Source: Medicines & Healthcare Products Regulatory Agency (GB) Revision Year: 2019 Publisher: Generics [UK] Ltd t/a Mylan, Station Close, Potters Bar, Herts. EN6 1TL, United Kingdom
Hypersensitivity to the active substance, eslicarbazepine or to any of the excipients listed in section 6.1.
Class I (immediate) hypersensitivity reactions including rash, pruritus, urticaria, angioedema and reports of anaphylaxis have been received in the post-marketing period. Cases of anaphylaxis and angioedema involving the larynx, glottis, lips and eyelids have been reported in patients after taking the first or subsequent doses of oxcarbazepine. If a patient develops these reactions after treatment with oxcarbazepine, the drug should be discontinued and an alternative treatment started.
Patients who have exhibited hypersensitivity reactions to carbamazepine should be informed that approximately 25-30% of these patients may experience hypersensitivity reactions (e.g. severe skin reactions) with oxcarbazepine (see section 4.8).
Hypersensitivity reactions, including multi-organ hypersensitivity reactions, may also occur in patients without a history of hypersensitivity to carbamazepine. Such reactions can affect the skin, liver, blood and lymphatic system or other organs, either individually or together in the context of a systemic reaction (see section 4.8). In general, if signs and symptoms suggestive of hypersensitivity reactions occur Oxcarbazepine Mylan should be withdrawn immediately.
Serious dermatological reactions, including Stevens-Johnson syndrome, toxic epidermal necrolysis (Lyell’s syndrome) and erythema multiforme, have been reported very rarely in association with the use of oxcarbazepine. Patients with serious dermatological reactions may require hospitalisation, as these conditions may be life-threatening and very rarely be fatal. Oxcarbazepine associated cases occurred in both children and adults. The median time to onset was 19 days. Several isolated cases of recurrence of the serious skin reaction when rechallenged with oxcarbazepine were reported. Patients who develop a skin reaction with oxcarbazepine should be promptly evaluated and oxcarbazepine withdrawn immediately unless the rash is clearly not drug related. In case of treatment withdrawal, consideration should be given to replacing oxcarbazepine with other antiepileptic drug therapy to avoid withdrawal seizures. Oxcarbazepine should not be restarted in patients who discontinued treatment due to a hypersensitivity reaction (see section 4.3).
HLA-B*1502 in individuals of Han Chinese and Thai origin has been shown to be strongly associated with the risk of developing the severe cutaneous reactions known as Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN), when treated with carbamazepine. The chemical structure of oxcarbazepine is similar to that of carbamazepine, and it is possible that patients who are positive for HLA-B*1502 may also be at risk for SJS/TEN after treatment with oxcarbazepine. There are some data that suggest that such an association exists for oxcarbazepine. The prevalence of HLA-B*1502 carrier is about 10% in Han Chinese and Thai populations. Whenever possible, these individuals should be screened for this allele before starting treatment with carbamazepine or a chemically-related active substance. If patients of these origins are tested positive for HLA-B*1502 allele, the use of oxcarbazepine may be considered if the benefits are thought to exceed risks.
Because of the prevalence of this allele in other Asian populations (e.g. above 15% in the Philippines and Malaysia), testing genetically at risk populations for the presence of HLA-B*1502 may be considered.
The prevalence of the HLA-B*1502 allele is negligible in e.g. European descent, African, Hispanic populations sampled, and in Japanese and Koreans (< 1%).
Allele frequencies refer to the percentage of chromosomes in the population that carry a given allele. Since a person carries two copies of each chromosome, but even one copy of the HLA-B* 1502 allele may be enough to increase the risk of SJS, the percentage of patients who may be at risk is nearly twice the allele frequency.
There are some data that suggest HLA-A*3101 is associated with an increased risk of carbamazepine induced cutaneous adverse drug reactions including SJS, TEN, Drug rash with eosinophilia (DRESS), or less severe acute generalised exanthematous pustulosis (AGEP) and maculopapular rash in people of European descent and the Japanese.
The frequency of the HLA-A*3101 allele varies widely between ethnic populations. HLA-A*3101 allele has a prevalence of 2 to 5% in European populations and about 10% in Japanese population.
The presence of HLA-A*3101 allele may increase the risk for carbamazepine induced cutaneous reactions (mostly less severe) from 5.0% in general population to 26.0% among subjects of European ancestry, whereas its absence may reduce the risk from 5.0% to 3.8%.
