Consumer medicine information

Promozio 250/100

Atovaquone; Proguanil hydrochloride

BRAND INFORMATION

Brand name

Promozio 250/100

Active ingredient

Atovaquone; Proguanil hydrochloride

Schedule

S4

 

Consumer medicine information (CMI) leaflet

Please read this leaflet carefully before you start using Promozio 250/100.

What is in this leaflet

Please read this leaflet carefully before you take Promozio 250/100.

This leaflet answers some common questions about Promozio 250/100. It does not contain all of the available information.

It does not take the place of talking to your doctor or pharmacist.

All medicines have risks and benefits. Your doctor has weighed the expected benefits of you taking Promozio 250/100 against the risks this medicine could 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 is Promozio 250/100 used for?

Promozio 250/100 belongs to a broad group of medicines called antimalarials.

It contains in one tablet a mixture of two antimalarial medicines which work well when taken together. One medicine is atovaquone and the other is proguanil hydrochloride.

Promozio 250/100 is used to prevent or treat the type of malaria infection known as Plasmodium falciparum malaria. Plasmodium falciparum belongs to one particular family of malaria parasites. It affects the blood and liver. Promozio 250/100 works by killing this parasite.

Promozio 250/100 is not addictive.

Before you take Promozio 250/100

Do not take it:

You must not take Promozio 250/100 if:

  • you have ever had an allergic reaction to atovaquone (Wellvone™) or proguanil hydrochloride (Paludrine), or any of the ingredients listed at the end of this leaflet (See "Ingredients").
  • the expiry date (EXP) printed on the pack has passed.
  • the packaging is torn or shows signs of tampering

Tell your doctor if:

You must tell your doctor if:

  • you are allergic to foods, dyes, preservatives or any other medicines.
  • in the past Promozio 250/100 has been ineffective for you.
  • after taking Promozio 250/100, your symptoms of malaria have returned after improving for a time.
  • you have diarrhoea (loose bowel motions). This may interfere with the absorption of Promozio 250/100.
  • you have kidney problems.
  • you are taking any medicines containing warfarin, rifampicin, rifabutin, tetracycline, metoclopramide or indinavir.
  • you are taking any other medicines, including medicines you buy without a prescription.
  • you are breastfeeding, pregnant or trying to become pregnant.

How do I take Promozio 250/100?

How much to take

Take Promozio 250/100 as directed by your doctor or pharmacist.

Prevention of malaria:

Adults:
One Promozio 250/100 tablet daily.

In order to prevent malaria, it is important that you take your Promozio 250/100 every day. Start taking it 1 or 2 days before travelling to a country (or countries) where you are at risk of getting malaria. Continue daily dosing while you are there and for 7 days after leaving.

Whilst in a malarious area, use of personal protection such as permethrin impregnated bednets and topical insect repellents is also strongly recommended.

Treatment of malaria:

Adults:
Four Promozio 250/100 tablets, once a day, for three days.

How to take it

Swallow each tablet whole. Promozio 250/100 works better if you take it with food or a milky drink and at about the same time each day.

If you vomit within one hour of taking Promozio 250/100 take another dose as soon as you can. In the event of diarrhoea, normal dosing should be continued and personal protection should be used (repellants, bednets).

How long to take it for

Prevention of malaria:
Promozio 250/100 should be taken 1 or 2 days before travelling to a country (countries) where you are at risk of getting malaria, and continued daily while you are there and for 7 days after leaving.

Treatment of malaria:
Promozio 250/100 should be taken for three days in a row.

Do not stop taking Promozio 250/100, or change the dose without first checking with your doctor.

Use in children

Promozio 250/100 is not recommended for the treatment of malaria in children.

What do I do if I take too much? (Overdose)

Immediately telephone your doctor or Poisons Information Centre (telephone 131126) for advice, if you think you or anyone else may have taken too much Promozio 250/100, even if there are no signs of discomfort or poisoning.

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

While you are taking Promozio 250/100

Things you must do

Tell your doctor if, for any reason, you have not taken your medicine exactly as directed.

If you forget to take a dose, take another as soon as possible. Then go on as before. Otherwise, your doctor may think that it was not working as it should and change your treatment unnecessarily.

Things you must not do

Do not give this medicine to anyone else, even if their symptoms seem similar to yours.

Do not use Promozio 250/100 to treat any other complaints unless your doctor says to.

Things to be careful of

Be careful driving or operating machinery until you know how Promozio 250/100 affects you.

Promozio 250/100 generally does not cause any problems with your ability to drive a car or operate machinery.

What are the side effects?

Check with your doctor as soon as possible if you think you are experiencing any side effects or allergic reactions due to taking Promozio 250/100, even if the problem is not listed below.

