Monistat 7 Vaginal Cream Product Monograph

INDICATIONS AND CLINICAL USE

MONISTAT* 7 Vaginal Cream and MONISTAT* 3 Vaginal Ovules are indicated for the local treatment of vulvovaginal candidiasis (moniliasis). MONISTAT* 7 DUAL-PAK and MONISTAT*

3 DUAL-PAK are indicated for the local treatment of vulvovaginal candidiasis (moniliasis) and for the relief of particularly severe external itching and irritation associated with vulvovaginal candidiasis.

Although vulvovaginal candidiasis may be more difficult to cure during pregnancy, pregnant patients can be treated with the same regimen as non-pregnant patients. The 3-day regimen

(MONISTAT* 3) is preferred, with the 1 or 7-day regimens (MONISTAT* 1 or MONISTAT* 7)

providing effective alternatives.

No significant difference in therapeutic cure rate (therapeutic cure includes both symptomatic and microbiological cure) was reported between the pregnant and non-pregnant patient groups who participated in clinical evaluations of the 3-day (ovules) or 7-day (suppositories + cream)

treatment regimens.

Similarly, users and non-users of oral contraceptives who participated in these clinical evaluations experienced therapeutic cure rates which did not differ significantly.

In addition, no statistically significant differences in therapeutic cure rates were noted between patients undergoing dosage regimens of varying duration (1, 3, 7, 10, and 14 day).

CONTRAINDICATIONS

Patients known to be hypersensitive to this drug or any of its ingredients.

PRECAUTIONS

1. 1. Patients should not use MONISTAT* vaginal preparations for self-medication if vaginal pruritus or discomfort is occurring for the first time. In this instance, a physician must be consulted to establish the diagnosis of vulvovaginal candidiasis.
2. 2. Patients should not use MONISTAT* vaginal preparations for self-medication if pain in the back or lower abdomen, fever or malodorous vaginal discharge are present, as a condition more serious than vulvovaginal candidiasis may exist.
3. 3. Patients should be advised to discontinue medication if sensitization or other signs of irritation (rash or hives, burning, blistering, redness) not present before therapy occur.
4. 4. Intractable candidiasis may be the presenting symptom of unrecognized diabetes; thus appropriate urine/blood studies may be indicated in patients not responding to treatment. In any case, if a patient is unresponsive to therapy appropriate microbiological studies should be repeated to confirm the diagnosis of vulvovaginal candidiasis and to rule out other pathogens.
5. 5. Pregnant patients should be advised either to exercise caution in the use of the vaginal applicator for the cream or the suppository or to insert the suppository digitally.
6. 6.

   Follow-up reports on infants born to twenty-six pregnant patients who participated in

   European and North American clinical evaluations of Miconazole Nitrate 100 mg

   Suppositories and infants born to 167 of 263 pregnant patients (some follow-up reports are not yet available) who participated in North American clinical evaluations of Miconazole

   Nitrate 2% Cream administered in a 14-day regimen described no complications or adverse effects attributed to this therapeutic agent. Nevertheless, since miconazole nitrate is absorbed in small amounts from the human vagina, MONISTAT* vaginal preparations should not be used by pregnant or nursing women unless the physician considers it essential to the welfare of the patient.

7. 7. During therapy it may be advisable to instruct the patient to abstain from intercourse.
8. 8.

   Miconazole nitrate preparations reduce the effectiveness of latex condoms and diaphragms.

   Therefore, concurrent use of the suppository or ovule with natural rubber products such as vaginal diaphragms or condoms is not recommended.

9. 9. Miconazole administered systemically is known to inhibit CYP3A4/2C9. Due to the limited systemic availability after vaginal application, clinically relevant interactions occur very rarely. In patients on oral anticoagulants, such as warfarin, caution should be exercised and the anticoagulant effect should be monitored ^{(9, 10)}.

ADVERSE REACTIONS

The standard for defining frequency terms will be based on the Council for International

Organizations of Medical Science (CIOMS) convention. Specifically:

Very common =1/10

Common =1/100 and <1/10

Uncommon =1/1,000 and <1/100

Rare =1/10,000 and <1/1,000

Very rare <1/10,000, including isolated reports

In general, the complaints reported with miconazole nitrate therapy involved vulvovaginal burning, itching, irritation, pelvic cramping and edema as well as hives, rash and headache.

Clinical trial data

A total of 1,089 patients participated in international clinical evaluations of Miconazole Nitrate formulated as the 2% Cream and administered in dosage regimens of varying duration. Of these, fifty-nine patients reported reactions which were possibly drug related but not severe enough to cause discontinuation of therapy, four patients discontinued therapy due to vulvovaginal burning and itching, and one patient discontinued therapy due to hives.

A total of 1,724 patients participated in international clinical evaluations of Miconazole Nitrate formulated as the 100 mg Suppository and administered in dosage regimens of varying duration. Of these, three patients reported reactions which were interpreted as minor treatment emergent signs and symptoms (burning, itching, edema) and considered by the investigators to be non-therapy related. No patients were reported to have discontinued therapy due to drug related reasons.

The three-day treatment with MONISTAT* 400 mg Vaginal Ovules was exceptionally well tolerated by a total of 410 patients in three clinical studies, without any related side effects.

However, the generally reported complaints referred to above could be expected with this dosage form and regimen as well.

The MONISTAT* DUAL-PAK products combine a small amount (9 gram) of miconazole nitrate cream (MONISTAT* Derm) to be applied externally during a course of therapy with MONISTAT*

7 Vaginal Suppositories or MONISTAT* 3 Vaginal Ovules so a similar safety and efficacy profile as with each individually could be expected.

