1 Name of Medicine
Calcipotriol.
2 Qualitative and Quantitative Composition
Daivonex ointment contains calcipotriol 50 microgram per gram.
Daivonex ointment contains the anhydrous form of calcipotriol.
For full list of excipients, see Section 6.1 List of Excipients.
3 Pharmaceutical Form
Daivonex is a topical ointment. It is a smooth, white preservative free ointment base.
4.1 Therapeutic Indications
Daivonex ointment is indicated for the topical treatment of chronic stable plaque type psoriasis vulgaris, in adults and children (see Section 4.4 Special Warnings and Precautions for Use, Paediatric population). In adult patients, Daivonex ointment may also be used in combination with systemic acitretin or ciclosporin.
4.2 Dose and Method of Administration
Adults.
Daivonex ointment therapy.
Daivonex ointment should be applied topically to the affected area once or twice daily (i.e. in the morning and/or in the evening). Initially, twice daily application of the ointment is usually preferred. Application may then be reduced to once daily, provided individual clinical response is satisfactory. After satisfactory improvement has occurred, treatment should be discontinued.
If recurrence develops after reduction in frequency of application or after discontinuation, the treatment may be reinstituted at the initial dosage. Experience is lacking in the use of calcipotriol for periods longer than 1 year.
The maximum recommended weekly dose of Daivonex ointment is 100 g/week. When using a combination of ointment and cream the total maximum dose should not exceed 100 g per week.
It should be noted that there are no long-term clinical studies assessing the safety of using Daivonex ointment during exposure to sunlight. Therefore, all psoriasis-affected areas treated with calcipotriol should be, where possible, protected from direct sunlight and UV light with items of clothing. Furthermore, topical calcipotriol should only be used with UV radiation if the physician and patient consider that the potential benefits outweigh the potential risks.
Combination therapy.
Twice daily application of Daivonex ointment in combination with systemic ciclosporin or acitretin has been shown to enhance the efficacy of ciclosporin or acitretin (see Section 5.1 Pharmacodynamic Properties, Clinical trials).
Paediatric population.
Daivonex ointment therapy. Children under 6 years.
There is limited experience of using Daivonex ointment in this age group. A maximum safe dose has not been established.
Children aged 6 to 12 years.
Daivonex ointment should be applied to the affected area twice daily. Maximum weekly dose should not exceed 50 g.
Children over 12 years.
Daivonex ointment should be applied to the affected area twice daily. Maximum weekly dose should not exceed 75 g.
Combination therapy. There is no experience of use of Daivonex ointment in combination with other therapies for psoriasis in children.
Daivonex ointment should not be used for more than 8 weeks in children.
Method of administration.
Daivonex ointment is indicated for topical use only and not for ophthalmic use.4.3 Contraindications
Allergic sensitisation to any constituent of Daivonex ointment.
Patients with known disorders of calcium metabolism.
Not for ophthalmic use.
4.4 Special Warnings and Precautions for Use
In view of the risk of hypercalcaemia secondary to excessive absorption of calcipotriol when there is extensive skin involvement, Daivonex ointment should not be used for severe extensive psoriasis. In children under 6 years, the maximum safe dose has not been established; in children 6 to 12 years, the maximum weekly dose should not exceed 50 g; and in children over 12 years, the maximum weekly dose should not exceed 75 g. In adults, the maximum dosage of 100 g ointment per week should not be exceeded. When using a combination of ointment and cream the total maximum dose should not exceed 100 g per week.
Daivonex ointment is not recommended for use in patients with generalised pustular psoriasis, guttate psoriasis and erythrodermic exfoliative psoriasis.
Daivonex ointment is not recommended for use on the face since it may give rise to itching and erythema of the facial skin. Patients should be instructed to wash their hands after using Daivonex ointment to avoid inadvertent transfer of ointment to the face from other body areas. Should facial dermatitis develop in spite of these precautions, calcipotriol therapy should be discontinued.
Daivonex ointment should be used cautiously in skin folds, where the natural occlusion may give rise to an increase of any irritant effect of calcipotriol. Occlusive dressings should not be used as they may increase absorption of calcipotriol.
Treatment with Daivonex ointment in adults in the recommended amounts up to 100 g/week for 1 year does not generally result in changes in laboratory values. Hypercalcaemia has been reported rarely at the recommended dose (i.e. up to 100 g/week) of Daivonex ointment when used for the approved indication. Serum calcium and renal function should be monitored at 3 monthly intervals during periods of usage of topical calcipotriol. If the serum calcium level is observed to be elevated, treatment with Daivonex ointment should be discontinued and the condition should be treated appropriately. The levels of serum calcium should be measured once weekly until the serum calcium levels return to normal values.
