POM: Prescription only medicine
This information is intended for use by health professionals
Neupro 1 mg/24 h transdermal patchEach patch releases 1 mg of rotigotine per 24 hours. Each patch of 5 cm2 contains 2.25 mg of rotigotine.
Neupro 3 mg/24 h transdermal patchEach patch releases 3 mg of rotigotine per 24 hours. Each patch of 15 cm2 contains 6.75 mg of rotigotine.For the full list of excipients, see section 6.1.
Neupro 1 mg/24 h transdermal patchThe outside of the backing layer is tan-coloured and imprinted with 'Neupro 1 mg/24 h'.
Neupro 3 mg/24 h transdermal patchThe outside of the backing layer is tan-coloured and imprinted with 'Neupro 3 mg/24 h'.
PosologyThe dose recommendations made are in nominal dose.A single daily dose should be initiated at 1 mg/24 h. Depending on the individual patient response, the dose may be increased in weekly increments of 1 mg/24 h to a maximum dose of 3 mg/24 h. The need for treatment continuation should be reconsidered every 6 months. Neupro is applied once a day. The patch should be applied at approximately the same time every day. The patch remains on the skin for 24 hours and will then be replaced by a new one at a different site of application. If the patient forgets to apply the patch at the usual time of the day or if the patch becomes detached, another patch should be applied for the remainder of the day.
Treatment discontinuationNeupro should be discontinued gradually. The daily dose should be reduced in steps of 1 mg/24 h with a dose reduction preferably every other day, until complete withdrawal of Neupro (see section 4.4). Following this procedure, rebound (worsening of symptoms beyond initial intensity after discontinuation of treatment) has not been observed.
Hepatic impairmentAdjustment of the dose is not necessary in patients with mild to moderate hepatic impairment. Caution is advised when treating patients with severe hepatic impairment, which may result in lower rotigotine clearance. Rotigotine has not been investigated in this patient group. A dose reduction might be needed in case of worsening of the hepatic impairment.
Renal impairmentAdjustment of the dose is not necessary in patients with mild to severe renal impairment, including those requiring dialysis. Unexpected accumulation of rotigotine levels may also occur at acute worsening of renal function (see section 5.2).
Paediatric populationThe safety and efficacy of rotigotine in children and adolescents have not yet been established. Currently available data are described in section 5.2 but no recommendation on a posology can be made.
Method of administrationNeupro is for transdermal use.The patch should be applied to clean, dry, intact healthy skin on the abdomen, thigh, hip, flank, shoulder, or upper arm. Reapplication to the same site within 14 days should be avoided. Neupro should not be placed on skin that is red, irritated or damaged (see section 4.4).
Use and handlingEach patch is packed in a sachet and should be applied directly after the sachet has been opened. One half of the release liner should be removed and the sticky side should be applied and pressed firmly to the skin. Then, the patch is fold back and the second part of the release liner is removed. The sticky side of the patch should not be touched. The patch should be pressed down firmly with the palm of the hand for about 30 seconds, so that it sticks well.The patch should not be cut into pieces.
Magnetic resonance imaging and cardioversionThe backing layer of Neupro contains aluminium. To avoid skin burns, Neupro should be removed if the patient has to undergo magnetic resonance imaging (MRI) or cardioversion.
Orthostatic hypotensionDopamine agonists are known to impair the systemic regulation of the blood pressure resulting in postural/orthostatic hypotension. These events have also been observed during treatment with rotigotine, but the incidence was similar to that observed in placebo-treated patients.It is recommended to monitor blood pressure, especially at the beginning of treatment, due to the general risk of orthostatic hypotension associated with dopaminergic therapy.
SyncopeIn clinical studies with rotigotine, syncope has been observed at a rate that was similar to that observed in patients treated with placebo. Because patients with clinically relevant cardiovascular disease were excluded in these studies, patients with severe cardiovascular disease should be asked about symptoms of syncope and pre-syncope.
