Primary Hypercholesterolaemia
Ezetimibe co-administered with an HMG-CoA reductase inhibitor (statin) is indicated as
adjunctive therapy to diet for use in patients with primary (heterozygous familial and nonfamilial)
hypercholesterolaemia who are not appropriately controlled with a statin alone.
Ezetimibe monotherapy is indicated as adjunctive therapy to diet for use in patients with
primary (heterozygous familial and non-familial) hypercholesterolaemia in whom a statin is
considered inappropriate or is not tolerated.

Prevention of Cardiovascular Events
Ezetimibe is indicated to reduce the risk of cardiovascular events (see section 5.1) in patients
with coronary heart disease (CHD) and a history of acute coronary syndrome (ACS) when
added to ongoing statin therapy or initiated concomitantly with a statin.

Homozygous Familial Hypercholesterolaemia (HoFH)
Ezetimibe co-administered with a statin, is indicated as adjunctive therapy to diet for use in
patients with HoFH. Patients may also receive adjunctive treatments (e.g. LDL apheresis).

Homozygous Sitosterolaemia (Phytosterolaemia)
Ezetimibe is indicated as adjunctive therapy to diet for use in patients with homozygous
familial sitosterolaemia.

 

Posology
The patient should be on an appropriate lipid-lowering diet and should continue on this diet
during treatment with Ezetimibe.

Route of administration is oral. The recommended dose is one Ezetimibe 10 mg tablet daily.
Ezetimibe can be administered at any time of the day, with or without food.

When Ezetimibe is added to a statin, either the indicated usual initial dose of that particular
statin or the already established higher statin dose should be continued. In this setting, the
dosage instructions for that particular statin should be consulted.

Use in Patients with Coronary Heart Disease and ACS Event History
For incremental cardiovascular event reduction in patients with coronary heart disease and
ACS event history, Ezetimibe 10 mg may be administered with a statin with proven
cardiovascular benefit.

Co-administration with bile acid sequestrants
Dosing of Ezetimibe should occur either ≥ 2 hours before or ≥ 4 hours after administration of
a bile acid sequestrant.

Elderly
No dosage adjustment is required for elderly patients (see section 5.2).

Paediatric population
Initiation of treatment must be performed under review of a specialist.
Children and adolescents ≥ 6 : The safety and efficacy of ezetimibe in children aged 6 to 17
years has not been established. Current available data are described in sections 4.4, 4.8, 5.1 and
5.2 but no recommendation on a posology can be made.

When Ezetimibe is administered with a statin, the dosage instructions for the statin in children
should be consulted.
Children <6 years: The safety and efficacy of Ezetimibe in children aged < 6 years has not been
established. No data are available.

Hepatic impairment
No dosage adjustment is required in patients with mild hepatic impairment (Child-Pugh score
5 to 6). Treatment with Ezetimibe is not recommended in patients with moderate (Child-Pugh
score 7 to 9) or severe (Child-Pugh score > 9) liver dysfunction (see sections 4.4 and 5.2).

Renal impairment
No dosage adjustment is required for renally impaired patients (see section 5.2).

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1. When Ezetimibe is co-administered with a statin, please refer to the SPC for that particular medicinal product. Therapy with Ezetimibe co-administered with a statin is contraindicated during pregnancy and lactation. Ezetimibe co-administered with a statin is contraindicated in patients with active liver disease or unexplained persistent elevations in serum transaminases.

When Ezetimibe is co-administered with a statin, please refer to the SPC for that particular
medicinal product.
Liver Enzymes
In controlled co-administration trials in patients receiving Ezetimibe with a statin, consecutive
transaminase elevations (≥ 3 X the upper limit of normal [ULN]) have been observed. When
Ezetimibe is co-administered with a statin, liver function tests should be performed at initiation
of therapy and according to the recommendations of the statin (see section 4.8).

In the IMProved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVEIT),
18,144 patients with coronary heart disease and ACS event history were randomised to
receive ezetimibe/simvastatin 10/40 mg daily (n = 9067) or simvastatin 40 mg daily (n = 9077).
During a median follow-up of 6.0 years, the incidence of consecutive elevations of
transaminases (≥3 X ULN) was 2.5% for ezetimibe/simvastatin and 2.3% for simvastatin (see
section 4.8).
In a controlled clinical study in which over 9000 patients with chronic kidney disease were
randomised to receive Ezetimibe 10 mg combined with simvastatin 20 mg daily (n = 4650) or
placebo (n = 4620) (median follow-up period of 4.9 years), the incidence of consecutive
elevations of transaminases (> 3 X ULN) was 0.7% for Ezetimibe combined with simvastatin
and 0.6% for placebo (see section 4.8).
Skeletal Muscle
In post-marketing experience with Ezetimibe, cases of myopathy and rhabdomyolysis have
been reported. Most patients who developed rhabdomyolysis were taking a statin
concomitantly with Ezetimibe. However, rhabdomyolysis has been reported very rarely with
Ezetimibe monotherapy and very rarely with the addition of Ezetimibe to other agents known
to be associated with increased risk of rhabdomyolysis. If myopathy is suspected based on
muscle symptoms or is confirmed by a creatine phosphokinase (CPK) level > 10 times the
ULN, Ezetimibe, any statin, and any of these other agents that the patient is taking
concomitantly should be immediately discontinued. All patients starting therapy with
Ezetimibe should be advised of the risk of myopathy and told to report promptly any
unexplained muscle pain, tenderness or weakness (see section 4.8).
In IMPROVE-IT, 18,144 patients with coronary heart disease and ACS event history were
randomised to receive ezetimibe/simvastatin 10/40 mg daily (n = 9067) or simvastatin 40 mg
daily (n = 9077). During a median follow-up of 6.0 years, the incidence of myopathy was 0.2%
for ezetimibe/simvastatin and 0.1% for simvastatin, where myopathy was defined as
unexplained muscle weakness or pain with a serum CK ≥ 10 times ULN or two consecutive
observations of CK ≥ 5 and < 10 times ULN. The incidence of rhabdomyolysis was 0.1% for
ezetimibe/simvastatin and 0.2% for simvastatin, where rhabdomyolysis was defined as unexplained muscle weakness or pain with a serum CK ≥ 10 times ULN with evidence of renal
injury, ≥ 5 times ULN and < 10 times ULN on two consecutive occasions with evidence of
renal injury or CK ≥ 10,000 IU/L without evidence of renal injury (see section 4.8).
In a clinical trial in which over 9000 patients with chronic kidney disease were randomised to
receive Ezetimibe 10 mg combined with simvastatin 20 mg daily (n = 4650) or placebo (n =
4620) (median follow-up 4.9 years), the incidence of myopathy/rhabdomyolysis was 0.2% for
Ezetimibe combined with simvastatin and 0.1% for placebo (see section 4.8).
Hepatic impairment
Due to the unknown effects of the increased exposure to ezetimibe in patients with moderate
or severe hepatic impairment, Ezetimibe is not recommended (see section 5.2).
Paediatric population
Efficacy and safety of Ezetimibe in patients 6 to10 years of age with heterozygous familial or
non-familial hypercholesterolaemia have been evaluated in a 12-week placebo-controlled
clinical trial. Effects of ezetimibe for treatment periods > 12 weeks have not been studied in
this age group (see sections 4.2, 4.8, 5.1 and 5.2).
Ezetimibe has not been studied in patients younger than 6 years of age (see sections 4.2 and
4.8).
Efficacy and safety of Ezetimibe co-administered with simvastatin in patients 10 to 17 years
of age with heterozygous familial hypercholesterolaemia have been evaluated in a controlled
clinical trial in adolescent boys (Tanner Stage II or above) and in girls who were at least one
year post-menarche.
In this limited controlled study, there was generally no detectable effect on growth or sexual
maturation in the adolescent boys or girls, or any effect on menstrual cycle length in girls.
However, the effects of ezetimibe for a treatment period > 33 weeks on growth and sexual
maturation have not been studied (see sections 4.2 and 4.8).
The safety and efficacy of Ezetimibe co-administered with doses of simvastatin above 40mg
daily have not been studied in paediatric patients 10 to 17 years of age.

