nipple discharge.

Pediatric use

Finasteride is not indicated for use in children.

Safety and effectiveness in children have not been established.

4.5 Interaction with other medicinal products and other forms of interaction

No clinically significant drug interactions have been identified. Finasteride does not appear to significantly affect the cytochrome P450-linked drug metabolizing enzyme system. Although the risk for finasteride to affect the pharmacokinetics of other drugs is estimated to be small, it is probable that inhibitors and inducers of cytochrome P450 3A4 will affect the plasma concentration of finasteride. However based on established safety margins, any increase due to concomitant use of such inhibitors is unlikely to be of clinical significance .The following medicinal products have been investigated in man, and no clinically significant interactions have been found: propanolol, digoxin, glibenclamide, warfarin, theophylline and phenazone .

4.6 Fertility, pregnancy and lactation

Finasteride is not indicated in women (see section 4.3).

Pregnancy: Finasteride is contra-indicated in women when they are or may potentially be pregnant (see section 4.3).

Because of the ability of Type II 5a-Reductase-inhibitors to inhibit conversion of testosterone to dihydrotestosterone, these drugs, including finasteride, might cause abnormalities of the external genitalia of a male foetus when administered to a pregnant woman (see section 5.3).

In animal developmental studies, dose-dependent development of hypospadias were observed in the male off spring of pregnant rats given finasteride at doses ranging from 100 g/kg/day to 100 mg/kg/day, at an incidence of 3.6% to 100%. Additionally, pregnant rats produced male offspring with decreased prostatic and seminal vesicular weights, delayed preputial separation, transient nipple development and decreased anogenital distance, when given finasteride at doses below the recommended human dose. The critical period during which these effects can be induced has been defined in rats as days 16-17 of gestation

The changes described above are expected pharmacological effects of Type II 5 a-reductase inhibitors. Many of the changes, such as hypospadias, observed in male rats exposed in utero to finasteride are similar to those reported in male infants with a genetic deficiency of Type II 5 a-reductase. It is for these reasons that finasteride is contra-indicated in women who are or may potentially be pregnant.

No effects were seen in female offspring exposed in utero to any dose of finasteride.

Exposure to finasteride - risk to male foetus.

Finasteride tablets have a film coating, which prevents contact with the active ingredient provided that the tablets have not been broken or crushed.

Small amounts of finasteride have been recovered from the semen in subjects receiving finasteride 5 mg/day. It is not known whether a male foetus may be adversely affected if his mother is exposed to the semen of a patient being treated with finasteride. When the patient’s sexual partner is or may potentially be pregnant, the patient is recommended to minimise exposure of his partner to semen.

Lactation: Finasteride 5 mg film-coated tablets are not indicated for use in women. It is not known whether finasteride is excreted in breast milk.

4.7 Effects on ability to drive and use machines

There is no known data to show that Finasteride 5 mg film-coated tablets influence the ability to drive and the capacity to operate machinery.

4.8 Undesirable effects

The most common adverse effects are impotence and reduced libido. These adverse reactions occur early in the course of therapy and resolve with continued treatment in the majority of patients.

The adverse reactions reported during clinical trials and/or post-marketing use are listed in the table below.

Frequency of adverse reactions is determined as follows:

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). The frequency of adverse reactions reported during post-marketing use cannot be determined as they are derived from spontaneous reports.

System Organ Class	Frequency: adverse reaction
Immune system disorders	Rare: hypersensitivity reactions including swelling of the lips and face
Psychiatric disorders	Common: decreased libido Unknown: decreased libido that may continue after

	discontinuation of therapy, depression
Cardiac disorders	Unknown: palpitation
Hepatobiliary disorders	Unknown: increased hepatic enzymes
Skin and subcutaneous tissue disorders	Common: rash Rare: pruritus, urticaria
Reproductive system and breast disorders	Very common: impotence Common: Tenderness of the male breast / enlargement (gynaecomastia), ejaculation disorder Uncommon: , testicular pain, Very rare: breast secretion, breast nodules Unknown: erectile dysfunction which may continue after discontinuation of treatment; male infertility and/or poor seminal quality. Normalization or improvement of seminal quality has been reported after discontinuation of finasteride
Investigations	Common: decreased volume of ejaculate
Nervous system disorders	Unknown: Somnolence

In addition, the following has been reported in clinical trials and post-marketing use: male breast cancer (see 4.4 Special warnings and precautions for use).

