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AstraZeneca UK Limited

Horizon Place, 600 Capability Green, Luton, Bedfordshire, LU1 3LU
Telephone: +44 (0)1582 836 000
Fax: +44 (0)1582 838 000
Medical Information Direct Line: 0800 783 0033
Medical Information e-mail: medical.informationuk@astrazeneca.com
Customer Care direct line: +44 (0)1582 837 837
Medical Information Fax: +44 (0)1582 838 003

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Summary of Product Characteristics last updated on the eMC: 22/08/2012
SPC Rhinocort Aqua 64 micrograms, nasal spray


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1. Name of the medicinal product

Rhinocort® Aqua, 64 micrograms, nasal spray


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2. Qualitative and quantitative composition

Each actuation contains: Budesonide 64 micrograms (1.28 mg/ml).

For excipients, see 6.1.


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3. Pharmaceutical form

Nasal spray, suspension.


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4. Clinical particulars

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4.1 Therapeutic indications

Seasonal and perennial allergic rhinitis and vasomotor rhinitis. Treatment of nasal polyps.


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4.2 Posology and method of administration

For nasal inhalation. Dosage should be individualised.

Rhinitis (Adults including elderly)

Recommended start dose

Once daily dosing

Twice daily dosing

256 micrograms per day

Two applications of 64 micrograms into each nostril each morning

or

If good effect is achieved, one application of 64 micrograms

One application of 64 micrograms into each nostril morning and evening

Nasal Polyps (Adults including elderly)

Recommended start dose

Once daily dosing

Twice daily dosing

256 micrograms per day

Not applicable

One application of 64 micrograms into each nostril morning and evening.

The patient should be informed that the full effect of Rhinocort is not achieved until after a few days treatment. Treatment of seasonal rhinitis should, if possible, start before exposure to allergens. Treatment can be continued for up to 3 months.

Patients should be reminded of the importance of taking this medicine regularly.

The dose should be titrated to the lowest dose at which effective control of symptoms is achieved.

Children: There are insufficient data to recommend the use of Rhinocort Aqua in children. However, it is unlikely that the risk/benefit ratio in children is different from that in adults.


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4.3 Contraindications

Hypersensitivity to budesonide or to any of the excipients.


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4.4 Special warnings and precautions for use

Special care is demanded in treatment of patients transferred from oral steroids to Rhinocort where disturbances of the hypothalamic-pituitary-adrenal (HPA) axis could be expected.

Special care is needed in patients with fungal and viral infections of the airways and in patients with active or quiescent pulmonary tuberculosis.

Concomitant treatment of seasonal rhinitis may sometimes be necessary to counteract eye symptoms caused by the allergy. In continuous long-term treatment, the nasal mucosa should be inspected regularly e.g. every 6 months.

Reduced liver function affects the elimination of corticosteroids, causing lower elimination rate and higher systemic exposure. Be aware of possible systemic side effects.

Systemic effects of nasal corticosteroids may occur, particularly at high doses prescribed for prolonged periods. These effects are much less likely to occur than with oral corticosteroids and may vary in individual patients and between different corticosteroid preparations. Potential systemic effects may include Cushing's syndrome, Cushingoid features, adrenal suppression, growth retardation in children and adolescents, cataract, glaucoma and more rarely, a range of psychological or behavioural effects including psychomotor hyperactivity, sleep disorders, anxiety, depression or aggression (particularly in children).

Paediatric population

The long-term effects of nasal glucocorticosteroids in children are not fully known. Physicians should closely follow the growth of children taking glucocorticosteroids for longer term by any route, and weigh the benefits of the glucocorticosteroid therapy against the possibility of growth suppression. If growth is slowed, therapy should be reviewed with the aim of reducing the dose of nasal corticosteroid, if possible, to the lowest dose at which effective control of symptoms is maintained. In addition, consideration should also be given to referring the patient to a paediatric specialist.

Treatment with higher than recommended doses may result in clinically significant adrenal suppression. If there is evidence for higher than recommended doses being used, additional systemic corticosteroid cover should be considered during periods of stress or elective surgery.

In vivo studies have shown that oral administration of itraconazole and ketoconazole (known inhibitors of CYP3A4 activity in the liver and in the intestinal mucosa, see also section 4.5 Interactions) may cause an increase in the systemic exposure to budesonide. This is of limited clinical importance for short-term (1-2 weeks) treatment with itraconazole or ketoconazole, but should be taken into consideration during long-term treatment.


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4.5 Interaction with other medicinal products and other forms of interaction

Rhinocort has not been observed to interact with any drug used for the treatment of rhinitis.

