4.1. Therapeutic indications

Cholestagel/Colesevelam co-administered with a 3-hydroxy-3-methyl-glutaryl-coenzyme A (HMG-CoA) reductase inhibitor (statin) is indicated as adjunctive therapy to diet to provide an additive reduction in low-density lipoprotein cholesterol (LDL-C) levels in adult patients with primary hypercholesterolaemia who are not adequately controlled with a statin alone.

Cholestagel/Colesevelam as monotherapy is indicated as adjunctive therapy to diet for reduction of elevated total-cholesterol and LDL-C in adult patients with primary hypercholesterolaemia, in whom a statin is considered inappropriate or is not well-tolerated.

Cholestagel/Colesevelam can also be used in combination with ezetimibe, with or without a statin, in adult patients with primary hypercholesterolaemia, including patients with familial hypercholesterolaemia (see section 5.1).

4.2. Posology and method of administration

Posology

Combination therapy

The recommended dose of Cholestagel/Colesevelam for combination with a statin with or without ezetimibe is 4 to 6 tablets per day. The maximum recommended dose is 6 tablets per day taken as 3 tablets twice per day with meals or 6 tablets taken once per day with a meal. Clinical trials have shown that Cholestagel/Colesevelam and statins can be co-administered or dosed apart, and that Cholestagel/Colesevelam and ezetimibe can be co-administered or dosed apart.

Monotherapy

The recommended starting dose of Cholestagel/Colesevelam is 6 tablets per day taken as 3 tablets twice per day with meals or 6 tablets once per day with a meal. The maximum recommended dose is 7 tablets per day.

During therapy, the cholesterol-lowering diet should be continued, and serum total-C, LDL-C and triglyceride levels should be determined periodically during treatment to confirm favourable initial and adequate long-term responses.

When a drug interaction cannot be excluded with a concomitant medicinal product for which minor variations in the therapeutic level would be clinically important, or where no clinical data are available on co-administration, Cholestagel/Colesevelam should be administered at least four hours before or at least four hours after the concomitant medication in order to minimize the risk of reduced absorption of the concomitant medication (see section 4.5).

Elderly population

There is no need for dose adjustment when Cholestagel/Colesevelam is administered to elderly patients.

Paediatric population

The safety and efficacy of Cholestagel/Colesevelam in children aged 0 to 17 years have not yet been established. Currently available data are described in section 5.1 but no recommendation on a posology can be made.

Method of administration

Cholestagel/Colesevelam tablets should be taken orally with a meal and liquid.

The tablets should be swallowed whole and not broken, crushed or chewed.

4.3. Contraindications

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

• Bowel or biliary obstruction

4.4. Special warnings and precautions for use

Secondary causes of hypercholesterolaemia

Prior to initiating therapy with Cholestagel/Colesevelam, if secondary causes of hypercholesterolaemia (i.e., poorly controlled diabetes mellitus, hypothyroidism, nephrotic syndrome, dysproteinaemias, obstructive liver disease) are considered, these should be diagnosed and properly treated.

Interaction with ciclosporin

For patients on ciclosporin starting or stopping Cholestagel/Colesevelam or patients on Cholestagel/Colesevelam with a need to start ciclosporin: Cholestagel/Colesevelam reduces the bioavailability of ciclosporin (see also section 4.5). Patients starting on ciclosporin already taking Cholestagel/Colesevelam should have their ciclosporin blood concentrations monitored as normal and their dose adjusted as normal. Patients starting on Cholestagel/Colesevelam already taking ciclosporin should have their blood concentrations monitored prior to combination therapy and frequently monitored immediately starting co-therapy with the ciclosporin dose adjusted accordingly. It should be noted that stopping Cholestagel/Colesevelam therapy will result in increased ciclosporin blood concentrations. Therefore, patients taking both ciclosporin and Cholestagel/Colesevelam should have their blood concentrations monitored prior to and frequently after when Cholestagel/Colesevelam therapy is stopped with their ciclosporin dose adjusted accordingly.

Effects on triglyceride levels

Caution should be exercised when treating patients with triglyceride levels greater than 3.4 mmol/L due to the triglyceride increasing effect with Cholestagel/Colesevelam. Safety and efficacy are not established for patients with triglyceride levels greater than 3.4 mmol/L, since such patients were excluded from the clinical studies.

The safety and efficacy of Cholestagel/Colesevelam in patients with dysphagia, swallowing disorders, severe gastrointestinal motility disorders, inflammatory bowel disease, liver failure or major gastrointestinal tract surgery have not been established. Consequently, caution should be exercised when Cholestagel/Colesevelam is used in patients with these disorders.

