- timolol maleate
POM: Prescription only medicine
This information is intended for use by health professionals
Excipient with known effectBenzalkonium chloride 200 micrograms / ml.For the full list of excipients, see section 6.1.
Recommended dosage for adults (including the elderly)Recommended therapy is one eye drop in the affected eye(s) once daily. If one dose is missed, treatment should continue with the next dose as planned. The dose should not exceed one drop in the affected eye(s) daily.
Paediatric populationThe safety and efficacy in children and adolescents has not yet been established.
Method of AdministrationPrecautions to be taken before handling or administering the medicinal product.Contact lenses should be removed before instillation of the eye drops and may be reinserted after 15 minutes (see section 4.4). If more than one topical ophthalmic drug is being used, the drugs should be administered at least five minutes apart.When using nasolacrimal occlusion or closing the eyelids for 2 minutes, the systemic absorption is reduced. This may result in a decrease in systemic side effects and an increase in local activity.
Systemic effectsLike other topically applied ophthalmic agents, latanoprost and timolol are absorbed systemically. Due to the beta-adrenergic component timolol, the same types of cardiovascular, pulmonary and other adverse reactions as seen with systemic beta-adrenergic blocking agents may occur. The incidence of systemic ADRs after topical ophthalmic administration is lower than for systemic administration. To reduce the systemic absorption, see section 4.2.
Cardiac disordersIn patients with cardiovascular diseases (e.g. coronary heart disease, Prinzmetal's angina, and cardiac failure) and hypotension therapy with beta-blockers should be critically assessed and the therapy with other active substances should be considered. Patients with cardiovascular diseases should be watched for signs of deterioration of these diseases and of adverse reactions. Due to its negative effect on conduction time, beta-blockers should only be given with caution to patients with first degree heart block.Cardiac reactions, and rarely, death in association with cardiac failures have been reported following administration of timolol.
Vascular disordersPatients with severe peripheral circulatory disturbance/disorders (i.e. severe forms of Raynaud's disease or Raynaud's syndrome) should be treated with caution.
Respiratory disordersRespiratory reactions including death due to bronchospasm in patients with asthma have been reported following administration of some ophthalmic beta- blockers. Latanoprost / Timolol 50 micrograms / ml + 5 mg / ml Eye Drops, Solution should be used with caution, in patients with mild/moderate chronic obstructive pulmonary disease (COPD) and only if the potential benefit outweighs the potential risk.
Hypoglycaemia/diabetesBeta-blockers should be administered with caution in patients subject to spontaneous hypoglycaemia or to patients with labile diabetes, as beta-blockers may mask the signs and symptoms of acute hypoglycaemia.
HyperthyroidismBeta-blockers may also mask the signs of hyperthyroidism.
Corneal diseasesOphthalmic beta-blockers may induce dryness of eyes. Patients with corneal diseases should be treated with caution.
Other beta-blocking agentsThe effect on intra-ocular pressure or the known effects of systemic beta-blockade may be potentiated when timolol is given to the patients already receiving a systemic beta-blocking agent. The response of these patients should be closely observed. The use of two topical beta-adrenergic blocking agents is not recommended (see section 4.5).
Anaphylactic reactionsWhile taking beta-blockers, patients with a history of atopy or a history of severe anaphylactic reaction to a variety of allergens may be more reactive to repeated challenge with such allergens and unresponsive to the usual doses of adrenaline used to treat anaphylactic reactions.
Choroidal detachmentChoroidal detachment has been reported with administration of aqueous suppressant therapy (e.g. timolol, acetazolamide) after filtration procedures.
Surgical anaesthesiaBeta-blocking ophthalmological preparations may block systemic beta-agonist effects e.g. of adrenaline. The anaesthesiologist should be informed when the patient is receiving timolol.
Concomitant therapyTimolol may interact with other drugs, see section 4.5. The use of two local beta-blockers or two local prostaglandins is not recommended.
