复方新药阿地溴铵/富马酸福莫特罗吸入干粉 Duaklir Genuair(aclidinium bromide/formoterol fumarate inhalation powder)为慢性阻塞性肺病(COPD)患者改善肺功能症状. 近日，慢性阻塞性肺病(COPD)复方新药Duaklir Genuair(阿地溴铵/富马酸福莫特罗，340/12mcg)获得欧盟批准，用作一种维持性支气管扩张剂，以减轻COPD成人患者的疾病症状。 Duaklir Genuair是由2种已上市的长效支气管扩张剂组成的固定剂量复方药物，其中，bromide(阿地溴铵)是一种新颖的长效毒蕈碱拮抗剂(LAMA)，formoterol fumarate(富马酸福莫特罗)是一种长效β2受体激动剂(LABA)。Duaklir Genuair通过干粉吸入器Genuair给药，每日2次，是首个与单药相比使呼吸喘促表现出统计学意义显著改善的LAMA/LABA复方药。 据估计，目前全球范围内大约有3亿慢性阻塞性肺病(COPD)患者，改善肺功能及管理日常症状(如喘促气短)对于COPD的临床管理非常重要。 Duaklir Genuair 340micrograms /12micrograms inhalation powder 1. Name of the medicinal product Duaklir Genuair 340micrograms /12micrograms inhalation powder 2. Qualitative and quantitative composition Each delivered dose (the dose leaving the mouthpiece) contains 396 micrograms of aclidinium bromide (equivalent to 340 micrograms of aclidinium) and 11.8 micrograms of formoterol fumarate dihydrate. This corresponds to a metered dose of 400 micrograms of aclidinium bromide (equivalent to 343 micrograms of aclidinium) and a metered dose of 12 micrograms of formoterol fumarate dihydrate. Excipients with known effect: Each delivered dose contains approximately 11 mg lactose (as monohydrate). For the full list of excipients, see section 6.1. 3. Pharmaceutical form Inhalation powder. White or almost white powder in a white inhaler with an integral dose indicator and a turquoise dosage button. 4. Clinical particulars 4.1 Therapeutic indications Duaklir Genuair is indicated as a maintenance bronchodilator treatment to relieve symptoms in adult patients with chronic obstructive pulmonary disease (COPD). 4.2 Posology and method of administration Posology The recommended dose is one inhalation of Duaklir Genuair 340 micrograms /12 micrograms twice daily. If a dose is missed, it should be taken as soon as possible and the next dose should be taken at the usual time. A double dose should not be taken to make up for a forgotten dose. Elderly population No dose adjustments are required in elderly patients (see section 5.2). Renal impairment No dose adjustments are required in patients with renal impairment (see section 5.2). Hepatic impairment No dose adjustments are required in patients with hepatic impairment (see section 5.2). Paediatric population There is no relevant use of Duaklir Genuair in children and adolescents (under 18 years of age) in the indication of COPD. Method of administration For inhalation use. Patients should be instructed on how to administer the product correctly. For detailed instructions, please refer to the patient leaflet. Patients should be advised to carefully read them. Overview of the instructions for use of Duaklir Genuair To use the Genuair inhaler there are 2 steps patients need to perform after removing the cap. Patients should hold the Genuair inhaler horizontally with the mouthpiece towards them and the turquoise button facing straight up. STEP 1: Patients should PRESS the turquoise button all the way down (image 1) and then RELEASE it (image 2). Remind patients NOT TO CONTINUE TO HOLD THE TURQUOISE BUTTON DOWN. Patients should check that the control window is green. It means the inhaler is ready to use (image 3). IF THE COLOURED CONTROL WINDOW IS RED, PATIENTS SHOULD REPEAT PRESS AND RELEASE ACTIONS (SEE STEP 1). STEP 2: Patients should inhale STRONGLY and DEEPLY through the mouthpiece (image 4). Patients should keep breathing in, even after they have heard the inhaler "click". • Patients should check that the control window has turned to red from green, which indicates they have inhaled correctly (image 5). IF THE COLOURED CONTROL WINDOW IS STILL GREEN, PATIENTS SHOULD REPEAT INHALING STRONGLY AND DEEPLY THROUGH THE MOUTHPIECE (SEE STEP 2). Remind patients that after removing the Genuair inhaler from their mouth they should hold their breath for as long as is comfortable, then breathe out slowly through their nose. After inhalation, patients should remember to replace the protective cap. Some patients may experience a mild sweet or slightly bitter taste, depending on the patient, when inhaling the medicinal product. The patient should not take an extra dose if they do not taste anything after inhaling. The Genuair inhaler has a dose indicator to show approximately how many doses are left in the inhaler. Every Genuair inhaler will deliver at least 60 doses. When a red striped band appears in