Kusapin

Oxcarbazepine.

Each film-coated tablet contains: Oxcarbazepine USP 300 mg.
Excipients/Inactive Ingredients: Microcrystalline cellulose, crosspovidone, polyvinyl pyrollidone, colloidal anhydrous silica, magnesium stearate, opadry yellow 04F82783, isopropyl alcohol & purified water.

Pharmacotherapeutic group: Antiepileptics. ATC code: N03AF02.
Pharmacology: Pharmacodynamics: Pharmacodynamic effects: The pharmacological activity of oxcarbazepine is primarily exerted through the metabolite (MHD) (see Pharmacokinetics as follows). The mechanism of action of oxcarbazepine and MHD is thought to be mainly based on blockade of voltage-sensitive sodium channels, thus resulting in stabilisation of hyperexcited neural membranes, inhibition of repetitive neuronal firing, and diminishment of propagation of synaptic impulses. In addition, increased potassium conductance and modulation of high-voltage activated calcium channels may also contribute to the anticonvulsant effects. No significant interactions with brain neurotransmitter or modulator receptor sites were found.
Oxcarbazepine and its active metabolite (MHD) are potent and efficacious anticonvulsants in animals. They protected rodents against generalised tonic-clonic and, to a lesser degree, clonic seizures, and abolished or reduced the frequency of chronically recurring partial seizures in Rhesus monkeys with aluminum implants. No tolerance (i.e. attenuation of anticonvulsive activity) against tonic-clonic seizures was observed when mice and rats were treated daily for 5 days or 4 weeks, respectively, with oxcarbazepine or MHD.
Pharmacokinetics: Absorption: Following oral administration of oxcarbazepine, it is completely absorbed and extensively metabolised to its pharmacologically active metabolite (MHD).
After single dose administration of 600 mg oxcarbazepine to healthy male volunteers under fasted conditions, the mean C_max value of MHD was 34 μmol/l, with a corresponding median t_max of 4.5 hours.
In a mass balance study in man, only 2 % of total radioactivity in plasma was due to unchanged oxcarbazepine, approximately 70 % was due to MHD, and the remainder attributable to minor secondary metabolites which were rapidly eliminated.
Food has no effect on the rate and extent of absorption of oxcarbazepine, therefore, Kusapin can be taken with or without food.
Distribution: The apparent volume of distribution of MHD is 49 litres.
Approximately 40 % of MHD is bound to serum proteins, predominantly to albumin. Binding was independent of the serum concentration within the therapeutically relevant range. Oxcarbazepine and MHD do not bind to alpha-1-acid glycoprotein.
Oxcarbazepine and MHD cross the placenta. Neonatal and maternal plasma MHD concentrations were similar in one case.
Metabolism: Oxcarbazepine is rapidly reduced by cytosolic enzymes in the liver to MHD, which is primarily responsible for the pharmacological effect of oxcarbazepine. MHD is metabolised further by conjugation with glucuronic acid. Minor amounts (4 % of the dose) are oxidised to the pharmacologically inactive metabolite (10, 11-dihydroxy derivative, DHD).
Elimination: Oxcarbazepine is cleared from the body mostly in the form of metabolites which are predominantly excreted by the kidneys. More than 95 % of the dose appears in the urine, with less than 1 % as unchanged oxcarbazepine. Faecal excretion accounts for less than 4 % of the administered dose. Approximately 80 % of the dose is excreted in the urine either as glucuronides of MHD (49 %) or as unchanged MHD (27 %), whereas the inactive DHD accounts for approximately 3 % and conjugates of oxcarbazepine account for 13% of the dose.
Oxcarbazepine is rapidly eliminated from the plasma with apparent half-life values between 1.3 and 2.3 hours. In contrast, the apparent plasma half-life of MHD averaged 9.3 ± 1.8 h.
Dose proportionality: Steady-state plasma concentrations of MHD are reached within 2 - 3 days in patients when oxcarbazepine is given twice a day. At steady-state, the pharmacokinetics of MHD are linear and show dose proportionality across the dose range of 300 to 2,400 mg/day.
Special populations: Patients with hepatic impairment: The pharmacokinetics and metabolism of oxcarbazepine and MHD were evaluated in healthy volunteers and hepatically impaired subjects after a single 900 mg oral dose. Mild to moderate hepatic impairment did not affect the pharmacokinetics of oxcarbazepine and MHD. Oxcarbazepine has not been studied in patients with severe hepatic impairment.
Patients with renal impairment: There is a linear correlation between creatinine clearance and the renal clearance of MHD. When oxcarbazepine is administered as a single 300 mg dose, in renally impaired patients (creatinine clearance < 30 mL/min) the elimination half-life of MHD is prolonged by 60-90 % (16 to 19 hours) with a two fold increase in AUC compared to adults with normal renal function (10 hours).
Children: The pharmacokinetics of oxcarbazepine was evaluated in clinical trials in paediatric patients taking oxcarbazepine in the dose range 10-60 mg/kg/day. Weight-adjusted MHD clearance decreases as age and weight increases approaching that of adults. The mean weight-adjusted clearance in children 4 to 12 years of age is approximately 40% higher than that of adults. Therefore, MHD exposure in these children is expected to be about two-thirds that of adults when treated with a similar weight-adjusted dose. As weight increases, for patients 13 years of age and above, the weight-adjusted MHD clearance is expected to reach that of adults.
Pregnancy: Data from a limited number of women indicate that MHD plasma levels may gradually decrease throughout pregnancy (see Use in Pregnancy & Lactation).
Elderly: Following administration of single (300 mg) and multiple doses (600 mg/day) of oxcarbazepine in elderly volunteers (60 - 82 years of age), the maximum plasma concentrations and AUC values of MHD were 30% - 60% higher than in younger volunteers (18 - 32 years of age). Comparisons of creatinine clearances in young and elderly volunteers indicate that the difference was due to age-related reductions in creatinine clearance. No special dose recommendations are necessary because therapeutic doses are individually adjusted.
Gender: No gender related pharmacokinetic differences have been observed in children, adults, or the elderly.