The metabolism of budesonide is primarily mediated by CYP3A4, a subfamily of cytochrome P450. Inhibitors of this enzyme, e.g. itraconazole and ketoconazole, can therefore increase systemic exposure to budesonide several times. Since there is no data to support a dosage recommendation, the combination should be avoided. If this is not possible, the period between treatments should be as long as possible and a reduction of the Rhinocort dose could also be considered. However, the use of itraconazole or ketoconazole concomitant with Rhinocort Aqua for shorter periods is of limited importance, see section 4.4 Special warnings and precautions for use.

Raised plasma concentrations of and enhanced effects of corticosteroids have been observed in women also treated with oestrogens and contraceptive steroids, but no effect has been observed with Rhinocort and concomitant intake of low dose combination oral contraceptives.

Because adrenal function may be suppressed, an ACTH stimulation test for diagnosing pituitary insufficiency might show false results (low values).


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4.6 Pregnancy and lactation

Results from prospective epidemiological studies and from worldwide post marketing experience indicate no increased risk for overall congenital malformations from the use of inhaled or intranasal budesonide during early pregnancy. As with other drugs the administration of Rhinocort during pregnancy requires that the benefits for the mother are weighed against the risk for the foetus.

Budesonide is excreted in breast milk. However, at therapeutic doses of Rhinocort no effects on the breast fed child are anticipated. Rhinocort can be used during breast feeding.

Maintenance treatment with inhaled Rhinocort (200 or 400 micrograms twice daily) in asthmatic nursing women results in negligible systemic exposure to budesonide in breast-fed infants.

In a pharmacokinetic study, the estimated daily infant dose was 0.3% of the daily maternal dose for both dose levels, and the average plasma concentration in infants was estimated to be 1/600th of the concentrations observed in maternal plasma, assuming complete infant oral bioavailability. Budesonide concentrations in infant plasma samples were all less than the limit of quantification.

Based on data from inhaled budesonide and the fact budesonide exhibits linear PK properties within the therapeutic dosage intervals after nasal, inhaled, oral and rectal administrations at therapeutic doses of budesonide, exposure to the breast-fed child is anticipated to be low.


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4.7 Effects on ability to drive and use machines

Rhinocort Aqua does not affect the ability to drive or operate machinery.


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4.8 Undesirable effects

Adverse reactions, which have been associated with budesonide, are given below, listed by system organ class and frequency. Frequency is defined as: very common (≥1/10), common (≥1/100 and <1/10), uncommon (≥1/1000 and <1/100), rare (≥1/10 000 and <1/1000), very rare (<1/10 000) and not known (reported spontaneously and cannot be estimated from available post marketing data).

Immune system disorders

Uncommon

Immediate and delayed hypersensitivity reactions including urticaria, rash, dermatitis angioedema and pruritus

Very rare

Anaphylactic reaction

Endocrine disorders

Rare

Signs and symptoms of systemic corticosteroid effects, including adrenal suppression and growth retardation

Eye disorders

Unknown

Raised intraocular pressure or Glaucoma

Cataract

Respiratory, thoracic and mediastinal disorders

Common

Haemorrhagic secretion and epistaxis

Nasal Irritation (sneezing, stinging and dryness)

Very rare

Nasal septum perforation

Ulceration of mucous membrane

Systemic effects of nasal corticosteroids may occur, particularly when prescribed at high doses for prolonged periods (see section 4.4).

Paediatric population

Growth retardation has been reported in children receiving intranasal steroids. Due to the risk of growth retardation in the paediatric population, growth should be monitored as described in section 4.4.


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4.9 Overdose

Acute overdose with Rhinocort even in excessive doses, is not expected to be a clinical problem.

Inhalation of high doses of corticosteroids may lead to suppression of the hypothalamic-pituitary-adrenal (HPA) axis function.


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5. Pharmacological properties

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5.1 Pharmacodynamic properties

Budesonide is a non-halogenated glucocorticosteroid with a high local anti-inflammatory action within the respiratory tract.

ATC code: R01A D05


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5.2 Pharmacokinetic properties

Bioavailablity of oral budesonide in man is low (11-13%) due to an extensive first-pass metabolism in the liver.

The systemic availability of budesonide from Rhinocort Aqua, with reference to the metered dose is 33%. In adults, the maximal plasma concentration after administration of 256 micrograms budesonide from Rhinocort Aqua is 0.64 nM and is reached within 0.7 hours. The AUC after administration of 256 micrograms budesonide from Rhinocort Aqua is 2.7 nmolxh/L in adults.