Treatment with Daivonex ointment should be discontinued after satisfactory improvement has occurred and may be restarted if recurrence should develop after discontinuation.
The use of Daivonex ointment for continuous treatment periods exceeding 1 year has not been studied.
The stability of calcipotriol in sunlight and UV light has not been demonstrated. No clinical trials have been conducted with calcipotriol in Australia, where there is a potential to be exposed to high levels of UV radiation. Therefore, treated areas should be protected from sunlight and UV light, particularly where exposure may be considerable for reasons such as occupation. Furthermore, topical calcipotriol should only be used with UV radiation if the physician and patient consider that the potential benefits outweigh the potential risks.
The decision to administer Daivonex ointment in combination with systemic or physical therapy requires careful consideration. Information on the dosages and risks associated with systemic or physical therapies can be found in the product information documents for the respective systemic therapies, or in standard texts, which should be consulted. Systemic or physical therapy poses serious risks of toxicity, and such therapy administered in combination with topical Daivonex ointment should be reserved for those adults with refractory psoriasis who are considered suitable for systemic or physical therapy.
For combination therapy with either UVA or UVB there are no safety and efficacy data beyond 10 weeks.
Use in hepatic impairment.
Safety has not been established in patients with hepatic impairment.
Use in renal impairment.
Safety has not been established in patients with renal impairment.
Use in the elderly.
No data available.
Paediatric population.
There are no long term efficacy and safety data in children. Daivonex ointment should not be used for more than 8 weeks in children.
Experience of the use of Daivonex ointment in children under 6 years of age is limited. A maximum safe dose has not been established.
In children 6 to 12 years, the maximum weekly dose should not exceed 50 g and in children over 12 years, the maximum weekly dose should not exceed 75 g.
Effects on laboratory tests.
No data available.4.5 Interactions with Other Medicines and Other Forms of Interactions
There is no experience of concomitant therapy with other topical antipsoriatic drugs applied to the same skin area.
Daivonex ointment should not be used concurrently with calcium or vitamin D supplements or with drugs which enhance the systemic availability of calcium without appropriate and regular monitoring.
4.6 Fertility, Pregnancy and Lactation
Effects on fertility.
Studies in rats, at doses up to 54 microgram/kg/day (318 microgram/m2/day) of calcipotriol, demonstrated no impairment of fertility or general reproductive performance.
(Category B1)
Safety for use in pregnancy has not been established. Studies in animals have shown an increase in the incidence of skeletal variations in rats (wavy ribs, extra ribs, incomplete development of skull bones) at oral doses of 18 mg/kg/day and in rabbits (reduced skeletal ossification) at oral doses of 36 mg/kg/day. The significance of these findings for humans is not known. Therefore Daivonex ointment should not be used during pregnancy unless benefits clearly outweigh the risks.
It is not known whether calcipotriol is excreted in breast milk, therefore, Daivonex ointment should be used during lactation only if the benefits clearly outweigh the risks.
Daivonex ointment should not be applied to the chest area during breast feeding to avoid possible ingestion by infants.4.7 Effects on Ability to Drive and Use Machines
Not relevant.
4.8 Adverse Effects (Undesirable Effects)
The estimation of the frequency of adverse reactions is based on a pooled analysis of data from clinical studies and spontaneous reporting.
The most frequently reported adverse reactions during treatment are pruritus, skin irritation and erythema.
Systemic reactions (hypercalcaemia and hypercalciuria) have been reported. The risk of developing such reactions increases if the recommended total dose is exceeded (see Section 4.4).
Adverse reactions are listed by MedDRA SOC and the individual adverse reactions are listed starting with the most frequently reported. Within each frequency grouping, adverse reactions are presented in the order of decreasing seriousness.
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.
Approximately 25% of the patients treated with Daivonex ointment* could experience an adverse reaction. These reactions are usually mild. See Table 1.
Adults.
In the clinical trial program conducted for Daivonex ointment, more than 1360 adult patients were evaluated for safety of calcipotriol. Adverse reactions following treatment with Daivonex ointment were reported in 23% of patients and it was necessary to stop calcipotriol therapy in 2% of patients.
The majority of adverse events reported with Daivonex ointment were localised to the skin at the site of application. Lesional/perilesional irritation was reported in 17% of patients, which included irritant contact dermatitis (on and around psoriatic lesions), flaking at the edge of lesions, increased sensitivity, tender psoriatic lesions and vesicles on psoriatic lesions.
