4.1. Therapeutic indications

Primary Hypercholesterolaemia

Ezetimibe co-administered with an HMG-CoA reductase inhibitor (statin) is indicated as adjunctive therapy to diet for use in patients with primary (heterozygous familial and nonfamilial) hypercholesterolaemia who are not appropriately controlled with a statin alone.

Ezetimibe monotherapy is indicated as adjunctive therapy to diet for use in patients with primary (heterozygous familial and nonfamilial) hypercholesterolaemia in whom a statin is considered inappropriate or is not tolerated.

Prevention of Cardiovascular Events

Ezetimibe is indicated to reduce the risk of cardiovascular events (see section 5.1) in patients with coronary heart disease (CHD) and a history of acute coronary syndrome (ACS) when added to ongoing statin therapy or initiated concomitantly with a statin.

Homozygous Familial Hypercholesterolaemia (HoFH)

Ezetimibe coadministered with a statin, is indicated as adjunctive therapy to diet for use in patients with HoFH. Patients may also receive adjunctive treatments (e.g., LDL apheresis).

Homozygous Sitosterolaemia (Phytosterolaemia)

Ezetrol is indicated as adjunctive therapy to diet for use in patients with homozygous familial sitosterolaemia.

4.2. Posology and method of administration

Posology

The patient should be on an appropriate lipid-lowering diet and should continue on this diet during treatment with Ezetimibe.

Method of administration

Route of administration is oral. The recommended dose is one Ezetimibe 10 mg tablet daily. Ezetimibe can be administered at any time of the day, with or without food.

When Ezetimibe is added to a statin, either the indicated usual initial dose of that particular statin or the already established higher statin dose should be continued. In this setting, the dosage instructions for that particular statin should be consulted.

Use in Patients with Coronary Heart Disease and ACS Event History

For incremental cardiovascular event reduction in patients with coronary heart disease and ACS event history, Ezetimibe 10 mg may be administered with a statin with proven cardiovascular benefit.

Coadministration with bile acid sequestrants

Dosing of Ezetimibe should occur either ≥ 2 hours before or ≥ 4 hours after administration of a bile acid sequestrant.

Elderly

No dosage adjustment is required for elderly patients (see section 5.2).

Paediatric population

Initiation of treatment must be performed under review of a specialist.

Children and adolescents ≥ 6: The safety and efficacy of ezetimibe in children aged 6 to 17 years has not been established. Current available data are described in sections 4.4, 4.8, 5.1 and 5.2 but no recommendation on a posology can be made.

When Ezetimibe is administered with a statin, the dosage instructions for the statin in children should be consulted.

Children <6 years: The safety and efficacy of Ezetimibe in children aged < 6 years has not been established. No data are available.

Hepatic impairment

No dosage adjustment is required in patients with mild hepatic impairment (Child-Pugh score 5 to 6). Treatment with Ezetimibe is not recommended in patients with moderate (Child-Pugh score 7 to 9) or severe (Child-Pugh score > 9) liver dysfunction (see sections 4.4 and 5.2).

Renal impairment

No dosage adjustment is required for renally impaired patients (see section 5.2).

4.3. Contraindications

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

When Ezetimibe is co-administered with a statin, please refer to the SPC for that particular medicinal product.

Therapy with Ezetimibe co-administered with a statin is contraindicated during pregnancy and lactation.

Ezetimibe co-administered with a statin is contraindicated in patients with active liver disease or unexplained persistent elevations in serum transaminases.

4.4. Special warnings and precautions for use

When Ezetimibe is co-administered with a statin, please refer to the SPC for that particular medicinal product.

Liver Enzymes

In controlled co-administration trials in patients receiving ezetimibe with a statin, consecutive transaminase elevations (≥ 3X the upper limit of normal [ULN]) have been observed. When ezetimibe is co-administered with a statin, liver function tests should be performed at initiation of therapy and according to the recommendations of the statin (see section 4.8.).

