2012年5月14日美国食品药品监督管理局(FDA)已完成一项多发性硬化症(MS)药物芬戈莫德[fingolimod](Gilenya)首次剂量后死亡的患者报告的评价。管理局还评价了芬戈莫德的另外临床试验和上市后数据，包括死于心血管事件或未知原因患者的报告。FDA未能确定性结论芬戈莫德与任何死亡相关。 但是，根据其数据的再评价，FDA保持关注芬戈莫德首次剂量后的心血管作用。数据显示，虽然芬戈莫德的最大降低心率作用通常发生在首次剂量的6小时内，有些患者中最大效应可能发生晚至首次剂量后20小时。 因为这个理由，现在某些预先存在或最近(过去6个月内)心脏情况或卒中，或正在服用某些抗心律失常药患者禁忌使用芬戈莫德. FDA继续建议开始使用芬戈莫德所有患者首次剂量后监视心动过缓的体征至少6小时。FDA现建议对开始用芬戈莫德所有患者每小时测量脉搏和血压。给药前和观察期结束应进行心电图(ECG或EKG) 测试。心血管监视应继续直至任何症状解决。 此外，FDA现在还建议过去6小时处于较高风险或不能耐受心动过缓患者心血管监视时间扩展包括连续过夜ECG监视，这些较高风险患者包括如下： （1）芬戈莫德首次剂量给药后发生心动过缓 （2）某些预先存在情况其心动过缓可能耐受很差 （3）接受减慢心率或房室传导其它药物治疗 （4）芬戈莫德开始前，或心血管监视期任何时间QT间期延长 （5）接受延长QT间期和引起尖端扭转型室性心动过速其它药物治疗 数据总结 2011年12月，FDA发出一个药物安全性通讯(DSC)关注1例MS患者死于服用芬戈莫德首次剂量24小时内根据报道的资料，不能确定死亡原因。患者还有扩展脑干MS病变；这类病变曾伴骤死。患者还服用2中血压药物(美托洛尔[metoprolol]和氨氯地平[amlodipine]),也可影响心率；不知道它们是否在死亡中起作用。在得到数据的基础上，不能除外芬戈莫德首次剂量和患者死亡间间的联系，但是，没有药物在死亡中起作用的任何明确证据。 在接到本例后，FDA重新评价与临床试验芬戈莫德对心率和血压有关的影响的数据，包括来自正在被FDA批准药物时的数据。分析24小时Holter监视心率变化证实芬戈莫德降低心率作用是双相的，初期6小时内减低，和给药后约12至20小时第二次减毒，部分与昼夜节律相关。 为了允许首次剂量后对在6-至24-小时期间可能严重症状性心动过缓适当反应，FDA的结论在头6小时内经受心率<45 搏动/分钟或药后6小时最低心率6小时后仍可能进一步心动过缓患者中将审慎扩展监视期超过6小时。 此外，为了减低与心动过缓或房室传导阻滞相关风险，现建议有某些预先存在情况，例如QT延长，和在接受减慢心率或房室传导同时药物患者中扩展监视。 FDA在得到关于芬戈莫德心血管安全性任何重要新信息时将交流。 适应证和用途 芬戈莫德是一种神经鞘氨醇1-磷酸受体调节剂适用于复发性多发性硬化症患者的治疗减少临床加重的频数和延缓身体残疾的积蓄。 剂量和给药方法 （1）推荐剂量：0.5mg口服每天1次，有或无食物。 （2）首次剂量监视： 1）首次剂量后观察所有患者心动过缓的体征和症状至少6小时，每小时脉搏和血压测量。在给药前和观察期结束时获得ECG。 2）发生心率<45 bpm，或新开始二度或更高房室传导阻滞患者应监视直至发现解决。给药后在观察期结束时心率最低患者应监视直至心率增加。 3）在经受症状性心动过缓患者中，开始连续ECG监视直至症状已解决；如治疗心动过缓需要药理学干预，应在一种医疗设备连续ECG监视连续过夜，和对第二次给药应重复首次剂量监视方法。 4）处在症状性心动过缓或心脏阻滞较高风险患者因为一种共存医学情况或某些同时用药应用连续ECG监视观察过夜. 5）在基线或观察期时延长QTc间期患者，或服用尖端扭转型室性心动过速已知风险药物应用连续ECG监视过夜观察 剂型和规格 0.5mg硬胶囊. 禁忌证 （1）最近(在过去6个月内)发生：心肌梗死，不稳定性心绞痛，卒中，短暂性缺血发作，失代偿心衰需要住院，或类III/IV心衰 （2）存在Mobitz氏II型二度或三度AV阻滞或病态窦房结综合征或史，除非患者有心脏起搏器 （3）基线QTc间期500 ms （4）用类Ia或类III抗心律失常药治疗 警告和注意事项 （1）芬戈莫德首次剂量后心率和/或房室传导减慢：监视患者。 （2）感染：芬戈莫德可能增加感染的风险。开始用芬戈莫德治疗前应得到最近完全血细胞计数CBC。治疗期间监视感染的体征和症状和在终止后共2个月。在有活动性急性或慢性感染患者中不要开始芬戈莫德治疗。 （3）黄斑水肿：可能发生有或无视力症状。在开始芬戈莫德前应进行一项眼科学评价和在治疗开始后3-4个月后。在基线和患者的常规评价时监视视力。有糖尿病患者或葡萄膜炎史时增加风险和应有常规眼科评价。 （4）用芬戈莫德减低肺功能测试：当临床指示时得到肺活量和肺扩散一氧化碳[diffusion lung capacity for carbon monoxide, DLCO]。 （5）肝效应：芬戈莫德可能增加肝转氨酶。开始芬戈莫德前应得到最近肝酶结果。如怀疑肝损伤评估肝酶。如果发生显著肝损伤终止芬戈莫德。 （6）胎儿风险：用芬戈莫德时和停止后2个月有生育能力妇女应使用有效避孕药。 不良反应 最常见不良反应(发生率10%和> 安慰剂)：头痛，流感，腹泻，背痛，肝转氨酶升高和咳嗽。 药物相互作用 （1）酮康唑：因为同时全身使用酮康唑[ketoconazole]时芬戈莫德暴露增加70%和不良反应风险较大，严密监视患者。 （2）疫苗：芬戈莫德治疗时，和停止后2个月时，由于感染风险，避免或减毒疫苗。 特殊人群中使用 （1）妊娠：根据动物数据，可能致胎儿危害。可得到妊娠注册。 （2）儿童患者：未确定安全性和有效性。 （3）肝受损：严密监视严重肝受损患者，因芬戈莫德暴露加倍，和不良反应风险较大。 Table of Contents This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse reactions. 1. Name of the medicinal product GILENYA 0.5mg hard capsules 2. Qualitative and quantitative composition Each capsule contains 0.5 mg fingolimod (as hydrochloride). For the full list of excipients, see section 6.1. 3. Pharmaceutical form Hard capsule Capsule of 16 mm with bright yellow opaque cap and white opaque body; imprint with black ink, “FTY0.5 mg” on cap and two radial bands imprinted on the body with yellow ink. 4. Clinical particulars 4.1 Therapeutic indications Gilenya is indicated as single disease modifying therapy in highly active relapsing remitting multiple sclerosis for the following adult patient groups: - Patients with high disease activity despite treatment with a beta-interferon. These patients may be defined as those who have failed to respond to a full and adequate course (normally at least one year of treatment) of beta-interferon. Patients should have had at least 1 relapse in the previous year while on therapy, and have at least 9 T2-hyperintense lesions in cranial MRI or at least 1 Gadolinium-enhancing lesion. A “non-responder” could also be defined as a patient with an unchanged or increased relapse rate or ongoing severe relapses, as compared to the previous year. - Patients with rapidly evolving severe relapsing remitting multiple sclerosis defined by 2 or more disabling relapses in one year, and with 1 or more Gadolinium enhancing lesions on brain MRI or a significant increase in T2 lesion load as compared to a previous recent MRI. 4.2 Posology and method of administration The treatment should be initiated and supervised by a physician experienced in multiple sclerosis. Posology The recommended dose of Gilenya is one 0.5 mg capsule taken orally once daily. Gilenya can be taken with or without food. The same first dose monitoring as for treatment initiation is recommended when treatment is interrupted for: • 1 day or more during the first 2 weeks of treatment. • more than 7 days during weeks 3 and 4 of treatment. • more than 2 weeks after one month of treatment. If the treatment interruption is of shorter duration than the above, the treatment should be continued with the next dose as planned (see section 4.4). Patients can switch directly from beta interferon or glatiramer acetate to Gilenya provided there are no signs of relevant treatment-related abnormalities, e.g. neutropenia. Special populations Elderly population Gilenya should be used with caution in patients aged 65 years and over due to insufficient data on safety and efficacy (see section 5.2). Renal impairment Gilenya was not studied in patients with renal impairment in the multiple sclerosis pivotal studies. Based on clinical pharmacology studies, no dose adjustments are needed in patients with mild to severe renal impairment. Hepatic impairment Gilenya must not be used in patients with severe hepatic impairment (Child-Pugh class C) (see section 4.3). Although no dose adjustments are needed in patients with mild or moderate hepatic impairment, caution should be exercised when initiating treatment in these patients (see sections 4.4 and 5.2). Diabetic patients Gilenya has not been studied in multiple sclerosis patients with concomitant diabetes mellitus. Gilenya should be used with caution in these patients due to a potential increase in the risk of macular oedema (see sections 4.4 and 4.8). Regular ophthalmological examinations should be conducted in these patients to detect macular oedema. Paediatric population The safety and efficacy of Gilenya in children aged 0 to 18 years have not yet been established. Currently available data are described in section 5.2 but no recommendation on a posology can be made. 4.3 Contraindications Known immunodeficiency syndrome. Patients with increased risk for opportunistic infections, including immunocompromised patients (including those currently receiving immunosuppressive therapies or those immunocompromised by prior therapies). Severe active infections, active chronic infections (hepatitis, tuberculosis). Known active malignancies, except for patients with cutaneous basal cell carcinoma. Severe liver impairment (Child-Pugh class C). Hypersensitivity to the active substance or to any of the excipients listed in section 6.1. 