Consumer medicine information

Agomelatine Lupin

Agomelatine

BRAND INFORMATION

Brand name

Agomelatine Lupin

Active ingredient

Agomelatine

Schedule

S4

 

Consumer medicine information (CMI) leaflet

Please read this leaflet carefully before you start using Agomelatine Lupin.

What is in this leaflet

This leaflet answers some common questions about Agomelatine Lupin.

It does not contain all of the available information. It does not take the place of talking to your doctor or pharmacist.

All medicines have benefits and risks. Your doctor has weighed the risks of you taking Agomelatine Lupin against the benefits they expect it will have for you.

If you have any concerns about taking this medicine, talk to your doctor or pharmacist.

Keep this leaflet with your medicine. You may need to read it again.

What Agomelatine Lupin is used for

Agomelatine Lupin is used in the treatment of depression or to help prevent depression returning, and is only available with a doctor’s prescription. The symptoms of depression vary from one person to another, but commonly include persistent sadness, loss of interest in favourite activities, feelings of worthlessness, sleep problems, feeling of being slowed down, feelings of anxiety or changes in appetite and weight. Changes in your daily sleep and appetite patterns are examples of disturbances of your ‘body clock’ that occur commonly in depression.

Agomelatine Lupin can help regulate your ‘body clock’ (circadian rhythm) with positive benefits on mood and sleep in depression.

Agomelatine Lupin is not addictive. In clinical studies Agomelatine Lupin had no effect on sexual function. Agomelatine Lupin is not recommended for children, adolescents (under 18 years old) or elderly patients aged 75 or older.

Your doctor may prescribe Agomelatine Lupin for another purpose. Ask your doctor if you have any questions about why Agomelatine Lupin has been prescribed for you.

Before you take Agomelatine Lupin

There are some people who shouldn't take Agomelatine Lupin. Please read the list below. If you think any of these situations apply to you or you have any questions, please see your doctor.

When you must not take it

Do not take Agomelatine Lupin if:

  • you suffer from liver disease or you know your liver does not work properly (hepatic impairment);
  • routine blood tests show levels of liver enzymes have increased to more than 3 times the upper limit of normal;
  • you are currently taking fluvoxamine (a drug used in the treatment of depression) or ciprofloxacin (an antibiotic used to treat infections);
  • you have an allergy toAgomelatine Lupin or nay of the ingredients (including lactose) listed at the end of this leaflet.

Do not take Agomelatine Lupin if the expiry date (Exp.) printed on the pack has passed.

Do not take Agomelatine Lupin if the packaging is torn or shows signs of tampering.

Before you start to take it

A routine blood test should be performed before treatment to check how your liver is functioning. If you have increased levels of liver enzymes your doctor will decide if Agomelatine Lupin is right for you.

You may be at risk of liver problems if you are overweight, obese or have diabetes or if you are taking medicines known to affect your liver (ask your doctor if you are unsure which medicines these might be).

Tell your doctor if you have ever experienced or develop an episode of bipolar disorder, mania or hypomania (extreme upward mood swings or irritable mood).

Your doctor should be made aware if you have a history of dementia.

Tell your doctor if you are pregnant, plan to become pregnant or are breast-feeding.

Talk to your doctor about how much alcohol you drink. People who drink excessive quantities of alcohol should not take Agomelatine Lupin. Excessive alcohol may cause liver problems and may make depression worse.

Tell your doctor if you are smoking more than 15 cigarettes/day.

If you have not told your doctor about any of the above, tell them before you start taking Agomelatine Lupin.

Taking other medicines

Tell your doctor if you are taking any other medicines, including any that you buy without a prescription from a pharmacy, supermarket or health food shop.

Tell your doctor if you are taking propranolol (a medicine sometimes used to treat heart problems.)

If you are not sure whether you are taking any of these medicines, check with your doctor or pharmacist.

Your doctor and pharmacist have more information on medicines to be careful with or avoid while taking Agomelatine Lupin.

How to take Agomelatine Lupin

Always take Agomelatine Lupin exactly as your doctor has told you. You should check with your doctor or pharmacist if you are not sure.

Swallow Agomelatine Lupin tablets whole with some water in the evening at bedtime.

Agomelatine Lupin can be taken with or without food.

How much to take

The usual dose of Agomelatine Lupin is one tablet in the evening at bedtime. In some cases your doctor may prescribe two tablets (50 mg) to be taken together in the evening at bedtime. You should not take more than the maximum recommended dose of 50 mg daily.

Do not change your dose without the advice of your doctor even if you feel better.

Follow all directions given to you by your doctor and pharmacist carefully.

How long to take Agomelatine Lupin for

Current experience with medications to treat depression shows that treatment for six months or longer provides the best opportunity of long-term recovery from a first episode of depression. For those who have previously had depression, a longer period of treatment will usually be recommended.

With Agomelatine Lupin, some people experience improvements in mood and sleep within two weeks of starting treatment. As people respond differently to medications, do not become discouraged if you do not notice a difference right away.

Continue taking Agomelatine Lupin until your doctor advises you to stop. Even when you are feeling better, your doctor would usually continue to give you Agomelatine Lupin for some time to help to prevent your depression from returning.

If you forget to take it

If you forget to take your Agomelatine Lupin skip the dose you missed, take your next planned dose at the usual time and continue as normal.

To avoid confusion, it is recommended that you leave the tablet you missed in the tablet strip and continue on with the next day's tablet.

Do not try to make up for missed doses. Simply take one dose per day.

If you are not sure what to do, ask your doctor or pharmacist.

If you take too much (overdose)

Immediately telephone your doctor, or the Poisons Information Centre (telephone 13 11 26), or go to Accident and Emergency at the nearest hospital, if you think you or anyone else may have taken too much Agomelatine Lupin. Do this even if there are no signs of discomfort or poisoning. You may need urgent medical attention.

It is important that you do not take more Agomelatine Lupin tablets than your doctor has prescribed.

The experience of overdoses with Agomelatine Lupin is limited but reported symptoms include stomach pain, drowsiness, tiredness, agitation, anxiety, dizziness, blue-ish discolouration of the skin or mucous membranes and/or a general feeling of being unwell.

If you do take more than you have been prescribed, contact your doctor immediately for advice.

If anyone accidentally swallows any of your Agomelatine Lupin tablets, immediately telephone your doctor, or the Poisons Information Centre (telephone 13 11 26). Do this even if there are no signs of discomfort or poisoning.

While you are taking Agomelatine Lupin

Your liver function

Agomelatine Lupin is processed by the liver. Before you started taking Agomelatine Lupin a blood test was required to check your liver function. While you are taking Agomelatine Lupin you will need further blood tests to check your liver continues to function properly.

These tests should be performed:

  • before the start of treatment and before a dose increase to 50 mg (dose should only be increased by your doctor);

and then around:

  • 3 weeks,
  • 6 weeks,
  • 12 weeks, and
  • 24 weeks.

These blood test results will help your doctor decide whether Agomelatine Lupin is suitable for you.

Agomelatine Lupin may sometimes affect the results of these blood tests.

You may also have tests to check that your liver is working properly if you start to take medicines that interfere with how the body processes Agomelatine Lupin.

Talk to your doctor about how much alcohol you drink.

