Finasteride 5 mg film-coated tablets

Finasteride is indicated for the treatment and control of benign prostatic hyperplasia (BPH) in patients with an enlarged prostate to:

- cause regression of the enlarged prostate, improve urinary flow and improve the symptoms associated with BPH

- reduce the incidence of acute urinary retention and reduce need for surgery including transurethral resection of the prostate (TURP) and prostatectomy.

Finasteride 5 mg tablets should only be administered in patients with an enlarged prostate (prostate volume above ca. 40 ml).

Posology

The recommended dosage is one 5 mg tablet daily with or without food.

Finasteride can be administered alone or in combination with the alpha-blocker doxazosin (see section 5.1 'Pharmacodynamic properties').

Even if improvement can be seen within a short time, treatment for at least 6 months may be necessary in order to determine objectively whether a satisfactory response to treatment has been achieved.

Dosage in the elderly

Dosage adjustments are not necessary although pharmacokinetic studies have shown that the elimination rate of finasteride is slightly decreased in patients over the age of 70.

Dosage in hepatic insufficiency

There are no data available in patients with hepatic insufficiency (See section 4.4 Special warnings and precautions for use).

Dosage in renal insufficiency

Dosage adjustments are not necessary in patients with varying degrees of renal insufficiency (with creatinine clearance down to as low as 9 ml/min) as in pharmacokinetic studies renal insufficiency was not found to affect the elimination of finasteride. Finasteride has not been studied in patients on haemodialysis.

Paediatric population

Finasteride is not intended for use in children. Safety and efficacy in children have not yet been established.

Method of administration

For oral use only.

The tablet should be swallowed whole and must not be divided or crushed (See section 6.6).

Finasteride is not indicated for use in women or children. Finasteride is contraindicated in the following:

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

• Pregnancy – Use in women when they are or may potentially be pregnant (see section 4.6 Fertility, pregnancy and lactation).

General information

- To avoid obstructive complications it is important that patients with large residual urine and/or heavily decreased urinary flow are carefully controlled. The possibility of surgery should be an option.

- Consultation with an urologist should be considered in patients treated with finasteride.

- Finasteride contains lactose monohydrate. Patients with rare hereditary problems of galactose intolerance, total lactase deficiency or glucose- galactose malabsorption should not take this medicine.

- Finasteride contains sodium. This medicine contains less than 1 mmol sodium (23 mg) per tablet, that is to say essentially 'sodium-free'.

Effects on prostate-specific antigen (PSA) and prostate cancer detection

No clinical benefit has yet been demonstrated in patients with prostate cancer treated with finasteride 5 mg. Patients with BPH and elevated serum prostate specific antigen (PSA) were monitored in controlled clinical studies with serial PSAs and prostate biopsies. In these BPH studies, finasteride 5 mg did not appear to alter the rate of prostate cancer detection and the overall incidence of prostate cancer was not significantly different in patients treated with finasteride 5 mg or placebo.

Digital rectal examination, and, if necessary, determination of prostate-specific- antigen (PSA) in serum should be carried out on patients prior to initiating therapy with finasteride 5 mg and periodically during treatment to rule out prostate cancer. Generally, when PSA assays are performed a baseline PSA >10 ng/mL (Hybritech) prompts further evaluation and consideration of biopsy; for PSA levels between 4 and 10 ng/mL, further evaluation is advisable. There is considerable overlap in PSA levels among men with and without prostate cancer. Therefore, in men with BPH, PSA values within the normal reference range do not rule out prostate cancer regardless of treatment with finasteride 5 mg. A baseline PSA <4 ng/mL does not exclude prostate cancer.

Finasteride 5 mg causes a decrease in serum PSA concentrations by approximately 50% in patients with BPH, even in the presence of prostate cancer. This decrease in serum PSA levels in patients with BPH treated with finasteride 5 mg should be considered when evaluating PSA data and does not rule out concomitant prostate cancer. This decrease is predictable over the entire range of PSA values, although it may vary in individual patients. Analysis of PSA data from over 3000 patients in the 4-year, double-blind, placebo-controlled finasteride Long-Term Efficacy and Safety Study (PLESS) confirmed that in typical patients treated with finasteride 5 mg for six months or more, PSA values should be doubled for comparison with normal ranges in untreated men. This adjustment preserves the sensitivity and specificity of the PSA assay and maintains its ability to detect prostate cancer.

Any sustained increase in PSA levels of patients treated with finasteride 5mg should be carefully evaluated, including consideration of non-compliance to finasteride 5 mg therapy.

Percent free PSA (free to total PSA ratio) is not significantly decreased by finasteride 5 mg and remains constant even under the influence of finasteride 5 mg. When percent free PSA is used as an aid in the detection of prostate cancer, no adjustment to its value is necessary.

