Atectura Breezhaler

Indacaterol acetate, mometasone furoate.

Atectura Breezhaler 150 micrograms/80 micrograms inhalation powder, hard capsules: Each capsule contains 150 mcg of indacaterol (as acetate) and 80 mcg of mometasone furoate.
Each delivered dose (the dose that leaves the mouthpiece of the inhaler) contains 125 mcg of indacaterol (as acetate) and 62.5 mcg of mometasone furoate.
Atectura Breezhaler 150 micrograms/160 micrograms inhalation powder, hard capsules: Each capsule contains 150 mcg of indacaterol (as acetate) and 160 mcg of mometasone furoate.
Each delivered dose (the dose that leaves the mouthpiece of the inhaler) contains 125 mcg of indacaterol (as acetate) and 127.5 mcg of mometasone furoate.
Atectura Breezhaler 150 micrograms/320 micrograms inhalation powder, hard capsules: Each capsule contains 150 mcg of indacaterol (as acetate) and 320 mcg of mometasone furoate.
Each delivered dose (the dose that leaves the mouthpiece of the inhaler) contains 125 mcg of indacaterol (as acetate) and 260 mcg of mometasone furoate.
Excipient(s) with known effect: Each capsule contains approximately 25 mg of lactose monohydrate.
Excipients/Inactive Ingredients: Capsule content: Lactose monohydrate.
Capsule shell: Gelatin, Printing ink.

Pharmacotherapeutic group: Drugs for obstructive airway diseases, adrenergics in combination with corticosteroids or other drugs, excl. anticholinergics. ATC code: R03AK14.
Pharmacology: Pharmacodynamics: Mechanism of action: This medicinal product is a combination of indacaterol, a long-acting beta₂-adrenergic agonist (LABA), and mometasone furoate, an inhaled synthetic corticosteroid (ICS).
Indacaterol: The pharmacological effects of beta₂-adrenoceptor agonists, including indacaterol, are at least in part attributable to increased cyclic-3', 5'-adenosine monophosphate (cyclic AMP) levels, which cause relaxation of bronchial smooth muscle.
When inhaled, indacaterol acts locally in the lung as a bronchodilator. Indacaterol is a partial agonist at the human beta₂-adrenergic receptor with nanomolar potency. In isolated human bronchus, indacaterol has a rapid onset of action and a long duration of action.
Although beta₂-adrenergic receptors are the predominant adrenergic receptors in bronchial smooth muscle and beta1-receptors are the predominant receptors in the human heart, there are also beta₂-adrenergic receptors in the human heart comprising 10% to 50% of the total adrenergic receptors.
Mometasone furoate: Mometasone furoate is a synthetic corticosteroid with high affinity for glucocorticoid receptors and local anti-inflammatory properties. In vitro, mometasone furoate inhibits the release of leukotrienes from leukocytes of allergic patients. In cell culture, mometasone furoate demonstrated high potency in inhibition of synthesis and release of IL-1, IL-5, IL-6 and TNF-alpha. It is also a potent inhibitor of leukotriene production and of the production of the Th2 cytokines IL-4 and IL-5 from human CD4+ T-cells.
Pharmacodynamic effects: The pharmacodynamic response profile of this medicinal product is characterised by rapid onset of action within 5 minutes after dosing and sustained effect over the 24-hour dosing interval, as evidenced by improvements in trough forced expiratory volume in the first second (FEV1) improvements versus comparators 24 hours after dosing.
No tachyphylaxis to the lung function benefits of this medicinal product was observed over time.
QTc interval: The effect of this medicinal product on the QTc interval has not been evaluated in a thorough QT (TQT) study. For mometasone furoate, no QTc-prolonging properties are known.
Clinical efficacy and safety: Two phase III randomised, double-blind studies (PALLADIUM and QUARTZ) of different durations evaluated the safety and efficacy of Atectura Breezhaler in adult and adolescent patients with persistent asthma.
The PALLADIUM study was a 52-week pivotal study evaluating Atectura Breezhaler 125 mcg/127.5 mcg once daily (N=439) and 125 mcg/260 mcg once daily (N=445) compared to mometasone furoate 400 mcg once daily (N=444) and 800 mcg per day (given as 400 mcg twice daily) (N=442), respectively. A third active control arm included subjects treated with salmeterol/fluticasone propionate 50 mcg/500 mcg twice daily (N=446). All subjects were required to have symptomatic asthma (ACQ-7 score ≥1.5) and were on asthma maintenance therapy using an inhaled synthetic corticosteroid (ICS) with or without LABA for at least 3 months prior to study entry. At screening, 31% of patients had history of exacerbation in the previous year. At study entry, the most common asthma medications reported were medium dose of ICS (20%), high dose of ICS (7%) or low dose of ICS in combination with a LABA (69%).
The primary objective of the study was to demonstrate superiority of either Atectura Breezhaler 125 mcg/127.5 mcg once daily over mometasone furoate 400 mcg once daily or Atectura Breezhaler 125 mcg/260 mcg once daily over mometasone furoate 400 mcg twice daily in terms of trough FEV1 at week 26.
At week 26, Atectura Breezhaler 125 mcg/127.5 mcg and 125 mcg/260 mcg once daily both demonstrated statistically significant improvements in trough FEV1 and Asthma Control Questionnaire (ACQ-7) score compared to mometasone furoate 400 mcg once or twice daily, respectively (see Table 1). Findings at week 52 were consistent with week 26.
Atectura Breezhaler 125 mcg/127.5 mcg and 125 mcg/260 mcg once daily both demonstrated a clinically meaningful reduction in the annual rate of moderate or severe exacerbations (secondary endpoint), compared to mometasone furoate 400 mcg once and twice daily (see Table 1).
Results for the most clinically relevant endpoints are described in Table 1.
Lung function, symptoms and exacerbations: (See Table 1.)