Constipation

Cholestagel/Colesevelam can induce or worsen present constipation. The risk of constipation should especially be considered in patients with coronary heart disease and angina pectoris.

Anticoagulants

Anticoagulant therapy should be monitored closely in patients receiving warfarin or similar agents, since bile acid sequestrants, like Cholestagel/Colesevelam, have been shown to reduce absorption of vitamin K and therefore interfere with warfarin's anticoagulant effect (see also section 4.5).

Oral contraceptives

Cholestagel/Colesevelam can affect the bioavailability of the oral contraceptive pill when administered simultaneously. It is important to ensure that Cholestagel/Colesevelam is administered at least 4 hours after the oral contraceptive pill to minimise the risk of any interaction (see also section 4.5).

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

In general

Cholestagel/Colesevelam may affect the bioavailability of other medicinal products. Therefore when a drug interaction cannot be excluded with a concomitant medicinal product for which minor variations in the therapeutic level would be clinically important, Cholestagel/Colesevelam should be administered at least four hours before or at least four hours after the concomitant medication to minimize the risk of reduced absorption of the concomitant medication. For concomitant medications which require administration via divided doses, it should be noted that the required dose of Cholestagel/Colesevelam can be taken once a day.

When administering medicinal products for which alterations in blood levels could have a clinically significant effect on safety or efficacy, physicians should consider monitoring serum levels or effects.

Interaction studies have only been performed in adults.

In interaction studies in healthy volunteers, Cholestagel/Colesevelam had no effect on the bioavailability of digoxin, metoprolol, quinidine, valproic acid, and warfarin. Cholestagel/Colesevelam decreased the Cmax and AUC of sustained-release verapamil by approximately 31% and 11%, respectively. Since there is a high degree of variability in the bioavailability of verapamil, the clinical significance of this finding is unclear.

Co-administration of colesevelam and olmesartan decreases the exposure of olmesartan. Olmesartan should be administered at least 4 hours prior to colesevelam.

There have been very rare reports of reduced phenytoin levels in patients who have received Cholestagel/Colesevelam administered with phenytoin.

Anticoagulant therapy

Anticoagulant therapy should be monitored closely in patients receiving warfarin or similar agents, since bile acid sequestrants, like Cholestagel/Colesevelam, have been shown to reduce absorption of vitamin K and therefore interfere with warfarin's anticoagulant effect. Specific clinical interaction studies with colesevelam and vitamin K have not been performed.

Levothyroxine

In an interaction study in healthy volunteers, Cholestagel/Colesevelam reduced the AUC and Cmax of levothyroxine when administered either concomitantly or after 1 hour. No interaction was observed when Cholestagel/Colesevelam was administered at least four hours after levothyroxine.

Oral contraceptive pill

In an interaction study in healthy volunteers, Cholestagel/Colesevelam reduced the Cmax of norethindrone as well as the AUC and Cmax of ethinylestradiol when administered simultaneously with the oral contraceptive pill. This interaction was also observed when Cholestagel/Colesevelam was administered one hour after the oral contraceptive pill. However no interaction was observed when Cholestagel/Colesevelam was administered four hours after the oral contraceptive pill.

Ciclosporin

In an interaction study in healthy volunteers, co-administration of Cholestagel/Colesevelam and ciclosporin significantly reduced the AUC0-inf and Cmax of ciclosporin by 34% by 44%, respectively. Therefore advice is given to closely monitor ciclosporin blood concentrations (see also section 4.4). In addition, based on theoretical grounds Cholestagel/Colesevelam should be administered at least 4 hours after ciclosporin in order to further minimise the risks related to the concomitant administration of ciclosporin and Cholestagel/Colesevelam. Furthermore, Cholestagel/Colesevelam should always be administered at the same times consistently since the timing of intake of Cholestagel/Colesevelam and ciclosporin could theoretically influence the degree of reduced bioavailability of ciclosporin.

Statins

When Cholestagel/Colesevelam was co-administered with statins in clinical studies, an expected add- on LDL-C lowering effect was observed, and no unexpected effects were observed.

Cholestagel/Colesevelam had no effect on the bioavailability of lovastatin in an interaction study.

Antidiabetic agents

Co-administration of colesevelam and metformin extended-release (ER) tablets increases the exposure of metformin. Patients receiving concomitant metformin ER and colesevelam should be monitored for clinical response as is usual for the use of anti-diabetes drugs.

Colesevelam binds to glimepiride and reduces glimepiride absorption from the gastrointestinal tract. No interaction was observed when glimepiride was taken at least 4 hours before colesevelam.

Therefore glimepiride should be administered at least 4 hours prior to colesevelam.

