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Scheduling delegate's final decisions: ACMS, October 2014

Scheduling medicines and poisons

23 October 2014

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Part A - Final decisions on matters referred to an expert advisory committee

1. Scheduling proposals referred to the July 2014 meeting of the Advisory Committee on Medicines Scheduling (ACMS#12)

1.1 Amorolofine

Scheduling proposal

The medicines scheduling delegate considered a proposal to amend the Schedule 2 amorolfine entry to exempt from scheduling preparations for the treatment of onychomycoses (fungal infections of the nail).

The delegate referred the proposal to the Advisory Committee on Medicines Scheduling (ACMS) for advice.

Substance summary

Amorolfine is a morpholine derivative with antifungal activity. It acts by interfering with the synthesis of sterols essential for the functioning of fungal cell membranes. Amorolfine is active in vitro against a wide variety of pathogenic and opportunistic fungi including dermatophytes, Blastomyces dermatitidis, Candida spp., Histoplasma capsulatum, and Sporothrix schenckii. It also has variable activity against Aspergillus spp. However, despite its in vitro activity, amorolfine is inactive when given systemically and this limits its use to topical application for superficial infections.

For the treatment of nail infections caused by dermatophytes, yeasts, and moulds a lacquer containing the equivalent of 5% amorolfine is painted onto the affected nail once or sometimes twice weekly until the nail has regenerated. Treatment generally needs to be continued for 6 to 12 months. For skin infections, including dermatophyte infections, a cream containing the equivalent of 0.25% amorolfine is applied once daily for at least 2 to 3 weeks (up to 6 weeks for foot infections) and continued for 3 to 5 days after clinical cure is achieved.

Scheduling status

Amorolfine is currently listed in Schedule 2 and Schedule 4 of the SUSMP.

Schedule 2

AMOROLFINE for topical use except in preparations for the treatment of tinea pedis.

Schedule 4

AMOROLFINE except:

  1. when included in Schedule 2; or
  2. in preparations for the treatment of tinea pedis.
Scheduling history

In February 1995, the National Drug and Poisons Scheduling Committee (NDPSC) considered the outcome of the 173rd Australian Drug Evaluation Committee (ADEC) meeting, which approved the registration of amorolfine. Based on this approval, the committee scheduled amorolfine in Schedule 4.

The NDPSC considered a proposal to place amorolfine in Schedule 2 for topical preparations containing 5% or less of the substance for the treatment of nail infections in February 1998. The committee felt that with inadequate safety data regarding the long term use, the ADEC consideration of the product for registration and the concern that consumers could not accurately diagnosis the condition without medical advice, the scheduling remained appropriate as Schedule 4.

The sponsor requested the committee to reconsider the proposal in May 1998. The sponsor provided further information addressing the NDPSC concerns and the committee noted that other aspects of the application were not give adequate consideration. The committee decided to review the application, pending information from the sponsor.

Amorolfine next appeared in the scheduling history records in August 1999. During this time, a Schedule 3 entry for the substance had been either considered or recommended, but no record of this could be located. Based on a recommendation from the Trans-Tasman Harmonisation Working Party (TTHWP), the Schedule 4 and 3 entries were to be amended and a new Schedule 2 entry was to be created for topical preparations containing 0.25% or less of amorolfine. This recommendation was in line with New Zealand’s entry for creams treating tinea pedis and the Schedule 3 equivalent for nail lacquers. The committee also agreed on an Appendix H entry for the substance.

During discussions at the November 1999 meeting, the committee noted that the amendments suggested in August 1999 followed the consideration of proposals from the product sponsor and the TTHWP, with the sponsor requesting the Schedule 3 entry and Appendix H listing and the TTHWP recommending the Schedule 2 entry. The NDPSC supported the proposals and the committee accepted the findings of the AHMAC committee in relation to the matters mentioned in subsection 52E (1) of the Act. The Schedule 4 and 3 entries were amended and the Schedule 2 entry outlined in August 1999 was accepted.