The frequency of this allele is estimated to be less than 5% in the majority of Australian, Asian, African and North American populations with some exceptions within 5 to 12%. Frequency above 15% has been estimated in some ethnic groups in South America (Argentina and Brazil), North America (US Navajo and Sioux, and Mexico Sonora Seri) and Southern India (Tamil Nadu) and between 10% to 15% in other native ethnicities in these same regions.
Allele frequencies refer to the percentage of chromosomes in the population that carry a given allele. Since a person carries two copies of each chromosome, but even one copy of the HLA-A*3101 allele may be enough to increase the risk of SJS, the percentage of patients who may be at risk is nearly twice the allele frequency.
There are insufficient data supporting a recommendation for HLA-A*3101 screening before starting carbamazepine or chemically-related compounds treatment.
If patients of European descent or Japanese origin are known to be positive for HLA-A*3101 allele, the use of carbamazepine or chemically-related compounds may be considered if the benefits are thought to exceed risks.
Genetic screening results must never substitute appropriate clinical vigilance and patient management. Many Asian patients positive for HLA-B* 1502 and treated with oxcarbazepine will not develop SJS/TEN, and patients negative for HLA- B* 1502 of any ethnicity can still develop SJS/TEN. The same is true for HLA-A*3101 with respect to risk of SJS, TEN, DRESS, AGEP or maculopapular rash. The development of these severe cutaneous adverse reactions and its related morbidity due to other possible factors such as AED dose, compliance, concomitant medications, co- morbidities, and the level of dermatologic monitoring have not been studied.
If testing for the presence of the HLA-B*1502 allele is performed, high-resolution “HLA-B*1502 genotyping” is recommended. The test is positive if either one or two HLA-B* 1502 alleles are detected, and negative if no HLA- B* 1502 alleles are detected. Similarly, if testing for the presence of the HLA-A*3101 allele is performed, high resolution “HLA-A*3101 genotyping” is recommended. The test is positive if either one or two HLA-A*3101 alleles are detected, and negative if no HLA-A*3101 alleles are detected.
Risk of seizure aggravation has been reported with oxcarbazepine. The risk of seizure aggravation is seen especially in children but may also occur in adults. In case of seizure aggravation, oxcarbazepine should be discontinued.
Serum sodium levels below 125 mmol/l, usually asymptomatic and not requiring adjustment of therapy, have been observed in up to 2.7 % of oxcarbazepine treated patients. Experience from clinical trials shows that serum sodium levels returned towards normal when the oxcarbazepine dosage was reduced, discontinued or the patient was treated conservatively (e.g. restricted fluid intake). In patients with pre-existing renal conditions associated with low sodium levels (e.g. inappropriate ADH secretion like syndrome) or in patients treated concomitantly with sodium-lowering medicinal products (e.g. diuretics, desmopressin) as well as NSAIDs (e.g. indometacin), serum sodium levels should be measured prior to initiating therapy.
Thereafter, serum sodium levels should be measured after approximately two weeks and then at monthly intervals for the first three months during therapy, or according to clinical need. These risk factors may apply especially to elderly patients. For patients on oxcarbazepine therapy when starting on sodium-lowering medicinal products, the same approach for sodium checks should be followed. In general, if clinical symptoms suggestive of hyponatraemia occur in oxcarbazepine therapy (see section 4.8), serum sodium measurement may be considered. Other patients may have serum sodium levels assessed as part of their routine laboratory studies.
All patients with cardiac insufficiency and secondary heart failure should have regular weight measurements to determine occurrence of fluid retention. In case of fluid retention or worsening of the cardiac condition, serum sodium levels should be checked. If hyponatraemia is observed, water restriction is an important counter-measurement. As oxcarbazepine may, very rarely, lead to impairment of cardiac conduction, patients with pre-existing conduction disturbances (e.g. atrioventricular-block, arrhythmia) should be followed carefully.
Hypothyroidism is an adverse drug reaction (with “unknown” frequency, see section 4.8) of oxcarbazepine. Considering the importance of thyroid hormones in children’s development after birth, thyroid function monitoring is recommended in the paediatric age group while on Oxcarbazepine therapy.
Very rare cases of hepatitis have been reported, which in most of the cases resolved favourably. When a hepatic event is suspected, liver function should be evaluated and discontinuation of Oxcarbazepine Mylan should be considered. Caution should be exercised when treating patients with severe hepatic impairment (see sections 4.2 and 5.2).
In patients with impaired renal function (creatinine clearance less than 30 mL/min), caution should be exercised during oxcarbazepine treatment especially with regard to the starting dose and up titration of the dose. Plasma level monitoring of MHD may be considered (see section 4.2 and 5.2).
