Calcipotriene and Betamethasone Dipropionate: Package Insert and Label Information (Page 2 of 3)

8.2 Lactation

Risk Summary

There is no information regarding the presence of topically administered calcipotriene and betamethasone dipropionate in human milk, the effects on the breastfed infant, or the effects on milk production. Concentrations of calcipotriene in plasma are low after topical administration, and therefore, concentrations in human milk are likely to be low [see Clinical Pharmacology (12.3)]. It is not known whether topical administration of large amounts of betamethasone dipropionate could result in sufficient systemic absorption to produce detectable quantities in human milk (see Clinical Considerations). The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for Calcipotriene and Betamethasone Dipropionate Topical Suspension and any potential adverse effects on the breastfed child from Calcipotriene and Betamethasone Dipropionate Topical Suspension or from the underlying maternal condition.

Clinical Considerations

To minimize potential exposure to the breastfed infant via breast milk, use Calcipotriene and Betamethasone Dipropionate Topical Suspension on the smallest area of skin and for the shortest duration possible while breastfeeding. Advise breastfeeding women not to apply Calcipotriene and Betamethasone Dipropionate Topical Suspension directly to the nipple and areola to avoid direct infant exposure [see Use in Specific Populations (8.4)].

8.4 Pediatric Use

The safety and effectiveness of calcipotriene and betamethasone dipropionate topical suspension for the treatment of plaque psoriasis of the scalp have been established in pediatric patients age 12 to 17 years. The use of calcipotriene and betamethasone dipropionate topical suspension for this indication is supported by evidence from adequate and well-controlled trials in adults and from uncontrolled trials in pediatric subjects that enrolled 109 adolescents with moderate psoriasis of the scalp. After 4 weeks of once daily treatment with calcipotriene and betamethasone dipropionate topical suspension, HPA axis suppression was observed in 3% of adolescents with psoriasis of the scalp and 16% of adolescents with psoriasis of the scalp and body. [see Warnings and Precautions (5.2), Adverse Reactions (6.1), and Clinical Pharmacology (12.2)].

Because of a higher ratio of skin surface area to body mass, pediatric patients are at a greater risk than adults of systemic toxicity when treated with topical corticosteroids. Pediatric patients are, therefore, also at greater risk of HPA axis suppression and adrenal insufficiency with the use of topical corticosteroids including calcipotriene and betamethasone dipropionate topical suspension [see Clinical Pharmacology (12.2)].

Rare systemic toxicities such as Cushing’s syndrome, linear growth retardation, delayed weight gain, and intracranial hypertension have been reported in pediatric patients, especially those with prolonged exposure to large doses of high potency topical corticosteroids. Local adverse reactions including striae have also been reported with use of topical corticosteroids in pediatric patients.

The safety and effectiveness of Calcipotriene and Betamethasone Dipropionate Topical Suspension in pediatric patients less than 12 years of age have not been established.

Additional pediatric use information is approved for LEO Pharma A/S’s Taclonex® (calcipotriene and betamethasone dipropionate) Topical Suspension. However, due to LEO Pharma A/S’s marketing exclusivity rights, this drug product is not labeled with that information.

8.5 Geriatric Use

Clinical studies of calcipotriene and betamethasone dipropionate topical suspension in plaque psoriasis on non-scalp areas included 124 subjects who were 65 years of age or older, and 36 were 75 years of age or older. Clinical studies of calcipotriene and betamethasone dipropionate topical suspension in subjects with psoriasis of the scalp included 334 subjects who were 65 years or older and 84 subjects who were 75 years or older.

No overall differences in safety or effectiveness of calcipotriene and betamethasone dipropionate topical suspension were observed between these subjects and younger subjects, and other reported clinical experience has not identified any differences in response between elderly and younger subjects, but greater sensitivity of some older individuals cannot be ruled out.

11 DESCRIPTION

Calcipotriene and Betamethasone Dipropionate Topical Suspension contains calcipotriene hydrate and betamethasone dipropionate. It is for topical use only. Calcipotriene hydrate is a synthetic vitamin D3 analog.