Adverse events, regardless of causality, reported in 2 Phase 3 clinical trials are shown in the table below. A total of 537 women with microbiologically confirmed candidiasis and symptoms

(e.g. vulvovaginal itching, burning/irritation), or signs of vulvar erythema, edema, excoriation, or vaginal erythema or edema were treated with miconazole intravaginally: randomly assigned to either a single 1,200 mg capsule, or a 7-day application of 2% vaginal cream. There was no placebo reference. Safety was self-assessed daily on a diary card. Included in the table are adverse events reported by >5% of subjects in either treatment group.

Postmarketing data

Adverse events which may be causally related to the administration of MONISTAT* that have come to light as a result of reports received in relation to administration of the marketed product are provided in this section. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

Immune system disorders

Allergic conditions, including anaphylactic and anaphylactoid reactions, angioneurotic edema

Skin and subcutaneous tissue disorders

Urticaria, pruritus, rash

Reproductive system and breast disorders

Pelvic pain (cramping), genital burning sensation, genital pruritus female, vaginal irritation, vaginal discharge

General disorders and administration site conditions

Application site reactions

SYMPTOMS AND TREATMENT OF OVERDOSAGE

MONISTAT* products are intended for local application and not for oral use.

MONISTAT* 3 DUAL-PAK contains 1380 mg miconazole nitrate. Approximately 50% of an oral dose is absorbed from the gastrointestinal tract. Hence, the maximum possible systemic exposure if the entire contents of the MONISTAT* 3 DUAL-PAK were to be accidentally or deliberately ingested would be equivalent to 690 mg. This represents the lowest dose administered IV to adults (600 - 1800 mg) and compares favourably to the IV dose that would be administered to a one-year-old child (400 mg). Consequently, the possibility of acute overdosage is remote.

However, although highly unlikely to occur, in the event of a substantial overdose, and if taken concomitantly with other drugs (e.g. coumarin derivatives, oral hypoglycaemics or phenytoin), the effects and side effects of the other drugs can be increased.

DOSAGE AND ADMINISTRATION

MONISTAT* 7 Vaginal Cream: One 5 g applicatorful of MONISTAT* 7 Vaginal Cream

(equivalent to 100 mg miconazole nitrate) administered intravaginally once daily at bedtime for 7 consecutive days.

MONISTAT* 3 Vaginal Ovule: One 400 mg ovule administered intravaginally once daily at bedtime for 3 consecutive days.

A course of therapy with the cream or ovule may be repeated if the patient remains symptomatic and if it has been determined by appropriate smears and cultures that the infecting organism is still miconazole susceptible Candida.

Dual-Paks: (To be used when symptoms are particularly extensive): One 100 mg suppository

(MONISTAT* 7) or one 400 mg ovule (MONISTAT* 3) administered intravaginally once daily at bedtime for 7 (MONISTAT* 7) or 3 (MONISTAT* 3) consecutive days, respectively. Apply a thin layer of the cream to external areas twice daily, in the morning and evening. Massage gently until the cream disappears. Apply cream as required for external itching for up to 7 days. PHARMACEUTICAL INFORMATION

Proper Name: Miconazole Nitrate

Chemical Name: 1-{2,4-dichloro-ß-[(2,4-dichlorobenzyl)oxy]phenethyl}-

-imidazole nitrate.

Structural Formula:

·HNO₃

Molecular Formula: C₁₈H₁₄Cl₄N₂O·HNO₃

Molecular Weight: 479.16

Melting Point: 178 - 184 EC

Description:

Miconazole nitrate is a white, crystalline or microcrystalline powder, very slightly soluble in water

(0.03%) and very slightly to slightly soluble in most common organic solvents and dilute inorganic acids.

Composition:

MONISTAT* 7 Vaginal Cream and MONISTAT* Derm Cream (found in MONISTAT* 7 and

MONISTAT* 3 Dual-Paks*) are water miscible, white creams containing 2% miconazole nitrate

N

N

C l

C H 2 O C H2

C l

C l

CH C l

as the active ingredient. Nonmedicinal ingredients: benzoic acid, cetyl alcohol, isopropyl myristate, polysorbate 60, potassium hydroxide, propylene glycol, purified water, stearyl alcohol.

Each white egg-shaped MONISTAT* 7 Vaginal Suppository found in the MONISTAT* 7 Dual-

Pak* contains 100 mg miconazole nitrate as the active ingredient. Nonmedicinal ingredients:

hydrogenated vegetable oil base.

MONISTAT* 3 Vaginal Ovules contain 400 mg of miconazole nitrate in a creamy to white viscous medium of mineral oil and white petrolatum. Nonmedicinal ingredients: gelatin, glycerin, mineral oil, sodium ethylparaben, sodium propylparaben, titanium dioxide, white petrolatum.

Stability and Storage Recommendations:

MONISTAT* preparations should be stored at controlled room temperature (15°C - 30°C).

AVAILABILITY OF DOSAGE FORMS

MONISTAT* 7 Vaginal Cream (miconazole nitrate 2%) is available in an individual package containing 7 prefilled applicators each containing 5 g of cream.

MONISTAT* 3 Vaginal Ovules (miconazole nitrate 400 mg) are available in individual packages each containing three ovules sufficient for one 3-day course of therapy and 3 vaginal applicators.

MONISTAT* 7 DUAL-PAK* Package - Each package contains seven MONISTAT* 7 Vaginal

Suppositories (miconazole nitrate 100 mg) sufficient for one 7-day course of therapy, a vaginal applicator and a 9 g tube of MONISTAT* DERM Cream (miconazole nitrate 2%).

MONISTAT* 3 DUAL-PAK* Package - Each package contains three MONISTAT* 3 Vaginal

Ovules (miconazole nitrate 400 mg) sufficient for one 3-day course of therapy, 3 vaginal applicators and a 9 g tube of MONISTAT* DERM Cream (miconazole nitrate 2%).

