Consumer medicine information

APO-Latanoprost/ Timolol Eye Drops

Latanoprost; Timolol

BRAND INFORMATION

Brand name

APO-Latanoprost/Timolol

Active ingredient

Latanoprost; Timolol

Schedule

SUMMARY CMI

APO-LATANOPROST/TIMOLOL 0.05/0.5 Eye Drops

Consumer Medicine Information (CMI) summary

The full CMI on the next page has more details. If you are worried about using this medicine, speak to your doctor or pharmacist.

1. Why am I using APO-LATANOPROST/TIMOLOL?

APO-LATANOPROST/TIMOLOL contains the active ingredient latanoprost and timolol maleate. APO-LATANOPROST/TIMOLOL eye drops are used to lower raised pressure in the eye and to treat glaucoma.

For more information, see Section 1. Why am I using APO-LATANOPROST/TIMOLOL? in the full CMI.

2. What should I know before I use APO-LATANOPROST/TIMOLOL?

Do not use if you have ever had an allergic reaction to latanoprost, timolol maleate or any of the ingredients listed at the end of the CMI.

Talk to your doctor if you have any other medical conditions, take any other medicines, or are pregnant or plan to become pregnant or are breastfeeding.

For more information, see Section 2. What should I know before I use APO-LATANOPROST/TIMOLOL? in the full CMI.

3. What if I am taking other medicines?

Some medicines may interfere with APO-LATANOPROST/TIMOLOL and affect how it works.

A list of these medicines is in Section 3. What if I am taking other medicines? in the full CMI.

4. How do I use APO-LATANOPROST/TIMOLOL?

The usual dose is one drop into the affected eye or eyes, once daily.
If you are wearing soft contact lenses, remove them before putting the drops in your eye.
If using other eye drops in addition to latanoprost/timolol, wait at least 5 minutes before putting any other drops in your eye(s).
Be careful not to touch the dropper tip against your eye, eyelid or anything else.

More instructions can be found in Section 4. How do I use APO-LATANOPROST/TIMOLOL? in the full CMI.

5. What should I know while using APO-LATANOPROST/TIMOLOL?

Things you should do	Remind any doctor, dentist or pharmacist you visit that you are using APO-LATANOPROST/TIMOLOL To make sure your medicine is working properly, have your eye pressure checked regularly. Tell your doctor if you develop an eye infection, receive an eye injury, or have eye surgery.
Things you should not do	Do not stop using this medicine suddenly or change the dosage. Do not give this medicine to anyone else, even if they have the same condition as you.
Driving or using machines	Be careful driving or operating machinery until you know how this medicine affects you.
Looking after your medicine	Before opening the eye drops, keep the bottle in its box in a refrigerator (2-8°C), protected from light. After opening the eye drops, keep the bottle in its box in a cool place where the temperature stays below 25°C, but do not refrigerate. Keep the box properly closed and protected from light.

For more information, see Section 5. What should I know while using APO-LATANOPROST/TIMOLOL? in the full CMI.

6. Are there any side effects?

There are a number of side effects associated with this medicine. Tell your doctor or pharmacist as soon as possible if you do not feel well whilst you are taking APO-LATANOPROST/TIMOLOL, even if you do not think it is connected to this medicine.

For more information, including what to do if you have any side effects, see Section 6. Are there any side effects? in the full CMI.

FULL CMI

APO-LATANOPROST/TIMOLOL 0.05/0.5 Eye Drops

Active ingredient(s): Latanoprost and Timolol maleate

Consumer Medicine Information (CMI)

This leaflet provides important information about using APO-LATANOPROST/TIMOLOL. You should also speak to your doctor or pharmacist if you would like further information or if you have any concerns or questions about using APO-LATANOPROST/TIMOLOL.

Where to find information in this leaflet:

1. Why am I using APO-LATANOPROST/TIMOLOL?
2. What should I know before I use APO-LATANOPROST/TIMOLOL?
3. What if I am taking other medicines?
4. How do I use APO-LATANOPROST/TIMOLOL?
5. What should I know while using APO-LATANOPROST/TIMOLOL?
6. Are there any side effects?
7. Product details

1. Why am I using APO-LATANOPROST/TIMOLOL?

APO-LATANOPROST/TIMOLOL contains the active ingredient latanoprost and timolol maleate. APO-LATANOPROST/TIMOLOL are used to lower raised pressure in the eye and to treat glaucoma.

Latanoprost belongs to a group of medicines called prostaglandin agonists. Timolol maleate belongs to a group of medicines called beta-blockers.

Glaucoma is a condition in which the pressure of fluid in the eye may be high, damaging the back of the eye to result in gradual loss of sight. There are usually no symptoms of glaucoma. Untreated glaucoma can lead to serious problems, including total blindness.

How it works

Latanoprost and timolol work together to reduce the amount of fluid in the eye, allowing the eye to return to a normal pressure.

Although APO-LATANOPROST/TIMOLOL helps control your glaucoma it does not cure it. So you must keep using it until your doctor tells you to stop.

2. What should I know before I use APO-LATANOPROST/TIMOLOL?

Warnings

Do not use APO-LATANOPROST/TIMOLOL if:

You are allergic to latanoprost, timolol, or any of the ingredients listed at the end of this leaflet.
Always check the ingredients to make sure you can use this medicine.
Do not take this medicine if you have or have had any of the following medical conditions:
- asthma, or a history of asthma, COPD (emphysema) or other breathing problems.
- certain heart conditions, such as a very slow heart rate, an irregular heartbeat or heart failure.

Check with your doctor if you:

Have any other medical conditions:
- heart disease
- lung disease
- circulation problems
- other types of glaucoma or eye conditions
- diabetes
- myasthenia gravis
- hyperthyroidism
Take any medicines for any other condition.
Tell your doctor if you are planning to have surgery.

