Betagan

1. Name Of The Medicinal Product

Betagan Eye Drops 0.5% w/v

2. Qualitative And Quantitative Composition

One ml solution contains 5.0 mg levobunolol hydrochloride, equivalent to 4.4 mg levobunolol.

Excipient(s): Contains benzalkonium chloride 0.04 mg/ml.

For a full list of excipients, see section 6.1.

3. Pharmaceutical Form

Eye Drops, Solution

A clear, colourless to light yellow solution.

4. Clinical Particulars

4.1 Therapeutic Indications

Reduction of intraocular pressure in chronic open-angle glaucoma and ocular hypertension.

4.2 Posology And Method Of Administration

Method of administration: topical into the conjunctival sac.

Adults (including the elderly)

The usual dose is one drop instilled in the affected eye(s) once or twice daily. Because of diurnal variations in intraocular pressure, satisfactory response is best determined by measuring the intraocular pressure at different times of the day.

Use in Children

Betagan is not recommended for use in children due to lack of safety and efficacy data.

If required, Betagan may be used with other agents to lower intra-ocular pressure. The use of two topical beta-adrenergic blocking agents is not recommended (see section 4.4).

Intraocular pressure should be measured approximately four weeks after starting treatment with Betagan as a return to normal ocular pressure can take a few weeks.

As with any eye drops, to reduce possible systemic absorption, it is recommended that the lachrymal sac be compressed at the medial canthus (punctual occlusion) for one minute. This should be performed immediately following the instillation of each drop.

Transfer from other beta-blocking treatment

When another beta blocking agent is being used treatment must be discontinued after a full day of therapy. Start treatment with Betagan the next day with one drop of Betagan topically applied into the conjunctival sac in the affected eye(s) once or twice a day.

If Betagan is to replace a combination of anti-glaucoma products, only a single product should be removed at a time.

Use in renal and hepatic impairment

Levobunolol hydrochloride has not been studied in patients with hepatic or renal impairment. Therefore, caution should be used in treating such patients (see section 4.4).

4.3 Contraindications

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

Reactive airway disease including bronchial asthma (or a history of bronchial asthma) or severe chronic obstructive pulmonary disease.

Sinus bradycardia; second and third degree atrioventricular block not controlled with a pace maker; overt cardiac failure or cardiogenic shock;

4.4 Special Warnings And Precautions For Use

Like other topically applied ophthalmic agents, Betagan may be absorbed systemically so the same types of cardiovascular and pulmonary adverse reactions as seen with systemic beta-blockers may occur.

Caution should be exercised in treating patients with severe or unstable and uncontrolled cardiovascular disease including first degree atrioventricular block. Cardiac failure should be adequately controlled before beginning therapy. Patients with a history of severe cardiac disease should be watched for signs of cardiac failure and have their pulse rates checked.

Cardiac and respiratory reactions, including death due to bronchospasm in patients with asthma, and, rarely, death in association with cardiac failures have been reported following administration of levobunolol.

The effect on intra-ocular pressure or the known effects of systemic beta-blockade may be exaggerated when Betagan is given to patients already receiving a systemic beta blocking agent. The response of these patients should be closely observed. The use of two topical beta-adrenergic blocking agents is not recommended.

In patients with angle closure glaucoma, the immediate objective of treatment is to reopen the angle. This requires constricting the pupil with a miotic. Betagan has little or no effect on the pupil. When Betagan is used to reduce elevated intra-ocular pressure in angle-closure glaucoma it should be used with a miotic and not alone.

In patients with severe renal impairment on dialysis, treatment with levobunolol has been associated with pronounced hypotension.

Levobunolol may impair compensatory tachycardia and increase risk of hypotension when used in conjunction with anaesthetics. The anaesthetist must be informed if the patient is using Betagan.

Beta-blockers may also mask the signs of hyperthyroidism and cause worsening of Prinzmetal angina, severe peripheral and central circulatory disorders and hypotension. Betagan must be used with caution in patients with metabolic acidosis and untreated phaeochromocytoma.

Beta-adrenergic blocking agents should be administered with caution in patients subject to spontaneous hypoglycaemia or to uncontrolled diabetic patients (especially those with labile diabetes) as beta-blockers may mask the signs and symptoms of acute hypoglycaemia. The indicatory signs of acute hypoglycaemia may be masked, in particular tachycardia, palpitations and sweating.

Betagan should be used with caution in patients with depression, cerebral or coronary insufficiency, Raynaud's phenomenon, orthostatic hypotension, or thromboangiitis obliterans.

While taking beta-blockers, patients with a history of atopy or a history of severe anaphylactic reaction to a variety of allergens may be unresponsive to the usual dose of adrenaline used to treat anaphylactic reactions.

As with systemic beta-blockers, if discontinuation of treatment is needed in patients with coronary heart disease, therapy should be withdrawn gradually to avoid rhythm disorders, myocardial infarction or sudden death.

Choroidal detachment after filtration procedures has been reported with administration of aqueous suppressant therapy (e.g. timolol, acetazolamide).

