SUMMARY OF PRODUCT CHARACTERISTICS NAME OF THE MEDICINAL PRODUCT
1mg: Livazo 1mg film-coated tablets. 2mg: Livazo 2mg film-coated tablets. 4mg: Livazo 4mg film-coated tablets. 2. QUALITATIVE AND QUANTITATIVE COMPOSITION
1mg: Each film-coated tablet contains pitavastatin calcium equivalent to 1mg pitavastatin.
Excipient(s) include 63.085mg Lactose monohydrate.
For a full list of excipients see Section 6.1.
2mg: Each film-coated tablet contains pitavastatin calcium equivalent to 2mg pitavastatin.
Excipient(s) include 126.17mg Lactose monohydrate.
For a full list of excipients see Section 6.1.
4mg: Each film coated tablet contains pitavastatin calcium equivalent to 4mg pitavastatin.
Excipient(s) include 252.34mg Lactose monohydrate.
For a full list of excipients see Section 6.1.
3. PHARMACEUTICAL
Round white film-coated tablets embossed ‘KC’ on one face and ‘1’ on the reverse.
Round white film-coated tablets embossed ‘KC’ on one face and ‘2’on the reverse.
Round white film-coated tablets embossed ‘KC’ on one face and ‘4’on the reverse.
4. CLINICAL PARTICULARS
4.1 Therapeutic indications
Livazo is indicated for the reduction of elevated total cholesterol (TC) and LDL-C, in adult patients with primary hypercholesterolaemia, including heterozygous familial hypercholesterolaemia, and combined (mixed) dyslipidaemia, when response to diet and other non-pharmacological measures is inadequate. 4.2 Posology and method of administration
For oral use only and should be swallowed whole. Livazo can be taken at any time of the day with or without food. It is desirable that the patient takes the tablet at the same time each day. Statin therapy is generally more effective in the evening due to the circadian rhythm of lipid metabolism. Patients should be on a cholesterol lowering diet before treatment. It is important that patients continue dietary control during treatment.
Pitavastatin 1mg, 2mg & 4mg film-coated tablets
The usual starting dose is 1mg once daily. Adjustment of dose should be made at intervals of 4 weeks or more. Doses should be individualized according to LDL-C levels, the goal of therapy and patient response. Most patients will require a 2mg dose (see Section 5.1). The maximum daily dose is 4mg.
No dosage adjustment is required (see Sections 5.1 and 5.2).
Pitavastatin should not be used in children aged below 18 years because safety and efficacy has not been established. No data are currently available.
No dosage adjustment is required in mild renal impairment but pitavastatin should be used with caution. Data with 4mg dose are limited in all grades of impaired renal function. Therefore 4mg dose should ONLY be used with close monitoring after graded dose titration. In those with severe renal impairment 4mg dose is not recommended (see Sections 4.4 and 5.2).
The 4mg dose is not recommended in patients with mild to
moderate impaired hepatic function. A maximum daily dose of 2mg may be given with close monitoring (see Sections 4.4 and 5.2).
4.3 Contraindications Livazo is contraindicated:
in patients with known hypersensitivity to pitavastatin or to any of the excipients or other
in patients with severe hepatic impairment, active liver disease or unexplained persistent
elevations in serum transaminases (exceeding 3 times the upper limit of normal [ULN])
in patients receiving concomitant ciclosporin
during pregnancy, while breast feeding and in women of child bearing potential not taking
Special warnings and precautions for use
Muscle Effects In common with other HMG-CoA reductase inhibitors (statins), there is the potential for myalgia, myopathy and, rarely, rhabdomyolysis to develop. Patients should be asked to report any muscle symptoms. Creatine kinase (CK) levels should be measured in any patient reporting muscle pain, muscle tenderness or weakness especially if accompanied by malaise or fever. Creatine kinase should not be measured following strenuous exercise or in the presence of any other plausible cause of CK increase which may confound interpretation of the result. When elevated CK concentrations (>5x ULN) are noted, a confirmatory test should be performed within 5 to 7 days.
