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نشرة الممارس الصحي نشرة معلومات المريض بالعربية نشرة معلومات المريض بالانجليزية صور الدواء بيانات الدواء
  SFDA PIL (Patient Information Leaflet (PIL) are under review by Saudi Food and Drug Authority)

Cholib contains two different active substances: fenofibrate (belongs to the group called ‘fibrates’) and simvastatin (belongs to the group called ‘statins’). They are both used to lower levels of total cholesterol, “bad” cholesterol (LDL cholesterol), and fatty substances called triglycerides in the blood. In addition, they both raise levels of “good” cholesterol (HDL cholesterol).

 

What should I know about cholesterol and triglycerides?

 

Cholesterol is one of several fats found in your blood. Your total cholesterol is made up mainly of LDL and HDL cholesterol.

 

LDL cholesterol is often called ‘bad’ cholesterol because it can build up in the walls of your arteries and form plaque. Over time, this plaque build-up can lead to a clogging of your arteries.

 

HDL cholesterol is often called ‘good’ cholesterol because it helps keep the ‘bad’ cholesterol from building up in the arteries and because it protects against heart disease.

 

Triglycerides are another fat in your blood. They may raise your risk of having heart problems.

 

In most people, there are no signs of cholesterol or triglycerides problems at first. Your doctor can measure your lipids with a simple blood test. Visit your doctor regularly to keep track of your lipids level.

 

Cholib is used in adults at high risk of problems like heart attack and stroke who have high blood levels of 2 types of fats (triglycerides and LDL cholesterol). It is given to lower triglycerides and

 

increase the good cholesterol (HDL cholesterol) in patients whose bad cholesterol (LDL cholesterol) is already controlled with simvastatin alone in a dose of 20 mg.

 

You must continue a low fat diet or other measures (e.g. exercise, weight reduction) during treatment with Cholib.


1.                  Do not take Cholib:

·               If you are allergic to fenofibrate or simvastatin or any of the other ingredients of Cholib (listed in section 6)

·               If you are allergic to peanut, arachis oil, soya lecithin or related substances

·               If while taking other medicines, you have had an allergic reaction or skin damage from sunlight or UV light (these medicines include other fibrates and an anti-inflammatory medicine called “ketoprofen”)

·               If you have liver or gallbladder problems

·               If you have pancreatitis (inflamed pancreas which causes abdominal pain), which is not caused by high levels of fats in the blood

·               If you have moderate or severe kidney problems

·               If you have a history of muscle problems during treatment to lower the level of fats in the blood with either of the active substances in this medicine, or with other statins (such as atorvastatin, pravastatin or rosuvastatin) or fibrates (such as bezafibrate or gemfibrozil)

·               If you are already taking the following medicines:

o     danazol (a man-made hormone used to treat endometriosis)

o     ciclosporin (a medicine often used in organ transplant patients)

o     itraconazole, ketoconazole, fluconazole or posaconazole (medicines for fungal infections)

o     HIV protease inhibitors such as indinavir, nelfinavir, ritonavir and saquinavir (medicines used for HIV infection and AIDS)

o     erythromycin, clarithromycin, or telithromycin (medicines for bacterial infections)

o     nefazodone (a medicine for depression)

·               If you are already being treated and will continue your treatment with:

o     a fibrate (e.g. gemfibrozil)

o     a statin (medicines to lower the levels of fats in the blood, e.g. simvastatin, atorvastatin)

·               If you are under 18 years of age

·               If you are pregnant or breast-feeding

 

Do not take Cholib if any of the above applies to you. Check with your doctor or pharmacist if you are not sure.

 

Warnings and precautions:

 

Talk to your doctor or pharmacist before taking Cholib if:

 

·               you have an underactive thyroid gland (hypothyroidism)

·               you are due to have an operation. You may need to stop taking Cholib for a short time.

·               you drink large amounts of alcohol (more than 21 units (210 mL) a week of pure alcohol)

·               you have chest pain and are feeling breathless. These may be signs of a blood clot in the lung (pulmonary embolism)

·               you have severe lung disease

·               you have kidney disease

·               you or a close family member have a muscle problem which runs in the family

 

·               you are taking or, in the last 7 days, have taken or been given a medicine called fusidic acid (a medicine for bacterial infection)

 

If any of the above applies to you, talk to your doctor or pharmacist before taking Cholib. Check with your doctor or pharmacist if you are not sure.

 

Also tell your doctor or pharmacist if you have a muscle weakness that is constant. Additional tests and medicines may be needed to diagnose and treat this.

 

Your doctor should do a blood test before you start taking Cholib. This is to check how well your liver is working.

 

Your doctor may also want you to have blood tests to check how well your liver is working after you start taking Cholib.

 

While you are on this medicine your doctor will monitor you closely if you have diabetes or are at risk of developing diabetes. You are likely to be at risk of developing diabetes if you have high levels of sugars and fats in your blood, are overweight and have high blood pressure.

 

Your doctor may do a blood test to check your muscles before and after starting treatment.

 

Children and adolescents

 

Cholib must not be given to children and adolescents (age below 18 years).

 

Other medicines and Cholib:

 

It is particularly important to tell your doctor or pharmacist if you are taking, have recently taken or might take any other medicines. This also concerns medicines obtained without a prescription including herbal medicines.

 

Tell your doctor or pharmacist if you are taking any of the following medicines:

 

o      danazol (a man-made hormone used to treat endometriosis)

o      ciclosporin (a medicine often used in organ transplant patients)

o      itraconazole, ketoconazole, fluconazole or posaconazole (medicines for fungal infections)

o      HIV protease inhibitors such as indinavir, nelfinavir, ritonavir and saquinavir (medicines used for HIV infection and AIDS)

o      erythromycin, clarithromycin, or telithromycin (medicines for bacterial infections)

o      nefazodone (a medicine for depression) o  a fibrate (e.g. fenofibrate, gemfibrozil) o    a statin (e.g. simvastatin, atorvastatin)

 

Do not take Cholib if any of the above applies to you. Check with your doctor or pharmacist if you are not sure.

 

In particular tell your doctor or pharmacist if you are taking any of the following medicines (taking Cholib with any of these medicines can increase the risk of muscle problems):

 

·               high doses of at least 1 gram per day of niacin (nicotinic acid) or a treatment containing niacin (medicine for lowering fat levels in the blood)

·               colchicine (a medicine used to treat gout)

 

Do not take fusidic acid (a medicine for bacterial infections) while using this medicine.

 

As well as the medicines listed previously, tell your doctor or pharmacist if you are taking, have recently taken or might take any of the following medicines:

 

·               anticoagulants such as warfarin, fluindione, phenprocoumone or acenocoumarol (medicines to prevent blood clots)

·               pioglitazone (a particular class of medicines to treat diabetes)

·               rifampicin (a medicine used to treat tuberculosis)

 

If any of the above applies to you, talk to your doctor or pharmacist before taking Cholib. Check with your doctor or pharmacist if you are not sure.

 

Cholib with food and drink

 

Grapefruit juice contains one or more components that alter how the body uses Cholib. Do not consume grapefruit juice with Cholib as it may increase your risk of muscle problems.

 

Pregnancy and breast-feeding

 

·               Do not take Cholib if you are pregnant, trying to get pregnant or think you may be pregnant. If you get pregnant while taking Cholib, stop taking it immediately and contact your doctor.

·               Do not take Cholib if you are breast-feeding or plan to breast-feed your baby, because it is not known if the medicine passes into breast milk.

 

If you are pregnant or breast-feeding, think you may be pregnant or are planning to have a baby, ask your doctor or pharmacist for advice before taking this medicine.

 

Driving and using machines

 

Cholib is not expected to affect you being able to drive or use tools or machines. However, it should be taken into account that some people get dizzy after taking Cholib.

 

Important information about some of the ingredients of Cholib

 

Cholib contains types of sugars called lactose and sucrose. If you have been told by your doctor that you have an intolerance to some sugars, talk to your doctor before taking this medicine.

 

Cholib contains soya lecithin. If you are allergic to peanut, soya or arachis oil do not use Cholib. Cholib contains sunset yellow FCF (E110) that may cause allergic reactions.


Always take this medicine exactly as your doctor or pharmacist has told you. Check with your doctor or pharmacist if you are not sure.

 

Your doctor will determine the appropriate strength for you, depending on your condition, your current treatment and your personal risk status.

The usual dose is one tablet per day.

You can take Cholib with or without food. Swallow the tablet with a glass of water. Do not crush or chew the tablet.

 

You should continue a low-fat diet or other measures (e.g. exercise, weight reduction) whilst taking Cholib.

 

If you take more Cholib than you should

 

If you have taken more Cholib than you should or if someone else has taken your medicine, tell your doctor or pharmacist or contact your nearest hospital

 

If you forget to take Cholib

 

Do not take a double dose to make up for a forgotten tablet. Take the next tablet at your regular time on the next day. If you are worried about this, talk to your doctor or pharmacist.

 

If you have any further questions on the use of this medicine, ask your doctor or pharmacist.

 

 


Like all medicines, Cholib can cause side effects, although not everybody gets them.

 

·               Unexplained muscle pain, tenderness, or weakness may be sign of muscle break down. Therefore please contact your doctor immediately if you experience these symptoms. This is because on rare occasions, there have been cases of serious muscle problems including muscle breakdown resulting in kidney damage; and very rare deaths have occurred. Compared to a fibrate or a statin alone, the risk of muscle breakdown is increased when you take these 2 medicines together, as in Cholib. It is higher in female patients or in patients 65 years or older.

 

Some patients have experienced the following serious side effects whilst taking fenofibrate or simvastatin (both active substances in Cholib):

 

·               allergic reaction - the signs may include swelling of the face, lips, tongue or throat, which may cause difficulty in breathing

·               Hypersensitivity reaction to Cholib with symptoms like: pain or inflammation of the joints, inflammation of blood vessels, unusual bruising, skin eruptions and swelling, hives, skin sensitivity to the sun, fever, flushing, shortness of breath and feeling unwell, lupus-like disease picture (including rash, joint disorders, and effects on white blood cells)

·               cramps or painful, tender or weak muscles - these may be signs of muscle inflammation or breakdown, which can cause kidney damage or even death

·               stomach pain - this may be a sign that your pancreas is inflamed (pancreatitis)

·               chest pain and feeling breathless - these may be signs of a blood clot in the lung (pulmonary embolism)

·               pain, redness or swelling in the legs - these may be signs of a blood clot in the leg (deep vein thrombosis)

·               yellowing of the skin and whites of the eyes (jaundice), or an increase in liver enzymes - these may be signs of an inflamed liver (hepatitis and hepatic failure)

·               increased sensitivity of your skin to sunlight, sun lamps and sunbeds

 

If any of the previously listed serious side effects happen, stop taking Cholib and tell your doctor immediately or go to the emergency room at your nearest hospital - you may need urgent medical treatment.