Kusapin is indicated for: The treatment of partial seizures with or without secondary generalized tonic-clonic seizures.
Monotherapy or adjunctive therapy in adults and children of 6 years of age and above.

Dosage: In mono and adjunctive therapy, treatment with Kusapin is initiated with a clinically effective dose given in two divided doses. The dose may be increased depending on the clinical response of the patient. When other antiepileptic medicinal products are replaced by Kusapin, the dose of the concomitant antiepileptic medicinal product (s) should be reduced gradually on initiation of Kusapin therapy. In adjunctive therapy, as the total antiepileptic medicinal product load of the patient is increased, the dose of concomitant antiepileptic medicinal product(s) may need to be reduced and/or the Kusapin dose increased more slowly (see Interactions).
Therapeutic drug monitoring: The therapeutic effect of oxcarbazepine is primarily exerted through the active metabolite 10-monohydroxy derivative (MHD) of oxcarbazepine (see Pharmacology under Actions).
Plasma level monitoring of oxcarbazepine or MHD is not routinely warranted. However, may be useful in situations where an alteration in MHD clearance is to be expected (see Precautions). In such situations, the dose of oxcarbazepine may be adjusted (based on plasma levels measured 2-4 hours post dose) to maintain peak MHD plasma levels < 35 mg/L.
Adults: Monotherapy: Recommended initial dose: Kusapin should be initiated with a dose of 600 mg/day (8-10 mg/kg/day) given in 2 divided doses.
Maintenance dose: If clinically indicated, the dose may be increased by a maximum of 600 mg/day increments at approximately weekly intervals from the starting dose to achieve the desired clinical response.
Therapeutic effects are seen at doses between 600 mg/day and 2,400 mg/day.
Controlled monotherapy trials in patients not currently being treated with antiepileptic medicinal products showed 1,200 mg/day to be an effective dose; however, a dose of 2,400 mg/day has been shown to be effective in more refractory patients converted from other antiepileptic medicinal products to Kusapin monotherapy.
Maximum recommended dose: In a controlled hospital setting, dose increases up to 2,400 mg/day have been achieved over 48 hours.
Adjunctive therapy: Recommended initial dose: Kusapin should be initiated with a dose of 600 mg/day (8-10 mg/kg/day) given in 2 divided doses.
Maintenance dose: If clinically indicated, the dose may be increased by a maximum of 600 mg/day increments at approximately weekly intervals from the starting dose to achieve the desired clinical response.
Therapeutic responses are seen at doses between 600 mg/day and 2,400 mg/day.
Maximum recommended dose: Daily doses from 600 to 2,400 mg/day have been shown to be effective in a controlled adjunctive therapy trial, although most patients were not able to tolerate the 2,400 mg/day dose without reduction of concomitant antiepileptic medicinal products, mainly because of CNS-related adverse events. Daily doses above 2,400 mg/day have not been studied systematically in clinical trials.
Elderly (65 years old and above): No special dose recommendations are necessary in elderly patients because therapeutic doses are individually adjusted. Dosage adjustments are recommended in elderly patients with renal impairment (creatinine clearance <30 ml/min) (see information as follows on dosage in renal impairment).
Close monitoring of sodium levels is required in patients at risk of hyponatremia (see Precautions).
Patients with hepatic impairment: No dosage adjustment is required for patients with mild to moderate hepatic impairment. Oxcarbazepine has not been studied in patients with severe hepatic impairment, therefore, caution should be exercised when dosing severely impaired patients (see Pharmacology: Pharmacokinetics under Actions).
Patients with renal impairment: In patients with impaired renal function (creatinine clearance less than 30 ml/min) Oxcarbazepine therapy should be initiated at half the usual starting dose (300 mg/day) and increased, in at least weekly intervals, to achieve the desired clinical response (see Pharmacology: Pharmacokinetics under Actions).
Dose escalation in renally impaired patients may require more careful observation.
Paediatric population: Recommended initial dose: In mono- and adjunctive therapy, Kusapin should be initiated with a dose of 8-10 mg/kg/day given in 2 divided doses.
Maintenance dose: In adjunctive therapy trials, a maintenance dose of 30-46 mg/kg/day, achieved over two weeks, is shown to be effective and well tolerated in children. Therapeutic effects were seen at a median maintenance dose of approximately 30 mg/kg/day.
Maximum recommended dose: If clinically indicated, the dose may be increased by a maximum of 10 mg/kg/day at approximately weekly intervals from the starting dose, to a maximum dose of 46 mg/kg/day, to achieve the desired clinical response (see Pharmacology: Pharmacokinetics under Actions).
Kusapin is recommended for use in children of 6 years of age and above. Safety and efficacy have been evaluated in controlled clinical trials involving approximately 230 children aged less than 6 years (down to 1 month). Kusapin is not recommended in children aged less than 6 years since safety and efficacy have not been adequately demonstrated.
All the previously mentioned dosing recommendations (adults, older people and children) are based on the doses studied in clinical trials for all age groups. However, lower initiation doses may be considered where appropriate.
Method of administration: The tablets are scored and can be broken into two halves in order to make it easier for the patient to swallow the tablet. Kusapin can be taken with or without food.

