Active ingredients: Fluconazole
WINCH100 mg hard capsules
WINCH150 mg hard capsules
WINCH200 mg hard capsules
Indications Why is Winch used? What is it for?
WINCH belongs to a group of medicines called "antifungals". The active ingredient is fluconazole.
WINCH is used to treat yeast infections and can be used to prevent candida infections. The most common cause of yeast infections is a yeast called Candida.
Adults
Your doctor may prescribe this medicine to treat the following fungal infections:
- Cryptococcal meningitis - a "fungal infection of the brain
- Coccidioidomycosis - a disease of the bronchopulmonary system
- Infections caused by Candida and found in the bloodstream, organs (e.g. heart, lungs), or urinary tract
- Mucosal candidiasis - oral mucosal infection, throat infection and mouth inflammation from dental prosthesis
- Genital candidiasis - infection of the vagina or penis
- skin infections - eg athlete's foot, ringworm, itching in the genital area, nail infections
WINCH can be prescribed for:
- Preventing the recurrence of cryptococcal meningitis
- Prevent the reappearance of mucosal candidiasis
- Decrease recurrences of vaginal candidiasis
- prevent Candida infections (if your immune system is weak or not working properly)
Children and adolescents (0 to 17 years)
Your doctor may prescribe this medicine to treat the following fungal infections:
- Mucosal candidiasis - infection of the oral mucosa, infection of the throat
- Infections caused by Candida and found in the bloodstream, organs (e.g. heart, lungs), or urinary tract
- Cryptococcal meningitis - a "fungal infection of the brain
WINCH can be prescribed for:
- prevent Candida infections (if your immune system is weak or not working properly).
- prevent the recurrence of cryptococcal meningitis
Contraindications When Winch should not be used
Do not take WINCH if you
- is allegic (hypersensitive) to flucoanzol, to other medicines that you have used to treat fungal infections or to one of the other ingredients of WINCH. Symptoms could be itching, redness of the skin or difficulty in breathing
- takes astemizole, terfenadine (antihistamine medicines used to treat allergies)
- take cisapride (used to treat stomach disorders)
- take pimozide (used to treat mental disorders)
- take quinidine (used to treat heart arrhythmias)
- take erythromycin (antibiotic used to treat bacterial infections)
Precautions for use What you need to know before taking Winch
Tell your doctor if
- have liver or kidney problems
- suffer from heart disease, including cardiac arrhythmia
- have abnormal levels of potassium, calcium or magnesium in the blood.
- severe skin reactions (itching, redness of the skin or difficulty in breathing) appear.
Interactions Which drugs or foods can modify the effect of Winch
Taking other medicines
Tell your doctor immediately if you are taking astemizole, terfenadine (antihistamine used to treat allergies) or cisapride (used to treat stomach ailments) or pimozide (used to treat mental disorders) or quinidine (used to treat cardiac arrhythmias) or erythromycin (antibiotic used to treat bacterial infections), as they cannot be taken with WINCH (see section: "Do not take WINCH if you").
There are some medicines that can interact with WINCH. Tell your doctor if you are taking any of the following medicines:
- rifampicin or rifabutin (antibiotics to treat bacterial infections)
- alfentanil, fentanyl (anesthetics)
- amitriptyline, nortriptyline (antidepressants)
- amphotericin B, voriconazole (antifungals)
- medicines that thin the blood to prevent clots (warafrin or similar medicines)
- benzodiazepines (midazolam, triazolam or similar medicines) used to help you sleep or for anxiety
- carbamazepine, phenytoin (used to treat seizures)
- nifedipine, isradipine, amlodipine, felodipine and losartan (used to treat hypertension - high blood pressure)
- cyclosporine, everolimus, sirolimus or tacrolimus (used to prevent transplant rejection)
- cyclophosphamide, vinca alkaloids (vincristine, vinblastine or similar medicines) used to treat cancer
- halofantrine (used to treat malaria)
- statins (atorvastatin, simvastatin, fluvastatin and similar medicines) used to reduce high cholesterol levels
- methadone (used to treat pain)
- celecoxib, flurbiprofen, naproxen, ibuprofen, lornoxicam, meloxicam, diclofenac (non-steroidal anti-inflammatory drugs - NSAIDs)
- oral contraceptives
- prednisone (steroid)
- zidovudine, also known as AZT; saquinavir (used in HIV patients)
- medicines for diabetes such as chlorpromamide, glibenclamide, glipizide or tolbutamide
- theophylline (used to control asthma)
- vitamin A (food supplement)
Tell your doctor or pharmacist if you are taking or have taken any other medicines, even those not prescribed.
Taking WINCH with food and drink
You can take the medicine with or without food.
Warnings It is important to know that:
Pregnancy and breastfeeding
Tell your doctor if you are pregnant, trying to get pregnant or breastfeeding. You should not take WINCH while pregnant or breastfeeding unless your doctor has prescribed it for you.
Ask your doctor or pharmacist for advice before taking any medicine.
Driving and using machines
It should be borne in mind that dizziness or convulsions may occur while driving or operating machinery.
Important information about some of the ingredients of WINCH
This medicine contains a small amount of lactose (milk sugar). If you have been told by your doctor that you have an "intolerance to some sugars, contact your doctor before taking this medicinal product.
Dose, Method and Time of Administration How to use Winch: Posology
Always take your medicine exactly as your doctor has told you.
If in doubt, consult your doctor or pharmacist.
Swallow the capsule whole with a glass of water. It is best to take the capsules at the same time each day.
The usual doses of this medicine to be taken depending on the infection are listed below:
Teenagers aged 12 to 17
Always take the dose prescribed by your doctor (or the dosage for adults or for children).
Children up to 11 years
The maximum dose in children is 400 mg per day.
The dose will be based on the child's weight in kilograms.
Use in children aged 0 to 4 weeks
Use in children 3 to 4 weeks of age: the same dosage as described above but given once every 2 days. The maximum dose is 12 mg per kg of body weight every 48 hours.
Use in infants less than 2 weeks of age:
the same dosage as described above but administered once every 3 days. The maximum dose is 12 mg per kg of body weight every 72 hours.
Your doctor may sometimes prescribe doses other than these. Always take your medicine as directed by your doctor. If you are unsure, ask your doctor or pharmacist.
Use in the elderly
The same dose as for adults should be used unless you have kidney problems.
Use in patients with kidney problems
Your doctor may adjust the dosage based on your kidney function.