Like other medicines, Promozio 250/100 can cause some side effects. If they occur, they are most likely to be minor and temporary. However, some may be serious and need medical attention.

The following side-effects have been reported in persons taking Promozio 250/100 or the active ingredients (atovaquone or proguanil). Most of these have been mild and have not lasted very long:

  • Loss of appetite, feeling sick (nausea) and/or being sick (vomiting), stomach pain, diarrhoea
  • mouth ulcers
  • rash or itching
  • Headache, difficulty in sleeping, vivid or strange dreams and dizziness
  • Tiredness and loss of energy
  • Inflammation of the liver (hepatitis), yellow discolouration of the skin or eyes (jaundice)
  • Inflammation of blood vessels (vasculitis) which may be visible as red or purple raised spots on the skin, but can affect other parts of the body
  • Cough
  • Fever
  • Skin rash, which may blister and looks like small targets (central dark sports, surrounded by paler area with a dark ring around the edge (erythema multiforme)
  • Widespread rash with blisters and peeling skin, particularly occurring around the mouth, nose, eyes and genitals (Stevens-Johnson syndrome).

If you notice any of these symptoms contact a doctor urgently.

  • Seeing or hearing things that are not there (hallucinations).

Sometimes Promozio 250/100 is associated with abnormal blood tests of liver function. If this does happen it is most likely a temporary change, as blood tests of liver function become normal after completing the treatment.

Other abnormal blood tests reported with Promozio 250/100 include:

  • A reduction in the number of red blood cells (anaemia), white blood cells (neutropenia), or platelets (cells necessary for blood clotting).
  • An increase in amylase, which is an enzyme produced by the pancreas.
  • Low sodium (hyponatraemia).

STOP taking Promozio 250/100 and seek medical attention immediately if you experience any of the following severe allergy symptoms after taking Promozio 250/100. Although they are rare, these symptoms could be serious:

  • Sudden wheezing, tightness of the chest or throat, or difficulty breathing
  • Swollen eyelids, face, lips, tongue or other part of the body
  • Widespread rash

This is not a complete list of all possible side effects. Others may occur in some people and there may be some side effects not yet known.

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

How do I store Promozio 250/100?

Keep this medicine where children cannot reach it, such as in locked cupboard.

Keep Promozio 250/100 in a cool, dry place where it stays below 25°C.

Do not leave in a car, on a window sill or in the bathroom.

Keep Promozio 250/100 in its blister pack until it is time to take the tablets.

Return any unused or expired medicine to your pharmacist.

Product description

What Promozio 250/100 looks like

Promozio 250/100 tablets are pinkish brown to brown coloured, round with '404' engraved on one side and 'G' engraved on the other side. Promozio 250/100 tablets are supplied in blister packs of 12 tablets.

Ingredients

Promozio 250/100 tablets contain the active ingredients, atovaquone 250 mg and proguanil hydrochloride 100 mg.

Each tablet also contains microcrystalline cellulose, hydroxypropylcellulose, sodium starch glycollate, poloxamer, povidone, silica - colloidal anhydrous, magnesium stearate, and Opadry complete film coating system 03C86943 BROWN.

Supplier

Promozio 250/100 is supplied by:

Australia:

sanofi-aventis australia pty ltd
Building D, 12-24 Talavera Road
Macquarie Park NSW 2113
Australia
Tel: 1800 818 806

New Zealand:

sanofi-aventis new zealand limited
Level 8, 56 Cawley St
Ellerslie, Auckland
New Zealand
Tel: 0800 283 684

AUST R number
AUST R 259969

Date of preparation
07 June 2019

promozio-ccdsv8-cmiv2-07jun19

Published by MIMS August 2019

BRAND INFORMATION

Brand name

Promozio 250/100

Active ingredient

Atovaquone; Proguanil hydrochloride

Schedule

S4

 

1 Name of Medicine

Atovaquone and proguanil hydrochloride.

2 Qualitative and Quantitative Composition

Promozio 250/100 tablet is a fixed combination product containing atovaquone and proguanil hydrochloride.
Each Promozio 250/100 tablet contains atovaquone 250 mg and proguanil hydrochloride 100 mg.
For the full list of excipients, see Section 6.1 List of Excipients.

3 Pharmaceutical Form

Pinkish brown to brown coloured, circular, biconvex, bevelled-edged, film-coated tablets with ‘404’ debossed on one side and ‘G’ debossed on the other side.

4 Clinical Particulars

4.1 Therapeutic Indications

Promozio 250/100 is indicated for:
Prophylaxis of Plasmodium falciparum malaria in adults;
Treatment of Plasmodium falciparum malaria in adults.