Sudden onset of sleep and somnolenceRotigotine has been associated with somnolence and episodes of sudden sleep onset. Sudden onset of sleep during daily activities, in some cases without awareness of any warning signs, has been reported. Prescribers should continually reassess patients for drowsiness or sleepiness, as patients may not acknowledge drowsiness or sleepiness until directly questioned. A reduction of dosage or termination of therapy should be carefully considered.
Impulse control disordersPatients should be regularly monitored for the development of impulse control disorders. Patients and carers should be made aware that behavioural symptoms of impulse control disorders including pathologic gambling, increased libido, hypersexuality, compulsive spending or buying, binge eating and compulsive eating can occur in patients treated with dopamine agonists, including rotigotine. Dose reduction/tapered discontinuation should be considered if such symptoms develop.
Neuroleptic malignant syndromeSymptoms suggestive of neuroleptic malignant syndrome have been reported with abrupt withdrawal of dopaminergic therapy. Therefore, it is recommended to taper treatment (see section 4.2).
Abnormal thinking and behaviourAbnormal thinking and behaviour have been reported and can consist of a variety of manifestations including paranoid ideation, delusions, hallucinations, confusion, psychotic-like behaviour, disorientation, aggressive behaviour, agitation, and delirium.
Fibrotic complicationsCases of retroperitoneal fibrosis, pulmonary infiltrates, pleural effusion, pleural thickening, pericarditis and cardiac valvulopathy have been reported in some patients treated with ergot-derived dopaminergic agents. While these complications may resolve when treatment is discontinued, complete resolution does not always occur. Although these adverse reactions are believed to be related to the ergoline structure of these compounds, whether other, nonergot derived dopamine agonists can cause them is unknown.
NeurolepticsNeuroleptics given as antiemetic should not be given to patients taking dopamine agonists (see also section 4.5).
Ophthalmologic monitoringOphthalmologic monitoring is recommended at regular intervals or if vision abnormalities occur.
Heat applicationExternal heat (excessive sunlight, heating pads and other sources of heat such as sauna, hot bath) should not be applied to the area of the patch.
Application site reactionsApplication site skin reactions may occur and are usually mild or moderate in intensity. It is recommended that the application site should be rotated on a daily basis (e.g. from the right side to the left side and from the upper body to the lower body). The same site should not be used within 14 days. If application site reactions occur which last for more than a few days or are persistent, if there is an increase in severity, or if the skin reaction spreads outside the application site, an assessment of the risk/benefit balance for the individual patient should be conducted.If there is a skin rash or irritation from the transdermal system, direct sunlight on the area should be avoided until the skin heals, as exposure could lead to changes in the skin color.If a generalised skin reaction (e.g. allergic rash, including erythematous, macular, papular rash or pruritus) associated with the use of Neupro is observed, Neupro should be discontinued.
Peripheral oedemaPeripheral oedema has been observed in clinical trials conducted in patients with RLS.
AugmentationAugmentation may occur. Augmentation refers to the earlier onset of symptoms in the evening (or even the afternoon), increase in severity of symptoms, and spread of symptoms to involve other body parts. In long-term clinical studies with rotigotine, the majority of augmentation episodes were seen in the first and second years of treatment. Doses higher than the approved dose range for RLS should be avoided as this may lead to higher rates of augmentation (see section 5.1).
Sulphite sensitivityNeupro contains sodium metabisulphite, a sulphite that may cause allergic-type reactions including anaphylactic symptoms and life threatening or less severe asthmatic episodes in certain susceptible people.
Women of childbearing potential, contraception in femalesWomen of childbearing potential should use effective contraception to prevent pregnancy during treatment with rotigotine.
PregnancyThere are no adequate data from the use of rotigotine in pregnant women. Animal studies do not indicate any teratogenic effects in rats and rabbits, but embryo-toxicity was observed in rats and mice at materno-toxic doses (see section 5.3). The potential risk for humans is unknown. Rotigotine should not be used during pregnancy.
Breast-feedingBecause rotigotine decreases prolactin secretion in humans, inhibition of lactation is expected. Studies in rats have shown that rotigotine and/or its metabolite(s) are excreted in breast milk. In the absence of human data, breast-feeding should be discontinued.