Medical therapy of prostatic symptoms (MTOPS):

The MTOPS study compared finasteride 5 mg/day (n=768), doxazosin 4 or 8 mg/day (n=756), combination therapy of finasteride 5 mg/day and doxazosin 4 or 8 mg/day (n=786), and placebo (n=737). In this study, the safety and tolerability profile of the combination therapy was generally consistent with the profiles of the individual components. The incidence of ejaculation disorder in patients receiving combination therapy was comparable to the sum of incidences of this adverse experience for the two monotherapies Events without regard to drug relationship were: finasteride 8.3%, doxazosin 5.3%, combination 15.0%, placebo 3.9%. Besides adverse reactions related to “Nervous system disorders” were also observed with a greater frequency in patients receiving the combination (see table below).

MTOPS Table:

System	Placebo	Doxazosin	Finasteride	Finasteride
Organ Class	N =	N = 756	N = 768	+
	733			Doxazosin
				N = 786

	%	%	%	%
Patients with one or more undesirable effect	46.4	64.9	52.5	73.8
General Disorders	11.7	21.4	11.6	21.5
Asthenia	7.1	15.7	5.3	16.8
Cardiac Disorders	1 0. 4	23.1	12.6	22
Hypotension	0.7	3.4	1.2	1.5
Orthostatic Hypotension	8	16.7	9.1	17.8
Nervous System Disorders	16.1	28.4	19.7	36.3
Dizziness	8.1	17.7	7.4	23.2
Reduced Libido	5.7	7	10	11.6
Somnolence	1.5	3.7	1.7	3.1
Urino- genital Disorders	18.6	22.1	29.7	36.8
Ejaculation Disorders	2.3	4.5	7.2	14.1
Breast Enlargement	0.7	1.1	2.2	1.5
Impotency	12.2	14.4	18.5	22.6
Other Sexual Abnormaliti es	0.9	2	2.5	3.1

Other Long-Term Data

In a 7 year placebo-controlled trial that enrolled 18,882 healthy men, of whom 9060 had prostate needle biopsy data available for analysis, prostate cancer was detected in 803 (18.4%) men receiving finasteride and 1147 (24.4%) men receiving placebo. In the finasteride group, 280 (6.4%) men had prostate cancer with Gleason scores of 7-10 detected on needle biopsy vs 237 (5.1%) men in the placebo group. Additional analyses suggest that the increase in the prevalence of high-grade prostate cancer observed in the finasteride group may be explained by a detection bias due to the effect of finasteride on prostate volume. Of the total cases of prostate cancer diagnosed in this study, approximately 98% were classified as intracapsular (stage T1 or T2). The

relationship between long-term use of finasteride and tumours with Gleason scores of 7-10 is unknown.

Other Laboratory Test Findings: S When PSA laboratory determinations are evaluated, consideration should be given to the fact that PSA levels generally decrease in patients treated with finasteride (see section 4.4 special warnings and precautions for use). In most patients, a rapid decrease in PSA is seen within the first months of therapy, after which time PSA levels stabilize to a new baseline. The posttreatment baseline approximates half of the pre-treatment value. Therefore, in typical patients treated with finasteride for six months or more, PSA values should be doubled for comparison to normal ranges in untreated men.

For clinical interpretation see section 4.4 special warnings and precautions for use (Paragraph Effects on prostate specific antigen (PSA) and prostate cancer detection).

No other difference was observed in patients treated with Placebo or finasteride in Standard laboratory tests.

4.9 Overdose

Patients have received single doses of finasteride up to 400 mg and multiple doses up to 80 mg/day for up to three months without adverse effects. No specific treatment of overdosage with Finasteride is recommended.

5 PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Testosterone 5 a-reductase inhibitors ATC code: G04CB01

Finasteride is a synthetic 4-azasteroid, a specific competitive inhibitor of the intracellular enzyme Type-II-5a-reductase. The enzyme converts testosterone into the more potent androgen dihydrotestosterone (DHT). The prostate gland and, consequently, also the hyperplasic prostate tissue are dependent on the conversion of testosterone to DHT for their normal function and growth. Finasteride has no affinity for the androgen receptor.

