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84 X 100 mg
Dosage in type 1 Gaucher disease
Adults: The recommended starting dose for the treatment of patients with type 1 Gaucher disease is 100 mg three times a day. Temporary dose reduction to 100 mg once or twice a day may be necessary in some patients because of diarrhoea.
Paediatric population: The efficacy of Miglustat in children and adolescents aged 0-17 years with type 1 Gaucher disease has not been established. No data are available.
Dosage in Niemann-Pick type C disease
Adult: The recommended dose for the treatment of adult patients with Niemann-Pick type C disease is 200 mg three times a day.
Paediatric population: The recommended dose for the treatment of adolescent patients (12 years of age and above) with Niemann-Pick type C disease is 200 mg three times a day. Dosing in patients under the age of 12 years should be adjusted on the basis of body surface area: See prescribing information for full details. Temporary dose reduction may be necessary in some patients because of diarrhoea. The benefit to the patient of treatment with Miglustat should be evaluated on a regular basis. There is limited experience with the use of Miglustat in Niemann-Pick type C disease patients under the age of 4 years.
Elderly: There is no experience with the use of Miglustat in patients over the age of 70.
Renal impairment: Pharmacokinetic data indicate increased systemic exposure to miglustat in patients with renal impairment. In patients with an adjusted creatinine clearance of 50-70 ml/min/1.73 m2, administration should commence at a dose of 100 mg twice daily in patients with type 1 Gaucher disease and at a dose of 200 mg twice daily (adjusted for body surface area in patients below the age of 12) in patients with Niemann-Pick type C disease. In patients with an adjusted creatinine clearance of 30-50 ml/min/1.73 m2, administration should commence at a dose of 100 mg once daily in patients with type 1 Gaucher disease and at a dose of 100 mg twice daily (adjusted for body surface area in patients below the age of 12) in patients with Niemann-Pick type C disease. Use in patients with severe renal impairment (creatinine clearance < 30 ml/min/1.73 m2) is not recommended .
Hepatic impairment: Miglustat has not been evaluated in patients with hepatic impairment.
Method of administration: Miglustat can be taken with or without food.
Indicated for the oral treatment of mild to moderate type 1 Gaucher disease. Miglustat may be used only in the treatment of patients for whom enzyme replacement therapy is unsuitable. Miglustat is indicated for the treatment of progressive neurological manifestations in adult patients and paediatric patients with Niemann-Pick type C disease.
Hypersensitivity to the active substance or any of the excipients.
Tremor: Approximately 37% of patients in clinical trials in type 1 Gaucher disease, and 58% of patients in a clinical trial in Niemann-Pick type C disease reported tremor on treatment. In type 1 Gaucher disease, these tremors were described as an exaggerated physiological tremor of the hands. Tremor usually began within the first month, and in many cases resolved during treatment after between 1 and 3 months. Dose reduction may ameliorate the tremor, usually within days, but discontinuation of treatment may sometimes be required.
Gastrointestinal disturbances: Gastrointestinal events, mainly diarrhoea, have been observed in more than 80% of patients, either at the outset of treatment or intermittently during treatment. The mechanism is most likely inhibition of intestinal disaccharidases such as sucrase-isomaltase in the gastrointestinal tract leading to reduced absorption of dietary disaccharides. In clinical practice, miglustat-induced gastrointestinal events have been observed to respond to individualized diet modification (for example reduction of sucrose, lactose and other carbohydrate intake), to taking Miglustat between meals, and/or to anti-diarrhoeal medicinal products such as loperamide. In some patients, temporary dose reduction may be necessary. Patients with chronic diarrhoea or other persistent gastrointestinal events that do not respond to these interventions should be investigated according to clinical practice. Miglustat has not been evaluated in patients with a history of significant gastrointestinal disease, including inflammatory bowel disease.
