1. Name Of The Medicinal Product
Prialt 100 micrograms/ml solution for infusion
2. Qualitative And Quantitative Composition
One ml solution contains 100 μg ziconotide (as acetate).
1 ml vial: Each vial contains 100 μg ziconotide (as acetate).
5 ml vial: Each vial contains 500 μg ziconotide (as acetate).
For a full list of excipients, see section 6.1.
3. Pharmaceutical Form
Solution for infusion. Clear, colourless solution, free of visible particles.
4. Clinical Particulars
4.1 Therapeutic Indications
Ziconotide is indicated for the treatment of severe, chronic pain in adults who require intrathecal (IT) analgesia.
4.2 Posology And Method Of Administration
Treatment with ziconotide should only be undertaken by physicians experienced in intrathecal (IT) administration of medicinal products.
Adults (including the elderly
Dosing of ziconotide should be initiated at 2.4 μg/day and titrated on an individual patient basis according to the patient's analgesic response and adverse reactions. Patients should be titrated in dose increments of
Ziconotide must be administered as a continuous infusion via an intrathecal catheter, using an external or internally implanted mechanical infusion pump capable of delivering an accurate infusion volume. As the risk of meningitis secondary to prolonged catheterisation of the intrathecal space is greater with an external catheter infusion system, internal systems are recommended to administer ziconotide for prolonged periods. An external catheter system should only be used when an internal system cannot be implanted.
When low doses of ziconotide are required, for example when initiating titration, ziconotide must be diluted before use with preservative-free sodium chloride 9 mg/ml (0.9%) solution for injection. (see section 6.6).
Use in paediatric patients (< 18 years of age)
Prialt is not recommended for use in children below 18 years due to a lack of data on safety and efficacy. There is no experience in children.
Use in patients with impaired hepatic function
Studies have not been conducted in patients with impaired hepatic function. Caution should be exercised when ziconotide is administered to patients with impaired hepatic function.
Use in patients with impaired renal function
Studies have not been conducted in patients with impaired renal function. Caution should be exercised when ziconotide is administered to patients with impaired renal function.
Prialt is for intrathecal use only.
For instructions for use and handling, see section 6.6.
4.3 Contraindications
Hypersensitivity to the active substance or to any of the excipients.
Ziconotide is contraindicated in combination with IT chemotherapy (see section 4.5).
4.4 Special Warnings And Precautions For Use
Long-term use
Although ziconotide has been studied in long-term, open label efficacy and safety clinical trials, controlled studies of longer than 3 weeks duration have not been conducted (see section 5.1). Possible long-term local toxic effects on the spinal cord have not been excluded and preclinical data in this respect are limited (see section 5.3). Therefore, caution is needed during long-term treatment.
Route of administration
The administration of medicinal products by the intrathecal (IT) route carries the risk of potentially serious infections, such as meningitis, which may be life threatening. Meningitis due to the entrance of organisms along the catheter track or inadvertent contamination of the infusion system is a known complication of intrathecal medicinal product administration, especially with external systems.
Patients and physicians must be vigilant for typical symptoms and signs of meningitis.
The optimal intrathecal placement of the catheter tip has not been established. Lower catheter tip placement, e.g. at the lumbar level, may reduce the incidence of ziconotide-related neurological adverse reactions. Therefore, catheter tip placement should be carefully considered to allow adequate access to spinal nociceptive segments whilst minimising medicinal product concentrations at cerebral levels.
Only a small number of patients have received systemic chemotherapy and IT ziconotide. Caution should be exercised when ziconotide is administered to patients who are receiving systemic chemotherapy (see section 4.5).
Elevations in creatine kinase
Elevations in creatine kinase, which are usually asymptomatic, are common amongst patients on intrathecal ziconotide. Progressive elevation of the creatine kinase is uncommon. However monitoring of creatine kinase is recommended. In the event of progressive elevation, or clinically significant elevation in association with clinical features of myopathy or rhabdomyolysis, discontinuation of ziconotide should be considered.
Hypersensitivity reactions
Hypersensitivity reactions including anaphylaxis have not been observed during clinical trials and the immunogenicity of ziconotide administered by the IT route appears to be low. However, the potential for severe allergic reactions cannot be excluded.
