1. Name Of The Medicinal Product
Viridal Duo 10 micrograms/ml, Powder and Solvent for Solution for Injection.
2. Qualitative And Quantitative Composition
Alprostadil 10 micrograms (used as a 1:1 clathrate complex with alfadex).
For a full list of excipients see section 6.1
3. Pharmaceutical Form
Powder and solvent for solution for injection.
Double chamber glass cartridge containing lyophilised powder and solvent for reconstitution (0.9% w/v sodium chloride solution).
The powder is white and odourless, and the isotonic sodium chloride solution is clear. The powder dissolves immediately to yield a clear solution.
4. Clinical Particulars
4.1 Therapeutic Indications
As an adjunct to the diagnostic evaluation of erectile dysfunction in adult males.
Treatment of erectile dysfunction in adult males.
4.2 Posology And Method Of Administration
The drug solution should be prepared shortly before the injection.
Prior to injection the needle should be screwed onto the tip of the injector. After disinfecting the tip of the cartridge with one of the alcohol swabs, the cartridge should then be inserted into the injector. By screwing the thread part clockwise, the cartridge is fixed in the injector. Then, the dry substance, which is inside the front chamber of the cartridge, is reconstituted with 1 ml sterile sodium chloride solution 0.9% in the bottom chamber. While holding the device in a vertical position with the needle upwards, the thread part should be screwed slowly until it will not go any further. The solvent will by-pass the upper stopper into the front chamber and dissolve the dry substance within a few seconds. As soon as the dry substance is reconstituted, the larger external and the smaller inner protective cap have to be removed from the needle. The air should then be expelled out of the cartridge and the prescribed dose adjusted precisely.
Unused solution must be discarded immediately.
Viridal Duo is injected into either the right or the left cavernous body of the penile shaft. Once the needle is in the cavernous body, the injection should be done within 5 to 10 seconds and is very easy without much resistance if the needle is in the correct position.
The development of an erection will start approximately 5 – 15 minutes after the injection.
Dosage for injection in the clinic
Injections for diagnostic evaluation and dose titration must be performed by the attending physician. He will determine an individual dose suitable to produce an erectile response for diagnostic purposes.
The recommended starting dose is 2.5 mcg Viridal Duo in patients with primary psychogenic or neurogenic origin of erectile dysfunction. In all other patients with erectile dysfunction 5 mcg Viridal Duo should be used as a starting dose. Dose adjustments may be performed in increments of about 2.5 mcg to 5 mcg Viridal Duo. Most of the patients require between 10 and 20 mcg per injection. Some patients may need to be titrated to higher doses. Doses exceeding 20 mcg should be prescribed with particular care in patients with cardiovascular risk factors. The dose per injection should never exceed 40 mcg.
Dosage for self-injection therapy at home
Before starting treatment at home, each patient or the patient's partner has to be taught by a physician how to prepare the drug and perform the injection. In no cases should the injection therapy be started without precise instructions by the physician. The patient should only use his optimum individual dosage, which has been pre-determined by his physician using the above-mentioned procedure. This dose should allow the patient to have an erection at home, which should not last longer than one hour. If he experiences prolonged erections beyond 2 hours but less than 4 hours, the patient is recommended to contact his physician to re-establish the dose of the drug. Maximum injection frequency recommended is 2 or 3 times a week with an interval of at least 24 hours between the injections.
Follow-up
After the first injections and at regular intervals, e.g. every three months, the physician should re-evaluate the patient. Any local adverse reaction, e.g. haematoma, fibrosis or nodules should be noted and controlled. Following discussion with the patient, an adjustment of dosage may be necessary.
4.3 Contraindications
Hypersensitivity to the active substances or to any other ingredients.
Patients with diseases causing priapism e.g. sickle-cell disease, leukaemia and multiple myeloma or patients with anatomical deformation of the penis as cavernosal fibrosis or Peyronie's disease. Patients with penis implants should not use Viridal Duo.
Viridal Duo should not be used in men for whom sexual activity is contraindicated.
4.4 Special Warnings And Precautions For Use
The physician should carefully select patients suitable for self-injection therapy.
Sexual stimulation and intercourse can lead to cardiac and/or pulmonary events in patients with coronary heart disease, congestive heart failure or pulmonary disease. Viridal Duo should be used with care in these patient groups and patients should be examined and cleared for stress resistance by a cardiologist before treatment.
Viridal Duo should be used with care in patients who have experienced transient ischaemic attacks.
Patients who experience a prolonged erection lasting longer than four hours should contact their physician immediately. Therefore it is recommended that the patient has an emergency telephone number of his attending physician or of a clinic experienced in therapy of erectile dysfunction. Prolonged erection may damage penile erectile tissue and lead to irreversible erectile dysfunction.