The safety and efficacy of Ezetimibe co-administered with simvastatin have not been studied
in paediatric patients < 10 years of age (see sections 4.2 and 4.8).
The long-term efficacy of therapy with Ezetimibe in patients below 17 years of age to reduce
morbidity and mortality in adulthood has not been studied.
Fibrates
The safety and efficacy of Ezetimibe administered with fibrates have not been established.
If cholelithiasis is suspected in a patient receiving Ezetimibe and fenofibrate, gallbladder
investigations are indicated and this therapy should be discontinued (see sections 4.5 and 4.8).
Ciclosporin
Caution should be exercised when initiating Ezetimibe in the setting of ciclosporin. Ciclosporin
concentrations should be monitored in patients receiving Ezetimibe and ciclosporin (see section
4.5).
Anticoagulants
If Ezetimibe is added to warfarin, another coumarin anticoagulant, or fluindione, the
International Normalised Ratio (INR) should be appropriately monitored (see section 4.5).
Excipient
Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or
glucose-galactose malabsorption should not take this medicine.
Ezetimibe contains less than 1 mmol (23 mg) sodium per tablet, that is to say essentially
sodium-free.

In preclinical studies, it has been shown that ezetimibe does not induce cytochrome P450 drug
metabolising enzymes. No clinically significant pharmacokinetic interactions have been
observed between ezetimibe and drugs known to be metabolised by cytochromes P450 1A2,
2D6, 2C8, 2C9, and 3A4, or N-acetyltransferase.

In clinical interaction studies, ezetimibe had no effect on the pharmacokinetics of dapsone,
dextromethorphan, digoxin, oral contraceptives (ethinyl estradiol and levonorgestrel),
glipizide, tolbutamide, or midazolam during co-administration. Cimetidine, co-administered
with ezetimibe, had no effect on the bioavailability of ezetimibe.
Antacids
Concomitant antacid administration decreased the rate of absorption of ezetimibe but had no
effect on the bioavailability of ezetimibe. This decreased rate of absorption is not considered
clinically significant.
Cholestyramine
Concomitant cholestyramine administration decreased the mean area under the curve (AUC)
of total ezetimibe (ezetimibe + ezetimibe-glucuronide) approximately 55 %. The incremental
low-density lipoprotein cholesterol (LDL-C) reduction due to adding Ezetimibe to
cholestyramine may be lessened by this interaction (see section 4.2).
Fibrates
In patients receiving fenofibrate and Ezetimibe, physicians should be aware of the possible risk
of cholelithiasis and gallbladder disease (see sections 4.4 and 4.8).
If cholelithiasis is suspected in a patient receiving Ezetimibe and fenofibrate, gallbladder
investigations are indicated and this therapy should be discontinued (see section 4.8).
Concomitant fenofibrate or gemfibrozil administration modestly increased total ezetimibe
concentrations (approximately 1.5- and 1.7-fold respectively).
Co-administration of Ezetimibe with other fibrates has not been studied.
Fibrates may increase cholesterol excretion into the bile, leading to cholelithiasis. In animal
studies, ezetimibe sometimes increased cholesterol in the gallbladder bile but not in all species
(see section 5.3). A lithogenic risk associated with the therapeutic use of Ezetimibe cannot be
ruled out.

Statins
No clinically significant pharmacokinetic interactions were seen when ezetimibe was coadministered
with atorvastatin, simvastatin, pravastatin, lovastatin, fluvastatin, or rosuvastatin.
Ciclosporin
In a study of eight post-renal transplant patients with creatinine clearance of > 50 mL/min on
a stable dose of ciclosporin, a single 10-mg dose of Ezetimibe resulted in a 3.4-fold (range 2.3-
to 7.9-fold) increase in the mean AUC for total ezetimibe compared to a healthy control
population, receiving ezetimibe alone, from another study (n = 17). In a different study, a renal
transplant patient with severe renal impairment who was receiving ciclosporin and multiple
other medications demonstrated a 12-fold greater exposure to total ezetimibe compared to
concurrent controls receiving ezetimibe alone. In a two-period crossover study in twelve
healthy subjects, daily administration of 20 mg ezetimibe for 8 days with a single 100-mg dose
of ciclosporin on Day 7 resulted in a mean 15% increase in ciclosporin AUC (range 10%
decrease to 51% increase) compared to a single 100-mg dose of ciclosporin alone. A controlled
study on the effect of co-administered ezetimibe on ciclosporin exposure in renal transplant
patients has not been conducted. Caution should be exercised when initiating Ezetimibe in the
setting of ciclosporin. Ciclosporin concentrations should be monitored in patients receiving
Ezetimibe and ciclosporin (see section 4.4).
Anticoagulants
Concomitant administration of ezetimibe (10 mg once daily) had no significant effect on
bioavailability of warfarin and prothrombin time in a study of twelve healthy adult males.
However, there have been post-marketing reports of increased International Normalised Ratio
(INR) in patients who had Ezetimibe added to warfarin or fluindione. If Ezetimibe is added to
warfarin, another coumarin anticoagulant, or fluindione, INR should be appropriately
monitored (see section 4.4).
Paediatric population
Interaction studies have only been performed in adults.