In October 2005, the NDPSC reviewed the scheduling of amorolfine, including the TTHWP recommendations. They noted that in NZ, amorolfine products containing 0.25% or less of the substance for the treatment of tinea pedis were general sale (exempt from scheduling). Harmonisation was supported on the basis of history of safe use in NZ and the committee foreshadowed amending the Schedule 2 entry to exempt preparations for the treatment of tinea pedis.

In February 2006, the committee confirmed the foreshadowed decisions outlined in October 2005 on the grounds of harmonisation.

Amorolfine was considered as part of a group item relating to substances that are applied to nails and clarifying their scheduling entries in June 2006. The committee reviewed the history of the scheduling decisions, and discussed substance details and possible amendments to the amorolfine entries, in an effort to be consistent with other substance entries relating to the fungal treatment of nails. The members agreed that an amendment for consistency was not appropriate in this case.

In June 2010 the committee discussed an application from the product sponsor requesting that all topical use preparations of amorolfine, regardless of strength, be rescheduled from Schedule 3 to Schedule 2. The applicant stated that there was low potential for harm from inappropriate use and low abuse potential, low or well characterised incidence of adverse effects, the condition onychomycosis is easily recognisable by the consumer and amenable to short-term treatment and that there are positive benefits for consumers. The committee agreed to remove the Schedule 3 entry and place all topical preparations in Schedule 2 on the grounds the risk posed by the substance was similar to other schedule 2 anti-fungals and that any risk would be addressed by labelling. The exemption for preparations treating tinea pedis remained.

In June 2011, the medicines delegate agreed with an ACMS member's comments that now there was no longer a Schedule 3 entry for the substance, the Appendix H entry was no longer needed and the delegate decided that it would be removed.

Pre-meeting public submissions

Two submissions were received; both did not support the proposal. The first submission was of the belief that access to health professionals is required for correct use of treatments and that underlying or related health conditions associated with onychomycosis are examined and referred to medical practitioners where appropriate. Conveying similar reasons, the second submission felt that consumers using amorolfine should have the opportunity for immediate access to pharmacist advice to support appropriate self-medication practices, tailor therapy and promote optimal outcomes from therapy.

ACMS advice to the delegate

The ACMS recommended that the current scheduling of amorolfine remains appropriate.

The matters under subsection 52E (1) of the Therapeutic Goods Act 1989 considered relevant by the Committee included: b) the purpose for which a substance is to be used and the extent of use of a substance.

The reasons for the recommendation comprised the following:

  • The diagnosis of onychomycoses can be difficult and treatment requires long term use of amorolfine. Consequently, the patient will benefit from having access to professional advice in both initiating and maintaining treatment.
Delegate's interim decision

The interim decision is that the current scheduling of amorolfine remains appropriate.

Reasons for the decision are:

  • Concerns about the ability to self-diagnosis onychomycosis (or) fungal nail infections, particularly in people with diabetes. The main reason for this is that visible symptoms of fungal infections (discolouration of the nail) could mask those of underlying diabetic issues, such as impaired blood circulation. The minimum treatment period of onychomycoses is six months.
  • This interim decision is supported by the applicant's statement that diagnosis of onychomycoses is difficult and that public awareness of onychomycoses is limited.
  • No other comparable country has amorolfine available as a general sale product.
  • No other antifungal is exempt from scheduling except for the treatment of tinea pedis.
Delegate's considerations

The delegate considered the following in regards to this proposal:

  • Scheduling proposal;
  • Public submissions received;
  • ACMS advice;
  • Section 52E of the Therapeutic Goods Act 1989;
  • Scheduling factors1;
  • Other relevant information.
Public submissions on the interim decision

One submission was received that did not support delegate's interim decision on the basis that definitive diagnosis any fungal condition is difficult, people with diabetes are usually under care of a medical practitioner/specialist and the Consumer Medicine Information provides relevant advice.

Edited versions of these submissions are available at Public submissions on scheduling matters.

Delegate's final decision

The delegate notes the submission received in response to publication of the interim decision and confirms the interim decision as no evidence has been received to alter the interim decision. The delegate has confirmed that the reasons for the final decision are in keeping with those for the interim decision.

