Consumer medicine information

Enablex® [8598]

Darifenacin hydrobromide

BRAND INFORMATION

Brand name

Enablex Prolonged release tablets

Active ingredient

Darifenacin hydrobromide

Schedule

S4

 

Consumer medicine information (CMI) leaflet

Please read this leaflet carefully before you start using Enablex® [8598].

What is in this leaflet

This leaflet answers some common questions about Enablex.

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

The information in this leaflet was last updated on the date listed on the final page. More recent information on the medicine may be available.

You should ensure that you speak to your pharmacist or doctor to obtain the most up to date information on the medicine. You can also download the most up to date leaflet from
www.aspencmi.com.au

Those updates may contain important information about the medicine and its use of which you should be aware.

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

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

Keep this leaflet with the medicine.

You may need to read it again.

What Enablex is used for

Enablex is used to decrease the urgency and the frequency of urination.

Enablex works by relaxing the bladder smooth muscle and helps to decrease muscle spasm. This delays the initial desire and the urge to urinate.

Ask your doctor if you have any questions about why this medicine has been prescribed for you.

Your doctor may have prescribed it for another reason.

This medicine is available only with a doctor's prescription. It is not addictive.

Enablex is not recommended for use in children because there have been no studies of its effects in this age group.

Before you take Enablex

When you must not take it

Do not take Enablex if you have an allergy to darifenacin, the active ingredient, or to any of the other ingredients listed at the end of this leaflet.

Some of the symptoms of an allergic reaction may include shortness of breath, wheezing or difficulty breathing; swelling of the face, lips and tongue or other parts of the body; rash itching or hives on the skin.

Do not take Enablex if you have any of the following medical conditions:

  • a disorder of the eye called narrow angle glaucoma that is not being controlled with medicine
  • a blockage in the stomach or intestine
  • urinary tract blockage

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

In that case, return it to your pharmacist.

Before you start to take it

Tell your doctor if you have allergies to any other medicines, foods, dyes or preservatives.

Tell your doctor if you are pregnant or intend to become pregnant.

There is no information on the use of this medicine during pregnancy. Your doctor will discuss the possible risks and benefits involved.

Tell your doctor if you are breast-feeding or plan to breast-feed.

It is not known if the active ingredient of Enablex passes into breast milk and could affect your baby. Your doctor will discuss the possible risks and benefits of breast-feeding while taking Enablex.

Tell your doctor if you have or have had any medical conditions, especially the following:

  • heart problems
  • liver problems
  • narrow-angle glaucoma that is controlled with medicine
  • stomach, intestinal or large bowel problems, including chronic constipation.

Taking other medicines

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

Some medicines and Enablex may interfere with each other. These include:

  • some medicines used to treat fungal infections, such as ketoconazole, itraconazole and miconazole
  • some medicines used to treat depression, such as paroxetine, fluoxetine, nefazodone and tricyclic antidepressants
  • some medicines used to treat heart problems, such as digoxin and flecainide
  • cimetidine, a medicine used to treat stomach ulcers
  • ritonavir, a medicine used to treat HIV/AIDS
  • thioridazine, a medicine used to treat schizophrenia
  • a variety of other medicines that work in a similar way to Enablex.

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

If you have not told your doctor about any of the above, tell him/her before you start taking Enablex.

How to take Enablex

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

These instructions may differ from the information contained in this leaflet.

If you do not understand the instructions on the label, ask your doctor or pharmacist for help.

How much to take

The usual starting dose is one 7.5 mg tablet once a day.

If necessary, your doctor may increase your dose to one 15 mg tablet once a day, as early as two weeks after starting therapy.

If you have a problem with your liver or are taking certain medicines, your doctor may limit your dose to one 7.5 mg tablet once a day.

How to take it

Swallow the tablet whole with a glass of water. Do not chew, crush or divide the tablet.

You can take the tablet with or without food.

When to take it

Take Enablex at about the same time each day.

Taking your tablet at the same time each day will have the best effect. It will also help you remember when to take it.

If you forget to take it

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

Otherwise, take it as soon as you remember, and then go back to taking your medicine as you would normally.

