- Approval Id
- fc1e0cc8176c4e7a
- Drug Approval Emc Name
- Campona Airmaster 50 microgram/100 microgram/ dose inhalation powder, pre-dispensed
- Drug Name
- Campona Airmaster 50 microgram/100 microgram/ dose inhalation powder, pre-dispensed
- Company Name
- Genesis Pharmaceuticals
- Company Address
- 84 Pembroke Road, London, W8 6NX, UK
- Company Website
- //www.genesis-pharma.com
- Company Telephone
- 020 7201 0400
- Company Medical Info Direct Line
- 020 7201 0421
- Company Medical Info Email
- eupvg@genreg.eu
- Company Customer Care Direct Line
- 020 7201 0400
- Company Stock Availability
- 020 7201 0400
- Atc Code
- R03AK06
- Legal Category
- Prescription only medicine
- Authorisation Holder
- Activase Pharmaceuticals Limited
11 Boumpoulinas
Nicosia, 1060
Cyprus
- Authorisation Number
- PL 28444/0241
- Authorisation Date
- 07/01/2020
- Instruction Authorisation Holder
- Activase Pharmaceuticals Limited
11 Boumpoulinas
Nicosia, 1060
Cyprus
- Instruction Authorisation Number
- PL 28444/0241
- Instruction Authorisation Date
- 07/01/2020
- Instruction Composition
- Each single inhalation provides a delivered dose (the dose leaving the mouthpiece) of 47 micrograms of salmeterol (as salmeterol xinafoate) and 92 micrograms of fluticasone propionate. This corresponds to a pre-metered dose of 50 micrograms of salmeterol (as salmeterol xinafoate) and 100 micrograms fluticasone propionate.
\*\*Excipient with known effect\*\*
Each delivered dose contains approximately 13 milligrams of lactose (as monohydrate).
For the full list of excipients, see section 6.1.
- Instruction Dosage Form
- Inhalation powder, pre-dispensed.
Moulded plastic device containing a foil strip with 60 regularly placed blisters. Each blister contains pre-dispensed dose of white to off white inhalation powder.
- Instruction Clinical Particulars
- 4.1 Therapeutic indications
Campona Airmaster is indicated in adults and adolescents 12 years of age and older.
\*\*\*\*\*Asthma\*\*\*\*\*
Campona Airmaster is indicated in the regular treatment of asthma where use of a combination product (long- acting β2 agonist and inhaled corticosteroid) is appropriate:
- patients not adequately controlled with inhaled corticosteroids and 'as needed' inhaled short-acting β2 agonist
or
- patients already adequately controlled on both inhaled corticosteroid and long-acting β2 agonist
Note: Campona Airmaster 50 microgram /100 microgram strength is not appropriate in adults and children with severe asthma.4.2 Posology and method of administration
\*\*Posology\*\*
Patients are to be made aware that Campona Airmaster must be used daily for optimal benefit, even when asymptomatic.
Patients should be regularly reassessed by a doctor, so that the strength of Campona Airmaster they are receiving remains optimal and is only changed on medical advice\*\*. The dose should be titrated to the lowest dose at which effective control of symptoms is maintained. Where the control of symptoms is maintained with the lowest strength of the combination given twice daily then the next step could include a test of inhaled corticosteroid alone.\*\* As an alternative, patients requiring a long-acting β2 agonist could be titrated to Campona Airmaster given once daily if, in the opinion of the prescriber, it would be adequate to maintain disease control. In the event of once daily dosing when the patient has a history of nocturnal symptoms the dose should be given at night and when the patient has a history of mainly daytime symptoms the dose should be given in the morning.
Patients should be given the strength of Campona Airmaster containing the appropriate fluticasone propionate dosage for the severity of their disease. If an individual patient should require dosages outside the recommended regimen, appropriate doses of β2 agonist and/or corticosteroid should be prescribed.
\*Recommended Doses:\*
\*\*\*\*\*Asthma\*\*\*\*\*
\*Adults and adolescents 12 years and older:\*
- One inhalation of 50 micrograms salmeterol and 100 micrograms fluticasone propionate twice daily.
or
- One inhalation of 50 micrograms salmeterol and 250 micrograms fluticasone propionate twice daily.
A short-term trial of Campona Airmaster may be considered as initial maintenance therapy in adults or adolescents with moderate persistent asthma (defined as patients with daily symptoms, daily rescue use and moderate to severe airflow limitation) for whom rapid control of asthma is essential. In these cases, the recommended initial dose is one inhalation of 50 micrograms salmeterol and 100 micrograms fluticasone propionate twice daily. Once control of asthma is attained treatment should be reviewed and consideration given as to whether patients should be stepped down to an inhaled corticosteroid alone. Regular review of patients as treatment is stepped down is important.
A clear benefit has not been shown as compared to inhaled fluticasone propionate alone used as initial maintenance therapy when one or two of the criteria of severity are missing. In general, inhaled corticosteroids remain the first line treatment for most patients.
Campona Airmaster is not intended for the initial management of mild asthma. Campona Airmaster 50 microgram/100 micrograms strength is not appropriate in adults and children with severe asthma;
it is recommended to establish the appropriate dosage of inhaled corticosteroid before any fixed-combination can be used in patients with severe asthma.
\*Paediatric population\*
Campona Airmaster is not recommended for use in children aged under 12 years of age. The safety and efficacy of Campona Airmaster in children aged less than 12 years of age has not been established.
\*\*\*Special patient groups\*\*\*
There is no need to adjust the dose in elderly patients or in those with renal impairment.
There are no data available for use of Campona Airmaster in patients with hepatic impairment.
\*\*Method of administration\*\*
Inhalation use.
\*Required training\*
Campona Airmaster must be used correctly in order to achieve effective treatment. All patients must be advised to read the patient information leaflet carefully and follow the instructions for use as detailed in the leaflet. All patients must be trained by the prescribing health care professional on how to use Campona Airmaster, especially if this is their first time in using this inhaler. This is to ensure that they understand how to use the inhaler correctly.
The use of Campona Airmaster follows three simple steps, which are outlined below:
1. The device is opened by depressing the red safety lock and primed by sliding the light pink (for 50/100 microgram strength) mouthpiece cover until a “click” is heard.
2. The patient must first exhale. The mouthpiece is then placed in the mouth and the lips closed round it. The dose can then be inhaled through the inhaler by breathing in steadily and deeply. The inhaler is then removed from the mouth and the patient must hold their breath for about 10 seconds or as long as is comfortable.
3. The patient must then be instructed to breathe out gently and close the inhaler cover until a “click” is heard.
Patients must also be advised to rinse their mouth afterwards with water and spit it out and/or brush their teeth after inhaling.4.3 Contraindications
Hypersensitivity to the active substances or to any of the excipients listed in section 6.1.4.4 Special warnings and precautions for use
\*\*Deterioration of disease\*\*
Campona Airmaster should not be used to treat acute asthma symptoms for which a fast- and short- acting bronchodilator is required. Patients should be advised to have their inhaler to be used for relief in an acute asthma attack available at all times.
Patients should not be initiated on Campona Airmaster during an exacerbation, or if they have significantly worsening or acutely deteriorating asthma.
Serious asthma-related adverse events and exacerbations may occur during treatment with Campona Airmaster. Patients should be asked to continue treatment but to seek medical advice if asthma symptoms remain uncontrolled or worsen after initiation on Campona Airmaster.
Increased requirements for use of reliever medication (short-acting bronchodilators), or decreased response to reliever medication indicate deterioration of control and patients should be reviewed by a physician.
Sudden and progressive deterioration in control of asthma is potentially life-threatening and the patient should undergo urgent medical assessment. Consideration should be given to increasing corticosteroid therapy.
Once asthma symptoms are controlled, consideration may be given to gradually reducing the dose of Campona Airmaster. Regular review of patients as treatment is stepped down is important. The lowest effective dose of Campona Airmaster should be used (see section 4.2).
\*\*Cessation of therapy\*\*
Treatment with Campona Airmaster should not be stopped abruptly in patients with asthma due to risk of exacerbation. Therapy should be down-titrated under physician supervision.
\*\*Caution with special diseases\*\*
As with all inhaled medication containing corticosteroids, Campona Airmaster should be administered with caution in patients with active or quiescent pulmonary tuberculosis and fungal, viral or other infections of the airway. Appropriate treatment should be promptly instituted, if indicated.
\*\*Cardiovascular effects\*\*
Rarely, Campona Airmaster may cause cardiac arrhythmias e.g. supraventricular tachycardia, extrasystoles and atrial fibrillation, and a mild transient reduction in serum potassium at high therapeutic doses Campona Airmaster should be used with caution in patients with severe cardiovascular disorders or heart rhythm abnormalities and in patients with diabetes mellitus, thyrotoxicosis, uncorrected hypokalaemia or patients predisposed to low levels of serum potassium.
\*\*Hyperglycaemia\*\*
There have been very rare reports of increases in blood glucose levels (see section 4.8) and this should be considered when prescribing to patients with a history of diabetes mellitus.
\*\*Paradoxical bronchospasm\*\*
As with other inhalation therapy paradoxical bronchospasm may occur with an immediate increase in wheezing and shortness of breath after dosing. Paradoxical bronchospasm responds to a rapid-acting bronchodilator and should be treated straightaway. Campona Airmaster should be discontinued immediately, the patient assessed and alternative therapy instituted if necessary.
\*\*Beta 2 adrenoreceptor agonists\*\*
The pharmacological side effects of β2 agonist treatment, such as tremor, palpitations and headache, have been reported, but tend to be transient and reduce with regular therapy.
\*\*Excipients\*\*
Campona Airmaster contains approximately 13 milligram/dose of lactose monohydrate. This amount does not normally cause problems in lactose intolerant people. The excipient lactose contains small amounts of milk proteins, which may cause allergic reactions.