Cognitive and neuropsychiatric adverse reactions
Cognitive and neuropsychiatric adverse reactions, particularly confusion, are common in patients treated with ziconotide. Cognitive impairment typically appears after several weeks of treatment. Episodes of acute psychiatric disturbances, such as hallucinations, paranoid reactions, hostility, aggressiveness, delirium, psychosis and manic reactions have been reported in patients treated with ziconotide. The ziconotide dose should be reduced or discontinued if signs or symptoms of cognitive impairment or neuropsychiatric adverse reactions develop, but other contributing causes should also be considered. The cognitive effects of ziconotide are typically reversible within 1 - 4 weeks after discontinuation of the medicinal product, but may persist in some cases.
In patients with severe chronic pain there is a higher incidence of suicide and suicide attempts than in the general population. Ziconotide may cause or worsen depression with the risk of suicide in susceptible patients.
Depression of Central Nervous System
Patients have experienced depressed levels of consciousness while receiving ziconotide. The patient usually remains conscious and breathing is not depressed. The event may be self limited, but ziconotide should be discontinued until the event resolves. The re-introduction of ziconotide is not recommended in these patients. Withdrawal of concomitant Central Nervous System (CNS) depressant medicinal products should also be considered as they may contribute to the reduced level of arousal.
4.5 Interaction With Other Medicinal Products And Other Forms Of Interaction
Specific clinical medicinal product interaction studies have not been conducted with ziconotide. However, low plasma ziconotide concentrations, metabolism by ubiquitous peptidases and relatively low plasma protein binding (see section 5.2) make metabolic-based interactions or plasma protein displacement type interactions between ziconotide and other medicinal products unlikely.
No clinical data are available on the interaction between IT chemotherapy and IT ziconotide. Ziconotide is contraindicated in combination with IT chemotherapy (see section 4.3).
Only a small number of patients have received systemic chemotherapy and IT ziconotide. Caution should be exercised when ziconotide is administered to patients who are receiving systemic chemotherapy (see section 4.4).
Medicinal products that affect specific peptidases/proteases would not be expected to impact upon ziconotide plasma exposure. Based on very limited clinical investigations, both angiotensin converting enzyme inhibitors (e.g., benazepril, lisinopril and moexipril) and HIV protease inhibitors (e.g., ritonavir, saquinavir, indinavir), have no readily apparent effect on plasma ziconotide exposure.
Ziconotide does not interact with opiate receptors. If discontinuing opiates when initiating ziconotide therapy, opiate withdrawal should be gradual. For patients being withdrawn from IT opiates, the IT opiate infusion dose should be gradually tapered over a few weeks and replaced with a pharmacologically equivalent dose of oral opiates. Adding IT ziconotide to stable doses of IT morphine (see section 5.1), is possible but requires special attention, as a high rate of neuropsychiatric adverse reactions (confusion/thinking abnormal, paranoid reactions and hallucinations, and abnormal gait), some of them serious, was observed in Study 202 despite a low dose of ziconotide. Vomiting and anorexia, and peripheral oedema were also observed when IT ziconotide was added to IT morphine. The addition of IT morphine to stable doses of IT ziconotide is better tolerated (pruritis has been reported). (See section 5.1).
An increased incidence of somnolence has been observed when ziconotide is administered concomitantly with systemic baclofen, clonidine, bupivacaine or propofol thus for the time being their simultaneous use is discouraged.
No data are available regarding the concomitant use of partial opioid agonists (e.g. buprenorphine) with ziconotide.
4.6 Pregnancy And Lactation
There are no adequate data from the use of ziconotide in pregnant women. Studies in animals have shown reproductive toxicity (see section 5.3). The potential risk for humans is unknown. Ziconotide should not be used during pregnancy unless clearly necessary.
It is not known whether ziconotide is excreted in breast milk, therefore it should not be administered to breast-feeding women unless clearly necessary.
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.
Ziconotide may cause confusion, somnolence and other neurological adverse reactions, therefore patients must be advised not to drive or operate machines if affected.
