Layal 5 mg tablets are indicated in the symptomatic treatment of allergic rhinitis (including persistent allergic rhinitis) and urticaria in adults and children aged 6 years and above

Posology

Adults and adolescents 12 years and above:

The daily recommended dose is 5 mg (1 tablet).

Elderly

Adjustment of the dose is recommended in elderly patients with moderate to severe renal impairment (see Renal impairment below).

Renal impairment

The dosing intervals must be individualised according to renal function. Refer to the following table and adjust the dose as indicated. To use this dosing table, an estimate of the patient's creatinine clearance (CLcr) in ml/min is needed. The CLcr (ml/min) may be estimated from serum creatinine (mg/dl) determination using the following formula:
CLcr = [140 - age{years)]* weight(kg) (*0.85 forwomen )

                72*serum creaiinim{mg / dl)

Dosing adjustments for patients with impaired renal function:

In paediatric patients suffering from renal impairment, the dose will have to be adjusted on an
individual basis taking into account the renal clearance of the patient and his body weight.
There are no specific data for children with renal impairment.
Hepatic impairment:
No dose adjustment is needed in patients with solely hepatic impairment. In patients with
hepatic impairment and renal impairment, adjustment of the dose is recommended (see Renal
impairment above).
Paediatric population
Children aged 6 to 12 years:
The daily recommended dose is 5 mg (1 film-coated tablet).
For children aged 2 to 6 years no adjusted dosage is possible with the tablet formulation. It is
recommended to use a pediatric formulation of levocetirizine.
Method of administration
The tablet must be taken orally, swallowed whole with liquid and may be taken with or without
food. It is recommended to take the daily dose in one single intake.
Duration of use:
Intermittent allergic rhinitis (symptoms experienced for less than four days a week or for less
than four weeks a year) has to be treated according to the disease and its history; it can be
stopped once the symptoms have disappeared and can be restarted again when symptoms
reappear. In case of persistent allergic rhinitis (symptoms experienced for more than four days
a week or for more than four weeks a year), continuous therapy can be proposed to the patient
during the period of exposure to allergens.
There is clinical experience with the use of levocetirizine for treatment periods of at least 6
months. In chronic urticaria and chronic allergic rhinitis, there is clinical experience of use of
cetirizine (racemate) for up to one year.

Precaution is recommended with concurrent intake of alcohol (see section 4.5).
Caution should be taken in patients with predisposing factors of urinary retention (e.g. spinal
cord lesion, prostatic hyperplasia) as levocetirizine may increase the risk of urinary retention.
Response to allergy skin tests are inhibited by antihistamines and a wash-out period (of 3 days)
is required before performing them.

Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or
glucose-galactose malabsorption should not take this medicine.
Pruritus may occur when levocetirizine is stopped even if those symptoms were not present
before treatment initiation. The symptoms may resolve spontaneously. In some cases, the

symptoms may be intense and may require treatment to be restarted. The symptoms should
resolve when the treatment is restarted.

Paediatric population
The use of the film-coated tablet formulation is not recommended in children aged less than 6
years since this formulation does not allow for appropriate dose adaptation. It is recommended
to use a paediatric formulation of levocetirizine.

No interaction studies have been performed with levocetirizine (including no studies with
CYP3A4 inducers); studies with the racemate compound cetirizine demonstrated that there
were no clinically relevant adverse interactions (with antipyrine, azithromycin, cimetidine,
diazepam, erythromycin, glipizide, ketoconazole and pseudoephedrine). A small decrease in
the clearance of cetirizine (16%) was observed in a multiple dose study with theophylline (400
mg once a day); while the disposition of theophylline was not altered by concomitant cetirizine
administration.
In a multiple dose study of ritonavir (600 mg twice daily) and cetirizine (10 mg daily), the
extent of exposure to cetirizine was increased by about 40% while the disposition of ritonavir
was slightly altered (-11%) further to concomitant cetirizine administration.
The extent of absorption of levocetirizine is not reduced with food, although the rate of
absorption is decreased.
In sensitive patients, the concurrent administration of cetirizine or levocetirizine and alcohol or
other CNS depressants may cause additional reductions in alertness and impairment of
performance.

