4.1. Therapeutic indications

Xalacom is indicated in adults (including the elderly) for the reduction of intraocular pressure (IOP) in patients with open angle glaucoma and ocular hypertension who are insufficiently responsive to topical beta-blockers or prostaglandin analogues.

4.2. Posology and method of administration

Posology

Adults (including the elderly)

Recommended therapy is one eye drop in the affected eye(s) once daily.

If one dose is missed, treatment should continue with the next dose as planned. The dose should not exceed one drop in the affected eye(s) daily.

Paediatric population

The safety and efficacy of Xalacom in children and adolescents has not been established.

Method of administration

Contact lenses should be removed before instillation of the eye drops and may be reinserted after 15 minutes (see section 4.4).

If more than one topical ophthalmic drug is being used, the drugs should be administered at least five minutes apart.

When using nasolacrimal occlusion or closing the eyelids for 2 minutes, the systemic absorption is reduced. This may result in a decrease in systemic side effects and an increase in local activity.

4.3. Contraindications

Xalacom is contraindicated in patients with:

• Reactive airway disease including bronchial asthma or a history of bronchial asthma, severe chronic obstructive pulmonary disease.

• Sinus bradycardia, sick sinus syndrome, sino-atrial block, second or third degree atrioventricular block not controlled with pace-maker, overt cardiac failure, cardiogenic shock.

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

4.4. Special warnings and precautions for use

Systemic effects

Like other topically applied ophthalmic agents, Xalacom is absorbed systemically. Due to the beta-adrenergic component timolol, the same types of cardiovascular, pulmonary and other adverse reactions as seen with systemic beta-adrenergic blocking agents may occur. Incidence of systemic ADRs after topical ophthalmic administration is lower than for systemic administration. To reduce the systemic absorption, see section 4.2.

Cardiac disorders

In patients with cardiovascular diseases (e.g. coronary heart disease, Prinzmetal's angina and cardiac failure) and hypotension therapy with beta-blockers should be critically assessed and the therapy with other active substances should be considered. Patients with cardiovascular diseases should be watched for signs of deterioration of these diseases and of adverse reactions.

Due to its negative effect on conduction time, beta-blockers should only be given with caution to patients with first degree heart block.

Cardiac reactions, and rarely, death in association with cardiac failures have been reported following administration of timolol.

Vascular disorders

Patients with severe peripheral circulatory disturbance/disorders (i.e. severe forms of Raynaud's disease or Raynaud's syndrome) should be treated with caution.

Respiratory disorders

Respiratory reactions, including death due to bronchospasm in patients with asthma have been reported following administration of some ophthalmic beta-blockers. Xalacom should be used with caution, in patients with mild/moderate chronic obstructive pulmonary disease (COPD) and only if the potential benefit outweighs the potential risk.

Hypoglycemia/diabetes

Beta-blockers should be administered with caution in patients subject to spontaneous hypoglycaemia or to patients with labile diabetes, as beta-blockers may mask the signs and symptoms of acute hypoglycaemia.

Beta-blockers may also mask the signs of hyperthyroidism.

Corneal diseases

Ophthalmic beta-blockers may induce dryness of eyes. Patients with corneal diseases should be treated with caution.

Other beta-blocking agents

The effect on intra-ocular pressure or the known effects of systemic beta-blockade may be potentiated when timolol is given to the patients already receiving a systemic beta-blocking agent. The response of these patients should be closely observed. The use of two topical beta-adrenergic blocking agents is not recommended (see section 4.5).

Anaphylactic reactions

While taking beta-blockers, patients with a history of atopy or a history of severe anaphylactic reaction to a variety of allergens may be more reactive to repeated challenge with such allergens and unresponsive to the usual doses of adrenaline used to treat anaphylactic reactions.

Choroidal detachment

Choroidal detachment has been reported with administration of aqueous suppressant therapy (e.g. timolol, acetazolamide) after filtration procedures.

Surgical anaesthesia

Beta-blocking ophthalmological preparations may block systemic beta-agonist effects e.g. of adrenaline. The anaesthesiologist should be informed when the patient is receiving timolol.

