Vresq 200mg Powder for Solution for Injection contains the active substance Voriconazole. Vresq 200mg Powder for Solution for Injection is an antifungal medicine. It works by killing or stopping the growth of the fungi that cause infections.

It is used for the treatment of patients (adults and children over the age of 2) with:

·        invasive aspergillosis (a type of fungal infection due to Aspergillus sp),

·        candidaemia (another type of fungal infection due to Candida sp) in non-neutropenic patients (patients without abnormally low white blood cells count),

·        serious invasive Candida sp. infections when the fungus is resistant to fluconazole (another antifungal medicine),

·        serious fungal infections caused by Scedosporium sp or Fusarium sp. (two different species of fungi).

Vresq 200mg Powder for Solution for Injection is intended for patients with worsening, possibly life-threatening, fungal infections.

Prevention of fungal infections in high-risk bone marrow transplant recipients.

This product should only be used under the supervision of a doctor.

Do not take Vresq 200mg Powder for Solution for Injection

-         If you are allergic to the active ingredient Vresq, or to any of the other ingredients of this medicine (listed in section 6).

It is very important that you inform your doctor or pharmacist if you are taking or have taken any other medicines, even those that are obtained without a prescription, or herbal medicines.

The medicines in the following list must not be taken during your course of Vresq 200mg Powder for Solution for Injection treatment:

·             Terfenadine (used for allergy)

·             Astemizole (used for allergy)

·             Cisapride (used for stomach problems)

·             Pimozide (used for treating mental illness)

·             Quinidine (used for irregular heartbeat)

·             Rifampicin (used for treating tuberculosis)

·             Efavirenz (used for treating HIV) in doses of 400 mg and above once daily

·             Carbamazepine (used to treat seizures)

·             Phenobarbital (used for severe insomnia and seizures)

·             Ergot alkaloids (e.g., ergotamine, dihydroergotamine; used for migraine)

·             Sirolimus (used in transplant patients)

·             Ritonavir (used for treating HIV) in doses of 400mg and more twice daily

·             St. John’s Wort (herbal supplement)

Warnings and precautions

Talk to your doctor, pharmacist, or nurse before receiving Vresq 200mg Powder for Solution for Injection if:

·             you have had an allergic reaction to other azoles.

·             you are suffering from or have ever suffered from liver disease. If you have liver disease, your doctor may prescribe a lower dose of Vresq 200mg Powder for Solution for Injection. Your doctor should also monitor your liver function while you are being treated with Vresq 200mg Powder for Solution for Injection by doing blood tests.

·             you are known to have cardiomyopathy, irregular heartbeat, slow heart rate or an abnormality of electrocardiogram (ECG) called ‘long QTc syndrome’.

You should avoid any sunlight and sun exposure while being treated. It is important to cover sun exposed areas of skin and use sunscreen with high sun protection factor (SPF), as an increased sensitivity of skin to the sun’s UV rays can occur. These precautions are also applicable to children.

While being treated with Vresq 200mg Powder for Solution for Injection:

·             Tell your doctor immediately if you develop

o   sunburn

o   severe skin rash or blisters

o   bone pain

If you develop skin disorders as described above, your doctor may refer you to a dermatologist, who after consultation may decide that it is important for you to be seen on a regular basis.

There is a small chance that skin cancer could develop with long-term use of Vresq 200mg Powder for Solution for Injection.

Your doctor should monitor the function of your liver and kidney by doing blood tests.

Children and adolescents

Vresq 200mg Powder for Solution for Injection should not be given to children younger than 2 years of age.

Other medicines and Vresq 200mg Powder for Solution for Injection

Please tell your doctor or pharmacist if you are taking, have recently taken or might take any other medicines, including those that are obtained without a prescription.

·             Some medicines, when taken at the same time as Vresq 200mg Powder for Solution for Injection, may affect the way Vresq 200mg Powder for Solution for Injection works or Vresq 200mg Powder for Solution for Injection may affect the way they work.

