Livial

Tibolone.

Each tablet contains 2.5 mg of tibolone.
Excipients/Inactive Ingredients: Livial 2.5 mg tablets contain potato starch, magnesium stearate, ascorbyl palmitate and lactose.

ATC code: G03CX01.
Pharmacology: Pharmacodynamics: Following oral administration, tibolone is rapidly metabolized into three compounds, which all contribute to the pharmacodynamic profile of Livial. Two of the metabolites (3α-OH-tibolone and 3β-OH-tibolone) have estrogenic-like activities, whereas the third metabolite (△4-isomer of tibolone) has progestogenic and androgenic-like activities.
Livial substitutes for the loss of estrogen production in postmenopausal women and alleviates menopausal symptoms. Livial prevents bone loss following menopause or ovariectomy.
Clinical trial information of Livial: Relief of estrogen-deficiency symptoms: Relief of menopausal symptoms generally occurs during the first few weeks of treatment.
Effects on the endometrium and bleeding patterns: There have been reports of endometrial hyperplasia and endometrial cancer in patients treated with Livial (see Precautions and Adverse Reactions).
Amenorrhea has been reported in 88% of women using Livial 2.5 mg after 12 months of treatment. Breakthrough bleeding and/or spotting has been reported in 32.6% of women during the first 3 months of treatment, and in 11.6% of women after 11-12 months of use.
Prevention of osteoporosis: Estrogen deficiency at menopause is associated with an increasing bone turnover and decline in bone mass. Protection appears to be effective for as long as treatment is continued. After discontinuation of HRT, bone mass is lost at a rate similar to that in untreated women.
In the LIFT study, Livial reduced the number of women (mean age 68 years) with new vertebral fractures compared to placebo during the 3 years of treatment (ITT: Livial to placebo odds ratio 0.57; 95% CI [0.42, 0.78]).
After 2 years of treatment with Livial (2.5 mg), the increase in lumbar spine bone mineral density (BMD) was 2.6 ± 3.8%. The percentage of women who maintained or gained BMD in lumbar zone during treatment was 76%. A second study confirmed these results.
Livial (2.5 mg) also had an effect on hip BMD. In one study, the increase after 2 years was 0.7 ± 3.9% at the femoral neck and 1.7 ± 3.0% at the total hip. The percentage of women who maintained or gained BMD in the hip region during treatment was 72.5%. A second study showed that the increase after 2 years was 1.3 ± 5.1% at the femoral neck and 2.9 ± 3.4% at the total hip. The percentage of women who maintained or gained BMD in the hip region during treatment was 84.7%.
Effects on the breast: In clinical studies mammographic density is not increased in women treated with Livial compared to placebo.
Pharmacokinetics: Following oral administration, tibolone is rapidly and extensively absorbed. Due to rapid metabolism, the plasma levels of tibolone are very low. The plasma levels of the △4-isomer of tibolone are also very low. Therefore some of the pharmacokinetic parameters could not be determined. Peak plasma levels of the 3α-OH and the 3β-OH metabolites are higher but accumulation does not occur. (See Table 1.)

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Excretion of tibolone is mainly in the form of conjugated (mostly sulfated) metabolites. Part of the administered compound is excreted in the urine, but most is eliminated via the feces.
The consumption of food has no significant effects on the extent of absorption.
The pharmacokinetic parameters for tibolone and its metabolites were found to be independent of renal function.
Toxicology: Preclinical safety data: In animal studies, tibolone had anti-fertility and embryotoxic activities by virtue of its hormonal properties. Tibolone was not teratogenic in mice and rats. It displayed teratogenic potential in the rabbit at near-abortive dosages (see Use in Pregnancy & Lactation). Tibolone is not genotoxic under in vivo conditions. Although a carcinogenic effect was seen in certain strains of rat (hepatic tumors) and mouse (bladder tumors), the clinical relevance of this is uncertain.