A benefit-risk evaluation is neccesary before using Viridal Duo in patients with pre-existing scarring, e.g. nodules of the cavernous body or pre-existing penile deviation or Peyronie's disease or clinically relevant phimosis, e.g. phimosis with risk of paraphimosis these patients should be treated with particular care, e.g. more frequent re-evaluation of the patient's condition.
Patients who have to be treated with alpha-adrenergic drugs due to prolonged erections (see: overdose) may in the case of concomitant therapy with monoamino-oxidase-inhibitors, develop a hypertensive crisis.
Other intracavernous drugs e.g. smooth muscle relaxing agents or alpha-adrenergic blocking agents may lead to prolonged erection and must not be used concomitantly. The effects of a combination therapy of alprostadil with oral, intraurethral or topical medicinal products for erectile dysfunction are currently unknown.
Patients with blood clotting disorders or patients on therapy influencing blood clotting parameters should be carefully selected for treatment by the treating physician and treated with special care, e.g. monitoring of the clotting parameters, patients should be thoroughly educated by the prescriber about the associated risks and advised to exercise sufficient manual pressure on the injection site. This is because of the increased risk of bleeding.
To prevent abuse, self-injection therapy with Viridal Duo should not be used by patients with drug addiction and/or disturbances of psychological or intellectual development.
In cases of excessive use, e.g. higher frequencies than recommended, an increased risk of penile scarring cannot be excluded.
Use of intracavernous alprostadil offers no protection from the transmission of sexually transmitted diseases. Individuals who use alprostadil should be counselled about the protective measures that are necessary to guard against the spread of sexually transmitted diseases, including the human immunodeficiency virus (HIV). In some patients, injection of Viridal Duo can induce a small amount of bleeding at the injection site. In patients infected with blood borne diseases, this could increase the transmission of such diseases to the partner. For this reason we recommend that a condom is used for intercourse after injecting Viridal Duo.
Viridal Duo is for intracavernous injection. Subcutaneous injection or injections at areas of the penis other than the cavernous body should be avoided.
The injection should be performed under hygienic conditions to avoid infections. In any condition that precludes safe self-injection like poor manual dexterity, poor visual acuity or morbid obesity, the partner should be trained in the injection technique and should perform the injection.
Up to now, there is no clinical experience in patients under 18 and over 75 years of age.
Viridal Duo does not interfere with ejaculation and fertility.
4.5 Interaction With Other Medicinal Products And Other Forms Of Interaction
Concomitant use of smooth muscle relaxing drugs like papaverine or other drugs inducing erection like alpha-adrenergic blocking agents may lead to prolonged erection and should not be used in parallel with Viridal Duo.
Risks exist when using alpha-adrenergic drugs to terminate prolonged erections in patients with cardiovascular disorders or receiving MAO inhibitors.
The effects of blood pressure lowering and vasodilating drugs may be increased.
4.6 Pregnancy And Lactation
The natural amount of PGE1 present in the sperm may be increased by the PGE1 present in Viridal Duo. In case the partner is pregnant, a condom should be used in order to avoid irritation of the vagina and a risk for the foetus.
4.7 Effects On Ability To Drive And Use Machines
Viridal Duo may rarely induce a transient drop of blood pressure with subsequent impairment of reactivity that could interfere with patient's ability to drive or operate machinery.
4.8 Undesirable Effects
Undesirable effects frequencies are defined as:
Very common (
Common (
Uncommon (
Rare (
Very rare (< 1/10,000).
During administration of Viridal Duo the following undesirable effects may be observed:
General disorders and administration site condition
Common: burning sensation during injection and after the injection, sensation of tension in the penis and pain of mostly mild intensity at the site of injection.
Uncommon: spotlike haemorrhage/ spotlike bruises at the site of puncture, haemosiderin deposits, reddening and swellings at the site of injection, swellings of the preputium or the glans, and headache.
Reproductive system and breast disorders
Common: fibrotic alterations (e.g. fibrotic nodules, plaques at the site of injection or in the corpus cavernosum) can occur during long-term treatment.
Uncommon: fibrotic alterations associated with slight penile axis deviations. Prolonged erections of more than 4 hours' duration are uncommon (mainly seen during dose titration).
Rare: fibrotic changes of the cavernous body during a long term treatment lasting up to 4 years.
Cardiac disorders
Rare: circulatory effects such as short periods of hypotension and/or vertigo or dizziness.
