- Approval Id
- e9b23bfddb0ed91e
- Drug Approval Emc Name
- Lacosamide Amarox 10 mg/ml solution for infusion
- Drug Name
- Lacosamide Amarox 10 mg/ml solution for infusion
- Company Name
- Amarox Limited
- Company Address
- Congress House, 3rd Floor, 14 Lyon Road, Harrow
- Company Website
- https://amaroxpharma.co.uk/
- Company Telephone
- +44(0)20397 20002
- Company Medical Info Direct Line
- +44(0)20397 20005
- Company Medical Info Email
- amarox_micc@mitoconbiopharma.com
- Company Customer Care Direct Line
- +44(0)20397 20002
- Atc Code
- N03AX18
- Legal Category
- Prescription only medicine
- Authorisation Holder
- Amarox Limited
Congress House, 14 Lyon Road
Harrow, HA1 2EN
United Kingdom
- Authorisation Number
- PL 49445/0175
- Authorisation Date
- 23/11/2023
- Instruction Authorisation Holder
- Amarox Limited
Congress House, 14 Lyon Road
Harrow, HA1 2EN
United Kingdom
- Instruction Authorisation Number
- PL 49445/0175
- Instruction Authorisation Date
- 23/11/2023
- Instruction Composition
- Each ml of solution for infusion contains 10 mg lacosamide.
Each vial of 20 ml solution for infusion contains 200 mg lacosamide.
\*\*Excipients with known effect:\*\*
Each ml of solution for infusion contains 2.99 mg sodium.
For the full list of excipients, see section 6.1
- Instruction Dosage Form
- Solution for infusion.
A clear, colourless solution.
- Instruction Clinical Particulars
- 4.1 Therapeutic indications
Lacosamide Amarox is indicated as monotherapy in the treatment of partial-onset seizures with or without secondary generalisation in adults, adolescents and children from 2 years of age with epilepsy.
Lacosamide Amarox is indicated as adjunctive therapy
• in the treatment of partial-onset seizures with or without secondary generalisation in adults, adolescents and children from 2 years of age with epilepsy.
• in the treatment of primary generalised tonic-clonic seizures in adults, adolescents and children from 4 years of age with idiopathic generalised epilepsy.4.2 Posology and method of administration
\*\*Posology\*\*
The physician should prescribe the most appropriate formulation and strength according to weight and dose.
Lacosamide therapy can be initiated with either oral administration (either tablets or syrup) or intravenous administration (solution for infusion). Solution for infusion is an alternative for patients when oral administration is temporarily not feasible. The overall duration of treatment with intravenous lacosamide is at the physician's discretion; there is experience from clinical studies with twice daily infusions of lacosamide for up to 5 days in adjunctive therapy. Conversion to or from oral and intravenous administration can be done directly without titration. The total daily dose and twice daily administration should be maintained. Monitor closely patients with known cardiac conduction problems, on concomitant medications that prolong PR interval, or with severe cardiac disease (e.g. myocardial ischemia, heart failure) when lacosamide dose is higher than 400 mg/day (see Method of administration below and section 4.4).
Lacosamide must be taken twice a day (approximately 12 hours apart).
The recommended posology for adults, adolescents and children from 2 years of age is summarised in the following table.
| | | |
| --- | --- | --- |
| \*\*\*\*Adolescents and children weighing 50 kg or more, and adults\*\*\*\* | | |
| \*\*Starting dose\*\* | \*\*Titration\*\* \*\*(incremental steps)\*\* | \*\*Maximum recommended dose\*\* |
| \*\*Monotherapy:\*\* 50 mg twice a day (100 mg/day) or 100 mg twice a day (200 mg/day) \*\*Adjunctive therapy:\*\* 50 mg twice a day (100 mg/day) | 50 mg twice a day (100 mg/day) at weekly intervals | \*\*Monotherapy:\*\* up to 300 mg twice a day (600 mg/day) \*\*Adjunctive therapy:\*\* up to 200 mg twice a day (400 mg/day) |
| \*\*Alternate initial dosage\\*\*\* (If applicable)\*\*:\*\* 200 mg single loading dose followed by 100 mg twice a day (200 mg/day) | | |
| \\* A loading dose may be initiated in patients in situations when the physician determines that rapid attainment of lacosamide steady state plasma concentration and therapeutic effect is warranted. It should be administered under medical supervision with consideration of the potential for increased incidence of serious cardiac arrhythmia and central nervous system adverse reactions (see section 4.8). Administration of a loading dose has not been studied in acute conditions such as status epilepticus. | | |
| | | |
| --- | --- | --- |
| \*\*\*\*Children from 2 years of age and adolescents weighing less than 50 kg\*\*\*\* | | |
| \*\*Starting dose\*\* | \*\*Titration\*\* \*\*(incremental steps)\*\* | \*\*Maximum recommended dose\*\* |
| \*\*Monotherapy and Adjunctive therapy:\*\* 1 mg/kg twice a day (2 mg/kg/day) | 1 mg/kg twice a day (2 mg/kg/day) at weekly intervals | \*\*Monotherapy:\*\* - up to 6 mg/kg twice a day (12 mg/kg/day) in patients ≥ 10 kg to < 40 kg - up to 5 mg/kg twice a day (10 mg/kg/day) in patients ≥ 40 kg to < 50 kg |
| \*\*Adjunctive therapy:\*\* - up to 6 mg/kg twice a day (12 mg/kg/day) in patients ≥ 10 kg to < 20 kg - up to 5 mg/kg twice a day (10 mg/kg/day) in patients ≥ 20 kg to < 30 kg - up to 4 mg/kg twice a day (8 mg/kg/day) in patients ≥ 30 kg to < 50 kg |
\*\*\*Adolescents and children weighing 50 kg or more, and adults\*\*\*
\*Monotherapy (in the treatment of partial-onset seizures)\*
The recommended starting dose is 50 mg twice a day (100 mg/day) which should be increased to an initial therapeutic dose of 100 mg twice a day (200 mg/day) after one week.
Lacosamide can also be initiated at the dose of 100 mg twice a day (200 mg/day) based on the physician's assessment of required seizure reduction versus potential side effects.
Depending on response and tolerability, the maintenance dose can be further increased at weekly intervals by 50 mg twice a day (100 mg/day), up to a maximum recommended daily dose of 300 mg twice a day (600 mg/day).
In patients having reached a dose greater than 200 mg twice a day (400 mg/day) and who need an additional antiepileptic medicinal product, the posology that is recommended for adjunctive therapy below should be followed.
\*Adjunctive therapy (in the treatment of partial-onset seizures or in the treatment of primary generalised tonic-clonic seizures)\*
The recommended starting dose is 50 mg twice a day (100 mg/day) which should be increased to an initial therapeutic dose of 100 mg twice a day (200 mg/day) after one week.
Depending on response and tolerability, the maintenance dose can be further increased at weekly intervals by 50 mg twice a day (100 mg/day), up to a maximum recommended daily dose of 200 mg twice a day (400 mg/day).
\*\*\*Children from 2 years of age and adolescents weighing less than 50 kg\*\*\*
The dose is determined based on body weight.
\*Monotherapy (in the treatment of partial-onset seizures)\*
The recommended starting dose is 1 mg/kg twice a day (2 mg/kg/day) which should be increased to an initial therapeutic dose of 2 mg/kg twice a day (4 mg/kg/day) after one week.
Depending on response and tolerability, the maintenance dose can be further increased by 1 mg/kg twice a day (2 mg/kg/day) every week. The dose should be gradually increased until the optimum response is obtained. The lowest effective dose should be used. In children weighing from 10 kg to less than 40 kg, a maximum dose of up to 6 mg/kg twice a day (12 mg/kg/day) is recommended. In children weighing from 40 to under 50 kg, a maximum dose of 5 mg/kg twice a day (10 mg/kg/day) is recommended.
The tables below provide examples of volumes of solution for infusion per administration depending on prescribed dose and body weight. The precise volume of solution for infusion is to be calculated according to the exact body weight of the child.
Monotherapy doses in the treatment of partial-onset seizures \*\*to be taken twice a day\*\* for children from 2 years of age \*\*weighing from 10 kg to less than 40 kg\*\*
| | | | | | | |
| --- | --- | --- | --- | --- | --- | --- |
| Week | Week 1 | Week 2 | Week 3 | Week 4 | Week 5 | Week 6 |
| Prescribed dose | 0.1 ml/kg (1 mg/kg) Starting dose | 0.2 ml/kg (2 mg/kg) | 0.3 ml/kg (3 mg/kg) | 0.4 ml/kg (4 mg/kg) | 0.5 ml/kg (5 mg/kg) | 0.6 ml/kg (6 mg/kg) Maximum recommended dose |
| Weight | Volume administered | | | | | |
| 10 kg | 1 ml (10 mg) | 2 ml (20 mg) | 3 ml (30 mg) | 4 ml (40 mg) | 5 ml (50 mg) | 6 ml (60 mg) |
| 15 kg | 1.5 ml (15 mg) | 3 ml (30 mg) | 4.5 ml (45 mg) | 6 ml (60 mg) | 7.5 ml (75 mg) | 9 ml (90 mg) |
| 20 kg | 2 ml (20 mg) | 4 ml (40 mg) | 6 ml (60 mg) | 8 ml (80 mg) | 10 ml (100 mg) | 12 ml (120 mg) |
| 25 kg | 2.5 ml (25 mg) | 5 ml (50 mg) | 7.5 ml (75 mg) | 10 ml (100 mg) | 12.5 ml (125 mg) | 15 ml (150 mg) |
| 30 kg | 3 ml (30 mg) | 6 ml (60 mg) | 9 ml (90 mg) | 12 ml (120 mg) | 15 ml (150 mg) | 18 ml (180 mg) |
| 35 kg | 3.5 ml (35 mg) | 7 ml (70 mg) | 10.5 ml (105 mg) | 14 ml (140 mg) | 17.5 ml (175 mg) | 21 ml (210 mg) |
Monotherapy doses in the treatment of partial-onset seizures \*\*to be taken twice a day\*\* for children and adolescents \*\*weighing from 40 kg to less than 50 kg\*\*(1)
| | | | | | |
| --- | --- | --- | --- | --- | --- |
| Week | Week 1 | Week 2 | Week 3 | Week 4 | Week 5 |
| Prescribed dose | 0.1 ml/kg (1 mg/kg) Starting dose | 0.2 ml/kg (2 mg/kg) | 0.3 ml/kg (3 mg/kg) | 0.4 ml/kg (4 mg/kg) | 0.5 ml/kg (5 mg/kg) Maximum recommended dose |
| Weight | Volume administered | | | | |
| 40 kg | 4 ml (40 mg) | 8 ml (80 mg) | 12 ml (120 mg) | 16 ml (160 mg) | 20 ml (200 mg) |
| 45 kg | 4.5 ml (45 mg) | 9 ml (90 mg) | 13.5 ml (135 mg) | 18 ml (180 mg) | 22.5 ml (225 mg) |
(1) Dosage in adolescents 50 kg or more is the same as in adults.
\*Adjunctive therapy (in the treatment of primary generalised tonic-clonic seizures from 4 years of age or in the treatment of partial-onset seizures from 2 years of age)\*
The recommended starting dose is 1 mg/kg twice a day (2 mg/kg/day) which should be increased to an initial therapeutic dose of 2 mg/kg twice a day (4 mg/kg/day) after one week.
Depending on response and tolerability, the maintenance dose can be further increased by 1 mg/kg twice a day (2 mg/kg/day) every week. The dose should be gradually adjusted until the optimum response is obtained. The lowest effective dose should be used. Due to an increased clearance compared to adults, in children weighing from 10 kg to less than 20 kg, a maximum dose of up to 6 mg/kg twice a day (12 mg/kg/day) is recommended. In children weighing from 20 to under 30 kg, a maximum dose of 5 mg/kg twice a day (10 mg/kg/day) is recommended and in children weighing from 30 to under 50 kg, a maximum dose of 4 mg/kg twice a day (8 mg/kg/day) is recommended, although in open-label studies (see sections 4.8 and 5.2), a dose up to 6 mg/kg twice a day (12 mg/kg/day) has been used by a small number of children from this latter group.
The tables below provide examples of volumes of solution for infusion per administration depending on prescribed dose and body weight. The precise volume of solution for infusion is to be calculated according to the exact body weight of the child.
