1. Name Of The Medicinal Product
Lecado 200/50 mg Modified-release Tablets
2. Qualitative And Quantitative Composition
Each prolonged-release tablet contains 200 mg levodopa and 50 mg carbidopa (as carbidopa monohydrate).
For a full list of excipients, see section 6.1.
3. Pharmaceutical Form
Prolonged-release tablets
Appearance: Orange-brown, round, biconvex tablets
4. Clinical Particulars
4.1 Therapeutic Indications
Idiopathic Parkinson's disease, in particular to shorten the 'off' period in patients who have previously been treated with immediate-release levodopa/decarboxylase inhibitors or with just levodopa and who showed motor fluctuations.
Experience with Lecado is limited in patients, who have not been previously treated with levodopa.
4.2 Posology And Method Of Administration
The daily dose of levodopa/carbidopa should be carefully determined. Patients should be monitored closely during the period of dose adjustment, especially with regard to the occurrence or exacerbation of nausea and abnormal involuntary movements, such as dyskinesia, chorea and dystonia. Blepharospasm could be an early sign of overdosing.
The pharmacokinetic properties of the prolonged-release tablets may be altered if the tablets are broken or chewed. Therefore the tablets must be swallowed whole.
Most other medicines, used to treat Parkinson's Disease, except for levodopa, can be continued during administration of levodopa/carbidopa. However their dosage may need to be adjusted.
Sudden withdrawal of Lecado therapy should be avoided wherever possible.
Since carbidopa prevents the reversal of levodopa effects caused by pyridoxine, Lecado 200/50 mg can be administered to patients who receive supplemental pyridoxine (Vitamin B6).
• Starting dose
Patients who have never before received Levodopa therapy
Lecado 100/25 mg is designed for use in patients, who have not previously had levodopa treatment or to aid titration in patients who receive Lecado 200/50 mg. The recommended starting dose is one tablet 100/25 mg two times per day. In patients who need more levodopa a daily dose of three to four tablets of Lecado 100/25 mg is usually well tolerated.
For Lecado 200/500 mg the recommended starting dose is one tablet two times per day.
The starting dose should not be higher than 600 mg levodopa per day and the doses should be administered with minimum intervals of six hours.
Dose adjustments should occur with intervals of at least two to four days.
Depending of the severity of the disease, six months of treatment may be required to achieve optimal disease control.
A guide to substitution for patients who are treated with the immediate-release combination of levodopa and decarboxylase inhibitor
Transferring to Lecado 200/50 mg should initially occur in a dose that supplies at most about 10% more levodopa per day when higher doses are indicated (more than 900 mg daily). Levodopa and decarboxylase inhibitor should be discontinued at least 12 hours before the administration of Lecado. The dose interval should be prolonged by 30 % to 50% at intervals of ranging from 4 – 12 hours. If the divided doses are not equal it is recommended to administer the lowest dose at the end of the day. The dose should be adjusted depending on the clinical reaction, as indicated below in Dose Adjustment. It could be that doses which supply maximally 30% more levodopa per day are necessary.
A guide for the substitution of Lecado prolonged-release treatment for immediate-release levodopa/carbidopa combinations is shown in the table below:
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*divided in 3 or more doses
Patients who are currently treated with just levodopa
Levodopa must be discontinued at least twelve hours before therapy with levodopa/carbidopa tablet is started.
In patients with a mild to moderate form of the disease the recommended starting dose is 200 mg levodopa / 50 mg carbidopa twice daily.
• Dose Adjustment
After the treatment is established the doses and the dose frequency can be increased or decreased depending on the therapeutic response. Most patients are adequately treated with 400 mg levodopa / 100 mg carbidopa to 1600 mg levodopa / 400 mg carbidopa per day, administered in divided doses at intervals ranging from four to twelve hours during the waking day. Higher doses (up to 2400 mg levodopa / 600 mg carbidopa) and shorter intervals (less than four hours) have been used, but are generally not recommended.
When doses of Lecado are given at intervals of less than four hours or if the divided doses are not equal, it is recommended to administer the lowest dose at the end of the day.
The effect of the first morning dose can be delayed in some patients for up to one hour compared to the usual reaction of the first morning dose of immediate-release Levodopa/Carbidopa.
Adjustments of the dosage should occur in intervals of at least three days.
• Maintenance dose
Because Parkinson's Disease is progressive, periodic clinical check-ups are recommended and an adjustment of the dose schedule of Lecado may be needed.