the dose indicator, this means the last dose is coming up and a new Genuair inhaler should be obtained. When the last dose has been prepared for inhalation, the turquoise button will not return to its full upper position, but will be locked in a middle position. The last dose may still be inhaled, but after that the Genuair inhaler cannot be used again and the patient should start using a new Genuair inhaler. The Genuair inhaler does not require cleaning but if necessary the outside of the mouthpiece may be wiped with a dry tissue or paper towel. Remind the patient NEVER to use water to clean the Genuair inhaler, as this may damage the medicinal product. 4.3 Contraindications Hypersensitivity to the active substances or to the excipient listed in section 6.1. 4.4 Special warnings and precautions for use Asthma Duaklir Genuair should not be used in asthma; clinical studies of Duaklir Genuair in asthma have not been conducted. Paradoxical bronchospasm In clinical studies, paradoxical bronchospasm was not observed with Duaklir Genuair at its recommended dose. However, paradoxical bronchospasm has been observed with other inhalation therapies. If this occurs, medicinal product should be stopped and other treatment will be considered. Not for acute use Duaklir Genuair is not indicated for the treatment of acute episodes of bronchospasm. Cardiovascular effects Patients with a myocardial infarction during the previous 6 months, unstable angina, newly diagnosed arrhythmia within the previous 3 months, QTc (Bazett's method) above 470 msec, or hospitalisation within the previous 12 months for heart failure functional classes III and IV as per the “New York Heart Association” were excluded from the clinical studies, therefore Duaklir Genuair should be used with caution in these patients groups. β2-adrenergic agonists may produce increases in pulse rate and blood pressure, electrocardiogram (ECG) changes such as T wave flattening, ST segment depression and prolongation of the QTc-interval in some patients. In case such effects occur, treatment may need to be discontinued. Long-acting β2-adrenergic agonists should be used with caution in patients with history of or known prolongation of the QTc-interval or treated with medicinal products affecting the QTc interval (see section 4.5). Systemic effect Duaklir Genuair should be used with caution in patients with severe cardiovascular disorders, convulsive disorders, thyrotoxicosis and phaeochromocytoma. Metabolic effects of hyperglycaemia and hypokalaemia may be observed with high doses of β2-adrenergic agonists. In Phase III clinical studies, the frequency of notable increases in blood glucose with Duaklir Genuair was low (0.1%) and similar to placebo. Hypokalaemia is usually transient, not requiring supplementation. In patients with severe COPD, hypokalaemia may be potentiated by hypoxia and concomitant treatment (see section 4.5). Hypokalaemia increases susceptibility to cardiac arrhythmias. Due to its anticholinergic activity, Duaklir Genuair should be used with caution in patients with symptomatic prostatic hyperplasia, urinary retention or narrow-angle glaucoma (even though direct contact of the product with the eyes is very unlikely). Dry mouth, which has been observed with anticholinergic treatment, may in the long term be associated with dental caries. Excipients Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine. 4.5 Interaction with other medicinal products and other forms of interaction COPD medicinal products Co-administration of Duaklir Genuair with other anticholinergic and/or long-acting β2-adrenergic agonist containing medicinal products has not been studied and is not recommended. Although no formal in vivo drug interaction studies have been performed with Duaklir Genuair, it has been used concomitantly with other COPD medicinal products including short-acting β2-adrenergic bronchodilators, methylxanthines, and oral and inhaled steroids without clinical evidence of drug interactions. Metabolic interactions In vitro studies have shown that aclidinium or its metabolites at the therapeutic dose are not expected to cause interactions with P-glycoprotein (P-gp) substrate drugs or drugs metabolised by cytochrome P450 (CYP450) enzymes and esterases. Formoterol does not inhibit the CYP450 enzymes at therapeutically relevant concentrations (see section 