Isolated cases of overdose have been reported. The maximum dose taken was approximately 48,000 mg.
Symptoms: Electrolyte and fluid balance conditions: Hyponatraemia.
Eye disorders: Diplopia, miosis, blurred vision.
Gastrointestinal disorders: Nausea, vomiting, hyperkinesia.
General disorders and administration site conditions: Fatigue.
Investigations: Respiratory rate depression, QTc prolongation.
Nervous system disorders: Drowsiness and somnolence, dizziness, ataxia and nystagmus, tremor, disturbances in coordination (coordination abnormal), convulsion, headache, coma, loss of consciousness, dyskinesia.
Psychiatric disorders: Aggression, agitation, confusional state.
Vascular disorders: Hypotension.
Respiratory, thoracic and mediastinal disorders: Dyspnoea.
Treatment: There is no specific antidote. Symptomatic and supportive treatment should be administered as appropriate. Removal of the medicinal product by gastric lavage and/or inactivation by administering activated charcoal should be considered.

Hypersensitivity to the active substance or to any of the excipients.

Hypersensitivity: Class I (immediate) hypersensitivity reactions including rash, pruritus, urticaria, angioedema and reports of anaphylaxis have been received in the post-marketing period. Cases of anaphylaxis and angioedema involving the larynx, glottis, lips and eyelids have been reported in patients after taking the first or subsequent doses of Oxcarbazepine. If a patient develops these reactions after treatment with Oxcarbazepine, the drug should be discontinued and an alternative treatment started.
Patients who have exhibited hypersensitivity reactions to carbamazepine should be informed that approximately 25-30% of these patients may experience hypersensitivity reactions (e.g. severe skin reactions) with Kusapin (see undesirable effects).
Hypersensitivity reactions, including multi-organ hypersensitivity reactions, may also occur in patients without history of hypersensitivity to carbamazepine. Such reactions can affect the skin, liver, blood and lymphatic system or other organs, either individually or together in the context of a systemic reaction (see Adverse Reactions). In general, if signs and symptoms suggestive of hypersensitivity reactions occur, Kusapin should be withdrawn immediately.
Dermatological effects: Serious dermatological reactions, including Stevens-Johnson syndrome, toxic epidermal necrolysis (Lyell's syndrome) and erythema multiforme, have been reported very rarely in association with Oxcarbazepine use. Patients with serious dermatological reactions may require hospitalization, as these conditions may be life-threatening and very rarely be fatal. Oxcarbazepine associated cases occurred in both children and adults. The median time to onset was 19 days. Several isolated cases of recurrence of the serious skin reaction when rechallenged with Oxcarbazepine were reported. Patients who develop a skin reaction with Kusapin should be promptly evaluated and Kusapin withdrawn immediately unless the rash is clearly not drug related. In case of treatment withdrawal, consideration should be given to replacing Kusapin with other antiepileptic drug therapy to avoid withdrawal seizures. Kusapin should not be restarted in patients who discontinued treatment due to a hypersensitivity reaction (see Contraindications).
HLA-B*1502 allele - in Han Chinese, Thai and other Asian populations: HLA-B* 1502 in individuals of Han Chinese and Thai origin has been shown to be strongly associated with the risk of developing the severe cutaneous reactions known as Stevens-Johnson syndrome (SJS) when treated with carbamazepine. The chemical structure of oxcarbazepine is similar to that of carbamazepine, and it is possible that patients who are positive for HLA-B*1502 may also be at risk for SJS after treatment with oxcarbazepine. There are some data that suggest that such an association exists for oxcarbazepine. The prevalence of HLA-B*1502 carrier is about 10% in Han Chinese and Thai populations. Whenever possible, these individuals should be screened for this allele before starting treatment with carbamazepine or a chemically-related active substance. If patients of these origins are tested positive for HLA-B*1502 allele, the use of oxcarbazepine may be considered if the benefits are thought to exceed risks.
Because of the prevalence of this allele in other Asian populations (e.g. above 15% in the Philippines and Malaysia), testing genetically at risk populations for the presence of HLA-B*1502 may be considered.
The prevalence of the HLA-B*1502 allele is negligible in e.g. European descent, African, Hispanic populations sampled, and in Japanese and Koreans (< 1%).
Allele frequencies refer to the percentage of chromosomes in the population that carry a given allele. Since a person carries two copies of each chromosome, but even one copy of the HLA-B*1502 allele may be enough to increase the risk of SJS, the percentage of patients who may be at risk is nearly twice the allele frequency.
HLA-A*3101 allele - European descent and Japanese populations: There are some data that suggest HLA-A*3101 is associated with an increased risk of carbamazepine induced cutaneous adverse drug reactions including SJS, TEN, Drug rash with eosinophilia (DRESS), or less severe acute generalized exanthematous pustulosis (AGEP) and maculopapular rash in people of European descent and the Japanese.
The frequency of the HLA-A*3101 allele varies widely between ethnic populations. HLA-A*3101 allele has a prevalence of 2 to 5% in European populations and about 10% in Japanese population.
The presence of HLA-A*3101 allele may increase the risk for carbamazepine induced cutaneous reactions (mostly less severe) from 5.0% in general population to 26.0% among subjects of European ancestry, whereas its absence may reduce the risk from 5.0% to 3.8%.
HLA-A*3101 allele - Other descents: The frequency of this allele is estimated to be less than 5% in the majority of Australian, Asian, African and North American populations with some exceptions within 5 to 12%. Frequency above 15% has been estimated in some ethnic groups in South America (Argentina and Brazil), North America (US Navajo and Sioux, and Mexico Sonora Seri) and Southern India (Tamil Nadu) and between 10% to 15% in other native ethnicities in these same regions.
Allele frequencies refer to the percentage of chromosomes in the population that carry a given allele. Since a person carries two copies of each chromosome, but even one copy of the HLA-A*3101 allele may be enough to increase the risk of SJS, the percentage of patients who may be at risk is nearly twice the allele frequency.
There are insufficient data supporting a recommendation for HLA-A*3101 screening before starting carbamazepine or chemically-related compounds treatment.
If patients of European descent or Japanese origin are known to be positive for HLA-A* 3101 allele, the use of carbamazepine or chemically-related compounds may be considered if the benefits are thought to exceed risks.