4.4 Special warnings and precautions for use Bradyarrhythmia Initiation of Gilenya treatment results in a transient decrease in heart rate and may also be associated with atrioventricular conduction delays, including the occurrence of isolated reports of transient, spontaneously resolving complete AV block (see sections 4.8 and 5.1). After the first dose, the decline in heart rate starts within one hour and is maximal within 6 hours. This post-dose effect persists over the following days, although usually to a milder extent, and usually abates over the next weeks. With continued administration, the average heart rate returns towards baseline within one month. However individual patients may not return to baseline heart rate by the end of the first month. Conduction abnormalities were typically transient and asymptomatic. They usually did not require treatment and resolved within the first 24 hours on treatment. If necessary, the decrease in heart rate induced by fingolimod can be reversed by parenteral doses of atropine or isoprenaline. All patients should have an ECG and blood pressure measurement performed prior to and 6 hours after the first dose of Gilenya. All patients should be monitored for a period of 6 hours for signs and symptoms of bradycardia with hourly heart rate and blood pressure measurement. Continuous (real time) ECG monitoring during this 6 hour period is recommended. Should post-dose bradyarrhythmia-related symptoms occur, appropriate clinical management should be initiated and monitoring should be continued until the symptoms have resolved. Should a patient require pharmacological intervention during the first-dose monitoring, overnight monitoring in a medical facility should be instituted and the first-dose monitoring should be repeated after the second dose of Gilenya. If the heart rate at 6 hours is the lowest since the first dose was administered (suggesting that the maximum pharmacodynamic effect on the heart may not yet be manifest), monitoring should be extended by at least 2 hours and until heart rate increases again. Additionally, if after 6 hours, the heart rate is <45 bpm, or the ECG shows new onset second degree or higher grade AV block or a QTc interval ≥500 msec, extended monitoring (at least overnight monitoring), should be performed, and until the findings have resolved. The occurrence at any time of third degree AV block should also lead to extended monitoring (at least overnight monitoring). Due to the risk of serious rhythm disturbances, Gilenya should not be used in patients with second degree Mobitz type II or higher AV block, sick-sinus syndrome, or sino-atrial heart block, a history of symptomatic bradycardia or recurrent syncope, or in patients with significant QT prolongation (QTc>470msec (female) or >450msec (male)). Since significant bradycardia may be poorly tolerated in patients with known ischaemic heart disease (including angina pectoris), cerebrovascular disease, history of myocardial infarction, congestive heart failure, history of cardiac arrest, uncontrolled hypertension or severe sleep apnoea, Gilenya should not be used in these patients. In such patients, treatment with Gilenya should be considered only if the anticipated benefits outweigh the potential risks. If treatment is considered, advice from a cardiologist should be sought prior to initiation of treatment in order to determine the most appropriate monitoring, at least overnight extended monitoring is recommended for treatment initiation (see also section 4.5). Gilenya has not been studied in patients with arrhythmias requiring treatment with class Ia (e.g. quinidine, disopyramide) or class III (e.g. amiodarone, sotalol) antiarrhythmic medicinal products. Class Ia and class III antiarrhythmic medicinal products have been associated with cases of torsades de pointes in patients with bradycardia. Since initiation of Gilenya treatment results in decreased heart rate, Gilenya should not be used concomitantly with these medicinal products. Experience with Gilenya is limited in patients receiving concurrent therapy with beta blockers, heart-rate-lowering calcium channel blockers (such as verapamil, diltiazem or ivabradine), or other substances which may decrease heart rate (e.g. digoxin, anticholinesteratic agents or pilocarpine). Since the initiation of Gilenya treatment is also associated with slowing of the heart rate (see also section 4.8, Bradyarrhythmia), concomitant use of these substances during Gilenya initiation may be associated with severe bradycardia and heart block. Because of the potential additive effect on heart rate treatment with Gilenya should not be initiated in patients who are concurrently treated with these substances (see also section 4.5). In such patients, treatment with Gilenya should be considered only if the anticipated benefits outweigh the potential risks. If treatment with Gilenya is considered, advice from a cardiologist should be sought regarding the switch to non heart-rate lowering medicinal products prior to initiation of treatment. If the heart-rate-lowering medication cannot be stopped, cardiologist's advice should be sought to determine appropriate first dose monitoring, at least overnight extended monitoring is recommended (see also section 4.5). The effects on heart rate and atrioventricular conduction may recur on re-introduction of Gilenya treatment depending on duration of the interruption and time since start of Gilenya treatment. The same first dose monitoring as for treatment initiation is recommended when treatment is interrupted for: • 1 day or more during the first 2 weeks of treatment. • more than 7 days during weeks 3 and 4 of treatment. • more than 2 weeks after one month of treatment. If the treatment interruption is of shorter duration than the above, the treatment should be continued with the next dose as planned. QT interval In a thorough QT interval study of doses of 1.25 or 2.5 mg fingolimod at steady-state, when a negative chronotropic effect of fingolimod was still present, fingolimod treatment resulted in a prolongation of QTcI, with the upper limit of the 90% CI ≤13.0 ms. There is no dose- or exposure-response relationship of fingolimod and QTcI prolongation. There is no consistent signal of increased incidence of QTcI outliers, either absolute or change from baseline, associated with fingolimod treatment. The clinical relevance of this finding is unknown. In the multiple sclerosis studies, clinically relevant effects on prolongation of the QTc-interval have not been observed but patients at risk for QT prolongation were not included in clinical studies. Medicinal products that may prolong QTc interval are best avoided in patients with relevant risk factors, for example, hypokalaemia or congenital QT prolongation. Infections A core pharmacodynamic effect of Gilenya is a dose-dependent reduction of the peripheral lymphocyte count to 20-30% of baseline values. This is due to the reversible sequestration of lymphocytes in lymphoid tissues (see section 5.1). Before initiating treatment with Gilenya, a recent complete blood count (CBC) (i.e. within 6 months) should be available. Assessments of CBC are also recommended periodically during treatment, and in case of signs of infection. Absolute lymphocyte count <0.2x109/l, if confirmed, should lead to treatment interruption until recovery, because in clinical