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Indications/Uses
Reduction of intraocular pressure (IOP) in patients with open angle glaucoma and ocular hypertension who are insufficiently responsive to topical beta-blockers or prostaglandin analogues.
Dosage/Direction for Use
Ocular use.
Recommended dosage for adults (including the elderly): Recommended therapy is one drop in the affected eye(s) once daily.
If one dose is missed, treatment should continue with the next dose as planned. The dose should not exceed one drop in the affected eye(s) daily.
Paediatric population: The safety and effectiveness of Latanoprost + Timolol in children and adolescents have not been established.
Method of administration: Avoid contact with soft contact lenses.
Contact lenses should be removed before instillation of the eye drops and may be reinserted after 15 minutes apart (see Precautions).
If more than one topical ophthalmic medicinal product is being used, the medicinal products should be administered at least five minutes apart.
When using nasolacrimal occlusion or closing the eyelids for 2 minutes, the systemic absorption is reduced. This may result in a decrease in systemic side effects and an increase in local activity.
Usage Instructions: Patients should be instructed to wash their hands before use and avoid allowing the tip of the container to come into contact with the eye or surrounding structures.
Patients should also be instructed that ocular solutions, if handled improperly, can become contaminated by common bacteria known to cause ocular infections. Serious damage to the eye and subsequent loss of vision may result from using contaminated solutions.
1. Before opening the dropper-container for the first time, make sure the cap is intact.
2. Open the dropper-container by turning the cap to the left.
3. Tilt the head back and gently pull down lower eyelid to form a pouch between the eye and eyelid.
4. Hold the dropper-container upside down and gently press with the thumb and forefinger in the middle of the dropper-container until one drop falls into the pouch. DO NOT LET THE EYE OR EYELID TOUCH THE DROPPER.
5.Repeat steps 3 and 4 in the other eye if the doctor has told the patient to do this.
6.Twist the cap back onto the dropper-container. Do not overtighten the cap.
Recommended dosage for adults (including the elderly): Recommended therapy is one drop in the affected eye(s) once daily.
If one dose is missed, treatment should continue with the next dose as planned. The dose should not exceed one drop in the affected eye(s) daily.
Paediatric population: The safety and effectiveness of Latanoprost + Timolol in children and adolescents have not been established.
Method of administration: Avoid contact with soft contact lenses.
Contact lenses should be removed before instillation of the eye drops and may be reinserted after 15 minutes apart (see Precautions).
If more than one topical ophthalmic medicinal product is being used, the medicinal products should be administered at least five minutes apart.
When using nasolacrimal occlusion or closing the eyelids for 2 minutes, the systemic absorption is reduced. This may result in a decrease in systemic side effects and an increase in local activity.
Usage Instructions: Patients should be instructed to wash their hands before use and avoid allowing the tip of the container to come into contact with the eye or surrounding structures.
Patients should also be instructed that ocular solutions, if handled improperly, can become contaminated by common bacteria known to cause ocular infections. Serious damage to the eye and subsequent loss of vision may result from using contaminated solutions.
1. Before opening the dropper-container for the first time, make sure the cap is intact.
2. Open the dropper-container by turning the cap to the left.
3. Tilt the head back and gently pull down lower eyelid to form a pouch between the eye and eyelid.
4. Hold the dropper-container upside down and gently press with the thumb and forefinger in the middle of the dropper-container until one drop falls into the pouch. DO NOT LET THE EYE OR EYELID TOUCH THE DROPPER.
5.Repeat steps 3 and 4 in the other eye if the doctor has told the patient to do this.
6.Twist the cap back onto the dropper-container. Do not overtighten the cap.
Overdosage
No data are available in humans with regard to overdose with Latanoprost + Timolol.
Symptoms of systemic timolol overdose are: Bradycardia, hypotension, bronchospasm and cardiac arrest. If such symptoms occur, the treatment should be symptomatic and supportive. Studies have shown that timolol does not dialyse readily.
Apart from ocular irritation and conjunctival hyperaemia no other ocular or systemic adverse reactions are known if latanoprost is overdosed.
If latanoprost is accidentally ingested orally the following information may be useful: Treatment: Gastric lavage if needed. Symptomatic treatment. Latanoprost is extensively metabolised during the first pass through the liver. Intravenous infusion of 3 micrograms/kg in healthy volunteers induced no symptoms, but a dose of 5.5-10 micrograms/kg caused nausea, abdominal pain, dizziness, fatigue, hot flushes and sweating. These symptoms were mild to moderate in severity and resolved without treatment, within 4 hours after terminating the infusion.
Symptoms of systemic timolol overdose are: Bradycardia, hypotension, bronchospasm and cardiac arrest. If such symptoms occur, the treatment should be symptomatic and supportive. Studies have shown that timolol does not dialyse readily.
Apart from ocular irritation and conjunctival hyperaemia no other ocular or systemic adverse reactions are known if latanoprost is overdosed.
If latanoprost is accidentally ingested orally the following information may be useful: Treatment: Gastric lavage if needed. Symptomatic treatment. Latanoprost is extensively metabolised during the first pass through the liver. Intravenous infusion of 3 micrograms/kg in healthy volunteers induced no symptoms, but a dose of 5.5-10 micrograms/kg caused nausea, abdominal pain, dizziness, fatigue, hot flushes and sweating. These symptoms were mild to moderate in severity and resolved without treatment, within 4 hours after terminating the infusion.
Contraindications
Latanoprost + Timolol is contraindicated in patients with: Reactive airway disease including bronchial asthma or a history of bronchial asthma, severe chronic obstructive pulmonary disease. Sinus bradycardia, sick sinus syndrome sino-atrial block, second or third degree atrioventricular block not controlled with pacemaker, overt cardiac failure, cardiogenic shock. Hypersensitivity to the active substances latanoprost and timolol.