Treatment of complaints resulting from the natural or artificial menopause. Women above 60 years of age should only start with Livial treatment when they are intolerant of, or contraindicated for, other medicinal products approved for the treatment of estrogen deficiency symptoms.
Prevention of osteoporosis in postmenopausal women at high risk of future fractures who are intolerant of, or contraindicated for, other medicinal products approved for the prevention of osteoporosis.

The dosage is one tablet per day. No dose adjustment is necessary for the elderly. The tablets should be swallowed with some water or other drink, preferably at the same time every day.
For initiation and continuation of treatment of postmenopausal symptoms, the lowest effective dose for the shortest duration (see Precautions) should be used.
A separate progestogen should not be added with Livial treatment.
Starting Livial: Women experiencing a natural menopause should commence treatment with Livial at least 12 months after their last natural bleed. In case of a surgical menopause, treatment with Livial may commence immediately.
Any irregular/unscheduled vaginal bleeding, either on or off HRT, should be investigated to exclude malignancy before starting Livial (see Contraindications).
Switching from a sequential or continuous combined HRT preparation: If changing from a sequential HRT preparation, treatment with Livial should start the day following completion of the prior regimen. If changing from a continuous-combined HRT preparation, treatment can start at any time.
Missed dose: A missed dose should be taken as soon as remembered, unless it is more than 12 hours overdue. In the latter case, the missed dose should be skipped and the next dose should be taken at the normal time. Missing a dose may increase the likelihood of breakthrough bleeding and spotting.

The acute toxicity of tibolone in animals is very low. Therefore, toxic symptoms are not expected to occur, even when several tablets are taken simultaneously. In cases of acute overdose, nausea, vomiting and vaginal bleeding in females may occur. No specific antidote is known. Symptomatic treatment can be given if necessary.

Pregnancy and lactation; Known, past or suspected breast cancer - Livial increased the risk of breast cancer recurrence in a placebo-controlled trial; Known or suspected estrogen-dependent malignant tumors (e.g. endometrial cancer); Undiagnosed genital bleeding; Untreated endometrial hyperplasia; Previous or current venous thromboembolism (deep venous thrombosis, pulmonary embolism); Known thrombophilic disorders (e.g. protein C, protein S, or antithrombin deficiency, see Precautions); Any history of arterial thromboembolic disease (e.g. angina, myocardial infarction, stroke or TIA); Acute liver disease or a history of liver disease as long as liver function tests have failed to return to normal; Known hypersensitivity to the active substance or to any of the excipients; Porphyria.

