4.1. Therapeutic indications

Hereditary tyrosinemia type 1 (HT-1)

Nitisinone is indicated for the treatment of adult and paediatric (in any age range) patients with confirmed diagnosis of hereditary tyrosinemia type 1 (HT-1) in combination with dietary restriction of tyrosine and phenylalanine.

Alkaptonuria (AKU)

Nitisinone is indicated for the treatment of adult patients with alkaptonuria (AKU).

4.2. Posology and method of administration

Posology

HT-1:

Nitisinone treatment should be initiated and supervised by a physician experienced in the treatment of HT-1 patients.

Treatment of all genotypes of the disease should be initiated as early as possible to increase overall survival and avoid complications such as liver failure, liver cancer and renal disease. Adjunct to the nitisinone treatment, a diet deficient in phenylalanine and tyrosine is required and should be followed by monitoring of plasma amino acids (see sections 4.4 and 4.8).

Starting dose HT-1

The recommended initial daily dose in the paediatric and adult population is 1 mg/kg body weight administered orally. The dose of nitisinone should be adjusted individually. It is recommended to administer the dose once daily. However, due to the limited data in patients with body weight <20 kg, it is recommended to divide the total daily dose into two daily administrations in this patient population.

Dose adjustment HT-1

During regular monitoring, it is appropriate to follow urine succinylacetone, liver function test values and alpha-fetoprotein levels (see section 4.4). If urine succinylacetone is still detectable one month after the start of nitisinone treatment, the nitisinone dose should be increased to 1.5 mg/kg body weight/day. A dose of 2 mg/kg body weight/day may be needed based on the evaluation of all biochemical parameters. This dose should be considered as a maximal dose for all patients.

If the biochemical response is satisfactory, the dose should be adjusted only according to body weight gain.

However, in addition to the tests above, during the initiation of therapy, switch from twice daily to once daily dosing or if there is a deterioration, it may be necessary to follow more closely all available biochemical parameters (i.e. plasma succinylacetone, urine 5aminolevulinate (ALA) and erythrocyte porphobilinogen (PBG)-synthase activity).

AKU:

Nitisinone treatment should be initiated and supervised by a physician experienced in the treatment of AKU patients.

The recommended dose in the adult AKU population is 10 mg once daily.

Special populations

There are no specific dose recommendations for elderly or patients that have renal or hepatic impairment.

Paediatric population

HT-1: The dose recommendation in mg/kg body weight is the same in children and adults. However, due to the limited data in patients with body weight <20 kg, it is recommended to divide the total daily dose into two daily administrations in this patient population.

AKU: The safety and efficacy of Nitisinone in children aged 0 to 18 years with AKU have not been established. No data are available.

Method of administration

The capsule may be opened and the content suspended in a small amount of water, apple juice, soft food, such as apple sauce, or formula diet, including amino acid modified infant formula with iron, immediately before intake.

Nitisinone is also available as a 4 mg/ml oral suspension for paediatric patients who have difficulties swallowing capsules.

It is recommended that if nitisinone treatment is initiated with food, this should be maintained on a routine basis, see section 4.5.

4.3. Contraindications

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

Mothers receiving nitisinone must not breast-feed (see sections 4.6 and 5.3).

4.4. Special warnings and precautions for use

Monitoring visits should be performed every 6 months; shorter intervals between visits are recommended in case of adverse events.

Monitoring of plasma tyrosine levels

It is recommended that a slit-lamp examination of the eyes is performed before initiation of nitisinone treatment and thereafter regularly, at least once a year. A patient displaying visual disorders during treatment with nitisinone should without delay be examined by an ophthalmologist.

HT-1: It should be established that the patient is adhering to his/her dietary regimen and the plasma tyrosine concentration should be measured. A more restricted tyrosine and phenylalanine diet should be implemented in case the plasma tyrosine level is above 500 micromol/l. It is not recommended to lower the plasma tyrosine concentration by reduction or discontinuation of nitisinone, since the metabolic defect may result in deterioration of the patient's clinical condition.

AKU: In patients who develop keratopathies, plasma tyrosine levels should be monitored. A diet restricted in tyrosine and phenylalanine should be implemented to keep the plasma tyrosine level below 500 micromol/l. In addition, nitisinone should be temporarily discontinued and may be reintroduced when the symptoms have been resolved.

Liver monitoring

HT-1: The liver function should be monitored regularly by liver function tests and liver imaging. It is recommended to also monitor serum alpha-fetoprotein concentrations. Increase in serum alpha- fetoprotein concentration may be a sign of inadequate treatment. Patients with increasing alpha- fetoprotein or signs of nodules in the liver should always be evaluated for hepatic malignancy.

Platelet and white blood cell (WBC) monitoring

It is recommended that platelet and WBC counts are monitored regularly for both HT-1 and AKU patients, as a few cases of reversible thrombocytopenia and leucopenia were observed during clinical evaluation of HT-1.

Concomitant use with other medicinal products

Nitisinone is a moderate CYP2C9 inhibitor. Nitisinone treatment may therefore result in increased plasma concentrations of co-administered medicinal products metabolized primarily via CYP2C9. Nitisinone treated patients who are concomitantly treated with medicinal products with a narrow therapeutic window metabolized through CYP2C9, such as warfarin and phenytoin, should be carefully monitored. Dose-adjustment of these co-administered medicinal products may be needed (see section 4.5).

