SUMMARY OF PRODUCT CHARACTERISTICS

1 NAME OF THE MEDICINAL PRODUCT

Fluconazole 150 mg Capsule

2 QUALITATIVE AND QUANTITATIVE COMPOSITION

Each capsule contains 150 mg of the active ingredient fluconazole.

Excipient:

Lactose: 111.96 mg (per capsule).

For a full list of excipients, see section 6.1.

3 PHARMACEUTICAL FORM

Size 1 hard gelatin capsules, blue opaque cap and body: marked with the code ‘FCZ 150’.

4    CLINICAL PARTICULARS

4.1    Therapeutic indications

Vaginal candidiasis, acute or recurrent. Candidal balanitis associated with vaginal candidiasis.

4.2 Posology and method of administration

For oral use.

Use in adults

Candidal vaginitis or balanitis: 150 mg single oral dose.

Not recommended in children under 16 years.

Use in the elderly

Not recommended in patients aged over 60 years.

Use in patients with impaired renal function

Fluconazole is excreted predominantly in the urine as unchanged drug. No adjustments in single dose therapy are required.

Method of Administration

Fluconazole capsules should be swallowed whole and may be taken without regard to meals.

4.3 Contraindications

-    Patients with known hypersensitivity to fluconazole or to related triazole anti-fungal agents or to any other ingredient in the formulation.

-    Patients who are taking cisapride, terfenadine or astemizole (see sections

4.4 and 4.5).

-    Patients with congenital or documented acquired QT prolongation.

-    Patients who are taking other medicaments that prolong the QT interval such as antiarrhythmics of classes IA and III.

-    Patients with electrolyte disturbance, particularly hypokalaemia and hypomagnesaemia.

-    Patients with clinically relevant bradycardia, cardiac arrythmia or severe cardiac insufficiency.

4.4 Special warnings and precautions for use

The product is intended for pharmacy availability without prescription and will include a leaflet which will advise the patient:

Do not use this Fluconazole 150 mg Capsule without first asking your pharmacist or doctor if:

• You are under 16 or over 60 years of age.

•    You are or have you ever been told that you are allergic to fluconazole or to other drugs of the same type (called triazoles) that are used to treat fungal infections.

•    You are allergic to any of the other ingredients in these capsules?

•    You are taking cisapride, terfenadine or astemizole. Fluconazole must not be taken by people who are taking one of these medicines because there is a risk of a serious rhythm disturbance of the heart.

•    You take medicine(s) to control your heart rate or rhythm. These drugs include quinidine, amiodarone, sotalol, disopyramide, but there are many others so check with your doctor or pharmacist before you take fluconazole.

•    You have a very slow heart rate or a serious heart rhythm disturbance or heart failure. Also, have you ever been told that you have a long QT interval (a type of heart rhythm disturbance that is found on ECG’s).

•    You suffer from low levels of potassium or magnesium in your blood.

•    You have a serious ongoing illness, such as cancer, or severe problems with your body, liver or kidneys. Fluconazole is particularly likely to cause changes in blood test results in such people.

•    You have AIDS. You can still take fluconazole but be aware that people who have AIDS are more likely to develop very severe skin reactions to fluconazole.

•    You developed problems with your liver while taking fluconazole previously. If so, you should not take fluconazole to treat vaginal thrush.

Women Only:

•    You are pregnant or trying to become pregnant or are breast feeding (see below).

•    You have any abnormal or irregular vaginal bleeding or a blood stained discharge.

•    You have vulval or vaginal sores, ulcers or blisters.

•    You are experiencing lower abdominal pain or burning on passing urine.

Men Only:

•    Your sexual partner does not have vaginal thrush.

•    You have penile sores, ulcers or blisters.

•    You have an abnormal penile discharge (leakage)

•    Your penis has started to smell.

•    You have pain passing urine.

The product should never be used again if the patient experiences a rash or anaphylaxis following use of the drug.