 

Some patients have experienced the following side effects whilst taking Cholib, fenofibrate or simvastatin:

 

Very common side effects (may affect more than 1 in 10 people):

 

·               Increase in the blood level of “creatinine” (substance excreted by the kidneys)

·               Increase in blood levels of “homocysteine” (too much of this amino acid in the blood is related to a higher risk of coronary heart disease, stroke and peripheral vascular disease, although a causal link has not been established)

 

Common side effects (may affect up to 1 in 10 people):

 

·               increase in blood platelets count

·               elevations in blood tests of liver function (transaminases)

·               digestive disturbances (stomach pain, nausea, vomiting, diarrhoea and flatulence)

·               infection of the upper respiratory tract

 

Uncommon side effects (may affect up to 1 in 100 people):

 

·               muscle problems

·               gallstones

·               rashes, itching, red patches on the skin

·               headache

·               sexual difficulties

 

Rare side effects (may affect up to 1 in 1,000 people):

 

·               low red blood cell count (anaemia)

·               numbness or weakness of the arms and legs

·               confusion

·               feeling dizzy

·               feeling exhausted (astenia)

·               increase in “urea” - produced by the kidneys - shown in tests

·               increase in “gamma-glutamyltransferase” - produced by the liver - shown in tests

·               increase in “alkaline phosphatase” - produced by the bile system - shown in tests

·               increase in “creatine phosphokinase” - produced by the muscle - shown in tests

·               drop in haemoglobin (that carries oxygen in blood) and white blood cells- shown in tests

·               trouble sleeping

·               poor memory or memory loss

·               hair loss

·               constipation

·               dyspepsia

 

The following side effects have also been reported but the frequency cannot be estimated from the available information (frequency not known):

 

·               severe allergic skin rash with blisters

·               complications of gall stones such as colic because of stones in bile duct, infection of the bile ducts or gall bladder

·               diabetes mellitus

·               erectile dysfunction

·               feeling depressed

·               sleep disturbances including nightmares

·               specific lung disease with difficulties breathing (called interstitial lung disease)

·               muscle weakness that is constant

 

·               increase in “glycosylated haemoglobin” and blood glucose levels - markers for blood glucose control in diabetes mellitus - shown in tests

 

Reporting of side effects

 

If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects not listed in this leaflet.

 

To report any side effect(s):

- National Pharmacovigilance Center (NPC)

o    Fax: +966-11-205-7662

o    SFDA Call Center: 19999

o    E-mail: npc.drug@sfda.gov.sa

o    Website: https://ade.sfda.gov.sa


Keep this medicine out of the sight and reach of children.

 

Shelf Life: 24 months

 

Do not use Cholib after the expiry date which is stated on the carton and the blister after EXP. The expiry date refers to the last day of that month.

 

Store below 30°C.

 

Do not throw away any medicines via wastewater or household waste. Ask your pharmacist how to throw away medicines you no longer use. These measures will help protect the environment.


The active substances are fenofibrate and simvastatin. Each tablet contains 145 mg of fenofibrate and 20 mg of simvastatin.

The other ingredients are: Tablet core:

Butylhydroxyanisole (E320), lactose monohydrate, sodium laurilsulfate, starch, pregelatinised (maize), docusate sodium, sucrose, citric acid monohydrate (E330), hypromellose (E464), crospovidone (E1202), magnesium stearate (E572), silicified microcrystalline cellulose (comprised of cellulose, microcrystalline and silica, colloidal anhydrous), ascorbic acid (E300).

 

Film-coat:

Poly (vinyl alcohol), partially hydrolysed (E1203), titanium dioxide (E171), talc (E553b), lecithin (derived from soya bean (E322)), xanthan gum (E415), iron oxide red (E172), iron oxide yellow (E172), sunset yellow FCF (E110).


The film-coated tablet (tablet) is a, oval, biconvex, tan coloured 19.3 x 9.3 mm tablet with beveled edges and the inscription 145/20 on one side. The tablets are provided in carton boxes with blisters containing 10, 30 or 90 tablets. Not all pack sizes may be marketed.

Marketing Authorisation Holder:

Abbott Laboratories Ltd.

Abbott House, Vanwall Business park

Vanwall Road, Maidenhead Berkshire

SL6 4XE, UK

 

Manufacturer:

Fournier Laboratories Ireland Limited, cork, Ireland.

 

Packaged by:

Mylan Laboratories SAS, Route de Belleville - Lieu-dit Maillard, 01400 Châtillon-sur- Chalaronne - France.


04/2023
  نشرة الدواء تحت مراجعة الهيئة العامة للغذاء والدواء (اقرأ هذه النشرة بعناية قبل البدء في استخدام هذا المنتج لأنه يحتوي على معلومات مهمة لك)

تحتوي أقراص كوليب على مادتين  فعالتين: مادة فينوفيبرات (والتي تنتمي إلى مجموعة يُطلق عليها "الفيبرات") ومادة سيمفاستاتين (والتي تنتمي إلى مجموعة يُطلق عليها "الستاتينات"). وتُستخدَم كلتا المادتين لخفض مستويات الكوليستيرول  الكلي، ومستويات الكوليستيرول "الضار" (الكوليستيرول الشحمي منخفض الكثافة)، فضلاً عن المواد الدهنية التي يُطلق عليها الدهون الثلاثية في الدم. بالإضافة إلى ذلك، تؤدي تلك المادتان إلى رفع مستويات الكوليستيرول " المفيد" (الكوليستيرول الشحمي مرتفع الكثافة).

 

ما الذي ينبغي معرفته عن الكوليستيرول والدهون الثلاثية؟

 

الكوليستيرول إحدى صور  عدة دهون موجودة في الدم. ويتكون الكوليستيرول  الكلي في الأساس من الكوليستيرول الشحمي منخفض الكثافة والكوليستيرول الشحمي مرتفع الكثافة.

 

ويُطلق على الكوليستيرول الشحمي منخفض الكثافة غالبًا اسم الكوليستيرول"الضار"؛ إذ قد يتراكم في جدران الشرايين، ويؤدي إلى تكوّن طبقة. وبمرور الوقت، قد يؤدي تراكم هذه الطبقة إلى انسداد في الشرايين.

 

ويُطلق على الكوليستيرول الشحمي مرتفع الكثافة غالبًا اسم الكوليستيرول " المفيد"؛ إذ يساعد في منع الكوليستيرول "الضار" من التراكم في الشرايين، كما يساعد في الوقاية من الإصابة بأمراض القلب.

 

وتمثّل الدهون الثلاثية صورة أخرى من صور الدهون في الدم. وقد تؤدي إلى ارتفاع خطر التعرّض لمشكلات في القلب.

 

ولا تظهر بوادر المشكلات في الكوليستيرول أو الدهون الثلاثية مع أغلب الناس في بادئ الأمر. ويمكن أن يقيس الطبيب الدهون في جسم المريض عن طريق اختبار بسيط في الدم. لذا؛ يُرجى زيارة الطبيب بانتظام لمتابعة مستوى الدهون في الجسم.

 

وتُستعمَل أقراص كوليب مع البالغين الذين يعانون من ارتفاع خطورة الإصابة بمشكلات من بينها النوبات القلبية والسكتة الدماغية، والذين يعانون من ارتفاع مستويات نوعين من الدهون في الدم (الدهون الثلاثية والكوليستيرول الشحمي منخفض الكثافة). وتُعطى الأقراص لخفض الدهون الثلاثية وزيادة الكوليستيرول "المفيد" (الكوليستيرول الشحمي مرتفع الكثافة) مع المرضى  الذين لديهم الكوليستيرول "الضار" (الكوليستيرول الشحمي منخفض الكثافة) منضبط بالفعل باستخدام العلاج  بمادة السيمفاستاتين وحدها في جرعة تبلغ 20 ملجم.

 

لذا؛ يجب على المريض أن يستمر في حمية غذائية منخفضة الدهون أو أي تدابير أخرى (مثل التمرينات الرياضية  و إنقاص الوزن) في أثناء العلاج باستخدام أقراص كوليب.

يجب تجنّب تناول أقراص كوليب في الحالات التالية:

o              إذا كان المريض يعاني من الحساسية تجاه مادة الفينوفيبرات أو مادة السيمفاستاتين أو أي مكون آخر من مكونات هذا الدواء (والمدرجة في القسم 6)

o              إذا كان المريض يعاني من الحساسية تجاه الفول السوداني أو زيت الفول السوداني أو ليسيثين فول الصويا أو مواد أخرى ذات صلة.

o              إذا تعرض المريض، في أثناء تناول الأدوية الأخرى، لتفاعل حساسية أو ضرر في البشرة من ضوء الشمس أو الأشعة فوق البنفسجية (تشمل هذه الأدوية الفيبرات الأخرى ودواءً مضادًا للالتهاب يُسمى "كيتوبروفين")

o              إذا كان المريض يعاني من مشكلات بالكبد أو المرارة

o              إذا كان المريض مصابًا بالتهاب البنكرياس (بنكرياس ملتهب يؤدي إلى ألم في المعدة)،  والذي لم يحدث بسبب ارتفاع مستويات الدهون في الدم

o              إذا كان المريض يعاني من مشكلات متوسطة أو شديدة بالكلى

o              إذا كان المريض قد سبق له التعرّض لمشكلات في العضلات في أثناء العلاج لخفض مستوى الدهون في الدم، إما  بسبب المواد الفعالة في هذه الأقراص، أو باستخدام أدوية الستاتينات الأخرى (مثل أتورفاستاتين أو برافاستاتين أو  روزوفاستاتين) أو باستخدام الفيبرات  (مثل بيزافيبرات أو جمفبروزيل)

o              إذا كان المريض يتناول الأدوية التالية بالفعل:

o              الدانازول (هرمونمصنع  يُستخدم لعلاج بطانة الرحم المهاجرة)

o            السيكلوسبورين (أحد الأدوية التي غالبًا ما تُستخدم مع مرضى زراعة الأعضاء)

o            الإيتراكونازول أو الكيتوكونازول أو الفلوكونازول أو البوساكونازول (أدوية لعلاج عدوى الفطريات)

o            مثبطات بروتياز فيروس نقص المناعة البشرية، مثل الأندينافير والنيلفينافير والريتونافير والساكوينافير (أدوية تُستخدم مع عدوى فيروس نقص المناعة البشرية ومرض الأيدز)

o            دواء الإريثروميسين  أو الكلاريثروميسين أو التيليثرومايسين (أدوية لعلاج العدوى البكتيرية)

o            النفازودون (دواء للاكتئاب)

o              إذا كان المريض قد خضع بالفعل للعلاج و سيستمر فيه بما يلي:

o            أحد أدوية الفيبرات (مثل الجمفبروزيل)

o            أحد أدوية الستاتين (أدوية لخفض مستويات الدهون في الدم، مثل السيمفاستاتين والأتورفاستاتين)

o               إذا كان عمر المريض أقل من 18 عامًا

o              إذا كانت المريضة حاملاً أو ترضع رضاعةً طبيعية

 

يجب تجنّب تناول كوليب إذا انطبق عليك أي مما سبق. واستشير الطبيب أو الصيدلي إذا لم تكون متأكد.

 

تحذيرات واحتياطات:

 

تحدث إلى الطبيب أو الصيدلي قبل تناول دوائك في الحالات التالية:

 

o              إذا كان المريض مصابًا  بمرض إنخفاض نشاط الغدة الدرقية (قصورالغدة الدرقية)

o              إذا اقترب موعد إجراء المريض لعملية جراحية. ربما يحتاج المريض إلى التوقف عن تناول أقراص كوليب لمدة قصيرة.

o              إذا كان المريض يشرب كميات كبيرة من المشروبات الكحولية (أكثر من 21 وحدة (210 ملليلترات) من الكحول النقي في الأسبوع)

o              إذا كان المريض مصابًا بألم في الصدر، أو يشعر بصعوبة في التنفس. قد تكون هذه علامات على الإصابة بجلطة دموية في الرئة ( الانسداد الرئوي)

o              إذا كان المريض يعاني من مرض شديد بالرئة

o              إذا كان المريض يعاني من مرض بالكلى

o              إذا كان المريض أو أحد أفراد أسرته المقربين قد تعرّضوا لمشكلة في العضلات و التي تنتشر بين أفراد الأسرة

 

o              إذا كان المريض يتناول، أو تناول خلال الأيام السبعة المنقضية، أحد الأدوية التي يُطلق عليها حمض الفوسيديك (أحد الأدوية لعلاج العدوى البكتيرية)

 

إذا انطبق على المريض أي من الأمور المذكورة أعلاه، فيُرجى التحدث إلى الطبيب أو الصيدلي قبل تناول أقراص كوليب. واستشر الطبيب أو الصيدلي إذا لم تكن متأكدًا.

 

يُرجى أيضًا إبلاغ الطبيب أو الصيدلي إذا كان المريض يعاني من ضعف مستمر في العضلات. وقد يلزم إجراء مزيد من الاختبارات والخضوع للعلاج بالأدوية لتشخيص المرض وعلاجه.