During treatment, you may be at risk of developing certain side effects. It is important you understand these risks and how to monitor for them. See additional information under Section 6. Are there any side effects?

Do not take this medicine after the expiry date printed on the pack or if the packaging is torn or shows signs of tampering.

If it has expired or is damaged, return it to your pharmacist for disposal.

Pregnancy and breastfeeding

Check with your doctor if you are pregnant or intend to become pregnant.

There is no adequate experience with this medicine in pregnant women.

Talk to your doctor if you are breastfeeding or intend to breastfeed.

One of the active ingredients in the medicine has been detected in breast milk. Because of the potential harm to the infant, nursing women should either stop using the eye drops or stop breastfeeding while using it.

3. What if I am taking other medicines?

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

Some medicines may interfere with APO-LATANOPROST/TIMOLOL and affect how it works.

These include:

Certain medicines used to treat high blood pressure or heart conditions or irregular heartbeats (e.g. beta-blockers, calcium channel blockers, digoxin, amiodarone, quinidine).
Some medicines used to treat depression (e.g. phenelzine, fluoxetine, paroxetine).
Some medicines used to treat Parkinson's disease (e.g. selegiline).
Adrenaline, used to treat asthma, slow or irregular heartbeat, acute allergic disorders and glaucoma.
Some medicines used to help you pass urine or restore normal bowel movements.
Narcotics used to treat moderate to severe pain (e.g. morphine).
Eye drops which contain an ingredient called thiomersal. If using such eye drops as well as latanoprost/timolol eye drops, you should wait at least 5 minutes between using the eye drops and latanoprost/timolol eye drops.
Medicines used to treat diabetes or high blood sugar.
Some other eye drops that contain a beta-blocker or a prostaglandin. The use of two or more beta-blocker eye drops and/or two or more prostaglandin eye drops at the same time is not recommended.

Check with your doctor or pharmacist if you are not sure about what medicines, vitamins or supplements you are taking and if these affect APO-LATANOPROST/TIMOLOL.

4. How do I use APO-LATANOPROST/TIMOLOL?

How much to use

The usual dose is one drop into the affected eye, or eyes, once daily.

When to use APO-LATANOPROST/TIMOLOL

Use the eye drops every day, at about the same time each day.

Using your eye drops at the same time each day will have the best effect on your eye pressure. It will also help you remember when to use the eye drops.

How to use APO-LATANOPROST/TIMOLOL

If you are wearing soft contact lenses, remove them before putting the drops in your eye.

The preservative in the eye drops (benzalkonium chloride) may be deposited in soft contact lenses. You can put your soft contact lenses back into your eyes 15 minutes after you have used the eye drops.

If using other eye drops in addition to latanoprost/timolol, wait at least 5 minutes before putting any other drops in your eye(s).

Be careful not to touch the dropper tip against your eye, eyelid or anything else.

Touching the dropper tip against something may contaminate the eye drops or give you an eye infection.

You may find it easier to put drops in your eye while you are sitting or lying down.

Wash your hands well with soap and water.
Twist off the protective overcap from the bottle.
Unscrew the inner cap.
Use your finger to gently pull down the lower eyelid of your affected eye.
Tilt your head back and look up.
Place the tip of the bottle close to but not touching your eye. Squeeze the bottle gently so that only one drop goes into your eye, then release the lower eyelid. Close your eye. Do not blink or rub your eye.
While your eye is closed, place your index finger against the inside corner of your eye and press against your nose for about two minutes. This will help to stop the medicine from draining through the tear duct to the nose and throat, from where it can be absorbed into other parts of your body. Ask your doctor for more specific instructions on this technique.
Screw the inner cap back on the bottle.
Wash your hands again with soap and water to remove any residue.

You may feel a slight burning sensation in the eye shortly after using the eye drops.

If this feeling persists, or is very uncomfortable, contact your doctor or pharmacist.

How long to take it for

Continue using the eye drops for as long as your doctor tells you.

Although latanoprost/timolol eye drops help control your glaucoma, it does not cure it. It is important to keep using it until your doctor tells you to stop.

If you forget to use APO-LATANOPROST/ TIMOLOL

APO-LATANOPROST/TIMOLOL should be used regularly at the same time each day.

If it is almost time for your next dose, skip the dose you missed and take your next dose when you are meant to.

Do not take a double dose to make up for the dose you missed.

If you use too much APO-LATANOPROST/ TIMOLOL

If you accidently put several drops in your eye(s) immediately rinse your eye(s) with warm water.

You should immediately:

phone the Poisons Information Centre
(by calling 13 11 26), or
contact your doctor, or
go to the Emergency Department at your nearest hospital.

You should do this even if there are no signs of discomfort or poisoning.

If latanoprost/timolol eye drops are accidently swallowed or if you use too many drops, you may feel:

light-headed or dizzy, faintness
very slow pulse rate
wheezing or difficulty in breathing
headache, nausea, abdominal pain, fatigue
hot flushes and sweating

5. What should I know while using APO-LATANOPROST/TIMOLOL?

Things you should do

To make sure your medicine is working properly, have your eye pressure checked regularly. Have your eyes checked regularly for any other changes, including a change in eye colour.

A slow change in eye colour, which may be permanent, has been reported to occur in some patients who use latanoprost/timolol eye drops. Your doctor will decide whether you should continue using the eye drops.

Call your doctor if you:

Develop an eye infection, receive an eye injury, or have eye surgery.

Your doctor may tell you to use a new container of the eye drops because of possible contamination of the old one or may advise you to stop your treatment with latanoprost/timolol.

Remind any doctor, dentist or pharmacist you visit that you are using APO-LATANOPROST/TIMOLOL.