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1.2 Calcium hydroxylapatite

Scheduling proposal

The medicines scheduling delegate considered a proposal to include calcium hydroxylapatite in preparations for injection or implantation when used for tissue augmentation or for cosmetic use in Schedule 4.

The delegate referred the proposal to the Advisory Committee on Medicines Scheduling (ACMS) for advice.

Substance summary

Hydroxylapatite (also known as hydroxyapatite) is a natural mineral with a composition similar to that of the mineral in bone. For therapeutic purposes, hydroxylapatite is prepared from bovine bone and contains, in addition to calcium and phosphate, trace elements, fluoride and other ions, proteins and glycosaminoglycans. It is given orally to patients requiring both calcium and phosphorus supplementation and hydroxylapatite with tricalcium phosphate has been used in bone grafts.

Hydroxylapatite derived from marine coral has been used in the construction of orbital implants for use after surgical removal of the eye. A form of hydroxyapatite referred to as calcium hydroxyapatite is used for correction of facial lipoatrophy in patients with HIV infection and as a cosmetic filler for moderate to severe facial wrinkles and folds.2

Scheduling status

Calcium hydroxylapatite is not specifically scheduled.

Scheduling history

Calcium hydroxylapatite has not been previously considered for scheduling therefore scheduling history is not available.

Pre-meeting public submissions

One public submission was received, asking the committee and the delegate to consider that the substance is used in dental bone grafting medical devices, entry could potentially impact on these products, suggested exempting the substance for dental use.

ACMS advice to the delegate

The ACMS recommended that calcium hydroxylapatite in preparations for injection or implantation when used for tissue augmentation or for cosmetic use be included in Schedule 4 with an implementation date of 1 February 2015.

The matters under subsection 52E (1) of the Therapeutic Goods Act 1989 considered relevant by the Committee included: a) the risks and benefits of the use of a substance; b) the purposes for which a substance is to be used and the extent of use of a substance; d) the dosage, formulation, labelling, packaging and presentation of a substance; and f) any other matters that the Secretary considers necessary to protect public health.

The reasons for the recommendation comprised the following:

  • There needs to be appropriate monitoring and reporting of adverse effects.
  • There is the potential for inappropriate off-label administration.
  • An injectable implant needs to be administered by a health practitioner who has knowledge and training in injection/implantation techniques, uses appropriate infection control procedures and undertakes appropriate follow-up. There is potential for serious adverse effects if the administration of the product is not undertaken by an appropriately trained and qualified practitioner.

There is potential for inappropriate advertising direct to consumers. Concurrent administration of local anaesthetic may be required and this should be administered by an appropriately qualified health practitioner.

Delegate's interim decision

The interim decision is that calcium hydroxylapatite in preparations for injection or implantation when used for tissue augmentation or for cosmetic use be included in Schedule 4 with an implementation date of 1 February 2015.

The reasons for the interim decision are:

  • An injectable implant needs to be administered by a health practitioner who has knowledge and training in injection/implantation techniques, uses appropriate infection control procedures and undertakes appropriate follow-up. There is potential for serious adverse effects if the administration of the product is not undertaken by an appropriately trained and qualified practitioner.
  • Concurrent administration of local anaesthetic may be required and this should be administered by an appropriately qualified health practitioner.
  • There is potential for inappropriate advertising direct to consumers.
  • There needs to be appropriate monitoring and reporting of adverse effects.
Delegate's considerations

The delegate considered the following in regards to this proposal:

  • Scheduling proposal;
  • Public submissions received;
  • ACMS advice;
  • Section 52E of the Therapeutic Goods Act 1989;
  • Scheduling factors3;
  • Other relevant information.
Public submissions on the interim decision

No public submissions were received.

Delegate's final decision

The delegate has confirmed that the reasons for the final decision are in keeping with those for the interim decision.

Schedule entry
Schedule 4 - New entry

CALCIUM HYDROXYLAPATITE in preparations for injection or implantation:

  1. for tissue augmentation; or
  2. for cosmetic use.

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1.3 Macitentan

Scheduling proposal

The medicines scheduling delegate considered a proposal to include macitentan in Appendix D, Item 2 and Appendix L.

The delegate referred the proposal to the Advisory Committee on Medicines Scheduling (ACMS) for advice.

