FURAMIST Nasal Spray (Fluticasone furoate )

Table of Content

Composition

Each spray contains:

Fluticasone furoate …………27.5 mcg

Dosage Form

Aqueous intranasal spray

Pharmacology

Pharmacodynamics

Fluticasone furoate is a synthetic trifluorinated corticosteroid with potent anti-inflammatory activity. The precise mechanism through which fluticasone furoate affects rhinitis symptoms is not known. Corticosteroids have been shown to have a wide range of actions on multiple cell types (e.g., mast cells, eosinophils, neutrophils, macrophages, lymphocytes) and mediators (e.g., histamine, eicosanoids, leukotrienes, cytokines) involved in inflammation. Specific effects of fluticasone furoate demonstrated in in vitro and in vivo models included activation of the glucocorticoid response element, inhibition of pro-inflammatory transcription factors such as nuclear factor-kappa B (NFkB), and inhibition of antigen-induced lung eosinophilia in sensitized rats.

Fluticasone furoate has been shown in vitro to exhibit a binding affinity for the human glucocorticoid receptor that is approximately 29.9 times that of dexamethasone and 1.7 times that of fluticasone propionate.

Pharmacokinetics

Absorption

Following intranasal administration of fluticasone furoate, most of the dose is eventually swallowed and undergoes incomplete absorption and extensive first-pass metabolism in the liver and gut, resulting in negligible systemic exposure. At the highest recommended intranasal dosage of 110 mcg once daily for up to 12 months in adults and up to 12 weeks in children, plasma concentrations of fluticasone furoate are typically not quantifiable despite the use of a sensitive HPLC-MS/MS assay with a lower limit of quantification (LOQ) of 10 pg/mL. However, in a few isolated cases (<0.3%) fluticasone furoate was detected in high concentrations above 500 pg/mL, and in a single case, the concentration was as high as 1,430 pg/mL in the 52-week study. There was no relationship between these concentrations and cortisol levels in these subjects. The reasons for these high concentrations are unknown.

Due to the low bioavailability by the intranasal route, the majority of the pharmacokinetic data was obtained via other routes of administration. Studies using oral solution and intravenous dosing of radiolabelled drug have demonstrated that at least 30% of fluticasone furoate is absorbed and then rapidly cleared from plasma. Oral bioavailability is on average 1.26%, and the majority of the circulating radioactivity is due to inactive metabolites.

Distribution

Following intravenous administration, the mean volume of distribution at steady state is 608 L.  Binding of fluticasone furoate to human plasma proteins is greater than 99%.

Metabolism

In vivo studies have revealed no evidence of cleavage of the furoate moiety to form fluticasone. Fluticasone furoate is cleared (total plasma clearance of 58.7 L/h) from systemic circulation principally by hepatic metabolism via the cytochrome P450 isozyme, CYP3A4. The principal route of metabolism is hydrolysis of the S-fluoromethyl carbothioate function to form the inactive 17beta-carboxylic acid metabolite.

Elimination

Fluticasone furoate and its metabolites are eliminated primarily in the faeces, accounting for approximately 101% and 90% of the orally and intravenously administered dose, respectively. Urinary excretion accounted for approximately 1% and 2% of the orally and intravenously administered dose, respectively. The elimination phase half-life averaged 15.1 hours following intravenous administration.

Indications

FURAMIST Nasal Spray is indicated for the treatment of the symptoms of seasonal and perennial allergic rhinitis in patients aged 2 years and older.

Dosage and Administration

FURAMIST Nasal Spray should be administered by the intranasal route only.

Adults and Adolescents (12 Years of Age and Older)

The recommended starting dosage is 110 mcg once daily administered as 2 sprays (27.5 mcg/spray) in each nostril. When the maximum benefit has been achieved and symptoms have been controlled, reducing the dosage to 55 mcg (1 spray in each nostril) once daily may be effective in maintaining control of allergic rhinitis symptoms.

Children (2 to 11 Years of Age)

The recommended starting dosage in children is 55 mcg once daily administered as 1 spray (27.5 mcg/spray) in each nostril. Children not adequately responding to 55 mcg may use 110 mcg (2 sprays in each nostril) once daily. Once symptoms have been controlled, the dosage may be decreased to 55 mcg once daily.

Contraindications

FURAMIST Nasal Spray is contraindicated in patients with a hypersensitivity to fluticasone or any of the ingredients. Hypersensitivity reactions, including anaphylaxis, angioedema, rash and urticaria may occur after administration of FURAMIST Nasal spray. Discontinue FURAMIST Nasal Spray if such reactions occur.

Warnings and Precautions

Local Nasal Effects

Epistaxis and Nasal Ulceration

In clinical studies of 2–52 weeks’ duration, epistaxis and nasal ulcerations were observed more frequently and some epistaxis events were more severe in patients treated with fluticasone furoate nasal spray than those who received placebo.