Things you must do

To make sure you have the best opportunity of long-term recovery from your depression, continue to take Agomelatine Lupin as long as your doctor recommends you to.

Tell your doctor if you have experienced or develop an episode of bipolar disorder, mania or hypomania (extreme upward mood swings or irritable mood).

Check with your doctor that your liver function tests are done as described in the “Your Liver Function” section above.

Seek advice from your doctor immediately if you develop signs or symptoms of potential liver problems (such as dark urine, light coloured faeces, yellow skin or eyes, pain in your upper right abdomen, new-onset and unexplained fatigue). Your doctor may advise you to stop taking Agomelatine Lupin.

Tell your doctor immediately if you become pregnant while taking Agomelatine Lupin.

Tell all doctors, dentists and healthcare professionals who are treating you that you are taking Agomelatine Lupin.

Do not take any other medications, whether they require a prescription or not, without first telling your doctor that you are taking Agomelatine Lupin as sometimes the action of one medicine may interfere with another.

Tell your doctor if, for any reason, you have not taken your medicine exactly as prescribed. Otherwise, your doctor may think that it was not effective and change your treatment unnecessarily.

Tell your doctor if you feel the tablets are not helping your condition.

Keep all of your doctor’s appointments so that your progress can be checked.

If you are being treated for depression, be sure to discuss with your doctor any problems you may have and how you feel, especially any feelings of severe sadness or bursts of unusual energy or anger.

If you have any thoughts about suicide or doing harm to yourself call your doctor immediately and also contact someone you trust.

All thoughts or talk about suicide or violence towards others or yourself are serious. Such thoughts may even occur after commencing antidepressant treatment, particularly before the full antidepressant effect is seen. Such thoughts are more likely to occur in young adults under 25 years of age.

If you or someone you know is showing any of the following common warning signs, either contact your doctor or healthcare professional or go to the nearest hospital for treatment:

  • worsening of your depression;
  • thoughts or talk about death or suicide;
  • thoughts or talk about self-harm or doing harm to others;
  • any recent attempts of self-harm;
  • an increase in aggressive behaviour, irritability or agitation.

In addition to talking to your doctor, confidential support and counselling services are available (in Australia) from LifeLine by calling 13 11 14.

You may find it helpful to tell a relative or close friend that you are depressed and ask them to read this leaflet. You might ask them to tell you if they think your depression is getting worse, or if they are worried about changes in your behaviour.

Things you must not do

You should not take Agomelatine Lupin together with certain medications (see also the “When you must not take it” section) such as: fluvoxamine (another medicine used in the treatment of depression) or ciprofloxacin (an antibiotic).

Do not give this medicine to anyone else even if their symptoms seem similar to yours or if they have the same condition as you.

Things to be careful of

Be careful driving or operating machinery until you know how Agomelatine Lupin affects you.

Speak to your doctor if you have any concerns.

It is recommended to avoid drinking alcohol while taking any antidepressant including Agomelatine Lupin.

Side effects and unwanted effects potentially due to treatment and/or your depression

Tell your doctor or pharmacist or go to the nearest hospital as soon as possible if you do not feel well while you are taking Agomelatine Lupin.

If any of the signs below occur then tell your doctor immediately or go to the Accident and Emergency department at your nearest hospital.

The possibility of a severe liver reaction exists, especially with excessive alcohol consumption and/ or with any other medication processed by the liver, eg. Agomelatine Lupin. Symptoms of severe liver reactions may include:

  • yellow colouring of the skin or whites of the eyes (jaundice);
  • abnormal bleeding or bruising;
  • confusion, loss of consciousness or hallucinations.

The possibility of a severe allergic reaction exists with any medication. The following are general signs and symptoms of an allergic reaction:

  • itching, skin rash or hives;
  • shortness of breath, wheezing or trouble breathing;
  • swelling of the face, lips, tongue or other parts of the body which may cause difficulty in swallowing or breathing.

Severe liver reactions and severe allergic reactions are very serious. Medical attention or hospitalisation may be required and should be sought urgently from a doctor or Accident and Emergency at the nearest hospital.

Agomelatine Lupin has been developed to treat people with depression and is usually well tolerated, however all medications may have unwanted effects in some people.

Increases in liver enzymes, and rarely inflammation of the liver, have been observed in some patients treated with Agomelatine Lupin. When Agomelatine Lupin was discontinued in these patients, the increases in liver enzymes usually returned to normal levels. This is why your doctor has asked you to have routine blood tests.

Some people taking Agomelatine Lupin for depression have reported the following adverse reactions, which may relate to their depression, general health or any of their treatments.

Very common side effects (may affect more than 1 in 10 people):

  • headache.

Common side effects (may effect up to 1 in 10 people):

  • sleepiness (somnolence), difficulty in sleeping (insomnia);
  • dizziness, abnormal dreams;
  • feeling sick (nausea), diarrhoea, constipation, abdominal pain, vomiting;
  • back pain;
  • tiredness;
  • anxiety;
  • increased level of liver enzymes in your blood;
  • weight increase.

Uncommon side effects (may effect up to 1 in 100 people):

  • mania/hypomania (see also “Before you start to take it” section);
  • suicidal thoughts or behaviour;
  • pins and needles in the fingers and toes (paraesthesia), restless legs syndrome (a disorder that is characterised by an uncontrollable urge to move the legs);
  • blurred vision;
  • ringing in the ears;
  • eczema, pruritus, urticarial (hives);
  • agitation, irritability, restlessness, aggressive behaviour;
  • nightmares;
  • confusion;
  • weight decease;
  • migraine;
  • excessive sweating (hyperhidrosis).

Rare side effects (may affect up to 1 in 1,000 people):

  • serious skin eruption (erythematous rash), face oedema (swelling) and angioedema (swelling of the face, lips, tongue and/or throat that may cause difficulty in breathing or swallowing);
  • hepatitis, yellow coloration of the skin or the whites of the eyes (jaundice), hepatic failure (isolated cases of death or liver transplantation have been reported in patients with hepatic risk factors);
  • hallucinations;
  • inability to remain still (due to physical and mental unrest);
  • inability to completely empty the bladder.

Do not be alarmed by this list of possible side effects. You may not experience any of them.

Ask your doctor or pharmacist to answer any questions you may have.

Other side effects not listed above may also occur in some patients. Tell your doctor if you notice anything that is making you feel unwell.

After taking Agomelatine Lupin

Storage

Keep Agomelatine Lupin where children cannot reach it. A locked cupboard at least one-and-a-half metres above the ground is a good place to store medicines.

Keep your tablets in a cool dry place where the temperature stays below 25oC in their original packaging in order to protect from moisture.

Do not store Agomelatine Lupin or any other medicine in the bathroom or near a sink.

Do not leave Agomelatine Lupin in the car or on window sills. Heat and dampness can destroy some medicines.

Disposal

If your doctor tells you to stop taking Agomelatine Lupin, or your tablets have passed their expiry date, ask your pharmacist what to do with any that are left over.

Product description

What it looks like

Agomelatine Lupin is a yellow, oblong, biconvex, film-coated tablet.

Each pack contains 28 film-coated tablets.

Ingredients

Active ingredient

The active ingredient in Agomelatine Lupin is agomelatine. Each Agomelatine Lupin tablet contains 25 mg of agomelatine.