Substance summary

Macitentan belongs to the same class of pharmaceuticals as bosentan and ambrisentan and the former sitaxentan (withdrawn globally due to liver toxicity) which are orally active endothelin receptor antagonists (ERAs). Macitentan, like bosentan, is a dual endothelin A and B receptor antagonist, which is different to ambrisentan which is specific for endothelin type A receptors.

Macitentan is proposed for the long-term treatment of pulmonary arterial hypertension (PAH) in patients of WHO Functional Class II to IV, as monotherapy or in combination with approved PAH treatments (phosphodiesterase-5 inhibitors or prostanoids) to delay disease progression.

Scheduling status

Macitentan is not currently scheduled in Australia. Macitentan has just been considered by the New Zealand Medsafe Committee as a prescription medication. It is also considered a prescription drug in the United States of America (USA), Canada and the European Union. Macitentan is considered by the USA as a Pregnancy Category X drug. In Canada and in the EU the substance is contraindicated during pregnancy and for nursing women.

Scheduling history

Macitentan has not been previously considered for scheduling therefore scheduling history is not available.

Pre-meeting public submissions

No submissions were received for this scheduling proposal.

ACMS advice to the delegate

The ACMS recommended that Macitentan be included in Appendix D, Item 6 as well as Appendix L with warning statements 7, 62 and 76 with an implementation date of 1 February 2015.

The matters under subsection 52E (1) of the Therapeutic Goods Act 1989 considered relevant by the Committee included: a) the risks and benefits of the use of a substance and c) the toxicity of the substance.

The reasons for the recommendation comprised the following:

  • Teratogenicity which is consistent with other substances in this class

The need for product information containing contraindications during pregnancy.

Delegate's interim decision

The interim decision is to include macitentan in Appendix D, Item 6 as well as Appendix L with warning statements 7, 62 and 76 with an implementation date of 1 February 2015.

The reasons for the interim decision are:

  • Its teratogenicity which is consistent with other substances in this class which have this scheduling.
  • The need for product information containing contraindications during pregnancy.
  • That it is considered by the USA as a Pregnancy Category X drug.

That in Canada and in the EU the substance is contraindicated during pregnancy and for nursing women.

Delegate's considerations

The delegate considered the following in regards to this proposal:

  • Scheduling proposal;
  • Public submissions received;
  • ACMS advice;
  • Section 52E of the Therapeutic Goods Act 1989;
  • Scheduling factors4;
  • Other relevant information.
Public submissions on the interim decision

No public submissions were received.

Delegate's final decision

The delegate has confirmed that the reasons for the final decision are in keeping with those for the interim decision.

Schedule entry
Appendix D, Item 6 - New entry

MACITENTAN for human use

Appendix L, Part 2 - New entry
Column 1
Substance
Column 2
Warning statement
Macitentan 7, 62 and 76

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1.4 Polycaprolactone

Scheduling proposal

The medicines scheduling delegate considered a proposal to include polycaprolactone in preparations for injection or implantation when used for tissue augmentation or for cosmetic use in Schedule 4.

The delegate referred the proposal to the Advisory Committee on Medicines Scheduling (ACMS) for advice.

Substance summary

A substance summary for polycaprolactone was not provided for this proposal.

Scheduling status

Polycaprolactone is not specifically scheduled.

Scheduling history

Polycaprolactone has not been previously considered for scheduling therefore scheduling history is not available.

Pre-meeting public submissions

No submissions were received for this scheduling proposal.

ACMS advice to the delegate

The ACMS recommended that polycaprolactone in preparations for injection or implantation when used for tissue augmentation or for cosmetic use be included in Schedule 4 with an implementation date of 1 February 2015.

The matters under subsection 52E (1) of the Therapeutic Goods Act 1989 considered relevant by the Committee included: a) the risks and benefits of the use of a substance; b) the purposes for which a substance is to be used and the extent of use of a substance; d) the dosage, formulation, labelling, packaging and presentation of a substance; and f) any other matters that the Secretary considers necessary to protect public health.