studies, fingolimod treatment was interrupted in patients with absolute lymphocyte count <0.2x109/l. Initiation of treatment with Gilenya should be delayed in patients with severe active infection until resolution. Before initiating Gilenya therapy, patients without a history of chickenpox or without vaccination against varicella zoster virus (VZV) should be tested for antibodies to VZV. VZV vaccination of antibody negative patients should be considered prior to commencing treatment with Gilenya, following which initiation of treatment with Gilenya should be postponed for 1 month to allow full effect of vaccination to occur. The immune system effects of Gilenya may increase the risk of infections (see section 4.8). Effective diagnostic and therapeutic strategies should be employed in patients with symptoms of infection while on therapy. During treatment, patients receiving Gilenya should be instructed to report symptoms of infection to their physician. Suspension of Gilenya should be considered if a patient develops a serious infection and consideration of benefit-risk should be undertaken prior to re-initiation of therapy. Elimination of fingolimod following discontinuation of therapy may take up to two months and vigilance for infection should therefore be continued throughout this period. Patients should be instructed to report symptoms of infection up to 2 months after discontinuation of fingolimod. Macular oedema Macular oedema with or without visual symptoms has been reported in 0.4% of patients treated with fingolimod 0.5 mg, occurring predominantly in the first 3-4 months of therapy (see section 4.8). An ophthalmological evaluation is therefore recommended at 3-4 months after treatment initiation. If patients report visual disturbances at any time while on therapy, evaluation of the fundus, including the macula, should be carried out. Patients with history of uveitis and patients with diabetes mellitus are at increased risk of macular oedema (see section 4.8). Gilenya has not been studied in multiple sclerosis patients with concomitant diabetes mellitus. It is recommended that multiple sclerosis patients with diabetes mellitus or a history of uveitis undergo an ophthalmological evaluation prior to initiating therapy and have follow-up evaluations while receiving therapy. Continuation of Gilenya in patients with macular oedema has not been evaluated. It is recommended that Gilenya be discontinued if a patient develops macular oedema. A decision on whether or not Gilenya therapy should be re-initiated after resolution of macular oedema needs to take into account the potential benefits and risks for the individual patient. Liver function During clinical trials, elevations 3-fold the upper limit of normal (ULN) or greater in liver transaminases occurred in 8% of patients treated with fingolimod 0.5 mg compared to 2% of placebo patients. Elevations 5-fold the ULN occurred in 2% of patients on fingolimod and 1% of patients on placebo. In clinical trials, fingolimod was discontinued if the elevation exceeded 5 times the ULN. Recurrence of liver transaminase elevations occurred with rechallenge in some patients, supporting a relationship to fingolimod. In clinical studies, transaminase elevations occurred at any time during treatment although the majority occurred within the first 12 months. Serum transaminase levels returned to normal within approximately 2 months after discontinuation of fingolimod. Gilenya has not been studied in patients with severe pre-existing hepatic injury (Child-Pugh class C) and should not be used in these patients (see section 4.3). Due to the immunosuppressive properties of fingolimod, initiation of treatment should be delayed in patients with active viral hepatitis until resolution. Recent (i.e. within last 6 months) transaminase and bilirubin levels should be available before initiation of treatment with Gilenya. In the absence of clinical symptoms, liver transaminases should be monitored at Months 1, 3, 6, 9 and 12 on therapy and periodically thereafter. If liver transaminases rise above 5 times the ULN, more frequent monitoring should be instituted, including serum bilirubin and alkaline phosphatase (ALP) measurement. With repeated confirmation of liver transaminases above 5 times the ULN, treatment with Gilenya should be interrupted and only re-commenced once liver transaminase values have normalised. Patients who develop symptoms suggestive of hepatic dysfunction, such as unexplained nausea, vomiting, abdominal pain, fatigue, anorexia, or jaundice and/or dark urine, should have liver enzymes checked and Gilenya should be discontinued if significant liver injury is confirmed (for example liver transaminase levels greater than 5-fold the ULN and/or serum bilirubin elevations). Resumption of therapy will be dependent on whether or not another cause of liver injury is determined and on the benefits to patient of resuming therapy versus the risks of recurrence of liver dysfunction. Although there are no data to establish that patients with pre-existing liver disease are at increased risk of developing elevated liver function tests when taking Gilenya, caution in the use of Gilenya should be exercised in patients with a history of significant liver disease. Interference with serological testing Since fingolimod reduces blood lymphocyte counts via re-distribution in secondary lymphoid organs, peripheral blood lymphocyte counts cannot be utilised to evaluate the lymphocyte subset status of a patient treated with Gilenya. Laboratory tests involving the use of circulating mononuclear cells require larger blood volumes due to reduction in the number of circulating lymphocytes. Blood pressure effects Patients with hypertension uncontrolled by medication were excluded from participation in premarketing clinical trials and special care is indicated if patients with uncontrolled hypertension are treated with Gilenya. In MS clinical trials, patients treated with fingolimod 0.5 mg had an average increase of approximately 3 mmHg in systolic pressure, and approximately 1 mmHg in diastolic pressure, first detected approximately 1 month after treatment initiation, and persisting with continued treatment. In the two-year placebo-controlled study, hypertension was reported as an adverse event in 6.1% of patients on fingolimod 0.5 mg and in 3.8% of patients on placebo. Therefore, blood pressure should be regularly monitored during treatment with Gilenya. Respiratory effects Minor dose-dependent reductions in values for forced expiratory volume (FEV1) and diffusion capacity for carbon monoxide (DLCO) were observed with Gilenya treatment starting at Month 1 and remaining stable thereafter. Gilenya should be used with caution in patients with severe respiratory disease, pulmonary fibrosis and chronic obstructive pulmonary disease (see also section 4.8). Prior treatment with immunosuppressants When switching patients from interferon or glatiramer acetate to Gilenya, a washout is not necessary, assuming any immune effects (i.e. cytopenia) of such therapies have resolved. Due to the long half-life of natalizumab, concomitant exposure, and thus concomitant immune effects, could occur for up to 2-3 months following discontinuation of natalizumab if Gilenya was immediately started. Therefore caution is required when switching patients from natalizumab to Gilenya. When switching from other immunosuppressive medications, the duration and mode of action of such substances must be considered when initiating Gilenya to avoid additive immune suppressive effects. Stopping therapy If a decision is made to stop treatment with Gilenya a 6 week interval without therapy is needed, based on half-life, to clear fingolimod from the circulation (see section 5.2). Lymphocyte counts progressively return to normal range within 1-2 months of stopping therapy (see section 5.1). Starting other therapies during this interval will result in concomitant exposure to fingolimod. Use of immunosuppressants soon after the discontinuation of Gilenya may lead to an additive effect on the immune system and caution is therefore indicated. 