Inactive ingredients

The tablets also contain:

  • silicified microcrystalline cellulose;
  • mannitol;
  • povidone;
  • colloidal anhydrous silica;
  • crospovidone;
  • sodium stearyl fumarate;
  • magnesium stearate.

The tablets do not contain gluten, lactose, sucrose, tartrazine or any other azo dyes.

Australian Registration Numbers

Agomelatine Lupin 25 mg: AUST R 318688

Distributor

Generic Health Pty Ltd
Suite 2, Level 2
19-23 Prospect Street
Box Hill, VIC, 3128
Australia

Email: [email protected]
Telephone: +61 3 9809 7900
Website: www.generichealth.com.au

This leaflet was prepared in March 2023.

Agomelatine Lupin Patient Guide

IMPORTANT INFORMATION – DO NOT DISCARD!

Agomelatine Lupin is an antidepressant that can help you to treat depression.

To get the best from your medicine, follow your doctor’s advice how to take Agomelatine Lupin, including dose, duration of treatment, associated follow up appointments, and blood tests.

Reporting of Side Effects

If you get any side effects, talk to your doctor, pharmacist or nurse. You can also report side effects to Generic Health using the contact details at the end of this Patient Guide. This includes any possible side effects not listed in the Consumer Medicine Information. You can also report side effects directly via the national reporting scheme website:
https://www.tga.gov.au/reporting-adverse-events

By reporting side effects, you can help provide more information on the safety of this medicine.

Recommendations to Avoid Liver Side Effects

Agomelatine Lupin can cause side effects which may include changes in how your liver works.

This Patient Guide provides you with advice on:

  • how to avoid liver side effects; and
  • what to do if liver side effects occur during treatment with Agomelatine Lupin.

Ask your doctor if you have any queries regarding this or for any further information.

Ask your doctor for advice if you:

  • have ever had liver problems;
  • are obese or overweight;
  • are diabetic;
  • drink alcohol;
  • are taking other medicines (some are known to affect the liver).

What to do to Avoid Liver Problems During Your Treatment

Have Regular Blood Tests

Why?

Your doctor will check that your liver is working properly before starting the treatment by running blood tests. The results will tell them how your liver is working and whether Agomelatine Lupin is suitable for you.

During treatment with Agomelatine Lupin, some patients may experience elevated levels of liver enzymes in their blood. The levels of these liver enzymes indicate whether your liver is working properly and are vital for the doctor when monitoring your treatment.

When?

Your doctor will perform blood tests:

  • before starting treatment or at dose increases;
  • after around 3 weeks;
  • after around 6 weeks;
  • after around 3 months; and
  • after around 6 months.

If your doctor increases the dose to 50 mg, the tests must be performed again.

Tell your prescribing doctor immediately if you find out via another healthcare professional that your blood liver enzymes increase during treatment.

Be Vigilant About Signs of Liver Problems

If you observe any of the following, your liver may not be working properly:

  • yellow skin/eyes;
  • darkening of the urine;
  • light coloured stools;
  • pain in the upper right abdomen (belly);
  • unusual fatigue (especially associated with other symptoms listed above).

Seek urgent advice from a doctor who may advise you to stop taking Agomelatine Lupin.

Your Blood Test Appointments

Remember: When taking Agomelatine Lupin, it is important that you have regular blood tests. The table below helps you to track your blood test appointments. Remember to bring this with you when you visit your doctor.

After Initiation of Treatment

Your doctor will decide if any further tests should be taken. Remember to bring this with you when you visit your doctor.

After Dose Increase

Your doctor will decide if any further tests should be taken. Remember to bring this with you when you visit your doctor.

Further Information

For further information, please contact your doctor or the Generic Health Medical Information Team on:

Phone: 03 9809 7900
Email: [email protected]

Published by MIMS June 2023

BRAND INFORMATION

Brand name

Agomelatine Lupin

Active ingredient

Agomelatine

Schedule

S4

 

Notes

Distributed by Generic Health Pty Ltd

1 Name of Medicine

Agomelatine.

2 Qualitative and Quantitative Composition

Agomelatine Lupin film-coated tablets contain 44.74 mg agomelatine-citric acid (equivalent to 25 mg agomelatine).
For the full list of excipients, see Section 6.1 List of Excipients.

3 Pharmaceutical Form

Agomelatine Lupin 25 mg are yellow, oblong biconvex film coated tablet.

4 Clinical Particulars

4.1 Therapeutic Indications

Treatment of major depression in adults including prevention of relapse.

4.2 Dose and Method of Administration

The recommended daily dose is one tablet taken orally at bedtime.
After two weeks of treatment, if there is no improvement in symptoms, the dose may be increased to 50 mg once daily, taken as a single dose of two tablets at bedtime. The maximum recommended dose should not be exceeded.
Dose escalation has been associated with an increased incidence of serum transaminase elevations. Dose increases to 50 mg should only occur following an assessment of the benefits and risk and assessment of liver function.
Liver function tests should be performed in all patients before initiation of treatment and before a dose increase to 50 mg. Treatment with Agomelatine Lupin should not be initiated if serum transaminase levels are > 3 times the upper limit of normal range, see Section 4.3 Contraindications; Section 4.4 Special Warnings and Precautions for Use.
During treatment transaminases should be monitored periodically after around 3, 6 (end of acute phase), 12, and 24 (end of maintenance phase) weeks with regimen to be repeated following dose increase to 50 mg and thereafter when clinically indicated, see Section 4.4 Special Warnings and Precautions for Use. Treatment should be discontinued if serum transaminase levels are > 3 times the upper limit of the normal range, see Section 4.3 Contraindications; Section 4.4 Special Warnings and Precautions for Use.

Treatment duration.

Patients with depression should be treated for a sufficient period of at least six months to ensure that they are free of symptoms.
Agomelatine Lupin (agomelatine) tablets may be taken with or without food.

Switching to agomelatine from other antidepressants (SSRIs or SNRIs).

Patients may experience discontinuation symptoms after cessation from an SSRI/ SNRI antidepressant. The product information of the actual SSRI/SNRI should be consulted on how to withdraw the treatment to avoid discontinuation symptoms. Agomelatine Lupin (agomelatine) can be started immediately while tapering the dosage of an SSRI//SNRI, see Section 4.3 Contraindications; Section 5.1 Pharmacodynamic Properties.

Children and adolescents.

Agomelatine Lupin (agomelatine) is not recommended for use in children and adolescents aged < 18 years due to a lack of data on safety and efficacy, see Section 4.4 Special Warnings and Precautions for Use.

Elderly patients.

Agomelatine Lupin (agomelatine) should not be used for the treatment of major depressive episodes in elderly patients with dementia since the safety and efficacy of Agomelatine Lupin (agomelatine) have not been established in these patients.
The efficacy and safety of agomelatine (25 to 50 mg/day) have been established in elderly patients with MDD (aged < 75 years). No adjustment in the usual dose is recommended for elderly patients with MDD (aged < 75 years) solely because of their age.
As efficacy has not been established in very elderly patients aged ≥ 75 years Agomelatine Lupin (agomelatine) should not be used in this patient group, see Section 4.4 Special Warnings and Precautions for Use.

