Pfizer Healthcare Ireland

Caverject 5 micrograms, Powder and Solvent for Solution for Injection

Caverject 10 micrograms, Powder and Solvent for Solution for Injection

Caverject 20 micrograms, Powder and Solvent for Solution for Injection

Caverject 5 micrograms, Powder and Solvent for Solution for Injection

Alprostadil 5 micrograms

When reconstituted, each 1ml delivers a dose of 5 micrograms of alprostadil.

Excipients: also includes benzyl alcohol 7.96 mg per 1ml of reconstituted solution

Caverject 10 micrograms, Powder and Solvent for Solution for Injection

Alprostadil 10 micrograms

When reconstituted, each 1ml delivers a dose of 10 micrograms of alprostadil.

Excipients: also includes benzyl alcohol 7.96 mg per 1ml of reconstituted solution.

Caverject 20 micrograms, Powder and Solvent for Solution for Injection

Alprostadil 20 micrograms.

When reconstituted, each 1ml delivers a dose of 20 micrograms of alprostadil.

Excipients: each 1ml of reconstituted solution contains 7.96 mg benzyl alcohol

For a full list of excipients, see section 6.1

Powder and solvent for solution for injection.

Powder: A white to off-white lyophilised powder

Solvent: A clear, colourless liquid.

Caverject is indicated for the treatment of erectile dysfunction in adult males due to neurogenic, vasculogenic, psychogenic or mixed aetiology.

Caverject may be a useful adjunct to other diagnostic tests in the diagnosis of erectile dysfunction.

Caverject is administered by direct intracavernous injection. A 1/2-inch, 27 to 30 gauge needle is generally recommended. The dose of Caverject should be individualised for each patient by careful titration under supervision by a physician.

The intracavernosal injection must be done under sterile conditions. The site of injection is usually along the dorsolateral aspect of the proximal third of the penis. Visible veins should be avoided. Both the side of the penis that is injected and the site of injection should be alternated; prior to the injection, the injection site must be cleansed with an alcohol swab.

To reconstitute Caverject using the prefilled diluent syringe: flip off the plastic cap from the vial, and use one of the swabs to wipe the rubber cap. Fit the 22 gauge needle to the syringe.

Inject the 1 ml of diluent into the vial, and shake to dissolve the powder entirely. Withdraw slightly more than the required dose of Caverject solution, remove the 22 gauge needle, and fit the 30 gauge needle. Adjust volume to the required dose for injection. Following administration, any unused contents of the vial or syringe should be discarded.

A. As an aid to aetiologic diagnosis.

i) Subjects without evidence of neurological dysfunction; 20 micrograms alprostadil to be injected into the corpus cavernosum and massaged through the penis. Should an ensuing erection persist for more than one hour detumescent therapy (please refer to Section 4.9 - Overdose) should be employed to prevent a risk of priapism prior to the subject leaving the clinic.

Over 80% of subjects may be expected to respond to a single 20 micrograms dose of alprostadil. At the time of discharge from the clinic, the erection should have subsided entirely and the penis must be in a completely flaccid state.

ii) Subjects with evidence of neurological dysfunction; these patients can be expected to respond to lower doses of alprostadil. In subjects with erectile dysfunction caused by neurologic disease/trauma the dose for diagnostic testing must not exceed 10 micrograms and an initial dose of 5 micrograms is likely to be appropriate. Should an ensuing erection persist for more than one hour detumescent therapy (please refer to Section 4.9 - Overdose) should be employed to prevent a risk of priapism prior to the subject leaving the clinic. At the time of discharge from the clinic, the erection should have subsided entirely and the penis must be in a completely flaccid state.

B. Treatment

The initial dose of alprostadil is 2.5 micrograms. The second dose should be 5 micrograms if there is a partial response, and 7.5 micrograms if there is no response. Subsequent incremental increases of 5 - 10 micrograms should be given until an optimal dose is achieved. If there is no response to the administered dose, then the next higher dose may be given within 1 hour. If there is a response, there should be at least a 1-day interval before the next dose is given. The usual maximum recommended frequency of injection is no more than once daily and no more than three times weekly.