Click on icon to see table/diagram/image

Pre-specified pooled analysis: Atectura Breezhaler 125 mcg/260 mcg once daily was also studied as an active comparator in another phase III study (IRIDIUM) in which all subjects had a history of asthma exacerbation requiring systemic corticosteroids in the past year. A pre-specified pooled analysis across the IRIDIUM and PALLADIUM studies was conducted to compare Atectura Breezhaler 125 mcg/260 mcg once daily to salmeterol/fluticasone 50 mcg/500 mcg twice daily for the endpoints of trough FEV1 and ACQ-7 at week 26 and annualised rate of exacerbations. The pooled analysis demonstrated that Atectura Breezhaler improved trough FEV1 by 43 ml (95% CI: 17, 69) and ACQ-7 score by -0.091 (95% CI: -0.153, -0.030) at week 26 and reduced the annualised rate of moderate or severe asthma exacerbations by 22% (RR: 0.78; 95% CI: 0.66, 0.93) and of severe exacerbations by 26% (RR: 0.74; 95% CI: 0.61, 0.91) versus salmeterol/fluticasone.
The QUARTZ study was a 12-week study evaluating Atectura Breezhaler 125 mcg/62.5 mcg once daily (N=398) compared to mometasone furoate 200 mcg once daily (N=404). All subjects were required to be symptomatic and on asthma maintenance therapy using a low-dose ICS (with or without LABA) for at least 1 month prior to study entry. At study entry, the most common asthma medications reported were low-dose ICS (43%) and LABA/low-dose ICS (56%). The primary endpoint of the study was to demonstrate superiority of Atectura Breezhaler 125 mcg/62.5 mcg once daily over mometasone furoate 200 mcg once daily in terms of trough FEV1 at week 12.
Atectura Breezhaler 125 mcg/62.5 mcg once daily demonstrated a statistically significant improvement in baseline trough FEV1 at week 12 and Asthma Control Questionnaire (ACQ-7) score compared to mometasone furoate 200 mcg once daily.
Results for the most clinically relevant endpoints are described in Table 2. (See Table 2.)

