4.1. Therapeutic indications

Nicorette Invisi Patch relieves and/or prevents craving and nicotine withdrawal symptoms in nicotine dependence, such as those arising from the use of tobacco or electronic cigarettes. It is indicated to aid quitting or reduction prior to quitting, to assist those who are unwilling or unable to use such products, and as a safer alternative to smoking tobacco for smokers and those around them.

Nicorette Invisi Patch is indicated in pregnant and lactating women making a quit attempt (see section 4.6).

4.2. Posology and method of administration

When making a quit attempt behavioural therapy, advice and support will normally improve the success rate.

It is intended that the patch is worn through the waking hours (approximately 16 hours) being applied on waking and removed at bedtime.

Smoking/Vaping Cessation

Adults (over 18 years of age)

For best results, most smokers/vapers are recommended to start on 25 mg / 16 hours patch (Step 1) and use one patch daily for 8 weeks. Gradual weaning from the patch should then be initiated. One 15 mg/16 hours patch (Step 2) should be used daily for 2 weeks followed by one 10 mg/16 hours patch (Step 3) daily for 2 weeks.

Dose

Duration

Step 1

Nicorette Invisi 25 mg Patch

First 8 weeks

Step 2

Nicorette Invisi 15 mg Patch

Next 2 weeks

Step 3

Nicorette Invisi 10 mg Patch

Last 2 weeks

Lighter smokers (i.e. those who smoke less than 10 cigarettes per day) and light to moderate vapers (e.g. vape infrequently or use low strength e-liquid) are recommended to start at Step 2 (15 mg) for 8 weeks and decrease the dose to 10 mg for the final 4 weeks.

Those who experience excessive side effects with the 25 mg / 16 hours patch (Step 1), which do not resolve within a few days, should change to a 15mg / 16 hours patch (Step 2). This should be continued for the remainder of the 8 week course, before stepping down to the 10 mg / 16 hours patch (Step 3) for 4 weeks. If symptoms persist the advice of a healthcare professional should be sought.

Adolescents (12 to 18 years)

The dose and method of use are as for adults however as data are limited in this age group, the recommended treatment duration is 12 weeks. If longer treatment is required, advice from a healthcare professional should be sought.

Smoking/Vaping Reduction/Pre-Quit

Smokers/vapers are recommended to use the patch to prolong smoke/vape- free intervals and with the intention to reduce smoking/vaping as much as possible.

The starting dose should follow the smoking/vaping cessation instructions above i.e. 25 mg (Step 1) is suitable for those who smoke 10 or more cigarettes per day or heavy vapers (e.g. vape frequently or use high strength e- liquid). Lighter smokers (i.e. those who smoke less than 10 cigarettes per day) and light to moderate vapers (e.g. vape infrequently or use low strength e- liquid) are recommended to start at Step 2 (15 mg).

Smokers/vapers starting on 25 mg patch (Step 1) should transfer to 15 mg patch (Step 2) as soon as cigarette consumption reduces to less than 10 cigarettes per day or vaping dependency decreases.

A quit attempt should be made as soon as the smoker/vaper feels ready. When making a quit attempt patients who have reduced to less than 10 cigarettes per day are recommended to continue at Step 2 (15 mg) for 8 weeks and decrease the dose to 10 mg (Step 3) for the final 4 weeks. When vapers have reduced their dependency sufficiently (e.g. vape infrequently or use low strength e-liquid), they should continue at Step 2 (15 mg) for 8 weeks and then step down to 10 mg (Step 3) for the final 4 weeks.

Temporary Abstinence

Use a Nicorette Invisi Patch in those situations when you can't or do not want to smoke/vape for prolonged periods (greater than 16 hours).

For shorter periods then an alternative intermittent dose form would be more suitable (e.g. Nicorette inhalator or gum).

Smokers of 10 or more cigarettes per day or heavy vapers (e.g. vape frequently or use high strength e-liquid) are recommended to use 25 mg patch. Lighter smokers (i.e. those who smoke less than 10 cigarettes per day) and light to moderate vapers (e.g. vape infrequently or use low strength e-liquid), are recommended to use 15 mg patch.

How to apply the patches

Nicorette Invisi Patch should be applied to clean, dry intact areas of hairless skin, for example on the hip, upper arm, or chest. These areas should be varied each day and the same site should not be used on consecutive days.

1. Wash your hands before applying the patch.

2. Cut open the pouch with scissors along the side, as indicated. Select a clean, dry, hairless intact area of skin, such as the hip, upper arm or chest.

3. Peel one part of the silvery aluminium backing away. Avoid touching the sticky surface of the patch with your fingers.

4. Apply the sticky part of the patch carefully onto the skin and peel off the remaining half of the silvery aluminium backing.

5. Press the patch firmly onto the skin with your palm or fingertips.

6. Rub your fingers firmly round the edge to ensure that the patch sticks firmly.

Use of skin oils or talc can prevent proper adhesion of the patch.

After removal, used patches should be disposed of carefully.

4.3. Contraindications

Nicorette Invisi Patches should not be administered to patients with known hypersensitivity to nicotine or any component of the patch.