Special Precautions
Systemic effects: Like other topically applied ophthalmic agents, Timolol is absorbed systemically. Due to beta-adrenergic component timolol, the same types of cardiovascular, pulmonary and other adverse reactions seen with systemic beta-adrenergic blocking agents may occur. Incidence of systemic ADRs after topical ophthalmic administration is lower than for systemic administration. To reduce the systemic absorption, see Dosage & Administration.
Cardiac disorders: In patients with cardiovascular diseases (e.g. coronary heart disease, Prinzmetal's angina and cardiac failure) and hypotension therapy with beta-blockers should be critically assessed and the therapy with other active substances should be considered. Patients with cardiovascular diseases should be watched for signs of deterioration of these diseases and of adverse reactions.
Due to its negative effect on conduction time, beta-blockers should only be given with caution to patients with first degree heart block.
Vascular disorders: Patients with severe peripheral circulatory disturbance/disorders (i.e. severe forms of Raynaud's disease or Raynaud's syndrome) should be treated with caution.
Respiratory disorders: Respiratory reactions, including death due to bronchospasm in patients with asthma have been reported following administration of some ophthalmic beta-blockers.
Latanoprost + Timolol should be used with caution in patients with mild/moderate chronic obstructive pulmonary disease (COPD) and only if the potential benefit outweighs the potential risk.
Hypoglycaemia/diabetes: Beta-blockers should be administered with caution in patients subject to spontaneous hypoglycaemia or to patients with labile diabetes, as beta-blockers may mask the signs and symptoms of acute hypoglycaemia.
Beta-blockers may also mask the signs of hyperthyroidism.
Corneal diseases: Ophthalmic β-blockers may induce dryness of eyes. Patients with corneal diseases should be treated with caution.
Other beta-blocking agents: The effect on intra-ocular pressure or the known effects of systemic beta-blockade may be potentiated when timolol is given to the patients already receiving a systemic beta-blocking agent. The response of these patients should be closely observed. The use of two topical beta-adrenergic blocking agents is not recommended (see Interactions).
Anaphylactic reactions: While taking beta-blockers, patients with a history of atopy or a history of severe anaphylactic reaction to a variety of allergens may be more reactive to repeated challenge with such allergens and unresponsive to the usual doses of adrenaline used to treat anaphylactic reactions.
Choroidal detachment: Choroidal detachment has been reported with administration of aqueous suppressant therapy (e.g. timolol, acetazolamide) after filtration procedures.
Surgical anaesthesia: β-blocking ophthalmological preparations may block systemic β-agonist effects e.g. of adrenaline. The anaesthesiologist should be informed when the patient is receiving timolol.
Concomitant therapy: Timolol may interact with other medicinal products, see also Interactions.
Ocular effects: Latanoprost may gradually change eye colour by increasing the amount of brown pigment in the iris. Similar to experience with latanoprost eye drops, increased iris pigmentation was seen in 16-20% of all patients treated with latanoprost/timolol for up to one year (based on photographs). This effect has predominantly been seen in patients with mixed coloured irides, i.e. green-brown, yellow-brown or blue/grey-brown, and is due to increased melanin content in the stromal melanocytes of the iris. Typically the brown pigmentation around the pupil spreads concentrically towards the periphery in affected eyes, but the entire iris or parts of it may become more brownish. In patients with homogeneously blue, grey, green or brown eyes, the change has only rarely been seen during two years of treatment in clinical trials with latanoprost.
The change in iris colour occurs slowly and may not be noticeable for several months to years and it has not been associated with any other symptoms or pathological changes.
No further increase in brown iris pigment has been observed after discontinuation of treatment, but the resultant colour change may be permanent.
Neither naevi nor freckles of the iris have been affected by treatment.
Accumulation of pigment in the trabecular meshwork or elsewhere in the anterior chamber has not been observed, but patients should be examined regularly and, depending on the clinical situation, treatment may be stopped if increased iris pigmentation ensues.
Before treatment is instituted patients should be informed of the possibility of a change in eye colour. Unilateral treatment can result in permanent heterochromia.
There is no documented experience with latanoprost in inflammatory, neovascular, chronic angle closure or congenital glaucoma, in open angle glaucoma of pseudophakic patients and in pigmentary glaucoma. Latanoprost has no or little effect on the pupil, but there is no documented experience in acute attacks of closed angle glaucoma. Therefore, it is recommended that Latanoprost + Timolol should be used with caution in these conditions until more experience is obtained.
Latanoprost should be used with caution in patients with a history of herpetic keratitis, and should be avoided in cases of active herpes simplex keratitis and in patients with a history of recurrent herpetic keratitis specifically associated with prostaglandin analogues.
Macular oedema, including cystoid macular oedema, has been reported during treatment with latanoprost. These reports have mainly occurred in aphakic patients, in pseudophakic patients with a torn posterior lens capsule, or in patients with known risk factors for macular oedema. Latanoprost + Timolol should be used with caution in these patients.
Anti-doping test: The use of Latanoprost + Timolol may produce positive results in doping controls.
Use of contact lenses: Latanoprost + Timolol contains benzalkonium chloride, which is commonly used as a preservative in ophthalmic products. Benzalkonium chloride has been reported to cause punctate keratopathy and/or toxic ulcerative keratopathy, may cause eye irritation and is known to discolour soft contact lenses. Close monitoring is required with frequent or prolonged use of Latanoprost + Timolol in dry eye patients, or in conditions where the cornea is compromised.