Patients with renal impairment.

No relevant modification in agomelatine pharmacokinetic parameters in patients with severe renal impairment has been observed. However, as only limited clinical data on the use of agomelatine in patients with depression and severe or moderate renal impairment with major depressive episodes is available, caution should be exercised when prescribing Agomelatine Lupin (agomelatine) to these patients.

Patients with hepatic impairment.

Agomelatine Lupin (agomelatine) is contraindicated in patients with hepatic impairment, see Section 4.3 Contraindications.

Treatment discontinuation.

No dose tapering is needed on treatment discontinuation, as Agomelatine Lupin (agomelatine) does not induce discontinuation symptoms after abrupt treatment cessation.

4.3 Contraindications

Agomelatine is contraindicated in patients:
with a history of previous hypersensitivity to the active ingredient or any of the excipients;
with hepatic impairment (i.e. cirrhosis or active liver disease) or transaminases exceeding 3 times the upper limit of normal, see Section 4.4 Special Warnings and Precautions for Use; Section 4.2 Dose and Method of Administration;
taking potent CYP1A2 inhibitors (e.g. fluvoxamine, ciprofloxacin).

4.4 Special Warnings and Precautions for Use

Monitoring of liver function.

Caution should be exercised before initiation of treatment and close surveillance should be performed during continuing treatment, especially during combined use with medicines associated with risk of hepatic injury or where risk factors for hepatic injury are present.
In post-marketing experience cases of liver injury, including elevations of liver enzymes (> 10 times upper limit of the normal range), hepatic failure, hepatitis and jaundice have been reported in patients treated with agomelatine, most often during the first months of treatment, see Section 4.8 Adverse Effects (Undesirable Effects).
Isolated cases of transplantation or death in patients with hepatic failure have been reported following the use of agomelatine. Some patients had hepatic risk factors. This highlights the importance of performing liver function tests in all patients.
The pattern of liver damage is predominantly hepatocellular with serum transaminases usually returning to normal levels following discontinuation of agomelatine. In clinical trials, elevations of serum transaminases (> 3 times the upper limit of the normal range) have been observed in patients treated with agomelatine more commonly on a 50 mg dose.

Before initiation of treatment.

Treatment with agomelatine should only be initiated after careful consideration of the benefits and risk in patients with hepatic injury risk factors e.g.:
overweight, obesity, non-alcoholic fatty liver disease, diabetes or use with medicines associated with risk of hepatic injury;
alcohol use disorder and/or substantial alcohol intake.
Baseline liver function tests should be performed in all patients before initiation of treatment. Treatment with agomelatine should not be initiated if serum transaminase levels are > 3 times the upper limit of the normal range, see Section 4.3 Contraindications. Caution should be exercised when agomelatine is administered to patients with pre-treatment elevated transaminases (i.e. between the upper limit of the normal ranges and up to ≤ 3 times the upper limit of the normal range).

Frequency of liver function tests.

Before starting treatment and then: around 3 weeks; around 6 weeks (end of acute phase); around 12 weeks; around 24 weeks (end of maintenance phase); thereafter when clinically indicated.
When increasing the dosage, liver function tests should again be performed at the same frequency as when starting treatment. Patients who develop any increased serum transaminases should have their liver function tests repeated within 48 hours.

During treatment.

Therapy should be discontinued immediately if any of the following are observed:
an increase in serum transaminases > 3 times the upper limit of normal, see Section 4.3 Contraindications;
signs or symptoms of potential liver injury (such as dark urine, light coloured stools, yellow skin/eyes, pain in the upper right abdomen, sustained new-onset and unexplained fatigue).
Liver function tests should continue to be performed regularly following discontinuation of therapy until serum transaminases return to normal.

Suicide ideation / suicidality.

In clinical trials, agomelatine is not associated with an increased risk of suicide ideation / suicidality.
The risk of suicide attempt is inherent in depression and may persist until significant remission occurs. This risk must be considered in all patients with depression.
Patients with depression may experience worsening of their depressive symptoms and/or the emergence of suicidal ideation and behaviours (suicidality) whether or not they are taking antidepressant medications, and this risk may persist until significant remission occurs. As improvement may not occur during the first few weeks or more of treatment, patients should be closely monitored for clinical worsening and suicidality, especially at the beginning of a course of treatment, or at the time of dose changes, either increases or decreases. Patients with a history of suicide-related events or those exhibiting suicidality prior to commencement of treatment are known to be at greater risk of suicidal thoughts or suicide attempts, and should be monitored during treatment.
Consideration should be given to changing the therapeutic regimen, including possibly discontinuing the medication, in patients whose depression is persistently worse or whose emergent suicidality is severe, abrupt in onset, or was not part of the patient's presenting symptoms. Patients (and caregivers of patients) should be alerted about the need to monitor for any worsening of their condition and/or the emergence of suicidal ideation/ behaviour or thoughts of harming themselves and to seek medical advice immediately if these symptoms present. Patients with comorbid depression associated with other psychiatric disorders being treated with antidepressants should be similarly observed for clinical worsening and suicidality.
Pooled analyses of 24 short-term (4 to 16 weeks), placebo controlled trials of nine antidepressant medicines (SSRIs and others) in 4,400 children and adolescents with MDD (16 trials), obsessive compulsive disorder (four trials) or other psychiatric disorders (four trials) have revealed a greater risk of adverse events representing suicidality during the first few months of treatment in those receiving antidepressants. The average risk of such events in patients treated with an antidepressant was 4% compared with 2% of patients given placebo. There was considerable variation in risk among the antidepressants, but there was a tendency towards an increase for almost all antidepressants studied.
The risk of suicidality was most consistently observed in the MDD trials, but there were signals of risk arising from trials in other psychiatric indications (obsessive compulsive disorder and social anxiety disorder) as well. No suicides occurred in these trials. It is unknown whether the suicidality risk in children and adolescent patients extends to use beyond several months. The nine antidepressant medications in the pooled analyses included five SSRIs (citalopram, fluoxetine, fluvoxamine, paroxetine, sertraline) and four non-SSRIs (bupropion, mirtazapine, nefazodone, venlafaxine).
A further pooled analysis of short-term placebo controlled trials of antidepressant medicines (SSRIs and others) showed the increased risk of suicidality during the initial treatment period (generally the first one to two months) extends to young adults (aged 18-24 years) with MDD and other psychiatric disorders. These trials did not show an increase in the risk of suicidality with antidepressants compared to placebo in adults beyond age 24; there was a reduction in risk with antidepressants compared to placebo in adults aged 65 years and older.
Symptoms of anxiety, agitation, panic attacks, insomnia, irritability, hostility (aggressiveness), impulsivity, akathisia (psychomotor restlessness), hypomania and mania have been reported in adults, adolescents and children being treated with antidepressants for MDD as well as for other indications, both psychiatric and non-psychiatric. Although a causal link between the emergence of such symptoms and either worsening of depression and/or emergence of suicidal impulses has not been established, there is concern that such symptoms may be precursors of emerging suicidality.
Families and caregivers of children and adolescents being treated with antidepressants for MDD or for any other condition (psychiatric or non-psychiatric) should be informed about the need to monitor these patients for the emergence of agitation, irritability, unusual changes in behaviour and other symptoms described above, as well as the emergence of suicidality, and to report such symptoms immediately to healthcare providers. It is particularly important that monitoring be undertaken during the initial few months of antidepressant treatment or at times of dose increase or decrease.
When treatment duration was considered the incidence of suicidal events was 0.28 per 100 patient-months for agomelatine compared with 0.50 per 100 patient-months for placebo.

