4.1. Therapeutic indications

Symptomatic treatment of severe sialorrhoea (chronic pathological drooling) in children and adolescents aged 3 years and older with chronic neurological disorders.

4.2. Posology and method of administration

Glycopyrronium bromide tablets are recommended for short-term intermittent use (see section 4.4 and 5.1).

Glycopyrronium bromide tablets should be prescribed by physicians experienced in the treatment of patients with neurological disorders.

Posology

The dosing schedule for Glycopyrronium bromide 1mg and 2mg tablets is based on the weight of the child with an initial dosing of 0.02 mg/kg to be given orally three times daily and titrated in increments of 0.02 mg/kg every 7 days based on therapeutic response and adverse reactions. The maximum recommended dose is 0.1 mg/kg three times daily not to exceed 1.5-3 mg per dose based upon weight (see Table).

During a four-week titration period, dose should be increased no more frequently than weekly using the titration schedule to minimise anticholinergic adverse events. Increase of dose should occur only after it is clear that the dose level is well tolerated and monitoring of the increase is in place. Prior to each dose increase, a review of the tolerability of the current dose level should be made with the patient's caregiver.

Younger children may be more susceptible to adverse events and this should be kept in mind when dose adjustments are made.

Following the dose titration period, the child's sialorrhoea should be monitored, in conjunction with the carer at no longer than 3 monthly intervals, to assess changes in efficacy and/or tolerability over time, and the dose adjusted accordingly.

Dosing table for children and adolescents aged 3 years and older (week intervals between increased dose increments)

Weight

Dose Level 1

Dose Level 2

Dose Level 3

Dose Level 4

Dose Level 5

kg

(~0.02 mg/kg)

(~0.04 mg/kg)

(~0.06 mg/kg)

(~0.08 mg/kg)

(~0.1 mg/kg)

13-17

0.3 mg

0.6 mg

0.9 mg

1.2 mg

1.5 mg

18-22

0.4 mg

0.8 mg

1.2 mg

1.6 mg

2.0 mg

23-27

0.5 mg*

1.0 mg

1.5 mg

2.0 mg

2.5 mg

28-32

0.6 mg

1.2 mg

1.8 mg

2.4 mg

3.0 mg

33-37

0.7 mg

1.4 mg

2.1 mg

2.8 mg

3.0 mg

38-42

0.8 mg

1.6 mg

2.4 mg

3.0 mg

3.0 mg

43-47

0.9 mg

1.8 mg

2.7 mg

3.0 mg

3.0 mg

≥48

1.0 mg

2.0 mg

3.0 mg

3.0 mg

3.0 mg

* 0.5mg dose can be achieved by taking ½ of a 1mg tablet.

For doses which cannot be achieved using the tablet formulation, other pharmaceutical forms of glycopyrronium bromide are available.

Glycopyrronium Bromide tablets are not recommended for use in children younger than 3 years.

Adult population

Glycopyrronium Bromide tablets are indicated for the paediatric population only. There is limited clinical trial evidence on the use of glycopyrronium in the adult population with pathological drooling.

Elderly population

Glycopyrronium Bromide tablets are indicated for the paediatric population only. The elderly have a longer elimination half-life and reduced medicinal product clearance as well as limited data to support efficacy in short-term use. As such Glycopyrronium Bromide tablets should not be used in patients over the age of 65 years.

Renal Impairment

Elimination of glycopyrronium is severely impaired in patients with renal failure. Glycopyrronium is contraindicated in those with severe renal failure (see section 4.3). For patients with Mild to moderate renal impairment (eGFR <90 - ≥30 ml/min/1.73m2) doses should be reduced by 30%.

Hepatic impairment

Clinical studies have not been conducted in patients with hepatic impairment. Glycopyrronium is cleared predominantly from the systemic circulation by renal excretion and hepatic impairment is not thought to result in a clinically relevant increase in systemic exposure of glycopyrronium.

Other licensed glycopyrronium products are not all interchangeable on a milligram-for-milligram basis due to differences in bioavailability; please refer to the approved posology of the product if changing between products.

Method of administration

For oral administration only.

For patients who cannot swallow tablets, other pharmaceutical forms can be used.

Co-administration with food results in a marked decrease in systemic medicinal product exposure. Dosing should be at least one hour before or at least two hours after meals or at consistent times with respect to food intake. High fat food should be avoided. Where the patient's specific needs determine that co-administration with food is required, dosing of the medicinal product should be consistently performed during food intake (see section 5.2).

In exceptional circumstances it may not be possible to administer the tablets orally, please refer to recommendations in section 6.6.