Clinical studies show a rapid reduction of the serum DHT levels of 70%, which leads to a reduction on prostate volume. After 3 months, a reduction of approx. 20% in the volume of the gland occurs, and the shrinking continues and reaches approximately 27% after 3 years. Marked reduction takes place in the periurethral zone immediately surrounding the urethra. Urodynamic measurements have also confirmed a significant reduction of detrusor pressure as a result of the reduced obstruction.

Significant improvements in maximum urinary flow rate and symptoms have been obtained after a few weeks, compared with the start of treatment. Differences from placebo have been documented at 4 and 7 months, respectively.

All efficacy parameters have been maintained over a 3-year follow-up period.

Effects of four years treatment with finasteride on incidence of acute urine retention need for surgery, symptom-score and prostate volume:

In clinical studies of patients with moderate to severe symptoms of BPH, an enlarged prostate on digital rectal examination and low residual urinary volumes, finasteride reduced the incidence of acute retention of urine from 7/100 to 3/100 over four years and the need for surgery (TURP or prostatectomy) from 10/100 to 5/100. These reductions were associated with a 2-point improvement in QUASI-AUA symptom score (range 0-34), a sustained regression in prostate volume of approximately 20% and a sustained increase in urinary flow rate.

Medical therapy of prostatic symptoms

The Medical Therapy of Prostatic Symptoms (MTOPS) Trial was a 4- to 6-year study in 3047 men with symptomatic BPH who were randomised to receive finasteride 5 mg/day, doxazosin 4 or 8 mg/day*, the combination of finasteride 5 mg/day and doxazosin 4 or 8 mg/day*, or placebo. The primary endpoint was time to clinical progression of BPH, defined as a >4 point confirmed increase from baseline in symptom score, acute urinary retention, BPH-related renal insufficiency, recurrent urinary tract infections or urosepsis, or incontinence. Compared to placebo, treatment with finasteride, doxazosin, or combination therapy resulted in a significant reduction in the risk of clinical progression of BPH by 34(p=0.002), 39 (p<0.001), and 67% (p<0.001), respectively. The majority of the events (274 out of 351) that constituted BPH progression were confirmed >4 point increases in symptom score; the risk of symptom score progression was reduced by 30 (95% CI 6 to 48%), 46 (95% CI 25 to 60%), and 64% (95% CI 48 to 75%) in the finasteride, doxazosin, and combination groups, respectively, compared to placebo. Acute urinary retention accounted for 41 of the 351 events of BPH progression; the risk of developing acute urinary retention was reduced by 67( p=0.011), 31 (p=0.296), and 79% (p=0.001) in the finasteride, doxazosin, and combination groups, respectively, compared to placebo. Only the finasteride and combination therapy groups were significantly different from placebo.

* Titrated from 1 mg to 4 or 8 mg as tolerated over a 3-week period

In this study the safety and tolerability profile of combined treatment was broadly similar to the profile of each of the drugs taken separately. However, undesirable effects concerning the"nervous system" and "uro-genital system" organ classes were observed more frequently when the two drugs were used in combination (see section 4.8).

5.2 Pharmacokinetic properties

Absorption:

The bioavailability of finasteride is approx. 80%. Peak plasma concentrations are reached approx. 2 hours after drug intake, and absorption is complete after 6-8 hours.

Distribution:

Binding to plasma proteins is approx. 93%. Clearance and volume of distribution are approx. 165 ml/min (70-279 ml/min) and 76 l (44-96 l), respectively. Accumulation of small amounts of finasteride is seen on repeated administration. After a daily dose of 5 mg the lowest steadystate concentration of finasteride has been calculated to be 8-10 ng/ml, which remains stable over time.

Biotransformation:

Finasteride is metabolised in the liver. Finasteride does not significantly affect the cytochrome P 450 enzyme system. Two metabolites with low 5a-reductase-inhibiting effects have been identified.

Elimination:

The plasma half-life averages 6 hours (4-12 hours) (in men >70 years of age, 8 hours, range 6-15 hours).

After administration of radioactively labelled finasteride, approx. 39% (3246%) of the given dose is excreted in the urine in the form of metabolites. Virtually no unchanged finasteride is recovered in the urine. Approximately 57% (51-64%) of the total dose is excreted in the faeces.