In patients with chronic eye inflammation and corneal dystrophy Betagan should only be applied in the event of stringent diagnosis & under continuous monitoring at short intervals.

Skin rashes and/or dry eyes associated with the use of beta-blockers have been reported. The incidence is small and symptoms have stopped on withdrawal of the beta-blockers. Discontinuation of the use of beta blockers should be considered if these symptoms are reported but cessation of treatment should be gradual.

The preservative in Betagan, benzalkonium chloride, may cause eye irritation. Remove contact lenses prior to application and wait at least 15 minutes before reinsertion. Benzalkonium chloride is known to discolour soft contact lenses. Avoid contact with soft contact lenses.

Betagan contains sodium metabisulphite which may rarely cause severe hypersensitivity reactions and bronchospasm.

Athletes should be aware that Betagan contains levobunolol that may induce a positive result in anti-doping controls.

4.5 Interaction With Other Medicinal Products And Other Forms Of Interaction

No interaction studies have been performed

Although specific drug interactions studies have not been conducted with Betagan, the theoretical possibility of an additive or potentiating effect with CNS depressants (alcohol, barbiturates, opiates, sedatives, or anaesthetics) should be considered.

There is potential for additive effects resulting in hypotension, and/or marked bradycardia when eye drops with levobunolol are administered concomitantly with oral calcium channel blockers, Rauwolfia alkaloids, guanethidine, beta-blocking agents, anti-arrhythmics, digitalis glycosides or parasympathomimetics.

Caution should be exercised and patients must be monitored when Betagan is used concomitantly with oral beta-adrenergic blocking agents, because of the potential for additive effects on systemic blockade.

Enhanced hypotensive effect is seen when baclofen is given with beta-blockers. Since some systemic absorption may follow topical application of beta-blockers, regular blood pressure monitoring is advised.

Although levobunolol has little effect on the size of the pupil, mydriasis has occasionally been reported when levobunolol has been used with mydriatic agents such as adrenaline.

Beta-blockers may increase the hypoglycaemic effect of antidiabetic agents. Beta-blockers can mask the signs and symptoms of hypoglycaemia (see section 4.4)

The hypertensive reaction to sudden withdrawal of clonidine can be potentiated when taking beta-blockers.

Potentiated systemic beta-blockade (e.g., decreased heart rate) has been reported during combined treatment with quinidine and levobunolol, possibly because quinidine inhibits the metabolism of levobunolol via the P450 enzyme, CYP2D6.

Concomitant use of a beta-blocker with anaesthetic drugs may attenuate compensatory tachycardia and increase the risk of hypotension (see section 4.4), and therefore the anaesthetist must be informed if the patient is using Betagan.

Caution must be exercised if Betagan is used concomitantly with iodine contrast products or intravenously administered lidocaine.

Cimetidine may increase the plasma concentrations of levobunolol.

No data on the level of circulating catecholamines after Betagan administration are available. Caution, however, is advised in patients taking medication which can affect the metabolism and uptake of circulating amines e.g. chlorpromazine, methylphenidate, reserpine because of possible additive effects and the production of hypotension and/or marked bradycardia, which may produce vertigo, syncope or postural hypotension.

Although specific drug interactions studies have not been conducted with Betagan, known additive IOP lowering effect with prostamides, prostaglandins, alpha-agonists, carbonic anhydrase inhibitors and pilocarpine should be considered.

4.6 Pregnancy And Lactation

Pregnancy

There are no adequate data for the use of Betagan in pregnant women. Betagan should not be used during pregnancy unless clearly necessary.

Epidemiological studies have not revealed malformative effects but show a risk for intra uterine growth retardation when beta-blockers are administered by the oral route. In addition, signs and symptoms of beta-blockade (e.g. bradycardia, hypotension, respiratory distress and hypoglycaemia) have been observed in the neonate when beta-blockers have been administered until delivery. If Betagan is administered until delivery, the neonate should be carefully monitored during the first days of life. Animal studies with levobunolol have shown reproductive toxicity at doses significantly higher than would be used in clinical practice.

Lactation

Levobunolol is excreted in breast milk. Betagan should not be used by breast-feeding women.

4.7 Effects On Ability To Drive And Use Machines

Betagan has minor influence on the ability to drive and use machines. Betagan may cause transient blurring of vision, fatigue and/or drowsiness which may impair the ability to drive or operate machines. The patient should wait until these symptoms have cleared before driving or using machinery.

