Requip Xl 8 Mg Prolonged-Release Tablets
SUMMARY OF PRODUCT CHARACTERISTICS
1 NAME OF THE MEDICINAL PRODUCT
Requip® XL Y 8 mg prolonged-release tablets.
2 QUALITATIVE AND QUANTITATIVE COMPOSITION 8 mg ropinirole
Excipient(s) with known effect:
Lactose
For the full list of excipients, see section 6.1.
3 PHARMACEUTICAL FORM
Prolonged-release tablet.
Red capsule-shaped, film-coated tablets marked "GS" on one side and "5CC" on the other.
4 CLINICAL PARTICULARS
4.1 Therapeutic indications
Treatment of Parkinson’s disease under the following conditions:
• Initial treatment as monotherapy, in order to delay the introduction of levodopa
• In combination with levodopa, over the course of the disease, when the effect of levodopa wears off or becomes inconsistent and fluctuations in the therapeutic effect occur (“end of dose” or “on-off’ type fluctuations)
4.2 Posology and method of administration
Oral use.
Individual dose titration against efficacy and tolerability is recommended. Ropinirole prolonged-release tablets should be taken once a day and at a similar time each day. The tablets must be swallowed whole and must not be chewed, crushed or divided.
The tablets may be taken with or without food. A high fat meal may double the AUC and Cmax in some individuals (See 5.2 Pharmacokinetics).
Adults
Initial titration
The starting dose of ropinirole prolonged-release tablets is 2 mg once daily for the first week; this should be increased to 4 mg once daily from the second week of treatment. A therapeutic response may be seen at a dose of 4 mg once daily of ropinirole prolonged-release tablets.
Patients who initiate treatment with a dose of 2 mg/day of ropinirole prolonged-release tablets and who experience side effects that they cannot tolerate, may benefit from switching to treatment with ropinirole film-coated (immediate release) tablets at a lower daily dose, divided into three equal doses.
Therapeutic regimen
Patients should be maintained on the lowest dose of ropinirole prolonged-release tablets that achieves symptomatic control.
If sufficient symptomatic control is not achieved or maintained at a dose of 4 mg once daily of ropinirole prolonged-release tablets, the daily dose may be increased by 2 mg at weekly or longer intervals up to a dose of 8 mg once daily of prolonged-release tablets.
If sufficient symptomatic control is still not achieved or maintained at a dose of 8 mg once daily of ropinirole prolonged-release tablets, the daily dose may be increased by 2 mg to 4 mg at two weekly or longer intervals. The maximum daily dose of ropinirole prolonged-release tablets is 24 mg.
It is recommended that patients are prescribed the minimum number of ropinirole prolonged-release tablets that are necessary to achieve the required dose by utilising the highest available strengths of ropinirole prolonged-release tablets.
When ropinirole prolonged-release tablets are administered as adjunct therapy to levodopa, it may be possible to gradually reduce the levodopa dose, depending on the clinical response. In clinical trials, the levodopa dose was reduced gradually by approximately 30% in patients receiving ropinirole prolonged-release tablets concurrently. In patients with advanced Parkinson’s disease receiving ropinirole prolonged-release tablets in combination with L-dopa, dyskinesias can occur during the initial titration of ropinirole prolonged-release tablets. In clinical trials it was shown that a reduction of the L-dopa dose may ameliorate dyskinesia (see also 4.8 Undesirable effects).
When switching treatment from another dopamine agonist to ropinirole, the marketing authorisation holder’s guidance on discontinuation should be followed before initiating ropinirole.
As with other dopamine agonists, it is necessary to discontinue ropinirole treatment gradually by reducing the daily dose over the period of one week (see section 4.4). Switching from ropinirole immediate release tablets to ropinirole prolonged-release tablets
Patients may be switched overnight from ropinirole immediate release tablets to ropinirole prolonged-release tablets.
The dose of ropinirole prolonged-release tablets should be based on the total daily dose of immediate release formulation that the patient was receiving. The recommended dose for switching from ropinirole immediate release tablets to ropinirole prolonged-release tablets are provided in the following table. If patients are taking a different total daily dose of ropinirole immediate release tablets to those
typically prescribed doses as shown in the table, they should be switched to the nearest available dose of ropinirole prolonged-release tablets as stated in the table:
|
Ropinirole immediate release tablets (Requip) Total daily dose (mg) |
Ropinirole prolonged-release tablets (Requip XL) Total daily dose (mg) |
|
0.75 - 2.25 |
2 |
|
3 - 4.5 |
4 |
|
6 |
6 |
|
7.5 - 9 |
8 |
|
12 |
12 |
|
15 - 18 |
16 |
|
21 |
20 |
|
24 |
24 |
After switching to Requip XL prolonged-release tablets, the dose may be adjusted depending on the therapeutic response (see “Initial titration” and “Therapeutic regimen” above).