Things you should not do

Do not stop using this medicine suddenly.
If you stop using the eye drops, your eye pressure may rise again and damage to your eyes may occur.
Do not give this medicine to anyone else, even if they have the same condition as you.
Do not take your medicine to treat any other complaint unless your doctor tells you to.

Driving or using machines

Be careful before you drive or use any machines or tools until you know how APO-LATANOPROST/TIMOLOL affects you.

These eye drops generally do not cause any problems with your ability to drive a car or operate machinery. However, it may cause blurred vision in some people. Make sure you know how you react to the eye drops or that your vision is clear before driving a car or operating machinery.

Looking after your medicine

Keep your medicine in its bottle until it is time to take it.
Before opening the eye drops, keep the bottle in its box in a refrigerator (2-8°C), protected from light.
After opening the eye drops, keep the bottle in its box in a cool place where the temperature stays below 25°C, but do not refrigerate. Keep the box properly closed and protected from light.
Do not store your medicine, or any other medicine, in the bathroom or near a sink. Do not leave it on a windowsill or in the car. Do not store the eye drops in pockets of your clothes.
Heat and dampness can destroy some medicines.
Put the top on the bottle right away after use to avoid contaminating the eye drops.

Store it in a cool dry place away from moisture, heat or sunlight; for example, do not store it:

in the bathroom or near a sink,
in the car or on window sills or,
Do not store the eye drops in pockets of your clothes.

Keep it where young children cannot reach it.

When to discard your medicine

Write the date on the bottle when you open the eye drops and throw out any remaining solution after four weeks. Open a new bottle every 4 weeks.

Eye drops contain a preservative which helps prevent germs growing in the solution for the first four weeks after opening the bottle. After this time there is a greater risk that the drops may become contaminated and cause an eye infection.

If your doctor tells you to stop taking this medicine or the expiry date has passed, ask your pharmacist what to do with the remaining solution.

Getting rid of any unwanted medicine

If you no longer need to use this medicine or it is out of date, take it to any pharmacy for safe disposal.

Do not use this medicine after the expiry date.

6. Are there any side effects?

All medicines can have side effects. If you do experience any side effects, most of them are minor and temporary. However, some side effects may need medical attention.

See the information below and, if you need to, ask your doctor or pharmacist if you have any further questions about side effects.

Less serious side effects

Less serious side effects

What to do

A slow change in eye colour over a period of time. The iris may become browner in colour and appear darker. This change may be permanent and more noticeable if you are only being treated in one eye
Blurred vision, double vision or other visual problems
Allergic reactions including redness, swelling and/or itching of the eye
Burning, grittiness or stinging of the eyes
Eye pain
Redness or watering of the eye(s)
Irritation or feeling of having something in the eye, dry eyes
Discharge, itching of the eye(s), crusty eyelashes
Drooping eye lid(s)
Darkening, thickening, lengthening or increase in the number of lashes and fine hair on the eyelids
Misdirected eye lashes sometimes causing eye irritation
Darkening of the skin of the eyelids
Crusting, redness, thickening, itching or burning eye lids
Sensitivity to light
Headache
Tiredness, weakness, sleepiness
Ringing or buzzing in the ears
Difficulty sleeping, nightmares
Change in mood such as depression, anxiety or nervousness
Confusion, disorientation or memory loss
Hallucinations
stomach complaints, including nausea, vomiting, pain, diarrhoea
Loss of appetite
Dry mouth
Change to sense of taste
Cold hands or feet, numbness or tingling in the fingers or toes
Numbness, tingling and colour change (white, blue then red) in fingers when exposed to the cold (Raynaud's Phenomenon)
Numbness or tingling in the fingers or toes
Cough
Nasal congestion
Hair loss or thinning
Less desire for sex, impotence or sexual dysfunction
Muscle or joint pain
Skin rash

Speak to your doctor if you have any of these less serious side effects and they worry you.

Serious side effects

Serious side effects	What to do
Fast irregular heartbeat Dizziness and light headedness, which may be due to low blood pressure Skin rash, itching Swelling of hands, feet ankles or legs	Call your doctor straight away, or go straight to the Emergency Department at your nearest hospital if you notice any of these serious side effects.

Very serious side effects

Very serious side effects

What to do

Wheezing, difficulty in breathing (asthma or worsening asthma)
Shortness of breath; swelling of the face, lips, tongue, throat, which may cause difficulty in swallowing or breathe, or other parts of the body; rash, itching or hives on the skin (signs of an allergic reaction)
Very slow pulse, chest pain
Fainting
Severe and sudden onset of pinkish, itchy swellings on the skin, also called hives or nettle rash
White deposits or plaque in the cornea causing the transparent front part of your eye to look white or cloudy.

Go straight to the Emergency Department at your nearest hospital if you notice any of these very serious side effects.

Tell your doctor or pharmacist if you notice anything else that may be making you feel unwell.

Other side effects not listed here may occur in some people.

Reporting side effects

After you have received medical advice for any side effects you experience, you can report side effects to the Therapeutic Goods Administration online at www.tga.gov.au/reporting-problems. By reporting side effects, you can help provide more information on the safety of this medicine.

Always make sure you speak to your doctor or pharmacist before you decide to stop taking any of your medicines.

7. Product details

This medicine is only available with a doctor's prescription.

What APO-LATANOPROST/TIMOLOL contains

Active ingredient (main ingredient)	Each 1 mL of the eye drops contains 50 micrograms of latanoprost and 5 mg timolol (equivalent to 6.83 mg timolol maleate). Each drop contains 1.5 micrograms of latanoprost and 150 micrograms of timolol.
Other ingredients (inactive ingredients)	Sodium chloride Monobasic sodium phosphate dihydrate Dibasic sodium phosphate dodecahydrate Benzalkonium chloride (as a preservative) Hydrochloric acid or sodium hydroxide (for pH adjustment) Purified water

Do not take this medicine if you are allergic to any of these ingredients.