Immune system disorders
Rare: allergic reactions ranging from cutaneous hypersensitivity such as rash, erythema, urticaria to anaphylactic/anaphylactoid reactions.
4.9 Overdose
Symptoms
Full rigid erections lasting more than four hours.
If the patient experiences a prolonged erection, he is advised to contact his attending physician or a urologic clinic nearby immediately.
Treatment strategy
Treatment of prolonged erection should be done by a physician experienced in the field of erectile dysfunction. If prolonged erection occurs, the following is recommended:
If the erection has lasted less than six hours:
− observation of the erection because spontaneous flaccidity frequently occurs.
If the erection has lasted longer than six hours:
− cavernous body injection of alpha-adrenergic substances (e.g. phenylephrine or epinephrine (adrenaline)). Risks exist when using drugs in patients with cardiovascular disorders or receiving MAO inhibitors. All patients should be monitored for cardiovascular effects when these drugs are used to terminate prolonged erections.
or
− aspiration of blood from the cavernous body.
Accidental systemic injection of high doses
Single dose rising tolerance studies in healthy volunteers indicated that single intravenous doses of alprostadil from 1 to 120 mcg were well tolerated. Starting with a 40 mcg bolus intravenous dose, the frequency of drug-related adverse events increased in a dose-dependent manner, characterised mainly by facial flushing.
5. Pharmacological Properties
5.1 Pharmacodynamic Properties
ATC Code: Other urologicals G04BX 05
Alprostadil [Prostaglandin E1 (PGE1)], the active ingredient of Viridal Duo, is an endogenous compound derived from the essential fatty acid dihomogammalinolenic acid. Alprostadil is a potent smooth muscle relaxant that produces vasodilation and occurs in high concentrations in the human seminal fluid. Pre-contracted isolated preparations of the human corpus cavernosum, corpus spongiosum and cavernous artery were relaxed by alprostadil, while other prostanoids were less effective. Alprostadil has been shown to bind to specific receptors in the cavernous tissue of human and non-human primates.
The binding of alprostadil to its receptors is accompanied by an increase in intracellular cAMP levels. Human cavernosal smooth muscle cells respond to alprostadil by releasing intracellular calcium. Since relaxation of smooth muscle is associated with a reduction of the cytoplasmic free calcium concentration, this effect may contribute to the relaxing activity of this prostanoid.
Intracavernous injection of alprostadil in healthy monkeys resulted in penile elongation and tumescence without rigidity. The cavernous arterial blood flow was increased for a mean duration of 20 min. In contrast, intracavernous application of alprostadil to rabbits and dogs caused no erectile response.
Systemic intravascular administration of alprostadil leads to a vasodilation and reduction of systemic peripheral vascular resistance. A decrease in blood pressure can be observed after administration of high doses. Alprostadil has also been shown in animal and in vitro tests to reduce platelet reactivity and neutrophil activation. Additional alprostadil activity has been reported: increase in fibrinolytic activity of fibroblasts, improvement of erythrocyte deformability and inhibition of erythrocyte aggregation; inhibition of the proliferative and mitotic activity of non-striated myocytes; inhibition of cholesterol synthesis and LDL-receptor activity; and an increase in the supply of oxygen and glucose to ischaemic tissue along with improved tissue utilisation of these substrates.
5.2 Pharmacokinetic Properties
After reconstitution, alprostadil (PGE1) dissociates from the α-cyclodextrin clathrate, and the two components have independent fates.
In symptomatic volunteers, systemic mean endogenous PGE1 venous plasma concentrations measured before intracavernous injection are approximately 1pg/ml. After injection of 20 mcg of alprostadil, the PGE1 venous plasma concentrations increase rapidly to concentrations of about 10-20 pg/ml. The PGE1 plasma concentrations return to concentrations close to the baseline within a few minutes. Approximately 90% of PGE1 found in plasma is protein-bound.
Metabolism
Enzymatic oxidation of the C15-hydroxy group and reduction of the C13,14 double bond produce the primary metabolites, 15-keto-PGE1, PGEo (13,14-dihydro-PGE1) and 15-keto-PGEo. Only PGEo and 15-keto-PGEo have been detected in human plasma. Unlike the 15-keto metabolites, which are less pharmacologically active than the parent compound, PGEo has a potency similar to that of PGE1 in most respects.
In symptomatic volunteers, the mean endogenous PGEo venous plasma concentrations measured before an intracavernous injection are approximately 1 pg/ml. After the injection of 20 mcg of alprostadil, the PGEo plasma concentrations increase to concentrations of about 5 pg/ml.
Excretion
After further degradation of the primary metabolites by beta and omega oxidation, the resulting, more polar metabolites are excreted primarily with the urine (88%) and the faeces (12% ) and there is no evidence of tissue retention of PGE1 or its metabolites.