Dose interruption or discontinuation
If treatment is interrupted for one day or more, re-initiation by dose titration on ropinirole immediate release tablets should be considered.
If it is necessary to discontinue ropinirole treatment, this should be done gradually by reducing the daily dose over the period of one week.
Renal impairment
In parkinsonian patients with mild to moderate renal impairment (creatinine clearance between 30 and 50 ml/min) no change in the clearance of ropinirole was observed, indicating that no dosage adjustment is necessary in this population.
A study into the use of ropinirole in patients with end stage renal disease (patients on haemodialysis) has shown that a dose adjustment in these patients is required as follows:
The recommended initial dose of ReQuip XL is 2 mg once daily. Further dose escalations should be based on tolerability and efficacy. The recommended maximum dose is 18 mg/day in patients receiving regular dialysis. Supplemental doses after dialysis are not required.
The use of ropinirole in patients with severe renal impairment (creatinine clearance less than 30 ml/min) without regular haemodialysis has not been studied.
Hepatic impairment
The use of ropinirole in patients with hepatic impairment has not been studied. Administration of ropinirole to such patients is not recommended.
Elderly
The clearance of ropinirole is decreased by approximately 15% in patients aged 65 years or above. Although a dose adjustment is not required, ropinirole dose should be individually titrated, with careful monitoring of tolerability, to the optimal clinical response. In patients aged 75 years and above, slower titration during treatment initiation may be considered.
Children and adolescents
Ropinirole prolonged-release tablets are not recommended for use in children below 18 years of age due to a lack of data on safety and efficacy.
4.3 Contra-indications
Hypersensitivity to ropinirole or to any of the excipients listed in section 6.1. Severe renal impairment (creatinine clearance <30ml/min) without regular haemodialysis.
Hepatic impairment.
4.4 Special warnings and precautions for use
Due to the risk of hypotension, blood pressure monitoring is recommended, particularly at the start of treatment, in patients with severe cardiovascular disease (in particular coronary insufficiency).
Patients with a history or presence of major psychotic disorders should only be treated with dopamine agonists if the potential benefits outweigh the risks (see also section 4.5).
Impulse control disorders
Patients should be regularly monitored for the development of impulse control disorders. Patients and carers should be made aware that behavioural symptoms of impulse control disorders including pathological gambling, increased libido, hypersexuality, compulsive spending or buying, binge eating and compulsive eating can occur in patients treated with dopamine agonists including ReQuip XL. Dose reduction/tapered discontinuation should be considered if such symptoms develop. Impulse control disorders were reported especially at high doses and were generally reversible upon reduction of the dose or treatment discontinuation. Risk factors such as a history of compulsive behaviours were present in some cases (see section 4.8).
Ropinirole has been associated with somnolence and episodes of sudden sleep onset, particularly in patients with Parkinson's disease. Sudden onset of sleep during daily activities, in some cases without awareness or warning signs, has been reported (see section 4.8). Patients must be informed of this and advised to exercise caution while driving or operating machines during treatment with ropinirole. Patients who have experienced somnolence and/or an episode of sudden sleep onset must refrain from driving or operating machines. Furthermore, a reduction of dosage or termination of therapy may be considered.
Neuroleptic malignant syndrome
Symptoms suggestive of neuroleptic malignant syndrome have been reported with abrupt withdrawal of dopaminergic therapy. Therefore it is recommended to taper treatment (see section 4.2).
Requip XL tablets are designed to release medication over a 24hr period. If rapid gastrointestinal transit occurs, there may be risk of incomplete release of medication, and of medication residue being passed in the stool.
This medicinal product also contains lactose. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.
4.5 Interaction with other medicinal products and other forms of interaction
There is no pharmacokinetic interaction between ropinirole and L-dopa or domperidone which would necessitate dosage adjustment of these drugs. Neuroleptics and other centrally active dopamine antagonists, such as sulpiride or metoclopramide, may diminish the effectiveness of ropinirole and therefore, concomitant use of these medicinal products should be avoided.
Ropinirole is principally metabolised by the cytochrome P450 enzyme CYP1A2. A pharmacokinetic study (with a ropinirole film-coated (immediate-release) tablet dose of 2 mg, three times a day) in Parkinson’s disease patients, revealed that ciprofloxacin increased the Cmax and AUC of ropinirole by 60% and 84% respectively, with a potential risk of adverse events. Hence, in patients already receiving ropinirole, the dose of ropinirole may need to be adjusted when medicinal products know to inhibit CYP1A2, e.g. ciprofloxacin, enoxacin, cimetidine or fluvoxamine, are introduced or withdrawn.