What APO-LATANOPROST/TIMOLOL looks like

APO-LATANOPROST/TIMOLOL is clear and colourless solution in a 5 mL plastic bottle with a dropper and screw cap. (AUST R 304898).

When you first receive the eye drop bottle, it will appear half-full. This corresponds to 2.5 mL of eye drop solution, giving a minimum of 80 drops. This volume is enough to last 4 weeks if used in both eyes.

Who distributes APO-LATANOPROST/TIMOLOL

Arrotex Pharmaceuticals Pty Ltd
15-17 Chapel Street
Cremorne VIC 3121

This leaflet was prepared in August 2024

Published by MIMS October 2024

BRAND INFORMATION

Brand name

APO-Latanoprost/Timolol

Active ingredient

Latanoprost; Timolol

Schedule

1 Name of Medicine

Latanoprost and timolol maleate.

2 Qualitative and Quantitative Composition

The active ingredients in APO-Latanoprost/Timolol eye drops are latanoprost and timolol maleate. APO-Latanoprost/Timolol eye drops is a sterile, isotonic solution containing 50 micrograms/mL of latanoprost and 5 mg/mL of timolol (6.83 mg timolol maleate) in an aqueous buffer solution of pH 6.0.
Each 5 mL bottle contains 2.5 mL of the eye drop solution corresponding to a minimum of 80 drops of solution. One drop contains approximately 1.5 microgram latanoprost and 150 microgram timolol.
For the full list of excipients, see Section 6.1 List of Excipients.

3 Pharmaceutical Form

Eye drops, solution.
The solution is a clear and colourless liquid, filled in a polyethylene container.

4 Clinical Particulars

4.1 Therapeutic Indications

Reduction of elevated intraocular pressure in patients with open angle glaucoma and ocular hypertension who are insufficiently responsive to beta-blockers, prostaglandins or other intraocular pressure lowering medications. Latanoprost/timolol eye drops should not be used to initiate therapy.

4.2 Dose and Method of Administration

Dosage.

Recommended dosage for adults (including the elderly).

Recommended therapy is one eye drop in the affected eye(s) once daily. If one dose is missed, treatment should continue with the next dose as normal.
The use of latanoprost and timolol eye drops may be considered in patients who require both timolol and latanoprost, but it is unknown whether patients who are adequately controlled with timolol given twice daily plus latanoprost given once daily will be as well controlled with latanoprost and timolol eye drops given once daily. Latanoprost and timolol eye drops should not be used to initiate therapy.
Latanoprost and timolol eye drops should not be given more than once daily because latanoprost is most effective at this dosage. If there is inadequate response to latanoprost and timolol eye drops, consideration should be given to using the individual agents with timolol dose twice daily.

Method of administration.

Each bottle is for individual patient use only. Discard 4 weeks after opening.
If more than one topical ophthalmic drug is being used, the eye drop products should be administered at least 5 minutes apart.
Systemic absorption can be minimised by pressure on the tear duct immediately after application of the eye drop.

Use with contact lenses.

The contact lenses should be removed before instillation of the eye drops and may be reinserted after 15 minutes (see Section 4.4 Special Warnings and Precautions for Use).

4.3 Contraindications

Reactive airway disease including bronchial asthma, a history of bronchial asthma, or severe chronic obstructive pulmonary disease.
Sinus bradycardia, sick sinus syndrome, sinoatrial block, second or third degree atrioventricular block, overt cardiac failure, or cardiogenic shock.
Known hypersensitivity to any component in latanoprost/timolol eye drops.

4.4 Special Warnings and Precautions for Use

Systemic effects.

Cardiovascular/respiratory reactions.

Like other topically applied ophthalmic agents, latanoprost/timolol eye drops may be absorbed systemically. Due to the beta-adrenergic component timolol, the same types of adverse reactions seen with systemic beta-blockers may occur including aggravation of Prinzmetal's angina, aggravation of severe peripheral and central circulatory disorders, bradycardia and hypotension.
Respiratory and cardiac reactions, including death due to bronchospasm in patients with asthma and, death associated with cardiac failure have been reported following administration of timolol. Cardiac failure should be adequately controlled before treatment. Patients with a history of severe cardiac disease should be monitored closely for signs of cardiac failure.
Due to its negative effect on conduction time, beta-blockers should only be given with caution to patients with first degree heart block.
Patients with severe peripheral circulatory disturbance/disorders (i.e. severe forms of Raynaud's disease or Raynaud's syndrome) should be treated with caution.
Timolol maleate should be used with caution, in patients with mild/moderate chronic obstructive pulmonary disease (COPD) and only if the potential benefit outweighs the potential risk.
A gradual withdrawal of beta-adrenergic blocking agents prior to major surgery may be considered. Beta-adrenergic blocking agents impair the ability of the heart to respond to beta-adrenergically mediated reflex stimuli, which may augment the risk of general anaesthesia in surgical procedures. Protracted severe hypotension during anaesthesia and difficulty restarting and maintaining the heartbeat, have been reported. During surgery, the effects of beta-adrenergic blocking agents may be reversed by sufficient doses of adrenergic agonists.
Beta-blocking ophthalmological preparations may block systemic beta-agonist effects e.g. of adrenaline. The anaesthesiologist should be informed when the patient is receiving timolol.

Hypersensitivity reactions.

While taking beta-blockers, patients with a history of atopy or a history of severe anaphylactic reaction to a variety of allergens may be more reactive to repeated challenge with such allergens, either accidental, diagnostic or therapeutic. Such patients may be unresponsive to the usual doses of adrenaline used to treat anaphylactic reactions.

Concomitant therapy.

