4.1. Therapeutic indications

Donepezil is indicated for the symptomatic treatment of mild to moderately severe Alzheimer's dementia.

4.2. Posology and method of administration

Posology

Adults/Elderly:

Treatment is initiated at 5 ml (5 mg)/day (once-a-day dosing) by filling the dosing spoon to the line of 5ml. Donepezil Hydrochloride 1mg/1ml Oral Solution should be taken orally, in the evening, just prior to retiring, and can be taken with or without food.

In case of sleep disturbances including abnormal dreams, nightmares or insomnia (see section 4) intake of Donepezil Hydrochloride 1mg/1ml Oral Solution in the morning,

The 5 mg/day dose should be maintained for at least one month in order to allow the earliest clinical responses to treatment to be assessed and to allow steady-state concentrations of donepezil hydrochloride to be achieved. Following a one-month clinical assessment of treatment at 5 mg/day, the dose of Donepezil Hydrochloride 1mg/ml Oral Solution can be increased to 10 ml (10 mg)/day (once-a-day dosing), by filling the dosing spoon to the line of 10ml. The maximum recommended daily dose is 10 mg. Doses greater than 10 mg/day have not been studied in clinical trials.

Treatment should be initiated and supervised by a physician experienced in the diagnosis and treatment of Alzheimer's dementia. Diagnosis should be made according to accepted guidelines (e.g. DSM IV, ICD 10). Therapy with donepezil should only be started if a caregiver is available who will regularly monitor drug intake for the patient. Maintenance treatment can be continued for as long as a therapeutic benefit for the patient exists. Therefore, the clinical benefit of donepezil should be reassessed on a regular basis. Discontinuation should be considered when evidence of a therapeutic effect is no longer present. Individual response to donepezil cannot be predicted.

Upon discontinuation of treatment, a gradual abatement of the beneficial effects of Donepezil Hydrochloride 1mg/1ml Oral Solution is seen.

Renal and hepatic impairment:

A similar dose schedule can be followed for patients with renal impairment, as clearance of donepezil hydrochloride is not affected by this condition.

Due to possible increased exposure in mild to moderate hepatic impairment (see section 5.2), dose escalation should be performed according to individual tolerability. There are no data for patients with severe hepatic impairment.

Children:

Donepezil Hydrochloride 1mg/1ml Oral Solution is not recommended for use in children and adolescents below 18 years of age.

Method of administration

For oral use

4.3. Contraindications

Donepezil is contraindicated in patients with a known hypersensitivity to donepezil hydrochloride or piperidine derivatives.

It is also contraindicated in patients with hereditary fructose intolerance and patients with hypersensitivity to metabisulphites or any other excipients used in the formulation (see also section 4.8 undesirable effects).

4.4. Special warnings and precautions for use

The use of Donepezil in patients with severe Alzheimer's dementia, other types of dementia or other types of memory impairment (e.g., age-related cognitive decline), has not been investigated.

Anaesthesia: Donepezil, as a cholinesterase inhibitor, is likely to exaggerate succinylcholine-type muscle relaxation during anaesthesia.

Cardiovascular Conditions: Because of their pharmacological action, cholinesterase inhibitors may have vagotonic effects on heart rate (e.g. bradycardia). The potential for this action may be particularly important to patients with "sick sinus syndrome" or other supraventricular cardiac conduction conditions, such as sinoatrial or atrioventricular block.

There have been reports of syncope and seizures. In investigating such patients the possibility of heart block or long sinusal pauses should be considered.

There have been post-marketing reports of QTc interval prolongation and Torsade de Pointes (see sections 4.5 and 4.8). Caution is advised in patients with pre-existing or family history of QTc prolongation, in patients treated with drugs affecting the QTc interval, or in patients with relevant pre-existing cardiac disease (e.g. uncompensated heart failure, recent myocardial infarction, bradyarrhythmias), or electrolyte disturbances (hypokalaemia, hypomagnesaemia). Clinical monitoring (ECG) may be required.

Gastrointestinal Conditions: Patients at increased risk for developing ulcers, e.g. those with a history of ulcer disease or those receiving concurrent nonsteroidal anti-inflammatory drugs (NSAIDs), should be monitored for symptoms. However, the clinical studies with Donepezil showed no increase, relative to placebo, in the incidence of either peptic ulcer disease or gastrointestinal bleeding.

Genitourinary: Although not observed in clinical trials of Donepezil, cholinomimetics may cause bladder outflow obstruction.

Neurological Conditions: Seizures: Cholinomimetics are believed to have some potential to cause generalised convulsions. However, seizure activity may also be a manifestation of Alzheimer's Disease.

Cholinomimetics may have the potential to exacerbate or induce extrapyramidal symptoms.