Overdose What to do if you have taken too much Winch
If you take more WINCH than you should
Taking too many capsules at once could cause you problems. Contact your doctor immediately or go to the nearest hospital.
In the event of an accidental overdose, symptoms may include hearing, seeing, feeling and thinking things that are not real (hallucinations and paranoid behavior). Symptomatic treatment (with adequate supportive measures and possibly gastric lavage) may be appropriate.
If you forget to take WINCH
Do not take a double dose to make up for any forgotten doses. If you forget to take a dose, take it as soon as possible. If it is time for your next dose, skip the missed dose.
If you have any further questions on the use of this medicine, ask your doctor or pharmacist.
Side Effects What are the side effects of Winch
Like all medicines, WINCH can cause side effects, although not everybody gets them.
Some people experience allergic reactions although severe allergic reactions occur rarely. If you experience any of the following symptoms tell your doctor immediately.
- sudden wheezing, difficulty in breathing or tightness in the chest
- swelling of the eyelids, face or lips
- itching all over the body, red skin or itchy red spots
- skin rashes
- severe skin reactions, such as a rash that causes blisters (can affect the mouth and tongue)
WINCH can affect the liver. Symptoms of liver problems include:
- tiredness;
- loss of appetite;
- He retched;
- yellowing of the skin and whites of the eyes (jaundice).
If you get any of these symptoms, stop taking Duflucan and tell your doctor right away.
Other side effects:
If any of the side effects gets serious, or if you notice any side effects not listed in this leaflet, please tell your doctor or pharmacist.
Common side effects, which occur in 1 to 10 users in 100, are as follows:
- headache;
- stomach upset, diarrhea, nausea, vomiting;
- increases in liver function values in blood tests;
- skin rashes.
Uncommon side effects, which occur in 1 to 10 users in 1,000, are as follows:
- reduction in red blood cells which can cause paleness, weakness or breathlessness;
- decreased appetite;
- insomnia, drowsiness;
- seizures, dizziness, sensation of vertigo, tingling, pricking or numbness, change in taste;
- constipation, difficulty in digestion, flatulence, dry mouth;
- muscular pain;
- liver damage and yellowing of the skin and eyes (jaundice);
- swelling, blistering (hives) itching, increased sweating;
- fatigue, general malaise, fever.
Rare side effects, which occur in 1 to 10 users in 10,000, are as follows:
- lower than normal levels of white blood cells, which help defend against infection, and platelets, which make it possible for blood to clot;
- change in skin discolouration (red or purple) which may be caused by a reduction in platelets, other changes in blood cells;
- changes in the chemical composition of the blood (high levels of cholesterol, fat);
- low levels of potassium in the blood;
- chills;
- altered electrocardiogram (ECG), change in heart rhythm and rate;
- liver failure;
- allergic reactions (sometimes severe), including rash with widespread blistering and peeling of the skin, severe skin reactions, swelling of the lips and face; - hair loss.
If any of the side effects gets serious, or if you notice any side effects not listed in this leaflet, please tell your doctor or pharmacist.
Expiry and Retention
Keep out of the reach and sight of children.
Do not use WINCH after the expiry date which is stated on the label (EXP). The expiry date refers to the last day of the month.
Do not store above 30 ° C.
Medicines should not be disposed of via wastewater or household waste.
Ask your pharmacist how to throw away medicines you no longer use. This will help protect the environment.
Composition and pharmaceutical form
What does WINCH
WINCH 100 mg hard capsules
1 capsule contains: Active ingredient: Fluconazole 100 mg
Excipients: lactose monohydrate, pregelatinised starch, magnesium stearate, colloidal anhydrous silica, sodium lauryl sulfate.
Capsule: gelatin, titanium dioxide (E 171), yellow iron oxide (E 172).
WINCH 150 mg hard capsules
1 capsule contains: Active ingredient: Fluconazole 150 mg
Excipients: lactose monohydrate, pregelatinised starch, magnesium stearate, colloidal anhydrous silica, sodium lauryl sulfate.
Capsule: gelatin, titanium dioxide (E 171).
WINCH 200 mg hard capsules
1 capsule contains: Active ingredient: Fluconazole 200 mg
Excipients: lactose monohydrate, pregelatinised starch, magnesium stearate, colloidal anhydrous silica, sodium lauryl sulfate.
Capsule: gelatin, titanium dioxide (E 171).
What WINCH 100 mg, 150 mg and 200 mg hard capsules look like and contents of the pack
Hard capsules.
- Box containing 10 capsules of 100 mg.
- Box containing 2 capsules of 150 mg.
- Box containing 7 capsules of 200 mg.
Source Package Leaflet: AIFA (Italian Medicines Agency). Content published in January 2016. The information present may not be up-to-date.
To have access to the most up-to-date version, it is advisable to access the AIFA (Italian Medicines Agency) website. Disclaimer and useful information.
01.0 NAME OF THE MEDICINAL PRODUCT
HARD WINCH CAPSULES
02.0 QUALITATIVE AND QUANTITATIVE COMPOSITION
WINCH 100 mg hard capsules
Each hard capsule contains 100 mg fluconazole
Excipients: Each hard capsule also contains 115 mg lactose monohydrate
WINCH 150 mg hard capsules
Each hard capsule contains 150 mg fluconazole
Excipients: Each hard capsule also contains 172.5 mg lactose monohydrate
WINCH 200 mg hard capsules
Each hard capsule contains 200 mg fluconazole
Excipients: Each hard capsule also contains 230 mg lactose monohydrate
For the full list of excipients, see section 6.1.
03.0 PHARMACEUTICAL FORM
Hard capsule.
04.0 CLINICAL INFORMATION
04.1 Therapeutic indications
WINCH is indicated in the following fungal infections (see section 5.1).
WINCH is indicated in adults for the treatment of:
Cryptococcal meningitis (see section 4.4);
Coccidioidomycosis (see section 4.4);
Invasive candidiasis;
Mucosal candidiasis, including oropharyngeal candidiasis, esophageal candidiasis, candiduria and chronic mucocutaneous candidiasis;
Chronic atrophic oral candidiasis (dental prosthesis stomatitis), in the event that dental hygiene and topical treatment are insufficient;
Vaginal candidiasis, acute or recurrent, when local therapy is not appropriate;
Balanitis from Candida, when local therapy is not appropriate;
Dermatomycosis, including tinea pedis, tinea corporis, tinea cruris, tinea versicolor and skin infections from Candida, when systemic therapy is indicated;
Tinea unguinium (onychomycosis), when other treatments are not considered appropriate.