Drug/laboratory test interactions

Effect on levels of PSA

Serum PSA concentration is correlated with patient age and prostatic volume, and prostatic volume is correlated with patient age. When PSA laboratory determinations are evaluated, consideration should be given to the fact that PSA levels decrease in patients treated with finasteride 5 mg. In most patients, a rapid decrease in PSA is seen within the first months of therapy, after which time PSA levels stabilise to a new baseline. The post-treatment baseline approximates half of the pre-treatment value. Therefore, in typical patients treated with finasteride 5 mg for six months or more, PSA values should be doubled for comparison to normal ranges in untreated men. For clinical interpretation, see 'Effects on prostate-specific antigen (PSA) and prostate cancer detection' in this section. No other difference was observed in patients treated with placebo or finasteride in standard laboratory tests.

Breast cancer in men

Breast cancer has been reported in men taking finasteride 5 mg during clinical trials and the post-marketing period. Physicians should instruct their patients to promptly report any changes in their breast tissue such as lumps, pain, gynaecomastia or nipple discharge.

Paediatric population

Finasteride 5 mg is not indicated for use in children.

Safety and effectiveness in children have not been established.

Hepatic Insufficiency

The effect of hepatic insufficiency on the pharmacokinetics of finasteride has not been studied.

Mood alterations and depression

Mood alterations including depressed mood, depression and, less frequently, suicidal ideation have been reported in patients treated with finasteride 5 mg. Patients should be monitored for psychiatric symptoms and if these occur, the patient should be advised to seek medical advice.

No drug interactions of clinical importance have been identified. Finasteride is metabolized primarily via, but does not appear to affect significantly, the cytochrome P450 3A4 system. Although the risk for finasteride to affect the pharmacokinetics of other drugs is estimated to be small, it is probable that inhibitors and inducers of cytochrome P450 3A4 will affect the plasma concentration of finasteride. However, based on established safety margins, any increase due to concomitant use of such inhibitors is unlikely to be of clinical significance. The following medicinal products have been investigated in humans and no clinically meaningful interactions have been identified: propranolol, digoxin, glibenclamide, warfarin, theophylline and phenazone.

Pregnancy

Finasteride is contraindicated for use in women when they are or may potentially be pregnant (see section 4.3).

Because of the ability of type II 5α -reductase-inhibitors to inhibit conversion of testosterone to dihydrotestosterone, these drugs, including finasteride, might cause abnormalities of the external genitalia of a male foetus when administered to a pregnant woman (see sections 5.3 and 6.6).

Exposure to finasteride - risk to male foetus

Pregnant women and women who may become pregnant should not handle crushed or broken tablets of finasteride due to the risk of absorption of finasteride through the skin and the consequent potential risk to a male foetus (see 'Pregnancy' in this section).

Finasteride tablets are coated and will prevent contact with the active ingredient during normal handling, provided that the tablets have not been broken or crushed.

Small amounts of finasteride have been recovered from the semen in subjects receiving finasteride 5 mg/day. It is not known whether a male foetus may be adversely affected if his mother is exposed to the semen of a patient being treated with finasteride. When the patient's sexual partner is or may potentially be pregnant, the patient is recommended to minimise exposure of his partner to semen.

Breastfeeding

Finasteride 5 mg tablets are not indicated for use in women. It is not known whether finasteride is excreted in breast milk.

There are no data to suggest that finasteride affects the ability to drive or use machines.

The most frequent adverse reactions are impotence and decreased libido. These adverse reactions usually occur early in the course of therapy and resolve with continued treatment in the majority of patients.

The adverse reactions reported during clinical trials and/or post-marketing use are listed in the table below.

Frequency of adverse reactions is determined as follows:

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). The frequency of adverse reactions reported during post-marketing use cannot be determined as they are derived from spontaneous reports.

In addition, the following has been reported in clinical trials and post-marketing use: male breast cancer (see 4.4 Special warnings and precautions for use).

Medical therapy of prostatic symptoms (MTOPS)

The MTOPS study compared finasteride 5 mg/day (n=768), doxazosin 4 or 8 mg/day (n=756), combination therapy of finasteride 5 mg/day and doxazosin 4 or 8 mg/day (n=786), and placebo (n=737). In this study, the safety and tolerability profile of the combination therapy was generally consistent with the profiles of the individual components.

Combination therapy with doxazosin

The following adverse reactions were observed more frequently when finasteride was used concomitantly with the alpha-receptor antagonist doxazosin: Asthenia (16.8% (Placebo 7.1%), postural hypotension (17.8% (Placebo 8.0%), dizziness/vertigo 23.2% (Placebo 8.1%), and ejaculation disorders (14.1%/Placebo 2.3%).

