Nordurine 0.1 mg Tablets

Nordurine 0.1 mg Tablets

Each tablet contains desmopressin acetate 0.1 mg equivalent to desmopressin (free base) 89 micrograms.

Also contains lactose monohydrate, 123.7mg per tablet.

For the full list of excipients, see section 6.1.

Tablet.

White, oval, convex tablet with a single score. Engraving 0.1.

The scoreline is to facilitate breaking for ease of swallowing and not to divide into equal halves.

1. For the diagnosis and treatment of cranial diabetes insipidus including post-hypophysectomy polyuria/polydipsia and for the treatment of primary nocturnal enuresis in patients (from 5 to 65 years of age) with normal ability to concentrate urine.

2. Nordurine Tablets are indicated for the symptomatic treatment of nocturia in adults up to 65 years only, associated with nocturnal polyuria, i.e. nocturnal urine production exceeding bladder capacity.

General

Effect of food: Food intake may reduce the intensity and duration of the antidiuretic effect at low doses of desmopressin (see section 4.5).

In the event of signs or symptoms of water retention and/or hyponatraemia (headache, nausea/vomiting, weight gain, and, in severe cases, convulsions) treatment should be interrupted until the patient has fully recovered. When restarting treatment strict fluid restriction should be enforced (see section 4.4).

If adequate clinical effect is not achieved within 4 weeks following appropriate dose titration the medication should be discontinued.

Indication specific

Central diabetes insipidus:

Dosage is individual in diabetes insipidus but clinical experience has shown that the total daily dose normally lies in the range of 0.2 to 1.2 mg. A suitable starting dose in adults and children is 0.1 mg three times daily. This dosage regimen should then be adjusted in accordance with the patient's response. For the majority of patients, the maintenance dose is 0.1 mg to 0.2 mg three times daily.

Primary nocturnal enuresis:

The recommended initial dose is 0.2 mg at bedtime.

If this dose is not sufficiently effective, the dose may be increased up to 0.4 mg. Fluid restriction should be observed.

Nordurine Tablets are intended for treatment periods of up to 3 months. The need for continued treatment should be reassessed by means of a period of at least one week without Nordurine Tablets.

Nocturia:

The recommended initial dose is 0.1 mg at bedtime.

If this dose is not sufficiently effective after one week, the dose may be increased up to 0.2 mg and subsequently 0.4 mg by weekly dose escalations. Fluid restriction should be observed.

In nocturia patients, a frequency/volume chart should be used to diagnose nocturnal polyuria for at least 2 days before starting treatment. A night-time urine production exceeding the functional bladder capacity or exceeding 1/3 of the 24 hour urine production is regarded as nocturnal polyuria.

Special Populations

Elderly:

Older patients:

The initiation of treatment in older patients (patients over 65 years) is contraindicated in patients being treated for nocturia and primary nocturnal enuresis.

Dosage recommendation for older patients suffering from central diabetes insipidus is the same as for other age groups.

Renal Impairment

Nordurine Tablets are contraindicated in cases of moderate and severe renal insufficiency (creatinine clearance below 50 ml/min) (see section 4.3).

Hepatic Impairment

In vitro human liver microsome metabolism studies of desmopressin have shown that no significant amount is metabolized in the liver by the cytochrome P450 system. Thus human liver metabolism in vivo by the cytochrome P450 system is unlikely to occur. The effect of desmopressin on the PK of other drugs is likely to be minimal due to its lack of inhibition of the cytochrome P450 drug metabolizing system (see section 4.5).

Paediatric Population

Nordurine Tablets are indicated in Central Diabetes Insipidus and Primary Nocturnal Enuresis (see section 4.1 and indication specific information in 4.2 above). Dose recommendations are the same as in adults.

Nordurine Tablets are contraindicated in cases of:

o Habitual or psychogenic polydipsia (resulting in a urine production exceeding 40ml/kg/24 hours);

o A history of known or suspected cardiac insufficiency and other conditions requiring treatment with diuretics;

o Moderate and severe renal insufficiency (creatinine clearance below 50 ml/min);

o Known hyponatraemia;

o Syndrome of inappropriate ADH secretion;

o Hypersensitivity to desmopressin or to any of the excipients of Nordurine Tablets.

o Patients over the age of 65 for the treatment of primary nocturnal enuresis.

o Patients over the age of 65 for the treatment of nocturia.

Before prescribing Nordurine Tablets the diagnoses of psychogenic polydipsia and alcohol abuse should be excluded.

Special warnings:

When used for primary nocturnal enuresis and nocturia indications, the fluid intake must be limited to a minimum from 1 hour before until the next morning (at least 8 hours) after administration. Treatment without concomitant reduction of fluid intake may lead to water retention and/or hyponatraemia with or without accompanying warning signs and symptoms (headache, nausea/vomiting, weight gain, and, in severe cases, convulsions). All patients and, when applicable, their guardians should be carefully instructed to adhere to the fluid restrictions.