 

وينبغي أن يُجري الطبيب اختبارًا للدم قبل أن يبدأ المريض في تناول أقراص كوليب. وهذا لمراجعة مدى كفاءة عمل الكبد لدى المريض.

 

وقد يطلب الطبيب أيضًا من المريض إجراء اختبارات للدم لفحص مدى كفاءة عمل الكبد بعد البدء في تناول أقراص كوليب.

 

وفي أثناء الخضوع للعلاج بهذا الدواء،  سيتابع الطبيب مريضه عن كثب إذا كان  المريض يعاني من  أو معرض لخطر الإصابة بمرض السكّري. ومن المحتمل أن يتعرّض المريض لخطورة الإصابة بمرض السكّري إذا كان يعاني من ارتفاع مستويات السكر والدهون في الدم، ومن الوزن الزائد، ومن ارتفاع ضغط الدم.

 

وقد يُجري الطبيب اختبارًا للدم لفحص عضلات المريض قبل بدء العلاج وبعده.

 

الأطفال والمراهقون

 

يجب عدم إعطاء أقراص كوليب للأطفال والمراهقين (الأقل من 18 عامًا).

 

الأدوية الأخرى وأقراص كوليب:

 

من المهم إبلاغ الطبيب أو الصيدلي إذا كان المريض يتناول أي أدوية أخرى أو سبق أن تناولها مؤخرًا أو قد يتناولها. ويشمل هذا أيضًا الأدوية التي تؤخذ من دون وصفة طبية، بما في ذلك الأدوية العشبية.

 

 يُرجى إبلاغ الطبيب أو الصيدلي إذا كان المريض يتناول أي دواء من الأدوية التالية:

 

o              الدانازول (هرمون مصنع يُستخدم لعلاج بطانة الرحم المهاجرة)

o              السيكلوسبورين (أحد الأدوية التي غالبًا ما تُستخدم مع مرضى زراعة الأعضاء)

o              الإيتراكونازول أو الكيتوكونازول أو الفلوكونازول أو البوساكونازول (أدوية لعلاج عدوى الفطريات)

o              مثبطات بروتياز فيروس نقص المناعة البشرية، مثل الأندينافير والنيلفينافير والريتونافير والساكوينافير (أدوية تُستخدم مع عدوى فيروس نقص المناعة البشرية ومرض الأيدز)

o              دواء الإريثروميسين  أو الكلاريثروميسين أو التيليثرومايسين (أدوية لعلاج العدوى البكتيرية)

o              النفازودون (دواء للاكتئاب)

o              أحد أدوية الفيبرات (مثل الفينوفيبرات،الجمفبروزيل)

o              أحد أدوية الستاتينات (مثل السيمفاستاتين،الأتورفاستاتين)

 

يجب تجنّب تناول هذا الدواء إذا انطبق عليك أي مما سبق. واستشر الطبيب أو الصيدلي إذا لم تكن متأكدًا.

 

وعلى وجه التحديد، يُرجى إبلاغ الطبيب أو الصيدلي إذا كان المريض يتناول أيًا من الأدوية التالية (فقد يزيد تناول أقراص كوليب مع أي من هذه الأدوية من خطورة التعرّض لمشكلات العضلات):

 

o              جرعات مرتفعة تبلغ 1 جم على الأقل في اليوم من النياسين (حمض النيكوتينيك) أو علاج يحتوي على النياسين (أحد الأدوية التي تخفّض مستويات الدهون في الدم)

o              الكولشيسين (دواء يُستخدم لعلاج النقرس)

 

يُرجى عدم تناول حمض الفوسيديك (أحد الأدوية لعلاج العدوى البكتيرية) في أثناء تناول هذا الدواء.

 

بجانب الأدوية التي سبق ذكرها، يُرجى إبلاغ الطبيب أو الصيدلي في حالة تناول أي من الأدوية التالية، أو سبق تناولها، أو ربما يتناولها المريض:

 

o              الأدوية المضادة للتجلط، مثل الوارفارين أو الفلوينديون أو الفينبروكومون أو الأسينوكومارول (الأدوية التي تقي من الإصابة بجلطات الدم)

o              البيوغليتازون (فئة معينة من الأدوية لعلاج مرض السكري)

o              الريفامبيسين (دواء يُستخدم لعلاج مرض السل)

 

إذا انطبق على المريض أي من الأمور المذكورة أعلاه، فيُرجى التحدث إلى الطبيب أو الصيدلي قبل تناول أقراص كوليب. واستشر الطبيب أو الصيدلي إذا لم تكن متأكدًا.

 

تناول كوليب مع الطعام والشراب

 

يحتوي عصير الجريب فروت على مكوّن أو أكثر يغيّر من كيفية استخدام الجسم لأقراص كوليب. لذا؛ يُرجى عدم تناول عصير الجريب فروت مع أقراص كوليب؛ إذ قد تؤدي إلى زيادة خطورة الإصابة بمشكلات في العضلات.

 

الحمل والرضاعة الطبيعية

 

o               يجب عدم تناول أقراص كوليب إذا كانت المريضة حاملاً أو تخطط للحمل أو تظن أنها من الممكن أن تكون حاملاً. إذا أصبحت المريضة حاملاً في أثناء خضوعها للعلاج بأقراص كوليب، فيجب التوقف عن تناول الأقراص فورًا، والاتصال بالطبيب.

o               يجب عدم تناول أقراص كوليب إذا كانت المريضة تُرضع رضاعةً طبيعية أو تخطط لإرضاع طفلها رضاعة طبيعية؛ إذ لم يُعرف ما إذا كان الدواء يُفرَز في لبن الأم أم لا.

 

إذا كانت المريضة حاملاً أو ترضع رضاعة طبيعية أو تعتقد أنها ربما تكون حاملاً أو تخطط للحمل، فيُرجى استشارة الطبيب أو الصيدلي قبل تناول هذا الدواء.

 

القيادة واستخدام الآلات

 

لا يتوقع أن يؤثر دواء كوليب في قدرة المريض على القيادة أو استخدام أي أدوات أو آلات. ومع ذلك، ينبغي الأخذ في الحسبان أن بعض المرضى تعرّضوا للدوار بعد تناول أقراص كوليب.

 

معلومات مهمة عن بعض مكونات أقراص كوليب

 

تحتوي أقراص كوليب على أنواع من السكّر تُسمَّى باللاكتوز والسكروز. فإذا أبلغ الطبيب مريضه بأن جسمه لا يتحمّل بعض السكّريات، فيرجى التواصل مع الطبيب قبل تناول هذا الدواء.

 

وتحتوي أقراص كوليب على مادة ليسيثين فول الصويا. فإذا كان المريض يعاني من حساسية تجاه الفول السوداني أو زيت الفول السوداني أو زيت فول الصويا، فيَجب عدم استعمال أقراص كوليب. كما تحتوي أقراص كوليب على صبغة sunset yellow FCF الصفراء (E110) التي قد تسبب تفاعلات الحساسية.

https://localhost:44358/Dashboard

يُرجى الحرص دومًا على تناول هذا الدواء تمامًا حسب تعليمات الطبيب أو الصيدلي. واستشر الطبيب أو الصيدلي إذا لم تكن متأكدًا.

 

سيحدد الطبيب التركيز الملائم لك على حسب الحالة والعلاج الحالي وحالة  المخاطر الخاصة بك.

وتبلغ الجرعة المعتادة قرصًا واحدًا في اليوم.

ويمكنك تناول أقراص كوليب مع الطعام أو بدونه.

ابتلع القرص مع كوب من الماء.

لا تسحق القرص أو تمضغه.

 

ينبغي أن يستمر المريض في حمية غذائية منخفضة الدهون أو أي  احتياطات أخرى (مثل التمرينات الرياضية أو إنقاص الوزن) في أثناء العلاج باستخدام أقراص كوليب.

 

في حالة تناول جرعة أكبر مما ينبغي من أقراص كوليب

 

إذا تناول المريض جرعة أكبر مما ينبغي من أقراص كوليب أو إذا تناول شخص آخر دواءك، فيُرجى الاتصال بالطبيب أو الصيدلي أو بأقرب مستشفى

 

إذا نسيت تناول أقراص كوليب

 

يُرجى عدم تناول جرعة مزدوجة لتعويض الجرعة المنسية. وتناول القرص التالي في الموعد المنتظم في اليوم التالي. إذا كان المريض قلقًا بشأن هذا الأمر، فيُرجى التحدث مع الطبيب أو الصيدلي.

 

وإذا كانت لدى المريض أي أسئلة إضافية حول استخدام هذا الدواء، فيُرجى سؤال الطبيب أو الصيدلي.

كما هو الحال بالنسبة لجميع الأدوية، يمكن أن تتسبب أقراص كوليب في حدوث آثار جانبية، على الرغم من عدم  حدوثها في جميع المرضى.

 

وقد تكون الإصابة غير المفسرة بألم في العضلات أو ألم عند اللمس أو ضعف علامة على  انحلال العضلات. لذا؛ يُرجى استشارة

الطبيب فورًا في حالة التعرّض لهذه الأعراض.  ذلك لأنه في حالات نادرة حدثت حالات من الإصابة بمشكلات خطيرة في العضلات، بما         في ذلك انحلال العضلات الذي يؤدي إلى تلف الكلى؛ وقد سُجّلت حالات نادرة جدا من الوفيات. وبالمقارنة بأحد أدوية الفيبرات أو الستاتينات وحدها، تزداد خطورة الإصابة بانحلال العضلات عند تناول المريض لهذين الدواءين معًا، كما هو الحال مع أقراص كوليب. وتزداد خطورة الإصابة مع المريضات الإناث أو مع المرضى الذين تبلغ أعمارهم 65 عامًا فأكثر.

 

وقد تعرّض بعض المرضى للآثار الجانبية الخطيرة التالية في أثناء تناولهم لكل من الفينوفيبرات أو السيمفاستاتين (المادتان الفعالتان في أقراص كوليب):

 

o              تفاعل الحساسية - قد تتضمن العلامات تورم الوجه أو الشفتين أو اللسان أو الحلق؛ مما قد يؤدي إلى صعوبة في التنفس

o              تفاعل الحساسية المفرطة تجاه أقراص كوليب مثل: ألم او التهاب المفاصل ، التهاب الأوعية الدموية، كدمات غير معتادة، بزوغ في الجلد وتورّم، طفح جلدي، حساسية البشرة للشمس، الحمى، احمرار البشرة، ضيق التنفس والشعور بالإعياء، مرض شبيه بالذئبة (بما في ذلك الطفح الجلدي واعتلال المفاصل، فضلاً عن تأثيرات في خلايا الدم البيضاء)

o              التقلصات أو الألم أو اللين أو الضعف في العضلات – قد تكون هذه علامات على التهاب أو انحلال العضلات، والذي يمكن أن يؤدي إلى تلف الكلى أو حتى إلى الوفاة

o              ألم المعدة - قد يكون هذا علامة على أن البنكرياس قد التهب (التهاب البنكرياس)

o              ألم الصدر والإحساس بضيق في التنفس – قد تكون هذه علامات على الإصابة بجلطة دموية في الرئة ( الانسداد الرئوي)

o              ألم أو احمرار الساقين أو تورمهما – قد تكون هذه علامات على الإصابة بجلطة دموية في الساق (تجلط الأوردة العميقة)

o              اصفرار الجلد أو بياض العينين (اليرقان) أو الزيادة في إنزيمات الكبد – قد تكون هذه علامات على وجود التهاب في الكبد (الالتهاب الكبدي أو الفشل الكبدي)

o              زيادة حساسية بشرة المريض لأشعة الشمس والمصابيح الشمسية  وكراسي الاستلقاء للتشمس

 

في حالة حدوث أي من الآثار الجانبية الخطيرة التي سبق ذكرها، فيُرجى التوقف عن تناول أقراص كوليب، وإبلاغ الطبيب على الفور، أو الذهاب إلى غرفة الطوارئ في أقرب مستشفى؛ فربما يكون المريض بحاجة إلى علاج طبي عاجل.