Limitation of genetic screening: Genetic screening results must never substitute appropriate clinical vigilance and patient management. Many Asian patients positive for HLA-B*1502 and treated with Oxcarbazepine will not develop SJS/TEN, and patients negative for HLA-B*1502 of any ethnicity can still develop SJS/TEN. The same is true for HLA-A*3101 with respect to risk of SJS, TEN, DRESS, AGEP or maculopapular rash. The development of these severe cutaneous adverse reactions and its related morbidity due to other possible factors such as AED dose, compliance, concomitant medications, co-morbidities, and the level of dermatologic monitoring have not been studied.
Information for healthcare professionals: If testing for the presence of the HLA-B* 1502 allele is performed, high-resolution "HLA-B*1502 genotyping" is recommended. The test is positive if either one or two HLA-B*1502 alleles are detected and negative if no HLA-B*1502 alleles are detected. Similarly, if testing for the presence of the HLA-A*3101 allele is performed, high resolution "HLA-A*3101 genotyping" is recommended. The test is positive if either one or two HLA-A*3101 alleles are detected, and negative if no HLA-A*3101 alleles are detected.
Risk of seizure aggravation: Risk of seizure aggravation has been reported with Oxcarbazepine. The risk of seizure aggravation is seen especially in children but may also occur in adults. In case of seizure aggravation, Kusapin should be discontinued.
Hyponatraemia: Serum sodium levels below 125 mmol/l, usually asymptomatic and not requiring adjustment of therapy have been observed in up to 2.7% of Oxcarbazepine treated patients. Experience from clinical trials shows that serum sodium levels returned towards normal when the Oxcarbazepine dosage was reduced discontinued or the patient was treated conservatively (e.g. restricted fluid intake). In patients with pre-existing renal conditions associated with low sodium (e.g. inappropriate ADH secretion like syndrome) or in patients treated concomitantly with sodium-lowering medicinal products (e.g. diuretics, desmopressin) as well as NSAIDs (e.g. indometacin), serum sodium levels should be measured prior to initiating therapy. Thereafter, serum sodium levels should be measured after approximately two weeks and then at monthly intervals for the first three months during therapy, or according to clinical need. These risk factors may apply especially to elderly patients. For patients on Oxcarbazepine therapy when starting on sodium-lowering medicinal products, the same approach for sodium checks should be followed. In general, if clinical symptoms suggestive of hyponatraemia occur on Oxcarbazepine therapy (see Adverse Reactions), serum sodium measurement may be considered. Other patients may have serum sodium assessed as part of their routine laboratory studies.
All patients with cardiac insufficiency and secondary heart failure should have regular weight measurements to determine occurrence of fluid retention. In case of fluid retention or worsening of the cardiac condition, serum sodium should be checked. If hyponatraemia is observed, water restriction is an important counter-measurement. As oxcarbazepine may, very rarely, lead to impairment of cardiac conduction, patients with pre-existing conduction disturbances (e.g. atrioventricular-block, arrhythmia) should be followed carefully.
Hypothyroidism: Hypothyroidism is an adverse drug reaction (with "unknown" frequency, see undesirable effects) of oxcarbazepine. Considering the importance of thyroid hormones in children's development after birth, thyroid function monitoring is recommended in the pediatric age group while on Kusapin therapy.
Hepatic function: Very rare cases of hepatitis have been reported, which in most cases resolved favourably. When a hepatic event is suspected, liver function should be evaluated and discontinuation of Kusapin should be considered. Caution should be exercised when treating patients with severe hepatic impairment (see Dosage & Administration and Pharmacology: Pharmacokinetics under Actions).
Renal function: In patients with impaired renal function (creatinine clearance less than 30 mL/min), caution should be exercised during Kusapin treatment especially with regard to the starting dose and up titration of the dose. Plasma level monitoring of MHD may be considered (see Dosage & Administration and Pharmacology: Pharmacokinetics under Actions).
Hematological effects: Very rare reports of agranulocytosis, aplastic anemia and pancytopenia have been seen in patients treated with Oxcarbazepine during post-marketing experience (see Adverse Reactions).
Discontinuation of the medicinal product should be considered if any evidence of significant bone marrow depression develops.
Suicidal behaviour: Suicidal ideation and behaviour have been reported in patients treated with antiepileptic agents in several indications. A meta-analysis of randomized placebo controlled trials of antiepileptic drugs has also shown a small increased risk of suicidal ideation and behaviour. The mechanism of this risk is not known and the available data do not exclude the possibility of an increased risk for oxcarbazepine.
Therefore patients should be monitored for signs of suicidal ideation and behaviours and appropriate treatment should be considered. Patients (and caregivers of patients) should be advised to seek medical advice should signs of suicidal ideation or behaviour emerge.
Hormonal contraceptives: Female patients of childbearing age should be warned that the concurrent use of Kusapin with hormonal contraceptives may render this type of contraceptive ineffective (see Interactions). Additional non-hormonal forms of contraception are recommended when using Kusapin.
Alcohol: Caution should be exercised if alcohol is taken in combination with Kusapin therapy, due to a possible additive sedative effect.
Withdrawal: As with all antiepileptic medicinal products, Kusapin should be withdrawn gradually to minimise the potential of increased seizure frequency.
Monitoring of plasma levels: Although correlations between dosage and plasma levels of oxcarbazepine, and between plasma levels and clinical efficacy or tolerability are rather tenuous, monitoring of the plasma levels may be useful in the following situations in order to rule out noncompliance or in situations where an alteration in MHD clearance is to be expected, including: Changes in renal function (see Patients with renal impairment under Dosage & Administration).
Pregnancy (see Use in Pregnancy & Lactation and Pharmacology under Actions).
Concomitant use of liver enzyme-inducing drugs (see Interactions).
Effects on Ability to Drive and Use Machines: Adverse reactions such as dizziness, somnolence, ataxia, diplopia, blurred vision, visual disturbances, hyponatremia and depressed level of consciousness were reported with Oxcarbazepine (for complete list of ADRs see Adverse Reactions), especially at the start of treatment or in connection with dose adjustments (more frequently during the up titration phase). Patients should therefore exercise due caution when driving a vehicle or operating machinery.