This product contains lactose monohydrate. Patients with rare hereditary problems of galactose intolerance, the Lapp lactose deficiency or glucose-galactose malabsorption should not take this medicine.

Use of the product should be under specialist supervision with appropriate facilities available for monitoring and interpretation of response.

All patients on desmopressin therapy should be observed for the signs of symptoms associated with hyponatraemia (headache, nausea/vomiting, weight increased and, in severe cases, convulsions).

Care should be taken with patients who have reduced renal function (see section 4.2) and/or cardiovascular disease or cystic fibrosis (see section 4.3).

Patients being treated for primary nocturnal enuresis or nocturia should discontinue Nordurine Tablets during an episode of vomiting and/or diarrhoea until their fluid balance is once again normal.

Precautions

- Severe bladder dysfunction and outlet obstruction should be considered before starting treatment.

- Older patients and patients with low serum sodium levels may have an increased risk of hyponatraemia therefore Nordurine Tablets are contraindicated in patients being treated for primary nocturnal enuresis and nocturia.

- Treatment with desmopressin should be interrupted during acute intercurrent illnesses characterised by fluid and/or electrolyte imbalance (such as systemic infections, fever, and gastroenteritis).

- Precautions must be taken in patients at risk for increased intracranial pressure.

- Desmopressin should be used with caution in patients with conditions characterized by fluid and/or electrolyte imbalance.

- Precautions to avoid hyponatraemia including careful attention to fluid restriction and more frequent monitoring of serum sodium must be taken in case of concomitant treatment with drugs, which are known to induce SIADH, e.g. tricyclic antidepressants, selective serotonine reuptake inhibitors, chlorpromazine and carbamazepine, case of concomitant treatment with NSAIDs.

Substances, which are known to induce SIADH, e.g. tricyclic antidepressants, selective serotonine reuptake inhibitors, chlorpromazine and carbamazepine, as well as some antidiabetics of the sulfonylurea group particularly Chlorpropamide, may cause an additive antidiuretic effect leading to an increased risk of water retention/hyponatraemia (see section 4.4).

NSAIDs may induce water retention/hyponatraemia (see section 4.4).

Concomitant treatment with loperamide may result in a 3-fold increase of desmopressin plasma concentrations, which may lead to an increased risk of water retention/hyponatraemia.

Although not investigated, other drugs slowing intestinal transport might have the same effect.

It is unlikely that desmopressin will interact with drugs affecting hepatic metabolism, since desmopressin has been shown not to undergo significant liver metabolism in in vitro studies with human microsomes. However, formal in vivo interaction studies have not been performed.

The concomitant use of food decreases the rate and extent of absorption of Nordurine tablets by 40%. No significant effect was observed with respect to pharmacodynamics (urine production or osmolality).

Food intake may reduce the intensity and duration of the antidiuretic effect at low oral doses of desmopressin (see section 4.2).

Pregnancy:

Data on a limited number (n=53) of exposed pregnancies in women with diabetes insipidus as well as data on a limited number (n=54) of exposed pregnancies in women with von Willebrand disease indicate no adverse effects of desmopressin on pregnancy or on the health of the foetus/ newborn child. To date, no other relevant epidemiological data are available. Animal studies do not indicate direct or indirect harmful effects with respect to pregnancy, embryonal/foetal development, parturition or postnatal development.

Caution should be exercised when prescribing Nordurine tablets to pregnant women.

Fertility studies have not been done. In vitro analysis of human cotyledon models have shown that there is no transplacental transport of desmopressin when administered at therapeutic concentrations corresponding to recommended dose.

Lactation:

Results from analyses of milk from nursing mothers receiving high dose desmopressin (300 micrograms intranasal) indicate that the amounts of desmopressin that may be transferred to the child are considerably less than the amounts required to influence diuresis.

Nordurine Tablets have no or negligible influence on the ability to drive and use machines.

Summary of the safety profile

The most serious adverse reaction with desmopressin is hyponatraemia, which may cause headache, abdominal pain, nausea, vomiting, weight increase, dizziness, confusion, malaise, memory impairment, vertigo, falls and in severe cases convulsions and coma. The majority of adults treated for nocturia who develop hyponatraemia have developed low serum sodium after three days of dosing. In adults the risk of hyponatraemia increases with increasing dose of desmopressin and the risk has been found to be more prominent in women.

In adults the most commonly reported adverse reaction during treatment was headache (12%). Other common adverse reactions were hyponatraemia (6%), dizziness (3%), hypertension (2%), and gastrointestinal disorders (nausea (4%), vomiting (1%), abdominal pain (3%), diarrhoea (2%) and constipation (1%)). Less common is an influence of the sleep pattern/consciousness level presenting itself as e.g. insomnia (0.96%), somnolence (0.4%) or asthenia (0.06%). Anaphylactic reactions have not been seen in clinical trials but spontaneous reports have been received.

