Drug Description

Presentation

Indications

Idiopathic Parkinson's disease, in particular to shorten the 'off' period in patients who have previously been treated with immediate-release levodopa/decarboxylase inhibitors or with just levodopa and who showed motor fluctuations.

Experience with Lecado is limited in patients, who have not been previously treated with levodopa.

Adult Dosage

The daily dose of levodopa/carbidopa should be carefully determined. Patients should be monitored closely during the period of dose adjustment, especially with regard to the occurrence or exacerbation of nausea and abnormal involuntary movements, such as dyskinesia, chorea and dystonia. Blepharospasm could be an early sign of overdosing.

The pharmacokinetic properties of the prolonged-release tablets may be altered if the tablets are broken or chewed. Therefore the tablets must be swallowed whole.

Most other medicines, used to treat Parkinson's Disease, except for levodopa, can be continued during administration of levodopa/carbidopa. However their dosage may need to be adjusted.

Sudden withdrawal of Lecado therapy should be avoided wherever possible.

Since carbidopa prevents the reversal of levodopa effects caused by pyridoxine, Lecado can be administered to patients who receive supplemental pyridoxine (Vitamin B6).

• Starting dose

Patients who have never before received Levodopa therapy

Lecado 100/25 mg is designed for use in patients, who have not previously had levodopa treatment or to aid titration in patients who receive Lecado 200/50 mg. The recommended starting dose is one tablet 100/25 mg two times per day. In patients who need more levodopa a daily dose of three to four tablets of Lecado 100/25 mg is usually well tolerated.

For Lecado 200/500 mg the recommended starting dose is one tablet two times per day.

The starting dose should not be higher than 600 mg levodopa per day and the doses should be administered with minimum intervals of six hours.

Dose adjustments should occur with intervals of at least two to four days.

Depending of the severity of the disease, six months of treatment may be required to achieve optimal disease control.

Patients who are currently treated with just levodopa

Levodopa must be discontinued at least twelve hours before therapy with levodopa/carbidopa tablet is started.

In patients with a mild to moderate form of the disease the recommended starting dose is 200 mg levodopa / 50 mg carbidopa twice daily.

• Dose Adjustment

After the treatment is established the doses and the dose frequency can be increased or decreased depending on the therapeutic response. Most patients are adequately treated with 400 mg levodopa / 100 mg carbidopa to 1600 mg levodopa / 400 mg carbidopa per day, administered in divided doses at intervals ranging from four to twelve hours during the waking day. Higher doses (up to 2400 mg levodopa / 600 mg carbidopa) and shorter intervals (less than four hours) have been used, but are generally not recommended.

When doses of Lecado are given at intervals of less than four hours or if the divided doses are not equal, it is recommended to administer the lowest dose at the end of the day.

The effect of the first morning dose can be delayed in some patients for up to one hour compared to the usual reaction of the first morning dose of immediate-release Levodopa/Carbidopa.

Adjustments of the dosage should occur in intervals of at least three days.

• Maintenance dose

Because Parkinson's Disease is progressive, periodic clinical check-ups are recommended and an adjustment of the dose schedule of Lecado may be needed.

• Addition of other anti-Parkinson medications

Anti-cholinergics, dopamine agonists and amantadine can be administered concomitantly with Lecado. It might be necessary to adjust the dose Lecado when these medications are added to an ongoing treatment of Lecado.

• Interruption of the therapy

Patients should be carefully observed in case of a sudden reduction of the dose or if it is necessary to discontinue treatment with Lecado, particularly in the patient who is receiving anti-psychotics.

If anaesthetic is necessary, the administration of Lecado can be continued as long as the patient is allowed to take oral medications. In case of a temporary interruption of the therapy, the usual dose can be administered as soon as the patient is able to take the oral medications.

•Use in Children

The safety in patients under 18 years of age has not been established

• Use in the elderly

There is a wide experience in the use of combinations of levodopa and carbidopa in elderly patients. The recommendations set out above reflect the clinical data derived from this experience.

• Use in renal/hepatic impairment

No dose adjustment is necessary.

Contra Indications

Lecado is contraindicated in:

- patients with a hypersensitivity to levodopa, carbidopa or any of the excipients

- patients with narrow-angle glaucoma

- patients with severe heart failure

- severe cardiac arrhythmia

- acute stroke.

Lecado should not be given, when administration of a sympathomimetics is contra-indicated.

Non-selective mono-amino-oxydase (MAO) inhibitors and selective MAO type A inhibitors are contra-indicated for concomitant use with Lecado. The administration of these inhibitors should have been discontinued at least two weeks before starting the treatment with Lecado. Lecado can be taken concomitantly with the recommended dose of an MAO inhibitor, which is selective for MAO type B (for instance selegiline-HCl)

Special Precautions

In patients who are treated with just levodopa, treatment should have been discontinued for at 12 hours before starting with the therapy of Lecado.