Pregnancy
There are no or limited amount of data (less than 300 pregnancy outcomes) from the use of
levocetirizine in pregnant women. However, for cetirizine, the racemate of levocetirizine, a
large amount of data (more than 1000 pregnancy outcomes) on pregnant women indicate no
malformative or feto/ neonatal toxicity. Animal studies do not indicate direct or indirect
harmful effects with respect to pregnancy, embryo/fetal development, parturition or postnatal
development (see section 5.3).
The use of levocetirizine may be considered during pregnancy, if necessary.

Breast-feeding
Cetirizine, the race mate of levocetirizine, has been shown to be excreted in human. Therefore,
the excretion of levocetirizine in human milk is likely. Adverse reactions associated with
levocetirizine may be observed in breastfed infants. Therefore, caution should be exercised
when prescribing levocetirizine to lactating women.
Fertility
For levocetirizine no clinical data are available.

Comparative clinical trials have revealed no evidence that levocetirizine at the recommended
dose impairs mental alertness, reactivity or the ability to drive.
Nevertheless, some patients could experience somnolence, fatigue and asthenia under therapy
with levocetirizine. Therefore, patients intending to drive, engage in potentially hazardous
activities or operate machinery should take their response to the medicinal product into
account.

Clinical studies
Adults and adolescents above 12 years of age
In therapeutic studies in women and men aged 12 to 71 years, 15.1% of the patients in the
levocetirizine 5 mg group had at least one adverse drug reaction compared to 11.3% in the
placebo group. 91.6 % of these adverse drug reactions were mild to moderate.
In therapeutic trials, the dropout rate due to adverse events was 1.0% (9/935) with
levocetirizine 5 mg and 1.8% (14/771) with placebo.
Clinical therapeutic trials with levocetirizine included 935 subjects exposed to the medicinal
product at the recommended dose of 5 mg daily. From this pooling, following incidence of
adverse drug reactions were reported at rates of 1% or greater (common: ≥1/100 to <1/10)
under levocetirizine 5 mg or placebo:

Further uncommon incidences of adverse reactions (uncommon ≥1/1,000 to <1/100) like
asthenia or abdominal pain were observed.
The incidence of sedating adverse drug reactions such as somnolence, fatigue, and asthenia
was altogether more common (8.1%) under levocetirizine 5 mg than under placebo (3.1%).

Paediatric population
In two placebo-controlled studies in paediatric patients aged 6-11 months and aged 1 year to
less than 6 years, 159 subjects were exposed to levocetirizine at the dose of 1.25 mg daily for 2
weeks and 1.25mg twice daily respectively. The following incidence of adverse drug reactions
was reported at rates of 1% or greater under levocetirizine or placebo.

In children aged 6-12 years double blind placebo controlled studies were performed where 243
children were exposed to 5 mg levocetirizine daily for variable periods ranging from less than
1 week to 13 weeks. The following incidence of adverse drug reactions was reported at rates of
1% or greater under levocetirizine or placebo.

Post-marketing experience
Adverse reactions from post-marketing experience are per System Organ Class and per
frequency. The frequency is defined as follows: very common (≥1/10); common (≥1/100 to
<1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000),
not known (cannot be estimated from the available data)

• Immune system disorders:
Not known: hypersensitivity including anaphylaxis
• Metabolism and nutrition disorders:
Not known: increased appetite
• Psychiatric disorders:
Not known: aggression, agitation, hallucination, depression, insomnia, suicidal ideation
• Nervous system disorders:

Not known: convulsion, paraesthesia, dizziness, syncope, tremor, dysgeusia, Movement
disorders (including dystonia and oculogyric crisis tic, myoclonus, extrapyramidal symptoms
• Ear and labyrinth disorders:
Not known: vertigo
• Eyes disorders:
Not known: visual disturbances, blurred vision
• Cardiac disorders:
Not known: palpitations, tachycardia
• Respiratory, thoracic and mediastinal disorders:
Not known: dyspnoea
• Gastrointestinal disorders:
Not known: nausea, vomiting, diarrhoea
• Hepatobiliary disorders:
Not known: hepatitis