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

This may increase the chance of you getting an unwanted side effect.

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

If you have trouble remembering to take your medicine, ask your pharmacist for some hints.

How long to take it

Continue taking this medicine for as long as your doctor tells you to.

Enablex helps control your condition, but does not cure it. Therefore, you must take this medicine every day.

If you take too much (overdose)

Immediately telephone your doctor or pharmacist or the Poisons Information Centre (telephone 13 11 26), or go to accident and emergency at your nearest hospital, if you think that you or anyone else may have taken too much Enablex. Do this even if there are no signs of discomfort or poisoning.

Keep the telephone numbers for these places handy.

While you are taking Enablex

Things you must do

If you become pregnant while taking Enablex, tell your doctor.

Your doctor can discuss with you the risks of taking it while you are pregnant.

If you are about to be started on any new medicine, tell your doctor, dentist or pharmacist that you are taking Enablex.

Tell any other doctors, dentists, and pharmacists who are treating you that you are taking Enablex.

Things you must not do

Do not give this medicine to anyone else, even if their condition seems similar to yours.

Do not take it to treat any other complaints unless your doctor tells you to.

Things to be careful of

Be careful driving, operating machinery or doing jobs that require you to be alert while you are taking Enablex until you know how it affects you.

This medicine may cause dizziness or blurred vision in some people.

Side effects

Tell your doctor or pharmacist as soon as possible if you do not feel well while you are taking Enablex, even if you do not think it is connected with the medicine.

This medicine helps most people, but it may have unwanted side effects in a few people. All medicines can have side effects. Sometimes they are serious, most of the time they are not. You may need medical treatment if you get some of the side effects.

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

Ask your doctor or pharmacist if you notice any of the following and they worry you:

  • constipation
  • diarrhoea
  • stomach ache or indigestion
  • nausea or vomiting
  • nasal dryness
  • flatulence
  • dry or itchy skin
  • dry eyes
  • blurred or changed vision
  • dryness of the mouth, nose and throat
  • sore throat or cough
  • change in taste
  • mouth ulcers
  • swelling of the hands, ankles or feet
  • unusual tiredness, confusion or weakness
  • difficulty sleeping
  • dizziness
  • pain in the joints
  • discharge or itching in the vagina
  • signs of a possible urinary tract infection, such as pain on urination
  • urinary retention
  • fast or irregular heart beats
  • weight gain
  • excessive sweating
  • impotence

If any of the above symptoms are severe, tell your doctor immediately.

If any of the following happen, stop taking Enablex and tell your doctor immediately, or go to Accident and Emergency at your nearest hospital:

  • sudden signs of allergy such as rash, itching or hives on the skin, swelling of the face, lips, tongue or other parts of the body, shortness of breath, wheezing or trouble breathing.

Tell your doctor or pharmacist if you notice anything that is making you feel unwell.

Other side effects not listed above may occur in some patients. Some side effects, such as raised blood pressure, may not give you any symptoms and can only be found when tests are done.

After using Enablex

Storage

  • Keep your tablets in the original pack until it is time to take them.
  • Store the tablets in a cool dry place at room temperature.
  • Always keep the tablets away from direct sunlight and away from moisture.
  • Do not store Enablex or any other medicine in the bathroom or near a sink.
  • Do not leave it in the car or on window sills.

Keep the medicine 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.

Disposal

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

Product description

What it looks like

Enablex 7.5 mg tablets are round white tablets marked with "DF" on one side and "7.5" on the other side; packs of 28 tablets.

Enablex 15 mg tablets are round light-peach-coloured tablets marked with "DF" on one side and "15" on the other side; packs of 28 tablets.

Ingredients

Enablex contains 7.5 or 15 mg of the active ingredient, darifenacin (as the hydrobromide salt). The tablets also contain:

  • calcium hydrogen phosphate anhydrous
  • hypromellose
  • magnesium stearate

The 7.5 mg tablets contain Opadry White (00F18296). The 15 mg tablets contain Opadry Yellow (00F12951) and Opadry Red (00F15613).

