Xanthadu 0.02 Mg/3 Mg Film-Coated Tablets
SUMMARY OF PRODUCT CHARACTERISTICS
1 NAME OF THE MEDICINAL PRODUCT
Xanthadu 0.02 mg/3 mg film-coated tablets
2 QUALITATIVE AND QUANTITATIVE COMPOSITION
24 pink film-coated tablets (active tablets):
Each film-coated tablet contains 0.02 mg ethinylestradiol and 3 mg drospirenone.
Excipients with known effect: Lactose monohydrate 44 mg
4 white placebo (inactive) film-coated tablets:
The tablet does not contain active substances
Excipients with known effect: Lactose anhydrous 89.5 mg
For the full list of excipients, see section 6.1.
3 PHARMACEUTICAL FORM
Film-coated tablet.
The active tablet is pink, round film-coated tablet of 5.7 mm diameter.
The placebo tablet is white, round film-coated tablet of 5.7 mm diameter
4
CLINICAL PARTICULARS
4.1 Therapeutic indications
Oral contraception.
4.2 Posology and method of administration
Route of administration: oral use.
How to take Xanthadu
The tablets must be taken every day at about the same time, if necessary with a little liquid, in the order shown on blister strip. Tablet taking is continuous. One tablet is to be taken daily for 28 consecutive days. Each subsequent strip is started the day after the last tablet of the previous strip. Withdrawal bleeding usually starts on day 2-3 after starting the placebo tablets (last row) and may not have finished before the next strip is started.
How to start Xanthadu
• No preceding hormonal contraceptive use (in the past month)
Tablet-taking has to start on day 1 of the woman’s natural cycle (i.e. the first day of her menstrual bleeding).
• Changing from a combined hormonal contraceptive (combined oral contraceptive (COC), vaginal ring or transdermal patch)
The woman should start with Xanthadu preferably on the day after the last active tablet (the last tablet containing the active substances) of her previous COC, but at the latest on the day following the usual tablet-free or placebo tablet interval of her previous COC. In case a vaginal ring or transdermal patch has been used the woman should start using Xanthadu preferably on the day of removal, but at the latest when the next application would have been due.
• Changing from a progestogen-only-method (progestogen-only pill, injection, implant) or from a progestogen-releasing intrauterine system (IUS)
The woman may switch any day from the progestogen-only pill (from an implant or the IUS on the day of its removal, from an injectable when the next injection would be due) but should in all of these cases be advised to additionally use a barrier method for the first 7 days of tablet-taking.
• Following first-trimester abortion
The woman may start immediately. When doing so, she need not take additional contraceptive measures.
• Following delivery or second-trimester abortion
Women should be advised to start at day 21 to 28 after delivery or second-trimester abortion. When starting later, the woman should be advised to additionally use a barrier method for the first 7 days. However, if intercourse has already occurred, pregnancy should be excluded before the actual start of COC use or the woman has to wait for her first menstrual period.
For breastfeeding women see Section 4.6.
Management of missed tablets
Placebo tablets from the last (4th) row of the blister can be disregarded. However, they should be discarded to avoid unintentionally prolonging the placebo tablet phase. The following advice only refers to missed active tablets:
If the user is less than 24 hours late in taking any tablet, contraceptive protection is not reduced. The woman should take the tablet as soon as she remembers and should take further tablets at the usual time.
If she is more than 24 hours late in taking any tablet, contraceptive protection may be reduced. The management of missed tablets can be guided by the following two basic rules:
1. the recommended hormone-free tablet interval is 4 days, tablet- taking must never be discontinued for longer than 7 days
2. 7 days of uninterrupted tablet-taking are required to attain adequate suppression of the hypothalamic-pituitary-ovarian-axis.
Accordingly the following advice can be given in daily practice:
• Day 1-7
The user should take the last missed tablet as soon as she remembers, even if this means taking two tablets at the same time. She then continues to take tablets at her usual time. In addition, a barrier method such as a condom should be used for the next 7 days. If intercourse took place in the preceding 7 days, the possibility of a pregnancy should be considered. The more tablets are missed and the closer they are to the placebo tablet phase, the higher the risk of a pregnancy.
Day 8-14
The user should take the last missed tablet as soon as she remembers, even if this means taking two tablets at the same time. She then continues to take tablets at her usual time. Provided that the woman has taken her tablets correctly in the 7 days preceding the first missed tablet, there is no need to use extra contraceptive precautions. However, if she has missed more than 1 tablet, the woman should be advised to use extra precautions for 7 days.
• Day 15-24
The risk of reduced reliability is imminent because of the forthcoming placebo tablet phase.
