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Product Monograph PRODUCT MONOGRAPH NSATIVEX delta-9-tetrahydrocannabinol 27mg/ml (from Tetranabinex - Cannabis sativa L. extract) and cannabidiol 25mg/ml (from Nabidiolex - Cannabis sativa L. extract) Buccal spray Cannabinoid Analgesic Standard marketing authorization: SATIVEX® is useful as adjunctive treatment for symptomatic relief of spasticity in adult patients with multiple sclerosis (MS) who have not responded adequately to other therapy and who demonstrate meaningful improvement during an initial trial of therapy. Marketing authorization with conditions: SATIVEX® may be useful as adjunctive treatment for the symptomatic relief of neuropathic pain in adult patients with multiple sclerosis. Marketing authorization with conditions: SATIVEX® may be useful as adjunctive analgesic treatment in adult patients with advanced cancer who experience moderate to severe pain during the highest tolerated dose of strong opioid therapy for persistent background pain. Marketing authorisations with conditions reflect the promising nature of the clinical evidence and the need for confirmatory studies to verify the clinical benefit. Patients should be advised of the conditional nature of the authorizations with conditions. GW Pharma Ltd. Distributed in Canada by: Date of Revision: Salisbury, Wiltshire Bayer Inc., March 30, 2012 U.K. SP4 0JQ Toronto, Ontario M9W 1G6 Control No: 149598 Page 1 of 55 This product has been approved under the Notice of Compliance with Conditions (NOC/c) Policy for its uses in adult patients with MS neuropathic pain and with cancer pain. What is a Notice of Compliance with Conditions (NOC/c)? An NOC/c is a form of market approval granted to a product on the basis of promising evidence of clinical effectiveness following review of the submission by Health Canada. Products approved under Health Canada’s NOC/c policy are intended for the treatment, prevention or diagnosis of a serious, life-threatening or severely debilitating illness. They have demonstrated promising benefit, are of high quality and possess an acceptable safety profile based on a benefit/risk assessment. In addition, they either respond to a serious unmet medical need in Canada or have demonstrated a significant improvement in the benefit/risk profile over existing therapies. Health Canada has provided access to this product on the condition that sponsors carry out additional clinical trials to verify the anticipated benefit within an agreed upon time frame. What will be different about this Product Monograph? The following Product Monograph will contain boxed text at the beginning of each major section clearly stating the nature of the market authorization. Sections for which NOC/c status holds particular significance will be identified in the left margin by the symbol NOC/c. These sections may include, but are not limited to, the following: - Indications and Clinical Uses; - Mechanism of Action; - Warnings and Precautions; - Adverse Reactions; - Dosage and Administration; and - Clinical Trials. Adverse Drug Reaction Reporting and Re-Issuance of the Product Monograph Health care providers are encouraged to report Adverse Drug Reactions associated with normal use of these and all drug products to Health Canada’s Health Product Safety Information Division at 1-866-234-2345. The Product Monograph will be re-issued in the event of serious safety concerns previously unidentified or at such time as the sponsor provides the additional data in support of the product’s clinical benefit. Once the latter has occurred, and in accordance with the NOC/c policy, the conditions associated with market authorization will be removed. Page 2 of 55 Table of Contents PART I: HEALTH PROFESSIONAL INFORMATION...................................................... 4 SUMMARY PRODUCT INFORMATION............................................................................... 4 NOC/C INDICATIONS AND CLINICAL USE .................................................................... 6 NOC/C CONTRAINDICATIONS ......................................................................................... 7 NOC/C WARNINGS AND PRECAUTIONS ........................................................................ 8 DRUG DEPENDENCE/ABUSE LIABILITY ........................................................................ 12 NOC/C ADVERSE REACTIONS........................................................................................ 13 DRUG INTERACTIONS ........................................................................................................ 20 NOC/C DOSAGE AND ADMINISTRATION .................................................................... 22 OVERDOSAGE ...................................................................................................................... 