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

Nitisinone is metabolised in vitro by CYP 3A4 and dose-adjustment may therefore be needed when nitisinone is co-administered with inhibitors or inducers of this enzyme.

Based data from a clinical interaction study with 80 mg nitisinone at steady-state, nitisinone is a moderate inhibitor of CYP2C9 (2.3-fold increase in tolbutamide AUC), therefore nitisinone treatment may result in increased plasma concentrations of coadministered medicinal products metabolized primarily via CYP2C9 (see section 4.4). Nitisinone is a weak inducer of CYP2E1 (30% decrease in chlorzoxazone AUC) and a weak inhibitor of OAT1 and OAT3 (1.7-fold increase in AUC of furosemide), whereas nitisinone did not inhibit CYP2D6 (see section 5.2).

No formal food interactions studies have been performed with Nitisinone hard capsules. However, nitisinone has been co-administered with food during the generation of efficacy and safety data. Therefore, it is recommended that if nitisinone treatment with Nitisinone hard capsules is initiated with food, this should be maintained on a routine basis, see section 4.2.

4.6. Fertility, pregnancy and lactation

Pregnancy

There are no adequate data from the use of nitisinone in pregnant women. Studies in animals have shown reproductive toxicity (see section 5.3). The potential risk for humans is unknown. Nitisinone should not be used during pregnancy unless the clinical condition of the woman requires treatment with nitisinone. Nitisinone crosses the human placenta.

Breast-feeding

It is unknown whether nitisinone is excreted in human breast milk. Animal studies have shown adverse postnatal effects via exposure of nitisinone in milk. Therefore, mothers receiving nitisinone must not breast-feed, since a risk to the suckling child cannot be excluded (see sections 4.3 and 5.3).

Fertility

There are no data on nitisinone affecting fertility.

4.7. Effects on ability to drive and use machines

Nitisinone has minor influence on the ability to drive and use machines. Adverse reactions involving the eyes (see section 4.8) can affect the vision. If the vision is affected the patient should not drive or use machines until the event has subsided.

4.8. Undesirable effects

Summary of the safety profile

By its mode of action, nitisinone increases tyrosine levels in all nitisinonetreated patients. Eye-related adverse reactions, such as conjunctivitis, corneal opacity, keratitis, photophobia, and eye pain, related to elevated tyrosine levels are therefore common in both HT-1 and AKU patients. In the HT-1 population other common adverse reactions include thrombocytopenia, leucopenia, and granulocytopenia. Exfoliative dermatitis may occur uncommonly.

Tabulated list of adverse reactions

The adverse reactions listed below by MedDRA system organ class and absolute frequency, are based on data from clinical trials in patients with HT-1 and AKU and post-marketing use in HT-1. Frequency is 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), not known (cannot be estimated from the available data). Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness.

MedDRA system

Frequency in

Frequency in

Adverse reaction

Infections and infestations

Common

Bronchitis, pneumonia

Blood and lymphatic system disorders

Common

Thrombocytopenia, leucopenia, granulocytopenia

Uncommon

Leukocytosis

Eye disorders

Common

Conjunctivitis, corneal opacity, keratitis, photophobia

Very common2

Keratopathy

Common

Very common2

Eye pain

Uncommon

Blepharitis

Skin and subcutaneous tissue disorders

Uncommon

Exfoliative dermatitis, erythematous rash

Uncommon

Common

Pruritus, rash

Investigations

Very common

Very common

Elevated tyrosine levels

1 The frequency is based on one clinical study in AKU.

2 Elevated tyrosine levels are associated with eye-related adverse reaction. Patients in the AKU study did not have a diet restricted in tyrosine and phenylalanine.

Description of selected adverse reactions

Nitisinone treatment leads to elevated tyrosine levels. Elevated levels of tyrosine have been associated with eye-related adverse reactions, such as e.g. corneal opacities and hyperkeratotic lesions in HT-1 and AKU patients. Restriction of tyrosine and phenylalanine in the diet should limit the toxicity associated with this type of tyrosinemia by lowering tyrosine levels (see section 4.4).

In clinical studies of HT-1, granulocytopenia was only uncommonly severe (<0.5x109/L) and not associated with infections. Adverse reactions affecting the MedDRA system organ class 'Blood and lymphatic system disorders' subsided during continued nitisinone treatment.

Paediatric population

The safety profile in HT-1 is mainly based on the paediatric population since nitisinone treatment should be started as soon as the diagnosis of hereditary tyrosinemia type 1 (HT-1) has been established. From clinical study and post marketing data there are no indications that the safety profile is different in different subsets of the paediatric population or different from the safety profile in adult patients.

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

4.9. Overdose

Accidental ingestion of nitisinone by individuals eating normal diets not restricted in tyrosine and phenylalanine will result in elevated tyrosine levels. Elevated tyrosine levels have been associated with toxicity to eyes, skin, and the nervous system. Restriction of tyrosine and phenylalanine in the diet should limit toxicity associated with this type of tyrosinemia. No information about specific treatment of overdose is available.