• Addition of other anti-Parkinson medications
Anti-cholinergics, dopamine agonists and amantadine can be administered concomitantly with Lecado. It might be necessary to adjust the dose Lecado when these medications are added to an ongoing treatment of Lecado.
• Interruption of the therapy
Patients should be carefully observed in case of a sudden reduction of the dose or if it is necessary to discontinue treatment with Lecado, particularly in the patient who is receiving anti-psychotics. (see section 4.4).
If anaesthetic is necessary, the administration of Lecado can be continued as long as the patient is allowed to take oral medications. In case of a temporary interruption of the therapy, the usual dose can be administered as soon as the patient is able to take the oral medications.
• Use in Children
The safety in patients under 18 years of age has not been established
• Use in the elderly
There is a wide experience in the use of combinations of levodopa and carbidopa in elderly patients. The recommendations set out above reflect the clinical data derived from this experience.
• Use in renal/hepatic impairment
No dose adjustment is necessary.
4.3 Contraindications
Lecado is contraindicated in:
- patients with a hypersensitivity to levodopa, carbidopa or any of the excipients
- patients with narrow-angle glaucoma
- patients with severe heart failure
- severe cardiac arrhythmia
- acute stroke.
Lecado should not be given, when administration of a sympathomimetics is contra-indicated.
Non-selective mono-amino-oxydase (MAO) inhibitors and selective MAO type A inhibitors are contra-indicated for concomitant use with Lecado. The administration of these inhibitors should have been discontinued at least two weeks before starting the treatment with Lecado. Lecado can be taken concomitantly with the recommended dose of an MAO inhibitor, which is selective for MAO type B (for instance selegiline-HCl) (see section 4.5)
4.4 Special Warnings And Precautions For Use
In patients who are treated with just levodopa, treatment should have been discontinued for at 12 hours before starting with the therapy of Lecado.
Based on the pharmacokinetic profile of Lecado the onset of effect in patients with early morning dyskinesia may be slower than with immediate-release levodopa/ carbidopa. The incidence of dyskinesia is greater during treatment with Lecado in patients with an advanced stage of motor fluctuations than it is with an immediate-release tablet with a combination levodopa/carbidopa (16.5% versus 12.2%).
Dyskinesia can occur in patients who previously were treated with just levodopa, because carbidopa makes it possible for more levodopa to reach the brain, which causes more dopamine to be formed. The occurrence of dyskinesia may make it necessary to reduce the dose (see section 4.8).
Lecado can, just like levodopa, cause involuntary movements and mental disturbances. Patients with a history of severe involuntary movements or psychotic episodes when treated with levodopa alone or with carbidopa-levodopa combination should be observed carefully when Lecado is substituted. It is suspected that these reactions are the result of the increased dopamine in the brain after administration of levodopa, and the use of Lecado can cause a recurrence. It may be necessary to reduce the dose. All patients should be observed carefully for the development of depression with concomitant suicidal tendencies. Patients with past or current psychosis should be treated with caution.
Lecado should be discontinued when there is deterioration of any pre-exiting psychotic condition.
Levodopa has been associated with somnolence and episodes of sudden sleep onset. Sudden onset of sleep during daily activities, in some cases without awareness or warning signs, has been reported very rarely. Patients must be informed of this and advised to exercise caution while driving or operating machines during treatment with levodopa. Patients who have experienced somnolence or an episode of sudden sleep onset must refrain from driving or operating machines. A reduction of dosage or termination of therapy may be considered.
Lecado should be administered cautiously to patients with severe cardiovascular or pulmonary disease, bronchial asthma, renal, hepatic or endocrine disease or with a history of peptic ulcer disease, haematemesis or of convulsions.
Levodopa/Carbidopa should be administered cautiously to patients who have had a recent myocardial infarction, who have residual atrial, nodal or ventricular arrhythmia. In such patients cardiac function should be monitored with particular care during the period of initial dosage administration and titration.
Patients with chronic wide-angle glaucoma may be treated cautiously with Lecado provided the intraocular pressure is well controlled and the patient is monitored carefully for changes in eye pressure during the therapy.
A symptom complex resembling the neuroleptic malignant syndrome, including muscular rigidity, increased body temperature, mental changes and increased serum creatine phosphokinase, has been reported when anti Parkinsonian medication was withdrawn abruptly. Therefore patients should be carefully observed when the dose of carbidopa/levodopa combinations is abruptly reduced or discontinued, especially if the patient is receiving anti-psychotics.