Laboratory test findings:

When PSA laboratory determinations are evaluated, consideration should be given to the fact that PSA levels generally decrease in patients treated with finasteride (see section 4.4 Drug/laboratory test interactions).

Other Long-Term Data

In a 7-year placebo-controlled trial that enrolled 18,882 healthy men, of whom 9060 had prostate needle biopsy data available for analysis, prostate cancer was detected in 803 (18.4%) of men receiving finasteride and in 1147 (24.4%) men receiving placebo. In the finasteride group, 280 (6.4%) men had prostate cancer with Gleason scores of 7-10 detected on needle biopsy vs. 237 (5.1%) men in the placebo group. Additional analyses suggest that the increase in the prevalence of high-grade prostate cancer observed in the finasteride group may be explained by a detection bias due to the effect of finasteride on prostate volume. Of the total cases of prostate cancer diagnosed in this study, approximately 98% were classified as intracapsular (clinical stage T1 or T2) at diagnosis. The clinical significance of the Gleason 7-10 data is unknown.

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

Patients have taken single doses of finasteride up to 400 mg and multiple doses of up to 80 mg daily for 3 months without experiencing any adverse effects. No specific treatment in connection with overdosing of finasteride can be recommended.

Pharmacotherapeutic group: Testosterone-5α -reductase-inhibitors ATC-Code: G04CB 01

Mechanism of action

Finasteride is a synthetic 4-azasteroid, a specific competitive inhibitor of the intracellular enzyme Type-II-5α -reductase. The enzyme converts testosterone into the more potent androgen dihydrotestosterone (DHT). The prostate gland and, consequently, also the hyperplasic prostate tissue are dependent on the conversion of testosterone to DHT for their normal function and growth. Finasteride has no affinity for the androgen receptor.

Clinical efficacy and safety

Clinical studies show a rapid reduction of the serum DHT levels of 70%, which leads to a reduction of prostate volume. After 3 months, a reduction of approx. 20% in the volume of the gland occurs, and the shrinking continues and reaches approx. 27% after 3 years. Marked reduction takes place in the periurethral zone immediately surrounding the urethra. Urodynamic measurements have also confirmed a significant reduction of detrusor pressure as a result of the reduced obstruction.

Significant improvements in maximum urinary flow rate and symptoms have been obtained after a couple of weeks, compared with the start of treatment. Differences from placebo have been documented at 4 and 7 months, respectively.

All efficacy parameters have been maintained over a 3 year follow-up period.

Effects of four years treatment with finasteride on incidence of acute urine retention, need for surgery, symptom score and prostate volume:

In clinical studies of patients with moderate to severe symptoms of BPH, an enlarged prostate on digital rectal examination and low residual urinary volumes, finasteride reduced the incidence of acute retention of urine from 7/100 to 3/100 over four years and the need for surgery (TURP or prostatectomy) from 10/100 to 5/100. These reductions were associated with a 2 point improvement in QUASI-AUA symptom score (range 0-34), a sustained regression in prostate volume of approximately 20% and a sustained increase in urinary flow rate.

Medical therapy of prostatic symptoms

The Medical Therapy of Prostatic Symptoms (MTOPS) Trial was a 4- to 6-year study in 3047 men with symptomatic BPH who were randomised to receive finasteride 5 mg/day, doxazosin 4 or 8 mg/day*, the combination of finasteride 5 mg/day and doxazosin 4 or 8 mg/day*, or placebo. The primary endpoint was time to clinical progression of BPH, defined as a ³ 4 point confirmed increase from baseline in symptom score, acute urinary retention, BPH-related renal insufficiency, recurrent urinary tract infections or urosepsis, or incontinence. Compared to placebo, treatment with finasteride, doxazosin, or combination therapy resulted in a significant reduction in the risk of clinical progression of BPH by 34(p=0.002), 39 (p<0.001), and 67% (p<0.001), respectively. The majority of the events (274 out of 351) that constituted BPH progression were confirmed ³ 4 point increases in symptom score; the risk of symptom score progression was reduced by 30 (95% CI 6 to 48%), 46 (95% CI 25 to 60%), and 64% (95% CI 48 to 75%) in the finasteride, doxazosin, and combination groups, respectively, compared to placebo. Acute urinary retention accounted for 41 of the 351 events of BPH progression; the risk of developing acute urinary retention was reduced by 67( p=0.011), 31 (p=0.296), and 79% (p=0.001) in the finasteride, doxazosin, and combination groups, respectively, compared to placebo. Only the finasteride and combination therapy groups were significantly different from placebo.

* Titrated from 1 mg to 4 or 8 mg as tolerated over a 3-week period

In this study the safety and tolerability profile of combined treatment was broadly similar to the profile of each of the drugs taken separately. However, undesirable effects concerning the "nervous system" and "uro-genital system" organ classes were observed more frequently when the two drugs were used in combination (see section 4.8).