Avoid contact with soft contact lenses. Remove contact lenses prior application and wait at least 15 minutes before reinsertion. Known to discolour soft contact lenses. (See Dosage & Administration).
Effects on ability to drive and use machines: Latanoprost + Timolol has major influence on the ability to drive and use machines.
Instillation of eye drops may cause transient blurting of vision. Until this is resolved, patients should not drive or use machines.
Cardiac disorders: In patients with cardiovascular diseases (e.g. coronary heart disease, Prinzmetal's angina and cardiac failure) and hypotension therapy with beta-blockers should be critically assessed and the therapy with other active substances should be considered. Patients with cardiovascular diseases should be watched for signs of deterioration of these diseases and of adverse reactions.
Due to its negative effect on conduction time, beta-blockers should only be given with caution to patients with first degree heart block.
Vascular disorders: Patients with severe peripheral circulatory disturbance/disorders (i.e. severe forms of Raynaud's disease or Raynaud's syndrome) should be treated with caution.
Respiratory disorders: Respiratory reactions, including death due to bronchospasm in patients with asthma have been reported following administration of some ophthalmic beta-blockers.
Latanoprost + Timolol should be used with caution in patients with mild/moderate chronic obstructive pulmonary disease (COPD) and only if the potential benefit outweighs the potential risk.
Hypoglycaemia/diabetes: Beta-blockers should be administered with caution in patients subject to spontaneous hypoglycaemia or to patients with labile diabetes, as beta-blockers may mask the signs and symptoms of acute hypoglycaemia.
Beta-blockers may also mask the signs of hyperthyroidism.
Corneal diseases: Ophthalmic β-blockers may induce dryness of eyes. Patients with corneal diseases should be treated with caution.
Other beta-blocking agents: The effect on intra-ocular pressure or the known effects of systemic beta-blockade may be potentiated when timolol is given to the patients already receiving a systemic beta-blocking agent. The response of these patients should be closely observed. The use of two topical beta-adrenergic blocking agents is not recommended (see Interactions).
Anaphylactic reactions: While taking beta-blockers, patients with a history of atopy or a history of severe anaphylactic reaction to a variety of allergens may be more reactive to repeated challenge with such allergens and unresponsive to the usual doses of adrenaline used to treat anaphylactic reactions.
Choroidal detachment: Choroidal detachment has been reported with administration of aqueous suppressant therapy (e.g. timolol, acetazolamide) after filtration procedures.
Surgical anaesthesia: β-blocking ophthalmological preparations may block systemic β-agonist effects e.g. of adrenaline. The anaesthesiologist should be informed when the patient is receiving timolol.
Concomitant therapy: Timolol may interact with other medicinal products, see also Interactions.
Ocular effects: Latanoprost may gradually change eye colour by increasing the amount of brown pigment in the iris. Similar to experience with latanoprost eye drops, increased iris pigmentation was seen in 16-20% of all patients treated with latanoprost/timolol for up to one year (based on photographs). This effect has predominantly been seen in patients with mixed coloured irides, i.e. green-brown, yellow-brown or blue/grey-brown, and is due to increased melanin content in the stromal melanocytes of the iris. Typically the brown pigmentation around the pupil spreads concentrically towards the periphery in affected eyes, but the entire iris or parts of it may become more brownish. In patients with homogeneously blue, grey, green or brown eyes, the change has only rarely been seen during two years of treatment in clinical trials with latanoprost.
The change in iris colour occurs slowly and may not be noticeable for several months to years and it has not been associated with any other symptoms or pathological changes.
No further increase in brown iris pigment has been observed after discontinuation of treatment, but the resultant colour change may be permanent.
Neither naevi nor freckles of the iris have been affected by treatment.
Accumulation of pigment in the trabecular meshwork or elsewhere in the anterior chamber has not been observed, but patients should be examined regularly and, depending on the clinical situation, treatment may be stopped if increased iris pigmentation ensues.
Before treatment is instituted patients should be informed of the possibility of a change in eye colour. Unilateral treatment can result in permanent heterochromia.
There is no documented experience with latanoprost in inflammatory, neovascular, chronic angle closure or congenital glaucoma, in open angle glaucoma of pseudophakic patients and in pigmentary glaucoma. Latanoprost has no or little effect on the pupil, but there is no documented experience in acute attacks of closed angle glaucoma. Therefore, it is recommended that Latanoprost + Timolol should be used with caution in these conditions until more experience is obtained.
Latanoprost should be used with caution in patients with a history of herpetic keratitis, and should be avoided in cases of active herpes simplex keratitis and in patients with a history of recurrent herpetic keratitis specifically associated with prostaglandin analogues.
Macular oedema, including cystoid macular oedema, has been reported during treatment with latanoprost. These reports have mainly occurred in aphakic patients, in pseudophakic patients with a torn posterior lens capsule, or in patients with known risk factors for macular oedema. Latanoprost + Timolol should be used with caution in these patients.
Anti-doping test: The use of Latanoprost + Timolol may produce positive results in doping controls.
Use of contact lenses: Latanoprost + Timolol contains benzalkonium chloride, which is commonly used as a preservative in ophthalmic products. Benzalkonium chloride has been reported to cause punctate keratopathy and/or toxic ulcerative keratopathy, may cause eye irritation and is known to discolour soft contact lenses. Close monitoring is required with frequent or prolonged use of Latanoprost + Timolol in dry eye patients, or in conditions where the cornea is compromised.
Avoid contact with soft contact lenses. Remove contact lenses prior application and wait at least 15 minutes before reinsertion. Known to discolour soft contact lenses. (See Dosage & Administration).
Effects on ability to drive and use machines: Latanoprost + Timolol has major influence on the ability to drive and use machines.