In the IMProved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT), 18,144 patients with coronary heart disease and ACS event history were randomised to receive ezetimibe/simvastatin 10/40 mg daily (n=9067) or simvastatin 40 mg daily (n=9077). During a median follow-up of 6.0 years, the incidence of consecutive elevations of transaminases (≥3 X ULN) was 2.5% for ezetimibe/simvastatin and 2.3% for simvastatin. (See section 4.8).

In a controlled clinical study in which over 9000 patients with chronic kidney disease were randomised to receive ezetimibe 10 mg combined with simvastatin 20 mg daily (n=4650) or placebo (n=4620) (median followup period of 4.9 years), the incidence of consecutive elevations of transaminases (>3 X ULN) was 0.7% for ezetimibe combined with simvastatin and 0.6% for placebo (see section 4.8).

Skeletal Muscle

In post-marketing experience with ezetimibe, cases of myopathy and rhabdomyolysis have been reported. Most patients who developed rhabdomyolysis were taking a statin concomitantly with ezetimibe. However, rhabdomyolysis has been reported very rarely with ezetimibe monotherapy and very rarely with the addition of Ezetimibe to other agents known to be associated with increased risk of rhabdomyolysis. If myopathy is suspected based on muscle symptoms or is confirmed by a creatine phosphokinase (CPK) level >10 times the ULN, ezetimibe, any statin, and any of these other agents that the patient is taking concomitantly should be immediately discontinued. All patients starting therapy with ezetimibe should be advised of the risk of myopathy and told to report promptly any unexplained muscle pain, tenderness or weakness (see section 4.8).

In IMPROVE-IT, 18,144 patients with coronary heart disease and ACS event history were randomised to receive ezetimibe/simvastatin 10/40 mg daily (n=9067) or simvastatin 40 mg daily (n=9077). During a median followup of 6.0 years, the incidence of myopathy was 0.2% for ezetimibe/simvastatin and 0.1% for simvastatin, where myopathy was defined as unexplained muscle weakness or pain with a serum CK ≥10 times ULN or two consecutive observations of CK ≥5 and <10 times ULN. The incidence of rhabdomyolysis was 0.1% for ezetimibe/simvastatin and 0.2% for simvastatin, where rhabdomyolysis was defined as unexplained muscle weakness or pain with a serum CK ≥10 times ULN with evidence of renal injury, ≥5 times ULN and <10 times ULN on two consecutive occasions with evidence of renal injury or CK ≥10,000 IU/L without evidence of renal injury. (See section 4.8.)

In a clinical trial in which over 9000 patients with chronic kidney disease were randomised to receive ezetimibe 10 mg combined with simvastatin 20 mg daily (n=4650) or placebo (n=4620) (median followup 4.9 years), the incidence of myopathy/rhabdomyolysis was 0.2% for ezetimibe combined with simvastatin and 0.1% for placebo (see section 4.8).

Patients with hepatic impairment

Due to the unknown effects of the increased exposure to ezetimibe in patients with moderate or severe hepatic impairment, ezetimibe is not recommended (see section 5.2).

Paediatric population

Efficacy and safety of Ezetimibe in patients 6 to10 years of age with heterozygous familial or nonfamilial hypercholesterolemia have been evaluated in a 12-week Placebo-controlled clinical trial. Effects of ezetimibe for treatment periods > 12 weeks have not been studied in this age group (see sections 4.2, 4.8, 5.1 and 5.2).

Ezetimibe has not been studied in patients younger than 6 years of age (see sections 4.2 and 4.8.).

Efficacy and safety of Ezetimibe coadministered with simvastatin in patients 10 to 17 years of age with heterozygous familial hypercholesterolemia have been evaluated in a controlled clinical trial in adolescent boys (Tanner stage II or above) and in girls who were at least one year post-menarche.

In this limited controlled study, there was generally no detectable effect on growth or sexual maturation in the adolescent boys or girls, or any effect on menstrual cycle length in girls. However, the effects of ezetimibe for a treatment period > 33 weeks on growth and sexual maturation have not been studied (see sections 4.2 and 4.8).