Enablex does not contain sucrose, gluten, tartrazine or any other azo dyes.

Sponsor

Enablex tablets are supplied in Australia by:
Aspen Pharmacare Australia Pty Ltd
34-36 Chandos Street
St Leonards NSW 2065
Australia.

®= Registered Trademark

Enablex 7.5 mg AUST R 99418
Enablex 15 mg AUST R 99439

This leaflet was updated in May 2013.

BRAND INFORMATION

Brand name

Enablex Prolonged release tablets

Active ingredient

Darifenacin hydrobromide

Schedule

S4

 

Name of the medicine

Darifenacin hydrobromide.

Excipients

Anhydrous calcium hydrogen phosphate, hypromellose, magnesium stearate, Opadry White (00F18296) (7.5 mg tablets only), Opadry Yellow (00F12951) and Opadry Red (00F15613) (15 mg tablets only).

Description

Chemical name: (S)-2-{1-[2-(2,3- dihydrobenzofuran-5-yl) ethyl]-3-pyrrolidinyl}-2,2- diphenylacetamide hydrobromide. Molecular formula: C28H30N2O2.HBr. MW: 507.5. CAS: 133099-07-7. Darifenacin hydrobromide is a white to almost white monomorphic crystalline solid. The solubility of darifenacin hydrobromide in water is 6.03 mg/mL at 37°C, with a resulting pH of 5.5.

Pharmacology

Pharmacodynamics.

Darifenacin is a selective muscarinic M3-receptor antagonist that exhibits 9 to 59-fold selectivity for the human M3-receptor over human muscarinergic M1, M2, M4 and M5-receptors. The M3-receptor is the major subtype that controls urinary bladder muscle contraction.
Cystometric studies performed with darifenacin in patients with involuntary bladder contractions showed increased bladder capacity, increased volume threshold for unstable contractions and diminished frequency of unstable detrusor contractions after darifenacin treatment. These findings are consistent with the clinical observations of reduced frequency of incontinence, reduced frequency of micturition, reduced frequency of urgency and increased functional bladder capacity.
Consistent with its selectivity profile, the incidence of central nervous system adverse events at all doses was similar to placebo. The incidence of cardiovascular adverse events such as tachycardia was less than 1% for all doses and did not increase with dose. As expected from this class of drugs, prolonged colonic transit and reduced salivary flow were observed in a dose dependent manner.

Electrophysiology.

The effect of six day treatment with Enablex 15 mg and 75 mg on QT/QTc interval was evaluated in a multiple dose, double blind, randomised, placebo and active controlled (moxifloxacin 400 mg) parallel arm design study in 179 healthy adults (44% male, 56% female) aged 18 to 65. Subjects included 18% poor metabolisers and 82% extensive metabolisers. The QT interval was measured over a 24 hour period both predosing and at steady state.
The Enablex 75 mg dose was chosen because this achieves exposure similar to that observed in CYP2D6 poor metabolisers administered the highest recommended darifenacin dose (15 mg) in the presence of a potent CYP3A4 inhibitor. At the doses studied, Enablex did not result in QT/QTc interval prolongation at any time during steady state, while moxifloxacin treatment resulted in a mean increase from baseline QTcF of about 7.0 millisecond when compared to placebo. See Table 1.
In this study, darifenacin 15 and 75 mg doses demonstrated a mean heart rate change of 3.1 and 1.3 beats/minute, respectively, when compared to placebo. However, in the phase II/III clinical studies, the change in median heart rate following treatment with Enablex was no different from placebo.

Pharmacokinetics.

Absorption.

Darifenacin is rapidly and completely (> 98%) absorbed after oral administration, although oral bioavailability is limited by first pass metabolism (see Metabolism). The estimated mean oral bioavailability of darifenacin in extensive metabolisers at steady state is 15 and 19% for 7.5 and 15 mg prolonged release tablets, respectively. Maximum plasma levels are reached approximately seven hours after administration of the prolonged release tablets and steady-state plasma levels are achieved by the sixth day of dosing. At steady state, peak to trough fluctuations in darifenacin concentrations are small, thereby maintaining therapeutic plasma levels over the 24 hour dosing interval (see Figure 1).