4.5 Interaction with other medicinal products and other forms of interaction Anti-neoplastic, immunosuppressive or immune-modulating therapies Anti-neoplastic, immunosuppressive or immune-modulating therapies should not be co-administered due to the risk of additive immune system effects (see sections 4.3 and 4.4). Caution is also indicated when switching patients from long-acting therapies with immune effects, such as natalizumab or mitoxantrone (see section 4.4). In multiple sclerosis clinical studies the concomitant treatment of relapses with a short course of corticosteroids was not associated with an increased rate of infection. Vaccination During and for up to two months after treatment with Gilenya vaccination may be less effective. The use of live attenuated vaccines may carry a risk of infections and should therefore be avoided. Bradycardia-inducing substances Fingolimod has been studied in combination with atenolol and diltiazem. When fingolimod was used with atenolol in an interaction study in healthy volunteers, there was an additional 15% reduction of heart rate at fingolimod treatment initiation, an effect not seen with diltiazem. Treatment with Gilenya should not be initiated in patients receiving beta blockers, or other substances which may decrease heart rate, such as class Ia and III antiarrhythmics, calcium channel blockers (such as ivabradine, verapamil or diltiazem), digoxin, anticholinesteratic agents or pilocarpine because of the potential additive effects on heart rate (see sections 4.4 and 4.8). If treatment with Gilenya is considered in such patients, advice from a cardiologist should be sought regarding the switch to non heart-rate lowering medicinal products or appropriate monitoring for treatment initiation, at least overnight monitoring is recommended, if the heart-rate-lowering medication cannot be stopped. Pharmacokinetic interactions of other substances on fingolimod Fingolimod is metabolised mainly by CYP4F2. Other enzymes like CYP3A4 may also contribute to its metabolism. Co-administration of fingolimod with ketoconazole resulted in a 1.7-fold increase in fingolimod and fingolimod phosphate exposure (AUC). Caution should be exercised with substances that may inhibit CYP3A4 (protease inhibitors, azole antifungals, some macrolides such as clarithromycin or telithromycin). Pharmacokinetic interactions of fingolimod on other substances Fingolimod is unlikely to interact with substances mainly cleared by the CYP450 enzymes or by substrates of the main transporter proteins. Co-administration of fingolimod with ciclosporin did not elicit any change in the ciclosporin or fingolimod exposure. Therefore, fingolimod is not expected to alter the pharmacokinetics of medicinal products that are CYP3A4 substrates. Potent inhibitors of transporter proteins are not expected to influence fingolimod disposition. Co-administration of fingolimod with oral contraceptives (ethinylestradiol and levonorgestrel) did not elicit any change in oral contraceptive exposure. No interaction studies have been performed with oral contraceptives containing other progestagens, however an effect of fingolimod on their exposure is not expected. It is not known whether the concomitant administration of strong CYP450 inducers may decrease the exposure to fingolimod and fingolimod P. 4.6 Fertility, pregnancy and lactation Women of childbearing potential / Contraception in females Before initiation of Gilenya treatment, women of childbearing potential should be counselled regarding the potential for serious risk to the foetus and the need for effective contraception during treatment with Gilenya. Since it takes approximately two months to eliminate fingolimod from the body on stopping treatment (see section 4.4), the potential risk to the foetus may persist and contraception should be continued during that period. Pregnancy Before initiation of treatment in women of childbearing potential a negative pregnancy test result needs to be available. While on treatment, women should not become pregnant and active contraception is recommended. If a woman becomes pregnant while taking Gilenya, discontinuation of Gilenya is recommended. Animal studies have shown reproductive toxicity including foetal loss and organ defects, notably persistent truncus arteriosus and ventricular septal defect (see section 5.3). Furthermore, the receptor affected by fingolimod (sphingosine 1-phosphate receptor) is known to be involved in vascular formation during embryogenesis. There are very limited data from the use of fingolimod in pregnant women. There are no data on the effects of fingolimod on labour and delivery. Breast-feeding Fingolimod is excreted in milk of treated animals during lactation at concentrations 2-3-fold higher than that found in maternal plasma (see section 5.3). Due to the potential for serious adverse reactions to fingolimod in nursing infants, women receiving Gilenya should not breastfeed. Fertility Data from preclinical studies do not suggest that fingolimod would be associated with an increased risk of reduced fertility (see section 5.3). 4.7 Effects on ability to drive and use machines Gilenya has no or negligible influence on the ability to drive and use machines. However, dizziness or drowsiness may occasionally occur when initiating therapy with Gilenya. On initiation of Gilenya treatment it is recommended that patients be observed for a period of 6 hours (see section 4.4, Bradyarrhythmia). 