The safety and efficacy of Ezetimibe co-administered with doses of simvastatin above 40mg daily have not been studied in paediatric patients 10 to 17 years of age.

The safety and efficacy of Ezetimibe co-administered with simvastatin have not been studied in paediatric patients < 10 years of age (see sections 4.2 and 4.8).

The long-term efficacy of therapy with Ezetimibe in patients below 17 years of age to reduce morbidity and mortality in adulthood has not been studied.

Fibrates

The safety and efficacy of Ezetimibe administered with fibrates have not been established.

If cholelithiasis is suspected in a patient receiving Ezetimibe and fenofibrate, gallbladder investigations are indicated and this therapy should be discontinued (see sections 4.5 and 4.8).

Ciclosporin

Caution should be exercised when initiating Ezetimibe in the setting of ciclosporin. Ciclosporin concentrations should be monitored in patients receiving Ezetimibe and ciclosporin (see section 4.5).

Anticoagulants

If Ezetimibe is added to warfarin, another coumarin anticoagulant, or fluindione, the International Normalised Ratio (INR) should be appropriately monitored (see section 4.5).

Excipient

Ezetimibe contains lactose

Patients with rare hereditary problems of galactose intolerance, total lactase deficiency or glucose-galactose malabsorption should not take this medicine.

Ezetimibe contains sodium

This medicine contains less than 1 mmol sodium (23 mg) per tablet, that is to say essentially 'sodium-free'.

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

In preclinical studies, it has been shown that ezetimibe does not induce cytochrome P450 drug metabolising enzymes.

No clinically significant pharmacokinetic interactions have been observed between ezetimibe and drugs known to be metabolised by cytochromes P450 1A2, 2D6, 2C8, 2C9, and 3A4, or N-acetyltransferase.

In clinical interaction studies, ezetimibe had no effect on the pharmacokinetics of dapsone, dextromethorphan, digoxin, oral contraceptives (ethinyl estradiol and levonorgestrel), glipizide, tolbutamide, or midazolam during co-administration.Cimetidine, co-administered with ezetimibe, had no effect on the bioavailability of ezetimibe.

Antacids

Concomitant antacid administration decreased the rate of absorption of ezetimibe but had no effect on the bioavailability of ezetimibe. This decreased rate of absorption is not considered clinically significant.

Cholestyramine

Concomitant cholestyramine administration decreased the mean area under the curve (AUC) of total ezetimibe (ezetimibe + ezetimibe glucuronide) approximately 55 %. The incremental low density lipoprotein cholesterol (LDL-C) reduction due to adding Ezetimibe to cholestyramine may be lessened by this interaction (see section 4.2).

Fibrates

In patients receiving fenofibrate and Ezetimibe, physicians should be aware of the possible risk of cholelithiasis and gallbladder disease (see sections 4.4 and 4.8).

If cholelithiasis is suspected in a patient receiving Ezetimibe and fenofibrate, gallbladder investigations are indicated and this therapy should be discontinued (see section 4.8).

Concomitant fenofibrate or gemfibrozil administration modestly increased total ezetimibe concentrations (approximately 1.5 and 1.7 fold respectively).

Co-administration of Ezetimibe with other fibrates has not been studied.

Fibrates may increase cholesterol excretion into the bile, leading to cholelithiasis. In animal studies, ezetimibe sometimes increased cholesterol in the gallbladder bile but not in all species (see section 5.3). A lithogenic risk associated with the therapeutic use of Ezetimibe cannot be ruled out.

Statins

No clinically significant pharmacokinetic interactions were seen when ezetimibe was co-administered with atorvastatin, simvastatin, pravastatin, lovastatin, fluvastatin, or rosuvastatin.