CUSTOMER BROCHURE

This section is individualized to the specific product; therefore only a general form is included in this section of the Product Monograph.

BRAND NAME

GENERIC NAME AND STRENGTH

CURES MOST VAGINAL YEAST INFECTIONS

INDICATION

For the treatment of vaginal yeast infections (candidiasis). MONISTAT* 3 DUAL-PAK and

MONISTAT* 7 DUAL-PAK each contain MONISTAT* Derm Cream for the relief of particularly severe external itching and irritation associated with vaginal yeast infections.

WHAT IS A VAGINAL YEAST INFECTION?

A vaginal yeast infection is an imbalance in the vagina caused most commonly by an overgrowth of the yeast called Candida albicans. Candida is a common organism in the vagina.

When an imbalance occurs, such as when the normal pH balance of the vagina changes or when your hormonal balance changes, Candida can multiply. You can then get a vaginal yeast infection.

Some of the factors that can contribute to the development of a vaginal yeast infection are:

• Hormone level changes: menstrual cycle, pregnancy, birth control pills

  (with high estrogen), estrogen therapy (during menopause)

• Antibiotic use
• Uncontrolled diabetes

• Weakened immune system: HIV infection, corticosteroid therapy,

  chemotherapy

• Perfumed soaps, bubble baths, or douching

• Wet bathing suits, nylon underwear, and pantyhose can retain heat and moisture, creating an environment that encourages the growth of

  Candida.

SYMPTOMS OF VAGINAL YEAST INFECTIONS

There are many signs and symptoms of a yeast infection. They can include:

• Vaginal itching (ranging from mild to severe);
• A clumpy, white vaginal discharge that may look like cottage cheese¹;
• Vaginal soreness, irritation or burning, especially during intercourse;
• Rash or redness around the vagina.

¹A yellow/green discharge or a discharge that smells "fishy," may indicate that you have something other than a yeast infection. If this is the case, you should talk to your doctor before using MONISTAT*.

DIRECTIONS FOR USE

MONISTAT* 7 Vaginal Cream (Prefilled Applicators):

Many women find it more comfortable to use this product just before going to bed as this will reduce vaginal leakage. To begin treatment:

1. 1. Unscrew blue cap from prefilled applicator.
2. 2. Insert plunger into prefilled applicator by placing small, pointed end of plunger into the grey hole at the other end of the applicator (ie. not end that was covered by blue cap).
3. 3.

   Stand, squat or lie on your back with your knees bent. Hold the prefilled applicator at the plunger end. Gently insert the applicator into the vagina as far as it will comfortably go. Holding the applicator

   in place, gently depress the plunger. This will release the cream in the vagina. Remove the applicator and discard.

4. 4.

   Repeat steps 1 through 3 before going to bed on each of the next 6 evenings.

   You may want to use a deodorant-free mini-pad or pantyshield while using MONISTAT* as there may be some vaginal leakage.

   Tampons may absorb the medication; therefore, do not use them, day or night, for 7 days following treatment.

MONISTAT* 3 Vaginal Ovules:

Many women find it more comfortable to use this product just before going to bed as this will reduce vaginal leakage. To begin treatment:

1. 1. Remove one ovule from the strip by pushing it through the foil at the back.
2. 2. Place ovule in the top of the applicator.
3. 3. Stand, squat, or lie on your back with your knees bent. Hold the filled applicator by the barrel and gently insert the applicator into your vagina as far as it will comfortably go. Holding the applicator in place, gently push the inside piece of the applicator in. This will release the ovule in the vagina. Remove the applicator.
4. 4. Be sure to clean the applicator after each use. Pull the two pieces apart. Wash them with soap and warm water. To rejoin, gently push the inside piece into the outside piece as far as it will go.
5. 5.

   Repeat steps 1 through 4 before going to bed on each of the next two evenings.

   You may want to use a deodorant-free mini-pad or pantyshield while using MONISTAT* as there may be some vaginal leakage.

   Tampons may absorb the medication; therefore, do not use them, day or night, for 7 days following treatment.

MONISTAT* 7 DUAL-PAK:

MONISTAT* 7 Vaginal Suppository: Many women find it more

comfortable to use this product just before going to bed as this will reduce vaginal leakage. To begin treatment:

1. 1. Tear off a single suppository. Separate the plastic wrap with your thumb. With thumb and forefinger on each hand, hold the plastic tabs and pull apart.
2. 2. Place suppository in the top of the applicator.
3. 3. Stand, squat, or lie on your back with your knees bent. Hold the filled applicator by the barrel and gently insert the applicator into your vagina as far as it will comfortably go. Holding the applicator in place, gently push the inside piece of the applicator in. This will release the suppository in the vagina. Remove the applicator.
4. 4. Be sure to clean the applicator after each use. Pull the two pieces apart. Wash them with soap and warm water. To rejoin, gently push the inside piece into the outside piece as far as it will go.
5. 5.

   Repeat steps 1 through 4 before going to bed on each of the next six evenings.

   You may want to use a deodorant-free mini-pad or pantyshield while you are using MONISTAT* as there may be some vaginal leakage.

   Tampons may absorb the medication; therefore, do not use them, day or night, for 7 days following treatment.

MONISTAT* Derm Cream:

1. 1. Open the tube. To do this, unscrew the cap, turn the cap upside down and place the cap in the end of the tube. Push down firmly until the seal is broken.
2. 2. Apply a thin layer of cream to the itchy or irritated genital area.
3. 3. Massage gently until the cream disappears.
4. 4. Use the cream once or twice per day for up to 7 days as long as external symptoms persist.