5.2). Hypokalaemic treatment Concomitant treatment with methylxanthine derivatives, steroids, or non-potassium-sparing diuretics may potentiate the possible hypokalaemic effect of β2-adrenergic agonists, therefore caution is advised in their concomitant use (see section 4.4). β-adrenergic blockers β -adrenergic blockers may weaken or antagonise the effect of β2-adrenergic agonists. If β-adrenergic blockers are required (including eye drops), cardioselective beta-adrenergic blockers are preferred, although they should also be administered with caution. Other pharmacodynamic interactions Duaklir Genuair should be administered with caution to patients being treated with medicinal products known to prolong the QTc interval such as monoamine oxidase inhibitors, tricyclic antidepressants, antihistamines or macrolides because the action of formoterol, a component of Duaklir Genuair, on the cardiovascular system may be potentiated by these medicinal products. Medicinal products that are known to prolong the QTc interval are associated with an increased risk of ventricular arrhythmias. 4.6 Fertility, pregnancy and lactation Pregnancy There are no data available on the use of Duaklir Genuair in pregnant women. Studies in animals have shown fetotoxicity only at dose levels much higher than the maximum human exposure to aclidinium and adverse effects in reproduction studies with formoterol at very high systemic exposure levels (see section 5.3). Duaklir Genuair should only be used during pregnancy if the expected benefits outweigh the potential risks. Breast-feeding It is unknown whether aclidinium (and/or its metabolites) or formoterol are excreted in human milk. As studies in rats have shown excretion of small amounts of aclidinium (and/or its metabolites) and formoterol into milk, the use of Duaklir Genuair by breast-feeding women should only be considered if the expected benefit to the woman is greater than any possible risk to the infant. Fertility Studies in rats have shown slight reductions in fertility only at dose levels much higher than the maximum human exposure to aclidinium and formoterol (see section 5.3). Nevertheless, it is considered unlikely that Duaklir Genuair administered at the recommended dose will affect fertility in humans. 4.7 Effects on ability to drive and use machines Duaklir Genuair has no or negligible influence on the ability to drive and use machines. The occurrence of blurred vision or dizziness may influence the ability to drive or to use machines. 4.8 Undesirable effects The presentation of the safety profile is based on the experience with Duaklir Genuair and the individual components. Summary of the safety profile The safety experience with Duaklir Genuair comprised exposure at the recommended therapeutic dose for up to 12 months. Adverse reactions associated with Duaklir Genuair were similar to those of the individual components. As Duaklir Genuair contains aclidinium and formoterol, the type and severity of adverse reactions associated with each of the components may be expected with Duaklir Genuair. The most frequently reported adverse reactions with Duaklir Genuair were nasopharyngitis (7.9%) and headache (6.8%). Tabulated summary of adverse reactions The Duaklir Genuair clinical development programme was conducted in patients with moderate or severe COPD. A total of 1222 patients were treated with Duaklir Genuair 340 micrograms /12 micrograms. The frequencies assigned to the adverse reactions are based on crude incidence rates observed with Duaklir Genuair 340 micrograms /12 micrograms in the pooled analysis of randomised, placebo-controlled Phase III clinical studies of at least six months duration. The frequency of adverse reactions is 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) and not known (cannot be estimated from available data). System organ class Preferred term Frequency Infectious and infestations Nasopharyngitis3 Urinary tract infection1 Sinusitis2 Tooth abscess1 Common Immune system disorders Hypersensitivity4 Rare Angioedema4 Not known Metabolism and nutrition disorders Hypokalaemia3 Uncommon Hyperglycaemia3 Uncommon Psychiatric disorders Insomnia2 Anxiety2 Common Agitation3 Uncommon Nervous system disorders Headache3 Dizziness3 Tremor2 Common Dysgeusia3 Uncommon Eye disorders Blurred vision2 Uncommon Cardiac disorders Tachycardia2 