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Trileptal Side Effects, and Drug Interactions - Oxcarbazepine

Trileptal Side Effects, and Drug Interactions - Oxcarbazepine

SIDE EFFECTS

Most Common Adverse Events in All Clinical Studies

Adjunctive Therapy/Monotherapy in Adults Previously Treated with other AEDs: The most commonly observed (³5%) adverse experiences seen in association with Trileptal and substantially more frequent than in placebo treated patients were: dizziness, somnolence, diplopia, fatigue, nausea, vomiting, ataxia, abnormal vision, abdominal pain, tremor, dyspepsia, abnormal gait.

Approximately 23% of these 1537 adult patients discontinued treatment because of an adverse experience. The adverse experiences most commonly associated with discontinuation were: dizziness (6.4%), diplopia (5.9%), ataxia (5.2%), vomiting (5.1%), nausea (4.9%), somnolence (3.8%), headache (2.9%), fatigue (2.1%), abnormal vision (2.1%), tremor (1.8%), abnormal gait (1.7%), rash (1.4%), hyponatremia (1.0%).

Monotherapy in Adults not Previously Treated with other AEDs: The most commonly observed (³5%) adverse experiences seen in association with Trileptal in these patients were similar to those in previously treated patients.

Approximately 9% of these 295 adult patients discontinued treatment because of an adverse experience. The adverse experiences most commonly associated with discontinuation were: dizziness (1.7%), nausea (1.7%), rash (1.7%), headache (1.4%).

Adjunctive Therapy/Monotherapy in Pediatric Patients Previously Treated with other AEDs: The most commonly observed (³5%) adverse experiences seen in association with Trileptal in these patients were similar to those seen in adults.

Approximately 11% of these 456 pediatric patients discontinued treatment because of an adverse experience. The adverse experiences most commonly associated with discontinuation were: somnolence (2.4%), vomiting (2.0%), ataxia (1.8%), diplopia (1.3%), dizziness (1.3%), fatigue (1.1%), nystagmus (1.1%).

Incidence in Controlled Clinical Studies: The prescriber should be aware that the figures in Tables 3,4,5 and 6 cannot be used to predict the frequency of adverse experiences in the course of usual medical practice where patient characteristics and other factors may differ from those prevailing during clinical studies. Similarly, the cited frequencies cannot be directly compared with figures obtained from other clinical investigations involving different treatments, uses, or investigators. An inspection of these frequencies, however, does provide the prescriber with one basis to estimate the relative contribution of drug and nondrug factors to the adverse event incidences in the population studied.

Controlled Clinical Studies of Adjunctive Therapy/Monotherapy in Adults Previously Treated with other AEDs: Table 3 lists treatment-emergent signs and symptoms that occurred in at least 2% of adult patients with epilepsy treated with Trileptal or placebo as adjunctive treatment and were numerically more common in the patients treated with any dose of Trileptal. Table 4 lists treatment-emergent signs and symptoms in patients converted from other AED’s to either high dose Trileptal or low dose (300 mg) Trileptal. Note that in some of these monotherapy studies patients who dropped out during a preliminary tolerability phase are not included in the tables.

Table 3

Treatment-Emergent Adverse Event Incidence in a Controlled Clinical Study of Adjunctive Therapy in Adults (Events in at least 2% of patients treated with 2400 mg/day of Trileptal and numerically more frequent than in the placebo group)

Body System/ Adverse Event	Oxcarbazepine Dosage (mg/day)
	OXC 600 N=163 %	OXC 1200 N=171 %	OXC 2400 N=126 %	Placebo N=166 %
Body as a Whole
Fatigue	15	12	15	7
Asthenia	6	3	6	5
Edema Legs	2	1	2	1
Weight Increase	1	2	2	1
Feeling Abnormal	0	1	2	0
Cardiovascular System
Hypotension	0	1	2	0
Digestive System
Nausea	15	25	29	10
Vomiting	13	25	36	5
Pain Abdominal	10	13	11	5
Diarrhea	5	6	7	6
Dyspepsia	5	5	6	2
Constipation	2	2	6	4
Gastritis	2	1	2	1
Metabolic and Nutritional Disorders
Hyponatremia	3	1	2	1
Musculoskeletal System
Muscle Weakness	1	2	2	0
Sprains and Strains	0	2	2	1
Nervous System
Headache	32	28	26	23
Dizziness	26	32	49	13
Somnolence	20	28	36	12
Ataxia	9	17	31	5
Nystagmus	7	20	26	5
Gait Abnormal	5	10	17	1
Insomnia	4	2	3	1
Tremor	3	8	16	5
Nervousness	2	4	2	1
Agitation	1	1	2	1
Coordination Abnormal	1	3	2	1
EEG Abnormal	0	0	2	0
Nervous System (Cont’d)
Speech Disorder	1	1	3	0
Confusion	1	1	2	1
Cranial Injury Nos	1	0	2	1
Dysmetria	1	2	3	0
Thinking Abnormal	0	2	4	0
Respiratory System
Rhinitis	2	4	5	4
Skin and Appendages
Acne	1	2	2	0
Special Senses
Diplopia	14	30	40	5
Vertigo	6	12	15	2
Vision Abnormal	6	14	13	4
Accommodation Abnormal	0	0	2	0