In children the most commonly reported adverse reaction during treatment was headache (1%), less common were psychiatric disorders (affect lability (0.1%), aggression (0.1%), anxiety (0.05%), mood swings (0.05%), nightmare (0.05%)) which generally abated after treatment discontinuation and gastrointestinal disorders (abdominal pain (0.65%), nausea (0.35%), vomiting (0.2%) and diarrhoea (0.15%)). Anaphylactic reactions have not been seen in clinical trials but spontaneous reports have been received.

Tabulated summary of adverse reactions

Adults:

Based on the frequency of adverse drug reactions reported in clinical trials with oral desmopressin conducted in adults for treatment of Nocturia (N=1557) combined with the post marketing experience for all adult indications (incl Central Diabetes Insipidus). Reactions only seen in post marketing have been added in the 'Not known'-frequency column.

MedDRA Organ Class	Very common (>1/10)	Common (>1/100, <1/10)	Uncommon (>1/1,000, <1/100)	Rare (>1/10,000, <1/1,000)	Not known
Immune system disorders					Anaphylactic reaction
Metabolism and nutrition disorders		Hyponatraemia*			Dehydration**, Hypernatraemia**
Psychiatric disorders			Insomnia	Confusional state*
Nervous system disorders	Headache*	Dizziness*	Somnolence, paraesthesia		Convulsions*, Asthenia**, Coma*
Eye disorders			Visual impairment
Ear and labyrinth disorders			Vertigo*
Cardiac disorders			Palpitations
Vascular disorders		Hypertension	Orthostatic hypotension
Respiratory, thoracic and mediastinal disorders			Dyspnoea
Gastrointestinal disorders		Nausea*, Abdominal pain*, Diarrhoea, Constipation, Vomiting*	Dyspepsia, Flatulence, bloating and distension
Skin and subcutaneous tissue disorders			Sweating, Pruritus, Rash, Urticaria	Dermatitis allergic
Musculoskeletal and connective tissue disorders			Muscle spasms, Myalgia
Renal and urinary disorders		Bladder and urethral symptoms
General disorders and administration site conditions		Oedema, Fatigue	Malaise*, Chest pain, Influeza like illness
Investigations			Weight increased*, Hepatic enzyme increased, Hypokalaemia

* Hyponatraemia may cause headache, abdominal pain, nausea, vomiting, weight increase, dizziness, confusion, malaise, memory impairment, vertigo, falls, convulsions and coma

** Only seen in the CDI indication

Children and Adolescents:

Based on the frequency of adverse drug reactions reported in clinical trials with oral desmopressin conducted in children and adolescents for treatment of Primary Nocturnal Enuresis (N = 1923). Events only seen in post marketing have been added in the 'Not known' frequency column.

MedDRA Organ Class	Very common (>1/10)	Common (>1/100, <1/10)	Uncommon (>1/1,000, <1/100)	Rare (>1/10,000, <1/1,000)	Not known
Immune system disorders					Anaphylactic reaction
Metabolism and nutrition disorders					Hyponatraemia*
Psychiatric disorders			Affect lability**, Aggression***	Anxiety symptoms, Nightmare****, Mood swings****	Abnormal behaviour, Emotional disorder, Depression, Hallucination, Insomnia
Nervous system disorders		Headache*		Somnolence	Disturbance in attention, Psychomotor hyperactivity, Convulsions*
Vascular disorders				Hypertension
Respiratory, thoracic and mediastinal disorders					Epistaxis
Gastrointestinal disorders			Abdominal pain*, Nausea*, Vomiting*, Diarrhoea
Skin and subcutaneous tissue disorders					Dermatitis allergic, Rash, Sweating, Urticaria
Renal and urinary disorders			Bladder and urethral symptoms
General disorders and administration site conditions			Oedema peripheral, Fatigue	Irritability

* Hyponatraemia may cause headache, abdominal pain, nausea, vomiting, weight increase, dizziness, confusion, malaise, memory impairment, vertigo, falls, convulsions and coma

** Post marketing reported equally in children and adolescents (<18 years)

*** Post marketing almost exclusively reported in children and adolescents (<18 years)

****Post marketing reported primarily in children (<12 years)

Other special populations:

Elderly patients and patients with serum sodium levels in the lower range of normal may have an increased risk of developing hyponatraemia (see section 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 HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2. Tel: +353 1 6764971; Fax: +353 1 6762517; Website: www.hpra.ie; E-mail: medsafety@hpra.ie.

Overdose of Nordurine tablets leads to a prolonged duration of action with an increased risk of water retention and hyponatraemia.