Adjunctive therapy doses \*\*to be taken twice a day\*\* for children from 2 years of age \*\*weighing from 10 kg to less than 20 kg\*\*
| | | | | | | |
| --- | --- | --- | --- | --- | --- | --- |
| Week | Week 1 | Week 2 | Week 3 | Week 4 | Week 5 | Week 6 |
| Prescribed dose | 0.1 ml/kg (1 mg/kg) Starting dose | 0.2 ml/kg (2 mg/kg) | 0.3 ml/kg (3 mg/kg) | 0.4 ml/kg (4 mg/kg) | 0.5 ml/kg (5 mg/kg) | 0.6 ml/kg (6 mg/kg) Maximum recommended dose |
| Weight | Volume administered | | | | | |
| 10 kg | 1 ml (10 mg) | 2 ml (20 mg) | 3 ml (30 mg) | 4 ml (40 mg) | 5 ml (50 mg) | 6 ml (60 mg) |
| 15 kg | 1.5 ml (15 mg) | 3 ml (30 mg) | 4.5 ml (45 mg) | 6 ml (60 mg) | 7.5 ml (75 mg) | 9 ml (90 mg) |
Adjunctive therapy doses \*\*to be taken twice a day\*\* for children and adolescents \*\*weighing from 20 kg to less than 30 kg\*\*
| | | | | | |
| --- | --- | --- | --- | --- | --- |
| Week | Week 1 | Week 2 | Week 3 | Week 4 | Week 5 |
| Prescribed dose | 0.1 ml/kg (1 mg/kg) Starting dose | 0.2 ml/kg (2 mg/kg) | 0.3 ml/kg (3 mg/kg) | 0.4 ml/kg (4 mg/kg) | 0.5 ml/kg (5 mg/kg) Maximum recommended dose |
| Weight | Volume administered | | | | |
| 20 kg | 2 ml (20 mg) | 4 ml (40 mg) | 6 ml (60 mg) | 8 ml (80 mg) | 10 ml (100 mg) |
| 25 kg | 2.5 ml (25 mg) | 5 ml (50 mg) | 7.5 ml (75 mg) | 10 ml (100 mg) | 12.5 ml (125 mg) |
Adjunctive therapy doses \*\*to be taken twice a day\*\* for children and adolescents \*\*weighing from 30 kg to less than 50 kg\*\*
| | | | | |
| --- | --- | --- | --- | --- |
| Week | Week 1 | Week 2 | Week 3 | Week 4 |
| Prescribed dose | 0.1 ml/kg (1 mg/kg) Starting dose | 0.2 ml/kg (2 mg/kg) | 0.3 ml/kg (3 mg/kg) | 0.4 ml/kg (4 mg/kg) Maximum recommended dose |
| Weight | Volume administered | | | |
| 30 kg | 3 ml (30 mg) | 6 ml (60 mg) | 9 ml (90 mg) | 12 ml (120 mg) |
| 35 kg | 3.5 ml (35 mg) | 7 ml (70 mg) | 10.5 ml (105 mg) | 14 ml (140 mg) |
| 40 kg | 4 ml (40 mg) | 8 ml (80 mg) | 12 ml (120 mg) | 16 ml (160 mg) |
| 45 kg | 4.5 ml (45 mg) | 9 ml (90 mg) | 13.5 ml (135 mg) | 18 ml (180 mg) |
\*Initiation of lacosamide treatment with a loading dose\* (\*initial monotherapy or conversion to monotherapy in the treatment of partial-onset seizures or adjunctive therapy in the treatment of partial-onset seizures or adjunctive therapy in the treatment of primary generalised tonic-clonic seizures)\*
In adolescents and children weighing 50 kg or more, and adults, lacosamide treatment may also be initiated with a single loading dose of 200 mg, followed approximately 12 hours later by a 100 mg twice a day (200 mg/day) maintenance dose regimen. Subsequent dose adjustments should be performed according to individual response and tolerability as described above. A loading dose may be initiated in patients in situations when the physician determines that rapid attainment of lacosamide steady state plasma concentration and therapeutic effect is warranted. It should be administered under medical supervision with consideration of the potential for increased incidence of serious cardiac arrhythmia and central nervous system adverse reactions (see section 4.8). Administration of a loading dose has not been studied in acute conditions such as status epilepticus.
\*Discontinuation\*
If lacosamide has to be discontinued, it is recommended that the dose is reduced gradually in weekly decrements of 4 mg/kg/day (for patients with a body weight less than 50 kg) or 200 mg/day (for patients with a body weight of 50 kg or more) for patients who have achieved a dose of lacosamide ≥ 6 mg/kg/day or ≥ 300 mg/day, respectively. A slower taper in weekly decrements of 2 mg/kg/day or 100 mg/day can be considered, if medically necessary.
In patients who develop serious cardiac arrhythmia, clinical benefit/risk assessment should be performed and if needed lacosamide should be discontinued.
\*\*Special populations\*\*
\*Elderly (over 65 years of age)\*
No dose reduction is necessary in elderly patients. Age associated decreased renal clearance with an increase in AUC levels should be considered in elderly patients (see following paragraph 'renal impairment' and section 5.2). There is limited clinical data in the elderly patients with epilepsy, particularly at doses greater than 400 mg/day (see sections 4.4, 4.8, and 5.1).
\*Renal impairment\*
No dose adjustment is necessary in mildly and moderately renally impaired adult and paediatric patients (CLCR > 30 ml/min). In paediatric patients weighing 50 kg or more and in adult patients with mild or moderate renal impairment a loading dose of 200 mg may be considered, but further dose titration (> 200 mg daily) should be performed with caution. In paediatric patients weighing 50 kg or more and in adult patients with severe renal impairment (CLCR ≤ 30 ml/min) or with end-stage renal disease, a maximum dose of 250 mg/day is recommended and the dose titration should be performed with caution. If a loading dose is indicated, an initial dose of 100 mg followed by a 50 mg twice daily regimen for the first week should be used. In paediatric patients weighing less than 50 kg with severe renal impairment (CLCR ≤ 30 ml/min) and in those with end-stage renal disease, a reduction of 25 % of the maximum dose is recommended. For all patients requiring haemodialysis a supplement of up to 50 % of the divided daily dose directly after the end of haemodialysis is recommended. Treatment of patients with end-stage renal disease should be made with caution as there is little clinical experience and accumulation of a metabolite (with no known pharmacological activity).
\*Hepatic impairment\*
A maximum dose of 300 mg/day is recommended for paediatric patients weighing 50 kg or more and for adult patients with mild to moderate hepatic impairment.
The dose titration in these patients should be performed with caution considering co-existing renal impairment. In adolescents and adults weighing 50 kg or more, a loading dose of 200 mg may be considered, but further dose titration (> 200 mg daily) should be performed with caution. Based on data in adults, in paediatric patients weighing less than 50 kg with mild to moderate hepatic impairment a reduction of 25 % of the maximum dose should be applied. The pharmacokinetics of lacosamide has not been evaluated in severely hepatic impaired patients (see section 5.2). Lacosamide should be administered to adult and paediatric patients with severe hepatic impairment only when the expected therapeutic benefits are anticipated to outweigh the possible risks. The dose may need to be adjusted while carefully observing disease activity and potential side effects in the patient.
\*\*Paediatric population\*\*
Lacosamide is not recommended for use in children below the age of 4 years in the treatment of primary generalized tonic-clonic seizures and below the age of 2 years in the treatment of partial-onset seizures as there is limited data on safety and efficacy in these age groups.
Loading dose
Administration of a loading dose has not been studied in children. Use of a loading dose is not recommended in adolescents and children weighing less than 50 kg.
\*\*Method of administration\*\*
The solution for infusion is infused over a period of 15 to 60 minutes twice a day. An infusion duration of at least 30 minutes for administration > 200 mg per infusion (i.e. > 400 mg/day) is preferred.
Lacosamide Amarox solution for infusion can be administered intravenously without further dilution or can be diluted with sodium chloride 9 mg/ml (0.9 %) solution for injection, glucose 50 mg/ml (5 %) solution for injection or lactated Ringer's solution for injection.4.3 Contraindications
Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.
Known second- or third-degree atrioventricular (AV) block.4.4 Special warnings and precautions for use
\*\*Suicidal ideation and behaviour\*\*
Suicidal ideation and behaviour have been reported in patients treated with antiepileptic medicinal products in several indications. A meta-analysis of randomised placebo-controlled clinical studies of antiepileptic medicinal products has also shown a small increased risk of suicidal ideation and behaviour. The mechanism of this risk is not known and the available data do not exclude the possibility of an increased risk for lacosamide.
Therefore, patients should be monitored for signs of suicidal ideation and behaviours and appropriate treatment should be considered. Patients (and caregivers of patients) should be advised to seek medical advice should signs of suicidal ideation or behaviour emerge (see section 4.8).
\*\*Cardiac rhythm and conduction\*\*
Dose-related prolongations in PR interval with lacosamide have been observed in clinical studies. Lacosamide should be used with caution in patients with underlying proarrhythmic conditions such as patients with known cardiac conduction problems or severe cardiac disease (e.g. myocardial ischaemia/infarction, heart failure, structural heart disease or cardiac sodium channelopathies) or patients treated with medicinal products affecting cardiac conduction, including antiarrhythmics and sodium channel blocking antiepileptic medicinal products (see section 4.5), as well as in elderly patients.
In these patients it should be considered to perform an ECG before a lacosamide dose increase above 400 mg/day and after lacosamide is titrated to steady-state.
In the placebo-controlled clinical studies of lacosamide in epilepsy patients, atrial fibrillation or flutter were not reported; however, both have been reported in open-label epilepsy studies and in post-marketing experience.
In post-marketing experience, AV block (including second degree or higher AV block) has been reported. In patients with proarrhythmic conditions, ventricular tachyarrhythmia has been reported. In rare cases, these events have led to asystole, cardiac arrest and death in patients with underlying proarrhythmic conditions.
Patients should be made aware of the symptoms of cardiac arrhythmia (e.g. slow, rapid or irregular pulse, palpitations, shortness of breath, feeling lightheaded, fainting). Patients should be counselled to seek immediate medical advice if these symptoms occur.
\*\*Dizziness\*\*
Treatment with lacosamide has been associated with dizziness which could increase the occurrence of accidental injury or falls. Therefore, patients should be advised to exercise caution until they are familiar with the potential effects of the medicine (see section 4.8).
\*\*Excipients\*\*
This medicinal product contains 59.8 mg sodium per vial, equivalent to 3 % of the WHO recommended maximum daily intake of 2 g sodium for an adult.
\*\*Potential for new onset or worsening of myoclonic seizures\*\*
New onset or worsening of myoclonic seizures has been reported in both adult and paediatric patients with PGTCS, in particular during titration. In patients with more than one seizure type, the observed benefit of control for one seizure type should be weighed against any observed worsening in another seizure type.
\*\*Potential for electro-clinical worsening in specific paediatric epilepsy syndromes\*\*
The safety and efficacy of lacosamide in paediatric patients with epilepsy syndromes in which focal and generalised seizures may coexist have not been determined.4.5 Interaction with other medicinal products and other forms of interaction
Lacosamide should be used with caution in patients treated with medicinal products known to be associated with PR prolongation (including sodium channel blocking antiepileptic medicinal products) and in patients treated with antiarrhythmics. However, subgroup analysis in clinical studies did not identify an increased magnitude of PR prolongation in patients with concomitant administration of carbamazepine or lamotrigine.
\*\*\*In vitro\*\*\* \*\*data\*\*
Data generally suggest that lacosamide has a low interaction potential. \*In vitro\* studies indicate that the enzymes CYP1A2, CYP2B6, and CYP2C9 are not induced and that CYP1A1, CYP1A2, CYP2A6, CYP2B6, CYP2C8, CYP2C9, CYP2D6, and CYP2E1 are not inhibited by lacosamide at plasma concentrations observed in clinical studies. An \*in vitro\* study indicated that lacosamide is not transported by P-glycoprotein in the intestine. \*In vitro\* data show that CYP2C9, CYP2C19 and CYP3A4 are capable of catalysing the formation of the O-desmethyl metabolite.
\*\*\*In vivo\*\*\* \*\*data\*\*
Lacosamide does not inhibit or induce CYP2C19 and CYP3A4 to a clinically relevant extent. Lacosamide did not affect the AUC of midazolam (metabolised by CYP3A4, lacosamide given 200 mg twice a day) but Cmax of midazolam was slightly increased (30 %). Lacosamide did not affect the pharmacokinetics of omeprazole (metabolised by CYP2C19 and CYP3A4, lacosamide given 300 mg twice a day).
The CYP2C19 inhibitor omeprazole (40 mg once daily) did not give rise to a clinically significant change in lacosamide exposure. Thus, moderate inhibitors of CYP2C19 are unlikely to affect systemic lacosamide exposure to a clinically relevant extent.
Caution is recommended in concomitant treatment with strong inhibitors of CYP2C9 (e.g. fluconazole) and CYP3A4 (e.g. itraconazole, ketoconazole, ritonavir, clarithromycin), which may lead to increased systemic exposure of lacosamide. Such interactions have not been established \*in vivo\* but are possible based on \*in vitro\* data.
Strong enzyme inducers such as rifampicin or St. John's wort (Hypericum perforatum) may moderately reduce the systemic exposure of lacosamide. Therefore, starting or ending treatment with these enzyme inducers should be done with caution.
\*\*Antiepileptic medicinal products\*\*
In interaction studies lacosamide did not significantly affect the plasma concentrations of carbamazepine and valproic acid. Lacosamide plasma concentrations were not affected by carbamazepine and by valproic acid. Population pharmacokinetic analyses in different age groups estimated that concomitant treatment with other antiepileptic medicinal products known to be enzyme inducers (carbamazepine, phenytoin, phenobarbital, in various doses) decreased the overall systemic exposure of lacosamide by 25 % in adults and 17 % in paediatric patients.
\*\*Oral contraceptives\*\*
In an interaction study there was no clinically relevant interaction between lacosamide and the oral contraceptives ethinylestradiol and levonorgestrel. Progesterone concentrations were not affected when the medicinal products were co-administered.
\*\*Others\*\*
Interaction studies showed that lacosamide had no effect on the pharmacokinetics of digoxin. There was no clinically relevant interaction between lacosamide and metformin.
Co-administration of warfarin with lacosamide does not result in a clinically relevant change in the pharmacokinetics and pharmacodynamics of warfarin.
Although no pharmacokinetic data on the interaction of lacosamide with alcohol are available, a pharmacodynamic effect cannot be excluded.
Lacosamide has a low protein binding of less than 15 %. Therefore, clinically relevant interactions with other medicinal products through competition for protein binding sites are considered unlikely.4.6 Fertility, pregnancy and lactation
\*\*Women of childbearing potential\*\*
Physicians should discuss family planning and contraception with women of childbearing potential taking lacosamide (see Pregnancy).
If a woman decides to become pregnant, the use of lacosamide should be carefully re-evaluated.
\*\*Pregnancy\*\*
\*Risk related to epilepsy and antiepileptic medicinal products in general\*
For all antiepileptic medicinal products, it has been shown that in the offspring of treated women with epilepsy, the prevalence of malformations is two to three times greater than the rate of approximately 3 % in the general population. In the treated population, an increase in malformations has been noted with polytherapy, however, the extent to which the treatment and/or the illness is responsible has not been elucidated.