Tell your doctor if you are taking the following medicine, as treatment with Vresq 200mg Powder for Solution for Injection at the same time should be avoided if possible:

·             Ritonavir (used for treating HIV) in doses of 100 mg twice daily

Tell your doctor if you are taking either of the following medicines, as treatment with Vresq 200mg Powder for Solution for Injection at the same time should be avoided if possible, and a dose adjustment of Vresq may be required:

·             Rifabutin (used for treating tuberculosis). If you are already being treated with rifabutin your blood counts and side effects to rifabutin will need to be monitored.

·             Phenytoin (used to treat epilepsy). If you are already being treated with phenytoin your blood concentration of phenytoin will need to be monitored during your treatment with Vresq 200mg Powder for Solution for Injection and your dose may be adjusted.

Tell your doctor if you are taking any of the following medicines, as a dose adjustment or monitoring may be required to check that the medicines and/ or Vresq 200mg Powder for Solution for Injection are still having the desired effect:

·             Warfarin and other anticoagulants (e.g., phenprocoumon, acenocoumarol; used to slow down clotting of the blood)

·             Ciclosporin (used in transplant patients)

·             Tacrolimus (used in transplant patients)

·             Sulfonylureas (e.g., tolbutamide, glipizide, and glyburide) (used for diabetes)

·             Statins (e.g., atorvastatin, simvastatin) (used for lowering cholesterol)

·             Benzodiazepines (e.g midazolam, triazolam) (used for severe insomnia and stress)

·             Omeprazole (used for treating ulcers)

·             Oral contraceptives (if you take Vresq 200mg Powder for Solution for Injection whilst using oral contraceptives, you may get side effects such as nausea and menstrual disorders)

·             Vinca alkaloids (e.g., vincristine and vinblastine) (used in treating cancer)

·             Indinavir and other HIV protease inhibitors (used for treating HIV)

·             Non-nucleoside reverse transcriptase inhibitors (e.g., efavirenz, delavirdine, nevirapine) (used for treating HIV) (some doses of efavirenz can NOT be taken at the same time as Vresq 200mg Powder for Solution for Injection)

·             Methadone (used to treat heroin addiction)

·             Alfentanil and fentanyl and other short-acting opiates such as sufentanil (painkillers used for surgical procedures)

·             Oxycodone and other long-acting opiates such as hydrocodone (used for moderate to severe pain)

·             Non-steroidal anti-inflammatory drugs (e.g., ibuprofen, diclofenac) (used for treating pain and inflammation)

·             Fluconazole (used for fungal infections)

·             Everolimus (used for treating advanced kidney cancer and in transplant patients)

·             Tolvaptan (used to treat hyponatremia (low levels of sodium in your blood) or to slow kidney function decline in patients with polycystic kidney disease)

·             Letermovir (used for preventing cytomegalovirus (CMV) disease after bone marrow transplant)

·             Naloxegol: used to treat constipation specifically caused by pain medicines, called opioids, (e.g., morphine, oxycodone, fentanyl, tramadol, codeine)

·             Ivacaftor: used to treat cystic fibrosis

Pregnancy and breast-feeding

Vresq 200mg Powder for Solution for Injection must not be used during pregnancy, unless indicated by your doctor. Effective contraception must be used in women of childbearing potential. Contact your doctor immediately if you become pregnant while being treated with Vresq 200mg Powder for Solution for Injection.

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

Vresq 200mg Powder for Solution for Injection may cause blurring of vision or uncomfortable sensitivity to light. While affected, do not drive or operate any tools or machines. Tell your doctor if you experience this.

Vresq 200mg Powder for Solution for Injection contains cyclodextrins

This medicine contains 3200 mg of betadex sulfobutyl ether sodium in each vial. If you have a kidney disease, talk to your doctor before you receive this medicine.

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

Your doctor will determine your dose depending on your weight and the type of infection you have. Your doctor may change your dose depending on your condition.

The recommended dose for adults (including elderly patients) is as follows:

Depending on your response to treatment, your doctor may decrease the dose to 3 mg/kg twice daily.

