Coadministration of Qbrexza with anticholinergic medications may result in additive interaction leading to an increase in anticholinergic adverse effects [see Warnings and Precautions (5) and Adverse Reactions (6)]. Avoid coadministration of Qbrexza with other anticholinergic-containing drugs.
There are no available data on Qbrexza use in pregnant women to inform a drug-associated risk for adverse developmental outcomes. In pregnant rats, daily oral administration of glycopyrrolate (glycopyrronium bromide) during organogenesis did not result in an increased incidence of gross external or visceral defects [see Data]. When glycopyrrolate was administered intravenously to pregnant rabbits during organogenesis, no adverse effects on embryo-fetal development were seen. The available data do not support relevant comparisons of systemic glycopyrronium exposures achieved in the animal studies to exposures observed in humans after topical use of Qbrexza.
The estimated background risks of major birth defects and miscarriage for the indicated population are unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively.
Glycopyrrolate was orally administered to pregnant rats at dosages of 50, 200, and 400 mg/kg/day during the period of organogenesis. Glycopyrrolate had no effect on maternal survival, but significantly reduced mean maternal body weight gain over the period of dosing at all dosages evaluated. Mean fetal weight was significantly reduced in the 200 and 400 mg/kg/day dose groups. There were two litters with all resorbed fetuses in the 400 mg/kg/day dose group. There were no effects of treatment on the incidence of gross external or visceral defects. Minor treatment-related skeletal effects included reduced ossification of various bones in the 200 and 400 mg/kg/day dose groups; these skeletal effects were likely secondary to maternal toxicity.
Glycopyrrolate was intravenously administered to pregnant rabbits at dosages of 0.1, 0.5, and 1.0 mg/kg/day during the period of organogenesis. Glycopyrrolate did not affect maternal survival under the conditions of this study. Mean maternal body weight gain and mean food consumption over the period of dosing were lower than the corresponding control value in the 0.5 and 1.0 mg/kg/day treatment groups. There were no effects of treatment on fetal parameters, including fetal survival, mean fetal weight, and the incidence of external, visceral, or skeletal defects.
Female rats that were pregnant or nursing were orally dosed with glycopyrrolate daily at dosages of 0, 50, 200, or 400 mg/kg/day, beginning on day 7 of gestation, and continuing until day 20 of lactation. Mean body weight of pups in all treatment groups was reduced compared to the control group during the period of nursing, but eventually recovered to be comparable to the control group, post-weaning. No other notable delivery or litter parameters were affected by treatment in any group, including no effects on mean duration of gestation or mean numbers of live pups per litter. No treatment-related effects on survival or adverse clinical signs were observed in pups. There were no effects of maternal treatment on behavior, learning, memory, or reproductive function of pups.
There are no data on the presence of glycopyrrolate or its metabolites in human milk, the effects on the breastfed infant, or the effects on milk production. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for Qbrexza and any potential adverse effects on the breastfed infant from Qbrexza or from the underlying maternal condition.
The safety, effectiveness and pharmacokinetics of Qbrexza have been established in pediatric patients age 9 years and older for topical treatment of primary axillary hyperhidrosis [see Clinical Pharmacology (12.3)]. Use of Qbrexza in this age group is supported by evidence from two multicenter, randomized, double-blind, parallel-group, vehicle-controlled 4-week trials which included 34 pediatric subjects 9 years and older [see Adverse Reactions (6.1) and Clinical Studies (14)]. The safety and effectiveness of Qbrexza have not been established in pediatric patients under 9 years of age.
Clinical trials of Qbrexza did not include sufficient numbers of subjects age 65 years and older to determine whether they respond differently from younger subjects.
The elimination of glycopyrronium is severely impaired in patients with renal failure [see Clinical Pharmacology (12.3)].
Because glycopyrronium is a quaternary amine which does not easily cross the blood-brain barrier, symptoms of glycopyrronium overdosage are generally more peripheral in nature rather than central compared to other anticholinergic agents. Associated signs and symptoms related to excessive anticholinergic activity may include flushing, hyperthermia, tachycardia, ileus, urinary retention, loss of ocular accommodation and light sensitivity due to mydriasis.
In the case of overdose when symptoms are severe or life threatening, therapy may include:
- Managing per standard of care any acute conditions such as hyperthermia, coma, and/or seizures, as applicable, and managing any myoclonic or choreoathetoid movements which may lead to rhabdomyolysis in some cases of anticholinergic overdosage
- Managing severe urinary retention with catheterization if not spontaneously reversed within several hours
- Providing cardiovascular support and/or controlling arrhythmias
- Maintaining an open airway, providing ventilation as necessary
- Administering a quaternary ammonium anticholinesterase such as neostigmine to help alleviate severe and/or life threatening peripheral anticholinergic effects.