Ocular effectsLatanoprost may gradually change the eye colour by increasing the amount of brown pigment in the iris. Similar to experience with latanoprost eye drops, increased iris pigmentation was seen in 16-20% of all patients treated with Latanoprost / Timolol 50 micrograms / ml + 5 mg / ml Eye Drops, Solution for up to one year (based on photographs). This effect has predominantly been seen in patients with mixed coloured irides, i.e. green-brown, yellow-brown or blue/grey-brown, and is due to increased melanin content in the stromal melanocytes of the iris. Typically, the brown pigmentation around the pupil spreads concentrically towards the periphery in affected eyes, but the entire iris or parts of it may become more brownish. In patients with homogeneously blue, grey, green or brown eyes, the change has only rarely been seen during two years of treatment in clinical trials with latanoprost. The change in iris colour occurs slowly and may not be noticeable for several months to years and it has not been associated with any symptom or pathological changes. No further increase in brown pigment has been observed after discontinuation of treatment, but the resultant colour change may be permanent. Neither naevi nor freckles of the iris have been affected by treatment. Accumulation of pigment in the trabecular meshwork or elsewhere in the anterior chamber has not been observed but patients should be examined regularly and, depending on the clinical situation, treatment may be stopped if increased iris pigmentation ensues. Before treatment is instituted patients should be informed of the possibility of a change in eye colour. Unilateral treatment can result in permanent heterochromia. There is no documented experience with latanoprost in inflammatory, neovascular, or chronic angle closure glaucoma, in open angle glaucoma of pseudophakic patients and in pigmentary glaucoma. Latanoprost has no or little effect on the pupil but there is no documented experience in acute attacks of closed angle glaucoma. It is recommended, therefore, that Latanoprost / Timolol 50 micrograms / ml + 5 mg / ml Eye Drops, Solution should be used with caution in these conditions until more experience is obtained. Latanoprost should be used with caution in patients with a history of herpetic keratitis, and should be avoided in cases of active herpes simplex keratitis and in patients with a history of recurrent herpetic keratitis specifically associated with prostaglandin analogues.Macular oedema, including cystoid macular oedema, has been reported during treatment with latanoprost. These reports have mainly occurred in aphakic patients, in pseudophakic patients with a torn posterior lens capsule, or in patients with known risk factors for macular oedema. Latanoprost / Timolol should be used with caution in these patients.
Use of contact lensesLatanoprost / Timolol 50 micrograms / ml + 5 mg / ml Eye Drops, Solution contains benzalkonium chloride, which is commonly used as a preservative in ophthalmic products. Benzalkonium chloride has been reported to cause punctate keratopathy and/or toxic ulcerative keratopathy, may cause eye irritation and is known to discolour soft contact lenses. Close monitoring is required with frequent or prolonged use of Latanoprost / Timolol 50 micrograms / ml + 5 mg / ml Eye Drops, Solution in dry eye patients, or in conditions where the cornea is compromised. Contact lenses may absorb benzalkonium chloride and these should be removed before applying Latanoprost / Timolol 50 micrograms / ml + 5 mg / ml Eye Drops, Solution but may be reinserted after 15 minutes (see section 4.2).
LatanoprostThere are no adequate data from the use of latanoprost in pregnant women. Studies in animals have shown reproductive toxicity (see section 5.3). The potential risk for humans is unknown.
TimololThere are no adequate data for the use of timolol in pregnant women. Timolol should not be used during pregnancy unless clearly necessary. To reduce the systemic absorption, see section 4.2.Epidemiological studies have not revealed malformative effects, but show a risk for intra uterine growth retardation when beta-blockers are administered by the oral route. In addition, signs and symptoms of beta-blockade (e.g. bradycardia, hypotension, respiratory distress and hypoglycaemia) have been observed in the neonate when beta-blockers have been administered until delivery. If Latanoprost / Timolol 50 micrograms / ml + 5 mg / ml Eye Drops, Solution is administered until delivery, the neonate should be carefully monitored during the first days of life.Consequently Latanoprost / Timolol 50 micrograms / ml + 5 mg / ml Eye Drops, Solution should not be used during pregnancy (see section 5.3).
BreastfeedingBeta- blockers are excreted in breast milk. However, at therapeutic doses of timolol in eye drops it is not likely that sufficient amounts would be present in breast milk to produce clinical symptoms of beta-blockade in the infant. To reduce the systemic absorption, see section 4.2.Latanoprost and its metabolites may pass into breast milk. Latanoprost / Timolol 50 micrograms / ml + 5 mg / ml Eye Drops, Solution should not be used in women who are breast-feeding.
FertilityThere are no human data on the effects of Latanoprost / Timolol 50 micrograms / ml + 5 mg / ml Eye Drops, Solution on fertility.