4.8 Undesirable effects Summary of the safety profile A total of 1,703 patients on Gilenya (0.5 or 1.25 mg) constituted the safety population in the two Phase III studies in patients with relapsing-remitting multiple sclerosis (see section 5.1). Study D2301 (FREEDOMS) was a 2-year placebo-controlled clinical study in 854 patients treated with fingolimod (placebo: 418). In this study the most serious adverse reactions on Gilenya 0.5 mg were infections, macular oedema and transient atrioventricular block at treatment initiation. The most frequent adverse reactions (incidence ≥10%) on Gilenya 0.5 mg were headache, influenza, diarrhoea, back pain, liver enzyme elevations and cough. The most frequent adverse reaction reported for Gilenya 0.5 mg leading to treatment interruption was serum transaminase elevations (3.8%). The adverse reactions in Study D2302 (TRANSFORMS), a 1-year study in 849 patients treated with fingolimod which used interferon beta-1a as comparator, were generally similar to Study D2301, taking into account the differences in study duration. Adverse reactions reported with Gilenya 0.5 mg in Studies D2301 (FREEDOMS) and D2302 (TRANSFORMS) are shown below. Frequencies were defined using the following convention: 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). Within each frequency grouping, adverse reactions are ranked in order of decreasing seriousness. Tabulated list of adverse reactions Infections and infestations Very common:  Influenza viral infections Common:  Herpes viral infections Bronchitis Sinusitis Gastroenteritis Tinea infections Uncommon:  Pneumonia Blood and lymphatic system disorders Common:  Lymphopenia Leucopenia Psychiatric disorders Common:  Depression Uncommon:  Depressed mood Nervous system disorders Very common:  Headache Common:  Dizziness Paraesthesia Migraine Eye disorders Common:  Vision blurred Eye pain Uncommon:  Macular oedema* Cardiac disorders Common:  Bradycardia Atrioventricular block Vascular disorders Common:  Hypertension Respiratory, thoracic and mediastinal disorders Very common:  Cough Common:  Dyspnoea Gastrointestinal disorders Very common:  Diarrhoea Skin and subcutaneous tissue disorders Common:  Eczema Alopecia Pruritus Musculoskeletal and connective tissue disorders Very common:  Back pain General disorders and administration site conditions Common:  Asthenia Investigations Very common:  Alanine transaminase (ALT) increased Common:  Gamma-glutamyl transferase (GGT) increased Hepatic enzyme increased Liver function test abnormal Blood triglycerides increased Weight decreased Uncommon: Neutrophil count decreased * Not reported in Study D2301 (FREEDOMS) with Gilenya 0.5 mg. Frequency category is based on the incidence with Gilenya 0.5 mg (0.5% vs. 0.2% in the interferon beta-1a group) in Study D2302 (TRANSFORMS). Description of selected adverse reactions Infections In multiple sclerosis clinical studies the overall rate of infections (72%) and serious infections (2%) at the 0.5 mg dose was similar to placebo. However, lower respiratory tract infections, primarily bronchitis and, to a lesser extent, pneumonia were more common in Gilenya-treated patients. Two fatal cases of herpes infection occurred at the higher 1.25 mg dose: A case of herpes simplex encephalitis in a patient in whom initiation of acyclovir therapy was delayed by one week, and a case of primary disseminated varicella zoster infection in a patient not previously exposed to varicella receiving concomitant high-dose steroid therapy for a multiple sclerosis relapse. Macular oedema In multiple sclerosis clinical studies macular oedema occurred in 0.4% of patients treated with the recommended dose of 0.5 mg and 1.1% of patients treated with the higher dose of 1.25 mg. The majority of cases occurred within the first 3-4 months of therapy. Some patients presented with blurred vision or decreased visual acuity, but others were asymptomatic and diagnosed on routine ophthalmological examination. The macular oedema generally improved or resolved spontaneously after discontinuation of Gilenya. The risk of recurrence after re-challenge has not been evaluated. Macular oedema incidence is increased in multiple sclerosis patients with a history of uveitis (17% with a history of uveitis vs. 0.6% without a history of uveitis). Gilenya has not been studied in multiple sclerosis patients with diabetes mellitus, a disease which is associated with an increased risk for macular oedema (see section 4.4). In renal transplant clinical studies in which patients with diabetes mellitus were included, therapy with fingolimod 2.5 mg and 5 mg resulted in a 2-fold increase in the incidence of macular oedema. Bradyarrhythmia Initiation of Gilenya treatment results in a transient decrease in heart rate and may also be associated with atrioventricular conduction delays. In multiple sclerosis clinical studies the maximal decline in heart rate was seen within 6 hours after treatment initiation, with declines in mean heart rate of 12-13 beats per minute for Gilenya 0.5 mg. Heart rate below 40 beats per minute was rarely observed in patients on Gilenya 0.5 mg. The average heart rate returned towards baseline within 1 month of chronic treatment. Bradycardia was generally asymptomatic but some patients experienced mild to moderate symptoms, including hypotension, dizziness, fatigue and/or palpitations, which resolved within the first 24 hours after treatment initiation (see also sections 4.4 and 5.1).. In multiple sclerosis clinical studies first-degree atrioventricular block (prolonged PR interval on ECG) was detected after treatment initiation in 4.7% of patients on fingolimod 0.5 mg, in 2.8% of patients on intramuscular interferon beta-1a, and in 1.5% of patients on placebo. Second-degree atrioventricular block was detected in less than 0.5% patients on Gilenya 0.5 mg. In the post-marketing setting, isolated reports of transient, spontaneously resolving complete AV block have been observed during the six hour monitoring period with Gilenya. The patients recovered spontaneously. The conduction abnormalities observed both in clinical trials and post-marketing were typically transient, asymptomatic and resolved within the first 24 hours after treatment initiation. Although most patients did not require medical intervention, one patient on Gilenya 0.5 mg received isoprenaline for asymptomatic second-degree Mobitz I atrioventricular block. In the post-marketing setting, isolated delayed onset events, including transient asystole and unexplained death, have occurred within 24 hours of the first dose. These cases have been confounded by concomitant medicinal products and/or pre-existing disease. The relationship of such events to Gilenya is uncertain. Blood pressure In multiple sclerosis clinical studies Gilenya 0.5 mg was associated with an average increase of approximately 3 mmHg in systolic pressure and approximately 1 mmHg in diastolic pressure, manifesting approximately 1 month after treatment initiation. This increase persisted with continued treatment. Hypertension was reported in 6.1% of patients on fingolimod 0.5 mg and in 3.8% of patients on placebo. In the post-marketing setting, cases of hypertension have been reported within the first month of treatment initiation and on the first day of treatment that may require treatment with antihypertensive agents or discontinuation of Gilenya (see also section 4.4, Blood pressure effects). Liver transaminases In multiple sclerosis clinical studies 8% and 2% of patients treated with Gilenya 0.5 mg experienced asymptomatic elevation in serum levels of hepatic transaminases ≥3x ULN (upper limit of normal) and ≥5x ULN, respectively. Recurrence of liver transaminase elevations has occurred upon re-challenge in some patients, supporting a relationship to the medicinal product. In clinical studies, transaminase elevations occurred at any time during treatment although the majority occurred within the first 12 months. Serum transaminase levels returned to normal within approximately 2 months after discontinuation of Gilenya. In a small number of patients (N=10 on 1.25 mg, N=2 on 0.5 mg) who experienced liver transaminase elevations ≥5x ULN and who continued on Gilenya therapy, the elevations returned to normal within approximately 5 months (see also section 4.4, Liver function). Nervous system disorders In clinical studies, rare events involving the nervous system occurred in patients treated with fingolimod at higher doses (1.25 or 5.0 mg) including ischaemic and haemorrhagic strokes, posterior reversible encephalopathy syndrome and neurological atypical disorders, such as acute disseminated encephalomyelitis (ADEM)-like events. Rare cases of posterior reversible encephalopathy syndrome have also been reported at doses of 0.5 mg in both the clinical studies and the post-marketing setting. Vascular disorders Rare cases of peripheral arterial occlusive disease occurred in patients treated with fingolimod at higher doses (1.25 mg). Respiratory system Minor dose-dependent reductions in values for forced expiratory volume (FEV1) and diffusion capacity for carbon monoxide (DLCO) were observed with Gilenya treatment starting at Month 1 and remaining stable thereafter. At Month 24, the reduction from baseline values in percentage of predicted FEV1 was 3.1% for fingolimod 0.5 mg and 2.0% for placebo, a difference that resolved after treatment discontinuation. For DLCO the reductions at Month 24 were 3.8% for fingolimod 0.5 mg and 2.7% for placebo. Lymphomas There have been cases of lymphoma of different varieties, in both clinical studies and the post-marketing setting, including a fatal case of Epstein-Barr virus (EBV) positive B-cell lymphoma. The incidence of lymphoma (B-cell and T-cell) cases was higher in clinical trials than expected in the general population. 4.9 Overdose well tolerated in healthy volunteers. At 40 mg, 5 of 6 subjects reported mild chest tightness or discomfort which was clinically consistent with small airway reactivity. Fingolimod can induce bradycardia upon treatment initiation. The decline in heart rate usually starts within one hour of the first dose, and is steepest within 6 hours. The negative chronotropic effect of Gilenya persists beyond 6 hours and progressively attenuates over subsequent days of treatment (see section 4.4 for details). There have been reports of slow atrioventricular conduction, with isolated reports of transient, spontaneously resolving complete AV block (see sections 4.4 and 4.8). If the overdose constitutes first exposure to Gilenya, it is important to monitor patients with a continuous (real time) ECG and hourly measurement of heart rate and blood pressure, at least during the first 6 hours (see section 4.4). Additionally, if after 6 hours the heart rate is <45 bpm or if the ECG at 6 hours after the first dose shows second degree or higher AV block, or if it shows a QTc interval ≥500 msec, monitoring should be extended at least for overnight and until the findings have resolved. The occurrence at any time of third degree AV block should also lead to extended monitoring including overnight monitoring. Neither dialysis nor plasma exchange results in removal of fingolimod from the body. 5. Pharmacological properties 5.1 Pharmacodynamic properties Pharmacotherapeutic group: Selective immunosuppressants, ATC code: L04AA27 Mechanism of action Fingolimod is a sphingosine 1-phosphate receptor modulator. Fingolimod is metabolised by sphingosine kinase to the active metabolite fingolimod phosphate. Fingolimod phosphate binds at low nanomolar concentrations to sphingosine 1-phosphate (S1P) receptor 1 located on lymphocytes, and readily crosses the blood-brain barrier to bind to S1P receptor 1 located on neural cells in the central nervous system. By acting as a functional antagonist of S1P receptors on lymphocytes, fingolimod phosphate blocks the capacity of lymphocytes to egress from lymph nodes, causing a redistribution, rather than depletion, of lymphocytes. This redistribution reduces the infiltration of pathogenic lymphocyte cells into the central nervous system, where they would be involved in nerve inflammation and nervous tissue damage. Animal studies and in vitro experiments indicate that fingolimod may also act via interaction with S1P receptors on neural cells. Pharmacodynamic effects Within 4-6 hours after the first dose of fingolimod 0.5 mg, the lymphocyte count decreases to approximately 75% of baseline in peripheral blood. With continued daily dosing, the lymphocyte count continues to decrease over a two-week period, reaching a minimal count of approximately 500 cells/microlitre or approximately 30% of baseline. Eighteen percent of patients reached a minimal count below 200 cells/microlitre on at least one occasion. Low lymphocyte counts are maintained with chronic daily dosing. The majority of T and B lymphocytes regularly traffic through lymphoid organs and these are the cells mainly affected by fingolimod. Approximately 15-20% of T lymphocytes have an effector memory phenotype, cells that are important for peripheral immune surveillance. Since this lymphocyte subset typically does not traffic to lymphoid organs it is not affected by fingolimod. Peripheral lymphocyte count increases are evident within days of stopping fingolimod treatment and typically normal counts are reached within one to two months. Chronic fingolimod dosing leads to a mild decrease in the neutrophil count to approximately 80% of baseline. Monocytes are unaffected by fingolimod. Fingolimod causes a transient reduction in heart rate and decrease in atrioventricular conduction at treatment initiation (see sections 4.4 and 4.8). The maximal decline in heart rate is seen within 6 hours post dose, with 70% of the negative chronotropic effect achieved on the first day. With continued administration heart rate returns to baseline within one month. The decrease in heart rate induced by fingolimod can be reversed by parenteral doses of atropine or isoprenaline. Inhaled salmeterol has also been shown to have a modest positive chronotropic effect. With initiation of fingolimod treatment there is an increase in atrial premature contractions, but there is no increased rate of atrial fibrillation/flutter or ventricular arrhythmias or ectopy. Fingolimod treatment is not associated with a decrease in cardiac output. Autonomic responses of the heart, including diurnal variation of heart rate and response to exercise are not affected by fingolimod treatment. Fingolimod treatment with single or multiple doses of 0.5 and 1.25 mg for two weeks is not associated with a detectable increase in airway resistance as measured by FEV1 and forced