4.8 Undesirable Effects
The safety of ziconotide administered as a continuous intrathecal infusion has been evaluated in more than 1,400 patients participating in acute and chronic pain clinical trials. The duration of treatment has ranged from one-hour bolus infusion to continuous use for more than 6 years. The median exposure time was 43 days. The infusion dose rate ranged from 0.03 - 912 μg/day, with a median final dose rate of 7.2 μg/day.
In clinical trials, 88% of patients experienced adverse drug reactions (ADRs). The most commonly reported ADRs reported in long-term clinical trials were dizziness (42%), nausea (30%), nystagmus (23%), confusional state (25%), gait abnormal (16%), memory impairment (13%), vision blurred (14%) headache (12%), asthenia (13%), and vomiting (11%) and somnolence (10%). Most ADRs were mild to moderate in severity and resolved over time.
All ADRs reported in the intrathecal clinical trials with ziconotide (short- and long-term exposure) are listed below in order of frequency.
Very Common (
Common (
Uncommon (
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Psychiatric disorders | |
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General disorders and administration site conditions | |
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Investigations | |
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Specific comments and particular caution regarding meningitis, elevations of creatine kinase, and CNS adverse events can be found in Section 4.4
4.9 Overdose
In intravenous infusion studies, healthy male volunteers received ziconotide at doses of up to 70,000 μg/day or 3,200 times the maximum recommended daily intrathecal infusion dose. Postural hypotension was observed in almost all subjects who received high intravenous doses of ziconotide.
The maximum recommended intrathecal dose is 21.6 μg/day. The maximum intended intrathecal dose of ziconotide in clinical trials was 912 μg/day following upward titration over 7 days.
In one clinical study a male cancer patient received an accidental IT ziconotide overdose of 744 μg over a 24-hour period (31 μg/hour) and resumed treatment at the intended dose after experiencing a reduction in Visual Analog Scale of Pain Intensity (VASPI) from 82 to 2.5 mm. In some patients who received intrathecal doses greater than the maximum recommended dose, exaggerated pharmacological effects, e.g., ataxia, nystagmus, dizziness, stupor, depressed level of consciousness, muscle spasms, confusional state, sedation, hypotension, aphasia, speech disorder, nausea and vomiting were observed. There was no indication of respiratory depression. Most patients under observation recovered within 24 hours of withdrawal of the medicinal product.
General medical supportive measures should be administered to patients who receive an overdose until the exaggerated pharmacological effects of the medicinal product have resolved.
5. Pharmacological Properties
5.1 Pharmacodynamic Properties
Pharmacotherapeutic group: Analgesics; Other analgesics and antipyretics ATC code: N02BG08
This medicinal product has been authorised under “Exceptional Circumstances”. This means that due to the rarity of the disease it has not been possible to obtain complete information on this medicinal product. The European Medicines Agency will review any new information, which may become available every year and this SmPC will be updated as necessary.
Ziconotide is a synthetic analogue of a ω-conopeptide, MVIIA, found in the venom of the Conus magus marine snail. It is an N-type calcium channel blocker (NCCB). NCCs regulate neurotransmitter release in specific neuronal populations responsible for the spinal processing of pain. In binding to these neuronal NCCs ziconotide inhibits the voltage sensitive calcium current into primary nociceptive afferents terminating in the superficial layers of the dorsal horn of the spinal cord. In turn, this inhibits their release of neurotransmitters (including Substance P) and therefore, the spinal signalling of pain.
Though statistically significant relationships and reasonable correlation between cerebrospinal fluid (CSF) exposure (AUC, Cmax) and clinical response measures have been observed following 1 hour IT administration, no well-defined dose-concentration-response relationships have yet been identified. Many responsive patients obtain near-maximal analgesia within a few hours of delivery of an appropriate dose. However, maximal effects may be delayed for approximately 24 hours in some patients. Given the occurrence of analgesia and adverse drug reactions at similar doses, the recommended interval between dose increases is 48 hours or more. If necessary the dose can be decreased by any amount (including stopping the infusion) for the management of adverse drug reactions.
Nervous system adverse reactions, particularly dizziness, nausea and abnormal gait appear to be correlated with CSF exposure, though a definitive relationship has not been established.
Low plasma exposure occurs during IT infusion due to the low recommended IT infusion rates and relatively rapid plasma clearance (see section 5.2). Therefore, pharmacological effects related to systemic exposure should be minimal.