The doctor may decide to decrease the dose if you have mild to moderate cirrhosis.

Use in children and adolescents

The recommended dose for children and teenagers is as follows:

Depending on your response to treatment, your doctor may increase or decrease the daily dose.

Vresq 200mg Powder for Solution for Injection will be reconstituted and diluted to the correct concentration by your hospital pharmacist or nurse.

This will be given to you by intravenous infusion (into a vein) at a maximum rate of 3 mg/kg per hour over 1 to 3 hours.

If you or your child are taking Vresq 200mg Powder for Solution for Injection for prevention of fungal infections, your doctor may stop giving Vresq 200mg Powder for Solution for Injection if you or your child develop treatment related side effects.

If a dose of Vresq 200mg Powder for Solution for Injection has been forgotten

As you will be given this medicine under close medical supervision, it is unlikely that a dose would be missed. However, tell your doctor or pharmacist if you think that a dose has been forgotten.

If you stop taking Vresq 200mg Powder for Solution for Injection

Vresq 200mg Powder for Solution for Injection treatment will continue for as long as your doctor advises, however duration of treatment with Vresq 200mg Powder for Solution for Injection should be no more than 6 months.

Patients with a weakened immune system or those with difficult infections may require long-term treatment to prevent the infection from returning. You may be switched from the intravenous infusion to tablets once your condition improves.

When Vresq 200mg Powder for Solution for Injection treatment is stopped by your doctor you should not experience any effects.

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

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

If any side effects occur, most are likely to be minor and temporary. However, some may be serious and need medical attention.

Serious side effects – Stop taking Vresq 200mg Powder for Solution for Injection and see a doctor immediately

-          Rash

-          Jaundice; Changes in blood tests of liver function

-          Pancreatitis

Other side effects

Very common: may affect more than 1 in 10 people

-          Visual impairment (change in vision including blurred vision, visual colour alterations, abnormal intolerance to visual perception of light, colour blindness, eye disorder, halo vision, night blindness, swinging vision, seeing sparks, visual aura, visual acuity reduced, visual brightness, loss of part of the usual field of vision, spots before the eyes)

-          Fever

-          Rash

-          Nausea, vomiting, diarrhoea

-          Headache

-          Swelling of the extremities

-          Stomach pains

-          Breathing difficulties

-          Elevated liver enzymes

Common: may affect up to 1 in 10 people

-       Inflammation of the sinuses, inflammation of the gums, chills, weakness

-       Low numbers of some types, including severe, of red (sometimes immune-related) and/or white blood cells (sometimes with fever), low numbers of cells called platelets that help the blood to clot

-       Low blood sugar, low blood potassium, low sodium in the blood

-       Anxiety, depression, confusion, agitation, inability to sleep, hallucinations

-       Seizures, tremors or uncontrolled muscle movements, tingling or abnormal skin sensations, increase in muscle tone, sleepiness, dizziness

-       Bleeding in the eye

-       Heart rhythm problems including very fast heartbeat, very slow heartbeat, fainting

-       Low blood pressure, inflammation of a vein (which may be associated with the formation of a blood clot)

-       Acute breathing difficulty, chest pain, swelling of the face (mouth, lips and around eyes), fluid accumulation in the lungs

-       Constipation, indigestion, inflammation of the lips

-       Jaundice, inflammation of the liver and liver injury

-       Skin rashes which may lead to severe blistering and peeling of the skin characterized by a flat, red area on the skin that is covered with small confluent bumps, redness of the skin

-       Itchiness

-       Hair loss

-       Back pain

-       Kidney failure, blood in the urine, changes in kidney function tests

Uncommon: may affect up to 1 in 100 people

-       Flu-like symptoms, irritation and inflammation of the gastrointestinal tract, inflammation of the gastrointestinal tract causing antibiotic associated diarrhea, inflammation of the lymphatic vessels.