4.2 Dose and Method of Administration

The daily dose should be taken with food or a milky drink at the same time each day.
In the event of vomiting, within 1 hour of dosing, a repeat dose should be taken.
Promozio (250/100) should preferably be swallowed whole.

Prophylaxis.

Prophylaxis should start 1 to 2 days before entering a malaria-endemic area, and be continued daily until seven days after leaving the area.
If patients are unable to tolerate food, Promozio 250/100 tablets should be administered, but systemic exposure of atovaquone will be reduced.

Dosage in adults.

One Promozio 250/100 tablet daily.

Treatment.

Dosage in adults.

Four tablets as a single dose for three consecutive days.

Dosage in the elderly (prophylaxis and treatment).

A pharmacokinetic study indicates that no dosage adjustments are needed in the elderly (see Section 5.2 Pharmacokinetic Properties).

Dosage in hepatic impairment (prophylaxis and treatment).

A pharmacokinetic study indicates that no dosage adjustments are needed in patients with mild to moderate hepatic impairment. No studies have been conducted in patients with severe hepatic impairment. (See Section 5.2 Pharmacokinetic Properties).

Dosage in renal impairment (prophylaxis and treatment).

Pharmacokinetic studies indicate that no dosage adjustments are needed in patients with mild to moderate renal impairment. In patients with severe renal impairment (creatinine clearance < 30 mL/min) alternatives to Promozio 250/100 should be recommended for the treatment of acute P. falciparum malaria whenever possible (see Section 4.4 Special Warnings and Precautions for Use; Section 5.2 Pharmacokinetic Properties). For prophylaxis of P. falciparum malaria in patients with severe renal impairment see Section 4.3 Contraindications.

4.3 Contraindications

Promozio 250/100 is contraindicated in individuals with known hypersensitivity to atovaquone or proguanil hydrochloride or to any component of the formulation.
Promozio 250/100 is contraindicated for prophylaxis of P. falciparum malaria in patients with severe renal impairment (creatinine clearance < 30 mL/min).

4.4 Special Warnings and Precautions for Use

Promozio 250/100 has not been evaluated for the treatment of cerebral malaria or other severe manifestations of complicated malaria including hyperparasitaemia, pulmonary oedema or renal failure.
Safety and efficacy of atovaquone/proguanil hydrochloride combination tablet (250/100) for the treatment and prophylaxis of malaria in paediatric patients who weigh less than 11 kg have not been established.
In the event of recrudescent infections due to P. falciparum or failure of chemoprophylaxis, patients should be treated with a different blood schizonticide.
Parasite relapse occurred commonly when P. vivax malaria was treated with atovaquone/proguanil hydrochloride combination tablet (250/100) alone. Travellers with intense exposure to P. vivax or P. ovale, and those who develop malaria caused by either of these parasites, will require additional treatment with a drug such as primaquine that is active against hypnozoites.
Persons taking Promozio 250/100 for prophylaxis or treatment of malaria should take a repeat dose if they vomit within 1 hour of dosing. In the event of diarrhoea, normal dosing should be continued. Absorption of atovaquone may be reduced in patients with diarrhoea or vomiting, but diarrhoea or vomiting was not associated with reduced efficacy in clinical trials of atovaquone/proguanil hydrochloride combination tablet for malaria prophylaxis. However, as with other antimalarial agents, patients with diarrhoea or vomiting should be advised to continue to comply with personal protection measures (repellents, bednets).
In patients with acute malaria who present with diarrhoea or vomiting, alternative therapy should be considered. If Promozio 250/100 is used to treat malaria in these patients, parasitaemia should be closely monitored.
The co-administration of Promozio 250/100 with other antimalarial drugs has not been evaluated.
Parasitaemia should be closely monitored in patients receiving concurrent metoclopramide or tetracycline (see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).
The concomitant administration of atovaquone/proguanil hydrochloride combination tablet and rifampicin or rifabutin is not recommended (see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).

Use in hepatic impairment.

Pharmacokinetic studies indicate that no dosage adjustments are needed in patients with mild to moderate hepatic impairment. Promozio 250/100 has not been specifically studied in patients with severe hepatic impairment.

Use in renal impairment.

Pharmacokinetic studies indicate that no dosage adjustments are needed in patients with mild to moderate renal impairment. In patients with severe renal impairment (creatinine clearance < 30 mL/min) alternatives to Promozio 250/100 for treatment of acute P. falciparum malaria should be recommended whenever possible (see Section 4.2 Dose and Method of Administration; Section 4.3 Contraindications; Section 5.2 Pharmacokinetic Properties).