 

قد تعرّض بعض المرضى للآثار الجانبية التالية في أثناء تناول أقراص كوليب أو الفينوفيبرات أو السيمفاستاتين:

 

آثار جانبية شائعة للغاية (قد تؤثر في أكثر من شخص من بين 10 أشخاص):

 

o              ارتفاع في مستوى "الكرياتينين" في الدم (إحدى المواد التي تفرزها الكلى)

o              ارتفاع مستويات الهوموسيستين في الدم (ترتبط الزيادة الكبيرة في هذا الحمض الأميني في الدم بزيادة خطر الإصابة بأمراض القلب التاجية والسكتة الدماغية و أمراض الأوعية الدموية الطرفية، على الرغم من عدم التأكد من سبب ذلك الارتباط)

 

الآثار الجانبية الشائعة (يمكن أن تؤثر في شخص من بين 10 أشخاص):

 

o              ارتفاع عدد الصفائح الدموية في الدم

o              ارتفاع في اختبارات الدم لوظيفة الكبد (ناقلات الأمين)

o              اضطرابات الجهاز الهضمي (ألم في المعدة، غثيان، قيء، إسهال، انتفاخ البطن)

o              عدوى الجهاز التنفسي العلوي

 

الآثار الجانبية غير الشائعة (يمكن أن تؤثر في شخص من بين 100 شخص):

 

o              مشكلات في العضلات

o              الحصوات الصفراوية

o              الطفح الجلدي أو الحكة أو بقع حمراء على الجلد

o              الصداع

o              مشكلات جنسية

 

آثار جانبية نادرة (يمكن أن تؤثر في شخص من بين 1000 شخص):

 

o              انخفاض عدد كرات الدم الحمراء (فقر الدم)

o              تنميل الذراعين والساقين أو ضعفهما

o              الارتباك

o              الشعور بالدوخة

o              الشعور بالإرهاق (الضعف العام)

o              ارتفاع نسبة ’اليوريا‘ الذي تفرزه الكلى – ويظهر في الاختبارات

o              ارتفاع نسبة إنزيم "جاما جلوتاميل ترانسفيراز" - الذي يفرزه الكبد - ويظهر في الاختبارات

o              ارتفاع نسبة "الفوسفاتاز القلوي" - الذي يفرزه الجهاز الصفراوي - ويظهر في الاختبارات

o              ارتفاع نسبة "فسفوكيناز الكرياتين" - الذي تفرزه العضلات - ويظهر في الاختبارات

o              الانخفاض في نسبة الهيموجلوبين (الذي ينقل الأكسجين في الدم) وخلايا الدم البيضاء - ويظهر في الاختبارات

o              اضطرابات النوم

o              ضعف الذاكرة أو فقدانها

o               تساقط الشعر

o              الإمساك

o              عسر الهضم

 

سُجّلت الآثار الجانبية التالية أيضًا، إلا أنه لا يمكن تقدير معدل تكرارها من المعلومات المتوفرة (معدل تكرارها غير معروف):

 

o              طفح جلدي حاد بسبب الحساسية يصاحبه ظهور بثور

o              مضاعفات الإصابة بحصوات في المرارة، مثل حدوث مغص بسبب حصوات في القناة الصفراوية، أو عدوى القناة الصفراوية أو المرارة

o              مرض السكّري

o              ضعف الانتصاب

o              الشعور بالاكتئاب

o              اضطرابات النوم، بما في ذلك التعرّض للكوابيس

o              الإصابة بمرض معين في الرئة مع صعوبة في التنفس (يُطلق عليه مرض رئوي خلالي)

o              ضعف مستمر في العضلات

o              ارتفاع في "الهيموجلوبين الغليكوزيلاتي" ومستويات الجلوكوز في الدم - علامات التحكم في مستوى الجلوكوز في الدم في مرض السكري - ويظهر في الاختبارات

 

الإبلاغ عن الآثار الجانبية

 

إذا أُصبتَ بأي آثار جانبية، فتحدث مع الطبيب أو الصيدلي. يشمل هذا أي آثار جانبية محتملة غير مدرجة في هذه النشرة.

بالإبلاغ عن الأثار الجانبية فأنت تساعد على توفير المزيد من المعلومات حول أمان هذا الدواء.

 

للإبلاغ عن الأعراض الجانبية

-          المركز الوطني للتيقظ والسلامة الدوائية (NPC)

o         فاكس 7662-205-11-966+

o         مركز الاتصال: 19999

o         البريد الإلكتروني: npc.drug@sfda.gov.sa

o         الموقع الإلكتروني: https://ade.sfda.gov.sa

احفظ هذا الدواء بعيدًا عن متناول ومرأى الأطفال.

 

   فترة الصلاحية: 24 شهر

 

 

لا تستخدم دواء كوليب بعد تاريخ انتهاء الصلاحية المذكور على العبوة الكرتونية والشريط بعد الرمز EXP (انتهاء الصلاحية). يشير تاريخ انتهاء الصلاحية إلى آخر يوم في ذلك الشهر.

 

يخزن في درجة حرارة أقل من 30 درجة مئوية.

 

لا تتخلص من أي أدوية عبر مياه الصرف الصحي أو المخلفات المنزلية. اسأل الصيدلاني الذي تتعامل معه عن كيفية التخلص من الأدوية التي لم تعد تستخدمها. ستساعد هذه التدابير على حماية البيئة.

 

المواد الفعالة هي الفينوفيبرات والسيمفاستاتين.


 يحتوي كل قرص على 145 ملجم من الفينوفيبرات و20 ملجم من السيمفاستاتين.

المكونات الأخرى هي:

الجزء الأساسي من القرص:

مادة بوتيل هيدروكسي الأنيسول (E320)، أحادي هيدرات اللاكتوز، لوريل سلفات الصوديوم، نشا،

(الذرة) مضاف إليه جيلاتين مسبقًا، دوكوسات الصوديوم، السكروز،  حمض الستريك  أحادي الهيدرات (E330)، هايبروميلوز (E464)، كروسبوفيدون (E1202)، ستيرات المغنيسيوم (E572)، سليولوز بلوري مكروي (مكون من السليلوز دقيق التبلور والسيليكا اللامائية الغروية)، حمض الأسكوربيك (E300).

 

المادة المغلِّفة:

بولي (كحول فينيلي) متحلل جزئيًا (E1203)، ثاني أكسيد التيتانيوم (E171)، التالك (E553b)، مادة ليسيثين (المشتقة من فول الصويا (E322))، صمغ الزانثان (E415)، أكسيد الحديد الأحمر (E172)، أكسيد الحديد الأصفر (E172)، صبغة sunset yellow FCF الصفراء ((E110.

 

القرص المغلف عبارة عن قرص 19.3 × 9.3 مم وبيضاوي الشكل ومحدّب من الجانبين، بنيّ اللون مائل للون الأصفر، ومشطوف الحواف، محفور عليه 145/20 على أحد الجانبين.

تتوفر الأقراص في عبوات كرتونية مع شرائط تحتوي على 10 أقراص أو 30 قرصًا أو 90 قرصًا.

 

قد لا تتوفر جميع أحجام العبوات في الأسواق.

مالك رخصة التسويق:

أبوت لابوراتوريز ليميتد،

أبوت هاوس، فانوال بزنس بارك، 

فانوال رود، ميدينهيد بيركشر، إس إل 6 4 إكس إي، المملكة المتحدة

 

الجهة المصنعة:

فورنيير لابوراتوريز إيرلاندا ليميتد، كورك، إيرلاندا

 

تمت التعبئة بواسطة:

مايلان لابوراتوريز إس أي إس

طريق بيلفيل - ليو ديت ميلارد ، 

٠١٤٠٠ شاتيلون سور شالارون ، فرنسا

04/2023
 Read this leaflet carefully before you start using this product as it contains important information for you

Cholib 145 mg/20 mg film­coated tablets

One film-­coated tablet contains 145 mg of fenofibrate and 20 mg of simvastatin. Excipient(s) with known effect: One film­-coated tablet contains 160.1 mg of lactose (as monohydrate), 145 mg of sucrose, 0.7 mg of lecithin (derived from soya bean (E322)) and 0.17 mg of sunset yellow FCF (E110). For the full list of excipients, see section 6.1.

Film-­coated tablet (tablet). Oval, biconvex, tan coloured, 19.3 x 9.3 mm film­coated tablet with bevelled edges and the inscription 145/20 on one side and the Abbott logo “a” on the other side.

Cholib is indicated as adjunctive therapy to diet and exercise in high cardiovascular risk adult patients with mixed dyslipidaemia to reduce triglycerides and increase HDL­C levels when LDL­C levels are adequately controlled with the corresponding dose of simvastatin monotherapy.


Secondary causes of hyperlipidaemia, such as uncontrolled type 2 diabetes mellitus, hypothyroidism, nephrotic syndrome, dysproteinemia, obstructive liver disease, pharmacological treatment (like oral oestrogens), alcoholism should be adequately treated, before Cholib therapy is considered and patients should be placed on a standard cholesterol and triglycerides­lowering diet which should be continued during treatment.

Posology

The recommended dose is one tablet per day. Grapefruit juice should be avoided (see section 4.5).

Response to therapy should be monitored by determination of serum lipid values (total cholesterol (TC), LDL­C, triglycerides (TG)).

Elderly patients (≥ 65 years old)

No dose adjustment is necessary. The usual dose is recommended, except for decreased renal function with estimated glomerular filtration rate < 60 mL/min/1.73 m2 where Cholib is contraindicated (see section 4.3).

Patients with renal impairment

Cholib is contraindicated in patients with moderate to severe renal insufficiency whose estimated glomerular filtration rate is < 60 mL/min/1.73 m2 (see section 4.3).

Cholib should be used with caution in patients with mild renal insufficiency whose estimated glomerular filtration rate is 60 to 89 mL/min/1.73 m2 (see section 4.4).

Patients with hepatic impairment

Cholib has not been studied in patients with hepatic impairment and is therefore contraindicated in this population (see section 4.3).

Paediatric population

Cholib is contraindicated in children and adolescents up to 18 years old. (see section 4.3).

Method of administration

Each tablet should be swallowed whole with a glass of water. The tablets should not be crushed or chewed. They may be taken with or without food (see section 5.2).


• Hypersensitivity to the active substances, peanut, soya or to any of the excipients listed in section 6.1 (see also section 4.4) • Known photoallergy or phototoxic reaction during treatment with fibrates or ketoprofen • Active liver disease or unexplained persistent elevations of serum transaminases • Known gallbladder disease • Chronic or acute pancreatitis with the exception of acute pancreatitis due to severe hypertriglyceridaemia • Moderate to severe renal insufficiency (estimated glomerular filtration rate < 60 mL/min/1.73 m2) • Concomitant administration of fibrates, statins, danazol, ciclosporin or potent cytochrome P450 (CYP) 3A4 inhibitors (see section 4.5) • Paediatric population (age below 18 years) • Pregnancy and breast­feeding (see section 4.6) • Personal history of myopathy and/or rhabdomyolysis with statins and/or fibrates or confirmed creatine phosphokinase elevation above 5 times the upper limit of normal (ULN) under previous statin treatment (see section 4.4)

1.1  Muscle

Skeletal muscle toxicity, including rare cases of rhabdomyolysis with or without renal failure, has been reported with administration of lipid­lowering substances like fibrates and statins. The risk of myopathy with statins and fibrates is known to be related to the dose of each component and to the nature of the fibrate.

Reduced function of transport proteins

Reduced function of hepatic OATP transport proteins can increase the systemic exposure of simvastatin and increase the risk of myopathy and rhabdomyolysis. Reduced function can occur as the result of inhibition by interacting medicines (eg ciclosporin) or in patients who are carriers of the SLCO1B1 c.521T>C genotype.