Distribution.

Darifenacin is a lipophilic base and is 98% bound to plasma proteins (primarily to α1-acid glycoprotein). The steady-state volume of distribution (Vss) is estimated to be 163 L.
Based on free drug levels in animal cerebrospinal fluid and plasma, darifenacin shows negligible penetration of the blood brain barrier.

Metabolism.

Darifenacin is extensively metabolised by the liver following oral administration.
Metabolism is mediated by cytochrome P450 enzymes CYP2D6 and CYP3A4. The three main metabolic routes are as follows:
monohydroxylation in the dihydrobenzofuran ring;
dihydrobenzofuran ring opening;
N-dealkylation of the pyrrolidine nitrogen.
The initial products of the hydroxylation and N-dealkylation pathways are major circulating metabolites but none contributes significantly to the overall clinical effect of darifenacin.

Variability in metabolism.

A subset of individuals (approximately 7% of the Caucasian population) are poor metabolisers (PMs) of substrate for CYP2D6. Therefore, the metabolism of darifenacin in these poor metabolisers will be principally mediated via CYP3A4. Individuals with full CYP2D6 activity are referred to as extensive metabolisers.
Population pharmacokinetic analyses of phase III data indicated that, on average, steady-state exposure is 66% higher in poor metabolisers than in extensive metabolisers. However, there is considerable overlap between the ranges of exposures seen in these two populations and clinical experience confirms that there are no special dosing requirements for poor metabolisers.

Elimination.

Following administration of an oral dose of 14C-darifenacin solution to healthy volunteers, approximately 60% of the radioactivity was recovered in the urine and 40% in the faeces. Only a small percentage of the excreted dose was unchanged darifenacin (3%). Estimated darifenacin clearance is 40 L/hour for extensive metabolisers and 32 L/hour for poor metabolisers. The estimated half-life for darifenacin following chronic dosing is 12.8 to 18.7 hours.

The effect of food on pharmacokinetics.

Food had no effect on darifenacin pharmacokinetics during multiple dose administration of prolonged release tablets.

Gender influence on pharmacokinetics.

No special dosage requirements are necessary based on gender. A population pharmacokinetic analysis of patient data indicated that darifenacin exposure was 23% lower in males than females. In clinical studies, the safety and efficacy profiles were not affected by gender.

Pharmacokinetics in elderly patients.

There are no special dosage requirements for the elderly. A phase III population pharmacokinetic analysis of patient data (patients aged 60 to 89 years) indicated a trend for clearance to decrease with age by 19% per decade. The safety and efficacy profiles were not affected by age.

Pharmacokinetics in paediatric patients.

The pharmacokinetics of darifenacin have not been established in the paediatric population.

Pharmacokinetics in patients with impaired renal function.

A small study of subjects (n = 24) with varying degrees of renal impairment (creatinine clearance between 10 and 136 mL/minute) given darifenacin 15 mg once daily to steady state demonstrated no relationship between renal function and darifenacin clearance.

Pharmacokinetics in patients with impaired hepatic function.

Darifenacin pharmacokinetics were investigated in subjects with mild (Child-Pugh A) or moderate (Child-Pugh B) impairment of hepatic function given darifenacin 15 mg once daily to steady state. Mild hepatic impairment had no effect on the pharmacokinetics of darifenacin. However, protein binding of darifenacin was affected by moderate hepatic impairment. The fraction of unbound darifenacin increased from 1.7% in subjects with normal hepatic function to 4.5% in subjects with moderate hepatic impairment. After adjusting for plasma protein binding, unbound darifenacin exposure was estimated to be 4.7-fold higher in subjects with moderate hepatic impairment than in subjects with normal hepatic function.

