Prophylaxis of angina pectoris alone or in combination with other anti-anginal therapy.

Posology

Adults

Treatment should be initiated with one patch daily. If necessary, the dosage may be increased to two patches. The maximum daily dose is 20 mg, any increases or decreases in dose should be made gradually.

Elderly population

No specific information on use in the elderly is available, however there is no evidence to suggest that an alteration in dose is required.

Paediatric population

The safety and efficacy of this Deponit patch in children has not yet been established.

Method of administration

Dermal

It is recommended that the patch is applied to healthy, undamaged, relatively crease free and hairless skin. The best places to apply Deponit patches are the easily reached, fairly static areas at the front or side of the chest. However, Deponit patches may also be applied to the upper arm, thigh, abdomen or shoulder. Skin care products should not be used before applying the patch. The replacement patch should be applied to a new area of skin. Allow several days to elapse before applying a fresh patch to the same area of skin.

Tolerance may occur during chronic nitrate therapy. To avoid development of tolerance, the GTN patch should remain on the skin only for about 12-14 hours, to ensure a nitrate free interval of 10-12 hours. Additional anti-anginal therapy with drugs not containing nitro compounds should be considered for the nitrate-free interval if required.

As with any nitrate therapy, treatment with these patches should not be stopped abruptly. If the patient is being changed to another type of treatment, the two should overlap.

• Hypersensitivity to the active substance, to other nitro compounds or to any of the excipients listed in section 6.1

• Raised intracranial pressure including that caused by head trauma or cerebral haemorrhage

• Acute circulatory failure associated with marked hypotension (shock).

• Myocardial insufficiency due to obstruction, as in aortic or mitral stenosis or constrictive pericarditis.

• Marked anaemia

• Closed angle glaucoma

• Severe Hypotensive conditions (systolic blood pressure less than 90mmHg)

• Severe hypovolaemia

• Hypertrophic obstructive cardiomyopathy

• Aortic stenosis and mitral stenosis

• Constrictive pericarditis

• Cardiac tamponade

• Concomitant use of phosphodiesterase type-5 inhibitors. Phosphodiesterase type-5 inhibitors (e.g. sildenafil, tadalafil, vardenafil) have been shown to potentiate the hypotensive effects of nitrates, and their co-administration with nitrates or nitric oxide donors is therefore contra-indicated.

• During nitrate therapy, the soluble guanylate cyclase stimulator riociguat must not be used (see section 4.5).

Warnings:

In cases of recent myocardial infarction or acute heart failure, treatment with the preparation should be carried out cautiously under strict medical surveillance and/or haemodynamic monitoring.

Removal of the patch should be considered as part of the management of patients who develop significant hypotension.

Precautions:

This patch should be used with caution in patients with

• Severe hepatic or renal impairment

• Hypothyroidism

• Hypothermia

• Malnutrition

• A recent history of myocardial infarction

• Hypoxaemia or a ventilation/perfusion imbalance due to lung disease or ischaemic heart failure.

• Arterial Hypoxaemia due to severe anaemia (including G6PD deficiency induced forms), because in such patients the biotransformation of nitroglycerin is reduced.

• Alveolar hypoventilation a vasoconstriction occurs within the lung to shift perfusion from areas of alveolar hypoxia to better ventilated regions of the lung (Euler– Liljestrand mechanism).

• Angina pectoris, myocardial infarction, or cerebral ischaemia frequently suffer from abnormalities of the small airways (especially alveolar hypoxia).Under these circumstances vasoconstriction occurs within the lung to shift perfusion from areas of alveolar hypoxia to better ventilated regions of the lung. As a potent vasodilator, nitroglycerin could reverse this protective vasoconstriction and thus result in increased perfusion of poorly ventilated areas, worsening of the ventilation/perfusion imbalance, and a further decrease in the arterial partial pressure of oxygen.

• Methemoglobinemia

Following treatment with GTN, methemoglobinemia has been reported. Treatment of methaemoglobinemia with methylene blue is contraindicated in patients with glucose-6-phosphate deficiency or methemoglobin-reductase deficiency (see also section 4.9).

The patch is not indicated for use in acute angina attacks. In the event of an acute angina attack, sublingual treatment such as a spray or tablet should be used.

As with all nitrate preparations withdrawal of long-term treatment should be gradual by replacement with decreasing doses of long acting oral nitrates.

Also when transferring the patient on long-term therapy to another form of medication, nitroglycerin should be gradually withdrawn and overlapping treatment started.

If the patches are not used as indicated (see Section 4.2) tolerance to the medication could develop.