However, by adjusting the tablet-intake schedule, reduced contraceptive protection can still be prevented. By adhering to either of the following two options, there is therefore noneed to use extra contraceptive precautions, provided that in the 7 days preceding the first missed tablet the woman has taken all tablets correctly. If this is not the case, she should follow the first of these two options and use extra precautions for the next 7 days as well.
1. The user should take the last missed tablet as soon as she remembers, even if this means taking two tablets at the same time.
She then continues to take tablets at her usual time until the active tablets are used up. The 4 placebo tablets from the last row mustbe discarded. The next blister strip must be started right away.The user is unlikely to have a withdrawal bleed until the end of the active tablets section of the second blister strip, but she may experience spotting or breakthrough bleeding on tablet-taking days.
2. The woman may also be advised to discontinue active tablet-taking from the current blister strip. She should then take placebo tablets from the last row for up to 4 days, including the days she missed tablets, and subsequently continue with the next blister strip.
If the woman missed tablets and subsequently has no withdrawal bleed in the placebo tablet phase, the possibility of a pregnancy should be considered.
Advice in case of gastro-intestinal disturbances
In case of severe gastro-intestinal disturbances (e.g., vomiting or diarrhoea), absorption may not be complete and additional contraceptive measures should be taken. If vomiting occurs within 3-4 hours after active tablet-taking, a new (replacement) tablet should be taken as soon as possible. The new tablet should be taken within 24 hours of the usual time of tablet- taking if possible. If more than 24 hours elapse, the advice concerning missed tablets, as give in section 4.2 “Management of missed tablets”, is applicable. If the woman does not want to change her normal tablet-taking schedule, she has to take the extra tablet(s) from another blister strip.
How to postpone a withdrawal bleed
To delay a period the woman should continue with another blister strip of Xanthadu without taking the placebo tablets from her current strip. The extension can be carried on for as long as wished until the end of the active tablets in the second strip. During the extension the woman may experience breakthrough-bleeding or spotting. Regular intake of Xanthadu is then resumed after the placebo tablet phase.
To shift her periods to another day of the week than the woman is used to with her current scheme, she can be advised to shorten her forthcoming placebo tablet phase by as many days as she likes. The shorter the interval, the higher the risk that she does not have a withdrawal bleed and will experience breakthrough-bleeding and spotting during the subsequent strip (just as when delaying a period).
4.3 Contraindications
Combined oral contraceptives (COCs) should not be used in the presence of any of the conditions listed below. Should any of the conditions appear for the first time during COC use, the product should be stopped immediately.
• Venous thrombosis present or in history (deep venous thrombosis, pulmonary embolism)
• Arterial thrombosis present or in history (e.g. myocardial infarction) or prodromal conditions (e.g. angina pectoris and transient ischaemic attack)
• Cerebrovascular accident present or in history
• The presence of a severe or multiple risk factor(s) for arterial thrombosis:
• diabetes mellitus with vascular symptoms
• severe hypertension
• severe dyslipoproteinemia
• Hereditary or acquired predisposition for venous or arterial thrombosis, such as APC-resistance, antithrombin-III-deficiency, protein C deficiency, protein S deficiency, hyperhomocysteinemia and antiphospholipid-antibodies (anticardiolipin-antibodies, lupus anticoagulant)
• Presence or history of severe hepatic disease as long as liver function values have not returned to normal
• Severe renal insufficiency or acute renal failure
• Presence or history of liver tumours (benign or malignant)
• Known or suspected sex-steroid influenced malignancies (e.g. of the genital organs or the breasts)
• Undiagnosed vaginal bleeding
• History of migraine with focal neurological symptoms
Hypersensitivity to the active substances or to any of the excipients listed in section 6.1
4.4 Special warnings and precautions for use
If any of the conditions/risk factors mentioned below are present, the benefits of COC use should be weighed against the possible risks for each individual woman and discussed with the woman before she decides to start using it. In the event of aggravation, exacerbation or first appearance of any of these conditions or risk factors, the woman should contact her physician. The physician should then decide on whether COC use should be discontinued.
Circulatory Disorders
The use of any combined oral contraceptive (COC) carries an increased risk of venous thromboembolism (VTE) compared with no use. The excess risk of VTE is highest during the first year a womaninitially starts using a COC or when she restarts COC use after a pill-free interval of at least a month.
Epidemiological studies have shown that the incidence of VTE in women with no known risk factors for VTE who use low dose oestrogen (<0.05 mg ethinylestradiol) combined oral contraceptives ranges from about 20 cases per 100,000 woman-years (for levonorgestrel-containing COCs) to 40 cases per 100,000 women-years (for desogestrel/gestodene-containing COCs). This compares with 5 to 10 cases per 100,000 woman-years for non-users and 60 cases per 100,000 pregnancies. VTE is fatal in 1-2% of cases.