 

Patients carrying the SLCO1B1 gene allele (c.521T>C) coding for a less active OATP1B1 protein have an increased systemic exposure of simvastatin and increased risk of myopathy. The risk of high dose (80 mg) simvastatin related myopathy is about 1 % in general, without genetic testing. Based on the results of the SEARCH trial, homozygote C allele carriers (also called CC) treated with 80 mg have a 15% risk of myopathy within one year, while the risk in heterozygote C allele carriers (CT) is 1.5%. The corresponding risk is 0.3% in patients having the most common genotype (TT) (See section 5.2).

Immune­mediated necrotizing myopathy (IMNM)

There have been very rare reports of an immune­mediated necrotizing myopathy (IMNM) during or after treatment with some statins. IMNM is clinically characterized by persistent proximal muscle weakness and elevated serum creatine kinase, which persist despite discontinuation of statin treatment.

Measures to reduce the risk of myopathy caused by medicinal product interactions

The risk of muscle toxicity may be increased if Cholib is administered with another fibrate, statin, niacin, fusidic acid or other specific concomitant substances (for specific interactions see section 4.5). Physicians contemplating combined therapy with Cholib and lipid­modifying doses (≥ 1 g/day) of niacin (nicotinic acid) or medicinal products containing  niacin should carefully weigh the potential benefits and risks and should carefully monitor patients for any signs and symptoms of muscle pain, tenderness, or weakness, particularly during the initial months of therapy and when the dose of either medicinal product is increased.

The risk of myopathy and rhabdomyolysis is significantly increased by concomitant use of simvastatin with potent inhibitors of (CYP) 3A4 (see section 4.5).

Cholib must not be co­administered with fusidic acid. There have been reports of rhabdomyolysis (including some fatalities) in patients receiving a statin in combination with fusidic acid (see section 4.5). In patients where the use of systemic fusidic acid is considered essential, statin treatment should be discontinued throughout the duration of fusidic acid treatment. The patient should be advised to seek medical advice immediately if they experience any symptoms of muscle weakness, pain or tenderness.

Statin therapy may be re­introduced seven days after the last dose of fusidic acid. In exceptional circumstances, where prolonged systemic fusidic acid is needed e.g. for the treatment of severe infections, the need for co­administration of Cholib and fusidic acid should only be considered on a case by case basis and under close medical supervision.

Creatine kinase measurement

Creatine Kinase should not be measured following strenuous exercise or in the presence of any plausible alternative cause of Creatine Kinase increase as this makes value interpretation difficult. If Creatine Kinase levels are significantly elevated at baseline (> 5 x ULN), levels should be re­measured within 5 to 7 days later to confirm the results.

Before the treatment

All patients starting therapy, or whose dose of simvastatin is being increased, should be advised of the risk of myopathy and told to report promptly any unexplained muscle pain, tenderness or weakness.

Caution should be exercised in patients with pre­disposing factors for rhabdomyolysis. In order to establish a reference baseline value, a Creatine Kinase level should be measured before starting a treatment in the following situations:

•  Elderly ≥ 65 years

•  Female gender

•  Renal impairment

•  Uncontrolled hypothyroidism

 

•  Hypoalbuminaemia

•  Personal or familial history of hereditary muscular disorders

•  Previous history of muscular toxicity with a statin or a fibrate

•  Alcohol abuse

In such situations, the risk of treatment should be considered in relation to possible benefit, and clinical monitoring is recommended.

In order to establish a reference baseline value, creatine phosphokinase levels should be measured and clinical monitoring is recommended.

If a patient has previously experienced a muscle disorder on a fibrate or a statin, treatment with a different member of the class should only be initiated with caution. If Creatine Kinase levels are significantly elevated at baseline (> 5 x ULN), treatment should not be started.

If myopathy is suspected for any other reason, treatment should be discontinued.

Therapy with Cholib should be temporarily stopped a few days prior to elective major surgery and when any major medical or surgical condition supervenes.

Hepatic disorders

Increases in transaminase levels have been reported in some patients treated with simvastatin or fenofibrate. In the majority of cases these elevations were transient, minor and asymptomatic without the need for treatment discontinuation.

Transaminase levels have to be monitored before treatment begins, every 3 months during the first 12 months of treatment and thereafter periodically. Attention should be paid to patients who develop increase in transaminase levels and therapy should be discontinued if aspartate aminotransferase (AST) or also known as serum glutamic oxaloacetic transaminase (SGOT) and alanine aminotransferase (ALT) or also known as serum glutamic pyruvic transaminase (SGPT) levels increase to more than 3 times the upper limit of the normal range.

When symptoms indicative of hepatitis occur (e.g. jaundice, pruritus) and diagnosis is confirmed by laboratory testing, Cholib therapy should be discontinued.

Cholib should be used with caution in patients who consume substantial quantities of alcohol. Pancreatitis

Pancreatitis has been reported in patients taking fenofibrate (see sections 4.3 and 4.8). This occurrence may represent a failure of efficacy in patients with severe hypertriglyceridaemia, an induced pancreatic enzymes increase or a secondary phenomenon mediated through biliary tract stone or sludge formation with obstruction of the common bile duct.

Renal function

Cholib is contraindicated in moderate to severe renal impairment (see section 4.3).

Cholib should be used with caution in patients with mild renal insufficiency whose estimated glomerular filtration rate is 60 to 89 mL/min/1.73 m2 (see section 4.2).

Reversible elevations in serum creatinine have been reported in patients receiving fenofibrate monotherapy or co­ administered with statins. Elevations in serum creatinine were generally stable over time with no evidence for continued

 

increases in serum creatinine with long term therapy and tended to return to baseline following discontinuation of treatment.

During clinical trials, 10% of patients had a creatinine increase from baseline greater than 30 µmol/L with co­ administered fenofibrate and simvastatin versus 4.4% with statin monotherapy. 0.3% of patients receiving co­ administration had clinically relevant increases in creatinine to values > 200 µmol/L.

Treatment should be interrupted when creatinine level is 50% above the upper limit of normal. It is recommended that creatinine is measured during the first 3 months after initiation of treatment and periodically thereafter.

Interstitial lung disease

Cases of interstitial lung disease have been reported with some statins and with fenofibrate, especially with long term therapy (see section 4.8). Presenting features can include dyspnoea, non­productive cough and deterioration in general health (fatigue, weight loss and fever). If it is suspected a patient has developed interstitial lung disease, Cholib therapy should be discontinued.

Diabetes mellitus

Some evidence suggests that statins as a class raise blood glucose and in some patients, at high risk of future diabetes, may produce a level of hyperglycaemia where formal diabetes care is appropriate. This risk, however, is outweighed by the reduction in vascular risk with statins and therefore should not be a reason for stopping statin treatment. Patients at risk (fasting glucose 5.6 to 6.9 mmol/L, BMI>30 kg/m2, raised triglycerides, hypertension) should be monitored both clinically and biochemically according to national guidelines.

Veno­thromboembolic  events

In the FIELD study, a statistically significant increase was reported in the incidence of pulmonary embolism (0.7% in  the placebo group versus 1.1% in the fenofibrate group; p=0.022) and a statistically non significant increase in deep  vein thrombosis (placebo 1.0% 48/4900 patients) versus fenofibrate 1.4% (67/4895); p=0.074. The increased risk of venous thrombotic events may be related to the increased homocysteine level, a risk factor for thrombosis and other unidentified factors. The clinical significance of this is not clear. Therefore, caution should be exercised in patients with history of pulmonary embolism.

Excipients

As this medicinal product contains lactose, patients with rare hereditary problems of galactose intolerance, Lapp lactase deficiency or glucose­galactose malabsorption should not take this medicinal product.

As this medicinal product contains sucrose, patients with rare hereditary problems of fructose intolerance, glucose­ galactose malabsorption or sucrase­isomaltase insufficiency should not take this medicine.

This medicinal product contains sunset yellow FCF (E110) that may cause allergic reactions.


1.1  No interaction studies have been performed with Cholib.

Interactions relevant to monotherapies Inhibitors of CYP 3A4

Simvastatin is a substrate of cytochrome P450 3A4.

Potent inhibitors of cytochrome P450 3A4 increase the risk of myopathy and rhabdomyolysis by increasing the concentration of HMG­CoA reductase inhibitory activity in plasma during simvastatin therapy. Such inhibitors include

 

itraconazole, ketoconazole, posaconazole, erythromycin, clarithromycin, telithromycin, HIV protease inhibitors (e.g. nelfinavir), and nefazodone.

Combination with itraconazole, ketoconazole, posaconazole, HIV protease inhibitors (e.g. nelfinavir), erythromycin, clarithromycin, telithromycin and nefazodone is contraindicated (see section 4.3). If treatment with itraconazole, ketoconazole, posaconazole, erythromycin, clarithromycin or telithromycin is unavoidable, therapy with Cholib must be suspended during the course of treatment. Caution should be exercised when combining Cholib with certain other less potent

CYP 3A4 inhibitors: fluconazole, verapamil, or diltiazem (see sections 4.3 and 4.4). Danazol

The risk of myopathy and rhabdomyolysis is increased by concomitant administration of danazol with simvastatin. The dose of simvastatin should not exceed 10 mg daily in patients taking danazol. Therefore, the co­administration of Cholib with danazol is contraindicated (see section 4.3).

Ciclosporin

The risk of myopathy/rhabdomyolysis is increased by concomitant administration of ciclosporin with simvastatin. Although the mechanism is not fully understood, ciclosporin has been shown to increase the plasma exposure (AUC) to simvastatin acid, presumably due in part to inhibition of CYP 3A4 and OATP­1B1 transporter. Because the dose of simvastatin should not exceed 10 mg daily in patients taking ciclosporin, the co­administration of Cholib with ciclosporin is contraindicated (see section 4.3).

Amiodarone, amlodipine, diltiazem and verapamil

The risk of myopathy and rhabdomyolysis is increased by concomitant use of amiodarone, amlodipine, diltiazem or verapamil with simvastatin 40 mg per day.

In a clinical trial, myopathy was reported in 6% of patients receiving simvastatin 80 mg and amiodarone, versus 0.4% in patients on simvastatin 80 mg only.

Concomitant administration of amlodipine and simvastatin caused a 1.6­fold increase in exposure of simvastatin acid.

Concomitant administration of diltiazem and simvastatin caused a 2.7­fold increase in exposure of simvastatin acid, presumable due to inhibition of CYP 3A4.

Concomitant administration of verapamil and simvastatin resulted in a 2.3­fold increase in plasma exposure to simvastatin acid, presumably due, in part, to inhibition of CYP 3A4.

Therefore, the dose of Cholib should not exceed 145 mg/20 mg daily in patients taking amiodarone, amlodipine, diltiazem or verapamil.

Other statins and fibrates

Gemfibrozil increases the AUC of simvastatin acid by 1.9­fold, possibly due to inhibition of the glucuronidation pathway. The risk of myopathy and rhabdomyolysis is significantly increased by concomitant use of gemfibrozil with simvastatin. The risk of rhabdomyolysis is also increased in patients concomitantly receiving other fibrates or statins. Therefore, the co­administration of Cholib with gemfibrozil, other fibrates, or statins is contraindicated (see section 4.3).

Niacin (nicotinic acid)

Cases of myopathy/rhabdomyolysis have been associated with concomitant administration of statins and niacin (nicotinic acid) at lipid­modifying doses (≥ 1 g/day), knowing that niacin and statins can cause myopathy when given alone.

 

Physicians contemplating combined therapy with Cholib and lipid­modifying doses (≥ 1 g/day) of niacin (nicotinic acid) or medicinal products containing niacin should carefully weigh the potential benefits and risks and should carefully monitor patients for any signs and symptoms of muscle pain, tenderness, or weakness, particularly during the initial months of therapy and when the dose of either medicinal product is increased.

Fusidic acid

The risk of myopathy including rhabdomyolysis may be increased by the concomitant administration of systemic fusidic acid with statins. Co­administration of this combination may cause increased plasma concentrations of both agents.

The mechanism of this interaction (whether it is pharmacodynamics or pharmacokinetic, or both) is yet unknown. There have been reports of rhabdomyolysis (including some fatalities) in patients receiving this combination.