Treatment:

Although the treatment of hyponatraemia should be individualised, the following general recommendations can be given - discontinue the desmopressin treatment and institute fluid restriction, and symptomatic treatment if needed.

Pharmacotherapeutic group: vasopressin and analogues.

ATC code: H01B A02.

Nordurine Tablets contain desmopressin, a structural analogue of the natural pituitary hormone arginine vasopressin. The difference lies in the desamination of cysteine and substitution of L-arginine by D-arginine. This results in a considerably longer duration of action and a complete lack of pressor effect in the dosages clinically used. Desmopressin is a potent compound with an EC₅₀ value of 1.6 pg/ml, for the antidiuretic effect. After oral administration, an effect lasting from 6 to 14 hours or more can be expected.

Clinical trials with desmopressin tablets in the treatment of nocturia showed the following:

- A reduction of at least 50 % in the mean number of nocturnal voids was obtained in 39 % of patients with desmopressin compared to 5 % of patients with placebo (p<0.0001)

- The mean number of voids per night decreased by 44 % with desmopressin compared to 15 % with placebo (p<0.0001)

- The median duration of first undisturbed sleep period increased by 64% with desmopressin compared to 20 % with placebo (p<0.0001)

- The mean duration of first undisturbed sleep period increased by 2 hours with desmopressin compared to 31 minutes with placebo (p<0.0001)

Effect of treatment with individual oral dose of desmopressin between 0.1 and 0.4 mg during 3 weeks, compared with placebo (pooled data).

	Desmopressin		Placebo		Statistical significance vs. placebo
Variable	Mean baseline value	Mean value during 3 weeks of treatment	Mean baseline value	Mean value during 3 weeks of treatment
Number of nocturnal voids	2.97 (0.84)	1.68 (0.86)	3.03 (1.10)	2.54 (1.05)	p<0.0001
Nocturnal diuresis rate (ml/min)	1.51 (0.55)	0.87 (0.34)	1.55 (0.57)	1.44 (0.57)	p<0.0001
Duration of first undisturbed sleep period (min)	152 (51)	270 (95)	147 (54)	178 (70)	p<0.0001

Eight percent of the patients interrupted in the desmopressin dose titration phase due to adverse effects, and 2 % in the subsequent double-blind phase (0.63 % on desmopressin and 1.45 % on placebo).

The absolute bioavailability of desmopressin tablets is 0.16% with an SD of 0.17%. Mean maximum plasma concentration is reached within 2 hours.

Concomitant use of food decreases the rate and extent of absorption by 40%.

Distribution: The distribution of desmopressin is best described by a two-compartment distribution model with a volume of distribution during the elimination phase of 0.3-0.5 L/kg.

Biotransformation: The in-vivo metabolism of desmopressin has not been studied. In-vitro human liver microsome metabolism studies of desmopressin have shown that no significant amount is metabolized in the liver by the cytochrome P450 system. Thus human liver metabolism in vivo by the cytochrome P450 system is unlikely to occur. The effect of desmopressin on the PK of other drugs is likely to be minimal due to its lack of inhibition of the cytochrome P450 drug metabolizing system.

Elimination:

The total clearance of desmopressin has been calculated to 7.6 L/hr. The terminal half-life of desmopressin is estimated to be 2.8 hours. In healthy subjects the fraction excreted unchanged was 52% (44%-60%).

Linearity/non-linearity:

There are no indications of non-linearities in any of the pharmacokinetic parameters of desmopressin.

Characteristics in specific groups of patients:

Renal Impairment:

Depending on the degree of renal impairment the AUC and half-life increased with the severity of the renal impairment. In patients with moderate and severe renal impairment (creatinine clearance below 50ml/min) desmopressin is contraindicated.

Hepatic Impairment:

No studies performed.

Children:

The population pharmacokinetics of desmopressin tablets has been studied in children with PNE and no significant differences from adults were detected.

Non-clinical data reveal no special hazard for humans based on conventional studies of safety pharmacology, repeated dose toxicity, genotoxicity, toxicity to reproduction.

Carcinogenicity studies have not been performed with desmopressin, because it is very closely related to the naturally-occurring peptide hormone.

Lactose monohydrate

Potato starch

Povidone

Magnesium stearate

Not applicable

3 years

Do not store above 25°C.

Store in the original package and keep the bottle tightly closed in order to protect from light and moisture.

HDPE bottle with a child resistant PP cap and a dessicant capsule. Pack size of 30 or 90 tablets.

Not all pack sizes may be marketed.

No special requirements

Ferring Ireland Ltd

United Drug House

Magna Drive

Magna Business Park

Citywest Road

Dublin 24

Ireland

PA 1009/17/1

Date of first authorisation: 25 July 2003

Date of last renewal 24 July 2008

May 2015