Candida Infection

Evidence of localized infections of the nose with Candida albicans was seen on nasal exams in 7 of 2,745 patients treated with fluticasone furoate nasal spray during clinical trials and was reported as an adverse event in 3 patients. When such an infection develops, it may require treatment with appropriate local therapy and discontinuation of fluticasone furoate nasal spray. Patients using fluticasone furoate nasal spray over several months or longer should be examined periodically for evidence of Candida infection or other signs of adverse effects on the nasal mucosa.

Nasal Septal Perforation

Instances of nasal septal perforation have been reported in patients following the intranasal application of corticosteroids. There were no instances of nasal septal perforation observed in clinical studies with fluticasone furoate nasal spray.

Impaired Wound Healing

Because of the inhibitory effect of corticosteroids on wound healing, patients who have experienced recent nasal ulcers, nasal surgery, or nasal trauma should not use fluticasone furoate nasal spray until healing has occurred.

Glaucoma and Cataracts

Nasal and inhaled corticosteroids may result in the development of glaucoma and/or cataracts. Therefore, close monitoring is warranted in patients with a change in vision or with a history of increased intraocular pressure, glaucoma, and/or cataracts.

Hypersensitivity Reactions, Including Anaphylaxis

Hypersensitivity reactions, including anaphylaxis, angioedema, rash, and urticaria, may occur after administration of FURAMIST Nasal Spray. Discontinue FURAMIST Nasal Spray if such reactions occur.

Immunosuppression

Persons who are using drugs that suppress the immune system are more susceptible to infections than healthy individuals. Chickenpox and measles, for example, can take a more serious or even fatal course in susceptible children or adults using corticosteroids. In children or adults who have not had these diseases or have not been properly immunized, particular care should be taken to avoid exposure. How the dose, route, and duration of corticosteroid administration affect the risk of developing a disseminated infection is not known. The contribution of the underlying disease and/or prior corticosteroid treatment to the risk is also not known. If a patient is exposed to chickenpox, prophylaxis with varicella zoster immune globulin (VZIG) may be indicated. If a patient is exposed to measles, prophylaxis with pooled intramuscular immunoglobulin (IG) may be indicated. (See the respective package inserts for complete VZIG and IG prescribing information.) If chickenpox or measles develops, treatment with antiviral agents may be considered.

Corticosteroids should be used with caution, if at all, in patients with active or quiescent tuberculous infections of the respiratory tract, untreated local or systemic fungal or bacterial infections, systemic viral or parasitic infections, or ocular herpes simplex because of the potential for worsening of these infections.

Hypothalamic-Pituitary-Adrenal Axis Effects

When intranasal steroids are used at higher than recommended dosages or in susceptible individuals at recommended dosages, systemic corticosteroid effects such as hypercorticism and adrenal suppression may appear. If such changes occur, the dosage of fluticasone furoate nasal spray should be discontinued slowly, consistent with accepted procedures for discontinuing oral corticosteroid therapy.

The replacement of a systemic corticosteroid with a topical corticosteroid can be accompanied by signs of adrenal insufficiency. In addition, some patients may experience symptoms of corticosteroid withdrawal, e.g., joint and/or muscular pain, lassitude, and depression. Patients previously treated for prolonged periods with systemic corticosteroids and transferred to topical corticosteroids should be carefully monitored for acute adrenal insufficiency in response to stress. In those patients who have asthma or other clinical conditions requiring long-term systemic corticosteroid treatment, rapid decreases in systemic corticosteroid dosages may cause a severe exacerbation of their symptoms.

Effect on Growth

Corticosteroids may cause a reduction in growth velocity when administered to paediatric patients. Monitor the growth routinely of paediatric patients receiving fluticasone furoate nasal spray. To minimize the systemic effects of intranasal corticosteroids, including fluticasone furoate nasal spray, titrate each patient’s dose to the lowest dosage that effectively controls his/her symptoms. If growth is slowed, therapy should be reviewed with the aim of reducing the dose of nasal corticosteroid if possible, to the lowest dose at which effective control of symptoms is maintained.

Drug Interactions

Fluticasone furoate is cleared by extensive first-pass metabolism mediated by the cytochrome P450 isozyme, CYP3A4. Therefore, caution is required with the co-administration of fluticasone furoate nasal spray and ketoconazole or other potent CYP3A4 inhibitors. Co-administration of fluticasone furoate nasal spray with the potent CYP3A4 inhibitor, ritonavir, is not recommended because of the risk of systemic effects secondary to increased exposure to fluticasone furoate. High exposure to corticosteroids increases the potential for systemic side effects, such as cortisol suppression.

Enzyme induction and inhibition data suggest that fluticasone furoate is unlikely to significantly alter the cytochrome P450-mediated metabolism of other compounds at clinically relevant intranasal dosages.

Hepatic Impairment

Reduced liver function may affect the elimination of corticosteroids. Since fluticasone furoate undergoes extensive first-pass metabolism by the hepatic cytochrome P450 isozyme, CYP3A4, the pharmacokinetics of fluticasone furoate may be altered in patients with hepatic impairment. The systemic exposure would be expected to be higher than that observed had the study been conducted after multiple doses and/or in patients with severe hepatic impairment. Therefore, use fluticasone furoate nasal spray with caution in patients with severe hepatic impairment.