Ezetimibe co-administered with a statin is contraindicated during pregnancy and lactation (see
section 4.3), please refer to the SPC for that particular statin.
Pregnancy
Ezetimibe should be given to pregnant women only if clearly necessary. No clinical data are
available on the use of Ezetimibe during pregnancy. Animal studies on the use of ezetimibe in
monotherapy have shown no evidence of direct or indirect harmful effects on pregnancy,
embryofoetal development, birth or postnatal development (see section 5.3).
Lactation
Ezetimibe should not be used during lactation. Studies on rats have shown that ezetimibe is
secreted into breast milk. It is not known if ezetimibe is secreted into human breast milk.
Fertility
No clinical trial data are available on the effects of ezetimibe on human fertility. Ezetimibe had
no effect on the fertility of male or female rats (see section 5.3).

No studies on the effects on the ability to drive and use machines have been performed.
However, when driving vehicles or operating machines, it should be taken into account that
dizziness has been reported.

Tabulated list of adverse reactions (clinical studies and post-marketing experience)
In clinical studies of up to 112 weeks duration, Ezetimibe 10 mg daily was administered alone
in 2396 patients, with a statin in 11308 patients or with fenofibrate in 185 patients. Adverse
reactions were usually mild and transient. The overall incidence of side effects was similar
between Ezetimibe and placebo. Similarly, the discontinuation rate due to adverse experiences
was comparable between Ezetimibe and placebo.

Ezetimibe administered alone or co-administered with a statin:
The following adverse reactions were observed in patients treated with Ezetimibe (n = 2396)
and at a greater incidence than placebo (n = 1159) or in patients treated with Ezetimibe
coadministered with a statin (n = 11308) and at a greater incidence than statin administered
alone (n = 9361). Post-marketing Adverse reactions were derived from reports containing
Ezetimibe either administered alone or with a statin. Adverse reactions observed in clinical
studies of Ezetimibe (as a monotherapy or co-administered with a statin) or Ezetimibe reported
from post-marketing use either administered alone or with a statin are listed in Table 1. These
reactions are presented by system organ class and by frequency.
Frequencies are defined as: 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) and not known
(cannot be estimated from the available data).

System organ class Frequency	Adverse reaction
Blood and lymphatic system disorders
Not known	Thrombocytopaein
Immune system disorders
Not known	hypersensitivity; including rash; urticaria; anaphylaxis and angio-oedema
Metabolism and nutrition disorders
Uncommon	decreased appetite
Psychiatric disorders
Not known	depression
Nervous system disorders
Common	headache
Uncommon	paraesthesia
Not known	dizziness
Vascular disorders
Uncommon	hot flush; hypertension
Respiratory, thoracic and mediastinal disorders Uncommon Uncommon cough Not known dyspnoea Gastrointestinal disorders Common abdominal pain; diarrhoea; flatulence Uncommon dyspepsia; gastrooesophageal reflux disease; nausea; dry mouth; gastritis Not known pancreatitis; constipation Hepatobiliary disorders Not known hepatitis; cholelithiasis; cholecystitis Skin and subcutaneous tissue disorders Uncommon pruritus; rash; urticaria Not known erythema multiforme Musculoskeletal and connective tissue disorders Common myalgia Uncommon arthralgia; muscle spasms; neck pain; back pain; muscular weakness; pain in extremity Not known myopathy/rhabdomyolysis (see section 4.4) General disorders and administration site conditions Common fatigue chest pain; pain; asthenia; oedema peripheral Investigations Common ALT and/or AST increased Uncommon blood CPK increased; gamma-glutamyltransferase increased; liver function test abnormal

Ezetimibe co-administered with fenofibrate
Gastrointestinal disorders: abdominal pain (common)
In a multicentre, double-blind, placebo-controlled, clinical study in patients with mixed
hyperlipidaemia, 625 patients were treated for up to 12 weeks and 576 patients for up to 1 year.
In this study, 172 patients treated with Ezetimibe and fenofibrate completed 12 weeks of
therapy, and 230 patients treated with Ezetimibe and fenofibrate (including 109 who received
Ezetimibe alone for the first 12 weeks) completed 1 year of therapy. This study was not
designed to compare treatment groups for infrequent events. Incidence rates (95% CI) for
clinically important elevations (> 3 X ULN, consecutive) in serum transaminases were 4.5%
(1.9, 8.8) and 2.7% (1.2, 5.4) for fenofibrate monotherapy and Ezetimibe co-administered with
fenofibrate, respectively, adjusted for treatment exposure. Corresponding incidence rates for
cholecystectomy were 0.6% (0.0, 3.1) and 1.7% (0.6, 4.0) for fenofibrate monotherapy and
Ezetimibe co-administered with fenofibrate, respectively (see sections 4.4 and 4.5).