Table 4

Treatment-Emergent Adverse Event Incidence in Controlled Clinical Studies of Monotherapy in Adults Previously Treated with Other AEDs (Events in at least 2% of patients treated with 2400 mg/day of Trileptal and numerically more frequent than in the low dose control group)

Body System/ Adverse Event	Oxcarbazepine Dosage (mg/day)
	2400 N=86 %	300 N=86 %
Body as a Whole-General Disorder
Fatigue	21	5
Fever	3	0
Allergy	2	0
Edema Generalized	2	1
Pain Chest	2	0
Digestive System
Nausea	22	7
Vomiting	15	5
Diarrhea	7	5
Dyspepsia	6	1
Anorexia	5	3
Pain Abdominal	5	3
Mouth Dry	3	0
Hemorrhage Rectum	2	0
Toothache	2	1
Hemic and Lymphatic System
Lymphadenopathy	2	0
Infections and Infestations
Infection Viral	7	5
Infection	2	0
Metabolic and Nutritional Disorder
Hyponatremia	5	0
Thirst	2	0
Nervous System
Headache	31	15
Dizziness	28	8
Somnolence	19	5
Anxiety	7	5
Ataxia	7	1
Confusion	7	0
Nervousness	7	0
Insomnia	6	3
Tremor	6	3
Amnesia	5	1
Convulsions Aggravated	5	2
Emotional Lability	3	2
Hypoesthesia	3	1
Coordination Abnormal	2	1
Nystagmus	2	0
Speech Disorder	2	0
Respiratory System
Upper Respiratory Tract Infection	10	5
Coughing	5	0
Bronchitis	3	0
Pharyngitis	3	0
Skin and Appendages
Hot Flulshes	2	1
Purpura	2	0
Special Senses
Vision Abnormal	14	2
Diplopia	12	1
Taste Perversion	5	0
Vertigo	3	0
Ear Ache	2	1
Ear Infection Nos	2	0
Urogenital and Reproductive System
Urinary Tract Infection	5	1
Micturition Frequency	2	1
Vaginitis	2	0

Controlled Clinical Study of Monotherapy in Adults not Previously Treated with other AEDs:

Table 5 lists treatment-emergent signs and symptoms in a controlled clinical study of monotherapy in adults not previously treated with other AEDs that occurred in at least 2% of adult patients with epilepsy treated with Trileptal or placebo and were numerically more common in the patients treated with Trileptal.

Table 5

Treatment-Emergent Adverse Event Incidence in a Controlled Clinical Study of Monotherapy in Adults not Previously Treated with Other AEDs (Events in at least 2% of patients treated with Trileptal and numerically more frequent than in the placebo group)

Body System/ Adverse Event	Oxcarbazepine N=55 %	Placebo N=49 %
Body as a Whole
Falling Down Nos	4	0
Digestive System
Nausea	16	12
Diarrhea	7	2
Vomiting	7	6
Constipation	5	0
Dyspepsia	5	4
Musculoskeletal System
Pain Back	4	2
Nervous System
Dizziness	22	6
Headache	13	10
Ataxia	5	0
Nervousness	5	2
Amnesia	4	2
Coordination Abnormal	4	2
Tremor	4	0
Respiratory System
Upper Respiratory Tract Infection	7	0
Epistaxis	4	0
Infection Chest	4	0
Sinusitis	4	2
Skin and Appendages
Rash	4	2
Special Senses
Vision Abnormal	4	0

Controlled Clinical Studies of Adjunctive Therapy/Monotherapy in Pediatric Patients Previously Treated with other AEDs: Table 6 lists treatment-emergent signs and symptoms that occurred in at least 2% of pediatric patients with epilepsy treated with Trileptal or placebo as adjunctive treatment and were numerically more common in the patients treated with Trileptal.