If treatment with fusidic acid is necessary, Cholib treatment should be discontinued throughout the duration of the fusidic acid treatment. (Also see section 4.4).

Grapefruit juice

Grapefruit juice inhibits CYP 3A4. Concomitant intake of large quantities (over 1 liter daily) of grapefruit juice and simvastatin resulted in a 7­fold increase in plasma exposure to simvastatin acid. Intake of 240 mL of grapefruit juice in the morning and simvastatin in the evening also resulted in a 1.9­fold increase in plasma exposure to simvastatin acid. Intake of grapefruit juice during treatment with Cholib should therefore be avoided.

Colchicine

There have been reports of myopathy and rhabdomyolysis with the concomitant administration of colchicine and simvastatin in patients with renal insufficiency. Therefore, close clinical monitoring of such patients taking colchicine and Cholib is advised.

Vitamin K antagonists

Fenofibrate and simvastatin enhance effects of Vitamin K antagonists and may increase the risk of bleeding. It is recommended that the dose of those oral anticoagulants is reduced by about one third at the start of treatment and then gradually adjusted if necessary according to INR (International Normalised Ratio) monitoring. INR should be determined before starting Cholib and frequently enough during early therapy to ensure that no significant alteration of INR occurs. Once a stable INR has been documented, it can be monitored at the intervals usually recommended for patients on those oral anticoagulants. If the dose of Cholib is changed or discontinued, the same procedure should be repeated.

Cholib therapy has not been associated with bleeding in patients not taking anticoagulants. Glitazones

Some cases of reversible paradoxical reduction of HDL­C have been reported during concomitant administration of fenofibrate and glitazones. Therefore it is recommended to monitor HDL­C if Cholib is co­administered with a glitazone and stopping either therapy if HDL­C is too low.

Rifampicin

Because rifampicin is a potent CYP 3A4 inducer that interferes with simvastatin metabolism, patients undertaking long­ term rifampicin therapy (e.g. treatment of tuberculosis) may experience loss of efficacy of simvastatin. In normal volunteers, the plasma exposure to simvastatin acid was decreased by 93% with concomitant administration of rifampicin.

Effects on the pharmacokinetics of other medicinal products

Fenofibrate and simvastatin are not CYP 3A4 inhibitors or inducers. Therefore, Cholib is not expected to affect plasma concentrations of substances metabolised via CYP 3A4.

 

Fenofibrate and simvastatin are not inhibitors of CYP 2D6, CYP 2E1, or CYP 1A2. Fenofibrate is a mild to moderate inhibitor of CYP 2C9 and a weak inhibitor of CYP 2C19 and CYP 2A6.

Patients receiving co­administration of Cholib and drugs metabolised by CYP 2C19, CYP 2A6, or especially CYP 2C9 with a narrow therapeutic index should be carefully monitored and, if necessary, dose adjustment of these drugs is recommended.

Interaction between simvastatin and fenofibrate

Effects of repeated administration of fenofibrate on the pharmacokinetics of single or multiple doses of simvastatin have been investigated in two small studies (n=12) followed by a larger one (n= 85) in healthy subjects.

In one study the AUC of the simvastatin acid (SVA), a major active metabolite of simvastatin, was reduced by 42% (90% CI 24%­56%) when a single dose of 40 mg simvastatin was combined with repeated administration of fenofibrate 160 mg. In the other study [Bergman et al, 2004] repeated co­administration of both simvastatin 80 mg and fenofibrate 160 mg led to a reduction in the AUC of the SVA of 36% (90% CI 30%­42%). In the larger study a reduction of 21% (90% CI 14%­27%) in AUC of SVA was observed after repeated co­administration of simvastatin 40 mg and fenofibrate 145 mg in the evening. This was not significantly different from the 29% (90% CI 22%­35%) reduction in AUC of SVA observed when co­administration was 12 hours apart: simvastatin 40 mg in the evening and fenofibrate 145 mg in the morning.

Whether fenofibrate had an effect on other active metabolites of simvastatin was not investigated.

The exact mechanism of interaction is not known. In the available clinical data, the effect on LDL­C reduction was not considered to be significantly different to simvastatin monotherapy when LDL­C is controlled at the time of initiating treatment.

The repeated administration of simvastatin 40 or 80 mg, the highest dose registered, did not affect the plasma levels of fenofibric acid at steady state.

Prescribing recommendations for interacting substances are summarised in the table below (see also sections 4.2 and 4.3).

Interacting substancesPrescribing  recommendations

Potent CYP 3A4 inhibitors:

Itraconazole

Ketoconazole

Fluconazole

Posaconazole

Erythromycin

Clarithromycin

Telithromycin

HIV protease inhibitors (e.g. nelfinavir)

   Nefazodone
Contraindicated with Cholib

Danazol

Ciclosporin

Contraindicated with Cholib
Gemfibrozil, Other statins and fibratesContraindicated with Cholib

Amiodarone

Verapamil

Diltiazem

   Amlodipine
Do not exceed one Cholib 145 mg/20 mg per day, unless clinical benefit outweigh the risk
Niacin (nicotinic acid) ≥ 1 g/day

Avoid with Cholib unless clinical benefit outweigh the risk

 Monitor patients for any signs and symptoms of muscle pain, tenderness or weakness
  Fusidic acid Patients should be closely monitored. Temporary suspension of Cholib treatment may be considered
 Grapefruit juice Avoid when taking Cholib
 Vitamin K antagonists Adjust the dose of these oral anticoagulants according to INR monitoring
 Glitazones Monitor HDL­C and stop either therapy (glitazone or Cholib) if HDL­C is too low

 

 

 


Pregnancy

Cholib

As simvastatin is contraindicated during pregnancy (see hereafter), Cholib is contraindicated during pregnancy (see section 4.3).

Fenofibrate

There are no adequate data from the use of fenofibrate in pregnant women. Animal studies have shown embryo­toxic effects at doses in the range of maternal toxicity (see section 5.3). The potential risk for humans is unknown. Therefore, fenofibrate should only be used during pregnancy after a careful benefit/risk assessment.

Simvastatin

Simvastatin is contraindicated during pregnancy. Safety in pregnant women has not been established. Maternal treatment with simvastatin may reduce the foetal levels of mevalonate which is a precursor of cholesterol biosynthesis. For these reasons, simvastatin must not be used in women who are pregnant, trying to become pregnant or suspect they are pregnant. Treatment with simvastatin must be suspended for the duration of pregnancy or until it has been determined that the woman is not pregnant.

Breast­feeding

 

It is unknown whether fenofibrate, simvastatin and/or their metabolites are excreted in human milk. Therefore, Cholib is contraindicated during breast­feeding (see section 4.3).

Fertility

Reversible effects on fertility have been observed in animals (see section 5.3). There are no clinical data on fertility from the use of Cholib.


Fenofibrate has no or negligible influence on the ability to drive and use machines.

Dizziness has been reported rarely in post­marketing experience with simvastatin. This adverse reaction should be taken into account when driving vehicles or using machines under Cholib therapy.


1.1  Summary of the safety profile

The most commonly reported adverse drug reactions (ADRs) during Cholib therapy are increased blood creatinine, upper respiratory tract infection, increased platelet count, gastroenteritis and increased alanine­ aminotransferase.

Tabulated list of adverse reactions

During four double blind clinical trials of 24­week duration 1,237 patients have received treatment with co­administered fenofibrate and simvastatin. In a pooled analysis of these four trials, the rate of discontinuation due to treatment emergent adverse reactions was 5.0% (51 subjects on 1012) after 12 weeks of treatment with fenofibrate and simvastatin 145 mg/20 mg per day and 1.8% (4 subjects on 225) after 12 weeks of treatment with fenofibrate and simvastatin 145 mg/40 mg per day.

Treatment emergent adverse reactions reported in patients receiving co­administration of fenofibrate and simvastatin occurring are listed below by system organ class and frequency.

The adverse reactions of Cholib are in line with what is known from its two active substances: fenofibrate and simvastatin.

The frequencies of adverse reactions are ranked according to the following: 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).

Adverse reactions observed with the co­administration of fenofibrate and simvastatin (Cholib)

 

 System Organ Class  
 

 

 Infections and   infestations

 

 

Upper respiratory tract infection, Gastroenteritis Common
 Blood and lymphatic   disorders Platelet count increased Common 
 

Hepatobiliary disorders 

 

 Alanine­ aminotransferase  increased  Common

 

 Skin and subcutaneous tissue disorders

  Dermatitis and eczema 

 

Uncommon

 

Investigations

 

Blood creatinine increased (see sections 4.3 and 4.4)

 

very common

 

 

 

Description of selected adverse reactions

Blood creatinine increased: 10% of patient had a creatinine increase from baseline greater than 30 µmol/L with co­ administered fenofibrate and simvastatin versus 4.4% with statin monotherapy. 0.3% of patients receiving co­ administration had clinically relevant increases in creatinine to values >200 µmol/l.

Additional information on the individual active substances of the fixed dose combination

Additional adverse reactions associated with the use of medicinal products containing simvastatin or fenofibrate observed in clinical trials and postmarketing experience that may potentially occur with Cholib are listed below. Frequency categories are based on information available from simvastatin and fenofibrate Summary of Product Characteristics available in the EU.

  System Organ Class 

Adverse reactions

  (fenofibrate)
 

Adverse reactions

  (simvastatin)
 

Frequency

 Blood and lymphatic system disorders 

Haemoglobin decreased White blood cell count decreased 

 Anaemia rare 
 Immune system disorders  Hypersensitivity  rare 
 Metabolism and   nutrition disorders  Diabetes Mellitus****  not known
 Psychiatric disorders 

 Insomnia 

Sleep disorder, including nightmares, depression

 very rare

 

not known

 

 

Nervous system disorders 

 Headache

 

 

 

 

 

 

 Paresthesia, dizziness, peripheral neuropathy

Memory impairment/

Memory loss

  uncommon

 

 

rare 

 

 

 

 Vascular disorders Thromboembolism  (pulmonary embolism, deep vein thrombosis)*  

uncommon

 Respiratory, thoracic and mediastinal disorders   

Interstitial lung disease

 

not known

 

Gastrointestinal  disorders 

 

Gastrointestinal signs and  symptoms (abdominal pain, nausea, vomiting, diarrhoea, flatulence)

 

Pancreatitis*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Constipation, dyspepsia

 common

 

 

 

uncommon

 

 

 

 

 rare 

 Hepatobiliary disorders 

Transaminases  increased

 

 

 

 

 

 

Cholelithiasis

 

 

 

 

 

 

 

 

 

Complications of cholelithiasis (e.g. cholecystitis, cholangitis, biliary colic etc)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gamma­glutamyltransferase increase

 

Hepatitis/jaundice

Hepatic failure

 

common

 

 

 

 

 

 

 

uncommon

 

 

 

 

 

 

 

 

 

 

uncommon

 

 

 

 

 

rare 

 

 

very rare 

 

 

 

 Skin and subcutaneous tissue disorders

Severe cutaneous reactions (e.g erythema multiforme, Ste vens­ Johnson syndrome, toxic epidermal necrolysis, etc.)