Click on icon to see table/diagram/image

Paediatric population: In the PALLADIUM study, which included 106 adolescents (12-17 years old), the improvements in trough FEV1 at week 26 were 0.173 litres (95% CI: -0.021, 0.368) for Atectura Breezhaler 125 mcg/260 mcg once daily vs mometasone furoate 800 mcg (i.e. high doses) and 0.397 litres (95% CI: 0.195, 0.599) for Atectura Breezhaler 125 mcg/127.5 mcg once daily vs mometasone furoate 400 mcg once daily (i.e. medium doses).
In the QUARTZ study, which included 63 adolescents (12-17 years old), the Least Square means treatment difference for trough FEV1 at day 85 (week 12) was 0.251 litres (95% CI: 0.130, 0.371).
For the adolescent subgroups, improvements in lung function, symptoms and exacerbation reductions were consistent with the overall population.
Pharmacokinetics: Absorption: Following inhalation of Atectura Breezhaler, the median time to reach peak plasma concentrations of indacaterol and mometasone furoate was approximately 15 minutes and 1 hour, respectively.
Based on the in vitro performance data, the dose of each of the monotherapy components delivered to the lung is expected to be similar for the indacaterol/mometasone furoate combination and the monotherapy products. Steady-state plasma exposure to indacaterol and mometasone furoate after inhalation of the combination was similar to the systemic exposure after inhalation of indacaterol maleate or mometasone furoate as monotherapy products.
Following inhalation of the combination, the absolute bioavailability was estimated to be about 45% for indacaterol and less than 10% for mometasone furoate.
Indacaterol: Indacaterol concentrations increased with repeated once-daily administration. Steady state was achieved within 12 to 14 days. The mean accumulation ratio of indacaterol, i.e. AUC over the 24-h dosing interval on day 14 compared to day 1, was in the range of 2.9 to 3.8 for once-daily inhaled doses between 60 and 480 mcg (delivered dose). Systemic exposure results from a composite of pulmonary and gastrointestinal absorption; about 75% of systemic exposure was from pulmonary absorption and about 25% from gastrointestinal absorption.
Mometasone furoate: Mometasone furoate concentrations increased with repeated once-daily administration via the Breezhaler inhaler. Steady state was achieved after 12 days. The mean accumulation ratio of mometasone furoate, i.e. AUC over the 24-h dosing interval on day 14 compared to day 1, was in the range of 1.61 to 1.71 for once-daily inhaled doses between 62.5 and 260 mcg as part of the indacaterol/mometasone furoate combination.
Following oral administration of mometasone furoate, the absolute oral systemic bioavailability of mometasone furoate was estimated to be very low (<2%).
Distribution: Indacaterol: After intravenous infusion the volume of distribution (Vz) of indacaterol was 2,361 to 2,557 litres, indicating an extensive distribution. The in vitro human serum and plasma protein binding were 94.1 to 95.3% and 95.1 to 96.2%, respectively.
Mometasone furoate: After intravenous bolus administration, the Vd is 332 litres. The in vitro protein binding for mometasone furoate is high, 98% to 99% in concentration range of 5 to 500 ng/ml.
Biotransformation: Indacaterol: After oral administration of radiolabelled indacaterol in a human ADME (absorption, distribution, metabolism, excretion) study, unchanged indacaterol was the main component in serum, accounting for about one third of total drug-related AUC over 24 hours. A hydroxylated derivative was the most prominent metabolite in serum. Phenolic O-glucuronides of indacaterol and hydroxylated indacaterol were further prominent metabolites. A diastereomer of the hydroxylated derivative, an N-glucuronide of indacaterol, and C- and N-dealkylated products were further metabolites identified.
In vitro investigations indicated that UGT1A1 was the only UGT isoform that metabolised indacaterol to the phenolic O-glucuronide. The oxidative metabolites were found in incubations with recombinant CYP1A1, CYP2D6 and CYP3A4. CYP3A4 is concluded to be the predominant isoenzyme responsible for hydroxylation of indacaterol. In vitro investigations further indicated that indacaterol is a low-affinity substrate for the efflux pump P-gp.
In vitro the UGT1A1 isoform is a major contributor to the metabolic clearance of indacaterol. However, as shown in a clinical study in populations with different UGT1A1 genotypes, systemic exposure to indacaterol is not significantly affected by the UGT1A1 genotype.
Mometasone furoate: The portion of an inhaled mometasone furoate dose that is swallowed and absorbed in the gastrointestinal tract undergoes extensive metabolism to multiple metabolites. There are no major metabolites detectable in plasma. In human liver microsomes mometasone furoate is metabolised by CYP3A4.
Elimination: Indacaterol: In clinical studies which included urine collection, the amount of indacaterol excreted unchanged via urine was generally lower than 2% of the dose. Renal clearance of indacaterol was, on average, between 0.46 and 1.20 litres/hour. Compared with the serum clearance of indacaterol of 18.8 to 23.3 litres/hour, it is evident that renal clearance plays a minor role (about 2 to 6% of systemic clearance) in the elimination of systemically available indacaterol.
In a human ADME study in which indacaterol was given orally, the faecal route of excretion was dominant over the urinary route. Indacaterol was excreted into human faeces primarily as unchanged parent substance (54% of the dose) and, to a lesser extent, hydroxylated indacaterol metabolites (23% of the dose). Mass balance was complete with ≥90% of the dose recovered in the excreta.
Indacaterol serum concentrations declined in a multi-phasic manner with an average terminal half-life ranging from 45.5 to 126 hours. The effective half-life, calculated from the accumulation of indacaterol after repeated dosing, ranged from 40 to 52 hours which is consistent with the observed time to steady state of approximately 12 to 14 days.