Bipolar disorder / mania / hypomania.

A major depressive episode may be the initial presentation of bipolar disorder. It is generally believed that treating such an episode with an antidepressant alone can increase the likelihood of precipitation of a mixed/manic episode in patients at risk of bipolar disorder. Prior to initiating treatment with an antidepressant, patients should be adequately screened to determine if they are at risk for bipolar disorder; such screening should include a detailed psychiatric history, including a family history of suicide, bipolar disorder and depression.
As with other antidepressants, agomelatine should be used with caution in patients with history of bipolar disorder, mania or hypomania and should be discontinued if a patient develops manic symptoms.

Alcohol.

As with all antidepressants, patients should be advised to avoid alcohol consumption.

Combination with CYP1A2 inhibitors.

(See Section 4.3 Contraindications; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions; Section 5.1 Pharmacodynamic Properties.)
Use caution when combining agomelatine with moderate CYP1A2 inhibitors (e.g. propranolol) as these medicines may result in increased exposure to agomelatine.

Electroconvulsive therapy (ECT).

There is no experience with the combined use of agomelatine and ECT. In animals agomelatine has no proconvulsant properties. Therefore, adverse consequences of combined ECT and agomelatine treatment are considered to be unlikely.

Abuse potential.

Agomelatine has no abuse potential. This was assessed in healthy volunteer trials on a specific visual analogue scale or the Addiction Research Centre Inventory 49 (ARCI) check-list.

Use in hepatic impairment.

Agomelatine is contraindicated in patients with hepatic impairment (see Section 4.3 Contraindications).

Use in renal impairment.

As only limited clinical data on the use of agomelatine in patients with depression and severe or moderate renal impairment with major depressive episodes is available, caution should be exercised when prescribing agomelatine to these patients.

Use in the elderly.

Agomelatine should not be used for the treatment of major depressive episodes in elderly patients with dementia since the safety and efficacy of agomelatine have not been established in these patients.
No adjustment in the usual dose is recommended for elderly patients solely because of their age.
The efficacy and safety of agomelatine (25 to 50 mg/day) have been established in elderly patients with MDD (aged < 75 years).
As efficacy has not been demonstrated in elderly patients aged ≥ 75 years, agomelatine should not be used in this patient group, see Section 4.2 Dose and Method of Administration.

Paediatric use.

Use of agomelatine in children and adolescents (aged < 18 years) is not recommended as safety and efficacy have not been established in this age group.
In clinical trials among children and adolescents treated with other antidepressants, suicide-related behaviour (suicide attempt and suicidal thoughts), and hostility (predominantly aggression, oppositional behaviour and anger) were more frequently observed compared to those treated with placebo.

Effects on laboratory tests.

Interactions with laboratory tests have not been established.

4.5 Interactions with Other Medicines and Other Forms of Interactions

Potential interactions affecting agomelatine.

Agomelatine is metabolised mainly by cytochromes CYP1A2 (90%) and CYP2C9/19 (10%). Medicines that interact with these isoenzymes may decrease or increase the bioavailability of agomelatine.
Co-administration of agomelatine with potent CYP1A2 inhibitors such as fluvoxamine and ciprofloxacin is contraindicated. Fluvoxamine, a potent CYP1A2 and moderate CYP2C9 inhibitor, has been shown to markedly inhibit the metabolism of agomelatine resulting in a 60-fold (range 12-412) increase in agomelatine exposure.
Combination of agomelatine with oestrogens (moderate CYP1A2 inhibitors) results in a several fold increased exposure of agomelatine. While there was no specific safety signal in the 800 patients treated in combination with oestrogens, caution should be exercised when prescribing agomelatine with other moderate CYP1A2 inhibitors (e.g. propranolol) until more experience has been gained.
Rifampicin an inducer of all three cytochromes involved in the metabolism of agomelatine may decrease the bioavailability of agomelatine.
Fluconazole, a potent CYP2C9 and CYP2C19 inhibitor, has been shown not to effect the pharmacokinetics of agomelatine. See Table 1.
As the decrease in agomelatine exposure in cigarette smokers due to induction of CYP1A2 is not clinically relevant, no dose adjustment is necessary because a patient is a cigarette smoker, see Section 5.2 Pharmacokinetic Properties.

Use with other antidepressants.

Agomelatine should not be combined with fluvoxamine as fluvoxamine is a potent inhibitor of the metabolism of agomelatine, see Section 4.3 Contraindications. Caution should be taken when administering agomelatine with other antidepressants as the safety and efficacy of agomelatine in combination with other antidepressants has not been examined.
There is no pharmacokinetic or pharmacodynamic interaction between agomelatine and paroxetine.

Lithium.

There is no pharmacokinetic or pharmacodynamic interaction between agomelatine and lithium.

Benzodiazepines (lorazepam).

There is no pharmacokinetic or pharmacodynamic interaction between agomelatine and lorazepam.

Potential for agomelatine to affect other medicinal products.

Agomelatine inhibits neither CYP1A2 in vivo nor the other CYP450 in vitro and does not induce CYP450 isoenzymes in vivo. Therefore, agomelatine will not modify exposure to medicines metabolised by CYP450.
In healthy volunteers agomelatine did not modify the kinetics of theophylline, a CYP1A2 substrate.

Drugs highly bound to plasma protein.

Agomelatine does not modify free concentrations of drugs highly bound to plasma proteins (e.g. zolpidem, diazepam, sertraline, warfarin, oestrogen and salicylic acid) or vice versa.

4.6 Fertility, Pregnancy and Lactation

Effects on fertility.

Oral reproductive toxicity trials with agomelatine in rats showed no effect on fertility at plasma exposures of 60-100 fold human exposure at the maximal recommended clinical dose. No effect of agomelatine on juvenile rat behavioural performances, visual and reproductive function were observed. There were mild non dose dependent decreases in body weight and food intake, delayed preputial separation and decreased long bone growth related to the pharmacological properties and some minor (reversible) effects (e.g. decreased prostate weight with atrophy /decreased amount of seminal fluid, decreased weight of testis) on male reproductive tract without any impairment on reproductive performances.
(Category B1)
Animal trials do not indicate direct or indirect harmful effects with respect to pregnancy, embryofoetal development, parturition or postnatal development at systemic exposures (plasma AUC) of 100-fold or greater the human exposure at the maximal recommended clinical dose. Agomelatine and/or its metabolites passes into the placenta and foetuses of pregnant rats. No clinical data on exposed pregnancies are available. As a precautionary measure, it is recommended to avoid the use of agomelatine during pregnancy.
 It is not known whether agomelatine and/or its metabolites are excreted into human milk. Available pharmacodynamic/toxicological data in animals have shown excretion of agomelatine/metabolites in milk. There were no adverse effects on offspring following oral administration of agomelatine to rats from prior to mating until weaning, with systemic exposures (plasma AUC) of 100-fold human exposure at the maximal recommended clinical dose. The effects of agomelatine on the nursing infant have not been established. A risk to the newborns/infants cannot be excluded. A decision must be made whether to discontinue breast-feeding or to discontinue/abstain from agomelatine therapy following consideration of the relative benefits of breast feeding for the child and of therapy for the woman.

