- 1. Name of the medicinal product
- 2. Qualitative and quantitative composition
- 3. Pharmaceutical form
- 4. Clinical particulars
- 4.1 Therapeutic indications
- 4.2 Posology and method of administration
- 4.3 Contraindications
- 4.4 Special warnings and precautions for use
- 4.5 Interaction with other medicinal products and other forms of interaction
- 4.6 Fertility, pregnancy and lactation
- 4.7 Effects on ability to drive and use machines
- 4.8 Undesirable effects
- 4.9 Overdose
- 5. Pharmacological properties
- 5.1 Pharmacodynamic properties
- 5.2 Pharmacokinetic properties
- 5.3 Preclinical safety data
- 6. Pharmaceutical particulars
- 6.1 List of excipients
- 6.2 Incompatibilities
- 6.3 Shelf life
- 6.4 Special precautions for storage
- 6.5 Nature and contents of container
- 6.6 Special precautions for disposal and other handling
- 7. Marketing authorisation holder
- 8. Marketing authorisation number(s)
- 9. Date of first authorisation/renewal of the authorisation
- 10. Date of revision of the text
PosologyAdults:Premique Low Dose is taken in a continuous combined 28-day regimen of one tablet daily with no break between packs.In women who are not taking hormone replacement therapy or women who switch from another continuous combined hormone replacement therapy product, treatment may be started on any convenient day. In women transferring from a sequential hormone replacement therapy regimen, treatment should begin the day following completion of the prior regimen. For treatment of postmenopausal symptoms: Take one tablet per day. Breakthrough bleeding and spotting may occur in the early stages of Premique Low Dose therapy. If breakthrough bleeding persists and endometrial abnormality has been ruled out, a higher dose of treatment or cyclic therapy should be considered as an alternative.The lowest dose and regimen that will control symptoms should be chosen.
Maintenance/Continuation/Extended treatmentFor initiation and continuation of treatment of postmenopausal symptoms, the lowest effective dose for the shortest duration (see section 4.4) should be used. Patients should be re-evaluated periodically to determine if treatment for symptoms is still necessary.The benefits of the lower risk of endometrial hyperplasia and endometrial cancer due to adding a progestogen should be weighed against the increased risk of breast cancer (see sections 4.4 and 4.8). Forgotten tablet: If a tablet is forgotten, it should be taken as soon as the patient remembers, therapy should then be continued as before. If more than one tablet has been forgotten only the most recent tablet should be taken, the patient should not take double the usual dose to make up for missed tablets. Missed pills may cause breakthrough bleeding.Elderly:There are no special dosage requirements for elderly patients, but, as with all medicines, the lowest effective dose should be used.Paediatric population:Not recommended.
Method of administrationPremique is taken orally.
Medical examination/follow-upBefore initiating or reinstituting HRT, a complete personal and family medical history should be taken. Physical (including pelvic and breast) examination should be guided by this and by the contraindications and warnings for use. During treatment, periodic check-ups are recommended of a frequency and nature adapted to the individual woman. Women should be advised what changes in their breasts should be reported to their doctor or nurse (see 'Breast Cancer' below). Investigations, including appropriate imaging tools, e.g. mammography, should be carried out in accordance with currently accepted screening practices, modified to the clinical needs of the individual.
Conditions which need supervisionIf any of the following conditions are present, have occurred previously, and/or have been aggravated during pregnancy or previous hormone treatment, the patient should be closely supervised. It should be taken into account that these conditions may recur or be aggravated during treatment with Premique Low Dose, in particular:− Leiomyoma (uterine fibroids) or endometriosis− Risk factors for thromboembolic disorders (see below)− Risk factors for estrogen dependent tumours (e.g. 1st degree heredity for breast cancer)− Hypertension− Liver disorders (e.g. liver adenoma)− Diabetes mellitus with or without vascular involvement− Cholelithiasis− Migraine or (severe) headaches− Systemic lupus erythematosus (SLE)− A history of endometrial hyperplasia (see below)− Epilepsy− Asthma− Otosclerosis
Reasons for immediate withdrawal of therapyTherapy should be discontinued in case a contra-indication is discovered and in the following situations:− Jaundice or deterioration in liver function− Significant increase in blood pressure− New onset of migraine-type headache− Pregnancy
Endometrial hyperplasia and carcinomaIn women with an intact uterus the risk of endometrial hyperplasia and carcinoma is increased when estrogens are administered alone for prolonged periods. The reported increase in endometrial cancer risk among estrogen-only users varies from 2-to 12-fold greater compared with non-users, depending on the duration of treatment and estrogen dose (see section 4.8). After stopping treatment risk may remain elevated for at least 10 years.The addition of a progestogen for at least 12 days per month/28 day cycle or continuous combined estrogen-progestogen therapy in non-hysterectomised women prevents the excess risk associated with estrogen-only HRT. Unless there is a previous diagnosis of endometriosis it is not recommended to add a progestogen in hysterectomised women.The reduction in risk to the endometrium should be weighed against the increase in the risk of breast cancer of added progestogen (see 'Breast cancer' below and section 4.8). Break-through bleeding and spotting may occur during the first months of treatment. If break-through bleeding or spotting appears after some time on therapy, or continues after treatment has been discontinued, the reason should be investigated, which may include endometrial biopsy to exclude endometrial malignancy.
