1. Name Of The Medicinal Product
alli 27 mg chewable tablets
2. Qualitative And Quantitative Composition
Each chewable tablet contains 27 mg orlistat.
Excipients
Each chewable tablet contains 86.79 mg of lactose and 6.48 mg of sucrose (as monopalmitate).
For a full list of excipients, see section 6.1.
3. Pharmaceutical Form
Chewable tablet.
White to off-white, faceted, triangular shaped tablets of 12 mm, debossed with “alli”.
4. Clinical Particulars
4.1 Therapeutic Indications
alli is indicated for weight loss in adults who are overweight (body mass index, BMI, 2) and should be taken in conjunction with a mildly hypocaloric, lower-fat diet.
4.2 Posology And Method Of Administration
Posology
Adults
The recommended dose of alli is one 27 mg tablet to be taken three times daily. No more than three 27 mg tablets should be taken in 24 hours.
It is possible that the systemic absorption from 27 mg chewable tablets may be higher than that from 60 mg hard capsules. It is therefore recommended not to take two tablets at the same time.
Diet and exercise are important parts of a weight loss programme. It is recommended that a diet and exercise programme is started before beginning treatment with alli.
While taking orlistat, the patient should be on a nutritionally balanced, mildly hypocaloric diet that contains approximately 30% of calories from fat (e.g. in a 2,000 kcal/day diet, this equates to <67 g of fat). The daily intake of fat, carbohydrate and protein should be distributed over three main meals.
The diet and exercise programme should continue to be followed when treatment with alli is stopped.
Treatment should not exceed 6 months.
If patients have been unable to lose weight after 12 weeks of treatment with alli, they should consult their doctor or a pharmacist. It may be necessary to discontinue treatment.
Special populations
Elderly (>65 years old)
There are limited data on the use of orlistat in the elderly. However, as orlistat is minimally absorbed, no dose adjustment is necessary in the elderly.
Hepatic and renal impairment
The effect of orlistat in individuals with hepatic and/or renal impairment has not been studied. However, as orlistat is minimally absorbed, no dose adjustment is necessary in individuals with hepatic and/or renal impairment.
Paediatric population
The safety and efficacy of alli in children below 18 years of age has not been established. No data are available.
Method of administration
The tablet should be chewed immediately before, during or up to 1 hour after each main meal. If a meal is missed or contains no fat, the dose of orlistat should be omitted.
4.3 Contraindications
• Hypersensitivity to the active substance or to any of the excipients
• Concurrent treatment with ciclosporin (see section 4.5)
• Chronic malabsorption syndrome
• Cholestasis
• Pregnancy (see section 4.6)
• Breast-feeding (see section 4.6)
• Concurrent treatment with warfarin or other oral anticoagulants (see sections 4.5 and 4.8)
4.4 Special Warnings And Precautions For Use
Patients should be advised to adhere to the dietary recommendations they are given (see section 4.2). The possibility of experiencing gastrointestinal symptoms (see section 4.8) may increase when orlistat is taken with an individual meal or a diet high in fat.
Treatment with orlistat may potentially impair the absorption of fat-soluble vitamins (A, D, E and K) (see section 4.5). For this reason, a multivitamin supplement should be taken at bedtime.
As weight loss may be accompanied by improved metabolic control in diabetes, patients who are taking a medicinal product for diabetes should consult a doctor or pharmacist before starting treatment with alli, in case it is necessary to adjust the dose of the antidiabetic medicinal product.
Weight loss may be accompanied by an improvement in blood pressure and cholesterol levels. Patients who are taking a medicinal product for hypertension or hypercholesterolaemia should consult a doctor or pharmacist when taking alli, in case it is necessary to adjust the dose of these medicinal products.
Patients who are taking amiodarone should consult a doctor before starting treatment with alli (see section 4.5).
Cases of rectal bleeding have been reported in patients taking orlistat. If this occurs, the patient should consult a doctor.