 

 

 

Cutaneous hypersensitivity (e.g. Rash, pruritus, urticaria)

 

 

Alopecia

Photosensitivity  reactions

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hypersensitivity syndrome ***

not known

 

 

 

 

 

 

uncommon

 

 

 

 

 

rare 

 

 Musculoskeletal,  connective tissue disorders

 Muscle disorders (e.g. myalgia, myositis, muscular spasms and weakness)

 

 

 

 Rhabdomyolysis with or without renal failure (see section 4.4),

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Myopathy**

 

Tendinopathy

Immune­mediated necrotizing myopathy (see section 4.4)

 

 

  uncommon

 

 

 

 

rare

 

 

 

 

 

 

rare

 

unkown

 Reproductive system and breast disorders 

Sexual dysfunction

 

 

 

 

 

 

 

 

 

 

 

Erectile  dysfunction

 

 

 uncommon

 

 

 

 

not known

 

 

 General disorders and administration site conditions  Asthenia rare 
 Investigations 

  Blood homocysteine level increased (see section 4.4)*****

 

 

 

 

Blood urea increased

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Blood alkaline phosphatase increased

Blood creatine phosphokinase level increase

 

 

 

 

 

Glycosylated  haemoglobin increased

Blood glucose increased

 very common

 

 

 

 

 

rare 

 

 

 

 

 

 

 

rare 

 

 

 

 

 

 

 

 

not known

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Description of selected adverse reactions Pancreatitis

*  In the FIELD study, a randomised placebo­controlled trial performed in 9795 patients with type 2 diabetes mellitus, a statistically significant increase in pancreatitis cases was observed in patients receiving fenofibrate versus patients receiving placebo (0.8% versus 0.5%; p=0.031).

 

Thromboembolism

*  In the FIELD study, a statistically significant increase was reported in the incidence of pulmonary embolism (0.7% [32/4900 patients] in the placebo group versus 1.1% [53/4895 patients] in the fenofibrate group; p = 0.022) and a statistically non­significant increase in deep vein thromboses (placebo: 1.0% [48/4900 patients] versus fenofibrate 1.4% [67/4895 patients]; p=0.074).

Myopathy

** In a clinical trial, myopathy occurred commonly in patients treated with simvastatin 80 mg/day compared to patients treated with 20 mg/day (1.0% vs 0.02%, respectively).

 

Hypersensitivity  syndrome

*** An apparent hypersensitivity syndrome has been reported rarely which has included some of the following features: angioedema, lupus­like syndrome, polymyalgia rheumatica, dermatomyositis, vasculitis, thrombocytopenia, eosinophilia, erythrocyte sedimentation rate (ESR) increased, arthritis and arthralgia, urticaria, photosensitivity, fever, flushing, dyspnoea and malaise.

Diabetes mellitus

 

****Diabetes mellitus: Patients at risk (fasting glucose 5.6 to 6.9 mmol/L, BMI>30 kg/m2, raised triglycerides, hypertension) should be monitored both clinically and biochemically according to national guidelines.

Increased blood homocysteine level

***** In the FIELD study the average increase in blood homocysteine level in patients treated with fenofibrate was 6.5

µmol/L, and was reversible on discontinuation of fenofibrate treatment.

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.

 

 


To report any side effect(s):

- National Pharmacovigilance Center (NPC)

o    Fax: +966-11-205-7662

o    SFDA Call Center: 19999

o    E-mail: npc.drug@sfda.gov.sa

o    Website: https://ade.sfda.gov.sa

 


1.1  Cholib

No specific antidote is known. If an overdose is suspected, symptomatic treatment and appropriate supportive measures should be provided as required.

Fenofibrate

Only anecdotal cases of fenofibrate overdose have been received. In the majority of cases no overdose symptoms were reported. Fenofibrate cannot be eliminated by haemodialysis.

Simvastatin

A few cases of simvastatin overdose have been reported; the maximum dose taken was 3.6 g. All patients recovered without sequelae. There is no specific treatment in the event of overdose.

In this case, symptomatic and supportive measures should be adopted.


Pharmacotherapeutic group: Lipid modifying substances, HMG­CoA reductase inhibitors in combination with other lipid modifying substances, ATC code: C10BA04

Mechanism of action Fenofibrate

Fenofibrate is a fibric acid derivative whose lipid modifying effects reported in humans are mediated via activation of Peroxisome Proliferator Activated Receptor type alpha (PPARα).

Through activation of PPARα, fenofibrate activates lipoprotein lipase production and reduces production of apoprotein CIII. Activation of PPARα also induces an increase in the synthesis of apoproteins AI and AII.

Simvastatin

Simvastatin, which is an inactive lactone, is hydrolyzed in the liver to the corresponding active beta­hydroxyacid form which has a potent activity in inhibiting HMG­CoA reductase (3 hydroxy ­ 3 methylglutaryl CoA reductase). This enzyme catalyses the conversion of HMG­CoA to mevalonate, an early and rate­limiting step in the biosynthesis of cholesterol.

Cholib:

 

Cholib contains fenofibrate and simvastatin, which have different modes of action as described above. Pharmacodynamic  effects

Fenofibrate

Studies with fenofibrate on lipoprotein fractions show decreases in levels of LDL and VLDL cholesterol (VLDL­C). HDL­C levels are frequently increased. LDL and VLDL triglycerides are reduced. The overall effect is a decrease in the ratio of low and very low­density lipoproteins to high­density lipoproteins.

Fenofibrate also has a uricosuric effect leading to reduction in uric acid levels of approximately 25%. Simvastatin

Simvastatin has been shown to reduce both normal and elevated LDL­C concentrations. LDL is formed from very­low­ density protein (VLDL) and is catabolised predominantly by the high affinity LDL receptor. The mechanism of the LDL lowering effect of simvastatin may involve both reduction of VLDL­C concentration and induction of the LDL receptor, leading to reduced production and increased catabolism of LDL­C. Apolipoprotein B also falls substantially during treatment with simvastatin. In addition, simvastatin moderately increases HDL­C and reduces plasma TG. As a result of these changes the ratios of TC to HDL­C and LDL­C to HDL­C are reduced.

Cholib

The respective effects of simvastatin and fenofibrate are complementary. Clinical efficacy and safety

Cholib

Four pivotal clinical studies were carried out in the clinical program. Overall, 7,583 subjects with mixed dyslipidemia entered a 6 week statin run­in period. Of these, 2,474 subjects were randomized for 24 weeks treatment, 1,237 subjects received fenofibrate and simvastatin co­administration and 1,230 subjects received statin monotherapy all administered in the evening.

Statin type and dose used:

 

    Week 0 to Week 12  Week 0 to Week 12 Week 

Week 12 to Week 24

 

Week 12 to Week 24

 

 STUDY  Statin 6 weeks run­ in Statin monotherapy Fenofibrate/Simvastatin in combination Statin monotherapy 

Fenofibrate/Simvastatin in combination

0501 simvastatin 20 mg 

simvastatin 40 mg

 

simvastatin 20 mg

  

simvastatin 40 mg

 

simvastatin 40 mg

 0502 simvastatin 40 mg 

simvastatin 40 mg

 

simvastatin 40 mg

 

simvastatin 40 mg

 

simvastatin 40 mg

 0503 atorvastatin 10 mg 

atorvastatin 10 mg

 

simvastatin 20 mg

 

atorvastatin 20 mg

 

simvastatin 40 mg

 0504 pravastatin 40 mg 

pravastatin 40 mg

 

simvastatin 20 mg

 

pravastatin 40 mg

 

simvastatin 40 mg

 

Cholib 145/40

 

Study 0502 was evaluated a constant dose of fenofibrate­simvastatin combination and statin comparator throughout the 24 week double­blind period. The primary efficacy criterion was superiority of the combination fenofibrate 145 and simvastatin 40 mg versus simvastatin 40 mg on TG and LDL­C decrease and HDL­C increase at 12 weeks.

 

At 12 weeks and 24 weeks the combination of fenofibrate 145 mg and simvastatin 40 mg (F145/S40) showed superiority over simvastatin 40 mg (S40) for TG reduction and HDL­C increase.

The combination F145/S40 showed superiority over S40 for LDL­C reduction only at 24 weeks from a non­significant additional 1.2% reduction of LDL­C at 12 weeks to a statistically significant 7.2% reduction at 24 weeks.

                     % Change Mean (SD)

            TG, LDL­C and HDL­C Percent Change from Baseline to 12 and 24 Weeks Full Analysis Subject Sample
 

Lipid

parameter (mmol/L)
 

Feno 145+Simva 40

(N=221)
   

After 12 weeks

  % Change Mean (SD)

TG

 ­27.18 (36.18) ­0.74 (39.54) ­28.19
(­32.91, ­23.13)
 <0.001
 LDL-C  ­6.34 (23.53) ­5.21 (22.01) ­1.24
(­5.22, 2.7)
 0.539
 HDL-C  5.77 (15.97) ­0.75 (12.98) 6.46
(3.83, 9.09)
 <0.001
 After 24Weeks  % Change Mean (SD) 
TG ­22.66 (43.87) 1.81 (36.64) ­27.56
(­32.90, ­21.80)
 <0.001
LDL-C

­3.98 (24.16)

 3.07 (30.01) ­7.21
(­12.20, ­2.21)
 0.005
 HDL-C 5.08 (16.10) 0.62 (13.21) 4.65
(1.88, 7.42)
 0.001

 

*Treatment Comparison consists of the difference between the LS­means for Feno 145 + Simva 40 and Simva 40, as well as the corresponding 95% CI.

The results on the biological parameters of interest at 24 weeks are presented in the table below. F145/S40 demonstrated statistically significant superiority on all parameters except on ApoA1 increase.

 ANCOVA (analysis of covariance) of Percent Change in TC, non­HDL­C, ApoAI, ApoB, ApoB/ApoAI and fibrinogen from Baseline to 24 Weeks – Full Analysis Subject Sample
 Parameter Treatment Group N Means (SD) Treatment Comparison* P­value
 TC (mmol/L)

Feno 145 + Simva 40
 

Simva 40

213

 

203

 ­-4.95 (18.59)

 

1.69 (20.45)

 -6.76 (­10.31, ­  3.20)  <0.001
Non­HDL­C   (mmol/L

Feno 145 + Simva 40

 

  Simva 40

 213

 

203 

-7.62 (23.94)

 

2.52 (26.42)

 -10.33 (­14.94, ­5.72) <0.001
 Apo AI (g/L) Feno 145 + Simva 40

 

  Simva 40

 204 

 

194

 

 5.79 (15.96)

 

4.02 (13.37)

 

 2.34 (­0.32, 4.99) 0.084
 Apo B (g/L) Feno 145 + Simva 40

 

  Simva 40

 204

 

194 

 -2.95 (21.88)

 

6.04 (26.29)

­ -9.26 (­13.70, ­4.82) <0.001
 Apo B/Apo AI

 Feno 145 + Simva 40


  Simva 40

 204

 

194 

 -4.93 (41.66)

 

3.08 (26.85)

 -8.29 (­15.18, ­1.39) 0.019
 Fibrinogen* (g/L) Feno 145 + Simva 40

 

Simva 40

 

202

 

 

192

 

 -29 (0.04)

 

0.01 (0.05)

 

 ­-0.30 (­0.41, ­0.19) <0.001

 

*Treatment Comparison consists of the difference between the LS­means for Feno 145 + Simva 40 and Simva 40, as well as the corresponding 95% CI. LS (less square mean) SD (standard deviation)

Cholib 145/20

Study 0501 evaluated 2 different doses of fenofibrate­simvastatin combination compared to simvastatin 40 mg for a 24 week double­blind period. The primary efficacy criterion was superiority of the combination fenofibrate 145 and simvastatin 20 mg versus simvastatin 40 mg on TG decrease and HDL­C increase and non­inferiority for LDL­C decrease at 12 weeks.