The median dose at response is approximately 6.0 μg/day and approximately 75% of responsive patients require
There is no evidence of the development of pharmacological tolerance to ziconotide in patients. However, in view of limited data, the development of tolerance cannot be excluded. Examination of the patency of the intrathecal catheter should be considered if the required ziconotide dose continually increases and there is no benefit or increase in drug reactions.
There were three placebo-controlled clinical trials of IT ziconotide.
Two short-term studies, 95-001 (malignant pain) and 96-002 (non malignant pain), involving 366 patients, demonstrated the efficacy of IT ziconotide in severe chronic pain using the percent change in Visual Analog Scale of Pain Intensity (VASPI) as the primary efficacy measure. These studies were of short duration, 5 and 6 days respectively, and used a more rapid dose escalation and higher doses than recommended in Section 4.2.
Efficacy results from study 95-001
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aResponders were defined as those patients who 1) experienced a
SD – Standard Deviation.
Efficacy results from study 96-002
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aResponders were defined as those patients who 1) experienced a
b164 patients provided VASPI scores for ziconotide at the end of titration.
SD – Standard Deviation.
The aetiologies of pain in studies 95-001 (malignant pain) and 96-002 (non-malignant pain) were varied and included bone pain (n = 38) mostly due to bone metastases (n = 34), myelopathy (n = 38), half of whom had spinal cord injury with paralysis (n = 19), neuropathy (n = 79), radiculopathy (n = 24), spinal pain (n = 91) mostly due to failed back surgery (n = 82), and other aetiologies (n = 82). Some patients had more than one cause of pain. The efficacy of IT ziconotide was apparent in all groups.
Study 301 (n = 220) was of longer duration (21 days), involved more cautious up-titration and lower doses of IT ziconotide, and enrolled the most refractory population of patients studied in the three studies. All patients in the 301 study had failed IT therapy with combinations of analgesics and their physicians considered that 97% of the patients were refractory to currently available treatments. The majority had spinal pain (n = 134), especially failed back surgery (n = 110); a lower proportion had neuropathy (n = 36). Only five had malignant pain. The primary endpoint was the percent change in VASPI score. The efficacy of IT ziconotide in study 301 was lower than in the previous two, short-term studies. The frequency and severity of adverse events were also lower.
Efficacy results from study 301
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aResponders were defined as those who experienced a
SD – Standard Deviation.
Combination studies with IT Morphine
Clinical studies 201 and 202 indicate that the combination of IT ziconotide and IT morphine may effectively reduce pain and decrease systemic opioid use over a sustained period of time for patients whose pain was inadequately controlled with their maximum tolerated dose of IT ziconotide (median 8.7 μg/day, mean 25.7 μg/day – study 201) or with IT morphine (study 202) alone. When adding IT ziconotide to stable doses of IT morphine, as with the initiation of IT ziconotide monotherapy, the appearance of psychotic adverse events (e.g., hallucinations, paranoid reactions) or discontinuation due to increased adverse events may occur. (see section 4.5).
5.2 Pharmacokinetic Properties
The CSF pharmacokinetics of ziconotide have been studied following one-hour IT infusions of 1 - 10 μg of ziconotide in patients with chronic pain. The plasma pharmacokinetics following intravenous doses (0.3 – 10 μg/kg/24 hr) were also studied. IT and intravenous pharmacokinetics data are summarised below.
CSF and Plasma Pharmacokinetics of Ziconotide [mean ± SD (median)]
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CL = clearance; Vd = distribution volume; t½ = half life
Absorption: Following one-hour IT administration (1 – 10 μg), both cumulative exposure (AUC; range: 83.6 – 608 ng/h/ml) and peak exposure (Cmax; range: 16.4 – 132 ng/ml) values were variable and dose-dependent, but appeared only approximately dose-proportional. Plasma concentrations following continuous (
Distribution: Median ziconotide CSF volume of distribution (Vd: 99 ml) is between the spinal cord CSF volume (approximately 75 ml) and total CSF volume (approximately 130 ml). Ziconotide appears to distribute mainly within the CSF until transferred to the systemic circulation. Upon reaching the systemic circulation, ziconotide appears to be more extensively distributed, based on a plasma distribution volume of approximately 30 l and is only about 53% bound (non-specifically) to human plasma proteins.
