1. Name Of The Medicinal Product
Lipantil® Micro 200 mg, capsules.
2. Qualitative And Quantitative Composition
Each capsule contains 200 mg fenofibrate.
For excipients, see 6.1
3. Pharmaceutical Form
Orange, hard gelatin capsule.
4. Clinical Particulars
4.1 Therapeutic Indications
Lipantil® Micro 200mg is indicated as an adjunct to diet and other non-pharmacological treatment (e.g. exercise, weight reduction) for the following:
- Treatment of severe hypertriglyceridaemia with or without low HDL cholesterol.
- Mixed hyperlipidaemia when a statin is contraindicated or not tolerated.
- Mixed hyperlipidaemia in patients at high cardiovascular risk in addition to a statin when triglycerides and HDL cholesterol are not adequately controlled.
4.2 Posology And Method Of Administration
Adults
The recommended initial dose is one capsule taken daily during a main meal. In elderly patients without renal impairment, the normal adult dose is recommended. Since it is less well absorbed from an empty stomach, Lipantil Micro 200 should always be taken with food. Dietary restrictions instituted before therapy should be continued.
4.3 Contraindications
Lipantil Micro 200 is contra-indicated in children, in patients with severe liver dysfunction, gallbladder disease, biliary cirrhosis, severe renal disorders and in patients hypersensitive to fenofibrate or any component of this medication, known photoallergy or phototoxic reaction during treatment with fibrates or ketoprofen.
Chronic or acute pancreatitis with the exception of acute pancreatitis due to severe hypertriglyceridemia.
Use during pregnancy and lactation (see section 4.6).
4.4 Special Warnings And Precautions For Use
Secondary causes of dyslipidaemia, such as uncontrolled type 2 diabetes mellitus, hypothyroidism, nephrotic syndrome, dysproteinemia, obstructive liver disease, pharmacological treatment, alcoholism, should be adequately treated before fenofibrate therapy is initiated.
Response to therapy should be monitored by determination of serum lipid values (total cholesterol, LDL-C, triglycerides). If an adequate response has not been achieved after several months (e.g. 3 months) complementary or different therapeutic measures should be considered.
Renal function
In renal dysfunction the dose of fenofibrate may need to be reduced, depending on the rate of creatinine clearance. In this case, Lipantil Micro 67 (micronised fenofibrate) should be used, e.g. 2 capsules of Lipantil Micro 67 daily for creatinine clearance levels of <60 ml/min and 1 capsule of Lipantil Micro 67 daily for creatinine clearance levels of <20 ml/min.
It is recommended that creatinine is measured during the first three months after initiation of treatment and thereafter periodically. Treatment should be interrupted in case of an increase in creatinine levels > 50% of (upper limit of normal)
Use of Lipantil Micro 67 is also to be preferred in elderly patients with renal impairment where dosage reduction may be required.
Liver function abnormalities
Moderately elevated levels of serum transaminases may be found in some patients but rarely interfere with treatment. However, it is recommended that serum transaminases should be monitored every three months during the first twelve months of treatment. Treatment should be interrupted in the event of ALAT (SGPT) or ASAT (SGOT) elevations to more than 3 times the upper limit of the normal range or more than one hundred international units.
Pancreatitis
Pancreatitis has been reported in patients taking fenofibrate (see sections 4.3 and 4.8). This occurrence may represent a failure of efficacy in patients with severe hypertriglyceridaemia, a direct drug effect, or a secondary phenomenon mediated through biliary tract stone or sludge formation, resulting in the obstruction of the common bile duct.
Myopathy
Muscle toxicity, including rare cases of rhabdomyolysis, has been reported with administration of fibrates and other lipid-lowering agents. The incidence of this disorder increases in cases of hypoalbuminaemia and previous renal insufficiency. Patients with pre-disposing factors for myopathy and/or rhabdomyolysis, including age above 70 years, personal or familial history of hereditary muscular disorders, renal impairment, hypothyroidism and high alcohol intake, may be at an increased risk of developing rhabdomyolysis. For these patients, the putative benefits and risks of fenofibrate therapy should be carefully weighed up.