A pharmacokinetic interaction study in patients with Parkinson’s disease between ropinirole (with a ropinirole film-coated (immediate-release) tablet dose of 2 mg, three times a day) and theophylline, a substrate of CYP1A2, revealed no change in the pharmacokinetics of either ropinirole or theophylline.
Increased plasma concentrations of ropinirole have been observed in patients treated with high doses of oestrogens. In patients already receiving hormone replacement therapy (HRT), ropinirole treatment may be initiated in the normal manner. However, if HRT is stopped or introduced during treatment with ropinirole, dosage adjustment may be required.
Smoking is known to induce CYP1A2 metabolism, therefore if patients stop or start smoking during treatment with ropinirole, adjustment of dose may be required.
4.6 Fertility, pregnancy and lactation
Pregnancy
There are no adequate data from the use of ropinirole in pregnant women.
Studies in animals have shown reproductive toxicity (see section 5.3). As the potential risk for humans is unknown, it is recommended that ropinirole is not used during pregnancy unless the potential benefit to the patient outweighs the potential risk to the foetus.
Breast-feeding
Ropinirole should not be used in nursing mothers as it may inhibit lactation.
No human fertility data are available.
4.7 Effects on ability to drive and use machines
Ropinirole may have a major effect on the ability to drive and use machines.
Patients being treated with ropinirole and presenting with somnolence and/or sudden sleep episodes must be informed to refrain from driving or engaging in activities where impaired alertness may put themselves or others at risk of serious injury or death (e.g. operating machines) until such recurrent episodes and somnolence have resolved (see also section 4.4).
4.8 Undesirable effects
Adverse events are listed below by system organ class and frequency. Frequencies are defined as: 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), not known (cannot be estimated from the available data).
During clinical trials, the most commonly reported undesirable effects for ropinirole prolonged-release tablets were during monotherapy and dyskinesia during adjunctive therapy with levodopa.
The following adverse events were reported during clinical trials with ReQuip XL up to 24 mg/day.
|
In monotherapy |
In adjunct therapy | |
|
Psychiatric disorders | ||
|
Common |
Hallucinations |
Hallucinations |
|
Nervous system disorders | ||
|
Very common |
Somnolence |
Dyskinesia In patients with advanced Parkinson’s disease, dyskinesias can occur during the initial titration of ropinirole. In clinical trials it was shown that a reduction of the levodopa dose may ameliorate dyskinesia (see section 4.2). |
|
Common |
Dizziness (including vertigo), sudden onset of sleep |
Somnolence, dizziness (including vertigo), sudden onset of sleep |
|
Vascular disorders | ||
|
Common |
Postural hypotension, hypotension | |
|
Uncommon |
Postural hypotension, | |
|
hypotension | ||
|
Gastrointestinal disorders | ||
|
Very common |
Nausea | |
|
Common |
Constipation |
Nausea, constipation |
|
General disorders and administrative site conditions | ||
|
Common |
Oedema peripheral |
Oedema peripheral |
In addition to the above adverse drug reactions, the following events have been reported with ReQuip film-coated (immediate-release) tablets in patients with Parkinson’s disease during clinical trials (at doses up to 24 mg/day) and/or postmarketing reports,_
|
In monotherapy |
In adjunct therapy | |
|
Immune system disorders | ||
|
Not known |
Hypersensitivity reactions (including urticaria, angioedema, rash, pruritus). | |
|
Psychiatric disorders | ||
|
Common |
Confusion | |
|
Uncommon |
Psychotic reactions (other than hallucinations) including delirium, delusion, paranoia. |
Psychotic reactions (other than hallucinations) including delirium, delusion, paranoia. |
|
Not known |
Aggression* | |
|
Dopamine dysregulation syndrome | ||
|
* Aggression has been associated with psychotic reactions as well as compulsive symptoms | ||
|
Not known |
Impulse control disorders including pathological gambling, compulsive shopping, binge eating and hypersexuality and increased libido, have been reported in post marketing reports (see section 4.4) | |
|
Nervous system disorders | ||
|
Very common |
Syncope |
Somnolence |
|
Uncommon |
Sudden onset of sleep, excessive daytime somnolence |
Sudden onset of sleep, excessive daytime somnolence |
|
Ropinirole is associated with somnolence and has been associated uncommonly with excessive daytime somnolence and sudden sleep onset episodes. | ||
|
Vascular disorders | ||
|
Uncommon |
Postural hypotension or hypotension is rarely severe | |
|
Gastrointestinal disorders | ||
|
Very common |
Nausea | |
|
Common |
Vomiting, heartburn, |
Heartburn |
|
abdominal pain | ||
|
Hepatobiliary disorders | ||
|
Not known |
Hepatic reactions, mainly increased liver enzymes | |
|
General disorders and administrative site conditions | ||
|
Common |
Leg oedema | |
Impulse control disorders
Pathological gambling, increased libido, hypersexuality, compulsive spending or buying, binge eating and compulsive eating can occur in patients treated with dopamine agonists including ReQuip XL. (see section 4.4. ‘Special warnings and precautions for use’).
