4.1. Therapeutic indications

Fungal infections of the skin and nails caused by Trichophyton (eg. T. rubrum, T.mentagrophytes, T. verrucosum, T. violaceum), Microsporum canis and Epidermophyton floccosum.

1. Oral Lamisil is indicated in the treatment of ringworm (tinea corporis, tinea cruris and tinea pedis) where oral therapy is considered appropriate due to the site, severity or extent of the infection.

2. Oral Lamisil is indicated in the treatment of onychomycosis.

4.2. Posology and method of administration

Adults

250mg once daily.

The duration of treatment varies according to the indication and the severity of the infection.

Skin infections

Likely durations of treatment are as follows:

Tinea pedis (interdigital, plantar/moccasin type):

2 to 6 weeks

Tinea corporis:

4 weeks

Tinea cruris:

2 to 4 weeks

Onychomycosis

The duration of treatment for most patients is between 6 weeks and 3 months. Treatment periods of less than 3 months can be anticipated in patients with fingernail infection, toenail infection other than of the big toe, or patients of younger age. In the treatment of toenail infections, 3 months is usually sufficient although a few patients may require treatment of 6 months or longer. Poor nail outgrowth during the first weeks of treatment may enable identification of those patients in whom longer therapy is required.

Complete resolution of the signs and symptoms of infection may not occur until several weeks after mycological cure.

Additional information on special population

Liver impairment

Lamisil tablets are contraindicated for patients with chronic or active hepatic disease (see sections 4.3 Contraindications and 4.4 Special warnings and precautions for use).

Renal impairment

The use of Lamisil tablets has not been adequately studied in patients with renal impairment and is therefore not recommended in this population (see section 4.4 Special warnings and precautions for use and section 5.2 Pharmacokinetic properties).

Children

A review of safety experience with oral LAMISIL in children, which includes 314 patients involved in the UK LAMISIL Post Marketing Surveillance study, has shown that the adverse event profile in children is similar to that seen in adults. No evidence of any new, unusual or more severe reactions to those seen in the adult population have been noted. However, as data is still limited its use is not recommended.

Elderly

There is no evidence to suggest that elderly patients (aged 65 years or above) require different dosages or experience side-effects different to those of younger patients. The possibility of impairment of liver or kidney function should be considered in this age group (see Precautions).

Method of administration

The scored tablets are taken orally with water. They should preferably be taken at the same time each day and can be taken on an empty stomach or after a meal.

4.3. Contraindications

Known hypersensitivity to terbinafine or to any of the excipients of Lamisil tablets.

Chronic or active hepatic disease.

4.4. Special warnings and precautions for use

Liver Function

Lamisil tablets are contraindicated for patients with chronic or active hepatic disease. Before prescribing Lamisil tablets, a liver function test should be performed and any pre-existing liver disease should be assessed.

Hepatotoxicity may occur in patients with and without pre-existing liver disease therefore periodic monitoring (after 4-6 weeks of treatment) of liver function test is recommended. Lamisil tablets should be immediately discontinued in case of elevation of liver function test.

Very rare cases of serious liver failure (some with a fatal outcome, or requiring liver transplant) have been reported in patients treated with Lamisil tablets. In the majority of liver failure cases the patients had serious underlying systemic conditions (see sections 4.3 Contraindications and 4.8 Undesirable effects).

Patients prescribed Lamisil tablets should be instructed to report immediately any signs or symptoms suggestive of liver dysfunction such as pruritus, unexplained persistent nausea, decreased appetite, anorexia, jaundice, vomiting, fatigue, right upper abdominal pain, dark urine, or pale stools. Patients with these symptoms should discontinue taking oral terbinafine and the patient's liver function should be immediately evaluated.

Dermatological effects

Serious skin reactions (e.g. Stevens-Johnson syndrome, toxic epidermal necrolysis, drug rash with eosinophilia and systemic symptoms) have been very rarely reported in patients taking Lamisil tablets. If progressive skin rash occurs, Lamisil tablets treatment should be discontinued.

Lamisil should be used with caution in patients with pre-existing psoriasis, as very rare cases of exacerbation of psoriasis have been reported.