Concomitant therapy

Timolol may interact with other drugs see section 4.5.

Other prostaglandin analogues

The concomitant use of two or more prostaglandins, prostaglandin analogues, or prostaglandin derivatives is not recommended (see section 4.5).

Iris pigmentation changes

Latanoprost may gradually change eye colour by increasing the amount of brown pigment in the iris. Similar to experience with latanoprost eye drops, increased iris pigmentation was seen in16-20% of all patients treated with Xalacom for up to one year (based on photographs). This effect has predominantly been seen in patients with mixed coloured irides, i.e. green-brown, yellow-brown or blue/grey-brown, and is due to increased melanin content in the stromal melanocytes of the iris. Typically, the brown pigmentation around the pupil spreads concentrically towards the periphery in affected eyes, but the entire iris or parts of it may become more brownish. In patients with homogeneously blue, grey, green or brown eyes, the change has only rarely been seen during two years of treatment in clinical trials with latanoprost.

The change in iris colour occurs slowly and may not be noticeable for several months to years and it has not been associated with any symptom or pathological changes.

No further increase in brown iris pigment has been observed after discontinuation of treatment, but the resultant colour change may be permanent.

Neither naevi nor freckles of the iris have been affected by the treatment.

Accumulation of pigment in the trabecular meshwork or elsewhere in the anterior chamber has not been observed but patients should be examined regularly and, depending on the clinical situation, treatment may be stopped if increased iris pigmentation ensues.

Before treatment is instituted patients should be informed of the possibility of a change in eye colour. Unilateral treatment can result in permanent heterochromia.

Eyelid and eyelash changes

Eyelid skin darkening, which may be reversible, has been reported in association with the use of latanoprost.

Latanoprost may gradually change eyelashes and vellus hair in the treated eye; these changes include increased length, thickness, pigmentation, and number of lashes or hairs, and misdirected growth of eyelashes. Eyelash changes are reversible upon discontinuation of treatment.

Glaucoma

There is no documented experience with latanoprost in inflammatory, neovascular, or chronic angle closure glaucoma, in open angle glaucoma of pseudophakic patients and in pigmentary glaucoma. Latanoprost has no or little effect on the pupil but there is no documented experience in acute attacks of closed angle glaucoma. Therefore it is recommended that Xalacom should be used with caution in these conditions until more experience is obtained.

Herpetic keratitis

Latanoprost should be used with caution in patients with a history of herpetic keratitis, and should be avoided in cases of active herpes simplex keratitis and in patients with a history of recurrent herpetic keratitis specifically associated with prostaglandin analogues.

Macular oedema

Macular oedema, including cystoid macular oedema, has been reported during treatment with latanoprost. These reports have mainly occurred in aphakic patients, in pseudophakic patients with a torn posterior lens capsule, or in patients with known risk factors for macular oedema. Xalacom should be used with caution in these patients.

Preservative

Xalacom contains benzalkonium chloride, which is commonly used as a preservative in ophthalmic products. Benzalkonium chloride has been reported to cause punctuate keratopathy and/or toxic ulcerative keratopathy, may cause eye irritation. Close monitoring is required with frequent or prolonged use of Xalacom in dry eye patients, or in conditions where the cornea is compromised.

Contact lenses

Contact lenses may absorb benzalkonium chloride which is known to discolour soft contact lenses. Contact lenses should be removed before applying Xalacom but may be reinserted after 15 minutes (see section 4.2).

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

No specific drug interaction studies have been performed with Xalacom.

There have been reports of paradoxical elevations in intraocular pressure following the concomitant ophthalmic administration of two prostaglandin analogues. Therefore, the use of two or more prostaglandins, prostaglandin analogues, or prostaglandin derivatives is not recommended.

There is a potential for additive effects resulting in hypotension and/or marked bradycardia when ophthalmic beta-blockers solution is administered concomitantly with oral calcium channel blockers, beta-adrenergic blocking agents, antiarrhythmics (including amiodarone), digitalis glycosides, parasympathomimetics, guanethidine.

Potentiated systemic beta blockade (e.g., decreased heart rate, depression) has been reported during combined treatment with CYP2D6 inhibitors (e.g. quinidine, fluoxetine, paroxetine) and timolol.