Based on the pharmacokinetic profile of Lecado the onset of effect in patients with early morning dyskinesia may be slower than with immediate-release levodopa/ carbidopa. The incidence of dyskinesia is greater during treatment with Lecado in patients with an advanced stage of motor fluctuations than it is with an immediate-release tablet with a combination levodopa/carbidopa (16.5% versus 12.2%).

Dyskinesia can occur in patients who previously were treated with just levodopa, because carbidopa makes it possible for more levodopa to reach the brain, which causes more dopamine to be formed. The occurrence of dyskinesia may make it necessary to reduce the dose.

Lecado can, just like levodopa, cause involuntary movements and mental disturbances. Patients with a history of severe involuntary movements or psychotic episodes when treated with levodopa alone or with carbidopa-levodopa combination should be observed carefully when Lecado is substituted. It is suspected that these reactions are the result of the increased dopamine in the brain after administration of levodopa, and the use of Lecado can cause a recurrence. It may be necessary to reduce the dose. All patients should be observed carefully for the development of depression with concomitant suicidal tendencies. Patients with past or current psychosis should be treated with caution.

Lecado should be discontinued when there is deterioration of any pre-exiting psychotic condition.

Levodopa has been associated with somnolence and episodes of sudden sleep onset. Sudden onset of sleep during daily activities, in some cases without awareness or warning signs, has been reported very rarely. Patients must be informed of this and advised to exercise caution while driving or operating machines during treatment with levodopa. Patients who have experienced somnolence or an episode of sudden sleep onset must refrain from driving or operating machines. A reduction of dosage or termination of therapy may be considered.

Lecado should be administered cautiously to patients with severe cardiovascular or pulmonary disease, bronchial asthma, renal, hepatic or endocrine disease or with a history of peptic ulcer disease, haematemesis or of convulsions.

Levodopa/Carbidopa should be administered cautiously to patients who have had a recent myocardial infarction, who have residual atrial, nodal or ventricular arrhythmia. In such patients cardiac function should be monitored with particular care during the period of initial dosage administration and titration.

Patients with chronic wide-angle glaucoma may be treated cautiously with Lecado provided the intraocular pressure is well controlled and the patient is monitored carefully for changes in eye pressure during the therapy.

A symptom complex resembling the neuroleptic malignant syndrome, including muscular rigidity, increased body temperature, mental changes and increased serum creatine phosphokinase, has been reported when anti Parkinsonian medication was withdrawn abruptly. Therefore patients should be carefully observed when the dose of carbidopa/levodopa combinations is abruptly reduced or discontinued, especially if the patient is receiving anti-psychotics.

The use of levodopa/carbidopa is not advised during treatment for pharmacogenic extra-pyramidal reactions or Huntington's chorea.

Periodic evaluation of hepatic, haematopoietic, cardiovascular and renal function are recommended during extended therapy.

The safety and efficacy of Lecado has not been determined in infants and children and use in patients under the age of eighteen is not advised.

Pathological gambling, increased libido and hypersexuality have been reported in patients treated with dopamine agonists for Parkinson's disease, including Lecado.

Patients with Parkinson's disease show a possible increased risk of melanoma, but no confirmed association with levodopa therapy has been established.. Therefore caution should be exercised during treatment.

Laboratory tests

Carbidopa/levodopa preparations had given rise to abnormalities in several laboratory tests and these can also occur with Lecado. These include elevations of liver function tests, such as alkaline phosphatase, SGOT, SGPT, lactic acid dehydrogenase, bilirubin, blood urea nitrogen and a positive Coombs test.

Decreased haemoglobin and haematocrit, elevated serum glucose and white blood cells, bacteria and blood in the urine have also been reported with Levodopa/Carbidopa.

When a test strip is used to determine ketonuria, carbidopa/levodopa preparations can show a false positive result for urinary ketone bodies. This reaction is not altered by boiling the urine sample. False negative results can also occur in the examination of glycosuria with the use of glucose oxidase methods.

Interactions

Caution is needed in concomitant administration of Lecado with the following medicines:

Anti-hypertensives

Symptomatic orthostatic dysregulation has occurred when levodopa is added with a decarboxylase inhibitor to certain antihypertensives. Dose adjustment of antihypertensives may be necessary during the titration phase of treatment with Lecado.

Anti-depressants

There have been rare reports of adverse reactions, including hypertension and dyskinesia, resulting from the concomitant administration of tricyclic anti-depressants and carbidopa/levodopa preparations. (See section 4.3 for patients receiving mono-amine oxidase inhibitors).

Anti-cholinergics

Anti-cholinergics may act synergistically with levodopa to decrease tremor. However combined use may exacerbate abnormal involuntary movements. Anticholinergics may decrease the effects of levodopa by delaying its absorption. An adjustment of the dose of Levodopa/Carbidopa may be needed.

Other medicines

Dopamine-D2-receptor antagonists (for instance phenothiazines, butyrophenons, risperidone), benzodiazepines and isoniazide can reduce the therapeutic effect of levodopa. The beneficial effects of levodopa in Parkinson's disease may be reduced by phenytoin and papaverine. Patients taking these medications together with Lecado, should be observed carefully for loss of therapeutic response.