Nervous System Disorders:Uncommon: Headache.
Eye Disorders:Very common: Increased iris pigmentation. Common: Eye irritation (including stinging, burning and itching), eye pain. Uncommon: Eye hyperaemia, conjunctivitis, vision blurred, lacrimation increased, blepharitis, corneal disorders.
Skin and Subcutaneous Tissue Disorders:Uncommon: Skin rash, pruritus. Additional adverse events have been reported specific to the use of the individual components of Latanoprost / Timolol 50 micrograms / ml + 5 mg / ml Eye Drops, Solution in either in clinical studies, spontaneous reports or in the available literature.For latanoprost, these are:
Infection and Infestations:Herpetic Keratitis.
Nervous system disorders:Dizziness.
Eye Disorders:Eyelash and vellus hair changes (increased length, thickness, pigmentation, and number), punctate epithelial erosions, periorbital oedema, iritis/uveitis, macular oedema (in aphakic, pseudophakic patients with torn posterior lens capsules or in patients with known risk factors for macular oedema), dry eye, keratitis, corneal oedema and erosions, misdirected eyelashes sometimes resulting in eye irritation and iris cyst, photophobia, periorbital and lid changes resulting in deepening of eyelid sulcus
Cardiac Disorders:Aggravation of angina in patients with pre-existing disease, palpitations.
Respiratory, Thoracic and Mediastinal Disorders:Asthma, asthma aggravation, dyspnea.
Skin and Subcutaneous Tissue Disorders:Darkening of palpebral skin. Musculoskeletal, Connective Tissue and Bone Disorders: Joint pain, Muscle pain.
General disorders and Administration Site Conditions:Chest pain For timolol, these are:
Immune System Disorders:Systemic allergic reactions including angioedema, urticaria, localized and generalized rash, pruritus, anaphylactic reaction.Metabolism and nutrition disorders:Hypoglycaemia.
Psychiatric Disorders:Depression, memory loss, insomnia, nightmares.
Nervous System Disorders:Dizziness, paraesthesia, cerebral ischemia, cerebrovascular accident, increase in signs and symptoms of myasthenia gravis, syncope, and headache
Eye Disorders:Signs and symptoms of ocular irritation (e.g. burning, stinging, itching, tearing, redness), blepharitis, keratitis, blurred vision and choroidal detachment following filtration surgery (see section 4.4), decreased corneal sensitivity, dry eyes, corneal erosion ptosis, diplopia).
Ear and Labyrinth Disorders:Tinnitus
Cardiac Disorders:Palpitations, arrhythmia, bradycardia, cardiac arrest, congestive heart failure, chest pain, oedema, atrioventricular block, cardiac failure.
Vascular Disorders:Hypotension, Raynaud's phenomenon, cold hands and feet.
Respiratory, Thoracic and Mediastinal Disorders:Bronchospasm (predominantly in patients with pre-existing bronchospastic disease), dyspnoea, cough.
Gastrointestinal Disorders:Dysgeusia, nausea, diarrhoea, dyspepsia, dry mouth, abdominal pain, vomiting.
Skin and Subcutaneous Tissue Disorders:Alopecia, psoriasiform rash or exacerbation of psoriasis, skin rash.
Musculoskeletal and connective tissue disorders:Myalgia.
Reproductive system and breast disorders:Sexual dysfunction, decreased libido.
General Disorders and Administration Site Conditions:Asthenia/fatigueCases of corneal calcification have been reported very rarely in association with the use of phosphate containing eye drops in some patients with significantly damaged corneas.