Muscle toxicity should be suspected in patients presenting diffuse myalgia, myositis, muscular cramps and weakness and/or marked increases in CPK (levels exceeding 5 times the normal range). In such cases treatment with fenofibrate should be stopped.
The risk of muscle toxicity may be increased if the drug is administered with another fibrate or an HMG-CoA reductase inhibitor, especially in cases of pre-existing muscular disease. Consequently, the co-prescription of fenofibrate with a statin should be reserved to patients with severe combined dyslipidaemia and high cardiovascular risk without any history of muscular disease. This combination therapy should be used with caution and patients should be monitored closely for signs of muscle toxicity.
For hyperlipidaemic patients taking oestrogens or contraceptives containing oestrogen it should be ascertained whether the hyperlipidaemia is of primary or secondary nature (possible elevation of lipid values caused by oral oestrogen).
For patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption: although the amount of lactose contained in Lipantil Micro 200 mg is low, caution should be exercised in these patients (as no study has been formally conducted in this special population).
4.5 Interaction With Other Medicinal Products And Other Forms Of Interaction
Oral Anti-coagulants
Fenofibrate enhances oral anti-coagulant effect and may increase risk of bleeding. In patients receiving oral anti-coagulant therapy, the dose of anti-coagulant should be reduced by about one-third at the commencement of treatment and then gradually adjusted if necessary according to INR (International Normalised Ratio) monitoring.
HMG-CoA reductase inhibitors or Other Fibrates
The risk of serious muscle toxicity is increased if fenofibrate is used concomitantly with HMG-CoA reductase inhibitors or other fibrates. Such combination therapy should be used with caution and patients monitored closely for signs of muscle toxicity ( see section 4.4.).
There is currently no evidence to suggest that fenofibrate affects the pharmacokinetics of simvastatin.
Cyclosporin
Some severe cases of reversible renal function impairment have been reported during concomitant administration of fenofibrate and cyclosporin. The renal function of these patients must therefore be closely monitored and the treatment with fenofibrate stopped in the case of severe alteration of laboratory parameters.
Other
No proven clinical interactions of fenofibrate with other drugs have been reported, although in vitro interaction studies suggest displacement of phenylbutazone from plasma protein binding sites. In common with other fibrates, fenofibrate induces microsomal mixed-function oxidases involved in fatty acid metabolism in rodents and may interact with drugs metabolised by these enzymes.
4.6 Pregnancy And Lactation
There are no adequate data from the use of fenofibrate in pregnant women. Animal studies have not demonstrated any teratogenic effects. Embryotoxic effects have been shown at doses in the range of maternal toxicity (see section 5.3). The potential risk for humans is unknown.
There are no data on the excretion of fenofibrate and/or its metabolites into breast milk. It is therefore recommended that Lipantil Micro 200 should not be administered to women who are pregnant or are breast feeding.
4.7 Effects On Ability To Drive And Use Machines
No effect noted to date.
4.8 Undesirable Effects
Adverse reactions observed during Lipantil Micro 200 treatment are not very frequent (2 - 4 % of cases): they are generally minor, transient and do not interfere with treatment.
The most commonly reported adverse reactions include:
Gastrointestinal: Digestive, gastric or intestinal disorders (abdominal pain, nausea, vomiting, diarrhoea, and flatulence) moderate in severity.
Uncommon: Pancreatitis*
Cardiovascular system
Uncommon: Thromboembolism (pulmonary embolism, deep vein thrombosis)*
Skin: Reactions such as rashes, pruritus, urticaria or photosensitivity reactions; in individual cases (even after many months of uncomplicated use) cutaneous photosensitivity may occur with erythema, vesiculation or nodulation on parts of the skin exposed to sunlight or artificial UV light (e.g. sun lamp).