The use of an additional contraceptive method is recommended to prevent possible failure of oral contraception that could occur in case of severe diarrhoea (see section 4.5).
Patients with kidney disease should consult a doctor before starting treatment with alli, as the use of orlistat may rarely be associated with hyperoxaluria and oxalate nephropathy.
Hypothyroidism and/or reduced control of hypothyroidism may occur when orlistat and levothyroxine are co-administered (see section 4.5). Patients taking levothyroxine should consult a doctor before starting treatment with alli, as orlistat and levothyroxine may need to be taken at different times and the dose of levothyroxine may need to be adjusted.
Patients taking an antiepileptic medicinal product should consult a doctor before starting treatment with alli, as they should be monitored for possible changes in the frequency and severity of convulsions. If this occurs, consideration could be given to administering orlistat and antiepileptic medicinal products at different times (see section 4.5).
The chewable tablets contain lactose. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency, glucose-galactose malabsorption should not take this medicinal product.
The chewable tablets also contain sucrose. Patients with rare hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucrase-isomaltase insufficiency should not take this medicinal product.
4.5 Interaction With Other Medicinal Products And Other Forms Of Interaction
Ciclosporin
A decrease in ciclosporin plasma levels has been observed in a drug-drug interaction study and also reported in several cases, when orlistat was administered concomitantly. This could potentially lead to a decrease of immunosuppressive efficacy. Concurrent use of alli and ciclosporin is contraindicated (see section 4.3).
Oral anticoagulants
When warfarin or other oral anticoagulants are given in combination with orlistat, international normalised ratio (INR) values could be affected (see section 4.8). Concurrent use of alli and warfarin or other oral anticoagulants is contraindicated (see section 4.3).
Oral contraceptives
The absence of an interaction between oral contraceptives and orlistat has been demonstrated in specific drug-drug interaction studies. However, orlistat may indirectly reduce the availability of oral contraceptives and lead to unexpected pregnancies in some individual cases. An additional contraceptive method is recommended in case of severe diarrhoea (see section 4.4).
Levothyroxine
Hypothyroidism and/or reduced control of hypothyroidism may occur when orlistat and levothyroxine are taken at the same time (see section 4.4). This could be due to a decreased absorption of iodine salts and/or levothyroxine.
Antiepileptic medicinal products
Convulsions have been reported in patients treated concomitantly with orlistat and antiepileptic medicinal products e.g. valproate, lamotrigine, for which a causal relationship to an interaction cannot be excluded. Orlistat may decrease the absorption of antiepileptic medicinal products, leading to convulsions.
Fat soluble vitamins
Treatment with orlistat may potentially impair the absorption of fat-soluble vitamins (A, D, E and K).
The vast majority of subjects receiving up to 4 full years of treatment with orlistat in clinical studies had vitamin A, D, E and K and beta-carotene levels that stayed within normal range. However, patients should be advised to use a multivitamin supplement at bedtime to help ensure adequate vitamin intake (see section 4.4).
Acarbose
In the absence of pharmacokinetic interaction studies, alli is not recommended to be used by patients receiving acarbose.
Amiodarone
A decrease in plasma levels of amiodarone, when given as a single dose, has been observed in a limited number of healthy volunteers who received orlistat concomitantly. The clinical relevance of this effect in patients receiving amiodarone treatment remains unknown. Patients who are taking amiodarone should consult a doctor before starting treatment with alli. The dose of amiodarone may need to be adjusted during treatment with alli.
4.6 Pregnancy And Lactation
Women of childbearing potential / Contraception in males and females
The use of an additional contraceptive method is recommended to prevent possible failure of oral contraception that could occur in case of severe diarrhoea (see sections 4.4 and 4.5).
Pregnancy
For orlistat, no clinical data on exposed pregnancies are available. Animal studies do not indicate direct or indirect harmful effects with respect to pregnancy, embryonal/foetal development, parturition or postnatal development (see section 5.3).
alli is contraindicated in pregnancy (see section 4.3).