Clinical Trials

Enablex prolonged release tablets were evaluated for the treatment of patients with overactive bladder whose signs and symptoms included urgency, urge urinary incontinence, increased frequency, nocturia and reduced functional bladder capacity in four randomised, placebo controlled, multicentre, double blind, 12 week studies. The majority of patients were white (94%) and female (84%), with a mean age of 58 years, range 19 to 93 years. 33% of patients were ≥ 65 years of age. These characteristics were well balanced across treatment groups. 60% of patients had never received prior pharmacotherapy for overactive bladder and the intentional randomisation of subjects known to be responsive to, or tolerant of, anticholinergic therapy was avoided.
The three fixed dose studies included 1,059 patients. Of this total, 337 and 334 patients were treated with Enablex prolonged release tablets 7.5 and 15 mg daily, respectively. In addition, a dose titration study included 395 patients, of whom 268 initially received Enablex prolonged release tablets 7.5 mg daily with the option to increase to 15 mg daily after two weeks.
Tables 2 and 3 show the efficacy data from the placebo controlled studies of patients treated with Enablex 7.5 and 15 mg once daily for 12 weeks. A significant decrease in symptoms of urge urinary incontinence was observed.
Incontinence responders (see Table 4) were defined as patients who achieved a 50% or greater reduction from baseline in the number of incontinence episodes/week. Frequency responders (see Table 4) were defined as the proportion of patients with ≥ eight micturitions/day at baseline who achieved a normalisation of micturition, defined as a frequency of micturition of < eight micturitions/day.
As seen in Figure 2, significant improvement in the number of incontinence episodes/week was observed within the first two weeks in patients treated with Enablex 7.5 and 15 mg once daily compared to placebo. Further, these effects were sustained throughout the 12 week treatment period.
In a pooled analysis, significant improvements from baseline were also observed for key secondary efficacy endpoints, including the number of micturitions/day, the number and severity of urgency episodes, the average volume of urine passed/void and the number of incontinence episodes requiring a change of clothing or pads.
In a clinical study of 12 months duration at doses ranging from 7.5 to 30 mg, sustained improvements from baseline were observed in the number of incontinence episodes/week and in other key secondary efficacy endpoints including number of micturitions/day, episodes of urgency and average volume of urine passed/void.
On quality of life measures, darifenacin 7.5 and 15 mg were associated with statistically and clinically meaningful improvements over placebo in the incontinence impact, role limitations, social limitation and severity measures domains, as defined by the King's Health Questionnaire (KHQ). Darifenacin 15 mg was also associated with improvements on the emotions domain of the KHQ.

Indications

Enablex prolonged release tablets are indicated for the treatment of overactive bladder, with the symptoms of urgency, urge urinary incontinence or frequency of micturition.

Contraindications

Hypersensitivity to the active substance or to any of the excipients. Enablex is contraindicated in patients with urinary retention, gastric retention or uncontrolled narrow angle glaucoma.

Precautions

Concomitant conditions.

Enablex should be administered with caution to patients with autonomic neuropathy, hiatus hernia, clinically significant bladder outflow obstruction, risk for urinary retention, severe constipation (defined as two or less bowel movements/week) or gastrointestinal obstructive disorders, e.g. pyloric stenosis (see Contraindications).
Enablex should be used with caution in patients being treated for narrow angle glaucoma (see Contraindications).
As with other antimuscarinics, patients should be instructed to discontinue Enablex and seek immediate medical attention if they experience edema of the tongue or laropharynx, or difficulty breathing (see Adverse Effects).
Enablex should be used with caution in patients with risk of decreased gastrointestinal motility (see Contraindications), gastroesophagal reflux and/or who are concurrently taking medicinal products (such as oral bisphosphonates) that can cause or exacerbate oesophagitis.
Caution should be used when prescribing antimuscarinics to patients with pre-existing cardiac diseases.

Use in hepatic impairment.

There is a risk of increased exposure in this population (see Pharmacokinetics). No dose adjustment is required in patients with mild hepatic impairment (Child-Pugh A). For patients with moderate hepatic impairment (Child-Pugh B) or when coadministered with potent CYP3A4 inhibitors (e.g. ketoconazole, itraconazole, miconazole, nefazodone and ritonavir), the daily dose of Enablex should not exceed 7.5 mg. Enablex is not recommended for use in patients with severe hepatic impairment (Child-Pugh C) (see Dosage and Administration).