Neuroleptic Malignant Syndrome (NMS): NMS, a potentially life-threatening condition characterized by hyperthermia, muscle rigidity, autonomic instability, altered consciousness and elevated serum creatinine phosphokinase levels, has been reported to occur very rarely in association with donepezil, particularly in patients also receiving concomitant antipsychotics. Additional signs may include myoglobinuria (rhabdomyolysis) and acute renal failure. If a patient develops signs and symptoms indicative of NMS, or presents with unexplained high fever without additional clinical manifestations of NMS, treatment should be discontinued.

Pulmonary Conditions: Because of their cholinomimetic actions, cholinesterase inhibitors should be prescribed with care to patients with a history of asthma or obstructive pulmonary disease.

The administration of Donepezil Hydrochloride 1mg/ml Oral Solution concomitantly with other inhibitors of acetylcholinesterase, agonists or antagonists of the cholinergic system should be avoided.

Severe Hepatic Impairment: There are no data for patients with severe hepatic impairment.

Mortality in Vascular Dementia Clinical Trials

Three clinical trials of 6 months duration were conducted studying individuals meeting the NINDS-AIREN criteria for probable or possible vascular dementia (VaD). The NINDS- AIREN criteria are designed to identify patients whose dementia appears to be due solely to vascular causes and to exclude patients with Alzheimer's disease. In the first study, the mortality rates were 2/198 (1.0%) on donepezil hydrochloride 5 mg, 5/206 (2.4%) on donepezil hydrochloride 10 mg and 7/199 (3.5%) on placebo. In the second study, the mortality rates were 4/208 (1.9%) on donepezil hydrochloride 5 mg, 3/215 (1.4%) on donepezil hydrochloride 10 mg and 1/193 (0.5%) on placebo. In the third study, the mortality rates were 11/648 (1.7%) on donepezil hydrochloride 5 mg and 0/326 (0%) on placebo. The mortality rate for the three VaD studies combined in the donepezil hydrochloride group (1.7%) was numerically higher than in the placebo group (1.1%), however, this difference was not statistically significant. The majority of deaths in patients taking either donepezil hydrochloride or placebo appear to result from various vascular related causes, which could be expected in this elderly population with underlying vascular disease. An analysis of all serious non-fatal and fatal vascular events showed no difference in the rate of occurrence in the donepezil hydrochloride group relative to placebo.

In pooled Alzheimer's disease studies (n=4146), and when these Alzheimer's disease studies were pooled with other dementia studies including the vascular dementia studies (total n=6888), the mortality rate in the placebo groups numerically exceeded that in the donepezil hydrochloride groups.

Excipient Warnings

The product contains:

• Sorbitol (E420). This medicine contains 250mg sorbitol in each 1ml. Patients with hereditary fructose intolerance (HFI) should not take/be given this medicinal product. A 5ml dose of Donepezil 1mg/1ml Oral Solution supplies 1.25 g of sorbitol and a 10ml dose of Donepezil 1mg/ml Oral Solution supplies 2.5 g of sorbitol.

• Propylene Glycol (E1520). This product contains 311 mg propylene glycol in a 5ml dose and 622 mg of propylene glycol in a 10ml dose of Donepezil 1mg/1ml Oral Solution.

• Benzoic acid (E210). This product contains 4.17 mg benzoic acid/benzoate salt in a 5ml dose and 8.34mg of benzoic acid/benzoate salt in a 10ml dose of Donepezil 1mg/1ml Oral Solution.

• This product contains less than 1mmol sodium (23mg) per 5ml or 10ml dose, that is to say essentially “sodium-free”.

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

Donepezil hydrochloride and/or any of its metabolites do not inhibit the metabolism of theophylline, warfarin, cimetidine or digoxin in humans. The metabolism of donepezil hydrochloride is not affected by concurrent administration of digoxin or cimetidine. In vitro studies have shown that the cytochrome P450 isoenzymes 3A4 and to a minor extent 2D6 are involved in the metabolism of donepezil. Drug interaction studies performed in vitro show that ketoconazole and quinidine, inhibitors of CYP3A4 and 2D6 respectively, inhibit donepezil metabolism. Therefore, these and other CYP3A4 inhibitors, such as itraconazole and erythromycin, and CYP2D6 inhibitors, such as fluoxetine, could inhibit the metabolism of donepezil. In a study in healthy volunteers, ketokonazole increased mean donepezil concentrations by about 30%. Enzyme inducers, such as rifampicin, phenytoin, carbamazepine and alcohol may reduce the levels of donepezil. Since the magnitude of an inhibiting or inducing effect is unknown, such drug combinations should be used with care. Donepezil hydrochloride has the potential to interfere with medications having anticholinergic activity. There is also the potential for synergistic activity with concomitant treatment involving medications such as succinylcholine, other neuro-muscular blocking agents or cholinergic agonists or beta blocking agents that have effects on cardiac conduction.