Epidemiological studies have shown that the risk of VTE for drospirenone-containing COCs is higher than for levonorgestrel-containing COCs (so-called second generation preparations) and may be similar to the risk for desogestrel/ gestodene-containing COCs (so-called third generation preparations).
Epidemiological studies have also associated the use of combined COCs with an increased risk for arterial (myocardial infarction, transient ischaemic attack) thromboembolism.
Extremely rarely, thrombosis has been reported to occur in other blood vessels, e.g. hepatic, mesenteric, renal, cerebral or retinal veins and arteries, in contraceptive pill users. There is no consensus as to whether the occurrence of these events is associated with the use of hormonal contraceptives.
Symptoms of venous or arterial thrombotic/thromboembolic events or of a cerebrovascular accident can include:
• unusual unilateral leg pain and/ or swelling
• sudden severe pain in the chest, whether or not it radiates to the left arm
• sudden breathlessness
• sudden onset of coughing
• any unusual, severe, prolonged headache
• sudden partial or complete loss of vision
• diplopia
• slurred speech or aphasia
• vertigo
• collapse with or without focal seizure
• weakness or very marked numbness suddenly affecting one side or one part of the body
• motor disturbances
• ‘acute’abdomen
The risk for venous thromboembolic complications in COC users increases with:
• increasing age
• a positive family history (venous thromboembolism ever in a sibling or parent at relatively early age). If a hereditary predisposition is suspected, the woman should be referred to a specialist for advice before deciding about any COC use
• prolonged immobilisation, major surgery, any surgery to the legs, or major trauma. In these situations it is advisable to discontinue the pill (in the case of elective surgery at least four weeks in advance) and not resume until two weeks after complete remobilisation. Antithrombotic treatment should be considered if the pills have not been discontinued in advance
• obesity (body mass index over 30 kg/m2).
• there is no consensus about the possible role of varicose veins and superficial thrombophlebitis in the onset or progression of venous thrombosis
The risk of arterial thrombo-embolic complications or of a cerebrovascular accident in COC users increases with:
• increasing age
• smoking (women over 35 years should be strongly advised not to smoke if they wish to use an COC)
• dyslipoproteinemia
• hypertension
• migraine
• obesity (body mass index over 30 kg/m2)
• a positive family history (arterialthromboembolism ever in a sibling or parent at relatively early age). If a hereditary predisposition is suspected, the woman should be referred to a specialist for advice before deciding about any COC use
• valvular heart disease
• atrial fibrillation
The presence of one serious risk factor or multiple risk factors for venous or arterial disease, respectively, can also constitute a contra-indication. The possibility of anticoagulant therapy should also be taken into account. COC users should be specifically pointed out to contact their physician in case of possible symptoms of thrombosis. In case of suspected or confirmed thrombosis, COC use should be discontinued. Adequate alternative contraception should be initiated because of the teratogenicity of anticoagulant therapy (coumarins).
The increased risk of thromboembolism in the puerperium must be considered (for information on "Pregnancy and Lactation" see section 4.6).
Other medical conditions which have been associated with adverse vascular events include diabetes mellitus, systemic lupus erythematosus, haemolytic uremic syndrome and chronic inflammatory bowel disease (Crohn's disease or ulcerative colitis) and sickle cell disease.
An increase in frequency or severity of migraine during COC use (which may be prodromal of a cerebrovascular event) may be a reason for immediate discontinuation of the COC.
Tumours
An increased risk of cervical cancer in long-term users of COCs (>5 years) has been reported in some epidemiological studies, but there continues to be controversy about the extent to which this finding is attributable to the confounding effects of sexual behaviour and other factors such as human papilloma virus (HPV).
A meta-analysis from 54 epidemiological studies reported that there is a slightly increased relative risk (RR = 1.24) of having breast cancer diagnosed in women who are currently using COCs. The excess risk gradually disappears during the course of the 10 years after cessation of COC use. Because breast cancer is rare in women under 40 years of age, the excess number of breast cancer diagnoses in current and recent COC users is small in relation to the overall risk of breast cancer. These studies do not provide evidence for causation. The observed pattern of increased risk may be due to an earlier diagnosis of breast cancer in COC users, the biological effects of COCs or a combination of both. The breast cancers diagnosed in ever-users tend to be less advanced clinically than the cancers diagnosed in never-users.
In rare cases, benign liver tumours, and even more rarely, malignant liver tumours have been reported in users of COCs. In isolated cases, these tumours have led to life-threatening intra-abdominal haemorrhages. A hepatic tumour should be considered in the differential diagnosis when severe upper abdominal pain, liver enlargement or signs of intra-abdominal haemorrhage occur in women taking COCs.