Use in the elderly.

Pharmacokinetic studies indicate that no dosage adjustments are needed in the elderly.

Paediatric use.

Promozio 250/100 tablets should not be used in paediatric patients.

Effects on laboratory tests.

The effect of Promozio 250/100 on laboratory tests has not been studied.

4.5 Interactions with Other Medicines and Other Forms of Interactions

Proguanil may potentiate the anticoagulant effect of warfarin and other coumarin based anticoagulants. The mechanism of this potential drug interaction has not been established. Caution is advised when initiating or withdrawing malaria prophylaxis or treatment with Promozio 250/100 in patients on continuous treatment with coumarin based anticoagulants.
Concomitant treatment with tetracycline, metoclopramide, rifampicin and rifabutin have been associated with significant decreases in plasma concentration of atovaquone (see Section 4.4 Special Warnings and Precautions for Use). Concomitant administration of tetracycline and atovaquone/proguanil hydrochloride combination tablet reduced the plasma concentrations of atovaquone but had no effect on the efficacy of atovaquone/proguanil hydrochloride in curing Plasmodium falciparum malaria.
Concomitant administration of atovaquone and indinavir results in a 23% decrease in the Cmin of indinavir in healthy individuals. Caution should be exercised when prescribing atovaquone with indinavir due to the decrease in trough levels of indinavir.
In clinical studies of atovaquone in the treatment of diseases other than malaria, small decreases in plasma concentrations were associated with concomitant use of paracetamol, benzodiazepines, aciclovir, opiates, cephalosporins, antidiarrhoeal agents and laxatives. The implications of these observations for use with Promozio 250/100 are not known. In the same series of studies, the following medications were not associated with a change in steady state plasma concentrations of atovaquone: fluconazole, clotrimazole, ketoconazole, antacids, systemic corticosteroids, non-steroidal anti-inflammatory drugs, anti-emetic drugs (excluding metoclopramide) and H2-antagonists.
There is no information available on whether interactions occur between atovaquone and terfenadine or cisapride.
Atovaquone is highly protein bound (> 99%) but does not displace other highly protein bound drugs in vitro, indicating significant drug interactions arising from drug displacement are unlikely.
Coadministration of efavirenz with atovaquone/proguanil hydrochloride combination tablet may result in a decrease in exposure to atovaquone and proguanil. When given with efavirenz or boosted protease-inhibitors, atovaquone concentrations have been observed to decrease as much as 75%. Since decreased concentrations of atovaquone and proguanil may result in a decrease of antimalarial efficacy, concomitant administration should be avoided whenever possible.

4.6 Fertility, Pregnancy and Lactation

Effects on fertility.

There are no data on the effect of atovaquone on human fertility. Data from animal studies show that atovaquone does not affect reproductive potential or performance at oral doses of up to 1000 mg/kg (approximately 6.5 times human exposure at the maximum recommended clinical treatment dose, based on AUC). A study in rats showed no impairment of male or female fertility at oral proguanil doses up to 16 mg/kg/day (approximately 0.03 times human exposure at the recommended clinical treatment dose, based on AUC). However, there is some evidence from published animal studies that proguanil and/or its main metabolite, cycloguanil, may cause impairment of fertility/early embryonic loss. No fertility studies have been performed in animals with atovaquone in combination with proguanil.
Findings in repeat dose studies with the atovaquone and proguanil hydrochloride combination were entirely proguanil related. As proguanil has been used extensively and safely in the treatment and prophylaxis of malaria at doses similar to those used in Promozio 250/100, these findings are considered of little relevance in the clinical situation.
(Category B2)
The safety of the drug combination in human pregnancy has not been established. There is no information on effects of atovaquone administration during human pregnancy. Foetal death and malformation have rarely been reported in association with the use of proguanil. The relationship of these events to proguanil is not certain, and the overall number of reported events is low, given that the drug has been used in pregnant women for many years. Foetal loss is a known complication of Plasmodium falciparum malaria in pregnancy.
The proguanil component of Promozio 250/100 acts by inhibiting parasitic dihydrofolate reductase. There are no clinical data indicating that folate supplementation diminishes drug efficacy. For women of childbearing age receiving folate supplements to prevent neural tube birth defects, such supplements may be continued while taking Promozio 250/100.
Embryo-foetal development studies in animals with the combination of atovaquone and proguanil did not indicate any teratogenic potential in rats at doses up to 50:20 mg/kg/day (approximately 5 times the human exposure to atovaquone and 0.3 times human exposure to proguanil, based on treatment AUCs), nor in rabbits at doses up to 100:40 mg/kg/day (approximately 1 times the human exposure to atovaquone and 0.5 times the exposure to proguanil, based on treatment AUCs). In rabbits given atovaquone alone at 1200 mg/kg/day (approximately 1.4 times the estimated human exposure during treatment of malaria), an increased incidence of resorptions and decreased length and weight of foetuses was noted. These effects were observed only in the presence of maternal toxicity.
In a peri-postnatal study in rats dosed with proguanil alone up to 16 mg/kg/day (0.03 times the human exposure, based on treatment AUC), no treatment-related effects were seen in reproductive or other parameters in the F0, F1 and F2 generations.
However, as animal studies are not always predictive of human response, the use of atovaquone/proguanil hydrochloride in pregnancy should only be considered if the expected benefit to the mother outweighs the risk to the foetus.
 It is not known whether atovaquone is excreted into human milk. In a rat study, the atovaquone concentrations in milk were 30% of the concurrent atovaquone concentrations in maternal plasma. Proguanil is excreted in human milk in small quantities. Breast feeding is not recommended during treatment with Promozio 250/100.