MONISTAT* 3 DUAL-PAK:

MONISTAT* 3 Vaginal Ovules: Many women find it more comfortable to use this product just before going to bed as this will reduce vaginal leakage. To begin treatment:

1. 1. Remove one ovule from the strip by pushing it through the foil at the back.
2. 2. Place ovule in the top of the applicator.
3. 3. Stand, squat, or lie on your back with your knees bent. Hold the filled applicator by the barrel and gently insert the applicator into your vagina as far as it will comfortably go. Holding the applicator in place, gently push the inside piece of the applicator in. This will release the ovule in the vagina. Remove the applicator.
4. 4. Be sure to clean the applicator after each use. Pull the two pieces apart. Wash them with soap and warm water. To rejoin, gently push the inside piece into the outside piece as far as it will go.
5. 5.

   Repeat steps 1 through 4 before going to bed on each of the next two evenings.

   You may want to use a deodorant-free mini-pad or pantyshield while you are using MONISTAT* as there may be some vaginal leakage.

   Tampons may absorb the medication; therefore, do not use them, day or night, for 7 days following treatment.

MONISTAT* Derm Cream:

1. 1. Open the tube. To do this, unscrew the cap, turn the cap upside down and place the cap in the end of the tube. Push down firmly until the seal is broken.
2. 2. Apply a thin layer of cream to the itchy or irritated genital area.
3. 3. Massage gently until the cream disappears.
4. 4. Use the cream once or twice per day for up to 7 days as long as external symptoms persist.

FOR BEST RESULTS:

1. 1. Be sure to use for x days in a row even if your symptoms go away before the xth day.
2. 2. Apply the recommended amount, even during your menstrual period.
3. 3.

   Dry the outside vaginal area thoroughly after a shower, bath, or swim.

   Change out of a wet bathing suit or damp workout clothes as soon as possible. A dry area is less likely to encourage the growth of yeast.

4. 4. Wipe from front to rear (away from the vagina) after a bowel movement.
5. 5. Avoid perfumed soaps, bubble baths or douching which may cause vaginal irritation and upset the normal balance.
6. 6. Do not scratch the affected area as this can cause more irritation.
7. 7. Discuss with your doctor any medication you are now taking. Certain types of medication can make your vagina more prone to infection.
8. 8. Wear cotton underwear. Nylon underwear and pantyhose can retain heat and moisture, creating an environment that encourages the growth of Candida.
9. 9. If your male sexual partner has any penile itching, redness, or discomfort, he should talk to his doctor and mention that you are treating a yeast infection.
10. 10. To prevent transmission of the infection, do not allow others to use your washcloth or towel.

PRECAUTIONS

If you have any or all of the symptoms of a yeast infection (vaginal itching, burning, white discharge) and if at some time in the past your doctor has told you that these symptoms are due to a yeast infection, then use

MONISTAT* as directed. If, however, you have never had these symptoms before, you should consult your doctor so that your condition can be properly diagnosed.

This product is only effective in treating vaginal infections caused by yeast. It does not treat other infections and does not prevent pregnancy.

Do not take by mouth.

Talk to your doctor if you have fever, pain in the back or lower abdomen, or foul-smelling vaginal discharge before or during the use of this medication. You may have a more serious condition.

Relief of symptoms should begin within 3 days, but if complete relief is not felt within 7 days, the infection worsens or your symptoms return within 2 months, then you may have something other than a yeast infection. You should talk to your doctor.

If you are pregnant or think you may be, or are breastfeeding, use this product only under the advice and supervision of a doctor.

Oral anticoagulants (blood thinning medication): If you are taking an oral blood thinning medication, such as warfarin, talk to a doctor or pharmacist before using MONISTAT* products, as bruising or bleeding may occur.

While side effects are rare, the following side effects might occur with the use of MONISTAT*: abdominal cramping, headaches, hives and skin rash. Sometimes a temporary increase in redness, itching, burning and/or irritation can occur at the start of treatment. This will not reduce the effectiveness of the product. (The next sentence is for MONISTAT* 3

‘Information for the Consumer’ section only): If you experience a temporary increase in burning with MONISTAT* 3, you may want to use a

MONISTAT* 7 therapy the next time you have a vaginal yeast infection.

(The next sentence is for both MONISTAT* 3 and 7 ‘Information for the

Consumer’ sections): Talk to your doctor if burning persists or if any unusual symptoms develop.

If skin rash, hives, abdominal cramps or new irritation occurs, discontinue use and call your doctor. If you are sensitive or allergic to any

MONISTAT* product, do not use without talking to your doctor first.

Tampons may absorb the medication, therefore, do not use them, day or night, for 7 days following treatment.

This medication reduces the effectiveness of latex condoms and diaphragms. Do not rely on them to prevent sexually transmitted diseases or pregnancy while using MONISTAT*.

If you are at increased risk for sexually transmitted diseases, have multiple partners or change partners often, talk to a doctor before starting each treatment.

This product should not be used by children under 12 years of age unless advised to do so by a doctor. Please keep this and all drugs out of the reach of children.

Various medical conditions can damage the body's normal defenses against infection. One of the most serious of these conditions is infection with the human immunodeficiency virus (HIV - the virus that is associated with AIDS). Infection with HIV causes the body to be more susceptible to infections, including vaginal yeast infections. If you may have been exposed to HIV and are experiencing either frequently recurring vaginal yeast infections or, especially, vaginal yeast infections that do not clear up easily with proper treatment, you should see your doctor promptly.

Monistat* 7 Vaginal Cream:

Each prefilled applicator is overwrapped for your protection. Do not use if the overwrap is missing or not sealed.

MONISTAT* 3 Vaginal Ovules:

Each ovule is indiviually wrapped. If the ovule is unwrapped or the packaging is damaged in any way, do not use.