The use of levodopa/carbidopa is not advised during treatment for pharmacogenic extrapyramidal reactions or Huntington's chorea.
Periodic evaluation of hepatic, haematopoietic, cardiovascular and renal function are recommended during extended therapy.
The safety and efficacy of Lecado 200/50 mg has not been determined in infants and children and use in patients under the age of eighteen is not advised.
Pathological gambling, increased libido and hypersexuality have been reported in patients treated with dopamine agonists for Parkinson's disease, including Lecado 200/50 mg.
Patients with Parkinson's disease show a possible increased risk of melanoma, but no confirmed association with levodopa therapy has been established.. Therefore caution should be exercised during treatment.
Laboratory tests
Carbidopa/levodopa preparations had given rise to abnormalities in several laboratory tests and these can also occur with Lecado. These include elevations of liver function tests, such as alkaline phosphatase, SGOT, SGPT, lactic acid dehydrogenase, bilirubin, blood urea nitrogen and a positive Coombs test.
Decreased haemoglobin and haematocrit, elevated serum glucose and white blood cells, bacteria and blood in the urine have also been reported with Levodopa/Carbidopa.
When a test strip is used to determine ketonuria, carbidopa/levodopa preparations can show a false positive result for urinary ketone bodies. This reaction is not altered by boiling the urine sample. False negative results can also occur in the examination of glycosuria with the use of glucose oxidase methods.
4.5 Interaction With Other Medicinal Products And Other Forms Of Interaction
Caution is needed in concomitant administration of Lecado with the following medicines:
Anti-hypertensives
Symptomatic orthostatic dysregulation has occurred when levodopa is added with a decarboxylase inhibitor to certain antihypertensives. Dose adjustment of antihypertensives may be necessary during the titration phase of treatment with Lecado 200/50 mg.
Anti-depressants
There have been rare reports of adverse reactions, including hypertension and dyskinesia, resulting from the concomitant administration of tricyclic anti-depressants and carbidopa/levodopa preparations. (See section 4.3 for patients receiving mono-amine oxidase inhibitors).
Anti-cholinergics
Anti-cholinergics may act synergistically with levodopa to decrease tremor. However combined use may exacerbate abnormal involuntary movements. Anticholinergics may decrease the effects of levodopa by delaying its absorption. An adjustment of the dose of Levodopa/Carbidopa may be needed.
Other medicines
Dopamine-D2-receptor antagonists (for instance phenothiazines, butyrophenons, risperidone), benzodiazepines and isoniazide can reduce the therapeutic effect of levodopa. The beneficial effects of levodopa in Parkinson's disease may be reduced by phenytoin and papaverine. Patients taking these medications together with Lecado, should be observed carefully for loss of therapeutic response.
Concomitant use of selegiline and levodopa-carbidopa may be associated with severe orthostatic hypotension. (See also section 4.3)
COMT inhibitors (tolcapone, entacapone)
Concomitant use of COMT (Catechol-O-Methyl Transferase) inhibitors and levodopa/carbidopa can increase the bioavailability of levodopa. The dose of levodopa/ carbidopa may possibly need adjusting.
Amantadine has a synergistic effect with levodopa and may increase levodopa-related side events. An adjustment of the dose of levodopa/carbidopa may be needed.
Metoclopramide increases gastric emptying and may increase the bioavailability of Lecado.
Sympathomimetics may increase cardiovascular side events related to levodopa
Concomitant use of ferrous sulphate and levodopa-carbidopa can lead to a reduction in the bioavailability of levodopa.
As levodopa competes with certain amino acids, the absorption of levodopa can be impaired in some patients who are on a protein rich diet.
The effect of administration of antacids and Lecado on the bioavailability of levodopa has not been studied.
4.6 Pregnancy And Lactation
Pregnancy
Insufficient data on the use of levodopa/carbidopa in pregnant women. The results of animal studies have shown reproduction toxicity. (see section 5.3). The potential human risk to the embryo or the foetus is not known.
Lecado should not be used during pregnancy. Any woman of childbearing potential who is receiving Lecado 200/50 mg must practise effective contraception.
Lactation
Levodopa is secreted in breast milk in significant quantities. While using Lecado 200/50mg women should not breast-feed.
4.7 Effects On Ability To Drive And Use Machines
There are no known data on the effect of this product on the ability to drive. Certain side effects such as sleepiness and dizziness may influence the ability to drive or use machines.