Pitavastatin 1mg, 2mg & 4mg film-coated tablets
Before Treatment In common with other statins, Livazo should be prescribed with caution in patients with pre-disposing factors for rhabdomyolysis. A creatinine kinase level should be measured, to establish a reference baseline, in the following situations:
personal or family history of hereditary muscular disorders,
previous history of muscular toxicity with a fibrate or another statin,
history of liver disease or alcohol abuse,
elderly patients (over 70 years) with other predisposing risk factors for rhabdomyolysis,
In such situations, clinical monitoring is recommended and the risk of treatment should be considered in relation to the possible benefit. Treatment with Livazo should not be started if CK values are >5x ULN. During Treatment Patients must be encouraged to report muscle pain, weakness or cramps immediately. Creatine kinase levels should be measured and treatment stopped if CK levels are elevated (>5x ULN). Stopping treatment should be considered if muscular symptoms are severe even if CK levels are ≤5x ULN. If symptoms resolve and CK levels return to normal, then re-introduction of Livazo may be considered at a dose of 1mg and with close monitoring. Liver Effects In common with other statins, Livazo should be used with caution in patients with a history of liver disease or who regularly consume excessive quantities of alcohol. Liver function tests should be performed prior to initiating treatment with Livazo and then periodically during treatment. Livazo treatment should be discontinued in patients who have a persistent increase in serum transaminases (ALT and AST) exceeding 3x ULN. Renal Effects Livazo should be used with caution in patients with moderate or severe renal impairment. Dose increments should be instituted only with close monitoring. In those with severe renal impairment, 4mg dose is not recommended (see Section 4.2). Interstitial Lung Disease Exceptional cases of interstitial lung disease have been reported with some statins, especially with long term therapy (see Section 4.8). Presenting features can include dyspnoea, non-productive cough and deterioration in general health (fatigue, weight loss and fever). If it is suspected a patient has developed interstitial lung disease, statin therapy should be discontinued. Other effects A temporary suspension of Livazo is recommended for the duration of treatment with erythromycin, other macrolide antibiotics or fusidic acid (see Section 4.5). Livazo should be used with caution in patients taking drugs known to cause myopathy (e.g. fibrates or niacin see Section 4.5). The tablets contain lactose. Patients with the rare hereditary problems of galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.
Pitavastatin 1mg, 2mg & 4mg film-coated tablets
Interaction with other medicinal products and other forms of interaction
Pitavastatin is actively transported into human hepatocytes by multiple hepatic transporters (including organic anion transporting polypeptide, OATP), which may be involved in some of the following interactions. Ciclosporin: Co-administration of a single dose of ciclosporin with Livazo at steady state resulted in a 4.6-fold increase in pitavastatin AUC. The effect of steady state ciclosporin on steady state Livazo is not known. Livazo is contraindicated in patients being treated with ciclosporin (see section 4.3). Erythromycin: Co-administration with Livazo resulted in a 2.8-fold increase in pitavastatin AUC. A temporary suspension of Livazo is recommended for the duration of treatment with erythromycin or other macrolide antibiotics. Gemfibrozil and other fibrates: The use of fibrates alone is occasionally associated with myopathy. Co-administration of fibrates with statins has been associated with increased myopathy and rhabdomyolysis. Livazo should be administered with caution when used concomitantly with fibrates (see Section 4.4). In Pharmacokinetic studies co-administration of Livazo with Gemfibrozil resulted in a 1.4-fold increase in pitavastatin AUC with Fenofibrate AUC increased 1.2-fold. Niacin: Interaction studies with Livazo and niacin have not been conducted. The use of niacin alone has been associated with myopathy and rhabdomyolysis