Biotransformation: Ziconotide is a peptide consisting of 25 naturally-occurring amino acids of the L-configuration, and does not appear to be appreciably metabolised in the CSF. Following passage into the systemic circulation, ziconotide is expected to be primarily susceptible to proteolytic cleavage by various ubiquitous peptidases/proteases present in most organs (e.g., kidney, liver, lung, muscle, etc.), and thus degraded to peptide fragments and its individual constituent free amino acids. The generated free amino acids are expected to be taken up by cellular carrier systems and either subjected to normal intermediary metabolism or used as substrates for constitutive biosynthetic processes. Due to the wide distribution of these peptidases it is not expected that hepatic or renal impairment would affect the systemic clearance of ziconotide. The biological activity of the various expected proteolytic degradation products has not been assessed. It is unlikely that the degradation products of ziconotide will have significant biological activity, as peptides consisting of the individual peptide loop structures have been found to have binding affinities for N-type voltage sensitive calcium channels that are several orders of magnitude lower than that of the parent (ziconotide) compound.
Elimination: Mean ziconotide CL (0.38 ml/min) approximates adult human CSF turnover rate (0.3 - 0.4 ml/min). Hence, ziconotide appears to be mainly eliminated from the CSF (mean t½ = 4.6 hr) by bulk flow of CSF out of the CNS through the arachnoid villi with subsequent transfer into the systemic circulation. Very low circulating plasma concentrations of ziconotide may be observed following IT administration due to both the low IT infusion rate and relatively rapid plasma clearance. The mean plasma elimination half-life (t½) is 1.3 hr. Ziconotide is a relatively small molecular weight peptide (MW = 2,639) and is filtered by the kidney glomerulus, but only minimal amounts of ziconotide (< 1%) are recovered in human urine following intravenous infusion. This is because almost all of the filtered active substance is rapidly endocytosed and ultimately transported back to the systemic circulation.
Specific populations: Although only limited data are available, there is no obvious effect of race, height, weight, gender or age on CSF ziconotide exposure after IT administration. No formal studies assessing the impact of renal or hepatic dysfunction have been conducted; however, given that peptidases are present in various body organs, it is not anticipated that renal or hepatic dysfunction will significantly impact systemic exposure of ziconotide.
5.3 Preclinical Safety Data
Preclinical toxic effects related to ziconotide administration were observed only at exposures considered sufficiently in excess of the human exposure to indicate little risk in clinical use.
In subchronic continuous intrathecal infusion studies in rats and dogs, behavioural effects were seen at doses
The long-term consequences to neuronal function of continuous N-type calcium-channel block have not been demonstrated in experimental animals. Changes in neurological signalling have not been studied in experimental animals. Ziconotide did not induce bacterial gene mutation and was not genotoxic. Chronic animal studies have not been performed to assess the carcinogenic potential of ziconotide. However, ziconotide did not induce cell transformation in the in vitro Syrian hamster embryo (SHE) assay and did not increase cell proliferation (pre-neoplastic lesion formation) or apoptosis after subchronic intrathecal exposure in dogs.
In rat fertility studies, there were no effects in males while reductions in corpora lutea; implantation sites and number of live embryos were observed in females. No adverse effects on female reproduction and post-natal development in rats were seen at systemic exposures up to 2,300 times human exposures at the maximum recommended intrathecal dose.
Ziconotide was not teratogenic in rats and rabbits at exposures < 100 times human plasma levels.
These results do not indicate a significant risk to humans due to the relatively high systemic exposures needed to elicit these effects in rats and rabbits.
6. Pharmaceutical Particulars
6.1 List Of Excipients
Methionine
Sodium chloride
Water for injections
Hydrochloric acid (pH adjuster)
Sodium hydroxide (pH adjuster)
6.2 Incompatibilities
This medicinal product must not be mixed with other medicinal products except those mentioned in section 6.6.
6.3 Shelf Life
3 years
Chemical and physical in use stability has been demonstrated for 60 days at 37°C.
From a m
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