WINCH is indicated in adults for the prophylaxis of:
Recurrence of cryptococcal meningitis in patients at high risk of relapse.
Recurrence of oropharyngeal or esophageal candidiasis in HIV-infected patients at high risk of relapse.
To reduce the incidence of recurrent vaginal candidiasis (4 or more episodes per year).
Prophylaxis of candidemia in patients with prolonged neutropenia (e.g. patients with malignant haematological disorders undergoing chemotherapy or patients receiving hematopoietic stem cell transplantation (see section 5.1)).
WINCH is indicated in full-term newborns, infants, infants, children and adolescents from 0 to 17 years:
WINCH is used in the treatment of mucosal candidiasis (oropharyngeal and oesophageal), invasive candidiasis, cryptococcal meningitis and in the prophylaxis of candidiasis in immunocompromised patients. WINCH can be used as maintenance therapy to prevent relapse of cryptococcal meningitis in children with a high risk of relapse (see section 4.4).
Therapy can be instituted before culture or other laboratory test results are known, but when results become available, anti-infective therapy should be adjusted accordingly.
Official guidelines for the appropriate use of antifungals should be considered.
04.2 Posology and method of administration
Dosage
Dosage should be based on the nature and severity of the fungal infection. Treatment of infections requiring multiple dosing should continue until clinical parameters or other laboratory tests demonstrate that the active fungal infection has cleared. An inadequate treatment period could lead to recurrence of the active infection.
Special populations
Senior citizens
Dosage should be adjusted based on renal function (see "Renal impairment').
Renal impairment
No adjustments are required when performing single dose therapy. However, when repeated dose therapy of fluconazole is used in patients with renal insufficiency (including the pediatric population), a starting dose of between 50 mg and 400 mg should be administered, based on the recommended daily dose for the indication. initial loading dose, the daily dosage (depending on the indication) should be modified according to the following scheme:
Patients on regular dialysis should receive 100% of the recommended dose after each dialysis session; on days without dialysis, patients should receive a reduced dose based on creatinine clearance.
Hepatic impairment
Limited data are available in patients with hepatic impairment, therefore fluconazole should be administered with caution in patients with hepatic impairment (see sections 4.4 and 4.8).
Pediatric population
In the pediatric population the maximum dose of 400 mg / day should not be exceeded.
As with similar infections in adults, the duration of treatment is based on the clinical and mycological response. WINCH is administered as a single daily dose.
For pediatric patients with impaired renal function, see dosing under "Renal impairment". The pharmacokinetics of fluconazole have not been studied in the pediatric population with renal insufficiency (for "term neonates" who often show mainly renal immaturity see below).
Infants, infants and children (28 days to 11 years):
Teenagers (12 to 17 years):
Based on weight and pubertal development, the physician will need to assess which posology is the most appropriate (adults or children). Clinical data indicate that children have a higher clearance of fluconazole than that found in adults. A dose of 100, 200 and 400 mg in adults corresponds to a dose of 3, 6 and 12 mg / kg in children, to achieve comparable systemic exposure.
The safety and efficacy for the indication genital candidiasis in the pediatric population have not been established. Safety data currently available for the other pediatric indications are described in section 4.8. In cases where treatment of genital candidiasis in adolescents (12 to 17 years) is absolutely necessary, the dosage should be the same as for adults.
Term infants (0 to 27 days):
Excretion of fluconazole in neonates occurs slowly. There are few pharmacokinetic data to support this posology in term neonates (see section 5.2).
Method of administration
WINCH can be administered either orally or via intravenous infusion, depending on the patient's clinical status. When switching from the intravenous to the oral route, or vice versa, it is not necessary to change the daily dosage.
The capsules must be swallowed whole and regardless of food intake.
04.3 Contraindications
Hypersensitivity to the active substance, to related azole compounds, or to any of the excipients (see section 6.1).
Concomitant administration of terfenadine is contraindicated in patients receiving multiple dose WINCH therapy ≥ 400 mg / day based on the results of a multiple dose interaction study. Concomitant administration of other drugs that prolong the QT interval and are metabolised via cytochrome P450 (CYP) 3A4, such as cisapride, astemizole, pimozide, quinidine and erythromycin, is contraindicated in patients receiving fluconazole therapy (see sections 4.4 and 4.5).
04.4 Special warnings and appropriate precautions for use
Tinea capitis
Fluconazole has been studied for the treatment of tinea capitis in children. It was shown not to be superior to griseofulvin and the overall success rate was less than 20%. Therefore WINCH should not be used for the tinea capitis.
Cryptococcosis
Evidence of fluconazole efficacy in the treatment of cryptococcosis of other sites (eg, cutaneous and pulmonary cryptococcosis) is limited and therefore no dosage recommendations are possible.
Deep endemic mycoses
The evidence for the efficacy of fluconazole in the treatment of deep endemic mycoses such as paracoccidioidomycosis, lymphocutaneous sporotrichosis and histoplasmosis is limited and therefore no dosage recommendations are possible.
Renal system
WINCH should be administered with caution in patients with renal impairment (see section 4.2).
Hepatobiliary system
WINCH should be administered with caution in patients with hepatic impairment (see section 4.2).
WINCH has been associated with rare cases of severe, sometimes fatal, liver toxicity, especially in patients with severe underlying disease. In cases of hepatotoxicity associated with fluconazole it was not possible to establish a relationship with the daily dose used, the duration of therapy, the sex or age of the patient. The hepatotoxicity of fluconazole was generally reversible upon discontinuation of treatment.
Patients who exhibit liver function abnormalities during fluconazole therapy should be carefully monitored for the possible onset of more severe liver damage.
Patients should be informed of symptoms indicative of severe hepatic effects (significant asthenia, anorexia, persistent nausea, vomiting and jaundice). Treatment with fluconazole should be stopped immediately and the patient should consult the physician.
Cardiovascular system
Some azoles, including fluconazole, have been associated with a prolongation of the QT interval on the electrocardiogram. During the post-marketing phase, very rare cases of QT interval prolongation and torsades de pointes have occurred in patients taking WINCH. These cases included seriously ill patients with multiple confounding risk factors, such as structural heart disease, abnormalities. electrolytes and concomitant medications which may have contributed to the rhythm abnormalities.