Calcipotriene Hydrate

Calcipotriene hydrate is a vitamin D analog and has the chemical name 9,10-secochola-5,7,10(19),22- tetraene-1,3,24-triol,24-cyclopropyl-,monohydrate, (1α,3β,5Z,7E,22E,24S) with the empirical formula C27 H40 O3 •H2 O a molecular weight of 430.6, and the following structural formula (calcipotriene hydrate is a white to almost white, crystalline compound):

chemical-structure-1

Betamethasone Dipropionate

Betamethasone dipropionate is a synthetic corticosteroid and has the chemical name pregna-1,4-diene-3,20-dione-9-fluoro-11-hydroxy-16-methyl-17,21-bis (1-oxypropoxy)-(11ß,16ß), with the empirical formula C28 H37 FO7 , a molecular weight of 504.6, and the following structural formula (betamethasone dipropionate is a white to almost white, crystalline powder):

chemical-structure-2
(click image for full-size original)

Calcipotriene and Betamethasone Dipropionate Topical Suspension

Each gram of Calcipotriene and Betamethasone Dipropionate Topical Suspension contains 50 mcg of calcipotriene (equivalent to 52.2 mcg of calcipotriene hydrate) and 0.643 mg of betamethasone dipropionate (equivalent to 0.5 mg of betamethasone) in a base of hydrogenated castor oil, polyoxypropylene stearyl ether, all-rac -alpha-tocopherol, butylhydroxytoluene, and mineral oil. Calcipotriene and Betamethasone Dipropionate Topical Suspension is an odorless, clear to slightly off-white suspension.

12 CLINICAL PHARMACOLOGY

12.1 Mechanism of Action

Calcipotriene and Betamethasone Dipropionate Topical Suspension combines the pharmacological effects of calcipotriene hydrate as a synthetic vitamin D3 analog and betamethasone dipropionate as a synthetic corticosteroid. However, while their pharmacologic and clinical effects are known, the exact mechanisms of their actions in the treatment of plaque psoriasis of the scalp and body are unknown.

12.2 Pharmacodynamics

Hypothalamic-Pituitary-Adrenal (HPA) Axis Suppression:

HPA axis suppression was evaluated in four trials (Trial A, B, C, and D) following the application of calcipotriene and betamethasone dipropionate topical suspension. In all these trials, adrenal suppression was defined by a 30-minute post-stimulation cortisol level ≤18 mcg/dL.

In Trial A, HPA axis suppression was evaluated in adult subjects (N=32) with extensive psoriasis involving at least 30% of the scalp and, in total, 15-30% of the body surface area. Treatment consisted of once daily application of calcipotriene and betamethasone dipropionate topical suspension on the scalp in combination with calcipotriene and betamethasone dipropionate ointment on the body for 4 to 8 weeks. Adrenal suppression was observed in 5 of 32 subjects (16%) after 4 weeks of treatment and in 2 of 11 subjects (18%) who continued treatment for 8 weeks.
In Trial B, HPA axis suppression was evaluated in adult subjects (N=43) with extensive psoriasis involving 15-30% of the body surface area (including the scalp). Treatment consisted of once daily application of calcipotriene and betamethasone dipropionate topical suspension to the body (including the scalp in 36 out of 43 subjects) for 4 to 8 weeks. Adrenal suppression was observed in 3 out of 43 subjects (7%) after 4 weeks of treatment and in none of the 36 subjects (0%) who continued treatment for 8 weeks.
In Trial C, HPA axis suppression was evaluated in pediatric subjects 12 to 17 years (N=30) with plaque psoriasis of the scalp involving at least 20% of the scalp area. Treatment consisted of once daily application of calcipotriene and betamethasone dipropionate topical suspension to the affected area on the scalp for up to 8 weeks. Adrenal suppression was observed in 1 of 30 evaluable subjects (3%) after 4 weeks of treatment and in no subjects (0%) who continued treatment for 8 weeks [see Use in Specific Populations (8.4)].
In Trial D, HPA axis suppression was evaluated in a subset of pediatric subjects aged 12 to 17 years (N=31) with plaque psoriasis of the scalp and body involving 10% to 29% of the body surface area. Adrenal suppression was observed in 5 of 31 subjects (16%): 3 subjects after 4 weeks of treatment, 1 subject after 8 weeks of treatment and 1 subject after both 4 and 8 weeks of treatment [see Use in Specific Populations (8.4)].

Effects on Calcium Metabolism

The effect on calcium metabolism was evaluated following the application of calcipotriene and betamethasone dipropionate topical suspension (these trials are described above).