Absorption

The oral bioavailability of finasteride is approximately 80%. Peak plasma concentrations are reached approx. 2 hours after administration, and absorption is complete after 6-8 hours. Bioavailability is not affected by food.

Distribution

Binding to plasma proteins is approximately 93%. Clearance and volume of distribution are approximately 165 ml/min (70-279 ml/min) and 76 l (44-96 l), respectively. Accumulation of small amounts of finasteride is seen on repeated administration. After a daily dose of 5 mg, finasteride plasma concentrations of about 8-10 ng/mL were achieved and remained stable over time.

Finasteride was found in the liquor of men who were treated with finasteride for 7-10 days, but the substance appears not to be concentrated preferentially in the liquor. Finasteride has also been found in the semen of men who received finasteride 5 mg per day.

Biotransformation

Finasteride is oxidatively metabolized in the liver. After oral administration of a dose of finasteride to men, two metabolites of finasteride were identified which have only a small part of the 5α -reductase-inhibitory activity of finasteride.

Elimination

The average plasma elimination half life is a mean of 6 hours (4-12 hours).The plasma clearance is approximately 165 ml/min. After oral administration of finasteride to men, 39% of the dose was excreted in the urine in the form of metabolites, while 57% of the total dose was excreted in the faeces. Virtually no unchanged drug was excreted in the urine.

The elimination rate is slightly reduced in the elderly. With increasing age, the half- life increases from an average of six hours for men aged 18-60 to eight hours for men over 70. This finding has no clinical significance and therefore dose reduction is not necessary.

Renal impairment

No dose adjustment is necessary in patients with renal insufficiency. In patients with chronic renal impairment (creatinine clearance of 9-55 ml / min), AUC, maximum plasma concentrations, half-life and protein binding of unchanged finasteride after a single dose of 14C-finasteride were consistent with those found in healthy volunteers. In patients with renal impairment, the excretion of metabolites via the kidneys was reduced. This reduction was accompanied by an increased excretion of metabolites in the faeces. The plasma concentration of metabolites was significantly higher in patients with renal impairment (based on a 60% increase in total radioactivity AUC). However, finasteride is well tolerated by BPH patients with normal renal function who received up to 80 mg / day for 12 weeks, with the exposure of these patients to metabolites likely to be much greater. In patients with renal insufficiency who are not on dialysis, it is therefore not necessary to adjust the dosage because the therapeutic width of finasteride is sufficient and because a correlation between creatinine clearance and accumulation was not demonstrable.

Non-clinical data reveal no special hazard for humans based on conventional studies of repeated dose toxicity, genotoxicity, and carcinogenic potential.

Reproduction toxicology studies in male rats have demonstrated reduced prostate and seminal vesicular weights, reduced secretion from accessory genital glands and reduced fertility index (caused by the primary pharmacological effect of finasteride). The clinical relevance of these findings is unclear.

As with other 5-alpha-reductase inhibitors, femininisation of male rat fetuses has been seen with administration of finasteride in the gestation period. Intravenous administration of finasteride to pregnant rhesus monkeys at doses up to 800 ng/day during the entire period of embryonic and foetal development resulted in no abnormalities in male fetuses. This dose is about 60 to120 times higher than the estimated amount in semen of a man who have taken 5 mg finasteride, and to which a woman could be exposed via semen. In confirmation of the relevance of the Rhesus model for human foetal development, oral administration of finasteride 2 mg/kg/day (the systemic exposure (AUC) of monkeys was slightly higher (3x) than that of men who have taken 5 mg finasteride, or approximately 1 to 2 million times the estimated amount of finasteride in semen) to pregnant monkeys resulted in external genital abnormalities in male fetuses. No other abnormalities were observed in male fetuses and no finasteride-related abnormalities were observed in female fetuses at any dose.

Tablet core:

Lactose monohydrate

Microcrystalline cellulose

Starch pregelatinized

Sodium starch glycolate

Docusate Sodium

Magnesium Stearate

Film -Coating:

Hypromellose (E464)

Titanium dioxide (E171)

Indigo carmine aluminium lake (E132)

Talc

Iron oxide yellow (E172)

Not applicable.

3 years

This medicinal product does not require any special storage conditions.

Blister Pack: Aluminium-PVC/PE/PVDC

Pack sizes 15, 28, 30, 50, 90, 98 or 100 film-coated tablets.

Not all pack sizes may be marketed.

Women who are pregnant or may become pregnant should not handle finasteride tablets especially if crushed or broken because of the possibility of absorption of finasteride and the subsequent potential risk to a male foetus (see section 4.6 Fertility, pregnancy and lactation).

Any unused medicinal product or waste material should be disposed of in accordance with local requirements.