4.7 Effects on Ability to Drive and Use Machines

There have been no studies to investigate the effect of atovaquone and proguanil hydrochloride on driving performance or the ability to operate machinery. Detrimental effect on such activities is not predicted from the pharmacology of the component drugs.

4.8 Adverse Effects (Undesirable Effects)

As Promozio 250/100 contains both atovaquone and proguanil hydrochloride, the type and severity of adverse reactions associated with each of the compounds may be expected. However, at the doses employed for both treatment and prophylaxis of malaria, adverse reactions are generally mild and of limited duration. There is no evidence of added toxicity following concurrent administration of the two compounds.

Prophylaxis.

Individuals > 40 kg.

The nature and frequency of adverse reactions reported in clinical trials of atovaquone/proguanil hydrochloride combination tablet for the prophylaxis of malaria in individuals weighing > 40 kg were similar to those reported with placebo or the active comparator drug (mefloquine or chloroquine/proguanil). However, patients receiving combination atovaquone/proguanil hydrochloride had fewer neuropsychiatric and gastrointestinal adverse reactions than patients receiving mefloquine and chloroquine/proguanil respectively. Overall, combination atovaquone/proguanil hydrochloride has a better safety profile than mefloquine or chloroquine/proguanil (see Tables 1 and 2).

Treatment.

The nature and frequency of adverse experiences reported in controlled clinical trials of atovaquone and proguanil hydrochloride for the treatment of malaria were generally similar in patients treated with the combination or with a comparator antimalarial drug. This suggests that the adverse experiences are largely due to the disease rather than to study drugs (see Table 3).
Of the seven severe or treatment limiting adverse experiences reported in clinical trials with atovaquone and proguanil hydrochloride, three were considered to be treatment related; two were reports of nausea and/or vomiting and one report of an anaphylactic reaction. During clinical trials, two subjects receiving atovaquone monotherapy experienced psychiatric symptoms. One subject had a history of psychiatric illness and the other a history of drug and alcohol abuse. Two subjects receiving atovaquone/proguanil hydrochloride had seizures; in one of these cases the patient successfully continued treatment. Both subjects had a prior history of seizures and the investigators did not consider the events attributable to the atovaquone/proguanil hydrochloride treatment.
Adverse events are listed below by system organ class and frequency. Frequencies are defined as: very common (≥ 1/10), common (≥ 1/100 and < 1/10), uncommon (≥ 1/1000 and < 1/100), rare (≥ 1/10,000 and < 1/1000) and very rare (< 1/10,000). Very common, common and uncommon events were determined from clinical trial data. Rare and very rare events were generally derived from spontaneous data. The frequency classification “Not known” has been applied to those events where a frequency could not be estimated from the available data.
A summary of adverse events identified during world-wide post-approval use of atovaquone/proguanil hydrochloride combination tablet or its components, atovaquone and proguanil hydrochloride is provided below.

Blood and lymphatic system disorders.

Common: anaemia1, neutropenia2.
Not known: pancytopenia in patients with severe renal impairment4.

Immune system disorders.

Not known: angioedema4, anaphylaxis3, vasculitis.

Metabolism and nutritional disorders.

Common: anorexia1, hyponatraemia2.
Uncommon: elevated amylase levels2 occurred in patients treated with atovaquone.

Psychiatric disorders.

Rare: hallucinations1.

Nervous system disorders.

Very common: Headache1.
Common: Insomnia1, dizziness1.

Gastrointestinal disorders.

Very common: abdominal pain1, nausea2, vomiting1, diarrhoea1.
Uncommon: stomatitis1.
Not known: gastric intolerance4, oral ulceration4.