Patients being treated with levodopa and presenting with somnolence or an episode of sudden sleep onset must be advised 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
During controlled clinical studies in patients with moderate to severe motor fluctuations Lecado caused no side effects which were unique to the modified release formulation.
Blood and lymphatic system disorders
Rare (
Very rare (<1/10,000): Agranulocytosis
Metabolism and nutrition disorders
Common (
Uncommon (
Psychiatric disorders
Common (
Rare (
Unknown frequency: Patients treated with dopamine agonists for treatment of Parkinson's disease, including Lecado 100/25 mg, especially at high doses, have been reported as exhibiting signs of pathological gambling, increased libido and hypersexuality, generally reversible upon reduction of the dose or treatment discontinuation.
Levodopa/carbidopa is associated with somnolence and has been associated very rarely with excessive daytime somnolence and sudden sleep onset episodes.
Nervous system disorders
Common (
Bradykinesia (on-off episodes) may appear some months to years after the beginning of treatment with levodopa and is probably related to the progression of the disease. The adaptation of dose schedule and dose intervals may be required.
Uncommon (
Rare (
Eye disorders
Rare (
Blepharospasm can be an early sign of overdosage.
Cardiac disorders
Common (
Vascular disorders
Common (
Uncommon (
Rare (
Respiratory, thoracic and mediastinal disorders
Uncommon (
Rare (
Gastrointestinal disorders
Common (
Uncommon (
Rare (
Skin and subcutaneous tissue disorders
Uncommon (
Rare (
Musculoskeletal, connective tissue and bone disorders
Uncommon (
Renal and urinary disorders
Uncommon (
Rare (
General disorders and administration site conditions
Uncommon (
4.9 Overdose
The treatment of an acute overdose of Lecado 200/50 mg is in general the same as that of an acute overdose of levodopa: However, pyridoxine has no effect on the reversal of the action of Lecado. Electrocardiographic monitoring should be used and the patient observed carefully for the development of cardiac arrhythmias. If necessary an appropriate antiarrhythmic therapy should be given.
The possibility that the patient took other medications together with Lecado 200/50 mg should be taken into consideration. To date experience with dialysis has not been reported. Therefore its value in the treatment of overdose is unknown.
5. Pharmacological Properties
5.1 Pharmacodynamic Properties
Pharmaco-therapeutic group: levodopa: dopaminergics; carbidopa: dopadecarboxylase inhibitor
ATC code: N04BA02
Lecado is a combination of carbidopa, an aromatic amino acid decarboxylase inhibitor, and levodopa, the metabolic precursor of dopamine, in the form of a prolonged-release tablet on a polymer base for use in the treatment of Parkinson's Disease.
Lecado is particularly useful in the reduction of the “off” period in patients previously treated with the immediate-release levodopa/decarboxylase inhibitor combination who have had dyskinesia and motor fluctuations.
Patients with Parkinson's Disease who were treated with preparations that contained levodopa, can develop motor fluctuations which are characterized by the wearing off effect of a dose, dyskinesia in the peak dose and akinesia. The advanced form of motor fluctuations ( “on-off” phenomenon) is characterized by unpredictable fluctuations from mobility to immobility. Although the causes of the motor fluctuations are not completely clear, it has been shown that they can be reduced by treatment schedules that provide a stable plasma concentration of levodopa.
Levodopa relieves the symptoms of Parkinson's disease by being decarboxylated to dopamine in the brain. Carbidopa, which does not pass the blood/brain barrier, inhibits only the extracerebral decarboxylation of levodopa, making more levodopa available for transport to the brain and subsequent conversion to dopamine. Therefore it is normally not necessary to administer high doses of levodopa at frequent intervals. Gastro-intestinal and cardio-vascular side-effects, in particular those which can be attributed to the dopamine formed in the extracerebral tissues, are avoided totally or partially by the reduced dose.
During clinical trials patients with motor fluctuations experienced a shorter “off” period with levodopa and carbidopa in modified form in comparison with an immediate-release tablet of a combination of levodopa and carbidopa. The reduction of the “off” time is rather small (about 10%) and the incidence of dyskinesia was slightly increased after administration of levodopa+carbidopa prolonged-release compared to treatment with an immediate-release tablet of a combination of levodopa and carbidopa. In patients without motor fluctuations levodopa+carbidopa prolonged-release provided, under controlled circumstances, the same therapeutic advantage in less frequent doses than the immediate-release tablet with a combination of levodopa and carbidopa. Improvement of other symptoms of Parkinson's Disease did not generally take place.