Women of child-bearing potential and contraceptive measures: Oxcarbazepine may result in a failure of the therapeutic effect of oral contraceptive drugs containing ethinylestradiol (EE) and levonorgestrel (LNG) (see Precautions and Interactions). Women of child bearing potential should be advised to use highly effective contraception (preferably non-hormonal; e.g. intrauterine implants) while on treatment with Oxcarbazepine.
Pregnancy: Risk related to epilepsy and antiepileptic medicinal products in general: In the treated population, an increase in malformations has been noted with polytherapy, particularly in polytherapy including valproate.
Moreover, effective anti-epileptic therapy must not be interrupted, since the aggravation of the illness is detrimental to both the mother and the foetus.
Risk related to oxcarbazepine: There is moderate amount of data on pregnant women (300-1000 pregnancy outcomes). However, the data on oxcarbazepine associated with congenital malformation is limited. There is no increase in the total rate of malformations with Oxcarbazepine as compared with the rate observed in the general population (2-3%). Nevertheless, with this amount of data, a moderate teratogenic risk cannot be completely excluded.
Taking these data into consideration: If women receiving Oxcarbazepine become pregnant or plan to become pregnant, the use of this product should be carefully re-evaluated. Minimum effective doses should be given, and monotherapy whenever possible should be preferred at least during the first three months of pregnancy.
During pregnancy, an effective antiepileptic oxcarbazepine treatment must not be interrupted, since the aggravation of the illness is detrimental to both the mother and the foetus.
Monitoring and prevention: Some antiepileptic medicinal products may contribute to folic acid deficiency, a possible contributory cause of foetal abnormality. Folic acid supplementation is recommended before and during pregnancy. As the efficacy of this supplementation is not proved, a specific antenatal diagnosis should be offered even for women with a supplementary treatment of folic acid.
Data from a limited number of women indicate that plasma levels of the active metabolite of oxcarbazepine, the 10-monohydroxy derivative (MHD), may gradually decrease throughout pregnancy. It is recommended that clinical response should be monitored carefully in women receiving Oxcarbazepine treatment during pregnancy to ensure that adequate seizure control is maintained. Determination of changes in MHD plasma concentrations should be considered. If dosages have been increased during pregnancy, postpartum MHD plasma levels may also be considered for monitoring.
In the newborn child: Bleeding disorders in the newborn have been reported with hepatic inductor antiepileptic drugs. As a precaution, vitamin K₁ should be administered as a preventive measure in the last few weeks of pregnancy and to the newborn.
Breast-feeding: Oxcarbazepine and its active metabolite (MHD) are excreted in human breast milk. A milk-to-plasma concentration ratio of 0.5 was found for both. The effects on the infant exposed to Oxcarbazepine by this route are unknown. Therefore, Oxcarbazepine should not be used during breast-feeding.
Fertility: There are no human data on fertility. In rats, oxcarbazepine had no effects on fertility.
Effects on reproductive parameters in female rats were observed for MHD at doses comparable to those in humans.

