Seasonal and perennial allergic rhinitis and vasomotor rhinitis. Treatment of nasal polyps.

Dosage should be individualized.

The patient should be informed that the full effect of Cortrief NS is not achieved until after a few days treatment.
Treatment of seasonal rhinitis should, if possible, start before exposure to allergens. Treatment can be continued for up to 3months.
Patients should be reminded of the importance of taking this medicine regularly.
The dose should be titrated to the lowest dose at which effective control of symptoms is achieved.
Paediatric population:
There are insufficient data to recommend the use of Cortrief NS in children. However, it is unlikely that the risk/benefit ratio in children is different from that in adults.

Method of administration
For nasal inhalation.

Special care is demanded in treatment of patients transferred from oral steroids to Cortrief NS where disturbances of the hypothalamic-pituitary-adrenal (HPA) axis could be expected.
Special care is needed in patients with fungal and viral infections of the airways and in patients with active or quiescent pulmonary tuberculosis.
Concomitant treatment of seasonal rhinitis may sometimes be necessary to counteract eye symptoms caused by the allergy. In continuous long-term treatment, the nasal mucosa should be inspected regularly e.g. every 6 months.
Reduced liver function affects the elimination of corticosteroids, causing lower elimination rate and higher systemic exposure. Be aware of possible systemic side effects.
Systemic effects of nasal corticosteroids may occur, particularly at high doses prescribed for prolonged periods.
These effects are much less likely to occur than with oral corticosteroids and may vary in individual patients and between different corticosteroid preparations. Potential systemic effects may include Cushing's syndrome, Cushingoid features, adrenal suppression, growth retardation in children and adolescents, cataract, glaucoma and more rarely, a range of psychological or behavioural effects including psychomotor hyperactivity, sleep disorders, anxiety, depression or aggression (particularly in children).
Visual disturbance
Visual disturbance may be reported with systemic and topical corticosteroid use. If a patient presents with symptoms such as blurred vision or other visual disturbances, the patient should be considered for referral to an ophthalmologist for evaluation of possible causes which may include cataract, glaucoma or rare diseases such as central serous chorioretinopathy (CSCR) which have been reported after use of systemic and topical corticosteroids.
Paediatric population
The long-term effects of nasal glucocorticosteroids in children are not fully known. Physicians should closely follow the growth of children taking glucocorticosteroids for longer term by any route, and weigh the benefits of the glucocorticosteroid therapy against the possibility of growth suppression. If growth is slowed, therapy should be reviewed with the aim of reducing the dose of nasal corticosteroid, if possible, to the lowest dose at which effective control of symptoms is maintained. In addition, consideration should also be given to referring the patient to a paediatric specialist.
Treatment with higher than recommended doses may result in clinically significant adrenal suppression. If there is evidence for higher than recommended doses being used, additional systemic corticosteroid cover should be considered during periods of stress or elective surgery.
In vivo studies have shown that oral administration of itraconazole and ketoconazole (known inhibitors of CYP3A4 activity in the liver and in the intestinal mucosa, see also section 4.5 Interactions) may cause an increase in the systemic exposure to budesonide. This is of limited clinical importance for short-term (1-2 weeks) treatment with itraconazole or ketoconazole, but should be taken into consideration during long-term treatment.

Cortrief NS has not been observed to interact with any drug used for the treatment of rhinitis.
The metabolism of budesonide is primarily mediated by CYP3A4, a subfamily of cytochrome P450. Inhibitors of this enzyme, e.g. itraconazole and ketoconazole, can therefore increase systemic exposure to budesonide several times.
Since there is no data to support a dosage recommendation, the combination should be avoided. If this is not possible, the period between treatments should be as long as possible and a reduction of the Cortrief NS dose could also be considered. However, the use of itraconazole or ketoconazole concomitant with Cortrief NS for shorter periods are of limited importance, see section 4.4 Special warnings and precautions for use.
Raised plasma concentrations of and enhanced effects of corticosteroids have been observed in women also treated with oestrogens and contraceptive steroids, but no effect has been observed with Cortrief NS and concomitant intake of low dose combination oral contraceptives.
Because adrenal function may be suppressed, an ACTH stimulation test for diagnosing pituitary insufficiency might show false results (low values).