Very rare reports of agranulocytosis, aplastic anaemia and pancytopenia have been seen in patients treated with oxcarbazepine during post-marketing experience (see section 4.8).
Discontinuation of the medicinal product should be considered if any evidence of significant bone marrow depression develops.
Suicidal ideation and behaviour have been reported in patients treated with antiepileptic medicinal products in several indications. A meta-analysis of randomised placebo controlled trials of antiepileptic drugs has also shown a small increased risk of suicidal ideation and behaviour. The mechanism of this risk is not known and the available data do not exclude the possibility of an increased risk for oxcarbazepine.
Therefore patients should be monitored for signs of suicidal ideation and behaviours and appropriate treatment should be considered. Patients (and caregivers of patients) should be advised to seek medical advice should signs of suicidal ideation or behaviour emerge.
Female patients of childbearing age should be warned that the concurrent use of Oxcarbazepine with hormonal contraceptives may render this type of contraceptive ineffective (see section 4.5). Additional non-hormonal forms of contraception are recommended when using oxcarbazepine.
Caution should be exercised if alcohol is taken in combination with oxcarbazepine therapy, due to a possible additive sedative effect.
As with all antiepileptic medicinal products, oxcarbazepine should be withdrawn gradually to minimise the potential of increased seizure frequency.
Although correlations between dosage and plasma levels of oxcarbazepine, and between plasma levels and clinical efficacy or tolerability are rather tenuous, monitoring of the plasma levels may be useful in the following situations in order to rule out noncompliance or in situations where an alteration in MHD clearance is to be expected, including:
This medicinal product contains lactose. Patients with rare hereditary problems of galactose intolerance, total lactase deficiency or glucose-galactose malabsorption should not take this medicinal product.
Oxcarbazepine and its pharmacologically active metabolite (the monohydroxy derivative, MHD) are weak inducers in vitro and in vivo of the cytochrome P450 enzymes CYP3A4 and CYP3A5 responsible for the metabolism of a very large number of medicinal products, for example, immunosuppressants (e.g. ciclosporin, tacrolimus), oral contraceptives (see below), and some other antiepileptic medicinal products (e.g. carbamazepine) resulting in a lower plasma concentration of these medicinal products (see table below summarising results with other antiepileptic medicinal products).
In vitro, oxcarbazepine and MHD are weak inducers of UDP-glucuronyl transferases (effects on specific enzymes in this family are not known). Therefore, in vivo oxcarbazepine and MHD may have a small inducing effect on the metabolism of medicinal products which are mainly eliminated by conjugation through the UDP-glucuronyl transferases. When initiating treatment with oxcarbazepine or changing the dose, it may take 2 to 3 weeks to reach the new level of induction.
In case of discontinuation of oxcarbazepine therapy, a dose reduction of the concomitant medications may be necessary and should be decided upon by clinical and/or plasma level monitoring. The induction is likely to gradually decrease over 2 to 3 weeks after discontinuation.
Hormonal contraceptives: Oxcarbazepine was shown to have an influence on the two components, ethinylestradiol (EE) and levonorgestrel (LNG), of an oral contraceptive. The mean AUC values of EE and LNG were decreased by 48-52% and 32-52% respectively. Therefore, concurrent use of oxcarbazepine with hormonal contraceptives may render these contraceptives ineffective (see section 4.4). Another reliable contraceptive method should be used.
Oxcarbazepine and MHD inhibit CYP2C19. Therefore, interactions could arise when co-administering high doses of oxcarbazepine with medicinal products that are mainly metabolised by CYP2C19 (e.g. phenytoin). Phenytoin plasma levels increased by up to 40% when oxcarbazepine was given at doses above 1,200 mg/day (see table below summarising results with other anticonvulsants). In this case, a reduction of co-administered phenytoin may be required (see section 4.2).
Potential interactions between oxcarbazepine and other antiepileptic medicinal products were assessed in clinical studies. The effect of these interactions on mean AUCs and Cmin are summarised in the following table.