Paediatric (6 to 17 years of age) Patients
In a study involving paediatric (6 to 10 years of age) patients with heterozygous familial or
non-familial hypercholesterolaemia (n = 138), elevations of ALT and/or AST (≥ 3 X ULN,
consecutive) were observed in 1.1% (1 patient) of the ezetimibe patients compared to 0% in
the placebo group. There were no elevations of CPK (≥ 10 X ULN). No cases of myopathy
were reported.
In a separate study involving adolescent (10 to 17 years of age) patients with heterozygous
familial hypercholesterolaemia (n = 248), elevations of ALT and/or AST (≥ 3 X ULN,
consecutive) were observed in 3% (4 patients) of the ezetimibe/simvastatin patients compared
to 2% (2 patients) in the simvastatin monotherapy group; these figures were respectively 2%
(2 patients) and 0% for elevation of CPK (≥ 10 X ULN). No cases of myopathy were reported.
These trials were not suited for comparison of rare adverse drug reactions.
Patients with Coronary Heart Disease and ACS Event History
In the IMPROVE-IT study (see section 5.1), involving 18144 patients treated with either
ezetimibe/simvastatin 10/40 mg (n = 9067; of whom 6% were uptitrated to
ezetimibe/simvastatin 10/80 mg) or simvastatin 40 mg (n = 9077; of whom 27% were uptitrated
to simvastatin 80 mg), the safety profiles were similar during a median follow-up period of 6.0
years. Discontinuation rates due to adverse experiences were 10.6% for patients treated with
ezetimibe/simvastatin and 10.1% for patients treated with simvastatin. The incidence of
myopathy was 0.2% for ezetimibe/simvastatin and 0.1% for simvastatin, where myopathy was
defined as unexplained muscle weakness or pain with a serum CK ≥ 10 times ULN or two
consecutive observations of CK ≥ 5 and < 10 times ULN. The incidence of rhabdomyolysis
was 0.1% for ezetimibe/simvastatin and 0.2% for simvastatin, where rhabdomyolysis was
defined as unexplained muscle weakness or pain with a serum CK ≥ 10 times ULN with
evidence of renal injury, ≥ 5 times ULN and < 10 times ULN on two consecutive occasions
with evidence of renal injury or CK ≥ 10,000 IU/L without evidence of renal injury. The
incidence of consecutive elevations of transaminases (≥ 3 X ULN) was 2.5% for
ezetimibe/simvastatin and 2.3% for simvastatin (see section 4.4). Gallbladder-related adverse
effects were reported in 3.1% vs 3.5% of patients allocated to ezetimibe/simvastatin and
simvastatin, respectively. The incidence of cholecystectomy hospitalisations was 1.5% in both
treatment groups. Cancer (defined as any new malignancy) was diagnosed during the trial in
9.4% vs 9.5%, respectively.
Patients with Chronic Kidney Disease
In the Study of Heart and Renal Protection (SHARP) (see section 5.1), involving over 9000
patients treated with a fixed dose combination of Ezetimibe 10 mg with simvastatin 20 mg
daily (n = 4650) or placebo (n = 4620), the safety profiles were comparable during a median
follow-up period of 4.9 years. In this trial, only serious adverse events and discontinuations

due to any adverse events were recorded. Discontinuation rates due to adverse events were
comparable (10.4% in patients treated with Ezetimibe combined with simvastatin, 9.8% in
patients treated with placebo). The incidence of myopathy/rhabdomyolysis was 0.2% in
patients treated with Ezetimibe combined with simvastatin and 0.1% in patients treated with
placebo. Consecutive elevations of transaminases (> 3X ULN) occurred in 0.7% of patients
treated with Ezetimibe combined with simvastatin compared with 0.6% of patients treated with
placebo (see section 4.4). In this trial, there were no statistically significant increases in the
incidence of pre-specified adverse events, including cancer (9.4% for Ezetimibe combined with
simvastatin, 9.5% for placebo), hepatitis, cholecystectomy or complications of gallstones or
pancreatitis.
Laboratory values:
In controlled clinical monotherapy trials, the incidence of clinically important elevations in
serum transaminases (ALT and/or AST ≥ 3 X ULN, consecutive) was similar between
Ezetimibe (0.5%) and placebo (0.3%). In co-administration trials, the incidence was 1.3% for
patients treated with Ezetimibe co-administered with a statin and 0.4% for patients treated with
a statin alone. These elevations were generally asymptomatic, not associated with cholestasis,
and returned to baseline after discontinuation of therapy or with continued treatment (see
section 4.4).
In clinical trials, CPK > 10 X ULN was reported for 4 of 1674 (0.2%) patients administered
Ezetimibe alone vs 1 of 786 (0.1%) patients administered placebo, and for 1 of 917 (0.1%)
patients co-administered Ezetimibe and a statin vs 4 of 929 (0.4%) patients administered a
statin alone. There was no excess of myopathy or rhabdomyolysis associated with Ezetimibe
compared with the relevant control arm (placebo or statin alone) (see section 4.4).
To reports any side effect(s):
• Saudi Arabia
-The National Pharmacovigilance and Drug Safety Centre (NPC)
Fax: +966-11-205-7662
Call NPC at +966-11-2038222, Exts: 2317--2356-2340.
Toll free phone: 19999
E-mail: npc.drug@sfda.gov.sa
Website: www.sfda.gov.sa/npc
• Other GCC States:
Please contact the relevant competent authority.

 

In clinical studies, administration of ezetimibe, 50 mg/day to 15 healthy subjects for up to 14
days, or 40 mg/day to 18 patients with primary hypercholesterolaemia for up to 56 days, was generally well tolerated. In animals, no toxicity was observed after single oral doses of 5000
mg/kg of ezetimibe in rats and mice and 3000 mg/kg in dogs.
A few cases of overdosage with Ezetimibe have been reported; most have not been associated
with adverse experiences. Reported adverse experiences have not been serious. In the event of
an overdose, symptomatic and supportive measures should be employed.

Pharmacotherapeutic group: Other lipid modifying agents, ATC code: C10A X09
Mechanism of action
Ezetimibe is in a new class of lipid-lowering compounds that selectively inhibit the intestinal
absorption of cholesterol and related plant sterols. Ezetimibe is orally active and has a
mechanism of action that differs from other classes of cholesterol-reducing compounds (e.g.
statins, bile acid sequestrants [resins], fibric acid derivatives, and plant stanols). The molecular
target of ezetimibe is the sterol transporter, Niemann-Pick C1-Like 1 (NPC1L1), which is
responsible for the intestinal uptake of cholesterol and phytosterols.
Ezetimibe localises at the brush border of the small intestine and inhibits the absorption of
cholesterol, leading to a decrease in the delivery of intestinal cholesterol to the liver; statins
reduce cholesterol synthesis in the liver and together these distinct mechanisms provide
complementary cholesterol reduction. In a 2-week clinical study in 18 hypercholesterolaemic
patients, Ezetimibe inhibited intestinal cholesterol absorption by 54%, compared with placebo.
Pharmacodynamic effects
A series of preclinical studies was performed to determine the selectivity of ezetimibe for
inhibiting cholesterol absorption. Ezetimibe inhibited the absorption of [14C]-cholesterol with
no effect on the absorption of triglycerides, fatty acids, bile acids, progesterone, ethinyl
estradiol, or fat-soluble vitamins A and D.
Epidemiologic studies have established that cardiovascular morbidity and mortality vary
directly with the level of total-C and LDL-C and inversely with the level of HDL-C.