when used as a monotherapy. Thus Livazo should be administered with caution when used concomitantly with niacin. Fusidic acid: There have been reports of severe muscle problems such as rhabdomyolysis attributed to interactions between fusidic acid and statins. A temporary suspension of Livazo is recommended for the duration of treatment with fusidic acid (see section 4.4). Rifampicin: Co-administration with Livazo at the same time resulted in a 1.3-fold increase in pitavastatin AUC due to reduced hepatic uptake Protease inhibitors: Co-administration with Livazo at the same time may result in minor changes in pitavastatin AUC. Ezetimibe and its glucuronide metabolite inhibit the absorption of dietary and biliary cholesterol. Co-administration of Livazo had no effect on plasma ezetimibe or the glucuronide metabolite concentrations and ezetimibe had no impact on pitavastatin plasma concentrations. Inhibitors of CYP3A4: Interaction studies with itraconazole and grapefruit juice, known inhibitors of CYP3A4, had no clinically significant effect on the plasma concentrations of pitavastatin. Digoxin, a known P-gp substrate, did not interact with Livazo. During co-administration there was no significant change in either pitavastatin or digoxin concentrations. Warfarin: The steady-state pharmacokinetics and pharmacodynamics (INR and PT) of warfarin in healthy volunteers was unaffected by the co-administration of Livazo 4mg daily. However, as for other statins, patients receiving warfarin should have their prothrombin time or INR monitored when Livazo is added to their therapy.
Pitavastatin 1mg, 2mg & 4mg film-coated tablets
Pregnancy and lactation
Pregnancy Livazo is contraindicated during pregnancy (see Section 4.3). Women of childbearing potential must take appropriate contraceptive precautions during treatment with Livazo. Since cholesterol and other products of cholesterol biosynthesis are essential for the development of the fetus, the potential risk for inhibition of HMG-CoA reductase outweighs the advantage of treatment during pregnancy. Animal studies show evidence of reproductive toxicity, but no teratogenic potential (see Section 5.3). If the patient is planning to become pregnant, treatment should be stopped at least one month prior to conception. If a patient becomes pregnant during use of Livazo, treatment must be discontinued immediately. Lactation Livazo is contraindicated during lactation (see Section 4.3). Pitavastatin is excreted in rat milk. It is not known whether it is excreted in human milk. 4.7 Effects on ability to drive and use machines
There is no pattern of adverse events that suggests that patients taking Livazo will have any impairment of ability to drive and use hazardous machinery, but it should be taken into account that there have been reports of dizziness and somnolence during treatment with Livazo. 4.8 Undesirable
Summary of the safety profile In controlled clinical trials, at the recommended doses, less than 4% of Livazo treated patients were withdrawn due to adverse events. The most commonly reported pitavastatin related adverse reaction in controlled clinical trials was myalgia. Summary of adverse reactions Adverse reactions and frequencies observed in worldwide controlled clinical trials and extension studies, at the recommended doses, are listed below by system organ class. Frequencies are defined as: 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) and not known. Blood and the lymphatic system disorders Uncommon: Anaemia Metabolism and nutrition disorders Uncommon: Anorexia Psychiatric disorders Uncommon: Insomnia Nervous system disorders Common: Headache Uncommon: Dizziness, Dysgeusia, Somnolence Eye disorders Rare: Visual acuity reduced Ear and labyrinth disorders Uncommon: Tinnitus
Pitavastatin 1mg, 2mg & 4mg film-coated tablets