Instillation of eye drops may cause transient blurting of vision. Until this is resolved, patients should not drive or use machines.
Use In Pregnancy & Lactation
Pregnancy: Latanoprost: There are no adequate data from the use of lantanoprost in pregnant women. Studies in animals have shown reproductive toxicity (see Pharmacology: Toxicology: Preclinical safety data under Actions). The potential risk for humans is unknown.
Timolol: There are no adequate data for the use of timolol in pregnant women. Timolol should not be used during pregnancy unless clearly necessary. To reduce the systemic absorption see Dosage & Administration.
Epidemiological studies have not revealed malformative effects but show a risk for intra uterine growth retardation when beta-blockers are administered by the oral route. In addition, signs and symptoms of beta-blockade (e.g. bradycardia, hypotension, respiratory distress and hypoglycaemia) have been observed in the neonate when beta-blockers have been administered until delivery. If Latanoprost + Timolol is administered until delivery, the neonate should be carefully monitored during the first days of life.
Consequently, Latanoprost + Timolol should not be used during pregnancy (see Pharmacology: Toxicology: Preclinical safety data under Actions).
Breastfeeding: Beta-blockers are excreted in breast milk. However, at therapeutic doses of timolol in eye drops it is not likely that sufficient amounts would be present in breast milk to produce clinical symptoms of beta-blockade in the infant. To reduce the systemic absorption, see Dosage & Administration.
Latanoprost and its metabolites may pass into breast milk. Latanoprost + Timolol should therefore not be used in women who are breastfeeding.
Fertility: Latanoprost: No effects on male and female fertility in rats have been established.
Timolol: No effects on male and female fertility in rats were shown.
Timolol: There are no adequate data for the use of timolol in pregnant women. Timolol should not be used during pregnancy unless clearly necessary. To reduce the systemic absorption see Dosage & Administration.
Epidemiological studies have not revealed malformative effects but show a risk for intra uterine growth retardation when beta-blockers are administered by the oral route. In addition, signs and symptoms of beta-blockade (e.g. bradycardia, hypotension, respiratory distress and hypoglycaemia) have been observed in the neonate when beta-blockers have been administered until delivery. If Latanoprost + Timolol is administered until delivery, the neonate should be carefully monitored during the first days of life.
Consequently, Latanoprost + Timolol should not be used during pregnancy (see Pharmacology: Toxicology: Preclinical safety data under Actions).
Breastfeeding: Beta-blockers are excreted in breast milk. However, at therapeutic doses of timolol in eye drops it is not likely that sufficient amounts would be present in breast milk to produce clinical symptoms of beta-blockade in the infant. To reduce the systemic absorption, see Dosage & Administration.
Latanoprost and its metabolites may pass into breast milk. Latanoprost + Timolol should therefore not be used in women who are breastfeeding.
Fertility: Latanoprost: No effects on male and female fertility in rats have been established.
Timolol: No effects on male and female fertility in rats were shown.
Adverse Reactions
For latanoprost, the majority of adverse reactions relate to the ocular system. In data from the extension phase of the latanoprost/timolol trials, 16 - 20% of patients developed increased iris pigmentation, which may be permanent. In an open 5-year latanoprost safety study, 33% of patients developed iris pigmentation (see Precautions). Other ocular adverse reactions are generally transient and occur on dose administration. For timolol, the most serious adverse reactions are systemic in nature, including bradycardia, arrhythmia, congestive heart failure, bronchospasm and allergic reactions.
Like other topically applied ophthalmic drugs, timolol is absorbed into the systemic circulation. This may cause similar undesirable effects as seen with systemic beta-blocking agents. Incidence of systemic ADRs after topical ophthalmic administration is lower than for systemic administration. Listed adverse reactions include reactions seen within the class of ophthalmic beta-blockers.
Latanoprost/timolol-related adverse reactions seen in clinical trials are listed as follows.
Adverse reactions are categorised by frequency as follows: Very common (≥1/10);Common (≥1/100 to <1/10);Uncommon (≥1/1,000 to <1/100);Rare (≥1/10,000 to <1/1,000);Very rare (<1/10,000); Not known: cannot be estimated from the available data.
Nervous System Disorders: Uncommon: Headache.
Eye disorders: Very common: Increased iris pigmentation; mild to moderate conjunctival hyperaemia; eye irritation (burning grittiness, itching, stinging and foreign body sensation); eye and vellus hair changes (increased length, thickness, pigmentation and number) (vast majority of reports in Japanese population).
Common: Transient punctate epithelial erosions, mostly without symptoms; blepharitis; eye pain.
Uncommon: Eyelid oedema: dry eye; keratitis; vision blurred; conjunctivitis.
Rare: Iritis/uveitis (the majority of reports in patients with concomitant predisposing factors); macular oedema; symptomatic corneal oedema and erosions; periorbital oedema; misdirected eyelashes sometimes resulting in eye irritation; extra row of cilia at the aperture of the meibomian glands (distichiasis).
Not known: Iris cyst.
Skin and subcutaneous tissue disorders: Uncommon: Skin rash, pruritus.
Additional adverse reactions have been reported specific to the use of the individual components of Latanoprost + Timolol in either clinical studies, spontaneous reports or in the available literature.
For latanoprost, these are: Infections and Infestations: Herpetic Keratitis.
Nervous system disorders: Dizziness.
Eye disorders: Very common: Eyelash and vellus hair changes (increased length, thickness, pigmentation, and number), Punctate corneal epithelial erosions, periorbital oedema, iritis/uveitis, macular oedema (in aphakic, pseudophakic patients with tom posterior lens capsules or in patients with known risk factors for macular oedema), dry eye, keratitis, corneal oedema and erosions, misdirected eyelashes sometimes resulting in eye irritation, iris cyst.
