1. Name Of The Medicinal Product
Voltarol® Ophtha
2. Qualitative And Quantitative Composition
Eye drop solution containing 0.1% (w/v) diclofenac sodium in a preservative-free formulation.
3. Pharmaceutical Form
Eye drop solution presented in single dose units for administration by instillation in the conjunctival sac.
4. Clinical Particulars
4.1 Therapeutic Indications
i. Inhibition of peroperative miosis during cataract surgery (Voltarol Ophtha has no intrinsic mydriatic properties and does not replace standard mydriatic agents).
ii. Treatment of post-operative inflammation in cataract surgery.
iii. Control of ocular pain and discomfort associated with corneal epithelial defects after excimer PRK surgery or accidental non- penetrating trauma.
iv. Control of inflammation after Argon Laser Trabeculoplasty (ALT).
v. The relief of the ocular signs and symptoms of Seasonal Allergic Conjunctivitis (SAC).
vi. Treatment of inflammation and discomfort after strabismus surgery
vii. Treatment of ocular pain and discomfort after radial keratotomy
4.2 Posology And Method Of Administration
Voltarol Ophtha eye drop solution is for instillation into the conjunctival sac only. It should never be injected subconjunctivally, nor should it be directly introduced into the anterior chamber of the eye.
Adults:
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NOTE: The contents remain sterile until the original closure is broken. Each Voltarol Ophtha SDU is for single use only. Discard the single dose unit immediately after use. Patients must discard residual contents after use.
Paediatric use: Voltarol Ophtha and Voltarol Ophtha CD are not indicated for use in children. Paediatric experience is limited to a few published clinical studies in strabismus surgery.
4.3 Contraindications
Patients with known hypersensitivity to any of the ingredients.
Like other non-steroidal anti-inflammatory agents, Voltarol Ophtha is also contraindicated in patients in whom attacks of asthma, urticaria or acute rhinitis are precipitated by acetylsalicylic acid or by other drugs with prostaglandin synthetase inhibiting activity. Intraocular use during surgical procedure is also contraindicated. There is the potential for cross-sensitivity to acetylsalicylic acid, phenylacetic acid derivatives, and other nonsteroidal anti-inflammatory agents.
4.4 Special Warnings And Precautions For Use
The anti-inflammatory activity of ophthalmic non-steroidal anti-inflammatory agents (NSAIDs) may mask the onset and/or progression of ocular infections. In the presence of infection, or if there is a risk of infection, appropriate therapy (e.g. antibiotics) should be given concurrently with Voltarol Ophtha.
Although there have been no reported adverse events, there is a theoretical possibility that patients receiving other medications which may prolong bleeding time, or with known haemostatic defects may experience exacerbation with Voltarol Ophtha.
Caution should be exercised when topical NSAIDs such as diclofenac are used concomitantly with topical steroids (see section 4.5 Interaction with other medicinal products and other forms of interaction).
Following instillation of the eye drops, nasolacrimal occlusion or closing the eyes for 3 minutes may reduce the systemic absorption. This may result in a decrease in systemic side effects and an increase in local activity.
4.5 Interaction With Other Medicinal Products And Other Forms Of Interaction
Concomitant use of topical NSAIDs such as diclofenac and topical steroids in patients with significant pre-existing corneal inflammation may increase the risk of developing corneal complications, therefore caution should be used.
To prevent the active substances from being washed out when additional ophthalmic medication is used, an interval of at least 5 minutes between each application should be adhered to.
4.6 Pregnancy And Lactation
Pregnancy
There are no data on the use of Voltarol Ophtha or Voltarol Ophtha Multidose 0.1% in pregnancy. Studies in animals with diclofenac have shown reproductive toxicity (see Section 5.3).
1st and 2nd Trimester: Animal studies have so far shown no risk to the foetus but no controlled studies in pregnant women are available.
3rd Trimester: Voltarol Ophtha should not be used, due to possible risk of premature closure of the ductus arteriosus and possible inhibition of contractions.
Lactation
Diclofenac is excreted in breast milk. However at therapeutic doses of Voltarol Ophtha no effects on the suckling child are anticipated. Use of ocular diclofenac is not recommended during breast feeding unless the expected benefits outweigh the possible risks.
4.7 Effects On Ability To Drive And Use Machines
Patients with blurred vision should refrain from driving a vehicle or operating machines.
4.8 Undesirable Effects
The most frequently observed adverse reaction is a transient, mild to moderate eye irritation.
Other less frequently observed reactions are eye pain, eye pruritus, ocular hyperaemia and blurred vision immediately after instillation of the eye drops.
Punctate keratitis or corneal disorders have been observed, usually after frequent application.