Finasteride has been found to cross the blood-brain barrier. Small amounts of finasteride have been recovered in the seminal fluid of treated. In 2 studies of healthy subjects (n=69) receiving finasteride 5 mg/day for 6-24 weeks, finasteride concentrations in semen ranged from undetectable (<0.1 ng/ml) to 10.54 ng/ml. In an earlier study using a less sensitive assay, finasteride concentrations in the semen of 16 subjects receiving finasteride 5 mg/day ranged from undetectable (<1.0 ng/ml) to 21 ng/ml. Thus, based on a 5-ml ejaculate volume, the amount of finasteride in semen was estimated to be 50-to 100-fold less than the dose of finasteride (5 pg) that had no effect on circulating DHT levels in men (see also section 5.3.).

In patients with chronic renal impairment, whose creatinine clearance ranged from 9-55 ml/min, the disposition of a single dose of 14C-finasteride was not different from that in healthy volunteers (see section 4.2). Protein binding also did not differ in patients with renal impairment. A portion of the metabolites which normally is excreted renally was excreted in the faeces. It therefore appears that faecal excretion increases commensurate to the decrease in urinary excretion of metabolites. Dosage adjustment in non-dialysed patients with renal impairment is not necessary.

5.3 Preclinical safety data

Non-clinical data reveal no special hazard for humans based on conventional studies of repeated dose toxicity, genotoxicity, and carcinogenic potential. Reproduction toxicology studies in male rats have demonstrated reduced prostate and seminal vesicular weights, reduced secretion from accessory genital glands and reduced fertility index (caused by the primary pharmacological effect of finasteride). The clinical relevance of these findings is unclear.

As with other 5-alpha-reductase inhibitors, femininisation of male rat foetuses has been seen with administration of finasteride in the gestation period. Intravenous administration of finasteride to pregnant rhesus monkeys at doses up to 800 ng/day during the entire period of embryonic and foetal development resulted in no abnormalities in male foetuses. This dose is about 60-120 times higher than the estimated amount in semen of a man who have taken 5 mg finasteride, and to which a woman could be exposed via semen. The reproductive toxicity is believed to be mediated via the intended inhibition of 5a-reductase. Taken into account the species enzyme difference in sensitivity to finasteride inhibition the margin of pharmacological exposure would be about 4 times. In confirmation of the relevance of the Rhesus model for human foetal development, oral administration of finasteride 2 mg/kg/day (the systemic exposure (AUC) of monkeys was below or in the range of that of men who have taken 5 mg finasteride, or approximately 1-2 million times the estimated mount of Finasteride in semen) to pregnant monkeys resulted in external genital abnormalities in male foetuses. No other abnormalities were observed in male foetuses and no finasteride-related abnormalities were observed in female foetuses at any dose.”

6 PHARMACEUTICAL PARTICULARS

6.1 List of excipients

Core:

Lactose monohydrate Cellulose, microcrystalline Sodium starch glycolate (Type A)

Starch pregelatinised (maize)

Docusate sodium Magnesium stearate

Film-coating:

Hydroxypropyl cellulose

Hypromellose Titanium dioxide

Talc

Indigo carmine aluminium lake (E132)

Iron oxide yellow (E172)

6.2 Incompatibilities

Not Applicable

6.3 Shelf life

3 Years

6.4 Special precautions for storage

This medicinal product does not require any special temperature storage conditions.

6.5 Nature and contents of container

PVC/PE/PVDC/Aluminium blister

Pack sizes : 10, 14, 15, 20, 28, 30, 45, 50, 60, 90, 98, 100 or 120 tablets. Not all pack sizes may be marketed.

6.6 Special precautions for disposal

Women who are pregnant or may become pregnant must not handle crushed or broken Finasteride tablets because of the possibility of absorption of finasteride and the subsequent potential risk to a male foetus. Finasteride tablets have a film coating, which prevents contact with the active ingredient provided that the tablets have not been broken or crushed.

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

7 MARKETING AUTHORISATION HOLDER

Medreich Plc Warwick House Plane Tree Crescent Feltham TW13 7HF

8 MARKETING AUTHORISATION NUMBER(S)

PL 21880/0052

9 DATE OF FIRST AUTHORISATION/RENEWAL OF THE

AUTHORISATION

05/08/2010

DATE OF REVISION OF THE TEXT

05/02/2014