FertilityFor information on fertility studies, please see section 5.3.
Summary of the safety profileBased on the analysis of pooled placebo-controlled clinical trials comprising a total of 748 Neupro- and 214 placebo-treated patients, 65.5% of the patients on Neupro and 33.2% of patients on placebo reported at least one adverse reaction.At the beginning of therapy dopaminergic adverse reactions such as nausea and vomiting may occur. These are usually mild or moderate in intensity and transient even if treatment is continued.Adverse drug reactions (ADRs) reported in more than 10% of patients treated with Neupro are nausea, application site reactions, asthenic conditions and headache.In trials where the application sites were rotated as reflected in the instructions provided in the SmPC and package leaflet, 34.2% of 748 patients using Neupro, experienced application site reactions. The majority of application site reactions were mild or moderate in intensity, limited to the application areas and resulted in discontinuation of Neupro in 7.2% of subjects.Discontinuation rateThe discontinuation rate was studied in 3 clinical trials ranging up to 3 years in duration. The percentage of subjects discontinuing was 25-38% over the first year, 10% in the second year, and 11% in the third year. Periodic assessment of efficacy should be performed, along with evaluation of safety, including augmentation.
Tabulated list of adverse reactionsThe following table covers adverse drug reactions from the pooled studies mentioned above in patients with Restless Legs Syndrome and from post-marketing experience. Within the system organ classes, adverse reactions are listed under headings of frequency (number of patients expected to experience the reaction), using the following categories: very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000); not known (cannot be estimated from the available data). Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness.
System/organ classes acc. to MedDRA
Immune system disorders
Hypersensitivity, which may include angioedema, tongue oedema and lip oedema
Sleep attacks/sudden onset of sleep, sexual desire disordersa (incl. hypersexuality, libido increased), insomnia, sleep disorder, abnormal dreams, impulse-control disordersa,d (incl. pathological gambling, stereotypy/ punding, binge eating/eating disorderb, compulsive shoppingc)
Obsessive-compulsive disorder, agitationd
Aggressive behaviour/ aggressionb, disorientationd
Dopamine dysregulation syndromec, perception disturbancese (incl. hallucination, hallucination visual, hallucination auditory, illusion), nightmaree, paranoiae, confusional statee, psychotic disordere, delusione, deliriume
Nervous system disorders
Dizzinesse, disturbances in consciousness
NECe (incl. syncope, syncope vasovagal, loss of consciousness), dyskinesiae, dizziness posturale, lethargye, convulsione
Vision blurrede, visual impairmente, photopsiae
Ear and labyrinth disorders
Palpitationse, atrial fibrillatione, supraventricular tachycardiae
Respiratory, thoracic and mediastinal disorders
Constipatione, dry mouthe, abdominal paine, diarrhoeac
Skin and subcutaneous tissue disorders
Erythemae, hyperhidrosise, pruritus generalisede, skin irritatione, dermatitis contacte, rash generalisede
Reproductive system and breast disorder
General disorders and administration site conditions
Application and instillation site reactionsa (incl. erythema, pruritus, irritation, rash, dermatitis, vesicles, pain, eczema, inflammation, swelling, discolouration, papules, exfoliation, urticaria, hypersensitivity), asthenic conditionsa (incl. fatigue, asthenia, malaise)
Irritability, oedema peripheral
Weight decreasede, hepatic enzyme increasede (incl. AST, ALT, GGT), weight increasede, heart rate increasede, CPK increasedd,e
Injury, poisoning and procedural complications
Musculoskeletal and connective tissue disorders
Description of selected adverse reactions
Sudden onset of sleep and somnolenceRotigotine has been associated with somnolence including excessive daytime somnolence and sudden sleep onset episodes. In isolated cases sudden onset of sleep occurred while driving and resulted in motor vehicle accidents (see also sections 4.4 and 4.7).
Impulse control disordersPathological gambling, increased libido, hypersexuality, compulsive spending or buying, binge eating and compulsive eating can occur in patients treated with dopamine agonists, including rotigotine (see section 4.4).