With the use of the higher-dosed COCs (50 ethinylestradiol) the risk of
endometrial and ovarian cancer is reduced. Whether this also applies to lower-dosed COCs remains to be confirmed.
Other conditions
The progestin component in Xanthadu is an aldosterone antagonist with potassium sparing properties. In most cases, no increase of potassium levels is to be expected. In a clinical study, however in some patients with mild or moderate renal impairment and concomitant use of potassium-sparing medicinal products serum potassium levels slightly, but not significantly, increased during drospirenone intake. Therefore, it is recommended to check serum potassium during the first treatment cycle in patients presenting with renal insufficiency and a pretreatment serum potassium in the upper reference range, and particularly during concomitant use of potassium sparing medicinal products. See also section 4.5.
Women with hypertriglyceridemia, or a family history thereof, may be at an increased risk of pancreatitis when using COCs.
Although small increases in blood pressure have been reported in many women taking COCs, clinically relevant increases are rare. Only in these rare cases an immediate discontinuation of COC use is justified. If, during the use of a COC in preexisting hypertension, constantly elevated blood pressure values or a significant increase in blood pressure do not respond adequately to antihypertensive treatment, the COC must be withdrawn. Where considered appropriate, COC use may be resumed if normotensive values can be achieved with antihypertensive therapy.
The following conditions have been reported to occur or deteriorate with both pregnancy and COC use, but the evidence of an association with COC use is inconclusive: jaundice and/or pruritus related to cholestasis; gallstones; porphyria; systemic lupus erythematosus; haemolytic uremic syndrome; Sydenham's chorea; herpes gestationis; otosclerosis-related hearing loss.
In women with hereditary angioedema exogenous estrogens may induce or exacerbate symptoms of angioedema.
Acute or chronic disturbances of liver function may necessitate the discontinuation of COC use until markers of liver function return to normal. Recurrence of cholestatic jaundice and/or cholestasis-related pruritus which previously occurred during pregnancy or during previous use of sex steroids necessitates the discontinuation of COCs.
Although COCs may have an effect on peripheral insulin resistance and glucose tolerance, there is no evidence for a need to alter the therapeutic regimen in diabetics using low-dose COCs (containing < 0.05 mg ethinylestradiol). However, diabetic women should be carefully observed, particularly in the early stage of COC use.
Worsening of endogenous depression, of epilepsy, of Crohn's disease and of ulcerative colitis has been reported during COC use.
Chloasma may occasionally occur, especially in women with a history of chloasma gravidarum. Women with a tendency to chloasma should avoid exposure to the sun or ultraviolet radiation whilst taking COCs.
Each pink tablet of this medicinal product contains 44 mg lactose monohydrate per tablet, each white tablet contains 89.5 mg lactose anhydrous.Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption who are on a lactose-free diet should take this amount into consideration.
Medical examination/consultation
Prior to the initiation or reinstitution of Xanthadu a complete medical history (including family history) should be taken and pregnancy must be ruled out. Blood pressure should be measured and a physical examination should be performed, guided by the contra-indications (see section 4.3) and warnings (see section 4.4). The woman should also be instructed to carefully read the user leaflet and to adhere to the advice given. The frequency and nature of examinations should be based on established practice guidelines and be adapted to the individual woman.
Women should be advised that oral contraceptives do not protect against HIV infections (AIDS) and other sexually transmitted diseases.
Reduced efficacy
The efficacy of COCs may be reduced in the event of e.g. missed active tablets (see section 4.2), gastro-intestinal disturbances during active tablet taking (see section 4.2) or concomitant medication (see section 4.5).
Reduced cycle control
With all COCs, irregular bleeding (spotting or breakthrough bleeding) may occur, especially during the first months of use. Therefore, the evaluation of any irregular bleeding is only meaningful after an adaptation interval of about three cycles.
If bleeding irregularities persist or occur after previously regular cycles, then nonhormonal causes should be considered and adequate diagnostic measures are indicated to exclude malignancy or pregnancy. These may include curettage.
In some women withdrawal bleeding may not occur during the placebo tablet phase. If the COC has been taken according to the directions described in section 4.2, it is unlikely that the woman is pregnant. However, if the COC has not been taken according to these directions prior to the first missed withdrawal bleed or if two withdrawal bleeds are missed, pregnancy must be ruled out before COC use is continued.
4.5 Interaction with other medicinal products and other forms of interaction
Note: The prescribing information of concomitant medications should be consulted to identify potential interactions.
• Influence of other medicinal products on Xanthadu
Interactions between oral contraceptives and other medicinal products may lead to breakthrough bleeding and/or contraceptive failure. The following interactions have been reported in the literature.