4.8 Undesirable Effects

Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness. The following terminologies have been used in order to classify the occurrence of undesirable effects: Very Common (

Psychiatric Disorders

Not known: Depression

Nervous System Disorders

Not known: Ataxia, Confusion, Dizziness, Somnolence Lethargy, Headache,

Eye Disorders

Very Common: Eye irritation, Conjunctival irritation

Common: Blepharitis, Conjunctivitis

Not known: Dry eye, Corneal reflex decreased, Iridocyclitis, Keratitis, Visual disturbance, Eye/Eyelids pruritus, Eye/Eyelid oedema, Eye discharge, Lacrimation increased

Cardiac Disorders

Not known: Syncope, Bradycardia, Atrioventricular block, Palpitations

Vascular Disorders

Not known: Hypotension

Respiratory, Thoracic, and Mediastinal Disorders

Not known: Asthma, Dyspnoea, Throat irritation, Nasal discomfort

Gastrointestinal Disorders

Not known: Nausea,

Skin and Subcutaneous Tissue Disorders

Not known: Urticaria, Dermatitis, Rash, Erythema, Skin exfoliation, Lichenoid keratosis, Pruritus

General Disorders and Administration Site Conditions

Not known: Face oedema, Fatigue

The following events have been reported with systemic beta-blocker formulations and may occur with the topical formulation:

Nervous System Disorders: Sleep disturbance

Psychiatric disorders: Impotence, hallucinations, nightmares

Cardiac Disorders: Cardiac failure,

Vascular disorders: Cold extremities, Raynaud's phenomenon, worsening intermittent claudication

Gastrointestinal Disorders: Abdominal pain upper, vomiting, diarrhea

Respiratory, Thoracic, and Mediastinal Disorders: Bronchospasm,

Endocrine disorders: Hypoglycaemia

Skin and Subcutaneous Tissue Disorders: Angioedema (Quincke's oedema), cutaneous (see section 4.4) and psoriasis-like symptoms

4.9 Overdose

There are no data available on human overdosage with Betagan, which is unlikely to occur via the ocular route. Should accidental ocular overdosage occur, flush the eye(s) with water or normal saline. If accidentally ingested, systemic symptoms may result and efforts to decrease further absorption may be appropriate. The symptoms associated with systemic overdosage are most likely to be bradycardia, hypotension, bronchospasm and cardiac failure. Therapy for overdosage of a beta-adrenergic agent should be instituted, such as intravenous administration of atropine sulphate 0.25 to 2 mg to induce vagal blockade. Conventional therapy for hypotension, bronchospasm, heart block and cardiac failure may be necessary.

5. Pharmacological Properties

Pharmacotherapeutic group: Beta blocking agents

ATC code: S01ED 03

5.1 Pharmacodynamic Properties

Levobunolol is a non-cardioselective beta-adrenoceptor blocking agent, equipotent at both beta-1 and beta-2 receptors. Levobunolol does not have significant local anaesthetic (membrane-stabilizing) or intrinsic sympathomimetic activity. Betagan has shown to be as effective as Timolol in lowering intraocular pressure.

Because of levobunolol's affinity for beta-1 receptors there exists the theoretical possibility of a negative inotropic effect.

Betagan when instilled in the eye will lower elevated intraocular pressure as well as normal intraocular pressure, whether or not accompanied by glaucoma. Elevated intraocular pressure presents a major risk factor in the pathogenesis of glaucomatous field loss. The higher the level of intraocular pressure, the likelihood of optic nerve damage and visual field loss.

The primary mechanism of the ocular hypotensive activity of levobunolol hydrochloride is likely to be a decrease in aqueous humour production. There is little effect on pupil size or accommodation.

The blurred vision and night blindness often associated with miotics would not be expected with the use of Betagan. Patients with cataracts avoid the inability to see around lenticular opacities caused by pupil constriction.

5.2 Pharmacokinetic Properties

The onset of action of one drop of Betagan can be detected one hour after instillation with the maximum effect seen between 2 and 6 hours. A significant decrease can be maintained for up to 24 hours following a single dose. The half lives of orally ingested levobunolol and of its active metabolite dihydrolevobunolol are between 6 and 7 hours.

5.3 Preclinical Safety Data

Not applicable.

6. Pharmaceutical Particulars

6.1 List Of Excipients

Benzalkonium chloride

Disodium edetate

Poly(vinyl alcohol)

Sodium chloride

Sodium phosphate, dibasic, heptahydrate

Potassium dihydrogen phosphate

Sodium metabisulphite (E223)

Sodium hydroxide or hydrochloric acid to adjust pH

Purified water

6.2 Incompatibilities

None known.

6.3 Shelf Life

24 months unopened.

Discard 28 days after first opening.

6.4 Special Precautions For Storage

Do not store above 25°C.

Keep the bottle in the outer carton in order to protect from light.

6.5 Nature And Contents Of Container

Bottle and dropper tip made of low density polyethylene. The cap is either a "traditional", high impact, polystyrene cap or a high impact polystyrene compliance cap (C-Cap) with an external rotating sleeve indicating daily dosage status. Both have a safety seal to ensure integrity. 10 ml bottles. Not all pack sizes may be marketed.

6.6 Special Precautions For Disposal And Other Handling

No special instructions.

7. Marketing Authorisation Holder

Allergan Limited

Marlow International

The Parkway

Marlow

Buckinghamshire, SL7 1YL

United Kingdom

8. Marketing Authorisation Number(S)

PL 00426/0060

9. Date Of First Authorisation/Renewal Of The Authorisation

23^rd March 1989 / 14^th July 2005

10. Date Of Revision Of The Text

March 2011