Mometasone furoate: After intravenous bolus administration, mometasone furoate has a terminal elimination T½ of approximately 4.5 hours. A radiolabelled, orally inhaled dose is excreted mainly in the faeces (74%) and to a lesser extent in the urine (8%).
Interactions: Concomitant administration of orally inhaled indacaterol and mometasone furoate under steady-state conditions did not affect the pharmacokinetics of either active substance.
Linearity/non-linearity: Systemic exposure of mometasone furoate increased in a dose proportional manner following single and multiple doses of Atectura Breezhaler 125 mcg/62.5 mcg and 125 mcg/260 mcg in healthy subjects. A less than proportional increase in steady-state systemic exposure was noted in patients with asthma over the dose range of 125 mcg/62.5 mcg to 125 mcg/260 mcg. Dose proportionality assessments were not performed for indacaterol as only one dose was used across all dose strengths.
Paediatric population: Atectura Breezhaler may be used in adolescent patients (12 years of age and older) at the same posology as in adults.
Special populations: A population pharmacokinetic analysis in patients with asthma after inhalation of indacaterol/mometasone furoate indicated no significant effect of age, gender, body weight, smoking status, baseline estimated glomerular filtration rate (eGFR) and FEV1 at baseline on the systemic exposure to indacaterol and mometasone furoate.
Patients with renal impairment: Due to the very low contribution of the urinary pathway to total body elimination of indacaterol and mometasone furoate, the effects of renal impairment on their systemic exposure have not been investigated (see Dosage & Administration).
Patients with hepatic impairment: The effect of indacaterol/mometasone furoate has not been evaluated in subjects with hepatic impairment. However, studies have been conducted with the monotherapy components (see Dosage & Administration).
Indacaterol: Patients with mild and moderate hepatic impairment showed no relevant changes in Cmax or AUC of indacaterol, nor did protein binding differ between mild and moderate hepatic impaired subjects and their healthy controls. No data are available for subjects with severe hepatic impairment.
Mometasone furoate: A study evaluating the administration of a single inhaled dose of 400 mcg mometasone furoate by dry powder inhaler to subjects with mild (n=4), moderate (n=4), and severe (n=4) hepatic impairment resulted in only 1 or 2 subjects in each group having detectable peak plasma concentrations of mometasone furoate (ranging from 50 to 105 pcg/ml). The observed peak plasma concentrations appear to increase with severity of hepatic impairment; however, the numbers of detectable levels (assay lower limit of quantification was 50 pcg/ml) were few.
Other special populations: There were no major differences in total systemic exposure (AUC) for both compounds between Japanese and Caucasian subjects. Insufficient pharmacokinetic data are available for other ethnicities or races.
Toxicology: Preclinical safety data: The non-clinical assessments of each monotherapy and of the combination product are presented as follows.
Indacaterol and mometasone furoate combination: The findings during the 13-week inhalation toxicity studies were predominantly attributable to the mometasone furoate component and were typical pharmacological effects of glucocorticoids. Increased heart rates associated with indacaterol were apparent in dogs after administration of indacaterol/mometasone furoate or indacaterol alone.
Indacaterol: Effects on the cardiovascular system attributable to the beta₂-agonistic properties of indacaterol included tachycardia, arrhythmias and myocardial lesions in dogs. Mild irritation of the nasal cavity and larynx was seen in rodents.
Genotoxicity studies did not reveal any mutagenic or clastogenic potential.
Carcinogenicity was assessed in a two-year rat study and a six-month transgenic mouse study. Increased incidences of benign ovarian leiomyoma and focal hyperplasia of ovarian smooth muscle in rats were consistent with similar findings reported for other beta₂-adrenergic agonists. No evidence of carcinogenicity was seen in mice.
All these findings occurred at exposures sufficiently in excess of those anticipated in humans.
Following subcutaneous administration in a rabbit study, adverse effects of indacaterol with respect to pregnancy and embryonal/foetal development could only be demonstrated at doses more than 500-fold those achieved following daily inhalation of 150 mcg in humans (based on AUC0-24 h).
Although indacaterol did not affect general reproductive performance in a rat fertility study, a decrease in the number of pregnant F1 offspring was observed in the peri- and post-natal developmental rat study at an exposure 14-fold higher than in humans treated with indacaterol. Indacaterol was not embryotoxic or teratogenic in rats or rabbits.
Mometasone furoate: All observed effects are typical of the glucocorticoid class of compounds and are related to exaggerated pharmacological effects of glucocorticoids. Mometasone furoate showed no genotoxic activity in a standard battery of in vitro and in vivo tests.
In carcinogenicity studies in mice and rats, inhaled mometasone furoate demonstrated no statistically significant increase in the incidence of tumours.
Like other glucocorticoids, mometasone furoate is a teratogen in rodents and rabbits. Effects noted were umbilical hernia in rats, cleft palate in mice and gallbladder agenesis, umbilical hernia and flexed front paws in rabbits. There were also reductions in maternal body weight gains, effects on foetal growth (lower foetal body weight and/or delayed ossification) in rats, rabbits and mice, and reduced offspring survival in mice. In studies of reproductive function, subcutaneous mometasone furoate at 15 mcg/kg prolonged gestation and difficult labour occurred, with a reduction in offspring survival and body weight.