-       Inflammation of the thin tissue that lines the inner wall of the abdomen and covers the abdominal organ

-       Enlarged lymph glands (sometimes painful), failure of blood marrow, increased eosinophil

-       Depressed function of the adrenal gland, underactive thyroid gland

-       Abnormal brain function, Parkinson-like symptoms, nerve injury resulting in numbness, pain, tingling or burning in the hands or feet

-       Problems with balance or coordination

-       Swelling of the brain

-       Double vision, serious conditions of the eye including pain and inflammation of the eyes and eyelids, abnormal eye movement, damage to the optic nerve resulting in vision impairment, optic disc swelling

-       Decreased sensitivity to touch

-       Abnormal sense of taste

-       Hearing difficulties, ringing in the ears, vertigo

-       Inflammation of certain internal organs-pancreas and duodenum, swelling and inflammation of the tongue

-       Enlarged liver, liver failure, gallbladder disease, gallstones

-       Joint inflammation, inflammation of the veins under the skin (which may be associated with the formation of a blood clot)

-       Inflammation of the kidney, proteins in the urine, damage to the kidney

-       Very fast heart rate or skipped heartbeats, sometimes with erratic electrical impulses

-       Abnormal electrocardiogram (ECG)

-       Blood cholesterol increased; blood urea increased

-       Allergic skin reactions (sometimes severe), including life-threatening skin condition that causes painful blisters and sores of the skin and mucous membranes, especially in the mouth, inflammation of the skin, hives, sunburn or severe skin reaction following exposure to light or sun, skin redness and irritation, red or purple discoloration of the skin which may be caused by low platelet count, eczema

-       Infusion site reaction

-       Allergic reaction or exaggerated immune response

Rare: may affect up to 1 in 1000 people

-       Overactive thyroid gland

-       Deterioration of brain function that is a serious complication of liver disease

-       Loss of most fibres in the optic nerve, clouding of the cornea, involuntary movement of the eye

-       Bullous photosensitivity

-       A disorder in which the body’s immune system attacks part of the peripheral nervous system

-       Heart rhythm or conduction problems (sometimes life threatening)

-       Life threatening allergic reaction

-       Disorder of blood clotting system

-       Allergic skin reactions (sometimes severe), including rapid swelling (oedema) of the dermis, subcutaneous tissue, mucosa, and submucosal tissues, itchy or sore patches of thick, red skin with silvery scales of skin, irritation of the skin and mucous membranes, life-threatening skin condition that causes large portions of the epidermis, the skin's outermost layer, to detach from the layers of skin below

-       Small dry scaly skin patches, sometimes thick with spikes or ‘horns’

Side effects with frequency not known:

-       Freckles and pigmented spots

Other significant side effects whose frequency is not known, but should be reported to your doctor immediately:

-       Skin cancer

-       Inflammation of the tissue surrounding the bone

-       Red, scaly patches or ring-shaped skin lesions that may be a symptom of an autoimmune disease called cutaneous lupus erythematosus

Reactions during the infusion have occurred uncommonly with Vresq (including flushing, fever, sweating, increased heart rate and shortness of breath). Your doctor may stop the infusion if this occurs.

As Vresq has been known to affect the liver and the kidney, your doctor should monitor the function of your liver and kidney by doing blood tests. Please advise your doctor if you have any stomach pains or if your stools have a different consistency.

There have been reports of skin cancer in patients treated with Vresq for long periods of time.

Sunburn or severe skin reaction following exposure to light or sun was experienced more frequently in children. If you or your child develops skin disorders, your doctor may refer you to a dermatologist, who after consultation may decide that it is important for you or your child to be seen on a regular basis. Elevated liver enzymes were also observed more frequently in children.

If any of these side effects persist or are troublesome, please tell your doctor.

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

Do not use this medicine after the expiry date which is stated on the label. The expiry date refers to the last day of that month.

Store below 30°C.

Once reconstituted, Vresq 200mg Powder for Solution for Injection should be used immediately, but, if necessary, may be stored for up to 24 hours at 2°C - 8°C (in a refrigerator). Reconstituted Vresq 200mg Powder for Solution for Injection needs to be diluted with a compatible infusion solution first before it is infused. (Please refer to the end of this leaflet for further information).

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