Renal and urinary disorders:
Not known: dysuria, urinary retention
• Skin and subcutaneous tissue disorders:
Not known: angioneurotic oedema, fixed drug eruption, pruritus, rash, urticaria
• Musculoskeletal, connective tissues, and bone disorders:
• Not known: myalgia, arthralgia
• General disorders and administration site conditions:
Not known: oedema
• Investigations:
Not known: weight increased, abnormal liver function tests

Description of selected adverse reactions
After levocetirizine discontinuation, pruritus has been reported.

To reports any side effect (s):

Symptoms
Symptoms of overdose may include drowsiness in adults. In children, agitation and restlessness
may initially occur, followed by drowsiness.
Management of overdoses
There is no known specific antidote to levocetirizine.
Should overdose occur, symptomatic or supportive treatment is recommended. Gastric lavage
may be considered shortly after ingestion of the drug. Levocetirizine is not effectively removed
by haemodialysis.

Pharmacotherapeutic group: antihistamine for systemic use, piperazine derivatives,
ATC code: R06A E09.
Mechanism of action
Levocetirizine, the (R) enantiomer of cetirizine, is a potent and selective antagonist of
peripheral H1-receptors.
Binding studies revealed that levocetirizine has high affinity for human H1-receptors (Ki = 3.2
nmol/l). Levocetirizine has an affinity 2-fold higher than that of cetirizine (Ki = 6.3 nmol/l).
Levocetirizine dissociates from H1-receptors with a half-life of 115 ± 38 min.

After single administration, levocetirizine shows a receptor occupancy of 90% at 4 hours and
57% at 24 hours.
Pharmacodynamic studies in healthy volunteers demonstrate that, at half the dose,
levocetirizine has comparable activity to cetirizine, both in the skin and in the nose.

Pharmacodynamic effects
The pharmacodynamic activity of levocetirizine has been studied in randomised, controlled
trials:
In a study comparing the effects of levocetirizine 5 mg, desloratadine 5 mg, and placebo on
histamine-induced wheal and flare, levocetirizine treatment resulted in significantly decreased
wheal and flare formation which was highest in the first 12 hours and lasted for 24 hours,
(p<0.001) compared with placebo and desloratadine.
The onset of action of levocetirizine 5 mg in controlling pollen-induced symptoms has been
observed at 1 hour post drug intake in placebo controlled trials in the model of the allergen
challenge chamber.
In vitro studies (Boyden chambers and cell layers techniques) show that levocetirizine inhibits
eotaxin-induced eosinophil transendothelial migration through both dermal and lung cells. A
pharmacodynamic experimental study in vivo (skin chamber technique) showed three main
inhibitory effects of levocetirizine 5 mg in the first 6 hours of pollen-induced reaction,
compared with placebo in 14 adult patients: inhibition of VCAM-1 release, modulation of
vascular permeability and a decrease in eosinophil recruitment.

Clinical efficacy and safety
The efficacy and safety of levocetirizine has been demonstrated in several double-blind,
placebo controlled, clinical trials performed in adult patients suffering from seasonal allergic
rhinitis, perennial allergic rhinitis, or persistent allergic rhinitis. Levocetirizine has been shown
to significantly improve symptoms of allergic rhinitis, including nasal obstruction in some
studies.
A 6-month clinical study in 551 adult patients (including 276 levocetirizine-treated patients)
suffering from persistent allergic rhinitis (symptoms present 4 days a week for at least 4
consecutive weeks) and sensitized to house dust mites and grass pollen demonstrated that
levocetirizine 5 mg was clinically and statistically significantly more potent than placebo on
the relief from the total symptom score of allergic rhinitis throughout the whole duration of the
study, without any tachyphylaxis. During the whole duration of the study, levocetirizine
significantly improved the quality of life of the patients.
In a placebo-controlled clinical trial including 166 patients suffering from chronic idiopathic
urticaria, 85 patients were treated with placebo and 81 patients with levocetirizine 5 mg once
daily over six weeks. Treatment with levocetirizine resulted in significant decrease in pruritus
severity over the first week and over the total treatment period as compared to placebo.
Levocetirizine also resulted in a larger improvement of health-related quality of life as assessed
by the Dermatology Life Quality Index as compared to placebo.
Chronic idiopathic urticaria was studied as a model for urticarial conditions. Since histamine
release is a causal factor in urticarial diseases, levocetirizine is expected to be effective in