Timolol may interact with other drugs (also see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).
The effect on intraocular pressure or the known effects of systemic beta-blockade may be exaggerated when latanoprost/timolol eye drops are given to patients already receiving an oral beta-blocking agent. There have been reports of paradoxical elevations in IOP following the concomitant ophthalmic administration of two prostaglandin analogues. Therefore, the use of two or more local beta-blockers or two or more local prostaglandins, prostaglandin analogues, or prostaglandin derivatives is not recommended.

Hypoglycaemia.

Beta-blockers should be administered with caution in patients subject to spontaneous hypoglycaemia or to diabetic patients (especially those with labile diabetes) who are receiving insulin or oral hypoglycaemic agents. Beta-blockers may increase the hypoglycaemic effect of agents used to treat diabetes and may mask the signs and symptoms of acute hypoglycaemia.

Hyperthyroidism.

Therapy with beta-blockers may mask certain signs and symptoms of hyperthyroidism and abrupt withdrawal of therapy may precipitate a worsening of symptoms.

Myasthenia gravis.

Therapy with beta-blockers may aggravate symptoms of myasthenia gravis.

Ocular effects.

Iris pigmentation changes.

Latanoprost may gradually change the eye colour by increasing the amount of brown pigment in the iris. This effect has predominantly been seen in patients with mixed coloured irides, i.e. green brown, yellow brown or blue/grey brown, and is due to increased melanin content in the stromal melanocytes of the iris. Typically the brown pigmentation around the pupil spreads concentrically towards the periphery in affected eyes, but the entire iris or parts of it may become more brownish. In patients with homogenously blue, grey, green or brown eyes, the change has only rarely been seen during two years of treatment in clinical trials with latanoprost.
The change in iris colour occurs slowly and may not be noticeable for several months to years and it has not been associated with any symptom or pathological changes.
No further increase in brown iris pigment has been observed after discontinuation of treatment, but the resultant colour change may be permanent.
Neither naevi nor freckles of the iris have been affected by treatment.
Accumulation of pigment in the trabecular meshwork or elsewhere in the anterior chamber has not been observed but patients should be examined regularly and, depending on the clinical situation, treatment may be stopped if increased iris pigmentation ensues.
Before treatment is instituted patients should be informed of the possibility of a change in eye colour. Unilateral treatment can result in permanent heterochromia.

Eyelid and eyelash changes.

Eyelid skin darkening, which may be reversible, has been reported in association with the use of latanoprost.
Latanoprost may gradually change eyelashes and vellus hair in the treated eye; these changes include increased length, thickness, pigmentation, and number of lashes or hairs, and misdirected growth of eyelashes. Eyelash changes are reversible upon discontinuation of treatment.

Glaucoma.

There is no or limited experience with latanoprost or latanoprost/timolol in inflammatory, neovascular, chronic angle closure or congenital glaucoma, in open angle glaucoma of pseudophakic patients and in pigmentary glaucoma. Latanoprost has no or little effect on the pupil but there is no experience in acute attacks of closed angle glaucoma. Therefore it is recommended that the eye drops should be used with caution in these conditions until more experience is obtained.

Herpetic keratitis.

Latanoprost should be used with caution in patients with a history of herpetic keratitis, and should be avoided in cases of active herpes simplex keratitis and in patients with a history of recurrent herpetic keratitis specifically associated with prostaglandin analogues.

Macular oedema.

Macular oedema, including cystoid macular oedema, has been reported during treatment with latanoprost. These reports have mainly occurred in aphakic patients, in pseudophakic patients with a torn posterior lens capsule, or in patients with known risk factors for macular oedema. Latanoprost/timolol eye drops should be used with caution in these patients.

Choroidal detachment and corneal disease.

Choroidal detachment after filtration procedures has been reported with the administration of ocular hypotensive agents.
Ophthalmic beta-blockers may induce dryness of eyes. Patients with corneal diseases should be treated with caution.

Use of contact lenses.

Latanoprost/timolol eye drops contains benzalkonium chloride which may be absorbed by contact lenses. Several contact lens soaking solutions contain thiomersal which may also form a precipitate with the benzalkonium chloride (see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions). Therefore contact lenses should be removed before instillation of the eye drops and may be reinserted after 15 minutes.

Use in the elderly.

See Section 4.2 Dose and Method of Administration.

Paediatric use.

Latanoprost/timolol eye drops is not recommended for use in children. Safety and effectiveness in children have not been established.

Effects on laboratory tests.

No data available.

4.5 Interactions with Other Medicines and Other Forms of Interactions

No specific interaction studies have been performed with latanoprost/timolol eye drops.
The potential exists for additive effects resulting in hypotension, and/or marked bradycardia when timolol ophthalmic drops are administered with oral calcium channel blockers, catecholamine depleting drugs or beta-adrenergic blocking agents, antiarrhythmics (including amiodarone and quinidine), digitalis glycosides, parasympathomimetics, narcotics and monoamine oxidase (MAO) inhibitors.
Potentiated systemic beta-blockade (e.g. decreased heart rate, depression) has been reported during combined treatment with CYP2D6 inhibitors (e.g. quinidine, fluoxetine, paroxetine) and timolol.
Although the eye drops alone has little or no effect on pupil size, mydriasis has occasionally been reported when timolol is given with adrenaline.
Beta-blockers may increase the hypoglycaemic effect of antidiabetic agents (see Section 4.4 Special Warnings and Precautions for Use, Hypoglycaemia).
In vitro studies have shown that precipitation occurs when eye drops containing thiomersal are mixed with benzalkonium chloride, the preservative used in latanoprost/timolol eye drops. If such drugs are used they should be administered with an interval of at least five (5) minutes between applications. Similarly several contact lens soaking solutions contain thiomersal (see Section 4.4 Special Warnings and Precautions for Use, Use of contact lenses).