Recurrent use (men and women): Patients should be advised to consult their physician if the symptoms have not been relieved within one week of taking a Fluconazole 150 mg Capsule. Fluconazole 150 mg Capsules can be used if the candidal infection returns after 7 days. However, if the candidal infection recurs more than twice within six months, patients should be advised to consult their physician.

In some patients, particularly those with serious underlying diseases such as AIDS and cancer, abnormalities in haematological, hepatic, renal and other biochemical function test results have been observed during multiple-dose treatment with fluconazole but the clinical significance and relationship to treatment is uncertain.

In cases of hepatotoxicity, no obvious relationship to total daily dose of fluconazole, duration of therapy, sex or age of the patient has been observed; the abnormalities have usually been reversible on discontinuation of fluconazole therapy. However, fluconazole should not be given to patients who developed clinical signs or symptoms consistent with liver disease during previous treatment with fluconazole.

Patients have rarely developed exfoliative cutaneous reactions, such as Stevens-Johnson syndrome and toxic epidermal necrolysis, during or after treatment with fluconazole. AIDS patients are more prone to the development of severe cutaneous reactions to many medicinal products.

Patients who developed a rash that was considered attributable to fluconazole during previous therapy should not receive fluconazole again, even as single dose therapy.

Lactose intolerance: the 150 mg capsules contain approximately 112 mg of lactose. This amount is not thought likely to cause symptoms in patients with lactose intolerance.

4.5 Interaction with other medicinal products and other forms of interaction

The following combinations are contra-indicated:

Cisapride (CYP3A4 substrate): There have been reports about cardiac cases including torsades de pointes in patients receiving fluconazole concomitantly with cisapride. Concomitant treatment with fluconazole and cisapride is contra-indicated.

Terfenadine (CYP3A4 substrate): Due to the occurrence of serious cardiac dysrhythmias secondary to prolongation of the QTc-interval in patients receiving azole antifungal drugs concomitantly with terfenadine, interaction studies have been performed. One study with 200mg fluconazole daily did not show any prolongation of the QTc-interval. Another study with 400mg and 800mg fluconazole daily showed that fluconazole 400mg or more daily significantly increases the plasma level of terfenadine when taken concomitantly. There have been spontaneous case-reports of palpitations, tachycardia, dizziness and chest pain in patients taking concomitant fluconazole and terfenadine. Concomitant treatment with terfenadine and fluconazole is contra-indicated.

Astemizole (CYP3A4 substrate): Astemizole overdoses have led to prolonged QT interval and severe ventricular arrhythmia, torsades de pointes and cardiac arrest. Concomitant treatment with fluconazole and astemizole is contra-indicated due to the potential for serious, potentially fatal, cardiac effects.

Effect of fluconazole on the metabolism of other medicinal products:

Fluconazole is a potent inhibitor of cytochrome P450 (CYP) isoenzyme 2C9 and a moderate inhibitor of CYP3A4. Besides the observed/documented interactions listed below there is a risk of increased plasma concentrations of other medicinal products metabolised by CYP2C9 or CYP3A4 (e.g. ergot-alkaloids, quinidine) when coadministered with fluconazole. Therefore, care should always be taken when using these combinations and the patients should be carefully monitored. The enzyme-inhibiting effect of fluconazole may persist for 4-5 days after end of fluconazole treatment due to the long fluconazole half-life.

Alfentanil (CYP3A4 substrate): Concomitant intake of fluconazole 400 mg and alfentanil 20 pg/kg intravenously in healthy volunteers increased the alfentanil AUC₁₀ approximately 2-fold and decreased the clearance by 55%, probably through inhibition of CYP3A4. Adjustment of the alfentanil dose may be required.

Amitriptyline: Several case reports have described the development of increased amitriptyline concentrations and signs of tricyclic toxicity when amitriptyline was used in combination with fluconazole. Co-administration of fluconazole with nortriptyline, the active metabolite of amitriptyline, has been reported to result in increased nortriptyline levels. Due to the risk of amitriptyline toxicity, consideration should be given to monitoring amitriptyline levels and making dose adjustments as may be necessary.