Gastrointestinal disorders Common: Constipation, Diarrhoea, Dyspepsia, Nausea Uncommon: Abdominal Pain, Dry Mouth, Vomiting Rare: Glossodynia, pancreatitis acute Hepato-biliary disorders Uncommon: Transaminases (aspartate aminotransferase, alanine aminotransferase) increased Rare: Jaundice cholestatic Skin and subcutaneous tissue disorders Uncommon: Pruritus, Rash Rare: Urticaria, Erythema Musculoskeletal, connective tissue and bone disorders Common: Myalgia, Arthralgia Uncommon: Muscle spasms Renal and urinary disorders Uncommon: Pollakiuria General disorders and administration site conditions Uncommon: Asthenia, Malaise, Fatigue, Peripheral Oedema Elevated blood creatinine kinase of >3 times the upper limit of normal (ULN) occurred in 49 out of 2800 (1.8%) patients receiving Livazo in the controlled clinical trials. Levels of ≥10 times ULN with concurrent muscle symptoms were rare and only observed in one patient out of 2406 treated with 4mg Livazo (0.04%) in the clinical trial programme. Post Marketing Experience A two year prospective post-marketing surveillance study was conducted in nearly 20,000 patients in Japan. The overwhelming majority of the 20,000 patients in the study were treated with 1mg or 2mg pitavastatin and not 4mg. 10.4% of patients reported adverse events for which a causal relationship to pitavastatin could not be ruled out and 7.4% of patients withdrew from therapy due to adverse events. The myalgia rate was 1.08%. The majority of adverse events were mild. Adverse event rates were higher over 2 years in patients with a history of drug allergy (20.4%), or hepatic or renal disease (13.5%). Adverse reactions and frequencies observed in the prospective post-marketing surveillance study but not in worldwide controlled clinical trials, at the recommended doses are listed below. Hepato-biliary disorders Rare: Hepatic function abnormal, Liver disorder Musculoskeletal, connective tissue disorders Rare: Myopathy, Rhabdomyolysis In the post-marketing surveillance study there were two reports of rhabdomyolysis requiring hospitalisation (0.01% of patients). In addition there are unsolicited post-marketing reports of skeletal muscle effects including myalgia and myopathy in Livazo treated patients at all recommended doses. Reports of rhabdomyolysis, with and without acute renal failure, including fatal rhabdomyolysis have also been received.
Pitavastatin 1mg, 2mg & 4mg film-coated tablets
Statin class effects The following adverse events have been reported with some statins:
Sleep disturbances, including nightmares
Exceptional cases of interstitial lung disease, especially with long term therapy (see Section 4.4)
4.9 Overdose There is no specific treatment in the event of overdose. The patient should be treated symptomatically and supportive measures instituted as required. Liver function and CK levels should be monitored. Haemodialysis is unlikely to be of benefit. 5. PHARMACOLOGICAL PROPERTIES
Mechanism of Action Pitavastatin competitively inhibits HMG-CoA reductase, the rate-limiting enzyme in the biosynthesis of cholesterol, and inhibits cholesterol synthesis in the liver. As a result the expression of LDL receptors in the liver is increased, promoting the uptake of circulating LDL from the blood, decreasing total cholesterol (TC) and LDL-cholesterol (LDL-C) concentrations in the blood. Its sustained inhibition of hepatic cholesterol synthesis reduces VLDL secretion into the blood, reducing plasma triglyceride (TG) levels. Pharmacodynamic Effects Livazo reduces elevated LDL-C, total cholesterol and triglycerides and increases HDL-cholesterol (HDL-C). It reduces Apo-B, and produces variable increases in Apo-A1 (see Table 1). It also reduces non-HDL-C and elevated TC/HDL-C, and Apo-B/Apo-A1 ratios. Dose response in patients with primary hypercholesterolaemia (Adjusted mean percent change from baseline over 12 weeks)
1mg 52 -33.3 -22.8 9.4 -14.8 -24.1 8.5 2mg 49 -38.2 -26.1 9.0 -17.4 -30.4 5.6 4mg 50 -46.5 -32.5 8.3 -21.2 -36.1 4.7 *unadjusted
Clinical efficacy In controlled clinical studies which enrolled a total of 1687 patients with primary hypercholesterolaemia and mixed dyslipidaemia, including 1239 patients treated at the therapeutic doses (mean baseline LDL-C about 4.8 mmol/L), Livazo consistently reduced LDL-C, TC, non- HDL-C, TG and Apo-B concentrations and elevated HDL-C and Apo-A1 concentrations. TC/HDL- C and Apo-B/Apo-A1 ratios were reduced. LDL-C was reduced by 38 to 39% with Livazo 2mg and 44 to 45% with Livazo 4mg. The majority of patients taking 2mg achieved the European Atherosclerosis Society (EAS) treatment target for LDL-C (<3 mmol/L).