 

  Mean Percent Change from Baseline to 12 Weeks
Full Analysis Subject Sample
 Parameter Feno 145+Simva 20 (N=493)
Mean (SD)
 Simva 40 (N=505)
Mean (SD
 Treatment Comparison* P­value
 TG (mmol/L) ­-28.20 (37.31) -4.60 (40.92) -26.47 (­30.0, ­22.78) <0.001
 LDL­C (mmol/L) ­-5.64 (23.03) -10.51 (22.98) 4.75 (2.0, 7.51) NA 
 HDL­C (mmol/L) 7.32 (15.84) 1.64 (15.76) 5.76 (3.88, 7.65) <0.001
 TC (mmol/L) ­-6.00 (15.98) ­-7.56 (15.77) 1.49 (­0.41, 3.38) 0.123
 Non­HDL­C (mmol/L) -9.79 (21.32) -9.79 (20.14) -0.11 (­2.61,2.39) 0.931
 Apo AI (g/L) 3.97 (13.15) 0.94 (13.03) 2.98 (1.42,4.55) <0.001
 Apo B (g/L) -6.52 (21.12) -7.97 (17.98) 1.22 (­1.19,3.63) 0.320
 Apo B/Apo AI -8.49 (24.42) -7.94 (18.96) -0.73 (­3.44,1.97) 0.595
 Fibrinogen (g/L) -0.31 (0.70) -0.02 (0.70) --0.32 (­0.40,­0.24) <0.001

*Treatment Comparison: difference between the LS Means for Feno 145 + Simva 20 and Simva 40, as well as the associated 95% confidence interval

After the first 12 weeks of treatment, the combination of fenofibrate 145 mg and simvastatin 20 mg showed superiority over simvastatin 40 mg for TG reduction and HDL­C increase but did not meet the criteria for non­inferiority on LDL­C. The combination of fenofibrate 145 mg with simvastatin 20 mg demonstrated statistically significant superiority on apoA1 increase and fibrinogen decrease compared to simvastatin 40 mg.

Supportive study

The Action to Control Cardiovascular Risk in Diabetes (ACCORD) lipid trial was a randomized placebo­controlled study of 5,518 patients with type 2 diabetes mellitus treated with fenofibrate in addition to simvastatin. Fenofibrate plus simvastatin therapy did not show any significant differences compared to simvastatin monotherapy in the composite primary outcome of non­fatal myocardial infarction, non­fatal stroke, and cardiovascular death (hazard ratio [HR] 0.92, 95% CI 0.79­1.08, p = 0.32; absolute risk reduction: 0.74%). In the pre­specified subgroup of dyslipidaemic patients, defined as those in the lowest tertile of HDL­C (≤ 34 mg/dl or 0.88 mmol/L) and highest tertile of TG (≥ 204 mg/dl or 2.3 mmol/L) at baseline, fenofibrate plus simvastatin therapy demonstrated a 31% relative reduction compared to simvastatin monotherapy for the composite primary outcome (hazard ratio [HR] 0.69, 95% CI 0.49­0.97, p=0.03; absolute risk reduction: 4.95%). Another prespecified subgroup analysis identified a statistically significant treatment­ by­gender interaction (p=0.01) indicating a possible treatment benefit of combination therapy in men (p=0.037) but a potentially higher risk for the primary outcome in women treated with combination therapy compared to simvastatin monotherapy (p=0.069). This was not observed in the aforementioned subgroup of patients with dyslipidaemia but there was also no clear evidence of benefit in dyslipidaemic women treated with fenofibrate plus simvastatin, and a possible harmful effect in this subgroup could not be excluded.

Paediatric population

The European Medicines Agency has waived the obligation to submit the results of studies with Cholib in all subsets of the paediatric population in combined dyslipidaemia (see section 4.2 for information on paediatric use).

 


The geometric mean ratios and 90% CIs for the comparison of AUC, AUC(0­t) and Cmax of the active metabolites, fenofibric acid and simvastatin acid, of the fixed dose combination Cholib 145 mg/20 mg tablet and the co­ administration of the separate 145 mg fenofibrate and 20 mg simvastatin tablets as used in the clinical program, were all within the 80­125% bioequivalence interval.

The geomean maximum plasma level (Cmax) of the inactive parent simvastatin was 2.7 ng/mL for the fixed dose combination Cholib 145 mg/20 mg tablet and 3.9 ng/mL for the co­administration of the separate 145 mg fenofibrate and 20 mg simvastatin tablets as used in the clinical program.

The geometric mean ratios and 90% CIs for the comparison of plasma exposure (AUC and AUC(0­t)) to simvastatin after administration of the fixed dose combination Cholib 145 mg/20 mg tablet and after co­administration of the separate 145 mg fenofibrate and 20 mg simvastatin tablets as used in the clinical program, were within the 80­125% bioequivalence interval.

Absorption

 

 

Maximum plasma concentrations (Cmax) of fenofibrate occur within 2 to 4 hours after oral administration. Plasma concentrations are stable during continuous treatment in any given individual.

Fenofibrate is water­insoluble and must be taken with food to facilitate absorption. The use of micronised fenofibrate and NanoCrystal® technology for the formulation of the fenofibrate 145 mg tablet enhances its absorption.

Contrarily to previous fenofibrate formulations, the maximum plasma concentration and overall exposure of this formulation is independent from food intake.

A food­effect study involving administration of this formulation of fenofibrate 145 mg tablets to healthy male and female subjects under fasting conditions and with a high fat meal indicated that exposure (AUC and Cmax) to fenofibric acid is not affected by food.

Therefore, fenofibrate in Cholib may be taken without regard to meals.

Kinetic studies following the administration of a single dose and continuous treatment have demonstrated that the drug does not accumulate.

Simvastatin is an inactive lactone which is readily hydrolyzed in vivo to the corresponding beta­hydroxyacid, a potent inhibitor of HMG­CoA reductase. Hydrolysis takes place mainly in the liver; the rate of hydrolysis in human plasma is very slow.

Simvastatin is well absorbed and undergoes extensive hepatic first­pass extraction. The extraction in the liver is dependent on the hepatic blood flow. The liver is the primary site of action of the active form. The availability of the beta­hydroxyacid to the systemic circulation following an oral dose of simvastatin was found to be less than 5% of the dose. Maximum plasma concentration of active inhibitors is reached approximately 1­2 hours after administration of simvastatin. Concomitant food intake does not affect the absorption.

The pharmacokinetics of single and multiple doses of simvastatin showed that no accumulation of medicinal product occurred after multiple dosing.

Distribution

Fenofibric acid is strongly bound to plasma albumin (more than 99%). The protein binding of simvastatin and its active metabolite is > 95%. Biotransformation and Elimination

After oral administration, fenofibrate is rapidly hydrolyzed by esterases to the active metabolite fenofibric acid. No unchanged fenofibrate can be detected in the plasma. Fenofibrate is not a substrate for CYP 3A4. No hepatic microsomal metabolism is involved.

The drug is excreted mainly in the urine. Practically all the drug is eliminated within 6 days. Fenofibrate is mainly excreted in the form of fenofibric acid and its glucuronide conjugate. In elderly patients, the fenofibric acid apparent total plasma clearance is not modified.

Kinetic studies following the administration of a single dose and continuous treatment have demonstrated that the drug does not accumulate. Fenofibric acid is not eliminated by hemodialysis.

Mean plasma half­life: the plasma elimination half­life of fenofibric acid is approximately 20 hours.

Simvastatin is a substrate of CYP 3A4. Simvastatin is taken up actively into the hepatocytes by the transporter OATP1B1. The major metabolites of simvastatin present in human plasma are the beta­hydroxyacid and four additional active metabolites. Following an oral dose of radioactive simvastatin to man, 13% of the radioactivity was excreted in the urine and 60% in the faeces within 96 hours. The amount recovered in the faeces represents absorbed medicinal

 

product equivalents excreted in bile as well as unabsorbed medicinal product. Following an intravenous injection of the beta­hydroxyacid metabolite, its half­life averaged 1.9 hours. An average of only 0.3% of the intravenous dose was excreted in urine as inhibitors.

Effects of repeated administration of fenofibrate on the pharmacokinetics of single or multiple doses of simvastatin have been investigated in two small studies (n=12) followed by a larger one (n=85) in healthy subjects.

In one study the AUC of the simvastatin acid (SVA), a major active metabolite of simvastatin, was reduced by 42% (90% CI 24%­56%) when a single dose of 40 mg simvastatin was combined with repeated administration of fenofibrate 160 mg. In the other study [Bergman et al, 2004] repeated co­administration of both simvastatin 80 mg and fenofibrate 160 mg led to a reduction in the AUC of the SVA of 36% (90% CI 30%­42%). In the larger study a reduction of 21% (90% CI 14%­27%) in AUC of SVA was observed after repeated co­administration of simvastatin 40 mg and fenofibrate 145 mg in the evening. This was not significantly different from the 29% (90% CI 22%­35%) reduction in AUC of SVA observed when co­administration was 12 hours apart: simvastatin 40 mg in the evening and fenofibrate 145 mg in the morning.

Whether fenofibrate had an effect on other active metabolites of simvastatin was not investigated.

The exact mechanism of interaction is not known. In the available clinical data, the effect on LDL­C reduction was not considered to be significantly different to simvastatin monotherapy when LDL­C is controlled at the time of initiating treatment.

The repeated administration of simvastatin 40 or 80 mg, the highest dose registered, did not affect the plasma levels of fenofibric acid at steady state.

Special populations

Carriers of the SLCO1B1 gene c.521T>C allele have lower OATP1B1 activity. The mean exposure (AUC) of the main active metabolite, simvastatin acid is 120% in heterozygote carriers (CT) of the C allele and 221% in homozygote (CC) carriers relative to that of patients who have the most common genotype (TT). The C allele has a frequency of 18% in the European population. In patients with SLCO1B1 polymorphism there is a risk of increased exposure of simvastatin, which may lead to an increased risk of rhabdomyolysis (see section 4.4).

 


No preclinical studies have been performed with the fixed dose combination Cholib. Fenofibrate

Acute toxicity studies have yielded no relevant information about specific toxicity of fenofibrate.

In a three­month oral nonclinical study in the rat species with fenofibric acid, the active metabolite of fenofibrate,  toxicity for the skeletal muscles (particularly those rich in type I ­slow oxidative­ myofibres) and cardiac degeneration, anemia and decreased body weight were seen at exposure levels ≥50­ fold the human exposure for the skeletal toxicity and >15 fold for the cardiomyotoxicity.

Reversible ulcers and erosions in the gastro­intestinal tract occurred in dogs treated during 3 months at exposures approximately 7­fold the clinical AUC.

Studies on mutagenicity of fenofibrate have been negative.

In rats and mice, liver tumours have been found in carcinogenicity studies, which are attributable to peroxisome proliferation. These changes are specific to rodents and have not been observed in other species at comparable dose levels. This is of no relevance to therapeutic use in man.

 

Studies in mice, rats and rabbits did not reveal any teratogenic effect. Embryotoxic effects were observed at doses in the range of maternal toxicity. Prolongation of the gestation period and difficulties during delivery were observed at high doses.

No effects on fertility were detected in non­clinical reproductive toxicity studies conducted with fenofibrate. However reversible hypospermia and testicular vacuolation and immaturity of the ovaries were observed in a repeat­dose toxicity study with fenofibric acid in young dogs.

Simvastatin

Based on conventional animal studies regarding pharmacodynamics, repeated dose toxicity, genotoxicity and carcinogenicity, there are no other risks for the patient than may be expected on account of the pharmacological mechanism. At maximally tolerated doses in both the rat and the rabbit, simvastatin produced no fetal malformations, and had no effects on fertility, reproductive function or neonatal development.


Tablet core:

Butylhydroxyanisole (E320)

Lactose monohydrate

Sodium laurilsulfate

Starch, pregelatinised (maize)

Docusate sodium

Sucrose

Citric acid monohydrate (E330)

Hypromellose (E464)

Crospovidone (E1202)

Magnesium stearate (E572)

Silicified microcrystalline cellulose (comprised of cellulose, microcrystalline and silica, colloidal anhydrous)

Ascorbic acid (E300)

Film­coating:

Poly (vinyl alcohol), partially hydrolysed (E1203) Titanium dioxide (E171)

Talc (E553b)

Lecithin (derived from soya bean (E322))

Xanthan gum (E415)

Iron oxide red (E172)

Iron oxide yellow (E172)

Sunset yellow FCF (E110)


Not applicable.


2 years.

Store below 30°C.


Alu/Alu blisters

Pack sizes: 10, 30 and 90 film­coated tablets.

Not all pack sizes may be marketed.


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


Abbott Laboratories Ltd. Abbott House, Vanwall Business park Vanwall Road, Maidenhead Berkshire SL6 4XE, UK

21 / 10 / 2016
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