The first injections of alprostadil must be done by medically trained personnel. After proper training and instruction, alprostadil may be injected at home. If self-administration is planned, the physician should make an assessment of the patient's skill and competence with the procedure. It is recommended that patients are regularly monitored (e.g. every 3 months) particularly in the initial stages of self injection therapy when dose adjustments may be needed.

The dose that is selected for self-injection treatment should provide the patient with an erection that is satisfactory for sexual intercourse. It is recommended that the dose administered produces a duration of the erection not exceeding one hour. If the duration is longer, the dose should be reduced. The majority of patients achieve a satisfactory response with doses in the range of 5 to 20 micrograms. Doses of greater than 60 micrograms of alprostadil are not recommended. The lowest effective dose should be used.

Caverject should not be used in patients who have a known hypersensitivity to any of the constituents of the product; in patients who have conditions that might predispose them to priapism, such as sickle cell anaemia or trait, multiple myeloma, or leukaemia; or in patients with anatomical deformation of the penis, such as angulation, cavernosal fibrosis, or Peyronie's disease. Patients with penile implants should not be treated with Caverject.

Caverject should not be used in men for whom sexual activity is inadvisable or contraindicated.

Prolonged erection and/or priapism may occur. Patients should be instructed to report to a physician any erection lasting for a prolonged time period, such as 4 hours or longer. Treatment of priapism should not be delayed more than 6 hours (please refer to Section 4.9 - Overdose).

Painful erection is more likely to occur in patients with anatomical deformations of the penis, such as angulation, phimosis, cavernosal fibrosis, Peyronie's disease or plaques. Penile fibrosis, including angulation, fibrotic nodules and Peyronie's disease may occur following the intracavernosal administration of Caverject. The occurrence of fibrosis may increase with increased duration of use. Regular follow-up of patients, with careful examination of the penis, is strongly recommended to detect signs of penile fibrosis or Peyronie's disease. Treatment with Caverject should be discontinued in patients who develop penile angulation, cavernosal fibrosis, or Peyronie's disease.

Patients on anticoagulants such as warfarin or heparin may have increased propensity for bleeding after the intracavernous injection.

Underlying treatable medical causes of erectile dysfunction should be diagnosed and treated prior to initiation of therapy with Caverject.

Use of intracavernosal alprostadil offers no protection from the transmission of sexually transmitted diseases. Individuals who use alprostadil should be counselled about the protective measures that are necessary to guard against the spread of sexually transmitted diseases, including the human immunodeficiency virus (HIV). In some patients, injection of Caverject can induce a small amount of bleeding at the site of injection. In patients infected with blood-born diseases, this could increase the transmission of such diseases to their partner.

Reconstituted solutions of Caverject are intended for single use only, they should be used immediately and not stored.

Caverject 5 micrograms, Powder and Solvent for Solution for Injection

Caverject 10 micrograms, Powder and Solvent for Solution for Injection

Patients with rare hereditary problems of galactose intolerance, the Lapp lactose deficiency or glucose-galactose malabsorption should not take this medicine.

Caverject 20 micrograms, Powder and Solvent for Solution for Injection

Contains benzyl alcohol which may cause toxic reactions and allergic reactions.

No known interactions. Caverject is not intended for co-administration with any other agent for the treatment of erectile dysfunction.

Not applicable. (High doses of alprostadil (0.5 to 2.0 mg/kg subcutaneously) had an adverse effect on the reproductive potential of male rats, although this was not seen with lower doses (0.05 to 0.2 mg/kg). Alprostadil did not affect rat spermatogenesis at doses 200 times greater than the proposed human intrapenile dose.)

Not applicable.

Cardiac disorders

Uncommon: Supraventricular extrasystole

Congential, familial and genetic disorders

Uncommon: Phimosis

Eye disorders

Uncommon: Mydriasis

Gastrointestinal disorders

Common: Nausea; dry mouth, abdominal pain

General disorders and administration site conditions

Common: Haematoma at the site of the injection; ecchymosis at the site of injection; injection site oedema, flu-like syndrome

Uncommon: Injection site haemorrhage; injection site inflammation; injection site itching; non-generalised weakness

Not Known: Injection site sensitivity, injection site swelling; irritation

Investigations

Uncommon: Increased serum creatinine

Injury, poisoning and procedural complications

Common: Trauma

Infections and infestations

Common: Upper respiratory infection, sinusitis

Not Known: Yeast infection

Musculoskeletal, connective tissue and bone disorders

Common: Leg pain, buttocks pain

Uncommon: Leg cramps, back pain

Neoplasms, benign, malignant and unspecified (incl. cysts and polyps)