The effect on intraocular pressure or the known effects of systemic beta-blockade may be potentiated when Xalacom is given to patients already receiving an oral beta-adrenergic blocking agent, and the use of two or more topical beta-adrenergic blocking agents is not recommended.

Mydriasis resulting from concomitant use of ophthalmic beta-blockers and adrenaline (epinephrine) has been reported occasionally.

The hypertensive reaction to sudden withdrawal of clonidine can be potentiated when taking beta-blockers.

Beta-blockers may increase the hypoglycaemic effect of anti-diabetic agents. Beta-blockers can mask the signs and symptoms of hypoglycaemia (see section 4.4).

4.6. Fertility, pregnancy and lactation

Pregnancy

Latanoprost

There are no adequate data from the use of latanoprost in pregnant women. Studies in animals have shown reproductive toxicity (see section 5.3). The potential risk for humans is unknown.

Timolol

There are no adequate data for the use of timolol in pregnant women. Timolol should not be used during pregnancy unless clearly necessary. To reduce the systemic absorption, see section 4.2.

Epidemiological studies have not revealed malformative effects but show a risk for intra uterine growth retardation when beta-blockers are administered by the oral route. In addition, signs and symptoms of beta-blockade (e.g. bradycardia, hypotension, respiratory distress and hypoglycaemia) have been observed in the neonate when beta-blockers have been administered until delivery. If Xalacom is administered until delivery, the neonate should be carefully monitored during the first days of life.

Consequently Xalacom should not be used during pregnancy (see section 5.3).

Breast‑feeding

Beta-blockers are excreted in breast milk. However, at therapeutic doses of timolol in eye drops it is not likely that sufficient amounts would be present in breast milk to produce clinical symptoms of beta-blockade in the infant. To reduce the systemic absorption, see section 4.2.

Latanoprost and its metabolites may pass into breast milk. Xalacom should therefore not be used in women who are breast-feeding.

Fertility

Neither Latanoprost nor timolol have been found to have any effect on male or female fertility in animal studies.

4.7. Effects on ability to drive and use machines

Xalacom has minor influence on the ability to drive and use machines. In common with other eye preparations, instillation of eye drops may cause transient blurring of vision. Until this has resolved, patients should not drive or use machines.

4.8. Undesirable effects

For latanoprost, the majority of adverse reactions relate to the ocular system. In data from the extension phase of the Xalacom pivotal trials, 16 - 20% of patients developed increased iris pigmentation, which may be permanent. In an open 5 year latanoprost safety study, 33% of patients developed iris pigmentation (see section 4.4). Other ocular adverse reactions are generally transient and occur on dose administration. For timolol, the most serious adverse reactions are systemic in nature, including bradycardia, arrhythmia, congestive heart failure, bronchospasm and allergic reactions.

Like other topically applied ophthalmic drugs, timolol is absorbed into the systemic circulation. This may cause similar undesirable effects as seen with systemic beta blocking agents. Incidence of systemic ADRs after topical ophthalmic administration is lower than for systemic administration. Listed adverse reactions include reactions seen within the class of ophthalmic beta-blockers.

Treatment related adverse reactions seen in clinical trials with Xalacom are listed below.

Adverse reactions are categorized by frequency as follows: very common (≥1/10), common (≥1/100 to <1/10), uncommon (≥1/1000 to <1/100), rare (≥1/10,000 to <1/1000) and very rare (<1/10,000), not known (frequency cannot be estimated from the available data).

Table 1: Adverse reactions seen in Xalacom trials

System Organ Class

Very common

(≥1/10)

Common

≥ 1/100 to < 1/10

Uncommon

≥ 1/1,000 to < 1/100

Nervous system disorders

Headache

Eye disorders

Iris hyperpigmentation

Eye pain, eye irritation (including stinging, burning, itching, foreign body sensation)

Corneal disorders, conjunctivitis, blepharitis, eye hyperaemia, vision blurred, lacrimation increased

Skin and subcutaneous tissue disorders

Rash, pruritus

Additional adverse reactions have been reported specific to the use of the individual components of Xalacom in either clinical studies, spontaneous reports or in the available literature.