\*\*Systemic corticosteroid effects\*\*
Systemic effects may occur with any inhaled corticosteroid, particularly at high doses prescribed for long periods. These effects are much less likely to occur than with oral corticosteroids. Possible systemic effects include Cushing's syndrome, Cushingoid features, adrenal suppression, decrease in bone mineral density, cataract and glaucoma and more rarely, a range of psychological or behavioural effects including psychomotor hyperactivity, sleep disorders, anxiety, depression or aggression (particularly in children) (see Paediatric population sub-heading below for information on the systemic effects of inhaled corticosteroids in children and adolescents). \*\*It is important, therefore, that the patient is reviewed regularly and the dose of inhaled corticosteroid is reduced to the lowest dose at which effective control of asthma is maintained.\*\*
\*\*Adrenal function\*\*
Prolonged treatment of patients with high doses of inhaled corticosteroids may result in adrenal suppression and acute adrenal crisis. Very rare cases of adrenal suppression and acute adrenal crisis have also been described with doses of fluticasone propionate between 500 and less than 1,000 micrograms. Situations, which could potentially trigger acute adrenal crisis include trauma, surgery, infection or any rapid reduction in dosage. Presenting symptoms are typically vague and may include anorexia, abdominal pain, weight loss, tiredness, headache, nausea, vomiting, hypotension, decreased level of consciousness, hypoglycaemia, and seizures. Additional systemic corticosteroid cover should be considered during periods of stress or elective surgery.
The benefits of inhaled fluticasone propionate therapy should minimise the need for oral steroids, but patients transferring from oral steroids may remain at risk of impaired adrenal reserve for a considerable time. Therefore these patients should be treated with special care and adrenocortical function regularly monitored. Patients who have required high dose emergency corticosteroid therapy in the past may also be at risk. This possibility of residual impairment should always be borne in mind in emergency and elective situations likely to produce stress, and appropriate corticosteroid treatment must be considered. The extent of the adrenal impairment may require specialist advice before elective procedures.
\*\*Interactions with other medicinal products\*\*
Ritonavir can greatly increase the concentration of fluticasone propionate in plasma. Therefore, concomitant use should be avoided, unless the potential benefit to the patient outweighs the risk of systemic corticosteroid side effects. There is also an increased risk of systemic side effects when combining fluticasone propionate with other potent CYP3A inhibitors (see section 4.5).
Concomitant use of systemic ketoconazole significantly increases systemic exposure to salmeterol. This may lead to an increase in the incidence of systemic effects (e.g. prolongation in the QTc interval and palpitations). Concomitant treatment with ketoconazole or other potent CYP3A4 inhibitors should therefore, be avoided unless the benefits outweigh the potentially increased risk of systemic undesirable effects of salmeterol treatment (see section 4.5).
\*\*Visual disturbance\*\*
Visual disturbance may be reported with systemic and topical corticosteroid use. If a patient presents with symptoms such as blurred vision or other visual disturbances, the patient should be considered for referral to an ophthalmologist for evaluation of possible causes which may include cataract, glaucoma or rare diseases such as central serous chorioretinopathy (CSCR) which have been reported after use of systemic and topical corticosteroids.
\*\*Paediatric population\*\*
Campona Airmaster is not recommended for use in children under 12 years of age (see section 4.2).
Adolescents < 16 years taking high doses of fluticasone propionate (typically ≥ 1,000 micrograms/day) may be at particular risk. Systemic effects may occur, particularly at high doses prescribed for long periods. Possible systemic effects include Cushing's syndrome, Cushingoid features, adrenal suppression, acute adrenal crisis and growth retardation in adolescents and more rarely, a range of psychological or behavioural effects including psychomotor hyperactivity, sleep disorders, anxiety, depression or aggression. Consideration should be given to referring the adolescent to a paediatric respiratory specialist.
It is recommended that the height of adolescent receiving prolonged treatment with inhaled corticosteroid is regularly monitored. \*\*The dose of inhaled corticosteroid should be reduced to the lowest dose at which effective control of asthma is maintained.\*\*4.5 Interaction with other medicinal products and other forms of interaction
β adrenergic blockers may weaken or antagonise the effect of salmeterol. Both non-selective and selective β blockers should be avoided unless there are compelling reasons for their use. Potentially serious hypokalaemia may result from β2 agonist therapy. Particular caution is advised in acute severe asthma as this effect may be potentiated by concomitant treatment with xanthine derivatives, steroids and diuretics.
Concomitant use of other β adrenergic containing medicinal products can have a potentially additive effect.
\*\*Fluticasone Propionate\*\*
Under normal circumstances, low plasma concentrations of fluticasone propionate are achieved after inhaled dosing, due to extensive first pass metabolism and high systemic clearance mediated by cytochrome CYP3A4 in the gut and liver. Hence, clinically significant interactions with other active substances mediated by fluticasone propionate are unlikely.
In an interaction study in healthy subjects with intranasal fluticasone propionate, ritonavir (a highly potent cytochrome CYP3A4 inhibitor) 100 mg b.i.d. increased the fluticasone propionate plasma concentrations several hundred fold, resulting in markedly reduced serum cortisol concentrations.
Information about this interaction is lacking for inhaled fluticasone propionate, but a marked increase in fluticasone propionate plasma levels is expected. Cases of Cushing's syndrome and adrenal suppression have been reported. The combination should be avoided unless the benefit outweighs the increased risk of systemic glucocorticoid side effects.
In a small study in healthy volunteers, the slightly less potent CYP3A inhibitor ketoconazole increased the exposure of fluticasone propionate after a single inhalation by 150 %. This resulted in a greater reduction of plasma cortisol as compared with fluticasone propionate alone. Co-treatment with other potent CYP3A inhibitors, such as itraconazole and cobicistat-containing products, and moderate CYP3A inhibitors, such as erythromycin, is also expected to increase the systemic fluticasone propionate exposure and the risk of systemic side effects. Combinations should be avoided unless the benefit outweighs the potential increased risk of systemic corticosteroid side-effects, in which case patients should be monitored for systemic corticosteroid side-effects.
\*\*Salmeterol\*\*
\*Potent CYP3A4 inhibitors\*
Co-administration of ketoconazole (400 mg orally once daily) and salmeterol (50 micrograms inhaled twice daily) in 15 healthy subjects for 7 days resulted in a significant increase in plasma salmeterol exposure (1.4-fold Cmax and 15-fold AUC). This may lead to an increase in the incidence of other systemic effects of salmeterol treatment (e.g. prolongation of QTc interval and palpitations) compared with salmeterol or ketoconazole treatment alone (see section 4.4).
Clinically significant effects were not seen on blood pressure, heart rate, blood glucose and blood potassium levels. Co-administration with ketoconazole did not increase the elimination half-life of salmeterol or increase salmeterol accumulation with repeat dosing.
The concomitant administration of ketoconazole should be avoided, unless the benefits outweigh the potentially increased risk of systemic side effects of salmeterol treatment. There is likely to be a similar risk of interaction with other potent CYP3A4 inhibitors (e.g. itraconazole, telithromycin, ritonavir).
\*Moderate CYP 3A4 inhibitors\*
Co-administration of erythromycin (500 mg orally three times a day) and salmeterol (50 micrograms inhaled twice daily) in 15 healthy subjects for 6 days resulted in a small but non-statistically significant increase in salmeterol exposure (1.4-fold Cmax and 1.2-fold AUC). Co-administration with erythromycin was not associated with any serious adverse effects.4.6 Fertility, pregnancy and lactation
\*\*Fertility\*\*
There are no data in humans. However, animal studies showed no effects of salmeterol or fluticasone propionate on fertility.
\*\*Pregnancy\*\*
A large amount of data on pregnant women (more than 1,000 pregnancy outcomes) indicates no malformative or feto/neonatal toxicity related to salmeterol and fluticasone propionate. Animal studies have shown reproductive toxicity after administration of β2 adrenoreceptor agonists and glucocorticosteroids (see section 5.3).
Administration of Campona Airmaster to pregnant women should only be considered if the expected benefit to the mother is greater than any possible risk to the fetus.
The lowest effective dose of fluticasone propionate needed to maintain adequate asthma control should be used in the treatment of pregnant women.
\*\*Breastfeeding\*\*
It is unknown whether salmeterol and fluticasone propionate/metabolites are excreted in human milk.
Studies have shown that salmeterol and fluticasone propionate, and their metabolites, are excreted into the milk of lactating rats.
A risk to breastfed newborns/infants cannot be excluded. A decision must be made whether to discontinue breastfeeding or to discontinue Campona Airmaster therapy taking into account the benefit of breastfeeding for the child and the benefit of therapy for the woman.4.7 Effects on ability to drive and use machines
Campona Airmaster has no or negligible influence on the ability to drive and use machines.4.8 Undesirable effects
\*\*Summary of safety profile\*\*
As Campona Airmaster contains salmeterol and fluticasone propionate, the type and severity of adverse reactions associated with each of the compounds may be expected. There is no incidence of additional adverse events following concurrent administration of the two compounds.
Adverse events which have been associated with salmeterol/fluticasone propionate are given below, listed by system organ class and frequency. Frequencies are defined as: very common (≥ 1/10), common (≥ 1/100 to < 1/10), uncommon (≥ 1/1,000 to < 1/100), rare (≥ 1/10,000 to < 1/1,000) and not known (cannot be estimated from the available data). Frequencies were derived from clinical trial data. The incidence in placebo was not taken into account.
| | | |
| --- | --- | --- |
| \*\*System organ class\*\* | \*\*Adverse event\*\* | \*\*Frequency\*\* |
| Infections and infestations | Candidiasis of the mouth and throat | Common |
| Oesophageal candidiasis | Rare |
| Immune system disorders | Hypersensitivity reactions with the following manifestations: | |
| Cutaneous hypersensitivity reactions | Uncommon |
| Angioedema (mainly facial and oropharyngeal oedema) | Rare |
| Respiratory symptoms (dyspnoea) | Uncommon |
| Respiratory symptoms (bronchospasm) | Rare |
| Anaphylactic reactions including anaphylactic shock | Rare |
| Endocrine disorders | Cushing's syndrome, Cushingoid features, Adrenal suppression, Growth retardation in children and adolescents, Decreased bone mineral density | Rare2 |
| Metabolism and nutrition disorders | Hyperglycaemia | Uncommon2 |
| Psychiatric disorders | Anxiety | Uncommon |
| Sleep disorders | Uncommon |
| Behavioural changes, including psychomotor hyperactivity and irritability (predominantly in children) | Rare |
| Depression, aggression (predominantly in children) | Not Known |
| Nervous system disorders | Headache | Very Common1 |
| Tremor | Uncommon |
| Eye disorders | Cataract | Uncommon |
| Glaucoma | Rare2 |
| Vision, blurred (see also section 4.4) | Not Known2 |
| Cardiac disorders | Palpitations | Uncommon |
| Tachycardia | Uncommon |
| Cardiac arrhythmias (including supraventricular tachycardia and extrasystoles). | Rare |
| Atrial fibrillation | Uncommon |
| Angina pectoris | Uncommon |
| Respiratory, thoracic and mediastinal disorders | Throat irritation | Common |
| Hoarseness/dysphonia | Common |
| Paradoxical bronchospasm | Rare2 |
| Musculoskeletal and connective tissue disorders | Muscle cramps | Common |
| Arthralgia | Common |
| Myalgia | Common |
1 Reported commonly in placebo
2 See section 4.4
\*\*Description of selected adverse reactions\*\*
The pharmacological side effects of β2 agonist treatment, such as tremor, palpitations and headache, have been reported, but tend to be transient and reduce with regular therapy.