Hepatobiliary disorders.

Common: elevated liver enzyme levels2.
Not known: hepatitis3, cholestasis.
Clinical trial data for atovaquone/proguanil hydrochloride combination tablet indicated that abnormalities in liver function tests were reversible and not associated with untoward clinical events.

Skin and subcutaneous tissue disorders.

Common: rash1.
Uncommon: hair loss1, urticaria1.
Not known: Stevens-Johnson syndrome3, erythema multiforme3.

General disorders and administration site conditions.

Common: fever1.

Respiratory, thoracic and mediastinal disorders.

Common: cough1.
1. Frequency calculated from atovaquone/proguanil hydrochloride clinical trials.
2. Frequency taken from atovaquone label. Patients participating in clinical trials with atovaquone have received higher doses and have often had complications of advance Human Immunodefficiency Virus (HIV) disease. Therefore, the casual relationship between the adverse experiences and atovaquone is difficult to evaluate. These events may have been seen at a lower frequency or not at all in clinical trials with atovaquone/proguanil hydrochloride.
3. Observed from post-marketing spontaneous reports and the frequency is therefore not known.
4. Observed with proguanil and the frequency is therefore not known.

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.

4.9 Overdose

In cases of suspected overdose, symptomatic and supportive therapy should be given as appropriate.
For information on the management of overdose, contact the Poison Information Centre on 131126 (Australia).

5 Pharmacological Properties

5.1 Pharmacodynamic Properties

Mechanism of action.

The constituents of Promozio 250/100, atovaquone and proguanil hydrochloride interfere with two different pathways in the biosynthesis of pyrimidines, required for nucleic acid replication. The mechanism of action of atovaquone against P. falciparum is via inhibition of mitochondrial electron transport, at the level of the cytochrome bc1 complex, and collapse of mitochondrial membrane potential. One mechanism of action of proguanil, via its metabolite cycloguanil, is inhibition of dihydrofolate reductase, which disrupts deoxythymidylate synthesis. Proguanil also has antimalarial activity independent of its metabolism to cycloguanil, and proguanil, but not cycloguanil, is able to potentiate the ability of atovaquone to collapse mictochondrial membrane potential in malaria parasites. This latter mechanism may explain the synergy seen when atovaquone and proguanil are used in combination, as in Promozio 250/100.

Microbiology.

Atovaquone is active against Plasmodium spp (in vitro IC50 against P. falciparum 0.23-1.43 nanogram/mL).
The antimalarial activity of proguanil is exerted via the primary metabolite cycloguanil (in vitro IC50 against various P. falciparum strains of 4-20 nanogram/mL). Some activity of proguanil and another metabolite, 4-chlorophenylbiguanide, is seen in vitro at 0.6-3.0 microgram/mL.
In in vitro studies of P. falciparum, the combination of atovaquone and proguanil was shown to be synergistic. This enhanced efficacy was also demonstrated in clinical studies.

Clinical trials.

The safety and effectiveness of atovaquone/proguanil hydrochloride tablets (250/100) have been established in studies of up to 12 weeks in adult subjects.

Prophylaxis of malaria (individuals > 40 kg).

The safety and efficacy of atovaquone/proguanil hydrochloride tablets (250/100) in the prophylaxis of P. falciparum malaria was demonstrated in five randomised, double-blind clinical studies. Three placebo-controlled parallel group studies were conducted in residents of malaria endemic areas (MALB2001, MALB3001 and MALB3003), and two active-controlled studies were conducted in non-immune travellers (MALB30010 and MALB30011).
There were 473 patients in placebo-controlled studies, 232 of whom received one atovaquone/proguanil hydrochloride tablet (250/100) daily for 10-12 weeks of chemoprophylaxis, and 241 received placebo. Prevention of parasitaemia was the primary endpoint in the studies.
Atovaquone/proguanil hydrochloride had an overall efficacy of 97% (range 95-100%) for prevention of P. falciparum parasitaemia and an adverse event profile similar to placebo.
There were 1975 patients in active controlled studies, 993 of whom received one atovaquone/proguanil hydrochloride tablet (250/100) daily at the recommended dose (see Section 4.2 Dose and Method of Administration), 471 received mefloquine weekly (1 to 3 weeks before until 4 weeks after travel) and 511 patients received chloroquine weekly (1 week before until 4 weeks after travel) plus daily proguanil (1-2 days before until 4 weeks after travel). Frequency of adverse events was the primary endpoint and development of confirmed falciparum malaria within 60 days after leaving the malaria-endemic area was the secondary endpoint in the studies. No patients receiving atovaquone/proguanil hydrochloride or mefloquine contracted malaria (efficacy 100%), and 3 patients receiving chloroquine/proguanil contracted malaria (efficacy at least 70%). Patients receiving atovaquone/proguanil hydrochloride experienced fewer neuropsychiatric and gastrointestinal adverse reactions than patients receiving mefloquine and chloroquine/proguanil respectively.