Breast-feeding
As it is not known whether orlistat is secreted into human milk, alli is contraindicated during breast-feeding (see section 4.3).
Fertility
Animal studies do not indicate harmful effects with respect to fertility.
4.7 Effects On Ability To Drive And Use Machines
Orlistat has no or negligible influence on the ability to drive and use machines.
4.8 Undesirable Effects
Adverse reactions to orlistat are largely gastrointestinal in nature and related to the pharmacologic effect of the medicinal product on preventing the absorption of ingested fat.
The gastrointestinal adverse reactions identified from clinical trials with orlistat 60 mg of 18 months to 2 years duration were generally mild and transient. They generally occurred early in treatment (within 3 months) and most patients experienced only one episode. Consumption of a diet low in fat will decrease the likelihood of experiencing adverse gastrointestinal reactions (see section 4.4).
Adverse reactions are listed below by system organ class and frequency. Frequencies are defined as: very common (
The frequencies of adverse reactions identified during post-marketing use of orlistat are not known as these reactions were reported voluntarily from a population of uncertain size.
Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness.
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†It is plausible that treatment with orlistat can lead to anxiety in anticipation of or secondary to gastrointestinal adverse reactions.
4.9 Overdose
Single doses of 800 mg orlistat and multiple doses of up to 400 mg three times daily for 15 days have been studied in normal weight and obese subjects without significant clinical findings. In addition, doses of 240 mg three times daily have been administered to obese patients for 6 months. The majority of orlistat overdose cases received during post-marketing reported either no adverse reactions or adverse reactions that are similar to those reported with recommended doses of orlistat.
In the event of an overdose, medical advice should be sought. Should a significant overdose of orlistat occur, it is recommended that the patient be observed for 24 hours. Based on human and animal studies, any systemic effects attributable to the lipase-inhibiting properties of orlistat should be rapidly reversible.
5. Pharmacological Properties
5.1 Pharmacodynamic Properties
Pharmacotherapeutic group: antiobesity preparations, excl. diet products, peripherally acting antiobesity products, ATC code A08AB01.
Orlistat is a potent, specific and long-acting inhibitor of gastrointestinal lipases. It exerts its therapeutic activity in the lumen of the stomach and small intestine by forming a covalent bond with the active serine site of the gastric and pancreatic lipases. The inactivated enzyme is thus unavailable to hydrolyse dietary fat, in the form of triglycerides, into absorbable free fatty acids and monoglycerides.
Pharmacodynamic equivalence of alli 27 mg chewable tablets and alli 60 mg hard capsules has been established using a faecal fat excretion model.
From clinical studies, it has been estimated that orlistat 60 mg taken three times daily blocks the absorption of approximately 25% of dietary fat. The effect of orlistat results in an increase in faecal fat as early as 24 to 48 hours after dosing. Upon discontinuation of therapy, faecal fat content returns to pre-treatment levels, usually within 48 to 72 hours.
Two double-blind, randomised, placebo-controlled studies in adults with a BMI 2 support the efficacy of orlistat 60 mg taken three times daily in conjunction with a hypocaloric, lower-fat diet. The primary parameter, change in body weight from baseline (time of randomisation), was assessed for body weight over time (Table 1) and the percentage of subjects who lost
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The weight loss induced by orlistat 60 mg conferred other important health benefits after 6 months of treatment in addition to weight loss. The mean relative change in total cholesterol was -2.4% for orlistat 60 mg (baseline 5.20 mmol/l) and +2.8% for placebo (baseline 5.26 mmol/l). The mean relative change in LDL cholesterol was -3.5% for orlistat 60 mg (baseline 3.30 mmol/l) and +3.8% for placebo (baseline 3.41 mmol/l). For waist circumference, the mean change was -4.5 cm for orlistat 60 mg (baseline 103.7 cm) and -3.6 cm for placebo (baseline 103.5 cm). All comparisons against placebo were statistically significant.