Carcinogenicity, mutagenicity and impairment of fertility.

Two year carcinogenicity studies with dietary administration of darifenacin were conducted in mice and rats. No evidence of drug related carcinogenicity was revealed in mice (up to 100 mg/kg/day) or rats (up to 15 mg/kg/day). These doses correspond to unbound darifenacin exposure levels approximately 32 times (mice) and 10 times (rats) human exposure at the maximum recommended human dose (MRHD): 15 mg.
Darifenacin was neither mutagenic (bacterial and mammalian cell mutation assays) nor clastogenic (human lymphocyte assay) when tested in vitro in the presence and absence of metabolic activation. No chromosomal aberrations were observed in an in vivo mouse bone cytogenetics assay following systemic exposure to darifenacin at levels > 32 times human exposures at the MRHD.
No significant effects on fertility were observed in male or female rats treated with darifenacin (two weeks (female) or nine weeks (male) prior to and throughout mating) at oral doses up to 50 mg/kg/day, corresponding to approximately 55 times the human area under the curve (AUC) at the MRHD.

Use in pregnancy.

(Category B3)
Darifenacin and/or its metabolites cross the placenta in rats and rabbits. There was no evidence of teratogenicity in rats or rabbits following oral administration of darifenacin during the period of organogenesis and fetogenesis at doses up to 50 and 30 mg/kg/day, respectively (59 and 28 times the MRHD, based on unbound AUC).
At these maternotoxic doses, darifenacin caused delayed ossification of sacral and caudal vertebrae in rats and increased postimplantation loss/ decreased fetal viability in rabbits.
When oral treatment of rats at this dose was extended throughout organogenesis and fetogenesis, gestation and lactation, additional findings included increased gestation length, dystocia, reductions in birthweight, postnatal survival and growth of offspring and altered indices of offspring behaviour.
At the no observed effect level (NOEL) for pup developmental effects (10 mg/kg/day), the relative systemic exposure to darifenacin was approximately nine times that anticipated at the MRHD (based on AUC). Animal studies do not indicate direct or indirect harmful effects with respect to fertility, pregnancy and embryofetal development. The safety of darifenacin in human pregnancy has not been established and, because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if the benefit to the mother outweighs the potential risk to the fetus.

Use in lactation.

Darifenacin is excreted into the milk of rats. It is not known whether darifenacin is excreted into human milk and, therefore, caution should be exercised before Enablex is administered to a breastfeeding woman.

Use in children.

No studies have been performed in children. Therefore, until more information is available, Enablex is not recommended for use in children.

Effects on ability to drive and use machinery.

No studies of the effects of Enablex on the ability to drive and use machines have been performed. However, antimuscarinics, e.g. Enablex, may produce dizziness or blurred vision. Patients should not drive vehicles, use machines or perform other tasks which require alertness if they experience these adverse events.

Interactions

Effects of other medicinal products on darifenacin.

Darifenacin metabolism is primarily mediated by the cytochrome P450 enzymes CYP2D6 and CYP3A4. Therefore, drugs which inhibit these enzymes may alter darifenacin pharmacokinetics when they are coadministered (see Pharmacokinetics).

CYP2D6 inhibitors.

No special dosing requirements are necessary in the presence of CYP2D6 inhibitors, although the risk of adverse events may be increased following concomitant treatment of darifenacin with CYP2D6 inhibitors, e.g. paroxetine, cimetidine and fluoxetine and caution should be exercised.

CYP3A4 inhibitors.

No special dosing requirements are necessary in the presence of moderate CYP3A4 inhibitors (e.g. fluconazole, erythromycin). The daily dose of darifenacin should not exceed 7.5 mg when coadministered with potent CYP3A4 inhibitors (e.g. ketoconazole, itraconazole, miconazole, nefazodone, ritonavir).

Ketoconazole.