Electrocardiogram QTc prolonged2 Palpitations3 Uncommon Respiratory, Thoracic and mediastinal disorders Cough3 Common Dysphonia2 Throat irritation3 Uncommon Bronchospasm, including paradoxical4 Rare Gastrointestinal disorders Diarrhoea3 Nausea3 Dry mouth2 Common Skin and subcutaneous tissue disorders Rash3 Pruritus3 Uncommon Musculoskeletal and connective tissue disorders Myalgia2 Muscle spasms2 Common Renal and urinary disorders Urinary retention3 Uncommon General disorders and administration site conditions Oedema peripheral3 Common Investigations Blood creatine phosphokinase increased1 Common Blood pressure increased3 Uncommon 1 Adverse reactions observed with Duaklir Genuair, but not reported in the SmPC of the individual components 2 Adverse reactions observed with Duaklir Genuair and reported in the SmPC of at least one of the individual components 3 Adverse reactions reported in the SmPC of at least one of the individual components, but reported with Duaklir Genuair 340/12 micrograms at an incidence lower than or comparable to that of placebo. 4 Adverse reactions reported in the SmPC of at least one of the individual components, but not observed with Duaklir Genuair 340/12 micrograms; frequency category according to section 4.8 of Summary of Product Characteristics of the individual components. Reporting of suspected adverse reactions Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions (see details below): United Kingdom Yellow Card Scheme, Website: www.mhra.gov.uk/yellowcard Ireland HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2, Tel: +353 1 6764971, Fax: +353 1 6762517, Website: www.hpra.ie, e-mail: medsafety@hpra.ie 4.9 Overdose There is limited evidence on the management of overdose with Duaklir Genuair. High doses of Duaklir Genuair may lead to exaggerated anticholinergic and/or β2-adrenergic signs and symptoms; the most frequent of which include blurred vision, dry mouth, nausea, muscle spasm, tremor, headache, palpitations and hypertension. DUAKLIR Genuair should be discontinued in case of overdose. Supportive and symptomatic treatment is indicated. 5. Pharmacological properties 5.1 Pharmacodynamic properties Pharmacotherapeutic group: Drugs for obstructive airway diseases, adrenergics in combination with anticholinergics, ATC code: R03AL05 Mechanism of action Duaklir Genuair contains two bronchodilators: aclidinium is a long-acting muscarinic antagonist (also known as an anticholinergic) and formoterol is a long-acting β2-adrenergic agonist. The combination of these substances with different mechanisms of action results in additive efficacy compared to that achieved with either component alone. As a consequence of the differential density of muscarinic receptors and β2-adrenoceptors in the central and peripheral airways of the lung, muscarinic antagonists should be more effective in relaxing central airways and β2-adrenergic agonists should be more effective in relaxing peripheral airways; relaxation of both central and peripheral airways with combination treatment may contribute to its beneficial effects on lung function. Further information regarding these two substances is provided below. Aclidinium is a competitive, selective muscarinic receptor antagonist, with a longer residence time at the M3 receptors than the M2 receptors. M3 receptors mediate contraction of airway smooth muscle. Inhaled aclidinium bromide acts locally in the lungs to antagonise M3 receptors of airway smooth muscle and induce bronchodilation. Aclidinium has also been shown to provide benefits to patients with COPD in terms of symptoms reduction, improvement in disease-specific health status, reduction in exacerbation rates and improvements in exercise tolerance. Since aclidinium bromide is quickly broken down in plasma, the level of systemic anticholinergic undesirable effects is low. Formoterol is a potent selective β2-adrenoceptor agonist. Bronchodilation is induced by causing direct relaxation of airway smooth muscle as a consequence of the increase in cyclic AMP through activation of adenylate cyclase. In addition to improving pulmonary function, formoterol has been shown to improve symptoms and quality of life in patients with COPD. Pharmacodynamic effects Clinical efficacy studies showed that Duaklir Genuair provides clinically meaningful improvements in lung function (as measured by the forced