4.6 Fertility, Pregnancy and Lactation

Effects on fertility.

Fertility studies with latanoprost/timolol eye drops have not been conducted. Latanoprost or timolol maleate alone had no effects on male or female fertility in rats when administered at 250 microgram/kg/day IV or 300 mg/kg/day PO respectively.
(Category C)
Embryofoetal development studies with latanoprost have been performed in rats and rabbits. Latanoprost and/or its metabolites cross the placenta of rats. In rabbits, latanoprost caused embryofoetal toxicity characterised by increased incidences of late resorption and reduced foetal weight at 5 microgram/kg/day IV and total litter resorption at > 50 microgram/kg/day IV. No embryofoetal effects were seen in rabbits at 1 microgram/kg/day IV and in rats at up to 250 microgram/kg/day IV.
Timolol maleate was not teratogenic in mice, rats and rabbits. Embryofoetal development studies with timolol maleate in mice and rabbits showed no evidence of embryofoetal toxicity at oral doses up to 50 mg/kg/day. At higher doses, increases in resorptions and foetal variations (14 ribs and hypoplastic sternebrae) were noted in mice (1000 mg/kg/day) and increased resorption in rabbits (> 90 mg/kg/day). In rats, delayed ossification was seen at > 50 mg/kg/day and a decreased number of caudal vertebral bodies and arches and an increase in hypoplastic sternebrae were noted at 500 mg/kg/day.
There are no adequate and well controlled studies in pregnant women. Therefore, latanoprost/timolol eye drops should not be used during pregnancy.
There are limited experimental animal and no human data available on the pharmacokinetics of latanoprost in lactation. Latanoprost and its metabolites may pass into breast milk.
Timolol maleate has been detected in human milk following oral and ocular administration. Because of the potential for serious adverse reactions from latanoprost/timolol eye drops in nursing infants, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.

4.7 Effects on Ability to Drive and Use Machines

In common with other eye preparations, instillation of eye drops may cause transient blurring of vision. Until this has resolved, patients should not drive or use machines.

4.8 Adverse Effects (Undesirable Effects)

No adverse events specific for latanoprost/timolol eye drops have been observed in clinical studies. The adverse events have been limited to those earlier reported for latanoprost and timolol.

Adverse events from clinical trials.

Adverse events occurring at a frequency of ≥ 1% in three randomised, double blind comparative trials (004, 005 and 053) are presented in Tables 1 and 2.

The following additional adverse events have been reported with the single component latanoprost:

Eye disorder.

Eye irritation (burning, grittiness, itchiness, stinging, tearing, redness and foreign body sensation), punctate keratitis, macular oedema, corneal oedema, corneal erosions, eyelash and vellus hair changes of the eyelid (increased length, thickness, pigmentation, and number of eyelashes), trichiasis, blurred vision, periorbital and lid changes resulting in deepening of the eyelid sulcus, darkening of the palpebral skin of the eyelid, localized skin reactions on the eyelid.

Respiratory, thoracic and mediastinal disorders.

Asthma, asthma aggravation and acute asthma attacks.

Skin and subcutaneous tissue disorders.

Rash.

Musculoskeletal and connective tissue disorders.

Myalgia, arthralgia.

General disorders and administration site conditions.

Chest pain.

Infections and infestations.

Herpetic keratitis.
The following additional adverse events have been reported with the single component timolol by ocular administration:

Eye disorders.

Visual disturbances including refractive changes, hypoaesthesia eye, signs and symptoms of ocular irritation (e.g. burning, stinging, itching, tearing, redness), vision blurred, dry eyes, corneal erosion, diplopia, ptosis, choroidal detachment (following filtration surgery).

Ear and labyrinth disorders.

Tinnitus.

Cardiovascular disorders.

Bradycardia, arrhythmia, atrioventricular block, hypotension, heart block, congestive heart failure, palpitation, cardiac arrest, cardiac failure, worsening of angina pectoris.

Vascular disorder.

Claudication, cold hands and feet, hypotension, Raynaud's phenomenon.

Respiratory, thoracic and mediastinal disorders.

Bronchospasm (predominantly in patients with pre-existing bronchospastic disease), respiratory failure, pulmonary oedema and nasal congestion.

General disorders and administration site conditions.

Asthenia, fatigue and oedema.

Skin and subcutaneous tissue disorders.

Alopecia, pseudopemphigoid, psoriasiform rash or exacerbation of psoriasis.

Immune system disorders.

Signs and symptoms of allergic reactions including anaphylaxis, angioedema, urticaria, pruritus, localised and generalised rash.

Nervous system disorders.

Cerebral vascular accident, cerebral ischaemia, increase in signs and symptoms of myasthenia gravis, paraesthesia, somnolence, headache, syncope.

Psychiatric disorders.

Nightmares, behavioural changes and psychiatric disturbances including confusion, hallucinations, anxiety, disorientation, nervousness and memory loss.

Gastrointestinal disorders.

Nausea, diarrhoea, dry mouth, dysgeusia, vomiting, abdominal pain, and retroperitoneal fibrosis.

Metabolism and nutrition disorders.

Anorexia, masked symptoms of hypoglycaemia in diabetic patients.

Musculoskeletal and connective tissue disorders.

Myalgia, systemic lupus erythematosus.

Reproductive system and breast disorder.

Decreased libido, Peyronie's disease, sexual dysfunction, and impotence.

Post-marketing experience.

The following additional adverse drug reactions have been observed post-marketing with the single component latanoprost and may also be relevant for the latanoprost and timolol combination.

Eye disorders.

Iris cyst, pseudopemphigoid of the ocular conjunctiva.

Cardiac disorders.

Unstable angina, angina, palpitations.

Gastrointestinal disorders.

Nausea, vomiting.

Skin and subcutaneous tissue disorders.

Pruritus.