Moreover, effective antiepileptic therapy must not be interrupted, since the aggravation of the illness is detrimental to both the mother and the foetus.
\*Risk related to lacosamide\*
There are no adequate data from the use of lacosamide in pregnant women. Studies in animals did not indicate any teratogenic effects in rats or rabbits, but embryotoxicity was observed in rats and rabbits at maternal toxic doses (see section 5.3). The potential risk for humans is unknown.
Lacosamide should not be used during pregnancy unless clearly necessary (if the benefit to the mother clearly outweighs the potential risk to the foetus). If women decide to become pregnant, the use of this product should be carefully re-evaluated.
\*\*Breast-feeding\*\*
Lacosamide is excreted in human breast milk. A risk to the newborns/infants cannot be excluded. It is recommended that breast-feeding should be discontinued during treatment with lacosamide.
\*\*Fertility\*\*
No adverse reactions on male or female fertility or reproduction were observed in rats at doses producing plasma exposures (AUC) up to approximately 2 times the plasma AUC in humans at the maximum recommended human dose (MRHD).4.7 Effects on ability to drive and use machines
Lacosamide has minor to moderate influence on the ability to drive and use machines. Lacosamide treatment has been associated with dizziness or blurred vision.
Accordingly, patients should be advised not to drive or to operate other potentially hazardous machinery until they are familiar with the effects of lacosamide on their ability to perform such activities.4.8 Undesirable effects
\*\*Summary of safety profile\*\*
Based on the analysis of pooled placebo-controlled clinical studies in adjunctive therapy in 1,308 patients with partial-onset seizures, a total of 61.9 % of patients randomised to lacosamide and 35.2 % of patients randomised to placebo reported at least 1 adverse reaction. The most frequently reported adverse reactions (≥ 10 %) with lacosamide treatment were dizziness, headache, nausea and diplopia. They were usually mild to moderate in intensity. Some were dose-related and could be alleviated by reducing the dose. Incidence and severity of central nervous system (CNS) and gastrointestinal (GI) adverse reactions usually decreased over time.
In all of these controlled clinical studies, the discontinuation rate due to adverse reactions was 12.2 % for patients randomised to lacosamide and 1.6 % for patients randomised to placebo. The most common adverse reaction resulting in discontinuation of lacosamide therapy was dizziness.
Incidence of CNS adverse reactions such as dizziness may be higher after a loading dose.
Based on the analysis of data from a non-inferiority monotherapy clinical study comparing lacosamide to carbamazepine controlled release (CR), the most frequently reported adverse reactions (≥ 10 %) for lacosamide were headache and dizziness. The discontinuation rate due to adverse reactions was 10.6 % for patients treated with lacosamide and 15.6 % for patients treated with carbamazepine CR.
The safety profile of lacosamide reported in a study conducted in patients aged 4 years and older with idiopathic generalised epilepsy with primary generalised tonic-clonic seizures (PGTCS) was consistent with the safety profile reported from the pooled placebo-controlled clinical studies in partial-onset seizures. Additional adverse reactions reported in PGTCS patients were myoclonic epilepsy (2.5 % in the lacosamide-group and 0 % in the placebo-group) and ataxia (3.3 % in the lacosamide-group and 0 % in the placebo-group). The most frequently reported adverse reactions were dizziness and somnolence. The most common adverse reactions resulting in discontinuation of lacosamide therapy were dizziness and suicidal ideation. The discontinuation rate due to adverse reactions was 9.1 % in the lacosamide group and 4.1 % in the placebo group.
\*\*Tabulated list of adverse reactions\*\*
The table below shows the frequencies of adverse reactions which have been reported in clinical studies and post-marketing experience. The frequencies are defined as follows: very common (≥ 1/10), common (≥ 1/100 to < 1/10), uncommon (≥ 1/1,000 to < 1/100) and not known (frequency cannot be estimated from available data). Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness.
| | | | | |
| --- | --- | --- | --- | --- |
| System organ class | Very common | Common | Uncommon | Not known |
| Blood and lymphatic disorders | | | | Agranulocytosis(1) |
| Immune system disorders | | | Drug hypersensitivity(1) | Drug reaction with eosinophilia and systemic symptoms (DRESS)(1,2) |
| Psychiatric disorders | | Depression Confusional state Insomnia(1) | Aggression Agitation(1) Euphoric mood(1) Psychotic disorder(1) Suicide attempt (1) Suicidal ideation Hallucination (1) | |
| Nervous system disorders | Dizziness Headache | Myoclonic seizures(3) Ataxia Balance disorder Memory impairment Cognitive disorder Somnolence Tremor Nystagmus Hypoesthesia Dysarthria Disturbance in attention Paraesthesia | Syncope(2) Coordination abnormal Dyskinesia | Convulsion |
| Eye disorders | Diplopia | Vision blurred | | |
| Ear and labyrinth disorders | | Vertigo Tinnitus | | |
| Cardiac disorders | | | Atrioventricular block(1,2) Bradycardia(1,2) Atrial Fibrillation(1,2) Atrial Flutter(1,2) | Ventricular tachyarrhythmia(1) |
| Gastrointestinal disorders | Nausea | Vomiting Constipation Flatulence Dyspepsia Dry mouth Diarrhoea | | |
| Hepatobiliary disorders | | | Liver function test abnormal(2) Hepatic enzyme increased (> 2x ULN)(1) | |
| Skin and subcutaneous tissue disorders | | Pruritus Rash(1) | Angioedema(1) Urticaria(1) | Stevens-Johnson syndrome(1) Toxic epidermal necrolysis(1) |
| Musculoskeletal and connective tissue disorders | | Muscle spasms | | |
| General disorders and administration site conditions | | Gait disturbance Asthenia Fatigue Irritability Feeling drunk Injection site pain or discomfort(4) Irritation(4) | Erythema(4) | |
| Injury, poisoning and procedural complications | | Fall Skin laceration Contusion | | |
(1) Adverse reactions reported in post marketing experience.
(2) See Description of selected adverse reactions.
(3) Reported in PGTCS studies.
(4) Local adverse reactions associated with intravenous administration.
\*\*Description of selected adverse reactions\*\*
The use of lacosamide is associated with dose-related increase in the PR interval. Adverse reactions associated with PR interval prolongation (e.g. atrioventricular block, syncope, bradycardia) may occur.
In adjunctive clinical studies in epilepsy patients the incidence rate of reported first-degree AV Block is uncommon, 0.7 %, 0 %, 0.5 % and 0 % for lacosamide 200 mg, 400 mg, 600 mg or placebo, respectively. No second- or higher degree AV Block was seen in these studies. However, cases with second- and third-degree AV Block associated with lacosamide treatment have been reported in post-marketing experience. In the monotherapy clinical study comparing lacosamide to carbamazepine CR the extent of increase in PR interval was comparable between lacosamide and carbamazepine.
The incidence rate for syncope reported in pooled adjunctive therapy clinical studies is uncommon and did not differ between lacosamide (n=944) treated epilepsy patients (0.1 %) and placebo (n=364) treated epilepsy patients (0.3 %). In the monotherapy clinical study comparing lacosamide to carbamazepine CR, syncope was reported in 7/444 (1.6 %) lacosamide patients and in 1/442 (0.2 %) carbamazepine CR patients.
Atrial fibrillation or flutter were not reported in short term clinical studies; however, both have been reported in open-label epilepsy studies and in post-marketing experience.
\*Laboratory abnormalities\*
Abnormalities in liver function tests have been observed in placebo-controlled clinical studies with lacosamide in adult patients with partial-onset seizures who were taking 1 to 3 concomitant antiepileptic medicinal products. Elevations of ALT to ≥ 3x ULN occurred in 0.7 % (7/935) of lacosamide patients and 0 % (0/356) of placebo patients.
\*Multiorgan hypersensitivity reactions\*
Multiorgan hypersensitivity reactions (also known as Drug Reaction with Eosinophilia and Systemic Symptoms, DRESS) have been reported in patients treated with some antiepileptic medicinal products. These reactions are variable in expression but typically present with fever and rash and can be associated with involvement of different organ systems. If multiorgan hypersensitivity reaction is suspected, lacosamide should be discontinued.
\*\*Paediatric population\*\*
The safety profile of lacosamide in placebo-controlled (255 patients from 1 month to less than 4 years of age and 343 patients from 4 years to less than 17 years of age) and in open-label clinical studies (847 patients from 1 month to less than or equal to 18 years of age) in adjunctive therapy in paediatric patients with partial-onset seizures was consistent with the safety profile observed in adults. As data available in paediatric patients younger than 2 years of age is limited, lacosamide is not indicated in this age range.
The additional adverse reactions observed in the paediatric population were pyrexia, nasopharyngitis, pharyngitis, decreased appetite, abnormal behaviour and lethargy. Somnolence was reported more frequently in the paediatric population (≥ 1/10) compared to the adult population (≥ 1/100 to < 1/10).
\*\*Elderly population\*\*
In the monotherapy study comparing lacosamide to carbamazepine CR, the types of adverse reactions related to lacosamide in elderly patients (≥ 65 years of age) appear to be similar to that observed in patients less than 65 years of age. However, a higher incidence (≥ 5 % difference) of fall, diarrhoea and tremor has been reported in elderly patients compared to younger adult patients. The most frequent cardiac-related adverse reaction reported in elderly compared to the younger adult population was first-degree AV block. This was reported with lacosamide in 4.8 % (3/62) in elderly patients versus 1.6 % (6/382) in younger adult patients. The discontinuation rate due to adverse events observed with lacosamide was 21.0 % (13/62) in elderly patients versus 9.2 % (35/382) in younger adult patients. These differences between elderly and younger adult patients were similar to those observed in the active comparator group.
\*\*Reporting of suspected adverse reactions\*\*
Reporting 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 Store4.9 Overdose
\*\*Symptoms\*\*
Symptoms observed after an accidental or intentional overdose of lacosamide are primarily associated with CNS and gastrointestinal system.
• The types of adverse reactions experienced by patients exposed to doses above 400 mg up to 800 mg were not clinically different from those of patients administered recommended doses of lacosamide.
• Reactions reported after an intake of more than 800 mg are dizziness, nausea, vomiting, seizures (generalised tonic-clonic seizures, status epilepticus). Cardiac conduction disorders, shock and coma have also been observed. Fatalities have been reported in patients following an intake of acute single overdose of several grams of lacosamide.
\*\*Management\*\*
There is no specific antidote for overdose with lacosamide. Treatment of lacosamide overdose should include general supportive measures and may include haemodialysis if necessary (see section 5.2).
- Instruction Pharmacology
- 5.1 Pharmacodynamic properties
Pharmacotherapeutic group: antiepileptics, other antiepileptics, ATC code: N03AX18
\*\*Mechanism of action\*\*
The active substance, lacosamide (R-2-acetamido-N-benzyl-3-methoxypropionamide) is a functionalised amino acid.
The precise mechanism by which lacosamide exerts its antiepileptic effect in humans remains to be fully elucidated. \*In vitro\* electrophysiological studies have shown that lacosamide selectively enhances slow inactivation of voltage-gated sodium channels, resulting in stabilization of hyperexcitable neuronal membranes.
\*\*Pharmacodynamic effects\*\*
Lacosamide protected against seizures in a broad range of animal models of partial and primary generalised seizures and delayed kindling development.
In non-clinical experiments lacosamide in combination with levetiracetam, carbamazepine, phenytoin, valproate, lamotrigine, topiramate or gabapentin showed synergistic or additive anticonvulsant effects.
\*\*Clinical efficacy and safety (partial-onset seizures)\*\*
\*\*Adult population\*\*
\*Monotherapy\*
Efficacy of lacosamide as monotherapy was established in a double-blind, parallel group, non-inferiority comparison to carbamazepine CR in 886 patients 16 years of age or older with newly or recently diagnosed epilepsy. The patients had to present with unprovoked partial-onset seizures with or without secondary generalisation. The patients were randomised to carbamazepine CR or lacosamide, provided as tablets, in a 1:1 ratio. The dose was based on dose-response and ranged from 400 to 1,200 mg/day for carbamazepine CR and from 200 to 600 mg/day for lacosamide. The duration of the treatment was up to 121 weeks depending on the response.
The estimated 6-month seizure freedom rates were 89.8 % for lacosamide-treated patients and 91.1 % for carbamazepine CR treated patients using the Kaplan-Meier survival analysis method. The adjusted absolute difference between treatments was -1.3 % (95 % CI: -5.5, 2.8). The Kaplan-Meier estimates of 12-month seizure freedom rates were 77.8 % for lacosamide-treated patients and 82.7 % for carbamazepine CR treated patients.
The 6-month seizure freedom rates in elderly patients of 65 and above (62 patients in lacosamide, 57 patients in carbamazepine CR) were similar between both treatment groups. The rates were also similar to those observed in the overall population. In the elderly population, the maintenance lacosamide dose was 200 mg/day in 55 patients (88.7 %), 400 mg/day in 6 patients (9.7 %) and the dose was escalated to over 400 mg/day in 1 patient (1.6 %).
\*Conversion to monotherapy\*
The efficacy and safety of lacosamide in conversion to monotherapy has been assessed in a historical-controlled, multicentre, double-blind, randomised study. In this study, 425 patients aged 16 to 70 years with uncontrolled partial-onset seizures taking stable doses of 1 or 2 marketed antiepileptic medicinal products were randomised to be converted to lacosamide monotherapy (either 400 mg/day or 300 mg/day in a 3:1 ratio). In treated patients who completed titration and started withdrawing antiepileptic medicinal products (284 and 99 respectively), monotherapy was maintained in 71.5 % and 70.7 % of patients respectively for 57-105 days (median 71 days), over the targeted observation period of 70 days.