expiratory volume in 1 second [FEV1]) over 12 hours following administration. Duaklir Genuair demonstrated a rapid onset of action within 5 minutes of the first inhalation relative to placebo (p<0.0001). The onset of action of Duaklir Genuair was comparable to the effect of the fast-acting β2-agonist formoterol 12 micrograms. Maximal bronchodilator effects (peak FEV1) relative to baseline were evident from day one (304 ml) and were maintained over the 6-month treatment period (326 ml). Cardiac electrophysiology No clinically relevant effects of Duaklir Genuair on ECG parameters (including QT-interval) compared with aclidinium, formoterol and placebo were seen in Phase III studies of 6 to 12 months duration conducted in approximately 4,000 patients with COPD. No clinically significant effects of Duaklir Genuair on cardiac rhythm were observed on 24-hour Holter monitoring in a subset of 551 patients, of whom 114 received Duaklir Genuair twice daily. Clinical Efficacy and Safety The Phase III clinical development programme included approximately 4,000 patients with a clinical diagnosis of COPD and comprised two 6-month randomised, placebo- and active-controlled studies (ACLIFORM-COPD and AUGMENT), a 6-month extension of the AUGMENT study and a further 12-month randomised controlled study. During these studies, patients were permitted to continue their stable treatment with inhaled corticosteroids, low doses of oral corticosteroids, oxygen therapy (if less than 15h/day) or methylxanthines and to use salbutamol as rescue medication. Efficacy was assessed by measures of lung function, symptomatic outcomes, disease-specific health status, rescue medication use, and exacerbations. In long-term safety studies, Duaklir Genuair was associated with sustained efficacy when administered over a one-year treatment period with no evidence of tachyphylaxis. Effects on lung function Duaklir Genuair 340/12 micrograms twice daily consistently provided clinically meaningful improvements in lung function (as assessed by FEV1, forced vital capacity and inspiratory capacity) compared with placebo. In Phase III studies, clinically meaningful bronchodilator effects were seen within 5 minutes of the first dose and were maintained over the dosing interval. There was a sustained effect over time in the six months and one year Phase III studies. FEV1 at 1 hour post-dose and trough FEV1 (compared to aclidinium 400 micrograms and formoterol 12 micrograms, respectively) were defined as co-primary endpoints in both 6-month pivotal Phase III studies to demonstrate the bronchodilator contributions of formoterol and aclidinium in Duaklir Genuair, respectively. In study ACLIFORM-COPD, Duaklir Genuair showed improvements in FEV1 at 1 hour post-dose relative to placebo and aclidinium of 299 ml and 125 ml, respectively (both p<0.0001) and improvements in trough FEV1 relative to placebo and formoterol of 143 ml and 85 ml, respectively (both p<0.0001). In study AUGMENT, Duaklir Genuair showed improvements in FEV1 at 1 hour post-dose relative to placebo and aclidinium of 284 ml and 108 ml (both p<0.0001), respectively, and improvements in trough FEV1 relative to placebo and formoterol of 130 ml (p<0.0001) and 45 ml (p=0.01), respectively. Symptom relief and disease-specific health status benefits Breathlessness and other symptomatic outcomes: Duaklir Genuair provided a clinically meaningful improvement in breathlessness (assessed by the Transition Dyspnoea Index [TDI]) with an improvement in the TDI focal score at 6 months compared to placebo of 1.29 units in study ACLIFORM-COPD (p<0.0001) and 1.44 units in study AUGMENT (p<0.0001). The percentages of patients with clinically meaningful improvements in TDI focal score (defined as an increase of at least 1 unit) were higher with Duaklir Genuair than with placebo in ACLIFORM-COPD (64.8% compared to 45.5%; p<0.001) and AUGMENT (58.1% compared to 36.6%; p<0.0001). The pooled analysis of these two studies showed Duaklir Genuair to be associated with statistically significantly greater improvements in TDI focal score compared to aclidinium (0.4 units, p=0.016) or formoterol (0.5 units, p=0.009). In addition, a higher percentage of patients receiving Duaklir Genuair responded with a clinically meaningful improvement in TDI focal score compared to either aclidinium or formoterol (61.9% compared