In a drug interaction study when an Enablex 7.5 mg once daily dose was given to steady state and coadministered with the potent CYP3A4 inhibitor ketoconazole 400 mg, mean darifenacin Cmax increased to 11.2 nanogram/mL in EMs (n = 10) and 55.4 nanogram/mL in one PM subject (n = 1). Mean AUC increased to 143 and 939 nanogram.hour/mL in EMs and in one PM subject, respectively. When an Enablex 15 mg daily dose was given with ketoconazole, mean darifenacin Cmax increased to 67.6 nanogram/mL and 58.9 nanogram/mL in EMs (n = 3) and in one PM subject (n = 1), respectively. Mean AUC increased to 1,110 and 931 nanogram.hour/mL in EMs and in one PM subject, respectively.

Effects of darifenacin on other medicinal products.

CYP2D6 substrates.

Caution should be exercised when darifenacin is used concomitantly with medications that are predominantly metabolised by CYP2D6 and which have a narrow therapeutic window, e.g. flecainide, thioridazine, or tricyclic antidepressants, e.g. imipramine.

CYP3A4 substrates.

Darifenacin had no clinically relevant effect on the exposure of the CYP3A4 substrate midazolam and had no effect on the pharmacokinetics of the oral contraceptives, levonorgestrel or ethinyloestradiol.

P-glycoprotein inhibitors.

Darifenacin is a substrate of the drug efflux transporter P-glycoproteins. The in vivo effect of P-glycoproteins inhibition on darifenacin exposure has not been studied.

Warfarin.

Standard therapeutic prothrombin time monitoring for warfarin should be continued. The effect of warfarin on prothrombin time was not altered when coadministered with darifenacin.

Digoxin.

Therapeutic drug monitoring for digoxin should be performed when initiating and ending darifenacin treatment as well as changing the darifenacin dose. Darifenacin 30 mg once daily (two times greater than the recommended daily dose) coadministered with digoxin at steady state resulted in a small increase in digoxin exposure.

Antimuscarinic agents.

The concomitant use of darifenacin with other antimuscarinic agents may increase the frequency and/or severity of antimuscarinic pharmacological effects, e.g. dry mouth, constipation and blurred vision. The potentiation of anticholinergic effects with antiparkinson agents and tricyclic antidepressants may also occur if antimuscarinic agents are used concurrently with such medicinal products. However, no studies involving the interaction with antiparkinson agents and tricyclic antidepressants have been performed.

Adverse Effects

During the clinical development of Enablex, a total of 7,271 patients and volunteers have been exposed to phase I to III clinical trials for up to one year duration of therapy for overactive bladder and other indications.
The phase II and III overactive bladder clinical trial program for Enablex included 2,678 patients who were treated with Enablex prolonged release tablets 3.75 to 45 mg once daily for up to 12 months.
Of this total, 1,059 patients participated in three 12 week, phase III, fixed dose efficacy and safety studies. Of this total, 337 and 334 patients were treated with Enablex prolonged release tablets, 7.5 and 15 mg daily, respectively.

Adverse events in clinical trials.

Table 5 lists the adverse events reported (regardless of causality) in 1% or more patients treated with Enablex 7.5 or 15 mg prolonged release tablets in fixed dose, placebo controlled phase III studies. Adverse events were reported by 54.0 and 65.6% of patients receiving Enablex prolonged release tablets, 7.5 and 15 mg once daily, respectively, and by 48.7% of patients receiving placebo.
The majority of adverse events in Enablex treated subjects were mild or moderate and mostly occurred during the first two weeks of treatment. The incidence of serious adverse events was similar for 7.5 mg, 15 mg and placebo. The profile of adverse events remained consistent across all populations and doses studied.
The most frequently reported adverse events were dry mouth and constipation. However, the patient discontinuation rates due to these events were low.
Consistent with M3-muscarinic receptor selectivity, the incidence of central nervous system adverse events at all doses was similar to placebo. The incidence of cardiovascular adverse events, e.g. tachycardia, was less than 1% at all doses and did not increase with dose.
In clinical trials of volunteers and patients (n = 964 treated, n = 261 placebo), clinically significant changes in QT interval were not observed with Enablex up to and including 60 mg once daily, the highest dose studied.
Discontinuations due to any adverse events occurred in 1.2 and 4.5% of Enablex 7.5 and 15 mg patients treated in fixed dose placebo controlled trials, respectively and in 1.3% of placebo subjects. There were no discontinuations due to laboratory test abnormalities.
Long-term safety was evaluated in 410 patients for six months and 106 patients for one year. The long-term safety profile of darifenacin was similar to that observed in the short-term pivotal studies.