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.
4.9 Overdose
The symptoms of ropinirole overdose are generally related to its dopaminergic activity. These symptoms may be alleviated by appropriate treatment with dopamine antagonists such as neuroleptics or metoclopramide.
5 PHARMACOLOGICAL PROPERTIES
5.1 Pharmacodynamic properties
Pharmacotherapeutic group
Dopamine agonist.
ATC code: N04BC04 Mechanism of action
Parkinson's disease is characterised by a marked dopamine deficiency in the nigral striatal system. Ropinirole is a non-ergoline D2/D3 dopamine agonist that alleviates this deficiency by stimulating striatal dopamine receptors.
Ropinirole acts in the hypothalamus and pituitary to inhibit the secretion of prolactin. Clinical efficacy
A 36-week, double-blind, three-period crossover study, in monotherapy with a primary end point of change from period baseline in Unified Parkinson’s Disease Rating Scale (UPDRS) total motor score was conducted in 161 patients with early phase Parkinson’s disease. A subgroup analysis of patients initiated on monotherapy treatment with ropinirole immediate release tablets and switched overnight to the nearest equivalent dose of ropinirole prolonged-release tablets was consistent with similar efficacy from equivalent mg for mg doses. The adjusted mean difference between ropinirole prolonged-release tablets and Requip film-coated (immediate-release) tablets at study-endpoint was 0.7 points (95% CI: [-1.51, 0.10], p=0.0842).
Following the overnight switch to a similar dose of the alternative tablet formulation, there was no difference in the adverse event profile and less than 3% of patients required a dose adjustment (all dose adjustments were increases by one dose level. No patients required a dose increase).
A 24-week, double-blind, placebo-controlled, parallel group study in patients with Parkinson’s disease who were not optimally controlled on levodopa demonstrated that adjunctive therapy of ropinirole prolonged-release tablets results in clinically relevant and statistically significant superiority over placebo in a change from baseline in awake time “off’ (adjusted mean treatment difference -1.7 hours (95% CI: [-2.34, -1.09], p<0.0001). This was supported by secondary efficacy parameters of change from baseline in total awake time “on” (+1.7 hours (95% CI [1.06, 2.33], p<0.0001) and total awake time “on” without troublesome dyskinesias (+1.5 hours (95% CI: [0.85, 2.13], p<0.0001). Importantly, there was no indication of an increase from baseline in awake time “on” with troublesome dyskinesias, either from diary card data or from the UPDRS items.
Study of the effect of ropinirole on cardiac repolarisation
A thorough QT study conducted in male and female healthy volunteers who received doses of 0.5, 1, 2 and 4 mg of ropinirole film-coated (immediate release) tablets once daily showed a maximum increase of the QT interval duration nat the 1 mg dose of 3.46 milliseconds (point estimate) as compared to placebo. The upper bound of the one sided 95% confidence interval for the largest mean effect was less than 7.5 milliseconds. The effect of ropinirole at higher doses has not been systematically evaluated.
The available clinical data from a thorough QT study do not indicate a risk of QT prolongation at doses of ropinirole up to 4 mg/day. A risk of QT prolongation cannot be excluded as a thorough QT study at doses up to 24 mg/day has not been conducted.
5.2 Pharmacokinetic properties
Absorption
Bioavailability of ropinirole is approximately 50% (36-57%). Following oral administration of ropinirole prolonged-release tablets, plasma concentrations of ropinirole increase slowly, with a median time to Cmax of between six and ten hours.
In a steady-state study in Parkinson’s disease patients receiving 12 mg of Requip XL once daily, a high fat meal increased the systemic exposure to ropinirole as shown by an average 20% increase in AUC (90% CI [1.12, 1.28]) and an average 44% increase in Cmax (90% CI[1.34, 1.56]). Tmax was delayed by 3.0 hours. However, in the studies that established the safety and efficacy of Requip XL, patients were instructed to take study medication without regard to food intake.