providing symptomatic relief for other urticarial conditions, in addition to chronic idiopathic
urticaria.
ECGs did not show relevant effects of levocetirizine on QT interval.

Paediatric population
The paediatric safety and efficacy of levocetirizine tablets has been studied in two placebo
controlled clinical trials including patients aged 6 to 12 years and suffering from seasonal and
perennial allergic rhinitis, respectively. In both trials, levocetirizine significantly improved
symptoms and increased health-related quality of life.
In children below the age of 6 years, clinical safety has been established from several short- or
long -term therapeutic studies:

- one clinical trial in which 29 children 2 to 6 years of age with allergic rhinitis were treated
with levocetirizine 1.25 mg twice daily for 4 weeks
- one clinical trial in which 114 children 1 to 5 years of age with allergic rhinitis or chronic
idiopathic urticaria were treated with levocetirizine 1.25 mg twice daily for 2 weeks
- one clinical trial in which 45 children 6 to 11 months of age with allergic rhinitis or chronic
idiopathic urticaria were treated with levocetirizine 1.25 mg once daily for 2 weeks
- one long-term (18 months) clinical trial in 255 levocetirizine - treated atopic subjects aged 12
to 24 months at inclusion
The safety profile was similar to that seen in the short-term studies conducted in children 1 to 5
years of age.

The pharmacokinetics of levocetirizine are linear with dose- and time-independent with low
inter-subject variability. The pharmacokinetic profile is the same when given as the single
enantiomer or when given as cetirizine. No chiral inversion occurs during the process of
absorption and elimination.
Absorption
Levocetirizine is rapidly and extensively absorbed following oral administration. In adults,
peak plasma concentrations are achieved 0.9 h after dosing. Steady state is achieved after two
days. Peak concentrations are typically 270 ng/ml and 308 ng/ml following a single and a
repeated 5 mg o.d. dose, respectively. The extent of absorption is dose-independent and is not
altered by food, but the peak concentration is reduced and delayed.

Distribution
No tissue distribution data are available in humans, neither concerning the passage of
levocetirizine through the blood-brain-barrier. In rats and dogs, the highest tissue levels are
found in liver and kidneys, the lowest in the CNS compartment.
In humans, levocetirizine is 90% bound to plasma proteins. The distribution of levocetirizine is
restrictive, as the volume of distribution is 0.4 l/kg.

Biotransformation

The extent of metabolism of levocetirizine in humans is less than 14% of the dose and
therefore differences resulting from genetic polymorphism or concomitant intake of enzyme
inhibitors are expected to be negligible. Metabolic pathways include aromatic oxidation, Nand
O- dealkylation and taurine conjugation. Dealkylation pathways are primarily mediated by
CYP 3A4 while aromatic oxidation involved multiple and/or unidentified CYP isoforms.
Levocetirizine had no effect on the activities of CYP isoenzymes 1A2, 2C9, 2C19, 2D6, 2E1
and 3A4 at concentrations well above peak concentrations achieved following a 5 mg oral
dose.
Due to its low metabolism and absence of metabolic inhibition potential, the interaction of
levocetirizine with other substances, or vice-versa, is unlikely.

Elimination

The plasma half-life in adults is 7.9 ± 1.9 hours. The half-life is shorter in small children. The
mean apparent total body clearance in adults is 0.63 ml/min/kg. The major route of excretion of
levocetirizine and metabolites is via urine, accounting for a mean of 85.4% of the dose.
Excretion via faeces accounts for only 12.9% of the dose. Levocetirizine is excreted both by
glomerular filtration and active tubular secretion.