4.7 Effects on Ability to Drive and Use Machines

No trials on the effects on the ability to drive and use machines have been performed. While clinical pharmacodynamic trials have shown that agomelatine treatment does not impair cognitive or psychomotor function in healthy volunteers, dizziness and somnolence were reported during clinical trials. As with all psychoactive medicines, patients should be cautioned about their ability to drive a car or operate machinery.

4.8 Adverse Effects (Undesirable Effects)

In clinical trials, over 8,000 patients with depression have received agomelatine.
In clinical trials dose escalation was associated with an increase in liver function abnormalities. The incidence of ALT and/or AST elevations > 3x ULN according to agomelatine dose in clinical trials was: 0.6% on agomelatine 1-10 mg (4/679 patients), 1.25% on agomelatine 25 mg (68/5,253 patients), 2.6% on agomelatine 50 mg (68/2,751 patients) and 3.5% on agomelatine 100 mg (2/57 patients), compared to 0.5% in the placebo group (8/1,629 patients) - see Section 4.4 Special Warnings and Precautions for Use. Whilst 1-10 mg and 100 mg doses were included in dose ranging trials, these are not within the approved therapeutic dose range of 25 mg to 50 mg, see Section 4.2 Dose and Method of Administration.
Patients with depression display a number of symptoms that are associated with the illness itself. It is therefore sometimes difficult to ascertain which symptoms are a result of the illness itself and which are a result of treatment with agomelatine. Adverse reactions were usually mild or moderate and occurred within the first two weeks of treatment. The most common adverse reactions were nausea, dizziness and headache, which were also commonly reported in the placebo treatment group. These adverse reactions were usually transient and did not generally lead to cessation of therapy (see Table 2 where all adverse events > 1% are listed including adverse reactions identified with a * symbol).

The following additional adverse reactions were reported during clinical trials of agomelatine in patients with MDD.

Adverse reactions are listed below using the following convention: 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), not known (cannot be estimated from the available data) and have not been corrected for placebo. The frequencies are shown as: (agomelatine vs placebo).

Nervous system disorders.

Uncommon: paraesthesia (0.9% vs 0.1%), migraine (0.9% vs 0.65%).

Psychiatric disorders.

Uncommon: suicidal thoughts or behaviour, see Section 4.4 Special Warnings and Precautions for Use.

Eye disorders.

Uncommon: blurred vision (0.6% vs 0%).

Skin and subcutaneous tissue disorders.

Uncommon: eczema (0.2% vs 0.1%), hyperhidrosis (0.94% vs 0.79%).
Rare: erythematous rash (0.1% vs 0%).

Hepato-biliary disorders.

Common: increases (> 3 times the upper limit of the normal range) in ALT and/or AST (1.25% of patients on agomelatine 25 mg/day and 2.6% on agomelatine 50 mg/day vs 0.5% on placebo).
Rare: hepatitis (0.03% vs 0%).
There were no differences in the nature and frequency of adverse events between treatment groups regardless of gender or age.

Investigations.

Common: weight increased in patients on agomelatine 25/50 mg daily (1.4% vs 1.4%).
Uncommon: weight decreased in patients on agomelatine 25/50 mg daily (0.7% vs 0.9%).
The percentage of patients who spontaneously reported sexual side effects in the short-term placebo-controlled trials in depression was similar for agomelatine and placebo (1.2% and 1.1% respectively).

The following reactions have been reported in post-marketing experience#.

Skin and subcutaneous tissue disorders.

Uncommon#: pruritus, urticaria.
Rare#: face oedema and angioedema.

Gastrointestinal disorders.

Common#: vomiting.

Psychiatric disorders.

Common#: abnormal dreams.
Uncommon#: agitation and related symptoms (such as irritability and restlessness), aggression, nightmares, mania/hypomania (these symptoms may also be due to the underlying disease) see Section 4.4 Special Warnings and Precautions for Use, confusional state.
Rare#: hallucinations.

Hepato-biliary disorders.

Uncommon#: increased gamma-glutamyltransferase (GGT) (> 3 times the upper limit of the normal range).
Rare#: increased alkaline phosphatase (> 3 times the upper limit of the normal range), hepatic failure, see Section 4.4 Special Warnings and Precautions for Use, jaundice.

Nervous system disorders.

Uncommon#: restless leg syndrome.
Rare#: akathisia.

Ear and vestibular system disorders.

Uncommon#: tinnitus.

Renal and urinary disorders.

Rare#: urinary retention.

Musculoskeletal and connective tissue disorders.

Uncommon#: myalgia.
#Frequency estimated from clinical trials for adverse events detected from spontaneous reports.

Reporting suspected adverse effects.

Reporting suspected adverse reactions after registration 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 at http://www.tga.gov.au/reporting-problems.

4.9 Overdose

There is limited experience with agomelatine overdose. Experience with agomelatine in overdose has indicated that epigastralgia, somnolence, fatigue, agitation, anxiety, tension, dizziness, cyanosis or malaise have been reported. One person having ingested 2,450 mg of agomelatine, recovered spontaneously without cardiovascular and biological abnormalities. No specific antidotes for agomelatine are known. Management of overdose should consist of treatment of clinical symptoms and routine monitoring. Medical follow-up in a specialised environment is recommended.
For information on the management of overdose, contact the Poison Information Centre on 131126 (Australia).

5 Pharmacological Properties

5.1 Pharmacodynamic Properties

Mechanism of action.

Pharmacotherapeutic group: Other antidepressants (ATC-code: NO6AX22).
Agomelatine is a melatonin receptor (MT1 and MT2) agonist and 5-HT2C receptor antagonist. Agomelatine has shown an antidepressant-like effect in animal models of depression (learned helplessness test, despair test, chronic mild stress), in models with circadian rhythm desynchronisation and in models related to stress and anxiety.
In vitro studies indicate that agomelatine has no effect on monoamine uptake and no affinity for α or β adrenergic, histaminergic, cholinergic, dopaminergic, or benzodiazepine receptors. Agomelatine has no influence on the extracellular levels of serotonin and increases dopamine and noradrenaline release specifically in the prefrontal cortex. These properties may explain why, compared with other antidepressants, it has less gastrointestinal (e.g. vomiting, constipation) and sexual function (e.g. libido decrease) side effects, and no cardiovascular side effects in clinical trials.
In humans, agomelatine has positive phase shifting properties; it induces a phase advance of sleep, body temperature decline and melatonin onset.
Agomelatine resynchronises circadian rhythms in animal models of circadian rhythm disruption.
In patients with depression, treatment with agomelatine 25 mg increased slow wave sleep without modification of REM (Rapid Eye Movement) sleep amount or REM latency. Agomelatine 25 mg also induced an advance of the time of sleep onset and of minimum heart rate. From the first week of treatment, onset of sleep and the quality of sleep were significantly improved without daytime clumsiness as assessed by patients.
At therapeutic doses, in healthy volunteers, agomelatine preserves daytime alertness and memory, with no sedation in the morning following drug intake.