Monistat* 7 Dual-Pak*:

Each suppository is individually wrapped and the tube is sealed. If the suppository is unwrapped, the tube seal broken or the packaging is damaged in any way, do not use.

Monistat* 3 Dual-Pak*:

Each ovule is individually wrapped and the tube is sealed. If the ovule is unwrapped, the tube seal broken or the packaging is damaged in any way, do not use.

In case of accidental ingestion, call a doctor or Poison Control Centre at once.

STORAGE

Store at room temperature (15 - 30^oC).

MICROBIOLOGY

1.In Vitro

SUSCEPTIBILITY OF CANDIDA SPECIES TO MICONAZOLE

* Determined in Sabouraud broth culture medium

Electron microscopic examination was performed on C. albicans after treatment in vitro with different doses of miconazole: 5 ng, 1 mg, 2 mg and 5 mg/mL of culture (CYG medium) harvested twenty four hours later.

The ultrastructural data on the alterations induced by a low dose (5ng/mL)

of miconazole indicated that the drug exerts its effect primarily on the cell wall and plasmalemma. With higher doses, progressive degradation of cytoplasmic material was observed. Injured parts of the cellular material were sequestered from the rest of the cytoplasm and engulfed by the vacuole. The same degradation process was noted on the cell periphery.

Necrosis of cells, characterized by the loss of their normal shape and by severe alterations of every substructure was prominent at higher dose levels.

These ultrastructural findings firmly substantiate the fungistatic activity at low doses and the fungicidal activity at higher doses of miconazole. From the morphologic point of view, a clear dose relationship was established.

2.In Vivo

Adult guinea pigs pretreated with alloxan (200 mg/kg, i.m.) and infected with Candida albicans received daily topical treatment with 1 g of

ointment containing 2% miconazole, nystatin, or amphotericin B, for 14 days starting on the third day after infection.

Miconazole applied topically was effective in curing the lesions induced by C. albicans and was slightly superior to and faster-acting than nystatin and amphotericin B.

Oral doses of miconazole at 160 mg/kg and 40 mg/kg administered for 14 days were effective against Candida albicans-induced lesions. By comparison, oral nystatin and amphotericin B (160 mg/kg) and pimaricin

(40 mg/kg) had little effect on the course of the infection.

SUMMARY

*NOTE: Inhibition of growth was scored as follows (some spontaneous healing in controls by day 15) 0 = absence of lesions

1 = 1/4 the lesions of infected controls 2 = 1/2 the lesions of infected controls 3 = 3/4 the lesions of infected controls 4 = lesions corresponding to infected controls

PHARMACOLOGY

ANIMAL

1. 1. Tissue and Whole Animal

The agonist activity of miconazole on the guinea pig ileum, rabbit duodenum, rabbit spleen and rat stomach fundus tissue preparations is limited to a slight initial tonus increase observed with the rabbit duodenum preparation at concentrations of 2.5 - 10 mg/l. This compound is observed to antagonize the spasmogenic effects of bradykinin, serotonin, nicotine, eledoisin, angiotensin and histamine, but is devoid of

anticholinergic (rabbit duodenum), antiserotoninergic (rat stomach fundus) anti-a-adrenergic (rabbit spleen) and ß-adrenergic blocking (fowl rectal caecum) activity.

Miconazole given to mice in a single dose of 40 mg/kg had no influence on the licking reflex or other gross behavioural characteristics. In addition, rats treated with this regimen showed no autonomic or CNS induced effects. As well, no morphine-like properties, anticonvulsant effects or change in body temperature was recorded in this species. After repeated administration at this dose level (40 mg/kg/day for 7 consecutive days) no significant changes were again observed in behavioural characteristics and gross overall condition of pathological examination at autopsy.

1. 2. Metabolism and Pharmacokinetics
2. a) In Vitro

Rats (miconazole nitrate tritium labelled)

Incubation of tritium-labelled miconazole nitrate was carried out with the

10,000 gm supernatant fractions and microsomal fractions of the liver, lungs and kidneys of the Wistar rat. The major metabolite was

a-(2,4-dichloro-phenyl)-1H-imidazole-1-ethanol (R 14821). Whereas more than 70% of the drug was unmetabolized, this metabolite, resulting from an oxidative O - dealkylation by microsomal enzymes, amounted to about 20% of total reactivity. The microsomal enzymes responsible for this metabolic breakdown were twice as active in the liver as in the lungs or the kidneys.

Humans (miconazole nitrate tritium labelled on the 2-ethyl group)

The binding of miconazole nitrate to human plasma proteins, and the distribution of the drug in human blood, blood cell suspension and ghost cell suspension were studied by equilibrium dialysis. Human blood was obtained by venous puncture from health male (8) and female (3)

volunteers who had not taken any medication for at least two weeks, from patients (4) with chronic renal failure and from patients (4) who were under haemodialysis treatment.

Miconazole nitrate was found to bind very strongly to human plasma proteins. For example, a 4% HSA solution bound miconazole nitrate for

98% with an overall association constant of 91.6 x 103. Even a 1.5% human gamma globulin solution bound the drug for about 81% with an overall association constant of 8.0 x 103. The binding of miconazole nitrate to the plasma proteins amounted to 98.7%. In blood, 1.2% was distributed in the plasma water, 88.2% was bound to the plasma proteins and 10.6% to the blood cells.

The percentage of bound miconazole was not influenced by the total drug concentration within the tested range from 0.1 to 10.0 x 10-6M. In a blood cell suspension 97.6% of the drug was bound to the blood cells, probably due to the binding properties of not only the cell membranes but also inner constituents such as haemoglobin.

No significant sex differences and only minor individual differences were found for the plasma protein binding and the distribution of miconazole

nitrate in blood. Only very small differences were found between the plasma protein binding and the distribution of the drug in blood or normal subjects, of patients with chronic renal failure and of patients under haemodialysis treatment.