Anticoagulants (CYP2C9 substrate): Concomitant intake of fluconazole during warfarin treatment may prolong the prothrombin time up to 2-fold. This is likely to be due to an inhibition of warfarin metabolism via CYP2C9. As for other azoles there have been reports of bleeding (bruises, nose bleeding, gastrointestinal bleeding, blood in the urine and faeces) in connection with an increase of prothrombin time in patients concomitantly treated with warfarin. Prothrombin times must be closely monitored in patients on treatment with coumarin derivatives.

Benzodiazepines (CYP3A4 substrate): Concomitant intake of fluconazole 400 mg and midazolam 7.5 mg orally increased the midazolam AUC and half-life 3.7- fold and 2.2-fold, respectively, and also the psychomotor effects. Fluconazole 100 mg daily given concurrently with triazolam 0.25 mg orally increased the triazolam AUC and half-life 2.5-fold and 1.8-fold, respectively. Potentiated and prolonged effects of triazolam have been observed during concomitant treatment with concomitantly with fluconazole, a reduction of the benzodiazepine dose should be considered and the patients should be closely monitored.

Calcium channel antagonists (CYP3A4 substrates): Some dihydropyridine calcium channel antagonists (including nifedipine, isradipine, nicardipine, amlodipine, and felodipine) are metabolised via CYP3A4. Literature reports have documented substantial peripheral oedema and/or elevated calcium

antagonist serum concentrations during concurrent use of itraconazole and felodipine, isradipine, or nifedipine. An interaction might occur also with fluconazole.

Celecoxib (CYP2C9 substrate): In a clinical study, concomitant treatment with fluconazole 200 mg daily and celecoxib 200 mg resulted in a 68% and 134% increase in celecoxib Cmax and AUC, respectively. The interaction is believed to be due to inhibition of cytochrome P450 2C9 metabolism of celecoxib. Halving the Celecoxib dose is recommended in patients concurrently treated with fluconazole.

Ciclosporin (CYP3A4 substrate): Clinically significant interactions with ciclosporin have been shown at fluconazole doses of 200 mg and higher. In a pharmacokinetic study with renal transplant patients receiving fluconazole 200 mg daily and ciclosporin 2.7 mg/kg/day, there was an 1.8-fold increase in ciclosporin AUC and a 55% decrease in clearance. However, in another study, multiple dosing with fluconazole 100 mg daily did not influence cyclosporin concentrations in patients after bone marrow transplants. Plasma concentrations of ciclosporin should be monitored during treatment with fluconazole.

Didanosine: Although co-administration of didanosine and fluconazole appears to have little effect on the pharmacokinetics or efficacy of didanosine, the response to fluconazole should be monitored. It may be advantageous to administer fluconazole at some time prior to didanosine.

HMG-CoA reductase inhibitors (CYP2C9 or CYP3A4 substrates): The risk of myopathy is increased when fluconazole is administered concurrently with HMG CoA reductase inhibitors that are metabolised via CYP3A4, such as atorvastatin and simvastatin, or via CYP2C9, such as fluvastatin. Up to 200% individual increases in the area under the curve (AUC) of fluvastatin may occur as a result of the interaction between fluvastatin and fluconazole. Caution is warranted if concurrent administration of fluconazole and HMG-CoA reductase inhibitors is deemed necessary. The combination may require a dose reduction of the HMG CoA reductase inhibitors. Patients should be monitored for signs and symptoms of myopathy or rhabdomyolysis (muscle pain, tenderness or wekness) and creatine kinase (CK) levels. HMG-CoA therapy should be discontinued if CK levels show a marked increase, or if myopathy or rhabdomyolysis is diagnosed or suspected.

Losartan (CYP2C9 substrate): Fluconazole inhibits the conversion of losartan to its active metabolite (E-3174), which is responsible for a large part of the angiotensin II receptor antagonism that occurs with losartan therapy. Concomitant treatment with fluconazole might lead to increased concentrations of losartan and decreased concentrations of the active metabolite. It is recommended that patients receiving the combination be monitored for continued control of their hypertension.