to 55.7% and 57.0%, respectively; p=0.056 and p=0.100, respectively). Duaklir Genuair improved daily symptoms of COPD such as 'breathlessness', 'chest symptoms', 'cough and sputum' (assessed by E-RS total score) as well as overall night-time symptoms, overall early morning symptoms and symptoms limiting early morning activities compared to placebo, aclidinium and formoterol but the improvements were not always statistically significant. Aclidinium/formoterol did not statistically significantly reduce the average number of night-time awakenings due to COPD compared with placebo or formoterol. Health-related quality of life: Duaklir Genuair provided a clinically meaningful improvement in disease-specific health status (as assessed by the St. George's Respiratory Questionnaire [SGRQ]) in study AUGMENT, with an improvement in the SGRQ total score compared to placebo of -4.35 units (p<0.0001). The percentage of patients in AUGMENT who achieved a clinically meaningful improvement from baseline in SGRQ total score (defined as a decrease of at least 4 units) was higher with Duaklir Genuair than with placebo (58.2% compared to 38.7%, respectively; p<0.001). In study ACLIFORM-COPD, only a small decrease in SGRQ total score compared to placebo was observed due to an unexpectedly large placebo response (p=0.598) and the percentages of patients who achieved clinically meaningful improvements from baseline were 55.3% with Duaklir Genuair and 53.2% with placebo (p=0.669). In the pooled analysis of these two studies, Duaklir Genuair showed greater improvements in SGRQ total score compared to formoterol (-1.7 units; p=0.018) or aclidinium (-0.79 units, p=0.273). In addition, a higher percentage of patients receiving Duaklir Genuair responded with a clinically meaningful improvement in SGRQ total score compared to aclidinium and formoterol (56.6% compared to 53.9% and 52.2%, respectively; p=0.603 and p=0.270, respectively). COPD exacerbation reductions Pooled efficacy analysis of the two 6-month Phase III studies demonstrated a statistically significant reduction of 29% in the rate of moderate or severe exacerbations (requiring treatment with antibiotics or corticosteroids or resulting in hospitalisations) with Duaklir Genuair compared to placebo (rates per patient per year: 0.29 vs. 0.42, respectively; p=0.036). In addition, Duaklir Genuair statistically significantly delayed the time to first moderate or severe exacerbation compared to placebo (hazard ratio=0.70; p=0.027). Use of rescue medication Duaklir Genuair reduced the use of rescue medication over 6 months compared to placebo (by 0.9 puffs per day [p<0.0001]), aclidinium (by 0.4 puffs/day [p<0.001]) and formoterol (by 0.2 puffs/day [p=0.062]). Paediatric population The European Medicines Agency has waived the obligation to submit the results of studies with Duaklir Genuair in all subsets of the paediatric population in COPD (see section 4.2 for information on paediatric use). 5.2 Pharmacokinetic properties When aclidinium and formoterol were administered in combination by the inhaled route, the pharmacokinetics of each component showed no relevant differences from those observed when the medicinal products were administered separately. Absorption Following inhalation of a single dose of Duaklir Genuair 340/12 micrograms, aclidinium and formoterol were rapidly absorbed into plasma, reaching peak plasma concentrations within 5 minutes of inhalation in healthy subjects and within 24 minutes of inhalation in patients with COPD. The peak plasma concentrations at steady state of aclidinium and formoterol observed in patients with COPD treated with Duaklir Genuair twice daily for 5 days were reached within 5 minutes post-inhalation and were 128 pg/ml and 17 pg/ml, respectively. Distribution Whole lung deposition of inhaled aclidinium via Genuair averaged approximately 30% of the metered dose. The plasma protein binding of aclidinium determined in vitro most likely corresponded to the protein binding of the metabolites due to the rapid hydrolysis of aclidinium in plasma; plasma protein binding was 87% for the carboxylic acid metabolite and 15% for the alcohol metabolite. The main plasma protein that binds aclidinium is albumin. The plasma protein binding of formoterol is 61% to 64% (34% primarily to albumin). There is no saturation of binding sites in the concentration