As with other inhalation therapy paradoxical bronchospasm may occur with an immediate increase in wheezing and shortness of breath after dosing. Paradoxical bronchospasm responds to a rapid-acting bronchodilator and should be treated straightaway. Campona Airmaster should be discontinued immediately, the patient assessed, and alternative therapy instituted if necessary.
Due to the fluticasone propionate component, hoarseness and candidiasis (thrush) of the mouth and throat and, rarely, of the oesophagus can occur in some patients. Both hoarseness and incidence of candidiasis may be relieved by rinsing the mouth with water and/or brushing the teeth after using the product. Symptomatic mouth and throat candidiasis can be treated with topical anti-fungal therapy whilst still continuing with Campona Airmaster.
\*\*Paediatric population\*\*
Possible systemic effects include Cushing's syndrome, Cushingoid features, adrenal suppression and growth retardation in children and adolescents (see section 4.4). Children may also experience anxiety, sleep disorders and behavioural changes, including hyperactivity and irritability.
\*\*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 the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.4.9 Overdose
There are no data available from clinical trials on overdose with Campona Airmaster, however data on overdose with both active substances are given below:
\*\*Salmeterol\*\*
The signs and symptoms of salmeterol overdose are dizziness, increases in systolic blood pressure, tremor, headache and tachycardia. If Campona Airmaster therapy has to be withdrawn due to overdose of the β agonist component of the medicinal product, provision of appropriate replacement steroid therapy should be considered. Additionally, hypokalaemia can occur and therefore serum potassium levels should be monitored. Potassium replacement should be considered.
\*\*Fluticasone propionate\*\*
\*\*Acute:\*\* Acute inhalation of fluticasone propionate doses in excess of those recommended may lead to temporary suppression of adrenal function. This does not need emergency action as adrenal function is recovered in a few days, as verified by plasma cortisol measurements.
\*\*Chronic overdose of inhaled fluticasone propionate\*\*: Adrenal reserve should be monitored and treatment with a systemic corticosteroid may be necessary. When stabilised, treatment should be continued with an inhaled corticosteroid at the recommended dose. Refer to section 4.4: risk of adrenal suppression.
In cases of both acute and chronic fluticasone propionate overdose, Campona Airmaster therapy should be continued at a suitable dosage for symptom control.
- Instruction Pharmacology
- 5.1 Pharmacodynamic properties
| | |
| --- | --- |
| Pharmacotherapeutic group: | Adrenergics in combination with corticosteroids or other drugs, excl. anticholinergics. |
| ATC code: | R03AK06 |
\*\*Mechanism of action and pharmacodynamic effects\*\*
Campona Airmaster contains salmeterol and fluticasone propionate which have differing modes of action. The respective mechanisms of action of both active substances are discussed below:
\*Salmeterol:\*
Salmeterol is a selective long-acting (12 hour) β2 adrenoceptor agonist with a long side chain which binds to the exo-site of the receptor.
Salmeterol produces a longer duration of bronchodilation, lasting for at least 12 hours, than recommended doses of conventional short-acting β2 agonists.
\*Fluticasone propionate:\*
Fluticasone propionate given by inhalation at recommended doses has a glucocorticoid anti-inflammatory action within the lungs, resulting in reduced symptoms and exacerbations of asthma, with less adverse effects than when corticosteroids are administered systemically.
\*\*\*Clinical efficacy and safety\*\*\*
The studies described below (GOAL and SMART) were carried out with this same fixed dose combinatination(s), salmeterol xinafoate and fluticasone propionate, but studied a previously authorised product; the studies described were not carried out with Campona Airmaster.
\*Salmeterol/fluticasone propionate - Asthma clinical trials\*
A twelve month study (Gaining Optimal Asthma ControL, GOAL), in 3,416 adult and adolescent patients with persistent asthma, compared the safety and efficacy of salmeterol/fluticasone propionate versus inhaled corticosteroid (Fluticasone Propionate) alone to determine whether the goals of asthma management were achievable. Treatment was stepped up every 12 weeks until \\*\\* \*total control\* was achieved or the highest dose of study drug was reached. GOAL showed more patients treated with Salmeterol/fluticasone propionate achieved asthma control than patients treated with inhaled corticosteroid (ICS) alone and this control was attained at a lower corticosteroid dose.
\\* \*Well controlled\* asthma was achieved more rapidly with Salmeterol/fluticasone propionate than with ICS alone. The time on treatment for 50 % of subjects to achieve a first individual well controlled week was 16 days for Salmeterol/fluticasone propionate compared to 37 days for the ICS group. In the subset of steroid naive asthmatics the time to an individual well controlled week was 16 days in the Salmeterol/fluticasone propionate treatment compared to 23 days following treatment with ICS.
The overall study results showed:
| | | | | |
| --- | --- | --- | --- | --- |
| \*\*Percentage of patients attaining \\* Well Controlled (WC) and \\*\\* Totally Controlled (TC) asthma over 12 months\*\* | | | | |
| \*\*Pre-study treatment\*\* | \*\*Salmaterol/FP\*\* | | \*\*FP\*\* | |
| \*\*WC\*\* | \*\*TC\*\* | \*\*WC\*\* | \*\*TC\*\* |
| \*\*No ICS\*\* (SABA alone) | 78 % | 50 % | 70 % | 40 % |
| \*\*Low dose ICS\*\* (≤ 500 micrograms BDP or equivalent/day) | 75 % | 44 % | 60 % | 28 % |
| \*\*Medium dose ICS\*\* (> 500 to 1,000 micrograms BDP or equivalent/day) | 62 % | 29 % | 47 % | 16 % |
| \*\*Pooled results across the 3 treatment levels\*\* | 71 % | 41 % | 59 % | 28 % |
\\* Well controlled asthma; less than or equal to 2 days with symptom score greater than 1 (symptom score 1 defined as 'symptoms for one short period during the day'), SABA use on less than or equal to 2 days and less than or equal to 4 occasions/week, greater than or equal to 80 % predicted morning peak expiratory flow, no night-time awakenings, no exacerbations and side effects enforcing a change in therapy.
\\*\\* Total control of asthma; no symptoms, no SABA use, greater than or equal to 80 % predicted morning peak expiratory flow, no night-time awakenings, no exacerbations and no side effects enforcing a change in therapy.
The results of this study suggest that salmeterol/fluticasone propionate 50/100 micrograms bd may be considered as initial maintenance therapy in patients with moderate persistent asthma for whom rapid control of asthma is deemed essential (see section 4.2).
A double blind, randomised, parallel group study in 318 patients with persistent asthma aged ≥ 18 years evaluated the safety and tolerability of administering two inhalations twice daily (double dose) of Salmeterol/fluticasone propionate for two weeks. The study showed that doubling the inhalations of each strength of Salmeterol/fluticasone propionate for up to 14 days resulted in a small increase in β agonist-related adverse events (tremor; 1 patient [1 %] \*vs\* 0, palpitations; 6 [3 %] \*vs\* 1 [< 1 %], muscle cramps; 6[3 %] \*vs\* 1 [< 1 %]) and a similar incidence of inhaled corticosteroid-related adverse events (e.g. oral candidiasis; 6 [6 %] \*vs\* 16 [8 %], hoarseness; 2 [2 %] \*vs\* 4 [2 %]) compared to one inhalation twice daily. The small increase in β agonist-related adverse events should be taken into account if doubling the dose of Salmeterol/fluticasone propionate is considered by the physician in adult patients requiring additional short-term (up to 14 days) inhaled corticosteroid therapy.
\*\*Asthma\*\*
\*\*\*The Salmeterol Multi-center Asthma Research Trial (SMART)\*\*\*
The Salmeterol Multi-center Asthma Research Trial (SMART) was a 28-week US study that evaluated the safety of salmeterol compared to placebo added to usual therapy in adult and adolescent subjects. Although there were no significant differences in the primary endpoint of the combined number of respiratory-related deaths and respiratory-related life-threatening experiences, the study showed a significant increase in asthma-related deaths in patients receiving salmeterol (13 deaths out of 13,176 patients treated with salmeterol versus 3 deaths out of 3,179 patients on placebo). The study was not designed to assess the impact of concurrent inhaled corticosteroid use, and only 47 % of subjects reported ICS use at baseline.
\*\*Safety and efficacy of salmeterol-FP versus FP alone in asthma\*\*
Two multi-centre 26-week studies were conducted to compare the safety and efficacy of salmeterol-FP versus FP alone, one in adult and adolescent subjects (AUSTRI trial), and the other in paediatric subjects 4-11 years of age (VESTRI trial). For both studies, enrolled subjects had moderate to severe persistent asthma with history of asthma-related hospitalisation or asthma exacerbation in the previous year. The primary objective of each study was to determine whether the addition of LABA to ICS therapy (salmeterol-FP) was non-inferior to ICS (FP) alone in terms of the risk of serious asthma related events (asthma-related hospitalisation, endotracheal intubation, and death). A secondary efficacy objective of these studies was to evaluate whether ICS/LABA (salmeterol-FP) was superior to ICS therapy alone (FP) in terms of severe asthma exacerbation (defined as deterioration of asthma requiring the use of systemic corticosteroids for at least 3 days or an in-patient hospitalisation or emergency department visit due to asthma that required systemic corticosteroids).
A total of 11,679 and 6,208 subjects were randomized and received treatment in the AUSTRI and VESTRI trials, respectively. For the primary safety endpoint, non-inferiority was achieved for both trials (see Table below).