The reasons for the recommendation comprised the following:

  • There needs to be appropriate monitoring and reporting of adverse effects.
  • There is the potential for inappropriate off-label administration.
  • An injectable implant needs to be administered by a health practitioner who has knowledge and training in injection/implantation techniques, uses appropriate infection control procedures and undertakes appropriate follow-up. There is potential for serious adverse effects if the administration of the product is not undertaken by an appropriately trained and qualified practitioner.
  • There is potential for inappropriate advertising direct to consumers. Concurrent administration of local anaesthetic may be required and this should be administered by an appropriately qualified health practitioner.
Delegate's interim decision

The interim decision is that polycaprolactone in preparations for injection or implantation when used for tissue augmentation or for cosmetic use is included in Schedule 4 with an implementation date of 1 February 2015.

Reasons for the interim decision are:

  • An injectable implant needs to be administered by a health practitioner who has knowledge and training in injection/implantation techniques, uses appropriate infection control procedures and undertakes appropriate follow-up. There is potential for serious adverse effects if the administration of the product is not undertaken by an appropriately trained and qualified practitioner.
  • Concurrent administration of local anaesthetic may be required and this should be administered by an appropriately qualified health practitioner.
  • There needs to be appropriate monitoring and reporting of adverse effects.
  • There is potential for inappropriate advertising direct to consumers.
Delegate's considerations

The delegate considered the following in regards to this proposal:

  • Scheduling proposal;
  • Public submissions received;
  • ACMS advice;
  • Section 52E of the Therapeutic Goods Act 1989;
  • Scheduling factors5;
  • Other relevant information.
Public submissions on the interim decision

No public submissions were received.

Delegate's final decision

The delegate has confirmed that the reasons for the final decision are in keeping with those for the interim decision.

Schedule entry
Schedule 4 - New entry

POLYCAPROLACTONE in preparations for injection or implantation:

  1. for tissue augmentation; or
  2. for cosmetic use.

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1.5 Riociguat

Scheduling proposal

The medicines scheduling delegate considered a proposal to include riociguat in Appendix D, Item 2 and Appendix L.

Substance summary

Riociguat is a stimulator of soluble guanylate cyclase, an enzyme in the cardiopulmonary system, and increases production of the second messenger cyclic guanosine monophosphate (cGMP).

Adempas (riociguat) is proposed to be used in adult patients with chronic thromboembolic pulmonary hypertension and pulmonary arterial hypertension.

Scheduling status

Riociguat is not currently scheduled in Australia or New Zealand. It is, however, a prescription drug in the United States of America (USA), Canada and the European Union. Riociguat is considered by the USA as a Pregnancy Category X drug. In Canada and in the EU the substance is contraindicated during pregnancy and for nursing women.

Scheduling history

Riociguat has not been previously considered for scheduling therefore scheduling history is not available.

Pre-meeting public submissions

No submissions were received for this scheduling proposal.

ACMS advice to the delegate

The ACMS recommended that riociguat be included in Appendix D, Item 4 as well as Appendix L with warning statements 7, 62 and 76 with an implementation date of 1 February 2015.

The matters under subsection 52E (1) of the Therapeutic Goods Act 1989 considered relevant by the Committee included: c) the toxicity of the substance.

The reason for the recommendation comprised the following:

  • Teratogenic nature of the substance.
Delegate's interim decision

The interim decision is that riociguat is included in Appendix D, Item 4, as well as Appendix L with warning statements 7, 62 and 76 with an implementation date of 1 February 2015.

The reasons for the interim decision are:

  • The teratogenic nature of the substance.
  • FDA have stipulated a 1 month washout period
  • It is considered by the USA as a Pregnancy Category X drug.
  • That in Canada and in the EU the substance is contraindicated during pregnancy and for nursing women.
Delegate's considerations

The delegate considered the following in regards to this proposal:

  • Scheduling proposal;
  • Public submissions received;
  • ACMS advice;
  • Section 52E of the Therapeutic Goods Act 1989;
  • Scheduling factors6;
  • Other relevant information.
Public submissions on the interim decision

No public submissions were received.

Delegate's final decision

The delegate has confirmed that the reasons for the final decision are in keeping with those for the interim decision.