4.3. Contraindications

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

• Glaucoma

• Urinary retention

• Severe renal impairment (eGFR <30 ml/min/1.73m2, including those with end stage renal disease requiring dialysis

• History of intestinal obstruction, ulcerative colitis, paralytic ileus, pyloric stenosis and myasthenia gravis

• Pregnancy and breast-feeding

• Concomitant treatment with (see section 4.5);

o potassium chloride solid oral dose

o anticholinergics

4.4. Special warnings and precautions for use

Anticholinergic effects

Anticholinergic effects such as urinary retention, constipation and overheating due to inhibition of sweating may be dose dependent and difficult to assess in a disabled child. Monitoring by physicians and caregivers is required with adherence to the management instructions below:

Management of important anticholinergic side effects:

The carer should stop treatment and seek advice from the prescriber in the event of:

• constipation

• urinary retention

• pneumonia

• allergic reaction

• pyrexia

• very hot weather

• changes in behaviour

After evaluation, the prescriber should decide if treatment should be discontinued or if it should be continued at a lower dose.

Lack of long-term safety data

Published safety data are not available beyond 24 weeks treatment duration. Given the limited long-term safety data available and the uncertainties around the potential risk for carcinogenicity, total treatment duration should be kept as short as possible. If continuous treatment is needed (e.g. in a palliative setting) or the treatment is repeated intermittently (e.g. in the non palliative setting treating chronic disease) benefits and risks should be carefully considered on a case by case basis and treatment should be closely monitored.

Mild to moderate sialorrhoea

Due to the low likelihood of benefit and the known adverse effect profile, Glycopyrronium bromide tablets should not be given to children with mild to moderate sialorrhoea.

Cardiac disorders

Glycopyrronium should be used with caution in patients with acute myocardial infarction, hypertension, coronary artery disease, cardiac arrhythmias and conditions characterised by tachycardia (including thyrotoxicosis, cardiac insufficiency, cardiac surgery) due to the potential increase in heart rate, blood pressure and rhythm disorders produced by its administration. The carer should be advised to measure the pulse rate if the child seems unwell and report very fast or very slow heart rate.

Gastro-intestinal disorders

Antimuscarinics such as glycopyrronium should be used with caution in patients with gastro-oesophageal reflux disease, pre-existing constipation and diarrhoea.

Dental

Since reduced salivation can increase the risk of oral cavities and periodontal diseases, it is important that patients receive adequate daily dental hygiene and regular dental health checks.

Respiratory

Glycopyrronium can cause thickening of secretions, which may increase the risk of respiratory infection and pneumonia. Glycopyrronium should be discontinued if pneumonia is present.

CNS adverse events

Increased central nervous system effects have been reported in clinical trials including: irritability; drowsiness; restlessness; overactivity; short attention span; frustration; mood changes; temper outbursts or explosive behaviour; excessive sensitivity; seriousness or sadness; frequent crying episodes; fearfulness. Behavioural changes should be monitored.

As a consequence of its quaternary charge glycopyrronium has limited ability to penetrate the blood brain barrier, although the extent of penetration is unknown. Caution should be exercised in children with compromised blood brain barrier e.g. Intraventicular shunt, brain tumour, encephalitis.

Children below the age of 3 years

Glycopyrronium Bromide is not recommended for use in children below the age of 3 years since there is very limited data on the efficacy and safety of glycopyrronium in this age group.

Growth and development

The effects of glycopyrronium on the reproductive system have not been investigated.

Whilst clinical studies do not report any short or long-term effect of glycopyrronium on neurodevelopment or growth, no studies have been conducted to specifically address these issues.

Patients with rare hereditary problems of galactose intolerance, the total lactase deficiency, glucose-galactose malabsorption or fructose intolerance should not take this medicine. This is due to the presence of sorbitol (E420) in this medicine.

This medicinal product contains less than 1 mmol sodium (23 mg) per maximum dose, i.e. essentially is 'sodium free '.

4.5. Interaction with other medicinal products and other forms of interaction

No interaction studies have been performed.

Paediatric population

There are limited data available relating to interactions with other medicinal products in the paediatric age group.

The following medicinal product interaction information is relevant to glycopyrronium.

Contraindications of concomitant use

Concomitant use of the following medicinal products is contraindicated (see section 4.3):

Potassium chloride solid oral dose: glycopyrronium may potentiate the risk of upper gastrointestinal injury associated with oral solid formulations of potassium chloride due to increased gastrointestinal transit time creating a high localized concentration of potassium ions. An association with upper GI bleeding and small bowel ulceration, stenosis, perforation, and obstruction has been observed.