Cardiovascular.

In clinical trials, agomelatine had no effect on QT interval and no clinically-significant effect on heart rate, blood pressure and ECG tracings.

Withdrawal / discontinuation.

The abrupt discontinuation of agomelatine was evaluated in a specific active control trial (CL3-030) using the Discontinuation Emergent Signs and Symptoms (DESS) check-list. Patients with major depression were treated under double-blind conditions with agomelatine 25 mg or paroxetine 20 mg over a 12 week period. Only those who remitted at week eight and sustained that remission until week 12 were randomised to placebo or the initial active treatment for a two-week double-blind period. Patients discontinued from agomelatine to placebo were compared to those who continued treatment on agomelatine and, likewise for the active control paroxetine.
The abrupt discontinuation of agomelatine was not associated with discontinuation symptoms [p=0.250 for difference between the agomelatine and placebo groups]. The sensitivity of the trial was demonstrated by the presence of significant emergent discontinuation symptoms following the abrupt discontinuation of treatment with the active control paroxetine [p < 0.001 for difference between the paroxetine and placebo groups].

Sexual function.

No deleterious effect on sexual function (SEX-FX total score and SEX-FX sub-scores and items) was observed during agomelatine 50 mg treatment over 12 or 24-week treatment periods in a specific sexual dysfunction comparative trial in remitted depressed patients. There was a numerical trend towards less sexual emergent dysfunction on agomelatine 50 mg than venlafaxine 150 mg for SEX-FX drive arousal or orgasm scores but statistical separation was not achieved.
A separate pooled analysis of trials using the Arizona Sexual Experience Scale (ASEX) showed that agomelatine was not associated with sexual dysfunction. In healthy volunteers agomelatine did not affect sexual function, in contrast to paroxetine.

Clinical trials.

Acute treatment of major depressive disorder (MDD).

The efficacy and safety of agomelatine in the treatment of major depression have been studied in a clinical development programme including 8,084 patients treated with therapeutic doses of 25 mg or 50 mg. Among over 7,130 patients treated with agomelatine for between six weeks and one year, 2,356 patients were treated with agomelatine for six months and 1,094 patients were treated with agomelatine for one year.
Ten placebo-controlled trials have been performed to investigate the short-term efficacy of agomelatine in MDD in adults, with fixed dose and/or dose up-titration. At the end of treatment (over six or eight weeks), five one step up-titration trials and one of the fixed dose trials showed statistically the superiority of agomelatine over placebo on the primary outcome criterion HAM-D total score and consistent results across secondary criteria (trials CL2-014, CL3-042, CL3-043, CL3-069, CAGO178A2301 for 50 mg dose (but not 25 mg dose), CAGO178A2302 for 25 mg dose (but not 50 mg dose)). Response rates were statistically significantly higher with agomelatine compared with placebo. The response to treatment of MDD was defined as a decrease in HAM-D total score of at least 50% from baseline.). The superiority of agomelatine over placebo was shown after two weeks of treatment.
Agomelatine did not differentiate from placebo in two trials (CL3-022, CAGO178A2303) where the active control fluoxetine or paroxetine showed assay sensitivity. In these trials agomelatine was not compared directly with paroxetine or fluoxetine as these comparators were included only to validate the assay sensitivity of the trials. In two other trials (CL3-023, 024), it was not possible to draw any conclusions because the active controls, paroxetine and fluoxetine, failed to differentiate from placebo. See Table 3.
The short term efficacy of 25-50 mg/day of agomelatine was also demonstrated in trial CL3-046 which assessed the antidepressant efficacy of agomelatine as a secondary objective compared to sertraline (50-100 mg/day) over a double-blind treatment period of six weeks where male or female patients, aged 18-60 years fulfilling DSM-IV criteria for MDD, received agomelatine 25-50 mg/day or sertraline 50-100 mg/day (see Table 4).
The short term efficacy of agomelatine was also shown in trial CL3-045 which demonstrated the antidepressant efficacy of agomelatine vs fluoxetine after a double-blind treatment period of eight weeks where male or female patients, aged 18-65 years fulfilling DSM-IV criteria for MDD, received agomelatine 25-50 mg/day or fluoxetine 20-40 mg/day (see Table 5).
Superiority (CL3-045 and CL3-046) or non-inferiority (CL3-052, CL3-035, CL3-056 and CL3-063) with agomelatine has been shown in six short-term efficacy trials in heterogeneous populations of adult patients with depression compared to SSRI/SNRI (sertraline, escitalopram, fluoxetine or venlafaxine). The antidepressant effect was assessed with the HAMD-17 score either as the primary (two studies) or secondary endpoint (four studies).

Acute treatment of MDD in the elderly.

A double-blind, placebo-controlled eight week trial of agomelatine 25-50 mg/day in male and female patients with MDD aged ≥ 65 years (N=222, of which 151 were treated with agomelatine) demonstrated a statistically significant difference of 2.67 points on HAM-D total score, the primary outcome. Responder rate analysis favoured agomelatine. No improvement was observed in very elderly patients (≥ 75 years, N= 69, of which 48 were treated with agomelatine), and agomelatine should not be used in that group.

Prevention of relapse of depression.

The primary objective of trial CL3-041 was to assess the efficacy of agomelatine at flexible dose in the prevention of depressive relapse compared to placebo. In this trial, 492 patients received open label treatment with agomelatine 25 mg/day for eight to ten weeks, with an increase to 50 mg/day in patients who were not sufficiently improved after two weeks. Thereafter, the patients who responded to therapy (HAM-D total score ≤ 10) were randomised to receive treatment with agomelatine or placebo until relapse occurred for up to 44 weeks. 338 patients participated in the double blind, long-term portion of the trial: 165 were treated with agomelatine and 174 were treated with placebo. The primary efficacy criterion was the relapse, defined as HAM-D 17-item total score ≥ 16, or any withdrawal for lack of efficacy during the 44-week double-blind period.
The risk over time of relapse was significantly reduced by 54.2% in the agomelatine group compared to the placebo group in trial CL3-041 (see Figure 1). As is indicated in Table 6, the percentage of patients with a relapse during the 24-week double-blind period was more than two times lower in the agomelatine group than in the placebo group.
Results over the 44-week double-blind treatment period confirm the efficacy of agomelatine 25-50 mg to prevent depressive relapse in patients with MDD and showed the maintenance of long-term efficacy. The percentage of patients with a relapse over the whole 44-week double-blind period remained more than two times lower in the agomelatine group than in the placebo group (see Table 7).
As shown in Figure 2, the risk over time of relapse was significantly reduced by more than half, 56.3% in the agomelatine group compared to the placebo group.
In another relapse-prevention trial (CL3-021), agomelatine did not separate from placebo as a result of an unexplained low relapse rate in the placebo group which was unexpected and markedly lower than the mean placebo relapse rate reported in the literature.

Switching to agomelatine from other antidepressants (SSRIs or SNRIs).