range reached with therapeutic doses. Biotransformation Aclidinium is rapidly and extensively hydrolysed to its pharmacologically inactive alcohol- and carboxylic acid-derivatives. Plasma levels of the acid metabolite are approximately 100-fold greater than those of the alcohol metabolite and the unchanged active substance following inhalation. The hydrolysis occurs both chemically (non-enzymatically) and enzymatically by esterases, butyrylcholinesterase being the main human esterase involved in the hydrolysis. The low absolute bioavailability of inhaled aclidinium (<5%) is because aclidinium undergoes extensive systemic and pre-systemic hydrolysis whether deposited in the lung or swallowed. Biotransformation via CYP450 enzymes plays a minor role in the total metabolic clearance of aclidinium. In vitro studies have shown that aclidinium at the therapeutic dose or its metabolites do not inhibit or induce any of the cytochrome P450 (CYP450) enzymes and do not inhibit esterases (carboxylesterase, acetylcholinesterase and butyrylcholinesterase). In vitro studies have shown that aclidinium or its metabolites are not substrates or inhibitors of P-glycoprotein. Formoterol is eliminated primarily by metabolism. The prominent pathway involves direct glucuronidation, with O-demethylation followed by glucuronide conjugation being a further metabolic pathway. Cytochrome P450 isoenzymes CYP2D6, CYP2C19, CYP2C9 and CYP2A6 are involved in the O-demethylation of formoterol. Formoterol does not inhibit CYP450 enzymes at therapeutically relevant concentrations. Elimination Following inhalation of Duaklir Genuair 340/12 micrograms , aclidinium and formoterol showed terminal elimination half-lives of approximately 5 h and 8 h, respectively. Following intravenous administration of radiolabelled aclidinium 400 micrograms to healthy subjects, approximately 1% of the dose was excreted as unchanged aclidinium bromide in the urine. Up to 65% of the dose was eliminated as metabolites in the urine and up to 33% as metabolites in the faeces. Following inhalation of aclidinium 200 micrograms and 400 micrograms by healthy subjects or patients with COPD, the urinary excretion of unchanged aclidinium was very low at about 0.1% of the administered dose, indicating that renal clearance plays a minor role in the total aclidinium clearance from plasma. The major part of a dose of formoterol is transformed by liver metabolism followed by renal elimination. After inhalation, 6% to 9% of the delivered dose of formoterol is excreted in the urine unchanged or as direct conjugates of formoterol. Special populations Elderly patients No pharmacokinetics studies have been performed with aclidinium/formoterol in elderly subjects. Since no dosage adjustments are needed for either aclidinium or formoterol medicinal products in elderly patients, no dosage adjustment is warranted for aclidinium/formoterol in geriatric patients. Renally and hepatically impaired patients There are no data regarding the specific use of aclidinium/formoterol in patients with renal or hepatic impairment. Since no dosage adjustments are needed for either aclidinium or formoterol medicinal products in patients with renal or hepatic impairment, no dosage adjustment is warranted for aclidinium/formoterol. 5.3 Preclinical safety data Nonclinical data reveal no special hazard for humans with aclidinium and formoterol based on conventional studies of safety pharmacology, repeated dose toxicity, genotoxicity, and carcinogenic potential and toxicity to reproduction and development. Effects of aclidinium in nonclinical studies with respect to reproductive toxicity (fetotoxic effects) and fertility (slight decreases in conception rate, number of corpora lutea, and pre- and post-implantation losses) were observed only at exposures considered sufficiently in excess of the maximum human exposure indication to be of little relevance to clinical use. Formoterol showed reduced fertility (implantation losses) in rats, as well as decreased early postnatal survival and birth weight with high systemic exposure to formoterol. A slight increase in the incidence of uterine leiomyomas has been observed in rats and mice; an effect which is considered to be a class-effect in rodents after long-term exposure to high doses of β2-adrenoreceptor agonists. Nonclinical studies investigating the effects of aclidinium/formoterol on cardiovascular parameters showed increased heart rates and arrhythmias at exposures sufficiently in excess of the maximum human exposure indication to be of little relevance to clinical use. These effects are known exaggerated pharmacological responses observed with β2-agonists. 