Cardiac disorders: Aggravation of angina in patients with pre-existing disease, palpitations.
Respiratory, thoracic and mediastinal disorders: Asthma, asthma aggravation, dyspnoea.
Skin and subcutaneous tissue disorders: Darkening of palpebral skin.
Musculoskeletal and connective tissue disorders: Joint pain, muscle pain.
General disorders and administration site conditions: Chest pain.
For timolol, these are: Immune system disorders: Systemic allergic reactions including angiooedema, urticaria, localised and generalised rash, pruritus, anaphylactic reaction.
Metabolism and nutrition disorders: Hypoglycaemia.
Psychiatric disorders: Insomnia, depression, nightmares, memory loss.
Nervous system disorders: Syncope, cerebrovascular accident, cerebral ischemia, increases in signs and symptoms of myasthenia gravis, dizziness, paraesthesia, headache.
Eye disorders: Signs and symptoms of ocular irritation (e.g. burning, stinging, itching, tearing, redness), blepharitis, keratitis, blurred vision and choroidal detachment following filtration surgery (see Precautions), decreased corneal sensitivity, dry eyes, corneal erosion ptosis, diplopia.
Cardiac disorders: Bradycardia, chest pain, palpitations, oedema, arrhythmia, congestive heart failure, atrioventricular block, cardiac arrest, cardiac failure.
Vascular disorders: Hypotension, Raynaud's phenomenon, cold hands and feet.
Respiratory, thoracic and mediastinal disorders: Bronchospasm (predominantly in patients with pre-existing bronchospastic disease), dyspnoea, cough.
Gastrointestinal disorders: Dysgeusia, nausea, dyspepsia, diarrhoea, dry mouth, abdominal pain, vomiting.
Skin and subcutaneous tissue disorders: Alopecia, psoriasiform rash or exacerbation of psoriasis, skin rash.
Musculoskeletal and connective tissue disorders: Myalgia.
Reproductive system and breast disorders: Sexual dysfunction, decreased libido.
General Disorders and Administration Site Conditions: Asthenia/fatigue.
Like other topically applied ophthalmic drugs, timolol is absorbed into the systemic circulation. This may cause similar undesirable effects as seen with systemic beta-blocking agents. Incidence of systemic ADRs after topical ophthalmic administration is lower than for systemic administration. Listed adverse reactions include reactions seen within the class of ophthalmic beta-blockers.
Latanoprost/timolol-related adverse reactions seen in clinical trials are listed as follows.
Adverse reactions are categorised by frequency as follows: Very common (≥1/10);Common (≥1/100 to <1/10);Uncommon (≥1/1,000 to <1/100);Rare (≥1/10,000 to <1/1,000);Very rare (<1/10,000); Not known: cannot be estimated from the available data.
Nervous System Disorders: Uncommon: Headache.
Eye disorders: Very common: Increased iris pigmentation; mild to moderate conjunctival hyperaemia; eye irritation (burning grittiness, itching, stinging and foreign body sensation); eye and vellus hair changes (increased length, thickness, pigmentation and number) (vast majority of reports in Japanese population).
Common: Transient punctate epithelial erosions, mostly without symptoms; blepharitis; eye pain.
Uncommon: Eyelid oedema: dry eye; keratitis; vision blurred; conjunctivitis.
Rare: Iritis/uveitis (the majority of reports in patients with concomitant predisposing factors); macular oedema; symptomatic corneal oedema and erosions; periorbital oedema; misdirected eyelashes sometimes resulting in eye irritation; extra row of cilia at the aperture of the meibomian glands (distichiasis).
Not known: Iris cyst.
Skin and subcutaneous tissue disorders: Uncommon: Skin rash, pruritus.
Additional adverse reactions have been reported specific to the use of the individual components of Latanoprost + Timolol in either clinical studies, spontaneous reports or in the available literature.
For latanoprost, these are: Infections and Infestations: Herpetic Keratitis.
Nervous system disorders: Dizziness.
Eye disorders: Very common: Eyelash and vellus hair changes (increased length, thickness, pigmentation, and number), Punctate corneal epithelial erosions, periorbital oedema, iritis/uveitis, macular oedema (in aphakic, pseudophakic patients with tom posterior lens capsules or in patients with known risk factors for macular oedema), dry eye, keratitis, corneal oedema and erosions, misdirected eyelashes sometimes resulting in eye irritation, iris cyst.
Cardiac disorders: Aggravation of angina in patients with pre-existing disease, palpitations.
Respiratory, thoracic and mediastinal disorders: Asthma, asthma aggravation, dyspnoea.
Skin and subcutaneous tissue disorders: Darkening of palpebral skin.
Musculoskeletal and connective tissue disorders: Joint pain, muscle pain.
General disorders and administration site conditions: Chest pain.
For timolol, these are: Immune system disorders: Systemic allergic reactions including angiooedema, urticaria, localised and generalised rash, pruritus, anaphylactic reaction.
Metabolism and nutrition disorders: Hypoglycaemia.
Psychiatric disorders: Insomnia, depression, nightmares, memory loss.
Nervous system disorders: Syncope, cerebrovascular accident, cerebral ischemia, increases in signs and symptoms of myasthenia gravis, dizziness, paraesthesia, headache.
Eye disorders: Signs and symptoms of ocular irritation (e.g. burning, stinging, itching, tearing, redness), blepharitis, keratitis, blurred vision and choroidal detachment following filtration surgery (see Precautions), decreased corneal sensitivity, dry eyes, corneal erosion ptosis, diplopia.