Pregnancy:
Results from prospective epidemiological studies and from worldwide post marketing experience indicate no increased risk for overall congenital malformations from the use of inhaled or intranasal budesonide during early pregnancy. As with other drugs the administration of Cortrief NS during pregnancy requires that the benefits for the mother is weighed against the risk for the foetus.
Breast-feeding:
Budesonide is excreted in breast milk. However, at therapeutic doses of Cortrief NS no effects on the breast fed child are anticipated. Cortrief NS can be used during breast feeding.
Maintenance treatment with inhaled Cortrief NS (200 or 400 micrograms twice daily) in asthmatic nursing women results in negligible systemic exposure to budesonide in breast-fed infants.
In a pharmacokinetic study, the estimated daily infant dose was 0.3% of the daily maternal dose for both dose levels, and the average plasma concentration in infants was estimated to be 1/600th of the concentrations observed in maternal plasma, assuming complete infant oral bioavailability. Budesonide concentrations in infant plasma samples were all less than the limit of quantification.
Based on data from inhaled budesonide and the fact budesonide exhibits linear PK properties within the therapeutic dosage intervals after nasal, inhaled, oral and rectal administrations at therapeutic doses of budesonide, exposure to the breast-fed child is anticipated to be low.

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

Tabulated list of adverse reactions
Adverse reactions, which have been associated with budesonide, are given below, listed by system organ class and frequency. Frequencies are defined as: very common (≥1/10), common (≥1/100 and <1/10), uncommon (≥1/1000 and <1/100), rare (≥1/10 000 and <1/1000), very rare (<1/10 000) and not known (cannot be estimated from the available data).

In rare cases, signs or symptoms of systemic glucocorticosteroid-side effects such as Cushing's syndrome, Cushingoid features, psychomotor hyperactivity, sleep disorders, anxiety, depression or aggression (particularly in children), may occur with nasal glucocorticosteroids, probably depending on dose, exposure time, concomitant and previous corticosteroid exposure, and individual sensitivity (see section 4.4).
Paediatric population
Growth retardation has been reported in children receiving intranasal steroids. Due to the risk of growth retardation in the paediatric population, growth should be monitored as described in section 4.4.

TO REPORT ANY SIDE EFFECT(S):
Saudi Arabia: The National Pharmacovigilance and Drug Safety Centre (NPC)
o Fax: +966-11-205-7662
o Call NPC at +966-11-2038222, Exts: 2317-2356-2353-2354-2334-2340.
o Toll free phone: 8002490000
o E-mail: npc.drug@sfda.gov.sa
o Website: www.sfda.gov.sa/npc Other GCC States: - Please contact the relevant competent authority

Acute overdose with Cortrief NS even in excessive doses, is not expected to be a clinical problem.
Inhalation of high doses of corticosteroids may lead to suppression of the hypothalamic-pituitary-adrenal (HPA) axis function.

Pharmacotherapeutic group: Decongestants and other nasal preparations for topical use, corticosteroids.
ATC code: R01A D05
Budesonide is a non-halogenated glucocorticosteroid with a high local anti-inflammatory action within the respiratory tract.

Bioavailablity of oral budesonide in man is low (11-13%) due to an extensive first-pass metabolism in the liver.
The systemic availability of budesonide from Cortrief NS, with reference to the metered dose is 33%. In adults, the maximal plasma concentration after administration of 256 micrograms budesonide from Cortrief NS is 0.64 nM and is reached within 0.7 hours. The AUC after administration of 256 micrograms budesonide from Cortrief NS is 2.7 nmolxh/L in adults.