Neurological disorders: Headache.
General disorders: Fatigue.
Disorders of the ear: Vertigo.
Less frequently reported adverse reactions:
Liver: Moderately elevated levels of serum transaminases may be found in some patients but rarely interfere with treatment (see also section 4.4). Episodes of hepatitis have been reported very rarely. When symptoms (e.g. jaundice, pruritus) indicative of hepatitis occur, laboratory tests are to be conducted for verification and fenofibrate discontinued, if applicable (see Special Warnings). Development of gallstones has been reported.
Muscle: As with other lipid lowering agents, cases of muscle toxicity (diffuse myalgia, myositis, muscular cramps and weakness) and very rare cases of rhabdomyolysis have been reported. These effects are usually reversible when the drug is withdrawn (see Special Warnings).
In rare cases, the following effects are reported: Sexual asthenia and alopecia. Increases in serum creatinine and urea, which are generally slight, and also a slight decrease in haemoglobin and leukocytes may be observed.
Very rare cases of interstitial pneumopathies have been reported.
* In the FIELD-study, a randomized placebo-controlled trial performed in 9795 patients with type 2 diabetes mellitus, a statistically significant increase in pancreatitis cases was observed in patients receiving fenofibrate versus patients receiving placebo (0.8% versus 0.5%; p = 0.031). In the same study, a statistically significant increase was reported in the incidence of pulmonary embolism (0.7% in the placebo group versus 1.1% in the fenofibrate group; p = 0.022) and a statistically non-significant increase in deep vein thromboses (placebo: 1.0 % [48/4900 patients] versus fenofibrate 1.4% [67/4895 patients]; p = 0.074).
4.9 Overdose
No case of overdosage has been reported. No specific antidote is known. If overdose is suspected, treat symptomatically and institute appropriate supportive measures as required. Fenofibrate cannot be eliminated by haemodialysis.
5. Pharmacological Properties
5.1 Pharmacodynamic Properties
Serum Lipid Reducing Agents/Cholesterol and Triglyceride Reducers/Fibrates. ATC code:C10 AB 05.
Lipantil Micro 200 is a formulation containing 200mg of micronised fenofibrate; the administration of this product results in effective plasma concentrations identical to those obtained with 3 capsules of Lipantil Micro 67 containing 67mg of micronised fenofibrate.
The lipid-lowering properties of fenofibrate seen in clinical practice have been explained in vivo in transgenic mice and in human hepatocyte cultures by activation of Peroxisome Proliferator Activated Receptor type α (PPARα). Through this mechanism, fenofibrate increases lipolysis and elimination of triglyceride rich particles from plasma by activating lipoprotein lipase and reducing production of Apoprotein C-III. Activation of PPARα also induces an increase in the synthesis of Apoproteins A-I, A-II and of HDL cholesterol.
Epidemiological studies have demonstrated a positive correlation between abnormally increased serum lipid levels and an increased risk of coronary heart disease. The control of such dyslipidaemia forms the rationale for treatment with Lipantil Micro 200. However the possible beneficial and adverse long term consequences of drugs used in the management of dyslipidaemia are still the subject of scientific discussion. Therefore the presumptive beneficial effect of Lipantil Micro 200 on cardiovascular morbidity and mortality is as yet unproven.
There is evidence that treatment with fibrates may reduce coronary heart disease events but they have not been shown to decrease all cause mortality in the primary or secondary prevention of cardiovascular disease.