WINCH should be administered with caution to patients with these potential proarrhythmic conditions. Concomitant administration of other medicinal products that prolong the QT interval and are metabolised via cytochrome P450 (CYP) 3A4 is contraindicated (see sections 4.3 and 4.5).
Halofantrine
Halofantrine has been shown to prolong the QTc interval at the recommended therapeutic dose and is a substrate of CYP3A4. Concomitant use of fluconazole and halofantrine is therefore not recommended (see section 4.5).
Dermatological reactions
Rare episodes of exfoliative skin reactions, such as Stevens-Johnson syndrome and toxic epidermal necrolysis, have occurred with fluconazole therapy. Patients with AIDS are more prone to developing severe skin reactions to many medicines. If a skin rash attributable to fluconazole occurs in a patient receiving fluconazole for superficial fungal infections, treatment with this medicinal product should be discontinued. If patients with invasive / systemic fungal infections develop skin rash, they should be carefully monitored and fluconazole treatment discontinued if bullous lesions or erythema multiforme develop.
Hypersensitivity
In rare cases anaphylaxis has been reported (see section 4.3).
Cytochrome P450
Fluconazole potently inhibits cytochrome CYP2C9 and moderately inhibits cytochrome CYP3A4. Fluconazole also inhibits cytochrome CYP2C19. WINCH-treated patients who are concomitantly treated with drugs that have a narrow therapeutic window and are metabolised through CYP2C9, CYP2C19 and CYP3A4, should be monitored (see section 4.5).
Terfenadine
Concomitant administration of fluconazole at doses below 400 mg / day and terfenadine should be closely monitored (see sections 4.3 and 4.5).
Excipients
The capsules contain lactose monohydrate. Patients with rare hereditary problems of galactose intolerance, lactase deficiency, or glucose-galactose malabsorption should not take this medicine.
04.5 Interactions with other medicinal products and other forms of interaction
Concomitant use of the following medicinal products is contraindicated:
CisaprideCases of cardiac events including torsades de pointes have been reported in patients receiving concomitant administration of fluconazole and cisapride. A controlled study reported that concomitant administration of fluconazole 200 mg once daily and cisapride 20 mg four times daily leads to significantly increased plasma levels of cisapride and prolongation of the QTc interval. Co-administration of cisapride and fluconazole is contraindicated (see section 4.3).
Terfenadine: Interaction studies have been conducted following the occurrence of severe dysrhythmias following prolongation of the QTc interval in patients receiving other azole antifungals and terfenadine. A study conducted with a daily dose of 200 mg of fluconazole did not demonstrated a prolongation of the QTc interval. Another study with daily doses of fluconazole of 400 mg and 800 mg showed that administration of fluconazole in doses of 400 mg / day or higher significantly increased the plasma levels of terfenadine when administered concomitantly. Concomitant use of fluconazole at doses of 400 mg / day or higher and terfenadine is contraindicated (see section 4.3). Concomitant administration of fluconazole at doses below 400 mg / day and terfenadine should be closely monitored.
Astemizole: Concomitant use of fluconazole and astemizole may reduce the clearance of astemizole. The resulting increases in plasma concentrations of astemizole may lead to prolongation of the QT interval and the occurrence of rare cases of torsades de pointes. Concomitant administration of fluconazole and astemizole is contraindicated (see section 4.3).
Pimozide: Although it has not been studied in vitro or in vivo, concomitant administration of fluconazole and pimozide may result in inhibition of the metabolism of pimozide. The resulting increases in plasma concentrations may lead to prolongation of the QT interval and the occurrence of rare cases of torsades de pointes. Concomitant administration of fluconazole and pimozide is contraindicated (see section 4.3).
Quinidine: Although it has not been studied in vitro or in vivo, concomitant administration of fluconazole and quinidine may result in inhibition of the metabolism of quinidine. The use of quinidine has been associated with prolongation of the QT interval and the occurrence of rare cases of torsades de pointes. Concomitant administration of fluconazole and quinidine is contraindicated (see section 4.3).
Erythromycin: Concomitant use of fluconazole and erythromycin could increase the risk of cardiotoxicity (prolongation of the QT interval, torsades de pointes) and therefore of sudden cardiac death. Concomitant administration of fluconazole and erythromycin is contraindicated (see section 4.3).
Concomitant use of the following medicinal products is not recommended:
Halofantrine: Fluconazole may increase halofantrine plasma concentrations due to the inhibitory effect on CYP3A4.Concomitant use of fluconazole and halofantrine could increase the risk of cardiotoxicity (prolongation of the QT interval, torsades de pointes) and therefore of sudden cardiac death. The use of these two drugs in combination should therefore be avoided (see section 4.4).
Concomitant use of the following medicinal products involves precautions and dose adjustments:
Effects of other medicinal products on fluconazole
Rifampicin: Concomitant administration of fluconazole and rifampicin resulted in a 25% reduction in the AUC and a 20% reduction in the half-life of fluconazole. Therefore, in patients taking concomitant rifampicin, an increase in the dose of fluconazole should be considered.
Interaction studies have shown that no clinically significant changes in fluconazole absorption occur during concomitant administration of fluconazole with food, cimetidine, antacids or following total body irradiation for bone marrow transplantation.
Effects of fluconazole on other medicinal products
Fluconazole is a potent inhibitor of the cytochrome P450 (CYP) isoenzyme 2C9 and a moderate inhibitor of the CYP3A4 isoenzyme. Fluconazole is also an inhibitor of the CYP2C19 isoenzyme. In addition to the observed / documented interactions listed below, there is a risk of increased plasma concentrations of other compounds metabolised by isoenzymes CYP2C9 and CYP3A4 administered in combination with fluconazole. Therefore, great caution should be exercised. when prescribing these combinations and closely monitoring patients. The inhibitory effect of fluconazole on the enzyme remains 4-5 days after discontinuation of treatment due to the long half-life of fluconazole (see section 4.3).
Alfentanil: During concomitant treatment with intravenous fluconazole (400 mg) and intravenous alfentanil (20mcg / kg) in healthy volunteers, the AUC10 of alfentanil doubled, possibly due to inhibition of CYP3A4. Alfentanil dosage adjustment may be required. .
Amitriptyline, nortriptyline: Fluconazole increases the effect of amitriptyline and nortriptyline. 5-nortriptyline and / or S-amitriptyline can be measured at the start of concomitant therapy and after one week of treatment. If necessary, the amitriptyline / nortriptyline dosage should be adjusted.