For the treatment of postmenopausal symptoms, Livial should only be initiated for symptoms that adversely affect quality of life. In all cases, a careful appraisal of the risks and benefits should be undertaken at least annually and Livial should only be continued as long as the benefit outweighs the risk.
The risks of stroke, breast cancer and, in women with an intact uterus, endometrial cancer (see as follows and Adverse Reactions) for each woman should be carefully assessed, in the light of her individual risk factors and bearing in mind the frequency and characteristics of both cancers and stroke, in terms of their response to treatment, morbidity and mortality.
Evidence regarding the risks associated with HRT or tibolone in the treatment of premature menopause is limited. Due to the low level of absolute risk in younger women, however, the balance of benefits and risks for these women may be more favourable than in older women.
Medical examination/follow-up: Before initiating or reinstituting HRT or tibolone, a complete personal and family medical history should be taken. Physical (including pelvic and breast) examination should be guided by this and by the contraindications and warnings for use. During treatment, periodic check-ups are recommended of a frequency and nature adapted to the individual woman. Women should be advised what changes in their breasts should be reported to their doctor or nurse (see 'Breast cancer' as follows).
Investigations, including appropriate imaging tools, e.g. mammography, should be carried out in accordance with currently accepted screening practices, modified to the clinical needs of the individual.
Conditions which need supervision: If any of the following conditions are present, have occurred previously, and/or have been aggravated during pregnancy or previous hormone treatment, the patient should be closely supervised. It should be taken into account that these conditions may recur or be aggravated during treatment with Livial, in particular: Leiomyoma (uterine fibroids) or endometriosis; Risk factors for thromboembolic disorders (see as follows); Risk factors for estrogen dependent tumors, e.g. 1^st degree heredity for breast cancer; Hypertension; Liver disorders (e.g. liver adenoma); Diabetes mellitus with or without vascular involvement; Cholelithiasis; Migraine or (severe) headache; Systemic lupus erythematosis; A history of endometrial hyperplasia (see as follows); Epilepsy; Asthma; Otosclerosis.
Reasons for immediate withdrawal of therapy: Therapy should be discontinued in case a contraindication is discovered and in the following situations: Jaundice or deterioration in liver function; Significant increase in blood pressure; New onset of migraine-type headache.
Endometrial hyperplasia and carcinoma: The available data from randomized controlled trials are conflicting, however, observational studies have consistently shown that women who are prescribed Livial in normal clinical practice are at an increased risk of having endometrial cancer diagnosed (see Adverse Reactions). In these studies risk increased with increasing duration of use. Tibolone increases endometrial wall thickness, as measured by transvaginal ultrasound.
Break-through bleeding and spotting may occur during the first months of treatment (see Pharmacology: Pharmacodynamics under Actions). Women should be advised to report any break-through bleeding or spotting if it is still present after 6 months of treatment, if it starts beyond that time or if it continues after treatment has been discontinued. The woman should be referred for gynecological investigation, which is likely to include endometrial biopsy to exclude endometrial malignancy.
Breast cancer: Evidence with respect to breast cancer risk in association with tibolone is inconclusive. The Million Women Study (MWS) has identified a significant increase in the risk of breast cancer in association with use of the 2.5mg dose. This risk became apparent within a few years of use and increased with duration of intake, returning to baseline within a few (at most five) years after stopping treatment, see Adverse Reactions. These results could not be confirmed in a study using the General Practice Research Database (GPRD).
Ovarian cancer: Ovarian cancer is much rarer than breast cancer. Long-term (at least 5-10 years) use of estrogen-only HRT products has been associated with a slightly increased risk of ovarian cancer (see Adverse Reactions). Some studies including the Women's Health Initiative (WHI) trial suggest that the long-term use of combined HRTs may confer a similar, or slightly smaller risk (see Adverse Reactions). In the Million Women Study it was shown that the relative risk for ovarian cancer with use of tibolone was similar to the risk associated with use of other types of HRT.
Venous thromboembolism: Estrogen or estrogen-progestogen HRT is associated with a 1.3-3 fold risk of developing venous thromboembolism (VTE), i.e. deep vein thrombosis or pulmonary embolism. The occurrence of such an event is more likely in the first year of HRT than later (see Adverse Reactions). In an epidemiological study using a UK database, the risk of VTE in association with tibolone was lower than the risk associated with conventional HRT, but only a small proportion of women were current users of tibolone and a small increase in risk compared with non-use cannot be excluded.
Patients with known thrombophilic states have an increased risk of VTE and HRT or tibolone may add to this risk. HRT is therefore contraindicated in these patients (see Contraindications).
Generally recognized risk factors for VTE include use of estrogens, older age, major surgery, prolonged immobilization, obesity (BMI > 30 kg/m²), pregnancy/postpartum period, systemic lupus erythematosus (SLE), and cancer. There is no consensus about the possible role of varicose veins in VTE. As in all postoperative patients, prophylactic measures need be considered to prevent VTE following surgery. If prolonged immobilisation is to follow elective surgery temporarily stopping HRT or tibolone 4 to 6 weeks earlier is recommended. Treatment should not be restarted until the woman is completely mobilised.
In women with no personal history of VTE but with a first degree relative with a history of thrombosis at young age, screening may be offered after careful counselling regarding its limitations (only a proportion of thrombophilic defects are identified by screening). If a thrombophilic defect is identified which segregates with thrombosis in family members or if the defect is 'severe' (e.g, antithrombin, protein S, or protein C deficiencies or a combination of defects) HRT or tibolone is contraindicated.
Women already on anticoagulant treatment require careful consideration of the benefit-risk of use of HRT or tibolone.
If VTE develops after initiating therapy, the drug should be discontinued. Patients should be told to contact their doctors immediately when they are aware of a potential thromboembolic symptom (e.g. painful swelling of a leg, sudden pain in the chest, dyspnea).
Coronary artery disease (CAD): There is no evidence from randomized controlled trials of protection against myocardial infarction in women with or without existing CAD who received combined estrogen-progestagen or estrogen-only HRT. In an epidemiological study using the GPRD no evidence was found of protection against myocardial infarction in postmenopausal women who received tibolone.
Ischaemic stroke: Tibolone increases the risk of ischaemic stroke from the first year of treatment (see Adverse Reactions). The baseline risk of stroke is strongly age-dependent and so the effect of tibolone is greater with older age.
Other conditions: Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.
Livial is not intended for contraceptive use.
Treatment with Livial results in a marked dose-dependent decrease in HDL cholesterol (from -16.7% with a 1.25 mg dose to -21.8% for the 2.5 mg dose after 2 years). Total triglycerides and lipoprotein(a) levels were also reduced. The decrease in total cholesterol and VLDL-C levels was not dose-dependent. Levels of LDL-C were unchanged. The clinical implication of these findings is not yet known.
Estrogens may cause fluid retention, and therefore patients with cardiac or renal dysfunction should be carefully observed.
Women with pre-existing hypertriglyceridemia should be followed closely during estrogen replacement or HRT, since rare cases of large increases of plasma triglycerides leading to pancreatitis have been reported with estrogen therapy in this condition.
Treatment with Livial results in a very minor decrease of thyroid binding globulin (TBG) and total T4. Levels of total T3 are unaltered. Livial decreases the level of sex-hormone-binding globulin (SHBG), whereas the levels of corticoid binding globulin (CBG) and circulating cortisol are unaffected.
HRT use does not improve cognitive function. There is some evidence of increased risk of probable dementia in women who start using continuous combined or estrogen-only HRT after the age of 65.
Effects on ability to drive and use machines: Livial is not known to have any effects on alertness and concentration.