2.5% of patients developed face and scalp irritation, including in studies which stipulated that calcipotriol should not be used on the face and scalp, which is likely to be related to inadvertent transfer of the ointment from other body sites. There is also the potential for allergic and hypersensitivity reactions. Photosensitivity reaction and changes in pigmentation have also been reported during therapy with Daivonex ointment.
For comparison, adverse events at the site of application were reported in 9.2% of patients receiving placebo therapy and in 10.8% of patients treated with betamethasone valerate (0.1%) ointment and in 39% of patients treated with dithranol (up to 2%).
One unconfirmed case of Koebner phenomenon has been reported and one unconfirmed case of allergic reaction to Daivonex ointment. Occasionally, hypercalcaemia has been reported, usually related to excessive (greater than 100 g/week) use of the ointment.
Paediatric population.
The safety data for topical use of Daivonex ointment in children are based on the study described under Section 5.1 Pharmacodynamic Properties, Clinical trials. The most common adverse event was lesional and perilesional irritation, as was reported in adult patients. Daivonex ointment treatment was discontinued in 2.3% of paediatric patients due to adverse events. See Table 2.
Reporting of suspected adverse reactions.
Reporting suspected adverse reactions after authorisation of the medicine is important. It allows continued monitoring of the benefit/risk balance of the medicine. Healthcare professionals are asked to report any suspected adverse reactions at www.tga.gov.au/reporting-problems.4.9 Overdose
Hypercalcaemia has been reported rarely at the recommended dose of Daivonex ointment when used for the approved indication. Excessive use may cause elevated serum calcium, which rapidly subsides when treatment is discontinued; in such cases, the monitoring of serum calcium levels once weekly until the serum calcium returns to normal levels is recommended.
Contact the Poisons Information Centre on 131 126 for further advice on overdose management.
5 Pharmacological Properties
5.1 Pharmacodynamic Properties
Mechanism of action.
Calcipotriol is a non-steroidal antipsoriatic agent, derived from vitamin D. Calcipotriol exhibits a vitamin D-like effect by competing for the 1,25(OH)2D3 receptor.
Calcipotriol is as potent as 1,25(OH)2D3, the naturally occurring active form of vitamin D, in regulating cell proliferation and cell differentiation, but much less active than 1,25(OH)2D3 in its effect on calcium metabolism.
Calcipotriol induces differentiation and suppresses proliferation (without any evidence of a cytotoxic effect) of keratinocytes, thus reversing the abnormal keratinocyte changes in psoriasis. The therapeutic goal envisaged with calcipotriol is thus a normalisation of epidermal growth.
Clinical trials.
Clinical trials with Daivonex ointment undertaken in adults and children are summarised below.
Topical treatment of psoriasis in adults using twice daily calcipotriol 50 microgram/g ointment regimen.
Two double-blind, multicentre, randomised studies assessed the efficacy and safety of calcipotriol ointment 50 microgram/g twice daily vs betamethasone 17-valerate ointment 0.1% twice daily in patients with psoriasis. The mean study duration was 6 weeks. The primary efficacy endpoint was the percentage reduction of the Psoriasis Area and Severity Index (PASI) score. The mean reduction in PASI score was statistically significant (p < 0.001) favouring calcipotriol in one study (MC 288); there was no significant difference between treatments in the second study (MC 188). See Table 3.
Topical treatment of psoriasis in adults using once daily calcipotriol 50 microgram/g regimen.
Two double-blind, multicentre, randomised, vehicle-controlled studies of 8 weeks duration assessed the efficacy and safety of calcipotriol ointment 50 microgram/g once daily. Efficacy was assessed using the Psoriasis Grading Scale to score erythema, scaling, plaque elevation and overall severity. The primary efficacy parameter was the plaque elevation subscore. There was a statistically significant difference (p < 0.001) favouring calcipotriol. See Table 4.
Calcipotriol treatment of psoriasis with ciclosporin A in adults.
One double-blind, randomised, multicentre, vehicle-controlled study assessed the efficacy and safety of calcipotriol ointment 50 microgram/g twice daily with ciclosporin 2 mg/kg/day in patients with severe psoriasis for 6 weeks. Change in PASI score was the primary efficacy endpoint. There was a statistically significant difference (p < 0.01) favouring combination therapy. See Table 5.
Calcipotriol treatment of psoriasis with acitretin in adults.
One double-blind, multicentre, randomised, vehicle-controlled study assessed the efficacy and safety of calcipotriol ointment 50 microgram/g twice daily with acitretin (20-70 mg/day) for 12 weeks in patients with severe/extensive psoriasis unresponsive to topical treatment alone. The percentage of patients achieving marked improvement or clearance at the end of treatment was the primary efficacy endpoint. There was a statistically significant difference (p < 0.01) favouring combination therapy. See Table 6.