5.2 Pharmacokinetic Properties
Absorption
Studies in normal weight and obese volunteers have shown that the extent of absorption of orlistat was minimal. Plasma concentrations of intact orlistat were non-measurable (<5 ng/ml) 8 hours following oral administration of orlistat 360 mg.
In general, at therapeutic doses, detection of intact orlistat in plasma was sporadic and concentrations were extremely low (<10 ng/ml or 0.02 µmol), with no evidence of accumulation, which is consistent with minimal absorption.
Distribution
The volume of distribution cannot be determined because the active substance is minimally absorbed and has no defined systemic pharmacokinetics. In vitro, orlistat is >99% bound to plasma proteins (lipoproteins and albumin were the major binding proteins). Orlistat minimally partitions into erythrocytes.
Biotransformation
Based on animal data, it is likely that the metabolism of orlistat occurs mainly within the gastrointestinal wall. Based on a study in obese patients, of the minimal fraction of the dose that was absorbed systemically, two major metabolites, M1 (4-member lactone ring hydrolysed) and M3 (M1 with N-formyl leucine moiety cleaved), accounted for approximately 42% of the total plasma concentration.
M1 and M3 have an open beta-lactone ring and extremely weak lipase inhibitory activity (1,000- and 2,500-fold less than orlistat, respectively). In view of this low inhibitory activity and the low plasma levels at therapeutic doses (average of 26 ng/ml and 108 ng/ml, respectively), these metabolites are considered to be pharmacologically inconsequential.
Elimination
Studies in normal weight and obese subjects have shown that faecal excretion of the unabsorbed active substance was the major route of elimination. Approximately 97% of the administered dose was excreted in faeces and 83% of that as unchanged orlistat.
The cumulative renal excretion of total orlistat-related materials was <2% of the given dose. The time to reach complete excretion (faecal plus urinary) was 3 to 5 days. The disposition of orlistat appeared to be similar between normal weight and obese volunteers. Orlistat, M1 and M3 are all subject to biliary excretion.
5.3 Preclinical Safety Data
Nonclinical data reveal no special hazard for humans based on conventional studies of safety pharmacology, repeated dose toxicity, genotoxicity, carcinogenic potential, and toxicity to fertility, reproduction and development.
The medicinal use of orlistat is unlikely to represent a risk to the aquatic or terrestrial environment. However, any possible risk should be avoided (see section 6.6).
6. Pharmaceutical Particulars
6.1 List Of Excipients
Mannitol (E421)
Xylitol (E967)
Anhydrous lactose
Sodium starch glycolate
Microcrystalline cellulose (E460)
Povidone (E1201)
Glycerol dibehenate (E471)
Sucrose monopalmitate (E473)
Sodium stearyl fumarate
Macrogol stearate (E431)
6.2 Incompatibilities
Not applicable.
6.3 Shelf Life
2 years.
Discard any tablets stored in the carry case for more than one month.
6.4 Special Precautions For Storage
Do not store above 25°C.
Keep the container tightly closed in order to protect from moisture.
6.5 Nature And Contents Of Container
HDPE bottle with child resistant closure containing 42, 60, 84, 90 or 120 tablets. The bottle also contains two sealed canisters containing silica gel desiccant.
A polystyrene resin/polyurethane carry case (Shuttle) which can hold 3 tablets is included in each pack.
Not all pack sizes may be marketed.
6.6 Special Precautions For Disposal And Other Handling
Any unused product or waste material should be disposed of in accordance with local requirements.
7. Marketing Authorisation Holder
Glaxo Group Limited
Glaxo Wellcome House
Berkeley Avenue
Greenford
Middlesex
UB6 0NN
United Kingdom
8. Marketing Authorisation Number(S)
EU/1/07/401/012-016
9. Date Of First Authorisation/Renewal Of The Authorisation
Date of first authorisation: 23rd July 2007.
10. Date Of Revision Of The Text
Detailed information on this medicinal product is available on the European Medicines Agency website: http://www.ema.europa.eu
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