Pitavastatin 1mg, 2mg & 4mg film-coated tablets
In a controlled clinical trial in 942 patients aged ≥65 years (434 treated with Livazo 1mg, 2mg or 4mg) with primary hypercholesterolaemia and mixed dyslipidaemia (mean baseline LDL-C about 4.2 mmol/L), LDL-C values were reduced by 31%, 39.0% and 44.3%, respectively, and about 90% of patients reached the EAS treatment target. More than 80% of the patients were taking concomitant medications, but the incidence of adverse events was similar in all treatment groups and fewer than 5% of patients withdrew from the study due to adverse events. Safety and efficacy findings were similar in patients in the different age subgroups (65-69, 70-74, and ≥75 years). In controlled clinical trials which enrolled a total of 761 patients (507 treated with Livazo 4mg) who had primary hypercholesterolaemia or mixed dyslipidaemia, with 2 or more cardiovascular risk factors (mean baseline LDL-C about 4.1 mmol/L), or mixed dyslipidaemia with type 2 diabetes (mean baseline LDL-C about 3.6 mmol/L), approximately 80% achieved the relevant EAS target (either 3 or 2.5 mmol/L, depending on risk). LDL-C was reduced by 44% and 41%, respectively, in the patient groups. In long term studies of up to 60 weeks duration in primary hypercholesterolaemia and mixed dyslipidaemia, EAS target attainment has been maintained by persistent and stable reductions of LDL-C, and HDL-C concentrations have continued to increase. In a study in 1346 patients who had completed 12 weeks of statin therapy (LDL-C reduction 42.3%, EAS target attainment 69%, HDL-C elevation 5.6%), values after a further 52 weeks of treatment with pitavastatin 4mg were LDL-C reduction 42.9%, EAS target attainment 74%, HDL-C elevation 14.3%. A beneficial effect of pitavastatin on cardiovascular morbidity and mortality has not been demonstrated as no outcome studies were included in the clinical programme. 5.2 Pharmacokinetic properties
Absorption: Pitavastatin is rapidly absorbed from the upper gastrointestinal tract and peak plasma concentrations are achieved within one hour after oral administration. Absorption is not affected by food. Unchanged drug undergoes enterohepatic circulation and is well absorbed from the jejunum and ileum. The absolute bioavailability of pitavastatin is 51%. Distribution: Pitavastatin is more than 99% protein bound in human plasma, mainly to albumin and alpha 1-acid glycoprotein, and the mean volume of distribution is approximately 133 L. Pitavastatin is actively transported into hepatocytes, the site of action and metabolism, by multiple hepatic transporters including OATP1B1 and OATP1B3. Plasma AUC is variable with an approximately 4- fold range between the highest and lowest values. Studies with SLCO1B1 (the gene which encodes OATP1B1) suggests that polymorphism of this gene could account for much of the variability in AUC. Pitavastatin is not a substrate for p-glycoprotein. Metabolism: Unchanged pitavastatin is the predominant drug moiety in plasma. The principal metabolite is the inactive lactone which is formed via an ester-type pitavastatin glucuronide conjugate by UDP glucuronosyltransferase (UGT1A3 and 2B7). In vitro studies, using 13 human cytochrome P450 (CYP) isoforms, indicate that the metabolism of pitavastatin by CYP is minimal; CYP2C9 (and to a lesser extent CYP2C8) is responsible for the metabolism of pitavastatin to minor metabolites. Excretion: Unchanged pitavastatin is rapidly cleared from the liver in the bile, but undergoes enterohepatic recirculation, contributing to its duration of action. Less than 5% of pitavastatin is excreted in the urine. The plasma elimination half-life ranges from 5.7 hours (single dose) to 8.9 hours (steady state) and the apparent geometric mean oral clearance is 43.4 L/h after single dose. Effect of food: The maximum plasma concentration of pitavastatin was reduced by 43% when it was taken with a high-fat meal, but AUC was unchanged.