\*Adjunctive therapy\*
The efficacy of lacosamide as adjunctive therapy at recommended doses (200 mg/day, 400 mg/day) was established in 3 multicenter, randomised, placebo-controlled clinical studies with a 12-week maintenance period. Lacosamide 600 mg/day was also shown to be effective in controlled adjunctive therapy studies, although the efficacy was similar to 400 mg/day and patients were less likely to tolerate this dose because of CNS- and gastrointestinal-related adverse reactions. Thus, the 600 mg/day dose is not recommended. The maximum recommended dose is 400 mg/day. These studies, involving 1,308 patients with a history of an average of 23 years of partial-onset seizures, were designed to evaluate the efficacy and safety of lacosamide when administered concomitantly with 1-3 antiepileptic medicinal products in patients with uncontrolled partial-onset seizures with or without secondary generalisation. Overall the proportion of subjects with a 50 % reduction in seizure frequency was 23 %, 34 %, and 40 % for placebo, lacosamide 200 mg/day and lacosamide 400 mg/day.
The pharmacokinetics and safety of a single loading dose of intravenous lacosamide were determined in a multicenter, open-label study designed to assess the safety and tolerability of rapid initiation of lacosamide using a single intravenous loading dose (including 200 mg) followed by twice daily oral dosing (equivalent to the intravenous dose) as adjunctive therapy in adult subjects 16 to 60 years of age with partial-onset seizures.
\*\*Paediatric population\*\*
Partial-onset seizures have a similar pathophysiology and clinical expression in children from 2 years of age and in adults. The efficacy of lacosamide in children aged 2 years and older has been extrapolated from data of adolescents and adults with partial-onset seizures, for whom a similar response was expected provided the paediatric dose adaptations are established (see section 4.2) and safety has been demonstrated (see section 4.8).
The efficacy supported by the extrapolation principle stated above was confirmed by a double-blind, randomised, placebo-controlled clinical study. The study consisted of an 8-week baseline period followed by a 6-week titration period. Eligible patients on a stable dose regimen of 1 to ≤ 3 antiepileptic medicinal products, who still experienced at least 2 partial-onset seizures during the 4 weeks prior to screening with seizure-free phase no longer than 21 days in the 8-week period prior to entry into the baseline period, were randomised to receive either placebo (n=172) or lacosamide (n=171).
Dosing was initiated at a dose of 2 mg/kg/day in subjects weighing less than 50 kg or 100 mg/day in subjects weighing 50 kg or more in 2 divided doses. During the titration period, lacosamide doses were adjusted in 1or 2 mg/kg/day increments in subjects weighing less than 50 kg or 50 or 100 mg/day in subjects weighing 50 kg or more at weekly intervals to achieve the target maintenance period dose range.
Subjects must have achieved the minimum target dose for their body weight category for the final 3 days of the titration period to be eligible for entry into the 10-week maintenance period. Subjects were to remain on stable lacosamide dose throughout the maintenance period or were withdrawn and entered in the blinded taper period.
Statistically significant (p=0.0003) and clinically relevant reduction in partial-onset seizure frequency per 28 days from baseline to the maintenance period was observed between the lacosamide and the placebo group. The percent reduction over placebo based on analysis of covariance was 31.72 % (95 % CI: 16.342,44.277).
Overall, the proportion of subjects with at least a 50 % reduction in partial-onset seizure frequency per 28 days from baseline to the maintenance period was 52.9 % in the lacosamide group compared with 33.3 % in the placebo group.
The quality of life assessed by the Pediatric Quality of Life Inventory indicated that subjects in both lacosamide and placebo groups had a similar and stable health-related quality of life during the entire treatment period.
\*\*Clinical efficacy and safety (primary generalized tonic-clonic seizures)\*\*
The efficacy of lacosamide as adjunctive therapy in patients 4 years of age and older with idiopathic generalized epilepsy experiencing primary generalized tonic-clonic seizures (PGTCS) was established in a 24-week double-blind, randomized, placebo-controlled, parallel-group, multi-center clinical study. The study consisted of a 12-week historical baseline period, a 4-week prospective baseline period and a 24-week treatment period (which included a 6-week titration period and an 18-week maintenance period). Eligible patients on a stable dose of 1 to 3 antiepileptic drugs experiencing at least 3 documented PGTCS during the 16-week combined baseline period were randomized 1 to 1 to receive lacosamide or placebo (patients in the full analysis set: lacosamide n=118, placebo n=121; of them 8 patients in the ≥ 4 to < 12 years age group and 16 patients in the ≥ 12 to < 18 years range were treated with lacosamide and 9 and 16 patients, respectively with placebo).
Patients were titrated up to the target maintenance period dose of 12 mg/kg/day in patients weighing less than 30 kg, 8 mg/kg/day in patients weighing from 30 to less than 50 kg or 400 mg/day in patients weighing 50 kg or more.
| | | |
| --- | --- | --- |
| Efficacy variable Parameter | Placebo N=121 | Lacosamide N=118 |
| Time to second PGTCS | | |
| Median (days) | 77.0 | - |
| 95 % CI | 49.0, 128.0 | - |
| Lacosamide – Placebo | | |
| Hazard Ratio | 0.540 | |
| 95 % CI | 0.377, 0.774 | |
| p-value | < 0.001 | |
| Seizure freedom | | |
| Stratified Kaplan-Meier estimate (%) | 17.2 | 31.3 |
| 95 % CI | 10.4, 24.0 | 22.8, 39.9 |
| Lacosamide – Placebo | 14.1 | |
| 95 % CI | 3.2, 25.1 | |
| p-value | 0.011 | |
Note: For the lacosamide group, the median time to second PGTCS could not be estimated by Kaplan-Meier methods because ˃ 50% of patients did not experience a second PGTCS by Day 166.
The findings in the paediatric subgroup were consistent with the results of the overall population for the primary, secondary and other efficacy endpoints.5.2 Pharmacokinetic properties
\*\*Absorption\*\*
After intravenous administration, Cmax is reached at the end of infusion. The plasma concentration increases proportionally with dose after oral (100-800 mg) and intravenous (50-300 mg) administration.
\*\*Distribution\*\*
The volume of distribution is approximately 0.6 L/kg. Lacosamide is less than 15 % bound to plasma proteins.
\*\*Biotransformation\*\*
95 % of the dose is excreted in the urine as lacosamide and metabolites. The metabolism of lacosamide has not been completely characterised.
The major compounds excreted in urine are unchanged lacosamide (approximately 40 % of the dose) and its O-desmethyl metabolite less than 30 %.
A polar fraction proposed to be serine derivatives accounted for approximately 20 % in urine, but was detected only in small amounts (0-2 %) in human plasma of some subjects. Small amounts (0.5-2 %) of additional metabolites were found in the urine.
\*In vitro\* data show that CYP2C9, CYP2C19 and CYP3A4 are capable of catalysing the formation of the O-desmethyl metabolite but the main contributing isoenzyme has not been confirmed \*in vivo\*. No clinically relevant difference in lacosamide exposure was observed comparing its pharmacokinetics in extensive metabolisers (EMs, with a functional CYP2C19) and poor metabolisers (PMs, lacking a functional CYP2C19). Furthermore an interaction study with omeprazole (CYP2C19-inhibitor) demonstrated no clinically relevant changes in lacosamide plasma concentrations indicating that the importance of this pathway is minor. The plasma concentration of O-desmethyl-lacosamide is approximately 15 % of the concentration of lacosamide in plasma. This major metabolite has no known pharmacological activity.
\*\*Elimination\*\*
Lacosamide is primarily eliminated from the systemic circulation by renal excretion and biotransformation. After oral and intravenous administration of radiolabeled lacosamide, approximately 95 % of radioactivity administered was recovered in the urine and less than 0.5 % in the faeces. The elimination half-life of lacosamide is approximately 13 hours. The pharmacokinetics is dose-proportional and constant over time, with low intra- and inter-subject variability. Following twice daily dosing, steady state plasma concentrations are achieved after a 3 day period. The plasma concentration increases with an accumulation factor of approximately 2.
A single loading dose of 200 mg approximates steady-state concentrations comparable to 100 mg twice daily oral administration.
\*\*Pharmacokinetics in special patient groups\*\*
\*Gender\*
Clinical studies indicate that gender does not have a clinically significant influence on the plasma concentrations of lacosamide.
\*Renal impairment\*
The AUC of lacosamide was increased by approximately 30 % in mildly and moderately and 60 % in severely renal impaired patients and patients with end-stage renal disease requiring haemodialysis compared to healthy subjects, whereas Cmax was unaffected.
Lacosamide is effectively removed from plasma by haemodialysis. Following a 4-hour haemodialysis treatment, AUC of lacosamide is reduced by approximately 50 %. Therefore, dosage supplementation following haemodialysis is recommended (see section 4.2). The exposure of the O-desmethyl metabolite was several-fold increased in patients with moderate and severe renal impairment. In absence of haemodialysis in patients with end-stage renal disease, the levels were increased and continuously rising during the 24-hour sampling. It is unknown whether the increased metabolite exposure in end-stage renal disease subjects could give rise to adverse effects but no pharmacological activity of the metabolite has been identified.
\*Hepatic impairment\*
Subjects with moderate hepatic impairment (Child-Pugh B) showed higher plasma concentrations of lacosamide (approximately 50 % higher AUCnorm). The higher exposure was partly due to a reduced renal function in the studied subjects. The decrease in non-renal clearance in the patients of the study was estimated to give a 20 % increase in the AUC of lacosamide. The pharmacokinetics of lacosamide has not been evaluated in severe hepatic impairment (see section 4.2).
\*Elderly (over 65 years of age)\*
In a study in elderly men and women including 4 patients > 75 years of age, AUC was about 30 and 50 % increased compared to young men, respectively. This is partly related to lower body weight. The body weight normalized difference is 26 and 23 %, respectively. An increased variability in exposure was also observed. The renal clearance of lacosamide was only slightly reduced in elderly subjects in this study.
A general dose reduction is not considered to be necessary unless indicated due to reduced renal function (see section 4.2).
\*Paediatric population\*
The paediatric pharmacokinetic profile of lacosamide was determined in a population pharmacokinetic analysis using sparse plasma concentration data obtained in six placebo-controlled randomised clinical studies and five open-label studies in 1655 adult and paediatric patients with epilepsy aged 1 month to 17 years. Three of these studies were performed in adults, 7 in pediatric patients, and 1 in a mixed population. The administered lacosamide doses ranged from 2 to 17.8 mg/kg/day in twice daily intake, not to exceed 600 mg/day.
The typical plasma clearance was estimated to be 0.46 L/h, 0.81 L/h, 1.03 L/h and 1.34 L/h for paediatric patients weighing 10 kg, 20 kg, 30 kg and 50 kg respectively. In comparison, plasma clearance was estimated at 1.74 L/h in adults (70 kg body weight).
Population pharmacokinetic analysis using sparse pharmacokinetic samples from PGTCS study showed a similar exposure in patients with PGTCS and in patients with partial-onset seizures.5.3 Preclinical safety data
In the toxicity studies, the plasma concentrations of lacosamide obtained were similar or only marginally higher than those observed in patients, which leaves low or non-existing margins to human exposure.
A safety pharmacology study with intravenous administration of lacosamide in anesthetised dogs showed transient increases in PR interval and QRS complex duration and decreases in blood pressure most likely due to a cardiodepressant action. These transient changes started in the same concentration range as after maximum recommended clinical dosing. In anesthetised dogs and Cynomolgus monkeys, at intravenous doses of 15-60 mg/kg, slowing of atrial and ventricular conductivity, atrioventricular block and atrioventricular dissociation were seen.
In the repeated dose toxicity studies, mild reversible liver changes were observed in rats starting at about 3 times the clinical exposure. These changes included an increased organ weight, hypertrophy of hepatocytes, increases in serum concentrations of liver enzymes and increases in total cholesterol and triglycerides. Apart from the hypertrophy of hepatocytes, no other histopathologic changes were observed.
In reproductive and developmental toxicity studies in rodents and rabbits, no teratogenic effects but an increase in numbers of stillborn pups and pup deaths in the peripartum period, and slightly reduced live litter sizes and pup body weights were observed at maternal toxic doses in rats corresponding to systemic exposure levels similar to the expected clinical exposure. Since higher exposure levels could not be tested in animals due to maternal toxicity, data are insufficient to fully characterise the embryofetotoxic and teratogenic potential of lacosamide.
Studies in rats revealed that lacosamide and/or its metabolites readily crossed the placental barrier.
In juvenile rats and dogs, the types of toxicity do not differ qualitatively from those observed in adult animals. In juvenile rats, a reduced body weight was observed at systemic exposure levels similar to the expected clinical exposure. In juvenile dogs, transient and dose-related CNS clinical signs started to be observed at systemic exposure levels below the expected clinical exposure.
- Instruction Pharmaceutical Particulars
- 6.1 List of excipients
Water for injection
Sodium chloride
Hydrochloric acid (for pH adjustment)6.2 Incompatibilities
This medicinal product must not be mixed with other medicinal products except those mentioned in section 6.6.6.3 Shelf life
2 years.
Chemical and physical in-use stability has been demonstrated for 24 hours at temperatures up to 25°C for product mixed with the diluents mentioned in 6.6 and stored in Non-PVC bags and PVC bags.
From a microbiological point of view, the product should be used immediately. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and would not be longer than 24 hours at 2 to 8°C, unless dilution has taken place in controlled and validated aseptic conditions.6.4 Special precautions for storage
This medicinal product does not require any special storage conditions.
For storage conditions after dilution of the medicinal product, see section 6.3.6.5 Nature and contents of container
20 mL clear tubular glass vial, type-I with a serum GCB flurotec laminated rubber stopper and dark grey color flip of seal.