Concomitant use of selegiline and levodopa-carbidopa may be associated with severe orthostatic hypotension.

COMT inhibitors (tolcapone, entacapone)

Concomitant use of COMT (Catechol-O-Methyl Transferase) inhibitors and levodopa/carbidopa can increase the bioavailability of levodopa. The dose of levodopa/ carbidopa may possibly need adjusting.

Amantadine has a synergistic effect with levodopa and may increase levodopa-related side events. An adjustment of the dose of levodopa/carbidopa may be needed.

Metoclopramide increases gastric emptying and may increase the bioavailability of Lecado.

Sympathomimetics may increase cardiovascular side events related to levodopa

Concomitant use of ferrous sulphate and levodopa-carbidopa can lead to a reduction in the bioavailability of levodopa.

As levodopa competes with certain amino acids, the absorption of levodopa can be impaired in some patients who are on a protein rich diet.

The effect of administration of antacids and Lecado on the bioavailability of levodopa has not been studied.

Adverse Reactions

During controlled clinical studies in patients with moderate to severe motor fluctuations Lecado caused no side effects which were unique to the modified release formulation.

Blood and lymphatic system disorders

Rare (1/10,000 to <1/1,000): Leukopenia, haemolytic and non-haemolytic anaemia, thrombocytopenia

Very rare (<1/10,000): Agranulocytosis

Metabolism and nutrition disorders

Common (1/100 to < 1/10): Anorexia

Uncommon (1/1,000 to <1/100): Loss of weight, increased weight

Psychiatric disorders

Common (1/100 to < 1/10): Hallucinations, confusion, dizziness, nightmares, sleepiness, fatigue, sleeplessness, depression with very rare suicide attempts, euphoria, dementia, psychotic episodes, feeling of stimulation

Rare (1/10,000 to <1/1,000): Agitation, fear, reduced thinking capacity, disorientation, headache, increased libido, numbness, convulsions

Unknown frequency: Patients treated with dopamine agonists for treatment of Parkinson's disease, including Lecado 100/25 mg, especially at high doses, have been reported as exhibiting signs of pathological gambling, increased libido and hypersexuality, generally reversible upon reduction of the dose or treatment discontinuation.

Levodopa/carbidopa is associated with somnolence and has been associated very rarely with excessive daytime somnolence and sudden sleep onset episodes.

Nervous system disorders

Common (1/100 to < 1/10): Dyskinesia (a higher frequency of dyskinesia was seen with Lecado than with the immediate-release formulation of Levodopa/Carbidopa), chorea, dystonia, extrapyramidal and movement disorders, the “on-off”-appearance

Bradykinesia (on-off episodes) may appear some months to years after the beginning of treatment with levodopa and is probably related to the progression of the disease. The adaptation of dose schedule and dose intervals may be required.

Uncommon (1/1,000 to <1/100): Ataxia, increased tremor of the hands

Rare (1/10,000 to <1/1,000): Malignant neuroleptic syndrome, paraesthesia, falling, walking defects, trismus

Eye disorders

Rare (1/10,000 to <1/1,000): Hazy vision, blepharospasm, activation of a latent Horner's syndrome, double vision, dilated pupils, oculogyric crises

Blepharospasm can be an early sign of overdosage.

Cardiac disorders

Common (1/100 to < 1/10): Palpitations, irregular heartbeat

Vascular disorders

Common (1/100 to < 1/10): Orthostatic hypotension, inclination to faint, syncope

Uncommon (1/1,000 to <1/100): Hypertension

Rare (1/10,000 to <1/1,000): Phlebitis

Respiratory, thoracic and mediastinal disorders

Uncommon (1/1,000 to <1/100): Hoarseness, chest pain

Rare (1/10,000 to <1/1,000): Dyspnoea, abnormal breathing pattern

Gastrointestinal disorders

Common (1/100 to < 1/10): Nausea, vomiting, dry mouth, bitter taste

Uncommon (1/1,000 to <1/100): Constipation, diarrhoea, sialorrhoea, dysphagia, flatulence

Rare (1/10,000 to <1/1,000): Dyspepsia, gastro-intestinal pain, dark saliva, bruxism, hiccups, gastrointestinal bleeding, burning sensation of the tongue, duodenal ulceration

Skin and subcutaneous tissue disorders

Uncommon (1/1,000 to <1/100): Oedema

Rare (1/10,000 to <1/1,000): Angioedema, urticaria, pruritus, facial redness, hair loss, exanthema, increased perspiration, dark perspiration fluid, Schönlein-Henoch purpura

Musculoskeletal, connective tissue and bone disorders

Uncommon (1/1,000 to <1/100): Muscle spasms

Renal and urinary disorders

Uncommon (1/1,000 to <1/100): Dark urine

Rare (1/10,000 to <1/1,000): Urinary retention, urinary incontinence, priapism

General disorders and administration site conditions

Uncommon (1/1,000 to <1/100): Weakness, malaise, flare ups

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