Breast cancerThe overall evidence suggests an increased risk of breast cancer in women taking combined estrogen-progestogen and possibly also estrogen-only HRT, that is dependent on the duration of taking HRT.The randomised placebo-controlled trial, the Women's Health Initiative study (WHI), and epidemiological studies, including the Million Women Study (MWS), are consistent in finding an increased risk of breast cancer in women taking estrogen-progestogen combinations for HRT that becomes apparent after about 3 years (see section 4.8). For all HRT, an excess risk becomes apparent within a few years of use and increases with the duration of intake but returns to baseline within a few (at most five) years after stopping treatment. HRT, especially estrogen-progestogen combined treatment, increases the density of mammographic images which may adversely affect the radiological detection of breast cancer.
Ovarian CancerOvarian cancer is much rarer than breast cancer. Epidemiological evidence from a large meta-analysis suggests a slightly increased risk in women taking estrogen-only or combined estrogen-progestogen HRT, which becomes apparent within 5 years of use and diminishes over time after stopping.Some other studies, including the WHI trial, suggest that the use of combined HRTs may be associated with a similar or slightly smaller risk (see section 4.8).
Venous thromboembolismHormone replacement therapy (HRT) is associated with a 1.3-3 fold risk of developing venous thromboembolism (VTE) i.e. deep vein thrombosis or pulmonary embolism. The occurrence of such an event is more likely in the first year of HRT than later (see section 4.8). Patients with a history of VTE or known thrombophilic states have an increased risk of VTE. HRT may add to this risk. HRT is therefore contraindicated in these patients (see section 4.3). Personal or strong family history of thromboembolism or recurrent spontaneous abortion should be investigated in order to exclude a thrombophilic predisposition. Generally recognised risk factors for VTE include, use of estrogens, older age, major surgery, prolonged immobilisation, obesity (BMI > 30 kg/m2), pregnancy/postpartum period, systemic lupus erythematosus (SLE), and cancer. There is no consensus about the possible role of varicose veins in VTE. As in all postoperative patients scrupulous attention should be given to prophylactic measures to prevent VTE following surgery. Where prolonged immobilisation is liable to follow elective surgery, particularly abdominal or orthopaedic surgery to the lower limbs, consideration should be given to temporarily stopping HRT 4-6 weeks earlier, if this is possible. Treatment should not be restarted until the woman is completely mobilised.In women with no personal history of VTE but with a first degree relative with a history of thrombosis at young age, screening may be offered after careful counselling regarding its limitations (only a proportion of thrombophilic defects are identified by screening). If a thrombophilic defect is identified which segregates with thrombosis in family members or if the defect is 'severe' (e.g., antithrombin, protein S, or protein C deficiencies or a combination of defects) HRT is contraindicated.Women already on anticoagulant treatment require careful consideration of the benefit-risk of use of HRT.If venous thromboembolism develops after initiating therapy the drug should be discontinued. Patients should be told to contact their doctors immediately when they are aware of potential thromboembolic symptoms (e.g. painful swelling of a leg, sudden pain in the chest, dyspnoea).
Coronary artery disease (CAD)There is no evidence from randomised controlled trials of protection against myocardial infarction in women with or without existing CAD who received MPA.The relative risk of CAD during use of combined estrogen+progestogen HRT is slightly increased. As the baseline absolute risk of CAD is strongly dependent on age, the number of extra cases of CAD due to estrogen+progestogen use is very low in healthy women close to menopause, but will rise with more advanced age.
Ischaemic strokeCombined estrogen-progestogen and estrogen-only therapy are associated with an up to 1.5-fold increase in risk of ischaemic stroke. The relative risk does not change with age or time since menopause. However, as the baseline risk of stroke is strongly age-dependent, the overall risk of stroke in women who use HRT will increase with age (see section 4.8).
