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Erythromycin
Fluticasone Propionate
In a multiple-dose drug interaction trial, coadministration of orally inhaled fluticasone propionate (500 mcg twice daily) and erythromycin (333 mg 3 times daily) did not affect fluticasone propionate pharmacokinetics.
Salmeterol
In a repeat-dose trial in 13 healthy subjects, concomitant administration of erythromycin (a moderate CYP3A4 inhibitor) and salmeterol inhalation aerosol resulted in a 40% increase in salmeterol C max at steady state (ratio with and without erythromycin 1.4 [90% CI: 0.96, 2.03], P = 0.12), a 3.6-beat/min increase in heart rate ([95% CI: 0.19, 7.03], P <0.04), a 5.8-msec increase in QTc interval ([95% CI: -6.14, 17.77], P = 0.34), and no change in plasma potassium.
13 NONCLINICAL TOXICOLOGY
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
Fluticasone Propionate
Fluticasone propionate demonstrated no tumorigenic potential in mice at oral doses up to 1,000 mcg/kg (approximately 5 and 10 times the MRHDID for adults and children, respectively, on a mcg/m 2 basis) for 78 weeks or in rats at inhalation doses up to 57 mcg/kg (less than and approximately equivalent to the MRHDID for adults and children, respectively, on a mcg/m 2 basis) for 104 weeks.
Fluticasone propionate did not induce gene mutation in prokaryotic or eukaryotic cells in vitro. No significant clastogenic effect was seen in cultured human peripheral lymphocytes in vitro or in the in vivo mouse micronucleus test.
Fertility and reproductive performance were unaffected in male and female rats at subcutaneous doses up to 50 mcg/kg (approximately 0.5 times the MRHDID for adults on a mcg/m 2 basis).
Salmeterol
In an 18-month carcinogenicity study in CD-mice, salmeterol at oral doses of 1,400 mcg/kg and above (approximately 20 times the MRHDID for adults and children based on comparison of the plasma AUCs) caused a dose-related increase in the incidence of smooth muscle hyperplasia, cystic glandular hyperplasia, leiomyomas of the uterus, and ovarian cysts. No tumors were seen at 200 mcg/kg (approximately 3 times the MRHDID for adults and children based on comparison of the AUCs).
In a 24-month oral and inhalation carcinogenicity study in Sprague Dawley rats, salmeterol caused a dose-related increase in the incidence of mesovarian leiomyomas and ovarian cysts at doses of 680 mcg/kg and above (approximately 66 and 35 times the MRHDID for adults and children, respectively, on a mcg/m 2 basis). No tumors were seen at 210 mcg/kg (approximately 20 and 10 times the MRHDID for adults and children, respectively, on a mcg/m 2 basis). These findings in rodents are similar to those reported previously for other beta-adrenergic agonist drugs. The relevance of these findings to human use is unknown.
Salmeterol produced no detectable or reproducible increases in microbial and mammalian gene mutation in vitro. No clastogenic activity occurred in vitro in human lymphocytes or in vivo in a rat micronucleus test.
Fertility and reproductive performance were unaffected in male and female rats at oral doses up to 2,000 mcg/kg (approximately 195 times the MRHDID for adults on a mcg/m 2 basis).
13.2 Animal Toxicology and/or Pharmacology
Preclinical
Studies in laboratory animals (minipigs, rodents, and dogs) have demonstrated the occurrence of cardiac arrhythmias and sudden death (with histologic evidence of myocardial necrosis) when beta-agonists and methylxanthines are administered concurrently. The clinical relevance of these findings is unknown.
14 CLINICAL STUDIES
14.1 Asthma
Adult and Adolescent Subjects Aged 12 Years and Older
In clinical trials comparing fluticasone propionate and salmeterol inhalation powder with its individual components, improvements in most efficacy endpoints were greater with fluticasone propionate and salmeterol inhalation powder than with the use of either fluticasone propionate or salmeterol alone. In addition, clinical trials showed similar results between fluticasone propionate and salmeterol inhalation powder and the concurrent use of fluticasone propionate plus salmeterol at corresponding doses from separate inhalers.