Packs: 1 and 5 vials.
Not all pack sizes may be marketed.6.6 Special precautions for disposal and other handling
Product with particulate matter or discolouration should not be used.
This medicinal product is for single use only, any unused solution should be discarded. Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
Lacosamide Amarox solution for infusion was found to be physically compatible and chemically stable when mixed with the following diluents for at least 24 hours and stored in Non-PVC bags and PVC bags at temperatures up to 25°C.
\*\*Diluents:\*\*
Sodium chloride 9 mg/ml (0.9 %) solution for injection
Glucose 50 mg/ml (5 %) solution for injection (5% Dextrose)
Lactated Ringer's solution for injection.
- Instruction Content
- ## Composition
Each ml of solution for infusion contains 10 mg lacosamide.
Each vial of 20 ml solution for infusion contains 200 mg lacosamide.
\*\*Excipients with known effect:\*\*
Each ml of solution for infusion contains 2.99 mg sodium.
For the full list of excipients, see section 6.1
## Pharmaceutical Form
Solution for infusion.
A clear, colourless solution.
## Clinical Particulars
4.1 Therapeutic indications
Lacosamide Amarox is indicated as monotherapy in the treatment of partial-onset seizures with or without secondary generalisation in adults, adolescents and children from 2 years of age with epilepsy.
Lacosamide Amarox is indicated as adjunctive therapy
• in the treatment of partial-onset seizures with or without secondary generalisation in adults, adolescents and children from 2 years of age with epilepsy.
• in the treatment of primary generalised tonic-clonic seizures in adults, adolescents and children from 4 years of age with idiopathic generalised epilepsy.4.2 Posology and method of administration
\*\*Posology\*\*
The physician should prescribe the most appropriate formulation and strength according to weight and dose.
Lacosamide therapy can be initiated with either oral administration (either tablets or syrup) or intravenous administration (solution for infusion). Solution for infusion is an alternative for patients when oral administration is temporarily not feasible. The overall duration of treatment with intravenous lacosamide is at the physician's discretion; there is experience from clinical studies with twice daily infusions of lacosamide for up to 5 days in adjunctive therapy. Conversion to or from oral and intravenous administration can be done directly without titration. The total daily dose and twice daily administration should be maintained. Monitor closely patients with known cardiac conduction problems, on concomitant medications that prolong PR interval, or with severe cardiac disease (e.g. myocardial ischemia, heart failure) when lacosamide dose is higher than 400 mg/day (see Method of administration below and section 4.4).
Lacosamide must be taken twice a day (approximately 12 hours apart).
The recommended posology for adults, adolescents and children from 2 years of age is summarised in the following table.
| | | |
| --- | --- | --- |
| \*\*\*\*Adolescents and children weighing 50 kg or more, and adults\*\*\*\* | | |
| \*\*Starting dose\*\* | \*\*Titration\*\* \*\*(incremental steps)\*\* | \*\*Maximum recommended dose\*\* |
| \*\*Monotherapy:\*\* 50 mg twice a day (100 mg/day) or 100 mg twice a day (200 mg/day) \*\*Adjunctive therapy:\*\* 50 mg twice a day (100 mg/day) | 50 mg twice a day (100 mg/day) at weekly intervals | \*\*Monotherapy:\*\* up to 300 mg twice a day (600 mg/day) \*\*Adjunctive therapy:\*\* up to 200 mg twice a day (400 mg/day) |
| \*\*Alternate initial dosage\\*\*\* (If applicable)\*\*:\*\* 200 mg single loading dose followed by 100 mg twice a day (200 mg/day) | | |
| \\* A loading dose may be initiated in patients in situations when the physician determines that rapid attainment of lacosamide steady state plasma concentration and therapeutic effect is warranted. It should be administered under medical supervision with consideration of the potential for increased incidence of serious cardiac arrhythmia and central nervous system adverse reactions (see section 4.8). Administration of a loading dose has not been studied in acute conditions such as status epilepticus. | | |
| | | |
| --- | --- | --- |
| \*\*\*\*Children from 2 years of age and adolescents weighing less than 50 kg\*\*\*\* | | |
| \*\*Starting dose\*\* | \*\*Titration\*\* \*\*(incremental steps)\*\* | \*\*Maximum recommended dose\*\* |
| \*\*Monotherapy and Adjunctive therapy:\*\* 1 mg/kg twice a day (2 mg/kg/day) | 1 mg/kg twice a day (2 mg/kg/day) at weekly intervals | \*\*Monotherapy:\*\* - up to 6 mg/kg twice a day (12 mg/kg/day) in patients ≥ 10 kg to < 40 kg - up to 5 mg/kg twice a day (10 mg/kg/day) in patients ≥ 40 kg to < 50 kg |
| \*\*Adjunctive therapy:\*\* - up to 6 mg/kg twice a day (12 mg/kg/day) in patients ≥ 10 kg to < 20 kg - up to 5 mg/kg twice a day (10 mg/kg/day) in patients ≥ 20 kg to < 30 kg - up to 4 mg/kg twice a day (8 mg/kg/day) in patients ≥ 30 kg to < 50 kg |
\*\*\*Adolescents and children weighing 50 kg or more, and adults\*\*\*
\*Monotherapy (in the treatment of partial-onset seizures)\*
The recommended starting dose is 50 mg twice a day (100 mg/day) which should be increased to an initial therapeutic dose of 100 mg twice a day (200 mg/day) after one week.
Lacosamide can also be initiated at the dose of 100 mg twice a day (200 mg/day) based on the physician's assessment of required seizure reduction versus potential side effects.
Depending on response and tolerability, the maintenance dose can be further increased at weekly intervals by 50 mg twice a day (100 mg/day), up to a maximum recommended daily dose of 300 mg twice a day (600 mg/day).
In patients having reached a dose greater than 200 mg twice a day (400 mg/day) and who need an additional antiepileptic medicinal product, the posology that is recommended for adjunctive therapy below should be followed.
\*Adjunctive therapy (in the treatment of partial-onset seizures or in the treatment of primary generalised tonic-clonic seizures)\*
The recommended starting dose is 50 mg twice a day (100 mg/day) which should be increased to an initial therapeutic dose of 100 mg twice a day (200 mg/day) after one week.
Depending on response and tolerability, the maintenance dose can be further increased at weekly intervals by 50 mg twice a day (100 mg/day), up to a maximum recommended daily dose of 200 mg twice a day (400 mg/day).
\*\*\*Children from 2 years of age and adolescents weighing less than 50 kg\*\*\*
The dose is determined based on body weight.
\*Monotherapy (in the treatment of partial-onset seizures)\*
The recommended starting dose is 1 mg/kg twice a day (2 mg/kg/day) which should be increased to an initial therapeutic dose of 2 mg/kg twice a day (4 mg/kg/day) after one week.
Depending on response and tolerability, the maintenance dose can be further increased by 1 mg/kg twice a day (2 mg/kg/day) every week. The dose should be gradually increased until the optimum response is obtained. The lowest effective dose should be used. In children weighing from 10 kg to less than 40 kg, a maximum dose of up to 6 mg/kg twice a day (12 mg/kg/day) is recommended. In children weighing from 40 to under 50 kg, a maximum dose of 5 mg/kg twice a day (10 mg/kg/day) is recommended.
The tables below provide examples of volumes of solution for infusion per administration depending on prescribed dose and body weight. The precise volume of solution for infusion is to be calculated according to the exact body weight of the child.
Monotherapy doses in the treatment of partial-onset seizures \*\*to be taken twice a day\*\* for children from 2 years of age \*\*weighing from 10 kg to less than 40 kg\*\*
| | | | | | | |
| --- | --- | --- | --- | --- | --- | --- |
| Week | Week 1 | Week 2 | Week 3 | Week 4 | Week 5 | Week 6 |
| Prescribed dose | 0.1 ml/kg (1 mg/kg) Starting dose | 0.2 ml/kg (2 mg/kg) | 0.3 ml/kg (3 mg/kg) | 0.4 ml/kg (4 mg/kg) | 0.5 ml/kg (5 mg/kg) | 0.6 ml/kg (6 mg/kg) Maximum recommended dose |
| Weight | Volume administered | | | | | |
| 10 kg | 1 ml (10 mg) | 2 ml (20 mg) | 3 ml (30 mg) | 4 ml (40 mg) | 5 ml (50 mg) | 6 ml (60 mg) |
| 15 kg | 1.5 ml (15 mg) | 3 ml (30 mg) | 4.5 ml (45 mg) | 6 ml (60 mg) | 7.5 ml (75 mg) | 9 ml (90 mg) |
| 20 kg | 2 ml (20 mg) | 4 ml (40 mg) | 6 ml (60 mg) | 8 ml (80 mg) | 10 ml (100 mg) | 12 ml (120 mg) |
| 25 kg | 2.5 ml (25 mg) | 5 ml (50 mg) | 7.5 ml (75 mg) | 10 ml (100 mg) | 12.5 ml (125 mg) | 15 ml (150 mg) |
| 30 kg | 3 ml (30 mg) | 6 ml (60 mg) | 9 ml (90 mg) | 12 ml (120 mg) | 15 ml (150 mg) | 18 ml (180 mg) |
| 35 kg | 3.5 ml (35 mg) | 7 ml (70 mg) | 10.5 ml (105 mg) | 14 ml (140 mg) | 17.5 ml (175 mg) | 21 ml (210 mg) |
Monotherapy doses in the treatment of partial-onset seizures \*\*to be taken twice a day\*\* for children and adolescents \*\*weighing from 40 kg to less than 50 kg\*\*(1)
| | | | | | |
| --- | --- | --- | --- | --- | --- |
| Week | Week 1 | Week 2 | Week 3 | Week 4 | Week 5 |
| Prescribed dose | 0.1 ml/kg (1 mg/kg) Starting dose | 0.2 ml/kg (2 mg/kg) | 0.3 ml/kg (3 mg/kg) | 0.4 ml/kg (4 mg/kg) | 0.5 ml/kg (5 mg/kg) Maximum recommended dose |
| Weight | Volume administered | | | | |
| 40 kg | 4 ml (40 mg) | 8 ml (80 mg) | 12 ml (120 mg) | 16 ml (160 mg) | 20 ml (200 mg) |
| 45 kg | 4.5 ml (45 mg) | 9 ml (90 mg) | 13.5 ml (135 mg) | 18 ml (180 mg) | 22.5 ml (225 mg) |
(1) Dosage in adolescents 50 kg or more is the same as in adults.
\*Adjunctive therapy (in the treatment of primary generalised tonic-clonic seizures from 4 years of age or in the treatment of partial-onset seizures from 2 years of age)\*
The recommended starting dose is 1 mg/kg twice a day (2 mg/kg/day) which should be increased to an initial therapeutic dose of 2 mg/kg twice a day (4 mg/kg/day) after one week.
Depending on response and tolerability, the maintenance dose can be further increased by 1 mg/kg twice a day (2 mg/kg/day) every week. The dose should be gradually adjusted until the optimum response is obtained. The lowest effective dose should be used. Due to an increased clearance compared to adults, in children weighing from 10 kg to less than 20 kg, a maximum dose of up to 6 mg/kg twice a day (12 mg/kg/day) is recommended. In children weighing from 20 to under 30 kg, a maximum dose of 5 mg/kg twice a day (10 mg/kg/day) is recommended and in children weighing from 30 to under 50 kg, a maximum dose of 4 mg/kg twice a day (8 mg/kg/day) is recommended, although in open-label studies (see sections 4.8 and 5.2), a dose up to 6 mg/kg twice a day (12 mg/kg/day) has been used by a small number of children from this latter group.
The tables below provide examples of volumes of solution for infusion per administration depending on prescribed dose and body weight. The precise volume of solution for infusion is to be calculated according to the exact body weight of the child.