\*\*Serious asthma-related events in the 26-Week AUSTRI and VESTRI trials\*\*
| | | | | |
| --- | --- | --- | --- | --- |
| | AUSTRI | | VESTRI | |
| Salmeterol-FP (n = 5,834) | FP alone (n = 5,845) | Salmeterol-FP (n = 3,107) | FP alone (n = 3,101) |
| Composite endpoint (Asthma-related hospitalisation, endotracheal intubation, or death) | 34 (0.6 %) | 33 (0.6 %) | 27 (0.9 %) | 21 (0.7 %) |
| Salmeterol-FP/FP Hazard ratio (95 % CI) | 1.029 (0.638-1.662)a | | 1.285 (0.726-2.272)b | |
| Death | 0 | 0 | 0 | 0 |
| Asthma-related hospitalisation | 34 | 33 | 27 | 21 |
| Endotracheal intubation | 0 | 2 | 0 | 0 |
a If the resulting upper 95 % CI estimate for the relative risk was less than 2.0, then non-inferiority was concluded.
b If the resulting upper 95 % CI estimate for the relative risk was less than 2.675, then non-inferiority was concluded.
For the secondary efficacy endpoint, reduction in time to first asthma exacerbation for salmeterol-FP relative to FP was seen in both studies, however only AUSTRI met statistical significance:
| | | | | |
| --- | --- | --- | --- | --- |
| | AUSTRI | | VESTRI | |
| Salmeterol-FP (n = 5,834) | FP alone (n = 5,845) | Salmeterol-FP (n = 3,107) | FP alone (n = 3,101) |
| \*\*Number of subjects with an asthma exacerbation\*\* | 480 (8 %) | 597 (10 %) | 265 (9 %) | 309 (10 %) |
| \*\*Salmeterol-FP/FP\*\* \*\*Hazard ratio (95 % CI)\*\* | 0.787 (0.698, 0.888) | | 0.859 (0.729, 1.012) | |
\*\*Paediatric population\*\*
Campona Airmaster is not indicated in children under 12 years of age(see section 4.2). The studies described below were carried out with a previously authorised product; the studies described were not carried out with Campona Airmaster.
In trial SAM101667, in 158 children aged 6 to 16 years with symptomatic asthma, the combination of salmeterol/ fluticasone propionate is as efficacious as doubling the dose of fluticasone propionate in respect of symptom control and lung function. This study was not designed to investigate the effect on exacerbations.
In a 12-week trial of children aged 4 to 11 years [n = 257] treated with either salmeterol/fluticasone propionate 50/100 or salmeterol 50 micrograms + fluticasone propionate 100 micrograms both twice daily, both treatment arms experienced a 14 % increase in peak expiratory flow rate as well as improvements in symptom score and rescue salbutamol use. There were no differences between the two treatment arms. There were no differences in safety parameters between the two treatment arms.
In a 12-week trial of children 4 to 11 years of age [n = 203] randomized in a parallel-group study with persistent asthma and who were symptomatic on inhaled corticosteroid, safety was the primary objective. Children received either salmeterol/fluticasone propionate (50/100 micrograms) or fluticasone propionate (100 micrograms) alone twice daily. Two children on salmeterol/fluticasone propionate and 5 children on fluticasone propionate withdrew because of worsening asthma. After 12 weeks no children in either treatment arm had abnormally low 24-hour urinary cortisol excretion. There were no other differences in safety profile between the treatment arms.
\*\*\*Fluticasone propionate containing medications in asthma during pregnancy\*\*\*
An observational retrospective epidemiological cohort study utilising electronic health records from the United Kingdom was conducted to evaluate the risk of MCMs following first trimester exposure to inhaled FP alone and salmeterol-FP relative to non-FP containing ICS. No placebo comparator was included in this study.
Within the asthma cohort of 5,362 first trimester ICS-exposed pregnancies, 131 diagnosed MCMs were identified; 1,612 (30 %) were exposed to FP or salmeterol-FP of which 42 diagnosed MCMs were identified. The adjusted odds ratio for MCMs diagnosed by 1 year was 1.1 (95 %CI: 0.5-2.3) for FP exposed \*vs\* non-FP ICS exposed women with moderate asthma and 1.2 (95 %CI: 0.7-2.0) for women with considerable to severe asthma. No difference in the risk of MCMs was identified following first trimester exposure to FP alone versus salmeterol-FP. Absolute risks of MCM across the asthma severity strata ranged from 2.0 to 2.9 per 100 FP-exposed pregnancies which is comparable to results from a study of 15,840 pregnancies unexposed to asthma therapies in the General Practice Research Database (2.8 MCM events per 100 pregnancies).5.2 Pharmacokinetic properties
For pharmacokinetic purposes each component can be considered separately.
\*Salmeterol\*
Salmeterol acts locally in the lung therefore plasma levels are not an indication of therapeutic effects. In addition there are only limited data available on the pharmacokinetics of salmeterol because of the technical difficulty of assaying the active substance in plasma due to the low plasma concentrations at therapeutic doses (approximately 200 picogram /mL or less) achieved after inhaled dosing.
\*Fluticasone propionate\*
The absolute bioavailability of a single dose of inhaled fluticasone propionate in healthy subjects varies between approximately 5 to 11 % of the nominal dose depending on the inhalation device used.
In patients with asthma a lesser degree of systemic exposure to inhaled fluticasone propionate has been observed.
\*\*Absorption\*\*
Systemic absorption occurs mainly through the lungs and is initially rapid then prolonged. The remainder of the inhaled dose may be swallowed but contributes minimally to systemic exposure due to the low aqueous solubility and pre-systemic metabolism, resulting in oral availability of less than 1 %. There is a linear increase in systemic exposure with increasing inhaled dose.
\*\*Distribution\*\*
The disposition of fluticasone propionate is characterised by high plasma clearance (1,150 mL/min), a large volume of distribution at steady-state (approximately 300 L) and a terminal half-life of approximately 8 hours. Plasma protein binding is 91 %.
\*\*Biotransformation\*\*
Fluticasone propionate is cleared very rapidly from the systemic circulation. The main pathway is metabolism to an inactive carboxylic acid metabolite, by the cytochrome P450 enzyme CYP3A4. Other unidentified metabolites are also found in the faeces.
\*\*Elimination\*\*
The renal clearance of fluticasone propionate is negligible. Less than 5 % of the dose is excreted in urine, mainly as metabolites. The main part of the dose is excreted in faeces as metabolites and unchanged active substance.
\*\*\*Paediatric population\*\*\*
Campona Airmaster is not indicated for use in children under 12 years of age. The studies described below were carried out with a previously authorised product; the studies described were not carried out with Campona Airmaster.
In a population pharmacokinetic analysis utilizing data from 9 controlled clinical trials with different devices (dry powder inhaler, metered dose inhaler) that included 350 patients with asthma aged 4 to 77 years (174 patients 4 to 11 years of age) higher fluticasone propionate systemic exposure following treatment with salmeterol/fluticasone dry powder inhaler 50/100 compared to fluticasone propionate dry powder inhaler 100 were seen.
Geometric Mean Ratio [90 % CI] for the Salmeterol/fluticasone propionate \*vs\* fluticasone propionate dry powder inhaler Comparison in Children and Adolescent/Adult Populations
| | | | |
| --- | --- | --- | --- |
| \*\*\*Treatment (test vs ref)\*\*\* | \*\*\*Population\*\*\* | \*\*\*AUC\*\*\* | \*\*\*Cmax\*\*\* |
| \*Salmeterol/ fluticasone propionate dry powder inhaler 50/100 fluticasone propionate dry powder inhaler 100\* | \*Children (4–11yr)\* | \*1.20 [1.06 – 1.37]\* | \*1.25 [1.11 – 1.41]\* |
| \*Salmeterol/fluticasone propionate dry powder inhaler 50/100 fluticasone propionate dry powder inhaler 100\* | \*Adolescent/Adult (≥ 12yr)\* | \*1.52 [1.08 – 2.13]\* | \*1.52 [1.08 – 2.16]\* |
The effect of 21 days of treatment with salmeterol/fluticasone inhaler 25/50 micrograms (2 inhalations twice daily with or without a spacer) or salmeterol/fluticasone dry powder inhaler 50/100 micrograms (1 inhalation twice daily) was evaluated in 31 children aged 4 to 11 years with mild asthma. Systemic exposure to salmeterol was similar for salmeterol/fluticasone inhaler, salmeterol/fluticasone inhaler with spacer, and salmeterol/fluticasone dry powder inhaler (126 pg hr/mL [95 % CI: 70, 225], 103 pg hr/mL [95 % CI: 54, 200], and 110 pg hr/mL [95 % CI: 55, 219], respectively). Systemic exposure to fluticasone propionate was similar for salmeterol/fluticasone inhaler with spacer (107 pg hr/mL [95 % CI: 45.7, 252.2]) and salmeterol/fluticasone dry powder inhaler (138 pg hr/mL [95 % CI: 69.3, 273.2]), but lower for salmeterol/fluticasone inhaler (24 pg hr/mL [95 % CI: 9.6, 60.2]).”5.3 Preclinical safety data
The only safety concerns for human use derived from animal studies of salmeterol and fluticasone propionate given separately were effects associated with exaggerated pharmacological actions.
In animal reproduction studies, glucocorticosteroids have been shown to induce malformations (cleft palate, skeletal malformations). However, these animal experimental results do not seem to be relevant for man given recommended doses. Animal studies with salmeterol have shown embryofetal toxicity only at high exposure levels. Following co-administration, increased incidences of transposed umbilical artery and incomplete ossification of occipital bone were found in rats at doses associated with known glucocorticoid-induced abnormalities. Neither salmeterol xinafoate or fluticasone propionate have shown any potential for genetic toxicity.
- Instruction Pharmaceutical Particulars
- 6.1 List of excipients
Lactose monohydrate (which contains milk proteins).6.2 Incompatibilities
Not applicable.6.3 Shelf life
2 years.6.4 Special precautions for storage
Do not store above 30 °C.6.5 Nature and contents of container
The inhalation powder is contained in blister held on a formed aluminium/OPA/PVC base foil, with a peelable PETP-film/paper/PVC lidding foil. The blister is contained in a moulded white plastic device with a light pink (for 50/100 microgram strength) slidable mouthpiece cover, with a red safety lock.