Other conditions• Estrogens/progestogens may cause fluid retention and therefore patients with cardiac or renal dysfunction should be carefully observed. Patients with terminal renal insufficiency should be closely observed, since it is expected that the level of circulating active ingredients in Premique Low Dose is increased. • Women with pre-existing hypertriglyceridemia should be followed closely during estrogen replacement or hormone replacement therapy, since rare cases of large increases of plasma triglycerides leading to pancreatitis have been reported with estrogen therapy in this condition.• The use of estrogen may influence the laboratory results of certain endocrine tests and liver enzymes.Estrogens increase thyroid binding globulin (TBG), leading to increased circulating total thyroid hormone, as measured by protein-bound iodine (PBI), T4 levels (by column or by radio-immunoassay) or T3 levels (by radio-immunoassay). T3 resin uptake is decreased, reflecting the elevated TBG. Free T4 and free T3 concentrations are usually unaltered. Other binding proteins may be elevated in serum, i.e. corticoid binding globulin (CBG), sex-hormone-binding globulin (SHBG) leading to increased circulating corticosteroids and sex steroids, respectively. Free or biologically active hormone concentrations are usually unchanged. Other plasma proteins may be increased (angiotensinogen/renin substrate, alpha-I-antitrypsin, ceruloplasmin). Some patients dependent on thyroid hormone replacement therapy may require increased doses in order to maintain their free thyroid hormone levels in an acceptable range. Therefore, patients should have their thyroid function monitored more frequently when commencing concurrent treatment in order to maintain their free thyroid hormone levels in an acceptable range.• HRT use does not improve cognitive function. There is some evidence of increased risk of probable dementia in women who start using continuous combined or estrogen-only HRT after the age of 65.• There is an increase in the risk of gallbladder disease in women receiving HRT (see conditions that need supervision).• A worsening of glucose tolerance may occur in some patients on estrogen/progestogen therapy and therefore diabetic patients should be carefully observed while receiving hormone replacement therapy.• This product contains lactose monohydrate and sucrose. Patients with rare hereditary problems of galactose intolerance, fructose intolerance, the Lapp lactase deficiency, glucose-galactose malabsorption or sucrase-isomaltase insufficiency should not take this medicine.• Estrogens should be used with caution in individuals with severe hypocalcaemia.
Breast-feedingPremique Low Dose is not indicated during lactation.
Adverse drug reactions (ADRs)The adverse reactions listed in the table are based on post-marketing spontaneous (reporting rate), clinical trials and class-effects. Breast pain is a very common adverse event reported in ≥ 10% of patients.
|System Organ Class||Very Common ADRs ( >1/10)||Common ADRs ( >1/100, < 1/10)||Uncommon ADRs ( >1/1000, <1/100)||Rare ADRs ( >1/10000, <1/1000)||Very Rare ADRs ( <1/10000), isolated reports|
|Infections and infestations||Vaginitis||Vaginal candidiasis|
|Neoplasms benign and malignant (including cysts and polyps)||Fibrocystic breast changes, Ovarian cancer||Enlargement of hepatic hemangiomas|
|Immune system disorders||Anaphylactic/ anaphylactoid reactions, including urticaria and angioedema|
|Metabolism and nutrition disorders||Glucose intolerance||Exacerbation of porphyria; Hypocalcemia|
|Psychiatric disorders||Depression||Changes in libido; Mood disturbances||Irritability|
|Nervous system disorders||Dizziness; Headache; Migraine; Anxiety||Stroke; Exacerbation of epilepsy||Exacerbation of chorea|
|Eye disorders||Intolerance to contact lenses||Retinal vascular thrombosis|
|Cardiac disorders||Myocardial infarction|
|Vascular disorders||Pulmonary embolism||Superficial thrombophlebitis|
|Respiratory, thoracic and mediastinal disorders||Exacerbation of asthma|
|Gastrointestinal disorders||Nausea; Bloating; Abdominal pain||Vomiting; Pancreatitis|
|Hepatobiliary disorders||Gallbladder disease||None||Cholestatic jaundice|
|Skin and subcutaneous tissue disorders||Alopecia; Acne; Pruritus||Chloasma/melasma; Hirsutism; Pruritus; Rash|
|Musculoskeletal, connective tissue and bone disorders||Arthralgias; Leg cramps|
|Reproductive system & breast disorders||Breast pain||Breakthrough bleeding/ spotting, Dysmenorrhea; Breast tenderness, enlargement; Discharge||Change in menstrual flow; Change in cervical ectropion and secretion||Galactorrhoea; Increased size of uterine leiomyomata|
|General disorders and administration site conditions||Oedema|
|Investigations||Changes in weight (increase or decrease); Increased triglycerides||Increase in blood pressure|
Breast cancer risk• An up to 2-fold increased risk of having breast cancer diagnosed is reported in women taking combined estrogen-progestogen therapy for more than 5 years.• Any increased risk in users of estrogen-only therapy is substantially lower than that seen in users of estrogen-progestogen combinations. • The level of risk is dependent on the duration of use (see section 4.4). • Results of the largest randomised placebo-controlled trial (WHI-study) and largest epidemiological study (MWS) are presented.