Administration of Ezetimibe with a statin is effective in reducing the risk of cardiovascular
events in patients with coronary heart disease and ACS event history.
Clinical efficacy and safety
In controlled clinical studies, Ezetimibe either as monotherapy or co-administered with a statin
significantly reduced total cholesterol (total-C), low-density lipoprotein cholesterol (LDL-C),
apolipoprotein B (Apo B), and triglycerides (TG) and increased high-density lipoprotein
cholesterol (HDL-C) in patients with hypercholesterolaemia.
Primary Hypercholesterolaemia
In a double-blind, placebo-controlled, 8-week study, 769 patients with hypercholesterolaemia
already receiving statin monotherapy and not at National Cholesterol Education Program
(NCEP) LDL-C goal (2.6 to 4.1 mmol/L [100 to 160 mg/dL], depending on baseline
characteristics) were randomised to receive either Ezetimibe 10 mg or placebo in addition to
their on-going statin therapy.
Among statin-treated patients not at LDL-C goal at baseline (~82%), significantly more
patients randomised to Ezetimibe achieved their LDL-C goal at study endpoint compared to
patients randomised to placebo, 72% and 19%, respectively. The corresponding LDL-C
reductions were significantly different (25% and 4% for Ezetimibe versus placebo,
respectively). In addition, Ezetimibe, added to on-going statin therapy, significantly decreased
total-C, Apo B, TG and increased HDL-C, compared with placebo. Ezetimibe or placebo added
to statin therapy reduced median C-reactive protein by 10% or 0% from baseline, respectively.
In two, double-blind, randomised placebo-controlled, 12-week studies in 1719 patients with
primary hypercholesterolaemia, Ezetimibe 10 mg significantly lowered total-C (13%), LDL-C
(19%), Apo B (14%), and TG (8%) and increased HDL-C (3%) compared to placebo. In
addition, Ezetimibe had no effect on the plasma concentrations of fat-soluble vitamins A, D,
and E, no effect on prothrombin time, and, like other lipid lowering agents, did not impair
adrenocortical steroid hormone production.
In a multicenter, double-blind, controlled clinical study (ENHANCE), 720 patients with
heterozygous familial hypercholesterolaemia were randomised to receive ezetimibe 10 mg in

combination with simvastatin 80 mg (n = 357) or simvastatin 80 mg (n = 363) for 2 years. The
primary objective of the study was to investigate the effect of the ezetimibe/simvastatin
combination therapy on carotid artery intima-media thickness (IMT) compared to simvastatin
monotherapy. The impact of this surrogate marker on cardiovascular morbidity and mortality
is still not demonstrated.
The primary endpoint, the change in the mean IMT of all six carotid segments, did not differ
significantly (p = 0.29) between the two treatment groups as measured by B-mode ultrasound.
With ezetimibe 10 mg in combination with simvastatin 80 mg or simvastatin 80 mg alone,
intima-medial thickening increased by 0.0111 mm and 0.0058 mm, respectively, over the
study's 2 year duration (baseline mean carotid IMT 0.68 mm and 0.69 mm respectively.
Ezetimibe 10 mg in combination with simvastatin 80 mg lowered LDL-C, total-C, Apo B, and
TG significantly more than simvastatin 80 mg. The percent increase in HDL-C was similar for
the two treatment groups. The adverse reactions reported for ezetimibe 10 mg in combination
with simvastatin 80 mg were consistent with its known safety profile.
Paediatric population
In a multicentre, double-blind, controlled study, 138 patients (59 boys and 79 girls), 6 to 10
years of age (mean age 8.3 years) with heterozygous familial or non-familial
hypercholesterolaemia (HeFH) with baseline LDL-C levels between 3.74 and 9.92 mmol/L
were randomised to either Ezetimibe 10 mg or placebo for 12 weeks.
At week 12, Ezetimibe significantly reduced total-C (-21% vs. 0%), LDL-C (-28% vs. -1%),
Apo-B (-22% vs. -1%), and non-HDL-C (-26% vs. 0%) compared to placebo. Results for the
two treatment groups were similar for TG and HDL-C (-6% vs. +8%, and +2% vs. +1%,
respectively).
In a multicentre, double-blind, controlled study, 142 boys (Tanner Stage II and above) and 106
postmenarchal girls, 10 to 17 years of age (mean age 14.2 years) with heterozygous familial
hypercholesterolaemia (HeFH) with baseline LDL-C levels between 4.1 and 10.4 mmol/L were
randomised to either Ezetimibe 10 mg co-administered with simvastatin (10, 20 or 40 mg) or
simvastatin (10, 20 or 40 mg) alone for 6 weeks, co-administered Ezetimibe and 40 mg