Table 6

Treatment-Emergent Adverse Event Incidence in Controlled Clinical Studies of Adjunctive Therapy/Monotherapy in Pediatric Patients Previously Treated with Other AEDs (Events in at least 2% of patients treated with Trileptal and numerically more frequent than in the placebo group)

Body System/ Adverse Event	Oxcarbazepine N=171 %	Placebo N=139 %
Body as a Whole
Fatigue	13	9
Allergy	2	0
Asthenia	2	1
Digestive System
Vomiting	33	14
Nausea	19	5
Constipation	4	1
Dyspepsia	2	0
Nervous System
Headache	31	19
Somnolence	31	13
Dizziness	28	8
Ataxia	13	4
Nystagmus	9	1
Emotional Lability	8	4
Gait Abnormal	8	3
Tremor	6	4
Speech Disorder	3	1
Concentration Impaired	2	1
Convulsions	2	1
Muscle Contractions Involuntary	2	1
Respiratory System
Rhinitis	10	9
Pneumonia	2	1
Skin and Appendages
Bruising	4	2
Sweating Increased	3	0
Special Senses
Diplopia	17	1
Vision Abnormal	13	1
Vertigo	2	0

Other Events Observed in Association with the Administration of Trileptal

In the paragraphs that follow, the adverse events other than those in the preceding tables or text, that occurred in a total of 565 children and 1574 adults exposed to Trileptal and that are reasonably likely to be related to drug use are presented. Events common in the population, events reflecting chronic illness and events likely to reflect concomitant illness are omitted particularly if minor. They are listed in order of decreasing frequency. Because the reports cite events observed in open label and uncontrolled trials, the role of Trileptal in their causation cannot be reliably determined.

Body as a Whole: Fever, malaise, pain chest precordial, rigors, weight decrease.

Cardiovascular System: Bradycardia, cardiac failure, cerebral hemorrhage, hypertension, hypotension postural, palpitation, syncope, tachycardia.

Digestive System: Appetite increased, blood in stool, cholelithiasis, colitis, duodenal ulcer, dysphagia, enteritis, eructation, esophagitis, flatulence, gastric ulcer, gingival bleeding, gum hyperplasia, hematemesis, hemorrhage rectum, hemorrhoids, hiccup, mouth dry, pain biliary, pain right hypochondrium, retching, sialoadenitis, stomatitis, stomatitis ulcerative.

Hemic and Lymphatic System: Leukopenia, thrombocytopenia

Laboratory Abnormality: Gamma-GT increased, hyperglycemia, hypocalcemia, hypoglycemia, hypokalemia, liver enzymes elevated, serum transaminase increased.

Musculoskeletal System: Hypertonia muscle.

Nervous System: Aggressive reaction, amnesia, anguish, anxiety, apathy, aphasia, aura, convulsions aggravated, delirium, delusion, depressed level of consciousness, dysphonia, dystonia, emotional lability, euphoria, extrapyramidal disorder, feeling drunk, hemiplegia, hyperkinesia, hyperreflexia, hypoesthesia, hypokinesia, hyporeflexia, hypotonia, hysteria, libido decreased, libido increased, manic reaction, migraine, muscle contractions involuntary, nervousness, neuralgia, oculogyric crisis, panic disorder, paralysis, paroniria, personality disorder, psychosis, ptosis, stupor, tetany

Respiratory System: Asthma, dyspnea, epistaxis, laryngismus, pleurisy

Skin and Appendages: Acne, alopecia, angioedema, bruising, dermatitis contact, eczema, facial rash, flushing, folliculitis, heat rash, hot flushes, photosensitivity reaction, pruritus genital, psoriasis, purpura, rash erythematous, rash maculopapular, vitiligo

Special Senses: Accommodation abnormal, cataract, conjunctival hemorrhage, edema eye, hemianopia, mydriasis, otitis externa, photophobia, scotoma, taste perversion, tinnitus, xerophthalmia

Surgical and Medical Procedures: Procedure dental oral, procedure female reproductive, procedure musculoskeletal, procedure skin

Urogenital and Reproductive System: Dysuria, hematuria, intermenstrual bleeding, leukorrhea, menorrhagia, micturition frequency, pain renal, pain urinary tract, polyuria, priapism, renal calculus

Other: Systemic lupus erythematosus

Post-Marketing and Other Experience

The following adverse events not seen in controlled clinical trials have been observed in named patient programs or post-marketing experience:

Body as a Whole: multiorgan hypersensitivity disorders characterized by features such as rash, fever, lymphadenopathy, abnormal liver function tests, eosinophilia and arthralgia.

Skin and Appendages: Erythema multiforme, Stevens-Johnson syndrome, Toxic epidermal necrolysis

DRUG ABUSE AND DEPENDENCE

Abuse

The abuse potential of Trileptal^TM (oxcarbazepine) has not been evaluated in human studies.

Dependence

Intragastric injections of oxcarbazepine to four cynomolgus monkeys demonstrated no signs of physical dependence as measured by the desire to self administer oxcarbazepine by lever pressing activity.