Ciclosporin

In a study of eight post-renal transplant patients with creatinine clearance of > 50 mL/min on a stable dose of ciclosporin, a single 10 mg dose of Ezetimibe resulted in a 3.4-fold (range 2.3 to 7.9 fold) increase in the mean AUC for total ezetimibe compared to a healthy control population, receiving ezetimibe alone, from another study (n=17). In a different study, a renal transplant patient with severe renal impairment who was receiving ciclosporin and multiple other medications demonstrated a 12 fold greater exposure to total ezetimibe compared to concurrent controls receiving ezetimibe alone. In a two-period crossover study in twelve healthy subjects, daily administration of 20 mg ezetimibe for 8 days with a single 100 mg dose of ciclosporin on Day 7 resulted in a mean 15 % increase in ciclosporin AUC (range 10 % decrease to 51 % increase) compared to a single 100-mg dose of ciclosporin alone. A controlled study on the effect of coadministered ezetimibe on ciclosporin exposure in renal transplant patients has not been conducted.Caution should be exercised when initiating Ezetimibe in the setting of ciclosporin. Ciclosporin concentrations should be monitored in patients receiving Ezetimibe and ciclosporin (see section 4.4).

Anticoagulants

Concomitant administration of ezetimibe (10 mg once daily) had no significant effect on bioavailability of warfarin and prothrombin time in a study of twelve healthy adult males. However, there have been post-marketing reports of increased International Normalised Ratio (INR) in patients who had ezetimibe added to warfarin or fluindione. If ezetimibe is added to warfarin, another coumarin anticoagulant, or fluindione, INR should be appropriately monitored (see section 4.4).

Paediatric population

Interaction studies have only been performed in adults.

4.6. Fertility, pregnancy and lactation

Ezetimibe co-administered with a statin is contraindicated during pregnancy and lactation (see section 4.3), please refer to the SPC for that particular statin.

Pregnancy

Ezetimibe should be given to pregnant women only if clearly necessary. No clinical data are available on the use of ezetimibe during pregnancy. Animal studies on the use of ezetimibe in monotherapy have shown no evidence of direct or indirect harmful effects on pregnancy, embryofoetal development, birth or postnatal development (see section 5.3).

Breastfeeding

Ezetimibe should not be used during lactation. Studies on rats have shown that ezetimibe is secreted into breast milk. It is not known if ezetimibe is secreted into human breast milk.

Fertility

No clinical trial data are available on the effects of ezetimibe on human fertility. Ezetimibe had no effect on the fertility of male or female rats (see section 5.3).

4.7. Effects on ability to drive and use machines

No studies on the effects on the ability to drive and use machines have been performed. However, when driving vehicles or operating machines, it should be taken into account that dizziness has been reported.

4.8. Undesirable effects

Tabulated list of adverse reactions (clinical studies and postmarketing experience)

In clinical studies of up to 112 weeks duration, Ezetimibe 10 mg daily was administered alone in 2396 patients, with a statin in 11,308 patients or with fenofibrate in 185 patients. Adverse reactions were usually mild and transient. The overall incidence of side effects was similar between Ezetimibe and placebo. Similarly, the discontinuation rate due to adverse experiences was comparable between Ezetimibe and placebo.

Ezetimibe administered alone or coadministered with a statin:

The following adverse reactions were observed in patients treated with ezetimibe (n=2396) and at a greater incidence than placebo (n=1159) or in patients treated with ezetimibe coadministered with a statin (n=11308) and at a greater incidence than statin administered alone (n=9361). Postmarketing Adverse reactions were derived from reports containing ezetimibe either administered alone or with a statin. Adverse reactions observed in clinical studies of Ezetimibe (as a monotherapy or co-administered with a statin) or Ezetimibe reported from post-marketing use either administered alone or with a statin are listed in Table 1. These reactions are presented by system organ class and by frequency.

Frequencies are defined 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 (frequency cannot be estimated from the available data).