simvastatin or 40 mg simvastatin alone for the next 27 weeks, and open-label co-administered
Ezetimibe and simvastatin (10 mg, 20 mg, or 40 mg) for 20 weeks thereafter.
At Week 6, Ezetimibe co-administered with simvastatin (all doses) significantly reduced total-
C (38% vs 26%), LDL-C (49% vs 34%), Apo B (39% vs 27%), and non-HDL-C (47% vs 33%)
compared to simvastatin (all doses) alone. Results for the two treatment groups were similar
for TG and HDL-C (-17% vs -12% and +7% vs +6%, respectively). At Week 33, results were
consistent with those at Week 6 and significantly more patients receiving Ezetimibe and 40 mg
simvastatin (62%) attained the NCEP AAP ideal goal (< 2.8 mmol/L [110 mg/dL]) for LDL-C
compared to those receiving 40 mg simvastatin (25%). At Week 53, the end of the open label
extension, the effects on lipid parameters were maintained.
The safety and efficacy of Ezetimibe co-administered with doses of simvastatin above 40 mg
daily have not been studied in paediatric patients 10 to 17 years of age. The safety and efficacy
of Ezetimibe co-administered with simvastatin have not been studied in paediatric patients <
10 years of age.
The long-term efficacy of therapy with Ezetimibe in patients below 17 years of age to reduce
morbidity and mortality in adulthood has not been studied.
Prevention of Cardiovascular Events
The IMProved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT)
was a multicenter, randomised, double-blind, active-control study of 18,144 patients enrolled
within 10 days of hospitalisation for acute coronary syndrome (ACS; either acute myocardial
infarction [MI] or unstable angina [UA]). Patients had an LDL-C ≤ 125 mg/dL (≤ 3.2 mmol/L)
at the time of presentation with ACS if they had not been taking lipid-lowering therapy, or ≤
100 mg/dL (≤ 2.6 mmol/L) if they had been receiving lipid-lowering therapy. All patients were
randomised in a 1:1 ratio to receive either ezetimibe/simvastatin 10/40 mg (n = 9067) or
simvastatin 40 mg (n = 9077) and followed for a median of 6.0 years.
Patients had a mean age of 63.6 years; 76% were male, 84% were Caucasian, and 27% were
diabetic. The average LDL-C value at the time of study qualifying event was 80 mg/dL (2.1
mmol/L) for those on lipid-lowering therapy (n = 6390) and 101 mg/dL (2.6 mmol/L) for those
not on previous lipid-lowering therapy (n = 11594). Prior to the hospitalisation for the qualifying ACS event, 34% of the patients were on statin therapy. At one year, the average
LDL-C for patients continuing on therapy was 53.2 mg/dL (1.4 mmol/L) for the
ezetimibe/simvastatin group and 69.9 mg/dL (1.8 mmol/L) for the simvastatin monotherapy
group. Lipid values were generally obtained for patients who remained on study therapy.
The primary endpoint was a composite consisting of cardiovascular death, major coronary
events (MCE; defined as non-fatal myocardial infarction, documented unstable angina that
required hospitalisation, or any coronary revascularisation procedure occurring at least 30 days
after randomised treatment assignment) and non-fatal stroke. The study demonstrated that
treatment with ezetimibe when added to simvastatin provided incremental benefit in reducing
the primary composite endpoint of cardiovascular death, MCE, and non-fatal stroke compared
with simvastatin alone (relative risk reduction of 6.4%, p = 0.016). The primary endpoint
occurred in 2572 of 9067 patients (7-year Kaplan-Meier [KM] rate 32.72%) in the
ezetimibe/simvastatin group and 2742 of 9077 patients (7-year KM rate 34.67%) in the
simvastatin alone group (see Figure 1 and Table 2). This incremental benefit is expected to be
similar with coadministration of other statins shown to be effective in reducing the risk of
cardiovascular events. Total mortality was unchanged in this high risk group (see Table 2).
There was an overall benefit for all strokes; however there was a small non-significant increase
in haemorrhagic stroke in the ezetimibe-simvastatin group compared with simvastatin alone
(see Table 2). The risk of haemorrhagic stroke for ezetimibe coadministered with higher
potency statins in long-term outcome studies has not been evaluated.
The treatment effect of ezetimibe/simvastatin was generally consistent with the overall results
across many subgroups, including sex, age, race, medical history of diabetes mellitus, baseline
lipid levels, prior statin therapy, prior stroke, and hypertension.
Figure 1: Effect of Ezetimibe/Simvastatin on the Primary Composite Endpoint of
Cardiovascular Death, Major Coronary Event, or Non-fatal Stroke

Table 2
Major Cardiovascular Events by Treatment Group in All Randomised Patients in IMPROVEIT

VZ

outcome	Ezetimibe/Simvastatin 10/40 mga (n = 9067)		Simvastatin 40 mgb (n = 9077)		Hazard Ratio (95% CI)	p-value
	n	K-M % c	n	K-M % c
Primary Composite Efficacy Endpoint
(CV death, Major Coronary Events and non-fatal stroke)	2572	32.72%	2742	34.67%	0.936 (0.887, 0.988)	0.016
Secondary Composite Efficacy Endpoints
CHD death, nonfatal MI, urgent coronary revascularisation after 30 days	1322	7.52%	1448	18.88%	0.912 (0.847, 0.983)	0.016
MCE, non-fatal stroke, death (all causes)	3089	38.65%	3256	40.25%	0.948 (0.903, 0.996)	0.035
CV death, non-fatal MI, unstable angina requiring hospitalisation, any revascularisation, non-fatal stroke	2716	34.49%	2869	36.20%	0.945 (0.897, 0.996)	0.035
Cardiovascular death	537	6.89%	538	6.84%	1.000 (0.887, 1.127)	0.997
Major Coronary Event:
Non-fatal MI	945	12.77%	1083	14.41%	0.871 (0.798, 0.950)	0.002
Unstable angina requiring hospitalisation	156	2.06%	148	1.92%	1.059 (0.846, 1.326)	0.618
Coronary revascularisation after 30 days	1690	21.84%	1793	23.36%	0.947 (0.886, 1.012)	0.107
Non-fatal stroke	245	3.49%	305	4.24%	0.802 (0.678, 0.949)	0.010
All MI (fatal and non-fatal)	977	13.13%	1118	14.82%	0.872 (0.800, 0.950)	0.002
All stroke (fatal and non-fatal)	296	4.16%	345	4.77%	0.857 (0.734, 1.001)	0.052
Non-haemorrhagic stroke d	242	3.48%	305	4.23%	0.793 (0.670, 0.939)	0.007
Haemorrhagic stroke	59	0.77%	43	0.59%	1.377 (0.930, 2.040)	0.110
Death from any cause	1215	1231	15.28%	15.28%	0.989 (0.914, 1.070)	0.782

^a 6% were uptitrated to ezetimibe/simvastatin 10/80 mg.
^b 27% were uptitrated to simvastatin 80 mg.
^c Kaplan-Meier estimate at 7 years.
^d includes ischemic stroke or stroke of undetermined type.
Prevention of Major Vascular Events in Chronic Kidney Disease (CKD)
The Study of Heart and Renal Protection (SHARP) was a multi-national, randomised, placebocontrolled,
double-blind study conducted in 9438 patients with chronic kidney disease, a third
of whom were on dialysis at baseline. A total of 4650 patients were allocated to a fixed dose
combination of Ezetimibe 10 mg with simvastatin 20 mg and 4620 to placebo, and followed
for a median of 4.9 years. Patients had a mean age of 62 and 63% were male, 72% Caucasian,
23% diabetic and, for those not on dialysis, the mean estimated glomerular filtration rate
(eGFR) was 26.5 mL/min/1.73 m2. There were no lipid entry criteria. Mean LDL-C at baseline
was 108 mg/dL. After one year, including patients no longer taking study medication, LDL-C
was reduced 26% relative to placebo by simvastatin 20 mg alone and 38% by Ezetimibe 10 mg
combined with simvastatin 20 mg.
The SHARP protocol-specified primary comparison was an intention-to-treat analysis of
"major vascular events" (MVE; defined as nonfatal MI or cardiac death, stroke, or any
revascularisation procedure) in only those patients initially randomised to the Ezetimibe
combined with simvastatin (n = 4193) or placebo (n = 4191) groups. Secondary analyses
included the same composite analyzed for the full cohort randomised (at study baseline or at
year 1) to Ezetimibe combined with simvastatin (n = 4650) or placebo (n = 4620) as well as
the components of this composite.