In Trial A, elevated urinary calcium levels outside the normal range were observed in two subjects (one at 4 weeks and one at 8 weeks).
In Trial B, there was no change in mean serum or urinary calcium levels. Elevated urinary calcium levels outside the normal range were observed in two subjects (one at 4 weeks and one at 8 weeks).
In Trial C (N=109), including 31 subjects with at least 20% scalp involvement and 78 subjects with at least 10% scalp involvement, no cases of hypercalcemia and no clinically relevant changes in urinary calcium were reported.

12.3 Pharmacokinetics

Absorption

The systemic effect of calcipotriene and betamethasone dipropionate topical suspension in psoriasis was investigated in Trials A and B [see Clinical Pharmacology (12.2)].

In Trial A, the serum levels of calcipotriene and betamethasone dipropionate and their major metabolites were measured after 4 and 8 weeks of once daily application of calcipotriene and betamethasone dipropionate topical suspension on the scalp in combination with calcipotriene and betamethasone dipropionate ointment on the body. Calcipotriene and betamethasone dipropionate were below the lower limit of quantification in all serum samples of the 34 subjects evaluated. However, one major metabolite of calcipotriene (MC1080) was quantifiable in 10 of 34 (29%) subjects at week 4 and in 5 of 12 (42%) subjects at week 8. The major metabolite of betamethasone dipropionate, betamethasone 17-propionate (B17P) was also quantifiable in 19 of 34 (56%) subjects at week 4 and 7 of 12 (58%) subjects at week 8. The serum concentrations for MC1080 ranged from 20-75 pg/mL. The clinical significance of this finding is unknown.

In Trial B, the plasma levels of calcipotriene and betamethasone dipropionate and their major metabolites were measured after 4 weeks of once daily application of calcipotriene and betamethasone dipropionate topical suspension. Calcipotriene and its metabolite MC1080 were below the lower limit of quantification in all plasma samples. Betamethasone dipropionate was quantifiable in 4 of 43 (9) subjects. The metabolite of betamethasone dipropionate (B17P) was quantifiable in 16 of 43 (37%) subjects. The plasma concentrations of betamethasone dipropionate ranged from 30.9-63.5 pg/mL and that of its metabolite betamethasone 17-propionate ranged from 30.5-257 pg/mL. The clinical significance of this finding is unknown.

Elimination

Metabolism

Calcipotriene:
Calcipotriene metabolism following systemic uptake is rapid and occurs in the liver. The primary metabolites of calcipotriene are less potent than the parent compound.
Calcipotriene is metabolized to MC1046 (the α,ß-unsaturated ketone analog of calcipotriene),which is metabolized further to MC1080 (a saturated ketone analog). MC1080 is the major metabolite in plasma. MC1080 is slowly metabolized to calcitroic acid.
Betamethasone dipropionate:
Betamethasone dipropionate is metabolized to betamethasone 17-propionate and betamethasone, including the 6ß-hydroxy derivatives of those compounds by hydrolysis. Betamethasone 17-propionate (B17P) is the primary metabolite.

Additional pediatric use information is approved for LEO Pharma A/S’s Taclonex® (calcipotriene and betamethasone dipropionate) Topical Suspension. However, due to LEO Pharma A/S’s marketing exclusivity rights, this drug product is not labeled with that information.

13 NONCLINICAL TOXICOLOGY

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

When calcipotriene was applied topically to mice for up to 24 months at dosages of 3, 10, and 30 mcg/kg/day (9, 30, and 90 mcg/m2 /day, respectively), no significant changes in tumor incidence were observed when compared to control.

A 104-week oral carcinogenicity study was conducted with calcipotriene in male and female rats at doses of 1, 5 and 15 mcg/kg/day (6, 30, and 90 mcg/m2 /day, respectively). Beginning week 71, the dosage for high-dose animals of both genders was reduced to 10 mcg/kg/day (60 mcg/m2 /day). A treatment-related increase in benign C-cell adenomas was observed in the thyroid of females that received 15 mcg/kg/day. A treatment-related increase in benign pheochromocytomas was observed in the adrenal glands of males that received 15 mcg/kg/day. No other statistically significant differences in tumor incidence were observed when compared to control. The relevance of these findings to patients is unknown.

When betamethasone dipropionate was applied topically to CD-1 mice for up to 24 months at dosages approximating 1.3, 4.2, and 8.5 mcg/kg/day in females, and 1.3, 4.2, and 12.9 mcg/kg/day in males (up to 26 mcg/m2 /day and 39 mcg/m2 /day, in females and males, respectively), no significant changes in tumor incidence were observed when compared to control.