Atectura Breezhaler is indicated as a maintenance treatment of asthma in adults and adolescents 12 years of age and older not adequately controlled with inhaled corticosteroids and inhaled short-acting beta₂-agonists.

Posology: Adults and adolescents aged 12 years and over: The recommended dose is one capsule to be inhaled once daily.
Patients should be given the strength containing the appropriate mometasone furoate dosage for the severity of their disease and should be regularly reassessed by a healthcare professional.
The maximum recommended dose is 125 mcg/260 mcg once daily.
Treatment should be administered at the same time of the day each day. It can be administered irrespective of the time of the day. If a dose is missed, it should be taken as soon as possible. Patients should be instructed not to take more than one dose in a day.
Special populations: Elderly population: No dose adjustment is required in elderly patients (65 years of age or older) (see Pharmacology: Pharmacokinetics under Actions).
Renal impairment: No dose adjustment is required in patients with renal impairment (see Pharmacology: Pharmacokinetics under Actions).
Hepatic impairment: No dose adjustment is required in patients with mild or moderate hepatic impairment. No data are available for the use of the medicinal product in patients with severe hepatic impairment, therefore it should be used in these patients only if the expected benefit outweighs the potential risk (see Pharmacology: Pharmacokinetics under Actions).
Paediatric population: The posology in patients 12 years of age and older is the same posology as in adults. The safety and efficacy in paediatric patients below 12 years of age have not been established. No data are available.
Method of administration: For inhalation use only. The capsules must not be swallowed.
The capsules must be administered only using the inhaler provided (see Special precautions for disposal and other handling under Cautions for Usage) with each new prescription.
Patients should be instructed on how to administer the medicinal product correctly. Patients who do not experience improvement in breathing should be asked if they are swallowing the medicinal product rather than inhaling it.
The capsules must only be removed from the blister immediately before use.
After inhalation, patients should rinse their mouth with water without swallowing (see Precautions and Special precautions for disposal and other handling under Cautions for Usage).
For instructions on use of the medicinal product before administration, see Special precautions for disposal and other handling under Cautions for Usage.

General supportive measures and symptomatic treatment should be initiated in cases of suspected overdose.
An overdose will likely produce signs, symptoms or adverse effects associated with the pharmacological actions of the individual components (e.g. tachycardia, tremor, palpitations, headache, nausea, vomiting, drowsiness, ventricular arrhythmias, metabolic acidosis, hypokalaemia, hyperglycaemia, suppression of hypothalamic pituitary adrenal axis function).
Use of cardioselective beta blockers may be considered for treating beta₂-adrenergic effects, but only under the supervision of a physician and with extreme caution, since the use of beta₂-adrenergic blockers may provoke bronchospasm. In serious cases, patients should be hospitalised.

Hypersensitivity to the active substances or to any of the excipients listed in Description.