23 NOC/C ACTION AND CLINICAL PHARMACOLOGY................................................... 25 STORAGE AND STABILITY ................................................................................................ 27 SPECIAL HANDLING INSTRUCTIONS.............................................................................. 27 DOSAGE FORMS, COMPOSITION AND PACKAGING.................................................... 27 PART II: SCIENTIFIC INFORMATION ............................................................................. 29 PHARMACEUTICAL INFORMATION................................................................................ 29 NOC/C CLINICAL TRIALS ................................................................................................ 32 DETAILED PHARMACOLOGY ........................................................................................... 34 MICROBIOLOGY .................................................................................................................. 36 TOXICOLOGY ....................................................................................................................... 37 REFERENCES ........................................................................................................................ 49 PART III: CONSUMER INFORMATION............................................................................ 51 Page 3 of 55 NSATIVEX delta-9-tetrahydrocannabinol 27mg/ml (from Tetranabinex - Cannabis sativa L. extract) and cannabidiol 25mg/ml (from Nabidiolex - Cannabis sativa L. extract) PART I: HEALTH PROFESSIONAL INFORMATION NOC SATIVEX® is useful as adjunctive treatment for symptomatic relief of spasticity in adult patients with multiple sclerosis (MS) who have not responded adequately to other therapy and who demonstrate meaningful improvement during an initial trial of therapy. NOC/c SATIVEX® may be useful as adjunctive treatment for the symptomatic relief of neuropathic pain in adult patients with multiple sclerosis. SATIVEX® may be useful as adjunctive analgesic treatment in adult patients with advanced cancer who experience moderate to severe pain during the highest tolerated dose of strong opioid therapy for persistent background pain. Marketing authorisations with conditions reflect the promising nature of the clinical evidence and the need for confirmatory studies to verify the clinical benefit. Patients should be advised of the conditional nature of the authorizations with conditions. Page 4 of 55 SUMMARY PRODUCT INFORMATION Route of Pharmaceutical Form/Strength All Nonmedicinal Administration Ingredients Buccal Buccal spray Ethanol anhydrous Propylene glycol delta-9-tetrahydrocannabinol Peppermint oil 27mg/ml (from Tetranabinex - Cannabis sativa L. extract) and This is a full listing of all cannabidiol 25mg/ml (from nonmedicinal ingredients. Nabidiolex - Cannabis sativa L. extract) Page 5 of 55 INDICATIONS AND CLINICAL USE NOC SATIVEX® is useful as adjunctive treatment for symptomatic relief of spasticity in patients with multiple sclerosis (MS) who have not responded adequately to other therapy and who demonstrate meaningful improvement during an initial trial of therapy. NOC/c SATIVEX® may be useful as adjunctive treatment for the symptomatic relief of neuropathic pain in adult patients with multiple sclerosis (MS). The physician who elects to use SATIVEX® for extended periods should periodically re- evaluate the long-term usefulness of SATIVEX® for the individual patient. NOC/c SATIVEX® may be useful as adjunctive analgesic treatment in adult patients with advanced cancer who experience moderate to severe pain during the highest tolerated dose of strong opioid therapy for persistent background pain. Delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) are the principal active components in SATIVEX®. THC is a psychotropic agent which may produce physical and psychological dependence and has the potential to be abused. Both active components, THC and CBD, are scheduled under the Controlled Drugs and Substances Act. Geriatrics: There are limited data available on the use of SATIVEX® in elderly patients, therefore, the drug should be prescribed cautiously and carefully monitored in this patient population. Paediatrics (<18 years of age): The safety and efficacy of SATIVEX® have not been established in adolescents or children under 18 years of age, therefore SATIVEX® should not be used in adolescents or children. Page 6 of 55 CONTRAINDICATIONS SATIVEX® is contraindicated in: patients with known or suspected allergy to cannabinoids, propylene glycol, ethanol or peppermint oil patients with serious cardiovascular disease, such as ischaemic heart disease, arrhythmias, poorly controlled hypertension or severe heart failure patients with a history
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