Summary of antiepileptic medicinal product interactions with oxcarbazepine.:
| Antiepileptic medicinal product | Influence of oxcarbazepine on antiepileptic medicinal product | Influence of antiepileptic medicinal product on MHD | |||
|---|---|---|---|---|---|
| Co-administered | Concentration | Concentration | |||
| Carbamazepine | 0-22% decrease (30% increase of carbamazepine-epoxide) | 40% decrease | |||
| Clobazam | Not studied | No influence | Felbamate | Not studied | No influence |
| Lamotrigine | No influence | No influence | |||
| Phenobarbital | 14-15% increase | 30-31% decrease | |||
| Phenytoin | 0-40% increase | 29-35% decrease | |||
| Valproic acid | No influence | 0-18% decrease |
Strong inducers of cytochrome P450 enzymes and/or UGT (i.e. rifampicin, carbamazepine, phenytoin and phenobarbital) have been shown to decrease the plasma/serum levels of MHD (29-49%) in adults; in children 4 to 12 years of age, MHD clearance increased by approximately 35% when given one of the three enzyme-inducing antiepileptic medicinal products compared to monotherapy. Concomitant therapy of oxcarbazepine and lamotrigine has been associated with an increased risk of adverse events (nausea, somnolence, dizziness and headache). When one or several antiepileptic medicinal products are concurrently administered with oxcarbazepine, a careful dose adjustment and/or plasma level monitoring may be considered on a case by case basis, notably in paediatric patients treated concomitantly with lamotrigine.
No autoinduction has been observed with oxcarbazepine.
Cimetidine, erythromycin, viloxazine, warfarin and dextropropoxyphene had no effect on the pharmacokinetics of MHD.
The interaction between oxcarbazepine and MAOIs is theoretically possible based on a structural relationship of oxcarbazepine to tricyclic antidepressants.
Patients on tricyclic antidepressant therapy were included in clinical trials and no clinically relevant interactions have been observed.
The combination of lithium and oxcarbazepine might cause enhanced neurotoxicity.
Oxcarbazepine may result in a failure of the therapeutic effect of oral contraceptive medicinal products containing ethinylestradiol (EE) and levonorgestrel (LNG) (see sections 4.4 and 4.5). Women of child bearing potential should be advised to use highly effective contraception (preferably non-hormonal; e.g. intrauterine implants) while on treatment with oxcarbazepine.
In the treated population, an increase in malformations has been noted with polytherapy, particularly in polytherapy including valproate.
Moreover, effective anti-epileptic therapy must not be interrupted, since the aggravation of the illness is detrimental to both the mother and the foetus.
There is moderate amount of data on pregnant women (300-1000 pregnancy outcomes). However, the data on oxcarbazepine associated with congenital malformation is limited. There is no increase in the total rate of malformations with oxcarbazepine as compared with the rate observed with general population (2-3%). Nevertheless, with this amount of data, a moderate teratogenic risk cannot be completely excluded.
Taking these data into consideration:
Some antiepileptic medicinal products may contribute to folic acid deficiency, a possible contributory cause of foetal abnormality. Folic acid supplementation is recommended before and during pregnancy. As the efficacy of this supplementation is not proved, a specific antenatal diagnosis should be offered even for women with a supplementary treatment of folic acid.
Data from a limited number of women indicate that plasma levels of the active metabolite of oxcarbazepine, the 10-monohydroxy derivative (MHD), may gradually decrease throughout pregnancy. It is recommended that clinical response should be monitored carefully in women receiving oxcarbazepine treatment during pregnancy to ensure that adequate seizure control is maintained. Determination of changes in MHD plasma concentrations should be considered. If dosages have been increased during pregnancy, postpartum MHD plasma levels may also be considered for monitoring.
Bleeding disorders in the newborn have been reported with hepatic inductor antiepileptic medicinal products. As a precaution, vitamin K1 should be administered as a preventive measure in the last few weeks of pregnancy and to the newborn.
Oxcarbazepine and its active metabolite (MHD) are excreted in human breast milk. A milk-to-plasma concentration ratio of 0.5 was found for both. The effects on the infant exposed to oxcarbazepine by this route are unknown. Therefore, oxcarbazepine should not be used during breast-feeding.
There are no human data on fertility. In rats, oxcarbazepine had no effects on fertility.
Effects on reproductive parameters in female rats were observed for MHD at doses comparable to those in humans (see section 5.3).
Adverse reactions such as dizziness, somnolence, ataxia, diplopia, blurred vision, visual disturbances, hyponatraemia and depressed level of consciousness were reported with oxcarbazepine (for complete list of ADRs see section 4.8), especially at the start of treatment or in connection with dose adjustments (more frequently during the up titration phase). Patients should therefore exercise due caution when driving a vehicle or operating machinery.
The most commonly reported adverse reactions are somnolence, headache, dizziness, diplopia, nausea, vomiting and fatigue occurring in more than 10% of patients.