Adjunctive therapy doses \*\*to be taken twice a day\*\* for children from 2 years of age \*\*weighing from 10 kg to less than 20 kg\*\*
| | | | | | | |
| --- | --- | --- | --- | --- | --- | --- |
| Week | Week 1 | Week 2 | Week 3 | Week 4 | Week 5 | Week 6 |
| Prescribed dose | 0.1 ml/kg (1 mg/kg) Starting dose | 0.2 ml/kg (2 mg/kg) | 0.3 ml/kg (3 mg/kg) | 0.4 ml/kg (4 mg/kg) | 0.5 ml/kg (5 mg/kg) | 0.6 ml/kg (6 mg/kg) Maximum recommended dose |
| Weight | Volume administered | | | | | |
| 10 kg | 1 ml (10 mg) | 2 ml (20 mg) | 3 ml (30 mg) | 4 ml (40 mg) | 5 ml (50 mg) | 6 ml (60 mg) |
| 15 kg | 1.5 ml (15 mg) | 3 ml (30 mg) | 4.5 ml (45 mg) | 6 ml (60 mg) | 7.5 ml (75 mg) | 9 ml (90 mg) |
Adjunctive therapy doses \*\*to be taken twice a day\*\* for children and adolescents \*\*weighing from 20 kg to less than 30 kg\*\*
| | | | | | |
| --- | --- | --- | --- | --- | --- |
| Week | Week 1 | Week 2 | Week 3 | Week 4 | Week 5 |
| Prescribed dose | 0.1 ml/kg (1 mg/kg) Starting dose | 0.2 ml/kg (2 mg/kg) | 0.3 ml/kg (3 mg/kg) | 0.4 ml/kg (4 mg/kg) | 0.5 ml/kg (5 mg/kg) Maximum recommended dose |
| Weight | Volume administered | | | | |
| 20 kg | 2 ml (20 mg) | 4 ml (40 mg) | 6 ml (60 mg) | 8 ml (80 mg) | 10 ml (100 mg) |
| 25 kg | 2.5 ml (25 mg) | 5 ml (50 mg) | 7.5 ml (75 mg) | 10 ml (100 mg) | 12.5 ml (125 mg) |
Adjunctive therapy doses \*\*to be taken twice a day\*\* for children and adolescents \*\*weighing from 30 kg to less than 50 kg\*\*
| | | | | |
| --- | --- | --- | --- | --- |
| Week | Week 1 | Week 2 | Week 3 | Week 4 |
| Prescribed dose | 0.1 ml/kg (1 mg/kg) Starting dose | 0.2 ml/kg (2 mg/kg) | 0.3 ml/kg (3 mg/kg) | 0.4 ml/kg (4 mg/kg) Maximum recommended dose |
| Weight | Volume administered | | | |
| 30 kg | 3 ml (30 mg) | 6 ml (60 mg) | 9 ml (90 mg) | 12 ml (120 mg) |
| 35 kg | 3.5 ml (35 mg) | 7 ml (70 mg) | 10.5 ml (105 mg) | 14 ml (140 mg) |
| 40 kg | 4 ml (40 mg) | 8 ml (80 mg) | 12 ml (120 mg) | 16 ml (160 mg) |
| 45 kg | 4.5 ml (45 mg) | 9 ml (90 mg) | 13.5 ml (135 mg) | 18 ml (180 mg) |
\*Initiation of lacosamide treatment with a loading dose\* (\*initial monotherapy or conversion to monotherapy in the treatment of partial-onset seizures or adjunctive therapy in the treatment of partial-onset seizures or adjunctive therapy in the treatment of primary generalised tonic-clonic seizures)\*
In adolescents and children weighing 50 kg or more, and adults, lacosamide treatment may also be initiated with a single loading dose of 200 mg, followed approximately 12 hours later by a 100 mg twice a day (200 mg/day) maintenance dose regimen. Subsequent dose adjustments should be performed according to individual response and tolerability as described above. A loading dose may be initiated in patients in situations when the physician determines that rapid attainment of lacosamide steady state plasma concentration and therapeutic effect is warranted. It should be administered under medical supervision with consideration of the potential for increased incidence of serious cardiac arrhythmia and central nervous system adverse reactions (see section 4.8). Administration of a loading dose has not been studied in acute conditions such as status epilepticus.
\*Discontinuation\*
If lacosamide has to be discontinued, it is recommended that the dose is reduced gradually in weekly decrements of 4 mg/kg/day (for patients with a body weight less than 50 kg) or 200 mg/day (for patients with a body weight of 50 kg or more) for patients who have achieved a dose of lacosamide ≥ 6 mg/kg/day or ≥ 300 mg/day, respectively. A slower taper in weekly decrements of 2 mg/kg/day or 100 mg/day can be considered, if medically necessary.
In patients who develop serious cardiac arrhythmia, clinical benefit/risk assessment should be performed and if needed lacosamide should be discontinued.
\*\*Special populations\*\*
\*Elderly (over 65 years of age)\*
No dose reduction is necessary in elderly patients. Age associated decreased renal clearance with an increase in AUC levels should be considered in elderly patients (see following paragraph 'renal impairment' and section 5.2). There is limited clinical data in the elderly patients with epilepsy, particularly at doses greater than 400 mg/day (see sections 4.4, 4.8, and 5.1).
\*Renal impairment\*
No dose adjustment is necessary in mildly and moderately renally impaired adult and paediatric patients (CLCR > 30 ml/min). In paediatric patients weighing 50 kg or more and in adult patients with mild or moderate renal impairment a loading dose of 200 mg may be considered, but further dose titration (> 200 mg daily) should be performed with caution. In paediatric patients weighing 50 kg or more and in adult patients with severe renal impairment (CLCR ≤ 30 ml/min) or with end-stage renal disease, a maximum dose of 250 mg/day is recommended and the dose titration should be performed with caution. If a loading dose is indicated, an initial dose of 100 mg followed by a 50 mg twice daily regimen for the first week should be used. In paediatric patients weighing less than 50 kg with severe renal impairment (CLCR ≤ 30 ml/min) and in those with end-stage renal disease, a reduction of 25 % of the maximum dose is recommended. For all patients requiring haemodialysis a supplement of up to 50 % of the divided daily dose directly after the end of haemodialysis is recommended. Treatment of patients with end-stage renal disease should be made with caution as there is little clinical experience and accumulation of a metabolite (with no known pharmacological activity).
\*Hepatic impairment\*
A maximum dose of 300 mg/day is recommended for paediatric patients weighing 50 kg or more and for adult patients with mild to moderate hepatic impairment.
The dose titration in these patients should be performed with caution considering co-existing renal impairment. In adolescents and adults weighing 50 kg or more, a loading dose of 200 mg may be considered, but further dose titration (> 200 mg daily) should be performed with caution. Based on data in adults, in paediatric patients weighing less than 50 kg with mild to moderate hepatic impairment a reduction of 25 % of the maximum dose should be applied. The pharmacokinetics of lacosamide has not been evaluated in severely hepatic impaired patients (see section 5.2). Lacosamide should be administered to adult and paediatric patients with severe hepatic impairment only when the expected therapeutic benefits are anticipated to outweigh the possible risks. The dose may need to be adjusted while carefully observing disease activity and potential side effects in the patient.
\*\*Paediatric population\*\*
Lacosamide is not recommended for use in children below the age of 4 years in the treatment of primary generalized tonic-clonic seizures and below the age of 2 years in the treatment of partial-onset seizures as there is limited data on safety and efficacy in these age groups.
Loading dose
Administration of a loading dose has not been studied in children. Use of a loading dose is not recommended in adolescents and children weighing less than 50 kg.
\*\*Method of administration\*\*
The solution for infusion is infused over a period of 15 to 60 minutes twice a day. An infusion duration of at least 30 minutes for administration > 200 mg per infusion (i.e. > 400 mg/day) is preferred.
Lacosamide Amarox solution for infusion can be administered intravenously without further dilution or can be diluted with sodium chloride 9 mg/ml (0.9 %) solution for injection, glucose 50 mg/ml (5 %) solution for injection or lactated Ringer's solution for injection.4.3 Contraindications
Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.
Known second- or third-degree atrioventricular (AV) block.4.4 Special warnings and precautions for use
\*\*Suicidal ideation and behaviour\*\*
Suicidal ideation and behaviour have been reported in patients treated with antiepileptic medicinal products in several indications. A meta-analysis of randomised placebo-controlled clinical studies of antiepileptic medicinal products has also shown a small increased risk of suicidal ideation and behaviour. The mechanism of this risk is not known and the available data do not exclude the possibility of an increased risk for lacosamide.
Therefore, patients should be monitored for signs of suicidal ideation and behaviours and appropriate treatment should be considered. Patients (and caregivers of patients) should be advised to seek medical advice should signs of suicidal ideation or behaviour emerge (see section 4.8).
\*\*Cardiac rhythm and conduction\*\*
Dose-related prolongations in PR interval with lacosamide have been observed in clinical studies. Lacosamide should be used with caution in patients with underlying proarrhythmic conditions such as patients with known cardiac conduction problems or severe cardiac disease (e.g. myocardial ischaemia/infarction, heart failure, structural heart disease or cardiac sodium channelopathies) or patients treated with medicinal products affecting cardiac conduction, including antiarrhythmics and sodium channel blocking antiepileptic medicinal products (see section 4.5), as well as in elderly patients.
In these patients it should be considered to perform an ECG before a lacosamide dose increase above 400 mg/day and after lacosamide is titrated to steady-state.
In the placebo-controlled clinical studies of lacosamide in epilepsy patients, atrial fibrillation or flutter were not reported; however, both have been reported in open-label epilepsy studies and in post-marketing experience.
In post-marketing experience, AV block (including second degree or higher AV block) has been reported. In patients with proarrhythmic conditions, ventricular tachyarrhythmia has been reported. In rare cases, these events have led to asystole, cardiac arrest and death in patients with underlying proarrhythmic conditions.
Patients should be made aware of the symptoms of cardiac arrhythmia (e.g. slow, rapid or irregular pulse, palpitations, shortness of breath, feeling lightheaded, fainting). Patients should be counselled to seek immediate medical advice if these symptoms occur.
\*\*Dizziness\*\*
Treatment with lacosamide has been associated with dizziness which could increase the occurrence of accidental injury or falls. Therefore, patients should be advised to exercise caution until they are familiar with the potential effects of the medicine (see section 4.8).
\*\*Excipients\*\*
This medicinal product contains 59.8 mg sodium per vial, equivalent to 3 % of the WHO recommended maximum daily intake of 2 g sodium for an adult.
\*\*Potential for new onset or worsening of myoclonic seizures\*\*
New onset or worsening of myoclonic seizures has been reported in both adult and paediatric patients with PGTCS, in particular during titration. In patients with more than one seizure type, the observed benefit of control for one seizure type should be weighed against any observed worsening in another seizure type.
\*\*Potential for electro-clinical worsening in specific paediatric epilepsy syndromes\*\*
The safety and efficacy of lacosamide in paediatric patients with epilepsy syndromes in which focal and generalised seizures may coexist have not been determined.4.5 Interaction with other medicinal products and other forms of interaction
Lacosamide should be used with caution in patients treated with medicinal products known to be associated with PR prolongation (including sodium channel blocking antiepileptic medicinal products) and in patients treated with antiarrhythmics. However, subgroup analysis in clinical studies did not identify an increased magnitude of PR prolongation in patients with concomitant administration of carbamazepine or lamotrigine.
\*\*\*In vitro\*\*\* \*\*data\*\*
Data generally suggest that lacosamide has a low interaction potential. \*In vitro\* studies indicate that the enzymes CYP1A2, CYP2B6, and CYP2C9 are not induced and that CYP1A1, CYP1A2, CYP2A6, CYP2B6, CYP2C8, CYP2C9, CYP2D6, and CYP2E1 are not inhibited by lacosamide at plasma concentrations observed in clinical studies. An \*in vitro\* study indicated that lacosamide is not transported by P-glycoprotein in the intestine. \*In vitro\* data show that CYP2C9, CYP2C19 and CYP3A4 are capable of catalysing the formation of the O-desmethyl metabolite.
\*\*\*In vivo\*\*\* \*\*data\*\*
Lacosamide does not inhibit or induce CYP2C19 and CYP3A4 to a clinically relevant extent. Lacosamide did not affect the AUC of midazolam (metabolised by CYP3A4, lacosamide given 200 mg twice a day) but Cmax of midazolam was slightly increased (30 %). Lacosamide did not affect the pharmacokinetics of omeprazole (metabolised by CYP2C19 and CYP3A4, lacosamide given 300 mg twice a day).
The CYP2C19 inhibitor omeprazole (40 mg once daily) did not give rise to a clinically significant change in lacosamide exposure. Thus, moderate inhibitors of CYP2C19 are unlikely to affect systemic lacosamide exposure to a clinically relevant extent.
Caution is recommended in concomitant treatment with strong inhibitors of CYP2C9 (e.g. fluconazole) and CYP3A4 (e.g. itraconazole, ketoconazole, ritonavir, clarithromycin), which may lead to increased systemic exposure of lacosamide. Such interactions have not been established \*in vivo\* but are possible based on \*in vitro\* data.
Strong enzyme inducers such as rifampicin or St. John's wort (Hypericum perforatum) may moderately reduce the systemic exposure of lacosamide. Therefore, starting or ending treatment with these enzyme inducers should be done with caution.
\*\*Antiepileptic medicinal products\*\*
In interaction studies lacosamide did not significantly affect the plasma concentrations of carbamazepine and valproic acid. Lacosamide plasma concentrations were not affected by carbamazepine and by valproic acid. Population pharmacokinetic analyses in different age groups estimated that concomitant treatment with other antiepileptic medicinal products known to be enzyme inducers (carbamazepine, phenytoin, phenobarbital, in various doses) decreased the overall systemic exposure of lacosamide by 25 % in adults and 17 % in paediatric patients.
\*\*Oral contraceptives\*\*
In an interaction study there was no clinically relevant interaction between lacosamide and the oral contraceptives ethinylestradiol and levonorgestrel. Progesterone concentrations were not affected when the medicinal products were co-administered.
\*\*Others\*\*
Interaction studies showed that lacosamide had no effect on the pharmacokinetics of digoxin. There was no clinically relevant interaction between lacosamide and metformin.
Co-administration of warfarin with lacosamide does not result in a clinically relevant change in the pharmacokinetics and pharmacodynamics of warfarin.
Although no pharmacokinetic data on the interaction of lacosamide with alcohol are available, a pharmacodynamic effect cannot be excluded.
Lacosamide has a low protein binding of less than 15 %. Therefore, clinically relevant interactions with other medicinal products through competition for protein binding sites are considered unlikely.4.6 Fertility, pregnancy and lactation
\*\*Women of childbearing potential\*\*
Physicians should discuss family planning and contraception with women of childbearing potential taking lacosamide (see Pregnancy).
If a woman decides to become pregnant, the use of lacosamide should be carefully re-evaluated.
\*\*Pregnancy\*\*
\*Risk related to epilepsy and antiepileptic medicinal products in general\*
For all antiepileptic medicinal products, it has been shown that in the offspring of treated women with epilepsy, the prevalence of malformations is two to three times greater than the rate of approximately 3 % in the general population. In the treated population, an increase in malformations has been noted with polytherapy, however, the extent to which the treatment and/or the illness is responsible has not been elucidated.
Moreover, effective antiepileptic therapy must not be interrupted, since the aggravation of the illness is detrimental to both the mother and the foetus.
\*Risk related to lacosamide\*
There are no adequate data from the use of lacosamide in pregnant women. Studies in animals did not indicate any teratogenic effects in rats or rabbits, but embryotoxicity was observed in rats and rabbits at maternal toxic doses (see section 5.3). The potential risk for humans is unknown.