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5.3 Preclinical safety data

The acute toxicity of budesonide is low and of the same order of magnitude and type as that of the reference glucocorticoids studied (beclomethasone dipropionate, flucinolone acetonide). Results from subacute and chronic toxicity studies show that the systemic effects of budesonide are less severe than or similar to those observed after administration of the other glucocorticosteroids e.g. decreased body weight gain and atrophy of lymphoid tissues and adrenal cortex. An increased incidence of brain gliomas in male rats in a carcinogenicity study could not be verified in a repeat study, in which the incidence of gliomas did not differ between any of the groups on active treatment (budesonide, prednisolone, triamcinolone acetonide) and the control groups. Liver changes (primary hepatocellular neoplasms) found in male rats in the original carcinogenicity study were noted again in the repeat study with budesonide, as well as with the reference glucocorticosteroids. These effects are most probably related to a receptor effect and thus represent a class effect.

Available clinical experience shows no indication that budesonide or other glucocorticosteroids induce brain gliomas or primary heptocellular neoplasms in man. Budesonide has been used successfully in the treatment of seasonal allergic rhinitis for several years.

In animal reproduction studies, corticosteroids such as budesonide have been shown to induce malformations (cleft palate, skeletal malformations). However these animal experimental results do not appear to be relevant in humans at the recommended doses.

Animal studies have also identified an involvement of excess prenatal glucocorticosteroids in increased risk for intrauterine growth retardation, adult cardiovascular disease and permanent changes in glucocorticoid receptor density, neurotransmitter turnover and behaviour at exposures below the teratogenic dose range.


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6. Pharmaceutical particulars

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6.1 List of excipients

Disodium edetate

Potassium sorbate (E202)

Glucose anhydrous

Microcrystalline cellulose (E460)

Carboxymethylcellulose sodium (E466)

Polysorbate 80 (E433)

Hydrochloric acid

Purified water


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6.2 Incompatibilities

None known.


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6.3 Shelf life

2 years.


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6.4 Special precautions for storage

Use within 2 months of starting treatment.

Do not store above 30°C. Do not refrigerate or freeze.


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6.5 Nature and contents of container

Rhinocort Aqua is an aqueous solution of budesonide in either a 10 ml or 20 ml amber/brown glass (type II) bottle. Each bottle is fitted with a spray pump and contains either 120 or 240 actuations. Not all pack sizes may be available in the UK.


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6.6 Special precautions for disposal and other handling

Before using Rhinocort Aqua for the first time the nozzle must be primed (filled with the medicine). To do this the bottle is shaken and the protective cap removed. The bottle is then held upright and the nozzle pumped up and down several times (5-10 times) spraying into the air, until an even mist is seen. The priming effect remains for approximately 24 hours. If a longer period of time passes before the next dose is taken, the nozzle must be loaded with medicine again. This time it is sufficient to spray just once into the air.

a. The patient is then instructed to blow their nose. Next, the bottle needs to be shaken and the protective cap removed.

b. The bottle is then held upright, with one finger held on either side of the nozzle.

c. The tip of the nozzle is inserted into the nostril and the nozzle pressed down once (or more as instructed by the doctor). The spray is then administered into the other nostril in the same way. Note: it is not necessary to inhale at the same time as spraying.

d. The nozzle needs to be wiped with a clean tissue after use and the protective cap replaced. The bottle should be stored in an upright position.

e. Keeping the Rhinocort Aqua nozzle clean

The plastic nozzle of Rhinocort Aqua should be cleaned regularly and at any time the spray of medicine is not coming out as it should. If this happens, first the nozzle should be checked to ensure that it is primed with medicine (see earlier). If, after the nozzle is primed again, the pump is still not working, the nozzle should be cleaned by using the following instructions:

The plastic nozzle is removed with a clean tissue and washed in warm, not hot, water. The nozzle is then rinsed thoroughly, dried and then replaced onto the top of the bottle. The nozzle should not be unblocked with a pin or other sharp object. After cleaning, the nozzle must be primed (filled with medicine) again before use.


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7. Marketing authorisation holder

AstraZeneca UK Ltd.,

600 Capability Green,

Luton, LU1 3LU, UK.


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8. Marketing authorisation number(s)

PL 17901/0074


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9. Date of first authorisation/renewal of the authorisation

12 December 2003 / 30 July 2012


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10. Date of revision of the text

30 July 2012



More information about this product

Link to this document from your website: http://www.medicines.org.uk/emc/medicine/14343/SPC/


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