Common: Skin neoplasm

Nervous system disorders

Common: Headache

Uncommon: Vasovagal reactions; hypaesthesia, numbness, dizziness

Renal and urinary disorders

Uncommon: Haematuria; impaired urination; urinary frequency; urinary urgency

Not Known: Urethral bleeding

Reproductive system and breast disorders

Very Common: Penile pain

Common: Penile fibrosis (including angulation, fibrotic nodules and Peyronie's disease), abnormal ejaculation, genital pain, prostatic disorder, painful erection; priapism; testicular pain

Uncommon: Balanitis; penile warmth; pelvic pain; scrotal disorder (redness, pain, spermatocele); scrotal oedema; penile odema, testicular disorder (warmth, swelling, mass, thickening)

Respiratory, thoracic and mediastinal disorders

Uncommon: Nasal congestion, cough

Skin and subcutaneous tissue disorders

Uncommon: Rash; diaphoresis; non-application site pruritus, erythema

Vascular disorders

Common: Hypertension

Uncommon: hypotension; vasodilation

Not Known: Venous leak; peripheral vascular disorder; symptomatic hypotension

The pharmacotoxic signs of alprostadil are similar in all animal species and include depression, soft stools or diarrhoea and rapid breathing. In animals, the lowest acute LD₅₀ was 12 mg/kg which is 12,000 times greater than the maximum recommended human dose of 60 micrograms.

In man, prolonged erection and/or priapism are known to occur following intracavernous administration of vasoactive substances, including alprostadil. Patients should be instructed to report to a physician any erection lasting for a prolonged time period, such as 4 hours or longer.

The treatment of priapism (prolonged erection) should not be delayed more than 6 hours. Initial therapy should be by penile aspiration. Using aseptic technique, insert a 19-21 gauge butterfly needle into the corpus cavernosum and aspirate 20-50 ml of blood. This may detumesce the penis. If necessary, the procedure may be repeated on the opposite side of the penis until a total of up to 100 ml blood has been aspirated. If still unsuccessful, intracavernous injection of alpha-adrenergic medication is recommended. Although the usual contra-indication to intrapenile administration of a vasoconstrictor does not apply in the treatment of priapism, caution is advised when this option is exercised. Blood pressure and pulse should be continuously monitored during the procedure. Extreme caution is required in patients with coronary heart disease, uncontrolled hypertension, cerebral ischaemia, and in subjects taking monoamine oxidase inhibitors. In the latter case, facilities should be available to manage a hypertensive crisis. A 200 microgram/ml solution of phenylephrine should be prepared, and 0.5 to 1.0 ml of the solution injected every 5 to 10 minutes. Alternatively, a 20 microgram/ml solution of adrenaline should be used. If necessary, this may be followed by further aspiration of blood through the same butterfly needle. The maximum dose of phenylephrine should be 1 mg, or adrenaline 100 micrograms (5 ml of the solution). As an alternative metaraminol may be used, but it should be noted that fatal hypertensive crises have been reported. If this still fails to resolve the priapism, urgent surgical referral for further management, which may include a shunt procedure, is required.

Pharmacotherapeutic group: Drugs used in erectile dysfunction

ATC code: G04B E01

Alprostadil is present in various mammalian tissues and fluids. It has a diverse pharmacologic profile, among which some of its more important effects are vasodilation, inhibition of platelet aggregation, inhibition of gastric secretion, and stimulation of intestinal and uterine smooth muscle. The pharmacologic effect of alprostadil in the treatment of erectile dysfunction is presumed to be mediated by inhibition of alpha₁-adrenergic activity in penile tissue and by its relaxing effect on cavernosal smooth muscle.

Following intracavernous injection of 20 μg of alprostadil, mean peripheral levels of alprostadil at 30 and 60 minutes after injection are not significantly greater than baseline levels of endogenous PGE₁. Peripheral levels of the major circulating metabolite, 15-oxo-13,14-dihydro-PGE₁, increase to reach a peak 30 minutes after injection and return to pre-dose levels by 60 minutes after injection. Any alprostadil entering the systemic circulation from the corpus cavernosum will be rapidly metabolized. Following intravenous administration, approximately 80% of the circulating alprostadil is metabolized in one pass through the lungs, primarily by beta- and omega-oxidation.