Cases of QTc interval prolongation and Torsade de Pointes have been reported for donepezil. Caution is advised when donepezil is used in combination with other medicinal products known to prolong the QTc interval and clinical monitoring (ECG) may be required. Examples include:

Class IA antiarrhythmics (e.g. quinidine)

Class III antiarrhythmics (e.g. amiodarone, sotalol)

Certain antidepressants (e.g. citalopram, escitalopram, amitriptyline)

Other antipsychotics (e.g. phenothiazine derivatives, sertindole, pimozide, ziprasidone)

Certain antibiotics (e.g. clarithromycin, erythromycin, levofloxacin, moxifloxacin)

4.6. Fertility, pregnancy and lactation

Pregnancy: There are no adequate data from the use of donepezil in pregnant women. Studies in animals have not shown teratogenic effect but have shown peri and post natal toxicity (see section 5.3 preclinical safety data). The potential risk for humans is unknown. Donepezil Hydrochloride 1mg/1ml Oral Solution should not be used during pregnancy unless clearly necessary.

Lactation: Donepezil is excreted in the milk of rats. It is not known whether donepezil hydrochloride is excreted in human breast milk and there are no studies in lactating women. Therefore, women on donepezil should not breast feed.

4.7. Effects on ability to drive and use machines

Donepezil has minor or moderate influence on the ability to drive and use machines.

Dementia may cause impairment of driving performance or compromise the ability to use machinery. Furthermore, donepezil can induce fatigue, dizziness and muscle cramps, mainly when initiating or increasing the dose. The treating physician should routinely evaluate the ability of patients on donepezil to continue driving or operating complex machines.

4.8. Undesirable effects

The most common adverse events are diarrhoea, muscle cramps, fatigue, nausea, vomiting and insomnia.

Adverse reactions reported as more than an isolated case are listed below, by system organ class and by frequency. Frequencies are defined as: very common (> 1/10) common (>1/100, <1/10), uncommon (>1/1.000, <1/1.000): very rare (1/10000) and not known (cannot be estimated from available data).

System Organ Class

Very Common

Common

Uncommon

Rare

Very Rare

Not known

Infections and infestations

Common cold

Metabolism and nutrition disorders

Anorexia

Psychiatric disorders

Hallucinations**

Agitation**

Aggressive behaviour**

Abnormal dreams and Nightmares**

Libido increased

Hypersexuality

Nervous system disorders

Syncope*

Dizziness

Insomnia

Seizure*

Extrapyramidal symptoms

Neuroleptic Malignant Syndrome

Pleurothotonus (Pisa syndrome)

Cardiac disorders

Bradycardia

Sino-atrial block

Atrioventicular block

Polymorphic ventricular tachycardia including Torsade de Pointes; Electrocardiogram QT interval prolonged

Gastrointestinal disorders

Diarrhoea

Nausea

Vomiting

Abnominal disturbance

Gastrointestinal Haemorrhage

Gastric and Duodenal ulcers

Salivary hypersecretion

Hepato-biliary disorders

Liver dysfunction including hepatitis***

Skin and subcutaneous tissue and bone disorders

Rash

Pruritis

Musculoskeletal connective tissue disorders

Muscle cramps

**** Rhabdomyolysis

Renal and urinary disorders

Urinary incontinence

General disorders and administration site conditions

Headache

Fatigue

Pain

Investigations

Minor increase in serum concentration of muscle creatine kinase

Injury and poisoning

Accident including falls

*In investigating patients for syncope or seizure the possibility of heart block or long sinusal pauses should be considered (see section 4.4)

**Reports of hallucinations, abnormal dreams, agitation and aggressive behaviour have resolved on dose-reduction or discontinuation of treatment.

***In cases of unexplained liver dysfunction, withdrawal of Donepezil Hydrochloride 1mg/1ml Oral Solution should be considered.

****Rhabdomyolysis has been reported to occur independently of neuroleptic malignant syndrome and in close temporal association with donepezil initiation or dose increase.

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

4.9. Overdose

The estimated median lethal dose of donepezil hydrochloride following administration of a single dose in mice and rats is 45 and 32 mg/kg, respectively, or approximately 225 and 160 times the maximum recommended human dose of 10mg per day. Dose-related signs of cholinergic stimulation were observed in animals and included reduced spontaneous movement, prone position, staggering gait, lacrimation, clonic convulsions, depressed respiration, salivation, miosis, fasciculation and lower body surface temperature.

Overdosage with cholinesterase inhibitors can result in cholinergic crisis characterised by severe nausea, vomiting, salivation, sweating, bradycardia, hypotension, respiratory, depression, collapse and convulsions. Increasing muscle weakness is a possibility and may result in death if respiratory muscles are involved.

As in any case of overdose, general supportive measures should be utilised. Tertiary anticholinergics such as atropine may be used as an antidote for Donepezil Hydrochloride overdosage. Intravenous atropine sulphate titrated to effect is recommended: an initial dose of 1.0 to 2.0 mg IV with subsequent doses based upon clinical response. Atypical responses in blood pressure and heart rate have been reported with other cholinomimetics when co-administered with quaternary anticholinergics such as glycopyrrolate. It is not known whether donepezil hydrochloride and/or its metabolites can be removed by dialysis (haemodialysis, peritoneal dialysis or haemofiltration).