Procoralan · 4.5 Interaction with other medicinal products and other forms of interaction · 1

HOS-093992 · has-adverse-reaction-information · PDF-Seite 8

Summary of the safety profile The most common adverse reactions with ivabradine are luminous phenomena (phosphenes) (14.5%) and bradycardia (3.3%). They are dose dependent and related to the pharmacological effect of the medicinal product. 8 Tabulated list of adverse reactions The following adverse reactions have been reported during clinical trials and are ranked using the following frequency: 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). System Organ Class Frequency Preferred Term Blood and lymphatic system Uncommon Eosinophilia disorders Metabolism and nutrition Uncommon Hyperuricaemia disorders Nervous system disorders Common Headache, generally during the first month of treatment Dizziness, possibly related to bradycardia Uncommon* Syncope, possibly related to bradycardia Eye disorders Very common Luminous phenomena (phosphenes) Common Blurred vision Uncommon* Diplopia Visual impairment Ear and labyrinth disorders Uncommon Vertigo Cardiac disorders Common Bradycardia AV 1st degree block (ECG prolonged PQ interval) Ventricular extrasystoles Atrial fibrillation Uncommon Palpitations, supraventricular extrasystoles, ECG prolonged QT interval Very rare AV 2nd degree block, AV 3rd degree block Sick sinus syndrome Vascular disorders Common Uncontrolled blood pressure Uncommon* Hypotension,

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HOS-093988 · has-contraindication-information · PDF-Seite 4

- Hypersensitivity to the active substance or to any of the excipients listed in section 6.1 - Resting heart rate below 70 beats per minute prior to treatment - Cardiogenic shock - Acute myocardial infarction - Severe hypotension (< 90/50 mmHg) - Severe hepatic insufficiency - Sick sinus syndrome - Sino-atrial block - Unstable or acute heart failure - Pacemaker dependent (heart rate imposed exclusively by the pacemaker) - Unstable angina - AV-block of 3rd degree - Combination with strong cytochrome P450 3A4 inhibitors such as azole antifungals (ketoconazole, itraconazole), macrolide antibiotics (clarithromycin, erythromycin per os, josamycin, telithromycin), HIV protease inhibitors (nelfinavir, ritonavir) and nefazodone (see sections 4.5 and 5.2) - Combination with verapamil or diltiazem which are moderate CYP3A4 inhibitors with heart rate reducing properties (see section 4.5) - Pregnancy, lactation and women of childbearing potential not using appropriate contraceptive measures (see section 4.6)

HOS-093987 · has-indication-information · PDF-Seite 2

Symptomatic treatment of chronic stable angina pectoris Ivabradine is indicated for the symptomatic treatment of chronic stable angina pectoris in coronary artery disease adults with normal sinus rhythm and heart rate ≥ 70 bpm. Ivabradine is indicated: - in adults unable to tolerate or with a contraindication to the use of beta-blockers - or in combination with beta-blockers in patients inadequately controlled with an optimal beta- blocker dose. 2 Treatment of chronic heart failure Ivabradine is indicated in chronic heart failure NYHA II to IV class with systolic dysfunction, in adult patients in sinus rhythm and whose heart rate is ≥ 75 bpm, in combination with standard therapy including beta-blocker therapy or when beta-blocker therapy is contraindicated or not tolerated (see section 5.1).