Amphotericin B: Concomitant administration of fluconazole and amphotericin B in infected normal and immunosuppressed mice showed the following results: a mild additive antifungal effect in systemic infections due to C. albicans, no interaction in intracranial infections from Cryptococcus neoformans, and antagonism of the two drugs in systemic infections from A. fumigatus. The clinical significance of the results obtained in these studies is unknown.
Anticoagulants: In post-marketing experience, as with other azole antifungals, bleeding episodes (contusions, epistaxis, gastrointestinal bleeding, haematuria and melaena) have been reported in association with prolongation of prothrombin time in patients receiving concomitant fluconazole and warfarin therapy. During concomitant treatment with fluconazole and warfarin, the prothombin time was prolonged to double, possibly due to inhibition of warfarin metabolism via CYP2C9. In patients receiving coumarin anticoagulants concomitantly with fluconazole, the prothrombin time should be carefully monitored. Warfarin dosage adjustment may also be required.
Benzodiazepines (rapid effect), eg. midazolam, triazolamSignificant increases in midazolam concentrations and psychomotor effects have been observed following concomitant administration of oral midazolam and fluconazole. Concomitant intake of fluconazole 200 mg and midazolam 7.5 mg orally increased the AUC and half-life of midazolam 3.7- and 2.2-fold, respectively. Fluconazole 200 mg / day administered concomitantly with triazolam 0 , 25 mg orally increased the AUC and half-life of triazolam by 4.4 and 2.3 times, respectively. During concomitant treatment with fluconazole, potentiation and prolongation of the effects of triazolam were observed. When concomitant benzodiazepine therapy is required in patients receiving fluconazole, consideration should be given to a decrease in benzodiazepine dosage and appropriate patient monitoring.
Carbamazepine: Fluconazole inhibits the metabolism of carbamazepine and a 30% increase in serum carbamazepine levels has been observed. There is a risk that a toxic effect of carbamazepine will develop. Carbamazepine dosage adjustments may be required depending on measurements and / or effect of concentrations.
Calcium channel blockers: Some calcium channel blockers (nifedipine, isradipine, amlodipine, verapamil and felodipine) are metabolised by CYP3A4. Fluconazole may increase the systemic exposure of calcium channel blockers. Frequent monitoring for adverse events is advised.
Celecoxib: During concomitant treatment with fluconazole (200 mg / day) and celecoxib (200 mg), celecoxib Cmax and AUC increased by 68% and 134%, respectively. In combination with fluconazole, the dose of the celecoxib.
Cyclophosphamide: Concomitant treatment with cyclophosphamide and fluconazole results in an increase in serum bilirubin and serum creatinine. The two drugs can be used in combination, provided that the risk resulting from increases in serum levels of bilirubin and creatinine is taken into account.
Fentanyl: One fatal case of fentanyl intoxication due to possible interaction between fentanyl and fluconazole has been reported. In addition, fluconazole was found to significantly delay the elimination of fentanyl in healthy volunteers. Elevated concentrations of fentanyl can lead to respiratory depression. Patients should be monitored closely for the potential risk of respiratory depression. Dosage adjustments may be required. fentanyl.
HMG-CoA reductase inhibitors: The risk of myopathy and rhabdomyolysis is increased when fluconazole is co-administered with CYP3A4 metabolised HMG-CoA reductase inhibitors, such as atorvastatin and simvastatin, or CYP2C9, such as fluvastatin. If concomitant administration is necessary, the patient should be monitored as symptoms of myopathy and rhabdomyolysis may appear, and creatinine kinase should be monitored. Administration of HMG-CoA reductase inhibitors should be discontinued if a significant increase in creatinine kinase is found or if myopathy or rhabdiomyolysis is diagnosed or suspected.
Immunosuppressants (e.g. cyclosporine, everolimus, sirolimus and tacrolimus):
Cyclosporine: Fluconazole significantly increases the concentration and AUC of cyclosporine. An increase of 1.8 in the AUC of cyclosporine occurred during concomitant treatment of fluconazole 200 mg / day and cyclosporine (2.7 mg / kg / day). The two drugs can be used in combination, reducing the dosage of cyclosporine based on the concentration of cyclosporine itself.
Everolimus: Although no studies are available in vivo or in vitro, fluconazole may increase everolimus serum concentrations through inhibition of CYP3A4.
Sirolimus: Fluconazole increases plasma concentrations of sirolimus, presumably by inhibiting the metabolism of sirolimus via CYP3A4 and P-glycoprotein. The two drugs can be used in combination with a dose adjustment of sirolimus, based on the effect / concentration analyzes.
Tacrolimus: Fluconazole may increase the serum concentrations of orally administered tacrolimus by up to 5-fold due to inhibition of the metabolism of tacrolimus via CYP3A4 in the intestine. No significant pharmacokinetic alterations were found with intravenous administration of tacrolimus. Elevations in tacrolimus levels have been associated with nephrotoxicity. The dosage of orally administered tacrolimus should be reduced based on the concentrations of tacrolimus itself.
Losartan: Fluconazole inhibits the metabolism of losartan to its active metabolite (E-31 74), which underlies much of the angiotensin II receptor antagonist activity that occurs during treatment with losartan. Patients should be continuously monitored for blood pressure.
Methadone: Fluconazole may enhance serum methadone concentrations. Dosage adjustment of methadone may be required.
Non-steroidal anti-inflammatory drugs (NSAIDs): The CMAX and AUC of flurbiprofen increased by 23% and 81%, respectively, when administered in combination with fluconazole, compared to administration of flurbiprofen alone. Similarly, the CMAX and "AUC of the pharmacologically active isomer [S - (+) - ibuprofen] increased by 15% and 82%, respectively, when fluconazole was administered in combination with racemic ibuprofen (400 mg) compared to to the administration of racemic ibuprofen alone.
Although no specific studies have been conducted, fluconazole may increase the systemic exposure of other NSAIDs metabolised by CYP2C9 (eg naproxen, lornoxicam, meloxicam, diclofenac). Frequent monitoring for adverse events and NSAID-related toxicity is recommended. Dosage adjustments of NSAIDs may be required.
Phenytoin: Fluconazole inhibits the hepatic metabolism of phenytoin. Repeated concomitant administration of fluconazole 200 mg and phenytoin 250 mg intravenously caused a 75% increase in phenytoin AUC24 and 128% CMIN. When co-administered, phenytoin serum concentrations should be monitored to avoid toxicity of phenytoin.