Cardiac disorders: Bradycardia, chest pain, palpitations, oedema, arrhythmia, congestive heart failure, atrioventricular block, cardiac arrest, cardiac failure.
Vascular disorders: Hypotension, Raynaud's phenomenon, cold hands and feet.
Respiratory, thoracic and mediastinal disorders: Bronchospasm (predominantly in patients with pre-existing bronchospastic disease), dyspnoea, cough.
Gastrointestinal disorders: Dysgeusia, nausea, dyspepsia, diarrhoea, dry mouth, abdominal pain, vomiting.
Skin and subcutaneous tissue disorders: Alopecia, psoriasiform rash or exacerbation of psoriasis, skin rash.
Musculoskeletal and connective tissue disorders: Myalgia.
Reproductive system and breast disorders: Sexual dysfunction, decreased libido.
General Disorders and Administration Site Conditions: Asthenia/fatigue.
Drug Interactions
Specific medicinal product interaction studies have not been performed with Latanoprost + Timolol.
There have been reports of paradoxical elevations in intraocular pressure following the concomitant ophthalmic administration of two prostaglandin analogues. Therefore, the use of two or more prostaglandins, prostaglandin analogues, or prostaglandin derivatives is not recommended.
The effect on intraocular pressure or the known effects of systemic beta-blockade may be potentiated when Latanoprost + Timolol is given to patients already receiving an oral beta-adrenergic blocking agent, and the use of two or more topical beta-adrenergic blocking agents is not recommended.
There is a potential for additive effects resulting in hypotension and/or marked bradycardia when ophthalmic beta-blockers solution is administered concomitantly with oral calcium channel blockers, beta-adrenergic blocking agents, antiarrhythmics (including amiodarone), digitalis glycosides, parasympathomimetics, guanethidine.
Mydriasis has occasionally been reported when timolol was given with epinephrine. No specific drug interaction studies have been performed with timolol.
The hypertensive reaction to sudden withdrawal of clonidine can be potentiated when taking beta-blockers. Beta-blockers may increase the hypoglycaemic effect of anti-diabetic agents. Beta-blockers can mask the signs and symptoms of hypoglycaemia (see Precautions).
Potentiated systemic beta-blockade (e.g. decreased heart rate, depression) has been reported during combined treatment with CYP2D6 inhibitors (e.g. quinidine, fluoxetine, paroxetine) and timolol.
There have been reports of paradoxical elevations in intraocular pressure following the concomitant ophthalmic administration of two prostaglandin analogues. Therefore, the use of two or more prostaglandins, prostaglandin analogues, or prostaglandin derivatives is not recommended.
The effect on intraocular pressure or the known effects of systemic beta-blockade may be potentiated when Latanoprost + Timolol is given to patients already receiving an oral beta-adrenergic blocking agent, and the use of two or more topical beta-adrenergic blocking agents is not recommended.
There is a potential for additive effects resulting in hypotension and/or marked bradycardia when ophthalmic beta-blockers solution is administered concomitantly with oral calcium channel blockers, beta-adrenergic blocking agents, antiarrhythmics (including amiodarone), digitalis glycosides, parasympathomimetics, guanethidine.
Mydriasis has occasionally been reported when timolol was given with epinephrine. No specific drug interaction studies have been performed with timolol.
The hypertensive reaction to sudden withdrawal of clonidine can be potentiated when taking beta-blockers. Beta-blockers may increase the hypoglycaemic effect of anti-diabetic agents. Beta-blockers can mask the signs and symptoms of hypoglycaemia (see Precautions).
Potentiated systemic beta-blockade (e.g. decreased heart rate, depression) has been reported during combined treatment with CYP2D6 inhibitors (e.g. quinidine, fluoxetine, paroxetine) and timolol.
Caution For Usage
Incompatibilities: In vitro studies have shown that precipitation occurs when eye drops containing thiomersal are mixed with latanoprost. If such medicinal products are used concomitantly with Latanoprost + Timolol, the eye drops should be administered with an interval of at least five minutes.
Special precautions for disposal and other handling: No special requirements for disposal.
Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
Special precautions for disposal and other handling: No special requirements for disposal.
Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
Storage
Shelf life: Unopened dropper container 2 years.
After first opening the dropper container 4 weeks.
Special precautions for storage: Store in a refrigerator (2°C - 8°C). Store in the original package in order to protect from light.
After first opening: Do not store above 25°C.
Keep the dropper container in the outer carton in order to protect from light.
After first opening the dropper container 4 weeks.
Special precautions for storage: Store in a refrigerator (2°C - 8°C). Store in the original package in order to protect from light.
After first opening: Do not store above 25°C.
Keep the dropper container in the outer carton in order to protect from light.
Action
Pharmacotherapeutic group: Ophthalmological-beta blocking agents-timolol, combinations. ATC code: S01ED51.
Pharmacology: Pharmacodynamics: Clinical effects: In dose finding studies, latanoprost + timolol produced significantly greater decreases in mean diurnal IOP compared to latanoprost and timolol administered once daily as monotherapy. In two well controlled, double masked six-month clinical studies the IOP reducing effect of latanoprost + timolol was compared with latanoprost and timolol monotherapy in patients with an IOP of at least 25 mmHg or greater. Following a 2-4 week run-in with timolol (mean decrease in IOP from enrollment of 5 mm Hg), additional decreases in mean diurnal IOP of 3.1 with latanoprost + timolol, 2.0 with latanoprost and 0.6 mm Hg with timolol (twice daily) were observed after 6 months of treatment for latanoprost and timolol (twice daily), respectively. The IOP lowering effect of latanoprost + timolol was maintained in 6 month open label extensions of these studies.