Renal Impairment

Fluticasone furoate is not detectable in urine from healthy subjects following intranasal dosing. Less than 1% of dose-related material is excreted in the urine. No dosage adjustment is required in patients with renal impairment.

Pregnancy

Preganancy Category C

There are no adequate and well-controlled studies in pregnant women. Fluticasone furoate nasal spray should be used during pregnancy only if the potential benefit justifies the potential risk to the foetus.

Hypoadrenalism may occur in infants born of mothers receiving corticosteroids during pregnancy. Such infants should be carefully monitored.

Lactation

It is not known whether fluticasone furoate is excreted in human breast milk. However, other corticosteroids have been detected in human milk. Since there are no data from controlled trials on the use of intranasal fluticasone furoate by nursing mothers, caution should be exercised when fluticasone furoate nasal spray is administered to a nursing mother.

Pediatric Use

Controlled clinical trials with fluticasone furoate nasal spray included 1,224 patients aged 2 to 11 years and 344 adolescent patients aged 12 to 17 years.

The safety and effectiveness of fluticasone furoate nasal spray in children below 2 years of age have not been established.

Controlled clinical studies have shown that intranasal corticosteroids may cause a reduction in growth velocity in pediatric patients. This effect has been observed in the absence of laboratory evidence of HPA axis suppression, suggesting that growth velocity is a more sensitive indicator of systemic corticosteroid exposure in pediatric patients than some commonly used tests of HPA axis function. The long-term effects of reduction in growth velocity associated with intranasal corticosteroids, including the impact on final adult height, are unknown. The potential for “catch-up” growth following discontinuation of treatment with intranasal corticosteroids has not been adequately studied. The growth of pediatric patients receiving intranasal corticosteroids, including fluticasone furoate nasal spray, should be monitored routinely (e.g., via stadiometry). The potential growth effects of prolonged treatment should be weighed against the clinical benefits obtained and the risks/benefits of treatment alternatives. To minimize the systemic effects of intranasal corticosteroids, including fluticasone furoate nasal spray, each patient’s dose should be titrated to the lowest dosage that effectively controls his/her symptoms.

Geriatric Use

Clinical studies of fluticasone furoate nasal spray did not include sufficient numbers of subjects aged 65 years and older to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.

Undesirable Effects

Clinical Trials

Adults and Adolescents 12 Years of Age and Older

The most common adverse events (>1% incidence) reported with fluticasone furoate use in clinical trials are: Headache, epistaxis, pharyngolaryngeal pain, nasal ulceration, back pain, pyrexia, and cough.

Pediatric Patients 2 to 11 Years of Age

The most common adverse events (>3% incidence) reported with fluticasone furoate use are: headache, nasopharyngitis, epistaxis, pyrexia, pharyngolaryngeal pain and cough.

There were no differences in the incidence of adverse reactions based on gender or race. Pyrexia occurred more frequently in children 2 to <6 years of age compared with children 6 to <12 years.

In a long term (52-week) safety trial, epistaxis occurred more frequently in patients who received fluticasone furoate nasal spray than in patients who received placebo. Epitaxis tended to be more severe in patients treated with fluticasone furoate nasal spray.

Systemic and local corticosteroid use may result in the following:

  • Epistaxis, ulcerations, Candida albicans infection, impaired wound healing, and nasal septal perforation
  • Cataracts and glaucoma
  • Immunosuppression
  • Hypothalamic-pituitary-adrenal (HPA) axis effects, including growth reduction

Post Marketing Experience

In addition to adverse reactions reported from clinical trials, the following adverse reactions have been identified during postmarketing use of fluticasone furoate nasal spray. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. These events have been chosen for inclusion due to either their seriousness, frequency of reporting, or causal connection to fluticasone furoate or a combination of these factors.

Immune System Disorders

Hypersensitivity reactions, including anaphylaxis, angioedema, rash, and urticaria.

Respiratory, Thoracic, and Mediastinal Disorders

Rhinalgia, nasal discomfort (including nasal burning, nasal irritation, and nasal soreness), nasal dryness, and nasal septal perforation, Epistaxis, nasal ulceration

Nervous System Disorders

Headache

Eye Disorders

Transient ocular changes

Musculoskeletal and Connective Tissue Disorders (Children)

Growth retardation

Overdosage

There are no data on the effects of acute or chronic overdosage with fluticasone furoate nasal spray. Because of low systemic bioavailability and an absence of acute drug-related systemic findings in clinical studies , overdose is unlikely to require any therapy other than observation.

Intranasal administration of up to 2,640 mcg/day (24 times the recommended adult dose) of fluticasone furoate was administered to healthy human volunteers for 3 days. Single- and repeat-dose studies with orally inhaled fluticasone furoate doses of 50–4,000 mcg have shown decreased mean serum cortisol at doses of 500 mcg or higher. Chronic overdosage with any corticosteroid may result in signs or symptoms of hypercorticism.

Packaging Information

FURAMIST Nasal Spray: Sales pack contains 120 metered doses

Last Updated: December 2015
Last Reviewed: December 2015