HOS-093990 · has-interaction-information · PDF-Seite 6

Pharmacodynamic interactions Concomitant use not recommended QT prolonging medicinal products - Cardiovascular QT prolonging medicinal products (e.g. quinidine, disopyramide, bepridil, sotalol, ibutilide, amiodarone). - Non cardiovascular QT prolonging medicinal products (e.g. pimozide, ziprasidone, sertindole, mefloquine, halofantrine, pentamidine, cisapride, intravenous erythromycin). The concomitant use of cardiovascular and non cardiovascular QT prolonging medicinal products with ivabradine should be avoided since QT prolongation may be exacerbated by heart rate reduction. If the combination appears necessary, close cardiac monitoring is needed (see section 4.4). 6 Concomitant use with precaution Potassium-depleting diuretics (thiazide diuretics and loop diuretics) Hypokalemia can increase the risk of arrhythmia. As ivabradine may cause bradycardia, the resulting combination of hypokalemia and bradycardia is a predisposing factor to the onset of severe arrhythmias, especially in patients with long QT syndrome, whether congenital or substance-induced. Pharmacokinetic interactions Ivabradine is metabolised by CYP3A4 only and it is a very weak inhibitor of this cytochrome. Ivabradine was shown not to influence the metabolism and plasma concentrations of other CYP3A4 substrates (mild, moderate and strong inhibitors). CYP3A4 inhibitors and inducers are liable to interact with ivabradine and influence its metabolism and pharmacokinetics to a clinically significant extent. Interaction studies have established that CYP3A4 inhibitors increase ivabradine plasma concentrations, while inducers decrease them. Increased plasma concentrations of ivabradine may be associated with the risk of excessive bradycardia (see section 4.4). Contraindication of concomitant use Potent CYP3A4 inhibitors The concomitant use of potent CYP3A4 inhibitors such as azole antifungals (ketoconazole, itraconazole), macrolide antibiotics (clarithromycin, erythromycin per os, josamycin, telithromycin), HIV protease inhibitors (nelfinavir, ritonavir) and nefazodone is contraindicated (see section 4.3). The potent CYP3A4 inhibitors ketoconazole (200 mg once daily) and josamycin (1 g twice daily) increased ivabradine mean plasma exposure by 7 to 8 fold. Moderate CYP3A4 inhibitors Specific interaction studies in healthy volunteers and patients have shown that the combination of ivabradine with the

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HOS-093991 · has-pregnancy-information · PDF-Seite 8

Women of childbearing potential Women of childbearing potential should use appropriate contraceptive measures during treatment (see section 4.3). Pregnancy There are no or limited amount of data from the use of ivabradine in pregnant women. Studies in animals have shown reproductive toxicity. These studies have shown embryotoxic and teratogenic effects (see section 5.3). The potential risk for humans is unknown. Therefore, ivabradine is contraindicated during pregnancy (see section 4.3). Breast-feeding Animal studies indicate that ivabradine is excreted in milk. Therefore, ivabradine is contraindicated during breast-feeding (see section 4.3). Women that need treatment with ivabradine should stop breast-feeding, and choose for another way of feeding their child. Fertility Studies in rats have shown no effect on fertility in males and females (see section 5.3).

HOS-093989 · has-warning-information · PDF-Seite 4

Lack of benefit on clinical outcomes in patients with symptomatic chronic stable angina pectoris Ivabradine is indicated only for symptomatic treatment of chronic stable angina pectoris because ivabradine has no benefits on cardiovascular outcomes, e.g. myocardial infarction or cardiovascular death (see section 5.1). Measurement of heart rate 4 Given that the heart rate may fluctuate considerably over time, serial heart rate measurements, ECG or ambulatory 24-hour monitoring should be considered when determining resting heart rate before initiation of ivabradine treatment and in patients on treatment with ivabradine when titration is considered. This also applies to patients with a low heart rate, in particular when heart rate decreases below 50 bpm, or after dose reduction (see section 4.2). Cardiac arrhythmias Ivabradine is not effective in the treatment or prevention of cardiac arrhythmias and likely loses its efficacy when a tachyarrhythmia occurs (eg. ventricular or supraventricular tachycardia). Ivabradine is therefore not recommended in patients with atrial fibrillation or other cardiac arrhythmias that interfere with sinus node function. In patients treated with ivabradine the risk of developing atrial fibrillation is increased (see section 4.8). Atrial fibrillation has been more common in patients using concomitantly amiodarone or potent class I anti-arrhythmics. It is recommended to regularly clinically monitor ivabradine treated patients for the occurrence of atrial fibrillation (sustained or paroxysmal), which should also include ECG monitoring if clinically indicated (e.g. in case of exacerbated angina, palpitations, irregular pulse). Patients should be informed of signs and symptoms of atrial fibrillation and be advised to contact their physician if these occur. If atrial fibrillation develops during treatment, the balance of benefits and risks of continued ivabradine treatment should be carefully reconsidered. Chronic heart failure patients with intraventricular conduction defects (bundle branch block left, bundle branch block right) and ventricular dyssynchrony should be monitored closely. Use in patients with AV-block of 2nd degree Ivabradine is not recommended in patients with AV-block of 2nd degree. Use in patients with a low heart rate Ivabradine must not be initiated in patients with a pre-treatment resting heart rate below 70 beats per minute (bpm) (see section 4.3). If, du

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