Hepatic metabolism
Interactions can occur with drugs that induce hepatic enzymes which can result in increased clearance of sex hormones (e.g.phenytoin, barbiturates, primidone, carbamazepine, rifampicin, bosentan and HIV-medication (e.g ritonavir, nevirapine) and possibly also oxcarbazepine, topiramate, felbamate, griseofulvin and products containing the herbal remedy St. John's Wort (hypericumperforatum)). Maximal enzyme induction is generally seen in about 10 days but may then be sustained for at least 4 weeks after the cessation of drug therapy.
Interference with Enterohepatic circulation
Contraceptive failures have also been reported with antibiotics, such as penicillins and tetracyclines. The mechanism of this effect has not been elucidated.
Management
Women on short-term treatment with any of the above-mentioned classes of medicinal products or individual active substances (hepatic enzyme-inducing medicine) besides rifampicin should temporarily use a barrier method in addition to the COC, i.e. during the time of concomitant medicinal product administration and for 7 days after their discontinuation.
For women on rifampicin a barrier method should be used in addition to the COC during the time of rifampicin administration and for 28 days after its discontinuation.
In women on long-term treatment with hepatic enzyme-inducing active substances, another reliable, non-hormonal, method of contraception is recommended.
Women on treatment with antibiotics (beside rifampicin, see above) should use the barrier method until 7 days after discontinuation.
If concomitant medicinal product administration runs beyond the end of the active tablets in the current COC blister strip, the placebo tablets must be discarded and the next COC stripshould be started right away.
The main metabolites of drospirenone in human plasma are generated without involvement of the cytochrome P450 system. Inhibitors of this enzyme system are therefore unlikely to influence the metabolism of drospirenone.
• Influence of Xanthadu on other medicinal products
Oral contraceptives may affect the metabolism of certain other active substances. Accordingly, plasma and tissue concentrations may either increase (e.g. ciclosporin) or decrease (e.g. lamotrigine).
Based on in vitro inhibition studies and in vivo interaction studies in female volunteers using omeprazole, simvastatin and midazolam as marker substrate, an interaction of drospirenone at doses of 3 mg with the metabolism of other active substances is unlikely.
• Other interactions
In patients without renal insufficiency, the concomitant use of drospirenone and ACE-inhibitors or NSAIDs did not show a significant effect on serum potassium. Nevertheless, concomitant use of Xanthadu with aldosterone antagonists or potassium-sparing diuretics has not been studied. In this case, serum potassium should be tested during the first treatment cycle. See also section 4.4.
• Laboratory tests
The use of contraceptive steroids may influence the results of certain laboratory tests, including biochemical parameters of liver, thyroid, adrenal and renal function, plasma levels of (carrier) proteins, e.g. corticosteroid-binding globulin and lipid/lipoprotein fractions, parameters of carbohydrate metabolism and parameters of coagulation and fibrinolysis. Changes generally remain within the normal laboratory range. Drospirenone causes an increase in plasma renin activity and plasma aldosterone induced by its mild antimineralocorticoid activity.
4.6 Fertility, pregnancy and lactation
Pregnancy
Xanthadu is not indicated during pregnancy.
If pregnancy occurs during use of Xanthadu, the preparation should be withdrawn immediately. Extensive epidemiological studies have revealed neither an increased risk of birth defects in children born to women who used COCs prior to pregnancy, nor a teratogenic effect when COCs were taken inadvertently during pregnancy.
Animal studies have shown undesirable effects during pregnancy and lactation (see section 5.3). Based on these animal data, undesirable effects due to hormonal action of the active compounds cannot be excluded. However, general experience with COCs during pregnancy did not provide evidence for an actual adverse effect in humans.
The available data regarding the use of Xanthadu during pregnancy are too limited to permit conclusions concerning negative effects of Xanthadu on pregnancy, health of the foetus or neonate. To date, no relevant epidemiological data are available.
Breastfeeding
Lactation may be influenced by COCs as they may reduce the quantity and change the composition of breast milk. Therefore, the use of COCs should generally not be recommended until the breast-feeding mother has completely weaned her child. Small amounts of the contraceptive steroids and/or their metabolites may be excreted with the milk during COC use. These amounts may affect the child.
Fertility
Xanthadu is indicated for the prevention of pregnancy. For information on return to fertility, see section 5.1.
4.7 Effects on ability to drive and use machines
No studies on the effects on the ability to drive and use machines have been performed. No effects on ability to drive and use machines have been observed in users of COCs.
4.8 Undesirable effects
The following adverse drug reactions have been reported during use of Xanthadu.
The table below reports adverse reactions by MedDRA system organ classes (MedDRA SOCs). The frequencies are based on clinical trial data. The most appropriate MedDRA term is used to describe a certain reaction and its synonyms and related conditions.