Livial is contraindicated during pregnancy (see Contraindications). If pregnancy occurs during medication with Livial, treatment should be withdrawn immediately. For Livial no clinical data on exposed pregnancies are available. Studies in animals have shown reproductive toxicity (see Pharmacology: Toxicology: Preclinical safety data under Actions). The potential risk for humans is unknown.
Livial is contraindicated during lactation (see Contraindications).

This section describes undesirable effects, which were registered in 21 placebo-controlled studies (including the LIFT study), with 4079 women receiving therapeutic doses (1.25 or 2.5 mg) of Livial and 3476 women receiving placebo. The duration of treatment in these studies ranged from 2 months to 4.5 years. Table 2 shows the undesirable effects that occurred statistically significantly more frequently during treatment with Livial than with placebo. (See Table 2.)

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In market use, other undesirable effects that have been observed include: dizziness, rash, pruritus, seborrheic dermatosis, headache, migraine, visual disturbances (including blurred vision), gastrointestinal upset, depression, edema, effects on the musculoskeletal system such as arthralgia or myalgia and changes in liver function parameters.
Breast cancer risk: An up to 2-fold increased risk of having breast cancer diagnosed is reported in women taking combined estrogen-progestagen therapy for more than 5 years.
Any increased risk in users of estrogen-only and tibolone therapy is substantially lower than that seen in users of estrogen-progestagen combinations.
The level of risk is dependent on the duration of use (see Precautions).
Results of the largest epidemiological study (MWS) are presented. (See Table 3.)