Effects on spermatogenesis: Male patients should maintain reliable contraceptive methods while taking Miglustat . Studies in the rat have shown that miglustat adversely affects spermatogenesis and sperm parameters, and reduces fertility. Until further information is available, before seeking to conceive, male patients should cease Miglustat and maintain reliable contraceptive methods for a further 3 months.
Special populations: Due to limited experience, Miglustat should be used with caution in patients with renal or hepatic impairment. There is a close relationship between renal function and clearance of miglustat, and exposure to miglustat is markedly increased in patients with severe renal impairment. At present, there is insufficient clinical experience in these patients to provide dosing recommendations. Use of Miglustat in patients with severe renal impairment (creatinine clearance < 30 ml/min/1.73 m2) is not recommended.
Type 1 Gaucher disease: Although no direct comparisons with Enzyme Replacement Therapy (ERT) have been performed in treatment-naive patients with type 1 Gaucher disease, there is no evidence of Miglustat having an efficacy or safety advantage over ERT. ERT is the standard of care for patients who require treatment for type 1 Gaucher disease. The efficacy and safety of Miglustat has not been specifically evaluated in patients with severe Gaucher disease. Regular monitoring of vitamin B12 level is recommended because of the high prevalence of vitamin B12 deficiency in patients with type 1 Gaucher disease. Cases of peripheral neuropathy have been reported in patients treated with Miglustat with or without concurrent conditions such as vitamin B12 deficiency and monoclonal gammopathy. Peripheral neuropathy seems to be more common in patients with type 1 Gaucher disease compared to the general population. All patients should undergo baseline and repeat neurological evaluation. In patients with type 1 Gaucher disease, monitoring of platelet counts is recommended. Mild reductions in platelet counts without association with bleeding were observed in patients with type 1 Gaucher disease who were switched from ERT to Miglustat.
Niemann-Pick type C disease: The benefit of treatment with Miglustat for neurological manifestations in patients with Niemann-Pick type C disease should be evaluated on a regular basis, e.g. every 6 months; continuation of therapy should be re-appraised after at least 1 year of treatment with Miglustat. Mild reductions in platelet counts without association to bleeding were observed in some patients with Niemann-Pick type C disease treated with Miglustat . In patients included in the clinical trial, 40%-50% of patients had platelet counts below the lower limit of normal at baseline. Monitoring of platelet counts is recommended in these patients.
Paediatric population: Reduced growth has been reported in some paediatric patients with Niemann-Pick type C disease in the early phase of treatment with miglustat where the initial reduced weight gain may be accompanied or followed by reduced height gain. Growth should be monitored in paediatric and adolescent patients during treatment with Miglustat; the benefit/risk balance should be re-assessed on an individual basis for continuation of therapy.
Diarrhea, flatulence, abdominal pain, weight loss and tremor.
See prescribing information for full details.
Limited data suggest that co-administration of Miglustat and enzyme replacement with imiglucerase in patients with type 1 Gaucher disease may result in decreased exposure to miglustat (approximate reductions of 22% in Cmax and 14% in AUC were observed in a small parallel-group study). This study also indicated that Miglustat has no or limited effect on the pharmacokinetics of imiglucerase.
Pregnancy and Lactation
Pregnancy: There are no adequate data from the use of miglustat in pregnant women. Studies in animals have shown reproductive toxicity, including dystocia. The potential risk for humans is unknown. Miglustat crosses the placenta and should not be used during pregnancy.
Lactation: It is not known if miglustat is secreted in breast milk. Miglustat should not be taken during breast-feeding.
No acute symptoms of overdose have been identified. Zavesca has been administered at doses of up to 3000 mg/day for up to six months in HIV positive patients during clinical trials. Adverse events observed included granulocytopenia, dizziness and paraesthesia. Leukopenia and neutropenia have also been observed in a similar group of patients receiving 800 mg/day or higher dose.
Management: In case of overdose general medical care is recommended.
Storage: Store below 30oC.