The primary endpoint analysis showed that Ezetimibe combined with simvastatin significantly
reduced the risk of major vascular events (749 patients with events in the placebo group vs.
639 in the Ezetimibe combined with simvastatin group) with a relative risk reduction of 16%
(p = 0.001).
Nevertheless, this study design did not allow for a separate contribution of the monocomponent
ezetimibe to efficacy to significantly reduce the risk of major vascular events in patients with
CKD.
The individual components of MVE in all randomised patients are presented in Table 3.
Ezetimibe combined with simvastatin significantly reduced the risk of stroke and any
revascularisation, with non-significant numerical differences favouring Ezetimibe combined
with simvastatin for nonfatal MI and cardiac death.
Table 3
Major Vascular Events by Treatment Group in all randomised patients in SHARP^a

Outcome	Ezetimibe 10 mg combined with simvastatin 20 mg (n = 4650)	Placebo (n = 4620)	Risk Ratio (95% CI)	P-value
Major Vascular Events	701 (15.1%)	814 (17.6%)	0.85 (0.77-0.94)	0.001
Nonfatal MI	134 (2.9%)	159 (3.4%)	0.84 (0.66-1.05)	0.12
Cardiac Death	253 (5.4%)	272 (5.9%)	0.93 (0.78-1.10)	0.38
Any Stroke	171 (3.7%)	210 (4.5%)	0.81 (0.66-0.99)	0.038
Non-haemorrhagic Stroke	131 (2.8%)	174 (3.8%)	0.75 (0.60-0.94)	0.011
Haemorrhagic Stroke	45 (1.0%)	37 (0.8%)	1.21 (0.78-1.86)	0.40
Any Revascularisation	284 (6.1%)	352 (7.6%)	0.79 (0.68-0.93)	0.004
Major     Atherosclerotic     Events (MAE)b	526 (11.3%)	619 (13.4%)	0.83 (0.74-0.94)	0.002

aIntention-to-treat analysis on all SHARP patients randomised to Ezetimibe combined with simvstatin or placebo either at baseline or year 1

b MAE; defined as the composite of nonfatal myocardial infarction, coronary death, non- hemorrhagic stroke, or any revascularisation

The absolute reduction in LDL cholesterol achieved with Ezetimibe combined with simvastatin was lower among patients with a lower baseline LDL-C (<2.5 mmol/L) and patients on dialysis at baseline than the other patients, and the corresponding risk reductions in these two groups were attenuated.

Homozygous Familial Hypercholesterolaemia (HoFH)

 

A double-blind, randomised, 12-week study enrolled 50 patients with a clinical and/or genotypic diagnosis of HoFH, who were receiving atorvastatin or simvastatin (40 mg) with or without concomitant LDL apheresis. Ezetimibe co-administered with atorvastatin (40 or 80 mg) or simvastatin (40 or 80 mg), significantly reduced LDL-C by 15% compared with increasing the dose of simvastatin or atorvastatin monotherapy from 40 to 80 mg.

Homozygous Sitosterolaemia (Phytosterolaemia)

 

In a double-blind, placebo-controlled, 8-week trial, 37 patients with homozygous sitosterolaemia were randomised to receive Ezetimibe 10 mg (n = 30) or placebo (n = 7). Some patients were receiving other treatments (e.g. statins, resins). Ezetimibe significantly lowered the two major plant sterols, sitosterol and campesterol, by 21% and 24% from baseline, respectively. The effects of decreasing sitosterol on morbidity and mortality in this population are not known.

Aortic Stenosis

 

The Simvastatin and Ezetimibe for the Treatment of Aortic Stenosis (SEAS) study was a multi- center, double-blind, placebo-controlled study with a median duration of 4.4 years conducted in 1873 patients with asymptomatic aortic stenosis (AS), documented by Doppler-measured aortic peak flow velocity within the range of 2.5 to 4.0 m/s. Only patients who were considered not to require statin treatment for purposes of reducing atherosclerotic cardiovascular disease

risk were enrolled. Patients were randomised 1:1 to receive placebo or co-administered ezetimibe 10 mg and simvastatin 40 mg daily.

The primary endpoint was the composite of major cardiovascular events (MCE) consisting of cardiovascular death, aortic valve replacement (AVR) surgery, congestive heart failure (CHF) as a result of progression of AS, nonfatal myocardial infarction, coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), hospitalisation for unstable angina, and nonhaemorrhagic stroke. The key secondary endpoints were composites of subsets of the primary endpoint event categories.

Compared to placebo, ezetimibe/simvastatin 10/40 mg did not significantly reduce the risk of MCE. The primary outcome occurred in 333 patients (35.3%) in the ezetimibe / simvastatin group and in 355 patients (38.2%) in the placebo group (hazard ratio in the ezetimibe / simvastatin group, 0.96; 95% confidence interval, 0.83 to 1.12; p = 0.59). Aortic valve replacement was performed in 267 patients (28.3%) in the ezetimibe / simvastatin group and in 278 patients (29.9%) in the placebo group (hazard ratio, 1.00; 95% CI, 0.84 to 1.18; p = 0.97). Fewer patients had ischemic cardiovascular events in the ezetimibe / simvastatin group (n = 148) than in the placebo group (n = 187) (hazard ratio, 0.78; 95% CI, 0.63 to 0.97; p = 0.02), mainly because of the smaller number of patients who underwent coronary artery bypass grafting.