Patients should be warned not to discontinue or interrupt GTN patch therapy in order to use phosphodiesterase inhibitor-containing products (e. g. sildenafil, vardenafil, tadalafil).

During treatment with GTN alcohol should be avoided as it may potentiate the hypotensive and vasodilating effect of GTN (see section 4.5).

Concomitant treatment with other vasodilators (e.g. phosphodiesterase inhibitors such as sildenafil, vardenafil, tadalafil), calcium channel antagonists, ACE-inhibitors, monoamine oxidase inhibitors, beta-blockers, diuretics, antihypertensives, tricyclic antidepressants and major tranquillisers, as well as the consumption of alcohol, may potentiate the hypotensive effect of the preparation.

The blood pressure lowering effect of these patches will be increased if used together with phosphodiesterase inhibitors (e.g. sildenafil, vardenafil, tadalafil) which are used for erectile dysfunction (see Section 4.3). This might lead to life threatening cardiovascular complications. Patients who have recently taken phosphodiesterase inhibitors (e.g. sildenafil, vardenafil, tadalafil) therefore must not be treated with GTN. Patients who are on nitrate patch therapy therefore must not use phosphodiesterase inhibitors (e.g. sildenafil, vardenafil, tadalafil).

The use of GTN with riociguat, a soluble guanylate cyclase stimulator, is contraindicated (see section 4.3) since concomitant use can cause hypotension.

If administered concurrently, these patches may increase the blood level of dihydroergotamine and lead to coronary vasoconstriction.

The possibility that ingestion of non-steroidal anti-inflammatory drugs except Acetyl Salicylic acid might diminish the therapeutic response to the patch cannot be excluded.

Concurrent administration with Amifostine and acetyl salicylic acid may potentiate the hypotensive effect of the preparation.

Sapropterine (Tetrahydrobiopterine, BH4) is a cofactor for nitric oxide synthetase. Caution is recommended during concomitant use of sapropterine-containing medicine with all agents that cause vasodilation by affecting nitric oxide (NO) metabolism or action, including classical NO donors (e.g. glyceryl trinitrate (GTN), isosorbide dinitrate (ISDN), isosorbide 5-mononitrate (5-ISMN) and others).

Pregnancy and breast-feeding

Like any drug, Deponit 10 should be employed with caution during pregnancy, especially in the first 3 months.

These patches should not be used during pregnancy or lactation unless considered absolutely essential by the physician.

It is not known whether the active substance passes into the breast milk. Benefits to the mother must be weighed against risk to the child.

Fertility

Reproduction toxicity studies performed in rats and rabbits using various routes of administration did not reveal any effect on mating, fertility and general reproductive parameters. There is no data available on the effect of Deponit 10 on fertility in humans.

Glyceryl trinitrate can cause postural hypotension and dizziness. Patients should not drive or operate machinery if they feel affected.

Undesirable effects frequencies are defined as: very common (≥ 1/10), common (≥ 1/100,<1/10), uncommon (≥ 1/1,000,<1/100), rare ≥ 1/10,000,<1/1,000), very rare (<1/10,000), not known (cannot be estimated from the available data).

During administration of Deponit 10 the following undesirable effects may be observed:

Severe hypotensive responses have been reported for organic nitrates and include nausea, vomiting, restlessness, pallor and excessive perspiration.

During the treatment with these patches, a temporary hypoxaemia may occur due to a relative redistribution of the blood flow in hypoventilated alveolar areas. Particularly in patients with coronary artery disease this may lead to a myocardial hypoxia.

Like other nitrate preparations, GTN commonly causes dose-dependent headaches due to cerebral vasodilation. These often regress after a few days despite the maintenance of therapy. If headaches persist during intermittent therapy, they should be treated with mild analgesics. Unresponsive headaches are an indication for reducing the dosage of GTN or discontinuing treatment.

A slight reflex-induced increase in heart rate can be avoided by resorting, if necessary, to combined treatment with a beta-blocker.

Upon removal of the patch, any slight reddening of the skin will usually disappear within a few hours. The application site should be changed regularly to prevent local irritation.

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

By reporting side effects, you can help provide more information on the safety of this medicine.