Deterioration of disease: This medicinal product should not be used to treat acute asthma symptoms, including acute episodes of bronchospasm, for which a short-acting bronchodilator is required. Increasing use of short-acting bronchodilators to relieve symptoms indicates deterioration of control and patients should be reviewed by a physician.
Patients should not stop treatment without physician supervision since symptoms may recur after discontinuation.
It is recommended that treatment with this medicinal product should not be stopped abruptly. If patients find the treatment ineffective, they should continue treatment but must seek medical attention. Increasing use of reliever bronchodilators indicates a worsening of the underlying condition and warrants a reassessment of the therapy. Sudden and progressive deterioration in the symptoms of asthma is potentially life-threatening and the patient should undergo urgent medical assessment.
Hypersensitivity: Immediate hypersensitivity reactions have been observed after administration of this medicinal product. If signs suggesting allergic reactions occur, in particular angioedema (including difficulties in breathing or swallowing, swelling of the tongue, lips and face), urticaria or skin rash, treatment should be discontinued immediately and alternative therapy instituted.
Paradoxical bronchospasm: As with other inhalation therapy, administration of this medicinal product may result in paradoxical bronchospasm, which can be life-threatening. If this occurs, treatment should be discontinued immediately and alternative therapy instituted.
Cardiovascular effects of beta agonists: Like other medicinal products containing beta₂-adrenergic agonists, this medicinal product may produce a clinically significant cardiovascular effect in some patients, as measured by increases in pulse rate, blood pressure and/or symptoms. If such effects occur, treatment may need to be discontinued.
This medicinal product should be used with caution in patients with cardiovascular disorders (coronary artery disease, acute myocardial infarction, cardiac arrhythmias, hypertension), convulsive disorders or thyrotoxicosis, and in patients who are unusually responsive to beta₂-adrenergic agonists.
Patients with unstable ischaemic heart disease, a history of myocardial infarction in last 12 months, New York Heart Association (NYHA) class III/IV left ventricular failure, arrhythmia, uncontrolled hypertension, cerebrovascular disease or history of long QT syndrome and patients being treated with medicinal products known to prolong QTc were excluded from studies in the indacaterol/mometasone furoate clinical development programme. Thus safety outcomes in these populations are considered unknown.
While beta₂-adrenergic agonists have been reported to produce electrocardiographic (ECG) changes, such as flattening of the T wave, prolongation of QT interval and ST segment depression, the clinical significance of these observations is unknown.
Long-acting beta₂-adrenergic agonists (LABA) or LABA-containing combination products such as Atectura Breezhaler should therefore be used with caution in patients with known or suspected prolongation of the QT interval or who are being treated with medicinal products affecting the QT interval.
Hypokalaemia with beta agonists: Beta₂-adrenergic agonists may produce significant hypokalaemia in some patients, which has the potential to produce adverse cardiovascular effects. The decrease in serum potassium is usually transient, not requiring supplementation. In patients with severe asthma hypokalaemia may be potentiated by hypoxia and concomitant treatment, which may increase the susceptibility to cardiac arrhythmias (see Interactions).
Clinically relevant hypokalaemia has not been observed in clinical studies of indacaterol/mometasone furoate at the recommended therapeutic dose.
Hyperglycaemia: Inhalation of high doses of beta₂-adrenergic agonists and corticosteroids may produce increases in plasma glucose. Upon initiation of treatment, plasma glucose should be monitored more closely in diabetic patients.
This medicinal product has not been investigated in patients with Type I diabetes mellitus or uncontrolled Type II diabetes mellitus.
Prevention of oropharyngeal infections: In order to reduce the risk of oropharyngeal candida infection, patients should be advised to rinse their mouth or gargle with water without swallowing it or brush their teeth after inhaling the prescribed dose.
Systemic effects of corticosteroids: Systemic effects of inhaled corticosteroids may occur, particularly at high doses prescribed for prolonged periods. These effects are much less likely to occur than with oral corticosteroids and may vary in individual patients and between different corticosteroid preparations.
Possible systemic effects may include Cushing's syndrome, Cushingoid features, adrenal suppression, growth retardation in children and adolescents, decrease in bone mineral density, cataracts, glaucoma, and, more rarely, a range of psychological or behavioural effects including psychomotor hyperactivity, sleep disorders, anxiety, depression or aggression (particularly in children). It is therefore important that the dose of inhaled corticosteroid is titrated to the lowest dose at which effective control of asthma is maintained.
Visual disturbance may be reported with systemic and topical (including intranasal, inhaled and intraocular) corticosteroid use. Patients presenting with symptoms such as blurred vision or other visual disturbances should be considered for referral to an ophthalmologist for evaluation of possible causes of visual disturbances, 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.
This medicinal product should be administered with caution in patients with pulmonary tuberculosis or in patients with chronic or untreated infections.
Excipients: This medicinal product contains lactose. Patients with rare hereditary problems of galactose intolerance, total lactase deficiency or glucose-galactose malabsorption should not take this medicinal product.
Effects on ability to drive and use machines: This medicinal product has no or negligible influence on the ability to drive and use machines.