The systemic exposure to ropinirole is comparable for ropinirole prolonged-release tablets and ropinirole film-coated (immediate-release) tablets based on the same daily dose.
Distribution
Plasma protein binding of the drug is low (10-40%). Consistent with its high lipophilicity, ropinirole exhibits a large volume of distribution (approximately 7 l/kg).
Biotransformation
Ropinirole is primarily cleared by CYP1A2 metabolism and its metabolites are mainly excreted in the urine. The major metabolite is at least 100-times less potent than ropinirole in animal models of dopaminergic function.
Elimination
Ropinirole is cleared from the systemic circulation with an average elimination halflife of about six hours. The increase in systemic exposure (Cmax and AUC) to ropinirole is approximately proportional over the therapeutic dose range. No change in the oral clearance of ropinirole is observed following single and repeated oral administration. Wide inter-individual variability in the pharmacokinetic parameters has been observed. Following steady-state administration of ropinirole prolonged-release tablets, the inter-individual variability of Cmax was between 30% and 55% and for AUC was between 40% and 70%.
Special Patient Populations
Renal impairment: There was no change observed in the pharmacokinetics of ropinirole in Parkinson’s disease patients with mild to moderate renal impairment.
In patients with end stage renal disease receiving regular dialysis, oral clearance of ropinirole is reduced by approximately 30%. Oral clearance of the metabolites SKF-104557 and SKF-89124 were also reduced by approximately 80% and 60%, respectively. Therefore, the recommended maximum dose is limited to 18 mg/day in these patients with Parkinson’s disease.
5.3 Preclinical safety data
Reproductive toxicity
Administration of ropinirole to pregnant rats at maternally toxic doses resulted in decreased foetal body weight at 60 mg/kg/day (approximately twice the AUC at the maximum dose in humans), increased foetal death at 90 mg/kg/day (approximately 3 times the AUC at the maximum dose in humans) and digit malformations at 150 mg/kg/day (approximately 5 times the AUC at the maximum dose in humans). There were no teratogenic effects in the rat at 120 mg/kg/day (approximately 4 times the AUC at the maximum dose in humans) and no indication of an effect on development in the rabbit.
General toxicology
The toxicology profile is principally determined by the pharmacological activity of the drug (behavioural changes, hypoprolactinaemia, decrease in blood pressure and heart rate, ptosis and salivation). In the albino rat only, retinal degeneration was observed in a long term study at the highest dose (50 mg/kg/day), and was probably associated with an increased exposure to light.
Genotoxicity
Genotoxicity was not observed in a battery of in vitro and in vivo tests. Carcinogenicity
Two-year studies have been conducted in the mouse and rat at dosages up to 50 mg/kg. The mouse study did not reveal any carcinogenic effect. In the rat, the only drug-related lesions were Leydig cell hyperplasia/adenoma in the testis resulting from the hypoprolactinaemic effect of ropinirole. These lesions are considered to be a species specific phenomenon and do not constitute a hazard with regard to the clinical use of ropinirole.
Safety pharmacology
In vitro studies have shown that ropinirole inhibits hERG-mediated currents. The IC50 is 5-fold higher than the expected maximum plasma concentration in patients treated at the highest recommended dose (24 mg/day), see section 5.1.
6 PHARMACEUTICAL PARTICULARS
6.1 List of excipients
Tablet core
Hypromellose 2208, hydrogenated castor oil, carmellose sodium, povidone K29-32, maltodextrin, magnesium stearate, lactose monohydrate, anhydrous colloidal silica, mannitol (E421), ferric oxide yellow (E172) and glycerol dibehenate.
Film coat
Hypromellose 2910, ferric oxide yellow (E172), titanium dioxide (E171), ferric oxide black (E172), macrogol 400 and ferric oxide red (E172).
6.2 Incompatibilities
Not applicable.
6.3 Shelf life
3 years.
6.4 Special precautions for storage
Do not store above 25°C. Store in the original package.
6.5 Nature and contents of container
PVC/PCTFE/Aluminium blister packs or PVC/PCTFE/PVC-Aluminium/Paper child-resistant blister packs.
Packs of 28 or 84 prolonged-release tablets.
Not all pack sizes may be marketed.
6.6 Special precautions for disposal
No special requirements for disposal.
7 MARKETING AUTHORISATION HOLDER
SmithKline Beecham Limited Great West Road,
Brentford,
Middlesex TW8 9GS
Trading as:
GlaxoSmithKline UK Stockley Park West,
Uxbridge,
Middlesex UB11 1BT
8 MARKETING AUTHORISATION NUMBER(S)
PL 10592/0296
9 DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION 07/05/2008
10 DATE OF REVISION OF THE TEXT
09/08/2016