Million Women study Estimated additional risk of breast cancer after 5 years' use
|Age range (years)||Additional cases per 1000 never-users of HRT over a 5 year period*||Risk ratio & 95%CI#||Additional cases per 1000 HRT users over 5 years (95%CI)|
|estrogen only HRT|
|#Overall risk ratio. The risk ratio is not constant but will increase with increasing duration on use Note: Since the background incidence of breast cancer differs by EU country, the number of additional cases of breast cancer will also change proportionately.|
US WHI studies - additional risk of breast cancer after 5 years' use
|Age range (yrs)||Incidence per 1000 women in placebo arm over 5 years||Risk ratio & 95%CI||Additional cases per 1000 HRT users over 5 years (95%CI)|
|50-79||21||0.8 (0.7 1.0)||-4 (-6 0)**|
|CEE+MPA estrogen & progestogen|
|50-79||17||1.2 (1.0 1.5)||+4 (0 9)|
Endometrial cancer risk
Postmenopausal women with a uterusThe endometrial cancer risk is about 5 in every 1000 women with a uterus not using HRT.In women with a uterus, use of estrogen-only HRT is not recommended because it increases the risk of endometrial cancer (see section 4.4).Depending on the duration of estrogen-only use and estrogen dose, the increase in risk of endometrial cancer in epidemiology studies varied from between 5 and 55 extra cases diagnosed in every 1000 women between the ages of 50 and 65.Adding a progestogen to estrogen-only therapy for at least 12 days per cycle can prevent this increased risk. In the Million Women Study the use of five years of combined (sequential or continuous) HRT did not increase risk of endometrial cancer (RR of 1.0 (0.8-1.2)).
Ovarian cancerUse of estrogen-only or combined estrogen-progestogen HRT has been associated with a slightly increased risk of having ovarian cancer diagnosed (see section 4.4). A meta-analysis from 52 epidemiological studies reported an increased risk of ovarian cancer in women currently using HRT compared to women who have never used HRT (RR 1.43, 95% CI 1.31-1.56). For women aged 50 to 54 years taking 5 years of HRT, this results in about 1 extra case per 2000 users. In women aged 50 to 54 who are not taking HRT, about 2 women in 2000 will be diagnosed with ovarian cancer over a 5-year period.
Risk of venous thromboembolismHRT is associated with a 1.3-3-fold increased relative risk of developing venous thromboembolism (VTE), i.e. deep vein thrombosis or pulmonary embolism. The occurrence of such an event is more likely in the first year of using HT (see section 4.4). Results of the WHI studies are presented:
WHI Studies - Additional risk of VTE over 5 years' use
|Age range (years)||Incidence per 1000 women in placebo arm over 5 years||Risk ratio and 95%CI||Additional cases per 1000 HRT users|
|50-59||7||1.2 (0.6-2.4)||1 (-3 10)|
|Oral combined estrogen-progestogen|
|50-59||4||2.3 (1.2 4.3)||5 (1 - 13)|
Risk of coronary artery diseaseThe risk of coronary artery disease is slightly increased in users of combined estrogen-progestogen HRT over the age of 60 (see section 4.4).
Risk of ischaemic strokeThe use of estrogen-only and estrogen + progestogen therapy is associated with an up to 1.5 fold increased relative risk of ischaemic stroke. The risk of haemorrhagic stroke is not increased during use of HRT.This relative risk is not dependent on age or on duration of use, but as the baseline risk is strongly age-dependent, the overall risk of stroke in women who use HRT will increase with age (see section 4.4).
WHI studies combined - Additional risk of ischaemic stroke* over 5 years' use
|Age range (years)||Incidence per 1000 women in placebo arm over 5 years||Risk ratio and 95%CI||Additional cases per 1000 HRT users over 5 years|
|50-59||8||1.3 (1.1 1.6)||3 (1-5)|
Reporting of suspected adverse reactions:Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product.Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at www.mhra.gov.uk/yellowcard.