Treatment of malaria.

Eight clinical studies (5 controlled and 3 uncontrolled) were conducted in 1115 patients of atovaquone and/or proguanil hydrochloride administered for the treatment of falciparum malaria (see Section 4.2 Dose and Method of Administration).
The primary efficacy endpoint was the proportion of evaluable patients cured of acute malaria. Cure was defined by clearance of asexual parasitaemia within 7 days of initiation of treatment, without subsequent recrudescence during the 28 day follow-up period.
In the controlled clinical trials, the study population included only patients with uncomplicated falciparum malaria. The comparator was standard antimalarial therapy within the country in which the study was conducted. Treatment with combination of atovaquone and proguanil hydrochloride was curative in 98% of evaluable patients (combined result). The concurrent administration of atovaquone and proguanil hydrochloride was more efficacious in three studies and of equivalent efficacy in two trials as the respective comparator antimalarial regimen (see Table 4).
In uncontrolled studies conducted in Thailand using the recommended dose of atovaquone and proguanil hydrochloride, the cure rate of malaria was 100% in adults (n=24, P. falciparum).

5.2 Pharmacokinetic Properties

There are no pharmacokinetic interactions between atovaquone and proguanil at the recommended dose.

Absorption.

Atovaquone is a highly lipophilic compound with low aqueous solubility and poor oral bioavailability that varies with dose and diet.
Although there are no atovaquone bioavailability data in healthy subjects, in HIV-infected patients the absolute bioavailability of a 750 mg single dose of atovaquone tablets taken with food is 21% (90% CI: 17% - 27%).
Dietary fat taken with atovaquone increases the rate and extent of absorption. When taken with a standard breakfast containing 23 g of fat, AUC was increased 2-3 times and Cmax 5 times compared with fasting. Patients are recommended to take Promozio 250/100 tablets with food or a milky drink (see Section 4.2 Dose and Method of Administration).
Proguanil hydrochloride is rapidly and extensively absorbed regardless of food intake. Peak plasma concentrations occur between 2-4 hours after a single 200 mg dose. The absolute bioavailability is not known.
In a comparative bioavailability study in healthy adult volunteers, atovaquone 250 mg and proguanil 100 mg combination tablet administered as a single dose was bioequivalent to separate tablets of atovaquone 250 mg and proguanil hydrochloride 100 mg given concomitantly. In healthy adult subjects treated for 3 days, the pharmacokinetics of atovaquone, and proguanil and its metabolite cycloguanil, were not modified when atovaquone and proguanil were given alone or in combination as atovaquone 250 mg and proguanil 100 mg combination tablet.

Distribution.

Atovaquone is highly protein bound (> 99%) but does not displace other highly protein bound drugs in vitro, indicating significant drug interactions arising from displacement are unlikely.
Following oral administration, the volume of distribution of atovaquone in adults is approximately 7 to 8 L/kg.
Proguanil is 75% protein bound. Following oral administration, the volume of distribution of proguanil in adults is 25 L/kg.
In human plasma, the protein binding of atovaquone or proguanil was unaffected by the presence of the other drug.

Metabolism.

There is no evidence that atovaquone is metabolised. Greater than 90% of atovaquone is eliminated unchanged in the faeces with negligible excretion in urine.
Proguanil hydrochloride is partially metabolised to cycloguanil and 4-chlorophenyl biguanide with less than 40% being excreted unchanged in urine. These metabolites are also excreted in the urine. Conversion of proguanil to cycloguanil is mediated in the liver by cytochrome P450 3A4 and 2C19. Conversion of proguanil to cycloguanil may be reduced in some individuals, due to genetic polymorphism of the metabolising enzyme. During administration with Promozio 250/100, at the recommended doses, proguanil metabolism status appears to have no implications for treatment or prophylaxis of malaria.

Excretion.

The elimination half-life of atovaquone is about 2-3 days in adults.
Following oral administration, the clearance of atovaquone in adults is approximately 0.04 to 0.05 L/h/kg. Following oral administration, the clearance of proguanil in adults is 1.3 L/h/kg.
In adults the elimination half life for proguanil or cycloguanil is about 12-15 hours.

Pharmacokinetics in the elderly.