Table 1

Adverse Reactions

System organ class

Frequency

Adverse reaction

Blood and lymphatic system disorders

Not known

thrombocytopaenia

Immune system disorders

Not known

hypersensitivity; including rash; urticaria; anaphylaxis and angio-oedema

Metabolism and nutrition disorders

Uncommon

decreased appetite

Psychiatric disorders

Not known

depression

Nervous system disorders

Common

headache

Uncommon

paraesthesia

Not known

dizziness

Vascular disorders

Uncommon

hot flush; hypertension

Respiratory, thoracic and mediastinal disorders

Uncommon

cough

Not known

dyspnoea

Gastrointestinal disorders

Common

abdominal pain; diarrhoea; flatulence

Uncommon

dyspepsia; gastrooesophageal reflux disease; nausea; dry mouth; gastritis

Not known

pancreatitis; constipation

Hepatobiliary disorders

Not known

hepatitis; cholelithiasis; cholecystitis

Skin and subcutaneous tissue disorders

Uncommon

pruritus; rash; urticaria

Not known

erythema multiforme

Musculoskeletal and connective tissue disorders

Common

myalgia

Uncommon

arthralgia; muscle spasms; neck pain; back pain; muscular weakness; pain in extremity

Not known

myopathy/rhabdomyolysis (see section 4.4)

General disorders and administration site conditions

Common

fatigue

Uncommon

chest pain; pain; asthenia; oedema peripheral

Investigations

Common

ALT and/or AST increased

Uncommon

blood CPK increased; gamma-glutamyltransferase increased; liver function test abnormal

Ezetimibe co-administered with fenofibrate

Gastrointestinal disorders: abdominal pain (common)

In a multicentre, double-blind, placebo-controlled, clinical study in patients with mixed hyperlipidaemia, 625 patients were treated for up to 12 weeks and 576 patients for up to 1 year. In this study, 172 patients treated with ezetimibe and fenofibrate completed 12 weeks of therapy, and 230 patients treated with ezetimibe and fenofibrate (including 109 who received ezetimibe alone for the first 12 weeks) completed 1 year of therapy. This study was not designed to compare treatment groups for infrequent events. Incidence rates (95 % CI) for clinically important elevations (> 3 X ULN, consecutive) in serum transaminases were 4.5 % (1.9, 8.8) and 2.7 % (1.2, 5.4) for fenofibrate monotherapy and ezetimibe co-administered with fenofibrate, respectively, adjusted for treatment exposure. Corresponding incidence rates for cholecystectomy were 0.6 % (0.0, 3.1) and 1.7 % (0.6, 4.0) for fenofibrate monotherapy and ezetimibe co-administered with fenofibrate, respectively (see sections 4.4 and 4.5).

Paediatric (6 to 17 years of age) Patients

In a study involving paediatric (6 to 10 years of age) patients with heterozygous familial or nonfamilial hypercholesterolaemia (n=138), elevations of ALT and/or AST (≥ 3X ULN, consecutive) were observed in 1.1% (1 patient) of the ezetimibe patients compared to 0% in the placebo group. There were no elevations of CPK (≥ 10X ULN). No cases of myopathy were reported.

In a separate study involving adolescent (10 to 17 years of age) patients with heterozygous familial hypercholesterolaemia (n=248), elevations of ALT and/or AST (≥ 3X ULN, consecutive) were observed in 3% (4 patients) of the ezetimibe/simvastatin patients compared to 2% (2 patients) in the simvastatin monotherapy group; these figures were respectively 2% (2 patients) and 0% for elevation of CPK (≥ 10X ULN). No cases of myopathy were reported.

These trials were not suited for comparison of rare adverse drug reactions.