Pregnancy: There are insufficient data from the use of Atectura Breezhaler or its individual components (indacaterol and mometasone furoate) in pregnant women to determine whether there is a risk.
Indacaterol was not teratogenic in rats and rabbits following subcutaneous administration (see Pharmacology: Toxicology: Preclinical safety data under Actions). In animal reproduction studies with pregnant mice, rats and rabbits, mometasone furoate caused increased foetal malformations and decreased foetal survival and growth.
Like other medicinal products containing beta₂-adrenergic agonists, indacaterol may inhibit labour due to a relaxant effect on uterine smooth muscle.
This medicinal product should only be used during pregnancy if the expected benefit to the patient justifies the potential risk to the foetus.
Breast-feeding: There is no information available on the presence of indacaterol or mometasone furoate in human milk, on the effects on a breast-fed infant, or on the effects on milk production. Other inhaled corticosteroids similar to mometasone furoate are transferred into human milk. Indacaterol (including its metabolites) and mometasone furoate have been detected in the milk of lactating rats.
A decision must be made whether to discontinue breast-feeding or to discontinue/abstain from therapy, taking into account the benefit of breast-feeding for the child and the benefit of therapy for the woman.
Fertility: Reproduction studies and other data in animals did not indicate a concern regarding fertility in either males or females.

Summary of the safety profile: The most common adverse reactions over 52 weeks were asthma (exacerbation) (26.9%), nasopharyngitis (12.9%), upper respiratory tract infection (5.9%) and headache (5.8%).
Tabulated list of adverse reactions: Adverse drug reactions (ADRs) are listed by MedDRA system organ class (Table 3). The frequency of the ADRs is based on the PALLADIUM study. Within each system organ class, the adverse drug reactions are ranked by frequency, with the most frequent reactions first. Within each frequency grouping, adverse drug reactions are presented in order of decreasing seriousness. In addition, the corresponding frequency category for each adverse drug reaction is based on the following convention (CIOMS III): very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000). (See Table 3.)

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No specific interaction studies were conducted with indacaterol/mometasone furoate. Information on the potential for interactions is based on the potential for each of the monotherapy components.
Medicinal products known to prolong the QTc interval: Like other medicinal products containing a beta₂-adrenergic agonist, this medicinal product should be administered with caution to patients being treated with monoamine oxidase inhibitors, tricyclic antidepressants or medicinal products known to prolong the QT interval, as any effect of these on the QT interval may be potentiated. Medicinal products known to prolong the QT interval may increase the risk of ventricular arrhythmia (see Precautions and Pharmacology: Pharmacodynamics under Actions).
Hypokalaemic treatment: Concomitant hypokalaemic treatment with methylxanthine derivatives, steroids or non-potassium-sparing diuretics may potentiate the possible hypokalaemic effect of beta₂-adrenergic agonists (see Precautions).
Beta-adrenergic blockers: Beta-adrenergic blockers may weaken or antagonise the effect of beta₂-adrenergic agonists. Therefore, this medicinal product should not be given together with beta-adrenergic blockers unless there are compelling reasons for their use. Where required, cardioselective beta-adrenergic blockers should be preferred, although they should be administered with caution.
Interaction with CYP3A4 and P-glycoprotein inhibitors: Inhibition of CYP3A4 and P-glycoprotein (P-gp) has no impact on the safety of therapeutic doses of Atectura Breezhaler.
Inhibition of the key contributors of indacaterol clearance (CYP3A4 and P-gp) or mometasone furoate clearance (CYP3A4) raises the systemic exposure of indacaterol or mometasone furoate up to two-fold.
Due to the very low plasma concentration achieved after inhaled dosing, clinically significant interactions with mometasone furoate are unlikely. However, there may be a potential for increased systemic exposure to mometasone furoate when strong CYP3A4 inhibitors (e.g. ketoconazole, itraconazole, nelfinavir, ritonavir, cobicistat) are co-administered.
Co-treatment with CYP3A inhibitors, including cobicistat-containing products, is expected to increase the risk of systemic side-effects. The combination should be avoided unless the benefit outweighs the increased risk of systemic corticosteroid side-effects, in which case patients should be monitored for systemic corticosteroid side-effects.
Other long-acting beta₂-adrenergic agonists: The co-administration of this medicinal product with other medicinal products containing long-acting beta₂-adrenergic agonists has not been studied and is not recommended as it may potentiate adverse reactions (see Adverse Reactions and Overdosage).