Lacosamide should not be used during pregnancy unless clearly necessary (if the benefit to the mother clearly outweighs the potential risk to the foetus). If women decide to become pregnant, the use of this product should be carefully re-evaluated.
\*\*Breast-feeding\*\*
Lacosamide is excreted in human breast milk. A risk to the newborns/infants cannot be excluded. It is recommended that breast-feeding should be discontinued during treatment with lacosamide.
\*\*Fertility\*\*
No adverse reactions on male or female fertility or reproduction were observed in rats at doses producing plasma exposures (AUC) up to approximately 2 times the plasma AUC in humans at the maximum recommended human dose (MRHD).4.7 Effects on ability to drive and use machines
Lacosamide has minor to moderate influence on the ability to drive and use machines. Lacosamide treatment has been associated with dizziness or blurred vision.
Accordingly, patients should be advised not to drive or to operate other potentially hazardous machinery until they are familiar with the effects of lacosamide on their ability to perform such activities.4.8 Undesirable effects
\*\*Summary of safety profile\*\*
Based on the analysis of pooled placebo-controlled clinical studies in adjunctive therapy in 1,308 patients with partial-onset seizures, a total of 61.9 % of patients randomised to lacosamide and 35.2 % of patients randomised to placebo reported at least 1 adverse reaction. The most frequently reported adverse reactions (≥ 10 %) with lacosamide treatment were dizziness, headache, nausea and diplopia. They were usually mild to moderate in intensity. Some were dose-related and could be alleviated by reducing the dose. Incidence and severity of central nervous system (CNS) and gastrointestinal (GI) adverse reactions usually decreased over time.
In all of these controlled clinical studies, the discontinuation rate due to adverse reactions was 12.2 % for patients randomised to lacosamide and 1.6 % for patients randomised to placebo. The most common adverse reaction resulting in discontinuation of lacosamide therapy was dizziness.
Incidence of CNS adverse reactions such as dizziness may be higher after a loading dose.
Based on the analysis of data from a non-inferiority monotherapy clinical study comparing lacosamide to carbamazepine controlled release (CR), the most frequently reported adverse reactions (≥ 10 %) for lacosamide were headache and dizziness. The discontinuation rate due to adverse reactions was 10.6 % for patients treated with lacosamide and 15.6 % for patients treated with carbamazepine CR.
The safety profile of lacosamide reported in a study conducted in patients aged 4 years and older with idiopathic generalised epilepsy with primary generalised tonic-clonic seizures (PGTCS) was consistent with the safety profile reported from the pooled placebo-controlled clinical studies in partial-onset seizures. Additional adverse reactions reported in PGTCS patients were myoclonic epilepsy (2.5 % in the lacosamide-group and 0 % in the placebo-group) and ataxia (3.3 % in the lacosamide-group and 0 % in the placebo-group). The most frequently reported adverse reactions were dizziness and somnolence. The most common adverse reactions resulting in discontinuation of lacosamide therapy were dizziness and suicidal ideation. The discontinuation rate due to adverse reactions was 9.1 % in the lacosamide group and 4.1 % in the placebo group.
\*\*Tabulated list of adverse reactions\*\*
The table below shows the frequencies of adverse reactions which have been reported in clinical studies and post-marketing experience. The frequencies are defined as follows: very common (≥ 1/10), common (≥ 1/100 to < 1/10), uncommon (≥ 1/1,000 to < 1/100) and not known (frequency cannot be estimated from available data). Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness.
| | | | | |
| --- | --- | --- | --- | --- |
| System organ class | Very common | Common | Uncommon | Not known |
| Blood and lymphatic disorders | | | | Agranulocytosis(1) |
| Immune system disorders | | | Drug hypersensitivity(1) | Drug reaction with eosinophilia and systemic symptoms (DRESS)(1,2) |
| Psychiatric disorders | | Depression Confusional state Insomnia(1) | Aggression Agitation(1) Euphoric mood(1) Psychotic disorder(1) Suicide attempt (1) Suicidal ideation Hallucination (1) | |
| Nervous system disorders | Dizziness Headache | Myoclonic seizures(3) Ataxia Balance disorder Memory impairment Cognitive disorder Somnolence Tremor Nystagmus Hypoesthesia Dysarthria Disturbance in attention Paraesthesia | Syncope(2) Coordination abnormal Dyskinesia | Convulsion |
| Eye disorders | Diplopia | Vision blurred | | |
| Ear and labyrinth disorders | | Vertigo Tinnitus | | |
| Cardiac disorders | | | Atrioventricular block(1,2) Bradycardia(1,2) Atrial Fibrillation(1,2) Atrial Flutter(1,2) | Ventricular tachyarrhythmia(1) |
| Gastrointestinal disorders | Nausea | Vomiting Constipation Flatulence Dyspepsia Dry mouth Diarrhoea | | |
| Hepatobiliary disorders | | | Liver function test abnormal(2) Hepatic enzyme increased (> 2x ULN)(1) | |
| Skin and subcutaneous tissue disorders | | Pruritus Rash(1) | Angioedema(1) Urticaria(1) | Stevens-Johnson syndrome(1) Toxic epidermal necrolysis(1) |
| Musculoskeletal and connective tissue disorders | | Muscle spasms | | |
| General disorders and administration site conditions | | Gait disturbance Asthenia Fatigue Irritability Feeling drunk Injection site pain or discomfort(4) Irritation(4) | Erythema(4) | |
| Injury, poisoning and procedural complications | | Fall Skin laceration Contusion | | |
(1) Adverse reactions reported in post marketing experience.
(2) See Description of selected adverse reactions.
(3) Reported in PGTCS studies.
(4) Local adverse reactions associated with intravenous administration.
\*\*Description of selected adverse reactions\*\*
The use of lacosamide is associated with dose-related increase in the PR interval. Adverse reactions associated with PR interval prolongation (e.g. atrioventricular block, syncope, bradycardia) may occur.
In adjunctive clinical studies in epilepsy patients the incidence rate of reported first-degree AV Block is uncommon, 0.7 %, 0 %, 0.5 % and 0 % for lacosamide 200 mg, 400 mg, 600 mg or placebo, respectively. No second- or higher degree AV Block was seen in these studies. However, cases with second- and third-degree AV Block associated with lacosamide treatment have been reported in post-marketing experience. In the monotherapy clinical study comparing lacosamide to carbamazepine CR the extent of increase in PR interval was comparable between lacosamide and carbamazepine.
The incidence rate for syncope reported in pooled adjunctive therapy clinical studies is uncommon and did not differ between lacosamide (n=944) treated epilepsy patients (0.1 %) and placebo (n=364) treated epilepsy patients (0.3 %). In the monotherapy clinical study comparing lacosamide to carbamazepine CR, syncope was reported in 7/444 (1.6 %) lacosamide patients and in 1/442 (0.2 %) carbamazepine CR patients.
Atrial fibrillation or flutter were not reported in short term clinical studies; however, both have been reported in open-label epilepsy studies and in post-marketing experience.
\*Laboratory abnormalities\*
Abnormalities in liver function tests have been observed in placebo-controlled clinical studies with lacosamide in adult patients with partial-onset seizures who were taking 1 to 3 concomitant antiepileptic medicinal products. Elevations of ALT to ≥ 3x ULN occurred in 0.7 % (7/935) of lacosamide patients and 0 % (0/356) of placebo patients.
\*Multiorgan hypersensitivity reactions\*
Multiorgan hypersensitivity reactions (also known as Drug Reaction with Eosinophilia and Systemic Symptoms, DRESS) have been reported in patients treated with some antiepileptic medicinal products. These reactions are variable in expression but typically present with fever and rash and can be associated with involvement of different organ systems. If multiorgan hypersensitivity reaction is suspected, lacosamide should be discontinued.
\*\*Paediatric population\*\*
The safety profile of lacosamide in placebo-controlled (255 patients from 1 month to less than 4 years of age and 343 patients from 4 years to less than 17 years of age) and in open-label clinical studies (847 patients from 1 month to less than or equal to 18 years of age) in adjunctive therapy in paediatric patients with partial-onset seizures was consistent with the safety profile observed in adults. As data available in paediatric patients younger than 2 years of age is limited, lacosamide is not indicated in this age range.
The additional adverse reactions observed in the paediatric population were pyrexia, nasopharyngitis, pharyngitis, decreased appetite, abnormal behaviour and lethargy. Somnolence was reported more frequently in the paediatric population (≥ 1/10) compared to the adult population (≥ 1/100 to < 1/10).
\*\*Elderly population\*\*
In the monotherapy study comparing lacosamide to carbamazepine CR, the types of adverse reactions related to lacosamide in elderly patients (≥ 65 years of age) appear to be similar to that observed in patients less than 65 years of age. However, a higher incidence (≥ 5 % difference) of fall, diarrhoea and tremor has been reported in elderly patients compared to younger adult patients. The most frequent cardiac-related adverse reaction reported in elderly compared to the younger adult population was first-degree AV block. This was reported with lacosamide in 4.8 % (3/62) in elderly patients versus 1.6 % (6/382) in younger adult patients. The discontinuation rate due to adverse events observed with lacosamide was 21.0 % (13/62) in elderly patients versus 9.2 % (35/382) in younger adult patients. These differences between elderly and younger adult patients were similar to those observed in the active comparator group.
\*\*Reporting of suspected adverse reactions\*\*
Reporting 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 Store4.9 Overdose
\*\*Symptoms\*\*
Symptoms observed after an accidental or intentional overdose of lacosamide are primarily associated with CNS and gastrointestinal system.
• The types of adverse reactions experienced by patients exposed to doses above 400 mg up to 800 mg were not clinically different from those of patients administered recommended doses of lacosamide.
• Reactions reported after an intake of more than 800 mg are dizziness, nausea, vomiting, seizures (generalised tonic-clonic seizures, status epilepticus). Cardiac conduction disorders, shock and coma have also been observed. Fatalities have been reported in patients following an intake of acute single overdose of several grams of lacosamide.
\*\*Management\*\*
There is no specific antidote for overdose with lacosamide. Treatment of lacosamide overdose should include general supportive measures and may include haemodialysis if necessary (see section 5.2).
## Pharmacological Properties
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: antiepileptics, other antiepileptics, ATC code: N03AX18
\*\*Mechanism of action\*\*
The active substance, lacosamide (R-2-acetamido-N-benzyl-3-methoxypropionamide) is a functionalised amino acid.
The precise mechanism by which lacosamide exerts its antiepileptic effect in humans remains to be fully elucidated. \*In vitro\* electrophysiological studies have shown that lacosamide selectively enhances slow inactivation of voltage-gated sodium channels, resulting in stabilization of hyperexcitable neuronal membranes.
\*\*Pharmacodynamic effects\*\*
Lacosamide protected against seizures in a broad range of animal models of partial and primary generalised seizures and delayed kindling development.
In non-clinical experiments lacosamide in combination with levetiracetam, carbamazepine, phenytoin, valproate, lamotrigine, topiramate or gabapentin showed synergistic or additive anticonvulsant effects.
\*\*Clinical efficacy and safety (partial-onset seizures)\*\*
\*\*Adult population\*\*
\*Monotherapy\*
Efficacy of lacosamide as monotherapy was established in a double-blind, parallel group, non-inferiority comparison to carbamazepine CR in 886 patients 16 years of age or older with newly or recently diagnosed epilepsy. The patients had to present with unprovoked partial-onset seizures with or without secondary generalisation. The patients were randomised to carbamazepine CR or lacosamide, provided as tablets, in a 1:1 ratio. The dose was based on dose-response and ranged from 400 to 1,200 mg/day for carbamazepine CR and from 200 to 600 mg/day for lacosamide. The duration of the treatment was up to 121 weeks depending on the response.
The estimated 6-month seizure freedom rates were 89.8 % for lacosamide-treated patients and 91.1 % for carbamazepine CR treated patients using the Kaplan-Meier survival analysis method. The adjusted absolute difference between treatments was -1.3 % (95 % CI: -5.5, 2.8). The Kaplan-Meier estimates of 12-month seizure freedom rates were 77.8 % for lacosamide-treated patients and 82.7 % for carbamazepine CR treated patients.
The 6-month seizure freedom rates in elderly patients of 65 and above (62 patients in lacosamide, 57 patients in carbamazepine CR) were similar between both treatment groups. The rates were also similar to those observed in the overall population. In the elderly population, the maintenance lacosamide dose was 200 mg/day in 55 patients (88.7 %), 400 mg/day in 6 patients (9.7 %) and the dose was escalated to over 400 mg/day in 1 patient (1.6 %).
\*Conversion to monotherapy\*
The efficacy and safety of lacosamide in conversion to monotherapy has been assessed in a historical-controlled, multicentre, double-blind, randomised study. In this study, 425 patients aged 16 to 70 years with uncontrolled partial-onset seizures taking stable doses of 1 or 2 marketed antiepileptic medicinal products were randomised to be converted to lacosamide monotherapy (either 400 mg/day or 300 mg/day in a 3:1 ratio). In treated patients who completed titration and started withdrawing antiepileptic medicinal products (284 and 99 respectively), monotherapy was maintained in 71.5 % and 70.7 % of patients respectively for 57-105 days (median 71 days), over the targeted observation period of 70 days.
\*Adjunctive therapy\*
The efficacy of lacosamide as adjunctive therapy at recommended doses (200 mg/day, 400 mg/day) was established in 3 multicenter, randomised, placebo-controlled clinical studies with a 12-week maintenance period. Lacosamide 600 mg/day was also shown to be effective in controlled adjunctive therapy studies, although the efficacy was similar to 400 mg/day and patients were less likely to tolerate this dose because of CNS- and gastrointestinal-related adverse reactions. Thus, the 600 mg/day dose is not recommended. The maximum recommended dose is 400 mg/day. These studies, involving 1,308 patients with a history of an average of 23 years of partial-onset seizures, were designed to evaluate the efficacy and safety of lacosamide when administered concomitantly with 1-3 antiepileptic medicinal products in patients with uncontrolled partial-onset seizures with or without secondary generalisation. Overall the proportion of subjects with a 50 % reduction in seizure frequency was 23 %, 34 %, and 40 % for placebo, lacosamide 200 mg/day and lacosamide 400 mg/day.