Anticholinergics: concomitant use of anticholinergics may increase the risk of anticholinergic side effects. Anticholinergics may delay the gastrointestinal absorption of other anticholinergics administered orally and also increase the risk of anticholinergic side effects.

Concomitant use to be considered with caution

Concomitant use of the following medicinal products should be considered with caution:

Antispasmodics: glycopyrronium may antagonize the pharmacologic effects of gastrointestinal prokinetic active substances such as domperidone and metoclopramide.

Topiramate: glycopyrronium may potentiate the effects of oligohidrosis and hyperthermia associated with the use of topiramate, particularly in pediatric patients.

Sedating antihistamines: may have additive anticholinergic effects. A reduction in anticholinergic and/or antihistamine dosage may be necessary.

Neuroleptics/antipsychotics: the effects of active substances such as phenothiazines, clozapine and haloperidol may be potentiated. A reduction in anticholinergic and/or neuroleptic/antipsychotic dose may be necessary.

Skeletal muscle relaxants: Use of anticholinergics after administration of botulinum toxin may potentiate systemic anticholinergic effects.

Tricyclic antidepressants and MAOIs: may have additive anticholinergic effects. A reduction in anticholinergic and/or tricyclic antidepressants and MAOIs dosage may be necessary.

Opioids: active substances such as pethidine and codeine may result in additive central nervous system and gastrointestinal adverse effects, and increase the risk of severe constipation or paralytic ileus and CNS depression. If concomitant use cannot be avoided, patients should be monitored for potentially excessive or prolonged CNS depression and constipation.

Corticosteroids: Steroid-induced glaucoma may develop with topical, inhaled, oral or intravenous, steroid administration. Concomitant use may result in increased intraocular pressure via an open- or a closed-angle mechanism.

Other

Medicinal products with anticholinergic properties (e.g. antihistamines, antidepressants) may cause cumulative parasympatholytic effects including dry mouth, urinary retention, constipation and confusion, and an increased risk of anticholinergic intoxication syndrome.

4.6. Fertility, pregnancy and lactation

Women of child-bearing potential

Effective contraception should be considered prior to treating women of childbearing age, where appropriate.

Pregnancy

Glycopyrronium is contraindicated in pregnancy (see section 4.3). There are no data on the use of Glycopyrronium bromide tablets in pregnancy. The assessment of reproductive endpoints for glycopyrronium is limited (see section 5.3).

Breast-feeding

Safety in breast-feeding has not been established. Use while breast-feeding is contraindicated (see section 4.3).

Fertility

There are no data on the effects of Glycopyrronium Bromide tablets on male or female fertility. Reproductive performance in rats given glycopyrronium shows a decrease in the rate of conception and in survival rate at weaning. There are insufficient data in the public domain to adequately assess effects on the reproductive system in young adults (see section 5.3).

4.7. Effects on ability to drive and use machines

Glycopyrronium Bromide has moderate influence on the ability to drive and use machines. The anticholinergic effects of glycopyrronium may cause blurred vision, dizziness and other effects that may impair a patient's ability to perform skilled tasks such as driving, riding a bicycle and using machines. The undesirable effects are increased with increasing dose.

4.8. Undesirable effects

Summary of the safety profile

Adverse reactions are common with glycopyrronium due to its known pharmacodynamic anticholinergic effects. The efficacy of the medicinal product should be balanced against the adverse reactions and the dose monitored regularly and adjusted as necessary. The most common anticholinergic adverse reactions in the placebo-controlled studies (see section 5.1) related to the gastrointestinal system and were dry mouth, constipation, diarrhoea and vomiting, all of which occurred at a rate of ≥15%. The safety profile is further characterised by other symptoms, related to the anticholinergic effects at a rate of ≥15%, including urinary retention, flushing and nasal congestion.

Adverse reactions are more common with higher doses and prolonged use.

Tabulated summary of adverse reactions

Adverse reactions reported in the literature for trials using glycopyrronium for sialorrhoea in the paediatric population (including 2 placebo controlled trials, an uncontrolled safety study using glycopyrronium for a 6 month period, and 3 supportive studies with adverse event data in the target population) are listed by MedDRA system organ class (Table below). Within each system organ class, the adverse reactions are ranked by frequency, with the most frequent reactions first. Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness. In addition, the corresponding frequency category for each adverse reaction is based on the following convention: very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000); not known (cannot be estimated from the available data).