In view of the transdermal mode of delivery, an overdose of glyceryl trinitrate is unlikely to occur. However, in the unlikely event of an overdose, the symptoms could include the following:

• Fall in blood pressure ≤ 90 mmHg

• Collapse or syncope

• Paleness

• Sweating

• Weak pulse

• Reflex tachycardia

• Flushing

• Light-headedness on standing

• Headache

• Weakness

• Dizziness

• Nausea

• Vomiting

• Methaemoglobinaemia has been reported in patients receiving other organic nitrates. During glyceryl trinitrate biotransformation nitrite ions are released, which may induce methaemoglobinaemia and cyanosis with subsequent tachypnoea, anxiety, loss of consciousness and cardiac arrest. It can not be excluded that an overdose of glyceryl trinitrate may cause this adverse reaction

• In very high doses the intracranial pressure may be increased. This might lead to cerebral symptoms

General procedure:

• Since these patches are applied to the skin, removing the patch immediately stops delivery of the drug.

• General procedures in the event of nitrate-related hypotension

- Patient should be kept horizontal with the head lowered and legs raised or, if necessary, compression bandaging of the patient's legs.

- Supply oxygen

- Expand plasma volume

- For specific shock treatment admit patient to intensive care unit

Special procedure:

• Raising the blood pressure if the blood pressure is very low

• Treatment of methaemoglobinaemia

Treatment with intravenous methylene blue

- Initially 1 to 2 mg/kg, not exceeding 4 mg/kg of a 1% solution over 5 minutes.

- Repeat dose in 60 minutes if there is no response.

- Administer oxygen (if necessary)

- Initiate artificial ventilation

Treatment with methylene blue is contraindicated in patients with glucose-6-phosphate dehydrogenase (G-6-PD) deficiency or methaemoglobin reductase deficiency. (see also section 4.4).

Where treatment with methylene blue is contraindicated or is not effective, exchange transfusion and / or transfusion of packed red blood cells is recommended.

Resuscitation measures:

In case of signs of respiratory and circulatory arrest, initiate resuscitation measures immediately.

Pharmacotherapeutic group: Vasodilators used in Cardiac Diseases, organic nitrates, ATC Code: C01DA02

Pharmacodynamic effects

The main pharmacological activity of organic nitrates is the relaxation of smooth vascular muscles. The systemic vasodilation induces an increase of venous capacitance. Venous return is reduced. Ventricular volume, filling pressures and diastolic wall tension are diminished (preload reduction).

A diminished ventricular radius and reduced wall tension, lower myocardial energy and oxygen consumption, respectively.

The dilation of the large arteries near the heart leads to a decrease in both the systemic (reduction of afterload) and the pulmonary vascular resistance. In addition, this relieves the myocardium and lowers oxygen demands.

By dilating the large epicardial coronary arteries, glyceryl trinitrate enhances blood supply to the myocardium, improving its pump function and increasing the oxygen supply.

At molecular level, nitrates form nitric oxide (NO), which corresponds to the physical EDRF (endothelium derived relaxing factor). EDRF mediated production of cyclic guanosine monophosphate (CGMP) leads to relaxation of smooth muscle cells.

Absorption:

The transdermal absorption of glyceryl trinitrate circumvents the extensive hepatic first pass metabolism so the bioavailability is about 70% of that achieved after i.v. administration.

Distribution

The steady-state concentration in the plasma depends on the patch dosage and the corresponding rate of absorption. At a rate of absorption of 0.4 mg/h, the steady-state concentration is about 0.2 µ g/l on average. Plasma protein binding is about 60%.

Metabolism

Glyceryl trinitrate is metabolized to 1,2- and 1,3-dinitroglycerols. The dinitrates exert less vasodilatory activity than glyceryl trinitrate. The contribution to the overall effect is not known. The dinitrates are further metabolized to inactive mononitrates, glyceryl and carbon dioxide. The metabolism of glyceryl trinitrate, which is effected in the liver, but also in many other cells, e.g. the red blood cells, includes the separation of one or more nitrate groups.

Elimination

The elimination half-life of glyceryl trinitrate is 2-4 min. In addition to the metabolism of glyceryl trinitrate, there is a renal excretion of the catabolites.

Glyceryl trinitrate is a well-known active substance, established for more than a hundred years. Thus new preclinical studies have not been carried out with Deponit 10.

Acrylate/vinyl acetate copolymer (adhesive matrix)

Polypropylene (backing foil)

Polyethylene (siliconised release liner)

Not applicable.

Shelf life of the product as packaged for sale: 48 months.

Do not store above 25° C.

Multilaminate film/foil pouch with heat-sealed edges.

28 patches per carton.

The patch should be removed from the package just before application. After removal of the protective foil, the patch should be applied to unbroken, clean and dry skin that is smooth and with few hairs. The same area of skin should not be used again for some days.

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