Adverse drug reactions which have been associated with the use of Xanthadu as oral contraceptive or in the treatment of moderate acne vulgaris according to the MedDRA system organ classes and MedDRA terms
|
System Organ Class |
Common |
Uncommon |
Rare |
|
(MedDRA version 9.1 ) |
(>1/100 to<1/10) |
£1/1,000 to<1/100) |
£1/10,000 to<1/1,000) |
|
Infections and infestations |
Candidiasis | ||
|
Blood and lymphatic system disorders |
Anemia Thrombocythemia | ||
|
Immune system disorders |
Allergic reaction | ||
|
Endocrine disorders |
Endocrine disorder | ||
|
Metabolism and nutrition disorders |
Increased appetite Anorexia Hyperkalemia Hyponatremia | ||
|
Psychiatric disorders |
Emotional lability |
Depression Nervousness Somnolence |
Anorgasmia Insomnia |
|
Nervous system disorders |
Headache |
Dizziness Paresthesia |
Vertigo Tremor |
|
Eye disorders |
Conjunctivitis Dry eye Eye disorder | ||
|
Cardiac disorders |
Tachycardia |
|
Vascular disorders |
Migraine Varicose vein Hypertension |
Phlebitis Vascular disorder Epistaxis Syncope | ||
|
Gastrointestinal disorders |
Nausea |
Abdominal pain Vomiting Dyspepsia Flatulence Gastritis Diarrhoea |
Abdomen enlarged Gastrointestinal disorder Gastrointestinal fullness Hiatus hernia Oral candidiasis Constipation Dry mouth | |
|
Hepatobiliary disorders |
Biliary pain Cholecystitis | |||
|
Skin and subcutaneous tissue disorders |
Acne Pruritus Rash |
Chloasma Eczema Alopecia Dermatitis acneiform Dry skin Erythema nodosum Hypertrichosis Skin disorder Skin striae Contact dermatitis Photosensitive dermatitis Skin nodule | ||
|
Musculoskeletal and connective tissue disorders |
Back pain Pain in extremity Muscle cramps | |||
|
Reproductive system and breast disorders |
Breast pain Metrorrhagia* Amenorrhea |
Vaginal candidiasis Pelvic pain |
Dyspareunia Vulvovaginitis Postcoital |
|
Breast enlargement Fibrocystic breast Uterine/Vaginal bleeding* Genital discharge Hot flushes Vaginitis Menstrual disorder Dysmenorrhoea Hypomenorrhea Menorrhagia Vaginal dryness Papanicolaou smear suspicious Libido decreased |
bleeding Withdrawal bleeding Breast cyst Breast hyperplasia Breast neoplasm Cervical polyp Endometrial atrophy Ovarian cyst Uterine enlargement | ||
|
General disorders and administration site conditions |
Asthenia Sweating increased Edema (Generalized edema, peripheral edema, face edema) |
Malaise | |
|
Investigations |
Weight increase |
Weight decrease |
*bleeding irregularities usually subside during continued treatment
The following serious adverse events have been reported in women using COCs, which are discussed in section 4.4:
• Venous thromboembolic disorders;
• Arterial thromboembolic disorders;
• Hypertension;
• Liver tumours;
• Occurrence or deterioration of conditions for which association with COC use is not conclusive: Crohn's disease, ulcerative colitis, epilepsy, uterine myoma, porphyria, systemic lupus erythematosus, herpes gestationis, Sydenham's chorea, haemolytic uremic syndrome, cholestatic jaundice;
• Chloasma;
• Acute or chronic disturbances of liver function may necessitate the discontinuation of COC use until markers of liver function return to normal.
• In women with hereditary angioedema exogenous estrogens may induce or exacerbate symptoms of angioedema.
The frequency of diagnosis of breast cancer is very slightly increased among OC users. As breast cancer is rare in women under 40 years of age the excess number is small in relation to the overall risk of breast cancer. Causation with COC use is unknown. For further information, see sections 4.3 and 4.4.
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 national reporting system listed in Appendix V*.
4.9 Overdose
There has not yet been any experience of overdose with Xanthadu. On the basis of general experience with combined oral contraceptives, symptoms that may possibly occur in case of taking an overdose of active tablets are: nausea, vomiting and, in young girls, slight vaginal bleeding. There are no antidotes and further treatment should be symptomatic.
5 PHARMACOLOGICAL PROPERTIES
5.1 Pharmacodynamic properties
Pharmacotherapeutic group (ATC): Hormonal contraceptives for systemic use; Progestogens and estrogens, fixed combinations.
ATC Code: G03AA12
Pearl Index for method failure: 0.41 (upper two-sided 95 % confidence limit: 0.85).