Oral contraceptives: Two pharmacokinetic studies have been performed with a combined oral contraceptive and multiple dosing of fluconazole. 50 mg fluconazole did not influence any of the hormone concentrations, but 200 mg daily increased AUC ethinylestradiol and levonorgestrel by 40 and 24%, respectively. Thus, it is unlikely that multiple dosing of fluconazole at these doses is unlikely to impair the efficacy of combined oral contraceptive pills.

Phenytoin (CYP2C9 substrate): Intake of fluconazole 200 mg concomitantly with phenytoin 250 mg intravenously increased the phenytoin AUC by 75% and Cmin by 128 %. If it is necessary to administer both substances concomitantly, the plasma concentration of phenytoin must be controlled, and the phenytoin dose adjusted, in order to avoid toxic concentrations.

Prednisone (CYP3A4 substrate): A liver transplant recipient receiving prednisone experienced an Addisonian crisis when a three-month course of fluconazole was discontinued. The withdrawal of fluconazole was likely to have caused an increase in CYP3A4 activity, leading to an increase in the degradation of prednisone. Patients receiving long-term therapy with fluconazole and prednisone should be closely monitored for signs of adrenal insufficiency when fluconazole is withdrawn.

Rifabutin (CYP3A4 substrate): There have been reports that concomitant administration of fluconazole and rifabutin can lead to increased serum levels of rifabutin. Uveitis in patients treated concomitantly with fluconazole and rifabutin has been reported. Patients who receive rifabutin and fluconazole concomitantly must be closely followed.

Sulphonylureas (CYP2C9 substrate): It has been demonstrated that fluconazole prolongs the plasma half-life of concomitantly administered sulphonylurea drugs (chlorpropamide, glibenclamide, glipizide and tolbutamide) in healthy volunteers. Fluconazole and oral sulphonylurea derivatives may be used concomitantly in diabetics, but the possibility of development of hypoglycaemia must be kept in mind.

Tacrolimus and sirolimus (CYP3A4 substrates): Concomitant intake of fluconazole and tacrolimus 0.15 mg/kg b.i.d. increased tacrolimus Cmin 1.4 and 3.1-fold with fluconazole doses of 100 mg and 200 mg, respectively. Renal toxicity has been reported in patients concomitantly receiving fluconazole and tacrolimus. Although no interaction studies have been conducted with fluconazole and sirolimus, a similar interaction as with tacrolimus might be expected. Patients who receive tacrolimus or sirolimus and fluconazole concomitantly must be closely monitored for tacrolimus/sirolimus plasma levels and toxicity (anaemia, leucopenia, thrombocytopenia, hypokalaemia, diarrhoea).

Theophylline: In a placebo controlled interaction study, intake of fluconazole 200 mg for 14 days resulted in an 18% decrease in the mean plasma clearance of theophylline. Patients being treated with high doses of theophylline or with any other reason to be at increased risk of theophylline toxicity should be observed carefully during concomitant treatment with fluconazole and the dose of theophylline must be adjusted as necessary.

Trimetrexate: Medicaments such as fluconazole that inhibit the P450 enzyme system may cause interactions that increase trimetrexate plasma concentrations. If it is not possible to avoid concomitant administration of trimetrexate and fluconazole, trimetrexate serum levels and trimetrexate toxicity (bone marrow suppression, renal and hepatic dysfunction, and gastrointestinal ulceration) must be monitored carefully.

Zidovudine: Interaction studies showed increased zidovudine AUC by approximately 20% and 70% when taken concomitantly with fluconazole 200 mg or 400 mg daily, respectively, probably due to inhibiton of glucuronidation. Patients receiving this combination must be monitored for zidovudine related side-effects.