The inhaler is packaged within triple laminated foil pouch consisting of Polyester/ADH/Aluminium/ADH/Polyethylene Film.
The plastic devices are available in cardboard containers, which hold:
1 × 60 dose Campona Airmaster
or 2 x 60 dose Campona Airmaster
or 3 x 60 dose Campona Airmaster
or 10 x 60 dose Campona Airmaster
Not all pack sizes may be marketed.6.6 Special precautions for disposal and other handling
The Campona Airmaster releases a powder which is inhaled into the lungs. A dose indicator on the Campona Airmaster indicates the number of doses left. For detailed instructions for use see the Patient Information Leaflet.
Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
- Instruction Content
- ## Composition
Each single inhalation provides a delivered dose (the dose leaving the mouthpiece) of 47 micrograms of salmeterol (as salmeterol xinafoate) and 92 micrograms of fluticasone propionate. This corresponds to a pre-metered dose of 50 micrograms of salmeterol (as salmeterol xinafoate) and 100 micrograms fluticasone propionate.
\*\*Excipient with known effect\*\*
Each delivered dose contains approximately 13 milligrams of lactose (as monohydrate).
For the full list of excipients, see section 6.1.
## Pharmaceutical Form
Inhalation powder, pre-dispensed.
Moulded plastic device containing a foil strip with 60 regularly placed blisters. Each blister contains pre-dispensed dose of white to off white inhalation powder.
## Clinical Particulars
4.1 Therapeutic indications
Campona Airmaster is indicated in adults and adolescents 12 years of age and older.
\*\*\*\*\*Asthma\*\*\*\*\*
Campona Airmaster is indicated in the regular treatment of asthma where use of a combination product (long- acting β2 agonist and inhaled corticosteroid) is appropriate:
- patients not adequately controlled with inhaled corticosteroids and 'as needed' inhaled short-acting β2 agonist
or
- patients already adequately controlled on both inhaled corticosteroid and long-acting β2 agonist
Note: Campona Airmaster 50 microgram /100 microgram strength is not appropriate in adults and children with severe asthma.4.2 Posology and method of administration
\*\*Posology\*\*
Patients are to be made aware that Campona Airmaster must be used daily for optimal benefit, even when asymptomatic.
Patients should be regularly reassessed by a doctor, so that the strength of Campona Airmaster they are receiving remains optimal and is only changed on medical advice\*\*. The dose should be titrated to the lowest dose at which effective control of symptoms is maintained. Where the control of symptoms is maintained with the lowest strength of the combination given twice daily then the next step could include a test of inhaled corticosteroid alone.\*\* As an alternative, patients requiring a long-acting β2 agonist could be titrated to Campona Airmaster given once daily if, in the opinion of the prescriber, it would be adequate to maintain disease control. In the event of once daily dosing when the patient has a history of nocturnal symptoms the dose should be given at night and when the patient has a history of mainly daytime symptoms the dose should be given in the morning.
Patients should be given the strength of Campona Airmaster containing the appropriate fluticasone propionate dosage for the severity of their disease. If an individual patient should require dosages outside the recommended regimen, appropriate doses of β2 agonist and/or corticosteroid should be prescribed.
\*Recommended Doses:\*
\*\*\*\*\*Asthma\*\*\*\*\*
\*Adults and adolescents 12 years and older:\*
- One inhalation of 50 micrograms salmeterol and 100 micrograms fluticasone propionate twice daily.
or
- One inhalation of 50 micrograms salmeterol and 250 micrograms fluticasone propionate twice daily.
A short-term trial of Campona Airmaster may be considered as initial maintenance therapy in adults or adolescents with moderate persistent asthma (defined as patients with daily symptoms, daily rescue use and moderate to severe airflow limitation) for whom rapid control of asthma is essential. In these cases, the recommended initial dose is one inhalation of 50 micrograms salmeterol and 100 micrograms fluticasone propionate twice daily. Once control of asthma is attained treatment should be reviewed and consideration given as to whether patients should be stepped down to an inhaled corticosteroid alone. Regular review of patients as treatment is stepped down is important.
A clear benefit has not been shown as compared to inhaled fluticasone propionate alone used as initial maintenance therapy when one or two of the criteria of severity are missing. In general, inhaled corticosteroids remain the first line treatment for most patients.
Campona Airmaster is not intended for the initial management of mild asthma. Campona Airmaster 50 microgram/100 micrograms strength is not appropriate in adults and children with severe asthma;
it is recommended to establish the appropriate dosage of inhaled corticosteroid before any fixed-combination can be used in patients with severe asthma.
\*Paediatric population\*
Campona Airmaster is not recommended for use in children aged under 12 years of age. The safety and efficacy of Campona Airmaster in children aged less than 12 years of age has not been established.
\*\*\*Special patient groups\*\*\*
There is no need to adjust the dose in elderly patients or in those with renal impairment.
There are no data available for use of Campona Airmaster in patients with hepatic impairment.
\*\*Method of administration\*\*
Inhalation use.
\*Required training\*
Campona Airmaster must be used correctly in order to achieve effective treatment. All patients must be advised to read the patient information leaflet carefully and follow the instructions for use as detailed in the leaflet. All patients must be trained by the prescribing health care professional on how to use Campona Airmaster, especially if this is their first time in using this inhaler. This is to ensure that they understand how to use the inhaler correctly.
The use of Campona Airmaster follows three simple steps, which are outlined below:
1. The device is opened by depressing the red safety lock and primed by sliding the light pink (for 50/100 microgram strength) mouthpiece cover until a “click” is heard.
2. The patient must first exhale. The mouthpiece is then placed in the mouth and the lips closed round it. The dose can then be inhaled through the inhaler by breathing in steadily and deeply. The inhaler is then removed from the mouth and the patient must hold their breath for about 10 seconds or as long as is comfortable.
3. The patient must then be instructed to breathe out gently and close the inhaler cover until a “click” is heard.
Patients must also be advised to rinse their mouth afterwards with water and spit it out and/or brush their teeth after inhaling.4.3 Contraindications
Hypersensitivity to the active substances or to any of the excipients listed in section 6.1.4.4 Special warnings and precautions for use
\*\*Deterioration of disease\*\*
Campona Airmaster should not be used to treat acute asthma symptoms for which a fast- and short- acting bronchodilator is required. Patients should be advised to have their inhaler to be used for relief in an acute asthma attack available at all times.
Patients should not be initiated on Campona Airmaster during an exacerbation, or if they have significantly worsening or acutely deteriorating asthma.
Serious asthma-related adverse events and exacerbations may occur during treatment with Campona Airmaster. Patients should be asked to continue treatment but to seek medical advice if asthma symptoms remain uncontrolled or worsen after initiation on Campona Airmaster.
Increased requirements for use of reliever medication (short-acting bronchodilators), or decreased response to reliever medication indicate deterioration of control and patients should be reviewed by a physician.
Sudden and progressive deterioration in control of asthma is potentially life-threatening and the patient should undergo urgent medical assessment. Consideration should be given to increasing corticosteroid therapy.
Once asthma symptoms are controlled, consideration may be given to gradually reducing the dose of Campona Airmaster. Regular review of patients as treatment is stepped down is important. The lowest effective dose of Campona Airmaster should be used (see section 4.2).
\*\*Cessation of therapy\*\*
Treatment with Campona Airmaster should not be stopped abruptly in patients with asthma due to risk of exacerbation. Therapy should be down-titrated under physician supervision.
\*\*Caution with special diseases\*\*
As with all inhaled medication containing corticosteroids, Campona Airmaster should be administered with caution in patients with active or quiescent pulmonary tuberculosis and fungal, viral or other infections of the airway. Appropriate treatment should be promptly instituted, if indicated.
\*\*Cardiovascular effects\*\*
Rarely, Campona Airmaster may cause cardiac arrhythmias e.g. supraventricular tachycardia, extrasystoles and atrial fibrillation, and a mild transient reduction in serum potassium at high therapeutic doses Campona Airmaster should be used with caution in patients with severe cardiovascular disorders or heart rhythm abnormalities and in patients with diabetes mellitus, thyrotoxicosis, uncorrected hypokalaemia or patients predisposed to low levels of serum potassium.
\*\*Hyperglycaemia\*\*
There have been very rare reports of increases in blood glucose levels (see section 4.8) and this should be considered when prescribing to patients with a history of diabetes mellitus.
\*\*Paradoxical bronchospasm\*\*
As with other inhalation therapy paradoxical bronchospasm may occur with an immediate increase in wheezing and shortness of breath after dosing. Paradoxical bronchospasm responds to a rapid-acting bronchodilator and should be treated straightaway. Campona Airmaster should be discontinued immediately, the patient assessed and alternative therapy instituted if necessary.
\*\*Beta 2 adrenoreceptor agonists\*\*
The pharmacological side effects of β2 agonist treatment, such as tremor, palpitations and headache, have been reported, but tend to be transient and reduce with regular therapy.
\*\*Excipients\*\*
Campona Airmaster contains approximately 13 milligram/dose of lactose monohydrate. This amount does not normally cause problems in lactose intolerant people. The excipient lactose contains small amounts of milk proteins, which may cause allergic reactions.
\*\*Systemic corticosteroid effects\*\*
Systemic effects may occur with any inhaled corticosteroid, particularly at high doses prescribed for long periods. These effects are much less likely to occur than with oral corticosteroids. Possible systemic effects include Cushing's syndrome, Cushingoid features, adrenal suppression, decrease in bone mineral density, cataract and glaucoma and more rarely, a range of psychological or behavioural effects including psychomotor hyperactivity, sleep disorders, anxiety, depression or aggression (particularly in children) (see Paediatric population sub-heading below for information on the systemic effects of inhaled corticosteroids in children and adolescents). \*\*It is important, therefore, that the patient is reviewed regularly and the dose of inhaled corticosteroid is reduced to the lowest dose at which effective control of asthma is maintained.\*\*
\*\*Adrenal function\*\*
Prolonged treatment of patients with high doses of inhaled corticosteroids may result in adrenal suppression and acute adrenal crisis. Very rare cases of adrenal suppression and acute adrenal crisis have also been described with doses of fluticasone propionate between 500 and less than 1,000 micrograms. Situations, which could potentially trigger acute adrenal crisis include trauma, surgery, infection or any rapid reduction in dosage. Presenting symptoms are typically vague and may include anorexia, abdominal pain, weight loss, tiredness, headache, nausea, vomiting, hypotension, decreased level of consciousness, hypoglycaemia, and seizures. Additional systemic corticosteroid cover should be considered during periods of stress or elective surgery.