5.2 Pharmacokinetic Properties
Absorption
The pharmacokinetics of levodopa after administration of Levodopa+Carbidopa 100+25 mg in prolonged-release form compared to an immediate release Levodopa+Carbidopa has been studied in young healthy volunteers. After administration of Levodopa+Carbidopa 200+50 mg prolonged-release it took approximately two hours before maximal levodopa plasma levels were reached in comparison to 0.75 hours for the immediate-release tablet with a combination of levodopa and carbidopa. The mean maximal levodopa plasma levels were reduced 60% in Levodopa+Carbidopa 200+50 mg prolonged-release compared to immediate-release tablets with a combination of levodopa and carbidopa. The absorption of levodopa after the administration of Levodopa+Carbidopa 200+50 mg prolonged-release occurred continuously for four to six hours. In these studies the levodopa plasma concentrations fluctuated within closer margins than with the immediate-release tablet of levodopa and carbidopa. As the bio-availability of levodopa from Levodopa+Carbidopa 200+50 mg prolonged-release in comparison to an immediate-release tablet with a combination of levodopa and carbidopa is approximately 70%, the daily dose of levodopa in the modified release formulation should as a rule be higher than that of the immediate-release product.
The mean maximal plasma concentration of levodopa after the administration of a single dose Levodopa+Carbidopa 100+25 mg retard was approximately 70% of Levodopa+Carbidopa 200+50 mg retard.
The mean time to reach the maximal plasma concentrations could be reduced a little with Levodopa+Carbidopa 100+25 mg retard over Levodopa+Carbidopa 200+50 mg retard.
The pharmacokinetics of levodopa after administration of Levodopa+Carbidopa retard was also studied in patients with Parkinson´s Disease. Regular twice daily administering of Levodopa+Carbidopa 100+25 mg retard (varying from 50 mg carbidopa and 200 mg levodopa to 150 mg carbidopa and 600 mg levodopa) for three months showed no accumulation of levodopa in the plasma.
Intake of food had no influence on the absorption of levodopa. With regard to carbidopa the simultaneous intake of food resulted in a 50% AUC reduction and a 40% C-max reduction. The reduced plasma levels of carbidopa have no clinical relevance.
Distribution
Levodopa is widely distributed to most body tissues, but not to the central nervous because of extensive metabolism in the periphery. It is not bound to plasma proteins.
Levodopa crosses the blood-brain barrier by active but saturable transport system for large neutral amino acids.
Carbidopa does not cross the blood-brain barrier. Both Levodopa and carbidopa cross the placenta and are excreted in breast milk.
Metabolism and elimination
In the presence of carbidopa, levodopa is mainly metabolised to aminoacids and, to a less extent, to catecholamine derivates. All metabolites are excreted renally.
Following an oral dose approximately 50% is recorded in the urine.
5.3 Preclinical Safety Data
Animal studies with regard to the pharmacological safety and toxicity after repeated administration, mutagenicity studies and carcinogenicity investigations showed no particular risk for humans. In reproductive toxicity studies both levodopa and the combination of carbidopa/levodopa have caused visceral and skeletal malformations in rabbits.
6. Pharmaceutical Particulars
6.1 List Of Excipients
Hypromellose
Colloidal anhydrous silica
Fumaric acid
Sodium stearyl fumarate
Macrogol 6000
Quinoline yellow (E104)
Iron oxide yellow (E172)
Iron oxide red (E172)
Titanium dioxide (E171)
6.2 Incompatibilities
Not applicable
6.3 Shelf Life
4 years.
6.4 Special Precautions For Storage
This medicinal product does not require any special storage conditions.
6.5 Nature And Contents Of Container
Blister packs (Aluminium/Aluminium)
Pack sizes: 30, 50, 60 and 100 prolonged-release tablets
Not all package sizes will be marketed.
6.6 Special Precautions For Disposal And Other Handling
No special requirements
7. Marketing Authorisation Holder
Sandoz Ltd
Frimley Business Park,
Frimley,
Camberley,
Surrey,
GU16 7SR.
United Kingdom
8. Marketing Authorisation Number(S)
PL 04416/0857
9. Date Of First Authorisation/Renewal Of The Authorisation
31/03/2008
10. Date Of Revision Of The Text
11/2010
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