Medicinal products affecting the metabolism and/or excretion of fluconazole:

Hydrochlorothiazide: In a pharmacokinetic interaction study with healthy volunteers who concomitantly received fluconazole and multiple doses of hydrochlorothiazide the plasma concentrations of fluconazole increased by 40%. An effect of this size should not necessitate a change in the fluconazole dose regimen in patients who are concomitantly treated with diuretics, although the prescriber should bear this in mind.

Rifampicin (CYP45O inducer): Concomitant intake of fluconazole and rifampicin resulted in a 25% reduction of AUC and 20% reduction in the half-life of fluconazole. An increase in the dosage of fluconazole should be considered in patients concomitantly receiving rifampicin.

Pharmacodynamic interactions

Medicinal products that prolong QT interval: There have been cases reported in which fluconazole might have contributed to QT prolongation leading to serious cardiac arrhythmias. Patients treated concomitantly with fluconazole and other drugs that prolong QT interval should be carefully monitored, since an additive effect cannot be excluded.

Amphotericin B: In vitro and in vivo animal studies have found antagonism between amphotericin B and azole derivatives. The mechanism of action of imidazoles is to inhibit ergosterol synthesis in fungal cell membranes. Amphotericin B acts by binding to sterols in the cell membrane and changing membrane permeability. Clinical effects of this antagonism are to date unknown.

A similar effect may occur with amphotericin B cholesteryl sulfate complex.

Interaction studies have shown that no clinically significant change in absorption of fluconazole occurs with oral use together with food, cimetidine, antacids or after radiation therapy of the whole body in connection with bone marrow transplantation.

4.6 Fertility, pregnancy and lactation

There are no adequate and well controlled studies in pregnant women. There

have been reports of multiple congenital abnormalities in infants whose mothers were being treated for 3 or more months with high dose (400-800 mg/day) fluconazole therapy for coccidioidomycosis. The relationship between fluconazole and these events is unclear.

Fluconazole should not be used for the treatment of vaginal candidasis during pregnancy.

Use during lactation

Fluconazole is found in human breast milk at concentrations similar to plasma, hence its use in nursing mothers is not recommended.

4.7 Effects on ability to drive and use machines

Experience with fluconazole indicates that therapy is unlikely to impair a patient's ability to drive or use machinery. However, when driving or operating machines it should be taken into account that occasionally dizziness or seizures may occur.

4.8 Undesirable effects

The most common side effects observed during clinical trials and associated with fluconazole are:

Central and Peripheral Nervous System:

Headache.

Dermatological:

Skin rash, accompanies by eosinophilia and pruritis has been reported in about 5% of patients receiving fluconazole.

Abdominal pain, diarrhoea, flatulence, nausea.

In some patients, particularly those with serious underlying diseases such as AIDS and cancer, changes in renal and haematological function test results and hepatic abnormalities have been observed during treatment with fluconazole and comparative agents, but the clinical significance and relationship to treatment is uncertain (see Section 4.4 "Special warnings and precautions for use").

Liver/Biliary:

Hepatic toxicity including rare cases of fatalities, elevated alkaline phosphatase, elevated bilirubin, alanine aminotransferase (ALAT) and elevated aspartate aminotransferase (ASAT).

In addition, the following adverse events have occurred during post-marketing:

Allergic reactions:

Anaphylaxis (including angio-oedema, facial oedema and pruritis). Dermatological:

Alopecia, exfoliative skin disorders including Stevens-Johnson syndrome and toxic epidermal necrolysis.

Central and Peripheral Nervous System:

Dizziness, seizures.

Gastrointestinal:

Dyspepsia, vomiting.

Haematopoietic and Lymphatic:

Leukopenia including neutropenia and agranulocytosis, thrombocytopenia.

Immunological Anaphylaxis:

Liver/Biliarv:

Hepatic failure, hepatitis, hepatocellular necrosis, jaundice. Metabolic/Nutritional:

Hypercholesterolaemia, hypertriglyceridaemia, hypokalaemia. Other senses:

Taste perversion.

4.9 Overdose

In the event of overdosage, supportive measures and symptomatic treatment, with gastric lavage if necessary, may be adequate.