Adverse reactions reported with the use of eye drops containing phosphate buffers.

Cases of corneal calcification have been reported very rarely in association with the use of phosphate-containing eye drops in some patients with significantly damaged corneas.

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 www.tga.gov.au/reporting-problems and contact Arrotex Medical Information Enquiries/Adverse Drug Reaction Reporting on 1800 195 055.

4.9 Overdose

Symptoms.

There is no human data available on overdosage with latanoprost and timolol eye drops.
There have been reports of inadvertent overdosage with timolol maleate ophthalmic solution resulting in systemic effects similar to those seen with systemic beta-adrenergic blocking agents such as dizziness, headache, shortness of breath, bradycardia, hypotension, bronchospasm, and cardiac arrest. Apart from ocular irritation and conjunctival or episcleral hyperaemia, the ocular effects of latanoprost administered at high doses are not known.

Treatment.

If overdosage with latanoprost and timolol eye drops occurs, treatment should be symptomatic and supportive. Studies have shown that timolol is not readily dialyzable. If latanoprost and timolol eye drops is accidentally ingested the following information may be useful: one bottle contains 125 microgram latanoprost and 12.5 mg timolol. Both timolol and latanoprost are extensively metabolised in the liver. More than 90% of latanoprost is metabolised during the first pass through the liver. Intravenous infusion of up to 3 microgram/kg in healthy volunteers induced no symptoms but a dose of 5.5-10 microgram/kg caused nausea, abdominal pain, dizziness, fatigue, hot flushes, and sweating. These events were mild to moderate in severity and resolved without treatment within 4 hours after terminating the infusion. In patients with bronchial asthma bronchoconstriction was not induced by latanoprost when applied topically on the eyes in a dose of seven times the clinical dose of latanoprost.
For information on the management of overdose, contact the Poisons Information Centre on 131126 (Australia).

5 Pharmacological Properties

5.1 Pharmacodynamic Properties

Mechanism of action.

The eye drop consists of two components: latanoprost and timolol maleate. These two components decrease elevated intraocular pressure (IOP) by different mechanisms of action and the combined effect results in additional IOP reduction compared to either compound administered alone.

Latanoprost.

Latanoprost is a selective prostanoid F_2α receptor agonist which reduces IOP by increasing the outflow of aqueous humour. The main mechanism of action is increased uveoscleral outflow. In addition, some increase in outflow facility (decrease in trabecular outflow resistance) has been reported in man. Latanoprost has no significant effect on the production of aqueous humour or the blood aqueous barrier. Latanoprost has no or negligible effects on the intraocular blood circulation when used at the human clinical dose, as studied in monkeys. However, mild to moderate conjunctival or episcleral hyperaemia may occur during topical treatment.
Chronic treatment with latanoprost in monkey eyes which had undergone extracapsular lens extraction did not affect the retinal blood vessels as determined by fluorescein angiography. Latanoprost has not induced fluorescein leakage in the posterior segment of pseudophakic human eyes during short-term treatment. Latanoprost in clinical doses has not been found to have any significant pharmacologic effects on the cardiovascular or respiratory systems.

Timolol.

Timolol maleate is a beta₁ and beta₂ (nonselective) adrenergic receptor blocking agent that does not have significant intrinsic sympathomimetic, direct myocardial depressant, or local anaesthetic (membrane stabilising) activity. Timolol lowers IOP by decreasing the formation of aqueous humour in the ciliary epithelium. The precise mechanism of action is not clearly established.

Latanoprost/timolol eye drops.

Onset of action of the eye drops is within one hour and maximal effect occurs within six to eight hours. Adequate IOP reducing effect has been shown to be present up to 24 hours postdosage after multiple treatments.

Clinical trials.

Two 6 month, randomised, double blind, multicentre clinical studies were conducted to compare the IOP lowering effect of latanoprost/timolol eye drops dosed once daily to latanoprost 0.005% dosed once daily and timolol 0.5% dosed twice daily.
The inclusion criteria for patients in both studies consisted of adults with diagnoses of primary open angle glaucoma, pigmentary glaucoma, capsular glaucoma or ocular hypertension. Patients previously on IOP reducing therapy required an IOP at enrolment of ≥ 25 mmHg. Patients not previously on IOP reducing therapy required an IOP of ≥ 30 mmHg on enrolment. In the two studies, 92% and 84% of patients were reported to have been on IOP reducing therapy within 3 months prior to study start. Approximately 70% of these patients were on timolol therapy.
The mean diurnal IOP lowering effect of latanoprost/timolol eye drops was greater (1 to 3 mmHg) than that produced by monotherapy with either latanoprost 0.005% or timolol 0.5%. However, there are no data to show the optimal dose of these agents in combination.
Open label extensions of the 2 studies mentioned above were conducted for up to an additional 6 months. The IOP lowering effect of latanoprost/timolol eye drops was maintained during this period.

5.2 Pharmacokinetic Properties

Latanoprost.

Absorption.

Latanoprost is an isopropyl ester prodrug which is inactive, but after hydrolysis by esterases in the cornea to the acid of latanoprost, becomes biologically active.
The prodrug is well absorbed through the cornea and all of the drug that enters the aqueous humour is hydrolysed during the passage through the cornea.

Distribution.

Studies in man indicate that the peak concentration in the aqueous humour, approximately 30 nanogram/mL, is reached about two hours after topical administration of latanoprost alone. After topical application in monkeys latanoprost is distributed primarily in the anterior segment, the conjunctivae and the eye lids. Only minute quantities of the drug reach the posterior segment.
Reduction of the intraocular pressure in man starts about three to four hours after administration of latanoprost alone and maximum effect is reached after 8 to 12 hours. Pressure reduction is maintained for at least 24 hours.
The acid of latanoprost has a plasma clearance of 0.40 L/h*kg and a small volume of distribution, 0.16 L/kg, resulting in a rapid half-life in plasma, 17 minutes. After topical ocular administration the systemic bioavailability of the acid of latanoprost is 45%. The acid of latanoprost has a plasma protein binding of 87%.