The acute toxicity of budesonide is low and of the same order of magnitude and type as that of the reference glucocorticoids studied (beclomethasone dipropionate, flucinolone acetonide). Results from subacute and chronic toxicity studies show that the systemic effects of budesonide are less severe than or similar to those observed after administration of the other glucocorticosteroids e.g. decreased body weight gain and atrophy of lymphoid tissues and adrenal cortex. An increased incidence of brain gliomas in male rats in a carcinogenicity study could not be verified in a repeat study, in which the incidence of gliomas did not differ between any of the groups on active treatment (budesonide, prednisolone, triamcinolone acetonide) and the control groups. Liver changes (primary hepatocellular neoplasms) found in male rats in the original carcinogenicity study were noted again in the repeat study with budesonide, as well as with the reference glucocorticosteroids. These effects are most probably related to a receptor effect and thus represent a class effect.

Available clinical experience shows no indication that budesonide or other glucocorticosteroids induce brain gliomas or primary heptocellular neoplasms in man. Budesonide has been used successfully in the treatment of seasonal allergic rhinitis for several years.
In animal reproduction studies, corticosteroids such as budesonide have been shown to induce malformations (cleft palate, skeletal malformations). However, these animal experimental results do not appear to be relevant in humans at the recommended doses.
Animal studies have also identified an involvement of excess prenatal glucocorticosteroids in increased risk for intrauterine growth retardation, adult cardiovascular disease and permanent changes in glucocorticoid receptor density, neurotransmitter turnover and behaviour at exposures below the teratogenic dose range.

Dispersible Cellulose[75.00mg]
Dextrose Anhydrous [285.00 mg]
Polysorbate 80 [0.96 mg]
Disodium Edetate [0.60 mg]
Potassium Sorbate [7.20 mg]
Hydrochloric Acid [Q.S]
Purified Water [Q.S to 6.0ml]

Not applicable.

Store below 30C.
Do not refrigerate or freeze.

Cortrief NS is an aqueous solution of budesonide in 6 ml Amber colored glass bottle along with crimp on pump and polypropylene dispensing nozzle with cap.
Each bottle is fitted with a spray pump and contains 120 actuations.

Before using Cortrief NS for the first time the nozzle must be primed (filled with the medicine). To do this the bottle is shaken and the protective cap removed. The bottle is then held upright and the nozzle pumped up and down several times (5-10 times) spraying into the air, until an even mist is seen. The priming effect remains for approximately 24 hours. If a longer period of time passes before the next dose is taken, the nozzle must be loaded with medicine again. This time it is sufficient to spray just once into the air.
a. The patient is then instructed to blow their nose. Next, the bottle needs to be shaken and the protective cap removed.
b. The bottle is then held upright, with one finger held on either side of the nozzle.
c. The tip of the nozzle is inserted into the nostril and the nozzle pressed down once (or more as instructed by the doctor). The spray is then administered into the other nostril in the same way. Note: it is not necessary to inhale at the same time as spraying.
d. The nozzle needs to be wiped with a clean tissue after use and the protective cap replaced. The bottle should be stored in an upright position.
e. Keeping the Cortrief NS nozzle clean The plastic nozzle of Cortrief NS should be cleaned regularly and at any time the spray of medicine is not coming out as it should. If this happens, first the nozzle should be checked to ensure that it is primed with medicine (see earlier). If, after the nozzle is primed again, the pump is still not working, the nozzle should be cleaned by using the following instructions:
The plastic nozzle is removed with a clean tissue and washed in warm, not hot, water. The nozzle is then rinsed thoroughly, dried and then replaced onto the top of the bottle. The nozzle should not be unblocked with a pin or other sharp object. After cleaning, the nozzle must be primed (filled with medicine) again before use.
No special requirements for disposal.
Any unused medicinal product or waste material should be disposed of in accordance with local requirements.