The benefits of inhaled fluticasone propionate therapy should minimise the need for oral steroids, but patients transferring from oral steroids may remain at risk of impaired adrenal reserve for a considerable time. Therefore these patients should be treated with special care and adrenocortical function regularly monitored. Patients who have required high dose emergency corticosteroid therapy in the past may also be at risk. This possibility of residual impairment should always be borne in mind in emergency and elective situations likely to produce stress, and appropriate corticosteroid treatment must be considered. The extent of the adrenal impairment may require specialist advice before elective procedures.
\*\*Interactions with other medicinal products\*\*
Ritonavir can greatly increase the concentration of fluticasone propionate in plasma. Therefore, concomitant use should be avoided, unless the potential benefit to the patient outweighs the risk of systemic corticosteroid side effects. There is also an increased risk of systemic side effects when combining fluticasone propionate with other potent CYP3A inhibitors (see section 4.5).
Concomitant use of systemic ketoconazole significantly increases systemic exposure to salmeterol. This may lead to an increase in the incidence of systemic effects (e.g. prolongation in the QTc interval and palpitations). Concomitant treatment with ketoconazole or other potent CYP3A4 inhibitors should therefore, be avoided unless the benefits outweigh the potentially increased risk of systemic undesirable effects of salmeterol treatment (see section 4.5).
\*\*Visual disturbance\*\*
Visual disturbance may be reported with systemic and topical corticosteroid use. If a patient presents with symptoms such as blurred vision or other visual disturbances, the patient should be considered for referral to an ophthalmologist for evaluation of possible causes which may include cataract, glaucoma or rare diseases such as central serous chorioretinopathy (CSCR) which have been reported after use of systemic and topical corticosteroids.
\*\*Paediatric population\*\*
Campona Airmaster is not recommended for use in children under 12 years of age (see section 4.2).
Adolescents < 16 years taking high doses of fluticasone propionate (typically ≥ 1,000 micrograms/day) may be at particular risk. Systemic effects may occur, particularly at high doses prescribed for long periods. Possible systemic effects include Cushing's syndrome, Cushingoid features, adrenal suppression, acute adrenal crisis and growth retardation in adolescents and more rarely, a range of psychological or behavioural effects including psychomotor hyperactivity, sleep disorders, anxiety, depression or aggression. Consideration should be given to referring the adolescent to a paediatric respiratory specialist.
It is recommended that the height of adolescent receiving prolonged treatment with inhaled corticosteroid is regularly monitored. \*\*The dose of inhaled corticosteroid should be reduced to the lowest dose at which effective control of asthma is maintained.\*\*4.5 Interaction with other medicinal products and other forms of interaction
β adrenergic blockers may weaken or antagonise the effect of salmeterol. Both non-selective and selective β blockers should be avoided unless there are compelling reasons for their use. Potentially serious hypokalaemia may result from β2 agonist therapy. Particular caution is advised in acute severe asthma as this effect may be potentiated by concomitant treatment with xanthine derivatives, steroids and diuretics.
Concomitant use of other β adrenergic containing medicinal products can have a potentially additive effect.
\*\*Fluticasone Propionate\*\*
Under normal circumstances, low plasma concentrations of fluticasone propionate are achieved after inhaled dosing, due to extensive first pass metabolism and high systemic clearance mediated by cytochrome CYP3A4 in the gut and liver. Hence, clinically significant interactions with other active substances mediated by fluticasone propionate are unlikely.
In an interaction study in healthy subjects with intranasal fluticasone propionate, ritonavir (a highly potent cytochrome CYP3A4 inhibitor) 100 mg b.i.d. increased the fluticasone propionate plasma concentrations several hundred fold, resulting in markedly reduced serum cortisol concentrations.
Information about this interaction is lacking for inhaled fluticasone propionate, but a marked increase in fluticasone propionate plasma levels is expected. Cases of Cushing's syndrome and adrenal suppression have been reported. The combination should be avoided unless the benefit outweighs the increased risk of systemic glucocorticoid side effects.
In a small study in healthy volunteers, the slightly less potent CYP3A inhibitor ketoconazole increased the exposure of fluticasone propionate after a single inhalation by 150 %. This resulted in a greater reduction of plasma cortisol as compared with fluticasone propionate alone. Co-treatment with other potent CYP3A inhibitors, such as itraconazole and cobicistat-containing products, and moderate CYP3A inhibitors, such as erythromycin, is also expected to increase the systemic fluticasone propionate exposure and the risk of systemic side effects. Combinations should be avoided unless the benefit outweighs the potential increased risk of systemic corticosteroid side-effects, in which case patients should be monitored for systemic corticosteroid side-effects.
\*\*Salmeterol\*\*
\*Potent CYP3A4 inhibitors\*
Co-administration of ketoconazole (400 mg orally once daily) and salmeterol (50 micrograms inhaled twice daily) in 15 healthy subjects for 7 days resulted in a significant increase in plasma salmeterol exposure (1.4-fold Cmax and 15-fold AUC). This may lead to an increase in the incidence of other systemic effects of salmeterol treatment (e.g. prolongation of QTc interval and palpitations) compared with salmeterol or ketoconazole treatment alone (see section 4.4).
Clinically significant effects were not seen on blood pressure, heart rate, blood glucose and blood potassium levels. Co-administration with ketoconazole did not increase the elimination half-life of salmeterol or increase salmeterol accumulation with repeat dosing.
The concomitant administration of ketoconazole should be avoided, unless the benefits outweigh the potentially increased risk of systemic side effects of salmeterol treatment. There is likely to be a similar risk of interaction with other potent CYP3A4 inhibitors (e.g. itraconazole, telithromycin, ritonavir).
\*Moderate CYP 3A4 inhibitors\*
Co-administration of erythromycin (500 mg orally three times a day) and salmeterol (50 micrograms inhaled twice daily) in 15 healthy subjects for 6 days resulted in a small but non-statistically significant increase in salmeterol exposure (1.4-fold Cmax and 1.2-fold AUC). Co-administration with erythromycin was not associated with any serious adverse effects.4.6 Fertility, pregnancy and lactation
\*\*Fertility\*\*
There are no data in humans. However, animal studies showed no effects of salmeterol or fluticasone propionate on fertility.
\*\*Pregnancy\*\*
A large amount of data on pregnant women (more than 1,000 pregnancy outcomes) indicates no malformative or feto/neonatal toxicity related to salmeterol and fluticasone propionate. Animal studies have shown reproductive toxicity after administration of β2 adrenoreceptor agonists and glucocorticosteroids (see section 5.3).
Administration of Campona Airmaster to pregnant women should only be considered if the expected benefit to the mother is greater than any possible risk to the fetus.
The lowest effective dose of fluticasone propionate needed to maintain adequate asthma control should be used in the treatment of pregnant women.
\*\*Breastfeeding\*\*
It is unknown whether salmeterol and fluticasone propionate/metabolites are excreted in human milk.
Studies have shown that salmeterol and fluticasone propionate, and their metabolites, are excreted into the milk of lactating rats.
A risk to breastfed newborns/infants cannot be excluded. A decision must be made whether to discontinue breastfeeding or to discontinue Campona Airmaster therapy taking into account the benefit of breastfeeding for the child and the benefit of therapy for the woman.4.7 Effects on ability to drive and use machines
Campona Airmaster has no or negligible influence on the ability to drive and use machines.4.8 Undesirable effects
\*\*Summary of safety profile\*\*
As Campona Airmaster contains salmeterol and fluticasone propionate, the type and severity of adverse reactions associated with each of the compounds may be expected. There is no incidence of additional adverse events following concurrent administration of the two compounds.
Adverse events which have been associated with salmeterol/fluticasone propionate are given below, listed by system organ class and frequency. Frequencies are defined as: very common (≥ 1/10), common (≥ 1/100 to < 1/10), uncommon (≥ 1/1,000 to < 1/100), rare (≥ 1/10,000 to < 1/1,000) and not known (cannot be estimated from the available data). Frequencies were derived from clinical trial data. The incidence in placebo was not taken into account.
| | | |
| --- | --- | --- |
| \*\*System organ class\*\* | \*\*Adverse event\*\* | \*\*Frequency\*\* |
| Infections and infestations | Candidiasis of the mouth and throat | Common |
| Oesophageal candidiasis | Rare |
| Immune system disorders | Hypersensitivity reactions with the following manifestations: | |
| Cutaneous hypersensitivity reactions | Uncommon |
| Angioedema (mainly facial and oropharyngeal oedema) | Rare |
| Respiratory symptoms (dyspnoea) | Uncommon |
| Respiratory symptoms (bronchospasm) | Rare |
| Anaphylactic reactions including anaphylactic shock | Rare |
| Endocrine disorders | Cushing's syndrome, Cushingoid features, Adrenal suppression, Growth retardation in children and adolescents, Decreased bone mineral density | Rare2 |
| Metabolism and nutrition disorders | Hyperglycaemia | Uncommon2 |
| Psychiatric disorders | Anxiety | Uncommon |
| Sleep disorders | Uncommon |
| Behavioural changes, including psychomotor hyperactivity and irritability (predominantly in children) | Rare |
| Depression, aggression (predominantly in children) | Not Known |
| Nervous system disorders | Headache | Very Common1 |
| Tremor | Uncommon |
| Eye disorders | Cataract | Uncommon |
| Glaucoma | Rare2 |
| Vision, blurred (see also section 4.4) | Not Known2 |
| Cardiac disorders | Palpitations | Uncommon |
| Tachycardia | Uncommon |
| Cardiac arrhythmias (including supraventricular tachycardia and extrasystoles). | Rare |
| Atrial fibrillation | Uncommon |
| Angina pectoris | Uncommon |
| Respiratory, thoracic and mediastinal disorders | Throat irritation | Common |
| Hoarseness/dysphonia | Common |
| Paradoxical bronchospasm | Rare2 |
| Musculoskeletal and connective tissue disorders | Muscle cramps | Common |
| Arthralgia | Common |
| Myalgia | Common |
1 Reported commonly in placebo
2 See section 4.4
\*\*Description of selected adverse reactions\*\*
The pharmacological side effects of β2 agonist treatment, such as tremor, palpitations and headache, have been reported, but tend to be transient and reduce with regular therapy.