There is no clinically significant change in the average rate or extent of absorption of atovaquone or proguanil between elderly and young patients. Systemic availability of cyloguanil is higher in the elderly compared with young patients, but there is no clinically significant change in its elimination half-life (see Section 4.2 Dose and Method of Administration).

Pharmacokinetics in renal impairment.

In patients with mild to moderate renal impairment, oral clearance and/or AUC data for atovaquone, proguanil and cycloguanil are within the range of values observed in patients with normal renal function. Atovaquone Cmax and AUC are reduced in patients with severe renal impairment. The elimination half lives for proguanil and cycloguanil are prolonged in patients with severe renal impairment with corresponding increases in AUC, resulting in the potential of drug accumulation with repeated dosing (see Section 4.2 Dose and Method of Administration; Section 4.3 Contraindications; Section 4.4 Special Warnings and Precautions for Use).

Pharmacokinetics in hepatic impairment.

In patients with mild to moderate hepatic impairment, there is no clinically significant change in exposure to atovaquone compared with healthy patients. In patients with mild to moderate hepatic impairment there is an increase in proguanil AUC with no change in its elimination half life and there is a decrease in Cmax and AUC for cycloguanil. No data are available in patients with severe hepatic impairment. (See Section 4.2 Dose and Method of Administration; Section 4.4 Special Warnings and Precautions for Use).

5.3 Preclinical Safety Data

Genotoxicity.

There was no evidence that either atovaquone or proguanil alone were mutagenic in bacterial and mammalian cell gene mutation assays in vitro, and in mouse bone marrow micronucleus assays for chromosome damage in vivo. Cycloguanil, an active metabolite of proguanil, was negative in a bacterial mutagenicity assay but positive in both a mammalian cell mutagenicity assay and a mouse micronucleus test. As the genotoxicity of cycloguanil is prevented or moderated by the co-administration of folinic acid, it appears to be related to the inhibition of mammalian dihydrofolate reductase, causing a reduction in the nucleotide pool and a consequent perturbation of DNA synthesis rather than a direct interaction with DNA. Neither proguanil nor cycloguanil is likely to present a genotoxic risk at clinical exposure levels. Mutagenicity studies have not been performed with atovaquone in combination with proguanil.

Carcinogenicity.

Oncogenicity studies of atovaquone alone in mice showed an increased incidence of hepatocellular adenomas and carcinomas at all dose levels tested, yielding exposures approximately 5 to 8 times the average steady-state plasma concentrations in humans during prophylaxis of malaria. The pattern of associated histological findings observed in the liver, is consistent with a species specific, non genotoxic, neoplastic response. Studies in rats at oral dose levels of up to 500 mg/kg/day were negative. Atovaquone is unlikely to present a carcinogenic risk to humans at therapeutic doses.
Oncogenicity studies on proguanil alone showed no evidence of carcinogenicity in rats and mice at doses resulting in exposures approximately equal to those obtained in humans during prophylaxis of malaria but considerably below exposures obtained during treatment of malaria. Carcinogenicity studies have not been conducted with atovaquone in combination with proguanil.

6 Pharmaceutical Particulars

6.1 List of Excipients

Microcrystalline cellulose, hyprolose, sodium starch glycollate type A, poloxamer, povidone, colloidal anhydrous silica, magnesium stearate, Opadry complete film coating system 03C86943 Brown.

6.2 Incompatibilities

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

6.3 Shelf Life

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

6.4 Special Precautions for Storage

Store tablets below 25°C.

6.5 Nature and Contents of Container

Promozio 250/100 tablets are provided in PVC-PVDC/Al blister packs of 12 or 24 tablets.
Not all pack sizes are marketed.

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

Atovaquone is virtually insoluble in water (less than 2 x 10-4 mg/mL) and slightly soluble (1.7 mg/mL) in 0.1 M sodium hydroxide.
Proguanil hydrochloride is slightly soluble at 1 part in 110 parts of water and is sparingly soluble in alcohol (1 part in 40 parts of alcohol).
The chemical name of atovaquone is trans-2-[4-(4-chlorophenyl) cyclohexyl]-3-hydroxy-1,4 naphthoquinone. The molecular formula of atovaquone is C22H19ClO3 and it has a molecular weight of 366.84.
The chemical name of proguanil hydrochloride is 1-(4-chlorophenyl)-5-isopropyl-biguanide hydrochloride. The molecular formula of proguanil hydrochloride is C11H16ClN5.HCl and it has a molecular weight of 290.20.

Chemical structure.


CAS number.

Atovaquone.

The CAS Registry Number is 95233-18-4.

Proguanil hydrochloride.

The CAS Registry Number is 637-32-1.

7 Medicine Schedule (Poisons Standard)

S4.

Summary Table of Changes