Adverse reactions with suspected relationship to product.

The following adverse drug reactions, listed below, have been reported in clinical studies following treatment with Enablex and are listed according to system organ classes in MedDRA. Within each system organ class, the adverse drug reactions are ranked by frequency, with the most frequent reactions first. Within each frequency grouping, adverse drug reactions are presented in order of decreasing seriousness. In addition, the corresponding frequency category using the following convention (CIOMS III) is also provided for each adverse drug reaction: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1,000, < 1/100); rare (≥ 1/10,000, < 1/1,000) very rare (< 1/10,000), including isolated reports.

Psychiatric disorders.

Uncommon: insomnia, thinking abnormal.

Nervous system disorders.

Uncommon: dysgeusia, somnolence.

Eye disorders.

Uncommon: visual disturbance, including vision blurred.

Respiratory, thoracic and mediastinal disorders.

Common: nasal dryness.
Uncommon: dyspnoea, cough.

Gastrointestinal disorders.

Uncommon: flatulence, mouth ulceration.

Skin and subcutaneous tissue disorders.

Uncommon: hyperhidrosis. Not known: angioedema.

Renal and urinary disorders.

Uncommon: urinary retention, bladder pain.

Reproductive system and breast disorders.

Uncommon: erectile dysfunction.

General disorders and administration site conditions.

Uncommon: face oedema, oedema.

Investigations.

Uncommon: aspartate aminotransferase increased, alanine aminotransferase increased.

Injury, poisoning, and procedural complications.

Uncommon: injury.

Postmarketing experience.

The following events have been reported in association with darifenacin use in worldwide postmarketing experience.
Generalised hypersensitivity reactions including angioedema, with or without airway obstruction (see also Precautions) have been reported;
urinary retention;
palpitations.
Because these spontaneously reported events are from the worldwide postmarketing experience, the frequency of events and the role of darifenacin in their causation cannot be reliably determined.

Dosage and Administration

The recommended starting dose of Enablex prolonged release tablets is 7.5 mg once daily. For those patients requiring greater symptom relief, the dose may be increased to 15 mg daily, as early as two weeks after starting therapy, based on individual response.
Enablex prolonged release tablets should be taken once daily with liquid. They may be taken with or without food and should be swallowed whole and not chewed, divided or crushed.

Use in patients with hepatic or renal impairment.

For patients with moderate hepatic impairment (Child-Pugh B) or when coadministered with potent CYP3A4 inhibitors (e.g. ketoconazole, itraconazole, miconazole, nefazodone and ritonavir), the daily dose of Enablex should not exceed 7.5 mg. Enablex is not recommended for use in patients with severe hepatic impairment (Child-Pugh C) (see Precautions).
There are no special dosage requirements for patients with renal impairment.

Overdosage

Overdosage with antimuscarinic agents, includng Enablex, can result in severe antimuscarinic effects. Treatment should be symptomatic and supportive. In the event of overdosage, electrocardiogram (ECG) monitoring is recommended. Enablex has been administered in clinical trials at doses up to 75 mg (five times the maximum therapeutic dose) and signs of overdose were limited to abnormal vision.
Contact the Poisons Information Centre on 131 126 for advice on management.

Presentation

Prolonged release tablets (round, shallow, convex, marked DF on one side), 7.5 mg (white, marked 7.5 on reverse): 7's, 14's*, 28's, 56's*, 98's*; 15 mg (light peach, marked 15 on reverse): 7's*, 14's*, 28's, 56's*, 98's* (blister pack).
*Not currently marketed in Australia.

Storage

Store below 25°C. Protect from light.

Poison Schedule

S4.