Schedule entry
Appendix D, Item 4 - New entry

RIOCIGUAT for human use

Appendix L, Part 2 - New entry
Column 1
Substance
Column 2
Warning statement
Riociguat 7, 62 and 76

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1.6 Suvorexant

Scheduling proposal

The medicines scheduling delegate considered a proposal to include suvorexant in Appendix K.

The delegate referred the proposal to the Advisory Committee on Medicines Scheduling (ACMS) for advice.

Substance summary

Suvorexant is a dual orexin receptor antagonist and is indicated for the treatment of insomnia, characterised by difficulties with sleep onset and/or sleep maintenance.

Scheduling status

Suvorexant is not currently scheduled in Australia or New Zealand. It is currently under review by the Food and Drug Administration (FDA) in the United States of America (USA). The FDA is yet to approve suvorexant due to concerns regarding the safety and efficacy of the substance.

Scheduling history

Suvorexant has not been previously considered for scheduling therefore scheduling history is not available.

Pre-meeting public submissions

No submissions were received for this scheduling proposal.

ACMS advice to the delegate

The ACMS recommended that suvorexant be included in Appendix K with an implementation date of 1 February 2015.

The matters under subsection 52E (1) of the Therapeutic Goods Act 1989 considered relevant by the Committee included: a) the risks and benefits of the use of a substance and c) the toxicity of the substance.

The reasons for the recommendation comprised the following:

  • Pronounced sedation effect
  • Entry would be consistent with other sedative drugs in Appendix K
  • Long duration of action of the substance may impact on peoples’ ability to drive and operate machinery
  • Narrow therapeutic margin.
Delegate's interim decision

The interim decision is that suvorexant be included in Appendix K.

Reasons for the interim decision are:

  • Pronounced sedation effect
  • Entry would be consistent with other sedative drugs in Appendix K
  • Long duration of action of the substance may impact on peoples’ ability to drive and operate machinery
  • Narrow therapeutic margin of the substance.
Delegate's considerations

The delegate considered the following in regards to this proposal:

  • Scheduling proposal;
  • Public submissions received;
  • ACMS advice;
  • Section 52E of the Therapeutic Goods Act 1989;
  • Scheduling factors7;
  • Other relevant information.
Public submissions on the interim decision

No public submissions were received.

Delegate's final decision

The delegate has confirmed that the reasons for the final decision are in keeping with those for the interim decision.

Schedule entry
Appendix K - New entry

SUVOREXANT

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1.7 Tofactinib

Scheduling proposal

The medicines scheduling delegate considered a proposal to include tofacitinib in Appendix D and Appendix L.

The delegate referred the proposal to the Advisory Committee on Medicines Scheduling (ACMS) for advice.

Substance summary

Tofacitinib is a JAK1, 2 and 3 kinase inhibitor with some limited inhibitory activity against tyrosine kinase 2 (TyK2).

Scheduling status

Tofacitinib is not currently scheduled in Australia or New Zealand.

Scheduling history

Tofacitinib has not been previously considered for scheduling therefore scheduling history is not available.

Pre-meeting public submissions

No submissions were received for this scheduling proposal.

ACMS advice to the delegate

The ACMS recommended that tofacitinib does not require inclusion in Appendix D or Appendix L.

Delegate's interim decision

The interim decision is that tofacitinib does not require inclusion in Appendix D or Appendix L.

The reasons for the interim decision are:

  • Pregnancy is not contraindicated and as tofacitinib is considered pregnancy category D, it would not require an Appendix L listing.
  • As Appendix L is not required there is no need for a specialist prescription and hence does not require Appendix D listing.
  • USA has classified tofacitinib as Pregnancy Category C under their own classification system.
Delegate's considerations

The delegate considered the following in regards to this proposal:

  • Scheduling proposal;
  • Public submissions received;
  • ACMS advice;
  • Section 52E of the Therapeutic Goods Act 1989;
  • Scheduling factors8;
  • Other relevant information.
Public submissions on the interim decision

No public submissions were received.

Delegate's final decision

The delegate has confirmed that the reasons for the final decision are in keeping with those for the interim decision.

Footnotes

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