Reporting of suspected adverse reactionsReporting 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 Yellow card scheme at www.mhra.gov.uk/yellowcard
Mechanism of actionLatanoprost / Timolol 50 micrograms / ml + 5 mg / ml Eye Drops, Solution consists of two components: latanoprost and timolol maleate. These two components decrease elevated intraocular pressure (IOP) by different mechanisms of action and the combined effect results in additional IOP reduction compared to either compound administered alone. Latanoprost, a prostaglandin F2alpha analogue, is a selective prostanoid FP receptor agonist that reduces the IOP by increasing the outflow of aqueous humour. The main mechanism of action is increased uveoscleral outflow. Additionally, some increase in outflow facility (decrease in trabecular outflow resistance) has been reported in man. Latanoprost has no significant effect on the production of aqueous humour, the blood-aqueous barrier or the intraocular blood circulation. Chronic treatment with latanoprost in monkey eyes, which had undergone extracapsular lens extraction, did not affect the retinal blood vessels as determined by fluorescein angiography. Latanoprost has not induced fluorescein leakage in the posterior segment of pseudophakic human eyes during short term treatment. Timolol is a beta-1 and beta-2 (non-selective) adrenergic receptor blocking agent that has no significant intrinsic sympathomimetic, direct myocardial depressant or membrane-stabilising activity. Timolol lowers IOP by decreasing the formation of aqueous in the ciliary epithelium. The precise mechanism of action is not clearly established, but inhibition of the increased cyclic AMP synthesis caused by endogenous beta-adrenergic stimulation is probable. Timolol has not been found to significantly affect the permeability of the blood-aqueous barrier to plasma proteins. In rabbits, timolol was without effect on the regional ocular blood flow after chronic treatment.
Clinical effectsIn dose finding studies, Latanoprost/ Timolol produced significantly greater decreases in mean diurnal IOP compared to latanoprost and timolol administered once daily as monotherapy. In two well controlled, double masked six-month clinical studies the IOP reducing effect of Latanoprost/ Timolol was compared with latanoprost and timolol monotherapy in patients with an IOP of at least 25 mm Hg or greater. Following a 2-4 week run-in with timolol (mean decrease in IOP from enrollment of 5 mm Hg), additional decreases in mean diurnal IOP of 3.1, 2.0 and 0.6 mm Hg were observed after 6 months of treatment for Latanoprost/ Timolol (twice daily), respectively. The IOP lowering effect of Latanoprost/ Timolol was maintained in 6-month open label extension of these studies. Existing data suggest that evening dosing may be more effective in IOP lowering than morning dosing. However, when considering a recommendation of either morning or evening dosing, sufficient consideration should be given to the lifestyle of the patient and their likely compliance. It should be kept in mind that in case of insufficient efficacy of the fixed combination, results from studies indicate that the use of unfixed administration of Timolol bid and latanoprost once a day might be still efficient. Onset of action of Latanoprost / Timolol 50 micrograms / ml + 5 mg / ml Eye Drops, Solution is within one hour and maximal effect occurs within six to eight hours. Adequate IOP reducing effect has been shown to be present up to 24 hours post dosage after multiple treatments.
LatanoprostLatanoprost is an isopropyl ester prodrug, which per se is inactive but after hydrolysis by esterases in the cornea to the acid of latanoprost, becomes biologically active. The prodrug is well absorbed through the cornea and all drug that enters the aqueous humor is hydrolysed during the passage through the cornea. Studies in man indicate that the maximum concentration in the aqueous humour, approximately 15-30 ng/ml, is reached about 2 hours after topical administration of latanoprost alone. After topical application in monkeys latanoprost is distributed primarily in the anterior segment, the conjunctiva and the eye lids. The acid of latanoprost has a plasma clearance of 0.40 l/h/kg and a small volume of distribution, 0.16 l/kg, resulting in a rapid half life in plasma, 17 minutes. After topical ocular administration the systemic bioavailability of the acid of latanoprost is 45%. The acid of latanoprost has a plasma protein binding of 87%. There is practically no metabolism of the acid of latanoprost in the eye. The main metabolism occurs in the liver. The main metabolites, the 1, 2-dinor and 1, 2, 3, 4- tetranor metabolites, exert no or only weak biological activity in animal studies and are excreted primarily in the urine.
TimololThe maximum concentration of timolol in the aqueous humor is reached about 1 hour after topical administration of eye drops. Part of the dose is absorbed systemically and a maximum plasma concentration of 1 ng/ml is reached 10-20 minutes after topical administration of one eye drop to each eye once daily (300 micrograms/day). The half-life of timolol in plasma is about 6 hours. Timolol is extensively metabolised in the liver. The metabolites are excreted in the urine together with some unchanged Timolol.
Latanoprost / Timolol50 micrograms / ml + 5 mg / ml Eye Drops, Solution:No pharmacokinetic interactions between latanoprost and timolol were observed, although there was an approximate 2-fold increased concentration of the acid of latanoprost in aqueous humour 1-4 hours after administration of Latanoprost / Timolol 50 micrograms / ml + 5 mg / ml Eye Drops, Solution compared to monotherapy.