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Endometrial cancer risk: The endometrial cancer risk is about 5 in every 1000 women with a uterus not using HRT or tibolone.
The randomized placebo controlled trial that included women who had not been screened for endometrial abnormalities at baseline, and therefore reflected clinical practice, identified the highest risk of endometrial cancer, (LIFT study, mean age 68 years). In this study, no cases of endometrial cancer were diagnosed in the placebo group (n=1,773) after 2.9 years compared with 4 cases of endometrial cancer in the Livial group (n=1,746). This corresponds to a diagnosis of 0.8 additional case of endometrial cancer in every 1000 women who used Livial for one year in this study (see Precautions)."
Risk of ischaemic stroke: The relative risk of ischaemic stroke is not dependent on age or on duration of use, but as the baseline risk is strongly age-dependent, the overall risk of ischaemic stroke in women who use HRT or tibolone will increase with age, see Precautions.
A 2.9 year randomized controlled study has estimated a 2.2-fold increase in the risk of stroke in women (mean age 68 years) who used 1.25 mg Livial (28/2249) compared with placebo (13/2257). The majority (80%) of strokes were ischaemic.
The baseline risk of stroke is strongly age-dependent. Thus, the baseline incidence over a 5 year period is estimated to be 3 per 1000 women aged 50-59 years and 11 per 1000 women aged 60-69 years.
For women who use Livial for 5 years, the number of additional cases would be expected to be about 4 per 1000 users aged 50-59 years and 13 per 1000 users aged 60-69 years.
Other adverse reactions have been reported in association with estrogen and estrogen-progestogen treatment: Long term use of estrogen-only and combined estrogen-progestagen HRT has been associated with a slightly increased risk of ovarian cancer. In the Million Women Study 5 years of HRT resulted in 1 extra case per 2500 users. This study showed that the relative risk for ovarian cancer with tibolone was similar to the risk with other types of HRT.
HRT is associated with a 1.3-3-fold increased relative risk of developing venous thromboembolism (VTE), i.e. deep vein thrombosis or pulmonary embolism. The occurrence of such an event is more likely in the first year of using HRT (see Precautions). Results of the WHI studies are presented: (See Table 4.)

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The risk of coronary artery disease is slightly increased in users of combined estrogen-progestagen HRT over the age of 60 (see Precautions). There is no evidence to suggest that the risk of myocardial infarction with tibolone is different to the risk with other HRT.
Gall bladder disease; Skin and subcutaneous disorders: chloasma, erythema multiforme, erythema nodosum, vascular purpura; Probable dementia over the age of 65 (see Precautions).

Since Livial may increase blood fibrinolytic activity, it may enhance the effect of anticoagulants. This effect has been demonstrated with warfarin. Caution should therefore be exercised during the simultaneous use of Livial and anticoagulants, especially when starting or stopping concurrent Livial treatment. If necessary, the dose of warfarin should be adjusted.
There is limited information regarding pharmacokinetic interactions with tibolone. An in vivo study showed that simultaneous treatment of tibolone affects pharmacokinetics of the cytochrome P450 3A4 substrate midazolam to a moderate extent. Based on this, drug interactions with other CYP3A4 substrates might be expected.
CYP3A4 inducing compounds such as barbiturates, carbamazepine, hydantoins and rifampicin may enhance the metabolism of tibolone and thus affect its therapeutic effect.
Herbal preparations containing St. John's wort (Hypericum Perforatum) may induce the metabolism of oestrogens and progestagens via CYP3A4. Clinically, an increased metabolism of oestrogens and progestagens may lead to decreased effect and changes in the uterine bleeding profile.

Instructions for use and handling and disposal: Not applicable.
Incompatibilities: Not applicable.

Store in the original package and in the outer carton at 2-25°C.
Shelf-Life: 2 years.

Oestrogens, Progesterones & Related Synthetic Drugs

G03CX01 - tibolone ; Belongs to the class of other estrogens. Used in the treatment of menopausal symptoms.

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