When betamethasone dipropionate was administered via oral gavage to male and female Sprague Dawley rats for up to 24 months at dosages of 20, 60, and 200 mcg/kg/day (120, 260, and 1200 mcg/m2 /day, respectively), no significant changes in tumor incidence were observed when compared to control.

Calcipotriene did not elicit any genotoxic effects in the Ames mutagenicity assay, the mouse lymphoma TK locus assay, the human lymphocyte chromosome aberration test, or the mouse micronucleus test. Betamethasone dipropionate did not elicit any genotoxic effects in the Ames mutagenicity assay, the mouse lymphoma TK locus assay, or in the rat micronucleus test.

Studies in rats with oral doses of up to 54 mcg/kg/day (324 mcg/m2 /day) of calcipotriene indicated no impairment of fertility or general reproductive performance. Studies in male rats at oral doses of up to 200 mcg/kg/day (1200 mcg/m2 /day), and in female rats at oral doses of up to 1000 mcg/kg/day (6000 mcg/m2 /day), of betamethasone dipropionate indicated no impairment of fertility.

14 CLINICAL STUDIES

Clinical Trials Conducted in Subjects 18 Years and Older with Psoriasis of the Scalp

Two multicenter, randomized, double-blind trials were conducted in adult subjects with moderate to very severe psoriasis of the scalp.

In Trial One, 1,407 subjects were randomized to 1 of 4 treatment groups: calcipotriene and betamethasone dipropionate topical suspension, betamethasone dipropionate in the same vehicle, calcipotriene in the same vehicle, or the vehicle alone.
In Trial Two, 1,280 subjects were randomized to 1 of 3 treatment groups: calcipotriene and betamethasone dipropionate topical suspension, betamethasone dipropionate in the same vehicle, or calcipotriene in the same vehicle.

Both trials enrolled subjects with moderate to very severe psoriasis of the scalp. The majority of subjects had disease of moderate severity at baseline. Subjects were treated once daily for 8 weeks. Efficacy was assessed as the proportion of subjects at Week 8 with absent or very mild disease according to the Investigator’s Global Assessment of Disease Severity. “Clear” was defined as no evidence of redness, thickness or scaling. “Almost clear” was defined as an overall clinical picture of lesions with the presence of minimal erythema. Table 2 contains the response rates in each of these 2 trials.

Table 2. Percentage of Subjects with Clear or Almost Clear Disease

According to the Investigator’s Global Assessment of Disease Severity in Trials on Scalp

Calcipotriene and

Betamethasone

Dipropionate Topical

Suspension

Betamethasone

Dipropionate

in vehicle

Calcipotriene

in vehicle

Vehicle

Trial One

Week 2

(N=494)

55.5%

(N=531)

46.1%

(N=256)

18.4%

(N=126)

9.5%

Week 8

70.0%

63.1%

36.7%

19.8%

Trial Two

Week 2

(N=512)

47.1%

(N=517)

36.4%

(N=251)

12.7%

Week 8

67.2%

59.6%

41.0%

Clinical Trials Conducted in Subjects 18 Years and Older with Psoriasis of the Body

One multicenter, randomized, double-blind trial was conducted in subjects with mild to moderate plaque psoriasis on non-scalp areas, excluding face, axillae, and groin. In this trial, 1152 subjects were randomized to 1 of 4 treatment groups: calcipotriene and betamethasone dipropionate topical suspension, betamethasone dipropionate in the same vehicle, calcipotriene in the same vehicle, or the vehicle alone. Seventy eight percent (78%) of subjects had disease of moderate severity at baseline. Subjects were treated once daily for 8 weeks. Efficacy was assessed at Week 4 and Week 8 as the proportion of subjects who were “Clear” or “Almost clear” according to the Investigator’s Global Assessment of Disease Severity. Subjects with mild disease at baseline were required to be “Clear” to be considered a success. Table 3 contains the response rates in this trial.

Table 3. Percentage of Subjects with Clear or Almost Clear Disease

According to the Investigator’s Global Assessment of Disease Severity* in Trial on the Body

Calcipontriene and

Betamethasone

Dipropionate

Topical Suspension

(N=482)

Betamethasone

Dipropionate

in vehicle

(N=479)

Calcipotriene in vehicle

(N=96)

Vehicle

(N=95)

Week 4

13.3%

12.5%

5.2%

2.1%

Week 8

29.0%

21.5%

14.6%

6.3%

*Subjects with mild disease at baseline were required to be “Clear” to be considered a success.

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