1. b) In Vivo

Studies were conducted using miconazole labelled with tritium at C-2 of the imidazole ring or the ß-carbon of the ethyl side chain. It was noted that the tritium label at C-2 of the imidazole ring was labile.

Rats (miconazole tritium labelled at C-2 of the imidazole ring)

Five male Wistar rats were each given an oral dose of 40 mg/kg miconazole in PEG-200. During the four days when urine and faeces were collected, 66% of the total radioactivity administered was recovered;

62% after 48 hours. In the urine collected more than 37% of the radioactivity recovered was in the form of tritiated water. At autopsy (day

1. 4) blood, liver and brain tissues contained 1.9% of the administered radioactivity. Examination of the excreta by the inverse isotope dilution method revealed that 18% of the administered dose was excreted unchanged, 19%, as a-(2,4-dichlorophenyl)-imidazole-1-ethanol or its parent ketone and traces as imidazole.

Dogs and Rabbits (miconazole tritium labelled at C-2 of the imidazole ring)

In separate excretion and absorption studies involving 2 animals per study, miconazole was administered intravaginally in carbowax 1000 and wecobee FS and M (7:3) vehicles to beagle bitches (1 mL of 1% formulation) and New Zealand white rabbit doe (0.5 mL of 1%

formulation). In the excretion studies urine and faeces were collected for

12 days from the dogs and urine only from the rabbits. In both species the major percentage of the recovered radioactivity was obtained during the 3 days after dosing. In dogs greater than 60% of the radioactivity was in the urine where the carbowax vehicle was used whereas less than 50%

was recovered in the urine of dogs given miconazole in the wecobee vehicle. This observation was made with rabbits as well. In the absorption studies blood samples were obtained at 2, 4, 7 and 25 hours.

Peak levels in dogs occurred 4 - 7 hours after dosing whereas in rabbits blood levels peaked at 2 hours. The highest level in dogs (0.06 mg/mL)

was found with the carbowax vehicle as was the case with rabbits (0.17 -

0.18 mg/mL). At autopsy (25 hours) the vaginas were dissected and washed. Only 0.08% of the administered dose to dogs and 0.456% to rabbits was found in the tissues and washings.

Rabbits (miconazole tritium labelled in the b-carbon of the ethyl side chain)

Vaginal suppositories (2% miconazole) were administered to 2 New

Zealand White rabbits. Urine and faeces were collected daily and blood at 3, 6, 24, 72, 96, 144, and 168 hours. Most of the administered radioactivity (90% in one animal and 70% in the other) was excreted in eight days. Fifty percent of the tritium excreted was recovered in 2-3 days and found in the faeces. Maximum blood levels of tritium occurred 6 hours after dosing (0.95 mg/mL).

HUMAN

Vaginal Absorption Study

Miconazole Nitrate was administered as a 2% cream formulation for 14 consecutive days to 6 female patients (5 non-pregnant and 1 pregnant)

with confirmed diagnosis of vulvovaginal candidiasis (positive 10% KOH smear and NICKERSON'S Medium culture). Patients were scheduled to have blood samples drawn pre-therapy and day 5, 10, 16, 22 and 44 for analysis of serum levels of unchanged miconazole.

The levels of systemic absorption of miconazole which occurred during the period of intravaginal administration of MONISTAT* Cream were minimal (1.7 - 4.2 ng/mL).

A consistent cumulative absorption was not evident and serum levels of miconazole declined rapidly after drug administration was discontinued

(1-3 days post-therapy levels ranged from 1.7 to 3.7 ng/mL; however, after day 9 post-therapy miconazole was not detectable in serum).

Another study of systemic absorption from a single dose of 5 grams of radiolabelled MONISTAT* Cream 2% applied intravaginally resulted in only about 1% of the total administered dose being recovered in the urine.

A published study which examined the systemic absorption of miconazole nitrate from a 1200mg Miconazole nitrate vaginal ovule in healthy women found low but measurable serum concentrations which remained steady for about 36 hours and then slowly declined. Mean systemic

bioavailability was about 1.4%.

Miconazole persists in the vagina for up to 72 hours after a single dose.

Plasma concentrations of miconazole are measurable within 2 hours of administration in some subjects, with maximal levels seen 12 to 24 hours after administration. Plasma concentrations decline slowly thereafter and were still measurable in most subjects 96 hours post-dose. A second dose administered 48 hours later resulted in a plasma profile similar to that of the first dose.

The small amount of miconazole that is absorbed is eliminated

predominantly in feces as both unchanged drug and metabolites over a four-day post-administration period. Smaller amounts of unchanged drug and metabolites also appear in urine. The mean apparent elimination half-life is 57 hours.

Summary of Clinical Efficacy and Safety

Clinical studies of miconazole nitrate (MONISTAT* brand) administered intravaginally in a dose of 100 mg for 7 consecutive days in the form of a cream (5 grams of 2% cream) and as a vaginal suppository have been

effective in yielding both mycological and clinical cure rates of approximately 80% - 90% for vulvovaginal candidiasis.

Three-day regimens using MONISTAT* vaginal ovules 400 mg or

MONISTAT* vaginal cream 200 mg inserted intravaginally for 3 consecutive nights also yielded comparable mycological and clinical results.

A one-day regimen using 1200 mg MONISTAT* vaginal ovules intravaginally for a single night has also been demonstrated to provide comparable efficacy and safety to 2% miconazole nitrate vaginal cream daily for 7 days.

In addition, in the treatment of vulvovaginal candidiasis the single dose

1200mg miconazole nitrate vaginal ovule regimen was shown in published studies to provide comparable efficacy to miconazole nitrate as

400mg vaginal ovules daily x 3 days, 100mg tampons daily x 5 days,

100mg vaginal inserts x 7 days, and to single dose clotrimazole 500mg vaginal inserts, single dose oral fluconazole 150mg, and oral ketoconazole 400mg daily x 5 days.