Special population

Renal impairment:
The apparent body clearance of levocetirizine is correlated to the creatinine clearance. It is
therefore recommended to adjust the dosing intervals of levocetirizine, based on creatinine
clearance in patients with moderate and severe renal impairment. In anuric end stage renal
disease subjects, the total body clearance is decreased by approximately 80% when compared
to normal subjects. The amount of levocetirizine removed during a standard 4-hour
hemodialysis procedure was < 10%.
Paediatric population:
Data from a paediatric pharmacokinetic study with oral administration of a single dose of 5 mg
levocetirizine in 14 children age 6 to 11 years with body weight ranging between 20 and 40 kg
show that Cmax and AUC values are about 2-fold greater than that reported in healthy adult
subjects in a cross-study comparison. The mean Cmax was 450 ng/ml, occurring at a mean
time of 1.2 hours, weight-normalized, total body clearance was 30% greater, and the
elimination half-life 24% shorter in this paediatric population than in adults. Dedicated
pharmacokinetic studies have not been conducted in paediatric patients younger than 6 years of
age. A retrospective population pharmacokinetic analysis was conducted in 323 subjects (181
children 1 to 5 years of age, 18 children 6 to 11 years of age, and 124 adults 18 to 55 years of
age) who received single or multiple doses of levocetirizine ranging from 1.25 mg to 30 mg.
Data generated from this analysis indicated that administration of 1.25 mg once daily to
children 6 months to 5 years of age is expected to result in plasma concentrations similar to
those of adults receiving 5 mg once daily.

Elderly
Limited pharmacokinetic data are available in elderly subjects. Following once daily repeat
oral administration of 30 mg levocetirizine for 6 days in 9 elderly subjects (65–74 years of
age), the total body clearance was approximately 33% lower compared to that in younger
adults. The disposition of racemic cetirizine has been shown to be dependent on renal function
rather than on age. This finding would also be applicable for levocetirizine, as levocetirizine
and cetirizine are both predominantly excreted in urine. Therefore, the levocetirizine dose
should be adjusted in accordance with renal function in elderly patients.

Gender
Pharmacokinetic results for 77 patients (40 men, 37 women) were evaluated for potential effect
of gender. The half-life was slightly shorter in women (7.08 ± 1.72 hr) than in men (8.62 ±
1.84 hr); however, the body weight-adjusted oral clearance in women (0.67 ± 0.16 ml/min/kg)
appears to be comparable to that in men (0.59 ± 0.12 ml/min/kg). The same daily doses and
dosing intervals are applicable for men and women with normal renal function.

Race
The effect of race on levocetirizine has not been studied. As levocetirizine is primarily renally
excreted, and there are no important racial differences in creatinine clearance, pharmacokinetic
characteristics of levocetirizine are not expected to be different across races. No race-related
differences in the kinetics of racemic cetirizine have been observed.

Hepatic impairment
The pharmacokinetics of levocetirizine in hepatically impaired subjects have not been tested.
Patients with chronic liver diseases (hepatocellular, cholestatic, and biliary cirrhosis) given 10
or 20 mg of the racemic compound cetirizine as a single dose had a 50% increase in half life
along with a 40% decrease in clearance compared to healthy subjects.

Pharmacokinetic / pharmacodynamic relationship
The action on histamine-induced skin reactions is out of phase with the plasma concentrations.

Non-clinical data reveal no special hazard for humans based on conventional studies of safety
pharmacology, repeated dose toxicity, genotoxicity, carcinogenic potential, toxicity to
reproduction.

Lactose Monohydrate

Maize Starch
Colloidal Silicon Dioxide
Magnesium Stearate
Sunset Yellow
Excipients with known effect: 65.0mg Lactose Monohydrate

Not applicable.

Store below 30°C.

Layal tablets are packaged in PVC/ PVDC clear aluminium foil blisters.
Pack sizes of: 10 and 30 tablets

No special requirements for disposal