Conjugated EstrogensThe active ingredients are primarily the sulfate esters of estrone, equilin sulfates, 17α-estradiol and 17β-estradiol. These substitute for the loss of estrogen production in menopausal women, and alleviate menopausal symptoms.
Progestogen:As estrogens promote the growth of the endometrium, unopposed estrogens increase the risk of endometrial hyperplasia and cancer. The addition of a progestogen reduces but does not eliminate the estrogen-induced risk of endometrial hyperplasia in non-hysterectomised women.
Relief of estrogen-deficiency symptomsIn a 1-year clinical trial (n=2,808), vasomotor symptoms were assessed for efficacy during the first 12 weeks of treatment in a subset of symptomatic women (n=241) who had at least 7 moderate or severe hot flushes daily or 50 moderate to severe hot flushes during the week before randomisation. Premique 0.625mg/2.5mg (conjugated estrogens/medroxyprogesterone acetate) was shown to be statistically better than placebo at weeks 4, 8 and 12 for relief of both frequency and severity of moderate to severe vasomotor symptoms.In two clinical trials, the incidence of amenorrhoea (no bleeding or spotting) increased over time in women treated with Premique 0.625 mg/2.5 mg. Amenorrhoea was seen in 68% of women at cycle 6 and 77% of women at cycle 12. Breakthrough bleeding and/or spotting appeared in 48% during the first 3 months, and in 24% of women during months 10-12 of treatment.
AbsorptionPremique Low Dose contains a formulation of medroxyprogesterone acetate (MPA) that is immediately released and conjugated estrogens that are slowly released over several hours. Following single dose administration of Premique under fasting conditions, the time taken to reach the peak plasma concentration (Tmax) was 6 9 hours and the peak plasma concentration (Cmax±SD) was 149±52 pg/ml and 83± 32pg/ml for the unconjugated estrogens, estrone and equilin, respectively. Peak plasma concentration (Cmax±SD) of 724±475 pg/ml was reached at 2 hours (Tmax) for MPA.When single doses of Premique were administered with a high-fat meal, there was a two-fold increase in MPA Cmax (1830±1050 pg/ml) and AUC was increased by approximately 30%. Food had little or no significant effect on the exposure of unconjugated and conjugated estrogens. These changes to MPA Cmax and AUC after a high fat meal are not considered to be clinically meaningful as the pharmacokinetics of MPA are highly variable and safety of a wide range of MPA doses up to 10mg have been demonstrated.Premique can be administered with or without food.
DistributionThe distribution of exogenous estrogens is similar to that of endogenous estrogens. Estrogens are widely distributed in the body and are generally found in higher concentrations in the sex hormone target organs. Estrogens circulate in the blood largely bound to sex hormone binding globulin (SHBG) and albumin. MPA is approximately 90% bound to plasma proteins but does not bind to SHBG.
BiotransformationExogenous estrogens are metabolised in the same manner as endogenous estrogens. Circulating estrogens exist in a dynamic equilibrium of metabolic interconversions. These transformations take place mainly in the liver. Estradiol is converted reversibly to estrone, and both can be converted to estriol, which is the major urinary metabolite. Estrogens also undergo enterohepatic recirculation via sulfate and glucuronide conjugation in the liver, biliary secretion of conjugates into the intestine, and hydrolysis in the gut followed by reabsorption. In postmenopausal women a significant proportion of the circulating estrogens exists as sulfate conjugates, especially estrone sulfate, which serves as a circulating reservoir for the formation of more active estrogens. Metabolism and elimination of MPA occur primarily in the liver via hydroxylation, with subsequent conjugation and elimination in the urine.
EliminationEstradiol, estrone and estriol are excreted in the urine along with glucuronide and sulfate conjugates. Most metabolites of MPA are extracted as glucuronide conjugates with only minor amounts secreted as sulfates.
|Tablet core:||Lactose Monohydrate Microcrystalline Cellulose Hypromellose 2208, K100M Magnesium Stearate Purified Water|
|Tablet coating:||Sucrose Microcrystalline Cellulose Hydroxypropyl Cellulose Hypromellose, 2910, E6 Hypromellose, 2910, E15 Polyethylene Glycol 400 Purified Water Eudragit NE 30 D (30% solids) (Ethyl Acrylate and Methacrylate Copolymer Dispersion) Spectrablend Yellow 88101N020 1 Purified Water Opaglos® 2, Clear, 98Z19173 2 Purified Water|
|Printing on tablet:||Opacode® WB NS-78-17821, Black Ink (Purified Water, Iron Oxide Black (E172), Isopropyl Alcohol, Propylene Glycol, Hypromellose 2910)|
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