Paediatric population. Topical treatment of psoriasis in children using twice daily calcipotriol 50 microgram/g ointment.
One double-blind, multicentre, randomised, vehicle-controlled study assessed the safety and efficacy of calcipotriol 50 microgram/g ointment in children of 2 to 14 years with mild to moderate psoriasis not involving more than 30% of the body surface area.
The study was of 8 weeks duration. The primary efficacy end point was the change in PASI score. Nine of the 77 children in the trial were under the age of 7 years; 22.2% of children below 7 years of age received calcipotriol. There was no statistically significant change observed over placebo. See Table 7.
5.2 Pharmacokinetic Properties
Pharmacokinetic studies with 3H-calcipotriol have been performed in rats and minipigs. Oral absorption of calcipotriol was approximately 60% in rats and 40% in minipigs. The half-life of calcipotriol was 12 minutes in rats and 60 minutes in minipigs. The major metabolite of calcipotriol, MC1080, was present in the first plasma sample at 5 minutes; its half-life was 54 minutes in rats and 1.8 hours in minipigs. Drug-related radioactivity was excreted in urine and faeces, and clearance was considered to be almost exclusively metabolic, as less than 5% of the administered radioactivity was excreted at the time of disappearance of all calcipotriol from plasma. Determination of the tissue distribution of calcipotriol was complicated by the appearance of 3H-H2O from the metabolic degradation of 3H-calcipotriol. Autoradiography studies performed in rats, however, established that calcipotriol concentrations were highest in the liver, kidney and intestine. No drug-related radioactivity was present 24 hours after administration of 3H-calcipotriol.
Two main metabolites of calcipotriol, MC1046 and MC1080, were present in supernatants from minipigs, rabbit and human liver homogenates, and in plasma samples from rats and minipigs. Although the necessity of using very high dosages of calcipotriol precludes the study of calcipotriol metabolism in humans, the present evidence strongly suggests that calcipotriol metabolism is qualitatively similar in rats, minipigs, rabbits and humans.
Bioavailability studies of calcipotriol ointment in psoriatic and healthy patients demonstrated that approximately 2-10% of calcipotriol from the applied dose was systemically absorbed.
5.3 Preclinical Safety Data
Genotoxicity.
Calcipotriol did not elicit any genotoxic effects in in vitro assays for gene mutations (Ames mutagenicity assay and mouse lymphoma TK locus assay) or chromosomal damage (human lymphocyte chromosome aberration test or mouse micronucleus test).
Carcinogenicity.
A dermal carcinogenicity study with calcipotriol in mice showed no indications of increased carcinogenic risks. Calcipotriol solution was applied topically for up to 24 months at doses of 3, 10 and 30 microgram/kg/day (corresponding to 9, 30 and 90 microgram/m2/day). The high-dose was considered to be the maximum tolerated dose for dermal treatment of mice with calcipotriol.
Survival was decreased at 10 and 30 microgram/kg/day, particularly in the males. The reduced survival was associated with an increased incidence of obstructive uropathy, most probably caused by treatment-related changes in the urinary composition. This is an expected effect of treatment with high doses of calcipotriol or other vitamin D analogues. There were no dermal effects and no dermal or systemic carcinogenicity.
In a study where albino hairless mice were repeatedly exposed to both ultraviolet (UV) radiation and topically applied calcipotriol for 40 weeks at the same dose levels as in the dermal carcinogenicity study, a reduction in the time required for UV radiation to induce the formation of skin tumours was observed (statistically significant in males only), suggesting that calcipotriol may enhance the effect of UV radiation to induce skin tumours. The clinical relevance of these findings is unknown.6 Pharmaceutical Particulars
6.1 List of Excipients
Dibasic sodium phosphate dihydrate, disodium edetate dihydrate dl-alpha tocopherol, liquid paraffin, polyoxyethylene stearyl ether (also known as steareth-2), propylene glycol, purified water, white soft paraffin.
6.2 Incompatibilities
Not applicable.
6.3 Shelf Life
Unopened container: 2 years.
After first opening of container: 6 months.
6.4 Special Precautions for Storage
Store below 25°C.
For ease of application, do not refrigerate.
6.5 Nature and Contents of Container
Daivonex ointment is available in aluminium tubes of 15 g, 30 g, 100 g, or 120 g.
6.6 Special Precautions for Disposal
Any unused medicine or waste material should be disposed of in accordance with local requirements.
6.7 Physicochemical Properties
Chemical structure.
CAS number.
Calcipotriol anhydrous: 112965-21-6.7 Medicine Schedule (Poisons Standard)
S4 (Prescription Medicine).
Summary Table of Changes