Tabulated list of adverse reactions

Adverse reaction

Frequency

Infections and infestations

Upper respiratory tract infection

Common

Pneumonia

Common

Urinary tract infection

Common

Psychiatric disorders

Irritability

Very common

Agitation

Common

Drowsiness

Common

Restlessness

Not known

Overactivity

Not known

Short attention span

Not known

Frustration

Not known

Mood variable

Not known

Temper tantrum

Not known

Intermittent explosive disorder

Not known

Sensitivity, shyness, and social withdrawal disorder specific to childhood or adolescence

Not known

Feeling sad

Not known

Crying

Not known

Fear

Not known

Nervous system disorders

Headache

Uncommon

Insomnia

Not known

Eye disorders

Mydriasis

Uncommon

Nystagmus

Uncommon

Angle-closure glaucoma

Not known

Photophobia

Not known

Dry eyes

Not known

Cardiac disorders

Flushing

Very common

Transient bradycardia

Not known

Respiratory, thoracic and mediastinal disorders

Nasal congestion

Very common

Epistaxis

Common

Reduced bronchial secretions

Very common

Sinusitis

Not known

Gastrointestinal disorders

Dry mouth

Very common

Constipation

Very common

Diarrhoea

Very common

Vomiting

Very common

Halitosis

Uncommon

Oesophageal candidiasis

Uncommon

Gastrointestinal motility disorder

Uncommon

Pseudo-obstruction

Uncommon

Nausea

Not known

Skin and subcutaneous tissue disorders

Rash

Common

Dryness of the skin

Not known

Inhibition of sweating

Not known

Renal and urinary disorders

Urinary retention

Very common

Urinary urgency

Not known

General disorders and administration site conditions

Pyrexia

Common

Dehydration

Uncommon

Thirst in hot weather

Uncommon

Angioedema

Not known

Allergic reaction

Not known

Description of selected adverse reactions

Urinary retention

Urinary retention is a known adverse reaction associated with anticholinergic medicinal products (15%). Glycopyrronium treatment should be withdrawn until the urinary retention resolves.

Pneumonia

Pneumonia is a known adverse reaction associated with anticholinergic medicinal products (7.9%). Glycopyrronium treatment should be withdrawn until the pneumonia resolves.

Constipation

Constipation is a known adverse reaction associated with anticholinergic medicinal products (30%). Glycopyrronium treatment should be withdrawn until the constipation resolves.

Central Nervous System

Although glycopyrronium has limited ability to cross the blood brain barrier, increased central nervous system effects have been reported in clinical trials (23%). Such effects should be discussed with the carer during treatment reviews and a dose reduction considered.

Cardiac disorders

Glycopyrronium is known to have an effect on heart rate and blood pressure at doses used during anaesthesia although clinical trials in children with chronic drooling have not shown this effect. An effect on the cardiovascular system should be considered when assessing tolerability.

Haematology and chemistry

A decrease of >10% from the normal reference range at baseline for absolute neutrophil (11.2%) and red blood cell (11.1%) count, and increases >10% from the normal reference range at baseline for monocyte (16.7%) and absolute monocyte (11.2%) counts has been seen. Decreases >10% from the normal reference range at baseline were observed for carbon dioxide (15.1%), bicarbonate (13.3%), and creatinine (10.7%) concentrations.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation 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 via the Yellow Card Scheme Website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

4.9. Overdose

Symptoms

Overdose of glycopyrronium can result in anticholinergic syndrome, produced by the inhibition of cholinergic neurotransmission at muscarinic receptor sites. Clinical manifestations are caused by CNS effects, peripheral nervous system effects, or both. Common manifestations include flushing, dry skin and mucous membranes, mydriasis with loss of accommodation, altered mental status and fever. Additional manifestations include sinus tachycardia, decreased bowel sounds, functional ileus, urinary retention, hypertension, tremulousness and myoclonic jerking.

Management

Patients presenting with anticholinergic toxicity should be transported to the nearest emergency facility with advanced life support capabilities. Pre-hospital gastrointestinal decontamination with activated charcoal is not recommended because of the potential for somnolence and seizures and the resulting risk of pulmonary aspiration. At hospital, activated charcoal can be administered if the patient's airways can be adequately protected. Physostigmine salicylate is recommended when tachydysrhythmia with subsequent hemodynamic compromise, intractable seizure, severe agitation or psychosis is present.

Patients and/or parents/caregivers should be counselled to ensure an accurate dose is given each time, in order to prevent the harmful consequences of anticholinergic reactions of glycopyrronium seen with dosing errors or overdose.