Topical overdosing of Qbrexza could result in an increased incidence or severity of local skin reactions. Administration of Qbrexza under occlusive conditions may result in an increase in anticholinergic effects, including dry mouth and urinary hesitation.
Qbrexza (glycopyrronium) cloth, 2.4% is an anticholinergic drug available as a clear, colorless to pale yellow solution on a single-use pre-moistened cloth (an absorbent polypropylene pad) packaged in a pouch for topical administration. Each pouch contains 105 mg glycopyrronium tosylate, equivalent to 66 mg of glycopyrronium. The inactive ingredients are citric acid, dehydrated alcohol, purified water, and sodium citrate.
Glycopyrronium tosylate is chemically described as pyrrolidinium, 3-[(2-cyclopentyl-2-hydroxy-2-phenylacetyl)oxy]-1,1-dimethyl-, 4-methylbenzensulfonate, hydrate (1:1:1) with an empirical formula of C26 H37 NO7 S and a molecular weight of 507.6. The structural formula is represented below:
Glycopyrronium is a competitive inhibitor of acetylcholine receptors that are located on certain peripheral tissues, including sweat glands. In hyperhidrosis, glycopyrronium inhibits the action of acetylcholine on sweat glands, reducing sweating.
The pharmacodynamics of Qbrexza are not known.
The pharmacokinetics of glycopyrronium were evaluated in adult and pediatric patients with primary axillary hyperhidrosis following Qbrexza once daily applied to the axillae for 5 days. The mean ± SD exposures of glycopyrronium are presented in Tables 3 and 4. There was no evidence of accumulation.
|Abbreviations: Maximum concentration (Cmax ), Area under the time concentration curve (AUC) between 0 and 6 hours following administration of Qbrexza (AU0-6h ), AUC between 0 and 24 hours following administration of Qbrexza (AUC0-24h )|
|Cmax (ng/mL)||0.08 ± 0.04|
|AUC0-6h (h∗ ng/mL)||0.2 ± 0.14|
|AUC0-24h (h∗ ng/mL)||0.88 ± 0.57|
|Median Tmax (Range) (h)||1 (0, 10)|
After IV administration, glycopyrronium has a mean volume of distribution in children aged 1 to 14 years of approximately 1.3 to 1.8 L/kg, with a range from 0.7 to 3.9 L/kg. In adults aged 60-75 years, the volume of distribution was lower (0.42 L/kg ± 0.22).
A small proportion of glycopyrronium is metabolized following IV administration. The metabolic pathway for glycopyrronium is not characterized.
Following administration of a single radiolabeled IV glycopyrronium dose to adult subjects who underwent surgery for cholelithiasis, approximately 85% of total radioactivity was excreted in urine and < 5% was present in bile drainage. Greater than 80% of the radioactivity in both urine and bile was unchanged drug.
The pharmacokinetics of glycopyrronium were not evaluated in pregnant women or patients with hepatic impairment.
The mean ± SD exposures of glycopyrronium in pediatric subjects following Qbrexza once daily for 5 days are presented in Table 4. There was no evidence of accumulation.
|Cmax (ng/mL)||0.07 ± 0.06|
|AUC0-6h (h∗ ng/mL)||0.18 ± 0.13|
|AUC0-24h (h∗ ng/mL)||Not calculated|
|Median Tmax (Range) (h)||1.5 (0, 6)|
Patients with Renal Impairment
Following a 4 mcg/kg IV dose of a glycopyrronium formulation for IV use, mean glycopyrronium AUC (10.6 mcg·h/L), CL (0.43 L/h/kg) and 3-hour urinary excretion (0.7%) were significantly different in uremic subjects undergoing renal transplantation surgery than those of healthy subjects (3.73 mcg·h/L, 1.14 L/h/kg, and 50%, respectively).
Pharmacokinetics of Qbrexza in subjects with renal impairment has not been studied.
In Vitro Studies
In vitro studies indicated that under the conditions of clinical use, Qbrexza is not expected to induce cytochrome P450 (CYP) enzymes 1A2, 2B6 and 3A4; or inhibit 1A2, 2B6, 2C8, 2C9, 2C19, 2D6 and 3A4.
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