Existing data suggest that evening dosing is more effective in IOP lowering than morning dosing. However, when considering a recommendation of either morning or evening dosing, sufficient consideration should be given to the lifestyle of the patient and their likely compliance.
It should be kept in mind that in case of insufficient efficacy of the fixed combination, results from studies indicate that the use of unfixed administration of timolol bid and latanoprost once a day might be still efficient.
Onset of action of Latanoprost + Timolol is within one hour and maximal effect occurs within six to eight hours. Adequate IOP reducing effect has been shown to be present for 24 hours post-dose after multiple treatments.
Mechanism of action: Latanoprost + Timolol contains two active substances: latanoprost and timolol maleate. These two components decrease elevated intraocular pressure (IOP) by different mechanisms of action, and the combined effect results in additional IOP reduction compared to either compound administered alone.
Latanoprost, a prostaglandin F2α analogue, is a selective prostanoid FP receptor agonist that reduces the IOP by increasing the outflow of aqueous humour. The main mechanism of action is increased uveoscleral outflow. Additionally, some increase in outflow facility (decrease in trabecular outflow resistance) has been reported in man. Latanoprost has no significant effect on the production of aqueous humour, the blood-aqueous barrier or the intraocular blood circulation. Chronic treatment with latanoprost in monkey eyes, which had undergone extracapsular lens extraction, did not affect the retinal blood vessels as determined by fluorescein angiography. Latanoprost has not induced fluorescein leakage in the posterior segment of pseudophakic human eyes during short-term treatment.
Timolol is a beta-1 and beta-2 (non-selective) adrenergic receptor blocking agent that has no significant intrinsic sympathomimetic, direct myocardial depressant or membrane-stabilising activity. Timolol lowers IOP by decreasing the formation of aqueous in the ciliary epithelium.
The precise mechanism of action is not clearly established, but inhibition of the increased cyclic AMP synthesis caused by endogenous beta-adrenergic stimulation is probable. Timolol has not been found to significantly affect the permeability of the blood-aqueous barrier to plasma proteins. In rabbits, timolol was without effect on ocular blood flow after chronic treatment.
Pharmacokinetics: Latanoprost: Latanoprost is an isopropyl ester prodrug, which per se is inactive, but after hydrolysis by esterases in the cornea to the acid of latanoprost, becomes biologically active. The prodrug is well absorbed through the cornea, and all drugs that enter the aqueous humour is hydrolysed during the passage through the cornea. Studies in man indicate that the maximum concentration in the aqueous humour approximately 15-30 ng/mL, is reached about 2 hours after topical administration of latanoprost alone. After topical application in monkey eyes latanoprost is distributed primarily in the anterior segment, the conjunctiva and the eye lids.
The acid of latanoprost has a plasma clearance of 0.40 L/h/kg and a small volume of distribution (0.16 L/kg), resulting in a rapid half life in plasma, 17 minutes. After topical ocular administration the systemic bioavailability of the acid of latanoprost is 45%. The acid of latanoprost has a plasma protein binding of 87%.
There is practically no metabolism of the acid of latanoprost in the eye. The main metabolism occurs in the liver. The main metabolites, the 1,2-dinor and 1,2,3,4-tetranor metabolites, exert no or only weak biological activity in animal studies and are excreted primarily in the urine.
Timolol: The maximum concentration of timolol in the aqueous humour is reached about 1 hour after topical administration of eye drops. Part of the dose is absorbed systemically, and a maximum plasma concentration of 1 ng/mL is reached 10-20 minutes after topical administration of one eye drop to each eye once daily (300 micrograms/day). The half life of timolol in plasma is about 6 hours. Timolol is extensively metabolised in the liver. The metabolites are excreted in the urine together with unchanged timolol.
Latanoprost + Timolol: No pharmacokinetic interactions between latanoprost and timolol were observed although there was an approximate 2-fold increased concentration of the acid of latanoprost in aqueous humour 1-4 hours after administration of Latanoprost + Timolol compared to monotherapy.
Toxicology: Preclinical safety data: The ocular and systemic safety profile of the two active substances is well established. No adverse ocular or systemic effects were seen in rabbits treated topically with the fixed combination or with concomitantly administered latanoprost and timolol ophthalmic solutions. Safety pharmacology, genotoxicity and carcinogenicity studies with each of the components revealed no special hazards for humans. Latanoprost did not affect corneal wound healing in the rabbit eye, whereas timolol inhibited the process in the rabbit and the monkey eye when administered more frequently than once a day.
For latanoprost, no effects on male and female fertility in rats and no teratogenic potential in rats and rabbits have been established. No embryotoxicity was observed in rats after intravenous doses of up to 250 micrograms/kg/day. However, latanoprost caused embryofetal toxicity, characterised by increased incidence of late resorption and abortion and by reduced foetal weight, in rabbits at intravenous doses of 5 micrograms/kg/day (approximately 100 times the clinical dose) and above. Timolol showed no effects on male and female fertility in rats or teratogenic potential in mice, rats and rabbits.
Pharmacology: Pharmacodynamics: Clinical effects: In dose finding studies, latanoprost + timolol produced significantly greater decreases in mean diurnal IOP compared to latanoprost and timolol administered once daily as monotherapy. In two well controlled, double masked six-month clinical studies the IOP reducing effect of latanoprost + timolol was compared with latanoprost and timolol monotherapy in patients with an IOP of at least 25 mmHg or greater. Following a 2-4 week run-in with timolol (mean decrease in IOP from enrollment of 5 mm Hg), additional decreases in mean diurnal IOP of 3.1 with latanoprost + timolol, 2.0 with latanoprost and 0.6 mm Hg with timolol (twice daily) were observed after 6 months of treatment for latanoprost and timolol (twice daily), respectively. The IOP lowering effect of latanoprost + timolol was maintained in 6 month open label extensions of these studies.