Overall Pearl Index (method failure + patient failure): 0.80 (upper two-sided 95% confidence limit: 1.30).
The contraceptive effect of Xanthadu is based on the interaction of various factors, the most important of which are seen as the inhibition of ovulation and the changes in the endometrium.
In a 3-cycle ovulation inhibition study comparing drospirenone 3 mg / ethinylestradiol 0.20 mg in a 24-day-regimen and a 21-day-regimen, the 24-day-regimen was associated with greater suppression of follicular development. After intentionally introduced dosing errors during the third cycle of treatment, a greater proportion of women in the 21-day-regimen showed ovarian activity including escape ovulations compared to the women taking the 24-day-regimen. Ovarian activity returned to pre-treatment levels during the post-treatment cycle in 91.8% of the women who took the 24-day regimen.
Xanthadu is a combined oral contraceptive with ethinylestradiol and the progestogen drospirenone. In a therapeutic dosage, drospirenone also possesses antiandrogenic and mild antimineralocorticoid properties. It has no estrogenic, glucocorticoid and antiglucocorticoid activity. This gives drospirenone a pharmacological profile closely resembling the natural hormone progesterone.
There are indications from clinical studies that the mild antimineralocorticoid properties of Xanthadu result in a mild antimineralocorticoid effect.
Two multicenter, double blind, randomized, placebo controlled studies were performed to evaluate the efficacy and safety of Xanthadu in women with moderate acne vulgaris.
After six months of treatment, in comparison with placebo, Xanthadu showed a statistically significantly greater reduction of 15.6% (49.3% versus 33.7%) in inflammatory lesions, 18.5% (40.6% versus 22.1%) in non-inflammatory lesions, and 16.5% (44.6% versus 28.1%) in total lesion counts. In addition, a higher percentage of subjects, 11.8% (18.6 % versus 6.8%), showed a ‘clear’ or ‘almost clear’ rating on the Investigator’s Static Global Assessment (ISGA) scale.
5.2 Pharmacokinetic properties
Absorption
Orally administered drospirenone is rapidly and almost completely absorbed. Maximum concentrations of the active substance in serum of about 38 ng/ml are reached at about 1-2 h after single ingestion. Bioavailability is between 76 and 85%. Concomitant ingestion of food has no influence on the bioavailability of drospirenone.
Distribution
After oral administration, serum drospirenone levels decrease with a terminal half-life of 31 h.
Drospirenone is bound to serum albumin and does not bind to sex hormone binding globulin (SHBG) or corticoid binding globulin (CBG). Only 3 - 5 % of the total serum concentrations of the active substance are present as free steroid. The ethinylestradiol-induced increase in SHBG does not influence the serum protein binding of drospirenone. The mean apparent volume of distribution of drospirenone is 3.7 ± 1.2 l/kg.
Biotransformation
Drospirenone is extensively metabolized after oral administration. The major metabolites in the plasma are the acid form of drospirenone, generated by opening of the lactone ring, and the 4,5-dihydro-drospirenone-3-sulfate, both of which are formed without involvement of the P450 system. Drospirenone is metabolized to a minor extent by cytochrome P450 3A4 and has demonstrated a capacity to inhibit this enzyme and cytochrome P450 1A1, cytochrome P450 2C9 and cytochrome P450 2C19 in vitro.
Elimination
The metabolic clearance rate of drospirenone in serum is 1.5 ± 0.2 ml/min/kg. Drospirenone is excreted only in trace amounts in unchanged form. The metabolites of drospirenone are excreted with the faeces and urine at an excretion ratio of about 1.2 to 1.4. The half-life of metabolite excretion with the urine and faeces is about 40h.
Steady-State Conditions
During a treatment cycle, maximum steady-state concentrations of drospirenone in serum of about 70 ng/ml are reached after about 8 days of treatment. Serum drospirenone levels accumulated by a factor of about 3 as a consequence of the ratio of terminal half-life and dosing interval.
SpecialPopulations
Effect of renal impairment
Steady-state serum drospirenone levels in women with mild renal impairment (creatinine clearance CLcr, 50-80 mL/min) were comparable to those of women with normal renal function. The serum drospirenone levels were on average 37 % higher in women with moderate renal impairment (CLcr, 30 - 50 mL/min) compared to those in women with normal renal function. Drospirenone treatment was also well tolerated by women with mild and moderate renal impairment. Drospirenone treatment did not show any clinically significant effect on serum potassium concentration.