As with other inhalation therapy paradoxical bronchospasm may occur with an immediate increase in wheezing and shortness of breath after dosing. Paradoxical bronchospasm responds to a rapid-acting bronchodilator and should be treated straightaway. Campona Airmaster should be discontinued immediately, the patient assessed, and alternative therapy instituted if necessary.
Due to the fluticasone propionate component, hoarseness and candidiasis (thrush) of the mouth and throat and, rarely, of the oesophagus can occur in some patients. Both hoarseness and incidence of candidiasis may be relieved by rinsing the mouth with water and/or brushing the teeth after using the product. Symptomatic mouth and throat candidiasis can be treated with topical anti-fungal therapy whilst still continuing with Campona Airmaster.
\*\*Paediatric population\*\*
Possible systemic effects include Cushing's syndrome, Cushingoid features, adrenal suppression and growth retardation in children and adolescents (see section 4.4). Children may also experience anxiety, sleep disorders and behavioural changes, including hyperactivity and irritability.
\*\*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 the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.4.9 Overdose
There are no data available from clinical trials on overdose with Campona Airmaster, however data on overdose with both active substances are given below:
\*\*Salmeterol\*\*
The signs and symptoms of salmeterol overdose are dizziness, increases in systolic blood pressure, tremor, headache and tachycardia. If Campona Airmaster therapy has to be withdrawn due to overdose of the β agonist component of the medicinal product, provision of appropriate replacement steroid therapy should be considered. Additionally, hypokalaemia can occur and therefore serum potassium levels should be monitored. Potassium replacement should be considered.
\*\*Fluticasone propionate\*\*
\*\*Acute:\*\* Acute inhalation of fluticasone propionate doses in excess of those recommended may lead to temporary suppression of adrenal function. This does not need emergency action as adrenal function is recovered in a few days, as verified by plasma cortisol measurements.
\*\*Chronic overdose of inhaled fluticasone propionate\*\*: Adrenal reserve should be monitored and treatment with a systemic corticosteroid may be necessary. When stabilised, treatment should be continued with an inhaled corticosteroid at the recommended dose. Refer to section 4.4: risk of adrenal suppression.
In cases of both acute and chronic fluticasone propionate overdose, Campona Airmaster therapy should be continued at a suitable dosage for symptom control.
## Pharmacological Properties
5.1 Pharmacodynamic properties
| | |
| --- | --- |
| Pharmacotherapeutic group: | Adrenergics in combination with corticosteroids or other drugs, excl. anticholinergics. |
| ATC code: | R03AK06 |
\*\*Mechanism of action and pharmacodynamic effects\*\*
Campona Airmaster contains salmeterol and fluticasone propionate which have differing modes of action. The respective mechanisms of action of both active substances are discussed below:
\*Salmeterol:\*
Salmeterol is a selective long-acting (12 hour) β2 adrenoceptor agonist with a long side chain which binds to the exo-site of the receptor.
Salmeterol produces a longer duration of bronchodilation, lasting for at least 12 hours, than recommended doses of conventional short-acting β2 agonists.
\*Fluticasone propionate:\*
Fluticasone propionate given by inhalation at recommended doses has a glucocorticoid anti-inflammatory action within the lungs, resulting in reduced symptoms and exacerbations of asthma, with less adverse effects than when corticosteroids are administered systemically.
\*\*\*Clinical efficacy and safety\*\*\*
The studies described below (GOAL and SMART) were carried out with this same fixed dose combinatination(s), salmeterol xinafoate and fluticasone propionate, but studied a previously authorised product; the studies described were not carried out with Campona Airmaster.
\*Salmeterol/fluticasone propionate - Asthma clinical trials\*
A twelve month study (Gaining Optimal Asthma ControL, GOAL), in 3,416 adult and adolescent patients with persistent asthma, compared the safety and efficacy of salmeterol/fluticasone propionate versus inhaled corticosteroid (Fluticasone Propionate) alone to determine whether the goals of asthma management were achievable. Treatment was stepped up every 12 weeks until \\*\\* \*total control\* was achieved or the highest dose of study drug was reached. GOAL showed more patients treated with Salmeterol/fluticasone propionate achieved asthma control than patients treated with inhaled corticosteroid (ICS) alone and this control was attained at a lower corticosteroid dose.
\\* \*Well controlled\* asthma was achieved more rapidly with Salmeterol/fluticasone propionate than with ICS alone. The time on treatment for 50 % of subjects to achieve a first individual well controlled week was 16 days for Salmeterol/fluticasone propionate compared to 37 days for the ICS group. In the subset of steroid naive asthmatics the time to an individual well controlled week was 16 days in the Salmeterol/fluticasone propionate treatment compared to 23 days following treatment with ICS.
The overall study results showed:
| | | | | |
| --- | --- | --- | --- | --- |
| \*\*Percentage of patients attaining \\* Well Controlled (WC) and \\*\\* Totally Controlled (TC) asthma over 12 months\*\* | | | | |
| \*\*Pre-study treatment\*\* | \*\*Salmaterol/FP\*\* | | \*\*FP\*\* | |
| \*\*WC\*\* | \*\*TC\*\* | \*\*WC\*\* | \*\*TC\*\* |
| \*\*No ICS\*\* (SABA alone) | 78 % | 50 % | 70 % | 40 % |
| \*\*Low dose ICS\*\* (≤ 500 micrograms BDP or equivalent/day) | 75 % | 44 % | 60 % | 28 % |
| \*\*Medium dose ICS\*\* (> 500 to 1,000 micrograms BDP or equivalent/day) | 62 % | 29 % | 47 % | 16 % |
| \*\*Pooled results across the 3 treatment levels\*\* | 71 % | 41 % | 59 % | 28 % |
\\* Well controlled asthma; less than or equal to 2 days with symptom score greater than 1 (symptom score 1 defined as 'symptoms for one short period during the day'), SABA use on less than or equal to 2 days and less than or equal to 4 occasions/week, greater than or equal to 80 % predicted morning peak expiratory flow, no night-time awakenings, no exacerbations and side effects enforcing a change in therapy.
\\*\\* Total control of asthma; no symptoms, no SABA use, greater than or equal to 80 % predicted morning peak expiratory flow, no night-time awakenings, no exacerbations and no side effects enforcing a change in therapy.
The results of this study suggest that salmeterol/fluticasone propionate 50/100 micrograms bd may be considered as initial maintenance therapy in patients with moderate persistent asthma for whom rapid control of asthma is deemed essential (see section 4.2).
A double blind, randomised, parallel group study in 318 patients with persistent asthma aged ≥ 18 years evaluated the safety and tolerability of administering two inhalations twice daily (double dose) of Salmeterol/fluticasone propionate for two weeks. The study showed that doubling the inhalations of each strength of Salmeterol/fluticasone propionate for up to 14 days resulted in a small increase in β agonist-related adverse events (tremor; 1 patient [1 %] \*vs\* 0, palpitations; 6 [3 %] \*vs\* 1 [< 1 %], muscle cramps; 6[3 %] \*vs\* 1 [< 1 %]) and a similar incidence of inhaled corticosteroid-related adverse events (e.g. oral candidiasis; 6 [6 %] \*vs\* 16 [8 %], hoarseness; 2 [2 %] \*vs\* 4 [2 %]) compared to one inhalation twice daily. The small increase in β agonist-related adverse events should be taken into account if doubling the dose of Salmeterol/fluticasone propionate is considered by the physician in adult patients requiring additional short-term (up to 14 days) inhaled corticosteroid therapy.
\*\*Asthma\*\*
\*\*\*The Salmeterol Multi-center Asthma Research Trial (SMART)\*\*\*
The Salmeterol Multi-center Asthma Research Trial (SMART) was a 28-week US study that evaluated the safety of salmeterol compared to placebo added to usual therapy in adult and adolescent subjects. Although there were no significant differences in the primary endpoint of the combined number of respiratory-related deaths and respiratory-related life-threatening experiences, the study showed a significant increase in asthma-related deaths in patients receiving salmeterol (13 deaths out of 13,176 patients treated with salmeterol versus 3 deaths out of 3,179 patients on placebo). The study was not designed to assess the impact of concurrent inhaled corticosteroid use, and only 47 % of subjects reported ICS use at baseline.
\*\*Safety and efficacy of salmeterol-FP versus FP alone in asthma\*\*
Two multi-centre 26-week studies were conducted to compare the safety and efficacy of salmeterol-FP versus FP alone, one in adult and adolescent subjects (AUSTRI trial), and the other in paediatric subjects 4-11 years of age (VESTRI trial). For both studies, enrolled subjects had moderate to severe persistent asthma with history of asthma-related hospitalisation or asthma exacerbation in the previous year. The primary objective of each study was to determine whether the addition of LABA to ICS therapy (salmeterol-FP) was non-inferior to ICS (FP) alone in terms of the risk of serious asthma related events (asthma-related hospitalisation, endotracheal intubation, and death). A secondary efficacy objective of these studies was to evaluate whether ICS/LABA (salmeterol-FP) was superior to ICS therapy alone (FP) in terms of severe asthma exacerbation (defined as deterioration of asthma requiring the use of systemic corticosteroids for at least 3 days or an in-patient hospitalisation or emergency department visit due to asthma that required systemic corticosteroids).
A total of 11,679 and 6,208 subjects were randomized and received treatment in the AUSTRI and VESTRI trials, respectively. For the primary safety endpoint, non-inferiority was achieved for both trials (see Table below).
\*\*Serious asthma-related events in the 26-Week AUSTRI and VESTRI trials\*\*
| | | | | |
| --- | --- | --- | --- | --- |
| | AUSTRI | | VESTRI | |
| Salmeterol-FP (n = 5,834) | FP alone (n = 5,845) | Salmeterol-FP (n = 3,107) | FP alone (n = 3,101) |
| Composite endpoint (Asthma-related hospitalisation, endotracheal intubation, or death) | 34 (0.6 %) | 33 (0.6 %) | 27 (0.9 %) | 21 (0.7 %) |
| Salmeterol-FP/FP Hazard ratio (95 % CI) | 1.029 (0.638-1.662)a | | 1.285 (0.726-2.272)b | |
| Death | 0 | 0 | 0 | 0 |
| Asthma-related hospitalisation | 34 | 33 | 27 | 21 |
| Endotracheal intubation | 0 | 2 | 0 | 0 |
a If the resulting upper 95 % CI estimate for the relative risk was less than 2.0, then non-inferiority was concluded.
b If the resulting upper 95 % CI estimate for the relative risk was less than 2.675, then non-inferiority was concluded.