DRUG INTERACTIONS

Oxcarbazepine can inhibit CYP2C19 and induce CYP3A4/5 with potentially important effects on plasma concentrations of other drugs. In addition, several AED’s that are cytochrome P450 inducers can decrease plasma concentrations of oxcarbazepine and MHD.

Oxcarbazepine was evaluated in human liver microsomes to determine its capacity to inhibit the major cytochrome P450 enzymes responsible for the metabolism of other drugs. Results demonstrate that oxcarbazepine and its pharmacologically active 10-monohydroxy metabolite (MHD) have little or no capacity to function as inhibitors for most of the human cytochrome P450 enzymes evaluated (CYP1A2, CYP2A6, CYP2C9, CYP2D6, CYP2E1, CYP4A9 and CYP4A11) with the exception of CYP2C19 and CYP3A4/5. Although inhibition of CYP 3A4/5 by OXC and MHD did occur at high concentrations, it is not likely to be of clinical significance. The inhibition of CYP-2C19 by OXC and MHD, however, is clinically relevant (see below).

In vitro, the UDP-glucuronyl transferase level was increased, indicating induction of this enzyme. Increases of 22% with MHD and 47% with oxcarbazepine were observed. As MHD, the predominant plasma substrate, is only a weak inducer of UDP-glucuronyl transferase, it is unlikely to have an effect on drugs that are mainly eliminated by conjugation through UDP-glucuronyl transferase (e.g., valproic acid, lamotrigine).

In addition, oxcarbazepine and MHD induce a subgroup of the cytochrome P450 3A family (CYP3A4 and CYP3A5) responsible for the metabolism of dihydropyridine calcium antagonists and oral contraceptives, resulting in a lower plasma concentration of these drugs.

As binding of MHD to plasma proteins is low (40%), clinically significant interactions with other drugs through competition for protein binding sites are unlikely.

Antiepileptic drugs

Potential interactions between Trileptal and other AEDs were assessed in clinical studies. The effect of these interactions on mean AUCs and C_min are summarized in Table 2:

Table 2: Summary of AED interactions with Trileptal

AED Co-administered	Dose of AED (mg/day)	Trileptal dose (mg/day)	Influence of Trileptal on AED Concentration (Mean change, 90% Confidence Interval)	Influence of AED On MHD Concentration (Mean change, 90% Confidence Interval)
Carbamazepine	400-2000	900	nc1	40% decrease [CI: 17% decrease, 57% decrease]
Phenobarbital	100-150	600-1800	14% increase [CI: 2% increase, 24% increase]	25% decrease [CI: 12% decrease, 51% decrease]
Phenytoin	250-500	600-1800	nc1,2	30% decrease [CI: 3% decrease, 48 % decrease]
		>1200-2400	up to 40% increase3 [CI: 12% increase, 60 % increase]
Valproic acid	400-2800	600-1800	nc1	18% decrease [CI: 13% decrease, 40 % decrease]

¹- nc denotes a mean change of less than 10%
²- Pediatrics
³- Mean increase in adults at high Trileptal doses

In vivo, the plasma levels of phenytoin increased by up to 40%, when Trileptal was given at doses above 1200 mg/day. Therefore, when using doses of Trileptal greater than 1200 mg/day during adjunctive therapy, a decrease in the dose of phenytoin may be required. The increase of phenobarbital level, however, is small (15%) when given with Trileptal.

Strong inducers of cytochrome P450 enzymes (i.e. carbamazepine, phenytoin and phenobarbital) have been shown to decrease the plasma levels of MHD (29-40%).

No autoinduction has been observed with Trileptal.

Hormonal contraceptives

Co-administration of Trileptal with an oral contraceptive has been shown to influence the plasma concentrations of the two hormonal components, ethinylestradiol (EE) and levonorgestrel (LNG). The mean AUC values of EE were decreased by 48% [90% CI: 22-65] in one study and 52% [90% CI: 38-52] in another study [1,2]. The mean AUC values of LNG were decreased by 32% [90% CI: 20-45] in one study and 52% [90% CI: 42-52] in another study. Therefore, concurrent use of Trileptal with hormonal contraceptives may render these contraceptives less effective (see PRECAUTIONS section). Studies with other oral or implant contraceptives have not been conducted.

Calcium Antagonists

After repeated co-administration of Trileptal, the AUC of felodipine was lowered by 28% [90% CI: 20-33].

Verapamil produced a decrease of 20% [90% CI: 18-27] of the plasma levels of MHD.

Other drug interactions

Cimetidine, erythromycin and dextropropoxyphene had no effect on the pharmacokinetics of MHD. Results with warfarin wshow no evidence of interaction with either single or repeated doses of Trileptal.

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