The pharmacokinetics and safety of a single loading dose of intravenous lacosamide were determined in a multicenter, open-label study designed to assess the safety and tolerability of rapid initiation of lacosamide using a single intravenous loading dose (including 200 mg) followed by twice daily oral dosing (equivalent to the intravenous dose) as adjunctive therapy in adult subjects 16 to 60 years of age with partial-onset seizures.
\*\*Paediatric population\*\*
Partial-onset seizures have a similar pathophysiology and clinical expression in children from 2 years of age and in adults. The efficacy of lacosamide in children aged 2 years and older has been extrapolated from data of adolescents and adults with partial-onset seizures, for whom a similar response was expected provided the paediatric dose adaptations are established (see section 4.2) and safety has been demonstrated (see section 4.8).
The efficacy supported by the extrapolation principle stated above was confirmed by a double-blind, randomised, placebo-controlled clinical study. The study consisted of an 8-week baseline period followed by a 6-week titration period. Eligible patients on a stable dose regimen of 1 to ≤ 3 antiepileptic medicinal products, who still experienced at least 2 partial-onset seizures during the 4 weeks prior to screening with seizure-free phase no longer than 21 days in the 8-week period prior to entry into the baseline period, were randomised to receive either placebo (n=172) or lacosamide (n=171).
Dosing was initiated at a dose of 2 mg/kg/day in subjects weighing less than 50 kg or 100 mg/day in subjects weighing 50 kg or more in 2 divided doses. During the titration period, lacosamide doses were adjusted in 1or 2 mg/kg/day increments in subjects weighing less than 50 kg or 50 or 100 mg/day in subjects weighing 50 kg or more at weekly intervals to achieve the target maintenance period dose range.
Subjects must have achieved the minimum target dose for their body weight category for the final 3 days of the titration period to be eligible for entry into the 10-week maintenance period. Subjects were to remain on stable lacosamide dose throughout the maintenance period or were withdrawn and entered in the blinded taper period.
Statistically significant (p=0.0003) and clinically relevant reduction in partial-onset seizure frequency per 28 days from baseline to the maintenance period was observed between the lacosamide and the placebo group. The percent reduction over placebo based on analysis of covariance was 31.72 % (95 % CI: 16.342,44.277).
Overall, the proportion of subjects with at least a 50 % reduction in partial-onset seizure frequency per 28 days from baseline to the maintenance period was 52.9 % in the lacosamide group compared with 33.3 % in the placebo group.
The quality of life assessed by the Pediatric Quality of Life Inventory indicated that subjects in both lacosamide and placebo groups had a similar and stable health-related quality of life during the entire treatment period.
\*\*Clinical efficacy and safety (primary generalized tonic-clonic seizures)\*\*
The efficacy of lacosamide as adjunctive therapy in patients 4 years of age and older with idiopathic generalized epilepsy experiencing primary generalized tonic-clonic seizures (PGTCS) was established in a 24-week double-blind, randomized, placebo-controlled, parallel-group, multi-center clinical study. The study consisted of a 12-week historical baseline period, a 4-week prospective baseline period and a 24-week treatment period (which included a 6-week titration period and an 18-week maintenance period). Eligible patients on a stable dose of 1 to 3 antiepileptic drugs experiencing at least 3 documented PGTCS during the 16-week combined baseline period were randomized 1 to 1 to receive lacosamide or placebo (patients in the full analysis set: lacosamide n=118, placebo n=121; of them 8 patients in the ≥ 4 to < 12 years age group and 16 patients in the ≥ 12 to < 18 years range were treated with lacosamide and 9 and 16 patients, respectively with placebo).
Patients were titrated up to the target maintenance period dose of 12 mg/kg/day in patients weighing less than 30 kg, 8 mg/kg/day in patients weighing from 30 to less than 50 kg or 400 mg/day in patients weighing 50 kg or more.
| | | |
| --- | --- | --- |
| Efficacy variable Parameter | Placebo N=121 | Lacosamide N=118 |
| Time to second PGTCS | | |
| Median (days) | 77.0 | - |
| 95 % CI | 49.0, 128.0 | - |
| Lacosamide – Placebo | | |
| Hazard Ratio | 0.540 | |
| 95 % CI | 0.377, 0.774 | |
| p-value | < 0.001 | |
| Seizure freedom | | |
| Stratified Kaplan-Meier estimate (%) | 17.2 | 31.3 |
| 95 % CI | 10.4, 24.0 | 22.8, 39.9 |
| Lacosamide – Placebo | 14.1 | |
| 95 % CI | 3.2, 25.1 | |
| p-value | 0.011 | |
Note: For the lacosamide group, the median time to second PGTCS could not be estimated by Kaplan-Meier methods because ˃ 50% of patients did not experience a second PGTCS by Day 166.
The findings in the paediatric subgroup were consistent with the results of the overall population for the primary, secondary and other efficacy endpoints.5.2 Pharmacokinetic properties
\*\*Absorption\*\*
After intravenous administration, Cmax is reached at the end of infusion. The plasma concentration increases proportionally with dose after oral (100-800 mg) and intravenous (50-300 mg) administration.
\*\*Distribution\*\*
The volume of distribution is approximately 0.6 L/kg. Lacosamide is less than 15 % bound to plasma proteins.
\*\*Biotransformation\*\*
95 % of the dose is excreted in the urine as lacosamide and metabolites. The metabolism of lacosamide has not been completely characterised.
The major compounds excreted in urine are unchanged lacosamide (approximately 40 % of the dose) and its O-desmethyl metabolite less than 30 %.
A polar fraction proposed to be serine derivatives accounted for approximately 20 % in urine, but was detected only in small amounts (0-2 %) in human plasma of some subjects. Small amounts (0.5-2 %) of additional metabolites were found in the urine.
\*In vitro\* data show that CYP2C9, CYP2C19 and CYP3A4 are capable of catalysing the formation of the O-desmethyl metabolite but the main contributing isoenzyme has not been confirmed \*in vivo\*. No clinically relevant difference in lacosamide exposure was observed comparing its pharmacokinetics in extensive metabolisers (EMs, with a functional CYP2C19) and poor metabolisers (PMs, lacking a functional CYP2C19). Furthermore an interaction study with omeprazole (CYP2C19-inhibitor) demonstrated no clinically relevant changes in lacosamide plasma concentrations indicating that the importance of this pathway is minor. The plasma concentration of O-desmethyl-lacosamide is approximately 15 % of the concentration of lacosamide in plasma. This major metabolite has no known pharmacological activity.
\*\*Elimination\*\*
Lacosamide is primarily eliminated from the systemic circulation by renal excretion and biotransformation. After oral and intravenous administration of radiolabeled lacosamide, approximately 95 % of radioactivity administered was recovered in the urine and less than 0.5 % in the faeces. The elimination half-life of lacosamide is approximately 13 hours. The pharmacokinetics is dose-proportional and constant over time, with low intra- and inter-subject variability. Following twice daily dosing, steady state plasma concentrations are achieved after a 3 day period. The plasma concentration increases with an accumulation factor of approximately 2.
A single loading dose of 200 mg approximates steady-state concentrations comparable to 100 mg twice daily oral administration.
\*\*Pharmacokinetics in special patient groups\*\*
\*Gender\*
Clinical studies indicate that gender does not have a clinically significant influence on the plasma concentrations of lacosamide.
\*Renal impairment\*
The AUC of lacosamide was increased by approximately 30 % in mildly and moderately and 60 % in severely renal impaired patients and patients with end-stage renal disease requiring haemodialysis compared to healthy subjects, whereas Cmax was unaffected.
Lacosamide is effectively removed from plasma by haemodialysis. Following a 4-hour haemodialysis treatment, AUC of lacosamide is reduced by approximately 50 %. Therefore, dosage supplementation following haemodialysis is recommended (see section 4.2). The exposure of the O-desmethyl metabolite was several-fold increased in patients with moderate and severe renal impairment. In absence of haemodialysis in patients with end-stage renal disease, the levels were increased and continuously rising during the 24-hour sampling. It is unknown whether the increased metabolite exposure in end-stage renal disease subjects could give rise to adverse effects but no pharmacological activity of the metabolite has been identified.
\*Hepatic impairment\*
Subjects with moderate hepatic impairment (Child-Pugh B) showed higher plasma concentrations of lacosamide (approximately 50 % higher AUCnorm). The higher exposure was partly due to a reduced renal function in the studied subjects. The decrease in non-renal clearance in the patients of the study was estimated to give a 20 % increase in the AUC of lacosamide. The pharmacokinetics of lacosamide has not been evaluated in severe hepatic impairment (see section 4.2).
\*Elderly (over 65 years of age)\*
In a study in elderly men and women including 4 patients > 75 years of age, AUC was about 30 and 50 % increased compared to young men, respectively. This is partly related to lower body weight. The body weight normalized difference is 26 and 23 %, respectively. An increased variability in exposure was also observed. The renal clearance of lacosamide was only slightly reduced in elderly subjects in this study.
A general dose reduction is not considered to be necessary unless indicated due to reduced renal function (see section 4.2).
\*Paediatric population\*
The paediatric pharmacokinetic profile of lacosamide was determined in a population pharmacokinetic analysis using sparse plasma concentration data obtained in six placebo-controlled randomised clinical studies and five open-label studies in 1655 adult and paediatric patients with epilepsy aged 1 month to 17 years. Three of these studies were performed in adults, 7 in pediatric patients, and 1 in a mixed population. The administered lacosamide doses ranged from 2 to 17.8 mg/kg/day in twice daily intake, not to exceed 600 mg/day.
The typical plasma clearance was estimated to be 0.46 L/h, 0.81 L/h, 1.03 L/h and 1.34 L/h for paediatric patients weighing 10 kg, 20 kg, 30 kg and 50 kg respectively. In comparison, plasma clearance was estimated at 1.74 L/h in adults (70 kg body weight).
Population pharmacokinetic analysis using sparse pharmacokinetic samples from PGTCS study showed a similar exposure in patients with PGTCS and in patients with partial-onset seizures.5.3 Preclinical safety data
In the toxicity studies, the plasma concentrations of lacosamide obtained were similar or only marginally higher than those observed in patients, which leaves low or non-existing margins to human exposure.
A safety pharmacology study with intravenous administration of lacosamide in anesthetised dogs showed transient increases in PR interval and QRS complex duration and decreases in blood pressure most likely due to a cardiodepressant action. These transient changes started in the same concentration range as after maximum recommended clinical dosing. In anesthetised dogs and Cynomolgus monkeys, at intravenous doses of 15-60 mg/kg, slowing of atrial and ventricular conductivity, atrioventricular block and atrioventricular dissociation were seen.
In the repeated dose toxicity studies, mild reversible liver changes were observed in rats starting at about 3 times the clinical exposure. These changes included an increased organ weight, hypertrophy of hepatocytes, increases in serum concentrations of liver enzymes and increases in total cholesterol and triglycerides. Apart from the hypertrophy of hepatocytes, no other histopathologic changes were observed.
In reproductive and developmental toxicity studies in rodents and rabbits, no teratogenic effects but an increase in numbers of stillborn pups and pup deaths in the peripartum period, and slightly reduced live litter sizes and pup body weights were observed at maternal toxic doses in rats corresponding to systemic exposure levels similar to the expected clinical exposure. Since higher exposure levels could not be tested in animals due to maternal toxicity, data are insufficient to fully characterise the embryofetotoxic and teratogenic potential of lacosamide.
Studies in rats revealed that lacosamide and/or its metabolites readily crossed the placental barrier.
In juvenile rats and dogs, the types of toxicity do not differ qualitatively from those observed in adult animals. In juvenile rats, a reduced body weight was observed at systemic exposure levels similar to the expected clinical exposure. In juvenile dogs, transient and dose-related CNS clinical signs started to be observed at systemic exposure levels below the expected clinical exposure.
## Pharmaceutical Particulars
6.1 List of excipients
Water for injection
Sodium chloride
Hydrochloric acid (for pH adjustment)6.2 Incompatibilities
This medicinal product must not be mixed with other medicinal products except those mentioned in section 6.6.6.3 Shelf life
2 years.
Chemical and physical in-use stability has been demonstrated for 24 hours at temperatures up to 25°C for product mixed with the diluents mentioned in 6.6 and stored in Non-PVC bags and PVC bags.
From a microbiological point of view, the product should be used immediately. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and would not be longer than 24 hours at 2 to 8°C, unless dilution has taken place in controlled and validated aseptic conditions.6.4 Special precautions for storage
This medicinal product does not require any special storage conditions.
For storage conditions after dilution of the medicinal product, see section 6.3.6.5 Nature and contents of container
20 mL clear tubular glass vial, type-I with a serum GCB flurotec laminated rubber stopper and dark grey color flip of seal.
Packs: 1 and 5 vials.
Not all pack sizes may be marketed.6.6 Special precautions for disposal and other handling
Product with particulate matter or discolouration should not be used.
This medicinal product is for single use only, any unused solution should be discarded. Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
Lacosamide Amarox solution for infusion was found to be physically compatible and chemically stable when mixed with the following diluents for at least 24 hours and stored in Non-PVC bags and PVC bags at temperatures up to 25°C.
\*\*Diluents:\*\*
Sodium chloride 9 mg/ml (0.9 %) solution for injection
Glucose 50 mg/ml (5 %) solution for injection (5% Dextrose)
Lactated Ringer's solution for injection.