Haematological effects

Very rare cases of blood dyscrasias (neutropenia, agranulocytosis, thrombocytopenia, pancytopenia) have been reported in patients treated with Lamisil tablets. Aetiology of any blood dyscrasias that occur in patients treated with Lamisil tablets should be evaluated and consideration should be given for a possible change in medication regimen, including discontinuation of treatment with Lamisil tablets.

Renal function

In patients with renal impairment (creatinine clearance less than 50 mL/min or serum creatinine of more than 300 micro mol/L) the use of Lamisil tablets has not been adequately studied, and therefore, is not recommended (see section 5.2 Pharmacokinetic properties).

Other

Lamisil should be used with caution in patients with lupus erythematosus as very rare cases of lupus erythematosus have been reported.

Excipient(s) with known effect

Lamisil tablets contain less than 1mmol sodium (23mg) per tablet, i.e. essentially 'sodium free'.

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

Effect of other medicinal products on terbinafine

The plasma clearance of terbinafine may be accelerated by drugs which induce metabolism and may be inhibited by drugs which inhibit cytochrome P450. Where co-administration of such agents is necessary, the dosage of Lamisil may need to be adjusted accordingly.

The following medicinal products may increase the effect or plasma concentration of terbinafine:

Cimetidine decreased the clearance of terbinafine by 30%.

Fluconazole increased the Cmax and AUC of terbinafine by 52% and 69% respectively, due to inhibition of both CYP2C9 and CYP3A4 enzymes. Similar increase in exposure may occur when other drugs which inhibit both CYP2C9 and CYP3A4 such as ketoconazole and amiodarone are concomitantly administered with terbinafine.

The following medicinal products may decrease the effect or plasma concentration of terbinafine:

Rifampicin increased the clearance of terbinafine by 100%.

Effect of terbinafine on other medicinal products

Terbinafine may increase the effect or plasma concentration of the following medicinal products:

Caffeine – Terbinafine decreased the clearance of caffeine administered intravenously by 21%.

Compounds predominantly metabolised by CYP2D6 – In vitro and in vivo studies have shown that terbinafine inhibits the CYP2D6-mediated metabolism. This finding may be of clinical relevance for patients receiving compounds predominantly metabolised by CYP2D6, e.g. certain members of the following drug classes, tricyclic antidepressants (TCA's), β-blockers, selective serotonin reuptake inhibitors (SSRIs), antiarrhythmics (including class 1A, 1B and 1C) and monoamine oxidase inhibitors (MAO-Is) Type B, especially if they also have a narrow therapeutic window (see section 4.4).

Terbinafine decreased the clearance of desipramine by 82%.

In studies in healthy subjects characterized as extensive metabolisers of dextromethorphan (antitussive drug and CYP2D6 probe substrate), terbinafine increased the dextromethorphan/dextrorphan metabolic ratio in urine by 16- to 97-fold on average. Thus, terbinafine may convert extensive CYP2D6 metabolisers (genotype) to poor metaboliser status (phenotype).

Information on other drug concomitantly used with Lamisil resulting in no or negligible interactions.

Studies undertaken in vitro and in healthy volunteers suggest that terbinafine shows negligible potential to inhibit or induce the clearance of most drugs that are metabolized via other cytochrome P450 enzymes (e.g. tolbutamine, terfenadine, triazolam, oral contraceptives) with exception of those metabolised through CYP2D6 (see below).

Terbinafine does not interfere with the clearance of antipyrine or digoxin.

There was no effect of terbinafine on the pharmacokinetics of fluconazole. Further there was no clinically relevant interaction between terbinafine and the potential comedications cotrimoxazole (trimethoprim and sulfamethoxazole), zidovudine or theophylline.

Some cases of menstrual disturbance (breakthrough bleeding and irregular cycle) have been reported in patients taking Lamisil concomitantly with oral contraceptives, although the incidence of these disorders remains within the background incidence of patients taking oral contraceptives alone.

Terbinafine may decrease the effect or plasma concentration of the following medicinal products:

Terbinafine increased the clearance of ciclosporin by 15%.

Rare cases of changes in INR and/or prothrombin time have been reported in patients receiving terbinafine concomitantly with warfarin.