The metabolites are excreted primarily by the kidney and excretion is essentially complete within 24 hours. There is no evidence of tissue retention of alprostadil or its metabolites following intravenous administration.

None stated.

Caverject 5 micrograms, Powder and Solvent for Solution for Injection:

Caverject 10 micrograms, Powder and Solvent for Solution for Injection:

Lactose Monohydrate

Sodium Citrate

Hydrochloric Acid

Sodium Hydroxide

Solvent

Benzyl Alcohol

Water for Injections

Caverject 20 micrograms, Powder and Solvent for Solution for Injection:

Lactose Monohydrate

Sodium Citrate anhydrous

Hydrochloric Acid (pH adjustment)

Sodium Hydroxide (pH adjustment)

Solvent

Benzyl Alcohol

Water for Injections

Caverject is not intended to be mixed or co-administered with any other products.

Lyophilised Powder:

2 years

Reconstituted Solution:

Must be used immediately and not stored.

Solvent

2 years.

Lyophilised Powder:

Reconstituted solution:

Reconstituted solutions are intended for single use only, they should be used immediately and not stored.

Diluent

Do not store above 25°C.

All presentations:

Lypophilised Powder:

1 x 5ml, type I Ph. Eur., clear, colourless glass vial, with flurocoated rubber stopper and an aluminium overseal with flip-off cap

Solvent:

1 x 2ml type I Ph. Eur., clear colourless glass syringe, with butyl rubber plunger stopper.

The package also includes antiseptic swabs containing Isopropyl alcohol BP.

Caverject 10 micrograms, Powder and Solvent for Solution for Injection only:

For hospital use only, a dose titration pack containing 8 individual boxes of Caverject 10 micrograms.

Caverject 5 micrograms, Powder and Solvent for Solution for Injection:

Caverject 10 micrograms, Powder and Solvent for Solution for Injection:

After reconstitution the product is a clear solution

The presence of benzyl alcohol in the reconstitution vehicle decreased the degree of binding to package surfaces. Therefore, a more consistent product delivery is produced when Bacteriostatic Water for Injection containing benzyl alcohol is used.

Use immediately after reconstitution.

Caverject 20 micrograms, Powder and Solvent for Solution for Injection:

For instructions regarding reconstitution of the product, please refer to section 4.2

After reconstitution the product is a clear solution. Do not use if the solution appears cloudy or contains particles. The presence of benzyl alcohol in the reconstitution vehicle decreased the degree of binding to package surfaces. Therefore, a more consistent product delivery is produced when Bacteriostatic Water for Injection containing benzyl alcohol is used.

Use immediately after reconstitution. Discard any unused material.

Caverject 5 micrograms, Powder and Solvent for Solution for Injection

Caverject 10 micrograms, Powder and Solvent for Solution for Injection

Pharmacia Limited

Ramsgate Road,

Sandwich, Kent,

CT13 9NJ,

United Kingdom

Caverject 20 micrograms, Powder and Solvent for Solution for Injection

Pharmacia Ireland

9 Riverwalk,

National Digital Park,

Citywest Business Campus,

Dublin 24.

Caverject 5 micrograms, Powder and Solvent for Solution for Injection- PA 16/46/2

Caverject 10 micrograms, Powder and Solvent for Solution for Injection- PA 16/46/3

Caverject 20 micrograms, Powder and Solvent for Solution for Injection-PA 936/9/5

Caverject 5 micrograms, Powder and Solvent for Solution for Injection

Caverject 10 micrograms, Powder and Solvent for Solution for Injection

Date of first authorisation: 4^th April 1997

Date of last renewal: 4^th April 2007

Caverject 20 micrograms, Powder and Solvent for Solution for Injection

Date of first authorisation: 13^th March 1995

Date of last renewal: 13^th March 2010

Caverject 5micrograms, Powder and Solvent for Solution for Injection – September 2009

Caverject 10 micrograms, Powder and Solvent for Solution for Injection – September 2009

Caverject 20 micrograms, Powder and Solvent for Solution for Injection – October 2011

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