For the secondary efficacy endpoint, reduction in time to first asthma exacerbation for salmeterol-FP relative to FP was seen in both studies, however only AUSTRI met statistical significance:
| | | | | |
| --- | --- | --- | --- | --- |
| | AUSTRI | | VESTRI | |
| Salmeterol-FP (n = 5,834) | FP alone (n = 5,845) | Salmeterol-FP (n = 3,107) | FP alone (n = 3,101) |
| \*\*Number of subjects with an asthma exacerbation\*\* | 480 (8 %) | 597 (10 %) | 265 (9 %) | 309 (10 %) |
| \*\*Salmeterol-FP/FP\*\* \*\*Hazard ratio (95 % CI)\*\* | 0.787 (0.698, 0.888) | | 0.859 (0.729, 1.012) | |
\*\*Paediatric population\*\*
Campona Airmaster is not indicated in children under 12 years of age(see section 4.2). The studies described below were carried out with a previously authorised product; the studies described were not carried out with Campona Airmaster.
In trial SAM101667, in 158 children aged 6 to 16 years with symptomatic asthma, the combination of salmeterol/ fluticasone propionate is as efficacious as doubling the dose of fluticasone propionate in respect of symptom control and lung function. This study was not designed to investigate the effect on exacerbations.
In a 12-week trial of children aged 4 to 11 years [n = 257] treated with either salmeterol/fluticasone propionate 50/100 or salmeterol 50 micrograms + fluticasone propionate 100 micrograms both twice daily, both treatment arms experienced a 14 % increase in peak expiratory flow rate as well as improvements in symptom score and rescue salbutamol use. There were no differences between the two treatment arms. There were no differences in safety parameters between the two treatment arms.
In a 12-week trial of children 4 to 11 years of age [n = 203] randomized in a parallel-group study with persistent asthma and who were symptomatic on inhaled corticosteroid, safety was the primary objective. Children received either salmeterol/fluticasone propionate (50/100 micrograms) or fluticasone propionate (100 micrograms) alone twice daily. Two children on salmeterol/fluticasone propionate and 5 children on fluticasone propionate withdrew because of worsening asthma. After 12 weeks no children in either treatment arm had abnormally low 24-hour urinary cortisol excretion. There were no other differences in safety profile between the treatment arms.
\*\*\*Fluticasone propionate containing medications in asthma during pregnancy\*\*\*
An observational retrospective epidemiological cohort study utilising electronic health records from the United Kingdom was conducted to evaluate the risk of MCMs following first trimester exposure to inhaled FP alone and salmeterol-FP relative to non-FP containing ICS. No placebo comparator was included in this study.
Within the asthma cohort of 5,362 first trimester ICS-exposed pregnancies, 131 diagnosed MCMs were identified; 1,612 (30 %) were exposed to FP or salmeterol-FP of which 42 diagnosed MCMs were identified. The adjusted odds ratio for MCMs diagnosed by 1 year was 1.1 (95 %CI: 0.5-2.3) for FP exposed \*vs\* non-FP ICS exposed women with moderate asthma and 1.2 (95 %CI: 0.7-2.0) for women with considerable to severe asthma. No difference in the risk of MCMs was identified following first trimester exposure to FP alone versus salmeterol-FP. Absolute risks of MCM across the asthma severity strata ranged from 2.0 to 2.9 per 100 FP-exposed pregnancies which is comparable to results from a study of 15,840 pregnancies unexposed to asthma therapies in the General Practice Research Database (2.8 MCM events per 100 pregnancies).5.2 Pharmacokinetic properties
For pharmacokinetic purposes each component can be considered separately.
\*Salmeterol\*
Salmeterol acts locally in the lung therefore plasma levels are not an indication of therapeutic effects. In addition there are only limited data available on the pharmacokinetics of salmeterol because of the technical difficulty of assaying the active substance in plasma due to the low plasma concentrations at therapeutic doses (approximately 200 picogram /mL or less) achieved after inhaled dosing.
\*Fluticasone propionate\*
The absolute bioavailability of a single dose of inhaled fluticasone propionate in healthy subjects varies between approximately 5 to 11 % of the nominal dose depending on the inhalation device used.
In patients with asthma a lesser degree of systemic exposure to inhaled fluticasone propionate has been observed.
\*\*Absorption\*\*
Systemic absorption occurs mainly through the lungs and is initially rapid then prolonged. The remainder of the inhaled dose may be swallowed but contributes minimally to systemic exposure due to the low aqueous solubility and pre-systemic metabolism, resulting in oral availability of less than 1 %. There is a linear increase in systemic exposure with increasing inhaled dose.
\*\*Distribution\*\*
The disposition of fluticasone propionate is characterised by high plasma clearance (1,150 mL/min), a large volume of distribution at steady-state (approximately 300 L) and a terminal half-life of approximately 8 hours. Plasma protein binding is 91 %.
\*\*Biotransformation\*\*
Fluticasone propionate is cleared very rapidly from the systemic circulation. The main pathway is metabolism to an inactive carboxylic acid metabolite, by the cytochrome P450 enzyme CYP3A4. Other unidentified metabolites are also found in the faeces.
\*\*Elimination\*\*
The renal clearance of fluticasone propionate is negligible. Less than 5 % of the dose is excreted in urine, mainly as metabolites. The main part of the dose is excreted in faeces as metabolites and unchanged active substance.
\*\*\*Paediatric population\*\*\*
Campona Airmaster is not indicated for use in children under 12 years of age. The studies described below were carried out with a previously authorised product; the studies described were not carried out with Campona Airmaster.
In a population pharmacokinetic analysis utilizing data from 9 controlled clinical trials with different devices (dry powder inhaler, metered dose inhaler) that included 350 patients with asthma aged 4 to 77 years (174 patients 4 to 11 years of age) higher fluticasone propionate systemic exposure following treatment with salmeterol/fluticasone dry powder inhaler 50/100 compared to fluticasone propionate dry powder inhaler 100 were seen.
Geometric Mean Ratio [90 % CI] for the Salmeterol/fluticasone propionate \*vs\* fluticasone propionate dry powder inhaler Comparison in Children and Adolescent/Adult Populations
| | | | |
| --- | --- | --- | --- |
| \*\*\*Treatment (test vs ref)\*\*\* | \*\*\*Population\*\*\* | \*\*\*AUC\*\*\* | \*\*\*Cmax\*\*\* |
| \*Salmeterol/ fluticasone propionate dry powder inhaler 50/100 fluticasone propionate dry powder inhaler 100\* | \*Children (4–11yr)\* | \*1.20 [1.06 – 1.37]\* | \*1.25 [1.11 – 1.41]\* |
| \*Salmeterol/fluticasone propionate dry powder inhaler 50/100 fluticasone propionate dry powder inhaler 100\* | \*Adolescent/Adult (≥ 12yr)\* | \*1.52 [1.08 – 2.13]\* | \*1.52 [1.08 – 2.16]\* |
The effect of 21 days of treatment with salmeterol/fluticasone inhaler 25/50 micrograms (2 inhalations twice daily with or without a spacer) or salmeterol/fluticasone dry powder inhaler 50/100 micrograms (1 inhalation twice daily) was evaluated in 31 children aged 4 to 11 years with mild asthma. Systemic exposure to salmeterol was similar for salmeterol/fluticasone inhaler, salmeterol/fluticasone inhaler with spacer, and salmeterol/fluticasone dry powder inhaler (126 pg hr/mL [95 % CI: 70, 225], 103 pg hr/mL [95 % CI: 54, 200], and 110 pg hr/mL [95 % CI: 55, 219], respectively). Systemic exposure to fluticasone propionate was similar for salmeterol/fluticasone inhaler with spacer (107 pg hr/mL [95 % CI: 45.7, 252.2]) and salmeterol/fluticasone dry powder inhaler (138 pg hr/mL [95 % CI: 69.3, 273.2]), but lower for salmeterol/fluticasone inhaler (24 pg hr/mL [95 % CI: 9.6, 60.2]).”5.3 Preclinical safety data
The only safety concerns for human use derived from animal studies of salmeterol and fluticasone propionate given separately were effects associated with exaggerated pharmacological actions.
In animal reproduction studies, glucocorticosteroids have been shown to induce malformations (cleft palate, skeletal malformations). However, these animal experimental results do not seem to be relevant for man given recommended doses. Animal studies with salmeterol have shown embryofetal toxicity only at high exposure levels. Following co-administration, increased incidences of transposed umbilical artery and incomplete ossification of occipital bone were found in rats at doses associated with known glucocorticoid-induced abnormalities. Neither salmeterol xinafoate or fluticasone propionate have shown any potential for genetic toxicity.
## Pharmaceutical Particulars
6.1 List of excipients
Lactose monohydrate (which contains milk proteins).6.2 Incompatibilities
Not applicable.6.3 Shelf life
2 years.6.4 Special precautions for storage
Do not store above 30 °C.6.5 Nature and contents of container
The inhalation powder is contained in blister held on a formed aluminium/OPA/PVC base foil, with a peelable PETP-film/paper/PVC lidding foil. The blister is contained in a moulded white plastic device with a light pink (for 50/100 microgram strength) slidable mouthpiece cover, with a red safety lock.
The inhaler is packaged within triple laminated foil pouch consisting of Polyester/ADH/Aluminium/ADH/Polyethylene Film.
The plastic devices are available in cardboard containers, which hold:
1 × 60 dose Campona Airmaster
or 2 x 60 dose Campona Airmaster
or 3 x 60 dose Campona Airmaster
or 10 x 60 dose Campona Airmaster
Not all pack sizes may be marketed.6.6 Special precautions for disposal and other handling
The Campona Airmaster releases a powder which is inhaled into the lungs. A dose indicator on the Campona Airmaster indicates the number of doses left. For detailed instructions for use see the Patient Information Leaflet.
Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