A specific controlled, three week trial (CL3-073) was conducted in 316 patients with MDD who had experienced insufficient improvement with paroxetine (an SSRI) or venlafaxine (an SNRI). When treatment was switched from these antidepressants to agomelatine, discontinuation symptoms arose after cessation of the SSRI or SNRI treatment, either after abrupt cessation or gradual cessation of the previous treatment. These discontinuation symptoms may be confounded with a lack of early benefit of agomelatine. The percentage of patients with at least one discontinuation symptom one week after the SSRI/SNRI treatment was stopped was lower in the long tapering group (gradual cessation of the previous SSRI/SNRI within two weeks) than in the short tapering group (gradual cessation of the previous SSRI/SNRI within one week) and in the abrupt substitution group (abrupt cessation): 56.1%, 62.6% and 79.8% respectively.

5.2 Pharmacokinetic Properties

Absorption.

Agomelatine is rapidly and well absorbed (≥ 80%) after oral administration. The peak plasma concentration is reached within one to two hours after administration of agomelatine. Absolute bioavailability is low (approximately 1% at the therapeutic oral dose), and is highly variable due to the first pass effect and the inter-individual differences of CYP1A2 activity. The bioavailability is increased in women compared to men.
Although not clinically relevant, the bioavailability is increased by intake of oral contraceptives and reduced by smoking. In the therapeutic dose-range, agomelatine exposure appears to increase proportionally with dose with saturation of the first pass effect occurring at supra-therapeutic doses (from 200 to 1200 mg).
Food intake (standard meal or high fat meal) reduced the peak concentration (Cmax) by approximately 20 - 30% but did not modify overall absorption or bioavailability. The variability is increased with high fat food.

Distribution.

Steady state volume of distribution is about 35 L. Plasma protein binding is 95% irrespective of concentration and is not modified with age and in patients with renal impairment but the free fraction is doubled in patients with hepatic impairment.

Metabolism.

Following oral administration, agomelatine is rapidly oxidized mainly by the hepatic cytochromes CYP1A2 (90%) and CYP2C9/CYP2C19 (10%). The major metabolites, hydroxylated and demethylated agomelatine, are not pharmacologically active and are rapidly conjugated and eliminated in the urine.

Excretion.

Elimination is rapid. The mean plasma half-life is between one and two hours. Clearance is high (about 1100 mL/min) and essentially metabolic. Excretion is mainly urinary (80%) and corresponds to metabolites. Urinary excretion of the unchanged compound is negligible. Pharmacokinetics remained unchanged following repeated administration.

Special populations.

Severe renal impairment.

In subjects with severe renal impairment the pharmacokinetic parameters Cmax and AUC were slightly higher than in healthy subjects. However, due to the high inter-individual variability of agomelatine pharmacokinetics, this result was not clinically relevant. Renal impairment did not affect the protein binding of agomelatine.

Hepatic impairment.

Following a single oral dose of 25 mg agomelatine in patients with hepatic impairment, Cmax increased by a factor of ~60 and ~110, while AUC increased by ~70-times and ~140-times, in mild (Child-Pugh score of 5 or 6) and moderate (Child-Pugh score of 7 to 9) hepatic impairment, respectively compared to healthy subjects. Both mild and moderate liver impairment increased the half-life of agomelatine by a factor of ~3. The unbound fraction of agomelatine was also increased in subjects with hepatic insufficiency. The inter-individual variability decreased with mild hepatic impairment, with a further decrease in moderate hepatic impairment, suggesting a progressive saturation of the hepatic first-pass effect. Agomelatine is therefore contraindicated in patients with hepatic impairment, see Section 4.3 Contraindications.

Gender, smoking and age.

No significant difference in exposure was shown between the young and the elderly as well as between males and females. Although not clinically relevant:
a 3.7-fold decrease in mean exposure was observed in volunteers without depression who were heavy smokers (≥ 15 cigarettes per day);
a decrease of 33% of agomelatine exposure has been shown in the smoker population (healthy volunteers and patients with depression smoking > 5 cigarettes per day) compared to non-smoker population, suggesting that cigarette smoking could induce CYP1A2 which is involved in the metabolism of agomelatine;
in a pharmacokinetic study in elderly patients (aged ≥ 65 years), mean AUC and mean Cmax were about 4-fold and 13-fold respectively higher for very elderly patients aged ≥ 75 years compared to elderly patients aged < 75 years, after an agomelatine dose of 25 mg. The results of that study were derived from a population pharmacokinetic analysis using data from saliva samples. No plasma samples were used in the study to determine or confirm correlation with the saliva samples. The total number of patients receiving agomelatine 50 mg was too low to draw any conclusions. No dose adaptation is recommended in elderly patients solely because of their age (up to the age of 75 years). Agomelatine should not be used in patients aged 75 years and older.

5.3 Preclinical Safety Data

Genotoxicity.

Based on results from a standard battery of in vitro and in vivo assays, agomelatine is not considered to have genotoxic potential in humans receiving the maximum proposed clinical dose.

Carcinogenicity.

Oral lifetime carcinogenicity trials with agomelatine were conducted in mice and rats. Male and female mice showed increased incidences of hepatocellular adenomas and hepatocellular carcinomas at systemic exposures (plasma AUC) about 15-fold human exposure at the maximal recommended clinical dose; the no-effect exposure was about 4-fold clinical exposure. Male rats showed an increased incidence of hepatocellular carcinomas at systemic exposures (plasma AUC) about 45-fold human exposure at the maximal recommended clinical dose; the no-effect exposure was about 8-fold clinical exposure. These effects were associated with liver enzyme induction in these species and are unlikely to be relevant to humans. In male and female rats, the frequency of benign mammary fibro adenomas was increased at high systemic exposures (30-fold or greater the exposure at the maximal recommended clinical dose) but remained within the historical control range. Malignant mammary tumours were not observed.

6 Pharmaceutical Particulars

6.1 List of Excipients

Agomelatine Lupin 25 mg film coated tablets contain the following excipients; silicified microcrystalline cellulose, mannitol, povidone, colloidal anhydrous silica, crospovidone, sodium stearylfumarate, magnesium stearate, stearic acid, hypromellose, macrogol 6000, titanium dioxide, purified talc and iron oxide yellow.

6.2 Incompatibilities

Incompatibilities were either not assessed or not identified as part of the registration of this medicine.

6.3 Shelf Life

In Australia, information on the shelf life can be found on the public summary of the Australian Register of Therapeutic Goods (ARTG). The expiry date can be found on the packaging.

6.4 Special Precautions for Storage

Agomelatine Lupin film coated tablets should be stored below 25°C in their original packaging in order to protect from moisture.

6.5 Nature and Contents of Container

Agomelatine Lupin film coated tablet are packed in OPA/Al/PVC/Al blisters of 28 tablets.

6.6 Special Precautions for Disposal

In Australia, any unused medicine or waste material should be disposed of by taking to your local pharmacy.

6.7 Physicochemical Properties

Chemical structure.


CAS number.

138112-76-2.
Chemical Name: N-[2-(7-methoxy-1-naphthyl)ethyl] acetamide.
Molecular Formula: C15H17NO2.
Molecular Weight: 243.3.
Agomelatine is practically insoluble in purified water (< 0.1 mg/mL) but freely soluble (> 100 mg/mL) in various organic solvents (96% ethanol, methanol, methylene chloride). Agomelatine has no asymmetric carbon atom.

7 Medicine Schedule (Poisons Standard)

S4 (Prescription Only Medicine).

Summary Table of Changes