4.4. Special warnings and precautions for use

Any risks that may be associated with NRT are substantially outweighed by the well-established dangers of continued smoking. The risks of continued vaping are not yet established.

A risk-benefit assessment should be made by an appropriate healthcare professional for patients with the following conditions:

Underlying cardiovascular disease: In stable cardiovascular disease this product presents a lesser hazard than continuing to smoke. However dependent smokers currently hospitalised as a result of myocardial infarction, unstable or worsening angina including Prinzmetal angina, severe dysrhythmia or CVA and who are considered to be haemodynamically unstable and/or who have uncontrolled hypertension should be encouraged to stop smoking with non-pharmacological interventions. If this fails, this product may be considered, but as data on safety in this patient group are limited, initiation should only be under medical supervision. The risks of continued vaping are not yet established.

Diabetes mellitus: Patients with diabetes mellitus should be advised to monitor their blood sugar levels more closely than usual when quitting and NRT is initiated as reductions in nicotine induced catecholamine release can affect carbohydrate metabolism.

Renal or hepatic impairment: This product should be used with caution in patients with moderate to severe hepatic impairment and/or severe renal impairment as the clearance of nicotine or its metabolites may be decreased with the potential for increased adverse effects.

Seizures: Potential risks and benefits of nicotine should be carefully evaluated before use in subjects with a history of epilepsy as cases of convulsions have been reported in association with nicotine.

Danger in children: Doses of nicotine tolerated by adult and adolescent smokers or vapers can produce severe toxicity in children that may be fatal. Products containing nicotine should not be left where they may be misused, handled or ingested by children. After removal, the patch should be folded in half, adhesive side innermost, and placed inside the opened sachet, or in a piece of aluminium foil. The used patch should then be disposed of carefully, away from the reach of children or animals.

Phaeochromocytoma and uncontrolled hyperthyroidism: As nicotine causes release of catecholamines, this product should be used with caution in patients with uncontrolled hyperthyroidism or phaeochromocytoma.

Transferred dependence: Transferred dependence is rare and is both less harmful and easier to break than smoking dependence.

Stopping smoking: Polycyclic aromatic hydrocarbons in tobacco smoke induce the metabolism of drugs metabolised by CYP 1A2 (and possibly by CYP 1A1). When a smoker stops smoking, this may result in slower metabolism and a consequent rise in blood levels of such drugs. This is of potential clinical importance for products with a narrow therapeutic window, e.g. theophylline, clozapine and ropinirole.

Gastrointestinal disease: Nicotine may exacerbate symptoms in patients suffering from oesophagitis, gastric or peptic ulcers and NRT preparations should be used with caution in these conditions.

Generalised dermatological disorders: Patients with chronic generalised dermatological disorders such as psoriasis, chronic dermatitis or urticaria should not use this product.

Angioedema and urticaria have been reported.

Erythema may occur. If it is severe or persistent, treatment should be discontinued.

Minor skin reactions are seen at the patch application site in a proportion of patients when commencing treatment (see also section 4.8). If skin reactions become more severe or more generalized, patients should be advised to discontinue use of patches and seek further medical help regarding nicotine replacement therapy.

This product should be removed prior to undergoing any Magnetic Resonance Imaging (MRI) procedures to prevent the risk of burns.

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

No clinically relevant interactions between nicotine replacement therapy and other drugs have definitely been established. However nicotine may possibly enhance the haemodynamic effects of adenosine i.e. increase in blood pressure and heart rate and also increase pain response (angina-pectoris type chest pain) provoked by adenosine administration.

4.6. Fertility, pregnancy and lactation

Pregnancy

Stopping smoking is the single most effective intervention for improving the health of both the pregnant smoker and her baby, and the earlier abstinence is achieved the better. Ideally smoking cessation during pregnancy should be achieved without NRT. Nicotine passes to the foetus and affects its breathing movements and circulation. The effect on the circulation is dose-dependent. However, if the mother cannot (or is considered unlikely to) quit without pharmacological support, NRT may be used as the risk to the foetus is lower than that expected with smoking tobacco. Stopping completely is by far the best option but if this is not achievable Nicorette Invisi Patch may be used in pregnancy as a safer alternative to smoking. Because of the potential for nicotine-free periods, intermittent dose forms are preferable, but patches may be considered as an alternative if there is significant nausea and/or vomiting. If patches are used they should, if possible, be removed at night when the foetus would not normally be exposed to nicotine.

There is no or limited data regarding the effect of vaping in pregnancy.

Use of NRT by the pregnant smoker/vaper should only be initiated after advice from a health care professional.

Lactation

Nicotine should be avoided during breast-feeding. The relatively small amounts of nicotine found in breast milk during NRT use are less hazardous to the infant than second-hand smoke. Intermittent dose forms would minimize the amount of nicotine in breast milk and permit feeding when levels were at their lowest.

There is no or limited data regarding the effect of vaping in lactating women.

Use of NRT by breast feeding smokers/vapers should only be initiated after advice from a health care professional.