All miconazole nitrate regimens were well tolerated in clinical circumstances with mild vaginal itching, irritation and burning being the side effects observed.

TOXICOLOGY

ANIMAL

1. 1. Acute

Acute oral toxicity of miconazole (7-day mortality) was assessed in male white mice, male Wistar rats, female guinea pigs and male and female mongrel dogs. The compound was administered in a micronized aqueous suspension. The following values were obtained:

The intraperitoneal LD50 in male Swiss Webster mice was 670 mg/kg +

0.36 S.E.

1. 2. Subacute

Rats

Adult Wistar Rats (10 males and 10 females per dose group) were given miconazole at 80, 10 and 5 mg/kg/day in their diet for 13 weeks. All animals survived the test. The urine of treated animals was compared with the urine of control animals. Specific gravity was increased in the high dose group and urine pH was lowered in the intermediate and high dose groups. In addition, minor changes in liver, thymus, spleen and kidney were noted in the high dose group after histopathological examination. From these results the no-effect dose is calculated to be less than 80 mg/kg, but greater than 20 mg/kg.

Dogs

Adult Beagle dogs (3 males and 5 females per dose group) were given miconazole at 40, 20 and 2.5 mg/kg/day orally by capsule, 6 days a week, for 13 weeks. All animals survived the test. The following changes were noted: haematocrit and haemoglobin values were lowered in the high dose group; serum calcium and cholesterol and sulfhydryl values decreased in the intermediate and high dose groups and the odd animal in the high dose group salivated and would vomit subsequent to drug administration. At autopsy slight liver changes were noted in the high dose group animals. From these results the no-effect dose is calculated to be less than 40 mg/kg but greater than 10 mg/kg.

1. 3. Chronic

Rats

Adult Wistar rats (30 males and 30 females per dose group) were given miconazole at 160, 40 and 10 mg/kg/day in their diet. Interim sacrifices of

20 animals (10 males and 10 females) per dose level were made at 6 and

12 months, the remaining animals being sacrificed at the termination of the study (18 months). Histopathology showed some slight liver changes which appeared to be more pronounced in the males. However, this finding did not progress with time. No other significant findings were reported and miconazole was well tolerated up to 160 mg/kg over the study period.

Dogs

Adult Beagle dogs (3 males and 3 females per dose group) were given oral doses by capsule of miconazole at 20, 5 and 1.25 mg/kg/day, 6 days a week for 52 weeks. All animals survived the study period. Persistent increased alkaline phosphatase levels and slightly increased SGPT values were noted with the high dose group; however, all other measured parameters were normal. At autopsy no significant histopathological changes were evident.

1. 4. Reproductive Studies

Fertility in Rats

Adult Wistar rats (2 groups per dose level) were given miconazole at 320,

160 and 80 mg/kg in their diet as follows:

Group A: 20 males - drug given 60 days premating, 20 females - no drug

Group B: 20 males - no drug, 20 females - drug 14 days premating plus

21 days gestation

Females were sacrificed at day 22 of gestation. There was no difference between dose levels or groups A or B in pregnancy rate, but the number of dead foetuses and resorbed foetuses was increased in the high dose level. No abnormalities were noted among pups born to dosed females with the exception of two animals with rib deformities born to a high dose female. Based on the study findings, miconazole had no effect on the fertility of dosed males or females.

Peri-and Postnatal Studies in Rats

In one study, pregnant rats (20 animals per dose group) were given miconazole at 320, 160 and 80 mg/kg in their diet from day 16 of gestation through the 3 week lactation period. The gestation period was increased one day for the intermediate and high dose groups. In the test animals, litter size and the number of live foetuses at birth were slightly lower when compared to controls. In addition, body weight gains in the intermediate and high dose groups for the surviving pups were lower, whereas the birth weights of pups in the various groups had not differed.

In a second study pregnant Long-Evans derived rats (20 animals per dose group) were given miconazole, suspended in

carboxymethylcellulose at 80, 40 and 20 mg/kg by gastric gavage from day 14 of gestation through to day 21 post partum. In the high dose group a prolonged gestation period associated with an increase in the

number of still born pups was noted. Performance of the other dose groups was comparable to controls.

1. 5. Teratology

Rats

Pregnant rats (20 animals per dose group) were given miconazole at 160 and 80 mg/kg in their diet from day 6 to day 15 of gestation. On day 22 of gestation, foetuses were delivered by caesarean section. No

abnormalities were noted in this study either in the offspring or the reproductive performance of the dams.

Rabbits

Pregnant New Zealand white rabbits were given miconazole in

carboxymethylcellulose at 80 (17 animals), 40 (15 animals) and 20 (15 animals) mg/kg by gavage from day 7 to day 19 of gestation. On day 30 of gestation, the animals were sacrificed. No adverse effect was noted at the low or intermediate dose levels upon maternal mortality, pregnancy rate or early parturition or on foetal resorption, size, sex ratio or malformation. At the high dose level there was evidence of maternal and foetal toxicity as indicated by maternal weight loss during gestation, lengthened period of gestation and significant foetal resorption. However, at the high dose there was no indication of teratogenicity.

1. 6. Other Studies

Intravaginal irritation studies have been carried out in rabbits for 10 days with miconazole nitrate in the glycerides base suppository formulation

(100 mg per suppository single daily dose). Under the experimental conditions the glycerides base with or without miconazole nitrate has demonstrated a low order of irritation to the intact vaginal mucosa.