expiratory flow rate (FEF) 25-75. However, single fingolimod doses ≥5 mg (10-fold the recommended dose) are associated with a dose-dependent increase in airway resistance. Fingolimod treatment with multiple doses of 0.5, 1.25, or 5 mg is not associated with impaired oxygenation or oxygen desaturation with exercise or an increase in airway responsiveness to methacholine. Subjects on fingolimod treatment have a normal bronchodilator response to inhaled beta-agonists. Clinical efficacy and safety The efficacy of Gilenya has been demonstrated in two studies which evaluated once-daily doses of fingolimod 0.5 mg and 1.25 mg in patients with relapsing-remitting multiple sclerosis (RRMS). Both studies included patients who had experienced ≥2 relapses in the prior 2 years or ≥1 relapse during the prior year. Expanded Disability Status Score (EDSS) was between 0 and 5.5. Study D2301 (FREEDOMS) was a 2-year randomised, double-blind, placebo-controlled Phase III study of 1,272 patients (n=425 on 0.5 mg, 429 on 1.25 mg, 418 on placebo). Median values for baseline characteristics were: age 37 years, disease duration 6.7 years, and EDSS score 2.0. Outcome results are shown in Table 1. There were no significant differences between the 0.5 mg and the 1.25 mg doses as regards either endpoint. Table 1: Study D2301 (FREEDOMS): Main results Fingolimod 0.5 mg Placebo Clinical endpoints     Annualised relapse rate (primary endpoint) 0.18** 0.40 Percentage of patients remaining relapse-free at 24 months 70%** 46% Proportion with 3-month Confirmed Disability Progression† Hazard ratio (95% CI) 17% 0.70 (0.52, 0.96)* 24% MRI endpoints     Median (mean) number of new or enlarging T2 lesions over 24 months 0.0 (2.5)** 5.0 (9.8) Median (mean) number of Gd-enhancing lesions at Month 24 0.0 (0.2)** 0.0 (1.1) Median (mean) % change in brain volume over 24 months -0.7 (-0.8)** -1.0 (-1.3) Disability progression defined as 1-point increase in EDSS confirmed 3 months later p<0.001, *p<0.05 compared to placebo All analyses of clinical endpoints were intent-to-treat. MRI analyses used evaluable dataset. Patients who completed the 24-month core FREEDOMS study could enter a dose-blinded extension study (D2301E1) and receive fingolimod. In total, 920 patients entered (n=331 continued on 0.5 mg, 289 continued on 1.25 mg, 155 switched from placebo to 0.5 mg and 145 switched from placebo to 1.25 mg). After 12 months (month 36), 856 patients (93%) were still enrolled. Between months 24 and 36, the annualised relapse rate (ARR) for patients on fingolimod 0.5 mg in the core study who remained on 0.5 mg was 0.17 (0.21 in the core study). The ARR for patients who switched from placebo to fingolimod 0.5 mg was 0.22 (0.42 in the core study). Comparable results were shown in a replicate 2-year randomised, double-blind, placebo-controlled Phase III study on fingolimod in 1,083 patients (n=358 on 0.5 mg, 370 on 1.25 mg, 355 on placebo) with RRMS (D2309; FREEDOMS 2). Median values for baseline characteristics were: age 41 years, disease duration 8.9 years, EDSS score 2.5. Table 2: Study D2309 (FREEDOMS 2): Main results Fingolimod 0.5 mg Placebo Clinical endpoints     Annualised relapse rate (primary endpoint) 0.21** 0.40 Percentage of patients remaining relapse-free at 24 months 71.5%** 52.7% Proportion with 3-month Confirmed Disability Progression† 25% 29% Hazard ratio (95% CI) 0.83 (0.61, 1.12)   MRI endpoints     Median (mean) number of new or enlarging T2 lesions over 24 months 0.0 (2.3)** 4.0 (8.9) Median (mean) number of Gd-enhancing lesions at Month 24 0.0 (0.4)** 0.0 (1.2) Median (mean) % change in brain volume over 24 months -0.71 (-0.86)** -1.02 (-1.28) † Disability progression defined as 1-point increase in EDSS confirmed 3 months later ** p<0.001 compared to placebo All analyses of clinical endpoints were intent-to-treat. MRI analyses used evaluable dataset. Study D2302 (TRANSFORMS) was a 1-year randomised, double-blind, double-dummy, active (interferon beta-1a)-controlled Phase III study of 1,280 patients (n=429 on 0.5 mg, 420 on 1.25 mg, 431 on interferon beta-1a, 30 µg by intramuscular injection once weekly). Median values for baseline characteristics were: age 36 years, disease duration 5.9 years, and EDSS score 2.0. Outcome results are shown in Table 3. There were no significant differences between the 0.5 mg and the 1.25 mg doses as regards study endpoints. Table 3: Study D2302 (TRANSFORMS): Main results Fingolimod 0.5 mg Interferon beta-1a, 30 μg Clinical endpoints     Annualised relapse rate (primary endpoint) 0.16** 0.33 Percentage of patients remaining relapse-free at 12 months 83%** 71% Proportion with 3-month Confirmed Disability Progression† Hazard ratio (95% CI) 6% 0.71 (0.42, 1.21) 8% MRI endpoints     Median (mean) number of new or enlarging T2 lesions over 12 months 0.0 (1.7)* 1.0 (2.6) Median (mean) number of Gd-enhancing lesions at 12 months 0.0 (0.2)** 0.0 (0.5) Median (mean) % change in brain volume over 12 months -0.2 (-0.3)** -0.4 (-0.5) Patients who completed the 12-month core TRANSFORMS study could enter a dose-blinded extension (D2302E1) and receive fingolimod. In total, 1,030 patients entered, however, 3 of these patients did not receive treatment (n=356 continued on 0.5 mg, 330 continued on 1.25 mg, 167 switched from interferon beta-1a to 0.5 mg and 174 from interferon beta-1a to 1.25 mg). After 12 months (month 24), 882 patients (86%) were still enrolled. Between months 12 and 24, the ARR for patients on fingolimod 0.5 mg in the core study who remained on 0.5 mg was 0.20 (0.19 in the core study). The ARR for patients who switched from interferon beta-1a to fingolimod 0.5 mg was 0.33 (0.48 in the core study). Pooled results of Studies D2301 and D2302 showed a consistent and statistically significant reduction in annualised relapse rate compared to comparator in subgroups defined by gender, age, prior multiple sclerosis therapy, disease activity or disability levels at baseline. Further analyses of clinical trial data demonstrate consistent treatment effects in highly active subgroups of relapsing remitting multiple sclerosis patients. The European Medicines Agency has deferred the obligation to submit the results of studies with Gilenya in one or more subsets of the paediatric population in multiple sclerosis (see section 4.2 for information on paediatric use). 