Cancer occurred more frequently in the ezetimibe / simvastatin group (105 versus 70, p = 0.01). The clinical relevance of this observation is uncertain as in the bigger SHARP trial the total number of patients with any incident cancer (438 in the ezetimibe/ simvastatin versus 439 placebo group) did not differ. In addition, in the IMPROVE-IT trial the total number of patients with any new malignancy (853 in the ezetimibe/simvastatin group versus 863 in the simvastatin group) did not differ significantly and therefore the finding of SEAS trial could not be confirmed by SHARP or IMPROVE-IT.

Absorption

After oral administration, ezetimibe is rapidly absorbed and extensively conjugated to a pharmacologically active phenolic glucuronide (ezetimibe-glucuronide). Mean maximum

 

 

plasma concentrations (Cmax) occur within 1 to 2 hours for ezetimibe-glucuronide and 4 to 12 hours for ezetimibe. The absolute bioavailability of ezetimibe cannot be determined as the compound is virtually insoluble in aqueous media suitable for injection.

Concomitant food administration (high fat or non-fat meals) had no effect on the oral bioavailability of ezetimibe when administered as Ezetimibe 10 mg tablets. Ezetimibe can be administered with or without food.

Distribution

 

Ezetimibe and ezetimibe-glucuronide are bound 99.7% and 88 to 92% to human plasma proteins, respectively.

Biotransformation

 

Ezetimibe is metabolised primarily in the small intestine and liver via glucuronide conjugation (a phase II reaction) with subsequent biliary excretion. Minimal oxidative metabolism (a phase I reaction) has been observed in all species evaluated. Ezetimibe and ezetimibe-glucuronide are the major drug-derived compounds detected in plasma, constituting approximately 10 to 20% and 80 to 90% of the total drug in plasma, respectively. Both ezetimibe and ezetimibe- glucuronide are slowly eliminated from plasma with evidence of significant enterohepatic recycling. The half-life for ezetimibe and ezetimibe-glucuronide is approximately 22 hours.

Elimination

 

Following oral administration of 14C-ezetimibe (20 mg) to human subjects, total ezetimibe accounted for approximately 93% of the total radioactivity in plasma. Approximately 78% and 11% of the administered radioactivity were recovered in the faeces and urine, respectively, over a 10-day collection period. After 48 hours, there were no detectable levels of radioactivity in the plasma.

Special Populations Paediatric population

The pharmacokinetics of ezetimibe are similar between children ≥ 6 years and adults. Pharmacokinetic data in the paediatric population < 6 years of age are not available. Clinical

 

 

experience in paediatric and adolescent patients includes patients with HoFH, HeFH, or sitosterolaemia.

Elderly

 

Plasma concentrations for total ezetimibe are about 2-fold higher in the elderly (≥ 65 years) than in the young (18 to 45 years). LDL-C reduction and safety profile are comparable between elderly and young subjects treated with Ezetimibe. Therefore, no dosage adjustment is necessary in the elderly.

Hepatic impairment

 

After a single 10-mg dose of ezetimibe, the mean AUC for total ezetimibe was increased approximately 1.7-fold in patients with mild hepatic impairment (Child-Pugh score 5 or 6), compared to healthy subjects. In a 14-day, multiple-dose study (10 mg daily) in patients with moderate hepatic impairment (Child-Pugh score 7 to 9), the mean AUC for total ezetimibe was increased approximately 4-fold on Day 1 and Day 14 compared to healthy subjects. No dosage adjustment is necessary for patients with mild hepatic impairment. Due to the unknown effects of the increased exposure to ezetimibe in patients with moderate or severe (Child-Pugh score

> 9) hepatic impairment, Ezetimibe is not recommended in these patients (see section 4.4). Renal impairment

After a single 10-mg dose of ezetimibe in patients with severe renal disease (n=8; mean CrCl

≤ 30 mL/min/1.73 m2), the mean AUC for total ezetimibe was increased approximately 1.5- fold, compared to healthy subjects (n = 9). This result is not considered clinically significant. No dosage adjustment is necessary for renally impaired patients.

An additional patient in this study (post-renal transplant and receiving multiple medications, including ciclosporin) had a 12-fold greater exposure to total ezetimibe.

Gender

 

Plasma concentrations for total ezetimibe are slightly higher (approximately 20%) in women than in men. LDL-C reduction and safety profile are comparable between men and women treated with Ezetimibe. Therefore, no dosage adjustment is necessary on the basis of gender.

Animal studies on the chronic toxicity of ezetimibe identified no target organs for toxic effects. In dogs treated for four weeks with ezetimibe (≥ 0.03 mg/kg/day) the choles-terol concentration in the cystic bile was increased by a factor of 2.5 to 3.5. However, in a one-year study on dogs given doses of up to 300 mg/kg/day no increased inci-dence of cholelithiasis or other hepatobiliary effects were observed. The significance of these data for humans is not known. A lithogenic risk associated with the therapeutic use of Ezetimibe cannot be ruled out.

 

In co-administration studies with ezetimibe and statins the toxic effects observed were essentially those typically associated with statins. Some of the toxic effects were more pronounced than observed during treatment with statins alone. This is attributed to pharmacokinetic and pharmacodynamic interactions in co-administration therapy. No such interactions occurred in the clinical studies. Myopathies occurred in rats only after exposure to doses that were several times higher than the human therapeutic dose (approximately 20 times the AUC level for statins and 500 to 2000 times the AUC level for the active metabolites).

 

In a series of in vivo and in vitro assays ezetimibe, given alone or co-administered with statins, exhibited no genotoxic potential. Long-term carcinogenicity tests on ezetimibe were negative.

 

Ezetimibe had no effect on the fertility of male or female rats, nor was it found to be teratogenic in rats or rabbits, nor did it affect prenatal or postnatal development. Ezetimibe crossed the placental barrier in pregnant rats and rabbits given multiple doses of 1000 mg/kg/day. The co- administration of ezetimibe and statins was not teratogenic in rats. In pregnant rabbits a small number of skeletal deformities (fused thoracic and caudal vertebrae, reduced number of caudal vertebrae) were observed. The co-administration of ezetimibe with lovastatin resulted in embryolethal effects.

Lactose Monohydrate Microcrystalline Cellulose Croscarmellose

Sodium Povidoe K29/32

Sodium Lauryl Sulphate Magnesium stearate Purified Water

Not applicable.

2 years

Do not store above 30 °C.

Keep out of reach and sight of children.

Immediate Container: 3X10’s tablets packed in Alu – PVC/PVDC blister

Secondary Container: Carton with PIL

No special requirements.