For latanoprost, these are:

Table 2: Adverse Reactions for Latanoprost

System Organ Class

Adverse Reactions

Infections and infestations

Herpetic keratitis

Nervous system disorders

Dizziness

Eye disorders

Eyelash and vellus hair changes of the eyelid (increased length, thickness, pigmentation, and number of eyelashes); punctate keratitis, periorbital oedema; iritis; uveitis; macular oedema including cystoid macular oedema dry eye; keratitis; corneal oedema; corneal erosion; trichiasis; iris cyst; photophobia; periorbital and lid changes resulting in deepening of the eyelid sulcus; eyelid oedema; localised skin reaction on the eyelids; pseudopemphigoid of the ocular conjunctiva+; darkening of the palpebral skin

Cardiac disorders

Angina; angina unstable; palpitations

Respiratory, thoracic and mediastinal disorders

Asthma; asthma aggravation; dyspnoea

Gastrointestinal disorders

Nausea*; vomiting*

Musculoskeletal and connective tissue disorders

Myalgia; arthralgia

General disorders and administration site conditions

Chest pain

*Identified post marketing with an estimated frequency of uncommon

+ May be potentially related to the preservative benzalkonium chloride

For timolol, these are:

Table 3: Adverse Reactions for Timolol Maleate (ocular administration)

System Organ Class

Adverse Reactions

Immune system disorders

Systemic allergic reactions including anaphylactic reaction, angioedema, urticaria, localised and generalised rash, pruritus

Metabolism and nutrition disorders

Hypoglycaemia

Psychiatric disorders

Memory loss, insomnia, depression, nightmares, hallucinations

Nervous system disorders

Cerebrovascular accident, cerebral ischaemia, dizziness, increases in signs and symptoms of myasthenia gravis, paraesthesia, headache, syncope

Eye disorders

Choroidal detachment following filtration surgery (see section 4.4), corneal erosion, keratitis, diplopia, decreased corneal sensitivity, signs and symptoms of ocular irritation (e.g., burning, stinging, itching, tearing and redness), dry eyes, ptosis, blepharitis, blurred vision

Ear and labyrinth disorders

Tinnitus

Cardiac disorders

Cardiac arrest, cardiac failure, atrioventricular block, congestive heart failure, chest pain, arrhythmia, bradycardia, oedema, palpitations

Vascular disorders

Cold hands and feet, hypotension, Raynaud's phenomenon

Respiratory, thoracic and mediastinal disorders

Bronchospasm (predominately in patients with pre‑existing bronchospastic disease), cough, dyspnoea

Gastrointestinal disorders

Abdominal pain, vomiting, diarrhoea, dry mouth, dysgeusia, dyspepsia, nausea

Skin and subcutaneous tissue disorders

Skin rash, psoriasiform rash, exacerbation of psoriasis, alopecia

Musculoskeletal and connective tissue disorders

Myalgia

Reproductive system and breast disorders

Sexual dysfunction, decreased libido

General disorders and administration site conditions

Asthenia, fatigue

Cases of corneal calcification have been reported very rarely in association with the use of phosphate containing eye drops in some patients with significantly damaged corneas.

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

No data are available in humans with regard to overdose with Xalacom.

Symptoms

Symptoms of systemic timolol overdose are: bradycardia, hypotension, bronchospasm and cardiac arrest.

Apart from ocular irritation and conjunctival hyperaemia, no other ocular or systemic side effects are known if latanoprost is overdosed.

Treatment

If symptoms of overdose occur the treatment should be symptomatic and supportive.

If accidentally ingested orally the following information may be useful:

Studies have shown that timolol does not dialyse readily Gastric lavage if needed. Latanoprost is extensively metabolised during the first pass through the liver. Intravenous infusion of 3 micrograms/kg in healthy volunteers induced no symptoms, but a dose of 5.5-10 micrograms/kg caused nausea, abdominal pain, dizziness, fatigue, hot flushes and sweating. These events were mild to moderate in severity and resolved without treatment, within 4 hours after terminating the infusion.