Existing data suggest that evening dosing is more effective in IOP lowering than morning dosing. However, when considering a recommendation of either morning or evening dosing, sufficient consideration should be given to the lifestyle of the patient and their likely compliance.
It should be kept in mind that in case of insufficient efficacy of the fixed combination, results from studies indicate that the use of unfixed administration of timolol bid and latanoprost once a day might be still efficient.
Onset of action of Latanoprost + Timolol is within one hour and maximal effect occurs within six to eight hours. Adequate IOP reducing effect has been shown to be present for 24 hours post-dose after multiple treatments.
Mechanism of action: Latanoprost + Timolol contains two active substances: latanoprost and timolol maleate. These two components decrease elevated intraocular pressure (IOP) by different mechanisms of action, and the combined effect results in additional IOP reduction compared to either compound administered alone.
Latanoprost, a prostaglandin F2α analogue, is a selective prostanoid FP receptor agonist that reduces the IOP by increasing the outflow of aqueous humour. The main mechanism of action is increased uveoscleral outflow. Additionally, some increase in outflow facility (decrease in trabecular outflow resistance) has been reported in man. Latanoprost has no significant effect on the production of aqueous humour, the blood-aqueous barrier or the intraocular blood circulation. Chronic treatment with latanoprost in monkey eyes, which had undergone extracapsular lens extraction, did not affect the retinal blood vessels as determined by fluorescein angiography. Latanoprost has not induced fluorescein leakage in the posterior segment of pseudophakic human eyes during short-term treatment.
Timolol is a beta-1 and beta-2 (non-selective) adrenergic receptor blocking agent that has no significant intrinsic sympathomimetic, direct myocardial depressant or membrane-stabilising activity. Timolol lowers IOP by decreasing the formation of aqueous in the ciliary epithelium.
The precise mechanism of action is not clearly established, but inhibition of the increased cyclic AMP synthesis caused by endogenous beta-adrenergic stimulation is probable. Timolol has not been found to significantly affect the permeability of the blood-aqueous barrier to plasma proteins. In rabbits, timolol was without effect on ocular blood flow after chronic treatment.
Pharmacokinetics: Latanoprost: Latanoprost is an isopropyl ester prodrug, which per se is inactive, but after hydrolysis by esterases in the cornea to the acid of latanoprost, becomes biologically active. The prodrug is well absorbed through the cornea, and all drugs that enter the aqueous humour is hydrolysed during the passage through the cornea. Studies in man indicate that the maximum concentration in the aqueous humour approximately 15-30 ng/mL, is reached about 2 hours after topical administration of latanoprost alone. After topical application in monkey eyes latanoprost is distributed primarily in the anterior segment, the conjunctiva and the eye lids.
The acid of latanoprost has a plasma clearance of 0.40 L/h/kg and a small volume of distribution (0.16 L/kg), resulting in a rapid half life in plasma, 17 minutes. After topical ocular administration the systemic bioavailability of the acid of latanoprost is 45%. The acid of latanoprost has a plasma protein binding of 87%.
There is practically no metabolism of the acid of latanoprost in the eye. The main metabolism occurs in the liver. The main metabolites, the 1,2-dinor and 1,2,3,4-tetranor metabolites, exert no or only weak biological activity in animal studies and are excreted primarily in the urine.
Timolol: The maximum concentration of timolol in the aqueous humour is reached about 1 hour after topical administration of eye drops. Part of the dose is absorbed systemically, and a maximum plasma concentration of 1 ng/mL is reached 10-20 minutes after topical administration of one eye drop to each eye once daily (300 micrograms/day). The half life of timolol in plasma is about 6 hours. Timolol is extensively metabolised in the liver. The metabolites are excreted in the urine together with unchanged timolol.
Latanoprost + Timolol: No pharmacokinetic interactions between latanoprost and timolol were observed although there was an approximate 2-fold increased concentration of the acid of latanoprost in aqueous humour 1-4 hours after administration of Latanoprost + Timolol compared to monotherapy.
Toxicology: Preclinical safety data: The ocular and systemic safety profile of the two active substances is well established. No adverse ocular or systemic effects were seen in rabbits treated topically with the fixed combination or with concomitantly administered latanoprost and timolol ophthalmic solutions. Safety pharmacology, genotoxicity and carcinogenicity studies with each of the components revealed no special hazards for humans. Latanoprost did not affect corneal wound healing in the rabbit eye, whereas timolol inhibited the process in the rabbit and the monkey eye when administered more frequently than once a day.
For latanoprost, no effects on male and female fertility in rats and no teratogenic potential in rats and rabbits have been established. No embryotoxicity was observed in rats after intravenous doses of up to 250 micrograms/kg/day. However, latanoprost caused embryofetal toxicity, characterised by increased incidence of late resorption and abortion and by reduced foetal weight, in rabbits at intravenous doses of 5 micrograms/kg/day (approximately 100 times the clinical dose) and above. Timolol showed no effects on male and female fertility in rats or teratogenic potential in mice, rats and rabbits.
MedsGo Class
Antiglaucoma Preparations
Features
Brand
Astimol
Full Details
Dosage Strength
50 mcg / 5 mg per ml
Drug Ingredients
- Latanoprost
- Timolol
Drug Packaging
Ophthalmic Solution 5ml
Generic Name
Latanoprost / Timolol
Dosage Form
Ophthalmic Solution
Registration Number
DR-XY45555
Drug Classification
Prescription Drug (RX)
Product Questions
Questions