5.3 Preclinical Safety Data
Studies on local tolerance following single and repeated intracavernous injections of alprostadil or alprostadil alfadex in rabbits and/or monkeys, in monkeys up to 6 months with daily injection revealed in general good local tolerance. Possible adverse effects like haematomas and inflammations are more likely related to the injection procedure.
Within the 6 months study in male monkeys, there were no adverse effects of alprostadil alfadex on male reproductive organs.
Alprostadil did not cause any adverse effects on fertility or general reproductive performance in male and female rats treated with 40-200 mcg/kg/day. The high dose of 200 mcg/kg/day is about 300 times the maximum recommended human dose on a body weight basis (MHRD < 1 mcg/kg).
Alprostadil was not fetotoxic or teratogenic at doses up to 5000 mcg/kg/day (7500 times the MHRD) in rats, 200 mcg/kg/day (300 times the MHRD) in rabbits and doses up to 20 mcg/kg/day (30 times the MHRD) in guinea pigs or monkeys.
Mutagenicity studies with alprostadil alfadex revealed no risk of mutagenicity.
6. Pharmaceutical Particulars
6.1 List Of Excipients
Powder for injection:
Lactose monohydrates
Alfadex
Diluent:
Sodium chloride
Water for injection.
6.2 Incompatibilities
It is not intended that this medicinal product be mixed with other medicinal products, therefore, in the absence of compatibility studies this medicinal product must not be mixed with other medicinal products.
6.3 Shelf Life
Shelf life for the product as packaged for sale: 4 years.
Shelf life after reconstitution: for immediate use only.
6.4 Special Precautions For Storage
Do not store above 25°C.
Store in the original package in order to protect from light.
6.5 Nature And Contents Of Container
Administration devices
1 reusable injector (starter kit)
1 double chamber cartridge with dry substance and 1 ml 0.9% sterile sodium chloride solution
1 injection needle 29G x ½ (0.33 mm x 12.7 mm)
1 alcohol swab to be obtained for each injection
1. Cartons containing one colourless glass double-chamber cartridge, one injection needle 29 G x ½ (0.33 mm x 12.7 mm) and one reusable injector (starter kit).
2. Cartons containing two colourless glass double-chamber cartridges, two injection needles 29 G x ½ (0.33 mm x 12.7 mm) and one reusable injector (starter kit).
3. Cartons containing one, two or six colourless glass double-chamber cartridges and corresponding number of injection needles 29 G x ½ (0.33 mm x 12.7 mm) without reusable injector.
Not all pack sizes may be marketed.
6.6 Special Precautions For Disposal And Other Handling
Fix the injection needle onto the front part of the injector.
Disinfect the tip of the cartridge with one of the alcohol swabs. Insert the cartridge into the re-usable injector and fix it by screwing the thread part. Dissolve the drug substance in the front chamber of the cartridge by completely screwing the thread-part into the injector thus moving both rubber stoppers to the top of the cartridge and allowing the solvent in to the bottom chamber to reach the dry substance via the bypass of the cartridge. Shake slightly until a clear solution is produced.
Expel the air and adjust the prescribed dosage precisely prior to intracavernous injection.
After preparation of the solution, the injection must be performed using aseptic procedures into either the left or right cavernous body of the penile shaft. Care should be taken not to inject into penile vessels or nerves on the upper side of the penis and into the urethra on the under side. The injection should be completed within 5 to 10 seconds and manual pressure should be applied to the injection site for 2 to 3 minutes.
Unused solution must be discarded immediately.
Advice
The content of the front chamber of the cartridge consists of a white, dry powder, which forms a compact layer, approximately 8 mm in height. The layer may show cracks and crumble slightly.
In case of damage to the cartridge, the usually dry content of the front chamber becomes moist and sticky and extensively loses volume. Viridal Duo must not be used in this case.
The bottom chamber contains the clear, colourless sodium chloride solvent solution.
The dry substance dissolves immediately after addition of the sodium chloride solution. Initially after reconstitution the solution may appear slightly opaque due to the presence of bubbles. This is of no relevance and disappears within a short time to give a clear solution.
Disposal of needle: disable needle then dispose of in a sharps container.
Disposal of cartridge: no special requirements.
7. Marketing Authorisation Holder
UCB Pharma Limited
208 Bath Road
Slough
Berkshire
SL1 3WE
United Kingdom
8. Marketing Authorisation Number(S)
PL 00039/0751
9. Date Of First Authorisation/Renewal Of The Authorisation
3rd September 2010
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