Prednisone: There was a case report of a liver transplant patient on prednisone who developed acute adrenocortical insufficiency after discontinuation of three months of fluconazole therapy. Discontinuation of fluconazole presumably resulted in an enhancement of CYP3A4 activity, which led to an increase in the metabolism of prednisone. Patients on long-term treatment with fluconazole and prednisone should be carefully monitored for the possible occurrence of adrenocortical insufficiency after discontinuation of fluconazole.
Rifabutin: Fluconazole increases the serum concentrations of rifabutin, resulting in an increase in the AUC of rifabutin by up to 80%. Cases of uveitis have been reported in patients on concomitant therapy with fluconazole and rifabutin. Therefore, symptoms of rifabutin toxicity must be taken into account in combination treatment.
Saquinavir: Fluconazole increases the AUC and CMIN of saquinavir by approximately 50% and 55%, respectively, due to inhibition of the hepatic metabolism of saquinavir by CYP3A4 and inhibition of P-glycoprotein. The interaction with saquinavir / ritonavir has not been studied and may be more pronounced. Dosage adjustments of saquinavir may be required.
Sulfonylureas: Fluconazole administered to healthy volunteers resulted in prolongation of the serum half-life of concomitantly administered orally administered suphonylureas (chlorpropamide, glibenclamide, glipizide and tolbutamide). During concomitant administration, frequent monitoring of blood glucose levels and a " adequate reduction of the sulphonylurea dosage.
Theophylline: In a placebo-controlled interaction study, administration of fluconazole 200 mg for 14 days resulted in an 18% reduction in mean plasma clearance of theophylline. Patients on high-dose theophylline therapy or who are at increased risk for theophylline-induced toxicity episodes should be closely monitored for signs of theophylline toxicity when concurrently taking fluconazole, and therapy should be adjusted accordingly if such signs occur. manifest.
Vinca alkaloids: Although no specific studies have been conducted, fluconazole may increase plasma levels of vinca alkaloids (eg vincristine and vinblastine), resulting in neurotoxicity, which is possible due to the inhibitory effect on CYP3A4.
Vitamin A: In a reported case in a patient on concomitant therapy with all-trans-retinoic acid (an acid form of vitamin A) and fluconazole, central nervous system related undesirable effects developed in the form of pseudotumor cerebri, which disappeared after discontinuation of fluconazole treatment. The two drugs can be used in combination, but the incidence of central nervous system related undesirable effects should be taken into account.
Voriconazole: (CYP2C9 and CYP3A4 inhibitors): Co-administration of oral voriconazole (400 mg Q12h for 1 day, then 200 mg Q12h for 2.5 days) and oral fluconazole (400 mg on day 1, then 200 mg Q24h for 4 days) in 8 healthy male subjects resulted in an increase in voriconazole CMAX and AUC by a mean of 57% (90% CI: 20%, 107%) and 79% (90% CI: 40% 128%) It has not been defined which reductions in the dose and / or frequency of voriconazole and fluconazole would eliminate this effect.If voriconazole is used sequentially after fluconazole, monitoring for voriconazole-associated adverse events is recommended.
Zidovudine: Fluconazole increases the CMAX and AUC of zidovudine by 84% and 74%, respectively, due to an approximately 45% decrease in zidovudine clearance. Similarly, the half-life of zidovudine was prolonged by approximately 128% following concomitant administration with fluconazole. Patients receiving this concomitant therapy should be monitored for possible occurrence of zidovudine-related adverse reactions. possibility of a reduction in zidovudine doses.
Azithromycin: An open, randomized, three-arm crossover study in 18 healthy volunteers determined the effects of a single oral dose of 1200 mg azithromycin on the pharmacokinetics of a single oral dose of 800 mg of fluconazole as well as the effects of fluconazole on pharmacokinetics. There was no significant pharmacokinetic interaction between fluconazole and azithromycin.
Oral contraceptives: Two pharmacokinetic studies were conducted with combined oral contraceptive therapy administered in combination with multiple doses of fluconazole. There were no relevant effects in the levels of the two hormones of patients receiving fluconazole 50 mg, while the AUC of ethinylestradiol and levonorgestrel in the group taking fluconazole 200 mg / day showed an increase of 40% and 24% respectively. Therefore, the use of multiple doses of fluconazole at these dosages does not change the efficacy of a combined oral contraceptive therapy.
04.6 Pregnancy and breastfeeding
Pregnancy
Data from several hundred pregnant women treated with standard doses of fluconazole (first trimester, did not show fetal side effects. In infants whose mothers were receiving high dose fluconazole therapy (400-800 mg / die) for coccidioidomycosis for a period ≥ 3 months, multiple congenital anomalies (including brachycephaly, auricular dysplasia, giant anterior fontanel, femoral curvature, and radiohumeral synostosis) have been reported. it's clear.
Studies in animals have shown reproductive toxicity (see section 5.3).
Fluconazole in standard doses and for short periods of treatment should not be used during pregnancy unless strictly necessary.
Fluconazole in high doses and / or for prolonged treatment periods should only be used during pregnancy for life-threatening infections.
Feeding time
Fluconazole passes into breast milk and reaches concentrations below plasma levels. Breastfeeding can be continued following administration of a standard single dose of fluconazole 200 mg or less. Breastfeeding is not recommended after repeated use or after high doses of fluconazole.
Fertility
Fluconazole had no effect on the fertility of male or female rats (see section 5.3).
04.7 Effects on ability to drive and use machines
No studies on the effects of WINCH on the ability to drive and use machines have been performed. Patients should be advised that dizziness or convulsions may occasionally occur (see section 4.8) during therapy with WINCH, and that they should not drive or operate machinery if any of these symptoms occur.
04.8 Undesirable effects
The most frequently reported adverse reactions (> 1/10) are headache, abdominal pain, diarrhea, nausea, vomiting, alanine aminostransferase increased, aspartate aminotransferase increased, alkaline phosphatase increased and rash.
The following adverse reactions have been observed and reported during treatment with fluconazole, with the following frequencies: very common (≥1 / 10); common (≥1 / 100,
Pediatric population
The type and incidence of adverse reactions and laboratory changes observed in pediatric clinical trials, with the exception of the indication for genital candidiasis, are comparable to those observed in adults.
04.9 Overdose
There have been reports of overdose with fluconazole and concomitant hallucinations and paranoid behavior have been reported.