Summary of the safety profile: The most commonly reported adverse reactions are somnolence, headache, dizziness, diplopia, nausea, vomiting and fatigue occurring in more than 10% of patients.
The safety profile is based on AEs from clinical trials assessed as related to Oxcarbazepine. In addition, clinically meaningful reports on adverse experiences from named patient programs and postmarketing experience were taken into account.
Adverse reactions are listed by MedDRA system organ class.
List of adverse reactions: Frequency estimate*: 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; unknown: cannot be estimated from the available data.
Within each system organ class, the adverse drug reactions are ranked by frequency, with the most frequent reactions first. Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness.
Blood and lymphatic system disorders: Uncommon: Leucopenia.
Very rare: Thrombocytopenia.
Unknown: Bone marrow depression, aplastic anemia, agranulocytosis, pancytopenia, neutropenia.
Immune system disorders: Very rare: Hypersensitivity^#.
Unknown: Anaphylactic reactions.
Endocrine disorders: Common: Weight increased.
Unknown: Hypothyroidism.
Metabolism and nutrition disorders: Common: Hyponatraemia^†.
Unknown: Inappropriate ADH secretion like syndrome with signs and symptoms of lethargy, nausea, dizziness, decrease in serum (blood) osmolality, vomiting, headache, confusional state or other neurological signs and symptoms.
Psychiatric disorders: Common: Agitation (e.g. nervousness), affect lability, confusional state, depression, apathy..
Nervous system disorders: Very common: Somnolence, headache, dizziness.
Common: Ataxia, tremor, nystagmus, disturbance in attention, amnesia.
Unknown: Speech disorders (including dysarthria); more frequent during up titration of Oxcarbazepine dose.
Eye disorders: Very common: Diplopia.
Common: Vision blurred, visual disturbance.
Ear and labyrinth disorders: Common: Vertigo.
Cardiac disorders: Very rare: Atrioventricular block, arrhythmia.
Vascular disorders: Unknown: Hypertension.
Gastrointestinal disorders: Very common: Vomiting, nausea.
Common: Diarrhoea, abdominal pain, constipation.
Very rare: Pancreatitis and/or lipase and/or amylase increase.
Hepato-biliary disorders: Very rare: Hepatitis.
Skin and subcutaneous tissue disorders: Common: Rash, alopecia, acne.
Uncommon: Urticaria.
Very rare: Stevens-Johnson syndrome, toxic epidermal necrolysis (Lyell's syndrome), angioedema, erythema multiforme (see Precautions).
Unknown: Drug Rash with Eosinophilia and Systemic Symptoms (DRESS)**, Acute Generalized Exanthematous Pustulosis (AGEP)**.
Musculoskeletal, connective tissue and bone disorders: Very rare: Systemic lupus erythematosus.
Unknown: There have been reports of decreased bone mineral density, osteopenia, osteoporosis and fractures in patients on long-term therapy with Oxcarbazepine. The mechanism by which Oxcarbazepine affects bone metabolism has not been identified.
General disorders and administration site conditions: Very common: Fatigue.
Common: Asthenia.
Investigations: Uncommon: Hepatic enzymes increased, blood alkaline phosphatase increased.
Unknown: Decrease in T4 (with unclear clinical significance).
Injury, poisoning and procedural complications: Unknown: Fall.
Description of selected adverse reactions: ^#Hypersensitivity (including multi-organ hypersensitivity) characterised by features such as rash, fever. Other organs or systems may be affected such as blood and lymphatic system (e.g. eosinophilia, thrombocytopenia, leucopenia, lymphadenopathy, splenomegaly), liver (e.g. hepatitis, abnormal liver function tests), muscles and joints (e.g. joint swelling, myalgia, arthralgia), nervous system (e.g. hepatic encephalopathy), kidneys (e.g. renal failure, nephritis interstitial, proteinuria), lungs (e.g. pulmonary oedema, asthma, bronchospasms, interstitial lung disease, dyspnea), angioedema.
^†Serum sodium levels below 125 mmol/l have been observed in up to 2.7 % of oxcarbazepine treated patients with frequency common. In most cases, the hyponatraemia is asymptomatic and does not require adjustment of therapy.
Very rarely, the hyponatraemia is associated with signs and symptoms such as seizures, encephalopathy, depressed level of consciousness, confusion, (see also Nervous system disorders as previously mentioned for further undesirable effects), vision disorders (e.g. blurred vision), hypothyroidism, vomiting, and nausea can develop during oxcarbazepine use. Low serum sodium levels generally occurred during the first 3 months of treatment with oxcarbazepine, although there were patients who first developed a serum sodium level <125 mmol/l more than 1 year after initiation of therapy.
**Adverse reactions from spontaneous reports and literature cases (frequency not known): The following adverse reactions have been derived from post-marketing experience with oxcarbazepine via spontaneous case reports and literature cases. Because these reactions are reported voluntarily from a population of uncertain size, it is not possible to reliably estimate their frequency which is therefore categorised as not known.
Pediatric population: Reporting of suspected adverse reactions: Reporting suspected adverse reactions after authorization 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.
Adverse Drug Reaction: Inform doctors about unexpected reactions after using drugs.