6. Pharmaceutical particulars 6.1 List of excipients Lactose monohydrate. 6.2 Incompatibilities Not applicable. 6.3 Shelf life 3 years. To be used within 60 days of opening the pouch. 6.4 Special precautions for storage This medicinal product does not require any special temperature storage conditions. Keep the Genuair inhaler protected inside the sealed pouch until the administration period starts. 6.5 Nature and contents of container The Genuair inhaler is a multicomponent device made of plastic (polycarbonate, acrylonitrile-butadiene-styrene, polyoxymethylene, polyester-butylene-terephthalate, polypropylene, polystyrene) and stainless steel. It is white-coloured with an integral dose indicator and a turquoise dosage button. The mouthpiece is covered with a removable turquoise protective cap. The inhaler is supplied sealed in a protective aluminium laminate pouch containing a desiccant sachet, placed in a cardboard carton. Carton containing 1 inhaler with 60 doses. Carton containing 3 inhalers each with 60 doses. Not all pack sizes may be marketed. 6.6 Special precautions for disposal and other handling Any unused medicinal product or waste material should be disposed of in accordance with local requirements. For instructions for use please see section 4.2. 7. Marketing authorisation holder Almirall, S.A. Ronda General Mitre, 151 E-08022 Barcelona Spain Tel. +34 93 291 30 00 Fax +34 93 291 31 80 8. Marketing authorisation number(s) EU/1/14/964/001 EU/1/14/964/002 9. Date of first authorisation/renewal of the authorisation Date of first authorisation: 19 November 2014 10. Date of revision of the text Detailed information on this medicinal product is available on the website of the European Medicines Agency http://www.ema.europa.eu About Duaklir® Genuair® Duaklir Genuair (aclidinium bromide/formoterol fumarate 340/12 mcg) is a fixed dose combination of two approved long-acting bronchodilators with different mechanisms of action and similar pharmocodynamic profiles. Aclidinium bromide is an anticholinergic or long acting muscarinic antagonist (LAMA) that produces bronchodilation by inhibiting the muscarinic M3 receptor in the airway smooth muscle. Formoterol fumarate is a long-acting beta-agonist (LABA) that stimulates the β2-receptors in the bronchial smooth muscle resulting in bronchodilation. Both aclidinium bromide (Eklira®) and formoterol fumarate are separately approved for the maintenance treatment of COPD in the United States and Europe. AstraZeneca owns the rights for the development and commercialisation of Almirall’s proprietary respiratory business as well as its pipeline of investigational novel therapies. About Genuair® Genuair is a multi-dose, pre-loaded dry powder inhaler with a unique combination of optical and acoustic signals to reassure patients that the dose has been taken correctly. The inhaler’s safety features ensure high levels of reliability while its easy-to-use features and design minimise the potential for misuse and are expected to increase patient acceptance and compliance. About Phase III Studies AUGMENT and ACLIFORM The Phase III clinical development programme included approximately 4,000 patients with a clinical diagnosis of COPD. The programme comprised of two 6-month randomised, control- and active-controlled studies, ACLIFORM-COPD (LAC 30) - (ACLIdinium/FORMoterol fumarate combination for Investigative use in the treatment of moderate to severe COPD) and AUGMENT (LAC 31) - (Aclidinium/formoterol FUmurate Combination for InvestiGative use in the TreatMENT of Moderate to Severe COPD); a 6-month extension of the AUGMENT study (LAC 36); and a further long-term 12-month randomised controlled study comparing aclidinium/formoterol 340/12 to formoterol (LAC 32). About COPD Chronic obstructive pulmonary disease (COPD) is a progressive and chronic disease which encompasses a number of lung conditions, including chronic bronchitis, emphysema and chronic obstructive airways disease. People with COPD have difficulty breathing due to persistent airflow limitation.