In the event of accidental overdose, symptomatic treatment may be required (with "adequate supportive therapy and possibly gastric lavage).
Fluconazole is mostly excreted in the urine; forced diuresis probably increases the rate of elimination. A 3-hour hemodialysis session decreases plasma levels by approximately 50%.
05.0 PHARMACOLOGICAL PROPERTIES
05.1 Pharmacodynamic properties
ATC classification
Pharmacotherapeutic group: Antifungals for systemic use, triazole derivatives, ATC code: J02AC01.
Mechanism of action
Fluconazole is a triazole antifungal. Its main mechanism of action is the inhibition of fungal cytochrome P-450 mediated 14 alpha-lanosterol demethylation, an essential step in the biosynthesis of fungal ergosterol.
The accumulation of 14 alpha-methyl-sterols is related to the consequent loss of ergosterol in the fungal cell membrane and could be the basis of the antifungal activity of fluconazole.
It was evident that fluconazole is more selective for fungal cytochrome P-450 enzymes than for various mammalian cytochrome P-450 enzyme systems.
It has been shown that fluconazole 50 mg / day administered up to 28 days does not alter the plasma concentration of testosterone in men, nor the concentration of steroids in women of childbearing age. Fluconazole administered at doses of 200 to 400 mg per day had no clinically significant effect on endogenous steroid levels or response to ACTH stimulation in healthy male volunteers. Interaction studies with antipyrine show that fluconazole 50 mg single or multiple doses does not alter its metabolism.
Sensitivity in vitro
In vitro, fluconazole exhibits antifungal activity against most species of Candida clinically most common (including C. albicans, C. parapsilosis, C. tropicalis). There C. glabrata shows a wide range of sensitivity while the C. krusei it is resistant to fluconazole.
Fluconazole also exhibits activity in vitro to Cryptococcus neoformans And Cryptococcus gattoi and also towards endemic yeasts Blastomyces dermatiditis, Coccidioides immitis, Histoplasma capsulatum And Paracoccidioides brasiliensis.
Pharmacokinetic / pharmacodynamic relationship (PK / PD)
In animal studies, there is a correlation between the MIC values and the efficacy against experimental mycoses due to the species to be Candida. In clinical trials, there is an almost 1: 1 linear relationship between AUC and fluconazole dose. There is also a direct, albeit imperfect, relationship between AUC or dose and an effective clinical response to treatment of oral candidiasis and, to a lesser extent, candidemia. Similarly, healing is less likely for infections caused by strains with a higher fluconazole MIC.
Resistance mechanism (s)
The Candida spp have developed some mechanisms of resistance to azole antifungals. Fungal strains that have developed one or more of these resistance mechanisms are known to exhibit elevated MICs to fluconazole, which has a negative impact on efficacy. in vivo and on a clinical level.
There have been reports of superinfections with the species from Candida other than C. albicans, which are often inherently insensitive to fluconazole (eg. Candida krusei). In these cases, alternative antifungal therapy may be required.
Breakpoints (EUCAST)
Based on analysis of PK / PD data, sensitivity in vitro and clinical response, the "EUCAST-AFST (European Committee on Antimicrobial susceptibility Testing-subcommittee on Antifungal Susceptibility Testing) determined the breakpoints for fluconazole for the species Candida (EUCAST Fluconazole rational document -version 2).
These have been divided into non-species related breakpoints, which were determined mainly on the basis of PK / PD data and are independent of the MIC distributions of individual species, and species related breakpoints, for the species most frequently associated with infections in the "man. The breakpoints are shown in the table below:
S = Sensitive, R = Resistant
A. = Non-species related breakpoints were determined primarily on the basis of PK / PD data and are independent of MIC distributions of individual species. They are used only for organisms that do not have specific breakpoints.
-- = Susceptibility testing not recommended as drug therapy is not the most suitable for this species. IE = There is insufficient evidence that drug therapy is suitable for this species.
05.2 "Pharmacokinetic properties
The pharmacokinetic properties of fluconazole are similar with both intravenous and oral administration.
Absorption
When administered orally, fluconazole is well absorbed, with plasma levels (and systemic bioavailability) greater than 90% of the levels achieved after intravenous administration. Oral absorption is not modified by the simultaneous intake of food. The peaks of plasma concentration in fasting are reached after a period between 30 and 90 minutes from the intake. Plasma concentrations are proportional to the administered doses.
90% of the level of steady-state it is reached after 4 or 5 days of repeated once daily dosing. Administration of a loading dose (on day 1) equal to twice the normal daily dose allows plasma levels to reach nearly 90% of levels steady-state already on the 2nd day.
Distribution
The apparent volume of distribution is comparable to the total amount of body water. Plasma protein binding is low (11-12%).
Fluconazole has good penetration into all organic fluids studied. Levels of fluconazole in saliva and sputum are similar to plasma levels. In patients with fungal meningitis, CSF fluconazole levels are approximately 80% of corresponding plasma levels.
Elevated skin concentrations of fluconazole, above serum concentrations, are reached in the stratum corneum, at the level of the epidermis and dermis and sweat glands. Fluconazole accumulates in the stratum corneum. Following the use of a 50 dose mg / day for 12 days a fluconazole concentration of 73 mcg / g was detected and 7 days after discontinuation of therapy the drug level was still equal to 5.8 mcg / g. Following administration of a weekly dose from 150 mg the concentration of fluconazole in the stratum corneum on the 7th day of therapy was 23.4 mcg / g and 7 days after the administration of the 2nd dose the levels were still equal to 7.1 mcg / g.
After 4 months of once-weekly 150 mg fluconazole, the fluconazole concentration was 4.05 mcg / g in healthy nails and 1.8 mcg / g in diseased nails. Furthermore, fluconazole was still available in nail samples 6 months after the end of therapy.
Biotransformation
Fluconazole is metabolised only to a minor extent. Of a radioactive dose, only 11% is excreted in modified form in the urine. Fluconazole is a selective inhibitor of CYP2C9 and CYP3A4 isoenzines (see section 4.5). Fluconaozlo is also an inhibitor of CYP2C19 isoenzyme.
Excretion
The plasma elimination half-life of fluconazole is approximately 30 hours. The primary route of elimination is renal: approximately 80% of the administered dose is found unchanged in the urine. The clearance of fluconazole is proportional to that of creatinine. There is no evidence of circulating metabolites.