Enzyme induction: Oxcarbazepine and its pharmacologically active metabolite (the monohydroxy derivative, MHD) are weak inducers in vitro and in vivo of the cytochrome P450 enzymes CYP3A4 and CYP3A5 responsible for the metabolism of a very large number of drugs, for example, immunosuppressants (e.g. ciclosporin, tacrolimus), oral contraceptives (see as follows), and some other antiepileptic medicinal products (e.g. carbamazepine) resulting in a lower plasma concentration of these medicinal products (see table as follows summarizing results with other antiepileptic medicinal products).
In vitro, oxcarbazepine and MHD are weak inducers of UDP-glucuronyl transferases (effects on specific enzymes in this family are not known). Therefore, in vivo oxcarbazepine and MHD may have a small inducing effect on the metabolism of medicinal products which are mainly eliminated by conjugation through the UDP-glucuronyl transferases. When initiating treatment with Kusapin or changing the dose, it may take 2 to 3 weeks to reach the new level of induction.
In case of discontinuation of Kusapin therapy, a dose reduction of the concomitant medications may be necessary and should be decided upon by clinical and/or plasma level monitoring. The induction is likely to gradually decrease over 2 to 3 weeks after discontinuation.
Hormonal contraceptives: Oxcarbazepine was shown to have an influence on the two components, ethinylestradiol (EE) and levonorgestrel (LNG), of an oral contraceptive. The mean AUC values of EE and LNG were decreased by 48-52 % and 32-52% respectively. Therefore, concurrent use of Kusapin with hormonal contraceptives may render these contraceptives ineffective (see Precautions). Another reliable contraceptive method should be used.
Enzyme inhibition: Oxcarbazepine and MHD inhibit CYP2C19. Therefore, interactions could arise when co-administering high doses of Oxcarbazepine with medicinal products that are mainly metabolised by CYP2C19 (e.g. phenytoin). Phenytoin plasma levels increased by up to 40 % when Oxcarbazepine was given at doses above 1,200 mg/day (see table as follows summarizing results with other anticonvulsants). In this case, a reduction of co-administered phenytoin may be required (see dosage and mode of administration).
Antiepileptic medicinal products: Potential interactions between Oxcarbazepine and other antiepileptic medicinal products were assessed in clinical studies. The effect of these interactions on mean AUCs and C_min are summarised in the following table. (See table.)