The Action to Control Cardiovascular Risk in Diabetes (ACCORD) lipid trial was a randomized placebo-controlled study of 5518 patients with type 2 diabetes mellitus treated with fenofibrate in addition to simvastatin. Fenofibrate plus simvastatin therapy did not show any significant differences compared to simvastatin monotherapy in the composite primary outcome of non-fatal myocardial infarction, non-fatal stroke, and cardiovascular death (hazard ratio [HR] 0.92, 95% CI 0.79-1.08, p = 0.32 ; absolute risk reduction: 0.74%). In the pre-specified subgroup of dyslipidaemic patients, defined as those in the lowest tertile of HDL-C (
Studies with fenofibrate on lipoprotein fractions show decreases in levels of LDL and VLDL cholesterol. HDL cholesterol levels are frequently increased. LDL and VLDL triglycerides are reduced. The overall effect is a decrease in the ratio of low and very low density lipoproteins to high density lipoproteins, which epidemiological studies have correlated with a decrease in atherogenic risk. Apolipoprotein-A and apolipoprotein-B levels are altered in parallel with HDL and LDL and VLDL levels respectively.
Regression of xanthomata has been observed during fenofibrate therapy.
Plasma uric acid levels are increased in approximately 20% of hyperlipidaemic patients, particularly in those with type IV disease. Lipantil Micro 200 has a uricosuric effect and is therefore of additional benefit in such patients.
Patients with raised levels of fibrinogen and Lp(a) have shown significant reductions in these measurements during clinical trials with fenofibrate.
5.2 Pharmacokinetic Properties
Absorption
The unchanged compound is not recovered in the plasma. Fenofibric acid is the major plasma metabolite. Peak plasma concentration occurs after a mean period of 5 hours following dosing.
Mean plasma concentration is 15μg/ml for a daily dose of 200mg of micronised fenofibrate, equivalent to 3 capsules of Lipantil Micro 67.
Steady state levels are observed throughout continuous treatments.
Fenofibric acid is highly bound to plasma albumin; it can displace antivitamin K compounds from protein binding sites and may potentiate their anti-coagulant effect.
The plasma half-life of elimination of fenofibric acid is approximately 20 hours.
Metabolism and excretion
The product is mainly excreted in the urine; 70% in 24 hours and 88% in 6 days, at which time the total excretion in urine and faeces reaches 93%. Fenofibrate is mainly excreted as fenofibric acid and its derived glucuroconjugate.
Kinetic studies after administration of repeated doses show the absence of accumulation of the product.
Fenofibric acid is not eliminated during haemodialysis.
5.3 Preclinical Safety Data
Chronic toxicity studies have yielded no relevant information about specific toxicity of fenofibrate.
Studies on mutagenicity of fenofibrate have been negative.
In rats and mice, liver tumours have been found at high dosages, which are attributable to peroxisome proliferation. These changes are specific to small rodents and have not been observed in other animal species. This is of no relevance to therapeutic use in man.
Studies in mice, rats and rabbits did not reveal any teratogenic effect. Embryotoxic effects were observed at doses in the range of maternal toxicity. Prolongation of the gestation period and difficulties during delivery were observed at high doses. No sign of any effect on fertility has been detected.
6. Pharmaceutical Particulars
6.1 List Of Excipients
Excipients: lactose monohydrate, pregelatinised starch, sodium laurilsulfate, crospovidone and magnesium stearate.
Composition of the capsule shell: gelatin, titanium dioxide (E171), ferrous oxide (E172) and erythrosine (E127).
6.2 Incompatibilities
No effect noted to date.
6.3 Shelf Life
3 years.
6.4 Special Precautions For Storage
Store in the original package. Do not store above 30°C.
6.5 Nature And Contents Of Container
Pack of 10, 28, 30 capsules in blisters (PVC/Aluminium).
*Not all pack sizes may be marketed.
6.6 Special Precautions For Disposal And Other Handling
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7. Marketing Authorisation Holder
Abbott Healthcare Products Ltd
Mansbridge Road
West End
Southampton
SO18 3JD
United Kingdom
8. Marketing Authorisation Number(S)
PL 00512/0390
9. Date Of First Authorisation/Renewal Of The Authorisation
November 1993/December 2003
10. Date Of Revision Of The Text
June 2011
11. LEGAL CATEGORY
POM