The long plasma elimination half-life forms the basis of single dose therapy for vaginal candidiasis, once daily and once weekly for other indications.
Pharmacokinetics in renal impairment
In patients with severe renal insufficiency (GFR
Dosage reduction is therefore necessary. Fluconazole is removed by hemodialysis and, to a lesser extent, by peritoneal dialysis. After a three-hour hemodialysis session, approximately 50% of the fluconazole is cleared from the blood.
Pharmacokinetics in children
Pharmacokinetic data were evaluated in 113 pediatric patients from 5 studies: 2 single dose studies, 2 multiple dose studies and one premature neonate study. The data from the first study could not be interpreted due to changes in wording during the course of the study. Additional data comes from a compassionate use study.
After administration of fluconazole at doses of 2-8 mg / kg to children aged 9 months to 15 years, an AUC of approximately 38 mcg h / ml was observed for doses of 1 mg / kg. The mean plasma elimination half-life of fluconazole ranged from 15 to 18 hours and the volume of distribution after multiple dose administration was approximately 880 ml / kg. A higher plasma elimination half-life was observed after single administration. , approximately 24 hours. This is comparable to the plasma elimination half-life of fluconazole after a single administration of 3 mg / kg intravenously to children aged 11 days to 11 months. The volume of distribution in this age group was approximately 950 ml / kg.
Experience with fluconazole in neonates is limited to pharmacokinetic studies in premature infants. For 12 preterm infants with gestational age of approximately 28 weeks, the mean age at first dose was 24 hours (range 9-36 hours) and the mean birth weight was 0.9 kg (range 0.75-1.10 kg). Seven patients completed the protocol; a maximum of five intravenous doses of 6 mg / kg of fluconazole were administered every 72 hours. On the first day, the mean half-life was 74 hours (range 44-185), and then decreased, on the seventh day, to an average value of 53 hours (range 30-131), until reaching, on the thirteenth day, a value of 47 hours (range 27-68). On the first day the area under the curve (mcg .h / ml) was 271 (range of 173-385), to then increase, on the seventh day, up to a value mean of 490 (range of 292-734) and decrease instead, on the thirteenth day, to the mean value of 360 (range of 167-566). On the first day, the volume of distribution (ml / kg) was 1183 (range of 1070-1470), then increased over time to reach a mean value of 1184 (range of 510-2130) on the seventh day, and 1328 (range of 1040-1680) on the thirteenth day.
Pharmacokinetics in the elderly
A pharmacokinetic study was conducted in 22 subjects, 65 years of age and older, who were given a single oral dose of 50 mg of fluconazole. Ten of these subjects were receiving diuretics at the same time. Cmax of 1.54 mcg / mL was recorded 1.3 hours after dosing. The mean AUC was 76.4 ± 20.3 mcg · h / mL and the mean half-life was 46.2 hours. These pharmacokinetic parameter values are higher than the similar values reported for healthy young male volunteers. Concomitant administration of diuretics did not significantly alter AUC or Cmax. Furthermore, creatinine clearance (74 ml / min), the percentage of drug found unchanged in urine (0-24 hours, 22%) and Renal clearance estimates of fluconazole (0.124 mL / min / kg) for the elderly were generally lower than for younger volunteers.
Therefore, the altered behavior of fluconazole in the organism of elderly patients appears to be related to the reduced renal function characteristic of this group of patients.
05.3 Preclinical safety data
Effects in preclinical studies were observed only at exposures considered to be well above the maximum human exposure levels, indicating little relevance to clinical use.
Carcinogenesis
Fluconazole showed no carcinogenic potential in mice and rats treated orally for 24 months at doses of 2.5, 5 or 10 mg / kg / day (approximately 2-7 times the recommended human dose). In male rats treated with 5 and 10 mg / kg / day an increased incidence of hepatocellular adenomas was found.
Impaired fertility
Fluconazole did not affect the fertility of male or female rats treated orally with daily doses of 5, 10 or 20 mg / kg or parenteral doses of 5, 25 or 75 mg / kg.
There were no effects on the fetus at doses of 5 or 10 mg / kg; at doses equal to or greater than 25 and 50 mg / kg, increases in fetal anatomical variants (supernumerary ribs, dilation of the renal pelvis) and delays in ossification were observed. At doses ranging from 80 mg / kg to 320 mg / kg c "was an increase in embryolethality in rats, and fetal abnormalities included wavy ribs, cleft palate, and craniofacial ossification abnormalities."
The onset of calving was slightly delayed with oral doses of 20 mg / kg and dystocia and prolongation of parturition were observed in some pregnant rats at 20 mg / kg and 40 mg / kg intravenously. This was followed by a slight increase in the number of stillbirths and a decrease in neonatal survival at these dosages. The effects on parturition in rats are consistent with the species-specific estrogen-reducing property induced by high doses of fluconazole. No such hormonal disturbance has occurred in women receiving fluconazole therapy (see section 5.1).
06.0 PHARMACEUTICAL INFORMATION
06.1 Excipients
Lactose monohydrate, pregelatinised starch, magnesium stearate, anhydrous colloidal silica, sodium lauryl sulfate.
Capsule: gelatin, titanium dioxide (E 171), yellow iron oxide (E 172) (only in 100 mg capsules).
06.2 Incompatibility
Not relevant.
06.3 Period of validity
3 years
06.4 Special precautions for storage
Do not store above 30 ° C.
06.5 Nature of the immediate packaging and contents of the package
WINCH 100 mg capsules: PVC / Al blister containing 10 capsules
WINCH 150 mg capsules: PVC / Al blister containing 2 capsules
WINCH 200 mg capsules: PVC / Al blister containing 7 capsules
06.6 Instructions for use and handling
Unused medicine and waste derived from this medicine must be disposed of in accordance with local regulations.
07.0 MARKETING AUTHORIZATION HOLDER
So.Se.PHARM S.r.l.
Via dei Castelli Romani, 22
00040 Pomezia (Rome)
Italy
08.0 MARKETING AUTHORIZATION NUMBER
WINCH 100mg hard capsules - 10 capsules - AIC 037766019
WINCH 150mg hard capsules - 2 capsules - AIC 037766021
WINCH 200mg hard capsules - 7 capsules - AIC 037766033
09.0 DATE OF FIRST AUTHORIZATION OR RENEWAL OF THE AUTHORIZATION
25.03.2008
10.0 DATE OF REVISION OF THE TEXT
18.02.2012 (Official Gazette)