Click on icon to see table/diagram/image

Strong inducers of cytochrome P450 enzymes and/or UGT (i.e. carbamazepine, phenytoin and phenobarbitone) have been shown to decrease the plasma levels of MHD (29-40 %) in adults; in children 4 to 12 years of age, MHD clearance increased by approximately 35% when given one of the three enzyme-inducing antiepileptic medicinal products compared to monotherapy. Concomitant therapy of Oxcarbazepine and lamotrigine has been associated with an increased risk of adverse events (nausea, somnolence, dizziness and headache). When one or several antiepileptic medicinal products are concurrently administered with Oxcarbazepine, a careful dose adjustment and/or plasma level monitoring may be considered on a case by case basis, notably in paediatric patients treated concomitantly with lamotrigine.
No autoinduction has been observed with Kusapin.
Other medicinal product interactions: Cimetidine, erythromycin, viloxazine, warfarin and dextropropoxyphene had no effect on the pharmacokinetics of MHD.
The interaction between oxcarbazepine and MAOIs is theoretically possible based on a structural relationship of oxcarbazepine to tricyclic antidepressants.
Patients on tricyclic antidepressant therapy were included in clinical trials and no clinically relevant interactions have been observed.
The combination of lithium and oxcarbazepine might cause enhanced neurotoxicity.

Store below 30°C.
Shelf Life: 36 months.

Anticonvulsants

N03AF02 - oxcarbazepine ; Belongs to the class of carboxamide derivatives antiepileptic.

POM

FC tab 300 mg (yellow colored, capsule shaped, having break line on both sides) x 3 x 10's.