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 Website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.
SymptomsThe most likely adverse reactions would be those related to the pharmacodynamic profile of a dopamine agonist, including nausea, vomiting, hypotension, involuntary movements, hallucinations, confusion, convulsions and other signs of central dopaminergic stimulation.
ManagementThere is no known antidote for overdose of dopamine agonists. In case of suspected overdose, removal of the patch(es) should be considered because after removal of the patch(es) the active substance input is stopped and the plasma concentration of rotigotine decreases rapidly. The patient should be monitored closely, including heart rate, heart rhythm and blood pressure. Treatment of overdose may require general supportive measures to maintain the vital signs. Dialysis would not be expected to be beneficial as rotigotine is not eliminated by dialysis.If it is necessary to discontinue rotigotine, this should be done gradually to prevent neuroleptic malignant syndrome.
Mechanism of actionRotigotine is believed to elicit its beneficial effect on Parkinson's disease by activation of the D3, D2 and D1 receptors of the caudate-putamen in the brain.The precise mechanism of action of rotigotine as a treatment of RLS is unknown. It is thought that rotigotine may exert its activity mainly via dopamine receptors.
Pharmacodynamic effectsRegarding the functional activity at the various receptor subtypes and their distribution in the brain, rotigotine is a D2 and D3 receptor agonist acting also on D1, D4 and D5 receptors. With non-dopaminergic receptors, rotigotine showed antagonism at alpha2B and agonism at 5HT1A receptors, but no activity on the 5HT2B receptor.
Clinical efficacyThe efficacy of rotigotine was evaluated in 5 placebo-controlled trials with more than 1,400 patients with idiopathic Restless Legs Syndrome (RLS). Efficacy was demonstrated in controlled trials in patients treated for up to 29 weeks. The effect was maintained over a 6 months period. The changes from baseline in the International RLS Rating Scale (IRLS) and CGI-item 1 (severity of illness) were primary efficacy parameters. For both primary endpoints statistically significant differences have been observed for the doses 1 mg/24 h, 2 mg/24 h and 3 mg/24 h in comparison to placebo. After 6 months of maintenance treatment in patients with moderate to severe RLS, the baseline IRLS score improved from 30.7 to 20.7 for placebo and from 30.2 to 13.8 for rotigotine. The adjusted mean difference was -6.5 points (CI95% -8.7; -4.4, p <0.0001). CGI-I responder rates (much improved, very much improved) were 43.0% and 67.5% for placebo and rotigotine respectively (difference 24.5% CI 95%: 14.2%; 34.8%, p<0.0001).In a placebo-controlled, 7-week trial polysomnographic parameters were investigated. Rotigotine significantly reduced the periodic limb movement index (PLMI) from 50.9 to 7.7 versus 37.4 to 32.7 for placebo (p<0.0001).
AugmentationIn two 6-month, double-blind, placebo-controlled studies, clinically relevant augmentation was observed in 1.5% of rotigotine-treated patients versus 0.5% of placebo treated patients. In two open-label, follow-up studies over a subsequent 12 months, the rate of clinically relevant augmentation was 2.9%. None of these patients discontinued therapy because of augmentation. In a 5-year open-label treatment study, augmentation occurred in 11.9% of patients treated with the approved dosages for RLS (1-3 mg/24 h), and 5.1% were considered clinically significant. In this study, the majority of augmentation episodes occurred in the first and second years of treatment. Furthermore, in this study a higher dose of 4 mg/24 h that is unapproved in RLS was also used and led to higher rates of augmentation.
In a multicenter, double-blind, randomized, 2-way, crossover study in 52 outpatients, the skin adhesion of the improved room temperature patch formulation was compared to the cold storage formulation, using the 8 mg/24 h rotigotine patch. Skin adhesion was measured on 2 consecutive days of 24 hours patch application. The improved room temperature patch formulation showed better skin adhesion than the cold storage formulation with >90% of patches showing sufficient adhesion (i.e. >70% of the patch area adhering) compared to <83%. Comparable skin tolerability was reported for both formulations. The majority of erythema observed was mild and none severe.