Similar findings were reported for vaginal irritation studies in rabbits and monkeys (3 months) utilizing 1 gm carbowax suppositories containing miconazole nitrate 2% and in rabbits for periods ranging from 10 days to

3 months with miconazole nitrate in its 2% cream formulation (single daily dosage of 1 gm of cream; 5-7 mg/kg of miconazole). No evidence of systemic toxicity was noted.

Dermal and ocular studies on rabbits ranging from 24 hours to 1 month in duration have revealed little irritation when miconazole was utilized in the

2% cream formulation. Dose levels of miconazole in these studies were as high as 50 mg/kg/day. In addition, no evidence of systemic toxicity was apparent in these studies.

An ocular irritation study of miconazole nitrate formulated with mineral oil, white wax and liquid petrolatum was performed in rabbits for four weeks.

The results indicate that this 2% miconazole nitrate formulation when instilled into the eye once daily at a 0.1 mL dosage produces no irritation.

HUMAN

1. 1. Tolerance Study

Miconazole Nitrate in a 2% vaginal cream formulation or placebo cream was administered to female volunteers meeting the following criteria - adult, healthy, non-pregnant and free of vaginal pathology - twice daily for a period of 30 days for the purpose of comparing side effect patterns, defining any possible changes in hematologic and biochemical parameters and to ascertain the level of systemic absorption of miconazole from the vagina. Twenty-three subjects receiving active cream and 20 receiving placebo cream participated in this double-blind study.

Pre- and post-administration physical examination findings remained essentially unchanged.

Analysis of the findings of the daily vaginal examinations and patient complaints revealed that both the active and placebo creams were essentially non-irritating to the normal vaginal mucosa. All reports of vaginal itching or burning were mild in nature (7 subjects using active cream, 3 subjects using placebo cream).

A review of the laboratory reports indicated no consistent changes which would denote drug toxicity.

BIBLIOGRAPHY

1.Godefroi, E.F., Heeres, J., van Cutsem, J., and Janssen, P.A.J.: The preparation and antimycotic properties of derivatives of

1-phenethylimidazole. J. MED. CHEM., 12: 784-791 (1969).

2.Van Cutsem, J.M. and Thienpont, D.: Miconazole, a broad-spectrum antimycotic agent with antibacterial activity. CHEMOTHERAPY,

17:392-404 (1972).

1. 3. Bossche Vanden, H.: Biochemical effects of Miconazole on Fungi-I.

Effects on the uptake and/or utilization of purines, pyrimidines, nucleosides, amino acids and glucose by Candida albicans. BIOCHEM.

PHARMACOL. 23:887-888 (1974).

1. 4. Swamy, K.H.S., Sirsi, M., and Rao, G.R.: Studies on the mechanism of action of miconazole: p Effect of miconazole on respiration and cell permeability of Candida albicans. ANTIMICROB. AG. CHEMOTHER.,

5:420-425 (1974).

5.Data on File, Ortho Pharmaceutical

6.Van Den Bossche, H., Willemsens, G., Van Cutsem, J.M.: The Action of Miconazole on the Growth of Candida albicans. SABOURAUDIA.

13:63-73 (1975)

7.De Nollin, S., Borgers, M.: Scanning electron microscopy of Candida albicans after in vitro treatment with Miconazole. ANTIMICROB. AG.

CHEMOTHER. 7(5):704-711 (1975).

8.De Nollin, S., Borgers, M.: The ultrastructure of Candida albicans after in vitro treatment with Miconazole. SABOURAUDIA. 12:341-351 (1974).

1. 9. Thirion DJ, Zanetti LA. Potentiation of Warfarin’’s

Hypoprothrombinemic Effect with Miconazole Vaginal Suppositories.

Pharmacotherapy 2000;20(1):98-99.

1. 10. Lansdorp D, Bressers HP, Dekens-Konter JA, Meyboom RH.

Potentiation of Acenocoumarol During Vaginal Administration of

Miconazole. Br J Clin Pharmacol 1999;47:225-6.

1. 11. Johnson & Johnson Pharmaceutical Research & Development,

L.L.C.: Company Core Data Sheet for Miconazole Nitrate. November 9,

2004.

RELEVANT LITERATURE

1.Botter, A.A.: Further experiments with miconazole nitrate, a broad-spectrum antimycotic with antibacterial activity. MYKOSEN,

15(4):179-183 (1972).

1. 2. Brugmans, J., van Cutsem, J., Heykants, J., Schuermans, V., and

Thienpont, D.: Systemic antifungal potential, safety, biotransport and transport and transformation of miconazole nitrate. EUROP. J. CLIN.

PHARMACOL., 5:93-99 (1972).

1. 3. Godts, P., Vermylen, P., and van Cutsem, J.: Clinical evaluation of miconazole nitrate in the treatment of vaginal candidiasis.

ARZNEIM-FORSCH (DRUGS RES.) 21 (2):256-257 (1971).

1. 4. Proost, J.M., Maes-Dockx, F.M., Nelis, M.O., and van Cutsem, J.M.:

Miconazole in the treatment of mycotic vulvovaginitis. AM. J. OBSTET.

GYNECOL., 112(5):688-692 (1972).

1. 5. Thierry, M., Mrozowski, B.J., and van Kets, H .: Miconazole, a new broad-spectrum antimycotic, in the treatment of vaginal candidiasis.

MYKOSEN, 15:35-37 (1972).

1. 6. McEvoy, G.K. ed, American Hospital Formulary Services (AHFS)

Drug Information, American Society of Hospital Pharmacists Inc., 1994

1. 7. USP DI, Drug Information for the Health Care Professional, 14th ed.,

The United States Pharmacopeial Convention Inc., 1994

1. 8. Daneshmend TK, Systemic absorption of Miconazole from the vagina, Journal of Antimicrobial Chemotherapy 1986 (18): 507-511.