Patients with Coronary Heart Disease and ACS Event History

In the IMPROVE-IT study (see section 5.1), involving 18,144 patients treated with either ezetimibe/simvastatin 10/40 mg (n=9067; of whom 6% were uptitrated to ezetimibe/simvastatin 10/80 mg) or simvastatin 40 mg (n=9077; of whom 27% were uptitrated to simvastatin 80 mg), the safety profiles were similar during a median followup period of 6.0 years. Discontinuation rates due to adverse experiences were 10.6% for patients treated with ezetimibe/simvastatin and 10.1% for patients treated with simvastatin. The incidence of myopathy was 0.2% for ezetimibe/simvastatin and 0.1% for simvastatin, where myopathy was defined as unexplained muscle weakness or pain with a serum CK ≥10 times ULN or two consecutive observations of CK ≥5 and <10 times ULN. The incidence of rhabdomyolysis was 0.1% for ezetimibe/simvastatin and 0.2% for simvastatin, where rhabdomyolysis was defined as unexplained muscle weakness or pain with a serum CK ≥10 times ULN with evidence of renal injury, ≥5 times ULN and <10 times ULN on two consecutive occasions with evidence of renal injury or CK ≥10,000 IU/L without evidence of renal injury. The incidence of consecutive elevations of transaminases (≥3 X ULN) was 2.5% for ezetimibe/simvastatin and 2.3% for simvastatin (see section 4.4.). Gallbladder related adverse effects were reported in 3.1% vs 3.5% of patients allocated to ezetimibe/simvastatin and simvastatin, respectively. The incidence of cholecystectomy hospitalisations was 1.5% in both treatment groups. Cancer (defined as any new malignancy) was diagnosed during the trial in 9.4% vs 9.5%, respectively.

Patients with Chronic Kidney Disease

In the Study of Heart and Renal Protection (SHARP) (see section 5.1), involving over 9000 patients treated with a fixed dose combination of ezetimibe 10 mg with simvastatin 20 mg daily (n=4650) or placebo (n=4620), the safety profiles were comparable during a median followup period of 4.9 years. In this trial, only serious adverse events and discontinuations due to any adverse events were recorded. Discontinuation rates due to adverse events were comparable (10.4% in patients treated with ezetimibe combined with simvastatin, 9.8% in patients treated with placebo). The incidence of myopathy/rhabdomyolysis was 0.2% in patients treated with ezetimibe combined with simvastatin and 0.1% in patients treated with placebo. Consecutive elevations of transaminases (> 3X ULN) occurred in 0.7% of patients treated with ezetimibe combined with simvastatin compared with 0.6% of patients treated with placebo (see section 4.4.). In this trial, there were no statistically significant increases in the incidence of pre-specified adverse events, including cancer (9.4% for ezetimibe combined with simvastatin, 9.5% for placebo), hepatitis, cholecystectomy or complications of gallstones or pancreatitis.

Laboratory values:

In controlled clinical monotherapy trials, the incidence of clinically important elevations in serum transaminases (ALT and/or AST ≥ 3 X ULN, consecutive) was similar between ezetimibe (0.5 %) and placebo (0.3 %). In co-administration trials, the incidence was 1.3 % for patients treated with ezetimibe coadministered with a statin and 0.4 % for patients treated with a statin alone. These elevations were generally asymptomatic, not associated with cholestasis, and returned to baseline after discontinuation of therapy or with continued treatment (see section 4.4.).

In clinical trials, CPK >10 X ULN was reported for 4 of 1674 (0.2 %) patients administered ezetimibe alone vs 1 of 786 (0.1 %) patients administered placebo, and for 1 of 917 (0.1 %) patients co-administered ezetimibe and a statin vs 4 of 929 (0.4 %) patients administered a statin alone. There was no excess of myopathy or rhabdomyolysis associated with ezetimibe compared with the relevant control arm (placebo or statin alone) (see section 4.4).

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

In clinical studies, administration of ezetimibe, 50 mg/day to 15 healthy subjects for up to 14 days, or 40 mg/day to 18 patients with primary hypercholesterolaemia for up to 56 days, was generally well tolerated. In animals, no toxicity was observed after single oral doses of 5000 mg/kg of ezetimibe in rats and mice and 3000 mg/kg in dogs.

A few cases of overdosage with ezetimibe have been reported; most have not been associated with adverse experiences. Reported adverse experiences have not been serious. In the event of an overdose, symptomatic and supportive measures should be employed.