Co-administration of colesevelam and glipizide decreases the exposure of glipizide. Glipizide should be administered at least 4 hours prior to colesevelam.

Co-administration of Cholestagel/Colesevelam and glyburide (also known as glibenclamide) caused a decrease in the AUC0-inf and Cmax of glyburide by 32% and 47%, respectively. No interaction was observed when Cholestagel/Colesevelam was administered four hours after glyburide.

Co-administration of Cholestagel/Colesevelam and repaglinide had no effect on the AUC and caused a 19% reduction in the Cmax of repaglinide, the clinical significance of which is unknown. No interaction was observed when Cholestagel/Colesevelam was administered one hour after repaglinide.

No interaction was observed when Cholestagel/Colesevelam and pioglitazone were administered simultaneously in healthy volunteers

Ursodeoxycholic acid

Cholestagel/Colesevelam predominantly binds hydrophobic bile acids. In a clinical study Cholestagel/Colesevelam did not affect the faecal excretion of endogenous (hydrophilic) ursodeoxycholic acid. However, formal interaction studies with ursodeoxycholic acid have not been performed. As noted in general, when a drug interaction cannot be excluded with a concomitant medicinal product, Cholestagel/Colesevelam should be administered at least four hours before or at least four hours after the concomitant medication to minimise the risk of reduced absorption of the concomitant medication. Monitoring of the clinical effects of treatment with ursodeoxycholic acid should be considered.

Other forms of interaction

Cholestagel/Colesevelam did not induce any clinically significant reduction in the absorption of vitamins A, D, E or K during clinical studies of up to one year. However, caution should be exercised when treating patients with a susceptibility to vitamin K or fat-soluble vitamin deficiencies, such as patients with malabsorption. In these patients, monitoring vitamin A, D and E levels and assessing vitamin K status through the measurement of coagulation parameters is recommended and the vitamins should be supplemented if necessary.

4.6. Fertility, pregnancy and lactation

Pregnancy

No clinical data are available on the use of Cholestagel/Colesevelam in pregnant women. Animal studies do not indicate direct or indirect harmful effects with respect to pregnancy, embryonic/foetal development, parturition or postnatal development (see section 5.3). Caution should be exercised when prescribing to pregnant women.

Breast-feeding

The safety of Cholestagel/Colesevelam has not been established in breast-feeding women. Caution should be exercised when prescribing to breast-feeding women.

Fertility

There are no data on the effect of Cholestagel/Colesevelam on fertility in humans. A study conducted in rats did not result in any differences in reproductive parameters between the groups that might imply reproductive effects attributable to colesevelam.

4.7. Effects on ability to drive and use machines

Cholestagel/Colesevelam has no or negligible influence on the ability to drive and use machines.

4.8. Undesirable effects

Summary of the safety profile

The most frequently occurring adverse reactions are flatulence and constipation, found within the gastrointestinal disorders system organ class.

Tabulated list of adverse reactions

In controlled clinical studies involving approximately 1400 patients and during post-approval use, the following adverse reactions were reported in patients given Cholestagel/Colesevelam.

The reporting rate is classified as 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) and not known (cannot be estimated from the available data).

Nervous system disorders

Common: Headache

Gastrointestinal disorders

Very common: Flatulence*, constipation*

Common: Vomiting, diarrhoea*, dyspepsia*, abdominal pain, abnormal stools, nausea, abdominal distension

Uncommon: Dysphagia

Very rare: Pancreatitis

Not known: Intestinal obstruction*,**

Musculoskeletal and connective tissue disorders

Uncommon: Myalgia

Investigations

Common: Serum triglycerides increased

Uncommon :Serum transaminases increased

* see section below for further information

** adverse reactions from post-marketing experience

Description of selected adverse events

The background incidence of flatulence and diarrhoea were higher in patients receiving placebo in the same controlled clinical studies. Only constipation and dyspepsia were reported by a higher percentage among those receiving Cholestagel/Colesevelam, compared with placebo.

The incidence of intestinal obstruction is likely to be increased among patients with a history of bowel obstruction or removal.

Cholestagel/Colesevelam in combination with statins and in combination with ezetimibe was well tolerated and the adverse reactions observed were consistent with the known safety profile of statins or ezetimibe alone.

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 www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

4.9. Overdose

Since Cholestagel/Colesevelam is not absorbed, the risk of systemic toxicity is low. Gastrointestinal symptoms could occur. Doses in excess of the maximum recommended dose (4.5 g per day (7 tablets)) have not been tested.

Should overdosage occur, however, the chief potential harm would be obstruction of the gastrointestinal tract. The location of such potential obstruction, the degree of obstruction and the presence or absence of normal gut motility would determine treatment.