Trials Comparing Fluticasone Propionate and Salmeterol Inhalation Powder with Fluticasone Propionate Alone or Salmeterol Alone
Three (3) double-blind, parallel-group clinical trials were conducted with fluticasone propionate and salmeterol inhalation powder in 1,208 adult and adolescent subjects (aged 12 years and older, baseline FEV 1 63% to 72% of predicted normal) with asthma that was not optimally controlled on their current therapy. All treatments were inhalation powders given as 1 inhalation from a dry powder inhaler twice daily, and other maintenance therapies were discontinued.
Trial 1: Clinical Trial with Fluticasone Propionate and Salmeterol Inhalation Powder 100 mcg/50 mcg
This placebo-controlled, 12-week, U.S. trial compared fluticasone propionate and salmeterol inhalation powder 100 mcg/50 mcg with its individual components, fluticasone propionate 100 mcg and salmeterol 50 mcg. The trial was stratified according to baseline asthma maintenance therapy; subjects were using either ICS (n = 250) (daily doses of beclomethasone dipropionate 252 to 420 mcg; flunisolide 1,000 mcg; fluticasone propionate inhalation aerosol 176 mcg; or triamcinolone acetonide 600 to 1,000 mcg) or salmeterol (n = 106). Baseline FEV 1 measurements were similar across treatments: fluticasone propionate and salmeterol inhalation powder 100 mcg/50 mcg, 2.17 L; fluticasone propionate 100 mcg, 2.11 L; salmeterol, 2.13 L; and placebo, 2.15 L.
Predefined withdrawal criteria for lack of efficacy, an indicator of worsening asthma, were utilized for this placebo-controlled trial. Worsening asthma was defined as a clinically important decrease in FEV 1 or PEF, increase in use of VENTOLIN ® (albuterol, USP) Inhalation Aerosol, increase in night awakenings due to asthma, emergency intervention or hospitalization due to asthma, or requirement for asthma medication not allowed by the protocol. As shown in Table 4, statistically significantly fewer subjects receiving fluticasone propionate and salmeterol inhalation powder 100 mcg/50 mcg were withdrawn due to worsening asthma compared with fluticasone propionate, salmeterol, and placebo.
Fluticasone Propionate and Salmeterol Inhalation Powder 100 mcg/50 mcg (n = 87) | Fluticasone Propionate 100 mcg (n = 85) | Salmeterol 50 mcg (n = 86) | Placebo (n = 77) |
3% | 11% | 35% | 49% |
The FEV 1 results are displayed in Figure 1. Because this trial used predetermined criteria for worsening asthma, which caused more subjects in the placebo group to be withdrawn, FEV 1 results at Endpoint (last available FEV 1 result) are also provided. Subjects receiving fluticasone propionate and salmeterol inhalation powder 100 mcg/50 mcg had significantly greater improvements in FEV 1 (0.51 L, 25%) compared with fluticasone propionate 100 mcg (0.28 L, 15%), salmeterol (0.11 L, 5%), and placebo (0.01 L, 1%). These improvements in FEV 1 with fluticasone propionate and salmeterol inhalation powder were achieved regardless of baseline asthma maintenance therapy (ICS or salmeterol).
The effect of fluticasone propionate and salmeterol inhalation powder 100 mcg/50 mcg on morning and evening PEF endpoints is shown in Table 5.
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Efficacy Variable * | Fluticasone Propionate and Salmeterol Inhalation Powder 100 mcg/50 mcg (n = 87) | Fluticasone Propionate 100 mcg (n = 85) | Salmeterol 50 mcg (n = 86) | Placebo (n = 77) |
AM PEF (L/min) Baseline Change from baseline | 393 53 | 374 17 | 369 -2 | 382 -24 |
PM PEF (L/min) Baseline Change from baseline | 418 35 | 390 18 | 396 -7 | 398 -13 |
The subjective impact of asthma on subjects’ perception of health was evaluated through use of an instrument called the Asthma Quality of Life Questionnaire (AQLQ) (based on a 7 point scale where 1 = maximum impairment and 7 = none). Subjects receiving fluticasone propionate and salmeterol inhalation powder 100 mcg/50 mcg had clinically meaningful improvements in overall asthma-specific quality of life as defined by a difference between groups of ≥0.5 points in change from baseline AQLQ scores (difference in AQLQ score of 1.25 compared with placebo).
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