Metabolism and excretion.

There is practically no metabolism of the acid of latanoprost in the eye. The main metabolism occurs in the liver.
The main metabolites, the 1,2-dinor and 1, 2, 3, 4-tetranor metabolites, exert no or only weak biological activity in animal studies and are excreted primarily in the urine.

Timolol.

The maximum concentration of timolol in the aqueous humour is reached about 1 hour after topical administration of eye drops. Part of the dose is absorbed systemically and a maximum plasma concentration of 1 nanogram/mL is reached 10-20 minutes after topical administration of one eye drop to each eye once daily (300 microgram/day). The half-life of timolol in plasma is about 6 hours. Timolol is extensively metabolised in the liver. The metabolites are excreted in urine together with some unchanged timolol.

Latanoprost/timolol eye drops.

No pharmacokinetic interactions between latanoprost and timolol have been observed although the aqueous humour concentrations of the acid of latanoprost tended to be higher 1 to 4 hours after administration of the combination product compared to monotherapy with either agent.

5.3 Preclinical Safety Data

Genotoxicity.

Mutagenicity studies with latanoprost/timolol eye drops have not been conducted.
Latanoprost was not mutagenic in gene mutation assays in bacteria and mouse lymphoma L5178Y cells and was negative in studies of unscheduled DNA synthesis. Chromosome aberrations were observed with human lymphocytes in vitro but latanoprost did not induce micronucleus formation in vivo.
In vitro and in vivo studies with timolol maleate did not reveal a mutagenic potential.

Carcinogenicity.

Carcinogenicity studies with latanoprost/timolol eye drops have not been conducted.
Latanoprost was not carcinogenic in either rats or mice when administered by oral gavage at doses up to 170 microgram/kg/day for 24 and 20 months respectively.
No evidence of carcinogenicity was observed with timolol maleate at oral doses up to 100 mg/kg/day in rats and 50 mg/kg/day in mice. However, there was a statistically significant increase in the incidence of adrenal phaeochromocytomas in male rats administered 300 mg/kg/day. In female mice, statistically significant increases in the incidence of benign and malignant pulmonary tumours, benign uterine polyps and mammary carcinomas were found at 500 mg/kg/day. The increased incidence of mammary tumours was considered to be attributed to a species specific elevation in serum prolactin.

Animal toxicity.

No adverse ocular or systemic effects were seen in rabbits treated topically with fixed combinations of latanoprost and timolol maleate for up to 52 weeks or with concomitantly administered latanoprost and timolol ophthalmic solutions for 4 weeks.
In long-term ocular toxicity studies in monkeys, latanoprost has been shown to induce increased iris pigmentation. The pigmentation did not progress upon discontinuation of treatment. The results from preclinical studies have demonstrated that the primary mechanism of increased pigmentation is stimulation of melanin production in melanocytes of the iris stroma. There is no evidence of melanocyte proliferation.
Long-term ocular administration of latanoprost at a dose of 6 microgram/eye/day (4 times the daily human dose) to cynomolgus monkeys has also been shown to induce an increase or widening in the palpebral fissure. This effect was reversible upon discontinuation of the drug.
Timolol maleate did not produce any adverse ocular effects in rabbits and dogs, when administered as multiple daily topical doses for up to 52 and 104 weeks, respectively.

6 Pharmaceutical Particulars

6.1 List of Excipients

Sodium chloride, monobasic sodium phosphate dihydrate, disodium phosphate dodecahydrate, purified water and benzalkonium chloride (0.20 mg/mL) as a preservative agent with sodium hydroxide or hydrochloric acid for pH adjustment.

6.2 Incompatibilities

See Section 4.5 Interactions with Other Medicines and Other Forms of Interactions.

6.3 Shelf Life

In Australia, the 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

Store unopened bottle at 2° to 8°C (Refrigerate. Do not freeze.). Protect from light.
Store opened bottle below 25°C. Protect from light. Store in the outer cardboard carton.

6.5 Nature and Contents of Container

APO-Latanoprost/Timolol eye drops is available in 5 mL low density polyethelene (LDPE) bottles containing 2.5 mL solution and supplied in packs of 1 x 2.5 mL.

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.

Latanoprost.

Latanoprost is a prostaglandin F_2α analogue. It has a molecular weight of 432.58. It is a colourless to slightly yellow oil which is practically insoluble in water, freely soluble in ethanol, ethyl acetate, isopropanol, methanol, acetone and octanol, and very soluble in acetonitrile.
Sixty four isomers of latanoprost are possible however, for Latanoprost/timolol eye drops it is purified as a single isomer.

Chemical name: isopropyl-(Z)-7[(1R,2R,3R,5S)3,5-dihydroxy-2-[(3R)-3-hydroxy-5-phenyl-1-pentyl]cyclopentyl]-5-heptenoate according to IUPAC.
Chemical formula: C₂₆H₄₀O₅.
Molecular weight: 432.58.

Timolol maleate.

Timolol maleate is a beta-adrenergic receptor blocking agent. It has a molecular weight of 432.50. It is a white to off-white crystalline powder which is soluble in water, alcohol and practically insoluble in ether.

Chemical name: (S)-1-(tert-butylamino)-3-[(4-morpholino-1,2,5-thiadiazol-3-yl)oxy]-2-propanol maleate (1:1) (salt).
Molecular weight: 432.50.

CAS number.

Latanoprost.

130209-82-4.

Timolol maleate.

26921-17-5.

7 Medicine Schedule (Poisons Standard)

S4 - Prescription Only Medicine.

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