AbsorptionFollowing application, rotigotine is continuously released from the transdermal patch and absorbed through the skin. Steady-state concentrations are reached after one to two days of patch application and are maintained at a stable level by once daily application in which the patch is worn for 24 hours. Rotigotine plasma concentrations increase dose-proportionally over a dose range of 1 mg/24 h to 24 mg/24 h.Approximately 45% of the active substance within the patch is released to the skin in 24 hours. The absolute bioavailability after transdermal application is approximately 37%.Rotating the site of patch application may result in day-to-day differences in plasma levels. Differences in bioavailability of rotigotine ranged from 2% (upper arm versus flank) to 46% (shoulder versus thigh). However, there is no indication of a relevant impact on the clinical outcome.
DistributionThe in vitro binding of rotigotine to plasma proteins is approximately 92%.The apparent volume of distribution in humans is approximately 84 l/kg.
BiotransformationRotigotine is metabolised to a great extent. Rotigotine is metabolised by N-dealkylation as well as direct and secondary conjugation. In vitro results indicate that different CYP isoforms are able to catalyse the N-dealkylation of rotigotine. Main metabolites are sulfates and glucuronide conjugates of the parent compound as well as N-desalkyl-metabolites, which are biologically inactive.The information on metabolites is incomplete.
EliminationApproximately 71% of the rotigotine dose is excreted in urine and a smaller part of about 23% is excreted in faeces.The clearance of rotigotine after transdermal administration is approximately 10 l/min and its overall elimination half-life is 5 to 7 hours. The pharmacokinetic profile shows a biphasic elimination with an initial half-life of about 2 to 3 hours.Because the patch is administered transdermally, no effect of food and gastrointestinal conditions is expected.
Special patient groupsBecause therapy with Neupro is initiated at a low dose and gradually titrated according to clinical tolerability to obtain the optimum therapeutic effect, adjustment of the dose based on gender, weight, or age is not necessary.
Hepatic and renal impairmentIn subjects with moderate hepatic impairment or mild to severe renal impairment, no relevant increases of rotigotine plasma levels were observed. Neupro was not investigated in patients with severe hepatic impairment. Plasma levels of conjugates of rotigotine and its desalkyl metabolites increase with impaired renal function. However, a contribution of these metabolites to clinical effects is unlikely.
Paediatric populationLimited pharmacokinetic data obtained in adolescent patients with RLS (13-17 years, n=24) following treatment with multiple doses of 0.5 to 3mg/24h showed that systemic exposure to rotigotine was similar to that observed in adults. Efficacy/safety data is insufficient to establish a relation between exposure and response (see also paediatric information in section 4.2).
Backing layerPolyester film, siliconized, aluminized, colour coated with a pigment (titanium dioxide (E171), pigment yellow 95, pigment red 166) layer and imprinted (pigment red 144, pigment yellow 95, pigment black 7).
Self adhesive matrix layerPoly(dimethylsiloxane, trimethylsilyl silicate)-copolymerisate, Povidone K90, sodium metabisulphite (E223), ascorbyl palmitate (E304) and DL-α-tocopherol (E307).
Release linerTransparent fluoropolymer coated polyester film.
Peel off sachet in a plastic box: One side is composed of an ethylene copolymer (innermost layer), an aluminium foil, low density polyethylene film and paper; the other side is composed of polyethylene (innermost layer), aluminium, ethylene copolymer and paper.
The box contains 7, 14, 28, 30 or 84 (multipack containing 3 packs of 28) transdermal patches, individually sealed in sachets.
Not all pack sizes may be marketed.
UCB Pharma S.A.
Allée de la Recherche 60
Neupro 1 mg/24 h transdermal patchEU/1/05/331/038EU/1/05/331/040EU/1/05/331/041EU/1/05/331/044EU/1/05/331/056
Neupro 3 mg/24 h transdermal patchEU/1/05/331/047EU/1/05/331/049EU/1/05/331/050EU/1/05/331/053EU/1/05/331/058
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