The safety profile is based on adverse events (AEs) from clinical trials assessed as related to oxcarbazepine. In addition, clinically meaningful reports on adverse experiences from named patient programs and post-marketing experience were taken into account.
Adverse drug reactions are listed by MedRA system organ class.
Frequency estimate*:- 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.
Within each system organ class, the adverse drug reactions are ranked by frequency, with the most frequent reactions first. Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness.
Uncommon: Leucopenia
Very rare: Thrombocytopenia
Not known: Bone marrow depression, aplastic anaemia, agranulocytosis, pancytopenia, neutropenia.
Very rare: Hypersensitivity#
Not known: Anaphylactic reactions
Common: Weight increased
Not known: Hypothyroidism
Common: Hyponatraemia†
Very rare: Hyponatraemia associated with signs and symptoms such as seizures, encephalopathy, depressed level of consciousness, confusion (see also Nervous system disorders for further undesirable effects), vision disorders (e.g. blurred vision), hypothyroidism, vomiting, nausea†.
Not known: Inappropriate ADH secretion like syndrome with signs and symptoms of lethargy, nausea, dizziness, decrease in serum (blood) osmolality, vomiting, headache, confusional state or other neurological signs and symptoms.
Common: Agitation (e.g. nervousness), affect lability, confusional state, depression, apathy.
Very common: Somnolence, headache, dizziness.
Common: Ataxia, tremor, nystagmus, disturbance in attention, amnesia.
Not known: Speech disorders (including dysarthria); more frequent during up titration of oxcarbazepine dose.
Very common: Diplopia.
Common: Vision blurred, visual disturbance.
Common: Vertigo.
Very rare: Atrioventricular block, arrhythmia.
Not known: Hypertension.
Very common: Vomiting, nausea.
Common: Diarrhoea, abdominal pain, constipation
Very rare: Pancreatitis and/or lipase and/or amylase increase.
Very rare: Hepatitis.
Common: Rash, alopecia, acne.
Uncommon: Urticaria.
Very rare: Stevens-Johnson syndrome, toxic epidermal necrolysis (Lyell’s syndrome), angioedema, erythema multiforme (see section 4.4).
Not known: Drug Rash with Eosinophilia and Systemic Symptoms (DRESS), Acute Generalised Exanthematous Pustulosis (AGEP)
Very rare: Systemic lupus erythematosus.
Not known: There have been reports of decreased bone mineral density, osteopenia, osteoporosis and fractures in patients on long-term therapy with oxcarbazepine. The mechanism by which oxcarbazepine affects bone metabolism has not been identified.
Very common: Fatigue.
Common: Asthenia.
Uncommon: Hepatic enzymes increased, blood alkaline phosphatase increased.
Not known: Decrease in T4 (with unclear clinical significance).
Not known: Fall
* According to CIOMS III frequency classification
# Hypersensitivity (including multi-organ hypersensitivity) characterised by features such as rash, fever. Other organs or systems may be affected such as blood and lymphatic system (e.g. eosinophilia, thrombocytopenia, leucopenia, lymphadenopathy, splenomegaly), liver (e.g. hepatitis, abnormal liver function tests), muscles and joints (e.g. joint swelling, myalgia, arthralgia), nervous system (e.g. hepatic encephalopathy), kidneys (e.g. renal failure, nephritis interstitial, proteinuria), lungs (e.g. pulmonary oedema, asthma, bronchospasms, interstitial lung disease), angioedema.
† Serum sodium levels below 125 mmol/l have been observed in up to 2.7% of oxcarbazepine treated patients with frequency common (see section 4.4). In most cases, the hyponatriaemia is asymptomatic and does not require adjustment of therapy. Very rarely, the hyponatraemia is associated with signs and symptoms such as seizures, encephalopathy, depressed level of consciousness, confusion, (see also Nervous system disorders for further undesirable effects), vision disorders (e.g. blurred vision), hypothyroidism, vomiting, and nausea. Low serum sodium levels generally occurred during the first 3 months of treatment with oxcarbazepine, although there were patients who first developed a serum sodium levels <125 mmol/l more than 1 year after initiation of therapy (see section 4.4).
** Adverse drug reactions from spontaneous reports and literature cases (frequency not known): The following adverse drug reactions have been derived from post-marketing experience with oxcarbazepine via spontaneous case reports and literature cases. Because these reactions are reported voluntarily from a population of uncertain size, it is not possible to reliably estimate their frequency which is therefore categorised as not known.
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, website: http://www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.
Not applicable.
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