As fluconazole is largely excreted in the urine, forced volume diuresis would probably increase the elimination rate. A three hour haemodialysis session decreases plasma levels by approximately 50%.

5    PHARMACOLOGICAL PROPERTIES

5.1    Pharmacodynamic properties

ATC Code: JO2A CO1. The ATC-classification is: Antimycotics for systemic use; triazole derivatives.

Fluconazole belongs to the group of triazole antimycotics, specifically inhibiting fungal ergosterol synthesis.

5.2 Pharmacokinetic properties

After oral administration fluconazole is well absorbed and plasma levels (and systemic bioavailability) are over 90% of the levels achieved after intravenous

administration. Oral absorption is not affected by concomitant food intake. Peak plasma concentrations in the fasting state occur between 0.5 and 1.5 hours post-dose with a plasma elimination half-life of approximately 30 hours. Plasma concentrations are proportional to dose. Ninety percent steady-state levels are reached by day 4 -5 with multiple once daily dosing.

Administration of a loading dose (on day 1) of twice the usual daily dose enables plasma levels to approximate to 90% steady-state levels by day 2. The apparent volume of distribution approximates to total body water. Plasma protein binding is low (11-12%).

Fluconazole achieves good penetration in all body fluids studied. The levels of fluconazole in saliva and sputum are similar to plasma levels. In patients with fungal meningitis, fluconazole levels in the CSF are approximately 80% of the corresponding plasma levels.

High skin concentrations of fluconazole, above serum concentrations are achieved in the stratum corneum, epidermis-dermis and eccrine sweat. Fluconazole accumulates in the stratum corneum. At a dose of 50mg once daily, the concentration of fluconazole after 12 days was 73 microgram/g and 7 days after cessation of treatment the concentration was still 5.8 microgram/g

The major route of excretion is renal, with approximately 80% of the administered dose appearing in the urine as unchanged drug. Fluconazole clearance is proportional to creatinine clearance. There is no evidence of circulating metabolites.

The long plasma elimination half-life provides the basis for single dose therapy for genital candidiasis and once daily dosing for other indications.

Children metabolise fluconazole more rapidly. The half-life in children of 5-15 years is between 15.2 -17.6 hours, about half that of adults.

5.3 Preclinical safety data

Preclinical data from conventional studies on repeat-dose/general toxicity, genotoxicity or carcinogenicity indicate no special hazard for humans not already considered in other sections of the SPC.

In reproduction toxicity studies in rat an increased incidence of hydronephrosis and extension of renal pelvis was reported and embryonal lethality was increased. An increase in anatomical variations and delayed ossification was noted as well as prolonged delivery and dystocia, effects consistent with inhibition of oestrogen synthesis in rat. In reproduction toxicity studies in rabbits abortions were recorded. These effects were observed only at exposures in excess of the maximum human exposure.

6.1 List of excipients

Capsule contents:

Lactose Maize starch

Colloidal anhydrous silica Talc

Sodium lauryl sulphate

Capsule shells:

Gelatin

Patent blue (E131) Titanium dioxide (E171)

Printing ink:

Shellac

Propylene glycol Black iron oxide (E172)

6.2 Incompatibilities

None.

6.3 Shelf life

24 months.

6.4 Special precautions for storage

Do not store above 25°C. Store in the original package.

6.5 Nature and contents of container

Blister strip composed of: 25 micron Aluminium foil with 250 micron white opaque PVC film coated with 60 gsm PVdC.

Pack containing 1 capsule.

6.6 Special precautions for disposal

No special precautions are required.

7. MARKETING AUTHORISATION HOLDER

Cipla (EU) Limited

Hillbrow House

Hillbrow Road

Esher

Surrey

KT10 9NW

8 MARKETING AUTHORISATION NUMBER(S)

PL 36390/0029

9    DATE OF FIRST AUTHORISATION/RENEWAL OF THE

AUTHORISATION

10/02/2012

10 DATE OF REVISION OF THE TEXT

28/11/2012