5.2 Pharmacokinetic properties Pharmacokinetic data were obtained in healthy volunteers, in renal transplant patients and in multiple sclerosis patients. The pharmacologically active metabolite responsible for efficacy is fingolimod phosphate. Absorption Fingolimod absorption is slow (tmax of 12-16 hours) and extensive (≥85%). The apparent absolute oral bioavailability is 93% (95% confidence interval: 79-111%). Steady-state-blood concentrations are reached within 1 to 2 months following once-daily administration and steady-state levels are approximately 10-fold greater than with the initial dose. Food intake does not alter Cmax or exposure (AUC) of fingolimod. Fingolimod phosphate Cmax was slightly increased by 34% but AUC was unchanged. Therefore, Gilenya may be taken without regard to meals (see section 4.2). Distribution Fingolimod highly distributes in red blood cells, with the fraction in blood cells of 86%. Fingolimod phosphate has a smaller uptake in blood cells of <17%. Fingolimod and fingolimod phosphate are highly protein bound (>99%). Fingolimod is extensively distributed to body tissues with a volume of distribution of about 1,200±260 litres. Biotransformation Fingolimod is transformed in humans by reversible stereoselective phosphorylation to the pharmacologically active (S)-enantiomer of fingolimod phosphate. Fingolimod is eliminated by oxidative biotransformation mainly via the cytochrome P450 4F2 isoenzyme and subsequent fatty acid-like degradation to inactive metabolites, and by formation of pharmacologically inactive non-polar ceramide analogues of fingolimod. The main enzyme involved in the metabolism of fingolimod is partially identified and may be either CYP4F2 or CYP3A4. Following single oral administration of [14C] fingolimod, the major fingolimod-related components in blood, as judged from their contribution to the AUC up to 34 days post dose of total radiolabelled components, are fingolimod itself (23%), fingolimod phosphate (10%), and inactive metabolites (M3 carboxylic acid metabolite (8%), M29 ceramide metabolite (9%) and M30 ceramide metabolite (7%)). Elimination Fingolimod blood clearance is 6.3±2.3 l/h, and the average apparent terminal half-life (t1/2) is 6-9 days. Blood levels of fingolimod and fingolimod phosphate decline in parallel in the terminal phase, leading to similar half-lives for both. After oral administration, about 81% of the dose is slowly excreted in the urine as inactive metabolites. Fingolimod and fingolimod phosphate are not excreted intact in urine but are the major components in the faeces, with amounts representing less than 2.5% of the dose each. After 34 days, the recovery of the administered dose is 89%. Linearity Fingolimod and fingolimod phosphate concentrations increase in an apparently dose proportional manner after multiple once-daily doses of 0.5 mg or 1.25 mg. Characteristics in specific groups of patients The pharmacokinetics of fingolimod and fingolimod phosphate do not differ in males and females, in patients of different ethnic origin, or in patients with mild to severe renal impairment. In subjects with mild, moderate, or severe hepatic impairment (Child-Pugh class A, B, and C), no change in fingolimod Cmax was observed, but fingolimod AUC was increased respectively by 12%, 44%, and 103%. In patients with severe hepatic impairment (Child-Pugh class C), fingolimod-phosphate Cmax was decreased by 22% and AUC was not substantially changed. The pharmacokinetics of fingolimod-phosphate were not evaluated in patients with mild or moderate hepatic impairment. The apparent elimination half-life of fingolimod is unchanged in subjects with mild hepatic impairment, but is prolonged by about 50% in patients with moderate or severe hepatic impairment. Fingolimod should not be used in patients with severe hepatic impairment (Child-Pugh class C) (see section 4.3). Fingolimod should be introduced cautiously in mild and moderate hepatic impaired patients (see section 4.2). Clinical experience and pharmacokinetic information in patients aged above 65 years are limited. Gilenya should be used with caution in patients aged 65 years and over (see section 4.2). Paediatric population There are limited data available from a renal transplant study that included 7 children above 11 years of age (study FTY720A0115). The comparison of these data to those in adult healthy volunteers is of limited relevance and no valid conclusions can be drawn regarding the pharmacokinetic properties of fingolimod in children. 5.3 Preclinical safety data The preclinical safety profile of fingolimod was assessed in mice, rats, dogs and monkeys. The major target organs were the lymphoid system (lymphopenia and lymphoid atrophy), lungs (increased weight, smooth muscle hypertrophy at the bronchio-alveolar junction), and heart (negative chronotropic effect, increase in blood pressure, perivascular changes and myocardial degeneration) in several species; blood vessels (vasculopathy) in rats only at doses of 0.15 mg/kg and higher in a 2-year study, representing an approximate 4-fold margin based on the human systemic exposure (AUC) at a daily dose of 0.5 mg. No evidence of carcinogenicity was observed in a 2-year bioassay in rats at oral doses of fingolimod up to the maximally tolerated dose of 2.5 mg/kg, representing an approximate 50-fold margin based on human systemic exposure (AUC) at the 0.5 mg dose. However, in a 2-year mouse study, an increased incidence of malignant lymphoma was seen at doses of 0.25 mg/kg and higher, representing an approximate 6-fold margin based on the human systemic exposure (AUC) at a daily dose of 0.5 mg. Fingolimod was neither mutagenic nor clastogenic in animal studies. Fingolimod had no effect on sperm count/motility or on fertility in male and female rats up to the highest dose tested (10 mg/kg), representing an approximate 150-fold margin based on human systemic exposure (AUC) at a daily dose of 0.5 mg. Fingolimod was teratogenic in the rat when given at doses of 0.1 mg/kg or higher. The most common foetal visceral malformations included persistent truncus arteriosus and ventricular septum defect. The teratogenic potential in rabbits could not be fully assessed, however an increased embryo-foetal mortality was seen at doses of 1.5 mg/kg and higher, and a decrease in viable foetuses as well as foetal growth retardation was seen at 5 mg/kg. In rats, F1 generation pup survival was decreased in the early postpartum period at doses that did not cause maternal toxicity. However, F1 body weights, development, behaviour, and fertility were not affected by treatment with fingolimod. Fingolimod was excreted in milk of treated animals during lactation. Fingolimod and its metabolites crossed the placental barrier in pregnant rabbits. Environmental Risk Assessment (ERA) A risk for the environment due to use of Gilenya by patients with relapsing multiple sclerosis is not expected. 6. Pharmaceutical particulars 6.1 List of excipients Capsule core: Magnesium stearate Mannitol Capsule shell: Yellow iron oxide (E172) Titanium dioxide (E171) Gelatin Printing ink: Shellac (E904) Dehydrated alcohol Isopropyl alcohol Butyl alcohol Propylene glycol Purified water Strong ammonia solution Potassium hydroxide Black iron oxide (E172) Yellow iron oxide (E172) Titanium dioxide (E171) Dimethicone 6.2 Incompatibilities Not applicable. 6.3 Shelf life 2 years 6.4 Special precautions for storage Do not store above 25°C. Store in the original package in order to protect from moisture 6.5 Nature and contents of container PVC/PVDC/aluminium blister packs containing 7 or 28 hard capsules or multipacks containing 84 (3 packs of 28) hard capsules. PVC/PVDC/aluminium perforated unit dose blister packs containing 7x 1 hard capsules. Not all pack sizes may be marketed.