Pitavastatin 1mg, 2mg & 4mg film-coated tablets
Special populations
Elderly: In a pharmacokinetic study which compared healthy young and elderly (≥65 years) volunteers, pitavastatin AUC was 1.3-fold higher in elderly subjects. This has no effect on the safety or efficacy of Livazo in elderly patients in clinical trials. Gender: In a pharmacokinetic study which compared healthy male and female volunteers, pitavastatin AUC was increased 1.6-fold in women. This has no effect on the safety or efficacy of Livazo in women in clinical trials. Race: There was no difference in the pharmacokinetic profile of pitavastatin between Japanese and Caucasian healthy volunteers when age and body weight was taken into account. Paediatric: Pharmacokinetic data in the paediatric population are not available. Renal insufficiency: For patients with moderate renal disease and those on haemodialysis increases in AUC values were 1.8-fold and 1.7-fold respectively (see Section 4.2). Hepatic insufficiency: For patients with mild (Child-Pugh A) hepatic impairment AUC was 1.6 times that in healthy subjects, while for patients with moderate (Child-Pugh B) hepatic impairment AUC was 3.9-fold higher. Dose restrictions are recommended in patients with mild and moderate hepatic impairment (see Section 4.2). Livazo is contraindicated in patients with severe hepatic impairment. 5.3 Preclinical safety data
Non-clinical data reveal no special hazard for humans based on results from conventional studies of safety pharmacology, repeated dose toxicity, genotoxicity and carcinogenic potential. Indications of renal toxicity were seen in monkeys at exposures greater than those reached in adult humans administered the maximum daily dose of 4mg and urinary excretion plays a far greater role in the monkey than in other animal species. In vitro studies with liver microsomes indicate that a monkey-specific metabolite may be implicated. The renal effects observed in monkeys are unlikely to have clinical relevance for humans, however the potential for renal adverse reactions cannot be completely excluded. Pitavastatin had no effect on fertility or reproductive performance and there was no evidence of teratogenic potential. However, maternal toxicity was observed at high doses. A study in rats indicated maternal mortality at or near term accompanied by fetal and neonatal deaths at doses of 1 mg/kg/day (approximately 4 fold greater than the highest dose in humans on an AUC basis). No studies have been conducted in juvenile animals.
Pitavastatin 1mg, 2mg & 4mg film-coated tablets
6. PHARMACEUTICAL PARTICULARS List of excipients
Do not store above 25ºC. To protect from light keep blister in the outer carton. 6.5 Nature and contents of container
1mg: White PVdC coated PVC/AL blisters in cartons of 7, 28, 30, 90 or 100 tablets.
2mg: White PVdC coated PVC/AL blisters in cartons of 7, 28, 30, 90 or 100 tablets.
4mg: White PVdC coated PVC/AL blisters in cartons of 7, 28 or 30 tablets.
Special precautions for disposal
To protect the environment, do not dispose of via waste water or household waste. 7. MARKETING AUTHORISATION
1mg: PL32363/0011 2mg: PL32363/0001 4mg: PL32363/0002 9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION
Pitavastatin 1mg, 2mg & 4mg film-coated tablets
1mg: 12/08/2010 2mg: 12/08/2010 4mg: 12/08/2010 10. DATE OF REVISION OF THE TEXT
1mg: 18/11/2011 2mg: 18/11/2011 4mg: 18/11/2011
Lecture Notes—Song of Songs, Ruth, Lamentations, Esther --Megilloth: --Ecclesiastes— Used in the Celebration of Tabernacles --Song of Songs— Used in the Celebration of Passover --Ruth— Used in the Celebration of Shavuoth/Weeks --Lamentations— Used in the Celebration of Ninth of Ab --Esther— Used in the Celebration of Purim Song of Son
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