In patients with risk factors of corneal disorders such as during the use of corticosteroids or with concomitant diseases such as infections or rheumatoid arthritis, diclofenac has been associated, in rare cases, with ulcerative keratitis, corneal thinning, punctuate keratitis, corneal epithelium defect and corneal oedema, which might become sight-threatening. Most patients were treated for a prolonged period of time.
Allergic conditions have been reported for ocular reactions such as conjunctival hyperaemia, allergic conjunctivitis, eyelid erythema, oedema, and pruritus, and systemic hypersensitivity reactions such as urticaria, rash, eczema, erythema, pruritus, cough and rhinitis.
In rare cases dyspnoea and exacerbation of asthma have been reported.
4.9 Overdose
There is practically no risk of adverse effects due to accidental oral ingestion, since the eye drop solution in a block of 10 units contains only 3mg of diclofenac sodium, corresponding to about 1.8% of the recommended maximum daily adult dose of Voltarol after oral administration. By way of comparison, the maximum oral daily dose for diclofenac sodium recommended in children is 2mg/kg body weight.
5. Pharmacological Properties
5.1 Pharmacodynamic Properties
Voltarol Ophtha contains diclofenac sodium, a non-steroidal compound with pronounced anti-inflammatory and analgesic properties. Inhibition of prostaglandin biosynthesis, which has been demonstrated experimentally, is regarded as having an important bearing on its mechanism of action. Prostaglandins play a major role in the causation of inflammation and pain.
In clinical trials, Voltarol Ophtha has been found to:
i. inhibit miosis during cataract surgery
ii. reduce inflammation following surgical interventions
iii. reduce ocular pain and discomfort associated with corneal epithelial defects after excimer PRK surgery or accidental non-penetrating trauma.
iv. reduce the incidence of angiographic cystoid macular oedema after cataract surgery but clinical significance remains to be established.
v. reduce ocular inflammation and discomfort more effectively than topical steroids after strabismus surgery whilst avoiding steroidal adverse effects such as delayed conjunctival wound healing and raised intraocular pressure
vi. reduce ocular inflammation, pain and discomfort (photophobia, burning/stinging, foreign body sensation, deep headache-like ocular pain and itching) more effectively than placebo eye drops after corneal incisional surgery such as radial keratotomy.
The effective daily dose after ocular application of Voltarol Ophtha (approximately 0.25 - 0.5 mg diclofenac sodium) corresponds to less than 1% of the daily dose recommended for Voltarol in rheumatic indications.
5.2 Pharmacokinetic Properties
In rabbits, peak concentrations of 14C-labelled diclofenac could be demonstrated in the cornea and conjunctiva 30 minutes after application. The highest amounts are found in these two tissues and in the choroid and retina. Elimination was fast and almost complete after 6 hours.
Penetration of diclofenac into the anterior chamber has been confirmed in humans. No measurable levels of diclofenac could be found in humans after ocular application of diclofenac sodium eye drops.
5.3 Preclinical Safety Data
Preclinical data of systemically applied diclofenac from acute and repeated dose toxicity studies, as well as from genotoxicity and carcinogenicity studies revealed no specific hazard for humans at the intended therapeutic doses.
In reproductive and developmental toxicity studies systemic diclofenac has been shown to cross the placental barrier in mice and rats. Whilst no teratogenic effects have been demonstrated, maternally toxic doses were associated with dystocia, prolonged gestation, decreased foetal survival, and intrauterine growth retardation. The effects of diclofenac on fertility and delivery as well as the constriction of the ductus arteriosus in utero are pharmacological consequences of this class of prostaglandin synthesis inhibitors
Local ocular tolerance and toxicity of Voltarol Ophtha and Voltarol Ophtha Multidose 0.1% eye drops (containing hydroxypropyl-gamma cyclodextrin) were investigated and no evidence of toxicity and local adverse effects was found.
6. Pharmaceutical Particulars
6.1 List Of Excipients
Boric acid
Polyoxyl 35 castor oil
Tromethamine
Water for injections
6.2 Incompatibilities
None known to date
6.3 Shelf Life
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6.4 Special Precautions For Storage
Do not store above 25°C. Stable for 28 days after opening the blister.
6.5 Nature And Contents Of Container
Sealed single dose units composed of low density polyethylene granulate. Each unit contains 0.3ml solution. Available in packs of 5, 40.
6.6 Special Precautions For Disposal And Other Handling
No special requirements.
7. Marketing Authorisation Holder
Novartis Pharmaceuticals UK Ltd
Frimley Business Park
Frimley
Surrey
GU16 7SR
8. Marketing Authorisation Number(S)
PL 00101/0478
9. Date Of First Authorisation/Renewal Of The Authorisation
26 February 2009
10. Date Of Revision Of The Text
30 November 2011
LEGAL CATEGORY
POM
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