Incompatibilities: Not applicable.
Special precautions for disposal and other handling: The inhaler provided with each new prescription should be used. The inhaler in each pack should be disposed of after all capsules in that pack have been used.
Any unused medicinal product or waste material should be disposed of in accordance with local requirements.

Do not store above 30°C.
Store in the original package in order to protect from light and moisture and do not remove until immediately before use.

Instructions for handling and use: Read the full Instruction for Use before using the Atectura Breezhaler.
1. Insert: Step 1a: Pull off cap.
Step 1b: Open inhaler.
Step 1c: Remove capsule: Separate one of the blisters from the blister card.
Peel open the blister and remove the capsule.
Do not push the capsule through the foil.
Do not swallow the capsule.
Step 1d: Insert capsule: Never place a capsule directly into the mouthpiece.
Step 1e: Close inhaler.
2. Pierce and release: Step 2a: Pierce capsule once. Hold the inhaler upright. Pierce capsule by firmly pressing both side buttons at the same time.
You should hear a noise as the capsule is pierced. Only pierce the capsule once.
Step 2b: Release side buttons.
3: Inhale deeply: Step 3a: Breathe out fully: Do not blow into the inhaler.
Step 3b: Inhale medicine deeply: Place the mouthpiece in your mouth and close your lips firmly around it. Do not press the side buttons.
Breathe in quickly and as deeply as you can. During inhalation you will hear a whirring noise.
You may taste the medicine as you inhale.
Step 3c: Hold breath: Hold your breath for up to 5 seconds.
Step 3d: Rinse mouth: Rinse your mouth with water after each dose and spit it out.
Check: Check capsule if empty: Open the inhaler to see if any powder is left in the capsule.
If there is powder left in the capsule: Close the inhaler. Repeat steps 3a to 3d.
Remove empty capsule: Put the empty capsule in your household waste.
Close the inhaler and replace the cap.
Important Information: Atectura Breezhaler capsules must always be stored in the blister card and only removed immediately before use.
Do not push the capsule through the foil to remove it from the blister.
Do not swallow the capsule.
Do not use the Atectura Breezhaler capsules with any other inhaler.
Do not use the Atectura Breezhaler inhaler to take any other capsule medicine.
Never place the capsule into your mouth or the mouthpiece of the inhaler.
Do not press the side buttons more than once.
Do not blow into the mouthpiece.
Do not press the side buttons while inhaling through the mouthpiece.
Do not handle capsules with wet hands.
Never wash your inhaler with water.
Your Atectura Breezhaler Inhaler pack contains: One Atectura Breezhaler inhaler; One or more blister cards each containing either 10 Atectura Breezhaler capsules to be used in the inhaler.
Frequently Asked Questions: Why didn't the inhaler make a noise when I inhaled? The capsule may be stuck in the capsule chamber. If this happens, carefully loosen the capsule by tapping the base of the inhaler. Inhale the medicine again by repeating steps 3a to 3d.
What should I do if there is powder left inside the capsule? You have not received enough of your medicine. Close the inhaler and repeat steps 3a to 3d.
I coughed after inhaling - does this matter? This may happen. As long as the capsule is empty you have received enough of your medicine.
I felt small pieces of the capsule on my tongue - does this matter? This can happen. It is not harmful. The chances of the capsule breaking into small pieces will be increased if the capsule is pierced more than once.
Cleaning the inhaler: Wipe the mouthpiece inside and outside with a clean, dry, lint-free cloth to remove any powder residue. Keep the inhaler dry. Never wash your inhaler with water.
Disposing of the inhaler after use: Each inhaler should be disposed of after all capsules have been used. Ask your pharmacist how to dispose of medicines and inhalers that are no longer required.

Antiasthmatic & COPD Preparations

R03AK14 - indacaterol and mometasone ; Belongs to the class of adrenergics in combination with corticosteroids or other drugs, excluding anticholinergics. Used in the treatment of obstructive airway diseases.

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