Effect of hepatic impairment
In a single dose study, oral clearance (CL/F) was decreased approximately 50 % in volunteers with moderate hepatic impairment as compared to those with normal liver function. The observed decline in drospirenone clearance in volunteers with moderate hepatic impairment did not translate into any apparent difference in terms of serum potassium concentrations. Even in the presence of diabetes and concomitant treatment with spironolactone (two factors that can predispose a patient to hyperkalemia) an increase in serum potassium concentrations above the upper limit of the normal range was not observed. It can be concluded that drospirenone is well tolerated in patients with mild or moderate hepatic impairment (Child-Pugh B).
Ethnic groups
No clinically relevant differences in the pharmacokinetics of drospirenone or ethinylestradiol between Japanese and Caucasian women have been observed.
Ethinylestradiol
Absorption
Orally administered ethinylestradiol is absorbed rapidly and completely. Peak serum concentrations of about 33 pg/ml are reached within 1 - 2 hours after single oral administration. Absolute bioavailability as a result of presystemic conjugation and first-pass metabolism is approximately 60 %. Concomitant intake of food reduced the bioavailability of ethinylestradiol in about 25 % of the investigated subjects while no change was observed in the others.
Distribution
Serum ethinylestradiol levels decrease in two phases, the terminal disposition phase is characterized by a half-life of approximately 24 hours. Ethinylestradiol is highly but non-specifically bound to serum albumin (approximately 98.5 %), and induces an increase in the serum concentrations of SHBG and corticoid binding globulin (CBG). An apparent volume of distribution of about 5 l/kg was determined.
Metabolism
Ethinylestradiol is subject to presystemic conjugation in both small bowel mucosa and the liver. Ethinylestradiolis primarily metabolized by aromatic hydroxylation but a wide variety of hydroxylated and methylated metabolites are formed, and these are present as free metabolites and as conjugates with glucuronides and sulfate. The metabolic clearance rate of ethinylestradiol is about 5 ml/min/kg.
Elimination
Ethinylestradiol is not excreted in unchanged form to any significant extent. The metabolites of ethinylestradiol are excreted at a urinary to biliary ratio of 4:6. The half-life of metabolite excretion is about 1 day.
Steady-state conditions
Steady-state conditions are reached during the second half of a treatment cycle and serum levels of ethinylestradiol accumulate by a factor of about 2.0 to 2.3
5.3 Preclinical safety data
In laboratory animals, the effects of drospirenone and ethinylestradiol were confined to those associated with the recognised pharmacological action. In particular, reproduction toxicity studies revealed embryotoxic and fetotoxic effects in animals which are considered as species specific. At exposures exceeding those in users of Xanthadu, effects on sexual differentiation were observed in rat fetuses but not in monkeys.
6 PHARMACEUTICAL PARTICULARS
6.1 List of excipients
|
Active film-coated tablets (pink): | |
|
Tablet |
core: |
|
o |
Lactose monohydrate |
|
o |
Pregelatinized starch (maize) |
|
o |
Povidone K-30 (E1201) |
|
o |
Sodium croscarmellose |
|
o |
Polysorbate 80 (E433) |
|
o |
Magnesium stearate (E470b) |
|
Tablet |
film-coating: |
|
o |
Poly (vinyl alcohol) |
|
o |
Titanium dioxide (E171) |
|
o |
Macrogol 3350 |
|
o |
Talc (E553b) |
|
o |
Yellow iron oxide (E172) |
|
o |
Red iron oxide (E172) |
o Black iron oxide (E172)
Placebo film-coated tablets (white):
• Tablet core:
o Lactose anhydrous o Povidone K-30 (E1201) o Magnesium stearate (E470b)
• Tablet film-coating:
o Poly (vinyl alcohol) o Titanium dioxide (E171) o Macrogol 3350 o Talc (E553b)
6.2 Incompatibilities
Not applicable.
6.3 Shelf life
3 years.
6.4 Special precautions for storage
Store below 30°C.
6.5 Nature and contents of container
Clear to slightly opaque transparent PVC/PVdC-Al blister.
Pack sizes:
1 x 28 film-coated tablets (24 active tablets plus 4 placebo tablets) 3 x 28 film-coated tablets (24 active tablets plus 4 placebo tablets)
6 x 28 film-coated tablets (24 active tablets plus 4 placebo tablets) 13 x 28 film-coated tablets (24 active tablets plus 4 placebo tablets)
Not all pack sizes may be marketed.
6.6 Special precautions for disposal
Any unused product or waste material should be disposed of in accordance with local requirements
7 MARKETING AUTHORISATION HOLDER
Laboratorios Leon Farma, S.A.
C/ La Vallina s/n, Pol. Ind. Navatejera.
24008 - Navatejera, Leon.
Spain
8 MARKETING AUTHORISATION NUMBER(S)
PL 34518/0031
9 DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION
27/01/2014
10 DATE OF REVISION OF THE TEXT
07/11/2016