Fertility

In females tobacco smoking delays time to conception, decreases in-vitro fertilization success rates, and significantly increases the risk of infertility.

In males tobacco smoking reduces sperm production, increases oxidative stress, and DNA damage. Spermatozoa from smokers have reduced fertilizing capacity.

The specific contribution of nicotine to these effects in humans is unknown.

There is no or limited data regarding the effect of vaping on fertility.

4.7. Effects on ability to drive and use machines

This product has no or negligible influence on the ability to drive and use machines.

4.8. Undesirable effects

Effect of Smoking Cessation

Some symptoms may be related to nicotine withdrawal associated with stopping smoking. These can include irritability/aggression, dysphoria/depressed mood, anxiety, restlessness, poor concentration, increased appetite/weight gain, urges to smoke (cravings), night-time awakenings/sleep disturbance, decreased heart rate, dizziness, presyncopal symptoms, cough, constipation, gingival bleeding or nasopharyngitis.

Increased frequency of aphthous ulcer may occur after abstinence from smoking. The causality is unclear.

Effects of Vaping Cessation

The nicotine withdrawal effects of vaping cessation have not been established; however it is anticipated that many of the effects relating to nicotine withdrawal will be the same as those seen with tobacco smoking cessation.

Adverse Drug Reactions (ADRs)

This product may cause adverse reactions similar to those associated with nicotine given by other means, including smoking and vaping, and these are mainly dose-dependent. At recommended doses this product has not been found to cause any serious adverse effects. Excessive use of this product by those who have not been in the habit of inhaling tobacco smoke or vaping could possibly lead to nausea, faintness or headaches.

Most of the undesirable effects reported by the subjects occur during the early phase of treatment and are mainly dose dependent.

About 20% of Nicorette Invisi Patch users experience mild local skin reactions, during the first weeks of treatment. In some patients the skin reactions may become more severe e.g. skin blistering or a burning sensation or may be more generalized (see section 4.4).

Allergic reactions (including symptoms of anaphylaxis) occur rarely during use of this product.

Adverse events observed in patients treated with nicotine patch formulations during clinical trials and post-marketing surveillance are listed below by system organ class (SOC).

*Frequencies are defined in accordance with current guidance, as: *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 - cannot be estimated from the available data. ** Frequency category estimated using the “Rule of 3”

Body System

Reported adverse event (Preferred Term)

Incidence*

Immune system disorders

Hypersensitivitya#

Uncommon

Anaphylactic reactiona

Rare**

Nervous system disorders

Dizziness Headachea§

Common

Paraesthesiaa#

Uncommon

Seizures

Not known

Cardiac disorders

Palpitationsa

Tachycardiaa

Uncommon

Reversible atrial fibrillation

Very rare

Vascular disorders

Flushinga

Hypertensiona

Uncommon

Respiratory, Thoracic and Mediastinal Disorders

Dyspnoeaa

Uncommon

Gastrointestinal disorders

Nauseaa§

Vomitinga

Common

Gastrointestinal discomforta

Rare**

Skin and subcutaneous tissue disorders

Pruritus

Very common

Rasha

Urticariaa

Common

Hyperhidrosisa

Uncommon

Angioedemaa

Erythemaa

Rare**

Musculoskeletal and Connective Tissue Disorders

Myalgiab

Uncommon

Pain in extremity

Rare**

General disorders and administration site conditions

Application site reactions

Astheniaa

Chest discomfort and paina

Malaisa

Fatiguea#§

Uncommon

a Systemic effects;

b In vicinity/region of patch

# Although the frequency is <1% the PT occurred at a frequency ≥1% in another formulation in which the PT was identified as a systemic ADR.

§ Although the frequency in the active group is less than that of the placebo group, the frequency in the specific formulation in which the PT was identified as a systemic ADR was greater in the active group than the placebo group.

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

Symptoms: Symptoms of overdose with nicotine from this product may occur in smokers/vapers who have previously had a low nicotine intake from cigarettes /e-cigarettes or if other sources of nicotine are used concomitantly with this product.

Acute or chronic toxicity of nicotine in man is highly dependent on mode and route of administration. Adaptation to nicotine (e.g. in smokers/vapers) is known to significantly increase tolerability compared with non- smokers/vapers.

The minimum lethal dose of nicotine in a non-tolerant man has been estimated to be 40 to 60 mg. Symptoms of acute nicotine poisoning include nausea, vomiting, increased salivation, abdominal pain, diarrhoea, sweating, headache, dizziness, disturbed hearing and marked weakness. In extreme cases, these symptoms may be followed by hypotension, rapid or weak or irregular pulse, breathing difficulties, prostration, circulatory collapse and terminal convulsions.

Management of an overdose: All nicotine intake should stop immediately and the patient should be treated symptomatically. Remove the patch and rinse the application site with water. Artificial respiration should be instituted if necessary. Activated charcoal reduces the gastro-intestinal absorption of nicotine.

Doses of nicotine that are tolerated by adult smokers/vapers during treatment may produce severe symptoms of poisoning in children and may prove fatal. Suspected nicotine poisoning in a child should be considered a medical emergency and treated immediately.