4.6. Pregnancy and lactation

Pregnancy

Foetal toxicity and fertility studies in animals suggest no adverse effects. Since clinical experience in pregnant women is very limited, terbinafine tablets should not be used during pregnancy unless clinical condition of the woman requires treatment with oral terbinafine and the potential benefits for the mother outweigh any potential risks for the foetus.

Lactation

Terbinafine is excreted in breast milk and therefore mothers should not receive Lamisil treatment whilst breast-feeding.

Fertility

Foetal toxicity and fertility studies in animals suggest no adverse effects.

4.7. Effects on ability to drive and use machines

No studies on the effects of Lamisil tablets treatment on the ability to drive and use machines have been performed. Patients who experience dizziness as an undesirable effect should avoid driving vehicles or using machines.

4.8. Undesirable effects

Side effects are generally mild to moderate, and transient. The following adverse reactions have been observed in the clinical trials or during post-marketing experience.

Adverse reactions are ranked under headings of frequency, using the following convention:

Very common (≥ 1/10); Common (≥ 1/100, < 1/10); Uncommon (≥ 1/1,000, <1/100); Rare (≥ 1/10,000, < 1/1,000); Very rare (< 1/10,000), Not known (frequency cannot be estimated from available data).

Blood and lymphatic system disorders

Very rare

Neutropenia, agranulocytosis, thrombocytopenia

Not known

Anaemia, pancytopenia

Immune system disorders

Very rare

Anaphylactoid reactions (including angioedema), cutaneous and systemic lupus erythematosus

Not known

Anaphylactic reaction, serum sickness-like reaction

Metabolism and nutrition disorders

Very common

Decreased appetite

Psychiatric disorders

Not known

Anxiety and depressive symptoms

Nervous system disorders

Common

Headache

Uncommon

Dysgeusia* including ageusia*

* Hypogeusia, including ageusia, which usually recover within several weeks after discontinuation of the drug. Isolated cases of prolonged hypogeusia have been reported.

Rare

Paraesthesia, hypoaesthesia, dizziness

Not known

Anosmia including permanent anosmia, hyposmia

Eye disorders

Not known

Visual impairment, vision blurred, visual acuity reduced

Ear and labyrinth disorders

Very rare

Vertigo

Not known

Hypoacusis, impaired hearing, tinnitus

Vascular disorders

Not known

Vasculitis

Gastrointestinal disorders

Very common

Gastrointestinal symptoms (feeling of fullness abdominal distension, dyspepsia, nausea, abdominal pain, diarrhoea)

Not known

Pancreatitis

Hepatobiliary disorders

Rare

Cases of serious hepatic dysfunction, including hepatic failure, hepatic enzymes increased, jaundice, cholestasis and hepatitis. If hepatic dysfunction develops, treatment with Lamisil should be discontinued (see also Section 4.4). Very rare cases of serious liver failure have been reported (some with a fatal outcome, or requiring liver transplant). In the majority of liver failure cases the patients had serious underlying systemic conditions and a causal association with the intake of Lamisil was uncertain.

Skin and subcutaneous tissue disorders

Very common

Rash, urticaria

Very rare

Stevens-Johnson syndrome, toxic epidermal necrolysis), erythema multiforme, toxic skin eruption, dermatitis exfoliative, dermatitis bullous

Photosensitivity reactions

Alopecia

If progressive skin rash occurs, Lamisil treatment should be discontinued.

Not known

Psoriasiform eruptions or exacerbation of psoriasis. Serious skin reactions (e.g. acute generalized exanthematous pustulosis (AGEP))

Drug rash with eosinophilia and systemic symptoms

Musculoskeletal and connective tissue disorders

Very common

Musculoskeletal reactions (arthralgia, myalgia).

Not known

Rhabdomyolysis

General disorders

Rare

Malaise

Not known

Fatigue

Influenza-like illness, pyrexia

Investigations

Uncommon

Weight decreased**

**weight decreased secondary to dysgeusia

Not known

Blood creatine phosphokinase increased

Reporting of suspected adverse reactions

Reporting 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.

4.9. Overdose

A few cases of overdose (up to 5g) have been reported, giving rise to headache, nausea, upper abdominal pain and dizziness. The recommended treatment of overdosage consists of eliminating the drug, primarily by the administration of activated charcoal, and giving symptomatic supportive therapy if needed.